52 files changed, 36780 insertions, 0 deletions
diff --git a/.gitattributes b/.gitattributes
new file mode 100644
index 0000000..6833f05
--- /dev/null
+++ b/.gitattributes
@@ -0,0 +1,3 @@
+* text=auto
+*.txt text
+*.md text
diff --git a/24564-8.txt b/24564-8.txt
new file mode 100644
index 0000000..db37d16
--- /dev/null
+++ b/24564-8.txt
@@ -0,0 +1,12116 @@
+The Project Gutenberg eBook, A Manual of the Operations of Surgery, by
+Joseph Bell
+
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+
+
+
+Title: A Manual of the Operations of Surgery
+       For the Use of Senior Students, House Surgeons, and Junior Practitioners
+
+
+Author: Joseph Bell
+
+
+
+Release Date: February 11, 2008  [eBook #24564]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+
+***START OF THE PROJECT GUTENBERG EBOOK A MANUAL OF THE OPERATIONS OF
+SURGERY***
+
+
+E-text prepared by Michael Ciesielski, Pilar Somoza Fern�ndez, and the
+Project Gutenberg Online Distributed Proofreading Team
+(https://www.pgdp.net)
+
+
+
+Note: Project Gutenberg also has an HTML version of this
+      file which includes the original illustrations.
+      See 24564-h.htm or 24564-h.zip:
+      (https://www.gutenberg.org/dirs/2/4/5/6/24564/24564-h/24564-h.htm)
+      or
+      (https://www.gutenberg.org/dirs/2/4/5/6/24564/24564-h.zip)
+
+
+Transcriber's note:
+
+      Spelling mistakes have been left in the text to match the original,
+      except for obvious typographical errors.
+
+
+
+
+
+A MANUAL OF THE OPERATIONS OF SURGERY
+
+For the Use of Senior Students, House Surgeons, and
+Junior Practitioners.
+
+Illustrated.
+
+by
+
+JOSEPH BELL, F.R.C.S. EDIN.
+
+Lecturer on Clinical Surgery, Surgeon to the Royal Infirmary and to
+the Eye Infirmary, and Late Demonstrator of Anatomy
+in the University of Edinburgh.
+
+FIFTH EDITION, REVISED AND ENLARGED.
+
+
+
+
+
+
+
+Edinburgh: Maclachlan & Stewart,
+Booksellers to the University.
+London: Simpkin, Marshall, & Co.
+1883.
+
+
+
+
+TO THE MEMORY OF
+JAMES SYME, ESQ., F.R.C.S. AND F.R.S.E.
+SURGEON TO THE QUEEN IN SCOTLAND
+
+PROFESSOR OF CLINICAL SURGERY
+IN THE UNIVERSITY OF EDINBURGH
+ETC. ETC.
+
+THIS BOOK IS DEDICATED
+BY HIS OLD HOUSE-SURGEON AND ASSISTANT
+
+THE AUTHOR.
+
+
+
+
+PREFACE TO FIFTH EDITION.
+
+
+To retain the small size of the work and to keep it up to date have been
+the Author's aim in the Fifth Edition.
+
+
+20 MELVILLE STREET, EDINBURGH,
+_August 1883._
+
+
+
+
+PREFACE TO THE FIRST EDITION.
+
+
+Having been asked, year after year, by the members of my Class for
+Operative Surgery, to recommend to them some Manual of Surgical
+Operations which might at once guide them in their choice of operations,
+and give minute details as to the mode of performance, I have been
+gradually led to undertake the production of this little work.
+
+My aim has been to describe as simply as possible those operations which
+are most likely to prove useful, and especially those which, from their
+nature, admit of being practised on the dead body.
+
+In accordance with this plan, neither historical completeness of detail,
+nor much variety in the methods of performing any given operation, is to
+be expected. Hence, also, many omissions which would be unpardonable in
+the briefest system of Surgery are unavoidable. For example, excision of
+tumours and operations for necrosis are hardly mentioned, because for
+these no special instructions can well be given; for, while general
+principles may guide us to _what_ should be done, the special
+circumstances of each case must dictate _how_ it is to be done.
+
+In such a work as this, to attempt originality would be undesirable and
+intrusive; a judicious selection, a faithful compilation, are all that
+can be expected.
+
+That the selection of operations may sometimes show "Northern
+Proclivities" is possible; and this is perhaps not unnatural to a
+scholar and teacher in the Edinburgh School.
+
+An earnest endeavour has been used to make the references correct and
+copious: for any mistakes or omissions the author would crave
+indulgence.
+
+The four plates which precede the letterpress were drawn on wood (from
+original photographs) by Mr. D.W. Williamson, Melbourne Place, and the
+lines of incision for the various operations were added by the author.
+
+The rough woodcuts scattered through the work were drawn on wood by the
+author, and for their roughness he, not his engraver, is responsible. He
+also hopes that the references in the letterpress will be accepted as
+sufficient acknowledgment of the true ownership, in those few instances
+in which the idea of the diagram has been borrowed.
+
+It has been thought unnecessary to introduce woodcuts of surgical
+instruments, as the illustrated catalogues lately published by Weiss,
+Maw, and others, are sufficiently accurate.
+
+In excuse of the frequent baldness and brevity of the style, the author
+must point to the size and price of the work. Its composition would have
+been easier had its dimensions been greater.
+
+Though intended chiefly to guide the studies, on the dead subject, of
+students and junior practitioners, the author ventures to hope that the
+Manual may be useful to those who, in the public services, in the
+colonies, or in lonely country districts, find themselves constrained to
+attempt the performance of operations which, in the towns, usually fall
+to the lot of a few Hospital Surgeons.
+
+
+                                                     JOSEPH BELL.
+
+5 CASTLE TERRACE, EDINBURGH,
+       _July 1866._
+
+
+
+
+CONTENTS.
+
+
+CHAPTER I.
+
+LIGATURE OF ARTERIES.
+
+                                                                    PAGE
+
+Ligature of Arteries--General Maxims--Ligature of
+Aorta--Iliacs--Gluteal--Femoral--Popliteal--Innominate--Carotids--
+Lingual--Subclavian--Brachial, etc.,                                1-45
+
+
+CHAPTER II.
+
+AMPUTATIONS.
+
+Eras of Amputation--Flap and Circular compared--Special Amputation of
+Arm and Leg,                                                      46-107
+
+
+CHAPTER III.
+
+EXCISION OF JOINTS.
+
+Brief Historical Sketch--Comparison of Excisions with
+Amputations--Special Excisions of the six larger Joints--Excisions of
+smaller Joints and Bones,                                        108-146
+
+
+CHAPTER IV.
+
+OPERATIONS ON CRANIUM AND SCALP.
+
+Trephining--Excision of Wens,                                    147-150
+
+
+CHAPTER V.
+
+OPERATIONS ON THE EYE AND ITS APPENDAGES.
+
+Entropium and Ectropium--Trichiasis--Tarsal Tumours--On Lachrymal
+Organs--Mr. Bowman's Operation--Pterygium--Strabismus, convergent
+and divergent--Paracentesis of the Anterior Chamber--Operations
+for Cataract by Displacement, Solution, and Extraction--Various
+methods of Extraction--Operations for Artificial
+Pupil--Iridesis--Corelysis--Iridectomy--Excision of Staphyloma--Excision
+of Eyeball,                                                      151-174
+
+
+CHAPTER VI.
+
+OPERATIONS ON THE NOSE AND LIPS.
+
+Rhinoplastic Operations from Cheek, Forehead, and elsewhere--Removal of
+Nasal Polypi--Excision of Cancers of Lips--Cheiloplastic
+Operations--Operations for Harelip,                              175-187
+
+
+CHAPTER VII.
+
+OPERATIONS ON THE JAWS.
+
+Excision of Upper Jaw--Of Lower Jaw,                             188-195
+
+
+CHAPTER VIII.
+
+OPERATIONS ON MOUTH AND THROAT.
+
+For Salivary Fistula--Excision of Tongue, complete and partial--Fissures
+of the Palate, soft and hard--Excision of Tonsils,               196-205
+
+
+CHAPTER IX.
+
+OPERATIONS ON AIR PASSAGES.
+
+Larynx and
+Trachea--Tracheotomy--Tubes--Laryngotomy--OEsophagotomy--[see
+Addendum, p. 302],                                               206-217
+
+
+CHAPTER X.
+
+OPERATIONS ON THORAX.
+                                                                    PAGE
+Excision of Mamma--Paracentesis Thoracis,                        218-221
+
+
+CHAPTER XI.
+
+OPERATIONS ON ABDOMEN.
+
+Paracentesis Abdominis--Gastrotomy--Ovariotomy--Operation for
+Strangulated Hernia--Inguinal--Femoral--Umbilical--Operations for the
+Radical Cure of Hernia,                                          222-255
+
+
+CHAPTER XII.
+
+OPERATIONS ON PELVIS.
+
+Lithotomy--Varieties--Lithotrity--Operations for Stricture--Puncture of
+the Bladder--Phymosis--Amputation of
+Penis--Hydrocele--H�matocele--Castration--Operation for
+Fistula--Fissure--Polypi of Rectum--Piles,                       256-295
+
+
+CHAPTER XIII.
+
+TENOTOMY.
+
+On Tenotomy for Wry Neck and Club Foot,                          296-298
+
+
+CHAPTER XIV.
+
+OPERATIONS ON NERVES.
+
+Nerve-stretching--Nerve-cutting--Nerve suture,                   299-301
+
+
+ADDENDUM to Chapter IX.,                                             302
+
+INDEX,                                                           303-311
+
+
+
+
+LIST OF ILLUSTRATIONS.
+
+
+FIG.                                                                PAGE
+
+I.       Amputations of Fingers,                                      50
+
+II.      Diagram of Finger showing Articulations,                     50
+
+III.     Dubrueil's Amputation at Wrist (front view),                 57
+
+IV.       "             "             (dorsal view),                  57
+
+V.       Amputations of Toes,                                         69
+
+VI.      Excision of Wrist-joint--Lister's,                          126
+
+VII.     Operations for Ectropium and Entropium,                     151
+
+VIII.    Operation for Trichiasis--Streatfeild's,                    151
+
+IX.      Operation for Epiphora--Bowman's,                           155
+
+X.       Greenslade's Instrument for above,                          156
+
+XI.      Operations for Squint,                                      157
+
+XII.     Linear Extraction of Cataract,                              162
+
+XIII.    Flap Extraction of Cataract,                                162
+
+XIV.     Operation of Corelysis--Streatfeild's,                      171
+
+XV.      Operation for Staphyloma--Critchett's,                      172
+
+XVI.     Result of above,                                            172
+
+XVII.    Rhinoplastic Operation from Cheek,                          176
+
+XVIII.     "              "       Forehead,                          177
+
+XIX.     Operation on Lip, V-shaped incision,                        181
+
+XX.      Operation on Lip, by scissors,                              181
+
+XXI.     Operation for a new Lip, incisions,                         182
+
+XXII.    Operation for New Lip sewed up,                             182
+
+XXIII.   Diagram of Partial Fissure (Harelip),                       184
+
+XXIV.    Nelaton's Operation for ditto,                              184
+
+XXV.     Operation for Double Harelip,                               185
+
+XXVI.    Diagram of Double Harelip,                                  186
+
+XXVII.   Excision of Upper and Lower Jaws,                           189
+
+XXVIII.  Operation for Salivary Fistula,                             196
+
+XXIX.    Operation for Fissure in Soft Palate,                       201
+
+XXX.     Operation for Fissure in Hard Palate,                       203
+
+XXXI.    Diagram illustrating Operations on Air Passages,            207
+
+XXXII.   Diagram illustrating Operations for Hernia,                 241
+
+XXXIII.  Diagram of an Artificial Anus,                              253
+
+XXXIV.   Diagram of Section of Prostate,                             257
+
+XXXV.    Diagram of Membranous portion of Urethra,                   259
+
+XXXVI.   Diagram illustrating Puncture of Bladder,                   284
+
+XXXVII.  Diagram of Operation for Phymosis,                          286
+
+XXXVIII. Diagram of Amputation of Penis,                             287
+
+
+[Illustration]
+
+
+PLATE I.
+
+1. Ligature of Aorta--Sir A. Cooper's incision.
+
+2. Ligature of Aorta--South and Murray's incision.
+
+3. Ligature of Common Iliac.
+
+4. Ligature of External Iliac--Sir A. Cooper's.
+
+5. Ligature of Femoral in Scarpa's triangle.
+
+6. Ligature of Femoral below Sartorius.[1]
+
+7. Ligature of Innominate.
+
+8. Ligature of third part of Left Subclavian.
+
+9. Ligature of Axillary in its first part.
+
+10. Ligature of Axillary in its third part.
+
+11. Ligature of Brachial.
+
+12. Amputation of Arm by double flaps.
+
+13. Amputation at Shoulder-joint (1st method), showing portion of skin
+left uncut till the conclusion of the disarticulation.
+
+14. Amputation at Ankle-joint by internal flap--Mackenzie's.
+
+15-16. Amputation of Leg just above the Ankle-joint.
+
+17-18. Amputation below Knee--modified circular.
+
+19. Amputation through Condyles of Femur--Syme, and Pl. III. 5.
+
+20. Amputation at lower third of Thigh--Syme, and Pl. III. 6.
+
+
+A. Excision of Head of Humerus.
+
+B. Excision of Knee-joint; semilunar incision.
+
+
+FOOTNOTES:
+
+[1] This line is placed too low down; it should be in the middle third
+of the thigh.
+
+
+[Illustration]
+
+
+PLATE II.
+
+1. Amputation at lower third of Fore-arm--Teale's.
+
+2-2. Amputation at Shoulder-joint by large postero-external flap--2d
+method.
+
+3-3. Amputation at Shoulder-joint by triangular flap from deltoid--3d
+method.
+
+4-5. Amputation through Tarsus--Chopart's.
+
+6-7. Amputation at Knee-joint.
+
+8. Amputation by Single Flap--Carden's, and Pl. IV. 16.
+
+9-10. Amputation of Thigh--Teale's.
+
+
+A. Excision of Hip-joint.
+
+B-B. Excision of Ankle-joint--Hancock's incisions.
+
+
+[Illustration]
+
+
+PLATE III.
+
+1. Ligature of Popliteal.
+
+2. Amputation at Elbow-joint--posterior flap.
+
+3. Amputation at Shoulder-joint--posterior incision of first method, and
+Pl. I. 13.
+
+4. Amputation at Ankle-joint--Mackenzie's, and Pl. I. 14.
+
+5. Amputation through Condyles of Femur--Syme, and Pl. I. 19.
+
+6. Amputation at lower third of Thigh--Syme, and Pl. I. 20.
+
+7. Amputation at Knee--posterior incision.
+
+8. Amputation of Thigh--Spence's, and at Pl. IV. 18.
+
+9. Amputation at Hip-joint, and Pl. IV. 20.
+
+
+A. Excision of Shoulder-joint--deltoid flap.
+
+B. Excision of Shoulder-joint by posterior incision.
+
+C. Excision of Elbow-joint--H-shaped incision.
+
+D. Excision of Elbow-joint--linear incision.
+
+E. Excision of Hip-joint--Gross's.
+
+F. Excision of Os Calcis.
+
+G. Excision of Scapula.
+
+
+[Illustration]
+
+
+PLATE IV.
+
+1. Ligature of Carotid.
+
+2. Ligature of Subclavian (3d stage)--Skey's incision.
+
+3. Amputation at Wrist-joint--dorsal incision.
+
+4. Amputation at Wrist-joint--palmar incision.
+
+5. Amputation at Fore-arm--dorsal incision.
+
+6. Amputation at Fore-arm--palmar incision.
+
+7. Amputation at Elbow-joint--Anterior flap, and Pl. III. 3.
+
+8. Amputation at Arm--Teale's method.
+
+9. Amputation at Shoulder-joint--1st method, and Pl. III. 3.
+
+10-11. Amputation of Metatarsus--Hey's.
+
+12-13. Amputation at Ankle--Syme's.
+
+14-15. Amputation of Leg--posterior flap--Lee's.
+
+16. Amputation at Knee-joint--Carden's, and Pl. II. 8.
+
+17. Amputation of Thigh--B. Bell's.
+
+18. Amputation of Thigh--Spence's, and Pl. III. 8.
+
+19. Amputation of Thigh in middle third.
+
+20-20. Amputation at Hip-joint, and Pl. III. 9.
+
+
+A. Excision of Wrist--radial incision.
+
+B. Excision of Wrist--ulnar incision.
+
+
+
+
+CHAPTER I.
+
+LIGATURE OF ARTERIES.
+
+
+LIGATURE OF ARTERIES.--In a work of this nature there is no room for any
+discussion of the principles which should guide us in the selection of
+cases, or of the pathology of aneurism, or the local effects of the
+ligature on the vessels. One or two fundamental axioms may be given in a
+few words:--
+
+1. In selecting the spot for the application of the ligature, avoid as
+far as possible bifurcations, or the neighbourhood of large collateral
+branches.
+
+2. A free incision should be made through the skin and subjacent
+textures, till the sheath of the artery is reached and fairly exposed.
+
+3. The sheath must be opened and the artery cleaned with a sharp knife
+till the white external coat is clearly seen. The portion cleaned
+should, however, be as small as possible, consistent with thorough
+exposure, so that the ligature may be passed round the vessel without
+force.
+
+4. As the artery should never be raised from its bed, it is generally
+advisable to pass the needle only so far as just to permit the eye to be
+seen past the vessel. The ligature should then be seized by a pair of
+forceps and gently pulled through, the needle being cautiously
+withdrawn. When catgut is used, it is better to pass the unarmed needle
+till the eye is visible, then thread and withdraw it, thus pulling the
+catgut through.
+
+5. As a rule, the needle should be passed from the side of the vessel at
+which the chief dangers exist. This will generally be in the side at
+which the vein is.
+
+6. The ligature should be single, and consist of strong well-waxed silk,
+and should always be drawn as tight as possible, so as to divide the
+internal and middle coats of the vessel. In cases where the wound is to
+be treated with antiseptic precautions and an attempt at immediate union
+made, the ligature may be of strong catgut properly prepared, and both
+ends of it may be cut off.
+
+7. Before the ligature is tightened, it is well to feel that pressure
+between the ligature and the finger arrests the pulsation of the tumour.
+
+
+LIGATURE OF THE AORTA.--It has been found necessary in a few rare cases
+to place a ligature on the abdominal aorta; no case has as yet survived
+the operation beyond a very few days, but they have in their progress
+sufficiently proved that the circulation can be carried on, and gangrene
+does not necessarily result even after such a decided interference with
+vascular supply.
+
+_Operation._--The ligature may be applied in one of two ways, the choice
+being influenced by the nature of the disease for which it is done.
+
+1. A straight incision (Plate I. fig. 1) in the linea alba, just
+avoiding the umbilicus by a curve, and dividing the peritoneum, allows
+the intestines to be pushed aside, and the aorta exposed still covered
+by the peritoneum, as it lies in front of the lumbar vertebr�. The
+peritoneum must again be divided very cautiously at the point selected,
+and the aortic plexus of nerves carefully dissected off, in order that
+they may not be interfered with by the ligature. The ligature should
+then be passed round, tied, cut short, and the wound accurately sewed
+up.
+
+2. Without wounding the peritoneum.
+
+A curved incision (Plate I. fig. 2), with its convexity backwards, from
+the projecting end of the tenth rib to a point a little in front of the
+anterior superior spinous process of the ilium. At first through the
+skin and fascia only, this incision must be continued through the
+muscles of the abdominal wall, one by one, till the transversalis fascia
+is exposed, which must then be scraped through very cautiously, so as
+not to injure the peritoneum, which is to be detached from the fascia
+covering the psoas and iliacus muscles, and must be held inwards and out
+of the way by bent copper spatul�. The common iliac will then be felt
+pulsating, and on it the finger may easily be guided up until the aorta
+is reached.
+
+The really difficult part of the operation now begins: to isolate the
+vessel from the spine behind, the inferior cava on the right side, and
+the plexus of nerves in the cellular tissue all round. The cleaning of
+the vessel must be done in great measure by the finger-nail, and much
+dexterity will be required to pass the ligature without unnecessarily
+raising the vessel from its bed, especially as the vessel itself may
+very possibly be diseased, and the aneurism of the iliac trunk for which
+the operation is required will displace and confuse the parts, and may
+have set up adhesive inflammation.
+
+_Results._--Operation has been performed at least ten times. By the
+first method by Sir Astley Cooper and Mr. James; by the second by Drs.
+Murray and Monteiro, M'Guire, Heron Watson, and Stokes, and Mr. South,
+and Czerny of Heidelberg. All the cases proved fatal; Dr. Monteiro's
+survived for ten days, and eventually perished from h�morrhage; the rest
+all died at shorter intervals.
+
+
+LIGATURE OF COMMON ILIAC.--_Anatomical Note._--This short thick trunk
+varies slightly in its relations on the two sides of the body. As the
+aorta bifurcates on the left side of the body of the fourth lumbar
+vertebra, the common iliac of the right side would have a longer course
+to pursue than that on the left, if both ended at corresponding points.
+However, this is not always the case, as has been pointed out by Mr.
+Adams of Dublin, as the right common iliac often bifurcates sooner than
+the left does. With this slight difference, the position of the two
+vessels is precisely similar, each extending along the brim of the
+pelvis from the bifurcation of the aorta towards the sacro-iliac
+synchondrosis for about two inches. Sometimes the division takes place a
+little higher, even at the junction of the last lumbar vertebra and the
+sacrum. This variation depends chiefly on the length of the artery,
+which, as Quain has shown, varies from one inch and a half to more than
+three inches.
+
+The anterior surface of both arteries is covered by the peritoneum, and
+each is crossed by the ureter just as it bifurcates into its branches.
+
+The artery of the right side is in close contact behind with its
+corresponding vein, which at its upper part projects to the outside, and
+below to the inner side. The artery of the left side is less involved
+with its vein, which lies below it, and to the inside. The right is in
+contact with a coil of ileum, the left with the colon. The inferior
+mesenteric artery crosses the left one, while to the outside of both,
+and behind them, lie the sympathetic and obdurator nerves.
+
+There are no named branches from the common iliac.
+
+_Operation._--The chief difficulties to be encountered are--1. The close
+proximity of the peritoneum, and specially the risk there is that it has
+become adherent to the sac of the aneurism; 2. The depth of the parts,
+and tendency of the intestines to roll into the wound; 3. Specially on
+the right side, the proximity of the great veins. With these exceptions
+the passing of the ligature is not so difficult as in some situations,
+the lax cellular tissue in which the vessel lies generally yielding much
+more easily than the tough sheath which elsewhere, as in the femoral,
+requires accurate dissection.
+
+_Incision._--(Plate I. fig. 3.)--From a point about half an inch above
+the centre of Poupart's ligament, a crescentic incision should be made,
+at first extending upwards and outwards, so as to pass about one inch
+inside of the anterior superior spine of the ilium, and then prolonged
+upwards and inwards, as far as may be rendered necessary by the size of
+the aneurism or the depth of parts. It must extend through skin and
+superficial fascia, exposing the tendon of the external oblique, which
+must then be slit up to the full extent visible. The spermatic cord may
+then be easily exposed under the edge of the internal oblique, and the
+forefinger of the left hand inserted on the cord, and thus beneath the
+internal oblique and transversalis muscles, the peritoneum being quite
+safe below.
+
+On the finger these muscles may be safely divided to the full extent of
+the external incision. The deep circumflex iliac artery if possible
+should not be divided, but may bleed smartly and require a ligature.
+
+The peritoneum must then be very cautiously raised from the tumour, and
+supported, along with the intestines, by copper spatul�. The surgeon
+will rarely succeed in obtaining anything like a satisfactory view of
+the vessel, but can expose it for the ligature by the aid of his
+finger-nail. An ordinary aneurism-needle will generally suffice for the
+conveyance of the ligature.
+
+The difficulties may occasionally be much increased by special
+circumstances, such as great stoutness of the patient, and consequent
+thickness of the abdominal wall; or large size of the aneurism, which
+may cause alterations in the relation of parts and adhesion of the
+peritoneum. The ureter generally gives no trouble, as in pressing back
+the peritoneum it is adherent to it, and is removed along with it
+towards the middle line.
+
+_Results._--Are not by any means satisfactory.
+
+Out of twenty-two cases in which the common iliac has been tied for
+aneurism, eight recovered and fourteen died; while out of thirteen cases
+where it required ligature for h�morrhage after amputation, rupture of
+aneurism, etc., only one recovered.
+
+
+LIGATURE OF INTERNAL ILIAC.--Little need be added to the account just
+given of the operation for ligature of the common iliac, as precisely
+the same incisions are required. The operator having reached the
+bifurcation of the vessel, must, instead of tracing it upwards,
+endeavour to trace it downwards, and the same time inwards, into the
+basin of the pelvis. To do this his finger must cross the external iliac
+artery, which will pulsate under the joint of the ungual phalanx, while
+the pulp of the finger is touching the internal iliac,--the external
+iliac vein, which occupies the angle formed by the bifurcation of the
+artery, lying between these two points. The ligature should be applied
+within three-quarters of an inch from the bifurcation.
+
+_Anatomical Note._--This short thick trunk extends backwards and inwards
+(Ellis); downwards and backwards (Harrison), in front of the sacro-iliac
+synchondrosis, as far as the upper extremity of the great sacro-sciatic
+notch, a distance varying in the adult from one and a half to two inches
+in length. It forms a curve with its concavity forwards, and at its
+termination divides into, rather than gives off, its two or three
+principal branches. Its corresponding vein is in close contact behind,
+as also the lumbo-sacral nerve, the obdurator nerve to its outer side.
+The peritoneum covers it anteriorly, and it is crossed just at its
+commencement by the ureter. On the left side it is covered anteriorly by
+the rectum. Of its anatomical relations, that of the external iliac vein
+is perhaps the most important, as it is apt to interfere with the
+passing of the needle.
+
+_Results._--This vessel has been tied for aneurism of one or other of
+its branches, or for wound, about seventeen times.[2] Of these seven
+recovered; in ten the operation proved fatal, in most of them from
+secondary h�morrhage. In one case the h�morrhage occurred within twelve
+hours after the operation. The circulation of the parts supplied after
+the ligature is carried on mainly by the lumbar and lateral sacral
+branches, which become much developed even before the operation, in
+cases of aneurism.
+
+
+LIGATURE OF EXTERNAL ILIAC.--_Anatomical Note._--This artery extends
+from the bifurcation of the common iliac to the centre of Poupart's
+ligament, where it leaves the abdomen, passing under the ligament, and
+becomes the common femoral. Its upper extremity is thus not always
+constant, varying in position from the sacro-lumbar fibro-cartilage to
+the upper end of the sacro-iliac synchondrosis, or even a little lower
+down. Thus, though the position of the lower end is at a fixed point,
+the artery varies in length. In an adult male of moderate stature it is
+from three and a half to four inches in length. On the surface of the
+abdomen the position of this vessel would be indicated by a line drawn
+from about an inch on either side of the umbilicus to the middle of the
+space between the symphysis pubis and the crest of the ilium. Its
+relations to neighbouring parts are as follows:--The peritoneum lies _in
+front_ of it, separated from it only by a subperitoneal layer of loose
+fascia, in which the artery and vein lie, which varies much in
+consistence and amount, and which occasionally gives a good deal of
+trouble in the operation of ligature. Near its origin it is sometimes
+crossed by the ureter, and near its termination the genito-crural nerve
+lies on it. The spermatic vessels cross it, and occasionally a quantity
+of subperitoneal fat marks its course. _Externally._--The fascia-iliaca
+and some fibres of the psoas muscle separate it from the anterior
+crural nerve, which lies outside of the vessel, and at a somewhat deeper
+level, hidden amid the fibres of psoas and iliacus. _Internally._--The
+external iliac vein lies on the same plane, and to the inner side of the
+artery, at Poupart's ligament, on both sides of the body. As we trace it
+upwards we find that on the left side it lies internal to the artery in
+its whole course, while on the right side it becomes posterior to the
+artery as it approaches the bifurcation of the common iliac. Lastly,
+just before the vessel reaches Poupart, the circumflex iliac vein
+crosses it from within outwards.
+
+_Branches._--The two large branches to the wall of the abdomen, the
+epigastric and the circumflex iliac, rise a few lines above Poupart's
+ligament. Their position is unfortunately apt to vary upwards, to the
+extent of an inch and a half or even two inches, and they are important,
+as, besides being liable to be cut during the operation, their position
+very materially modifies the prognosis, as, if too high up, they
+interfere with the proper formation of the coagulum.
+
+_Operation._--Various plans of incision through the skin have been
+recommended by various operators, the chief difference being with regard
+to the part of the artery aimed at; the plan known as that of Mr.
+Abernethy, with various modifications, being intended to expose the
+artery pretty high up, and enable the surgeon to reach it from above;
+while the method going by the name of Sir Astley Cooper's exposes the
+lower part of the artery, and enables the surgeon to reach it from
+below. Though the latter is in some respects easier, the former method
+is generally to be preferred, being further from the seat of disease,
+and especially more out of the way of the epigastric and circumflex
+arteries.
+
+The higher operation (ABERNETHY'S modified).--An incision must be made
+through the skin about four inches in length, but longer in proportion
+to the amount of subcutaneous fat, and the depth of the pelvis,
+extending from a point one inch to the inside of the anterior superior
+spine of the ilium, to a point half an inch above the middle line of
+Poupart's ligament. It must be slightly curved, with its convexity
+looking outwards and downwards.[3]
+
+The subcutaneous cellular tissue and the tendon of the external oblique
+may then be divided freely in the same line. Then at some one point or
+other (generally easiest below), the internal oblique and transversalis
+muscles must be cautiously scraped through with the aid of the forceps,
+till the transversalis fascia is reached; they may then be freely
+divided by a probe-pointed bistoury (guarded by the finger pushed up
+below the muscles) to the required extent. The muscles being held aside
+by flat copper spatul�, the fascia transversalis must be carefully
+scratched through near the crest of the ilium, and thus the operator
+will be enabled to push the peritoneum inwards, and by the forefinger
+will easily recognise the pulsation of the artery lying on the soft brim
+of the pelvis.
+
+A branch of the circumflex iliac artery will very likely be cut in
+dissecting through the muscles, and must be secured, as also any
+branches of the epigastric which may be divided in the incisions through
+the abdominal wall (_ut supra_, p. 5).
+
+The operator should then, by pressing the peritoneum and its contents
+gently inwards, endeavour to see the vessel; if, from the depth of the
+pelvis, this cannot be done, the sense of touch will be in most cases
+sufficient to enable him to isolate the artery by the point of his
+finger-nail, or by the blunt aneurism-needle, from the vein. The
+ligature should be passed from the inner side to avoid including the
+vein, and thus there will be less chance of wounding the peritoneum
+from the convexity of the needle being applied to it. If possible, the
+genito-crural nerve should not be included in the ligature, but probably
+such an accident would do no great harm.
+
+It is of much more consequence to avoid injuring the peritoneum. This is
+sometimes very difficult, from the adhesions which are set up between
+the peritoneum, the artery, and especially the aneurism, as the result
+of pressure and inflammation. The accident of wounding the peritoneum
+has happened to Keate, Tait, Post, and others, and in some cases with
+perfect impunity. However, the peritoneum should be displaced as little
+as possible from its cellular connections, as such displacement
+increases the risk of diffuse inflammation of that membrane; and the
+vessel itself should be raised and disturbed as little as possible, lest
+destruction of the vasa vasorum cause ulceration of the weak coats and
+secondary h�morrhage.
+
+The operation from below (Plate I. fig. 4), SIR ASTLEY COOPER'S, is thus
+described by Mr. Hodgson:[4]--"A semilunar incision is made through the
+integuments in the direction of the fibres of the aponeurosis of the
+external oblique muscle. One extremity of the incision will be situated
+near the spine of the ilium; the other will terminate a little above the
+inner margin of the abdominal ring. The aponeurosis of the external
+oblique muscles will be exposed, and is to be divided throughout the
+extent, and in the direction of the external wound. The flap which is
+thus formed being raised, the spermatic cord will be seen passing under
+the margin of the internal oblique and transverse muscles. The opening
+in the fascia which lines the transverse muscle through which the
+spermatic cord passes, is situated in the mid space between the anterior
+superior spine of the ilium and the symphysis pubis. The epigastric
+artery runs precisely along the inner margin of this opening, beneath
+which the external iliac artery is situated. If the finger therefore be
+passed under the spermatic cord through this opening in the fascia, it
+will come in immediate contact with the artery which lies on the outside
+of the external iliac vein. The artery and vein are connected by dense
+cellular tissue, which must be separated to allow of the ligature being
+passed round the former."
+
+In comparing the two methods of operating, we find that while the latter
+is in some respects easier, and the vessel in it lies more superficial,
+it has certain disadvantages which more than counterbalance its
+advantages. Thus, first, the epigastric artery is very likely to be
+wounded. It may be said, Well, if so, the ends can be tied; but this
+tying is sometimes very difficult; and, as shown in Dupuytren's case of
+this accident, involves considerable interference with the peritoneum,
+and a possibly fatal peritonitis. Besides this, by cutting the
+epigastric you destroy an important agent which would have carried on
+the anastomosing circulation, and thus greatly increase the risk of
+gangrene. By this method, also, the artery is exposed too near to the
+seat of disease; and if found to be enlarged and involved in the
+aneurism, considerable difficulty may be experienced in reaching the
+upper part of the vessel. Again, ligature of the lower third or half of
+the vessel, which this method implies, is dangerous from the occasional
+high origin of the circumflex or epigastric, or both, rendering the
+formation of a clot much more difficult, and secondary h�morrhage much
+more likely.
+
+The circumflex iliac vein must also be remembered, as it crosses the
+artery from within outwards in the lower end of it, just before it goes
+under Poupart's ligament.
+
+However, the method may occasionally vary with the individual case. In
+every case of ligature of the great vessels of the abdomen, the bowels
+should be carefully evacuated before the operation, and the bladder
+emptied. A properly managed position, with the shoulders raised and the
+knees semiflexed, will greatly facilitate the gaining access to the
+vessel.
+
+In sewing up the wounds in the abdominal walls, advantage will be gained
+by putting in a certain number of stitches so deeply as to include the
+whole thickness of the muscles, and in the intervals between these deep
+ones to insert others less deeply, so as accurately to approximate the
+edges of the skin. This will both facilitate union and also render the
+occurrence of hernia less probable. This latter accident did occur in a
+case, otherwise successful, in which Mr. Kirby tied the external iliac.
+
+Both external iliacs have been tied in the same patient with success, on
+at least two occasions, once by Arendt, with an interval of only eight
+days between the operations; and a second time by Tait, at an interval
+of rather more than eleven months.
+
+This operation is in the great majority of cases performed for femoral
+aneurism, and naturally secondary h�morrhage is a too frequent result.
+Wounds of these great vessels generally result in so rapid death from
+h�morrhage as to give no time for surgical interference. One case,
+however, is recorded,[5] in which the external iliac was cut in a lad of
+seventeen by an accidental stab, and in which Drs. Layraud and Durand,
+who were almost instantly on the spot, succeeded in stopping the
+bleeding by compresses, till Velpeau arrived, who tied the vessel above
+with perfect success.
+
+Of the first twenty-two cases collected by Hodgson, fifteen recovered--a
+mortality of 31.81 per cent.; and of 153 in Norris's collection,
+including Cutter's cases, forty-seven died--a mortality of only 32.5 per
+cent.,--a very satisfactory result, considering the size of the vessel
+and the importance of its relations.
+
+
+LIGATURE OF GLUTEAL.--This vessel, though one of the branches of the
+internal iliac, approaches the surface so nearly as to be occasionally
+wounded. It is also, though very rarely, the subject of spontaneous
+aneurism. The principle of treatment and the operation to be selected in
+any given case, depends upon its origin, whether traumatic or
+spontaneous. For if traumatic, the wound must almost necessarily be
+accessible from the outside; the neighbouring part of the artery is
+probably healthy, and hence the case can be treated by the old
+operation, slitting up the tumour, and tying the vessel above and below
+the wound. When the aneurism is spontaneous, there is no guide to tell
+us where the aneurism may have first originated; it may be that it is
+high up in the pelvis, and that the visible tumour is only its expansion
+in the direction of least resistance, or the coats of the vessel may be
+extensively diseased. The only chance is ligature of the internal iliac.
+
+1. The old operation, or ligature of the gluteal artery in the hip.
+
+_Anatomical Note._--The gluteal is the largest branch of the internal
+iliac, and leaves the pelvis by the great sacro-sciatic notch just at
+the upper edge of the pyriformis muscle. After a very short course, it
+divides into superficial and deep branches opposite the posterior margin
+of the glutens minimus, between it and the pyriformis muscles.
+
+Very precise rules have been given to enable the operator to hit on the
+exact spot where the artery leaves the pelvis. These, though perhaps
+interesting anatomically, are quite useless in a surgical point of view,
+for the only reasons which could possibly induce a surgeon to cut down
+upon the gluteal in the living body, are the existence either of a wound
+of the vessel or an aneurism. In the first the flow of blood, in the
+second the tumour, would give sufficient guidance.
+
+In cases of traumatic aneurism the operation should be something like
+the following:--A free incision should be made into the tumour, dividing
+it in its long direction; the contents should be rapidly scooped out,
+and a finger placed on the bleeding point, just at the upper corner of
+the sciatic notch. This will at once stop the h�morrhage till the vessel
+can be secured. This sounds easy enough, and has been done several times
+with success. Thus, John Bell, by an incision two feet long, as he tells
+us in his hyperbolical language, was enabled to tie the vessel in the
+case of the leech-gatherer who had punctured the artery by a pair of
+long scissors. Carmichael of Dublin used a smaller incision, removed one
+or two pounds of clots, and tied the vessel, in a case of wound by a
+penknife.[6]
+
+Now, though both of these cases were eventually successful, both
+patients lost during the operation a very large quantity of blood; John
+Bell's especially could not be removed from the operating-table for a
+considerable time after the operation. The period at which the great
+loss of blood took place was the interval after the incision was made,
+and before the artery was exposed to view, _i.e._ the interval in which
+the surgeon was busy dislodging the clots from the cellular membrane,
+the sac of the false aneurism. The procedure devised by Mr. Syme to
+obviate this difficulty, and which was put in practice by him in several
+very trying cases, is best given in his own terse description of an
+operation in a case of traumatic gluteal aneurism:--
+
+"The patient having been rendered unconscious, and placed on his right
+side, I thrust a bistoury into the tumour, over the situation of the
+gluteal artery, and introduced my finger so as to prevent the blood from
+flowing, except by occasional gushes, which showed what would have been
+the effect of neglecting this precaution, while I searched for the
+vessel. Finding it impossible to accomplish the object in this way, I
+enlarged the wound by degrees sufficiently for the introduction of my
+fingers in succession, until the whole hand was admitted into the
+cavity, of which the orifice was still so small as to embrace the wrist
+with a tightness that prevented any continuous h�morrhage. Being now
+able to explore the state of matters satisfactorily, I found that there
+was a large mass of dense fibrinous coagulum firmly impacted into the
+sciatic notch; and, not without using considerable force, succeeded in
+disengaging the whole of this obstacle to reaching the artery, which
+would have proved very serious if it had been allowed to exist after the
+sac was laid open. The compact mass, which was afterwards found to be
+not less than a pound in weight, having been thus detached, so that it
+moved freely in the fluid contents of the sac, and the gentleman who
+assisted me being prepared for the next step of the process, I ran my
+knife rapidly through the whole extent of the tumour, turned out all
+that was within it, and had the bleeding orifice instantly under
+subjection by the pressure of a finger. Nothing then remained but to
+pass a double thread under the vessel, and tie it on both sides of the
+aperture."
+
+The bleeding in this case was thus rendered comparatively trifling, and
+the patient made a speedy and complete recovery. He returned home within
+six weeks after the operation.[7]
+
+2. In one case, at least, the gluteal artery has been tied with success
+(for traumatic aneurism) just where it leaves the pelvis, without the
+tumour being opened. This was in the practice of Professor Campbell of
+Montreal. The operation was a very difficult one, and while possible
+only in cases seen very early, and where the tumour is very small, does
+not appear to have any advantage over the old method.
+
+Cases of spontaneous aneurism of the gluteal artery should be treated by
+ligature of the internal iliac. Steven's and Syme's cases of ligature
+of the internal iliac were of this nature.
+
+Manuals of operative surgery occasionally devote pages to the
+description of special operations for the ligature of such arteries as
+the sciatic, epigastric, circumflex ilii, and pudic. They do not require
+ligature, except in cases of wound either of the vessels themselves or
+their branches; and, according to the modern principles of surgery in
+such cases, the ligature should be applied to the bleeding point, rather
+than to the vessel at a distance above it.
+
+
+LIGATURE OF FEMORAL.--Under this head we practically mean cases of
+ligature of the superficial femoral, for the common femoral, or (as
+called by some anatomists) the femoral, before the profunda is given
+off, very rarely requires to be tied. If it is wounded, of course the
+bleeding point must be sought, and the artery tied above and below it,
+but if an aneurism on the superficial femoral renders ligature of that
+trunk impossible, experience teaches that ligature of the external iliac
+gives better results than ligature of the common femoral. Erichsen
+asserts that out of twelve cases in which the common femoral has been
+tied, only three have succeeded, the others dying from secondary
+h�morrhage. The experience of the Dublin surgeons, Porter, Smyly, and
+Macnamara, has been more satisfactory, as in eight cases of this
+operation six were successful.[8] A ninth case was unsuccessful. Reasons
+to explain the danger are not far to seek, for the numerous small
+muscular branches, along with the superficial epigastric, circumflex,
+and pudic trunks, reduce the chances of a good coagulum in the common
+femoral to a minimum, even without taking into consideration the
+shortness of the trunk before the great profunda femoris is given off.
+For the common femoral artery is only from one to two inches in length,
+and if there are some rare cases in which it is a little later in its
+bifurcation, there are others in which it divides nearer to Poupart's
+ligament.
+
+The superficial femoral is the name given to the main trunk between the
+origin of the profunda, and the point at which, passing through the
+tendon of the adductor magnus, it receives the name of popliteal. During
+this long course it gives off no branch large enough or regular enough
+to receive a name, except one, the anastomotica magna, which rises in
+Hunter's canal, close to the end of the vessel, so in that respect it is
+peculiarly suitable for the application of a ligature. Again, in the
+upper part of its course, it is superficial, being covered only by skin
+and fascia. A short notice of its most important anatomical relations is
+necessary.
+
+For the first two inches or two inches and a half of its separate
+existence, the superficial femoral lies in Scarpa's triangle, covered,
+as we said, only by skin and fascia. This triangle is formed by the
+sartorius and adductor longus muscles which meet at its apex, and by
+Poupart's ligament, which defines its base. The artery lies almost
+exactly in the centre of the space, and at the apex is covered by the
+sartorius muscle. The spot where it goes under the sartorius is the one
+selected for the application of the ligature. The femoral vein lies to
+the inner side of the femoral artery in this triangle, but their mutual
+relations vary with the portion of the limb; for, on the level of
+Poupart's ligament, the artery and vein lie side by side on the same
+plane, but in different compartments of their sheath; as the artery
+dives below the sartorius, the vein is still on the inside, but on a
+plane slightly posterior; while, by the time they reach Hunter's canal,
+the vein has got completely behind the artery. The separate compartments
+of the sheath in which the vessels lie are much less marked as the
+vessels go down the limb, the septum between the artery and the vein
+being in most cases very ill marked, even at the level where the
+ligature is applied. The anterior crural nerve, which on the level of
+Poupart's ligament lay outside of the artery and on a plane somewhat
+posterior, has divided into numerous branches before it reaches the
+point of ligature. One of its branches requires to be mentioned, and may
+sometimes be noticed and avoided during the operation, namely the
+internal saphenous nerve, which, first lying external to the artery,
+crosses it in front, reaching its inner side just before it enters
+Hunter's canal, where it leaves the vessel accompanying the anastomotica
+magna branch.
+
+
+OPERATION OF LIGATURE OF THE FEMORAL--SCARPA'S SPACE.--The patient being
+placed on his back, and being brought very thoroughly under chloroform,
+the knee of the affected limb should be bent at an angle of about 120�,
+and supported on a pillow. Having previously ascertained the angle of
+junction of the sartorius and adductor, the surgeon should make an
+incision (Plate I. fig. 5) just over the pulsations of the vessel, in
+the middle line of the space, having its lower end quite over the
+sartorius muscle, and its upper one, at a distance from two and a half
+to three and a half inches, varying according to the amount of fat and
+muscle. The saphena vein can generally be recognised, and is almost
+always safe out of the way of this incision at its inner side.
+
+The first incision should divide the skin, superficial fascia, and fat,
+quite down to the fascia lata. The edges of the wound being held apart,
+the fascia should be carefully divided, and the sartorius exposed; its
+fibres can generally be easily enough recognised by their oblique
+direction; once recognised, the fascia should be dissected from it till
+its inner edge be gained, the corner of which should then be turned so
+that it may be held outwards by an assistant with a blunt hook. The
+sheath of the vessels is now exposed, and after having thoroughly
+satisfied himself of the position of the artery by the pulsation, the
+surgeon should carefully raise a portion of the sheath with the
+dissecting forceps, and open it freely enough to allow the coats of the
+artery to be distinctly seen. If the parts are deep, as in a fat or
+muscular patient, great advantage will be gained by seizing one edge of
+the sheath by a pair of spring forceps, and committing it to the care of
+an assistant, while the operator holds the other in his dissecting
+forceps; there is thus no fear of losing the orifice of the sheath,
+which without this precaution may easily happen, from the parts being
+confused with blood, or the position altered by movements of the
+patient. Now comes the stage of the operation on which, more than on
+anything else, success or failure depends. A _small_ portion of the
+vessel must be cleaned for the reception of the ligature, and it must be
+_thoroughly_ cleaned, so that the needle may be passed round it without
+bruising of the coats, or rupture of an unnecessary number of the vasa
+vasorum by rough attempts to force a passage for it. Hence all
+compromises, such as blunted instruments, silver knives, and the like,
+are dangerous, for in trying to avoid the Scylla of wounding the artery,
+they fall into the Charybdis, on the one hand, of isolating too much of
+the vessel and causing gangrene from want of vascular supply, or, on the
+other, expose the vein to the danger of injury by the aneurism-needle in
+their attempts to force it round an uncleaned vessel.
+
+The needle should in most cases be passed from the inner side, care
+being taken to avoid including the vein which is on the inner side and
+behind the vessel; the internal saphenous nerve, if seen, should be
+avoided. The needle must not be passed quite round the vessel raising it
+up, still less must the vessel be held up on the needle, as used to be
+done, as if the surgeon was surprised at his own success, but the needle
+should be passed just far enough to expose the end of the ligature,
+which must be seized by forceps and cautiously drawn through. It must
+then be tied very firmly and secured with a reef knot.
+
+The edges of the wound must be brought into accurate apposition, and
+secured by one or two stitches. If antiseptics are used, drainage should
+be provided for.
+
+From the very fact that ligature of the superficial femoral is a
+remarkably successful operation in causing consolidation of the aneurism
+and a rapid cure, there is also a corresponding danger that the limb be
+not sufficiently supplied with blood at first. The limb may very
+possibly become cold, and remain so for some hours at least after the
+operation. To avoid this as far as possible, it should be wrapped in
+cotton wadding, and very great care should be taken that it be not
+over-stimulated by hot applications, friction, or the like, any of which
+measures might very likely excite reaction, which would result in
+gangrene.
+
+Complete rest of the limb and of the whole body must be enjoined; the
+food must be nourishing and in moderate quantity. The chief danger is
+from gangrene of the limb, which is especially apt to result when the
+vein is wounded, or even too much handled during the operation.
+
+When properly performed, and in suitable cases, the operation is very
+successful. Mr. Syme tied this artery for aneurism thirty-seven times,
+and of these every one recovered. The statistics of Norris and Porta,
+who collected all the cases in which ligature of the femoral had been
+employed for _any_ cause, show a mortality of somewhat less than one in
+four. Rabe's table up to 1869 with the additional cases collected by Mr.
+Barwell to 1880 gives 297 cases with 53 deaths.[9] Mr. Hutchinson's
+table, again, of fifty cases collected from the records of Metropolitan
+Hospitals, shows the very startling result of sixteen deaths out of the
+fifty cases, or a mortality, in round numbers, of one-third.
+
+Certain anomalies have been observed in the distribution of the femoral
+vessels, of some importance as affecting the possibility of applying,
+and the result of, ligature; such as--1. A high division of the branches
+which afterwards become posterior tibial and peroneal. 2. A double
+superficial femoral, both branches of which may unite and form the
+popliteal, as in Sir Charles Bell's well-known case. 3. Absence of the
+artery altogether, as in Manec's case, where the popliteal was a
+continuation of an immensely enlarged sciatic.
+
+In such a case the absence of pulsation in front, and the presence of
+increased pulsation behind the limb, ought to prevent any fruitless
+attempt at search.
+
+
+LIGATURE OF THE SUPERFICIAL FEMORAL BELOW THE SARTORIUS MUSCLE.--This
+operation, though once common in France, and though the one recommended
+by Hunter himself, is now comparatively little used in this country; and
+rightly so; for while it has no advantage over the upper position, it is
+at once nearer the seat of disease, and the vessel is more deeply buried
+under muscles, and has a more distinct fibrous sheath, which requires
+division.
+
+It is, however, by no means a difficult operation, and is thus
+performed:--
+
+The limb being laid as before on the outside, and slightly bent, the
+skin shaved and the pulsation of the artery detected, an incision (Plate
+I. fig. 6) must be made from the lower edge of the sartorius muscle just
+as it crosses the vessel, along the course of the vessel, avoiding if
+possible the internal saphena vein.
+
+The sartorius when exposed must be drawn inwards. The fibrous canal
+filling the interspace between the abductor magnus and vastus internus
+is then recognised, and must be fairly opened; the artery is now seen
+lying in it, and over the vein which is posterior to it, but projects
+slightly on its outer side; the internal saphenous nerve is lying on the
+artery. The needle is best passed from without inwards so as to avoid
+the vein. The anastomotica magna is sometimes a large trunk, and has
+been mistaken for the femoral in this situation, and tied instead of it.
+
+
+LIGATURE OF THE POPLITEAL.--This operation is now hardly ever performed
+for aneurism, ligature of the superficial femoral having quite
+superseded it, and it is very rarely required for wounds, from the
+manner in which the vessel is protected by its position.
+
+Before the invention of the Hunterian principle of ligature at a
+distance, the old operation for popliteal aneurism consisted in cutting
+into the space, clearing out the contents of the aneurismal sac, and
+tying both ends of the vessel; from the depth of parts and the close
+connection of the popliteal vein, this operation was very rarely
+successful, and is now quite given up. If the vessel is wounded the
+bleeding point is the object to be aimed at, and is generally sufficient
+guide.
+
+In cases of h�morrhage for suppuration of an aneurismal sac, it might
+possibly be advisable, and there are certain cases of rupture of the
+artery, without the existence of an external wound, in which attempts
+have been made to save the limb by tying the vessel.[10] From the
+complexity of the parts, the numerous tendons, veins, and nerves crowded
+together in a narrow hollow, and chiefly from the great depth at which
+the artery lies, any attempt at ligature is very difficult. It is least
+so at the lower angle of the space, where, between the heads of the
+gastrocnemius, the vessel comes more to the surface, but is still
+overlapped by muscle.
+
+_Operation._--The patient lying on his face, a straight incision (Plate
+III. fig. 1), at least four inches in length, should be made over the
+artery, and thus nearer the inner than the outer hamstring; a strong
+fibrous aponeurosis will require division after the skin and superficial
+fascia are cut through, the limb is then to be flexed, and the tendons
+drawn aside with strong retractors; fat and lymphatic glands must next
+be dissected through, and then the vein and artery, lying on a sort of
+sheath of condensed cellular tissue, are seen, the vein lying above the
+artery and obscuring it. The vein must be drawn to the outside, and the
+thread passed round the artery, which lies close to the bone, on the
+ligamentum posticum of Winslowe.
+
+It is a very difficult subject to decide what operations should be
+described in a work of this character, on the vessels of the leg and
+foot. A very large number of distinct methods of operations on the
+various parts of the three chief arteries of the leg have been described
+by surgeons and anatomists, but specially by the latter.
+
+The fact is, however, that these complicated procedures are rarely
+required, for aneurisms of the arteries of the leg and foot are almost
+unknown, while in cases of wound of the vessel, or rupture resulting in
+traumatic aneurism, the proper treatment is not to tie the vessel higher
+up, but by dilating the wound and clearing out the clots, if required,
+to secure the bleeding point, and tie the vessel above and below.
+
+Again, a wound of the sole of the foot often gives rise to very severe
+and persistent h�morrhage, while the fasci� and complicated tendons
+render ligature of the vessel at the spot very difficult; yet ligature
+of either the anterior or posterior tibial would probably be
+insufficient; and to tie both these vessels, with possibly the peroneal
+and interosseous as well, would be a much more severe and dangerous
+procedure than ligature of the superficial femoral; while probably
+careful plugging of the wound, combined with flexion of the knee, will
+be found to stop the h�morrhage sooner than either of the more
+formidable methods.
+
+A competent knowledge of the anatomy of the part, and of the ordinary
+methods of checking h�morrhage, such as ligatures, graduated compresses,
+and styptics, aided by position, specially flexion of the knee after Mr.
+Ernest Hart's method, will suffice to enable the surgeon to check any
+h�morrhage of the foot or leg, without it being necessary to burden the
+memory with the three positions in which to tie the peroneal, or the
+various methods, more or less bloody and tedious, by which the posterior
+tibial in its upper third may be secured.
+
+     NOTE.--While, as a matter of surgical principle to guide our
+     practice on the living, I still hold very strongly the opinions
+     here expressed against special operations for ligature of the
+     arteries of the leg, and allow the sentences to stand as in the
+     first edition of this work, I insert in a note a brief description
+     of the more important ones, in deference to the advice of friends
+     and the urgent request of pupils, as these operations are used by
+     Examining Boards as tests of the operative dexterity of
+     candidates:--
+
+     1. ANTERIOR TIBIAL ARTERY IN LOWER HALF OF LEG.--_Anatomical
+     Note._--This vessel is related on its tibial side to the tibialis
+     anticus, and on its fibular, to the extensor longus digitorum
+     above, and the extensor pollicis below. The anterior tibial nerve
+     lies first on its outer side, then crosses the artery, and
+     eventually reaches its inner side near the foot. _Operation._--An
+     incision, at least three inches long, parallel with the outer edge
+     of the tibia, and about three-quarters of an inch from it, exposes
+     the deep fascia. This being divided, the outer edge of the tibialis
+     anticus must be found, and will be the guide to the artery, which,
+     surrounded by its ven� comites, lies very deeply between the
+     muscles.
+
+     2. Posterior Tibial.--_A._ In middle third of leg. Here the artery
+     is separated from the inner border of the tibia, by the flexor
+     longus digitorum, and is covered by the soleus. _Operation._--An
+     incision at least four inches long, along the inner margin of the
+     tibia, exposes the edge of the gastroenemius; then divide the
+     tendinous attachment, then expose the soleus, and divide its
+     attachment also; the deep fascia will then be seen; slit it up, and
+     the vessel will be found about an inch internal to the edge of the
+     bone. The nerve is there just crossing it.
+
+     Guthrie's, or the direct operation, has the very high authority of
+     the late Professor Spence in its favour. An incision through skin
+     and fascia in the middle of the back of the leg allows the two
+     heads of the gastrocnemius to be separated to the same extent. The
+     soleus is then to be scraped through in same direction, and its
+     deep aponeurotic surface carefully slit up. The artery and vein are
+     then easily seen.
+
+     B. In lower third of leg.--This is an easier and more scientific
+     operation, as it does not involve the division of great tendons. An
+     incision midway between the internal malleolus and the tendo
+     Achillis, parallel with both, will expose the very deep and strong
+     fascia in which the tendons lie. The artery, with its ven� comites,
+     occupies a central position, having the tendons of the tibialis
+     posticus and flexor communis in front between it and the internal
+     malleolus, and the posterior tibial nerve behind it, while the
+     flexor longus pollicis lies still nearer the tendo Achillis.
+
+
+     TABLE illustrating anastomotic circulation after ligature of
+     arteries of lower limb.
+
+     1. AORTA.--Epigastric and mammary of both sides. H�morrhoidal and
+     spermatic, with branches of pudic both deep and superficial.
+
+     2. COMMON ILIAC.--Internal iliac and branches, with those of the
+     other side, along with the following:--
+
+     3. EXTERNAL ILIAC.--Internal mammary and deep epigastric.
+
+     Iliolumbar and lumbar branches of aorta, with deep circumflex ilii.
+
+     Pudic from internal iliac, with superficial pudic of common
+     femoral.
+
+     Gluteal, sciatic, and obturator, with the circumflex and
+     perforating branches or deep femoral.
+
+     4. FEMORAL.--External circumflex, with external articular of
+     popliteal.
+
+     Perforating, with branches of gluteal and sciatic.
+
+     Profunda branches with anastomotica and articular branches.
+
+     Obturator and internal circumflex with anastomotica and superior
+     internal articular.
+
+     NOTE.--The importance of the articular branches of the popliteal
+     explain the danger of gangrene after a sudden rupture or increase
+     in size of a popliteal aneurism.
+
+
+LIGATURE OF THE INNOMINATE.--The performance of this extremely
+dangerous, in fact almost hopeless operation, is by no means so
+difficult as might be expected.
+
+The patient lying down with the shoulders raised and head thrown well
+back, the sternal attachment of the right sterno-mastoid must be very
+freely exposed. This may be done by an incision (Plate I. fig. 7) along
+its anterior edge from the upper edge of the sternum, as far as may be
+necessary; another about the same length along the upper edge of the
+clavicle, will meet the former at an acute angle, and will include a
+triangular flap of skin, which must be carefully dissected up. The
+sternal, and probably a portion of the clavicular attachment of the
+right sterno-mastoid, must then be cautiously divided. This being done,
+the sterno-hyoid and sterno-thyroid muscles require division immediately
+above their sternal attachments.
+
+A dense process of cervical fascia (just becoming thoracic) now covers
+the vessel, binding it on the right side to the right innominate vein,
+and on the left maintaining the relation of the innominate artery to the
+trachea. The inferior thyroid veins lie on this fascia, and must be
+drawn aside, not cut. The fascia is then to be scraped through very
+cautiously, exposing the root of the right carotid, which, being traced
+downwards, will lead to the innominate. The following parts lie in close
+relation to the vessel at the point of ligature, and must be
+avoided:--1. The left innominate vein crosses the artery in front from
+left to right, and must be drawn down. 2. The right innominate vein and
+right pneumogastric are in close contact with the artery on the right
+side; to avoid them the aneurism-needle must be entered on the outside
+(right of the vessel). 3. The apex of the right pleura and the trachea
+are in close contact behind, requiring the point of the needle to be
+kept close to the artery in bringing the thread round.
+
+It might have been expected that the sudden arrest of so large a
+proportion of the vascular supply of the body, so very near the heart,
+would cause serious, or even fatal symptoms; this, however, is not the
+case, no serious inconvenience of this sort being experienced; yet
+hitherto every case has proved fatal, either from secondary h�morrhage
+or inflammation of lungs and pleura.
+
+In fifteen well-authenticated, and in three more doubtful cases, the
+ligature has been applied; all of these died at periods varying from
+twelve hours (as in Hutin's case), to forty-two days as in Thomson's,
+and sixty-seven days (Graefe's).[11]
+
+A successful case of ligature of the innominate along with the right
+carotid and (after secondary h�morrhage) the right vertebral, in a
+mulatto aged thirty-two, for a subclavian aneurism, has been put on
+record by Dr. Smyth of New Orleans, in the _American Journal of Medical
+Science_ for July 1866.
+
+And here we may also note that Mr. Heath has lately treated a case of
+innominate aneurism by simultaneous ligature of the third part of the
+subclavian and the carotid. Both ligatures separated on the eighteenth
+day, and the tumour was much smaller some months afterwards.[12]
+
+Mr. R. Barwell has reported several most interesting cases in which
+simultaneous ligature of carotid and subclavian have proved of marked
+benefit in aortic as well as in innominate aneurisms.[13]
+
+In four cases the operation was attempted, but the operators had to
+desist before the application of the ligature, in consequence of the
+diseased state of the arterial coats. Of these, three died, and one
+(Professor Porter's of Dublin) case recovered, the patient leaving the
+hospital with the aneurism nearly consolidated.
+
+Dr. Peixotto of Portugal applied a precautionary ligature to the
+innominate in a case where secondary h�morrhage occurred from the
+carotid. The ligature was not tightened beyond what was necessary merely
+to cause flattening of the vessel. The patient made a good recovery.
+
+Professor George Porter of Dublin records an interesting case of
+subclavian aneurism, in which, after failing to close the axillary
+artery by acupressure, he applied L'Estrange's compressor to the
+innominate itself for three days, with temporary benefit. The patient
+eventually died of h�morrhage.[14]
+
+For a very full and interesting account of ligatures of vessels in root
+of neck we may refer to vol. iii. of the 1883 edition of _Holmes'
+Surgery_, pp. 119-122.
+
+
+LIGATURE OF COMMON CAROTID.--Though the anatomical relations of the
+right and left carotid are different at their origin, they so precisely
+resemble each other in the whole of that part of their course which is
+at all amenable to surgical treatment, that one description will suffice
+for both, and the necessary anatomy will be brought out quite
+sufficiently in the description of each operation.
+
+From its giving off no collateral branches, the common carotid artery
+may be tied at any part of its course.
+
+It has been tied successfully at the distance of only three-quarters,
+or, in one case by Porter, hardly to be imitated, one-eighth of an inch
+from the innominate, and up to an equal distance from its bifurcation.
+In choosing the part of the vessel for operation, the operator must be
+guided by the position of the aneurism, if on the vessel itself, but if
+the aneurism be distant, as in scalp or orbit, he need have regard to
+position simply as facilitating the operation.
+
+The easiest position in which to apply the ligature is just above the
+omohyoid muscle, the vessel being there superficial.
+
+
+LIGATURE ABOVE OMOHYOID.--Using the anterior border of the
+sterno-mastoid as a guide, but leaving it gradually above to a little
+nearer the mesial line, an incision (Plate IV. fig. 1), varying in
+length according to the depth of fat and cellular tissue in the neck,
+but with its central point opposite the upper border of the cricoid
+cartilage, must be made through skin, platysma, and superficial fascia.
+While making the incision the head should be held back, and the face
+slightly turned to the opposite side; the parts being now relaxed by
+position, the edges of the wound must be held apart by blunt hooks or
+copper spatul�, and the deep fascia carefully divided over the vessel,
+which will be recognised by the pulsation. It may be noted here that
+even in thin subjects the sterno-mastoid edge _invariably_ overlaps the
+vessel, though in many anatomical diagrams it would appear to be in part
+subcutaneous.
+
+The descendens noni may possibly be seen, but this is by no means
+invariably the case, crossing the sheath of the vessel very gradually
+from without inwards in its progress down the neck. It must be carefully
+displaced outwards.
+
+The sheath of the vessel is then to be cautiously opened to the extent
+of about half an inch. The internal jugular vein, possibly much
+distended, may overlap the artery on its outer side, and will require to
+be pressed, emptied, and held out of the way. A small portion of the
+artery being thoroughly separated from the sheath, the aneurism-needle
+must be passed from without inwards to avoid the vein, and keep as close
+to the artery as possible to avoid the vagus.
+
+The tendon of the omohyoid muscle, or, in muscular subjects, a portion
+of its anterior fleshy belly, may be seen crossing the vessel from
+above downwards and outwards at the lower angle of the wound.
+
+An enlarged lymphatic gland has occasionally given much trouble, by
+being mistaken for the vessel and cleaned, while the ligature has even
+been placed on a carefully isolated fasciculus of muscular fibres.
+
+
+LIGATURE OF CAROTID BELOW THE OMOHYOID.--An incision in precisely the
+same direction as the former, but at a slightly lower level, is
+required, but the dissection is rather more difficult. The edge of the
+sterno-mastoid when exposed must be drawn outwards; the sterno-hyoid and
+thyroid inwards; the omohyoid upwards; the sheath opened, and the
+descendens noni or its branches drawn to the tracheal side. The jugular
+vein and vagus are both at the outer side, and must be avoided, while
+the inferior thyroid artery and sympathetic nerve both lie behind the
+vessel, and may be included in the ligature if care be not taken.
+
+     VARIETIES.--_Sedillot's Operation._--To secure the artery still
+     lower in the neck: An incision two and a half inches long, from the
+     inner end of the clavicle obliquely upwards and outwards in the
+     interval between the sternal and clavicular attachments of the
+     sterno-mastoid; this divides the superficial textures; the two
+     portions of muscle must then be drawn apart. The internal jugular
+     vein lies in the interval, and must be drawn to the outside before
+     the artery can be seen at all, and it is this that makes this
+     operation very difficult and dangerous, especially on the left
+     side, where the vein is close to the artery, and probably even
+     crossing it from left to right. The thoracic duct is behind.
+
+     _Malgaigne's modification of the above_ is an improvement: to
+     expose the external attachment of the muscle, to cut it through and
+     turn it to the outside, as in the operation for ligature of the
+     innominate, then to divide or pull inwards sterno-hyoid and
+     sterno-thyroid, thus exposing the sheath. The needle must be passed
+     from without inwards.
+
+_Results._--Pilz has collected 600 cases, of which 43.16 per cent. died.
+The united tables of Norris and Wood give 188 cases, with a mortality of
+sixty, or nearly one in three. These tables include cases in which the
+vessel was tied for wounds, and as a preparatory step in the operation
+of removal of tumours of the jaw, etc. Later statistics give a very much
+lessened mortality, due chiefly to the use of animal ligatures.
+
+Of thirty-one cases in which it was tied for pulsating tumours of the
+orbit, only two died from the operation.[15] Rivington's statistics to a
+later date give forty-six cases on forty-four patients with six deaths.
+
+Both carotids have been tied in the same patient twenty-five times, at
+intervals of less than a year; and it is a very remarkable fact that
+only five of these fifty ligatures proved fatal,--two in which both were
+tied on the same day, and three in which the operation was performed to
+arrest h�morrhage from malignant disease of the face and jaws--from
+gunshot wound,--and from syphilitic ulceration.
+
+The external carotid, and also most of its principal branches, have been
+tied for aneurisms, wounds, goitres, enlargement of the tongue, vascular
+tumours on occiput and other lesions; also as a first stage in the
+operation of extirpation of the upper jaw, for the purpose of preventing
+h�morrhage. However, such operations are rare, and will probably become
+rarer still, and it is hardly necessary to describe the operations on
+each _seriatim_.
+
+Aneurism of the external carotid or branches are rare; if idiopathic,
+ligature of the common carotid will be found at once easier, not more
+dangerous, and more effectual than ligature of the branch; if traumatic,
+the aneurism itself should be attacked, and the bleeding point secured
+by a double ligature. Wounds are common enough, but if accessible at
+all, the injured vessel should be tied at the bleeding point; if
+inaccessible (and under this head we may include wounds of the internal
+carotid), the common carotid must be tied.
+
+No one would think of trying the superior thyroids for goitre, unless
+they were so manifestly enlarged, tortuous, and pulsating, as to render
+the operation so simple (from their superficial position) as to require
+no special directions; besides this, the cases in which it has been
+already done have given very little encouragement to repeat it.
+
+As cases may occur in which any diminution of the cerebral supply is
+contra-indicated, and thus the more difficult ligature of the external
+carotid may be preferred to the more simple operation on the common
+trunk, and as the lingual may require ligature near its root, in
+consequence of obstinate h�morrhage from the tongue, short directions
+are given for the performance of both these operations.
+
+
+1. LIGATURE OF EXTERNAL CAROTID.--Head in same position as for the
+common carotid. A straight incision parallel with the anterior edge of
+sterno-mastoid, but about half an inch in front of it, must begin almost
+at angle of jaw, and extend downwards nearly to the level of the thyroid
+cartilage. Cautiously divide skin, platysma, and fascia; the lower end
+of the parotid must be pulled upwards, and the veins, which are
+numerous, cautiously separated. The anterior border of the
+sterno-mastoid must be pulled backwards, and the digastric and
+stylo-hyoid forwards and inwards. The superior laryngeal nerve which
+lies behind the vessel must be avoided.
+
+
+2. LIGATURE OF LINGUAL.--To secure this vessel either before it becomes
+concealed by the hyo-glossus, or after it is under the muscle, a curved
+incision is necessary, following the line of the hyoid bone, and
+especially of its greater cornu, but a line or two above its upper
+border. After the skin and platysma are divided, the posterior belly of
+the digastric must be recognised, which again will guide to the
+posterior edge of the hyo-glossus. The edge of the sub-maxillary gland
+may very probably require to be raised out of the way. The artery can
+then be secured, either before it dips under the hyo-glossus muscle, or
+after it has done so, by the division of a few of its fibres on a
+director. Care is needed to avoid injury of the hypo-glossal nerve,
+which lies above the muscle.
+
+The internal carotid artery occasionally, but very rarely, is the
+subject of aneurism. It may, like any other artery, be wounded,
+especially from the fauces. The treatment of either of these lesions is
+ligature of the common carotid itself, in preference to ligature of the
+internal carotid. Guthrie's operation for securing the bleeding internal
+carotid at the injured spot, by dividing and turning up the ramus of the
+lower jaw, has never been performed in the living body, and is so
+difficult, dangerous, and unnecessary, as not to merit description.
+
+
+LIGATURE OF SUBCLAVIAN.--_Note._--In consequence of the difference in
+the origin, and variety in the anatomical relations of the right and
+left subclavian arteries, in so far at least as their first stage is
+concerned, it is necessary to give a very brief separate account of
+each.
+
+_Right Subclavian._--The innominate artery divides into the right
+subclavian and right carotid exactly behind the sterno-clavicular
+articulation. The right subclavian extends from this point in an arched
+form across the neck, between the scalene muscles, over the apex of the
+pleura, till, passing under cover of the clavicle, it changes its name
+to axillary at the lower end of the first rib. For convenience of
+description, the artery is divided into three parts, which have very
+various anatomical relations, and differ from each other much in their
+amenability to surgical treatment by ligature. The anterior scalenus
+muscle defines the three parts, the first extending to the inner border
+of the muscle, the second being concealed by the muscle, and the third
+reaching from its outer border to the lower border of the first rib.
+
+_Branches of the Subclavian._--While the deep relations of pleura,
+veins, and nerves can be noticed under the head of each operation in
+detail, one anatomical point must never be forgotten as influencing very
+much the success of all surgical interference with the subclavian
+arteries--_i.e._ the branches given off. To give any chance of success
+in the application of a ligature to such a large vessel, so near the
+heart, a large portion of artery free from branches is required, that
+the clot may be long, firm, and undisturbed. The first part of the
+subclavian gives off the vertebral, thyroid axis, and internal mammary;
+the second, the superior intercostal; while the third part has in most
+cases no branch whatever. In these anatomical differences we find the
+reason for the almost invariable fatality resulting on any interference
+with the first and second parts, and the comparative safety of ligature
+of the third part, without requiring to account for the difference on
+other grounds, such as depth of part, importance of nervous relations,
+or nearer proximity to the heart.
+
+The second and third parts of both arteries are so similar to each
+other, that a separate account is not required for the two sides.
+
+
+LIGATURE OF RIGHT SUBCLAVIAN.--_First Part._--_Operation._--An incision
+just at upper edge of sternum and right clavicle, extending from inner
+edge of _left_ sterno-mastoid transversely to outer border of right
+sterno-mastoid through skin, platysma, and exposing sterno-mastoid, to
+be joined at an angle by a second incision, which, two, three, or even
+four inches long, must extend along inner border of right
+sterno-mastoid. Flap to be raised upwards and outwards. The sternal
+attachment of the sterno-mastoid must then be cautiously divided, as
+also part or the whole of its clavicular attachment, according as room
+is required. The sterno-hyoid and thyroid muscles will then require
+similar division. The internal jugular will then be seen very
+prominent,[16] and will require to be drawn inwards or outwards,
+according to circumstances. The carotid and right subclavian arteries
+will then be felt lying close together crossed by the pneumogastric and
+recurrent nerves, the latter turning behind the subclavian. The nerves
+must be drawn inwards; the cardiac filaments of the sympathetic will
+then be observed, and drawn outwards. The subclavian vein lies below,
+concealed by the clavicle, and will probably not be seen during the
+operation. The needle should be passed round the artery from below
+upwards, care being taken not to injure the pleura, which lies beneath
+and behind the artery.
+
+_Results._--Twelve cases, all of which died; ten of h�morrhage, one of
+pleurisy and pericarditis, and one from py�mia. Attempted in one case by
+Mr. Butcher, but the artery was too much diseased to bear a ligature.
+The patient died on the fourth day.
+
+
+LIGATURE OF LEFT SUBCLAVIAN.--_First Part._--This operation, which has
+been described by some as impossible, has, I believe, been only once
+performed on the living body. _Operation._--Incisions as for the
+preceding operation, except being on the opposite side. After the skin,
+platysma, and muscles have been divided, as already described, the deep
+cervical fascia requires division close to the inner edge of the
+scalenus anticus. The artery lies excessively deep, and great difficulty
+is experienced in avoiding injury to the pleura and the thoracic duct.
+
+_Results._--Once performed by Dr. Rodgers of New York; death from
+h�morrhage on fifteenth day.
+
+_Anatomical Note._--The course of the left subclavian in its first stage
+is much straighter, as its origin is much deeper, than on the right
+side. The pneumogastric, phrenic, and cardiac nerves lie parallel to its
+course; the oesophagus and thoracic duct lie behind it, and to its inner
+side.
+
+
+LIGATURE OF SUBCLAVIAN.--_Second Part._--This very rare operation hardly
+requires a separate description, as the incisions necessary for ligature
+of the artery in its third part will, with very slight modifications, be
+sufficient for the purpose.
+
+It has, however, special elements of danger in it, involved in the
+unavoidable division, of part at least, or probably the whole, of the
+scalenus anticus. The phrenic nerve, from its position on that muscle,
+requires special care to avoid dividing it, and in most cases the
+internal jugular vein is also in the way. The branches of the thyroid
+axis, which cross the neck, are quite in the line of the incision. The
+lowest cord of the brachial plexus lies immediately behind the artery,
+between it and the middle scalenus. The pleura lies just below it. The
+subclavian vein is generally quite safe, running in front of the
+scalenus anticus, and at a lower level.
+
+The presence of the superior intercostal branch adds greatly to the
+danger of ligature of the vessel in this position, from its interfering
+with a proper clot.
+
+_Results._--Dupuytren[17] performed it successfully for a traumatic
+axillary aneurism. Auchincloss[18] did it for a large true aneurism, but
+the patient died sixty-eight and a half hours after the operation.
+Liston cut through the outer portion of the scalenus with success for an
+idiopathic aneurism. Thirteen have been collected by Wyeth with four
+recoveries and nine deaths.
+
+
+LIGATURE OF SUBCLAVIAN.--_Third Part._--For this comparatively common
+operation, various methods of procedure have been suggested and
+employed.
+
+In the dead body, where the axilla is free from swelling, and in thin
+patients, the artery in this third stage is tolerably superficial, and
+can be secured with ease. But in very muscular men, with short necks and
+well curved clavicles, and specially when the axilla is filled up with
+an aneurism, and the shoulder cannot be depressed, the operation becomes
+very difficult.
+
+_Operation of Ramsden, Liston, and Syme._--_Position._--The patient
+lying on his back with his shoulders supported by pillows, and his head
+lying back, and drawn to the opposite side; the shoulder of the affected
+side must be depressed as much as possible.
+
+_Incisions._--(Plate I. fig. 8.)--One through skin, superficial fascia,
+and platysma, along the upper edge of the clavicle, for at least three
+inches from the anterior edge of the trapezius to the posterior border
+of the sterno-mastoid, and in muscular subjects freely overlapping the
+edges of both muscles. Another two inches in length along posterior
+border of sterno-mastoid meets the first at an angle. On reflecting the
+chief flap thus made upwards and backwards, the external jugular will be
+seen, and, if possible, must be drawn to a side; if not, it must be
+divided, and both ends tied. The lower edge of the posterior belly of
+the omohyoid must then be sought; this leads at once to the posterior or
+outer margin of the scalenus anticus. The connection of the deep fascia
+to that muscle must then be very carefully scraped through, and by
+tracing the muscle to its insertion to the first rib, the artery is at
+once reached, lying behind the insertion. The pulsation of the vessel
+between the forefinger and the first rib will prove a great assistance;
+yet care is required, lest one of the branches of the brachial plexus be
+secured instead of the artery. The lowest cord lies very close to the
+vessel. The subclavian vein is not likely to give much trouble, from
+its being on a lower level, and (unless very much dilated) nearly
+concealed by the clavicle. The suprascapular artery is also hidden, but
+the transverse cervical crosses the very line of incision, and may give
+trouble, being occasionally much enlarged, so much so as even for a time
+to have been mistaken for the subclavian itself. If possible, both these
+branches should be saved, as being important means of carrying on the
+anastomosis for the future support of the limb.
+
+An absorbent gland is occasionally in the way, and has even been
+mistaken for the vessel and carefully cleaned. Such may be removed
+without scruple.
+
+Care must be taken not to injure the pleura, which lies immediately
+behind and below the vessel at the seat of ligature. Various
+instrumental devices have been invented for passing the ligature. The
+simplest seems still to be best, a common aneurism-needle with a
+considerable curve.
+
+     _Other methods of operating._--A single curved incision above the
+     clavicle, with its concavity upwards, of about three or four inches
+     long, with its inner end rather higher than the outer (Green,
+     Fergusson).
+
+     A linear transverse incision in the same situation (Velpeau).
+
+     A single linear incision perpendicular to the clavicle (Roux).
+
+     An arched incision (Plate IV. fig. 2) with its convexity outwards,
+     and its base on the posterior edge of the sterno-mastoid, from
+     three inches above the clavicle to the clavicular attachment of the
+     muscle (Skey).
+
+_Results._--Dr. Wyeth's Tables in 1877 give 251 cases with 134 or 53 per
+cent. of deaths.
+
+     The late Mr. Furner of Brighton reported a most interesting case,
+     in which he tied both subclavian arteries at an interval of two
+     years in the same patient, for axillary aneurisms, with success.
+
+
+LIGATURE OF AXILLARY.--_Anatomical Note._--This vessel, the next stage
+in the continuation of the subclavian downwards, may be defined
+surgically as extending from the clavicle to the lower border of the
+teres major. From the depth of the vessel at its upper part, the
+numerous nerves, and the close proximity of the vein, the surgeon has
+carefully to study the anatomical relations. It, like the subclavian, is
+commonly divided into three stages, and, also like the subclavian, these
+stages are defined by the relations of the artery to a muscle, the
+pectoralis minor. Surgically we may draw a very close parallel between
+the two vessels, for we find that in the axillary, as in the subclavian,
+the first stage is very deep, and very rarely amenable to ligature; the
+second, still deeper and more rarely attempted, as in both the operation
+involves division of a deep muscle; while the third stage in each is the
+one most frequently chosen by the surgeon.
+
+_First Stage._--Between the lower edge of the first rib and upper border
+of the pectoralis minor the vessel is deeply seated, contained in that
+process of deep fascia called the costo-coracoid membrane, and covered
+above by skin, platysma, and the clavicular portion of the pectoralis
+major. It lies on the first intercostal muscle and the upper digitation
+of the serratus magnus, while the cords of the brachial plexus are on
+its acromial side, and the axillary vein in close contact with it on its
+thoracic side, and frequently overlapping the artery.
+
+_Operation._--The great desideratum is free access. An incision (Plate
+I. fig. 9), semilunar in shape, with its convexity downwards, must
+extend from half an inch outside of the sterno-clavicular articulation
+to very near the coracoid process, stopping just before it arrives at
+the edge of the deltoid, in order to avoid injury of the cephalic vein.
+It must include skin, fascia, and platysma, and the flap must be thrown
+upwards. The clavicular portion of the pectoralis major must then be
+divided right across its fibres, which will retract. The arm must then
+be brought close to the side to relax the pectoralis minor, which must
+be drawn aside. The artery will then be felt pulsating, but hidden by
+the costo-coracoid membrane, which acts as its sheath. This must be
+carefully scratched through, the nerves pulled outwards, the vein
+avoided and pulled downwards and inwards, and the thread passed round
+from within outwards. (Manec, Hodgson, and, with slight modification in
+the incision through the skin, Chamberlaine.)
+
+     Ligature has been performed in this position by separating the
+     pectoralis and deltoid muscles, without dividing the muscular
+     fibres (Roux, Desault).
+
+     To attempt to gain access between the clavicular and sternal
+     portions of pectoralis major, as has been proposed by some, is
+     almost impracticable in the living body, from the position of the
+     vein, to which, rather than to the artery, this incision leads.
+
+
+LIGATURE OF AXILLARY, _in its second stage_, is not an advisable
+operation, when it is merely intended to throw a ligature round the
+artery for an aneurism lower down.
+
+It has been performed at least twice by Delpech, but it is a rude
+procedure; in his cases, after the muscle was cut, a dive with the
+finger was made to collect the whole mass of vessels and nerves, and
+bring them to the surface near the collar-bone; in this position it is
+said the artery was easily isolated and tied.
+
+In Mr. Syme's operation of cutting into large axillary aneurisms, and
+tying both ends of the vessel, the pectoralis minor may, indeed
+generally has, to be divided, and must take its chance without any
+special notice or precaution, in the sweeping, free incisions required.
+
+
+LIGATURE OF AXILLARY _in its third stage_.--This is an operation very
+much more common, more easy of accomplishment, and safer in its results
+than either of the preceding; the artery in this stage being more
+superficial, in fact almost subcutaneous.
+
+_Operation._--The arm being extended and supinated, an incision (Plate
+I. fig. 10) two and a half or three inches long, must be made in the
+base of the axilla over the artery, involving at first skin and
+superficial fascia only; the deep fascia is then exposed and must be
+carefully scraped through, avoiding injury of the basilic vein, if (as
+sometimes occurs) it has not yet dipped through the fascia. The vessel
+can now be felt; the median nerve which lies over the artery, or
+slightly to its outer side, must be drawn outwards, and the axillary
+vein, which lies at the thoracic side, but often overlaps the vessel,
+must be carefully drawn inwards. The ligature must then be passed from
+within outwards.
+
+When the patient is very fat or muscular, the coraco-brachialis muscle
+may be required as a guide to the vessel; but in general its superficial
+position renders any guide quite unnecessary, even in the dead body.
+
+_Anatomical Note._--While in each stage the axillary artery gives off
+branches, those arising from the third stage are by far the most
+important, especially the subscapular, which leaves it at the edge of
+the muscle of the same name. To avoid these the ligature should be
+applied as low down on the vessel as possible, and, in point of fact,
+the operation called ligature of the third stage of the axillary is,
+anatomically speaking, really ligature of the brachial high up, and
+where there is room at all, there will be the less chance of secondary
+h�morrhage, the greater the distance is between the ligature and the
+great subscapular branch.
+
+_Mr. Syme's Operation for Axillary Aneurism._--Description of the
+operation in his own words:--
+
+"Chloroform being administered, I made an incision along the outer edge
+of the sterno-mastoid muscle, through the platysma myoides and fascia of
+the neck, so as to allow a finger to be pushed down to the situation
+where the subclavian artery issues from under the scalenus anticus and
+lies upon the first rib. I then opened the tumour, when a tremendous
+gush of blood showed that the artery was not effectually compressed;
+but while I plugged the aperture with my hand, Mr. Lister, who assisted
+me, by a slight movement of his finger, which had been thrust deeply
+under the upper edge of the tumour, and through the clots contained in
+it, at length succeeded in getting command of the vessel. I then laid
+the cavity freely open, and with both hands scooped out nearly seven
+pounds of coagulated blood, as was ascertained by measurement. The
+axillary artery appeared to have been torn across, and as the lower
+orifice still bled freely, I tied it in the first instance. I next cut
+through the lessor pectoral muscle close up to the clavicle, and holding
+the upper end of the vessel between my finger and thumb, passed an
+aneurism-needle, so as to apply a ligature about half an inch above the
+orifice."[19]
+
+In a similar operation lately performed by the author for traumatic
+aneurism, the result of a stab, very little blood was lost, though no
+incision was made above the clavicle. The patient made a good
+recovery.[20]
+
+
+LIGATURE OF BRACHIAL.--To arrest h�morrhage from a wound of the artery
+itself, no special directions are required, except to enlarge the wound,
+and secure the vessel above and below the bleeding point. There are,
+however, rare cases in which for bleeding in the palm (after all other
+means have failed), or for aneurism lower down the arm, a ligature may
+be necessary.
+
+_Operation._--The biceps muscle, at its inner edge, is the best guide to
+the position of the incision, or if it be obscured by fat or oedema, a
+line extending from the axilla, just over the head of the humerus to the
+middle of the bend of the elbow will define its course. An incision
+(Plate I., fig. 11) three inches in length, about the middle of the arm
+(when you have the choice of position), through skin and superficial
+fascia, will expose the deep fascia, and probably the basilic vein.
+Drawing the latter aside, cautiously divide the deep fascia. The artery
+is then exposed, but in close relation to various nerves; of these the
+ones most likely to come in the way are--1. The median, which lies in
+front of, but a little to the outside of the artery, though in some rare
+cases it lies behind it; 2. The internal cutaneous; 3. The ulnar, both
+of which ought to be rather to the inside of the artery. Two brachial
+veins accompany and wind round the vessel, occasionally interlacing.
+Pulsation will, in the living body, usually suffice to distinguish the
+artery from the other textures, and the ligature may be passed from
+whichever side is most convenient.
+
+     _Note._--The relation of the median nerve to the vessel varies
+     according to the part of the arm--thus, as low as the insertion of
+     the coraco-brachialis it is to the outer side, as has been
+     described, it then crosses the vessel obliquely, and two inches
+     above the elbow it is on the inner side of the artery. Again, the
+     operator must never forget the possibility of there being a high
+     division of the artery. This occurs, Mr. Quain has shown, perhaps
+     once in every ten or eleven cases, and may necessitate ligature of
+     both trunks.
+
+In those cases (once much more frequent than at present) where an
+aneurism has formed after a wound of the brachial at the bend of the arm
+in venesection, the aneurism may be either circumscribed or diffuse.
+
+If circumscribed, it is advised by some surgeons, specially by the late
+Professor Colles of Dublin, that the brachial should be tied immediately
+above the tumour. In most cases of circumscribed, and in all such cases
+of diffuse aneurism, the preferable operation is boldly to lay open the
+tumour, turn out all the clots, seek for the wound in the artery, and
+tie the vessel above and below. A tourniquet above, or, better still, a
+trustworthy assistant, prevents all fear of h�morrhage, and such a
+radical operation exposes the limb to far less chance of gangrene than
+do any attempts at removing or lessening the tumour by pressure (as
+recommended by Cusack, Tyrrell, Harrison), and is much more certain
+than a mere ligature above.[21]
+
+
+LIGATURE OF VESSELS IN FORE-ARM.--Here, as also we found is the case in
+the leg, it is almost useless to go on giving exact directions as to the
+method of throwing a ligature round the vessels in all possible
+situations.
+
+For below the elbow spontaneous aneurism is almost unknown, and even
+traumatic aneurisms are extremely rare. It is therefore for h�morrhage
+only that the vessels are likely to require ligature, and it is a rule
+in surgery that to enlarge the wound and to apply a ligature above and
+below the bleeding point is better practice than to apply a ligature at
+a distance.
+
+In the case of wounds of the palmar arch, it is extremely difficult, and
+very apt to injure the future usefulness of the hand, thus to seek for
+the bleeding point under the palmar fascia, and for _these_, ligatures
+of radial and ulnar have occasionally been practised. However, as even
+this has proved ineffectual, and the interosseous has proved sufficient
+to continue the bleeding, ligature of the brachial at once is preferable
+to ligature of so many branches in the fore-arm.
+
+The use of graduated compresses, carefully applied, combined with
+flexion of the elbow over a bandage, will generally prove sufficient to
+check such h�morrhage from the palm, without having recourse to either
+of the above more severe measures.
+
+     _Note._--As in the lower limb at page 24, and for the same reasons,
+     I here insert a brief account of the methods of tying the ulnar and
+     radial arteries.
+
+     1. LIGATURE OF ULNAR.--Only admissible in the lower half of its
+     course. _Operation._--Use the tendon of the flexor carpi ulnaris as
+     a guide, and make an incision along its radial edge, at least two
+     inches in length; expose the deep fascia of the arm and then
+     cautiously divide it; then bending the hand, the flexor carpi
+     ulnaris is relaxed, and the artery is found lying pretty deeply
+     between it and the flexor sublimis digitorum. The ulnar nerve lies
+     at its ulnar side, and the ven� comites accompany the artery. In a
+     tolerably muscular arm, the incision will have to be about an inch
+     inside of the ulnar border of the limb.
+
+     2. RADIAL.--This artery lies more superficial than the preceding,
+     and may be tied at any part of its course.
+
+     _A._ Operation in upper part of fore-arm. Here the artery lies in
+     the interval between the supinator longus and the pronator radii
+     teres. In a muscular arm, the edge of the former muscle is the best
+     guide; in a fat one, the incision may be made in a line extending
+     from the centre of the bend of the arm to the inner edge of the
+     styloid process of the radius. The deep fascia must be exposed and
+     opened, and the muscles relaxed and held aside. The radial nerve
+     lies on the radial side of the vessel.
+
+     _B._ Operation in lower half of arm. Here the vessel is more
+     superficial, lying in the groove between the flexor carpi radialis
+     and supinator longus. An incision two inches in length, and
+     parallel with these tendons, easily exposes the artery. The nerve
+     is still on its radial side.
+
+     _C._ Operation at first metacarpal. The artery may be tied easily
+     enough in the triangular space bounded by the extensors of the
+     thumb, on the dorsum of the proximal end of the first metacarpal
+     bone. Skey[22] recommends a transverse,--Stephen Smith[23] and
+     others, a longitudinal incision. The author had lately to secure
+     the radial in its lower third, the superficialis vol�, and the
+     radial again in the triangular space, in a case where division of
+     the artery by a transverse cut had caused a large aneurism to form
+     close above the annular ligament.
+
+     TABLE illustrating anastomotic circulation after ligature of
+     arteries of neck and upper limb.
+
+     1. Common carotid.
+
+     (_a_) Across middle line: thyroids, linguals, facials, occipitals;
+     also terminal branches of external carotids; also internal carotids
+     by circle of Willis.
+
+     (_b_) Of same side: occipital with vertebral; superior thyroid with
+     inferior thyroid, etc.
+
+     2. Subclavian, 3d part.
+
+     Suprascapular with dorsal branches of subscapular; posterior
+     scapular with costal and muscular branches of subscapular. Thoracic
+     anastomosis between internal mammary and intercostals, with
+     branches of axillary.
+
+     3. Axillary and brachial. Anastomosis varies with the position of
+     the ligature, but is very free between the various muscular
+     branches of these vessels.
+
+
+FOOTNOTES:
+
+[2] Erichsen, _Surgery_. Sixth edition, vol. ii. p. 121.
+
+[3] The line 3 in Plate I. shows the direction required. It
+will not be necessary to carry the incision so far up for the external
+as for the common iliac.
+
+[4] _On the Arteries and Veins_, p. 421.
+
+[5] _Cyclop�dia of Practical Surgery_, vol. i. p. 277.
+
+[6] John Bell's _Prin. of Surg._, vol. i. 421; _Dublin Jour._,
+vol. iv. 321.
+
+[7] _Observations in Clinical Surgery_, Syme, pp. 171-3.
+
+[8] _Brit. Med. Jour._ 1867, Oct. 5.
+
+[9] _International Encyclop�dia of Surgery_, vol. iii. p. 466.
+
+[10] Poland, _Guy's Hosp. Report_, ser. iii. vol. vi.
+
+[11] Mr. W. Thomson's most interesting paper on this subject is
+full of information down to the latest date.
+
+[12] _Lancet_, Jan. 5, 1867.
+
+[13] _Lancet_, May 1879.
+
+[14] _Dublin Quarterly Journal_, Nov. 1867.
+
+[15] W. Zehender--Monatsbl. f�r Augenheilkunde. 1868.
+
+[16] Butcher, _Op. and Cons. Surgery_, p. 861.
+
+[17] _Le�ons Orales_, iv. 530.
+
+[18] _Ed. Med. and Surg. Journ._ vol. xlv.
+
+[19] _Observations in Clinical Surgery_, pp. 148, 149.
+
+[20] _Edin. Med. Journal_, March 1879.
+
+[21] See case of recurrence, Fergusson's _Practical Surgery_
+1st ed. p. 222.
+
+[22] _Operative Surgery_, p. 279.
+
+[23] _Surgical Operations_, p. 50.
+
+
+
+
+CHAPTER II.
+
+AMPUTATIONS.
+
+
+In ordinary surgical language the name Amputation is applied to all
+cases of removal of limbs, or portions of limbs, by the knife, though in
+strict accuracy it should be restricted to those cases in which a limb
+is removed _in the continuity of a bone_, its removal _at a joint_ being
+called a Disarticulation.
+
+The briefest outline of a history of amputation would fill a work much
+larger than the present. I may be allowed in a few sentences to attempt
+to show the principle on which such a sketch should be written, in
+describing the three great eras of progress in improvement of the
+methods of amputating.[24]
+
+I. Prior to the invention, or at least prior to the general
+introduction, of the ligature and the tourniquet, the great barrier to
+all improvement in operating was the impossibility of checking
+h�morrhage during an operation, and after its conclusion. Many surgeons
+would not amputate at all, others only through gangrenous parts; others
+more bold, only at the confines of parts in which gangrene had been
+artificially induced by tight ligatures.
+
+With the exception of Celsus, who in one place recommends a flap to be
+dissected up, and the bone thus divided at a higher level, all were in
+too great a hurry to get the operation completed to think of flaps. Cut
+through all the parts at the same level with a red-hot knife, if you
+will, like Fabricius Hildanus; by a single blow with a chisel and
+mallet, like Scultetus; or by a crushing guillotine, like Purmannus: or
+by two butchers' chopping-knives fixed in heavy blocks of wood, one
+fixed, the other falling in a grove, like Botal; and then try to check
+the bleeding by tying a pig's bladder over the face of the stump, like
+Hans de Gersdorf; or tying it up in the inside of a hen newly killed; or
+by plunging it at once into boiling pitch.
+
+We are the less surprised to read of Celsus's description of a flap
+operation, when we remember that it is almost certain that Celsus _was_
+acquainted with the ligature as a means of checking h�morrhage.[25]
+
+II. A new era was ushered in when, about 1560, Ambrose Par� invented, or
+re-introduced, the ligature as a means of arresting h�morrhage, but not
+for more than a century after this did the full benefit of his discovery
+begin to be felt, when the tourniquet was introduced by Morel at
+Besan�on in 1674, and James Young of Plymouth in 1678, and improved by
+Petit in 1708-10.
+
+_Now_ surgeons had time to look about them during an amputation, and to
+try to get a good covering for the bone, so that the stump might heal
+more rapidly and bear pressure better. Great improvements were rapidly
+made, and any history of these improvements would need to trace two
+great parallel lines, one the circular method, the other the flap
+operation.
+
+1. The old method in which the limb was lopped off by one sweep, all the
+tissues being divided at the same level, might be called the true
+circular. This, however, was soon improved--
+
+_A._ By Cheselden and Petit, who invented the double circular incision,
+in which first the skin and fat were cut and retracted, and then the
+muscle and bone were divided as high as exposed.
+
+_B._ By Louis, who improved this by making the first incision include
+the muscles also, the bone alone being divided at the higher level.
+
+_C._ By Mynors of Birmingham, who dissected the skin back like the
+sleeve of a coat, and thus gained more covering.
+
+_D._ Then comes the great improvement of Alanson, who first cut through
+skin and fat, and allowing them to retract, next exposed the bone still
+further up by cutting the muscles obliquely so as to leave the cut end
+of the bone in the apex of a conical cavity.
+
+_E._ An easier mode, fulfilling the same indications, is found in the
+triple incision of Benjamin Bell of Edinburgh, who in 1792 taught that
+first the skin and fat should be divided and retracted, next the
+muscles, and lastly the bone.
+
+_F._ A slight improvement on _E_, made by Hey of Leeds, who advised that
+the posterior muscles of the limb should be divided at a lower level
+than the anterior, to compensate for their greater range of contraction.
+
+2. In the progress of the flap operation fewer stages can be defined.
+Made by cutting from within outwards, after transfixion of the limb, the
+flaps varied in shape, size, position, and numbers, from the single
+posterior one of Verduyn of Amsterdam, to the two equal lateral ones of
+Vermale, and the equal anterior and posterior ones of the Edinburgh
+school.
+
+Then came the battle of the schools: flap or circular.
+
+_Flap._--Speedy, easy, and less painful; apt to retract, and that
+unequally.
+
+_Circular._--Leaving a smaller wound, but more slow in performance, and
+apt to leave a central adherent cicatrix.
+
+3. The last era in amputation began after the introduction of
+an�sthetics. Now speed in amputation is no object, and the surgeon has
+full time to shape and carve his flaps into the curves most suited for
+accurate apposition, and suitable relation of the cicatrix to the bone.
+It has also been brought clearly out that different methods of operating
+are suitable for different positions, and also that even in the same
+operation it is possible to unite the advantages of both the flap and
+the circular method.
+
+In the modified circular, which is best suited for amputation below the
+knee, in the long anterior flaps of Teale, Spence, and Carden, we have
+illustrations of the manner in which the advantages of both the flap and
+circular methods have been secured, without the disadvantages of either.
+The long anterior flap, not like Teale's to fold upon itself, but like
+Spence's and Carden's to hang over and shield the end of the bones, and
+the face of a transversely-cut short posterior flap, seems to be now the
+typical method for successful amputations. There may be exceptions, as
+when the anterior skin is more injured than the posterior, or where an
+anterior flap would demand too great sacrifice of length of limb, but as
+a rule it will be found the best method for the patient.
+
+
+AMPUTATION OF THE UPPER EXTREMITY.--The extreme importance of the human
+hand, its tactile sensibility, its grasping power, and the irreparable
+loss sustained by its removal, render the greatest caution necessary,
+lest we should remove a single digit or portion of one that might be
+saved. In cases of severe smashing injuries involving the fingers, it is
+the surgeon's bounden duty not recklessly to amputate the limb with neat
+flaps at the wrist-joint, but carefully to endeavour to save even a
+single finger from the wreck, though at the risk of a longer
+convalescence, or even of a profuse suppuration. While a toe or two, or
+a small longitudinal segment of the foot, may be comparatively useless,
+and a good artificial foot, with an ankle-joint stump, certainly
+preferable, a single finger, provided its motions are tolerably intact,
+will prove much more valuable to its possessor than the most ingeniously
+contrived artificial hand.
+
+[Illustration: FIG. I.]
+
+However, while in cases of extensive smash we endeavour to save anything
+we can, the case is very much altered when it is only one or two fingers
+that are injured. Here we find another principle brought into play, and
+our conservative surgery must be limited by the following consideration.
+In endeavouring to save a portion of the injured finger or fingers, will
+the saved portion interfere with the important movements of the
+uninjured ones? These two principles--1. Generally to save as much as we
+can; 2. Not to save anything which may be detrimental or in the
+way,--will guide us in describing the amputations of the upper
+extremity.
+
+[Illustration: FIG. II.]
+
+_Amputation of a distal phalanx._--This small operation is not very
+often required. In cases of whitlow in which the distal phalanx alone
+has necrosed, removal of the necrosed bone by forceps is generally all
+that is necessary. In cases of injury, however, in which nail and distal
+phalanx are both reduced to pulp, it will hasten recovery much to remove
+the extremity. There is no choice as to flap, the nail preventing an
+anterior one, so a flap long enough to fold over must be cut from the
+pulp of the finger in either of two ways (Fig. I. 1):--1. Holding the
+fragment to be removed in the left hand, and bending the joint, the
+surgeon makes a transverse cut across the back of the finger, right into
+and through the joint, cutting a long palmar flap from within outwards
+as he withdraws the knife.
+
+     _Note._--Some difficulty is often felt in making the dorsal
+     incision so as exactly and at once to hit the joint; the most
+     common mistake being, that the transverse incision is made too
+     high, and the knife, instead of striking the joint, only saws
+     fruitlessly at the neck of the bone above. To avoid this, the
+     surgeon should take as a guide to the joint, not the well-marked
+     and tempting-looking _dorsal_ fold in the skin, but the _palmar_
+     one, which exactly corresponds with the joint between the proximal
+     and middle phalanges, and is only about a line above the distal
+     articulation.--(Fig. II.)
+
+2. Making the long flap by transfixion, it may be held back by an
+assistant, and the joint cut into.
+
+_Amputation through the second phalanx._--If the distal phalanx be so
+much crushed that a flap cannot be obtained, two short semilunar lateral
+flaps may be dissected (Fig. I. 2) from the sides of the second phalanx,
+which may then be divided by the bone-pliers at the spot required.
+
+In cases of injury which do not admit of either of the preceding
+operations, it is quite possible to amputate either at the first joint,
+or even through the proximal phalanx. Patients are sometimes anxious for
+such operations in preference to amputation of the whole finger. The
+surgeon should, however, never amputate through a finger higher up than
+the distal end of the second phalanx, unless absolutely compelled by the
+patient, for the resulting stump, being no longer commanded by the
+tendons, will prove merely an incumbrance, and may possibly require a
+secondary operation at no distant date for its removal.
+
+This rule is applicable in cases in which a single finger is injured,
+and two or three complete ones are left; in cases where all the fingers
+have been mutilated every morsel should be left, and may be of use.
+
+_Amputation of a whole finger._--(Fig. I. 3)--This is an operation of
+great importance, from its frequency.
+
+If the third or fourth digits require amputation, it should be performed
+as follows:--The vessels of the arm being commanded, an assistant holds
+the hand, separating the fingers at each side of the one to be removed.
+The surgeon holding the finger to be removed, enters the point of a long
+straight bistoury exactly (some authorities say half an inch) above the
+metacarpo-phalangeal joint, and cuts from the prominence of the knuckle
+right into the angle of the web, then, turning inwards there, cuts
+obliquely into the palm to a point nearly opposite the one at which he
+set out.
+
+     _Note._--While most authorities agree with the direction in the
+     text regarding the palmar termination of the incision, I believe,
+     in most cases, it is not necessary to go so far, and that the
+     incisions may fitly meet in the palm at a point midway between a
+     point opposite to the knuckle, and the centre of the well-marked
+     "sulcus of flexion."
+
+He then repeats this incision on the other side, makes tense the
+ligaments, first at one side and then at the other, by drawing the
+finger to the opposite side, and cuts them. The tendons being cut, the
+finger is detached. The vessels being tied, one point of suture is put
+in on the dorsal aspect, and the fingers on each side tied together at
+their extremities, with a pad of lint between them.
+
+     _Modification._--Lisfranc's method is too long in its minute
+     description to give in detail. The principle is to make a semilunar
+     flap at one side (the one opposite the operator's right hand), by
+     cutting from without inwards, then to open the joint from this cut,
+     and, still keeping the edge of the knife close to the head of the
+     phalanx, cutting the other flap from within outwards. This can be
+     very rapidly done, but the last flap is apt to be irregular and
+     deficient, especially in those common cases, in which, after
+     whitlow or the like, the tissues are hard and brawny, and the skin
+     does not play freely.
+
+It is quite unnecessary to remove the head of the metacarpal, either for
+the sake of appearance, or to render healing more rapid, and its removal
+weakens the arch of the hand; where the cartilage is eroded by disease,
+the cartilage-covered portion can be scooped off by a gouge or removed
+entire by pliers, without interfering with the broad end to which the
+transverse ligament of the palm is attached. If required either for
+injury or disease, the metacarpal head may be easily removed by a single
+straight incision from the knuckle upwards, as far as the point at which
+it may be deemed necessary to saw it through, or better still, divide it
+with the bone-pliers. This incision should be made as a first step in
+the first incision for amputation of the finger, and the finger should
+not be disarticulated, but kept on, to aid by its leverage in separating
+the metacarpal head.
+
+_Amputation of the index or little fingers._--This operation differs
+from the preceding only in this, that care must be taken to make a good
+large flap on the free side of each; making the incision, which begins
+at the knuckle (Fig. I. 4), enclose a well-rounded flap, and not
+allowing it to enter the palm till it reaches the level of the web
+between the fingers. The metacarpal heads may here be cut obliquely with
+the bone-pliers, to prevent undue projection.
+
+_Amputation of one or more metacarpals._--These operations may be
+rendered necessary by disease or injury. If the latter demands their
+performance, no rules can be given for incisions or flaps, they must
+just be obtained where and how they can best be got. If for disease, a
+single dorsal incision (Fig. I. 5) over the bone will allow it to be
+dissected out of the hand.
+
+_N.B._--In no case, except that of the thumb, should any attempt be
+made to save a finger while its metacarpal is removed. (See _Excisions
+of Bones_.)
+
+_Amputation of first and fifth metacarpals._--Various special operations
+have been devised for speedy and elegant removal of these bones. Their
+disadvantages, etc., are fully detailed under _Amputations of the Foot_.
+
+The vascularity and consequent vitality of the tissues of the hand and
+arm sometimes afford very encouraging and satisfactory results in
+conservative operations.
+
+The following is an instance of what may be accomplished in a young
+healthy subject.
+
+A. A., �t. 18, ploughman, was harnessing a vicious horse, when it caught
+his right hand between its teeth, and gave a severe bite. On admission,
+I found the middle and ring fingers completely separated at the
+metacarpal joints, but each hanging on by a portion of skin, the middle
+by the skin on its radial side, the ring by that on its ulnar. The back
+and the palm were both stripped of skin up to the middle of the third
+and fourth metacarpal bones, which were exposed, but not fractured. As
+it was important for him to maintain the transverse arch of the hand
+intact, I determined to make an attempt to save the metacarpals, and
+finding that the skin on the radial side of the middle, and ulnar side
+of the ring fingers, was still warm, and apparently alive, I carefully
+dissected as long a flap as possible from each, and then folded them
+down, one at the front, the other at the back of the hand. The flaps
+survived, and the result was admirable, the patient being able in a very
+few weeks to guide the plough. The sensation in his new palm and back of
+the hand is very peculiar, they being still the fingers, so far as
+nervous supply is concerned.
+
+In amputations involving the metacarpals for injury, it is always
+important to avoid entering the carpo-metacarpal joint, hence if it can
+be done it is best to saw through the bones at the required level,
+rather than disarticulate. This rule should be observed even in those
+cases in which the thumb alone can be saved, for notwithstanding the
+isolation of the joint between the first metacarpal and the trapezium,
+it is very important for the future use of this one digit that the
+motions both of the wrist and carpal joints should be preserved entire.
+
+No exact rules can be given for the performance of these operations, as
+the size and positions of the flaps must be determined by the nature of
+the accident and the amount of skin left uninjured.
+
+In the rare condition where the greater part of the metacarpus is
+destroyed, and yet carpal joints are uninjured, a most useful artificial
+band, preserving the movements of the wrist, may be fitted on; and as
+much as possible should be saved, but in cases of injury, where the
+carpus is opened and the hand irreparably destroyed, the question
+arises, Where ought amputation to be performed? To this we answer that
+there appears no conceivable advantage to be gained by leaving all or
+any of the carpal bones. If successful, it would result only in the
+retention of a flapping joint, unless from there being no tendons to act
+upon it, except the tendon of the flexor carpi ulnaris attached to the
+pisiform, and there are several risks it would run in the inflammation
+of all the carpal joints, and the almost certain spread of this
+inflammation to the bursa underneath the flexor tendons, beyond the
+annular ligament, and up the arm among the muscles.
+
+
+AMPUTATION AT THE WRIST-JOINT.--This is an operation by no means
+frequent, and it has the advantages of preserving a long stump, and
+retaining the full movements of pronation and supination, in cases where
+the radio-ulnar joint is sound and uninjured, but in practice it is
+often found that fibrous adhesions limit to a great extent the motions
+of the two bones on each other, specially in those cases where the
+radio-ulnar joint has been diseased or injured.
+
+Another advantage is the extreme ease with which disarticulation may be
+performed on emergency, no saw being required, and the ordinary bistoury
+of the pocket-case being quite sufficient for cutting the flaps.
+
+_Operation._--By double flap. An incision (Plate IV. fig. 3) on the
+dorsal surface, extending in a semilunar direction from one styloid
+process to the other, will define a flap of skin only, which must be
+raised; the joint must then be opened by a transverse incision, and a
+long semilunar flap of skin and fascia should be shaped (Plate IV. fig.
+4) from the palm. Disarticulation is facilitated by the surgeon forcibly
+bending the wrist when he makes the transverse cut, and it will be found
+easier to shape the palmar flap from the outside by dissection, than to
+do it by transfixion after disarticulation, on account of the prominence
+of the pisiform on the inner side of the palm.
+
+     In the thin wasted wrists of the aged, or in any case where the
+     skin is very lax, this amputation may be very easily performed by
+     the circular method. While an assistant draws up the skin as much
+     as possible, the surgeon makes an accurate circular incision
+     through the skin, about an inch below the styloid processes, just
+     grazing the thenar and hypothenar eminences. Another circular sweep
+     just above the pisiform and unciform bones divides all the soft
+     textures, after which the joint may be opened, and, if necessary,
+     the styloid processes cut away with saw or pliers.
+
+     Amputation by a long single flap, either dorsal or palmar, may be
+     rendered necessary by accident. The palmar one of the two is
+     preferable; indeed, rather than trust for a covering to the thin
+     skin of the back of the hand, with its numerous tendons, it is
+     better to amputate an inch or two higher up through the fore arm.
+
+     The following amputation by external flap has been described (so
+     far as I can discover, for the first time) by Dr. Dubrueil, in his
+     work on operative Surgery:[26]--"Commencing just below the level of
+     the articulation, while the hand is pronated, the surgeon makes a
+     convex incision, beginning at the junction of the outer and middle
+     thirds of the arm behind, reaching at its summit the middle of the
+     dorsal surface of the first metacarpal, and terminating in front
+     just below the palmar surface of the joint, again at the junction
+     of the outer and middle thirds of the breadth of the arm. This flap
+     being raised, the wrist is disarticulated, beginning at the radial
+     side. A circular incision finishes the cutting of the skin." (Figs.
+     III. and IV.)
+
+[Illustration: FIG. III.[27]]
+
+[Illustration: FIG. IV.[27]]
+
+
+AMPUTATION THROUGH THE FORE-ARM.--The method of operating must, in the
+fore-arm, depend a good deal upon the part of the arm where you require
+to amputate, the muscularity of the limb, and the condition of the skin
+and subcutaneous cellular tissue.
+
+It must be remembered that a section of the fore-arm involves two bones,
+not, like the tibia and fibula, on a constant permanent relation in
+position to each other, but which rotate one upon another to an amount
+which varies with the part of the limb divided, and which rotation is a
+very important element in the future usefulness of the stump; again,
+that two sets of muscles occupy, one the back, the other the front of
+the limb, that these two are unequal in size, and that the outer sides
+or rather edges of each bone are subcutaneous; again, that these sets of
+muscles are comparatively fleshy in the upper two-thirds of the limb,
+and almost entirely tendinous in the lower third.
+
+Remembering these points, we find that certain things require our
+attention, and certain difficulties are present in amputation of the
+fore-arm, from which amputation of the arm, with its single bone and
+copious muscular covering on all sides, is completely free.
+
+Thus our flaps in the fore-arm must be antero-posterior; lateral flaps
+are an impossibility. Great care is requisite to cut them at all equal,
+from the inequality of the muscles on the two sides. In the lower third
+we cannot obtain available muscular flaps. Lastly, care must be taken
+lest, from the ever-varying relations of the two bones to each other in
+the varying positions of the limb, the surgeon mistake their position
+and pass his knife between them.
+
+The next question that arises is, Where are we to operate? In cases
+where we have a choice, is there here, as in the leg, any "point of
+election"? _No._ As a rule in the fore-arm, the surgeon should endeavour
+to save as much as possible; especially when nearing the middle of the
+fore-arm, he should try to save the insertion of the pronator teres, so
+important in its function of pronating the radius.
+
+
+AMPUTATION IN LOWER THIRD OF THE FORE-ARM.--By two flaps. These
+antero-posterior flaps must consist of skin only, as the tendons are
+only in the way, and thus should be made by dissection from without.[28]
+Making the dorsal one first, the surgeon should enter his knife at the
+palmar edge of the bone that is further from him, and cut a semilunar
+flap of skin only, finishing the incision quite on the palmar edge of
+the inner bone. The two ends of this incision must then be united by a
+similar semilunar flap of skin on the palmar side. The two flaps having
+been dissected back, he then clears the bones by a circular incision
+through tendons and muscles, not forgetting to pass the knife between
+the bones, and retracting all the soft parts, saws through the bones, at
+least half or probably three-quarters of an inch higher up. It is
+generally easiest to saw through both bones at once.
+
+_Long Dorsal Flap._--Where it is possible from laxity of the soft parts
+and the wrist not being much destroyed, to get a long flap from the back
+of the arm after Mr. Teale's method, a very good stump will result. This
+rule is, "In tracing the long flap a longitudinal line is drawn over the
+radius, so as to leave the radial vessels for the short flap (Plate II.
+fig. 1). At a distance equal to half the circumference of the limb,
+another line parallel to the former is drawn along the ulna. These are
+then joined at their lower ends, across the dorsal aspect of the wrist
+or fore-arm, by a transverse line equal in length to half the
+circumference of the fore-arm. The short flap is marked by a transverse
+line on the palmar aspect, uniting the long ones at their upper fourth.
+
+"The operator, in forming the long flap, makes the two longitudinal
+incisions merely through the integuments, but the transverse one is
+carried directly down to the bones. In dissecting the long flap from
+below upwards, the tissues of which it is composed must be separated
+close to the periosteum and interosseous membrane. The short flap is
+made by a transverse incision through all the structures down to the
+bones, care being taken to separate the parts upwards close to the
+periosteum and membrane." The stump must be placed in the prone
+position, "to allow the long dorsal flap to be the superior when the
+patient is recumbent, and thus fall over the ends of the bones."[29]
+
+The principal objection to the long dorsal rectangular flap (which
+makes an excellent covering) is, that unless it can be obtained from
+over the wrist-joint it requires the bones to be sawn so very high up.
+This may be avoided, to some extent, by making it shorter and rounded
+off, as in Carden's Amputation, _q.v._
+
+
+AMPUTATION IN UPPER TWO-THIRDS.--Where the fore-arm is very fat or
+fleshy, this amputation can be very easily performed by two equal
+antero-posterior flaps made by transfixion. In most cases, however, from
+the comparative leanness of the dorsal aspect of the limb, the following
+method will have the best result. The surgeon must, as in the former
+case, shape a rounded dorsal flap by dissection from without (Plate IV.
+fig. 5), embracing the whole breadth of the limb down to the palmar edge
+of both bones. Then at once he transfixes the two points of this dorsal
+flap, and cuts out an equal one from the anterior aspect of the limb
+(Plate IV. fig. 6). Dissecting up the dorsal flap he clears the bones at
+least half an inch above as before, and applies the saw.
+
+_N.B._--This operation should be performed even in cases where only an
+inch of radius can be retained, as the attachment of the biceps makes a
+very small stump of fore-arm wonderfully useful.
+
+
+AMPUTATION AT ELBOW-JOINT.--In cases where it is found impossible to
+save any portion of the fore-arm, disarticulation at the elbow-joint may
+be easily performed. This operation was proposed and performed so long
+ago as the days of Ambrose Par�,[30] was much approved by Dupuytren,
+Baudens, and Velpeau, had fallen into disuse for a time, but is now
+again recommended by some excellent surgeons, especially by Gross[31]
+and Ashhurst,[32] both of Philadelphia.
+
+It is tolerably easy to perform, and does not involve any sawing of
+bones, but the flaps are apt to be cut too short, unless care be taken,
+from the manner in which the trochlea projects downwards beyond the line
+of the condyles, so that if the base of an ordinary-shaped flap be made
+on a level with the condyles, it will prove insufficient to cover the
+bone. It may be performed either by the circular method (Velpeau), oval
+(Baudens), or by a long anterior and short posterior flap (Textor and
+Dupuytren). Probably the best method is by a long anterior flap when it
+can be obtained, thus:--The arm being placed in a slightly flexed
+position, the surgeon transfixes in front of the joint, in a line
+extending from the level of the external condyle to a point one inch
+below the internal condyle (Plate IV. fig. 7); the tissue should be held
+well forward at the moment of transfixion. The flap should be at least
+two and a half inches deep at its apex, which must be rounded off. The
+two ends of this flap may then be united behind by a semilunar incision
+(Plate III. fig. 2), which will separate the radial attachments. The
+ulna must then be cleared, and the triceps divided at its insertion.
+
+     _Modifications._--Dupuytren used to saw through the ulna, leaving
+     the olecranon attached. Velpeau opposed this, but it is again
+     recommended by Gross, who leaves the olecranon, and at the same
+     time improves the shape of the stump by sawing off the "inner
+     trochlea" on a level with the general surface.
+
+
+AMPUTATION OF THE ARM.--This amputation is best performed by double
+flap, and is the typical instance which exhibits all the advantages of
+two equal flaps made by transfixion, without any of the disadvantages of
+that method. These advantages are, easiness of performance, rapidity,
+excellent covering for the bone, with as little sacrifice of tissue as
+is possible, while the fact that the cicatrix is opposite the end of the
+bone is hardly a disadvantage in the arm (as it certainly is in the
+leg), as no weight has to be borne on it. When they can be obtained,
+anterior and posterior flaps are generally considered most satisfactory,
+but Mr. Spence prefers lateral ones, lest the line of union should be
+interfered with by the deltoid raising the bone. If the right arm has to
+be amputated, the operator standing at the inner side raises the
+anterior muscles with his left hand, and enters the knife just in front
+of the brachial vessels (Plate I. fig. 12); keeping as close as possible
+to the bone, he brings out the knife at a point exactly opposite, then
+with a brisk sawing motion, cuts a semicircular flap, taking care to
+bring out the knife more suddenly just at the end, in order to cut
+through the skin as perpendicularly to the arm as possible. The knife is
+again entered at the same point, carried behind the bone, and brought
+out at the same angle, and an exactly corresponding flap cut from the
+other side of the limb, the flaps are then retracted, the bone cleared
+by circular incision and sawn through as high up as it is exposed. In
+primary cases, where the muscles are firm and developed, the flaps
+should be cut a little concave.
+
+     _Modifications and Varieties._--Teale's method may of course be
+     used here as elsewhere. The internal line of incision (Plate IV.
+     fig. 8) should be made just in front of the brachial vessels. This
+     method requires the amputation to be performed higher up than would
+     otherwise be necessary (from the length of the anterior flap), and
+     this disadvantage is not counterbalanced by any special advantage
+     in the posterior retraction of the cicatrix.
+
+     In feeble flabby arms, the true circular operation is very easily
+     performed, and with good results. A circular sweep of the knife is
+     made through the skin alone, which is drawn up by an assistant,
+     while the surgeon separates it from the fascia; another circular
+     cut through fascia and muscles exposes the bone, which must then be
+     cleared and cut through at a still higher level.
+
+
+AMPUTATION AT THE SHOULDER-JOINT.--This operation, like that at the hip
+joint, can, from the nature of the joint to be covered, and the abundant
+soft parts in the normal state of the tissues, be performed on the dead
+in very various ways, by single, double, or triple flaps, by transfixion
+or dissection, rapidly or slowly. Hence manuals of operative surgery
+might collect at least twenty different methods, most of which have some
+recommendation, and all of which are practicable enough.
+
+When, however, we reflect that in the living body, in cases where
+amputation at the shoulder-joint is required at all, the severity of the
+accident, or the urgency of the disease, will, in general, leave no room
+for selection, we shall see how utterly valueless is any knowledge of
+mere methods of operating, and of how much greater importance it is that
+we should be simply thoroughly familiar with the anatomy of the joint.
+
+For example, an accident which necessitates amputation so high up has,
+in all probability, opened into the joint and destroyed the soft parts
+on at least one aspect; in such a case the flaps must be cut from the
+uninjured soft parts only. If an aneurism has rendered amputation
+through it and through the joint a last resource, the flap must be
+gained chiefly at least from the outside; a malignant tumour of the
+humerus will almost certainly prevent any transfixion, and require flaps
+to be made by dissection, wherever the skin is least likely to be
+involved. Again, some of the most vaunted and most rapid operations
+almost require for their success the integrity of the humerus, which has
+to make itself useful as a lever in disarticulation, while in most cases
+of accident we are amputating for compound injury of the humerus, almost
+certainly implying fracture with comminution.
+
+From its proximity to the trunk, h�morrhage is one of the chief dangers
+to be apprehended during this operation, especially from the axillary
+artery. As far as possible to obviate this danger, most plans of
+operating are based on the principle that the vessels and nerves should
+be the last tissues to be cut; in some they are not divided till after
+disarticulation.
+
+While a good assistant, to make pressure on the subclavian above the
+clavicle, is a most advisable precaution, too much must not be trusted
+to this pressure above, as the struggles of the patient and the
+spasmodic movements of the limb, which are so apt to occur under the
+stimulus of the knife, are apt to render futile the best efforts at
+compression.
+
+The operator should trust rather to making the incisions in such a
+manner that the great vessel be not divided till the hand of an
+assistant, or in default of a suitable one, his own left hand, is able
+to follow the knife and grasp the flap.
+
+The bleeding from the circumflex, subscapular, and posterior scapular
+arteries can easily be arrested by a dossil of lint till the great
+vessel is tied, and they can be secured.
+
+In cases where proper assistants cannot be had, temporary closure of the
+axillary vessel could easily be made by carrying a strong silver wire or
+silk ligature completely round the vessel by a curved needle before the
+incisions are commenced, and by tying this firmly over a pad of lint.
+
+Pressure on the artery above the clavicle is best made by the thumb of a
+strong assistant, who endeavours to compress it against the first rib;
+where the parts are deep and muscular, the padded handle of the
+tourniquet, or of a large door-key, will do as the agent of pressure.
+
+A brief notice of three of the best methods of operating will be quite
+sufficient to show what should be aimed at in shoulder-joint
+amputations:--
+
+#1.# In cases where the surgeon can choose his flaps, the following
+method will be found the most satisfactory, as resulting in the smallest
+possible wound, in having less risk of h�morrhage during the operation
+than any other method, and in providing excellent flaps.
+
+It is Larrey's method slightly modified.
+
+_Operation._--With a moderate-sized amputating knife an incision of
+about two inches in length, extending through all the tissues down to
+the bone, should be made from the edge of the acromion process to a
+point about one inch below the top of the humerus; from this latter
+point a curved incision, enclosing a semilunar flap, should be made on
+each side of the limb to the anterior and posterior folds of the axilla
+respectively (Plate IV. fig. 9, and Plate III. fig. 3). These flaps
+should then be dissected back, including the muscles and exposing the
+joint. When thoroughly exposed, the joint must then be opened from
+above, and the bone separated. One small portion of skin lying above the
+artery, vein, and nerves still remains to be divided (Plate I. fig. 13).
+This may be done by an oblique cut from within outwards, in such a
+direction as to form part of the anterior or internal incision, and with
+the precaution of having an assistant to command the vessels before they
+are divided. The resulting wound is almost perfectly ovoid, the flaps
+come together with great ease in a straight vertical line, which admits
+of easy and thorough drainage. Union is generally rapid. Larrey's
+success by this method was very remarkable: ninety out of a hundred
+cases in military practice were saved, notwithstanding the well-known
+risks of such operations.
+
+#2.# As good as the former, and nearly as universally applicable, is the
+method devised by Professor Spence, and practised by him in nearly every
+case:--"With a broad strong bistoury I cut down upon the inner aspect of
+the head of the humerus, immediately external to the coracoid process,
+and carry the incision down through the clavicular fibres of the deltoid
+and pectoralis major muscles till I reach the humeral attachment of the
+latter muscle, which I divide. I then with a gentle curve carry my
+incision across and fairly through the lower fibres of the deltoid
+towards, but not through, the posterior border of the axilla. Unless the
+textures be much torn, I next mark out the line of the lower part of the
+inner section by carrying an incision through the _skin and fat only_,
+from the point where my straight incision terminated, across the inside
+of the arm to meet the incision at the outer part. This insures accuracy
+in the line of union, but is not essential. If the fibres of the deltoid
+have been thoroughly divided in the line of incision, the flap so marked
+out, along with the posterior circumflex trunk, which enters its deep
+surface, can be easily separated from the bone and joint, and drawn
+upwards and backwards so as to expose the head and tuberosities, by the
+point of the finger without further use of the knife. The tendinous
+insertions of the capsular muscles, the long head of the biceps, and the
+capsule, are next divided by cutting directly upon the tuberosities and
+head of the bone; and the broad subscapular tendon especially, being
+very fully exposed by the incision, can be much more easily and
+completely divided than in the double-flap method. By keeping the large
+posterior flap out of the way by a broad copper spatula or the fingers
+of an assistant, and taking care to keep the edge of the knife close to
+the bone, the trunk of the posterior circumflex is protected. In regard
+to the axillary vessels, they can either be compressed by an assistant
+before completing the division of the soft parts on the axillary aspect,
+or to avoid all risk, the axillary artery may be exposed, tied, and
+divided between two ligatures so as to allow it to retract before
+dividing the other textures."[33]
+
+     Another, but not so good method of making an external flap, is the
+     following:--(_a._) For the right arm.--The patient lying well over
+     on his left side, the surgeon stands to the inside of the arm to be
+     removed. Seizing the deltoid in the left, with the right he passes
+     an amputating knife, seven or eight inches in length, from a point
+     a little nearer the clavicle than the middle space between the
+     acromion and coracoid processes; then, transfixing the base of the
+     deltoid, and just grazing the posterior surface of the humerus,
+     thrusts the knife downwards and backwards till it protrudes at the
+     posterior margin of the axilla. When doing this, it is important
+     that the arm be held outwards and backwards, and even upwards, as
+     far as possible to relax the deltoid; without this it will be
+     impossible to make the flap of the full size. The flap must then be
+     cut of as full length as can be obtained, four or five inches at
+     least. An assistant then holds it upwards, while the surgeon, or
+     (if the arm is very muscular) another assistant, brings the arm
+     forwards well across the patient's chest, thus exposing the
+     posterior aspect of the joint. This may have very possibly been
+     already opened during the transfixion; the attachments of muscles
+     must now be divided, the knife passed behind the head of the bone,
+     which is dislocated forwards, and a suitable flap of the tissues in
+     front cut from within outwards. The assistant is to follow the
+     knife with his finger and compress the vessels.
+
+     (_b._) If the left shoulder is to be amputated, the patient lying
+     on his right side, the surgeon stands behind him, and raising the
+     elbow of the limb to be removed from the side, and pulling it
+     slightly backwards, enters the knife at the posterior fold of the
+     axilla (Plate II. fig. 2), and passing the posterior aspect of the
+     head of the humerus, endeavours to protrude it as near the acromion
+     as possible; the flaps must be cut and the rest of the operation
+     performed in the manner we have just described for the other arm.
+
+#3.# Where the destruction of tissue has been chiefly below the joint, a
+very good flap may be obtained from above, composed chiefly of the
+deltoid muscle, and the skin over it. This may be made by transfixion at
+its base, but is better obtained by dissection from without.
+
+The surgeon cuts (Plate II. figs. 3, 3) in a semilunar direction (with
+the convexity downwards) from one side of the deltoid to the other,
+viz., from the root of the acromion to near the coracoid process; he
+then raises the large flap upwards and throws it back, opens the joint,
+disarticulates, passes the knife behind the head of the bone, and cuts
+out without attempting to save any flaps below, in a transverse
+direction. By this means the artery is still almost the last structure
+to be divided, and can be secured by a ready assistant. In cases where
+much injury has been done to the floor of the axilla and wall of chest,
+the deltoid flap must be made large in proportion, and triangular rather
+than semilunar in shape.
+
+_N.B._--The statistics of amputation at the shoulder-joint bring out
+some interesting facts: 1. That the primary amputations here are far
+more successful than secondary ones. Guthrie records nineteen cases of
+the former out of which only one died, while out of a similar number in
+which the amputation was secondary, fifteen died. In the Crimea, British
+surgeons had thirty-nine cases, with thirteen deaths; of thirty-three
+primary, nine died; and of six secondary, four were fatal.
+
+S.W. Gross's[34] statistics confirm this: of one hundred and
+seventy-eight primary, forty-six died--25.8 per cent.; ninety-five
+secondary, sixty-one died--64.2 per cent.
+
+
+AMPUTATIONS ABOVE THE SHOULDER-JOINT.--Under this head we may group the
+comparatively rare cases in which, from accident or disease, the removal
+of portions of the scapula and clavicle, or even the entire bones, is
+rendered necessary. That it is quite possible to survive such injuries
+has been frequently shown in cases of accident when the scapula along
+with the arm has been torn off, and yet the patient recovered.
+
+Encouraged by such cases, Gaetani Bey of Cairo removed the whole of
+scapula and part of the clavicle in a case where he had amputated at the
+shoulder for smash. The patient recovered. Heron Watson has had a
+similar case. Dr. George M'Lellan amputated arm and scapula in a youth
+of seventeen for an enormous encephaloid tumour. Fifty-one such cases
+are now on record.
+
+Syme amputated with success the arm along with the scapula and outer
+half of clavicle, in a case in which he had previously excised the head
+of the humerus for a tumour.[35]
+
+Gilbert, Mussey, Rigaud, Fergusson, and others have performed similar
+operations, secondary to amputation at the shoulder-joint, for cases of
+caries and malignant tumour. It is impossible to give any exact
+directions for the incisions which must be planned for individual cases,
+with two chief aims, to avoid h�morrhage as far as possible, and to
+leave abundance of skin. In operations on the scapula, it should be
+freely exposed by large enough incisions. (See _Excisions_.)
+
+
+AMPUTATIONS OF LOWER EXTREMITY.--Commencing with the most distal, and
+gradually working our way upwards, we find that partial amputations of
+the toes are extremely rare. Only in the case of the great toe is such
+an operation _ever_ admissible, for the other toes are so short, and the
+stumps left by amputation are at once so useless from their shortness,
+and so detrimental from the manner in which they project upwards and rub
+against the shoe, that any injury requiring partial amputation of a
+lesser toe is treated by its complete removal.
+
+[Illustration: FIG. V.]
+
+
+AMPUTATION OF DISTAL PHALANX OF GREAT TOE.--This is comparatively rarely
+required now. It used to be thought necessary for the cure of those not
+uncommon cases of exostosis of the distal phalanx, but it is now found
+that most of these can be cured by simply clipping off the exostosis.
+When necessary, however, and when the choice of flaps is possible, the
+best plan is by a long flap from the plantar surface (Fig. V. 4), as in
+the similar operation on the thumb; laying the edge of the knife over
+the dorsal aspect of the joint, cutting through it, and turning the edge
+of the knife round close to the bone, so as to cut out a large flap from
+the ball of the toe.
+
+
+AMPUTATION OF A SINGLE LESSER TOE--_second_, _third_, _or fourth_.--This
+operation is on exactly the same principle as that described for the
+corresponding finger; but it must be remembered that the
+metatarso-phalangeal joint is more deeply situated in the soft parts
+than is the metacarpo-phalangeal; and thus the commencement of the
+elliptical incision which is to surround the base of the toe must be
+proportionally higher up (Fig. V. 1). On the other hand, as it is very
+important to avoid as much as possible any cicatrix in the sole of the
+foot, the plantar end of the incision need not be carried to a point
+exactly opposite the one from which it set out, but it will be
+sufficient if it reaches the groove between the toe and sole. A little
+more care may thus be required in dissecting out the head of the first
+phalanx, but this is quite repaid by the cicatrix in the sole being
+avoided. Early division of flexor tendons renders disarticulation easy.
+
+
+AMPUTATION OF THE FIRST AND FIFTH TOES.--The incisions are conducted on
+the same principle as in the other operations, the operator being
+careful to preserve as much as possible (Fig. V. 2) of the hard useful
+pad of the inner and outer sides respectively.
+
+Most surgeons are now agreed that in these toes it is best not to remove
+the head of the metatarsal bone with the toe. Cutting off the large
+cartilaginous head obliquely with a pair of bone-pliers may prevent an
+awkward unseemly projection, but it does diminish the strength of the
+transverse arch of the foot.
+
+
+AMPUTATION OF ONE OR MORE TOES WITH THEIR METATARSALS.--It is not
+necessary to give very particular details regarding such operations, as
+the surgeon must be guided in the individual cases by the specialties of
+accident or disease.
+
+One or two guiding principles are important:--
+
+1. Having made up your mind at what point you are to cut the metatarsal,
+if the amputation be a partial one, or as to the exact position of the
+joint, if you intend to disarticulate, commence your dorsal incision
+(Fig. V. 3) at a point fully half an inch higher up than the selected
+spot, as free access is of the very last importance.
+
+2. Whenever it is possible, cut the bone through its continuity rather
+than disarticulate. Specially is this important in the case of the
+metatarsal bone of the great toe, that the insertion of the tendon of
+the peroneus longus may be saved. If, however, the terminal branch of
+the _dorsalis pedis_ artery be wounded, it may be necessary to
+disarticulate the first metatarsal to secure it rather than trust to
+compression to stop the bleeding.
+
+3. In cutting through the first and fifth metatarsals, remember to apply
+the bone-pliers obliquely, not transversely, so as to avoid unseemly
+projection.
+
+4. As far as possible avoid cutting into the sole at all.
+
+The plantar cicatrix is almost a fatal objection to a plan of removing
+the first and fifth toes and their metatarsals which has much otherwise
+in rapidity and elegance to recommend it. In the great toe, for example,
+it is performed as follows:--Seizing the soft parts of the inner edge of
+the foot in his left hand, the surgeon draws them _inwards_, transfixes
+just at the tarso-metatarsal joint, and, keeping as close as possible to
+the inner edge of the metatarsal bone, cuts the flap as long as to the
+middle of the first phalanx; then the soft parts of the foot being drawn
+as far _outwards_ as possible by an assistant, the surgeon enters his
+knife between the first and second toes, and succeeds in entering his
+former incision so as to separate the metatarsal bone without removing
+any skin. All that remains is to open the tarso-metatarsal joint. It is
+a very neat-looking operation, leaves a very good covering for the
+parts, and is performed with extreme rapidity. This last is not so much
+required in these days of an�sthetics, and the cicatrix in the sole is a
+very formidable objection to it.
+
+The simplest and shortest rule that can be given for the amputation of a
+toe, with the part or whole of its metatarsal, is to make one dorsal
+incision, commencing about a quarter of an inch above the spot at which
+you intend to divide the bone or to disarticulate, extending downwards
+in a straight line to the metatarso-phalangeal articulation, and then
+bifurcating so as to surround the base of the toe at the normal fold of
+the skin. The soft parts are then to be cleared from the
+metatarso-phalangeal joint, and the toe still being retained on the
+metatarsal bone, it should be carefully dissected up, avoiding any
+pricking of the soft parts below, till the joint is reached, or the spot
+at which the bone-pliers are to be applied is fully cleared.
+
+
+AMPUTATION OF THE ANTERIOR PORTION OF THE FOOT AT THE TARSO-METATARSAL
+JOINT--HEY'S OPERATION.--This operation, which is now comparatively
+rarely performed, has been invested with a halo of difficulty and
+complexity which is to a great extent unnecessary.
+
+There is no doubt that the anatomical conformation of the joints
+involved, especially the manner in which the head of the second
+metatarsal (Fig. V. C) projects upwards into the tarsus, and is locked
+between the cuneiform bones, renders disarticulation in the healthy foot
+rather difficult; but it must be remembered that in cases where for
+accident we have to deal with previously healthy tissues, it is quite
+unnecessary to disarticulate, a better result being attained by simply
+sawing the foot across in the line of the articulation; and again, where
+we have to operate for disease, the tissues are so matted, and the
+bones so soft, that complete removal of the metatarsus is much easier
+than it appears when practising on the dead subject.
+
+Very various plans of incision have been proposed. Mr. Hey's original
+procedure has not been much improved upon. His short account of it has
+at once surgical value and historical interest:--
+
+"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 incision through the integuments and muscles
+covering the metatarsal bones (Plate IV. figs. 10, 11). From each
+extremity 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 integuments and
+muscles forming the sole of the foot from the inferior part of the
+metatarsal bones, keeping the edge of my scalpel as near 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
+tarsus, which was easily effected, as the joints lie in a straight line
+across the foot. The projecting part of the first cuneiform bone which
+supports the great toe I was obliged to divide with a saw. The arteries,
+which required a ligature, being tied, I applied the flap which had
+formed the sole of the foot to the integuments which remained on the
+upper part, and retained them in contact by sutures....
+
+"The patient could walk with firmness and ease; she was in no danger of
+hurting the cicatrix by striking the place where the toes had been
+against any hard substance, for this part was covered with the strong
+integuments which had before constituted the sole of the foot. The
+cicatrix was situated upon the upper part of the foot, and had very
+little breadth, as the divided parts had been kept united after being
+brought into close contact."[36]
+
+_Lisfranc's method_ has, briefly, the following modifications.--Having
+fixed the position of the articulations of the first and fifth
+metatarsals with the tarsus, the operator unites them by a curved
+incision across the dorsum of the foot, with its convexity downwards. He
+then divides the dorsal ligaments over the articulations, opens the
+first from the inside, the fifth, fourth, and third from the outside, he
+then with a strong narrow-bladed knife divides the interosseous
+ligaments between the sides and end of the head of the second metatarsal
+and the cuneiforms, thus completing the disarticulation; bending the
+fore part of the foot downwards, he then keeps the edge of the knife
+close to the lower surface of the bones, separating the plantar
+ligaments, and cutting out a long plantar flap of skin and muscles.
+
+In every case it must be remembered that the upper end of the fifth
+metatarsal projects far up along the outer edge of the foot. Allowance
+must be made for this projection in commencing the incision. A rule
+given by Mr. Syme to guide the disarticulation of the three outer
+metatarsals will often be of service; it is this: "Having once entered
+the joint of the fifth, the knife must be drawn along in a direction of
+a line drawn towards the distal end of the first metatarsal; for the
+fourth, the direction must be changed to the middle of the same bone;
+and to open the third it will be necessary to come across the dorsum of
+the foot as if intending to reach the proximal end."
+
+To avoid the difficulties of disarticulation, Skey recommends cutting
+off the head of the second metatarsal with a pair of pliers. Baudens,
+Gu�rin, and others approve of sawing all the bones across in the line
+desired.
+
+Most surgeons are now agreed that in this operation it is better to make
+both flaps by cutting from without, in preference to transfixion of the
+plantar one from within. In cases where, from injury and disease, the
+plantar flap is deficient in size, it may be necessary to make the
+dorsal flap longer. However, the long plantar is preferable both from
+its superior hardness, and also because from its length it permits the
+cicatrix to be well on the dorsum of the foot, and therefore less likely
+to be injured by the pressure of the boot in front.
+
+
+AMPUTATIONS THROUGH THE TARSUS.--Various plans of amputating through the
+tarsus have been devised and described at great length. The most
+important of these is the operation of removal of the anterior portion
+of the foot, at the joints between the astragalus and scaphoid, and os
+calcis and cuboid, well known to the profession by the name of its first
+describer, Chopart.
+
+It has been so completely superseded by the infinitely preferable
+amputation at the ankle-joint of Mr. Syme, as rarely, if ever, to be
+practised in this country. Indeed, amputation at the ankle-joint may be
+said to have taken the place of all these amputations through the
+tarsus; for though cases are occasionally met with in which the
+limitation of the disease or injury may render Chopart's possible, and
+though at first sight it appears to have an advantage in removing less
+of the body, still the following objections are nearly fatal to its
+chance of being selected:--1. In cases of injury, through leaving a long
+stump, and, at first sight, a useful one, experience shows that the
+tendo Achillis sooner or later (being unopposed by the extensors of the
+toes) draws up the heel so as to make the end of the stump point, and
+the cicatrix press on the ground, rendering it unable to bear any
+weight. 2. In cases of removal for disease of the tarsus, the bones left
+behind, though apparently sound at the time, are almost sure to become
+eventually diseased.
+
+As it has an historical interest, and as this operation (defective as it
+is) had been the means of saving many legs prior to the invention of
+amputation at the ankle-joint, a brief description may be appended:--
+
+Chopart's own manner of operation was briefly somewhat as follows:--
+
+The tourniquet having been applied, the surgeon is to make a transverse
+incision through the skin which covers the instep, two inches from the
+ankle-joint. He is to divide the skin, and the extensor tendons, and the
+muscles in that situation, so as to expose the convexity of the tarsus.
+He is next to make on each side a small longitudinal incision, which is
+to begin below and a little in front of the malleolus, and is to end at
+one of the extremities of the first incision. After having formed in
+this way a flap of integuments, he is to let it be drawn upwards by the
+assistant who holds the leg. There is no occasion to dissect and reflect
+the flap, for the cellular substance connecting the skin with the
+subjacent aponeurosis is so loose, that it can easily be drawn up above
+the place where the joint of the calcaneum with the cuboides and that
+between the astragalus and scaphoides ought to be opened. The surgeon
+will penetrate the last the most easily, particularly by taking for his
+guide the eminence which indicates the attachment of the tibialis
+anticus muscle to the inside of the os naviculare. The joint of the os
+cuboides and os calcis lies pretty nearly in the same transverse line,
+but rather obliquely forwards. The ligaments having been cut, the foot
+falls back. The bistoury is then to be put down, and the straight knife
+used, with which a flap of the soft parts is to be formed under the
+tarsus and metatarsus, long enough to admit of being applied to the
+naked bones, so as entirely to cover them. It is to be maintained in
+position with three or four straps of adhesive plaster, etc.[37]
+
+Chopart's amputation, after an interval of comparative neglect, was
+introduced into this country by Mr. Syme in 1829. His method of
+performance is simpler and easier than Chopart's. He thus describes
+it:--"The blade of the knife employed should be about six inches long,
+and half an inch broad, sharp at the point and blunt on the back. The
+tourniquet ought to be applied immediately above the ankle, having
+compresses placed over the posterior and anterior tibial arteries. The
+surgeon should measure with his eye the middle distance between the
+malleolus externus and the head of the metatarsal bone of the little
+toe, which is the situation of the articulation between the os cuboides
+and os calcis. Placing his forefinger here, he ought to place his thumb
+on the other side of the foot directly opposite, which will show him
+where the os naviculare and astragalus are connected. An incision (Plate
+II. figs. 4 and 5) somewhat curved, with its convexity forward, is then
+to be made from one of these points to the other, when, instead of
+proceeding to disarticulate, the operator should transfix the sole of
+the foot from side to side at the extremities of the first incision, and
+carry the knife forwards so as to detach a sufficient flap, which must
+extend the whole length of the metatarsus to the balls of the toes. The
+disarticulation may finally be completed with great ease, as the shape
+of the articular surfaces concerned is very simple, and nearly
+transverse."[38] Regarding the method of disarticulating at the
+astragalo-calcaneal joint, and removing all the foot except the
+astragalus, no detail need be given. Malgaigne advises an internal flap,
+thus sacrificing the valuable pad of the heel. Roux, Verneuil, and
+others endeavour to save the pad. This operation, however, has now
+fallen almost completely into disuse.
+
+
+SUBASTRAGALOID AMPUTATION has been highly recommended. In it the flap is
+made as in Syme's, then anterior bones removed as in Chopart's, and os
+calcis grasped by lion forceps and twisted off, its attachment and the
+insertion of tendo Achillis being cautiously avoided. If flaps are
+scanty, head of astragulus may be cut off with a small saw.--Hancock and
+Ashurst.
+
+
+TRIPIER'S AMPUTATION[39] is a modification of above, the skin incisions
+being made as in Chopart's amputation, and then the calcaneum is sawn
+through on a level with the sustentaculum tali on a plane at right
+angles to the axis of the leg.
+
+
+AMPUTATION AT THE ANKLE-JOINT, OR SYME'S AMPUTATION.--This operation is
+one of much interest and great practical importance. In our cold
+variable climate caries of the bones of the tarsus, and strumous disease
+of the ankle-joint, are very common and very intractable maladies, and
+for both of these, when far advanced, Syme's amputation is the only
+justifiable procedure. When properly done, according to the _exact_ plan
+of its proposer, it removes the whole of the diseased parts and not an
+inch more, is an operation of very slight danger to life, and results
+almost invariably in a thoroughly useful comfortable stump. Much of its
+success depends on the manner in which it is performed, and as many
+surgical manuals are not sufficiently full, some positively in error
+regarding this point, and as very many modifications have been devised
+diminishing in value and applicability very much in proportion as they
+diverge from the original description, I think it advisable to describe
+the operation minutely, and point out in detail the parts of it which
+seem absolutely essential to success.
+
+_Operation._--The foot being held at a right angle to the leg, the point
+of a straight bistoury, with a pretty strong blade, should be entered
+just below the centre of the external malleolus (Plate IV. figs. 12,
+13), (1.) and then carried right across the integuments of the sole, in
+a straight line (or in the case of a prominent heel, slightly
+backwards), (2.) to a point at the same level on the opposite side. (3.)
+This incision should reach boldly through all the tissues down to the
+bone. Holding the heel in the fingers of his left hand, the operator
+then inserts his left thumb-nail into the incision, and pushes the flap
+downwards, as with the knife kept close to the bone, and cutting on it,
+he frees the flap from its attachments. The thumb-nail guards the knife
+from in any way scoring the flap. (4.) This process is continued till
+the tuberosity of the os calcis is fairly turned, and the tendo Achillis
+nearly reached. Shifting his left hand he then extends the foot, and
+joins the extremities of the first incision by a transverse one right
+across the instep. (5.) Thus he opens the joint between the astragalus
+and tibia, (6.) divides the lateral ligaments, disarticulates, and still
+keeping close to the bone, removes the foot by the division of the tendo
+Achillis.
+
+The lower ends of the tibia and fibula are then to be isolated from the
+soft parts, and a thin slice, including both malleoli, to be removed. If
+the disease of the joint has affected the lower end of the bone, slice
+after slice may be removed, till a healthy surface of cancellated
+texture is obtained. The vessels are then secured.
+
+_Dressing of the Stump._--From its peculiar shape and position, the
+escape of any blood into the stump is much to be deprecated, for as it
+cannot easily get out, on the one hand it gives pain, and may cause
+sloughing from its pressure, and on the other it is sure eventually to
+cause suppuration, and delay union. To avoid such results care must be
+taken to secure every vessel that can be seen; if there is any general
+oozing it is best merely to pass the sutures through the edges of the
+flaps, but not bring them together, thus leaving the stump open for some
+hours; then apply cold, and when the surfaces are fairly glazed over,
+remove any clots and bring the flaps together.[40]
+
+Another plan introduced by Mr. Syme was to make a longitudinal slit in
+the flap, through which all the ligatures are to be drawn; these give a
+dependent drain to any pus that may be formed, and by their presence
+greatly expedite the healing of the wound. Again, in cases where from
+the amount of disease existing before the operation, and the gelatinous
+thickening of the flap and neighbouring parts, much suppuration may be
+looked for, probably it will be found best to keep the flaps quite apart
+for some days, by stuffing the wound with lint, and aiming only at
+secondary union by granulations.
+
+A drainage tube passed through the breadth of the flap, and brought out
+at the angles, and retained for a few days, will do admirably.
+
+     _Notes._--(1.) If commenced further forward, as in Pirogoff's
+     modification, it will be found difficult to turn the corner of the
+     heel; if further back, the nutrition of the flap is endangered.
+
+     (2.) This is very important. In several well-known text-books, even
+     in the last edition of Gross's _Surgery_, the incision is figured
+     passing obliquely _forwards_. This is a fatal error, for besides
+     making a flap far too long, it forces the operator to cut fairly
+     into the hollow of the sole, quite off the prominence of the os
+     calcis, and he finds that it is utterly impossible to free his flap
+     without using great force, and inevitably scoring it in all
+     directions. Sloughing is almost inevitably the result.
+
+     (3.) The incision is to stop at least half-an-inch below the
+     internal malleolus. Most surgical manuals, even when they profess
+     to describe Mr. Syme's own method of operating, say that the
+     incision should extend from malleolus to malleolus. If this is
+     done, the flap becomes unsymmetrical, too long, and also the
+     posterior tibial artery, on which much of the vascular supply of
+     the flap depends, is cut. When the incision is properly made, the
+     vessel is not cut till after its division into the plantar
+     arteries.
+
+     (4.) Scoring the flap. Some may ask, Why do you object to a little
+     scoring, the tissues are thick enough, and besides, don't you
+     advise a slit in the flap yourself? Yes. One look at an injected
+     preparation will show that the vessels supplying this thick flap
+     come to it from its inner surface, and are inevitably cut across in
+     any scoring of it, and also, that scoring cuts across the vessels,
+     and _must_ divide dozens of them; the slit we make is parallel with
+     their course, and _may_ not divide one.
+
+     (5.) Across the instep. Some authors recommend a semilunar anterior
+     flap; this is quite unnecessary, increases bagging and delays
+     union. It can be required only in cases where the heel flap has
+     been destroyed or lessened by disease, or by operators in whose
+     hands the heel flaps occasionally slough.
+
+     (6.) It is not impossible that a careless operator may (by cutting
+     a little too low) miss the joint and get into the hollow of the
+     neck of the astragalus, where he may cut away for a long time
+     without making much progress.
+
+_Advantages._--1. It is wonderfully free of danger to life. It is very
+hard to obtain exact statistical information, but my experience is that
+the mortality is certainly not more than about 10 per cent., a very
+remarkable result when compared with that of amputations through the
+leg, the operation which used to be required for those cases which now
+require only amputation at the ankle-joint.
+
+In the Statistical Report by the Surgeon-General of the United States,
+9705 cases of amputation resulted in death, the proportions being as
+follows:--
+
+    Amputation of hip,         85 per cent. died.
+        "         thigh,       64        "
+        "         knee,        55        "
+        "         leg,         26        "
+    Amputation of ankle-joint, 13 per cent. died.
+        "         shoulder,    39        "
+        "         arm,         21        "
+        "         fore-arm,    16        "
+
+2. It is the most perfect stump that can be made, in fact the only one
+in the lower extremity which can bear pressure enough to support the
+weight of the body; all the others require the weight to be distributed
+over the general surface of the limb by means of apparatus. A good
+ankle-joint stump can bear the whole weight of the body, as when the
+patient hops on it without any artificial aid, or without even the
+interposition of a stocking between the stump and a stone floor. More
+than this, I have seen a patient who had both his feet amputated at the
+ankle-joint run without shoes or stockings on the stone passages,
+without even the aid of a stick, and with very great swiftness.
+
+The reason of this may be found in the nature of the flap itself,
+originally intended to bear the weight of the body, there being no
+cicatrix at the part on which pressure is borne. I have noticed that
+perfection in walking on an ankle-joint stump has a certain relation to
+the freedom of movement which the pad has over the face of the bone.
+This ought to be pretty considerable. It is explained by the new
+attachments formed by the tendons, and is under the control of the
+patient, being elicited when he is told to move his toes.
+
+It has been objected to this operation that the flap is apt to slough.
+When improperly performed, as when the flap is scored transversely in
+its separation, and especially when the flap is cut too long (as has
+been already noticed), this may occur; but that there is nothing
+whatever in the position or condition of the flap itself that at all
+necessitates its sloughing, is thoroughly proved by the following
+remarkable case, given by Mr. Syme in his volume of _Observations in
+Clinical Surgery_. I quote it entire:--
+
+"P.C., aged thirty-three, was admitted into the hospital on the 25th
+July 1860, in the following state:--He had been treated in the
+Manchester Infirmary for popliteal aneurism by pressure, so decidedly
+applied that it had caused an ulcer, of which the cicatrix remained; but
+without producing the effect desired. The femoral artery was then tied
+with success, in so far as the aneurism was concerned, but with the
+unpleasant sequel, some months afterwards, of mortification in the foot,
+which was thrown off, with the exception of the astragalus and os calcis
+with their integuments, a large raw surface being presented in front
+where the bone was bare. Although the patient was extremely weak, and
+the parts concerned might be supposed more than usually disposed to
+slough, I did not hesitate to perform the operation, with the speedy
+result of a most excellent stump and complete restoration to
+health."--Pp. 49, 50.
+
+The modifications of Mr. Syme's original operation have been very
+various. It will be unnecessary even to name them all. One or two may
+require notice. Retaining Mr. Syme's incisions in their integrity, some
+operators prefer not to disarticulate the foot, but remove it by sawing
+through the tibia and fibula at once, while still in connection with the
+foot. That most excellent surgeon and first-rate operator, Dr. Johnston
+of Montrose, used to prefer this method.
+
+In cases where the pad of the heel has been destroyed by disease or
+accident, so as to be partially or entirely unavailable for the flap,
+the late Dr. Richard Mackenzie[41] practised the following operation by
+internal flap:--With the foot and ankle projecting from the table with
+their internal aspect upwards, he entered the point of the knife (Plate
+I. fig. 14) in the mesial line of the posterior aspect of the ankle, on
+a level with the articulation, carried it down obliquely across the
+tendo Achillis towards the external border of the plantar aspect of the
+heel, along which it is continued in a semilunar direction. The incision
+is then curved across the sole of the foot, and terminates on the inner
+side of the tendon of the tibialis anticus, about an inch in front of
+the inner malleolus. The second incision (Plate III. fig. 4) is carried
+across the outer aspect of the ankle in a semilunar direction, between
+the extremities of the first incisions, the convexity of the incision
+downwards, and passing half an inch below the external malleolus.
+
+Precisely the same principle might supply the flap from the outer side
+in cases where the internal flap as well as the heel was deficient, but
+probably the nutrition of the external flap would be more doubtful.
+Neither the one nor the other is nearly so good as the true heel flap,
+and they are both only very poor substitutes for it when it cannot be
+had.
+
+The modification devised by Dr. Handyside does not seem to have any
+advantages over the original operation, and has not been adopted.
+
+The modification invented by Professor Pirogoff involves a much more
+important principle than any of the preceding. Instead of dissecting the
+flap from the posterior projecting portion of the os calcis, and
+removing the tarsus entire, he sawed off the posterior portion of the os
+calcis obliquely, leaving it in contact with the pad of skin, which is
+retained. Immediately after making the cut which defines the posterior
+flap and divides the tissues down to the bone, he opens the joint in
+front, disarticulates, and then putting on a narrow saw immediately
+behind the astragalus and over the sustentaculum tali, he saws the os
+calcis obliquely downwards and forwards till he reaches the first
+incision; then removes the ends of the tibia and fibula and brings up
+the slice of os calcis into contact with them.
+
+_Advantages._--It is easy of performance, saving the dissection from the
+heel, which some find so hard. It leaves a longer limb. It is said to
+bear pressure better, and there is certainly not so much chance of
+bagging of pus, and the mortality is exceedingly small, Hancock's
+collected cases giving only 8.6 per cent.; in cases of injury it is
+quite a warrantable operation.
+
+_Disadvantages._--It is contrary to sound principle in cases of disease,
+for it wilfully leaves a portion of the tarsus, in which disease is
+almost certain to return. It leaves too long a limb, for it is found
+that the shortening in Mr Syme's method is just sufficient to admit of a
+properly constructed spring being placed in the boot to make up for the
+loss of the elastic arch of the foot. It brings the firm pad of the heel
+too much forward, thus tending to lean the weight of the body on the
+softer tissues behind the heel. It takes much longer to unite and
+consolidate.
+
+The author has now, in a large number of cases of Syme's amputation for
+disease, found advantage in leaving the periosteum in the heel flap,
+_i.e._ he cuts fairly into the os calcis when dividing the skin of heel,
+and then using a periosteum scraper instead of the knife, it is quite
+easy to remove the whole of the periosteum from the bone; this results
+in a large and more rounded pad of great strength and thickness.
+
+In cases where from disease or injury it is impossible to obtain either
+a heel flap or a substitute lateral one, the question is, Where should
+amputation be performed?
+
+It was for a long time the opinion of nearly all the best surgeons, and
+still is the opinion of many, that amputation of the leg should be
+performed at what was known as the "seat of election," just below the
+knee, even in cases where abundance of soft parts could be obtained for
+an amputation much lower down. The rule in surgery, to save as much of
+the body as possible in every amputation, was in the leg believed to be
+set aside by objections which militated strongly against all the other
+operations in the leg except the one performed just below the knee. Very
+briefly, these were somewhat as follows:--1. Just above the ankle you
+have large bones with nothing to cover them except skin and tendons. 2.
+Higher up in the calf you have plenty of muscle, but it is all on one
+side, and that the wrong one; it is very heavy, very difficult to dress
+and keep in position, and then when you have succeeded with it, the
+muscle wastes away and the stump is flabby. 3. And chiefly, as in all
+the amputations of the leg, the cicatrices are so much in the way, and
+the bones are so ill covered, that the patient can never rest his leg on
+the stump itself, but has either to rest his weight on his patella
+impinging on the top of a bottle-shaped leg, or just to stick out his
+stump behind him and kneel on the top of his wooden leg; therefore it is
+no use to have a stump longer than a few inches; in fact, the longer the
+stump is the more it is in the way. And more than this, many of the
+stumps made near the ankle, or through the calf, are not only useless,
+but positively painful. The skin becomes attached to the bones, the
+cicatrix never properly firms at all, the patient can hardly bear the
+pressure of a stocking, far less can he make use of the limb. For these
+reasons, secondary amputations below the knee are of very common
+occurrence.
+
+Now, this idea has been much modified, and a few isolated cases in the
+past, and series of cases considerably more numerous in the present day,
+show that under certain conditions, and as a result of certain
+precautions in their performance, such operations are both warrantable
+and successful.
+
+In the past, as we find in an erudite note in South's Chelius, Dionis,
+White, and Bromfield had each of them many successful cases of
+amputation just above the ankle, successful in so far that artificial
+limbs could be used which preserved the motion of the knee, and gave
+the patient much more command of the limb than is possible with the
+short stump below the knee.
+
+A still more important point to be remembered is, that amputation just
+above the ankle is a much less fatal amputation than that just below the
+knee (Lister in _Holmes's Surgery_, 3d ed. vol. iii. p. 716; Gross, 6th
+ed. vol. ii. p. 1113; Ben. Bell, 6th edit. vol. vii. p. 312).
+
+There is little doubt, however, that the principle so much in vogue in
+the present day, of one long anterior or posterior flap, instead of two
+equal flaps, or of circular amputations, has done very much to make
+amputations at the ankle or through the calf justifiable and useful in
+bearing the weight of the body.
+
+
+AMPUTATION JUST ABOVE THE ANKLE.--Cases admitting of this operation must
+always be rare, for disease of the tarsus or ankle-joint hardly ever
+goes so far as to contra-indicate the performance of Mr. Syme's greatly
+preferable operation; and an accident which would require this operation
+from injury to the ankle would in most cases require an amputation a
+good deal higher up from the splintering of the tibia so apt to occur.
+
+In a suitable case the plan of the operation should be as follows:--A
+long anterior flap slightly rounded at the end should be cut (Plate I.
+figs. 15, 16)--from the outside, not by transfixion,--and the anterior
+muscles dissected up along with it. It should be long enough to fall
+down over the face of the bones at the point of section, and easily
+cover the point of the posterior flap, which is to be made by cutting
+through all the tissues with one bold transverse stroke of the knife.
+This operation, which is the plan of Mr. Teale of Leeds very slightly
+modified, is equally applicable at any point of the leg, with this
+difference only, that the length of the anterior flap must always be
+carefully proportioned to the mass of the muscular flap behind it has to
+cover in.
+
+This operation provides a skin covering, without any danger of the
+cicatrix being pressed on or becoming adherent.
+
+     The author has within the last few years operated nine times in
+     this manner, in cases of accident in which the heel flaps had been
+     completely destroyed; and seen a tenth case in which Mr. Syme did
+     so. All ten cases recovered completely and rapidly, and walked on
+     useful limbs, with the free movement of the knee-joint.
+
+Where from injury in a muscular patient a long anterior flap cannot be
+had, recourse should be had at once to the operation at the seat of
+election, rather than run the risk of pressure on the cicatrix by using
+a double flap operation, or trust that broken reed, the long posterior
+flap from the great muscles of the calf.
+
+In June 1865, Mr. Henry Lee described a method of operating which he
+hoped would unite the benefits of Mr. Teale's method to the ease of
+performance of the old flap from the calf. I append a short account of
+his method. From its position, however, it has the great disadvantage of
+retaining the discharges, and by its weight straining the stitches and
+weighing down the cicatrix:--
+
+
+LEE'S AMPUTATION _of the Leg by a long rectangular flap from the
+Calf_.--The operation described was performed according to Mr. Teale's
+method, as far as the external incisions were concerned, but the long
+flap was made from the back instead of from the front of the limb (Plate
+IV. figs. 14, 15). Two parallel incisions were made along the sides of
+the leg, these were met by a third transverse incision behind, which
+joined the lower extremities of the first two. These incisions, which
+formed the three sides of the square, extended through the skin and
+cellular tissue only. A fourth incision was made transversely through
+the skin in front of the leg so as to form a flap in this situation,
+one-fourth only of the length of the posterior flap. When the skin had
+somewhat retracted by its natural elasticity, an incision was made
+through the parts situated in front of the bones, which were reflected
+upwards to a level with the upper extremities of the first longitudinal
+incisions. The deeper structures at the back of the leg were then freely
+divided in the situation of the lower transverse incision. The conjoined
+gastrocnemius and soleus muscles were separated from the subjacent
+parts, and reflected as high as the anterior flap. The deeper layer of
+muscles, together with the large vessels and nerves, were divided as
+high as the incision would permit, and the bones sawn through in the
+usual way. The flaps were then adjusted in the manner recommended by Mr.
+Teale.[42]
+
+The patients were able to bear the weight of the body on the end of the
+stump.
+
+In cases of chronic disease, where the muscles are atrophied and
+condensed, the following posterior flap method may be used with
+advantage. It is approved of by Mr. Spence. An incision is made across
+the front of the leg from the _posterior edge_ of the fibula to the
+_posterior edge_ of the tibia, or _vice vers�_, according to the limb.
+The limb is then transfixed behind the bones from the same points, and a
+long and gently rounded posterior flap cut. The bones are then cleaned,
+and cut through at a little higher level.
+
+
+AMPUTATION IMMEDIATELY BELOW THE KNEE _at the_ "_true seat of
+election_."--The principles on which this operation is founded are--1.
+That a muscular flap is not necessary, skin being perfectly sufficient;
+2. That as the muscles retract they must be cut at a lower level than
+the bones, and as they retract unequally from their varying length, the
+cuts must be made with due reference to that inequality; 3. That no more
+of the tibia need be retained than what is just sufficient to retain
+the attachment of the ligamentum patell�, and to insure its vitality; 4.
+That the head of the fibula must be retained in every case, as in a
+certain proportion the tibio-fibular articulation communicates with the
+knee-joint.
+
+_Operation._--Two equal semilunar flaps of skin must be cut--from the
+outside, not by transfixion,--one anterior and external, the other
+posterior and internal, their extremities meeting at points about two
+inches below the tuberosity of the tibia on either side (Plate I. figs.
+17, 18). These must be reflected up, and with them a further extent of
+skin, embracing the whole circumference of the limb, must be dissected
+up (as if pulling off the fingers of a glove), so as to expose the bone
+one inch below the tuberosity. The anterior muscles being very close to
+their origin, and consequently being able to retract very slightly, must
+be cut as high as exposed, and the posterior ones about the middle of
+their exposed surface.
+
+The bones must then be sawn as high as exposed, with the following
+precautions:--1. In order to prevent splintering of the fibula,
+endeavour to saw it along with the tibia, so as to finish it first; 2.
+To prevent projection of a sharp prominence of the edge of the tibia,
+enter the saw obliquely a little higher up than where you intend to
+divide the bone, then withdraw it, and enter the saw again at right
+angles to the bone, and a line or two lower down. Some surgeons prefer
+to make this section afterwards with a finer saw or the bone-pliers.
+
+This operation is very frequently required to remedy painful and
+unhealed stumps, the result of amputations lower down, specially those
+in which the long posterior flap from the muscles of the calf has been
+used. In the above amputation the patient will not be able to rest the
+weight of his body on the _face_ of the stump, but by putting the limb
+into a well-padded case with soft rounded edges, the weight might be
+borne partly on the sides of the stump, and partly on the lower edge of
+the patella; and the patient will be able to walk with great comfort,
+preserving the use of his knee-joint.
+
+
+AMPUTATION AT THE KNEE-JOINT.--This "relic of ancient surgery," as Mr.
+Skey calls it, has been revived only of late years, and seems in certain
+cases to be a justifiable and successful operation.
+
+Practised by Fabricius Hildanus and Guillemeau in the sixteenth and
+seventeenth centuries, it had fallen into disuse till revived by Hoin,
+Velpeau, and Baudens, on the Continent, Professor Nathan Smith in
+America, and Mr. Lane in London.
+
+It is not possible that this operation can be at all frequent, since the
+cases in which it is applicable are comparatively rare; for, to be
+successful, the following conditions are essential:--1. That there be
+abundant skin in front of the knee-joint to make a long anterior flap;
+2. That the patella and articular surface of the femur are healthy.
+These conditions at once exclude nearly every case of disease or
+accident. If the joint is diseased some amputation through the thigh
+must be attempted; if injured, and the front of the knee is safe, it may
+very likely be possible to amputate below the knee. Hence this operation
+may be useful in cases where, for malignant disease, the _whole_ tibia
+requires removal, and yet the knee-joint is sound, or for gunshot
+injuries, in which the tibia is splintered but the soft tissues
+comparatively uninjured.
+
+_Operation._--A long anterior flap should be cut with a semilunar end
+(Plate II. figs. 6, 7), extending as far as the insertion of the
+ligamentum patell�. This flap, including the patella, should be thrown
+up, the joint cut into, and a short posterior flap made by transfixion.
+
+It is important to retain the patella, if possible, as it fills up the
+hollow between the condyles; it sometimes becomes anchylosed, but in
+other cases it remains freely mobile, and adds to the value of the
+stump.
+
+Professor Pancoast has practised an amputation at the knee-joint by
+three flaps, performed entirely by the scalpel, which, he says, results
+in a good stump. One flap, the anterior one, is longest and semilunar in
+shape, its convexity passing three inches below the tuberosity of the
+tibia; the other two are much smaller, and postero-lateral.[43]
+
+_Advantages._--The bone is not cut into at all, there is a free drain
+for matter, no tendency to retraction of the flaps, and the weight of
+the body is borne on skin previously habituated to pressure.
+
+     The statistics seem to be favourable: out of 55 cases, Continental,
+     American, and English, 21 died, a mortality of 38 per cent., while
+     in a table of 1055 cases of amputation of the thigh, 464 died,
+     being a mortality of 44 per cent. In some of the American cases the
+     articulating extremity of the femur seems to have been removed, as
+     in the following  operation:--
+
+
+AMPUTATION THROUGH THE CONDYLES OF THE FEMUR.--In the _London and
+Edinburgh Journal of Medical Science_ for 1845, Mr. Syme advocated a
+method of amputation through the condyles of the femur as specially
+suitable in case of diseased knee-joint. Amputation at this spot has
+certain advantages:--1. The shaft of the bone being untouched, there is
+no injury of the medullary cavity, and hence no fear of inflammation of
+its lining membrane. 2. There is less risk of exfoliation, the
+cancellated texture of the epiphysis not being liable to it. 3. Being
+close to the joint, the muscles are cut through where they are
+tendinous, thus very much diminishing the risk of retraction and
+consequent protrusion of the bone. 4. A large broad surface of bone is
+left to bear the weight of the body, and one which, like the ankle-joint
+stump, will round off and afford a comfortable pad over which the skin
+of the flap will freely play.
+
+One objection used to be urged against this mode of operating, the fear
+lest the thickened, brawny, and often ulcerated textures in the
+neighbourhood of a diseased knee-joint, would not make a good covering.
+This, however, is no longer a bugbear, as we see in cases of resection,
+where the diseased joint alone is taken away, how very soon all swelling
+and disease departs, once its cause is removed.
+
+Mr. Syme's original operation was briefly as follows:--With an ordinary
+amputating-knife make a lunated incision (Plate I. fig. 19) from one
+condyle to the other, across the front of the joint, on a level with the
+middle of the patella, divide the tissues down to the bones, and then
+draw the flap upwards, then cut the quadriceps extensor immediately
+above the patella. The point of the blade should then be pushed in at
+one end of the wound, thrust behind the femur, and made to appear at the
+other end; it should then be carried downwards (Plate III. fig. 5), so
+as to make a flap from the calf of the leg, about six or eight inches in
+length, in proportion to the thickness of the limb; the flap should then
+be slightly retracted, and the knife carried round the bone a little
+above the condyles to clear a way for the saw, which should be applied
+so as to leave the section as horizontal as possible.
+
+This method is now hardly ever used, as the following seems a much
+better one:--
+
+
+GRITTI'S[44] AMPUTATION.--In this two flaps are formed--an anterior long
+one rectangular and a posterior short one. The condyles of the femur are
+divided through their base, and the lower surface of patella is removed
+by a small saw, and then the surfaces of bone approximated.
+
+
+STOKES'S[45] MODIFICATION OF GRITTI'S AMPUTATION.--In this
+"supracondyloid" amputation, the femur is sawn just above the condyles,
+without going into the medullary canal. The anterior flap is oval, twice
+as long as posterior, and the patella is brought up after denudation
+against end of femur.
+
+
+CARDEN'S AMPUTATION AT THE CONDYLES OF THE FEMUR.[46]--The operation
+consists in reflecting a rounded or semi-oval flap of skin and fat from
+the front of the knee-joint, dividing everything else straight down to
+the bone, and sawing the bone slightly above the plane of the muscles,
+thus forming a flat-faced stump, with a bonnet of integument to fall
+over it.
+
+The operator standing on the right side of the limb, seizes it between
+his left forefinger and thumb at the spot selected for the base of the
+flap, and enters (Plate II. fig. 8) the point of the knife close to his
+finger, bringing it round through skin and fat below the patella to the
+spot pressed by his thumb; then turning the edge downwards at a right
+angle with the line of the limb, he passes it through to the spot where
+it first entered, cutting outwards through everything behind the bone
+(Plate IV. fig. 16). The flap is then reflected, and the remainder of
+the soft parts divided straight down to the bone; the muscles are then
+slightly cleared upwards, and I saw it applied.
+
+I have ventured to make a slight change in the method of performing this
+most excellent operation, for having found the posterior flap, as cut in
+the method above described, rather scanty in the earlier cases in which
+I have had occasion to perform it, after dissecting back the anterior
+flap and cutting into the knee-joint, I shape a slightly convex
+posterior flap of skin only, at least one and a half inches in length
+in adult, and allow it to retract before dividing the muscles by a
+circular cut to the bone, and have had every reason to be satisfied with
+the change.
+
+
+AMPUTATION OF THE THIGH.--Amputation of the thigh has been the favourite
+battle-ground where flap and circular, antero-posterior and lateral,
+long and short flaps, double, triple, and conical incisions, have
+striven with each other; so were I to attempt to describe one quarter of
+the various methods employed, I should need to rewrite the history of
+Amputation.
+
+It will suffice merely to describe the _best_ modes of amputating the
+thigh through its lower, middle, and upper thirds respectively, and at
+the hip-joint.
+
+In one word, it may be stated that, with the exception of those
+amputations performed through the lower third of the bone, the flap
+method is to be preferred, and the flaps should in almost every case be
+made by transfixion.
+
+In the lower third, however, the flap method, though exceedingly easy,
+and capable of very rapid performance, has certain defects; the chief of
+these being the tendency which the muscular flaps (the necessary result
+of transfixion) have to cause undue retraction, and hence protrusion of
+the bone. This is seen specially in the hamstrings, which from the great
+distance of their origin, and the purely longitudinal direction of their
+fibres, retract to a very great extent, much more than the anterior
+muscles can do from the pennate direction of their fibres, and the
+manner in which they are mutually bound down to each other and to the
+bone.
+
+Even in this one position, the lower third of the thigh, the methods
+that may be needed are various, and require separate notice;--for
+operations here are extremely frequent from the frequency of strumous
+disease of the knee-joint in our variable climate, and from the fact
+that compound fractures or dislocations of the knee-joint so very often
+necessitate amputation.
+
+In cases where the skin over the patella is uninjured and available, the
+operation by long anterior flap (either by Teale's method, or by Mr.
+Spence's modification of it, which curiously is almost exactly similar
+to the amputation of Benjamin Bell by a single flap) is suitable enough.
+But, I believe, preferable to either of these is the operation of Mr.
+Carden, already described. In cases where the knee-joint is injured, and
+the skin over the patella unavailable, and yet where it is not necessary
+to go higher up the limb, the modified circular amputation of Mr. Syme
+will be found very suitable.
+
+As it is in this lower third of the thigh that a very large proportion
+of the cases requiring a long anterior flap is to be found, it affords
+the best opportunity for comparing in their detail the three almost
+similar plans of B. Bell, Teale, and Spence--after which Mr. Syme's
+modified circular may be described.
+
+
+BENJAMIN BELL'S FLAP OPERATION ABOVE THE KNEE (reported in his own
+words, slightly abbreviated).--"When this operation is to be performed
+above the knee, it may be done either with one or two flaps, but it will
+commonly succeed best with one. The flap answers best on the fore part
+of the thigh, for here there is a sufficiency of the parts for covering
+the bones, and the matter passes more freely off than when the flap is
+formed behind.... The extreme point of the flap should reach to the end
+of the limb, unless the teguments are in any part diseased, in which
+case it must terminate where the disease begins, and its base should be
+where the bone is to be sawn. This will determine the length of the
+flap, and we should be directed with respect to the breadth of it by the
+circumference of the limb, for the diameter of a circle being somewhat
+less than a third of its circumference, although a limb may not be
+exactly circular, yet by attention to this we may ascertain with
+sufficient exactness the size of a flap for covering a stump (Plate IV.
+fig. 17). Thus a flap of four inches and a quarter in length will reach
+completely across a stump whose circumference is twelve inches; but as
+some allowance must be made for the quantity of skin and muscles that
+may be saved on the opposite side of the limb, by cutting them in the
+manner I have directed, and drawing them up before sawing the bone, and
+as it is a point of importance to leave the limb as long as possible,
+instead of four inches and a quarter, a limb of this size, when the
+first incision is managed in this manner, will not require a flap longer
+than three inches and a quarter, and so in proportion, according to the
+size of the limb. The flap at its base should be as broad as the breadth
+of the limb will permit, and should be continued nearly, although not
+altogether, of the same breadth till within a little of its termination,
+where it should be rounded off so as to correspond as exactly as may be
+with the figure of the sore on the back part of the limb. This being
+marked out, the surgeon, standing on the outside of the limb, should
+push a straight double-edged knife with a sharp point to the depth of
+the bone, by entering the point of it at the outside of the base of the
+intended flap; and carrying the point close to the bone, it must here be
+pushed through the teguments at the mark on the opposite side. The edge
+of the knife must now be carried downwards in such a direction as to
+form the flap, according to the figure marked out; and as it draws
+toward the end, the edge of it should be somewhat raised from the bone,
+so as to make the extremity of the flap thinner than the base, by which
+it will apply with more neatness to the surface of the sore. The flap
+being supported by an assistant, the teguments and muscles of the other
+parts of the limb should, by one stroke of the knife, be cut down to
+the bone, about an inch beneath where the bone is to be sawn; and the
+muscles being separated to this height from the bone with the point of a
+knife, the soft parts must all be supported with the leather retractors
+till the bone is sawn," etc., arteries tied, and dressings applied.[47]
+
+
+AMPUTATION OF THIGH BY RECTANGULAR FLAP--(Teale's).--I take the
+opportunity here of describing fully, and as far as possible in his own
+words, Mr. Teale's method of amputating, this being the situation where
+his method is most frequently available. The same principle may be
+applied to amputations at almost any other part of the body.
+
+After advising the surgeon to mark out the proposed line of incision
+with ink before the operation, he gives the following directions for
+fixing the exact size of the flap:--"Supposing the amputation to take
+place (Plate II. figs. 9, 10) at the lower part of the middle third of
+the thigh, the circumference of the limb is to be measured at the point
+where the bone is to be divided.[48] Assuming this to be sixteen inches,
+the long flap is to have its length and breadth each equal to half the
+circumference, namely, eight inches. Two longitudinal lines of this
+extent are then traced on the limb, and are met at their lower points by
+a transverse line of the same length. The inner longitudinal line should
+be first traced in ink as near as practicable to the femoral vessels,
+without including them within the range of the long flap. The outer
+longitudinal line, which is somewhat posterior, is next marked eight
+inches distant from the former and parallel to it. These two lines are
+then joined by a transverse line of the same extent, which falls upon
+the upper border of the patella, or upon some lower portion of this
+bone. The short flap is indicated by a transverse line passing behind
+the thigh, the length of this flap being one-fourth that of the long
+one; or, assuming the circumference of the limb to be sixteen inches,
+and the length of the long flap eight inches, the length of the short
+flap is two inches. The operator begins by making the two lateral
+incisions of the long flap through the _integuments only_. The
+transverse incision of this flap, supposing it to run along the upper
+edge of the patella, is made by a free sweep of the knife through the
+skin and tendinous structures down to the femur. Should the lower
+transverse line of the flap fall across the middle or lower part of the
+patella, the transverse incision can extend through the skin only, which
+must be dissected up as far as the upper border of the patella, at which
+place the tendinous structures are to be cut direct to the thigh-bone.
+The flap is completed by cutting the fleshy structures from below
+upwards close to the bone. The posterior short flap, containing the
+large vessels and nerves, is made by _one sweep_ of the knife down to
+the bone, the soft parts being afterwards separated from the bone close
+to the periosteum, as far upwards as the intended place of sawing.... In
+adjusting the flaps, the long one is folded over the end of the bone,
+and brought, by its transverse line, into union with the short flap, the
+two corresponding free angles of each being first united by suture. One
+or two additional stitches complete the transverse line of union. Care
+is now required in arranging the two lateral lines of union. As the long
+flap is folded upon itself so as to form a kind of pouch for the end of
+the bone, it is requisite that it should be held in its folded state by
+a point of suture on each side. Another stitch on each side secures the
+lateral line of the short flap to the corresponding part of the long
+one. A longitudinal line of union thus passes at right angles each end
+of the transverse line."[49]
+
+Mr. Teale's account of the resulting stumps is too long to quote entire,
+but in a few words, we find that by retraction of the short posterior
+flap, the cicatrix is drawn up quite behind and out of the way of the
+bone, that a soft mass without any large nerves or vessels is the result
+of the partial atrophy of the long flap, and that the patient is able to
+bear one-half, two-thirds, or even in some cases the entire weight of
+his body on the face of the stump. Such a power of support is to be
+found in no other flap except in Mr. Syme's amputation at the
+ankle-joint.
+
+
+SPENCE'S AMPUTATION BY A LONG ANTERIOR FLAP.[50]--The method used by Mr.
+Spence in amputations just above the knee-joint obtains the advantages
+of Teale's method, and avoids many of its disadvantages. He makes two
+flaps. The anterior one, which is to fall loosely over and cover in the
+posterior segment of the stump, must have a breadth fully equal to
+one-half of the circumference of the limb, and must be gently rounded at
+its extremity, so as to adjust itself readily to the curve of the cut
+margin of the posterior half of the stump. He begins the anterior
+incision below, or on a level with, the lower margin of the patella, and
+when the skin is retracted to a little above the patella, cuts down
+_obliquely_ to the bone, so as to divide the soft parts up to the base
+of the flap. For the posterior incision, he begins about two
+fingers'-breadth below the base of the anterior flap, and the assistant
+retracting the skin, the edge of the knife is carried obliquely up to
+the bone (in Alanson's manner) and the posterior soft parts divided, the
+bone is sawn through--or immediately above--the condyloid portion. Mr.
+Spence does not advise or practise this method high up. The results are
+good, for by these means the end of the bone has a thick covering,
+including muscular fibres, over it, and the cicatrix is not pressed
+upon in walking. The stump remains full, mobile, and fleshy, as in Mr.
+Teale's method, without the disadvantage which it has, in requiring the
+bone to be divided so far above the seat of injury or disease. This is
+an exceedingly good method of operating in the lower third of the thigh,
+in muscular patients the very best, and in all cases only equalled in
+value by Carden's method.
+
+The next is now hardly ever used here, except in cases where the skin
+over the patella is destroyed.
+
+
+MODIFIED CIRCULAR AT LOWER THIRD OF THIGH (Syme's).--Two equal semilunar
+flaps of skin should be cut (Plate I. fig. 20, Plate III. fig. 6), one
+anterior, the other posterior, their convexities being towards the knee.
+The skin and subcutaneous cellular tissue should be raised from the
+fascia, and then retracted to a further distance of at least two inches;
+the muscles should then be divided right down to the bone, on a level as
+high as they are exposed in front, and as low as they are exposed
+behind. This allows for the different amount of retraction at the two
+sides of the limb, and leaves the muscles cut on a level; the whole mass
+of muscles should then be drawn well up, and the bone exposed, and sawn
+through at a level about two inches higher than where it was first
+exposed by the anterior incision through the muscles.
+
+In very weak thin flabby limbs this process may be simplified by just at
+once including the muscles in the skin flaps, and carefully exposing the
+bone higher up. In performing the retraction the assistant should be
+cautioned not to overdo it, lest he strip the periosteum from the bone
+higher than is necessary. This is very easy to do in the weak limbs of
+strumous patients, and may cause exfoliation, and greatly delay cure.
+
+
+AMPUTATION IN THE MIDDLE THIRD OF THE THIGH.--A very short notice will
+suffice here. The exact position, shape, and size of the flaps must in
+every case be modified by the nature of the injury for which the
+operation is performed, taking the flaps where they can be obtained. As
+a general rule, a long anterior flap with a short posterior, on the
+principle described above, should be preferred. In cases where the long
+anterior cannot be obtained, two equal flaps should be made by
+transfixion. The flaps should always be antero-posterior, the lateral
+flaps introduced by Vermale, and indorsed by Chelius and Erichsen,
+having the great disadvantage of allowing the bone, which is drawn up by
+the psoas and iliacus, to project at the upper angle.
+
+Supposing the right thigh is to be amputated, the surgeon, standing on
+the inside of the leg, should raise the skin and muscles of the front of
+the limb in his left hand, and entering the knife just in front of the
+vessels, should transfix the limb, the knife passing in front of the
+bone, and including as nearly as possible an exact half of the limb
+(Plate IV. fig. 19); having by a sawing motion brought out the knife and
+cut a flap of the required length, the knife is re-entered at the same
+place, and passing behind the bone, the point must be brought out at the
+angle on the other side. Both flaps being then held back by an
+assistant, the bone is cleared by a circular turn of the knife, and the
+saw applied, the vessels are found cut high up in the inner angle of the
+posterior flap.
+
+In muscular patients it is often better to make the incision through the
+skin first and allow it to retract before transfixing; this is slower
+and not so brilliant looking, but avoids redundancy of muscle.
+
+
+AMPUTATION AT THE HIP-JOINT.--This operation, exceedingly dangerous from
+the amount of the body removed, the great h�morrhage, and the risk of
+py�mia, is of comparatively modern invention. Though the proportion of
+recoveries is at present to that of deaths about one to two or two and a
+half, it is still a perfectly justifiable operation in many cases of
+disease and injury.
+
+Like amputation at the shoulder, amputation at the hip has given rise to
+very many various methods of performance. Under the heads of single
+flap, double flap, oval, circular, and mixed flap and circular, at least
+twenty distinct methods have been put on record, and, including
+modifications, there are thirty-seven or thirty-eight different surgeons
+who have each their own plan of operation.
+
+The reason of this fearful complexity in its literature depends on this
+fact, that this amputation has generally been performed for cases of
+such severe injury of the limb, that no milder amputation was possible,
+and thus the flaps had to be taken just where the surgeon could get them
+best. And this will have to be the guiding principle in most amputations
+at this joint; the surgeon must just cut his coat according to his
+cloth--get his flaps where and how he can.
+
+In cases, however, where it is possible to have a choice, and to select
+the flaps, the following is, I believe, both the best and quickest
+method:--
+
+This is one of the very few operations in which quickness of performance
+is a desideratum; the use of an�sthetics has, in most other cases, given
+time for elaboration of flaps, and careful dissection; here the risk of
+loss of blood, specially from the posterior flap, renders rapid
+disarticulation imperative.
+
+_Amputation by double flap, anterior the longer._--In hip-joint
+amputations, besides the ordinary sponge-squeezers, two assistants are
+necessary, whose duties are exceedingly important.
+
+The first is to check h�morrhage. Pressing with a firm pad on the
+external iliac just as it passes the bone, he must be prepared, the
+instant the anterior flap is cut, to follow the knife and seize flap and
+artery in his hand, and he is to hold it there till all the vessels in
+the posterior flap are first tied.
+
+The second has to manage the limb, and on the manner in which he
+performs his duty much of the success and nearly all the celerity of the
+operation depend. While the surgeon is transfixing the anterior flap,
+this assistant is to support the limb in a slightly flexed position, so
+as to relax the muscles; the instant the flap is cut he is to extend the
+limb forcibly, and at the same time be careful not to abduct it in the
+least, but to turn the toes inward so as to bring the great trochanter
+well forwards on a level with the joint; if this precaution is
+neglected, the operator in making the posterior flap is almost certain
+to lock his knife in the hollow between the head of the bone and the
+great trochanter.
+
+If it is the left side, the operator, standing on the outside of the
+limb, enters the point of a long straight knife midway between the
+anterior superior spinous process of the ilium and the great trochanter,
+and passes it as close to the front of the joint as possible, making the
+point emerge close to the tuberosity of the ischium (Plate IV. fig.
+20-20). With a rapid sawing movement he then cuts a long anterior flap,
+avoiding any pointing of it, and endeavouring to make the curve equal.
+The fingers of the assistant must be inserted so as to follow the knife
+and seize the vessel even before it is divided. The flap being raised
+out of the way, the surgeon, without changing his knife (as used to be
+advised), opens the joint, divides the ligaments as they start up on the
+limb being extended and adducted, the round ligament, and the posterior
+part of the capsule; and then getting the knife fairly behind both the
+head of the bone and the trochanter, cuts the posterior flap as rapidly
+as possible. Instantly on the limb being separated, assistants should
+be ready with large dry sponges or pads of dry lint to press against the
+surface of the posterior flap, till the large branches, chiefly of the
+internal iliac, which are cut in it, are tied one by one.
+
+The lever invented by Mr. Richard Davy, by which the common iliac is
+compressed from the rectum, has in many cases proved of great service in
+preventing h�morrhage, but has dangers of its own in cases of abnormal
+position of rectum, or even in sudden movements of the patient.
+
+In every case the abdominal tourniquet will be found of great service in
+checking h�morrhage, during the operation of amputation at the
+hip-joint. It consists of an arch of steel fitted with a pad behind,
+which rests against the vertebral column, and a pad in front playing on
+a very fine and long screw, through an opening in the arch. When screwed
+down tightly on the aorta just before the incisions are commenced, it
+checks h�morrhage admirably without injuring the viscera. When this is
+applied, a method of amputation once practised by Mr. Syme, though not
+so rapid as the double-flap method by transfixion, will be found very
+easy, and to result in most excellent flaps. He cut an anterior flap in
+the usual manner by transfixion, then made a straight incision from its
+outer edge down to about two inches below the great trochanter, thus
+exposing it fully, and from the lower end of this incision transfixed
+again, cutting a posterior flap nearly equal in size to the anterior; a
+few strokes of the knife round the joint finished the disarticulation.
+The resulting flaps came together with great accuracy, and were not
+burdened with the great unequal masses of muscles so often noticed in
+the posterior flaps which are made by cutting from within outwards
+_after_ disarticulation.
+
+In some cases of amputation where the femur has been badly shattered, it
+is a good plan to amputate through the upper third of thigh, tie all the
+vessels, and then, aided by an incision at outer side, dissect out the
+head of the bone.
+
+Mr. Furneaux Jordan of Birmingham carries out this principle by first
+dividing the soft parts in circular direction low down the thigh, and
+then dissecting out the head of the bone from the muscles by a long
+incision on the outer aspect of the limb.
+
+     _Note._--In severe cases of smash when both lower limbs have
+     required amputation, the author has derived much assistance from
+     the method of managing the operation detailed below:--
+
+     _Double Primary Amputation of (both) Thighs from railway
+     smash_--_Rapid recovery._--G., a healthy-looking man, aged
+     twenty-seven, but looking much older, while driving a horse near
+     Granton, caught his foot on the edge of a rail at a point, fell,
+     and both his legs were run over by several loaded wagons. A special
+     engine was procured, his thighs tightly tied up, and he was sent up
+     to hospital at once.
+
+     I was in hospital at the time, so with as little delay as possible
+     he was placed on the operating table, and the necessity for
+     amputation being too evident, I obtained his leave to remove both
+     his legs above the knee; but his pulse was very feeble, and he was
+     intensely nervous, throwing his arms wildly about, panting for
+     breath, and looking very ill, cold, and exhausted.
+
+     I determined that by great rapidity he might be got off the table
+     alive, so operated in the following manner:--Fixing the tourniquet
+     firmly near both groins, I first amputated the right leg by
+     Carden's method, and tied the femoral only, wrapped up the stump in
+     a towel wrung out of carbolic solution 1-20, then took off the
+     other limb by Mr. Spence's method,--it had been injured higher than
+     the right, so that I could not save the condyles of the
+     femur,--then tied the femoral there, and fixed it up with another
+     towel; then returning to the first, I tied one or two large
+     branches which spouted, and rolled it up again, then back to the
+     left one, doing the same, and getting the tourniquet off both
+     limbs. On going back to the right the surface was nearly dry and
+     glazed, so, asking Dr. Maclaren, who assisted me, to stitch it up
+     and insert a drainage-tube, I did the same for the left, so rapidly
+     that the patient was in his bed with his limbs dressed and bandaged
+     in 24-1/2 minutes from the time he entered the hospital gate.
+
+     The strictest antiseptic precautions were observed, two engines
+     being used to furnish spray. Of course this great rapidity was due
+     to the fact that everything was ready, the assistants all in
+     hospital, admirably disciplined, and steam had been up in the spray
+     engines. Shock was comparatively trivial; his temperature once, and
+     only once, reached 100�. His stumps healed by first intention, and
+     he was in the garden on the seventh day after the operation.
+
+     I have now in three cases found the benefit of this mode of dealing
+     with double primary amputation in avoiding shock, lessening the
+     time needed, and greatly diminishing the number of vessels
+     requiring to be tied. In a previous case of double amputation for
+     railway smash at the knees, the patient was almost pulseless, and
+     had he been kept many minutes more on the table would not have left
+     it alive. He also rapidly recovered.
+
+     The case is interesting also as showing that, when the assistants
+     know their work, the strictest adherence to antiseptic precautions
+     need not in itself make either the operation or the dressing
+     tedious, though it can easily be made an excuse for much fussing
+     and many delays.[51]
+
+
+FOOTNOTES:
+
+[24] For details see article "Amputation" in Cooper's _Surgical
+Dictionary_, and the short sketch of the history in Mr. Lister's paper
+in the third volume of Holmes's _System of Surgery_.
+
+[25] See a most interesting foot-note to Professor Lister's paper on
+"Amputation," in Holmes's _System of Surgery_, vol. iii. pp. 52, 53.
+
+[26] _Manuel d'Op�rations chirurgicales._
+
+[27] FIG. IV. shows dorsal view of incision. FIG. III. shows face of
+completed stump; R, radial; U, ulnar.
+
+[28] As the surgeon will find it most convenient to stand on his own
+right side of the limb to be removed, the knife will be entered on the
+palmar side of the radius of the right arm, of the ulna of the left.
+
+[29] Teale, _On Amputation by Rectangular Flaps_, pp. 46-48.
+
+[30] Johnson's folio ed., p. 342.
+
+[31] Gross's _Surgery_, 6th ed. vol. ii. p. 1103.
+
+[32] _International Encyclop�dia of Surgery_, vol. i. p. 641.
+
+[33] Spence's _Surgery_, pp. 800, 801.
+
+[34] Gross's _Surgery_, 8vo., 6th ed., vol. ii., p. 1106.
+
+[35] _Excision of Scapula_, p. 33.
+
+[36] Hey's _Observations_, 3d ed. pp. 552, 556.
+
+[37] Roux's _Parallel between English and French Surgery_. Translation
+abridged from Cooper's _Surgical Dictionary_, p. 106.
+
+[38] Syme's _Principles_, 4th edit. p. 145.
+
+[39] _International Encyclop�dia_, vol. 1. p. 655.
+
+[40] _Observations in Clin. Surgery_, p. 48.
+
+[41] _Monthly Journal of Medical Science for 1849_, vol. ix. p. 951.
+
+[42] _Med. Times and Gazette_, June 3, 1865.
+
+[43] _Operative Surgery_, p. 170.
+
+[44] _Annali Universali de Medicina_, Milano, 1857.
+
+[45] _Med. Chir. Transactions of London_, vol. liii., p. 175.
+
+[46] Carden's (of Worcester) Pamphlet, pp. 5, 6; and _British Medical
+Journal_, 1864.
+
+[47] B. Bell's _Surgery_, 6th ed. vol. vii. pp. 336-339.
+
+[48] In diagram the amputation is drawn as if for middle third of thigh.
+
+[49] Teale, _op. cit._, pp. 34, 39.
+
+[50] _Edin. Med. Journal_, for April 1863.
+
+[51] _Edin. Medical Journal_, March 1879.
+
+
+
+
+CHAPTER III.
+
+EXCISION OF JOINTS.
+
+
+_Historical._--Beyond a passage ascribed to Hippocrates, but of very
+doubtful authenticity, and slight allusions in the works of Celsus and
+Paulus �gineta, the ancients give us no information whatever on this
+subject.
+
+Hippocrates says,--"Complete resections of bones in the neighbourhood of
+joints both in the foot, in the hand, in the tibia up to the malleoli,
+and in the ulna at its junction with the hand, and in many other places,
+are safe operations, if that fatal syncope does not at once occur, and
+continued fever does not attack the patient on the fourth day."
+
+Celsus and �gineta both advise the removal of protruding ends of bone in
+compound dislocations, but without giving any cases.
+
+From the days of these classic fathers of Surgery, we have hardly an
+indication of any attention whatever having been paid to their hints
+till quite within the last hundred years.
+
+The first distinct publication on the subject was by Henry Park of
+Liverpool, in a letter to Percival Pott in 1783. He proposed the removal
+of the articulating extremities of diseased elbow and knee-joints to
+obtain cures. He says he was led to this by its having been the
+invariable custom, for more than thirty years, at the Liverpool
+Infirmary, to take off the protruded extremities of bones in cases of
+compound dislocation.
+
+The chief credit, however, in practically elevating excisions into the
+catalogue of recognised surgical operations, is owing, British surgeons
+most cordially own, to two provincial surgeons of France, the Moreaus
+(father and son) of Bar-sur-Ornain. They took the lead in the most
+marked manner, having excised the shoulder in 1786, the wrist and elbow
+in 1794, knee and ankle in 1792, and had followed this up so well that,
+in 1803, the younger Moreau could boast, "the town has become in some
+sort the refuge of the unfortunate afflicted with carious joints, after
+they have tried all the means usually recommended by professional men,
+or have had recourse to empirical nostrums, or when amputation seemed to
+them the last resource."
+
+Moreau's papers and cases, which, between 1786 and 1789, he frequently
+read to the French Academy, were, some violently opposed, others utterly
+neglected by his compatriots, and many of them lost and buried in the
+unpublished papers of that body.
+
+And though diseased joints did not decline in frequency, and though
+injured ones were extremely numerous during these long years of European
+war, excisions were but rarely performed.
+
+With the exception of the removal of head of humerus after gunshot
+injury, hardly any British, and but very few French, limbs were saved by
+excision taking the place of amputation.
+
+The limbs that were saved by Percy by excision of the head of the
+humerus really owe their recovery and safety to the elder Moreau; for an
+operation of his, at which he was assisted by that distinguished
+military surgeon, gave the latter the hint, which he followed so
+successfully, that by 1795 he had performed it nineteen times, and had
+indoctrinated Sabatier, Larrey, and others, and elevated it into a
+recognised operation of military surgery.
+
+So far, however, as the application of the great improvement of the
+Moreaus to disease went, the French surgeons have little reason to
+boast, for it is to English surgery, and especially to one Edinburgh
+surgeon, that this class of operations owes nearly all its improvement
+in methods and frequency of performance.
+
+For though (as we shall see under the special heads) here and there one
+or two cases were performed, it was not till the publication of Mr.
+Syme's monograph on the excision of diseased joints, in 1831, that the
+importance and value of the discovery were fairly brought before the
+profession; and the conservative surgery, of which excision as preferred
+to amputation is the great type, must ever be associated with British
+surgeons--Syme, Fergusson, Mackenzie, Jones of Jersey, Butcher of
+Dublin.
+
+On the Continent--Langenbeck, Stromeyer, Heyfelder, Ollier, Esmarch of
+Kiel, specially in the surgical history of the first Schleswig-Holstein
+war, have followed up the example set them here.
+
+Before proceeding to describe the operations on the various joints, one
+or two questions may be briefly asked and answered by way of
+introduction.
+
+In what cases, or sorts of cases, are excisions suitable?
+
+1. In cases of compound injury or dislocation of a large joint, as used
+by Filkin, Park, White, and other English surgeons long ago. In hospital
+practice, or in private, where there is every advantage of rest, food,
+and appliances, such operations will frequently be found suitable where
+the joint is alone or chiefly the seat of injury, and where the general
+health seems fit to bear a prolonged suppuration. But long and sad
+experience has shown that, as a general rule in military practice, with
+the difficulties of transport, the generally bad sanitary state of the
+hospitals, and the want often of adequate dressings and attention,
+excisions are much more fatal than amputations, and, except in elbow and
+shoulder (_q.v._), should be as a general rule avoided.
+
+2. Excision for deformity (generally speaking for bony anchylosis) will
+require for decision the consideration of many points, _i.e._ the joint
+affected, the nature of the disease or injury which has caused the
+anchylosis: and in each case--(1.) the state of health of the patient;
+and (2.) his occupation, and the consequent position of limb which would
+suit him best. As a general rule, I believe, experience will prove that
+such operations on the lower extremity are almost absolutely
+inadmissible, except under very special urgency on the part of the
+patient, and a very high condition of health--while in the upper, the
+elbow-joint is the only one which you will ever be likely to be asked to
+remedy, or should comply with the request if asked; as the shoulder,
+even if anchylosed, will (1.) from its own weight generally become so in
+the most favourable position; and (2.) from the extreme mobility which
+the scapula can acquire, its anchylosis will not be so much felt.
+
+The elbow, however, from the frequency of fractures of the condyles of
+the humerus obliquely into the joint, and from the manner in which these
+are so often neither recognised nor properly treated, very often becomes
+anchylosed in the most awkward possible position, _i.e._ nearly
+straight; and operations undertaken for such deformities are in general
+both quite safe and very satisfactory. Mr. Syme had one case (resulting
+from a fall, causing a double fracture), in which both arms were thus
+firmly anchylosed in such a position that the sufferer could absolutely
+perform none of the commonest duties of life without assistance.
+Excision of both joints cured him.
+
+The author excised with success for disease the elbow-joint of a patient
+whose other arm had required the same operation.
+
+The occupation of the patient must always be taken into consideration
+when settling the position of an anchylosis, or the necessity or
+advantage of a resection.
+
+Thus, Bryant[52] tells of a painter who wished his arm to be fixed in a
+straight position, and of a turner whose knee at his own request was
+permitted to stiffen at a right angle, as that position allowed him to
+turn his wheel.
+
+3. _Excision for Disease of the Joint._--In our cold climate, so cursed
+by scrofula, and specially among the children of the labouring poor,
+such joint diseases are very prevalent, and whether the disease
+commences in the synovial membrane, the articular cartilages, or the
+heads of the bones, it frequently so disorganises the joint as to make
+it a question whether something must not be done to preserve the very
+life of the patient.
+
+The difficulty of diagnosing the cases in which excisions are suitable
+or necessary is often very great; and we must balance its
+performance--(1.) against the possibly good results of an expectant
+treatment; (2.) against amputation of the limb.
+
+(1.) _Against expectant Treatment._--The patient has youth on his side,
+could we give him fresh sea air, good diet, cod oil, etc., we might very
+likely obtain anchylosis; true, but he may die while trying for this
+anchylosis, and also this anchylosis, when got, may so lame or deform
+him that resection may still be required.
+
+These points must all be considered, but as a general rule, I would say
+that such attempts at preservation of the limb are much more
+justifiable, and longer justifiable in the hip and knee-joints than in
+the elbow or shoulder; for the results in the lower limb will probably
+be as good, if the patient survive, if not better, than those obtained
+by excision, while the danger of the operation is greater; while in the
+upper limb, the danger to life in operating is less than that of leaving
+the limb on, and the results obtained by a successful operation, with
+well-managed after treatment, are far more satisfactory than the best
+possible anchylosis.
+
+Another point bearing on this, of very great importance: In children,
+the most frequent subjects of such disease, excision of the lower limb
+may, by removing the epiphyses, cause to a very considerable degree
+disparity in their length, thus rendering them nearly useless, while in
+the upper such disparity is neither so extensive nor so injurious to the
+usefulness of the limb, which is not required for purposes of
+progression.
+
+In the hip-joint especially, all the resources of the art should be
+tried in the expectant treatment, for amputation at the hip-joint is
+hardly ever admissible for disease of the joint, while excision has
+anything but satisfactory statistics.
+
+(2.) _Against Amputation._--Many questions must be considered, chiefly
+under the heads of the separate joints:--
+
+1. As to the difficulties and dangers of the operations contrasted.
+
+Such as the following:--
+
+Excisions give the surgeon more trouble, require more manual dexterity;
+take longer to perform; are very painful operations. Not valid
+objections in these days of chloroform and operative surgery on the dead
+body.
+
+Excisions have the special peculiarity and danger of dealing chiefly
+with cancellated bone, broadened out, open, with numerous patulous
+canals for large veins, tending on any irritation or inflammation to set
+up a diffuse suppuration, and to culminate in phlebitis, myelitis, and
+other py�mic conditions.
+
+Excisions are performed through degenerate or disorganised, amputations
+through healthy, tissue.
+
+Excisions require extreme care and absolute rest (_i.e._ in lower limb)
+for many weeks and months after the operation.
+
+But, on the other hand,--
+
+Amputations remove a portion of the body; excisions a much less one.
+Amputations are always necessarily nearer the centre than the
+corresponding excisions, and statistics show that the fatality of
+operations increases in exact proportion as they approach the centre.
+
+A successful excision, especially in arm, saves a limb nearly perfect;
+an amputation at best is only the stump for a wooden one.
+
+On the whole, there is actually very little difference in the mortality
+of excisions and amputations.
+
+2. As to the results of the operation on the usefulness of the limb,
+depending on joint involved, age of patient, and amount of bone
+removed:--
+
+A. _Joint involved._--These must be noticed separately, but one thing is
+absolutely certain, that a much higher standard of usefulness, both in
+equality of length, amount of anchylosis, and position, is needed in the
+lower than in the upper limb. For a leg hanging like a flail, or
+shortened by some inches, is not so good for purposes of locomotion as a
+wooden leg is, while an arm, even though powerless at the elbow, and
+perhaps much shortened, can be so strengthened and supported by slings
+and bandages as to give a most useful hand, the complex movements and
+uses of the fingers of which no mechanism can at all imitate.
+
+B. _Age of Patient._--It must be remembered that excision in a child
+removes the epiphyses by which in great measure the growth of the bone
+is to be managed, and the stunted limb, especially in the leg, will
+eventually be of little advantage, though after the operation it looked
+excellently well, if a few years later it be found to be seven or eight
+inches shorter than its neighbour.
+
+C. _Amount of Bone removed._--From an erroneous view of the pathological
+changes in the bone affected, far too much was removed by many of the
+earlier operators, especially Moreau and Crampton.
+
+The reason that this is often still the case, is well seen in many
+preparations. The bones are thickened to a considerable distance, and
+covered with irregular warty excrescences. These, which used to be
+considered evidences of disease, are only compact new healthy bone,
+thrown out like the callus of a fracture in consequence of the
+irritation.
+
+In a word, what we require to remove is the following:--
+
+1. All the cartilage, dead or alive, healthy or diseased.
+
+2. Only the bone involving the articular extremities, in thin slices, or
+with the occasional use of the gouge, till a healthy bleeding surface is
+obtained.
+
+3. The synovial membrane, however gelatinous or thickened looking,
+really requires very little care or notice; it will disappear of itself,
+partly by sloughing, partly by absorption during the profuse
+suppuration.[53]
+
+
+EXCISION OF THE SHOULDER-JOINT.--Before considering the method of
+operating, a word or two is required on the subject of how much is to be
+removed, and in what cases the operation should be performed. The
+shoulder and hip joints are the only ones in which partial excision is
+ever admissible, indeed, in the shoulder excision of the head of the
+humerus only is in many cases found to be all that is necessary, while
+in all it is much less dangerous to life than when the glenoid cavity
+also requires to be interfered with.
+
+It is rarely necessary to remove more of the bone than merely its
+articular extremity (when performed for disease of the joint), and if
+possible this should be done inside the capsule, _i.e._ through an
+incision in the capsule, but without involving its attachment to the
+neck of the bone. When the glenoid is also diseased, mere gouging or
+scraping the cartilaginous surface will not suffice, but the neck must
+be thoroughly exposed, so that the whole cup of the glenoid may be
+removed by powerful forceps.
+
+_Cases suitable for Excision._--Cases of chronic disease of the head of
+the humerus (generally tubercular), or of chronic ulceration of the
+cartilages which has resisted counter-irritation. Cases of gunshot
+injury of the joint, or of compound dislocation, or fracture involving
+the joint. Cases of limited tumours affecting merely the head and upper
+third of the bone, and non-malignant in character. Anchylosis very
+rarely requires and would not be much benefited by such an operation.
+
+_Operation._--Though perhaps not the easiest, the following method is
+the one followed by the best results. It is suited especially for cases
+of caries or other disease of the joint, where the head of the humerus
+is either alone or chiefly affected:--
+
+A single straight incision (Plate I. fig. A.) is made from a point just
+external to the coracoid process downwards along the humerus for at
+least three inches. It corresponds almost exactly to the bicipital
+groove, and has the advantage of avoiding the great vessels and nerves.
+The long head of the biceps may then be raised from its groove, and
+drawn to a side so as to be preserved. This is deemed of importance by
+Langenbeck and others. Mr. Syme, however, did not attach much value to
+its preservation, as it is often diseased. The capsule, which is often
+much altered, perhaps in part destroyed, is then opened, and the tendons
+of the muscles which rotate the head of the humerus divided in
+succession, while the elbow is rotated first inwards and then outwards
+by an assistant so as to put them on the stretch. The arm being then
+forced backwards, the head of the bone can be protruded through the
+wound, and sawn off at the necessary distance down the shaft. The
+glenoid must then be carefully examined, and any diseased bone removed
+by the cutting pliers. One or two small branches supplying the anterior
+fold of the axilla are the only vessels divided, and may not even
+require ligature, unless, indeed, from necrosis, or to remove a tumour,
+a larger portion of the humerus than usual has been removed. If the
+limit of capsule has been infringed on below, the circumflex vessels may
+probably be cut, in which case the bleeding may be considerable.
+
+_N.B._--In cases of fracture of neck of humerus, or of compound gunshot
+injury, or where the head has been separated by necrosis from the shaft,
+or where, as has happened to Stanley and others, the bone broke in the
+endeavour to tilt the head out, the surgeon will require to seize the
+detached head with strong forceps, and dissect it out with care.
+
+_Other methods of Resection._--When from great thickening and induration
+of the soft parts, enlargement of the head of the bone, or other reason,
+the straight incision may be deemed insufficient for the purpose (and we
+may remark that there are comparatively few cases in which it is
+insufficient), access may be obtained to the joint by raising a flap
+from the deltoid (Plate III. fig. A). Its shape--V-shaped, semilunar, or
+ovoid--is not of much consequence, for there are no great nerves or
+vessels to wound on the outside of the joint, and the surgeon should be
+guided, as in all other operations on the joint, very much by the
+position of any pre-existing sinuses. This flap being raised upwards
+towards its base, very free access is gained to the joint.
+
+In these cases, fortunately comparatively rare, in which there is reason
+to believe that the glenoid is chiefly involved in disease, and yet that
+the disease can be removed without amputation, access will be gained
+most easily by an incision (Plate III. fig. B.) on the posterior surface
+of the joint, corresponding in size and direction to the linear incision
+in front. This gives a much easier mode of access to the glenoid. I have
+seen this practised in one very remarkable case by Mr. Syme, in which
+the glenoid cavity and neck of the scapula were extensively diseased,
+while the head of the bone was quite sound.
+
+_After-treatment_ is exceedingly simple; for the first day or two the
+shoulder is to be supported on a pillow with a simple pad in the axilla,
+if there is any tendency for the arm to drag inwards; after this the
+patient should be encouraged to sit up and move about with his arm in a
+sling, the elbow hanging freely down.
+
+_Results._--Hodge records ninety-six cases in which this excision was
+performed for gunshot injury, of which twenty-five proved fatal, and
+fifty for disease, of which only eight died,--results which are more
+encouraging than those of amputation at the shoulder-joint for disease;
+though for injury the mortality is much greater than Larrey's famous
+Statistics of Amputation, _q.v._ p. 65.
+
+Spence had thirty-three cases, with three deaths. He generally made a
+counter-opening behind to get rid of discharges, and inserted a
+drainage-tube.
+
+Gurlt's statistics of excision for gunshot injury give of 1661 cases
+1067 recoveries, 27 doubtful results, and 567 deaths, the mortality
+being 34.70 per cent.
+
+EXCISION OF THE ELBOW-JOINT--_In what cases should it be performed?_--1.
+For disease of the elbow-joint which has resisted ordinary remedies, and
+is wearing down the patient's strength, including caries, ulceration of
+cartilages, and gelatinous synovial degeneration.
+
+2. For wounds of the elbow penetrating the joint, the prognosis both as
+to the patient's life and the usefulness of his arm is much better after
+excision than after endeavours to save the joint without excision. This
+is especially the case when the wound of the joint is small and
+punctured, but if the case is seen early and treated by free drainage,
+with antiseptic precautions, excision may not be required.
+
+3. For anchylosis, in cases where after disease or injury the limb has
+stiffened in a bad position, especially when, with a straight elbow,
+the hand is rendered almost perfectly useless.
+
+_How much should be removed?_--In the elbow-joint, more than any other
+joint in the body, complete excision is absolutely necessary; any
+portion of the articular surface being left proves a source of
+unfavourable result.
+
+The surgeon is apt to err rather in removing too little than too much.
+For the removal of too little bone is, on the one hand, apt to result in
+long-standing sinuses, on the other, to induce anchylosis.
+
+In making the section of the bones, the saw ought to be applied to the
+humerus transversely just at the commencement of its condyloid
+projections, and to the radius and ulna, at least at a level with the
+base of the coronoid process of the ulna.
+
+But while removing enough, we must not be led into the error of removing
+too much. If this is done, as was done by Sir Philip Crampton in his
+first case, and as happens occasionally of necessity in cases of
+excision for gunshot wounds or other accidents, much of the power of the
+arm is lost as a consequence of the shortening and excessive mobility.
+
+A mistaken pathology sometimes deceives in the examination of the state
+of the bones, and causes an unnecessary amount to be removed. For in
+many cases of disease the bones in the neighbourhood of the joint are
+stimulated to an excessive amount of what is in reality Nature's effort
+at repair, and while the cartilaginous surfaces are denuded of
+cartilage, soft, and porous, the bones close by are roughened with a
+stalactitic-looking growth, projecting in knobs and angles. Now, if this
+be mistaken for disease and removed, too much will almost certainly be
+taken away, and the result will be unsatisfactory.
+
+Much less care need be taken exactly to discriminate and remove the
+diseased soft parts; indeed they may be left alone; the synovial
+membrane in a state of gelatinous degeneration sometimes presents a
+very formidable appearance of disease, but if the bones be properly
+removed, all this swelling will soon go down, and a healthy condition of
+parts succeed, without any clipping or paring on the surgeon's part.
+
+_Operation._--The back of the joint is of course chosen for the seat of
+the incisions, both because the bones are there just under the skin, and
+because the great vessels and nerves lie in front of the joint. The form
+and number of the incisions vary considerably, and ought to vary
+according to the nature of the case and the amount of disease or injury.
+
+Though it is now little used, for historical interest I retain the
+description of the H-shaped incision (Plate III. fig. C.), used first by
+Moreau, and re-introduced by Mr. Syme, and used by him for most of his
+very numerous cases.
+
+The posterior surface of the joint being exposed, the surgeon, with a
+strong straight bistoury, makes a transverse incision into the joint
+just above the olecranon. It should begin just far enough outside of the
+internal condyle to avoid the ulnar nerve, which the surgeon should
+protect by the forefinger of his left hand, and should extend
+transversely across to the outer condyle. From each end of this incision
+the surgeon should next make at a right angle two incisions, each about
+one inch and a half or two inches long, right down to the bone, thus
+marking out two quadrilateral flaps. These should next be raised from
+the bones, up and down, as much of the soft parts being retained in them
+as possible, so as to add to their thickness. The olecranon is thus
+exposed, and should be removed by saw or pliers by cutting into the
+greater sigmoid notch; the lateral ligaments must then be cut, if they
+are not already destroyed by the disease, and the humerus protruded, a
+proper amount of which is then to be sawn off in a transverse direction.
+The head of the radius is then easily removed by the bone-pliers, and
+the ulna also protruded, the attachment of the brachialis anticus to the
+coronoid process divided, and the bone sawn across just at the base of
+that process.
+
+Few vessels, if any, will require ligature, and the arm being bent to
+nearly a right angle, the transverse incision must be very carefully
+sewed up with silver sutures closely set and deeply placed, as much of
+the future success of the joint depends on the completeness of the
+primary union of this incision. The external incision may also be
+accurately adjusted, the internal one not so completely, to allow free
+vent for the discharge, which is aided by the ligatures, if any are
+required, being brought out at its lower angle. A figure-of-8 bandage
+should be applied over pads of dry lint, and the limb laid on a pillow.
+No splint is necessary; in a few days the patient will be able to rise
+and walk about.
+
+Passive motion should be begun so soon as the first inflammatory
+symptoms have passed off.
+
+If properly performed, in a tolerably healthy subject, the surgeon
+should not be satisfied with any results short of almost perfect
+restoration of motion in the joint. Flexion and extension to their full
+extent, with a very considerable amount of pronation and supination, are
+to be expected, with proper care, in a patient of average intelligence.
+
+Numerous cases are now on record where almost perfect performance of all
+the duties of life was retained after excision of the elbow-joint.[54]
+
+In most cases it is possible, and in nearly all advisable, to excise the
+joint by means of a less complicated incision. Thus one long vertical
+incision at the posterior surface, with its centre about midway between
+the ulna and the external condyle, with a transverse incision at right
+angles to it, and reaching almost to the internal condyle, has been
+often practised with a very good result.
+
+By nearly universal consent this single straight incision is now used,
+and when it is properly dressed and _drained_ gives admirable results.
+
+A single vertical incision (Plate III. fig. D.) without any transverse
+one, as long ago recommended by Chassaignac, is, in most cases, quite
+sufficient to give access. It is most suitable in cases of anchylosis,
+where there is little deposit of new bone, or in cases of disease of the
+joint, accompanied with little swelling or thickening of surrounding
+tissues. It has the advantage of avoiding the cicatrix of a transverse
+incision, which doubtless may, if at all a broad one, somewhat interfere
+with the future flexion of the limb, but, on the other hand, unless care
+is taken, it does _not_ give such free egress for the discharge, and
+when there is much delay in healing, the vertical incision may leave a
+cicatrix nearly as troublesome as the other.
+
+     The following modification, suggested and practised by the late Mr.
+     Maunder, seems to be a step in the right direction when it is
+     practicable. "After a longitudinal incision crossing the point of
+     the olecranon I next let the knife sink into the triceps muscle,
+     and divide it longitudinally into two portions, the inner one of
+     which is the more firmly attached to the ulna, while the outer
+     portion is continuous with the anconeus muscle, and sends some
+     tendinous fibres to blend with the fascia of the fore-arm. It is
+     these latter fibres that are to be scrupulously preserved.
+
+     "Two points have to be remembered: first, the ulnar nerve, often
+     unseen, must be lifted from its bed, and carried over the internal
+     condyle to a safe place, and then the outer portion of the triceps
+     muscle with its tendinous prolongation, the fascia of the fore-arm
+     and the anconeus muscle must be dissected up, as it were, in one
+     piece, sufficiently to allow of its being temporarily carried out
+     over the external condyle of the humerus."[55]
+
+     This method aids in retaining the power of _active_ extension of
+     the elbow-joint.
+
+Excision for osseous anchylosis in the extended position of the joint
+may be sometimes rendered very difficult by the density, firmness, and
+extensive hypertrophy of the bones, which become fused into one solid
+mass. Any attempt to isolate the bones, and remove the anchylosed joint
+entire, by incising the bones as if for disease, will both prove very
+laborious, and also probably end in doing some damage to the vessels and
+nerves in front. But by sawing through the anchylosis about its centre,
+as was pointed out many years ago by Mr. Syme, the fore-arm may be
+flexed, and the bones as easily displayed, cleaned, and removed, as in
+the operation for disease. In this operation, as there is less
+thickening of the skin and subjacent textures, and in consequence more
+risk of deficiency and even sloughing of the flaps made by the H-shaped
+incision, a single straight incision will serve the purpose admirably.
+
+Partial incisions of the elbow-joint are, as a rule, less successful and
+more dangerous to life than complete ones, except in cases of excision
+for anchylosis. Even in gunshot wounds, where the bones were previously
+healthy, and where uninjured portions might have been left with some
+hopes of success, this is the case.
+
+     Dr. Heron Watson has devised the following operation for cases of
+     anchylosis the result of injury:--(1.) A linear incision over ulnar
+     nerve at inner side of olecranon. (2.) The ulnar nerve to be
+     carefully turned over the inner condyle. (3.) A probe-pointed
+     bistoury to be introduced into the elbow-joint in front of the
+     humerus, and then behind and carried upwards, so as to divide the
+     upper capsular attachments in front and behind. (4.) A pair of
+     bone-forceps to be next employed to cut off the entire inner
+     condyle and trochlea of the humerus, and then introduced in the
+     opposite diagonal direction so as to detach the external condyle
+     and capitulum of the humerus from the shaft. (5.) The truncated and
+     angular end of the humerus to be divided, turned out through the
+     incision, and smoothed across at right angles to the line of the
+     shaft by means of the saw, whereby (6.) room might be afforded, so
+     that partly by twisting and partly by dissection the external
+     condyle and capitulum are removed without any division of the skin
+     on the outer side of the arm.[56] Six cases have had satisfactory
+     results.
+
+The mortality from this operation is considerably less than that from
+amputation of the arm. Of a series of excisions for disease, injury, and
+anchylosis, 22.15 per cent. died, while out of a similar series of
+amputations of the arm the mortality was 33.4 per cent.[57] Our
+mortality of excision of the elbow here is certainly much less than the
+above. All of the cases, between thirty and forty, in which I have done
+it have recovered with but one exception, and Mr. Syme lost only one
+during the time I was his assistant.
+
+Professor Spence lost only 16 in 189 cases, or 8.3 per cent.
+
+Gurlt's statistics for gunshot injury give a mortality of over 24 per
+cent.
+
+Out of 82 cases where the joint was excised for injury in the
+Schleswig-Holstein and Crimean campaigns, only 16 died; and out of 115
+cases in which the joint was excised for disease, only 15 died.
+
+The period after the injury at which the excision is performed seems to
+be important.
+
+                                                        Deaths.
+    Thus of 11 cases within first twenty-four hours,    1 = 1-11
+      "     20   "   between second and fourth days,    4 = 1-5
+      "      9   "      "    eighth and thirty-seventh, 1 = 1-9
+            --                                         --
+            40                                          6
+
+
+EXCISION OF THE WRIST.--Very various methods have been proposed and
+executed for the purpose of excising this joint. These vary much in
+difficulty and complexity, in proportion to the endeavours made to save
+the tendons from being cut.
+
+The principles which must guide all attempts at operative interference
+with this joint are--
+
+1. To remove all the diseased bone, including the cartilage-covered
+portions of the radius, ulna, and of the metacarpal bones, as little of
+these bones being removed as possible, beyond the cartilage-covered
+portions.
+
+2. To disturb the tendons as little as possible, especially to avoid
+isolating them from the cellular sheath.
+
+3. To commence passive motion of the fingers very soon after the
+operation.
+
+It is rarely possible to remove the carpal bones as a whole, from the
+diseased condition which renders the operation necessary, and the
+digging out of the various bones piecemeal renders the operation very
+tedious, especially if the proximal ends of the metacarpal bones are
+involved and require to be removed, hence this operation was practically
+impossible till after the discovery of an�sthesia.
+
+In describing the operation elaborated and described by Professor
+Lister, the type of the various plans in which the tendons are saved is
+given, while a very few words descriptive of the incisions used by
+others who cut the tendons will suffice.
+
+
+LISTER'S OPERATION OF EXCISION OF THE WRIST-JOINT.--Even an abridgment
+of Mr. Lister's account of his operation must necessarily be long,
+because the operation itself is so complicated and prolonged, and guided
+by such precise principles, as to render much abridgment almost
+impossible.
+
+A tourniquet is put on, to prevent oozing, which would conceal the state
+of the bones; any adhesions of the tendons must be then broken down by
+free movement of all the joints.
+
+_The radial incision_ (Plate IV. fig. A.) is then made. It commences at
+the middle of the dorsal aspect of the radius, on a level with the
+styloid process, passes as if going towards the inner side of the
+metacarpo-phalangeal joint of the thumb, in a line parallel to the
+extensor secundi internodii, but turns off at an angle as it passes the
+radial border of the second metacarpal, and then longitudinally
+downwards for half the length of that bone. The extensor carpi radialis
+brevior tendon is divided in the incision. The soft parts at the radial
+side are to be carefully dissected up, and the tendon of the extensor
+carpi radialis longior divided at its insertion. The cut tendons, and
+the extensor secundi internodii tendon and the radial artery can thus be
+pushed outwards, enabling the trapezium to be separated from the carpus
+by cutting-pliers. The extensor tendons being relaxed by bending back
+the hand, the soft parts must be cleared from the carpus as far as
+possible towards the ulnar side.
+
+[Illustration: FIG. VI.[58]]
+
+_The ulnar incision_ (Plate IV. fig. B.) extends from two inches above
+the end of the ulna, in a line between the bone and the flexor carpi
+ulnaris, straight down as far as the middle of the palmar aspect of the
+fifth metacarpal. The dorsal lip of this incision is then raised, and
+the tendon of the extensor carpi ulnaris cut at its insertion, and
+reflected up out of its groove in the ulna along with the skin. The
+extensor tendons are then raised from the carpus, and the dorsal and
+lateral ligaments of the wrist divided, the tendons still being left as
+far as possible undisturbed in their relation to the radius. In front
+the flexor tendons are cleared from the carpus, the pisiform bone
+separated from the others though not removed, and the hook of the
+unciform divided by pliers. The knife must not go further down than the
+base of the metacarpal bones, in case of dividing the deep palmar arch.
+The anterior ligament of the wrist being now divided, the carpus and
+metacarpus are to be separated by cutting-pliers, and the carpus
+extracted by strong sequestrum forceps. By forcible eversion of the
+hand, the ends of radius and ulna can be protruded at the ulnar
+incision; as little as possible should be removed, consistent with
+removing all the disease. The ulna should be cut obliquely, leaving the
+base of the styloid process, and removing all the cartilage-covered
+portion. A thin slice of the radius is then to be cut also with the saw,
+so thin as to remove only the bevelled ungrooved portion, and leaving
+the tendons as far as possible undisturbed in their grooves. The ulnar
+articular facet is to be snipped off with bone-pliers. If the bones are
+more deeply carious, the diseased parts must at all hazards be removed
+with pliers or gouge. The metacarpal bones must then be treated in
+precisely the same way, their ends sawn off and their articular facets
+snipped off with the bone-pliers longitudinally. The trapezium is then
+to be seized by forceps and carefully dissected out, the metacarpal bone
+of the thumb pared like the others, the articular surface of the
+pisiform removed, the rest of the bone being left if it is sound. The
+radial incision is stitched closely throughout, and also the ends of the
+ulnar incision, any ligature being brought out through the centre of the
+ulnar incision, which is kept open with a piece of lint, which also
+gives support to the extensor tendons.
+
+The after-treatment is important, the principal specialities being--(1.)
+early and free movement of the fingers; (2.) secure fixing of the wrist
+to procure consolidation. (1.) By passive motion of the joints of the
+knuckles and fingers, commenced on the second day, and continued daily
+after the operation; (2.) By a splint supporting the fore-arm and hand,
+the fingers being held in a semiflexed position by a large pad of cork
+fastened firmly on to the splint and made to fit the palm; this prevents
+the splint from slipping up the arm, and by a turn of a bandage insures
+fixation of the wrist-joint. The anterior part of this splint below the
+fingers may be gradually shortened, allowing more and more passive
+motion of the fingers, but the patient must wear it for months, indeed,
+till he finds his wrist as strong without it as with it.
+
+Among the various operations that have been devised, the following
+require notice:--Mr. Spence, Dr. Gillespie, Dr. Watson, and the author,
+use a single dorsal incision with excellent results, and find it quite
+easy to remove all the bones from it. Mr. Spence had sixteen cases
+without a death.
+
+     POSTERIOR SEMILUNAR FLAP, from carpal attachment of metacarpal of
+     index finger round to styloid process of ulna; dividing integuments
+     only, then separating the tendons of the common extensor
+     longitudinally, and drawing them aside by blunt hooks, the diseased
+     bones are removed piecemeal by curved parrot-bill forceps.[59]
+
+     POSTERIOR CURVED FLAP.--An incision down to the carpal bones,
+     extended from a point two lines to the ulnar side of the extensor
+     secundi internodii pollicis, and from a quarter to half an inch
+     below the radio-carpal articulation, swept in a curvilinear
+     direction downwards, close to the carpal extremities of the
+     metacarpal bones, to a point just below the end of the ulna. The
+     flap thus marked out was dissected up, and consisted of the
+     integuments, areolar tissue, and extensor tendons of the four
+     fingers, together with large deposits of fibrine, the products of
+     repeated and prolonged inflammatory action. The tendon of the
+     second extensor and its soft parts around were separated from the
+     bones. The remains of the ligaments were cut, flexion of the hand
+     protruded the carious ends of radius and ulna. The bones were then
+     dissected out, leaving the trapezium, which was not diseased, and
+     hand placed on a splint.[60]
+
+
+EXCISION OF THE HIP-JOINT.--The question as to the propriety of
+performing this operation in any case is still debated by some surgeons,
+and the selection of suitable cases for the operation is greatly
+modified by the varying opinions of the different schools of surgery.
+Enough here to describe the method of operating, and the amount of the
+bone which is to be removed.
+
+As in the shoulder-joint, the head of the femur is much more liable to
+disease, and, as a rule, much earlier attacked than is the acetabulum,
+but unfortunately the acetabulum does eventually become affected also in
+probably a much larger proportionate number of cases than the glenoid.
+Caries of the head, neck, and trochanters of the femur is a very common
+disease in this variable climate, and frequently connected with the
+strumous taint. After much suffering, abscesses form and discharge,
+giving considerable pain, and often end by carrying off the patient. As
+a result of the abscess and destruction of the ligaments, the head of
+the bone is apt to be displaced, and under some sudden muscular exertion
+or involuntary spasm, consecutive dislocation of the femur (generally on
+to the dorsum ilii) very often occurs.
+
+In such a case the operation of excision of the head of the femur is by
+no means difficult, and not excessively dangerous, especially in young
+children.
+
+_Operation._--It is hardly necessary, or indeed possible, to lay down
+exact rules for the performance of this operation, in so far as the
+external incisions are concerned, for the sinuses which exist ought in
+general to be made use of.
+
+When the surgeon has his choice, a straight incision (Plate II. fig.
+A.), parallel with the bone, extending from the top of the great
+trochanter downwards for about two inches, and also from the same point
+in a curved direction with the concavity forwards, upwards towards the
+position of the head of the bone (see diagram), will be found most
+convenient. The incisions should be carried boldly down to the bone,
+which will often be felt exposed and bathed in pus, any remains of the
+ligamentous structures must be cautiously divided with a probe-pointed
+bistoury, and then by bringing the knee of the affected side forcibly
+across the opposite thigh, with the toes everted, the head of the bone
+is forced out of the wound. The head, neck, and great trochanter should
+be fully exposed, and the saw applied transversely below the level of
+the trochanter, so as to remove it entire. If this is not done, it
+prevents discharge, protrudes at the wound, and besides this it is
+almost invariably diseased along with the head. Chain saws are quite
+unnecessary, it being in most cases easy to apply an ordinary one to the
+bone, if it is properly everted.
+
+Great care in the after-treatment is required to prevent undue
+shortening of the limb, or in the event of a cure to secure the most
+favourable position for the anchylosis. The femur occasionally tends to
+protrude at the wound, and hence may require to be counter-extended by
+splints. If required at all, the splint should be made with an iron
+elbow opposite the wound to admit of its being easily dressed. In most
+cases counter-extension may be best managed by a weight and pulley.
+
+Various forms of hammock swings to support the whole body, and slings of
+leather or canvas to support the limb only, have been found to aid
+recovery, and render the patient much more comfortable.
+
+When the acetabulum is also diseased the prognosis is much more
+unfavourable than when it is sound.
+
+The experiments of Heine and J�ger on the dead body, and operations by
+Hancock, Erichsen, and Holmes, on patients, have shown that in cases of
+extensive disease of the acetabulum it is quite possible by a prolonged
+and careful dissection to remove it all without injury of the pelvic
+viscera.
+
+The details of incisions for such an operation need scarcely be given,
+as they must vary in each case with the amount of bone diseased, and the
+position of the already existing sinuses. The amount of bone that _may_
+be removed varies much. Erichsen in one case excised "the upper end of
+the femur, the acetabulum, the rami of the pubis, and of the ischium, a
+portion of the tuber ischii, and part of the dorsum ilii."[61]
+
+A less formidable proceeding may be useful in cases where the acetabulum
+is diseased, but not deeply. The moderate use of an ordinary gouge may
+succeed in removing the diseased bone.
+
+Experience and the cold evidence of statistics prove, however, that the
+prognosis in any case is modified very much for the worse by the
+presence of any disease of the acetabulum, more than one-half of the
+cases proving fatal in which it is diseased, whether attempts to remove
+the disease of the acetabulum be made or not, and that those cases do
+best in which the head of the femur has been displaced, and lies outside
+the joint almost like a loose sequestrum among the soft parts.
+
+The results of excision of the hip have as yet been very discouraging,
+the mortality of the whole series of published cases being, according to
+Dr. Hodge's careful table, very little under 1 in every 2 cases, viz., 1
+in 2-5/53. Later statistics are however more favourable.
+
+Like all other excisions, the mortality increases very much with the
+patient's age.
+
+Thus of 103 completed cases in which the age is given, 53 recovered and
+50 died, but dividing the cases at the end of the sixteenth year, we
+find that of the children below this age 43 recovered and 29 died, a
+mortality of 40.2 per cent.; of the adults, 10 recovered, and 21 died,
+or a mortality of 67.6 per cent.
+
+If we remember the marvellous power of recovery from joint diseases we
+find in childhood, under the influence of good diet, cod-liver oil, and
+fresh air, we cannot shut our eyes to the fact that such results and
+such a mortality are by no means encouraging.
+
+From an extensive experience in a special hospital for hip-disease,
+where fresh air, abundant nourishment, and very excellent nursing are
+provided, the author is learning more and more to trust to the power of
+nature in the cure of even very advanced cases of hip-disease in
+children, and he believes that operation is rarely necessary, or even
+warrantable, except for the removal of sequestra.
+
+     Mr. Holmes's[62] statistics are interesting. He has operated on no
+     fewer than nineteen cases. Of these seven died, one after secondary
+     amputation at the hip. Another required amputation and recovered.
+     Two others died of other diseases without having used their limb.
+     Of the remaining nine, three were perfectly successful, four were
+     promising cases, and two unpromising.
+
+     Professor Spence in 19 cases had 6 deaths, or a mortality of 31.6
+     per cent.
+
+     Culbertson's collection gives out of 426 cases, 192 deaths, or 45
+     per cent.
+
+     Mr. Croft, whose skill and success as an operator are well known,
+     has recorded 45 cases of excision of hip in his own practice; of
+     these 16 died, 11 were under treatment, 18 had recovered, of which
+     16 had moveable joints and useful limb; the other two are
+     "potentially cured."[63]
+
+     Various other incisions have been devised for gaining access to the
+     joint. The most noticeable are those in which a flap is made
+     instead of a linear incision. Sedillot makes a semilunar or ovoid
+     flap, the base of which is just below the great trochanter, and
+     which includes it, the convexity being upwards and the flap being
+     turned down. Gross's modification of this is preferable, being
+     turned the opposite way, the convexity being downwards (Plate III.
+     fig. E.), and the flap thus being turned up.
+
+_Results in successful cases._--Of fifty-two in Hodge's table,
+thirty-one had useful limbs, six indifferent, three decidedly useless,
+four died within three years, and of the remaining eight no details are
+given.
+
+The shortening is always considerable, a high-heeled shoe being required
+in most cases; a stick is indispensable; in many, crutches are
+necessary.
+
+     Various operations have been devised for the treatment of osseous
+     anchylosis of the hip-joint when in a bad position. All are more or
+     less dangerous. Perhaps one of the least dangerous is the plan of
+     subcutaneous division of the neck of the femur by a narrow saw,
+     proposed by Mr. Adams of London. It is sometimes a very laborious
+     operation.
+
+
+EXCISION OF KNEE-JOINT.--_Removal of Bone._--In every case the excision
+of the joint ought to be complete. Some attempts have been made to save
+one or other of the articular surfaces, but they have proved failures.
+The patella has frequently been left when it was not diseased, as is
+often the case, but the results have not been such as to recommend such
+a practice.
+
+_Direction of Section of the Bones._--The bones should be cut
+transversely, and, as far as possible, be in accurate and complete
+apposition. A slight bevelling at the expense of the posterior margin
+will produce an anchylosis of the limb in a very slightly flexed
+position, which is found to aid the patient in walking.
+
+It has been proposed by some[64] to cut both bones obliquely, so as to
+obviate the difficulty of making the transverse surfaces parallel. This
+involves a still greater practical difficulty in keeping these oblique
+surfaces in position during the after-treatment.
+
+This plan might possibly be valuable in cases where the disease was
+limited to one or other edge of the bone.
+
+Among the various incisions recommended, the best seems to be the
+_Semilunar Incision_.
+
+_Operation._--The limb being held in an extended position, a single
+semilunar incision (Plate I. fig. B.) is made, entering the joint at
+once, and dividing the ligamentum patell�. It should extend from the
+inner side of the inner condyle of the femur to a corresponding point
+over the outer one, passing in front of the joint midway between the
+lower edge of the patella and tuberosity of the tibia. The flap is then
+dissected back, the ligaments divided, when by extreme flexion of the
+limb the articular surface of the tibia and femur are thoroughly
+exposed. The crucial ligaments must then be divided cautiously, and the
+articular portion of the femur cleaned anteriorly by the knife,
+posteriorly by the operator's finger, so far as possible to avoid injury
+of the artery. The whole articular surface of the femur must then be
+removed by a transverse cut with the saw as exactly as possible at a
+right angle with the axis of the bone. The amount of the femur which
+will require removal will in the adult vary from an inch to an inch and
+a half or even more. It _must_ involve all the bone normally covered by
+cartilage; and this being removed, if the section shows evidence of
+disease, slice after slice may require removal till a healthy surface is
+obtained. Occasionally, if the diseased portion appears limited, though
+deep, the application of a gouge may succeed in removing disease without
+involving too great shortening of the limb. Specially in children, it is
+of great importance to avoid removing the whole epiphysis. The tibia
+must then be exposed in a similar manner, and a thin slice removed; if
+the bone be tolerably healthy, even less than half an inch will prove
+quite sufficient.
+
+This method has an immense advantage in that it provides an excellent
+anterior flap for the amputation, which may be required in cases where
+the disease of bone is found too extensive to admit of the excision
+being practised.
+
+This method, with slight deviations, is substantially that of Richard
+Mackenzie of Edinburgh, Wood of New York, Jones of Jersey.
+
+H�morrhage must then be stopped, and that as thoroughly as possible, by
+torsion, cold, and pressure, and the flap brought accurately together
+with sutures.
+
+In some rare cases, it may be found necessary to divide the hamstring
+tendons to rectify spastic contraction of the muscles; but this can
+generally be done quite well from the original wound.
+
+Holt makes a dependent opening in the popliteal space for drainage. This
+is unnecessary if the incisions are made sufficiently far back, and if
+the wound is properly drained. It is unsafe, as approaching so close to
+the artery and veins. If much bagging takes place, the use of a
+drainage-tube will prove quite sufficient.
+
+_After-treatment._--Wire splints lined with leather and provided with a
+foot-piece; special box-splints with moveable sides, as Butcher's;[65]
+plaster-of-Paris moulds are used by Dr. P.H. Watson[66] of Edinburgh and
+others; this last form of dressing is the best, and allows the limb to
+be suspended from a Salter's swing.
+
+H-_shaped incision._--The internal incision should commence at
+a point about two inches below the articular surface of the tibia, and
+in a line with its inner edge; it should then be carried up along the
+femur in a direction parallel to the axis of the extended limb, so as to
+pass in front of the saphena vein, and thus avoid it, for a distance of
+five inches. The external incision, commencing just below the head of
+the fibula, must be carried upwards parallel to the preceding for the
+same distance. Both incisions must be made by a heavy scalpel with a
+firm hand, so as to divide all the tissues down to the bone. The
+vertical incisions are then united by a transverse one passing across
+just below the lower angle of the patella. The flaps thus formed must
+then be dissected up and down, and the internal and external lateral
+ligaments divided, thus thoroughly opening the joint and exposing the
+crucial ligaments. These must be divided carefully, remembering the
+position of the artery. The bones are then to be cleared and divided, as
+in the operation already described. This is the method of Moreau and
+Butcher.[67]
+
+_Patella and Ligamentum Patell� retained._--"A longitudinal incision,
+full four inches in extent, was made on each side of the knee-joint,
+midway between the vasti and flexors of the leg; these two cuts were
+down to the bones, they were connected by a transverse one just over the
+prominence of the tubercle of the tibia, _care being taken to avoid
+cutting by this incision the ligamentum patell�_; the flap thus defined
+was reflected upwards, the patella and the ligament were then freed and
+drawn over the internal condyle, and kept there by means of a broad,
+flat, and turned-up spatula; the joint was thus exposed, and after the
+synovial capsule had been cut through as far as could be seen, the leg
+was forcibly flexed, the crucial ligaments, almost breaking in the act,
+only required a slight touch of the knife to divide them completely. The
+articular surfaces of the bones were now completely brought to view, and
+the diseased portions removed by means of suitable saws, the soft parts
+being hold aside by assistants."[68]
+
+Results of Excision of Knee-joint:--Holmes's Table of recent cases from
+1873-1878--
+
+             245 cases; 25 deaths, and 47 failures.
+    Spence's--33 cases; 22 recovered, 11 died.
+
+
+BUCK'S OPERATION FOR ANCHYLOSED KNEE-JOINT.--The principle of this
+operation is to remove a triangular portion of bone, which is to include
+the surfaces of the femur and tibia, which have anchylosed in an awkward
+position, and by this means to set the bones free, and enable the limb
+to be straightened. Access to the joint may be obtained by either of
+the two methods already described. Sections of the bones are then to be
+made with the saw, so as to meet posteriorly a little in front of the
+posterior surface of the anchylosed joint, and thus remove a triangular
+portion of bone; the portion still remaining, and which still keeps up
+the deformity, is then to be broken through as best you can, either by a
+chisel, or a saw, or forced flexion. The ends are to be pared off by
+bone-pliers, and the surfaces brought into as close apposition as
+possible. The operation is a difficult one, a gap being generally left
+between the anterior edges of the bones, from the unyielding nature of
+the integuments behind, and the difficulty of removing the posterior
+projecting edges from their close proximity to the artery. Of twenty
+cases on record, eight died, and two required amputation.
+
+_Relation of Age to result in Excision of Knee-Joint from Hodge's
+Tables._
+
+Of 182 complete cases:--
+
+     68 below 16 years: 50 recovered--18 died; or 26 per cent. died.
+    114 above 16 years: 55 recovered--59 died; or 51.7 per cent. died.
+
+
+EXCISION OF THE ANKLE-JOINT.--_In what cases is it to be done, and how
+much bone is to be removed?_
+
+In cases of compound dislocation of the ankle-joint, the tibia and
+fibula are apt to be protruded either in front or behind. When this
+happens it is a dislocation generally very difficult to reduce, and when
+reduced to retain in position. In such cases, if there seems to be any
+chance of retaining the foot, excision of the articular ends of tibia
+and fibula greatly add to the probabilities in its favour. It may be
+done without any new wound, and, in general, by an ordinary surgeon's
+saw.
+
+When the astragalus does not protrude, it seems to matter little for the
+future result whether its articular surface be removed or not. When, on
+the other hand, it protrudes, as a result either of the displacement of
+the entire foot, or of a dislocation complete or partial of the
+astragalus itself, there is no doubt that excision either of its
+articular surface or of the entire bone will give very excellent
+results. J�ger reports twenty-seven such cases, with only one fatal, and
+one doubtful result.
+
+_In cases of disease of the Ankle-joint._--Excision has been performed a
+good many times, and should in most cases be complete. A work like this
+is not the place to discuss the propriety of operations so much as the
+method of performing them, but one remark may be permitted. Few points
+of surgical diagnosis are more difficult than it is to tell whether in
+any given case disease is confined to the ankle-joint, and whether or
+not the bones of the tarsus participate. If they do even to a slight
+extent, no operation which attacks the ankle-joint only has any
+reasonable chance of success. It may look well for a time, but sinuses
+remain, the irritation of the operation only hastens the progress of the
+disease of the bone, and the result will almost certainly be
+disappointing, amputation being almost the inevitable _dernier ressort_.
+
+_Methods of Operating_:--
+
+_Mr. Hancock_ has been very successful by the following method:--
+
+Commence the incision (Plate II. figs. B.B.) about two inches above and
+behind the external malleolus, and carry it across the instep to about
+two inches above and behind the internal malleolus. Take care that this
+incision merely divides the skin, and does not penetrate beyond the
+fascia. Reflect the flap so made, and next cut down upon the external
+malleolus, carrying your knife close to the edge of the bone, both
+behind and below the process, dislodge the peronei tendons, and divide
+the external lateral ligaments of the joint. Having done this, with the
+bone-nippers cut through the fibula, about an inch above the malleolus,
+remove this piece of bone, dividing the inferior tibio-fibular
+ligament, and then turn the leg and foot on the outside. Now carefully
+dissect the tendons of the tibialis posticus and flexor communis
+digitorum from behind the internal malleolus. Carry your knife close
+round the edge of this process, and detach the internal lateral
+ligament, then grasping the heel with one hand, and the front of the
+foot with the other, forcibly turn the sole of the foot downwards, by
+which the lower end of the tibia is dislocated and protruded through the
+wound. This done, remove the diseased end of the tibia with the common
+amputating saw, and afterwards with a small metacarpal saw placed upon
+the back of the upper articulating process of the astragalus, between
+that process and the tendo Achillis, remove the former by cutting from
+behind forwards. Replace the parts _in situ_; close the wound carefully
+on the inner side and front of the ankle; but leave the outside open,
+that there may be a free exit for discharge, apply water-dressing, place
+the limb on its outer side on a splint, and the operation is completed.
+
+Skin, external, and internal ligaments, and the bones are the only parts
+divided, no tendons and no arteries of any size.[69]
+
+_Barwell's_ method by _lateral incisions_ is briefly as follows:--
+
+On the outer side, an incision over the lower three inches of the fibula
+turns forward at the malleolus at an angle, and ends about half an inch
+above the base of the outer metatarsal. The flap is to be reflected,
+fibula divided about two inches from its lower end by the forceps, and
+dissected out, leaving peronei tendons uncut. A similar incision on the
+inner side terminates over the projection of the internal cuneiform
+bone; the sheaths of the tendons under inner angle are then to be
+divided, and the artery and nerve avoided; the internal lateral
+ligament is then to be divided, the foot twisted outwards, so as to
+protrude the astragalus and tibia at the inner wound. The lower end of
+the tibia and top of the astragalus are to be sawn off by a
+narrow-bladed saw passing from one wound to the other.[70]
+
+Dr. M. Buchanan of Glasgow has described an operation by which the joint
+can be excised through a single incision over the external malleolus.
+
+_Results._--So far as can be gathered from cases already published, the
+results are very often (at least in one out of every two cases)
+unsatisfactory. Sinuses remain, which do not heal, the limbs are
+useless, and amputation is in the end necessary.
+
+Langenbeck has performed it sixteen times during the last
+Schleswig-Holstein war (in 1864), and the Bohemian war in 1866, with
+only three deaths. In these cases the operation was subperiosteal.
+
+
+EXCISION OF THE SCAPULA.--More or less of the scapula has in many cases
+been removed along with the arm, and even with the addition of portion
+of the clavicle.
+
+Excision of the entire bone, leaving the arm, has been performed in two
+instances by Mr. Syme. The procedure must vary according to the nature
+and shape of the tumour on account of which the operation is performed.
+Mr. Syme operated as follows:--
+
+In the first case, one of cerebriform tumour of the bone, he "made an
+incision from the acromion process transversely to the posterior edge of
+the scapula, and another from the centre of this one directly downwards
+to the lower margin of the tumour. The flaps thus formed being reflected
+without much h�morrhage, I separated the scapular attachment of the
+deltoid, and divided the connections of the acromial extremity of the
+clavicle. Then, wishing to command the subscapular artery, I divided
+it, with the effect of giving issue to a fearful gush of blood, but
+fortunately caught the vessel and tied it without any delay. I next cut
+into the joint and round the glenoid cavity, hooked my finger under the
+coracoid process, so as to facilitate the division of its muscular and
+ligamentous attachments, and then pulling back the bone with all the
+force of my left hand, separated its remaining attachments with rapid
+sweeps of the knife." (Plate III. fig. G.)
+
+Mr. Syme's second case was also one of tumour of the scapula; the head
+of the humerus had been excised two years before.
+
+He removed it by two incisions, one from the clavicle a little to the
+sternal side of the coracoid, directed downwards to the lower boundary
+of the tumour, another transversely from the shoulder to the posterior
+edge of the scapula. The clavicle was divided at the spot where it was
+exposed, and the outer portion removed along with the scapula.[71]
+
+The author has in a case of osseous tumour removed the whole body of the
+scapula, leaving glenoid, spine, acromion and anterior margin with
+excellent result and a useful arm.
+
+Large portions of the shafts of the humerus, radius, and ulna have been
+removed for disease or accident, and useful arms have resulted; but as
+the operative procedures must vary in every case, according to the
+amount of bone to be removed, and the number and position of the
+sinuses, no exact directions can be given.
+
+For very interesting cases of such resections reference may be made to
+Wagner's treatise on the subject, translated and enlarged by Mr. Holmes,
+and to Williamson's _Military Surgery_, p. 227.
+
+
+EXCISION OF METACARPALS AND PHALANGES.--To _excise_ the metacarpal
+implies that the corresponding finger is left. Except in cases of
+necrosis, where abundance of new bone has formed in the detached
+periosteum, the results of such excisions do not encourage repetition,
+the digits which remain being generally very useless. It is quite
+different, however, if it is the thumb that is involved; and every
+effort should, in every case, be made to retain the thumb, even in the
+complete absence of its metacarpal bone. For the good results of a case
+in which Mr. Syme excised the whole metacarpal bone for a tumour, see
+his _Observations in Clinical Surgery_, p. 38.
+
+The operation is not difficult, and requires merely a straight incision
+over the dorsum, extending the whole length of the bone.
+
+In the same way the proximal phalanx of the thumb may be excised, and
+yet, if proper care be taken, a very useful limb be left. I quote entire
+the following case by Mr. Butcher of Dublin:--
+
+
+EXCISION OF PROXIMAL PHALANX OF THE THUMB.--
+
+The thumb of the right hand was crushed by the crank of a steam-engine.
+The proximal phalanx was completely shivered; its fragments were
+removed, the cartilage of the proximal end of the distal phalanx, and
+also of the head of the metacarpal bone, were pared off with a strong
+knife. The digit was put up on a splint fully extended. In about a month
+cure was nearly complete, a firm dense tissue took the place of the
+removed phalanx, and the power of flexing the unguinal was nearly
+complete.[72]
+
+
+EXCISION OF THE JOINTS OF THE FINGERS.--These operations may be
+performed for compound dislocation, specially when the thumb is injured;
+no directions can be given for the incisions.[73]
+
+In cases of disease it is rarely necessary or advisable to attempt to
+save a finger, but if the metacarpo-phalangeal joint of the thumb be
+affected, excision should be performed with the hope of saving the
+thumb. A single free incision on the radial side of the joint will give
+sufficient access.
+
+
+EXCISION OF THE OS CALCIS.--In those comparatively rare cases in which
+the os calcis is alone affected, the rest of the tarsus and the
+ankle-joint being healthy, a considerable difference of opinion exists
+as to the proper course to be followed. By some surgeons it is
+considered best merely to gain free access to the diseased bone, and
+then remove by a gouge all the softened and altered portions, leaving a
+shell of bone all round, of course saving the periosteum and avoiding
+interference with the joint. This operation requires no special detailed
+instruction. We find many surgeons, among them Fergusson and Hodge,
+supporters of this comparatively modest operation. The author has many
+times performed this operation with excellent results. Even when nothing
+but periosteum is left, the new bone becomes strong and of full size.
+
+Excision of the whole of the diseased bone at its joints, with or
+without an attempt to leave some of the periosteum, has been deemed
+necessary by others. Holmes, who has had considerable experience,
+removes the bone at once by the following incisions, without paying any
+reference to the periosteum:--
+
+_Operation._--An incision (Plate III. fig. F.) is commenced at the inner
+edge of the tendo Achillis, and drawn horizontally forwards along the
+outer side of the foot, somewhat in front of the calcaneo-cuboid joint,
+which lies midway between the outer malleolus and the end of the fifth
+metatarsal bone. This incision should go down at once upon the bone, so
+that the tendon should be felt to snap as the incision is commenced. It
+should be as nearly as possible on a level with the upper border of the
+os calcis, a point which the surgeon can determine, if the dorsum of the
+foot is in a natural state, by feeling the pit in which the extensor
+brevis digitorum arises. Another incision is then to be drawn vertically
+across the sole, commencing near the anterior end of the former
+incision, and terminating at the outer border of the grooved or internal
+surface of the os calcis, beyond which point it should not extend, for
+fear of wounding the posterior tibial vessels. If more room be required,
+this vertical incision may be prolonged a little upwards, so as to form
+a crucial incision. The bone being now denuded by throwing back the
+flaps, the first point is to find and lay open the calcaneo-cuboid
+joint, and then the joints with the astragalus. The close connections
+between these two bones constitute the principal difficulty in the
+operation on the dead subject; but these joints will frequently be found
+to have been destroyed in cases of disease. The calcaneum having been
+separated thus from its bony connections by the free use of the knife,
+aided, if necessary, by the lever, lion-forceps, etc., the soft parts
+are next to be cleaned off its inner side with care, in order to avoid
+the vessels, and the bone will then come away.[74]
+
+Attempts may occasionally be made in such an operation to save a portion
+of periosteum in attachment to the soft parts, but success or failure in
+this seems to have very little effect on the future result.
+
+     _Hancock's Method._--A single flap was formed in the sole, with the
+     convexity looking forwards, by an incision from one malleolus to
+     the other.
+
+     _Greenhow's Method._--Incisions made from the inner and outer
+     ankles, meeting at the apex of the heel, and then others extending
+     along the sides of the foot, the flaps being dissected back so as
+     to expose the bone and its connections.[75]
+
+
+EXCISION OF ASTRAGALUS.--A curved incision on the dorsum of the foot
+extending from one malleolus to the other, and as far forwards as the
+front of the scaphoid. The chief caution required is to divide all
+ligaments which hold the bone in place, and dissect it clean on all
+other parts before meddling with its posterior surface where the groove
+exists for the flexor longus pollicis tendon near which the posterior
+tibial vessels and nerve lie.[76]
+
+
+EXCISION OF ASTRAGALUS AND SCAPHOID.--An incision similar to the
+anterior one in Syme's amputation at the ankle. The flap was then turned
+back from the dorsum of the foot. The joint was then opened, the lateral
+ligaments of the ankle-joint divided, the foot dislocated so as to show
+the astragalo-calcanean ligaments, and allow them to be divided. The
+bones were then grasped with the lion-forceps and pulled forwards, while
+the posterior surface of the astragalus was very cautiously cleaned, so
+as to avoid the posterior tibial artery.[77]
+
+
+EXCISION OF METATARSO-PHALANGEAL JOINT OF GREAT TOE.--Butcher performs
+it by splitting up the sinuses leading to the carious joint, exposing it
+and cutting off with bone-pliers the anterior third of the metatarsal
+bone, and the proximal end of the first phalanx. He also cuts
+subcutaneously the extensor tendons to prevent them from cocking up the
+toe.[78] Pancoast prefers a semilunar incision. A lateral incision is
+usually to be preferred.
+
+The author has performed this excision frequently for disease; when the
+whole cartilages are removed and the wound is freely drained, an
+admirable result is obtained.
+
+In cases of compound dislocation of the head of the metatarsal bone, it
+will occasionally be found necessary to excise it either by the
+original, or a slightly enlarged wound.
+
+The author lately excised one-half of shaft of metatarsal and the
+corresponding half of proximal phalanx of great toe for exostosis, with
+antiseptic precautions. The result was a useful toe with a _mobile
+joint_.
+
+
+EXCISION OF METATARSAL BONE OF GREAT TOE.--For this operation a
+quadrilateral flap has been recommended, but this is quite unnecessary.
+A single straight incision along the inner border of the foot, extending
+the whole length of the bone, renders it very easy to remove the whole
+bone from joint to joint. This is an operation, however, which is rarely
+needed, and which would leave a very useless flail of a toe. The
+operation, which is at once more commonly required, and also gives
+promise of a more satisfactory result, is the one performed for
+cario-necrosis of the shaft only, and in the following manner:--
+
+A straight incision through all the tissues, including the periosteum,
+right down to the bone; then with nail or handle of the knife to
+separate the periosteum from the bone; then with a pair of bone-pliers
+or a fine saw to divide the shaft from both its extremities and remove
+it entire.[79]
+
+
+FOOTNOTES:
+
+[52] _On Diseases and Injuries of Joints_, p. 121.
+
+[53] For a very large amount of most interesting and valuable
+information on the whole subject of excisions of joints, I would refer
+to Dr. Hodge's most excellent work on this subject--_On Excisions of
+Joints_. By Richard M. Hodge, M.D., Boston, Massachusetts.
+
+[54] See Syme's _Observations on Clinical Surgery_, pp. 55, 57; Hodge
+_on Excision of Joints_, p. 63.
+
+[55] Maunder's _Operative Surgery_, 2d ed. p. 123.
+
+[56] _Edin. Med. Journal_, May 1873.
+
+[57] Quoted by Mr. Porter. _Dublin Quarterly Journal_ for May 1867, p.
+264.
+
+[58] A-A. Deep palmar arch; B. Trapezium; C. Articular surface of ulna;
+Dotted lines include the amount removed in Lister's earlier operations;
+Unshaded portions are those removed by Lister in cases where the disease
+is limited to the carpus. (Reduced from Lister's diagram in _Lancet_,
+1865.)
+
+[59] Skey, _Op. Surg._, 2d ed. p. 438.
+
+[60] Abridged from Butcher, _Op. and Con. Surgery_, p. 208.
+
+[61] _Science and Art of Surgery_, 3d ed. p. 745.
+
+[62] _On the Surgical Treatment of Children's Diseases_, pp. 454-6.
+
+[63] _Clinical Society's Transactions_, vol. xiii. p. 71.
+
+[64] Billroth of Vienna and Pelikan of St. Petersburg, quoted from
+Heyfelder by Hodge _on Excision of Joints_, p. 161.
+
+[65] _Operative and Conservative Surgery_, pp. 28, 138.
+
+[66] _On Excision of Knee-Joint_, pp. 18, 20.
+
+[67] _Operative and Conservative Surgery_, p. 169.
+
+[68] Mr. Jones of Jersey, _Med. Chir. Trans._, vol. xxxvii. p. 68.
+
+[69] _Lancet_, Oct. 1, 1859.
+
+[70] Barwell _On Diseased Joints_, p. 464.
+
+[71] Syme _On Excision of the Scapula_, pp. 13-26, 1864.
+
+[72] Butcher's _Operative and Conservative Surgery_, p. 225.
+
+[73] For an excellent case, see Annandale on _Diseases of the Finger and
+Toes_, p. 261.
+
+[74] Holmes's _Surgery_, 3d edition, vol. iii. p. 771.
+
+[75] _Brit. and Foreign Med. Chir. Review_ for July 1853.
+
+[76] Mr. Holmes in _Lancet_ for February 18, 1856.
+
+[77] _Ibid._ for May 1865.
+
+[78] Butcher, _Operative and Conservative Surgery_, p. 354.
+
+[79] See Butcher, _Operative and Conservative Surgery_, p. 356.
+
+
+
+
+CHAPTER IV.
+
+OPERATIONS ON CRANIUM AND SCALP.
+
+
+TREPHINING AND TREPANNING are the names given to operations for the
+removal of portions of the cranium by circular saws which play on a
+centre pivot. When the motion is given to the saw simply by rotation of
+the hand of the operator, as is common in this country, it is called
+_trephining_; when (as used to be the case in this country, and still is
+on the Continent) the motion is given by an instrument like a
+carpenter's brace, the operation is called _trepanning_.
+
+The nature of the operation varies according to the nature of the case
+for which it is performed. Thus (1.) it may be performed through the
+uninjured cranium in the hope of evacuating an abscess of the diploe or
+dura mater, or of relieving pressure caused by suppuration in the brain
+itself, or by extravasation into the brain or membranes; or (2.) it may
+be required in cases of punctured and depressed fracture for the purpose
+of removing projecting corners of bone and allowing elevation of the
+depressed portions; or (3.) it is sometimes used to remove a circular
+portion of bone in cases of epilepsy in which pain or tenderness is felt
+at some limited portion of the cranium.
+
+1. _In cases where the cranium and its coverings are entire._--There are
+certain positions where, if it is possible, the trephine should _not_ be
+applied. These are the longitudinal sinus, the anterior inferior angle
+of the parietal bone, where the middle meningeal artery is in the way,
+the occipital protuberance, and the various sutures. These being
+avoided, a crucial incision is to be made through the skin, and its
+flaps reflected. The pericranium should then be raised from the centre,
+for a space large enough to hold the crown of the trephine. The
+pericranium should never be removed, but carefully raised and preserved,
+as its presence will greatly aid in the restoration of bone.[80] The
+centre pin should then be projected for about the eighth of an inch and
+bored into the bone. On it as a centre the saw is then worked by
+semicircular sweeps in both directions alternately, till it forms a
+groove for itself. Whenever this groove is deep enough the pin should be
+retracted, lest from its projection it pierce the dura mater before the
+tables of the skull are cut through. Were the cranium always of the same
+thickness, and even of similar consistence, the operation would always
+be exceedingly easy; but in both these particulars different skulls vary
+much from each other, and thus by a rash use of the instrument the dura
+mater may possibly be injured. The tough outer table is more difficult
+to cut than the softer and more vascular diploe, and the inner table is
+denser than either, but more brittle. In many old skulls, however, the
+diploe is wanting altogether, and the two tables are amalgamated, and
+often very thin.
+
+Great care must be taken in every case to saw slowly, to remove the
+sawdust, and examine the track of the saw by a probe or quill, lest one
+part should be cut through quicker than another. The last turns of the
+instrument must specially be cautious ones. When the disk of bone does
+not at once come away in the trephine, the elevator or the special
+forceps for the purpose will easily remove it. If the abscess,
+extravasation, or exostosis be then discovered and removed, all that
+remains is to remove any sawdust or loose pieces of bone, and possibly
+to smooth off any sharp edges of the orifice by an instrument called the
+lenticular. This is very seldom required, and now hardly ever used.
+
+2. _In cases of depressed or punctured fracture_ the trephine is
+occasionally required (when symptoms of compression are present) for the
+purpose of enabling the depressed portion to be elevated. It is unsafe
+to apply it to the depressed or fractured bone, lest the additional
+pressure of the instrument should cause wound of the dura mater or
+brain. It is generally applied on some projecting corner of sound bone
+under which the depressed portion is locked, and hence it is rarely
+necessary to remove a complete circular portion. In fact very many cases
+of such displacement may be remedied more easily by a pair of strong
+bone-forceps, or a Hey's saw, applied to remove the projecting portion
+of sound bone. The same precautions must be used as in the operation
+already described, and the sawing must be done even more cautiously, as
+it is rarely more than a semicircle that requires cutting.
+
+In former days trephining was a much more frequent operation than it is
+now, and apparently more successful. The reason of the greater apparent
+success can easily be found in the fact that it was performed in many
+cases merely as a precautionary measure against dreaded inflammation of
+the brain, which probably never would have appeared at all, and that the
+operation itself is one by no means dangerous. Very numerous
+applications of the trephine have been made in the same individual--two,
+four, six, and even in one case twenty-seven disks having been removed
+from the same skull, and yet the patients have survived.
+
+
+TUMOURS OF THE SCALP, _Removal of_.--By far the most frequent are the
+encysted tumours, or wens. These consist of a thick firm cyst-wall,
+which contains soft, curdy, or pultaceous matter, sometimes almost
+fluid, at others dry and gritty. They are loosely attached in the
+subcutaneous cellular tissue, and unless they have become very large, or
+have been much pressed on, are non-adherent to the skin.
+
+The treatment is thus very simple. They should merely be transfixed by a
+sharp knife, the contents evacuated, and the cyst seized by strong
+dissecting forceps and twisted out.
+
+If they have once become adherent, they must be dissected out in the
+usual manner, after the adherent portion of skin has been defined by
+elliptical incisions.
+
+In the case of large wens on visible parts of scalp or face, the author
+avoids scar, by the following plan:--
+
+Make a small incision, two lines at most, through skin only, then with a
+blunt probe separate the cyst from the skin subcutaneously; then,
+pulling it to the wound with catch-forceps, empty the cyst and gradually
+pull it out, as if taking out an ovarian cyst. No scar but a dimple will
+remain.
+
+
+FOOTNOTES:
+
+[80] See case by the author in the _Edin. Med. Jour._ for June 1868.
+
+
+
+
+CHAPTER V.
+
+OPERATIONS ON EYE.
+
+_Operations on the Eye and its Appendages._
+
+
+OPERATIONS ON THE LIDS.--
+
+[Illustration: FIG. VII.[81]]
+
+[Illustration: FIG. VIII.[82]]
+
+1. FOR ENTROPIUM OR INVERSION OF THE LIDS, OFTEN COMBINED WITH
+TRICHIASIS, IRREGULARITY OF THE CILI�.--As in many cases the entropium
+seems to depend partly on a too great laxity of the skin of the lid,
+combined occasionally with spasm of the orbicularis, the simplest and
+most natural plan of operation is (_a_) to remove (Fig. VII. _a_) an
+elliptical portion of skin, extending transversely along the whole
+length of the affected lid, including the fibres of the orbicularis
+lying below it, and then to unite the edges with several points of fine
+suture. (_b_) An improvement on this in obstinate cases is proposed by
+Mr. Streatfeild (Fig. VIII.) He continues the same incision, but in
+addition removes a long narrow wedge-shaped portion of the tarsal
+cartilage, grooving it without entirely cutting it through, in such a
+manner that the retraction of the skin bends the cartilage backwards,
+thus everting to a very considerable extent the previously inverted
+cili�.[83]
+
+2. ECTROPIUM is the opposite condition from entropium; in it the eyelids
+are everted and the palpebral conjunctiva is exposed.
+
+If the result of cicatrix, of a burn, or of disease of bone, the
+treatment must be varied according to circumstances, and in many cases,
+skin must be transplanted to fill the gap.
+
+In the more usual cases resulting from chronic inflammation the
+following simple operations are required:--1. In mild cases the excision
+of an elliptical portion of conjunctiva may suffice, the edges must not
+be left to contract, but should be brought carefully together. 2. In
+more chronic cases, where all the tissues of the lid are very lax, it is
+necessary to remove (Fig. VII. _b_) a V-shaped portion of lid and skin,
+and then stitch it very carefully up with interrupted sutures.
+
+
+TUMOURS OF EYELIDS.--1. _Encysted tumours; cysts of the lids; tarsal
+tumour._--Under these and similar names are recognised a very frequent
+form of disease, chiefly in the upper lid: small tumours which rarely
+exceed half a pea in size, convex towards the skin, which is freely
+moveable over them; they give no pain, and are annoying only from their
+bulk and deformity.
+
+_Operation._--Evert the lid, incise the conjunctiva freely over the
+tumour, insert the blunt end of a probe and roughly stir up the contents
+of the cyst, thus evacuating it. If the tumour is large and of old
+standing it may be requisite to cut out an elliptical or circular
+portion of its conjunctival wall. The probe may require to be reapplied
+once or twice at intervals of two or three days, and in certain rare
+cases it may be necessary as a last resource freely to cauterise the
+inside of the cyst with the solid nitrate of silver.
+
+In _no_ case is it ever necessary to excise the tumour from the outside
+of the eyelid; when this has been done in error there frequently remains
+an awkward and unsightly scar.
+
+2. _Fibrous cysts_, frequently congenital, are met with in one
+situation, just over the external angular process of the frontal bone.
+These are larger in size than the preceding, ranging from the size of a
+barley pickle to that of an almond. Their treatment is excision by a
+prolonged and careful dissection from the periosteum, to which they
+almost invariably are adherent.
+
+
+OPERATIONS ON THE LACHRYMAL ORGANS.--In a system of ophthalmic surgery,
+various operative procedures might be detailed under this head,
+authorised and sanctioned by old custom. Excision of a diseased
+lachrymal gland, and removal of stones in the gland or ducts, need no
+special directions for their performance, and the operation immediately
+to be described, under the head of Mr. Bowman's operation, is applicable
+in almost every one of the diseased conditions of the lachrymal canal,
+sac, and nasal duct, to the exclusion of all the older methods.
+
+_Mr. Bowman's Operation._--In cases of obstruction of the punctum,
+canaliculus, and nasal duct, resulting in watery eye, accumulation of
+mucus in the canal, and dryness of the nose, great difficulty used to be
+experienced in the treatment. To pass a probe along the punctum was
+extremely difficult, in fact, possible only with a very small one, while
+the common operation of opening the dilated sac, through the skin, and
+then passing probes through this artificial opening, was found quite
+useless from the rapid closure of the wound, unless the treatment was
+followed up by the insertion and retention of a style in the nasal
+duct. This was painful, unsightly, often unsuccessful; and even in some
+cases dangerous, from the amount of irritation, suppuration, and even
+caries of the nasal bones which is set up.
+
+The principle of Mr. Bowman's most excellent operation is, that the
+punctum, canaliculus, and nasal duct resemble in many respects the
+urethral passage, and in cases of stricture require to be treated on the
+same principle. If, then, it were possible to pass instruments gradually
+increasing in size through the seat of stricture, it would be gradually
+dilated. It is, however, in the normal state of parts, impossible to
+pass any instrument beyond the size of a human hair past the curve which
+the canaliculus makes on its entrance to the duct, hence the proper
+dilatation cannot be performed. Again, it is found that the puncta,
+specially the lower one, are themselves very often to blame, in cases of
+watery eye, sometimes because they are inverted or everted, more often
+because, sympathising with the lid, they are turgid, angry, and
+inflamed, pouting and closed like the orifice of the urethra in a
+gonorrhoea.
+
+Mr. Bowman found that by slitting up the inferior punctum and
+canaliculus as far as the caruncula, several advantages were
+gained:--(1.) The swollen, angry, displaced punctum no longer impeded
+the entrance of the tears; (2.) and chiefly when the canaliculus was
+slit up, the curve, or rather angle, which impeded the passage of
+probes, was done away with, and the nasal duct could be readily and
+thoroughly dilated.
+
+_Operation._--The surgeon stands behind the patient, who is seated, and
+leans his head on the surgeon's chest. The affected lid is then drawn
+gently downwards on the cheek, so as to evert and thoroughly expose the
+lower punctum. Into this the surgeon introduces a fine probe of steel
+gilt, the first inch of which is very thin, especially at the point, and
+deeply grooved on one side, exactly like a small (and straight) Syme's
+stricture director.
+
+Keeping the canal relaxed by relaxing his hold on the lid, the surgeon
+now gently wriggles the probe along the canaliculus, gradually
+stretching it as the probe advances, so as to avoid catching of the
+sides of the canal before the point of the instrument, till he is
+satisfied that it has fairly entered the nasal duct. He then stretches
+the eyelid, brings the handle of the probe out over the cheek so as to
+evert the punctum as much as possible, and then with a fine
+sharp-pointed knife enters the groove (Fig. IX.), and fairly slits up
+the punctum and the canal to the full extent. The incision should be as
+straight as possible, and through the upper wall of the canaliculus. A
+dexterous turn of the instrument upwards on the forehead will generally
+enable it to be passed at once fairly into the nose through the nasal
+duct, the usual rule being observed of passing it downwards and slightly
+backwards, the handle of the probe passing just over the supraorbital
+notch.
+
+[Illustration: FIG. IX.[84]]
+
+For several days after the operation the probe will have to be passed,
+both to prevent the wound in the canaliculus from healing up, which it
+is too apt to do, and also to gradually dilate the nasal duct if it has
+been previously strictured. Probes and directors of various sizes are
+required; in fact very much the same instruments (in miniature) as are
+required for the treatment of stricture of the urethra.
+
+Mr. Greenslade has invented a very ingenious little instrument, of
+which, through his kindness, I am able to show a woodcut (Fig. X.), for
+slitting up the canaliculus without having to fit the knife in the
+groove.
+
+[Illustration: FIG. X.]
+
+PTERYGIUM, the reddish fleshy triangular growth, with its base at the
+inner canthus, and its apex spreading to and often over the cornea,
+requires invariably a small operation for its removal. In most cases it
+will be found sufficient merely to raise the lax portion over the
+sclerotic with forceps, and divide it freely, removing a transverse
+portion. If it has encroached upon the cornea, the portion interfering
+with vision must be dissected off with great care and removed.
+
+In some cases, however, it has been found that after removal of a large
+pterygium, a retraction of the caruncle and the semilunar fold is apt to
+take place, which renders the eyeball unpleasantly prominent. To avoid
+this the pterygium may be carefully dissected up from its apex to near
+its base, and then displaced laterally either upwards or downwards, its
+apex and sides being stitched to a previously prepared site of
+conjunctiva.
+
+
+OPERATION FOR CONVERGENT STRABISMUS.--_Division of the internal
+rectus._--_Subconjunctival operation._--The spring-wire speculum (C)
+separating the lids, the surgeon divides the conjunctiva by a pair of
+scissors in a horizontal line (Fig. XI. A A) from the inner margin of
+the cornea, a little below its transverse diameter to the caruncle,
+then snipping through the sub-conjunctival tissue, he passes a blunt
+hook bent at an obtuse angle under the tendon of the internal rectus,
+and endeavours by depressing the handle to project the point of the hook
+at the wound. Then with successive snips of the scissors he divides the
+tendon on the hook, close to its sclerotic margin. Lest it should not be
+freely divided, various dips with the hook may be made to catch any
+stray fibres left untouched; but very great care should be taken not to
+wound the conjunctiva beyond the first horizontal cut in it. The tendon
+being divided satisfactorily, the edges of conjunctiva should be
+replaced, and the eye closed for a few hours.
+
+[Illustration: FIG. XI.[85]]
+
+The original operation of Dieffenbach, now rarely practised, consisted
+in making an incision, B B, across the tendon, then, by cutting the
+areolar tissue exposing the insertion of the tendon, and dividing it
+freely; after which the sclerotic in the neighbourhood was to be cleaned
+and any band of fibres divided. There are risks on the one hand of a
+most unseemly exophthalmos with divergent squint, and on the other of a
+retraction of the semilunar fold, so that the sub-conjunctival operation
+is always preferable.
+
+
+OPERATIONS FOR DIVERGENT SQUINT.--This very serious deformity is often
+the result of the operation for convergent squint, and is associated
+with a fixed, leering, and prominent eye, and frequently with most
+annoying double vision.
+
+1. In a simple case of primary divergent strabismus (very rare) it is
+sufficient simply to divide the external rectus in the manner already
+described for division of the internal.
+
+2. If secondary to an operation for convergent squint, the indication is
+to restore the cut internal rectus to a position on the sclerotic a
+little behind its previous one, as the cause of the divergence is found
+in a complete detachment of the internal rectus. This is attempted in
+various ways.
+
+(1.) _Jules Gu�rin_ carefully divided the conjunctiva over it, and
+sought for the remains of the internal rectus, freeing it from its
+attachments. He then passed a thread through the sclerotic on the
+_outer_ side of the globe, and by pulling on it and fixing it across the
+nose, rotated the eye inwards, in the hope that the remains of the
+internal rectus would secure a new attachment.
+
+(2.) _Graefe's modification_ of this is more certain. Without any minute
+dissection he merely separated the internal rectus, along with the
+conjunctiva, and fascia over it, so that it can be pulled forwards, then
+cut the external rectus, and inverted the eyeball to a sufficient extent
+by means of a thread passed through the portion of the tendon of the
+external rectus, which remains attached to the sclerotic. The risk of
+all these operations, in which both muscles are divided, is protrusion
+of the eyeball from the removal of muscular tension.
+
+(3.) _Solomon's operation for the radical cure of extreme divergent
+strabismus_,[86] is at first sight a very curious one. Without going
+into all the details, the steps are as follows:--
+
+_a._ A square-shaped flap, with its attached base at the nasal side, is
+raised, containing the remains of the inner rectus and its adjacent
+parts.
+
+_b._ A flap similar in shape and size, but different in the position of
+its attached base, is made on the other side of the cornea. It is made
+by dividing the external rectus just behind its tendon, and then
+reflecting forwards the tendon with its conjunctiva.
+
+_c._ These two flaps are united over the vertical meridian of the cornea
+by sutures, three generally being sufficient. This entirely hides the
+cornea for a time, but eventually shrivels and contracts, and the
+remnants are to be cut off with scissors three weeks after the
+operation.
+
+
+PUNCTURE OF THE CORNEA.--_Paracentesis of the Anterior
+Chamber._--_Tapping of the Aqueous Humour._--This very simple operation
+is in many cases extremely useful. In cases of corneal ulcer, the result
+either of injury or disease, where there is much pain in the bone, and
+evidence of tension of the globe, it gives great relief, and when
+repeated at short intervals greatly hastens a cure. Sperino of Turin
+recommends its frequent use in cases of chronic glaucoma.
+
+_Operation._--The surgeon stands behind the patient, who is seated; the
+lids being fixed, the upper by the surgeon's left hand, and the lower by
+an assistant, the cornea is punctured a little in front of the sclerotic
+margin, either with a broad needle, or, what is as good, a well-worn
+Beer's knife. Care must be taken on entering the knife, on the one hand,
+not to wound the iris, which is sometimes arched forwards in the cases
+of commencing glaucoma, and, on the other, fairly to enter the anterior
+chamber, not merely split up the layers of the cornea. On withdrawing
+the cataract knife, the aqueous humour gets out by its side, aided by a
+slight turn of the knife, sometimes with great force, and in much larger
+quantity than usual. If the operation has been done by a needle, a blunt
+probe requires to be introduced on the removal of the needle. Once
+punctured, the remarkable fact is that the same wound suffices for many
+succeeding tappings, which are effected by pressing the probe into the
+wound day after day, sometimes several times a day, with great relief
+to the symptoms. If the probe is to be used for succeeding evacuations,
+the operator must be careful to remember the exact spot at which the
+needle or knife was entered. To facilitate remembering it, it is best,
+when nothing prevents it, to operate always in the same spot. Sperino
+chooses the horizontal meridian of the cornea at the temporal side, at
+the junction of the cornea and sclerotic.
+
+
+CATARACT OPERATIONS.--Here we cannot enter into any discussion of the
+pathology of cataract and the varieties of it. Enough for our purpose to
+know that the lens is in some cases hard, in others soft, and that thus
+in the latter it may be removed piecemeal, and by a small incision,
+while in the former, removal must be almost entire, and by a larger
+opening.
+
+In cataract, the lens, which should be transparent, has become opaque,
+and the object of treatment is to get it out of the line of sight, to
+prevent it from obstructing, now that it can no longer assist sight.
+
+The operations used for this end may be classed under three heads:--
+
+1. _Operations for the removal of the lens out of the way without its
+removal from the eye._--These used to be extensively practised under the
+name couching, and are of two kinds,--_Depression_, where the lens is
+simply pushed down from its place by a needle; _Reclination_, in which
+it is shoved backwards (turning on its transverse axis) as well as
+downwards. These are relics of old surgery, and very rarely practised by
+any oculists of eminence, as, though easy to perform, and with very
+flattering immediate results, the risks of chronic inflammation of the
+whole globe and injury to the retina are very great.
+
+2. _For solution._--THE NEEDLE OPERATION.--Suitable (among other cases)
+especially in congenital cataracts in infants, and in cases of diabetic
+cataract.
+
+The principle of this operation is that the lens, once the capsule is
+freely opened in front and the aqueous humour admitted, is found rapidly
+to become absorbed and disappear, if the cataract has been a soft one.
+
+_Operation._--A needle with a lance-shaped head is to be used. It should
+be so made that the rounded shaft of the needle is just large enough to
+play freely in the wound made by the broader point, and yet not so small
+as to allow the aqueous humour to escape rapidly. The pupil has been
+dilated, the patient is lying on his back, and the globe is fixed by
+forceps attached to the conjunctiva of the inner side of the eye, and
+held by an assistant. The surgeon then enters the needle close to the
+sclerotic margin of the cornea, carries it fairly on in the anterior
+chamber, till the centre of the pupil is reached. He then, by bringing
+forward the handle, projects the point backwards against the anterior
+capsule, which he freely lacerates with the point and edge in several
+directions.
+
+In infants, where processes of repair go on very rapidly, the whole lens
+may be freely broken up. In diabetic cataract, or indeed in all cases of
+solution, where the patient is adolescent or adult, or the eye at all
+weak, only a small portion of the lens should be attacked at one
+sitting.
+
+The needle should then be withdrawn gradually and with great care, that
+the broad axis of the blade be in exactly the same position in which it
+entered, _i.e._ flat and parallel with the iris, lest the iris be
+wounded, entangled, or prolapsed.
+
+The eye is then to be closed for twenty-four hours; if there is much
+pain, atropia must be freely used.
+
+_Varieties in the Operation._--Some use two needles at once for breaking
+up the lens. Some surgeons prefer to enter the needle through the
+sclerotic; this complicates the operation and renders it less certain,
+as the point of the needle is of course out of sight in its progress
+between the iris and the lens.
+
+Even in children this operation requires in most cases to be repeated at
+least once, while in adults it may be required at short intervals for
+many months.
+
+3. _By Extraction._--In these operations the lens is at once removed
+from the eye--
+
+(1.) By linear, or perhaps, more correctly, rectilinear incision. This
+method is specially suited for cases of soft cataract.
+
+_Operation._--A fine spear-shaped needle is very cautiously introduced
+through the cornea, about a line from its outer margin, and the anterior
+capsule lacerated, and the lens broken up, great care being taken not to
+injure the posterior capsule. The pupil must then be kept freely
+dilated, the wound heals at once, and the aqueous humour reaccumulates.
+
+[Illustration: FIG. XII.]
+
+[Illustration: FIG. XIII.]
+
+From three to six days after this first operation, a linear incision
+(Fig. XII.) is made in the outer side of the cornea by a straight stab
+from a double-edged knife, or rather spear. The size of the incision
+must vary with the size and consistence of the lens, and can be
+regulated by the breadth of the knife and the distance to which it is
+entered. By careful withdrawal of the knife, in many cases a large
+portion of the soft lens can be removed along with it, and then what
+remains must be cautiously lifted out by a flat spoon introduced through
+the wound, and behind the remains of the lens.
+
+Care must be taken lest any of the lens substance remain in the wound;
+with this precaution the incision generally heals rapidly, and with much
+less risk of general inflammation of the ball than in the ordinary flap
+operation of extraction.
+
+     EXTRACTION OF SOFT CATARACT BY SUCTION.--Mr. T. P. Teale, of
+     Leeds,[87] has invented an instrument by which the removal of soft
+     cataract is made more easy, through a linear incision by suction,
+     applied through the medium of a hollow curette furnished with an
+     india-rubber tube and mouth-piece.
+
+     The curette is of the usual size, but is roofed in (instead of
+     being merely grooved) to within one line of its extremity, thus
+     forming a tube flattened above, but terminating in a small cup.
+     This is screwed into an ordinary straight handle, which is hollow
+     for a short distance, far enough to join with a second tube fixed
+     at right angles to the handle, and into which the india-rubber pipe
+     and mouth-piece, through which suction is to be made, is attached.
+     In many cases it seems to serve its purpose extremely well.
+
+     Certain points require attention:--1. That the puncture to admit
+     the curette is large enough; 2. That its end be sufficiently
+     rounded; 3. Its open end must be held in the area of the pupil, and
+     not allowed to pass behind the iris, else there is great risk of
+     the iris being drawn in. Among other advantages claimed by its
+     inventor, the chief seems to be a more thorough removal of the lens
+     than by the ordinary means, and consequently less risk of opaque
+     deposit in the posterior capsule.
+
+(2.) EXTRACTION BY FLAP.--When properly performed in a suitable subject,
+and when free from accident, this operation is one of the most
+thoroughly beautiful and satisfactory in the whole domain of surgery;
+but it is difficult, and liable to many risks which neither skill nor
+caution can completely guard against.
+
+It is required in many cases of hard cataract, which are amenable
+neither to solution nor linear extraction.
+
+_Operation_ must be considered in various stages:--
+
+_a._ To make a flap of cornea large enough to permit of the removal of
+the entire lens without pressure or bruising. To make it of cornea only,
+to prevent the escape of the vitreous, and to avoid injury of the iris.
+
+The great difficulty in making the required section of the cornea is,
+that we are debarred from using scissors or any ordinary knife or
+scalpel in making it, for this reason, that the sawing movements
+required in all ordinary cutting are inadmissible here, as any
+withdrawal of the blade, however slight, would permit evacuation of the
+aqueous humour, and at once be followed by prolapse of the iris before
+the knife. Hence we are compelled to make the requisite flap by one
+steady push of a knife, which, too, must be of such a shape as in its
+entrance constantly to fill up the wound it makes. Very various shapes
+and sizes of knives have been proposed, the one called Beer's knife
+being the sort of model or common parent from which all the others are
+derived. It is triangular in shape, with a straight back, about 12-10ths
+of an inch in length, and 4-10ths broad at the base of the blade,
+tapering at a straight edge from its base to its point, and also
+diminishing in thickness to the point.
+
+Considerable difference of opinion exists as to the relative merits of
+an upper or lower section of the cornea. The general view at present
+seems to be that an upper section is to be preferred; but in cases where
+the surgeon is not ambidexterous, it is better that he should make the
+section which lies easiest to his hand than attempt an upper section in
+a less favourable position.
+
+The patient should be placed flat on his back, the lids should be gently
+opened, the upper one by the surgeon, the lower one by his assistant,
+who is to press the lid downwards against the malar bone without
+exercising any pressure on the ball. The eye should be still further
+steadied by the conjunctiva and subjacent cellular tissue on the inner
+side being seized by a pair of catch-forceps, still with no downward
+pressure on the ball. The point of the knife must then be introduced
+about a line from the outer sclerotic margin of the transverse diameter
+of the cornea (Fig. XIII.), the blade being held parallel with the
+fibres of the iris, pushed steadily across the anterior chamber, and
+protruded as nearly as possible at the corresponding spot at the inner
+side of the cornea. The aqueous humour should not escape till the
+section is completed. If it does, the iris is almost certainly projected
+forwards and entangled in the blade of the knife, a most annoying
+accident, and one which is not easily remedied. The books tell us of
+various manoeuvres by pressure or otherwise, by which the iris may be
+pushed back. Practically, however, if it has once occurred it is not
+easily saved from being cut. If a small portion only is involved, it is
+not of much consequence; if a large portion be in danger, it is
+sometimes necessary to withdraw the knife before the section is
+completed, and finish it with a probe-pointed, curved bistoury.
+
+If, however, the flap is safely finished, the lids should be gently
+allowed to close for a few seconds.
+
+On opening them again the surgeon must decide whether the corneal flap
+is sufficiently large to allow the lens to come out without force; if
+not, he must enlarge it either by the narrow probe-pointed "secondary
+knife" or by a pair of sharp scissors. Occasionally the lens, and even a
+little vitreous humour, may escape at once on the section being
+completed, but this is not to be desired.
+
+_b._ _Laceration of the Capsule of the Lens._--This is performed by
+insinuating a sharp curved needle under the corneal flap, avoiding the
+iris, and then tearing up the anterior capsule through the dilated
+pupil, the chief point to be attended to being that the capsule be
+lacerated in its entire length.
+
+_c._ _Removal of the Lens._--This must be done with the most extreme
+caution and gentleness, lest the vitreous humour be also evacuated. The
+surgeon's object is to tilt the lens so as to turn it slightly on its
+transverse axis, and cause the edge nearest the section to rise out of
+the capsule and appear at the wound. This is best done by gentle
+pressure at the required spot by the back of the needle, or by a common
+probe. When the lens begins to protrude the pressure must be very,
+gentle, lest it be forced out suddenly and the vitreous follow it.
+
+Soft portions of the lens are apt to remain adherent to the wound in the
+cornea. These must be removed by scoop or probe.
+
+_Varieties in the method of Flap Extraction._--Jacobsen of K�nigsberg in
+every case gives chloroform. He always makes his flap in the boundary
+line of the cornea and the sclerotic, through a vascular structure, and
+he believes that union is on this account more rapid, and after
+extraction removes that portion of the iris which appears to have been
+most exposed to bruising during the exit of the lens.
+
+The operation of extraction may in many cases be either preceded or
+followed by iridectomy, as proposed by Mooren, Von Graefe, and others.
+The following operation seems to diminish the risks to a very great
+extent:--
+
+     _Professor Von Graefe's Operation._--The lids are separated by a
+     speculum, and the eyeball is drawn down by forceps placed
+     immediately below the cornea. The point of a small knife, of which
+     the edge is directed upwards, is inserted at a point fully half a
+     line from the margin of the cornea near its upper part, so as to
+     enter the anterior chamber as peripherally as possible. The point
+     should not be directed at first towards the spot for
+     counterpuncture; nor till the knife has advanced fully three and a
+     half lines within the visible portion of the anterior chamber,
+     should the handle be lowered and the point directed so as to make
+     a symmetrical counterpuncture, which will give the external wound
+     a length of four and a half or five lines. As soon as the
+     resistance to the point is felt to be overcome, showing that the
+     counterpuncture is effected, the knife must at once be turned
+     forward, so that its back is directed almost to the centre of the
+     ideal sphere of the cornea, whether the conjunctiva is transfixed
+     or not, and the scleral border is divided by boldly pushing the
+     knife onwards and again drawing it backwards. This portion of the
+     operation is concluded by the formation of a conjunctival flap a
+     line and a half or two lines in length. A section thus made is
+     almost perpendicular to the cornea, a circumstance much
+     facilitating the passage of the lens, and the line of incision is
+     nearly straight, so that the wound does not gape. The iris should
+     be excised to the very end of the wound, and the capsule most
+     freely opened by a V-shaped laceration. Any lens, even the hardest,
+     may then be removed without the introduction of an instrument into
+     the eye, but Von Graefe's experience shows it to be advisable to
+     assist the evacuation by the hook in about one case in eight. In a
+     certain number of cases the lens will escape without difficulty
+     when the operator presses on the posterior lip of the wound,
+     especially when the back of the spoon is made to glide along the
+     sclera; should this not occur, Von Graefe uses a peculiar blunt
+     hook, or occasionally, though rarely, a spoon. A compressing
+     bandage is applied, and replaced at intervals.[88]
+
+We are recommended to perform it in two sets of cases:--
+
+1. Those in which the eye is known to be unhealthy and liable to
+inflammations, specially of iris, retina, or choroid. In cases where the
+patient has already lost an eye, Von Graefe thinks iridectomy should
+always precede extraction. In the above, then, it is a precautionary
+measure, and, if convenient, should be performed three, four, or even
+six weeks before the extraction.
+
+2. It is recommended to be performed at the same time as extraction in
+all cases in which the operation has presented any special difficulties,
+or has not gone smoothly, _e.g._ in cases where the lens has required
+much force to expel it, either from the flap of cornea being too small,
+or from adhesions between the lens and capsule; or, again, in cases in
+which there is a tendency to prolapse of the iris, in which any of the
+cortical substance has been necessarily left behind, or in which old
+adhesions had existed between the iris and capsule, or between the
+cornea and iris.
+
+
+OPERATIONS FOR ARTIFICIAL PUPIL.--The cases are by no means unfrequent
+in which it is necessary to remove or destroy a portion of the iris to
+admit light to the retina. In cases of excessive prolapse of the iris
+after extraction of the lens, where the iris has formed adhesions to the
+wound, and still more frequently in cases where central opacities of the
+cornea have fairly occluded the natural pupil, the only chance for
+vision is to enlarge the old one, or make a new pupil by removal of the
+iris.
+
+Very various operations have been proposed, and exceedingly numerous and
+complicated instruments invented for this purpose. We can notice here
+only one or two of the most approved procedures:--
+
+1. _Incision_ is the simplest.
+
+This is practicable and effectual only in cases where the iris is so far
+healthy as still to retain its contractile power, and so far free from
+adhesions as to be able to make use of it. The best example of such a
+case is that of a cataract, in which after extraction a prolapse of the
+iris has occurred to such an extent as to obliterate the pupil, and
+where, at the same time, the only adhesions are to the wound, none to
+the cornea.
+
+_Operation._--A double-edged needle is introduced through the cornea
+near its margin; on arriving at the place where the pupil ought to be,
+one edge is drawn against the iris, and divides it transversely, if
+possible, without injuring the lens; the fibres of the iris start back,
+contract, so that a sufficiently large central pupil may be obtained.
+
+2. _Excision._--In the far more frequent cases in which there exist
+adhesions between iris and cornea, or iris and anterior capsule,
+incision is not sufficient, and it is necessary to excise a portion of
+the iris.
+
+The simplest and safest operation is the following:--
+
+The patient recumbent, and the lids held apart by a speculum, the
+eyeball should be steadied by the forceps of an assistant. A broad
+cutting needle should then be introduced at the lower or outer edge of
+the corneal margin. This must be very gently withdrawn so as to retain
+as much aqueous humour as possible. Into the wound thus made the surgeon
+must introduce the blunt hook (known as Tyrrell's) at first with its
+point forwards, then, on arriving opposite the edge of the pupil, which
+it is intended to enlarge or replace, with its point turned backwards,
+so as to hook over the edge of the iris and thus drag on it. Once the
+hook has fairly got hold, it must again be rotated forwards, and
+withdrawn in the same direction as it was put in. The iris thus pulled
+out of the wound is to be cut off with a pair of fine scissors, so as to
+remove a sufficient amount to make a new pupil of the required size.
+
+But in those cases in which the whole or greater part of the pupillary
+margin is adherent, the blunt hook will not do, because there exists no
+edge round which to hook it. One of two plans is generally chosen to
+remedy this:--
+
+(1.) A free incision made with a double-edged needle; through this a
+pair of canula forceps is introduced, with which a portion of iris is
+seized and dragged to the external wound; it can then either be cut off
+or tied (see _Iridesis_); or,
+
+(2.) A previous attempt may be made to free a portion to form an edge to
+catch hold of, either by incision or by _Corelysis_ (_q.v._)
+
+
+IRIDESIS.--_Critchett's Operation of Ligature._[89]--Patient being put
+under chloroform, the ball is fixed by the wire speculum, and also by a
+fold of conjunctiva being seized by forceps. An opening is then made
+with a broad needle through the margin of the cornea, _close_ to the
+sclerotic, just large enough to admit the canula forceps, with which a
+small portion of iris close to its ciliary attachment is seized and
+drawn out; a piece of fine floss silk, previously tied in a small loop
+round the canula forceps, is slipped down and carefully tightened round
+the prolapsed portion. This speedily shrinks, and the loop may generally
+be removed about the second day. The chief advantage claimed for this
+method is the ease with which the size of the new pupil can be
+regulated. It is also suitable in cases of conical cornea, where it is
+wished to change the form of the pupil into a narrow slit.
+
+_N.B._--The ends of the ligature must be left sufficiently long to avoid
+any risk of their being drawn out of sight into the substance of the
+cornea, or even into the ball, by retraction of the fibres of the iris.
+
+
+CORELYSIS.--_Freeing of the Pupil._--An operative procedure for
+separating posterior adhesions of the iris to the lens. In it the
+surgeon hopes to act, not on the iris, as in the operations for
+artificial pupil, but only on the bands of false membrane which distort
+the pupil.
+
+The operation is briefly as follows:--The eye being firmly held by a
+wire speculum, and forceps pinching up the conjunctiva, a broad needle
+is passed rapidly through the cornea at a point which may give easy
+access to the adhesion to be torn through. This point is generally at
+the opposite margin of the irregular pupil, so that the needle may pass
+through the cornea in front of the one side of the iris, then through
+the orifice of the pupil, so as to reach the back of the other side. The
+needle is withdrawn gradually, so as to lose as little of the aqueous
+humour as possible, and then the spatula hook, called after the inventor
+of the operation, Mr. Streatfeild, is introduced. It is used first as a
+spatula, that is, with its blunt, though polished edge, to separate the
+adhesions, and if this is unsuccessful, as a hook (FIG. XIV.), so as to
+catch and tear them. In cases which resist the instrument used in both
+of these ways, Mr. Streatfeild has used very fine canula-scissors to cut
+the adhesions.[90] Such a further complication of the operation
+practically alters its character into an operation for artificial pupil,
+_q.v._
+
+[Illustration: FIG. XIV.[91]]
+
+
+IRIDECTOMY.--In cases of acute glaucoma, irido-choroiditis, and all deep
+inflammations of the eye in which the ocular tension is increased, also
+in certain cases of flap extraction already alluded to, the operation of
+iridectomy as originally proposed by Von Graefe will be found of use.
+
+_Operation._--The patient recumbent, and the eye absolutely fixed by
+speculum and forceps, a linear incision, varying in length from
+one-sixth to one-fourth of an inch, is made just at the margin of the
+cornea. The point of election is the upper pole of the cornea. The lens
+must not be wounded. The best instrument for making the section is an
+ordinary linear extraction knife, bent at an angle to admit of its being
+introduced from above. The iris will protrude through the wound, or, if
+adherent, must be drawn out by forceps, and then is to be cut off with
+scissors. The operation is rarely successful, unless a third, or at
+least a fourth, of the iris be removed.
+
+
+EXCISION OF A STAPHYLOMATOUS CORNEA.--There are certain cases in which
+the whole or greater part of the cornea bulges forward in a great blue
+projecting tumour. It is very ugly as it protrudes between the lids and
+prevents their closure; besides this, from its exposure it frequently
+inflames, even ulcerates, and has a most injurious effect on the other
+eye. In the cases suitable for operation vision is completely gone,
+without hope of its restoration by any operative procedure.
+
+The best thing for the patient is to have just enough of the staphyloma
+removed to enable the remains of the eyeball to form a good stump for an
+artificial eye. Various means have been suggested for doing this,
+varying in extent and severity from a mere shaving off the apex of the
+staphyloma to excision of the whole eyeball.
+
+By far the best method of operating is the one proposed and practised by
+Mr. Critchett.
+
+[Illustration: FIG. XV.[92]]
+
+[Illustration: FIG. XVI.[93]]
+
+The object of it is to remove an elliptical portion of the front of the
+staphyloma, or the whole staphyloma, when it is possible, and at the
+same time to prevent as far as possible the escape of the vitreous.
+
+_Operation._--Three, four, or five small curved needles armed with
+thread are passed through the staphyloma from above downwards, being
+each entered a little above the line of the intended upper incision, and
+brought out a little below the line of the intended lower one (Fig. XV.)
+
+To remove the included elliptical portion, Mr. Critchett pierces the
+sclerotic with a Beer's knife, just in front of the tendinous insertion
+of the external rectus. Through this incision a pair of probe-pointed
+scissors is introduced, and the piece cut just within the points of the
+needles. On the removal, the needles, which have retained the vitreous
+by their pressure, are drawn through and the threads cautiously tied.
+
+Union by first intention very often occurs, and an excellent stump is
+left with a narrow depressed transverse cicatrix[94] (Fig. XVI.)
+
+
+EXTIRPATION OF THE EYEBALL.--1. _Of the Eyeball only._--A circular
+incision should be made with curved scissors through the conjunctiva, a
+little beyond the corneal margin, then, beginning with the external
+rectus, muscle after muscle should be raised with the forceps, and
+divided, after which the optic nerve is cut through with the scissors. A
+slight preliminary extension outwards of the optic commissure will
+facilitate the dissection, and must be secured with metallic sutures;
+any vessels should be tied, and the orbit filled up with a light
+compress of charpie secured with a bandage.
+
+2. _Of the contents of the Orbit._--This may be required for malignant
+disease, but with a very poor prognosis. The optic commissure should be
+freely divided, and then, by bold strokes of curved scissors, or curved
+probe-pointed bistoury, the orbit may be fairly emptied by scooping out
+its contents. Even the periosteum may require to be scraped off, and the
+optic nerve divided as far back as possible. The h�morrhage may be
+pretty smart, but can generally be easily checked by compresses; if
+necessary, these can be soaked in the solution of the perchloride of
+iron.
+
+The author has done this operation many times, in cases extensive and of
+old standing, for malignant disease, melanotic and encephaloid. All have
+recovered, and in no instance has there been any trouble in stopping the
+bleeding.
+
+
+FOOTNOTES:
+
+[81] _a._ Elliptical incision for entropium; _b._ wedge-shaped incision
+for ectropium.
+
+[82] Fig. VIII. illustrates Streatfeild's operation for entropium.--_a._
+section of skin; _b._ section of levator palpebrae; _c._ section of
+cartilage of lid; _d._ section of conjunctiva; _e._ wedge-shaped portion
+excised.
+
+[83] _Ophthalmic Hospital Reports_, vol. i. p. 121.
+
+[84] Rough diagram of Bowman's operation, showing the grooved director
+in the punctum, and the knife in the groove just before it slits up the
+canaliculus.
+
+[85] Diagram of operations for convergent squint--A A, line of
+sub-conjunctival incision; B B, line of Dieffenbach's operation; C, wire
+speculum.
+
+[86] _The Radical Cure of Extreme Divergent Strabismus._ J. Vose
+Solomon, F.R.C.S., 1864.
+
+[87] _Ophthalmic Hospital Reports_, vol. iv. part ii. p. 197.
+
+[88] _Biennial Retrospect_ for 1865-66. Syd. Soc. pp. 363-4. For a
+thorough discussion of the merits of this operation, see papers by Von
+Graefe in _Brit. Med. Jour._ for 1867, vol. i. pp. 379, 446, 499, 657,
+765.
+
+[89] _Ophthalmic Hospital Reports_, vol. i. p. 224.
+
+[90] Streatfeild on Corelysis. _Ophthalmic Hospital Reports_, vol. ii.
+p. 309.
+
+[91] _a_ iris; _b_ lens; _c_ cornea. The hook is seen applied to the
+adhesion between lens and iris.
+
+[92] The staphyloma with the needles inserted, the lids held asunder by
+a spring speculum. The elliptical dotted line shows the amount to be
+removed; the vertical one, the position of the preliminary incision with
+the Beer's knife.
+
+[93] Resulting stump after the stitches are inserted.
+
+[94] _Ophthalmic Hospital Reports_, vol. iv. part 1.
+
+
+
+
+CHAPTER VI.
+
+OPERATIONS ON THE NOSE AND LIPS.
+
+
+RHINOPLASTIC OPERATIONS.--The operations for the restoration or repair
+of lost or mutilated noses are so various, and the minuteness of detail
+necessary for full description of them so great, that a complete account
+in a manual such as this is impossible; a brief notice of some of the
+most important varieties of the operation is all that can be given.
+
+_Principles._--1. It is necessary in every case that a suitable edge be
+prepared on which to fix the flap of skin, however obtained. To be
+suitable, this edge, should be (_a_) made in healthy skin, not in old or
+weak cicatrices; hence no trace of the original disease should be left;
+(_b_) it should be made thoroughly raw, by the removal of an appreciable
+amount of its edge; it should be pared, not merely scraped.
+
+2. It is useless to attempt to restore a nose unless the patient is in
+good general health, well nourished, and perfectly free from all remains
+of disease in the nose or its neighbourhood. The flaps which are to form
+the new nose may be obtained either from (1.) the cheeks; (2.) the
+forehead; (3.) a distant part either of the patient or of another
+person.
+
+(1.) _From the Cheeks._--When the cheeks are healthy, and specially if
+they are tolerably full and lax, the flaps from the cheeks produce much
+the most satisfactory result. As performed by Mr. Syme, the operation
+consists in the shaping of two equal flaps (A, A) from the skin of the
+cheek at each side, having the attachment above. A site for each flap is
+formed by the careful paring away of the whole thickness of the edge of
+the cavity of the lost organ (see Fig. XVII.)
+
+[Illustration: FIG. XVII.[95]]
+
+The flaps are then raised from their attachments to the upper jaw-bone,
+and approximated in the middle line by several points of metallic suture
+and the outer edges stitched to the raw surface on each side at a proper
+distance from the nasal orifice. If any septum remains of the old nose,
+it may be made very useful as a fixed point, a straight needle being
+thrust through one flap close to its outer lower edge, then through the
+septum, and out at a corresponding point of the other flap. The edges of
+the wound left in the cheek at each side can generally be, to a certain
+extent, approximated by silver stitches (B, B) and the triangular
+portion (C, C), which is necessarily left to heal by granulation, proves
+an advantage, as by its depression it enhances the apparent height and
+prominence of the new organ. The cavity should be very gently distended
+with lint, and may be supported by the blades of a small pair of
+forceps, applied so as to embrace the nose.
+
+(2.) _From the Forehead._--The Indian operation may be used as a last
+resource, in cases where, from disease, the cheeks also have suffered,
+and are not to be trusted to for flaps.
+
+_Operation._--1. It should be decided as to the shape and size of the
+portion of skin necessary, by fitting on pieces of soft leather or
+moulding wax. To allow for shrinking, the flap should be made at least
+one-third larger than is at first apparently necessary. The exact
+boundaries of the flap to be raised should then be marked out on the
+forehead by lightly pencilling it with nitrate of silver, the mark from
+which is not effaced by blood, as is sure to be the case with an ink
+line. Various shapes have been proposed for the flap varying in length
+of neck, in the shape of the angles, and especially in the arrangements
+made for the formation of a columna. Some (as Liston) prefer afterwards
+to provide for the columns separately, by a flap raised from the upper
+lip in a subsequent operation. The flap is then to be raised from the
+forehead, care being taken not to injure the periosteum. The incision is
+to be carried lower down on the side (generally the left), to which the
+flap is to be twisted. The flap is then to be brought round (Fig.
+XVIII.) and carefully fitted on to the edges previously prepared for its
+reception. The neck must be left as lax as possible, lest by tight
+twisting the supply of blood be cut off, and the flaps thus deprived of
+nourishment. Both silk and metallic sutures are recommended. Hamilton of
+Dublin,[96] after a large experience of both, prefers the former.
+
+[Illustration: FIG. XVIII.[97]]
+
+There are various risks; sloughing of the whole flap at once, shrinking
+of it after weeks or even months; certain inevitable drawbacks, as the
+cicatrix on the forehead, the very various and ludicrous changes of
+colour to which the new organ is subject,--these cannot be remedied by
+further operation. Two points generally require a second use of the
+knife a few weeks after:--(1.) The neck of the flap is sure to be
+redundant and prominent, but can be pared. (2.) The columna almost
+always requires improving, and, in Liston's method, to be made. He pared
+the inner surface of the apex of the nose, and then raised a central
+flap of the lip in the middle line, about a quarter of an inch broad,
+and extending from the remains of the old septum to the free border,
+raising it from the gum, and stitched the free end of it to the prepared
+apex, bringing together the two divided portions of the lip by ordinary
+harelip sutures. Tho columna, if redundant, could be shaved down, and it
+was found that the mucous surface very quickly became like skin on
+exposure.
+
+For other points with regard to the operation, reference may be made to
+the works of Liston and Skey, and Hamilton's monograph, referred to
+above.
+
+_Note._--The tongue and groove suture proposed by Professor Pancoast,
+and recommended by Professor Gross, is said to be specially suitable for
+such plastic operations. It is very complicated, as it requires one edge
+to be bevelled to a wedge shape, the other being grooved to include the
+wedge, thus opposing four raw surfaces, which are retained in contact by
+being transfixed by fine silk sutures.
+
+(3.) There are certain cases in which neither cheeks nor forehead are
+available for flaps, and yet the patients press very much for some
+operation. If they have patience and determination, the Taliacotian or
+Italian operation may be attempted.
+
+Without going into detail, the principle of it is as follows:--1. A
+piece of skin of suitable size was marked out over the left biceps, and
+defined by two longitudinal incisions, and raised from the subcutaneous
+cellular tissue, thus being left attached by its two ends only; a piece
+of linen was pulled below it. 2. After a few days the upper end was also
+divided, and the flap thus contracted. In a few days more the sides of
+the old nose were made raw, and the upper free surface of the flap also
+made raw and stitched to them, the arm being fastened up by a most
+elaborate series of bandages. 3. After a fortnight in this position, the
+last attachment of the flap to the arm was severed, and the new nose
+could then be modelled at pleasure.
+
+The literature of the subject is exceedingly curious, especially the
+cases in which the new material was obtained from an accommodating
+friend or servant.
+
+
+OPERATIVE TREATMENT OF LUPUS.--We may here notice a mode of treatment
+which has admirable results. The patient being put deeply under an
+an�sthetic, the surgeon with a sharp spoon carefully pares away all the
+diseased tissues, and then destroys the base either by nitric acid or a
+strong solution of chloride of zinc. The author has done this in a great
+number of cases with excellent effect.
+
+
+NASAL POLYPI, _Removal of._--Of these there are different kinds.
+
+1. ORDINARY MUCOUS POLYPI.--These grow from the spongy bones, generally
+the superior one, are non-malignant in their character, soft and
+vascular, often fill up the whole of both nasal cavities, and frequently
+hang down behind into the pharynx. The practical point to remember is
+that, however large and numerous they may be, they _invariably_ have
+their origin from a comparatively limited spot, the edge of the spongy
+bone, and _always_ hang from a narrow neck. Hence the treatment is easy
+and satisfactory, if the neck be attacked, and not the body of the
+tumour.
+
+Slightly curved, narrow-bladed forceps should be passed along by the
+side of the superior spongy bone, with their blades open, till the neck
+of the polypus is seized. Holding it firmly, the forceps should then be
+slowly twisted round till the neck is destroyed and the polypus
+detached. This should be repeated till the patient can blow freely
+through both nostrils. If attempts are made to seize the body of the
+polypus, it will break down under the forceps, bleed, and give much
+trouble.
+
+2. THE FIBROUS POLYPUS.--This form is fortunately much more rare than
+the other. It is almost invariably single, is attached to the posterior
+margin of the nares by a narrow but very strong root, is extremely firm
+in consistence, may grow to a large size so as to obstruct both
+nostrils, generally gives rise to severe and frequent h�morrhages. The
+h�morrhage _during_ any attempt to remove it is generally of the most
+severe character, but ceases _immediately_ on its complete detachment.
+
+We owe nearly all that we do know about the treatment of this form of
+polypus to Mr. Syme. His method is--By the ordinary polypus forceps
+described already, he seized the tumour through the nostril, and then
+with the fore and middle fingers of the left hand introduced behind the
+soft palate, he attacked the point of attachment, and by his nails,
+aided by the forceps, detached it from its narrow base.[98]
+
+3. MALIGNANT POLYPI should not be meddled with unless it is absolutely
+certain that the whole of the bone from which they grow can be removed
+also. This is very rarely the case. (See _Excision of Superior
+Maxilla_.)
+
+
+OPERATIONS ON THE LIPS.--1. Epithelial cancers of the lower lip are very
+frequent, and require removal.
+
+If the tumour or ulcer is small, and involves a considerable thickness
+of the lip, it is most easily removed by a V-shaped incision (Fig. XIX.
+A B A). Its shape permits the most accurate apposition of the cut
+surfaces; and if the lips are full and the tumour small, very slight
+trace of the operation will remain.
+
+[Illustration: FIG. XIX.[99]]
+
+Again, if the tumour be more extensive, involving a large portion of the
+prolabium, and yet not extending deeply into the substance of the lip,
+it may be very easily removed by a pair of curved scissors, applied in
+the direction shown in the diagram (Fig. XX. A B). The skin must then be
+stitched to the mucous membrane by numerous points of interrupted
+suture.
+
+[Illustration: FIG. XX.[100]]
+
+But if the tumour be at once extensive and deep, mere removal is not
+sufficient, but some provision must be made for supplying the blank left
+by the operation.
+
+In cases where a third, or even a half, of the lower lip has thus been
+removed, it may be found sufficient freely to dissect what is left of
+the lip from the gums, and thus approximate the cut surfaces in the
+middle line.
+
+This alone, however, would so much diminish the buccal orifice, and
+twist its corners, as to cause great deformity. The addition of an
+incision horizontally outwards, at one or both angles of the mouth,
+will do away with such risk, and allow the surfaces to come together
+without puckering; while by stitching the skin and mucous membrane
+together in the course of these horizontal incisions, we can increase
+the size of the buccal orifice almost _ad libitum_.
+
+Lastly, when the lower lip has been entirely removed, it is still
+possible to supply its place in the following manner, which was devised
+by Mr. Syme: The tumour being fairly isolated by a V-shaped incision
+(Fig. XXI.) C A C including the whole thickness of the lip, each of the
+incisions should be prolonged downwards and outwards, as shown by the
+dotted lines A D, A D. The flaps thus marked out must be separated from
+the bone, brought upwards, and approximated in the middle line. Possibly
+it may be necessary still further to enlarge the buccal orifice by short
+lateral incisions, C C. Whether these are required or not, silk
+stitches are to be introduced to unite the skin and mucous membrane
+along the lines A C. The gap left between D B D must be left to
+granulate, but in most cases may be very much diminished in size by
+additional sutures at its outer corners, near D. The granulating surface
+E E very rapidly heals up, leaving a dimple on each side, which rather
+improves the appearance, by adding to the prominence of the chin, B.
+
+[Illustration: FIG. XXI.[101]]
+
+[Illustration: FIG. XXII.[102]]
+
+THE OPERATIONS FOR HARELIP, though all conducted on the same general
+principles, vary considerably in extent required according to the
+position and size of the fissure or fissures to be remedied.
+
+1. _For Single Harelip._--Where the fissure extends only from the
+prolabium up to the attachment of the lip to the gums: this is very
+easily remedied, the chief risk being lest the surgeon should not remove
+enough of the edges of the fissure.
+
+_Operation._--Bleeding being controlled by an assistant, the surgeon
+fixes a pair of spring artery forceps into the mucous membrane and skin
+at the salient angle at each side of the fissure. Taking one of these in
+his left hand, he puts the edge to be pared on the stretch, and then
+with a sharp narrow straight bistoury he transfixes the lip at the point
+just beyond the upper angle of the fissure, and cuts outwards, being
+careful to remove the whole thinner part of the lip, and to leave the
+edge rather concave than convex. If left convex, or even quite straight,
+there is a risk that, after union has taken place, an angle remain
+showing the position of the cleft. The same is then to be done on the
+other side. The bleeding is then to be controlled by twisting the larger
+vessels, and if oozing still continues from the smaller ones, a pad of
+lint should be placed in the wound, and a few minutes' delay given, as,
+to facilitate immediate union, it is of the greatest importance that all
+h�morrhage should have ceased before the edges are brought together.
+
+When the bleeding has ceased, the edges should be approximated by two or
+more points of interrupted metallic suture inserted very deeply through
+the tissues, and taking a good hold of the edges of the wound. If the
+edges do not fit accurately, one or two horse-hair sutures will help.
+Some surgeons still prefer the old harelip needles secured by a
+figure-of-eight suture. A silk suture inserted through the prolabium is
+of great advantage, as it keeps the inner surface of the wound closed,
+which without it is very apt to be kept open by the pressure of the
+teeth or gums, and in infants by the movements of the tip of the tongue.
+
+     Various methods have been devised to utilise, if possible, the
+     portion of the edge of the lip which is separated during the
+     operation of refreshing the edges, for the purpose of filling up
+     the sort of cleft or gap which is apt to be noticed at the edge of
+     the prolabium. The most ingenious and simplest of these is that
+     proposed by M. Nelaton, for use in cases where the fissure does not
+     extend so far up as the nose. It consists in leaving the two
+     portions which are pared off (Fig. XXIII.) the sides of the cleft
+     attached to each other as well as to the free edge of the lip, then
+     pulling them down, so as to bring their bleeding surfaces into
+     apposition, and make a diamond-shaped wound instead of a triangular
+     cleft (Fig. XXIV.) When brought together by sutures a projection is
+     left at the edge of the lip; this, in most cases, disappears; if it
+     does not, it can easily be pared down.
+
+[Illustration: FIG. XXIII.[103]]
+
+[Illustration: FIG. XXIV.[104]]
+
+2. When the fissure, though single, extends upwards into the nose, the
+operation is more difficult, and the result frequently less
+satisfactory. The first thing to be done is to separate the lips from
+the gums, so as to make them more freely mobile. The whole edges of the
+cleft require refreshing.
+
+3. _Double Harelip_, without bony deformity, and where the intervening
+portion of the skin is vertical, does not project, and can be made
+useful for the new lip. Such cases are not very common, but when they do
+occur the question arises, How are they to be managed--in two separate
+operations or at once? I believe, in every case, at once. The central
+wedge-shaped portion is not large enough to extend downwards as far as
+the prolabium, but still should not be removed altogether, as it may be
+of great use, especially in bearing the columna nasi, and allowing its
+full development. The edges should be pared in the same way, and to the
+same extent as in single harelip, with the addition that the intervening
+portion should have its edges completely removed, and be left in the
+form of a wedge, with its apex downwards. The highest suture should be
+passed through first one side, then the base of the wedge, and then the
+other side; the second one through both, and the apex of the wedge; and
+a third should unite the prolabium, not including the wedge.
+
+[Illustration: FIG. XXV.[105]]
+
+4. _Double Harelip_ combined with fissures of the hard palate, and
+projection of a central bone. This is the analogue of the
+inter-maxillary bone in the lower animals, and bears the two middle
+incisor teeth, and projects very variously in different cases. In some
+it projects horizontally forwards in the most hideous manner, in others
+it lies at an angle more or less oblique; in very few does it maintain
+its proper position; when projecting forwards, and as the teeth also
+share in its projection, it entirely prevents approximation of the edges
+of the fissures by operation, so it must first be dealt with in one of
+two ways, either--
+
+[Illustration: FIG. XXVI.[106]]
+
+(1.) It may be at once removed with bone-pliers, the piece of skin over
+it being saved. This is the best that can be done in cases of old
+standing after the first year or two, though attempts have been made to
+break the neck of the projecting portion, and thus permit of its being
+shoved back.
+
+(2.) By gradual pressure by a spring truss, strapping, or a bandage, it
+may be forced back. This is possible only in cases where the deformity
+has been comparatively slight, and the patient has been seen early. The
+edges must then be pared and approximated as directed above.
+
+One or two points about the operation for harelip require a special
+notice:--
+
+1. _When to operate._--Great differences in opinion exist. Some say not
+before two or three years, others within two or three days, or even
+_hours_, after birth.
+
+Probably the safest time is not much earlier than the second month in
+very strong children, the fifth in weakly ones, up to the commencement
+of the first dentition; and when once dentition has commenced it is not
+so safe to operate till it is over.
+
+Prior to dentition the operation is attended with rather more risk, but
+again, if delayed, there is great risk that the teeth do not come in
+properly.
+
+2. With regard to the most delicate part of the operation, _the
+management of the prolabium_.--Some are satisfied, and I believe
+rightly, with careful apposition by a silk suture after a _sufficient_
+amount of the edges has been removed; others have proposed various plans
+to obviate any risk of an angle remaining.
+
+Malgaigne proposes to retain a small portion of the parings of the edge
+to make small flap at each side; Lloyd a single one from the long half
+of the lip, and brings it up under the opposite one, securing it with a
+stitch.
+
+
+FOOTNOTES:
+
+[95] Operation for formation of a new nose from the cheeks; A A, flaps
+approximated in middle line; B B, outer part of bed of flaps stitched
+up; C C, triangle at each side left to granulate.
+
+[96] _The Restoration of a Lost Nose by Operation_, p. 57; an excellent
+monograph on the subject.
+
+[97] Operation for formation of a new nose from the forehead:--_a_,
+prominence of flap which is to be used as septum; _b_, left-hand corner
+of flap, which is twisted and fastened at _c_; _d_, one of the tubes or
+quills over which the nose is moulded.--(_Modified from Bernard and
+Huette._)
+
+[98] Syme's _Observations in Clinical Surgery_, p. 132.
+
+[99] Diagram of V-shaped incision; A B A, dots showing points for
+sutures.
+
+[100] Diagram of incision for scooping out a shallow tumour by scissors.
+
+[101] Diagram of incisions:--C A C, outline of incision for removal; C A
+D, outline of flap on each side; B, prominence of chin; C C, dotted
+lines, showing incisions to enlarge mouth, if required.
+
+[102] Diagram of flaps in position:--A A, corners of flaps brought up
+and approximated by _silver_ sutures; C C, new lip got by lateral
+incisions, skin and mucous membrane being united by _silk_ threads; E E,
+gap left to granulate.
+
+[103] Fig. XXIII. shows the incision bounding the cleft.
+
+[104] Fig. XXIV. shows the diamond-shaped wound before the sutures are
+applied.
+
+[105] Diagram of operation for double harelip:--_a_, stitch through both
+sides and wedge-shaped portion, which also aids the septum; _b_, other
+stitches approximating edges.
+
+[106] Diagram of double harelip, with projecting bone:--_a_, central
+piece of lip, dotted lines showing incision; _b_, projecting bone
+bearing teeth, which are generally small and stunted.
+
+
+
+
+CHAPTER VII.
+
+OPERATIONS ON THE JAWS.
+
+
+1. EXCISION OF THE UPPER JAW.--With regard to the morbid conditions for
+which this operation is undertaken, it may be sufficient here to
+observe, that in no case can the operation be called justifiable in
+which the disease extends beyond the upper jaw-bone and the
+corresponding palate-bone, for unless the morbid growth be entirely
+removed, recurrence is inevitable, and no advantage is gained by the
+operation. It is undertaken for the removal of tumours of the antrum and
+of the alveolar margins, in all which cases the section for its removal
+must be made through healthy bone, and wide of the disease, so as to
+insure that the whole is removed. There are other cases in which the
+whole or part of the upper jaw has been removed for the purpose of
+giving access to disease behind, for example, to naso-pharyngeal polypi
+with extensive attachments.
+
+In describing the operation for the excision of the entire upper jaw, we
+have to consider--(1.) what incisions through the soft parts will expose
+the tumour best, and with least deformity; (2.) what bony processes
+require to be divided, and where. Very various incisions have been
+recommended by various authors; some describing three, in various
+directions, forming flaps of different sizes, while others, again, are
+satisfied with a very small division of the upper lip into the nose, or
+even attempt removal of the bone without any incision through the skin
+at all. These discrepancies depend in great measure on different views
+of what constitutes excision of the upper jaw, the more complicated ones
+contemplating removal of the whole bone anatomically so called,
+including the floor of the orbit, while the less complicated ones are
+suitable for cases in which a much less extensive removal is required.
+
+To remove the whole bone, an incision (Fig. XXVII. A) of the skin must
+extend from the angle of the mouth upwards and outwards in a slightly
+curved direction with its convexity downwards, as far on the malar bone
+as half an inch outside of the outer angle of the eye. The flaps must
+then be raised in both directions, the inner one specially dissected off
+the bones, so as to expose thoroughly the nasal cavity. It is of great
+importance thoroughly to display the floor of the orbit, so that the
+attachment of the orbital fascia may be accurately cut through, the
+inferior oblique muscle divided at its origin, and the eye and the fat
+of the orbit cautiously raised from its floor.
+
+[Illustration: FIG. XXVII.[107]]
+
+Three processes of bone then require attention and division.
+
+(1.) The articulation with the opposite bone in the hard palate. To
+divide this, one incisor tooth at least must be drawn, the soft palate
+divided by a knife to prevent laceration, and the thick alveolar portion
+sawn through in a longitudinal direction from before backwards.
+
+(2.) The articulation with the malar bone at the upper angle of the
+incision through the skin. This must be notched with a small saw in a
+direction corresponding to the articulation, and then wrenched asunder
+by a pair of strong bone-pliers.
+
+(3.) The nasal process of the upper jaw must now be divided by the
+pliers, one limb of which is cautiously inserted into the orbit, the
+other into the nose. If the disease extends high up in this process, it
+may be necessary partially to separate the corresponding nasal bone, and
+thus reach the suture between the nasal process and the frontal bone.
+The pliers must now be inserted into the groove already made by the saw
+on the hard palate, and the separation continued to the full extent
+backwards. A comparatively slight force exerted on the tumour either by
+the hand, or (when the tumour is small) by a pair of strong claw
+forceps, will suffice to break down the posterior attachments of the
+bone and remove it entire. The necessary laceration of the soft parts
+behind is so far an advantage, as it lessens the risk of h�morrhage from
+the posterior palatine vessels.
+
+The h�morrhage from this operation was at one time much dreaded, but is
+rarely excessive; very few vessels require ligature, except those
+divided in the early stages in making the skin flaps; the hollow left
+should be stuffed with lint, which may be soaked in the perchloride of
+iron should there be any oozing.
+
+The incisions recommended for this operation have been very various, and
+a knowledge of some of them may occasionally be useful, on account of
+specialities in the shape and size of the tumour. Liston "entered the
+bistoury over the external angular process of the frontal bone, and
+carried it down through the cheek to the corner of the mouth. Then the
+knife is to be pushed through the integument to the nasal process of the
+maxilla, the cartilage of the ala is detached from the bone, and lip cut
+through in the mesial line; the flap thus formed is to be dissected up
+and the bones divided."[108] Dieffenbach made an incision through the
+upper lip and along the back or prominent part of the nose, up towards
+the inner canthus, from whence he carried the knife along the lower
+eyelid, at a right angle to the first incision as far as the malar bone.
+
+In cases where the tumour is of moderate size, Sir W. Fergusson
+found[109] it sufficient to divide the upper lip by a single incision
+exactly in the middle line, this incision to be continued into one or
+both nostrils, if required. The ala of the nose is so easily raised, and
+the tip so moveable as to give great facilities to the operator for
+clearing the bone even to the floor of the orbit.
+
+In cases where the tumour is larger, or the bones more extensively
+affected, Sir W. Fergusson preferred an extension of the foregoing
+incision (Fig. XXVII. B) upwards along the edge of the nose almost to
+the angle of the eye, and thence at a right angle along the lower
+eyelid, as far as may be necessary, even to the zygoma. The advantages
+claimed for such procedures are that the deformity is less and the
+vessels are divided at their terminal extremities.
+
+
+2. EXCISION OF THE LOWER JAW.--Removal of portions, greater or smaller,
+of the lower jaw, for tumours, simple or malignant, are now operations
+of very frequent occurrence, while in some few cases the whole bone has
+been removed at both its articulations.
+
+The operative procedures vary much, according to the amount of bone
+requiring removal, and also the position of the portion to be excised.
+
+(1.) _Of a portion only of one side of the body of the bone._--This is
+perhaps the simplest form of operation, and is frequently required for
+tumours, specially for epulis.
+
+_Incision._--If the parts are tolerably lax and the tumour small, a
+single incision just at the lower edge of the bone, of a length rather
+greater than the piece of bone to be removed, will suffice; this will
+divide the facial artery, which must be tied or compressed,[110] while
+the surgeon, dissecting on the tumour, separates the flaps in front,
+cutting upwards into the mouth, and then detaches the mylohyoid below,
+and clears the bone freely from mucous membrane. He then, with a narrow
+saw, notches the bone beyond the tumour at each side, and, introducing
+strong bone-pliers into the notches, is enabled to separate the required
+portion. The wound is then stitched up, and a very rapid cure generally
+results with very little deformity, as the cicatrix is in shadow. If
+from the size of the tumour more room is needed, it can easily be got by
+an additional incision from the angle of the mouth joining the former.
+
+To prevent deformity, which is apt to result from the centre of the chin
+crossing the middle line, it is often a wise precaution to have a silver
+plate prepared fitting the molar teeth of both jaws on the sound side,
+and thus acting as a splint. Such a precaution may be required in any
+operation in which the lower jaw is sawn through.
+
+_N.B._--There are certain cases in which the epulis is small and
+confined to the alveolar margin, in which an attempt may be made to
+retain the base of the jaw entire, and remove the tumour without any
+incision of the skin. The mucous membrane on both sides being carefully
+dissected from the affected part, the bone may be sawn as before, but
+only through the alveolar portion, the groves of the saw converging as
+they penetrate, then by a pair of strong curved bone-pliers, the
+affected alveolar portion is to be scooped out without injuring the
+base. This proceeding, which has been practised by Syme, Fergusson,
+Pollock, the author in many cases, and others, leaves no deformity, but,
+it must be owned, is much more liable to the risk of recurrence of the
+disease, and for this reason is strongly condemned by Gross.
+
+_Note._--In this, as in all other operations on the jaws, the very first
+thing to be done is to draw the teeth at the spots at which the saw is
+to be applied.
+
+(2.) _Excision of a portion involving the Symphysis._--Free access is of
+importance. The best incision is probably one which (Fig. XXVII. C)
+commences at the angle of the mouth opposite the healthy portion of jaw,
+extends down to the place at which the saw is to be applied and then
+along the base of the jaw past the middle line to the other point of
+section. The flap is to be thrown up and the bone cleared. The next
+point to be noticed is, that when, in clearing the bone behind, the
+muscles attached to the symphysis are divided, the tongue loses its
+support, and unless watched may tend to fall backwards, embarrassing
+respiration and even perhaps choking the patient. The tongue, being
+confided to a special assistant, must be drawn well forwards. Various
+plans have been devised for keeping it in position, as stitching it to
+the point of the patient's nose; putting a ligature into its apex, and
+fastening it to the cheek by a piece of strapping, and transfixing its
+roots with a harelip needle, used to stitch up a central incision in the
+chin. The tendency to retraction very soon ceases, new attachments are
+formed by the muscles, and after the first five or six days there is
+very little risk of the tongue giving rise to any untoward consequences
+by its displacement.
+
+(3.) _Disarticulation of one, or both Joints._--When the portion of bone
+implicated involves disarticulation for its complete removal, the
+difficulty of the operation is much increased. The remarkably strong
+attachments of the joint, especially the relation of the temporal muscle
+to the coronoid process, and the close proximity of large arteries and
+nerves, especially the internal maxillary artery and the lingual nerve,
+render this disarticulation very difficult.
+
+The chief points to be attended to seem to be (1.) that the incision
+through the skin should extend quite up to the level of the
+articulation; (2.) that the bone should be sawn through at the other
+side of the tumour, and freely cleared from all its attachments, before
+any attempt be made at disarticulation, for by means of the tumour great
+leverage can be attained, so as to put the muscles on the stretch, and
+allow them to be safely divided; (3.) that the articulation should
+always be entered from the front, not from behind, and the inner side of
+the condyle should be very carefully cleaned, the surgeon cutting on the
+bone so as to avoid, if possible, the internal maxillary artery; (4.)
+free and early division of the attachment of the temporal muscle to the
+coronoid process.
+
+Disarticulation of the entire bone has been very rarely performed.[111]
+If necessary, it can be performed without any incision into the mouth,
+by one semilunar sweep from one articulation to the other, passing along
+the lower margin of each side of the body, and just below the symphysis
+of the chin.
+
+_Disarticulation of the Ramus without opening into the cavity of the
+Mouth._--That this operation is possible, though it may not be often
+required, is shown by the following case by Mr. Syme. It was a tumour of
+the ramus, extending only as far forwards as the wisdom-tooth:--
+
+"An incision was made from the zygomatic arch down along the posterior
+margin of the ramus, slightly curved with its convexity towards the
+ear, to a little way beyond the base of the jaw. The parotid gland and
+masseter muscle being dissected off the jaw, it was divided by
+cutting-pliers immediately behind the wisdom-tooth, after being notched
+with a saw. The ramus was then seized by a strong pair of tooth-forceps,
+and notwithstanding strong posterior attachments, was drawn outwards,
+its muscular connections divided and turned out entire. There was thus
+no wound of the mucous membrane of the mouth, the masseter and pterygoid
+muscles were not completely divided, and the facial artery was
+intact."[112]
+
+Fergusson[113] holds that even the very largest tumours of the lower jaw
+may be successfully removed without opening into the orifice of the
+mouth at all by division of the lips. A large lunated incision below the
+lower margin of the bone, with its ends extending upwards to within half
+an inch of the lips, will give free access, and yet avoid both
+h�morrhage and deformity, as the labial artery and vein are not cut, and
+there is no trouble in readjusting the lips. Some tumours of lower jaw
+can be removed without any wound of skin.
+
+
+FOOTNOTES:
+
+[107] Diagram of operations on the jaws:--A, incision for removal of the
+whole upper jaw; B, incision for removal of alveolar portion and antrum;
+C, incision for removing the larger half of lower jaw; the opposite side
+is the one supposed to be operated on, and the incision is crossing the
+symphysis and turning up at a right angle.
+
+[108] _Operative Surgery_, p. 265.
+
+[109] _Lancet_, July 1, 1865.
+
+[110] Temporary compression of the facial can be easily managed, in
+cases where it is of much importance to avoid loss of blood, by passing
+a needle from the outside through the skin above the vessel, then under
+the vessel, and out again through the skin below. A figure-of-eight
+suture can then be thrown round both ends of the needle, and the artery
+thus thoroughly compressed.
+
+[111] Syme, _Contributions to the Path. and Practice of Surgery_, p. 21;
+Carnochan of New York, _Cases in Surgery_.
+
+[112] _Contributions to the Path. and Prac. of Surgery_, pp. 23, 24.
+
+[113] _Lancet_, July 1, 1865.
+
+
+
+
+CHAPTER VIII.
+
+OPERATIONS ON MOUTH AND THROAT.
+
+
+SALIVARY FISTULA, _Operation for._--After a wound or abscess of the
+cheek, in which the parotid duct is implicated, a salivary fistula is
+very apt to remain. The saliva thus discharges in the cheek, giving rise
+to considerable annoyance, as well as injury to the digestion. It is by
+no means easy to cure this. Perhaps the best operation is the one of
+which a rude diagram is given (Fig. XXVIII.). The duct (C) communicates
+with the fistula (D). One end of a thread, either silken or metallic,
+should be passed through the fistula, and then as far backwards as
+convenient through the cheek into the mouth; the needle should then be
+withdrawn, the thread being left in. The other end being threaded should
+then be re-inserted at the fistula, and carried forwards in a similar
+manner; the needle should be again unthreaded in the mouth and
+withdrawn; the two ends should then be tied pretty tightly inside, and
+allowed to make their way by ulceration into the cavity of the mouth. A
+passage will thus be obtained for the saliva into the mouth, and every
+possible precaution should be taken to enable the external wound to
+close.
+
+[Illustration: FIG. XXVIII.[114]]
+
+
+EXCISION OF THE TONGUE, for malignant disease of the organ, may be
+either complete or partial. Complete excision affords a hope of
+permanent and complete relief from the disease, but it is an operation
+of extreme difficulty and danger. It may be performed in either of the
+following methods. The first is the only one in which absolute
+completeness of removal is insured.
+
+1. _Syme's method of excision._--The patient being seated on a chair,
+chloroform was not administered, so that the blood might escape
+forwards, and not pass into the pharynx. The operation is thus
+described:[115]--
+
+"Having extracted one of the front incisors, I cut through the middle of
+the lip and continued the incision down to the os hyoides, then sawed
+through the jaw in the same line, and insinuating my finger under the
+tongue as a guide to the knife, divided the mucous lining of the mouth,
+together with the attachment of the genio-hyoglossi. While the two
+halves of the bone were held apart, I dissected backwards, and cut
+through the hyoglossi, along with the mucous membrane covering them, so
+as to allow the tongue to be pulled forward, and bring into view the
+situation of the lingual arteries, which were cut and tied, first on one
+side, and then on the other. The process might now have been at once
+completed, had I not feared that the epiglottis might be implicated in
+the disease, which extended beyond the reach of my finger, and thus
+suffer injury from the knife if used without a guide. I therefore cut
+away about two-thirds of the tongue, and then being able to reach the os
+hyoides with my finger, retained it there while the remaining
+attachments were divided by the knife in my other hand close to the
+bone. Some small arterial branches having been tied, the edges of the
+wound were brought together and retained by silver sutures, except at
+the lowest part, where the ligatures were allowed to maintain a drain
+for the discharge of fluids from the cavity." The patient was able to
+swallow from a drinking-cup with a spout on the day following the
+operation, and was able to travel upwards of 200 miles within four weeks
+of the operation.
+
+2. _By the �craseur._--Nunneley of Leeds has recorded cases in which he
+made a small incision through the skin, and mylohyoid and geniohyoid
+muscles, and through this passed a curved needle bearing the chain of
+the �craseur completely round the base of the tongue. In one case the
+chain was unsatisfactory, but strong whipcord was introduced as it was
+withdrawn, and tied with all possible force. The organ eventually
+sloughed away, with a cure which lasted at least for some months.
+
+Sir James Paget operates as follows:--
+
+The patient is placed under the influence of chloroform, and the mouth
+held widely open. The tongue is then drawn forwards, the mucous membrane
+and soft parts of the floor of the mouth, including the attachment of
+the genio-hyoglossi to the symphysis being divided close to the bone.
+The steel wire of an �craseur is then passed round its root as low down
+as possible, slowly tightened, and the tongue thus divided through its
+whole thickness in a very few minutes. The bleeding is slight, being
+almost entirely from the parts cut with the knife. Recovery has been
+rapid in the recorded cases.[116]
+
+To Dr. George Buchanan of Glasgow the credit is due of the invention of
+the operation of removal of the half of the tongue in the median line.
+In at least one instance the cure after five years is still permanent.
+
+Partial excisions of the tongue are as unsatisfactory in their results
+as they are unsound in principle, yet many cases present themselves, in
+which, while the patient urges some operative measure for his relief,
+the tumour is so limited as not to warrant the exceedingly dangerous
+operation of complete excision.
+
+Portions may be removed in various ways:--
+
+1. By the knife. If in the apex, by a V-shaped incision; if in the
+lateral regions, by a bold free incision with a probe-pointed bistoury
+round the tumour.
+
+2. By ligature, drawn as tightly as possible, and, if the portion
+included be large, in successive portions.
+
+3. By the �craseur.
+
+Mr. Furneaux Jordan has removed the whole tongue with success by means
+of two �craseurs worked at the same time.[117]
+
+4. By the galvano-caustic wire.
+
+5. The author has in nine cases removed the affected half of the tongue
+by means of the thermo-cautery, first splitting it in the middle line
+and then cutting through the base with a curved platinum knife at a low
+red heat. In one only was there any trouble from h�morrhage, and all
+made good recoveries.
+
+Mr. Barwell has recorded (_Lancet_, 1879, vol. i.) an easy, safe, and
+comparatively painless mode of removing the tongue by �craseurs.
+
+Mr. Walter Whitehead,[118] of Manchester, has had a very large
+experience of an operation devised by himself, in which, after pulling
+the tongue well forward by a string previously introduced near its apex,
+and the mouth being held open by a gag, he detaches the organ from jaw
+and fauces by successive short snips with scissors, and then in same
+manner divides the muscles, tying or twisting the vessels as they bleed.
+His success has been very great by this method, though others who have
+tried it have sometimes found bleeding troublesome.
+
+It is comparatively seldom now necessary to split the jaw and perform
+Syme's operation, and in all operations on the tongue the thermocautory
+(Paquelin's) is of great use.
+
+Regnoli's method[119] may deserve a brief notice. A semilunar incision
+along the base of the jaw, from one angle to the other, detaches the
+muscles and soft structures, and is thrown down; the tongue is then
+drawn through the opening, and can be freely dealt with either by knife
+or ligature. After removal the flap is replaced.
+
+
+FISSURES IN THE PALATE.--The operations requisite for the cure of
+fissures in the soft and hard palates are so complicated in their
+details, that a small treatise would be required thoroughly to describe
+the various procedures.
+
+Different cases vary so much in the nature and amount of their
+deformity, that at least five different sets of cases have been
+described. It is sufficient here merely to describe the absolutely
+essential principles of the operations for the cure of fissures of the
+hard and soft palate respectively.
+
+In all operations on the palate, two conditions used to be considered
+requisite for success:--1. That the patient should have arrived at years
+of discretion, at twelve or fourteen years at least; that he be
+possessed of considerable firmness, and be extremely anxious for a cure,
+so as to give full and intelligent co-operation. 2. That for some days
+or weeks prior to the operation the mouth and palate should have been
+trained to open widely and to bear manipulation, without reflex action
+being excited. Professor Billroth of Vienna,[120] and Mr. Thomas
+Smith[121] of London, have had cases which prove the possibility of
+performing this operation in childhood, under chloroform, with the
+assistance, in the English cases, of a suitable gag, invented by Mr.
+Smith. The effect of the operation on the voice of the child has been
+very encouraging, as much more improvement takes place than in cases
+where the operation is performed late in life.
+
+_Fissure in the soft palate only_ appears as a triangular cleft, the
+apex of which is above, the base being a line between the points of the
+bifid uvula, which are widely separated. To cure this it is required--
+
+1. That the edges of the fissure should be brought together without
+strain or tightness. In small fissures this can generally be done easily
+enough; but where the fissure is extensive, some means must be used to
+relieve tension. For this, Sir William Fergusson long ago proposed the
+division of the palatal muscles, the levator, tensor, and
+palato-pharyngeus muscle of each side. The incisions in the palate for
+this purpose certainly aid apposition, but many surgeons entertain
+doubts whether the division of the muscles has much to do with the good
+result, and believe that the simple incisions in the mucous membrane, in
+a proper direction, are all that is required (see Fig. XXIX.).
+
+[Illustration: FIG. XXIX.[122]]
+
+2. That the edges of the fissure be made raw, so as to afford surfaces
+which will readily unite. Complicated instruments, such as knives of
+various strange shapes, have been devised for this purpose; an ordinary
+cataract knife, very sharp, and set on a long handle is perhaps the
+best. It greatly facilitates the section if the parts are tense, so the
+point of the uvula should be seized by an ordinary pair of spring
+forceps, and drawn across the roof of the mouth, while the knife should
+enter in the middle line, a little above the apex of the fissure, and
+make the cut downwards as in harelip.
+
+3. That sutures should be inserted to keep the edges in apposition, yet
+not so tightly as to cause ulceration. They may be either of metal,
+silver being preferable, or of fine silk well waxed. The metallic
+sutures are now generally preferred. Some dexterity is required in their
+introduction, and various instruments have been devised; the best seems
+to be a needle with a short curve fixed on a long handle, which should
+be entered on the (patient's) left side of the fissure in front, and
+brought out on the right side.
+
+If silk sutures be used, the chief difficulty, that of passing the
+thread through the second side from behind forwards, can be avoided in
+the following manner.[123] A curved needle is passed through one side of
+the fissure, and then towards the middle line, till its point is seen
+through the cleft. One of the ends of the thread is then seized by a
+long pair of forceps, and drawn through the cleft; the needle is then
+withdrawn, leaving the thread through the palate, and both ends are
+brought outside at the angle of the mouth. Another needle is then passed
+through a corresponding point at the opposite side of the palate, till
+its point again appears at the cleft; this time a double loop of the
+thread is also brought out through the cleft by the forceps into the
+mouth. If then the single thread of the first ligature which is in the
+cleft be passed through the loop of the second one also in the cleft, it
+is easy, by withdrawing the loop through the palate, to finish the
+stitch (see Fig. XXIX.). All the stitches should be passed and their
+position approved before any one be tied, and it is most convenient to
+secure them from above downwards. To prevent confusion, each pair of
+threads after being inserted should be left very long, and brought up
+to a coronet fixed on the brow, which is fitted with several pairs of
+hooks numbered for easy reference. This will prevent twisting of the
+threads or any mistake in tying.
+
+
+FISSURE OF THE HARD PALATE.--This may vary in extent from a very slight
+cleft in the middle line behind, up to a complete separation of the two
+halves of the jaw, including even the alveolar process in front, and
+sometimes complicated with harelip.
+
+To close such fissures by operation is difficult, as the breadth of the
+cleft is so great as to prevent the apposition of the edges when
+prepared, without such extreme tension as quite prevents any hope of
+union. Through the researches of Avery, Warren, Langenbeck, and others,
+a method has been discovered of closing such fissures by operation,
+which, though certainly not easy, is, when properly performed, generally
+successful.
+
+_Operation._--In addition to the usual paring of the edges of the cleft,
+an incision is made on each side of the palate, extending "from the
+canine tooth in front to the last molar behind,"[124] along the alveolar
+ridge (Fig. XXX.). The whole flap between the cleft and this incision on
+each side is then to be raised from the bone by a blunt rounded
+instrument slightly curved. With this the whole mucous membrane and as
+much of the periosteum as possible should be completely raised from the
+bone, attachments for nourishment of the flap being left in front and
+behind where the vessels enter.
+
+[Illustration: FIG. XXX.[125]]
+
+The flaps thus raised will be found to come together in the middle line,
+sometimes even to overlap, and, when united by suture, form a new
+palate at a lower level than the fissure, experience having shown that
+in cases of fissure the arch of the palate is always much higher than
+usual. The flaps do not slough, being well supplied with blood, unless
+they have been injured in their separation.
+
+The edges must be carefully united by various points of metallic suture,
+and the fissure of the soft palate closed at the same sitting, unless
+the patient has lost much blood, or is very much exhausted with the
+pain. The stitches may be left in for a week, or even ten days, unless
+they are exciting much irritation. The patient must exercise great
+self-control and caution in the character of his food and his manner of
+eating for ten days or a fortnight after the operation.
+
+
+EXCISION OF TONSILS.--To remove the whole tonsil is of course impossible
+in the living body, the operation to which the name of excision is given
+being only the shaving off of a redundant and projecting portion. When
+properly performed it is a very safe, and in adults a very easy
+operation, but in children it is sometimes rendered exceedingly
+difficult by their struggles, combined with the movements of the tongue
+and the insufficient access through the small mouth. Many instruments
+have been devised for the purpose of at once transfixing and excising
+the projecting portion; some of them are very ingenious and complicated.
+By far the best and safest method of removing the redundant portion is
+to seize it with a volsellum, and then cut it off by a single stroke of
+a probe-pointed curved bistoury; cutting from above downwards, and being
+careful to cut parallel with the great vessels.
+
+The ordinary volsellum is much improved for this purpose by the addition
+of a third hook in each tonsil placed between the others, with a shorter
+curve, and slightly shorter; this ensures the safe holding of the
+fragment removed, and prevents the risk of its falling down the throat
+of the patient.
+
+If both tonsils are enlarged they should both be operated on at the same
+sitting, and the pain is so slight that even children frequently make
+little objection to the second operation. Bleeding is rarely troublesome
+if the portion be at once fairly removed, but if in the patient's
+struggles the hook should slip before the cut is complete, the partially
+detached portion will irritate the fauces, cause coughing and attempts
+to vomit, and sometimes a troublesome h�morrhage.
+
+The plentiful use of cold water will generally be sufficient to stop the
+bleeding, though cases are on record in which the use of styptics, or
+even the temporary closure of a bleeding point by pressure, has been
+necessary.
+
+M. Guersant has operated on more than one thousand children, with only
+three cases of any trouble from h�morrhage, while four or five out of
+fifteen adults required either the actual cautery or the sesqui-chloride
+of iron.[126]
+
+
+FOOTNOTES:
+
+[114] Rough diagram of operation for salivary fistula:--A, section of
+cheek close to buccal orifice; B, section of zygoma, muscles, etc.; C,
+the duct of the parotid; D, the fistulous opening of the cheek; E E, the
+thread knotted inside the mouth; F, the palate.
+
+[115] _Lancet_, Feb. 4, 1865.
+
+[116] _Med. Times and Gazette_ for Feb. 10, 1866.
+
+[117] _Lancet_, April 20, 1872.
+
+[118] _Transactions International Medical Congress_, 1881, vol. ii. p.
+460.
+
+[119] Gross's _Surgery_, vol. ii. p. 472.
+
+[120] Langenbeck, _Archiv_, ii. p. 657.
+
+[121] _Med. Chir. Trans._ for 1867-8.
+
+[122] Diagram of staphyloraphy, chiefly to illustrate the passing of the
+threads:--_a_, the first thread; _b_, the second. The dotted line at
+edge of fissure shows amount to be removed; the other dotted lines
+showing size and position of the incision through the mucous membrane
+above.
+
+[123] Holmes's _Surgery_, vol. ii. pp. 504-513.
+
+[124] _Edinburgh Medical Journal_ for Jan. 1865, Mr. Annandale's
+instructive paper on "Cleft Palate."
+
+[125] Diagram of fissure of hard palate:--_a_, anterior palatine
+foramina; _b_, posterior palatine foramina with groove for artery; _c_,
+incisions requisite to free the soft structures.
+
+[126] Holmes's _Diseases of Children_, p. 555.
+
+
+
+
+CHAPTER IX.
+
+OPERATIONS ON AIR PASSAGES.
+
+
+OPERATIONS ON THE LARYNX AND TRACHEA.--The great air passage may be
+opened at three different situations, and to the operations at these
+different places the following names have been given:--
+
+_Laryngotomy_, when the opening is made in the interval between the
+cricoid and thyroid cartilages, through the crico-thyroid membrane.
+
+_Laryngo-tracheotomy_, when the cricoid cartilage and the upper ring of
+the trachea are divided.
+
+_Tracheotomy_, when the trachea itself is opened by the division of two,
+three, or more rings.
+
+Of these the last, _tracheotomy_, is by far the most frequent,
+important, difficult, and dangerous, and requires a very detailed
+description. Chassaignac[127] says "the only really rational operation
+for the opening of the air passages by the surgeon is tracheotomy."
+
+
+TRACHEOTOMY.--_Anatomy._--Between the cricoid cartilage and the level of
+the upper border of the sternum, the middle line of the neck is occupied
+by the upper portion of the trachea. Its depth from the surface varies,
+gradually increasing as the trachea descends, and varying very much
+according to the fatness, muscularity, and length of the neck. It is,
+however, almost subcutaneous at the commencement below the cricoid, and
+on the level of the sternum it is in most cases at least an inch from
+the surface, in many much deeper. Again, its length varies, even in the
+adult, from two and a half to three, or even four inches. This is
+important, as affecting the simplicity of the operation, which, as a
+rule, is easier the longer the neck is.
+
+The trachea has most important and complicated anatomical
+relations--some constant, others irregular.
+
+1. The carotid arteries and jugular veins lie at either side, but, where
+these are regular in their distribution, do not practically interfere in
+a well-conducted operation.
+
+2. The thyroid gland lies in close relation to the trachea, one lobe
+being at each side (Fig. XXXI. B B), and the isthmus of the thyroid
+crosses the trachea just over the second and third cartilaginous rings.
+In fat vascular necks, or where the thyroid is enlarged it may occupy a
+much larger portion of the trachea. The position of the isthmus
+practically divides the trachea into two portions in which it is
+possible to perform tracheotomy. Both have their advocates, but the
+balance of authority tends to support the operation below the thyroid. A
+separate notice of each will be required immediately.
+
+[Illustration: FIG. XXXI.[128]]
+
+3. The _muscles_ in relation to the trachea are the sterno-hyoid and
+sterno-thyroid of each side. The latter are the broadest, are in close
+contact across the trachea by the inner edges below, but gradually
+diverge as they ascend the neck. In thick-set, muscular necks, however,
+they are in close contact for a considerable distance, and require to
+be separated to give access to the trachea.
+
+The _arteries_ are in most cases unimportant; no named branch of any
+size ought to be divided in the operation. However, occasionally very
+free bleeding may result from the division of an abnormal _thyroidea
+ima_ running up the trachea to the thyroid body from the innominate, or
+even from the aorta itself.
+
+The _veins_ are very numerous and irregularly distributed. There is
+generally a large transverse communicating branch between the superior
+thyroid veins just above the isthmus. The isthmus itself has a large
+venous plexus over it. Below the isthmus the veins converge into one
+trunk (or sometimes two parallel ones) lying right in front of the
+trachea.
+
+4. The last anatomical point which may give trouble in normal necks is
+the thymus, which is present in children below the age of two, and
+covers the lower end of the trachea just above the level of the sternum.
+Where this is not only not diminished, but enlarged, as it sometimes is
+in unhealthy children, it may give a very great deal of trouble, rolling
+out at the wound and greatly embarrassing proceedings.
+
+Abnormalities are very various and sometimes very dangerous: vessels
+crossing the trachea, as the innominate did in Macilwain's case,[129] or
+where two brachiocephalic trunks are present, as recorded by
+Chassaignac.[130] One of the most frequent dangers to be guarded against
+is a possible dilatation of the aorta or aneurism of the arch. This may
+very possibly, as happened in one case to the author, give rise to
+suffocative paroxysms from its pressure on the recurrent laryngeal
+nerves. Tracheotomy may be deemed necessary, and there is a great risk,
+unless proper precautions be taken, of wounding the aorta, where it
+passes upwards in the jugular fossa. In the author's case the vessel had
+actually to be pushed downwards by the pulp of the forefinger while the
+trachea was opened, the knife being guided on the back of the nail of
+the same finger.
+
+
+THE OPERATION.--In a work of this kind it would be utterly impossible to
+go at all into the subject of what diseases, injuries, etc., warrant or
+require the operation. It is enough to describe the various methods of
+operating, their dangers and difficulties.
+
+1. _The operation above the isthmus of the thyroid._--A spot about a
+quarter or half of an inch in vertical diameter between the cricoid
+cartilage (Fig. XXXI.) and thyroid isthmus.
+
+_Advantages._--It is near the surface, the vessels are few and
+comparatively small. It is most suitable in cases of aneurism.
+
+Professor Spence[131] gives his sanction to the high operation in adults
+with thick short necks when the operation is performed for ulceration or
+papilloma of larynx or for spasm from aneurism, the low operation being
+still best in cases of croup or diphtheria.
+
+_Disadvantages._--The space is too small, requires very considerable
+disturbance of the thyroid isthmus, or actual division of it. It is too
+near the point where the disease is; so much so, that in most cases of
+croup or diphtheria it would be perfectly useless. However, if required,
+or if the operation lower down be contra-indicated, this may be
+performed easily enough. A straight incision being made in the middle
+line about one inch and a half in length, expose the upper ring by
+careful dissection, if possible draw aside the veins, and depress the
+thyroid isthmus, divide the rings thus exposed, and introduce the tube.
+
+_The operation below the isthmus._--This, though more difficult in its
+performance, is a much more scientific and satisfactory operation.
+Considerable coolness and a thorough knowledge of the anatomy of the
+part are absolutely required.
+
+The patient being in the recumbent posture, the shoulders should be well
+raised, and the head held back so as to extend the windpipe, and thus
+bring it as near as possible to the surface. A pillow, or the arm of an
+assistant, behind the neck will be of service.
+
+_N.B._--Be careful lest too great extension by an anxious assistant,
+accompanied by closure of the mouth, should choke the patient (whose
+breathing is of course already much embarrassed) before the operation be
+begun.
+
+Chloroform may occasionally be given, and, if well borne, renders the
+operation very much easier than it would otherwise be. An incision must
+then be made exactly in the median line of the neck, from a little below
+the cricoid cartilage, almost to the upper edge of the sternum; at first
+it should be through skin only, then the veins will be seen, probably
+turgid with dark blood; the larger ones should be drawn aside, if
+necessary divided, the bleeding stopped by gentle pressure. The deep
+fascia must then be cautiously divided, great care being taken to keep
+exactly in the middle line, and the contiguous edges of sterno-thyroid
+muscles separated from each other by the handle of the knife. A quantity
+of loose connective tissue, containing numerous small veins, must now be
+pushed aside, the thyroid isthmus pressed upwards, still with the handle
+of the knife. The forefinger must then be used to distinguish the rings
+of the trachea. If there is much convulsive movement of the larynx and
+trachea, they should be fixed by the insertion of a small sharp hook
+with a short curve, just below the cricoid cartilage, and this should be
+confided to an assistant. The surgeon should then, with the forefinger
+of his left hand, fix the trachea, and open it by a straight
+sharp-pointed scalpel, boldly thrusting it through the rings with a jerk
+or stab, the back of the knife being below, and divide two or three of
+the rings from below upwards. Any attempt to enter the trachea slowly
+with a blunt knife or trocar will probably be unsuccessful, as the
+rings, especially in children, give way before the knife, which merely
+approximates the sides of the trachea without opening it.
+
+_Question of H�morrhage._--It is often a question of some importance,
+and one which sometimes it is not easy to settle, how far attempts
+should be made completely to arrest the venous h�morrhage before opening
+the trachea.
+
+_On the one hand_, if not arrested, besides the risk of weakening the
+patient, we have to dread the much more serious complication of the
+admission of blood into the wound. And this is very serious in a patient
+whose respiration has already been much impeded, whose lungs are
+probably engorged, and who has certainly, by the mere existence of a
+wound in his trachea, lost the power of coughing properly; it must never
+be forgotten that a quantity of blood so trifling as to be at once
+ejected by a single cough in the case of a healthy chest, may be a fatal
+obstacle to respiration in one already weakened by disease. Thus any
+well-marked arterial h�morrhage from cut branches, or from the isthmus
+of the thyroid, must certainly be arrested prior to opening the trachea.
+Besides this, blood once having entered the bronchi is apt to extend
+into their smaller ramifications and prove a cause of death, by acting
+as a local irritation, and setting up intra-lobular suppurative
+pneumonia. The author has found this to be the case both after
+tracheotomy and still more frequently in suicide by cut throat.
+
+But, _on the other hand_, it is equally true that there is almost always
+a considerable amount of oozing from small venous radicles divided
+during the operation, which depends simply on the great venous
+engorgement resulting from the obstruction to the respiration, so that
+while to attempt to tie every point would be simply endless, we may be
+almost certain that the oozing will cease whenever the trachea is
+opened, and respiration fairly improved. Slight pressure on the wound is
+generally sufficient to stop the bleeding till the venous engorgement
+has disappeared.
+
+Of late years many tracheotomies have been done bloodlessly by use of
+the thermo-cautery, for division of the soft parts, but the subsequent
+sloughing of the wound is a great objection to this method.
+
+In cases of extreme urgency, all such minor considerations as
+suppression of venous oozing must be ignored, and the trachea simply
+opened as rapidly as possible. I had once to perform the operation after
+respiration had entirely ceased, and no pulse could be felt at the
+wrist, with no assistance except that of a female attendant. Merely
+feeling that no large arterial branch was in the way, I cut straight
+through all the tissues, opened the trachea, and commenced artificial
+respiration. The patient eventually recovered.
+
+_Question of Tubes, etc._--Once the trachea is opened, the next question
+is, How is the opening to be kept pervious? For the moment the handle of
+the scalpel is to be inserted in the wound, so as to stretch it
+transversely; this will probably suffice to allow of the escape of any
+foreign body. But where, to admit air, the wound is to be _kept_ open,
+how is this to be done? It used to be advised that an elliptical portion
+of the wall of the trachea be removed; this, though succeeding well
+enough for a time, was unscientific, as the wound always tended to
+cicatrise, and ended of course in permanent narrowing of the canal of
+the trachea. It may be necessary thus to excise a portion of the
+trachea, in cases where it is very intolerant of the presence of a
+tube. Such a case is recorded by Sir J. Fayrer of Calcutta.[132] Not
+much better is the proposal to insert a silk ligature in each side of
+the wound, and by pulling these apart thus mechanically to open the
+wound. This also is evidently a merely temporary expedient.
+
+Various canul� and tubes have been proposed. The ones recommended by the
+older surgeons had all one great fault; they were much too small, and
+were many of them straight, and thus liable to displacement. The
+smallness of their bore was their greatest objection, and Mr. Liston
+conferred a great benefit on surgery by his insisting upon the
+introduction of tubes with a larger bore, and with a proper curve, so as
+thoroughly to enter the trachea. The tube ought to be large enough to
+admit all the air required by the lungs, without hurrying the
+respiration in the least.
+
+There is a mistake made in the construction of many of the tubes even of
+the present day; the outer opening is large and full, while for
+convenience of insertion the tube tapers down to an inner opening,
+admitting perhaps not one-half as much air as the outer one does.
+
+It must be remembered that for some days there is great risk of the tube
+becoming occluded, by frothy blood or mucus, especially in cases of
+croup, and in children. To prevent this a double canula will be found of
+great service, providing only that it be remembered that the inner
+canula, not the outer merely, is to be made large enough to breathe
+through, and that the inner should project slightly beyond the outer
+one.
+
+The inner one can thus be removed at intervals and cleansed, by the
+nurse, without any risk of exciting spasm or dyspnoea by its absence
+and reintroduction.
+
+_After-treatment._--The after-treatment of a case in which tracheotomy
+has been performed demands great care and many precautions. For the
+first day or two the constant presence of an experienced nurse or
+student is always necessary to insure the patency of the tube. The
+temperature of the room should be equable and high, and it seems of
+importance that the air should be kept moist as well as warm by the use
+of abundance of steam.
+
+A piece of thin gauze, or other light protective material, should be
+placed over the mouth of the tube, to prevent the entrance of foreign
+bodies.
+
+In cases where the operation has been performed for some temporary
+inflammatory closure of the air passage, retention of the tube for a few
+days may suffice. It may then be removed, but it must be remembered that
+the wound will generally close with great rapidity, so that it is as
+well to be quite sure of the patency of the natural passage before the
+artificial one is allowed to close by the removal of the tube.
+
+In cases where from long-standing disease or severe accident the larynx
+is rendered totally unfit for work, and the tube has to be worn during
+the rest of the patient's life, care must be taken (1.) lest the tube do
+not fit accurately, in which case it may ulcerate in various directions,
+even into the great vessels;[133] (2.) lest the tube become worn, and
+lest the part within the windpipe fall into the trachea and suffocate
+the patient.[134]
+
+
+LARYNGOTOMY.--As a temporary expedient in cases of great urgency, where
+proper instruments and assistants are not at hand, laryngotomy is
+occasionally useful, though from the want of space without encroaching
+on the cartilages of the larynx, and from its close proximity to the
+disease, laryngotomy is by no means a suitable or permanently successful
+operation.
+
+In the adult, especially in males with long spare necks, the operation
+itself is exceedingly easy to perform. The crico-thyroid space (Fig.
+XXXI. A) is so distinctly shown by the prominence of the thyroid
+cartilage, and is so superficial that it is quite easy to open it in the
+middle line with a common penknife, there being merely the skin and the
+crico-thyroid membrane to be cut through, with very rarely any vessel of
+any size. The opening can then be kept patent by a quill or a small
+piece of flat wood. This simple operation has in many cases, where a
+foreign body has filled up the box of the larynx, succeeded in saving
+life, and even in cases of disease I have known it useful in giving time
+for the subsequent performance of tracheotomy.
+
+Easy as it appears and really is, cases are on record in which the
+thyro-hyoid space has been opened instead of the crico-thyroid, such
+operations being of course perfectly useless.
+
+The incision is best made transversely.
+
+
+LARYNGO-TRACHEOTOMY.--This modification consists in opening the air
+passage by the division of the cricoid cartilage vertically in the
+middle line, along with one or two of the upper rings of the trachea.
+
+It seems to combine all the dangers with none of the advantages of the
+other methods of operating. It is close to the disease, involves cutting
+a cartilage of the larynx, and almost certain wounding of the isthmus of
+the thyroid; and it is not easy to see what corresponding advantages it
+has over tracheotomy in the usual position.
+
+
+THYROTOMY is an operation by which the larynx is opened in the middle
+line by a vertical incision, and its halves separated, while any morbid
+growths are excised from the cords or ventricles. The merits and dangers
+of this operation have been discussed at length by Mr. Durham[135] and
+Dr. Morell Mackenzie.[136]
+
+
+LARYNGECTOMY OR EXCISION OF THE LARYNX, first performed by Dr. Heron
+Watson in 1866, has been lately frequently performed for carcinoma and
+sarcoma. Each case presents its own difficulties, which vary according
+to the amount and extent of the disease for which it is done.
+
+The trachea must be divided and tamponed by a Trendelenburg canula,
+after which the larynx must be carefully dissected out. The immediate
+mortality, _i.e._ in first ten days, is fifty per cent., and Dr. Gross
+holds that life has not been prolonged by the operation.[137]
+
+
+OESOPHAGOTOMY.--This operation is very rarely required, and has as yet
+been performed only for the removal of foreign bodies impacted in the
+oesophagus, and interfering with respiration and deglutition. To cut
+upon the flaccid empty oesophagus in the living body would be an
+extremely difficult and dangerous operation, from the manner in which it
+lies concealed behind the larynx, and in close contact with the great
+vessels. When it is distended by a foreign body, and specially if the
+foreign body has well-marked angles, the operation is not nearly so
+difficult. It has now been performed in forty-three cases at least, of
+which eight or nine have proved fatal. Seven, along with another in
+which he himself performed it with success, were recorded by Mr. Cock of
+Guy's Hospital.[138] Three others were performed by Mr. Syme, with a
+successful result. Of the seven cases collected by Mr. Cock only two
+died, one of pneumonia, the other of gangrene of the pharynx.
+
+_Operation._--Unless there is a very decided projection of the foreign
+body on the right, the left side of the neck should be chosen, as the
+oesophagus normally lies rather on the left of the middle line. An
+incision similar to that required for ligature of the carotid above the
+omohyoid should be made over the inner edge of the sterno-mastoid
+muscle; with it as a guide, the omohyoid may be sought and drawn
+downwards and inwards, the sheath of the vessels exposed and drawn
+outwards, the larynx slightly pushed across to the right, the thyroid
+gland drawn out of the way by a blunt hook, the superior thyroid either
+avoided or tied. The oesophagus is then exposed, and if the foreign
+body is large, it is easily recognised; if the foreign body be small, a
+large probang with a globular ivory head should then be passed from the
+fauces down to the obstruction; this will distend the walls of the
+oesophagus, and make it a much more easy and safe business to divide
+them to the required extent. The wound in the oesophagus should be
+longitudinal, and at first not larger than is required to admit the
+finger, on which as a guide the forceps may be introduced to remove the
+foreign body, or, if necessary, a probe-pointed bistoury still further
+to dilate the wound.
+
+For some days or even weeks the patient must be fed through an elastic
+catheter introduced through the nose and retained, or by an ordinary
+stomach-tube through the mouth. In introducing the latter there is
+always a risk of opening the wound. No special sutures for the wound in
+the oesophagus are required, nor is it advisable too closely to sew up
+the external wound.
+
+
+FOOTNOTES:
+
+[127] _Le�ons sur la Trach�otomie_, p. 10.
+
+[128] Rough diagram of larynx and trachea:--A, crico-thyroid space,
+_laryngotomy_; B B, dotted outline of thyroid isthmus and lobes, defines
+the upper and lower positions for _tracheotomy_; C, thyroid--D, cricoid
+cartilages; E, dotted outline of thymus gland in child of two years; F
+F, outline of clavicles and jugular fossa.
+
+[129] _Surgical Observations_, p. 335. See also Harrison _On the
+Arteries_, vol. i. p. 16.
+
+[130] _Le�ons sur la Trach�otomie_, p. 9.
+
+[131] _Lectures on Surgery_, 3d ed., vol. ii. p. 900.
+
+[132] _Clinical Surgery in India_ (1866), p. 143.
+
+[133] Mr. John Wood, _Path. Soc. Trans._, vol. xi. p. 20.
+
+[134] South's _Chelius_, vol. ii. p. 400; and case recorded by Spence,
+in _Ed. Med. Journal_, for August 1862.
+
+[135] _Med. Chir. Transactions of London_, 1872.
+
+[136] _British Med. Journal_ (Nos. 643, 644), 1873.
+
+[137] Gross's _Surgery_, 6th ed., vol. ii. p. 342.
+
+[138] _Guy's Hospital Reports_ for 1858.
+
+
+
+
+CHAPTER X.
+
+OPERATIONS ON THORAX.
+
+
+EXCISION OF MAMMA.--When the whole breast is to be removed, two
+incisions, inclosing an elliptical portion of skin along with the
+nipple, must be made in the direction of the fibres of the pectoralis
+muscle. The distance between the incisions at their broadest must depend
+upon the nature of the disease for which the operation is performed, and
+the extent to which the skin is involved; in every case the whole nipple
+should be removed. The incisions should, if possible, be parallel with
+the fibres of the pectoralis major, and extend across the full diameter
+of the breast. During the operation the arm should be extended so as to
+stretch both skin and muscle. The lower flap should be first raised and
+dissected downwards, with care that the cuts are made in the
+subcutaneous fat, and wide of the disease; the upper flap is then thrown
+open, and the edge of the gland raised, so that the fibres of the
+pectoralis are exposed below it. These should be cleanly dissected, so
+as to insure removal of the whole gland.
+
+Any bleeding during the operation can easily be checked by the fingers
+of an assistant, and if the arteries entering the gland from the axilla
+be divided last, they can be at once secured. If there are many bleeding
+points, the application of cold for a few hours before the wound is
+finally closed is a wise precaution.
+
+The requisite stitches may be inserted while the patient is under
+chloroform, but not tightened. The arm should then be brought down to
+the side, and a folded towel laid over the wound after it is finally
+closed. Great benefit results from the free use of drainage-tubes in
+most cases; for this purpose a dependent opening in the lower flap is
+often made.
+
+Surgeons now operate even when the axillary glands are diseased, and by
+a very free dissection and removal, even in hopeless-looking cases, life
+may be prolonged. To insure the removal of the lymphatic vessels as well
+as the glands, it is best not to separate the breast at its axillary
+margin, but keep it attached by the tail of lymphatics surrounded by
+fat, which will lead up to the glands. Section of the great pectoral
+muscle will aid the dissection.
+
+     When the tumour is very large, and the skin has been much stretched
+     and undermined, more complicated incisions may be necessary; these
+     must be governed a good deal by the presence and positions of
+     adhesions or ulcerations of the skin. The best direction, when the
+     surgeon has his choice, that these incisions can take, is that of
+     radii from the nipple, bisecting the flaps made by the original
+     elliptical incision.
+
+_N.B._--In operating for malignant disease, the one paramount
+consideration is that _all_ the disease be excised, however curious,
+inconvenient, or awkward, even insufficient, the flaps may look. Partial
+excisions are worse than useless.
+
+
+PARACENTESIS THORACIS, for the relief of pleurisy, acute and chronic,
+and empyema, is an operation of extreme simplicity.
+
+The proper selection of cases, the settling of the suitable position for
+the tapping, and the choosing of the suitable time for it, are more
+difficult, and not within the scope of the present work. On these
+subjects much information may be obtained from the papers of Dr.
+Bowditch of Boston, of Dr. Hughes and Mr. Cock,[139] and an exceedingly
+interesting and valuable paper by Dr. Warburton Begbie.[140]
+
+_Where_ is it to be performed? Not _above_ the sixth rib, else the
+opening is not sufficiently dependent; very rarely _below_ the eighth on
+the right side, and the ninth on the left. The intercostal space
+generally bulges outwards if fluid is present, and this bulging acts as
+an aid to diagnosis. As the intercostal artery lies under the lower edge
+of the upper rib in each space, the trocar should be entered not higher
+than the middle of the space; and because the artery is largest near the
+spine, and also the space is there deeply covered with muscle, the
+tapping should never be _behind_ the angle of the rib. In most of the
+manuals we are told to select a spot midway between the sternum and
+spine for the puncture; but Bowditch, Cock, and Begbie, who have had
+large experience, prefer, and I believe rightly, a position considerably
+behind this, _an inch_ or two below the angle of the scapula, between
+the seventh and eighth, or between the eighth and ninth ribs.
+
+The operation may be performed with a simple trocar and canula, round,
+about an eighth of an inch in diameter, and at least two inches in
+length. The point must be sharp, and it must be pushed in with
+considerable quickness, so as to penetrate, not merely push forwards,
+the pleura, which may be tough, and thicker than usual. Once the skin is
+pierced, the instrument must be directed obliquely upwards, so as to
+make the opening and position of the trocar dependent. When the trocar
+is withdrawn the fluid may be allowed to flow so long as it keeps in a
+full equable stream; whenever it becomes jerky and spasmodic, the canula
+should be removed _before_ the sucking noise of air entering the chest
+is heard.
+
+In more chronic cases, where the quantity of fluid is large, and
+especially if it is thick and curdy, the exhausting syringe of Mr.
+Bowditch is an improvement on the simple trocar and canula.
+
+It consists of a powerful syringe, which fits accurately to the trocar
+with which the puncture is made. There is a stop-cock between the trocar
+and syringe, and another at right angles to the syringe. The trocar
+being introduced, it is held firmly in position by an assistant, by
+means of a strong cross handle; the first stop-cock is then opened, and
+the syringe worked slowly till it is filled with fluid through the
+trocar, the other delivery stop-cock being closed. The first is then
+closed, and the second opened; the syringe is then emptied through the
+second into a basin. By a repetition of this process, the fluid can be
+removed at pleasure, without any risk of the entrance of air.
+
+     Dieulafoy's aspirateur, which the author has now used in a very
+     large number of cases, will be found the best method yet devised of
+     safely removing the fluid in cases of serous effusion. But in
+     severe cases of empyema the pus is sure to be reproduced in the
+     great majority, and then a free incision, with strict antiseptic
+     precautions, will be needed, and subsequent free drainage.
+
+     The author has used with great benefit silver tubes, like long
+     narrow trachea-tubes, with broad shields, to insure free drain.
+
+
+FOOTNOTES:
+
+[139] Both in _Guy's Hospital Reports_, second series, vol. ii.
+
+[140] _Edinburgh Medical Journal_ for June 1866.
+
+
+
+
+CHAPTER XI.
+
+OPERATIONS ON ABDOMEN.
+
+
+PARACENTESIS ABDOMINIS.--To withdraw fluid from the abdominal cavity is
+an exceedingly simple operation in itself, though certain precautions
+are necessary to render it safe.
+
+_Trocar._--The usual instrument used to be a simple round canula with a
+trocar, the point of which should be very sharp, and in the shape of a
+three-sided pyramid. It should be about three inches in length, and a
+quarter of an inch in diameter. It may for convenience have an
+india-rubber tube fixed to its side or end, for the purpose of conveying
+the fluid to the pail or basin, but any other additions or alterations
+have not been improvements. Lately surgeons have been diminishing the
+size of the tube so as to withdraw the fluid more slowly, and taking
+many precautions to insure the wound being kept aseptic.
+
+_Where to tap._--In the linea alba, midway between the umbilicus and
+pubes, or rather nearer the umbilicus. Here, there are no muscles nor
+vessels, the opening is a dependent one, and the bladder is quite out of
+the way of injury.
+
+_N.B._--It is a wise precaution, in every case where there is a
+possibility of doubt as to the state of the bladder, to pass a catheter.
+I have myself known at least one case in which a surgeon was asked to
+tap an over-distended bladder, as a case of ascites.
+
+_The Operation._--As there is great risk of syncope coming on during the
+operation, from the sudden relief to the pressure on the organs, a broad
+flannel bandage should be applied to the belly, the ends of which are
+split into three at each side, and crossed and interlaced behind. An
+assistant should stand at each side to make gradual pressure by pulling
+on the ends of the bandage, thus assisting the flow, and maintaining the
+pressure. A hole should be cut in the bandage at the spot where the
+puncture is to be made, and the trocar inserted by one firm push,
+without any preliminary incision, unless the patient is inordinately
+fat. As the trocar is withdrawn, the canula should be pushed still
+further in. The surgeon should be ready at once to close the canula with
+his thumb, if the flow begins to cease, lest air should be admitted. If
+the flow ceases from any cause before all the fluid seems to be
+evacuated, the trocar should _not_ be re-introduced, lest the intestines
+be wounded, but a blunt-headed perforated instrument fitting the canula
+should be inserted.
+
+When all the fluid that can be easily obtained is evacuated, the canula
+may be withdrawn, and a pad of lint secured over the wound by strapping.
+
+
+GASTROTOMY.--Cutting into the stomach for the extraction of a foreign
+body has now been performed at least ten times, and all but one
+recovered. A typical example is that by Dr. Bell of Davenport, who
+removed a bar of lead one pound in weight and ten inches in length, by
+an incision four inches in length from the umbilicus to the false ribs.
+The opening into the stomach was as small as possible, and required no
+sutures.
+
+
+GASTROSTOMY has within the last few years been practised very
+frequently. Gross has collected 79 cases, 57 of which were for carcinoma
+of oesophagus, all of which died within a few weeks, except eight who
+survived for periods varying from three to seven months. The results in
+cases of cicatricial and syphilitic strictures are more
+favourable.--Howse's method seems the best, consisting of two stages.
+
+1. A curved incision is made through the parietes parallel with, and a
+finger-breadth below, the lower margin of chest wall on left side, the
+peritoneum should be opened at the linea semilunaris, the stomach sought
+for, and then attached to the abdominal wall by an outer ring of sutures
+and to the edge of the wound by an inner ring. It should then be dressed
+with carbolised lint and supported by a bandage.
+
+2. A small opening should be made four or five days after the first
+stage and the patient should be fed through this opening.
+
+For full details, see Mr. Durham's paper in vol. i. of Holmes's Surgery,
+edition of 1883, pp. 801-4.
+
+
+GASTRECTOMY.--Excision of whole or part of the stomach is one of the
+latest developments of operative daring, first done as a regular
+operation by Pean in 1879, it has now been repeated sixteen times; four
+cases have survived the operation for more than ten days. The chief
+points to be attended to are prevention of death from shock and
+h�morrhage, and very careful stitching up of the wound. Considering the
+difficulty of the diagnosis, the danger of the operation, and the almost
+certain recurrence of the disease, the propriety of such operation seems
+very doubtful.
+
+
+OVARIOTOMY.--For the pathology of ovarian disease we must refer to Sir
+Spencer Wells's work on the subject, and to the smaller Monograph on
+Ovarian Pathology, by the late lamented Dr. Charles Ritchie, junior.
+
+Even the modifications in the method of operating which have been
+devised are so various and numerous, that if collected from the medical
+journals of the last ten years they would fill a large volume. Besides
+this, the operation of ovariotomy is one attended by so many
+complications, that individual cases vary from each other as much as do
+individual cases of hernia and tracheotomy; and as the specialities of
+each case require to be met by specialities of treatment, there is
+hardly any operation in surgery which requires greater readiness of
+invention, or more individual sagacity in the operator.
+
+To lay open the abdominal cavity from the sternum to the pubes, and
+rapidly dissect out of this cavity an enormous tumour with a narrow
+neck, the operator's only embarrassment being the peristaltic movements
+of the bowels, and his only care being to tie the neck of the tumour
+firmly with strong string, sew up the wound, and trust to nature, was an
+operation very easy to perform, and requiring free cutting rather than
+dexterity, and rashness more than true surgical insight.
+
+Such were the ovariotomies prior to 1857.
+
+An ovariotomy in 1883 is a very different business, varying in certain
+important particulars.
+
+(1.) Instead of the incision extending from sternum to pubes, it is now
+made as short as possible.
+
+(2.) Instead of being removed entire, the cyst is now emptied with the
+greatest possible care (prior to its removal), and none of the contents
+allowed to enter the peritoneal cavity.
+
+(3.) The pedicle is brought to the surface, and in every case where it
+is possible is secured outside the wound.
+
+Besides these three important and cardinal points, there are other minor
+matters almost equally essential; these are--(1.) The proper management
+of the adhesions and the thorough prevention of all h�morrhage from
+them; (2.) the stitching up of the external wound, including the
+peritoneum; (3.) the treatment of the patient during the first few days
+of convalescence.
+
+_Operation_ in a typical case, after the method of Sir Spencer Wells and
+Dr. Thomas Keith.--The patient having had her bowels gently opened on
+the previous day, and being as far as possible in her usual state of
+health, should be warmly clad in flannel, both in body and limb, and
+laid on an operating table of convenient height, in or near the room she
+is to occupy. No carrying from ward to operating theatre and back again
+is admissible. It will be found both cleanly and convenient to have a
+large india-rubber cloth over the whole abdomen, cut out in the centre
+so as to expose so much of the tumour as is necessary, but gummed on or
+otherwise secured to the sides of the abdomen, and thus protecting the
+clothes, and hanging down over the edge of the table; this will prevent
+all wetting of the clothes and unnecessary exposure of the patient's
+person, and can be easily removed after the operation. Chloroform being
+administered, the bladder is evacuated by means of a catheter, and the
+patient's head and shoulders are elevated on pillows. An incision is
+then made in the linea alba, between the umbilicus and pubes, for about
+four inches in length at first, so as to be large enough to admit the
+hand, through all the tissues down to and through the peritoneum. Care
+is necessary in dividing the peritoneum, on the one hand, not to divide
+too much, in which case the cyst-wall will be penetrated, and the
+contents effused into the peritoneal cavity; or, on the other hand, too
+little, in which case the peritoneum may be mistaken for the cyst, and
+separated from the transversalis fascia under the idea that adhesions
+exist. Once the peritoneal cavity is opened, the incision through the
+peritoneum must be extended to the full length of the external wound by
+a probe-pointed bistoury.
+
+The operator's hand must now be passed into the abdomen, and the tumour
+isolated from its connections as far as possible. When no adhesions
+exist it is extremely easy to pass the hand quite round the tumour,
+ascertain its relations to the uterus and Fallopian tubes, and the
+length and thickness of its pedicle. The presence of adhesions adds very
+seriously to the danger and duration of the operation. We will suppose
+at present that none exist in this typical case, and that the pedicle is
+found of a satisfactory size and shape. The surgeon now protrudes the
+anterior portion of the cyst-wall through the wound, and pierces it with
+a large trocar,[141] to which is attached an india-rubber tube, by means
+of which the effused fluid can be easily got rid of in any direction.
+During the escape of the fluid from the cyst a special assistant keeps
+up the tension by careful pressure on the abdomen. In cases where the
+cyst is multilocular, and thus only a portion of the contents of the
+tumour is at first evaluated, the operator should, by partially
+withdrawing the trocar, without removing it entirely from the cyst,
+endeavour to pierce and evacuate the other cysts, still through the
+original opening in the first one.
+
+While doing this, great care must be taken lest he pierce the external
+wall of the tumour, and let any of the contents escape into the
+abdominal cavity; to guard against this, the punctures should be made
+by the right hand, while the left, re-inserted into the abdomen,
+supports the cyst-wall.
+
+The tumour having been as far as possible emptied of its fluid contents,
+must now be dragged out of the wound, care being still taken lest any of
+its fluid contents escape into the peritoneal cavity. In favourable
+cases the pedicle is now brought easily into view. This may vary very
+much in length and thickness. It is sometimes entirely absent, the
+tumour being sessile on the broad ligament of the uterus; sometimes it
+is thick and strong, sometimes long and slender. The manner in which it
+is to be managed depends on its length and thickness. Varieties in
+treatment will be noticed immediately. We will suppose that it is four
+inches in length and one or two fingers in breadth. This is quite a
+suitable case for the use of the clamp, the principle involved in the
+use of which is, that the pedicle should be brought quite out of the
+abdomen through the wound and secured on the surface. The best form
+seems to be one made like a carpenter's callipers, with long but
+removable handles, and a very powerful fixing-screw.
+
+The blades of this clamp being protected by pads of lint should be made
+to embrace the pedicle close to the cyst, in a direction at right angles
+to the abdominal wound, and lying across it, the handles should then be
+removed, and pads of lint placed below the clamp to protect the skin.
+The cyst may now be cut away at some little distance above the clamp,
+enough being left to prevent all danger of its slipping. Further to
+avoid this danger, the pedicle may be transfixed by one or two needles
+above the clamp.
+
+The wound is now to be sewed up by several points of interrupted suture,
+some inserted very deeply through all the tissues, including even the
+peritoneum, others in the intervals of the first, including little more
+than the skin. They may be either of iron, silver, platinum,
+telegraph-wire (Mr. Clover's copper, coated with gutta-percha), or silk.
+It seems of very little consequence which is used. Sir Spencer Wells,
+after many trials, uses silk, as being removed with least pain to the
+patient, and really causing no more suppuration than the metallic ones
+do, if only removed early enough, viz., about the second or third day,
+by which time the union of the wound should be firm.
+
+The after-treatment should be very simple. Except under special
+circumstances, stimulants are rarely necessary, and indeed, to avoid
+vomiting, as little as possible should be given by the mouth during the
+first twenty-four hours. The patient should be allowed to suck a little
+ice to allay thirst, and opiate and nutritive enemata will be found
+quite sufficient to keep up the strength in ordinary cases. The urine
+should be drawn off by the catheter every six hours. The room should be
+kept quiet, and the temperature equable, so long as there is no
+interference with a plentiful supply of fresh air.
+
+Some of the specialities and abnormalities involving special risks may
+now be briefly noticed:--
+
+1. _Adhesions._--These vary much in amount, in position, in
+organisation, and danger.
+
+_a._ _In amount._--In certain cases no adhesions exist, while in others,
+omentum, intestines, tumour, uterus, and abdominal wall may be all
+matted together in one common mass.
+
+_b._ _In organisation._--Occasionally they are so soft and friable as to
+break down under the finger with ease, and so slightly organised as not
+to bleed at all in the process, while again they may be so firm and
+close as to require a careful and prolonged dissection, and so vascular
+as to require many points of ligature to be applied to large active
+vessels.
+
+_c._ There are special _dangers_ connected with the presence of these
+adhesions, and varying much in different cases. Thus adhesions to the
+intestines can generally be separated with comparative ease, and seem,
+as a rule, to require the application of fewer ligatures than those
+which unite the tumour to the abdominal wall. Adhesions to the wall are
+sometimes so firm as to be quite inseparable, and thus to necessitate
+some of the cyst-wall being left adherent. In Sir Spencer Wells's cases,
+adhesions to the liver and gall-bladder occasionally occurred, requiring
+careful dissection to separate them, and yet the patients all survived,
+while pelvic adhesions, especially to the bladder and uterus, on more
+than one occasion prevented the completion of the operation.
+
+Vascular adhesions to the wall which require many ligatures certainly
+add to the dangers of the case, while adhesions to the anterior wall of
+the abdomen render the operation, especially its first stages, much more
+difficult, preventing the cyst from being recognised.
+
+2. _The condition of the pedicle_ is of great importance. If it is too
+short, it prevents the use of the clamp, as if applied it is apt either
+to pull the uterus up, or, pulling the clamp down, to make undue
+traction on the wound, and rupture any adhesions. This is especially the
+case where much flatus is generated, or where the patient is naturally
+stout.
+
+_Treatment._--Where the pedicle is just long enough to allow the clamp
+to be applied, and yet too short to leave room for any distension of the
+abdomen without undue tension, the best plan is to transfix it with a
+stout double thread just below the clamp, tie it in two halves, and
+bring the threads out past the clamp, so that, if tension does occur,
+the clamp may be removed, the part beyond it cut off, and the rest
+allowed to slip back into the pelvis, the ligatures being kept out at
+the mouth of the wound.
+
+Or again, it is sometimes possible, after applying one clamp firmly as
+near the tumour as possible, to apply another above it when the greater
+part of the tumour has been cut away; when the second is firmly fixed
+it may then be safe to remove the first, and thus an artificially
+elongated pedicle is obtained.
+
+When still shorter, two plans remain for selection--(1.) to transfix the
+pedicle in one or more points, then, securing it in two, three, or more
+portions, cut it off above the ligatures and return it, leaving the
+ligatures at the lower end of the wound. This gives a free drain for
+pus, but theoretically the sloughing pedicle might be expected to set up
+peritonitis; (2.) to transfix and tie the pedicle with one or more loops
+of stout string, cut the ends off short, and return the whole affair,
+closing the external wound at once. Theoretically there are grave
+objections to this plan, but it has proved very successful, especially
+in the hands of Dr. Tyler Smith.
+
+Another ingenious modification, sometimes useful in a short narrow
+pedicle, is to tie it as close to the cyst as possible, bring the
+ligature out at the wound, and then with a strong harelip needle
+transfix the pedicle, along with both sides of the wound, just below the
+ligature.
+
+When the pedicle is excessively broad and stout, it should be transfixed
+by strong needles and double threads in various places, and thus tied in
+several portions. Absence of the pedicle greatly adds to the danger in
+any given case. Various plans have been tried, as cutting the attachment
+through slowly by the �craseur, ligature of each vessel separately, so
+many as twelve being sometimes required, and cauterising the stump. The
+latter, as used by Mr. Baker Brown, has met with a large measure of
+success, and is much used now.[142]
+
+Dr. Keith for a time operated with antiseptic precautions, but has now
+(1883) entirely given up the use of the spray, which he believes has
+especial dangers in abdominal surgery.
+
+
+OPERATION FOR STRANGULATED INGUINAL HERNIA.--The great rule to be
+remembered with regard to this, as well as all other operations for
+hernia, is, that the earlier it is performed the better chance the
+patient has. Once a fair trial has been given to the taxis, aided by
+proper position of the patient, the warm bath, and specially chloroform,
+the operation should be performed.
+
+The patient should be placed on his back with his shoulders elevated,
+and the knee of the affected side slightly bent. The groin should then
+be shaved, and the shape and size of the tumour, with the position of
+the inguinal canal, carefully studied. The surgeon should then lift up a
+fold of skin and cellular tissue, in a direction at right angles to the
+long axis of the tumour, and holding one side of this raised fold in his
+own left hand, commit the other to an assistant. He then transfixes this
+fold with a sharp straight bistoury, with its back towards the sac, and
+cuts outwards, thus at once making an incision along the axis of the
+hernia without any risk of wounding the sac or bowel. Any vessel that
+bleeds may now be tied. This incision will be found sufficiently large
+for most cases; if not, however, it can easily be prolonged either
+upwards or downwards. The surgeon must now devote his attention to
+exposing the neck of the sac, and in so doing, defining the external
+inguinal ring. The safest method of doing so is carefully to pinch up,
+with dissecting forceps, layer after layer of connective tissue,
+dividing each separately by the knife held with its flat side, not its
+edge, on the sac, and then by means of the finger or forceps raising
+each layer in succession and dividing it to the full extent of the
+external incision. It is not always an easy matter to recognise the
+sac, especially as the number of layers above it, which are described in
+the anatomical text-books, are often not at all distinct.
+
+The thickness of the connective tissue of the part varies immensely;
+sometimes six layers or even more can be separately dissected, while,
+again, one only may be found before the sac is exposed.
+
+If small and recent, the sac may be recognised by its bluish colour, and
+by the fact that it is possible to pinch up a portion of it between the
+finger and thumb, and thus to rub its opposed surfaces against each
+other.
+
+If large and of old standing, it is sometimes so thin as not to be
+recognisable, or again so enormously thickened, and so adherent, as to
+be defined with great difficulty.
+
+If it is small, _i.e._ when the whole tumour is under the size of an
+egg, it ought to be thoroughly isolated, and its boundaries everywhere
+defined. If large, and specially if adherent, the neck alone should be
+cleared.
+
+The sac thus being reached, the external abdominal ring should be
+clearly defined, and the finger passed into it so as if possible to
+determine the presence or absence of any constriction in it. If it feels
+tight, the internal pillar of the ring should then be cautiously divided
+on the finger by a probe-pointed narrow bistoury, in a direction
+parallel to the linea alba.
+
+At this stage the question comes to be considered as to whether the sac
+should or should not be opened. Much has been said and written on both
+sides.
+
+Not to open the sac avoids the risk of peritonitis, and of injury to the
+bowel; but, on the other hand, exposes the patient to the danger of the
+hernia being returned unreduced; for in many cases the stricture is to
+be found in the sac itself, and adhesions very rapidly form between
+coils of intestine in the sac and the inner wall. Again, not to open the
+sac prevents us from discovering the condition in which the bowl is; it
+may possibly be gangrenous, in which case such a return _en masse_ would
+be almost necessarily fatal.
+
+A general rule or two may be given here:--
+
+1. The sac should be opened in every case where there is any reason for
+doubt about the condition of the bowel, where there has been
+long-continued vomiting, or much tenderness on pressure.
+
+2. Even in cases in which there is every reason to believe the bowel is
+perfectly sound, the sac should be opened, unless the whole contents can
+be easily and completely reduced out of the sac into the belly, as in
+cases where this cannot be done there probably exist either a stricture
+in the neck of the sac itself, or adhesions of the bowel to the sac. We
+should endeavour to avoid opening the sac in cases of old scrotal hernia
+of large size, where the symptoms have not been urgent, especially in
+large unhealthy hospitals, as the risk of peritonitis is so great.
+Antiseptic precautions seem considerably to diminish the risk of opening
+the sac.
+
+If the sac then is not to be opened, the rest of the operation is very
+simple. Endeavour to reduce the bowel out of the sac, and then return
+the sac itself, unless the hernia is of old standing, and adhesions
+prevent its reduction. A few silver stitches to close the wound and a
+carefully adjusted pad are now all that is requisite.
+
+If the sac is to be opened, how can it be done with least danger to the
+bowel?
+
+If the hernia is small, and it is possible to define it all, the sac
+should be opened at its lower end, as _there_ a small quantity of serous
+fluid which intervenes between the sac and the bowel will be found.
+Where this is present, there is no danger of wounding the bowel, as the
+sac can be easily pinched up; but this is by no means invariably the
+case, so great care should always be taken. A small portion of the wall
+being thus pinched up should be divided in the same manner as the
+layers of cellular tissue were divided in exposing the sac. A few drops
+of serum will then escape, and the glistening surface of the bowel be
+exposed; the finger should then be introduced at the opening, and the
+incision enlarged by a probe-pointed bistoury. If the hernia is small
+the sac should be slit up to its full extent; if large, only a
+sufficient portion of the neck should be opened. As soon as the opening
+in the sac is large enough to admit the point of the operator's
+forefinger, it should be inserted so as to protect the intestines, and
+the remainder of the sac slit up on it as a guide.
+
+The sac thus opened, the next step is to divide the constriction,
+wherever it be. It is most likely to be found at the neck of the sac,
+just where it protrudes through the internal ring in an oblique hernia,
+or through the tendons of the transversalis and internal oblique, where
+the hernia is direct. Now, this constriction might be divided in any
+direction were it not for the risk of wounding the epigastric artery,
+and also of injuring the spermatic cord, which is in close relation to
+the neck of the sac of an oblique hernia.
+
+Wound of the epigastric artery is the chief danger, for in _all_ cases
+it is close to the neck of the sac. Were its position in relation to the
+neck of the sac constant, it might be easily avoided by an incision in
+the opposite direction; but as this relation varies according to the
+nature of the hernia, an element of danger is introduced. Thus, in
+oblique inguinal ruptures, where the sac passes out through the internal
+ring (Fig. XXXII. IR), the artery will always be found to the inside of
+the neck of the sac; while in direct herni�, where the bowel has made
+its escape through the triangle of Hesselbach (Fig. XXXII. +), and
+passed through the conjoint tendon straight to the external ring, the
+epigastric artery will be found on the outside of the neck of the sac.
+In recent herni� the differential diagnosis is comparatively easy, but
+in those of old standing and large size, in which the obliquity of the
+canal has been much diminished, it is almost impossible to tell of what
+kind the hernia originally was, and consequently to determine in which
+direction it is safe to incise the neck of the sac.
+
+Such being the case, the best rule is to incise the neck of the sac
+directly upwards, _i.e._ in a line parallel with the linea alba, and
+also to cut it very cautiously bit by bit, in every case, if possible,
+with the finger inserted as a guide to the position of a vessel and a
+protection to the gut.
+
+The spermatic vessels lie sometimes behind, sometimes on either side of
+the sac, and in very old herni� may be separated from each other so as
+really to surround the sac. The cut directly upwards is also the safest
+for them.
+
+All constrictions being overcome, it is not sufficient merely to push
+back the gut into the belly. Its condition must be carefully examined,
+and it must be decided whether the constriction has caused gangrene or
+not. To examine this properly, it is generally best to pull down an inch
+or two more of the gut, so as thoroughly to bring into view the
+constricted portion, as _it_ is most likely to be fatally nipped.
+
+It is not always easy to decide as to the condition of the bowel.
+Certain points must be observed:--
+
+(1.) _Colour._--There may be very great alteration in the colour of the
+bowel from congestion, and yet no gangrene. It may be dark red, claret,
+purple, or even have a brownish tint, and yet recover; where it is
+black, or a deep brown, the prognosis is unfavourable.
+
+(2.) _Glistening._--So long as the proper glistening appearance of the
+bowel remains, there is hope for it, even when the colour is bad; if it
+has lost it, and especially if, instead of being tense and shining, it
+is dull and flaccid and in wrinkles, the bowel is almost certainly
+gangrenous.
+
+(3.) _Thickness._--If much thickened, and especially if rough on the
+surface, the bowel has probably been forming adhesions to the sac, or to
+contiguous coils, and the prognosis is less favourable.
+
+(4.) _Smell._--The peculiar gangrenous odour on opening the sac is very
+characteristic. In cases where ulceration and perforation have occurred,
+the odour is f�cal.
+
+1. If, then, the bowel is tolerably healthy-looking, though discoloured,
+it should be returned gradually, not _en masse_, into the abdomen, the
+wound sewed up, and a pad of lint put on, with a bandage.
+
+2. If there are adhesions of bowel to sac or to a neighbouring coil, or
+of omentum to sac, the stricture should be freely divided, the
+protruding coils of intestine should be emptied of their contents, but
+no rash attempt made to force their return. Especially is this rule to
+be observed with protruded, swollen, or adherent omentum, for
+considerable risks attend any attempt at excision of the protruded
+portion--risks of h�morrhage, peritonitis, and ulceration of the
+contiguous bowel.
+
+If the bowel be returned, or even the continuity of the canal restored
+by the cutting of the stricture, though the bowel be not returned, no
+great risks accrue from the retention of a piece of omentum in the sac,
+in a position which it may possibly have already occupied for years.
+
+3. If the bowel is absolutely gangrenous, even in a very small portion
+of its length, no reduction should be attempted, but the gangrenous
+portion should be kept outside, with the hope that adhesive inflammation
+may be set up, so as to glue the bowel to the abdominal wall, prevent
+f�cal extravasation, and form a temporary artificial anus. If the
+gangrenous portion be very full of f�ces or flatus, incisions may be
+made into it. This should be avoided in cases where the patient is
+already much prostrated, as I have seen cases in which the opening of
+the bowel seemed to inflict a fatal shock.
+
+Enterectomy or excision of the gangrenous portion has recently been
+recommended and performed by some surgeons. The very high authority of
+the late Professor Spence is against such procedure.[143]
+
+Cases of gangrene of even large portions of bowel are by no means
+necessarily fatal. They may recover with an artificial anus, the remedy
+of which by surgical means we must notice in its proper place.
+
+
+OPERATION FOR STRANGULATED FEMORAL HERNIA.--While the general principles
+guiding treatment and ruling the conduct of the operation are the same
+as in inguinal, there are some differences in points of detail which
+render a brief separate description necessary.
+
+     A single word on the anatomy. Tracing a femoral rupture from within
+     outwards, we find that its first stage is to push its way through
+     the weak point of the arch formed by Poupart's ligament, that is,
+     the spot called the crural arch, bounded on its outer side by the
+     sheath of fascia which surrounds the femoral vein; above by
+     Poupart's ligament; on its inner side by the curved fibres of
+     Poupart's ligament, which, curving backwards, are inserted into the
+     ilio-pectineal line, have a sharp falciform edge, and have been
+     dignified by the special name of Gimbernat's ligament (Fig. XXXII.
+     G); and below by the os pubis itself. This arch or ring thus
+     bounded is, in the normal state of parts, filled by a layer of
+     fibrous texture, a little fat, and occasionally a small gland.
+     These parts are pushed forwards in the descent of the hernia, and
+     in a small recent one may be said to form a sort of inner covering;
+     in a larger and older one they are split by the hernia, and, while
+     forming a constriction round its neck, leave the fundus of the sac,
+     so far as they are concerned, quite uncovered.
+
+     A femoral hernia may stop there, satisfied with merely coming
+     through the ring, and, if sudden and recent in a healthy, well-knit
+     subject, such a rupture is exceedingly dangerous, the constriction
+     being very severe, and the consequent gangrene of the bowel very
+     rapid if unrelieved. In most cases, however, it makes its way still
+     further out, and the next covering it gains is from the cribriform
+     fascia. This is the layer of fibres, pierced (as its name implies)
+     with orifices for the passage of veins and lymphatics, which
+     stretches between the two curved edges of the saphenous opening. It
+     varies much in strength; when the rupture has been slow and
+     gradual, it will certainly add a covering of greater or less
+     thickness, but where the hernia is large and old we must not expect
+     to find many traces of the cribriform fascia, at least over the
+     fundus of the tumour.
+
+     The ordinary superficial fascia of the part, with its fat, nerves,
+     veins, and lymphatics, and the thin skin of the groin, are the only
+     remaining coverings. It is very remarkable how exceedingly thin all
+     the so-called coats become in large femoral herni� of long
+     standing, especially in thin old people.
+
+_Operation._--Various incisions are recommended. The one which gives
+freest access and exposes the sac best, is shaped like a T, the
+horizontal limb of which is oblique, the direction of the obliquity
+varying on the two sides. The horizontal incision should be made just
+over Poupart's ligament, and parallel to it, the centre of the incision
+corresponding to the neck of the sac, and its length varying according
+to the size of the tumour and the depth of the parts; the other should
+extend downwards from the centre of the former, as far as is necessary
+to display the whole sac. The first should be made by pinching up and
+transfixing the skin, the second by ordinary incision, to the same depth
+as the first. The small flaps thus made must now be thrown back; any
+vessels that have been divided are to be tied. Now, with great care and
+caution the surgeon is to pinch up and divide any layers of condensed
+cellular tissue which may still cover the sac, till it is thoroughly
+exposed to its full extent, and remove any glands which may intervene.
+
+The neck of the sac being exposed, it may be possible in some very
+exceptional cases to give the patient the benefit of the minor
+operation, which consists in leaving the sac unopened. In such a case
+(to be described immediately), the surgeon passes his finger along the
+neck of the sac as far as possible into the ring, and then with a
+probe-pointed bistoury very cautiously nicks the upper edge of
+Gimbernat's ligament, in one or more places, being careful to feel for
+any pulsation before dividing a single fibre. He may then be able to
+empty the sac of its contents, and return the bowel and omentum, still
+retaining the sac outside.
+
+On the other hand, where it is determined to open the sac, the pinching
+up of the sac must be managed with great care, to avoid injury of the
+bowel. There is generally a little fluid to be found at the fundus,
+which will protect the bowel. In one case in which Liston operated, he
+tells us, "there was no possibility of pinching up the sac, either with
+the fingers or forceps; it contained no fluid, and was impacted most
+firmly with bowel; very luckily the membrane was thin; and, observing a
+pelleton of fat underneath, I scratched very cautiously with the point
+of the knife in the unsupported hand, until a trifling puncture was
+made, sufficient to admit the blunt point of a narrow bistoury."[144] If
+the sac contains bowel and omentum, it is safer to open it over the
+omentum than over the bowel. When a small opening is made, an escape of
+the contained fluid takes place, and then the sac should be slit up as
+far as its neck by a probe-pointed bistoury, guided by the finger,
+introduced to protect the bowel, whenever the opening is sufficiently
+large. The forefinger must now be cautiously insinuated into the neck of
+the sac, the nail being directed to the bowel, the pulp to the
+crescentic margin of Gimbernat's ligament, and any constriction very
+cautiously divided. The bowel should then be drawn down a little, the
+constricted point carefully examined, and then returned or not,
+according to its condition.
+
+Two points require a brief separate notice:--
+
+1. In what direction is the crural arch to be divided? Not outwards
+certainly, on account of the vein, nor downwards, as the bone prevents
+that direction. Is it to be upwards or inwards? Not upwards, for such
+an incision would endanger the spermatic cord or round ligament, besides
+greatly weakening the abdominal wall by the division, partial or
+complete, of Poupart's ligament. Inwards then it must be; and little
+more need be said about it, were it not for the occasional existence of
+an abnormal course and distribution of the obturator artery.
+
+[Illustration: FIG. XXXII.[145]]
+
+The usual origin of this vessel is from the internal iliac, in which
+case (Fig. XXXII. N O) it never comes near the sac at all. In certain
+cases (1 in 3-1/2) it rises from the epigastric, and in a very few (1 in
+72) from the external iliac. If rising from either of the two last, it
+most commonly passes downwards at the outer side of the hernia, in which
+case (Fig. XXXII. S O) no harm can possibly result; but in a few rare
+cases, perhaps 1 in every 60 of those operated on, the vessel winds
+round the hernia (Fig. XXXII. O), crossing at its inner side, and thus
+may be (and has actually been) divided by a rash incision. With due
+care, however, and by cutting a very little at a time, even this danger
+may be avoided.
+
+2. Under what circumstances is it possible or justifiable to reduce a
+femoral hernia, without previously opening the sac? Only in certain very
+select cases, where the hernia is recent, the constricting parts lax,
+the general symptoms very mild, and where there is reason to believe the
+bowel has completely escaped injury by compression or the taxis. There
+are both difficulties and dangers in this so-called minor operation:--1.
+_Difficulties_, For it is not easy to divide the constriction without
+the assistance of the finger in the sac, and it is not easy to reduce
+the contents with the sac unopened, except through a much freer opening
+than is necessary when the bowel has been fairly exposed. 2. _Dangers_,
+Of reducing sac and viscera, together with the strangulation still kept
+up by tightness in the neck of the sac; or of supposing the sac is
+emptied while a knuckle of bowel still remains in it, and is
+strangulated; or, lastly, of reducing the intestine which has already
+become gangrenous. It is very remarkable how very soon gangrene may come
+on, in a case of a small recent femoral hernia, in which the fibrous
+tissues constricting the neck of the sac are tense and undilatable. A
+protrusion for eight hours has been sufficient to destroy the life of a
+knuckle of bowel.
+
+     A note here on a certain condition very frequent in femoral herni�,
+     which may occasionally give a good deal of trouble. Symptoms of
+     strangulation have been well marked, yet when the sac is opened
+     nothing is to be seen except a mass of omentum, perhaps tolerably
+     healthy-looking. To reduce this _en masse_ would be very unsafe;
+     it is necessary carefully to unravel it, and disengage the knuckle
+     of bowel which is almost certainly included in it, and which has
+     given rise to the symptoms of strangulation.
+
+
+OPERATION FOR STRANGULATED UMBILICAL HERNIA.--The operation is
+practically the same, whether the hernia is a true umbilical one, or one
+which with more strict accuracy might be called ventral. True umbilical
+hernia is a disease of infancy and childhood, being almost always
+congenital, and the viscera protrude through the umbilical aperture.
+This rarely requires operation, as it may generally be returned with
+ease, and even cured by a proper bandage and compress. Ventral hernia,
+commonly called _umbilical_, is generally a protrusion of viscera
+through a new preternatural aperture in the fibrous tissues close to the
+navel, may often attain a large size, is liable to strangulation, and is
+not easily palliated or cured.
+
+In either case the operation requires a very brief description. If the
+hernia is small, under the size of a hen's egg, a crucial incision
+through the thin skin which covers it will thoroughly expose the sac
+when the flaps are dissected back. The forefinger should then be
+inserted in the round opening, and the edges cautiously incised in
+several directions, each incision however being very small.
+
+If the rupture is large, a single linear, or a T-shaped incision,
+exposing the base of the tumour, will be sufficient to allow the
+requisite dilatation of the opening to be made. It is not at all
+necessary in every case to open the sac of the peritoneum. If required,
+it must be done with great caution, as the sac is generally very thin.
+In cases where the hernia is chiefly omental, the sac should be opened,
+lest a knuckle of bowel be inclosed and strangulated in the omentum.
+
+
+OBTURATOR HERNIA is an extremely rare lesion, and a large proportion of
+the recorded cases were discovered only after death. When diagnosed
+during life and strangulated, some have been reduced by taxis, and only
+a very few cases have been operated on, some with success. It is not
+likely that a diagnosis could be made, except in very emaciated
+patients, in whom pain at the obturator foramen was a prominent symptom,
+and in whom it could be ascertained positively that the crural ring was
+empty. An incision over the tumour, sufficient to allow the pectineus
+muscle to be exposed and divided, is necessary. The hernia may then be
+reduced without opening the sac, if recent; if of long standing, the sac
+must be opened. One case is recorded by Dr. Lorinzer, in which, after
+strangulation for eleven days, he opened the sac and found the bowel
+gangrenous. The patient had a f�cal fistula; but survived the operation
+for eleven months. Nuttel, Obr�, and Bransby Cooper have each diagnosed
+and treated such cases.[146]
+
+Other forms of hernia are so rare, and the treatment of each case must
+necessarily vary so much in its circumstances, as not to require or
+admit of any detailed account of the operations requisite for their
+relief.
+
+
+OPERATIONS FOR THE RADICAL CURE OF HERNIA.--The inconveniences and
+discomfort caused by even the best-adjusted trusses or bandages, the
+unsatisfactory support they afford, and the risk of their slipping and
+allowing the hernia to escape, have given rise to many attempts to cure
+hernia by operation.
+
+Even to enumerate these would be quite beyond the limits of the present
+volume; suffice it to classify a few of the most important of them
+according to the principle involved in each, and then give a very brief
+account of the method of operating which seems to be at once the most
+scientific, least dangerous, and most permanently useful.
+
+The question at issue is briefly this. We have, in a hernia, the
+following condition:--The walls of a great cavity are at one or more
+points specially weak, the contained viscera have protruded, either by
+extension and stretching of a natural opening, or by the formation of a
+new breach in the walls, and, in protruding, they have brought with them
+as a covering a serous membrane, extremely extensible, highly sensitive
+to injury, and, when injured, certain to resent it by severe, spreading,
+and dangerous inflammation.
+
+Do we desire to remedy this protrusion, we may act--
+
+1. On the intestines themselves; but for all surgical purposes, they are
+out of our reach. We cannot do more than, by diminishing their contents,
+diminish their volume, and by position and rest reduce to the utmost
+their tendency to protrude. This includes the medical and prophylactic
+treatment of hernia, or rather of the tendency to hernia.
+
+2. We may try what can be done with the _sac_ which the intestines have
+pushed down before them. Can it be obliterated? If it can, perhaps the
+intestines may be retained in their cavity. Very many plans of dealing
+with the sac have been tried.
+
+To cause obliteration of its cavity many methods have been proposed:--by
+ligature of it along with the spermatic cord, involving loss of the
+testicle, either by gradual separation, by sloughing, or by immediate
+removal;--by cutting into it, and then stitching it up;--by constricting
+it with wire, as in the _punctum aureum_; by pinching sac and coverings
+up, by passing needles under them as they emerge from the external ring,
+as Bonnet of Lyons did; by constricting sac alone with a double wire, by
+subcutaneous puncture, as Dr. Morton of Glasgow has done;--by severe
+pressure from the outside with a strong tight truss and a pad of wood,
+as proposed by Richter; by setons of threads or candlewicks, as proposed
+by Schuh of Vienna;--by injection of tincture of iodine or cantharides,
+as by Velpeau and Pancoast;--by the introduction into the sac of thin
+bladders of goldbeaters' skin, which were then filled with air, and were
+intended to excite inflammation, as in the radical cure of hydrocele; or
+by the still more severe method of Langenbeck, consisting in exposing
+the sac by a free incision at the superficial ring, separating it from
+the cord, and passing a ligature round the sac alone, leaving the
+ligatured portion in the scrotum either to become obliterated or to
+slough out. Schmucker of Berlin varied this, by cutting away the
+constricted portion below the ligature.
+
+The objections to these methods are various: the more gentle are
+uncertain and inefficient; of the more severe, some involve mutilation,
+by the loss or removal of the testicle; others, as those of Langenbeck
+and Schmucker, are very dangerous and fatal, by the inflammation
+spreading to the peritoneal cavity (20 to 30 per cent. died); while all
+of these methods afford at best only temporary relief. And this is only
+what might have been expected, for the sac was only a _result_ of the
+protrusion, not a _cause_; and so long as the weakness and insufficiency
+of the parietes of the abdomen remain, so long will the extensible
+loosely-attached peritoneum continue to furnish new sacs for visceral
+protrusions.
+
+3. We have now only the canal left to act upon; and the operations on
+the canal may be divided into two great classes:--
+
+(_a._) Those in which the operator attempts to plug up the dilated
+canal. (_b._) Those in which he tries to constrict it, by reuniting its
+separated sides.
+
+(_a._) Attempts to plug the canal have, in most cases, been made by
+invagination of the skin of the scrotum and its fascia. These have been
+very numerous and various in their adaptation of mechanical appliances,
+but have all been designed with the same object. Dzondi of Halle, and
+Jameson of Baltimore, incised lancet-shaped flaps of skin, and
+endeavoured to fix them by displacement over the ring. Gerdy invaginated
+a portion of scrotum and fascia into the enlarged canal, by the
+forefinger pushed it up, and secured it in its place by a thread passed
+from the point of his finger first through the invaginated skin, then
+through the abdominal walls, endeavouring to include the walls of the
+inguinal canal, causing the point of the needle to project some lines
+above the inguinal ring; the same process being effected with the other
+end of the thread on the other side of the finger, and the two ends
+which have been brought out near each other on the abdominal wall, being
+tied tightly over a cylinder of plaster. The ensheathed sac was then
+painted with caustic ammonia to excite inflammation, and a pad put on
+over all.
+
+Signoroni modified this by fixing the invaginated skin by a piece of
+female catheter, retained in its place by transfixion by three harelip
+needles, tied by twisted sutures.
+
+W�tzer of Bonn, again, modified this, by substituting a complicated
+instrument, consisting of a stout plug in the inguinal canal, held in
+position by needles which are passed through the anterior wall of the
+canal in the groin. Compression between plug and compress, with the
+intention of causing adhesion between skin, fascia, and sac, is then
+managed by means of a screw. The plug is retained for about seven days.
+
+Modifications of this method have been tried by Wells, Rothmund, and
+Redfern Davies, all aiming in the direction of simplicity; but by far
+the most simple and efficacious method on the W�tzer principle yet
+devised is that of Professor Syme, which he described in the pages of
+the _Edinburgh Medical Journal_ for May 1861, in which the invagination
+of integument is both simply and securely managed by strong threads, as
+in Gerdy's method, while a piece of bougie or gutta-percha, to which
+the threads are fixed, replaces W�tzer's expensive and complicated
+apparatus. Sir J. Fayrer of Calcutta has had a very large experience of
+W�tzer's method, and also of a plan of his own. Out of 102 cases by the
+latter method, 77 were cured, 9 relieved, 14 failed, and 2 died.[147]
+
+Mr. Pritchard of Bristol has proposed an additional step in operations
+on the invagination principle, consisting in the stripping of a thin
+slip of skin from the orifice of the cutaneous canal, and then putting a
+pin through the parts to get them to unite, and thus close the aperture
+completely.
+
+Now, what results follow these operations? At first they are almost
+invariably successful, but the complaint is that, in most cases, the
+rupture recurs. The principle is to plug up the passage by the
+mechanical presence of the invaginated skin, the plug being retained in
+position by adhesive inflammation between it and the edges of the
+dilated ring. But the ring is left dilated, or, indeed, generally its
+dilatation is increased; and as, on continued pressure from within, the
+new adhesions give way, or, as often happens, a new protrusion takes
+place in the circular _cul-de-sac_ necessarily left all round the apex
+of the invagination, the still lax ring and canal offer no resistance to
+the protrusion.
+
+(_b._) The principle of constriction of the canal by reuniting its
+separated sides. This is the principle of the various methods introduced
+by Mr. Wood of King's College, and described by him in his most able and
+exhaustive work.[148]
+
+He applies sutures through the sides of the dilated inguinal or crural
+canals, or umbilical openings, in such a manner as to insure their
+complete closure.
+
+1. _For inguinal hernia._--To stitch together the two sides of the canal
+with safety requires attention to several points--(1.) That it be done
+nearly, if not entirely, subcutaneously. (2.) That the protruding bowel
+should be kept out of the way, and not be transfixed by the needle. (3.)
+That the spermatic cord should be protected from injurious pressure.
+
+These different indications are attained by Mr. Wood by a very ingenious
+mode of operating, which I can describe here only briefly, and for a
+full description of which I must refer to Mr. Wood's own monograph
+already alluded to.
+
+For his first twenty cases Mr. Wood used strong hempen thread for the
+stitches; of late, however, he has proved the greater advantage of
+strong wire.
+
+When a large old hernia in an adult is the subject of operation, it is
+thus performed by Mr. Wood:--The pubes being shaved, and the patient put
+thoroughly under the influence of chloroform, the rupture is reduced,
+and the operator's forefinger forced up the canal so as to push every
+morsel of bowel fairly into the abdomen. An assistant then commands the
+internal ring by pressure, to prevent return of the rupture.
+
+An incision is made in the scrotum over the fundus of the sac, large
+enough to admit a forefinger and the large needle used in the operation;
+the edges of the skin are to be separated from the fascia below for
+about one inch all round. The forefinger is then to be passed in at the
+aperture and pushed upwards, invaginating the detached fascia before it,
+and it must be made to enter the inguinal canal far enough to define the
+lower border of the internal oblique muscle stretched over it. A large
+curved needle (unarmed) is then passed on the finger as a guide, through
+the internal oblique tendon, the internal portion of the ring, and the
+skin of the abdomen; it is then threaded and withdrawn. Again, the
+needle (now with a thread) is guided by the finger and pushed through
+Poupart's ligament and the external pillar of the ring as before; while
+by a little manipulation its point is made to protrude through the same
+opening in the skin as before, a loop of thread is now left there, and
+the needle, still threaded, is again withdrawn. The next stitch, still
+guided on the finger, takes up the tendinous layer of the triangular
+aponeurosis covering the outer border of the rectus tendon close to the
+pubic spine; the point of the needle is then turned obliquely, so as to
+protrude through the original puncture in the skin a third time, the
+needle is then freed from the thread and withdrawn, thus leaving two
+ends and one intermediate loop of thread all at the one opening. These
+are so arranged that when they are tightened they draw together the
+sides of the canal; they are then secured over a compress of lint. The
+compress is removed and the stitches loosened, at dates varying from the
+third to the seventh day.
+
+Mr. Wood now uses wire instead of thread. It has the advantage of
+greater firmness, excites less suppuration, and may be left much longer
+_in situ_, in consequence of which there is less risk of suppuration or
+py�mia, and more chance of a good consolidation of the parts.
+
+     In congenital herni�, and small ruptures in children and young
+     boys, Mr. Wood uses rectangular pins in the following manner:--The
+     scrotum being invaginated (without any incision through the skin)
+     as far as possible up the canal, a rectangular pin, with a
+     slightly-curved spear-pointed head, is passed through the skin of
+     the groin to the operator's forefinger; guided by it, it is brought
+     safely down the canal, and brought out through the skin of the
+     scrotum just over the fundus of the hernial sac. A second pin is
+     passed from the lower opening (still guided by the finger) in an
+     upward direction, transfixing in its course the posterior surface
+     of the outer pillar of the superficial ring, its point being
+     brought out through, or at least close to, the first puncture made
+     by the first pin. The pins are then locked in each other's
+     loops--the punctures and skin protected by lint or adhesive
+     plaster,--and the whole is retained by lint and a spica bandage.
+     The pins should generally be withdrawn about the tenth day.
+
+The author has now in many cases stitched with catgut the edges of the
+ring after the ordinary operation for hernia with the best effect.
+
+2. _For Femoral Rupture._--Cases suitable for operation are very
+infrequent; but should such a one be met with, Mr. Wood proposes the
+following operation on the same plan as the preceding. The hernia being
+fully reduced and the parts relaxed by position, an incision about an
+inch long should be made over the fundus of the tumour, and its edges
+raised so as to admit the finger fairly into the crural opening. The
+vein is then to be pushed inwards, and the needle passed through the
+pubic portion of the fascia lata of the thigh, and then through
+Poupart's ligament, appearing on the skin of the abdomen, a wire is then
+passed through the eye of the needle and hooked down, appearing through
+the wound, it is then withdrawn, and the needle again passed through the
+pubic portion of the fascia lata, but about three-quarters of an inch to
+the inside of the first puncture, then through Poupart's ligament again,
+and protruded through the same orifice in the skin; the other end of the
+wire is then hooked down as before, leaving a loop above, at the needle
+orifice, and two ends at the wound in the skin below. Both loops and
+ends must be managed as before.
+
+     The author after operating for the relief of strangulation in a
+     case of very large femoral hernia in a girl aged 23, stitched up
+     the neck of the sac, and also stitched it to Gimbernat's ligament.
+     The result for some months was admirable, though the hernia had
+     been a very difficult one to replace from its size, and had been
+     long in the habit of coming down. Eventually protrusion occurred to
+     a very slight extent, but a truss keeps it completely up.
+
+3. _For Umbilical Rupture._--The principle involved in Mr. Wood's
+operation for umbilical rupture is precisely the same as for inguinal
+and crural. It consists in stitching the two edges of the tendinous
+aperture by wire; the needle is passed on a sort of small scoop or
+broad grooved director, which at once invaginates the skin and protects
+the bowel. Two stitches are thus inserted on each side. For the
+ingenious method by which they are introduced subcutaneously, I must
+refer to the detailed description in Mr. Wood's monograph. The wires are
+thus twisted and tightened over a pad of lint or wood, drawing together
+the edges of the opening in the tendon.
+
+
+OPERATIONS FOR ARTIFICIAL ANUS.--In children the condition known as
+imperforate anus may sometimes be remedied by exploratory operations in
+the perineum, guided by the protrusion caused by the distended
+intestine. There are other cases, however, in which the rectum, as well
+as the anus, seems to be deficient, and in which, from the want of
+protrusion, there is no warrant for attempting an operation there; in
+these the only chance of life that remains is in an attempt to open the
+bowel higher up.
+
+In adults, again, absolute closure of the rectum and anus, and complete
+obstruction, may be the result of malignant disease, or even, very
+rarely, of simple organic stricture.
+
+In such cases, where the patient is tolerably strong and yet evidently
+doomed from the complete obstruction, an attempt at the formation of an
+artificial anus is warrantable, and in many cases afford great relief,
+and prolongs life for months.
+
+Without going into all the various positions proposed for such
+operations, I select the two most warrantable, which have borne the test
+of experience. These are--1. Colotomy in the left loin. This is
+applicable in the case of adults with rectal obstruction. 2. Colotomy in
+the left groin applicable in cases of imperforate anus and deficiency of
+rectum in infants.
+
+1. _Colotomy in the left loin_, generally known by the name of
+_Amussat's operation_.--The patient is laid upon his face, a pillow
+placed under the abdomen, rendering the left flank prominent. A
+transverse incision should then be made at a level about two
+finger-breadths above the crest of the ilium, extending from the outer
+edge of the erector spin� muscle forward for four or five inches,
+according to the fatness of the patient; the muscles must then be
+carefully divided till the transversalis fascia is exposed. It is then
+to be pinched up and divided, as in the operation for strangulated
+hernia. The muscular wall of the colon uncovered by peritoneum is then
+in most cases very easily recognised from its immense distension. The
+bowel should then be hooked up by a curved needle, two or three points
+at least secured to the margins of the wounds by stitches, and then the
+bowel should be opened by a longitudinal incision of at least an inch in
+length. When the distension has been great, there is generally a rush of
+fluid f�ces, which must be provided for, special care being taken lest
+any get into the cavity of the peritoneum.
+
+[Illustration: FIG. XXXIII.[149]]
+
+2. _Colotomy in the left groin_, for absence of anus and deficiency of
+rectum in newly born infants.--The dissections of Curling, Gosselin, and
+others have shown that in infants the operation of lumbar colotomy is
+very difficult, and its results uncertain, while it is comparatively
+easy to open the colon in the left groin. Huguier, again, has shown that
+in certain cases the colon is not to be found in the left groin, but is
+accessible in the right groin. This abnormality seems, as shown by
+Curling, to occur not oftener than once in every ten cases.
+
+_Operation._--An oblique incision from an inch and a half to two inches
+in length should be made in the left iliac region above Poupart's
+ligament, extending a little above the anterior-superior spinous process
+of the ilium. The fibres of the abdominal muscles should be divided on a
+director passed beneath them, and the peritoneum should next be
+cautiously opened to a sufficient extent. The colon will most likely
+protrude, but if small intestine appear the colon must be sought for
+higher up. A curved needle armed with a silk ligature should be passed
+lengthways through the coats of the upper part of the colon, and another
+inserted in the same way below, and the bowel, being drawn forwards,
+should then be opened by a longitudinal incision. The colon must
+afterwards be attached to the skin forming the margin of the wound by
+four sutures at the points of entry and exit of the needles.
+
+
+OPERATION FOR THE REMOVAL OF AN ARTIFICIAL ANUS, in cases where the
+bowel is patent below.--After the operation for hernia in a case where
+the bowel is gangrenous, the only hope of the patient's recovery
+consists in the formation of adhesions between the bowel and the
+external wound, and the presence, for a time at least, of an artificial
+anus. If adhesions do form, and the patient recovers, it becomes a
+matter of great importance for his future comfort that the canal of the
+intestine should be re-established, and the fistulous opening allowed to
+close. This, however, is by no means easy, as even when the portion of
+intestine destroyed has been very small, a septum or valve remains which
+directs the contents of the bowel outwards, and so long as it exists is
+an effectual obstacle to any of the f�cal contents passing into the
+distal portion of the bowel. This septum or �peron is formed by the
+mesenteric side of the two ends of the bowel. To destroy this without
+causing peritonitis is the aim of the surgeon, and it is not an easy
+matter to accomplish. To cut it away would at once open the peritoneal
+cavity, so the mode of treatment now adopted in the rare cases where it
+is necessary is that recommended by Dupuytren. The principle of it is to
+destroy the �peron by pressure so gradual as to cause adhesive
+inflammation between the two surfaces, and thus seal up the cavity of
+the peritoneum, before the continuance of the same pressure shall have
+caused sloughing of the septum. This is managed by the gradual
+approximation by a screw of the blades of a pair of forceps, to which
+Dupuytren gave the name Enterotome. The process, which extends over days
+and weeks, must be carefully watched lest the inflammation go too far.
+
+Plastic operations are occasionally required to close the opening after
+the passage is restored. For a good example of such an operation see
+_Edin. Med. Journal_ for August 1873, in which Mr. John Duncan describes
+a case.
+
+
+FOOTNOTES:
+
+[141] _Description of Sir Spencer Wells's Trocar._--"It consists of a
+hollow cylinder six inches long, and half an inch in diameter, within
+which another cylinder fitting it tightly plays. The inner one is cut
+off at its extremity, somewhat in the form of a pen, and is sharp. The
+sharp end is kept retracted within the outer cylinder by a spiral spring
+in the handle at the other end, but can be protruded by pressing on this
+handle when required for use. When thus protruded it is plunged into the
+cyst up to its middle; the pressure on the handle is taken off, and the
+cutting edge is retracted within its sheath. The fluid rushes into the
+tube, and escapes by an aperture in the side, to which an india-rubber
+tube is attached, the end of which drops into a bucket under the table.
+The instrument is furnished at its middle with two semicircular bars,
+carrying each four or five long curved teeth like a vulsellum. These
+teeth lie in contact with the outer surface of the cylinder, but can be
+raised from it by pressing two handles. When the cyst begins to be
+flaccid by the escape of the fluid, these side vulsellums are raised,
+and the adjoining part of the cyst is drawn up under the teeth, where it
+is firmly caught and compressed against the side of the tube."
+
+[142] For further details on the operations described above, reference
+may be made to Sir Spencer Wells's work on ovarian disease, and to the
+very valuable papers contributed by Dr. Thomas Keith to the _Edinburgh
+Medical Journal_. To the latter especially the author is indebted for
+much oral instruction, and for the opportunity of seeing his careful and
+dexterous mode of operating.
+
+[143] _Lect. on Surgery_, 3d ed., vol. ii. p. 998.
+
+[144] _Operative Surgery_, p. 462.
+
+[145] Rough diagram of abnormal course of obturator and its relation to
+the neck of a hernia. Parts seen from the inside: H, femoral hernia; A,
+femoral artery; V, femoral vein; E, epigastric artery; O, obturator from
+epigastric (dangerous); S O, obturator from epigastric (safe); N O,
+normal course of obturator; I R, internal inguinal ring; Sp C, spermatic
+chord and its vessels; G, Gimbernat's ligament; +, in triangle of
+Hesselbach.
+
+[146] Holmes's _Surgery_, 3d ed., 1883, vol. ii. p. 837.
+
+[147] _Clinical and Pathological Observations in India_, pp. 44, 325.
+
+[148] Wood _On Rupture_, 1863.
+
+[149] Diagram of an artificial anus, showing small sutures which unite
+the edges of the gut and the skin, and the large ones stitching up the
+wound beyond.
+
+
+
+
+CHAPTER XII.
+
+OPERATIONS ON PELVIS.
+
+
+LITHOTOMY.--However interesting and even instructive it might be, any
+history of the various operations for the removal of calculi from the
+bladder would be quite out of place in a manual such as this. It will be
+sufficient here to describe the operations recommended and practised in
+the present day.
+
+There are three different situations in which the bladder may be entered
+for the purpose of removing a calculus:--
+
+1. The perineum, where access is gained through the urethra, prostate,
+and neck of the bladder.
+
+2. Above the pubes, where the portion of bladder not covered by
+peritoneum is opened from above.
+
+3. From the rectum.
+
+
+1. LITHOTOMY THROUGH THE PERINEUM, by far the most frequent position for
+the operation.--Very various methods for its performance have been
+devised, differing in the nature and shape of the instruments employed,
+the direction and size of the incisions, the nature of the wound; but
+all resemble each other in certain very cardinal and important
+particulars. Thus all agree that it is absolutely necessary to enter the
+bladder at _one_ spot--the neck of the bladder; and that to do this
+safely the urethra must be opened, and some instrument previously
+introduced by the urethra is to be used as a guide for the knife. But an
+instrument in the urethra and bladder is surrounded for at least an inch
+of its course by the prostate; and thus the knife, gorget, or finger,
+which, guided by the instrument in the urethra, is intended to cut or
+dilate the entrance to the bladder for the purpose of allowing the
+calculus to be removed, cannot do this without also cutting or dilating
+this prostate gland. Experience has proved that much of the success of
+the operation depends upon the position and amount of incision made in
+this prostate gland. But it might be asked, Why can we not enter the
+bladder by one side, avoiding altogether its neck and this prostate
+gland? For this, among other reasons, that the bladder normally
+contains, and so long as the patient lives must contain, a certain
+quantity of a very irritating fluid. It is surrounded by the loose
+areolar tissue of the pelvis, into which, if any of this fluid escapes,
+abcesses will form and death probably ensue; this result will almost
+certainly follow any opening made into the bladder except at one spot.
+This spot is the neck of the bladder. Why does urinary infiltration not
+occur there? Because the fascia of the pelvis (which when entire can
+resist infiltration) is prolonged forwards at the neck of the bladder,
+over the prostate (Fig. XXXIV. PF), for which it forms a very strong
+funnel-like sheath. So long as this sheath is not cut where it covers
+the sides of the prostate, urinary infiltration of the pelvis is
+impossible, the urine being carried forwards and fairly out of the
+pelvis in this urine-tight funnel.
+
+[Illustration: FIG. XXXIV.[150]]
+
+But it may now be said, If this be the case, we are very much limited in
+the size of the incision we may make into the bladder. We cannot remove
+a large stone, for the prostate ought not to be larger than a good-sized
+chestnut, and any cut we might make through a chestnut without cutting
+out of its side must be very small. Very true; but fortunately the
+sheath of the prostate, unlike the rind of the chestnut, is very freely
+dilatable, and will allow the passage of a very considerable stone.
+
+Again, an inquirer might ask, If it is so dilatable, why should we run
+the risk of cutting the prostate at all? Why should we not introduce
+instruments gradually increasing in size into the membranous portion of
+the urethra, and thus dilate prostate and neck of bladder? For this
+reason, that the urethral canal passing through the prostate is itself
+lined immediately outside of the mucous membrane by a firm membranous
+sheath (Fig. XXXIV. RR), which resists dilatation to the utmost.
+Experience tells us that any attempts to dilate or even forcibly to tear
+this ring of fibrous texture are both ineffectual and dangerous, while a
+clean cut into it and through it into the substance of the prostate is
+at once effectual and comparatively safe.
+
+In a word, we can describe the relation of the prostate to the operation
+of lithotomy somewhat in this manner:--Its fibrous sheath surrounding
+the urethra must be cut freely. The gland substance may be cut and
+freely dilated by the finger. Its fibrous envelope must, as far as
+possible, be preserved intact, but this interferes the less with the
+operation, as it is comparatively freely dilatable.
+
+The firm lining of the urethra, which must be cut, is specially strong
+at its base, forming a tough resisting band just at the aperture of the
+bladder, which, unfortunately, is often so high up in the pelvis in
+tall patients, or in cases in which the prostate is much enlarged, as to
+be almost out of reach of the finger, and so far up the staff as perhaps
+to escape division. You will be warned of such an occurrence by the
+urine in the bladder failing to make its appearance; and if any attempt
+be made to dilate the opening and introduce the forceps without further
+incision of the base of the prostate, the result will very likely be
+fatal, generally from py�mic symptoms depending on a suppurative
+inflammation of the prostatic plexus of veins (Fig. XXXIV.). In fact,
+upon a recognition of this fact is founded the aphorism, "that cases in
+which the forceps have been introduced before the bladder fairly begins
+to empty its contents are generally fatal."
+
+[Illustration: FIG. XXXV.[151]]
+
+We have thus traced the necessary guiding principles as to our incisions
+from the bladder outwards through the prostatic portion of the urethra.
+We have next to discover what sort of an opening is necessary in the
+membranous portion of the urethra consistent with the fulfilment of the
+same conditions, namely, freedom of escape for the urine, and room
+enough to remove the stone. Both of these are gained at once by a free
+incision of the membranous portion, dividing especially those anterior
+fibres of the great sphincter muscle of the pelvis, the levator ani,
+which embrace the membranous portion, under the special names of
+compressor (Fig. XXV.) and levator urethr� (Guthrie's and Wilson's
+muscles).
+
+The principles which guide the position and size of the preliminary
+incisions which enable the urethra to be opened are very simple:--(1.)
+The wound in the perineum should be large enough to give free access to
+the urethra, and easy egress to the stone; (2.) It should be conical,
+with its base outwards, so as to favour escape of urine and prevent
+infiltration; (3.) It should not wound any important organ or vessel;
+that is, it must avoid the rectum, the corpus spongiosum, especially the
+bulb, if possible, the artery of the bulb, and in every case should
+leave the pudic artery intact.
+
+So far for broad general principles, which must guide all methods of
+successful lithotomy.
+
+
+THE LATERAL OPERATION.--_Operation of Cheselden._--(1.) _Instruments
+required._--A staff with a broad substantial handle, and a longer curve
+than the ordinary catheter requires, furnished with a very deep and wide
+groove, which occupies the space midway between its convexity and its
+left side. The one used should invariably be large enough to dilate
+fully the urethra.
+
+A knife, with its blade three or four inches in length, but sharp only
+for an inch and a half from its point, its back straight up to within a
+sixth of an inch of its point, and there deflected at an angle to the
+point, which again curves to the edge. The angle from the back to the
+point permits the knife to run more freely along the groove in the
+staff.
+
+A probe-pointed straight knife with a narrow blade may occasionally be
+useful in enlarging the incision in the prostate, when this is required
+by the size of the stone.
+
+Forceps of various sizes and shapes, some with the blades curved at an
+angle to reach stones lying behind an enlarged prostate, all with broad
+blades as thin as is consistent with perfect inflexibility, the blades
+hollowed and roughened in the inside, but without the projecting teeth
+sometimes recommended, which are dangerous from being apt to break the
+stone.
+
+A scoop to remove fragments or small stones, sometimes useful with the
+aid of the forefinger in lifting out a large one.
+
+A flexible tube of at least half an inch calibre, and about six inches
+long, rounded off and fenestrated above, fitted at its outer end with a
+ring and two eyelet-holes for the tapes, with which it is tied into the
+bladder.
+
+Prior to the operation the patient's health should be attended to, the
+stomach and bowels regulated, and any disorder of the kidneys or bladder
+as far as possible alleviated. If his health has been good and habits
+active, three or four days' confinement to his room on low diet, with a
+full purge the evening before the operation, is all the preparatory
+treatment that is necessary.
+
+It is of the utmost importance for the safety of the operation and the
+patient's comfort after it, that the rectum be completely unloaded
+before the operation, and the bowels so far emptied as to permit three
+or four days after the operation to elapse without any movement of the
+bowels being necessary. If there is any doubt as to the effect of the
+laxative, a large stimulant enema should be administered on the morning
+of the operation.
+
+_Position._--Much depends on the proper tying up of the patient. He
+should be placed with his breech projecting over the edge of a narrow
+table, with head slightly raised on a pillow, but the shoulders low. The
+hands are then to be secured each to its corresponding foot, by a strong
+bandage passing round wrist and instep, or by suitable leather anklets,
+the knees should be wide apart, and on exactly the same level, so that
+the pelvis may be quite straight. An assistant should be placed to take
+charge of each leg.
+
+The staff is next introduced and the stone felt; if there is little
+water in the bladder a few ounces may be injected, but this is rarely
+necessary, for the patient should be ordered to retain as much water as
+possible, and when he cannot retain it, injection of water may do harm,
+and will probably not be retained, but at once come away along the
+groove in the staff. The staff is then committed to a special assistant,
+who must be thoroughly up to his duty, and attend to the staff alone.
+
+Some surgeons direct the assistant to make the convexity of the staff
+bulge in the perineum, to enable the groove to be struck more easily. It
+will be, however, safer both for the rectum and the bulb, if the staff
+be hooked firmly up against the symphysis pubis, as advised by Liston.
+The same assistant can also keep the scrotum up out of the way.
+
+If the perineum has not been previously shaved, this is now done.
+
+The operator sits down on a low stool in front of the patient's
+breech, his instruments being ready to his hand, and then steadying
+the skin of the perineum with the fingers of his left hand, enters
+the point of the knife in the raphe of the perineum, midway between
+the anus and scrotum (one inch in front of anus--_Cheselden_,
+_Crichton_; one and a quarter--_Gross_, _Skey_, and _Brodie_; one
+and three-quarters--_Fergusson_; one inch behind the scrotum--_Liston_),
+and carries the incision obliquely downwards and outwards, in a line
+midway between the anus and tuberosity of the ischium. The length of the
+incision must vary with the size of the perineum, and the supposed size
+of the stone, but there is less risk in its being too large, so long as
+the rectum is safe, than in its being too small. Its depth should be
+greatest at its upper angle, where it has to divide the parts to the
+depth of the transverse muscle of the perineum, and least at its lower
+angle, where a deep incision is not required, and would be almost sure
+to wound the rectum.
+
+The forefinger of the left hand is now to be deeply inserted into the
+wound, and any remaining fibres of the levator ani in front are to be
+divided, the edge of the knife being directed from above downwards. The
+left forefinger being still used to push its way through the cellular
+tissue, the groove in the staff is now felt in the membranous portion of
+the urethra covered by the deep fascia of the perineum. Now comes the
+deeper part of the incision. Guided by the finger-nail of the left hand,
+the surgeon introduces the point of the knife into the groove of the
+staff. He then takes hold of the staff for a moment to feel that it is
+held up properly against the pubis, and in the middle line, and also
+that the knife is fairly in the groove. Giving the staff back again to
+the assistant, and keeping the rectum well out of the way by the left
+hand, he now steadily directs the knife along the groove of the staff
+till the bladder is fairly entered, and the ring at the base of the
+prostate completely divided. When this is the case a gush of urine takes
+place, following the withdrawal of the knife.
+
+When making the deep incision, and in the groove of the staff, the blade
+of the knife should lie neither vertical nor horizontal, but midway
+between the two, so as to make the section of the left lobe of the
+prostate in its longest diameter, that is, in a direction downwards and
+backwards (Fig. XXXIV. L).
+
+The knife is now withdrawn, and the left forefinger inserted. In most
+cases it will be long enough to reach the bladder and touch the stone,
+and may then be freely used by gradual pressure to dilate the wound;
+this may be done very freely when necessary for a large stone, if only
+the ring of fibrous tissue surrounding the urethra be first cut and the
+bladder fairly entered. Whenever the stone is felt by the finger, the
+assistant may withdraw the staff.
+
+When the operator has thus felt the stone and sufficiently dilated the
+wound, the next step is to introduce the forceps; this should be done
+under the guidance of the finger, and with the blades closed. When the
+stone is felt the blades should be opened very widely, slightly
+withdrawn, and then pushed in again, the lower one, if possible, being
+insinuated under the stone. The blades must be made fairly to grasp and
+contain the stone in their hollow, for if they only nibble at the end of
+an oval stone, extraction is impossible. Extraction should then be
+performed slowly, with alternate wrigglings of the forceps from side to
+side, so as gradually to dilate, not to tear, the prostate, and the
+operator must remember to pull in the axis of the pelvis, not against
+the os pubis or the promontory of the sacrum.
+
+If there is much resistance, it may possibly be caused by the stone
+having been caught in its longer axis, and this may be remedied by
+careful manipulation by means of the finger and forceps. If the stone is
+still too large to be extracted without greater force than is
+warrantable, there are still various expedients (see _infra_, pp. 265,
+270).
+
+In most cases, however, the stone is removed rapidly enough by the
+single incision. The finger, or a sound, must then be introduced to feel
+if any more stones are present. The closed forceps make a very effectual
+instrument for this purpose. Much information may be gained from the
+appearance of the first stone, the presence or absence of facets. Its
+smoothness or roughness enables us to form a pretty certain opinion; yet
+the bladder should always be carefully searched; and if the stone has
+been friable or broken in extraction, should be washed out by a current
+of water. Where the calculi are very numerous, or where many fragments
+have separated, the scoop will be found useful, both for detecting and
+removing them. All the stones being extracted, there is in most cases
+little or no bleeding (see _infra_, H�morrhage). The tube already
+described may now be inserted and tied into the bladder. It may be
+retained for forty-eight or seventy-two hours, according to
+circumstances. Care must be taken lest it be closed up by coagula during
+the first hour or two after the operation. In children the tube is not
+necessary, and from their restlessness might possibly do harm, but in
+adults (though neglected by some surgeons) experience shows it is a
+valuable adjunct in the after-treatment.
+
+Having thus traced the course of an ordinary uncomplicated case of
+lithotomy by the lateral operation, a brief notice is suitable of some
+of the obstacles and difficulties, some of the dangers and bad results
+which may be met with, and the best methods of overcoming them.
+
+1. _Large size of the stone_, as an obstacle to extraction. When, either
+from the enormous size of the stone, generally to be made out before the
+operation, or from some congenital or acquired deformity of the pelvis,
+it is obvious beforehand that the calculus cannot pass through the bony
+pelvis entire, a choice of two courses remains, either--
+
+(1.) The high or supra-pubic operation (_q.v. infra_); or (2.) Crushing
+of the calculus in the bladder, and removal piecemeal. Instruments of
+great strength have been devised for this latter operation. The risk to
+the bladder is very great, and fragments are apt to be left behind;
+these are sure to form nuclei of new calculi.
+
+2. _Peculiarities in the position or relations of the stone_ in the
+bladder:--
+
+(1.) It may lie in a sort of pouch behind the prostate, and thus be out
+of the reach of the forceps. This may be remedied by the use of curved
+forceps, or, better still, by the finger in the rectum to tilt up the
+stone into the bladder.
+
+(2.) It may lie above the pubis in the anterior wall of the bladder.
+Pressure on the hypogastrium, or the use of a strong probe as a hook,
+will generally suffice to dislodge it.
+
+(3.) The stone may be encysted. This is extremely rare, and, as
+Fergusson says, we hear more of these from bunglers who have operated
+only several times, than from those who have had large experience.
+
+3. _An enlarged prostate_ is at once a source of difficulty and of some
+danger.
+
+The distance of the bladder from the surface may be so very much
+increased by enlargement of the prostate as to render even the longest
+forefinger too short to reach the stone or even the bladder. This
+renders the introduction of the forceps more difficult and uncertain,
+the dilatation more prolonged, and the extraction more dangerous. If
+very large, the groove of the staff may not reach the bladder, and thus
+the deep incision may fail of cutting the ring at the base of the gland,
+and the urine may thus not escape, and all the dangers of laceration of
+the ring may result. Such cases may be well managed by the insertion of
+a straight deeply grooved staff into the insufficient incision, and
+fairly into the bladder, and on this, pushing a cutting gorget through
+the uncut portion of the gland. This insures a sufficient yet not
+dangerous incision, which we cannot so safely perform with the knife, as
+the parts are so far beyond the reach of the guiding forefinger.
+
+Under the head of risks after lithotomy we may class the following:--
+
+1. Sinking, or shock. In the very aged or very young, or after a very
+prolonged or painful operation, shock may now and then kill the patient
+within a few hours. Since the days of chloroform this result is
+extremely rare.
+
+2. H�morrhage seems to be a very infrequent risk. The transverse
+perineal artery, which is always cut in the operation, is small, and
+rarely bleeds much. If the bulb is wounded, as no doubt frequently
+occurs, the flow from it can easily be checked. The pudic is so well
+protected from any ordinary incision as to be practically safe; and if
+wounded by some frightfully extensive incision, it can be compressed
+against the tuberosity of the ischium.
+
+There is an abnormal distribution of the dorsal artery of the penis, in
+which, rising higher up than it ought, and coursing along the neck of
+the bladder, and the lateral lobe of the prostate, it may be divided.
+This may give trouble, and even result in fatal h�morrhage. Fortunately
+it is rare. The author has met with one case in a boy of eleven, in whom
+a very severe h�morrhage was not to be explained. The patient recovered
+without another bad symptom.
+
+Again, a general oozing may often appear a few hours after the
+operation, when the patient is warm in bed, apparently from the
+substance of the prostate. If raising the breech and the application of
+cold fail to arrest it, it may be necessary to plug the wound. This is
+done by stuffing it with long strips of lint round the tube. Great care
+must be then taken lest the tube become occluded.
+
+3. Infiltration of urine may occur as a result of a too free incision of
+the vesical fascia (in adults), and still more frequently of a too small
+external wound.
+
+Here it should be noticed that in children it is fortunately of very
+little consequence to preserve the integrity of the prostatic sheath of
+vesical fascia. In them the prostate is so exceedingly small and
+undeveloped, that even the forefinger could not be introduced into the
+bladder without a complete section of the prostate. Probably from the
+blander nature of their urine, and the greater vitality of their
+tissues, this is of less consequence, as it is rarely found that any bad
+effects result from this section.
+
+Among other risks we find peritonitis, inflammation of neck of bladder,
+inflammation of prostatic plexus of veins, resulting in py�mia,
+suppression of urine, and other kidney complications. For the symptoms
+and treatment of these there is no place in a mere manual of surgical
+operations.
+
+_Wound of rectum and recto-vesical fistula._--Such wounds were not
+uncommon, and in many cases unavoidable, before the days of chloroform,
+from the struggles of the patient; now they are comparatively rare, and
+should be still rarer. They probably occur in more cases than the
+surgeon is aware of, and heal up without his knowledge; we may arrive at
+this conclusion from the fact that small wounds are found in
+_post-mortem_ examinations of cases in which no such complication has
+been thought of.
+
+They occasionally heal without giving any trouble, but, at other times,
+as the external wound contracts, a communication forms between rectum
+and the urethra, in which the contents are apt to be interchanged in a
+most disagreeable manner, flatus passing per urethram, and urine per
+rectum.
+
+When it is evidently not going to heal spontaneously, the septum between
+the external orifice of the wound and the communication with the gut
+should be laid open, as in the operation for fistula _in ano_.
+
+     There are certain modifications and varieties in the method of
+     operating for stone through the perineum, which deserve at least a
+     brief notice:--
+
+     1. _The bilateral operation._--Though he was not the inventor,
+     Dupuytren's name is justly associated with this operation. The
+     principle of it is to divide both sides of the prostate equally, so
+     as to give more room for extraction of a large stone, without the
+     necessity of much laceration, or the risk of cutting through the
+     prostatic sheath of fascia.
+
+     _The operation._--A semilunar incision is made transversely across
+     the perineum, extending from a point midway between the right tuber
+     ischii and the anus, upwards, crossing the raphe nearly an inch
+     above the anus, and then curving downwards to a corresponding point
+     on the opposite side. The skin, superficial fascia, and a few of
+     the anterior fibres of the external sphincter, are thus divided,
+     and the groove of the staff sought by the forefinger. The
+     membranous portion of the urethra is then laid open in the middle
+     line, and the beak of a double lithotome cach� securely lodged in
+     the groove. It is then pushed into the bladder with its concavity
+     upwards, and when fairly in it is turned round, its blades
+     protruded to the required extent, and withdrawn with its concavity
+     downwards, thus dividing both lobes of the prostate in a direction
+     downwards and outwards (Fig. XXIV. D D). The operation is finished
+     in the usual manner. Though it is a comparatively easy operation,
+     and theoretically may be proved to have many advantages, experience
+     has shown that the results are not so favourable as those of the
+     ordinary lateral operation.
+
+     2. _Buchanan's medio-lateral operation_ on a rectangular
+     staff.--The staff is bent at a right angle three inches from the
+     end, and deeply grooved on its left side. This is introduced into
+     the urethra so that the angle projects the membranous portion of
+     the urethra close to the apex of the prostate and the terminal
+     straight portion enters the bladder parallel to the rectum. The
+     angle projects in the perineum, so that the operator with his left
+     forefinger in the rectum is enabled, by a stab with a long straight
+     bistoury (held horizontally and with the cutting edge to the left
+     side), at once to enter the groove, and, by following the groove,
+     the bladder. Whenever the escape of urine shows that the bladder is
+     fairly reached, the knife is withdrawn so as to make a lateral
+     section of the prostate, and then, with the finger still in the
+     rectum, to make an incision in the ischio-rectal fossa, of
+     sufficient size to allow the stone to be easily withdrawn.
+
+     The inventor claims for this method that it is easier, that there
+     is less risk of h�morrhage, wound of the rectum, and infiltration
+     of urine.
+
+     3. _Allarton's operation of median lithotomy_ suits admirably for
+     stones known to be small, but is quite unsuitable for large ones.
+     Probably in most cases it should be superseded by lithotrity.
+
+     _Operation._--A large curved staff with a central groove is to be
+     held firmly hooked up against the symphysis pubis, and then
+     steadied by the left forefinger in the rectum. The operator pierces
+     the raphe of the perineum with a long straight bistoury about half
+     an inch above the verge of the anus, enters the groove of the
+     staff, and cuts inwards, almost, but not quite, into the bladder.
+     In withdrawing the knife the wound in the urethra is enlarged
+     upwards towards the scrotum. A ball-pointed probe is then passed on
+     the staff into the bladder, the staff is withdrawn, and the finger,
+     guided by the probe, is used to dilate the neck of the bladder, to
+     an extent sufficient for the removal of the stone by a small pair
+     of forceps.
+
+     In this operation the prostate is hardly incised at all. The
+     results are not better than those of the lateral operation.
+
+2. LITHOTOMY ABOVE THE PUBES, _or the High Operation_.--In cases where,
+from the known size of the stone, or from the deformity of the bones of
+the pelvis, it is impossible that the stone can be extracted entire in
+the usual manner; in cases where the prostate is very much enlarged, or
+where there is any real or supposed likelihood of inflammation of the
+neck of the bladder, the supra-pubic operation _may_ be warrantable. Its
+performance is easy, it does not involve any wound of the peritoneum if
+properly performed, and there is no risk of h�morrhage. There are
+certainly great risks attending it of peritonitis and urinary
+infiltration.
+
+In more than one case this operation has been attended by wound of
+peritoneum and subsequent escape of intestines through the wound, even
+when dressed antiseptically and performed under spray.
+
+_Operation._--The patient lies on his back, with his head and shoulders
+slightly raised, so as to relax the abdominal muscles, and his legs
+hanging down over the edge of the table. If his bladder can bear it, it
+should be fully distended, either by voluntary retention of the urine,
+or by injection with tepid water. A vertical incision is then made in
+the middle line, separating the recti muscles from below upwards, care
+being taken to push the peritoneum well out of the way, which is easily
+done by the finger in the loose cellular tissue of the part. The
+anterior wall of the bladder is then exposed, uncovered by peritoneum;
+it must be opened with great care, also in the middle line, while the
+wound in the parietes is held aside by retractors. The wall of the
+bladder should be transfixed by a curved needle, and thus held in
+position before it is opened. The stone is then removed by a pair of
+straight forceps, generally with great ease. Attempts used to be made to
+leave a catheter or canula in the bladder wound to prevent infiltration.
+Probably the safest method now will be to close the bladder wound at
+once by metallic stitches, and stitching the abdominal wound carefully
+with deeply entered wires, to leave the patient on his back. When
+compared with the lateral operations the statistics of the supra-pubic
+operation are discouraging, the mortality being one in three and a half
+to one in four. But in cases where the stone is known to be very large
+and of firm consistence, the risks are probably less from this method
+than from lateral lithotomy, followed by efforts to crush the stone
+through the wound prior to its removal.
+
+The late Mr. George Bell, a most successful lithotomist, proposed to
+perform this operation in two stages. In a case of greatly enlarged
+prostate, where the bladder had been punctured above the pubes by a
+country surgeon for retention of urine, he dilated the track of the
+canula by means of sponge-tents gradually increased in size, and then
+succeeded in extracting through the dilated opening several large
+calculi. The case recovered, and may encourage similar attempts.
+
+3. OPERATIONS THROUGH THE RECTUM.--(_a._) _Sanson's Recto-vesical
+Operation._--The principle of this operation consisted in laying the two
+canals, the rectum and the urethra, into one. A large staff, grooved on
+its convexity, being inserted into the urethra, the operator, with the
+forefinger of his left hand in the rectum as a guide to the knife,
+pierces the anterior wall of the rectum, reaches the groove of the staff
+just in front of the prostate, and cutting outwards divides the rectum,
+the anterior fibres of levator ani, and the sphincter, as well as the
+skin of the perineum in the middle line. Entering the knife again into
+the groove of the staff, it is to be pushed right onwards into the
+bladder, dividing the prostate, and avoiding if possible the seminal
+vesicles and ducts; the stone is then very easily removed.
+
+Though this operation was supposed to lessen the risk of pelvic
+infiltration it is _not_ found to do so, and it adds the additional
+inconvenience of almost inevitable rectal fistula, through which the
+urine escapes. It is certainly a very easy operation, but the mortality
+is found to be greater than in the ordinary lateral operation.
+
+(_b._) _Lithotomy through the rectum above the prostate._--The presence
+of a small portion of bladder beyond the prostate in close relation to
+the rectum renders it possible, in cases where the prostate is not
+enlarged, to enter the bladder and remove a stone of moderate size,
+without interfering with the peritoneum, prostate, or neck of the
+bladder.
+
+This ingenious but difficult operation was performed for the first time
+by Drs. Sims and Bauer in 1859.
+
+I quote the brief notice of the operation by Dr. Sims from the _Lancet_
+of 1864 (vol. i. p. 111):--
+
+"The patient was placed on the left side, and my speculum was introduced
+into the rectum, exposing the anterior wall of the rectum, just as it
+would the vagina in the female. A sound was passed into the bladder. The
+doctor entered the blade of a bistoury in the triangular space bounded
+by the prostate, the vesicul� seminales, and the peritoneal
+reduplication. He passed the finger through this opening, felt the
+stone, and removed it with the forceps without the least trouble. The
+operation was done as quickly and as easily as it would have been in a
+female through the vaginal septum. After the removal of the stone, Dr.
+Bauer kindly asked me to close the wound with silver sutures, which I
+did, introducing some five or six wires, with the same facility as in
+the vagina. There was no leakage of urine. The patient recovered without
+the least trouble of any sort. The wires were removed on the eighth day,
+and on the ninth day the patient rode in a carriage with Dr. Bauer a
+distance of four or five miles, to call on, and report himself to, our
+distinguished countryman, Dr. Mott."
+
+The chief risks in this operation seem to be the chance of wounding the
+peritoneal _cul-de-sac_, as the amount of free space between it and the
+prostate seems to vary much in individuals and in races. Dr. Marion Sims
+mentioned to me in conversation that he believed this operation
+impossible in the negro race, from the greater projection downwards of
+the peritoneal reduplication. An enlarged prostate would be an
+insuperable objection. The use of silver wire, to close up the wound at
+once, diminishes very much any risk of recto-vesical fistula.
+
+
+LITHOTRITY OR LITHOTRIPSY.--There exist cases of stone in the bladder,
+which, under certain conditions, may be relieved without lithotomy, by
+an operation which crushes the stone into fragments small enough to be
+discharged through the urethra.
+
+To enter with any fulness into the history, literature, and varieties of
+this operation, and the instruments required, would in itself require a
+large volume. Suffice it here to describe the case suitable for the
+operation, the essentials required in the instrument, and the method of
+performance.
+
+1. _For a case to be suitable_ the _stone_ should not be too large, and
+especially not too hard, also there should not be too many of them.
+
+The _urethra_ should be capacious enough to let the instrument pass
+easily and painlessly.
+
+The _bladder_ should be large enough to contain four ounces of water at
+least, should not be much inflamed, and, on the other hand, should not
+be paralysed. Paralysis or want of tone in the bladder prevents the
+thorough evacuation of its contents, and still more the expulsion of the
+fragments of stone.
+
+2. _A good instrument_ should, as far as possible, combine strength with
+lightness. The curved portion of the fixed blade should be fenestrated
+to allow escape of the fragments and thorough closure of the
+instrument.
+
+The movable blade must be so arranged as to combine perfect ease of
+movement up and down in seeking for the stone, with a powerful, slow,
+and gradual approximation in crushing it. This can be managed by an
+ingenious arrangement, which leaves the movable blade under the control
+only of the operator's thumb till the stone is found, and yet, by
+touching a spring, gives him the advantage either of a fine screw or of
+a rack and pinion movement for crushing the stone.
+
+3. _Operation._--The patient being prepared by a free evacuation of the
+bowels, and the urethra having been previously fairly dilated, he is
+asked to retain his urine as long as possible, or, if he cannot do so, a
+few ounces of tepid water may be injected per urethram.
+
+He is then laid on a sofa or table, the breech being well raised by
+pillows, the shoulders low, the thighs and knees bent up and separated.
+The instrument, well warmed and oiled, is then introduced with the
+blades closed. When fairly into the bladder the search for the stone
+begins.
+
+There are differences of opinion regarding the best method of fishing
+for the stone; great patience and gentleness, with a thorough previous
+acquaintance with bladder manipulation, are required, whichever method
+be chosen.
+
+The two chief methods may be described as the English and the French,
+the latter, Civiale's, being now used by Sir Henry Thompson, and other
+English operators. Briefly, the two are:--
+
+(1.) _Heurteloup's and Sir B. C. Brodie's._--In this, after the
+instrument is fairly entered, its handle is elevated, thus depressing
+the curved extremity, the forceps are then opened, and, by being kept as
+low as possible in the bladder, it is hoped that the calculus will fall
+into the opened blades by its own weight. In this method the fundus is
+the scene of crushing, and there is a risk of injuring the sensitive
+neck of the bladder, especially at the moment of opening the blades.
+
+(2.) _Civiale's--Thompson's._--In this the pelvis is to be so elevated
+that the centre of the bladder and space beneath it give plenty of room
+for seizing the stone, and all contact with the wall of the bladder is
+(as far as possible) avoided.
+
+The instrument is introduced closed, and carried fairly away in to the
+posterior part of the bladder before it is opened at all. It probably
+grazes the stone in passing, and, if so, is directed to the side of the
+bladder in which the stone is _not_ lying. Then when nearly touching the
+posterior wall, the movable blade is withdrawn, the instrument inclined
+towards the stone lying unmoved in the most dependent part, and there
+seizes it generally with ease.
+
+If not felt, the blades are again to be opened, turned a little to the
+other side of the bladder, and then closed. Sir H. Thompson lays the
+greatest stress on the importance of always having the blades fairly
+opened before shifting their position, for if moved when closed, the
+very opening of the movable blade is certain to drive the stone out of
+the way and prevent its seizure.
+
+Certain rules are useful:--Move the axis of the instrument as little as
+possible; it should be kept in the centre of the bladder, so far in,
+that the movements of the male blade are quite free from the neck of the
+bladder and prostate, and the blades only should be moved in the bladder
+on the centre of the shaft as an axis. There should be no jerking once
+the stone is caught, and the crushing should be done as far as possible
+in the very centre of the bladder, the blades not touching any of the
+walls.
+
+After the stone is seized, do not crush till, by a turn of the blades
+from side to side, you discover that none of the mucous membrane of the
+bladder is caught in the instrument.
+
+The lithotrite is not meant to extract stones, but to crush them, hence
+never attempt to withdraw it unless the blades are in absolute
+apposition.
+
+Never attempt too much at one time. Sir H. Thompson holds that five
+minutes is the longest time that should be given, perhaps in most cases
+three minutes being long enough.
+
+While many surgeons will still agree with the above advice, Dr. Bigelow
+of Boston has lately been highly commending a method which he has called
+Litholapaxy, in which, at one sitting under chloroform, the stone is
+crushed and aspirated, or sucked out of the bladder at once.[152]
+
+     Since the above was written the operation of Litholapaxy has made
+     great strides in the favour of surgeons, and many stones that would
+     have been removed by lithotomy are now broken down by powerful
+     instruments at a single sitting, and removed piecemeal by the
+     suction apparatus.
+
+     S. W. Gross has collected 312 cases, of which 17 died or 5.45 per
+     cent., but of 180 done by experienced surgeons, Thompson, Bigelow,
+     Van Buren, Weir, and Stevenson only five died, or 3.33 per cent.,
+     while of 1470 cases of lithotrity, as formerly practised, 159, or
+     10.81, per cent. died.[153]
+
+
+OPERATIONS FOR STRICTURE OF URETHRA.--Under this head many manipulations
+and operations might be described; the very instruments devised being
+exceedingly numerous and complicated. Enough here to detail a few of the
+more simple and practical procedures under the different heads of--1.
+_Dilatation_ gradual and forced. 2. _Internal Division._ 3. _External
+Division._
+
+1. DILATATION.--Under this head we have--
+
+_a._ _Vital dilatation._--The passing of a succession of bougies,
+gradually increasing in diameter, at intervals of three or four days,
+for the purpose of exciting an amount of interstitial absorption in the
+new material constituting the stricture, sufficient to remove it.
+Passing a bougie, though certainly often very difficult, perhaps should
+hardly come into the category of surgical operations, yet to preserve a
+certain completeness in the account of stricture, a very brief
+description may be here inserted.
+
+The recumbent posture is in most cases to be preferred. The patient
+should lie flat on his back, with the knees slightly bent and separated,
+and the head and shoulders slightly raised on a pillow. The operator
+standing on the patient's left side, raises the penis in his left hand,
+and with the right introduces the instrument, previously warmed and
+oiled, into the meatus. He then pushes it very gently onwards, at the
+same time stretching the penis with the left hand, just so far as to
+efface any wrinkles in the mucous membrane, till the point reaches the
+bulbous portion. The axis of the instrument, which at first for
+convenience was over the left groin, has now gradually been approaching
+the middle line. When this is reached, the instrument should be raised
+from the abdomen, and the handle cautiously carried in the arc of a
+circle first upwards and then downwards, till, when the instrument is
+fairly into the bladder, the handle is depressed between the patient's
+thighs. While this is being done the operator's left hand should be
+withdrawn from the penis, and the points of the fingers applied to the
+perineum.
+
+In cases of difficulty certain points may be remembered:--
+
+(1.) That the point of the instrument may in the first inch or two be
+occasionally entangled in a lacuna in the roof, especially when a small
+instrument is used; hence the beak should be at first maintained against
+the inferior wall of the canal.[154]
+
+(2.) That the handle should not be depressed too soon; if it is, there
+is a risk of a false passage being made through the upper wall.
+
+(3.) The opposite error may force the point out of the urethra between
+the membranous portion and the rectum, and onwards into the substance of
+the prostate gland.
+
+And certain cautions may be given:--
+
+(1.) In every exploration of an unknown urethra the surgeon should
+commence with an instrument of medium size, certainly not less than No.
+7 or 8.
+
+(2.) In cases of difficulty occurring in the urethra behind the scrotum,
+invariably use the forefinger of the left hand in the rectum as a guide.
+
+(3.) Expression of pain on the part of the patient is no indication that
+a false passage is being made, nor its absence that the instrument is in
+the passage, for it is a remark of Mr. Syme, that passing an instrument
+through a stricture is generally more painful than making a false
+passage through the walls of the urethra.
+
+     An instrument may be passed, while the patient is erect, with the
+     following precautions:--The patient should stand with his back
+     against a wall, his arms supported on the back of a chair on each
+     side, heels eight or ten inches apart, and four or five inches from
+     the wall; his clothes thoroughly down, not merely opened. The
+     bougie should then be held nearly horizontal, with its concavity
+     over the left groin of the patient, the penis being raised in the
+     surgeon's left hand. Introduced thus for four or five inches, the
+     handle is gradually raised into the middle line of the abdomen, and
+     to the perpendicular; it is then to be lightly depressed, and, as
+     the point enters the bladder, brought down towards the operator
+     until it sinks beneath the horizontal line.
+
+_b._ _Mechanical dilatation_ is of two kinds, both very rarely
+used:--(1.) When an instrument cannot be passed, it consists of passing
+down day after day the point of an instrument (sometimes armed with
+caustic, sometimes not), and pressing it against the stricture till it
+is overcome.[155] (2.) When an instrument is introduced through an
+intractable stricture, and is left there either for some hours, or for
+some days, to excite what is called "suppuration" of the stricture.[156]
+
+_c._ _Forced dilatation._--Under this head we might describe at great
+length mechanical contrivances to force or rupture a stricture. A word
+or two on a few of the most important:--
+
+(1.) Conical bougies of steel or silver.
+
+(2.) Mr. Wakley's method, on which many others have been founded. He
+passed a small bougie or wire into the bladder, over which were slipped
+straight tubes of varying size, with perfect certainty that they could
+not leave the urethra.
+
+(3.) Mr. Holt's method.[157]--The principle of it is to rupture the
+stricture at once, so that a No. 12 catheter can immediately be passed
+into the bladder.
+
+He attains this object by means of an instrument composed of two grooved
+blades, united about one inch from their apex, into a conical sound,
+which at its apex is about the size of a No. 2 bougie. This is passed
+into the bladder, and the grooved blades are separated to any extent
+that is desired by passing down between them a straight rod equal in
+size of a No. 8, 10, or 12, bougie. To guide this properly it is made
+hollow, and it is passed down over a central wire which lies between the
+grooved blades of the instrument and is welded to the apex. A great
+improvement is effected on Mr. Holt's later instruments by this wire
+being made hollow, and fitted with a stilette, for by this means we can
+with certainty ascertain whether or not the instrument has been passed
+into the bladder. This instrument, which is an improvement upon one
+invented by Perr�ve nearly forty years ago, has been used on very many
+occasions by Mr. Holt and others with success. The risk to life, if the
+case be properly managed, is trifling, but, like every other means of
+treating stricture, it has the objection that the stricture is liable to
+recur, unless bougies be passed at intervals for months and years.
+
+Sir Henry Thompson has introduced and described another very ingenious
+instrument for the same purpose, constructed on somewhat similar
+principles. His account of it, to which I must refer, will be found in
+Holmes's _System of Surgery_, 1st ed. vol. iv. p. 399.
+
+2. INTERNAL DIVISION OF STRICTURE is a mode of treatment which by many
+surgeons is highly disapproved, yet of late years it has been more used
+than formerly, especially in resilient strictures. It may be done in two
+ways:--
+
+(1.) _From before backwards._--This method, to be at all admissible,
+requires a guide to be previously passed; a lancet-shaped blade may then
+be slipped down a groove in this guide till the stricture is divided.
+This is least objectionable in cases of stricture close to the meatus.
+
+(2.) _From behind forwards._--To make the incision thus, it is of course
+necessary that the stricture should be so far dilatable as to admit an
+instrument the point of which is large enough to contain the blade by
+which the stricture is to be divided. This will be found to be at least
+equal in size to a No. 3 or No. 4 catheter. In many instruments it is
+much larger.
+
+_Civiale's_ instrument for internal incision of the urethra from behind
+forwards has the very high recommendation of Sir H. Thompson.[158] It
+consists of a sound with a bulbous extremity (as large as a No. 5
+bougie) which contains a small blade, which can be made to project for
+such a distance as the operator wishes. It is passed through the
+stricture with the blade concealed, till the bulb is carried about
+one-third of an inch or more beyond the stricture; the blade is then
+projected, and the incision made by drawing it slowly but firmly
+outwards towards the meatus, with the blade towards the floor of the
+urethra, till the stricture is divided in its whole extent. Sir H.
+Thompson recommends this to be used in cases _where it is not that the
+stricture is of very small calibre, but that it is undilatable_, that
+prevents the cure. Many modifications of above have been devised by
+Lund, Teevan, and other surgeons, on similar principles.
+
+3. MR. SYME'S OPERATION OF EXTERNAL DIVISION.--Mr. Syme held that no
+stricture through which the water can escape should be called
+_impermeable_, for by patience and care the surgeon should always be
+able to pass a slender director through the stricture on which it may be
+divided with ease and certainty. The old operation of "perineal section"
+for so-called impermeable stricture is very different, being difficult,
+dangerous, and uncertain in its results.
+
+_Operation._--A director is passed into the stricture. Mr. Syme's
+directors are of different sizes, the smallest being in diameter less
+than an ordinary surgical probe. They are made of steel, are grooved on
+the convexity, and have this peculiarity, that while the lower half is
+small, the upper is of full size (No. 8 or 10), the difference in
+calibre occurring quite abruptly. The presence of this "shoulder" on the
+staff enables the operator to ascertain exactly the position of the
+stricture, and also to tell when it is fully divided without the
+necessity of withdrawing the instrument.
+
+This being fairly in the stricture, the patient is put in the position
+for lithotomy, an assistant holds the staff in his right hand, drawing
+up the scrotum with his left.
+
+The surgeon then makes an incision in the middle line over the
+stricture for the necessary distance, from above downwards, till he
+exposes the urethra, and feels exactly the shoulder of the staff. Care
+must be taken not to go past the urethra at either side. When he
+distinctly feels the outline of the staff, he takes it in his left hand,
+and a short sharp-pointed bistoury in his right. It should be held
+firmly in the palm of the hand, with the back of the blade resting on
+the forefinger, the pulp of which guides the point to the groove, and
+guards it when making the incision; the knife is to be placed on the
+groove beyond (_on the bladder side_) of the stricture, and brought
+forwards, slowly cutting through _the whole_ stricture; till the
+shoulder of the staff is reached. It requires strength and precision to
+divide thoroughly the indurated stricture, which is apt to elude the
+knife.
+
+The shoulder of the staff can now be passed through the stricture if the
+operation is complete; if not, the incision must be extended, always in
+the middle line, and guided by the groove. When thoroughly divided, the
+staff is now to be withdrawn, and a full-sized catheter with a double
+curve passed into the bladder. This should _not_ be furnished with a
+stop-cock or plug, lest the bladder should by inadvertence be allowed to
+be too full, and extravasation into the cellular tissue of the urethra
+take place along the side of the instrument.
+
+The catheter should be tied in, and left for two, sometimes for three
+days, when it can generally be removed with safety, and a bougie should
+be passed at intervals of three or four, till the wound is healed. To
+prevent recurrence of the stricture, it is a wise precaution to pass an
+instrument at intervals for many months after the cure is apparently
+complete.
+
+In certain cases, where the stricture is far back and the urinary
+symptoms severe, Mr. Syme found advantage from the introduction of a
+shorter double-curved catheter (only about nine inches long) through
+the wound into the bladder, where it should be left for three days.
+This seems to diminish the risk of rigors, and other symptoms of fever,
+which are apt to occur when the urine is allowed for the first time to
+pass over the wound.
+
+_Perineal Section_ is an operation both dangerous and difficult; as Sir
+Astley Cooper used to say, "the surgeon who performs it requires to have
+a long summer's day before him."
+
+No director or guide can be passed. A full-sized catheter must be passed
+as far as possible _up_ to the stricture, and held firmly in the middle
+line. The patient must be tied up in lithotomy position on a table in
+the very best light that can be obtained. The perineum being shaved, an
+incision must be made in the middle line from over the point of the
+catheter to the verge of the anus, if the stricture extends far back.
+
+The urethra should then be opened over the catheter, the edges of the
+mucous membrane held to each side by silk threads passed through them;
+and the surgeon must endeavour to pass a fine probe into the opening of
+the stricture; if this can be done, it is comparatively easy to slit the
+stricture up. If not, the surgeon must simply seek for the remains of
+the urethra by slow, cautious dissection in the middle line. If
+successful, a catheter must be secured in the bladder in the usual way.
+
+A stricture near the orifice, or, as it is not uncommon, involving
+merely the meatus, can be treated with great ease in the above manner by
+division on a grooved probe. When quite close to the orifice, with a
+well-defined hardness, as of a ring round the urethra, it may be divided
+subcutaneously by a tenotomy knife or other narrow-bladed instrument. It
+is not necessary to keep a catheter in the bladder in cases where the
+stricture has been in front of the scrotum.
+
+
+PUNCTURE OF THE BLADDER.--A patient and dexterous use of the catheter
+prevents this operation from being often required; still, circumstances
+may arise in which it is found impossible to enter the bladder _per vias
+naturales_. In such a case the bladder may be punctured from the outside
+by a curved trocar and canula, in either of two situations.
+
+1. _From above the pubis._--This operation is a very simple one, and
+when the bladder is distended need not imply a wound of the peritoneum.
+
+_Operation._--A preliminary incision, varying in length according to the
+amount of fat, should be made above the pubis exactly in the middle
+line; the edges of the recti should be separated, the peritoneum pushed
+out of the way and upwards by the finger, and a curved trocar plunged
+into the distended bladder obliquely backwards. The canula should be
+retained for a day or two, and then a flexible catheter with a shield
+inserted instead. Such instruments have been worn for years. The
+aspirateur pneumatique of Dr. Dieulafoy will be found an exceedingly
+useful instrument for puncture of bladder and removal of urine. The
+author has now used it very frequently with the best results. Its
+advantage is that the urine is removed through an aperture so small as
+to allow of the withdrawal and reintroduction of the canula as often as
+is necessary.
+
+[Illustration: FIG. XXXVI.[159]]
+
+2. _From the Rectum._--Except in cases of enlargement of the prostate,
+it is at once easier and safer to puncture the bladder from the rectum.
+The well-known triangular space uncovered by peritoneum, with its apex
+in front close to the prostate, and bounded on either side by the vasa
+deferentia and vesicul� seminales, can be easily reached by a curved
+trocar. This should be guided by one, or, still better, by two fingers,
+into the rectum, with its concavity upwards, and the point should be
+pushed upwards by depression of the handle, whenever it is fairly behind
+the prostate. The trocar may then be withdrawn, and the canula retained
+for at least forty-eight hours by a suitable bandage. Mr. Cock, of Guy's
+Hospital, had a special canula for the purpose, which expands at its
+extremity after its introduction, and thus is not apt to slip.[160] Some
+surgeons insist that the surgeon should be able to ascertain the
+existence of fluctuation between the finger in the rectum, and the other
+hand above the pubes. This is exceedingly difficult to elicit when the
+bladder is very much distended, and from the constrained position of the
+finger in the bowel.
+
+
+PHYMOSIS.--Elongation of the prepuce, with contraction of its orifice,
+in most cases congenital, sometimes so extreme as to cause difficulty in
+micturition, and frequently preventing the uncovering of the glans.
+
+_Operation._--In all well-marked cases, the following is required:--The
+elongated prepuce should be pulled forwards by a pair of catch-forceps,
+and a circle of skin and mucous membrane removed by a single stroke of a
+bistoury, or by sharp scissors. Care should be taken lest the glans be
+included in the incision, as has happened in _at least_ one instance.
+The skin will then be found to retract very freely beyond the glans, but
+the mucous membrane is found still to cover the glans, and its orifice
+is still constricted. It must then be slit up (Fig. XXXVII. _b b_) on
+the dorsum of the glans, with probe-pointed scissors, as far as the
+corona, and the glans will then be thoroughly exposed. The edges of
+mucous membrane and skin should then be stitched to each other by at
+least five or six fine silk sutures, any bleeding points having been
+first carefully secured. The angles will in time round off, and a
+wonderfully seemly prepuce be obtained. This operation may be done as a
+method of cure for obstinate enuresis in cases in which the prepuce is
+very long and redundant, even when it is not too tight. The author has
+done this in more than twenty cases with excellent results.
+
+[Illustration: FIG. XXXVII.[161]]
+
+     _Varieties._--When the prepuce is narrowed at its orifice without
+     being redundant in length, a milder operation will prove
+     sufficient. The principle is the same as in the former, but the
+     amount of incision is less, and nothing is removed. Two methods are
+     possible:--
+
+     1. _By scissors._--The blunt point of a pair of scissors is
+     introduced through the preputial orifice, the other blade being
+     outside, and the skin and mucous membrane are divided for about
+     half an inch; the skin being then retracted, the mucous membrane is
+     still further divided by one or two additional snips, and then the
+     edges of skin and mucous membrane are stitched together by one or
+     two points of suture.
+
+     2. _By knife._--A director being introduced within the prepuce, a
+     narrow-bladed knife is guided along it, and pushed through the
+     prepuce from within, and then made to divide skin and mucous
+     membrane from within outwards. Stitches as before.
+
+     _N.B._--Be careful lest the director pass into the meatus
+     urinarius, and the glans be split up.
+
+     Again, some surgeons prefer two lateral incisions instead of one
+     dorsal one. In this case skin and mucous membrane should be divided
+     by scissors for about a quarter of an inch, and then a single
+     stitch inserted in the angle of junction. This has been further
+     modified by Cullerier, who proposed the division of the tight
+     mucous membrane only, in three or four points. He used a pair of
+     scissors with one sharp and one probe-pointed blade, the sharp one
+     thrust in between skin and mucous membrane, the blunt one between
+     the mucous membrane and the glans.
+
+
+AMPUTATION OF THE PENIS.--This exceedingly simple operation is performed
+by a single stroke of an amputating knife, drawn along from heel to
+point, while the penis is stretched in the operator's left hand. As
+there is more risk of redundancy than of deficiency of the skin, no
+attempt is made to save it. Numerous vessels in the corpora cavernosa
+require ligature. Amputation of the penis may be done bloodlessly by the
+thermo-cautery even close to its root. Transfix the root of corpora
+cavernosa by a needle; above this pass two or three turns of an elastic
+ligature; then slowly divide at a low red heat the skin and corpora
+cavernosa below the needles; split the urethra after dividing its mucous
+membrane with a knife. The author has done this several times with ease
+and rapid healing.
+
+[Illustration: FIG. XXXVIII.[162]]
+
+The chief risk is stricture of the orifice of the urethra. To prevent
+this, several modifications of the operation have been introduced.
+
+1. _Ricord's method._[163]--After the amputation the surgeon seizes with
+forceps the mucous membrane of the urethra, and with a pair of scissors
+makes four slits in it, so as to form four equal flaps, and with a silk
+ligature stitches each of these to the skin. Contraction of the
+cicatrix will thus tend to open rather than close the urethral orifice.
+
+2. _Teale's method._[164]--He slits up, by a bistoury on a director, the
+urethra and skin over it for about two-thirds of an inch, and then
+stitches the one to the other, thus making it a long oval dependent
+orifice (Fig. XXXVIII.).
+
+3. _Miller's proposed method._[165]--"A narrow-bladed knife is first
+used to transfix the penis between the spongy and cavernous bodies close
+to the root; the knife having been carried forwards for an inch and a
+half, its edge is turned perpendicularly downwards, and the urethra and
+skin flap are divided, the cavernous bodies and dorsal integument being
+then cut perpendicularly upwards where the knife was originally entered
+for transfixion. A button-hole is afterwards made in the lower flap,
+though which the corpus spongiosum and urethra protrude, while the flap
+itself is turned upwards, and attached dorsally and laterally, so as to
+cover in the exposed cavernous structure."
+
+
+HYDROCELE.--The very simple operation necessary for hydrocele is thus
+performed:--The surgeon supports the tumour in his left hand so as to
+project it forwards, and make the scrotum as tense as possible in front.
+Having carefully ascertained the exact position of the testicle, which
+can generally be easily enough done by a finger accustomed to
+discriminate the difference between a soft solid, and a bag tensely
+filled with fluid, aided by the peculiar sensation of the testicle when
+squeezed, the surgeon enters a trocar and canula about an eighth of an
+inch in diameter into the distended cavity of the tunica vaginalis, near
+the fundus of the swelling. When it is evident the instrument is fairly
+entered, and not till then, the trocar is withdrawn, and the fluid
+allowed completely to drain off. When it ceases to flow the surgeon
+places his forefinger over the end of the canula to prevent the entrance
+of air, till he fits into its orifice a suitable syringe containing two
+drachms of the tincture of iodine, made according to the Edinburgh
+Pharmacopoeia: the tincture of the British Pharmacopoeia is not
+sufficiently strong. Having injected this cautiously into the cavity,
+the canula is withdrawn, and the surgeon, seizing the now flaccid
+scrotum in his right hand, gives it a thorough shake, so as to spread
+the iodine over as much as possible of the inner wall. When properly
+performed this very simple procedure very rarely fails to produce a
+radical cure; though less thorough operations, such as mere evacuation
+of the fluid, less stimulating injections, unguents introduced on
+probes, and the like, often fail of success, and thus give encouragement
+to absurdities, such as wire-setons, or to more severe operations, such
+as laying open the sac.
+
+
+H�MATOCELE.--When the contents of the sac of the tunica vaginalis are
+found to be grumous instead of simply serous, or when, as often happens,
+only pure blood escapes when the fluid is nearly evacuated, it is found
+that simple evacuation and injection are very rarely sufficient to
+effect a cure.
+
+After they have been fairly tried, the sac of the h�matocele should be
+laid open in its full extent; any large vessels which bleed should be
+tied, and the cavity then stuffed with lint. When the lint can be
+removed, which will be after two or three days, the edges of the wound
+should be brought closely together, and the cavity will then rapidly
+heal up from the bottom, and be obliterated by secondary union of
+granulations.
+
+In cases where the walls of the cavity are enormously thickened, or
+even, as sometimes happens, almost bony in consistence, an elliptical
+portion may be removed with advantage.
+
+
+EXCISION OF TESTICLE.--This operation is rarely required except for
+tumours of the testicle. Hence the size of the incision necessary must
+vary much with the size of the tumour; and the amount of skin to be
+removed (if any) on the amount of adhesions it has formed to the tumour.
+
+One or two points must be attended to in every case of extirpation of a
+testicle:--
+
+1. The incision should commence over the cord just outside of the
+external ring, and be continued fairly over the tumour to its base.
+
+2. As to removal of skin, some surgeons advise that none should be taken
+away, others that a considerable quantity can be spared. There is
+certainly less risk of secondary h�morrhage if a portion be removed,
+than when a flaccid empty bag is left. The author invariably removes a
+very large quantity of skin if the tumour is large, as there is much
+more rapid healing, and the resulting scrotum is much more comfortable
+for the patient.
+
+3. The cord should be exposed at the beginning of the operation, raised
+from its bed and given to an assistant, who should compress it gently,
+not from any fear of its escape into the abdomen, but to prevent
+h�morrhage. If the tumour has been very large and heavy, the cord will
+have been much stretched, and if divided too high up, may really give
+trouble by its elasticity, unless the above precaution is taken. The
+cord then having been divided close to the tumour, the latter is
+removed, care being taken not to include the sound testicle in the
+removal. All the vessels are then to be tied or twisted, and the
+spermatic artery is to be secured alone, not, as used to be the case,
+included in a common ligature with the other constituents of the cord.
+Secondary h�morrhage is very apt to occur from small scrotal branches
+which may have escaped notice during the operation.
+
+
+OPERATIONS ON THE ANUS AND ITS NEIGHBOURHOOD.--FISTULA IN ANO.--While
+much might be written on the pathology of fistula, and a good deal even
+on its diagnosis, a very few words will suffice to describe the simple
+and effectual operation for its relief.
+
+Dismissing at once all so-called palliatives, drugs, unguents, pressure,
+and injections, as mere waste of time, and holding that the only method
+of cure consists in laying the fistula fairly open, the question narrows
+itself into this: What is the best method of laying it open? Prior to
+the discovery by Ribes of the great principle that the internal orifice
+of the sinus is always within an inch or an inch and a half of the
+orifice of the anus, the operations for fistula were most unnecessarily
+severe; the gut used to be divided as far up as the sinuses extended;
+and large portions of the anus used to be excised bodily along with the
+sinuses. It is now a much simpler and more satisfactory operation.
+
+_Operation._--A common silver probe bent to the required shape is passed
+into the external opening, or, if there are more than one, into the
+largest and oldest one. The forefinger of the left hand being introduced
+into the rectum, the probe is passed through the internal orifice, and
+its point brought out by the anus. The portion of tissue raised by the
+probe can then be easily divided with the certainty that the fistula is
+laid fully open. Anal fistul� have been divided by the elastic ligature,
+but it seems slower in action and more painful, with no counterbalancing
+advantages.
+
+     The author has for last few years operated almost exclusively by a
+     long knife which is continued into a steel probe. The probe is
+     passed up the fistula, then into the bowel, and is hooked out at
+     the anus, and in being simply pushed on the knife cuts the
+     fistula--tuto, cito, et jucunde, the patient rarely knowing that
+     more has been done than an exploration.
+
+     In cases where, from the hardness and density of the parts it is
+     impossible to pass the probe and bring it out at the anus, a strong
+     probe-pointed bistoury may be passed in by the external orifice
+     till its probe-point can be felt by the finger in the bowel at the
+     internal opening. Supported by the finger it can then be made to
+     cut outwards till the whole septum is divided.
+
+
+FISSURE OF THE ANUS, ULCER OF THE ANUS, resemble each other alike in the
+exceeding annoyance which they give to the sufferer, and in the
+simplicity of the treatment needed.
+
+_Operation._--Once the presence of either is determined by the finger in
+the anus, a sharp-pointed curved bistoury should be introduced,
+transfixing the base of the fissure or ulcer, and then guided on the
+finger, completely dividing it, so as to change the ragged ulceration
+into a simple wound which will rapidly heal.
+
+
+PROLAPSUS ANI, _Operation for_.--Complete prolapsus in which the whole
+gut is involved, as seen in the very young and the very aged, is suited
+for palliative rather than radical treatment.
+
+Cases of prolapsus of the mucous membrane only, as is not uncommon in
+connection with or as a result of h�morrhoids in adults, give
+opportunity for operative interference.
+
+We may act on either the skin or mucous membrane, or both at once.
+
+1. _The skin_ is often found loose, and arranged in radiating folds
+round the anus. In such cases, as recommended first by Dupuytren, some
+of these projecting folds may be removed. Again it may be prolapsed in a
+great loose ring or circular fold round the margin, forming an
+exaggerated external pile; in such a case the loose fold may be fairly
+excised with curved scissors, as recommended by Hey of Leeds.
+
+The first of these methods is apt to be insufficient, the second again
+has the risk of removing too much.
+
+2. If the protrusion is chiefly mucous membrane exposed in folds, or a
+ring, which is generally outside, one of two methods of treatment may be
+tried:--
+
+_a._ By ligature, as recommended by Mr. Copeland. Raising a longitudinal
+fold of the mucous membrane, he passed a ligature round it as if it were
+a pile. There is less chance of the ligature slipping if a double thread
+be used and its base thus transfixed. Three, four, or even more folds
+may be thus treated.
+
+_b._ When the mucous membrane has been so long exposed as to have lost
+many of its characters, and to resemble leather in its toughness,
+excision will be found less painful and much more rapid than ligature.
+
+A longitudinal fold at each side of the anus should be pinched up and
+excised by a pair of probe-pointed curved scissors. There is always a
+certain amount of risk of h�morrhage following such an operation. The
+risk is lessened and the result improved by stitching up the wound in
+the mucous membrane before the protruded portion of bowel is returned.
+
+
+POLYPI OF THE RECTUM.--Pedunculated growths varying in consistence,
+shape, and size, but resembling each other in having a distinct stalk,
+and in frequently being protruded at stool.
+
+_Operation._--Invariably by ligature, which may be single round the
+stalk, if the tumour be globular and with a distinct narrow stalk, or by
+transfixion, if (as sometimes happens) the tumour be of uniform
+thickness throughout, like a worm.
+
+
+H�MORRHOIDS OR PILES.--In the treatment of piles it is the differential
+diagnosis that is troublesome and occasionally difficult; the operative
+interference required is generally very simple, if the nature of the
+case be rightly determined.
+
+_External piles._--_Operation._--The apex of the soft flabby excrescence
+should be seized by a pair of catch-forceps, and it should be cut off
+close to its base with a knife, or, what is better, a pair of curved
+scissors. Any little vessel which jets may then be secured. If, instead
+of numerous individual tumours, a ring of skin round the anus be
+involved, the whole of it should be shaved off, but not very close to
+its base, lest too great contraction of the anal orifice should ensue.
+
+     If the surgeon, after excising a pile or piles, will take the
+     trouble to stitch up the wound with catgut, he will find the cure
+     much more rapid and less painful than when this is omitted.
+
+_Internal piles._--Incision is extremely dangerous, from the vascularity
+of the parts, and their being so inaccessible from their position within
+the sphincter ani. Hence ligature is safer and equally effectual. The
+patient should be directed to sit over hot water, and strain till the
+whole of his piles are fairly protruded. The surgeon should then
+transfix the base of each separately with a curved needle bearing a
+strong double thread. The needle being cut off, the threads should be
+very firmly tied, each isolating its own half of the pile. The tying
+should be exceedingly tight, so as to cause instant and complete
+strangulation and death of the tumours. All the piles should be tied at
+the same sitting. If the piles are very small they may be secured
+without transfixion in a single noose after being seized by a hook or
+forceps. There is greater risk of the noose slipping than when the base
+has been transfixed.
+
+The strangulated masses must then be returned into the bowel, and the
+patient kept in bed or on a sofa till the ligatures separate, which is
+generally not till the fourth or fifth day. A certain amount of urinary
+irritation, showing itself sometimes in strangury, sometimes in complete
+retention, occasionally follows this operation.
+
+Mr. Smith of King's College, and many other surgeons, treat internal
+piles by means of an ivory clamp to hold them tight, while they are
+burned off by the actual cautery or the thermo-cautery at a low red
+heat. They claim that py�mia more rarely follows this mode.
+
+     There are certain cases in which the lower inch or two of the
+     rectum are found red and congested, and in which every stool is
+     followed by the loss of a certain quantity of florid arterial
+     blood, and yet no distinct h�morrhoidal tumour is to be seen. In
+     such cases the ligature is not applicable, and relief is obtained
+     by the application of pure nitric acid, or other potential caustics
+     to the bleeding surface, as recommended by Houston, Lee, Smith,
+     Ashton, and others. These cases are comparatively rare, and
+     whenever they can be applied, the ligature is much simpler, safer,
+     and more certain.
+
+_Venous piles._--When a sudden effusion of blood has occurred into one
+of the varicose veins or sinuses of a congested anus, an oval or rounded
+tumour is felt, very tense, shining, and painful. To slit it freely up
+with an abscess lancet, and evert the clot inside, at once relieves all
+the symptoms.
+
+
+FOOTNOTES:
+
+[150] Diagram of section of prostate seen from the inside:--PF, pelvic
+fascia or prostatic sheath; RR, ring which must be cut; L, position of
+incision in the lateral operation; DD, position of incisions in the
+bilateral operation.
+
+[151] Diagram of muscles of membranous portion of urethra seen from the
+inside:--SS, section of os pubis; U, urethra; G, Guthrie's muscle,
+compressor urethr�; W, Wilson's muscle, levator urethr�.
+
+[152] _Boston Medical and Surgical Journal_, May 29, 1879.
+
+[153] Gross, _Surgery_, 6th ed. vol. ii. p. 736.
+
+[154] Holmes's _Surgery_, vol. iv. p. 392.
+
+[155] See Miller's _Practice of Surgery_, p. 212.
+
+[156] Solly's _Surgical Experiences_, pp. 537, 538, etc.
+
+[157] _The Immediate Treatment of Stricture._ By Bernard Holt, F.R.C.S.
+London. Third Edition, 1868.
+
+[158] Holmes's _System of Surgery_, 1st ed. vol. iv. p. 403.
+
+[159] Diagram of puncture of the bladder:--B, bladder; SP, symphysis
+pubis; SC, scrotum; _b_, bulb; _pr_, peritoneum; P, prostate; R, rectum;
+S, sacrum and coccyx.
+
+[160] _Med. Chir. Trans._, vol. XXXV.
+
+[161] Diagram of operation for phymosis:--_a_, glans penis; _b b_,
+mucous membrane exposed by retraction of the skin, and slit up; _c d_,
+sutures introduced and ready to be tied, uniting the skin and mucous
+membrane.
+
+[162] To illustrate Teale's operation:--_c_, section of penis _b_,
+thread inserted uniting mucous membrane and skin; _a_, thread tied.
+
+[163] _Med. Times and Gazette_, vol. xix. p. 354.
+
+[164] Miller's _System of Surgery_, p. 1255.
+
+[165] Miller's _System of Surgery_, p. 1256.
+
+
+
+
+CHAPTER XIII.
+
+TENOTOMY.
+
+
+For convenience' sake I group under this one head certain operations
+used for the relief of distortion, in which muscles or tendons are
+divided subcutaneously. Since the discovery of the principle by Delpech,
+and the application of it by Stromeyer, Dieffenbach, Little, and
+countless successors, it has been used for very many cases for which it
+is totally inapplicable, _e.g._ for the division of the muscles of the
+back in spinal curvature. Still there remain several deformities for the
+relief of which subcutaneous tenotomy is a most important remedy; chief
+among these are Wry Neck and Club-foot.
+
+
+OPERATION FOR WRY NECK.--_Subcutaneous section of the
+sterno-mastoid._--In what cases of wry neck is this operation suitable?
+In those only in which the muscles are the starting-point of the
+mischief. These are sometimes congenital, more frequently they commence
+in childhood. In cases where the distortion depends on disease of the
+cervical vertebr�, or is secondary to curvature of the spine, division
+of the muscle is worse than useless.
+
+_Operation._--A tenotomy knife, which should be sharp-pointed, narrow in
+the blade, with a blunt back, should be introduced through the skin a
+little to one side of the sternal portion of the affected muscle, passed
+along with its flat edge between the skin and the tendon, till it has
+fairly crossed the tendon; the blade should then be turned so that by a
+gradual sawing motion the edge may be made to divide the tendon about an
+inch above the sternum. A distinct snap will then be felt or heard, and
+the position of the head will be at once much improved. Exercise, warm
+bathing, and rubbing, will generally suffice to complete the cure,
+without it being necessary to call in the aid of the instrument-maker
+with his expensive apparatus.[166]
+
+
+OPERATIONS FOR CLUB-FOOT.--The following are the tendons which _may_
+require division in the cure of club-foot, and the operations for their
+division.
+
+1. _The tendo Achillis._--There are very few cases of true club-foot
+which can be successfully treated without division of the tendo
+Achillis. While in talipes equinis it is generally the only disturbing
+agent, in talipes varus and valgus it invariably increases and maintains
+the deformity, which the tibiales or peronei seem to originate.
+
+_Operation._--The foot being held at about a right angle with the leg,
+the operator should pinch up the skin over the tendon, introduce the
+knife flatwise, a little to one side of the tendon, till its point is
+nearly projecting at the other, then turn the edge on the tendon and cut
+inwards with a sawing motion till the tendon gives way with a distinct
+snap, and the foot can be completely flexed with ease.
+
+     Dr. Little[167] recommends that the tendon should be divided from
+     before backwards. There is more risk by this method of wounding the
+     skin, and thus losing the subcutaneous character of the operation.
+
+     Professor Pancoast[168] divides the inferior portion of the soleus
+     muscle instead of the tendo Achillis.
+
+2. _Tibialis posticus._--Next in frequency and importance to that of the
+tendo Achillis, division of this tendon is much more difficult to
+perform. It may be performed either above or below the ankle.
+
+(_a._) _Above the ankle._--The blade of a tenotomy knife should be
+entered perpendicularly at the posterior margin of the tibia, half an
+inch or an inch above the internal malleolus, so as to pass between the
+bone and the tendon of the tibialis posticus, the blade directed towards
+the latter; the assistant should now evert the foot, the operator
+pressing the blade against the tendon.[169]
+
+(_b._) _Below the ankle, close to the attachment to the scaphoid._ This
+is the better position of the two when the position of the tendon can be
+made out, which is not always the case, especially in cases of old
+standing.
+
+Raising the skin just over the astragalo-scaphoid joint, the knife
+should be entered with its blade downwards, and across the tendon, and
+should be made to cut on the bone, while an assistant everts the foot
+till the tendon gives way with a distinct snap.
+
+3. _Tibialis anticus_ may in like manner be divided either just above
+the ankle, or at its insertion. When it requires division it can
+generally be made so prominent as to render its division comparatively
+easy.
+
+4. _Peronei._--These do not often require division, cases of talipes
+valgus being usually paralytic in character. If necessary they can be
+cut as they cross the fibula.
+
+5. _The plantar fascia_, may require division; when this is the case, it
+is so prominent as to render the operation very easy, if conducted on
+the principles mentioned above.
+
+
+FOOTNOTES:
+
+[166] Syme's _Pathology and Practice of Surgery_, p. 220.
+
+[167] Holmes's _Surgery_, vol. iii. p. 573.
+
+[168] Cross's _Surgery_, vol. ii. p. 273, 3d ed.
+
+[169] Miller's _System of Surgery_, p. 1339; Holmes's _Surgery_, vol.
+iii. p. 571.
+
+
+
+
+CHAPTER XIV.
+
+OPERATIONS ON NERVES.
+
+
+NERVE-STRETCHING.--Surgical literature in last ten years is full of
+cases in which nerves have been stretched for all manner of diseases
+with varying success: an example of the operative procedure may
+suffice:--
+
+1. Stretching of the great sciatic either for sciatica, sclerosis, or
+locomotor ataxia.
+
+_Operation._--A line drawn from the centre of the space between the
+tuberosity of the ischium or the great trochanter to a corresponding
+point between the condyles of the femur will give the direction. A free
+incision in this line three or four inches in length--the nerve lies
+just below the the femoral aponeurosis, beneath the edge of gluteal
+fold, requiring no muscular fibres to be divided. It must be raised from
+its bed and boldly stretched or elongated into a loop. Symington's
+experiments have shown that in the average adult 130 lb. are required to
+break the nerve.
+
+2. The facial has been stretched for spasm. The trunk is easily reached
+by an incision extending from near the external auditory meatus to the
+angle of the jaw, which enables the parotid to be pushed forward and the
+edge of the sterno-mastoid pulled backwards.
+
+
+NEUROTOMY AND NEURECTOMY.--Chiefly performed for neuralgia of the fifth
+nerve.
+
+_a._ This is a very easy operation if directed at the terminal branches
+only of the nerve, where they make their exit from the frontal,
+supraorbital, and mental foramina. The author has done it in very
+numerous cases, and with great relief, if care be taken to destroy the
+nerve in the foramen to some extent--a sharp-pointed thermo-cautery does
+this easily and safely.
+
+_b._ The more severe and radical operation of cutting out a portion of
+the trunk of the fifth nerve just after it has left the skull, and
+destroying Meckel's ganglion, has been done pretty frequently, chiefly
+by American surgeons--in various ways.
+
+1. _Carnochan's Operation._--Exposing the whole front wall of antrum,
+its cavity is opened into from the front by a large trephine. The lower
+wall of the infra-orbital canal is cut away by a chisel, the posterior
+wall of the antrum by a smaller trephine, the nerve thus isolated is
+traced up to and past Meckel's ganglion, which is removed close to the
+foramen rotundum by cutting the nerve by curved blunt-pointed scissors.
+
+2. _Pancoast's Operation._--Expose the coronoid process by a free
+incision, divide it at its root and throw it up, then expose and tie
+internal maxillary artery, after which the upper portion of the external
+pterygoid is to be detached from the sphenoid, thus exposing the nerve
+leaving foramen ovale; the second portion is deeper and not so easily
+got at.
+
+3. The spinal accessory occasionally may be divided before it enters the
+sterno-mastoid in cases of spasmodic wry neck, with great advantage.
+This operation is an easy one; the sterno-mastoid edge being once fairly
+exposed, the nerve is easily seen, and a piece should be cut out at
+least half an inch in length.
+
+
+NERVE SUTURE is occasionally practised with great advantage in cases
+where nerves have been divided either by accident or in operation.
+Catgut seems to be the best medium, and cases are on record in which,
+even after months of separation and subsequent paralysis, improvement
+has followed an operation for refreshing and joining the divided ends.
+
+
+
+
+ADDENDUM TO CHAPTER IX.
+
+
+DR. SOLIS COHEN has recently (in a paper read before the Philadelphia
+College of Physicians, April 4, 1883) collected the notes of sixty-five
+cases of excision of the entire larynx. Fifty-six of these were done for
+cancer, and the remainder for sarcomata, papillomata, etc. Of the
+fifty-six done for cancer, forty are reported as having died, either
+shortly after the operation from shock or pneumonia, or a few months
+later from recurrence of the disease. In two instances the disease had
+recurred, but death had not been reported when the paper was read.
+Fourteen remain in which neither death nor recurrence had been reported.
+Dr. Cohen's conclusion is that laryngectomy does not tend to the
+prolongation of life, and thinks that the greatest good to the greater
+number appears better secured by dependence on the palliative operation
+of tracheotomy.
+
+
+
+
+INDEX.
+
+
+Abdomen, operations on, 222.
+
+Abernethy on ligature of external iliac, 8.
+
+Adams on anatomy of common iliac, 4.
+  on hip deformity, 133.
+
+�gineta, Paulus, on excision of joints, 108.
+
+Allarton on median lithotomy, 269.
+
+Amputation and excision contrasted, 113.
+
+Amputation at ankle-joint (Syme's), 78.
+  of anterior portion of foot (Hey's), 73.
+  of arm, 62.
+  at elbow-joint, 61.
+  through femur, condyles of, 92.
+  of fingers, 51-54.
+  of fore-arm, 58.
+  at hip-joint, 102.
+  at knee-joint, 92.
+  of penis, 286.
+  at shoulder-joint, 63.
+  at tarsus (Chopart's), 75.
+  at thigh, 94.
+  double primary of thigh, 106.
+  of toes, 69.
+  at wrist-joint, 56.
+
+Amussat's operation, 252.
+
+Anchylosis of elbow, excision for, 122.
+
+Ankle-joint, excision of, 137.
+
+Annandale on staphyloraphy, 203.
+
+Anus, artificial, operation for, 252.
+  artificial, removal of, 254.
+
+Arendt, ligature of external iliac, 12.
+
+Astragalus, excision of, 145.
+
+Auchincloss on ligature of subclavian, 36.
+
+Avery, hard palate, fissures of, 203.
+
+
+Barwell on excision of ankle-joint, 139.
+  on excision of tongue, 199.
+
+Baudens on amputation at elbow-joint, 61.
+  on amputation of anterior portion of foot, 75.
+  on amputation at knee-joint, 92.
+
+Bauer on recto-vesical lithotomy, 272.
+
+Begbie, Dr. Warburton, on paracentesis thoracis, 220.
+
+Bell, Benjamin, on amputation, 49.
+  on amputation of ankle, 86.
+  on amputation of thigh, 96.
+
+Bell, Sir Charles, on ligature of femoral, 22.
+
+Bell, George, on supra-pubic lithotomy, 271.
+
+Bell, John, on ligature of gluteal, 14.
+
+Bey, Gaetani, on amputation above the shoulder-joint, 70.
+
+Bigelow, Dr., on litholapaxy, 276.
+
+Billroth, Dr., on fissure of palate, 200.
+
+Bladder, puncture of, 284.
+
+Bonnet on radical cure of hernia, 245.
+
+Botal on amputation, 47.
+
+Bowditch on paracentesis thoracis, 221.
+
+Bowman's operation, lachrymal canal, 153.
+
+Brachial, ligature of, 242.
+
+Brodie, Sir B. C., on lithotomy, 262.
+  on lithotrity, 274.
+
+Bromfield, amputation of leg, 86.
+
+Brown, Baker, ovariotomy, 231.
+
+Bryant, on excision of joints, 112.
+
+Buchanan, Dr. A., on lithotomy, 269.
+
+Buchanan, Dr. G., on excision of tongue, 198.
+
+Buchanan, Dr. M., on excision of ankle, 140.
+
+Buck's operation for anchylosis, 136.
+
+Butcher, ligature of subclavian, 35.
+  excision of joints, 110.
+  excision of wrist-joint, 128.
+  excision of knee-joint, 135.
+  excision of metacarpals. 142.
+
+
+Campbell, Professor, on ligature of gluteal, 15.
+
+Carden's amputation at condyles of femur, 50, 94.
+
+Carmichael on ligature of gluteal, 14.
+
+Carnochan on neurectomy, 300.
+
+Carotid, ligature of common, 28.
+  ligature of external, 32.
+
+Cataract operations, 160.
+
+Celsus on amputation, 48.
+  on excision of joints, 108.
+
+Chamberlaine, on ligature of axillary, 40.
+
+Chassaignac on tracheotomy, 206.
+
+Cheiloplastics, Syme on, 178.
+
+Cheselden on amputation, 49.
+  on lithotomy, 260.
+
+Chopart's amputation, 75.
+
+Civiale on lithotrity, 275.
+
+Club-foot, operations for, 297.
+
+Cock on oesophagotomy, 216.
+  paracentesis thoracis, 220.
+  on puncture of bladder, 285.
+
+Colles on ligature of brachial, 44.
+
+Cooper, Sir Astley, on ligature of aorta and iliacs, 3, 10.
+  on perineal section. 276.
+
+Cornea, puncture of, 159.
+  staphylomatous, excision of a, 168.
+
+Corelysis, 170.
+
+Crampton, Sir Philip, on excision, 119.
+
+Crichton on lithotomy, 262.
+
+Critchett's operation of iridesis, 169.
+  operation for staphyloma, 172.
+
+Croft, Mr., on hip disease, 132.
+
+Culbertson on excision of hip, 132.
+
+Cullerier on phymosis, 287.
+
+Curling on operation for artificial anus, 253.
+
+Cusack on treatment of brachial aneurism, 43.
+
+
+Davies, Redfern, on radical cure of hernia, 244.
+
+Davy's (Mr. Richard), lever, 105.
+
+Desault on ligature of axillary, 40.
+
+Dieffenbach on excision of upper jaw, 191.
+
+Dieulafoy's aspirateur, 284.
+
+Dionis' amputation of leg, 87.
+
+Dubrueil, amputation at wrist, 57.
+
+Duncan, Mr. J., on artificial anus, 254.
+
+Dupuytren on ligature of iliac, 11.
+  on ligature of subclavian, 36.
+  amputation at elbow-joint, 62.
+  removal of artificial anus, 254.
+  on bilateral lithotomy, 268.
+
+Durand, case of h�morrhage from iliac, 12.
+
+Durham on thyrotomy, 215.
+
+Dzondi on radical cure of hernia, 246.
+
+
+Elbow-Joint, amputation at, 62.
+
+Ellis on anatomy of iliac arteries, 6.
+
+Ectropium, 152.
+
+Entropium, 151.
+
+Erichsen on excision of hip, 130.
+
+Esmarch on excision of joints, 110.
+
+Excision and amputation contrasted, 112.
+
+Excision of ankle-joint, 138.
+  of astragalus, 145.
+  of elbow-joint, 118.
+  of hip-joint, 128.
+  of jaw, upper, 188.
+  of jaw, lower, 191.
+  of knee-joint, 133.
+  of mamma, 216.
+  of scapula, 139.
+  of shoulder-joint, 115.
+  of testicle, 290.
+  of tongue, 197.
+  of tonsils, 203.
+  of wrist-joint, 125.
+
+Eye, operations on, 151.
+
+Eyeball, extirpation of the, 173.
+
+Eyelid, tumours on the, 152.
+
+
+Fayrer, Sir J., on tracheotomy, 212.
+  on radical cure of hernia, 248.
+
+Femoral, ligature of, 18.
+  superficial, ligature of, in Scarpa's space, 19.
+  in Hunter's canal, 21.
+
+Femur, amputation through condyles of, 92.
+
+Fergusson, Sir W., on ligature of subclavian, 38.
+  on amputation at shoulder-joint, 70.
+  on excision of joints, 110.
+  on excision of upper jaw, 191.
+  on excision of lower jaw, 195.
+  on fissures of palate, 201.
+  on lithotomy, 262.
+
+Filkin on excision of joints, 110.
+
+Fingers, amputation of, 51.
+
+Fissures in the palate, soft, 200.
+  in the palate, hard, 202.
+  of anus, 292.
+
+Fistula, salivary, operations for, 192.
+  in ano, operation for, 291.
+
+Fore-arm, amputation through the, 58.
+  ligature of vessels in, 44.
+
+Forster, Mr. Cooper, on gastrotomy, 224.
+
+Furner, ligature of both subclavians, 38.
+
+
+Gastrectomy, 224.
+
+Gastrostomy, 223.
+
+Gastrotomy, 223.
+
+Gersdorf, Hans de, on amputation, 48.
+
+Gerdy on radical cure of hernia, 246.
+
+Gilbert, amputation above the shoulder-joint, 68.
+
+Gillespie on excision of wrist-joint, 128.
+
+Gluteal, ligature of, 12.
+
+Gosselin on colotomy, 253.
+
+Graefe on strabismus, 158.
+  on cataract operations, 166.
+  or iridectomy, 171.
+
+Green on ligature of subclavian, 38.
+
+Greenhow on excision of os calcis, 144.
+
+Greenslade on Bowman's operation, 156.
+
+Gritti's amputation, 93
+
+Gross on amputation at elbow-joint, 61.
+  on amputation, 81-87.
+  on excision of hip, 132.
+  on lithotomy, 262.
+  on rhinoplastic operation, 178.
+  on excision of lower jaw, 192.
+
+Gu�rin, Jules, on amputation of toes, 76.
+  on operation for strabismus, 158.
+
+Guersant on excision of tonsils, 205.
+
+Guillemeau on amputation at knee-joint, 91.
+
+Gurlt's statistics, 118, 124.
+
+
+H�morrhoids, operations for, 294.
+
+H�matocele, operation for, 289.
+
+Hamilton on rhinoplastic operations, 177.
+
+Hancock on excision of hip, 130.
+  on excision of ankle, 138.
+  on excision of os calcis, 144.
+
+Harelip, operations for, 183.
+
+Harrison on anatomy of iliac, 6.
+  on brachial aneurism, 44.
+
+Hart, Mr. Ernest, on flexion of limbs, 24.
+
+Heath's case of aneurism of innominate, 28.
+
+Heine on excision of hip, 130.
+
+Hernia, strangulated inguinal, 232.
+  strangulated femoral, 237.
+  strangulated umbilical, 242.
+  strangulated obturator, 243.
+  radical cure of, 244.
+
+Heurtloup on lithotrity, 274.
+
+Hey on amputation, 48, 73.
+
+Heyfelder on excisions, 110, 130.
+
+Hildanus, Fabricius, on amputation, 47, 91.
+
+Hip-joint, amputation at the, 102.
+  excision of, 128.
+
+Hippocrates on excision of joints, 108.
+
+Hodgson, statistics of aneurism, 12.
+  ligature of axillary, 40.
+
+Hodge on excisions 112, 132.
+
+Hoin on amputation at knee-joint, 92.
+
+Holmes on excision of hip, 130, 132, 144.
+
+Holt's operation for stricture, 279.
+
+Howse, Mr., on gastrotomy, 224.
+
+Hughes, Dr. on paracentesis thoracis, 220.
+
+Huguier on colotomy, 253.
+
+Hunter on ligature of femoral, 21.
+
+Hutchinson's statistics, 20.
+
+Hydrocele, operation for, 288.
+
+
+Iliac, ligature of common, 3.
+  ligature of external, 7.
+
+Iliac, ligature of internal, 6.
+
+Innominate, ligature of the, 26.
+
+Iridectomy, 171.
+
+Iridesis, 169.
+
+
+Jacobson on cataract operations, 166.
+
+J�ger on excision of hip, 130.
+
+James, Mr., on ligature of aorta, 3.
+
+Jameson on radical cure of hernia, 246.
+
+Jaw, excision of upper, 188.
+  excision of lower, 191.
+
+Johnston, Dr., on amputation at ankle-joint, 84.
+
+Joints, excision of, 108.
+
+Jones on excision of joints, 110, 134, 136.
+
+Jordan, Mr. F., on amputation, 106;
+  on excision of tongue, 199.
+
+
+Keith, Dr. Thomas, on ovariotomy, 224-227.
+
+Kirby, Mr., on ligature of iliac, 12.
+
+Knife, Beer's description of, 164.
+
+Knee, amputation below and above, 90, 91.
+  amputation at, 91.
+  joint, excision of, 132.
+
+
+Lachrymal organs, operations on the, 153.
+
+Lane, Mr., on amputation at knee-joint, 91.
+
+Langenbeck on excision of joints, 110, 140.
+  on fissure in hard palate, 203.
+  on radical cure of hernia, 245.
+
+Larrey on amputation at shoulder, 64.
+  on excision of joints, 109.
+
+Larynx, operations on the, 206.
+
+Laryngectomy, 216.
+  Dr. Solis Cohen on, 302.
+
+Laryngotomy, 214.
+
+Laryngo-tracheotomy, 215.
+
+Layraud, Dr., case of h�morrhage from iliac, 12.
+
+Lee, Mr. Henry, amputation of leg, 88.
+
+Ligature of the aorta, 2.
+  of the axillary, 38, 39, 40.
+  of the brachial, 42.
+  of the carotid, common, 29, 30.
+  of the carotid, external, 32.
+  of the femoral, 18, 21.
+  of the gluteal, 12.
+  of the iliac, 3.
+  of the iliac, external, 7.
+  of the iliac, internal, 6.
+  of the innominate, 26.
+  of the lingual, 32.
+  of the popliteal, 22.
+  of the subclavian, 33-37.
+  of the vessels in fore-arm, 45.
+
+Lips, operations on the, 180.
+
+Lisfranc on amputation, 52, 74.
+
+Lister, Professor, on Syme's amputation, 87.
+  on excision of wrist, 125.
+
+Liston, Mr., on ligature of subclavian, 36, 37.
+  on rhinoplastic operations, 177.
+  on excision of upper jaw, 186.
+  tracheotomy, 213.
+  on femoral hernia, 240.
+  on lithotomy, 262.
+
+Litholapaxy, Dr. Bigelow on, 276.
+
+Lithotomy, 255.
+
+Lithotrity, 278.
+
+Little on club-foot, 297.
+
+Lloyd on harelip, 187.
+
+Lorinzer on obturator hernia, 244.
+
+Louis on amputation, 48.
+
+Lower extremity, amputations of, 68.
+
+Lupus, operative treatment of, 179.
+
+
+Macilwain on tracheotomy, 208.
+
+Mackenzie, Dr. Morell, on thyrotomy, 215.
+
+Mackenzie, Dr. R., on modification of Syme's amputation, 83.
+  on excision of joints, 110, 134.
+
+Malgaigne on Chopart's amputation, 77.
+  on harelip, 187.
+
+Mamma, excision of, 218.
+
+Manec on ligature of axillary, 40.
+
+Maunder on excision of the elbow-joint, 122.
+
+Maclennan, Dr. G., on amputation above the shoulder-joint, 69.
+
+Metacarpals, amputation of, 54.
+  excision of, 141.
+
+Metatarsals, amputation of, 72.
+
+Miller on amputation of penis, 288.
+
+Monteiro, Dr., on ligature of aorta, 3.
+
+Mooren on cataract operations, 166.
+
+Moreaus, the, on excision of joints, 109, 114, 120, 132, 134.
+
+Morel, tourniquet invented by, 47.
+
+Morton, Dr., on radical cure of hernia, 245.
+
+Murray, Dr., on ligature of aorta, 3.
+
+Mussey, case of amputation, 70.
+
+Mynors on amputation, 48.
+
+
+Nasal polypi, removal of, 179.
+
+Needle operation for cataract, 160.
+
+Nelaton on harelip, 184.
+
+Nerve-stretching, 299.
+
+Nerve suture, 300.
+
+Neurectomy, 299.
+
+Neurotomy, 299.
+
+Norris's statistics, 12, 20, 31.
+
+Nunneley on excision of tongue, 198.
+
+
+Oesophagotomy, 216.
+
+Ollier on excision of joints, 110.
+
+Os calcis, excision of, 143.
+
+Ovariotomy, 224.
+
+
+Paget on excision of tongue, 198.
+
+Palate, fissures in soft, 200.
+  fissures in hard, 202.
+
+Pancoast, Professor, on rhinoplastic operations, 178.
+  on radical cure of hernia, 245.
+  on neurectomy, 300.
+  on club-foot, 297.
+
+Paracentesis thoracis, 219.
+  abdominis, 222.
+
+Par�, Ambrose, on amputation, 47.
+  on amputation at elbow-joint, 60.
+
+Park on excision of joints, 110.
+
+Peixotto, Dr., on ligature of innominate, 27.
+
+Penis, amputation of, 287.
+
+Perineal section, operation of, 273.
+
+Percy on excision of joints, 109.
+
+Phymosis, operation for, 285.
+
+Pirogoff's modification of Syme's amputation, 80, 84.
+
+Pollock on excision of lower jaw, 193.
+
+Polypi, nasal, removal of, 179.
+  anal, removal of, 293.
+
+Popliteal, ligature of, 22.
+
+Porta's statistics, 20.
+
+Porter, Professor, on ligature of innominate, 27.
+  on ligature of common carotid, 28.
+  statistics of amputation, 122.
+
+Post on ligature of iliac, 10.
+
+Pritchard, Mr., radical cure of hernia, 248.
+
+Prolapsus ani, 292.
+
+Pterygium, operation for, 156.
+
+Puncture of bladder, 284.
+
+Pupil, operations for artificial, 168.
+
+Purmannus on amputation, 48.
+
+
+Quain on anatomy of iliac, 4.
+  on anatomy of brachial, 43.
+
+
+Regnoli on excision of tongue, 199.
+
+Rhinoplastic operations, 175.
+
+Richter on radical cure of hernia, 245.
+
+Ricord on amputation of penis, 287.
+
+Rigaud on amputation above the shoulder-joint, 67.
+
+Ritchie, Dr. Charles, on ovariotomy, 224.
+
+Rodgers, Dr., on ligature of subclavian, 36.
+
+Rothmund on radical cure of hernia, 247.
+
+Roux on ligature of subclavian, 38.
+  on ligature of axillary, 40,
+  on Chopart's amputation, 77, 78.
+
+
+Sabatier on excision of joints, 109.
+
+Salivary fistula, operation for, 196.
+
+Sanson on recto-vesical lithotomy, 271.
+
+Scalp, tumours of the, removal of 149.
+
+Scapula, excision of (Syme), 140.
+
+Schuh on radical cure of hernia, 245.
+
+Schmucker on radical cure of hernia, 246.
+
+Scultetus on amputation, 46.
+
+Sedillot's operation for ligature of carotid, 30.
+  on excision of hip, 132.
+
+Shoulder-joint, amputation at the, 66.
+  excision of, 115.
+
+Signoroni on radical cure of hernia, 247.
+
+Sims, Dr. M., on lithotomy, 272.
+
+Smith, Dr. Nathan, on amputation at knee-joint, 91.
+
+Smith, Thomas, on staphyloraphy, 200.
+
+Smith, Dr. Tyler, on ovariotomy, 231.
+
+Smyth on subclavian aneurism, 27.
+
+Skey on ligature of subclavian, 38.
+  on amputation, 74, 91.
+  on excision of wrist, 127.
+  on rhinoplastic operation, 178.
+  on lithotomy, 262.
+
+Solis Cohen, Dr., on laryngectomy, 302.
+
+Solomon on strabismus, 158.
+
+South on ligature of aorta, 3.
+
+Spence, Professor, on amputation, 50, 66, 89, 100.
+  on excision of shoulder, elbow, and wrist joints, 118, 124, 128, 136.
+
+Sperino on puncture of cornea, 159.
+
+Stanley on excision of shoulder, 117.
+
+Steven, Professor, on ligature of internal iliac, 15.
+
+Strabismus, convergent, 156.
+  divergent, 157.
+
+Streatfeild on entropium, 151.
+  on corelysis, 170.
+
+Stricture, operation for, 276.
+
+Stokes's amputation, 94.
+
+Stromeyer on excision of joints, 110.
+
+Subclavian, ligature of right, 34.
+  ligature of left, 35.
+
+Surgeon-General, United States, statistical report by, 82.
+
+Syme, Mr., on amputation at ankle-joint, 78.
+  on amputation through condyles of femur, 92.
+  on amputation at hip-joint, 106.
+  on amputation above the shoulder-joint, 73.
+  on modified circular amputation, 101.
+  on axillary aneurism, operation for, 41.
+  on cheiloplastic operation, 181.
+  Chopart's amputation introduced by, 77.
+  on excision of lower jaw, 191.
+  on excision of joints, 111-120.
+  on excision of scapula, 140.
+  on excision of tongue, 197.
+  on ligature of femoral, 20.
+  on ligature of gluteal, 14, 15.
+  on radical cure of hernia, 247.
+  on Hey's operation, 73.
+  on oesophagotomy, 216.
+  on removal of polypi, 180.
+  on rhinoplastic operation, 175.
+  on stricture, 278-282.
+
+
+Tait on ligature of iliac, 10, 12.
+
+Taliacotian operation, 178.
+
+Tarso-metatarsal joint, amputation at, 72.
+
+Tarsus, amputation through the, 75.
+
+Teale on amputation, 50.
+  on amputation of fore-arm, 59.
+  on amputation of arm, 63.
+  on amputation of leg, 89.
+  on amputation of thigh, 98.
+  on amputation of penis, 288.
+
+Teale, T. P., on cataract, 163.
+
+Tenotomy, 296.
+
+Testicle, excision of, 290.
+
+Textor on amputation at elbow-joint, 60.
+
+Thigh, amputations of, 96.
+
+Thompson on lithotrity, 275.
+  on stricture, 277.
+
+Thorax, operations on the, 218.
+
+Thyrotomy, 215.
+
+Toes, amputations of, 68.
+
+Tongue, excision of, 197.
+
+Tonsils, excision of, 203.
+
+Tracheotomy, 206-214.
+
+Trephining and trepanning, 147.
+
+Trichiasis, 151.
+
+Tripier's amputation, 78.
+
+Trocar of Sir S. Wells described, 227.
+
+Tumours of scalp, removal of, 149.
+  of eyelids, removal of, 152.
+
+Tyrrell on treatment of brachial aneurism, 43.
+
+
+Upper extremity, amputation of, 50.
+
+Urethra, stricture of, 276.
+
+
+Velpeau on ligature of iliac, 12.
+  on ligature of subclavian, 38.
+  on amputation at elbow-joint, 60.
+  on amputation at knee-joint, 91.
+  on radical cure of hernia, 245.
+
+Vermale on amputation of thigh, 102.
+
+Verneuil on Chopart's amputation, 78.
+
+Vessels of fore-arm, ligature of, 44.
+
+
+Wakley on stricture, 279.
+
+Warren on fissure of hard palate, 203.
+
+Watson, Dr. P. H., on excision, 135.
+  on excision of elbow-joint, 123.
+  on laryngectomy, 216.
+
+Wells, Sir Spencer, on ovariotomy, 224-229.
+  trocar, 227.
+  hernia, radical cure of, 247.
+
+White on amputation of leg, 86.
+ on excision of joints, 110.
+
+Whitehead, Mr. W., on excision of tongue, 199.
+
+Willet on oesophagotomy, 216.
+
+Wood's statistics, 30.
+  on joints, 134.
+  on radical cure of hernia, 248-251.
+
+Wry neck, operation for, 296.
+
+Wrist-joint, amputation at, 55.
+  excision of, 124.
+
+W�tzer on radical cure of hernia, 247.
+
+Wyeth, Dr., statistics, 36, 38.
+
+
+Young, James, tourniquet introduced by, 47.
+
+
+Zehender's statistics, 30.
+
+
+
+***END OF THE PROJECT GUTENBERG EBOOK A MANUAL OF THE OPERATIONS OF
+SURGERY***
+
+
+******* This file should be named 24564-8.txt or 24564-8.zip *******
+
+
+This and all associated files of various formats will be found in:
+https://www.gutenberg.org/dirs/2/4/5/6/24564
+
+
+
+Updated editions will replace the previous one--the old editions
+will be renamed.
+
+Creating the works from public domain print editions means that no
+one owns a United States copyright in these works, so the Foundation
+(and you!) can copy and distribute it in the United States without
+permission and without paying copyright royalties.  Special rules,
+set forth in the General Terms of Use part of this license, apply to
+copying and distributing Project Gutenberg-tm electronic works to
+protect the PROJECT GUTENBERG-tm concept and trademark.  Project
+Gutenberg is a registered trademark, and may not be used if you
+charge for the eBooks, unless you receive specific permission.  If you
+do not charge anything for copies of this eBook, complying with the
+rules is very easy.  You may use this eBook for nearly any purpose
+such as creation of derivative works, reports, performances and
+research.  They may be modified and printed and given away--you may do
+practically ANYTHING with public domain eBooks.  Redistribution is
+subject to the trademark license, especially commercial
+redistribution.
+
+
+
+*** START: FULL LICENSE ***
+
+THE FULL PROJECT GUTENBERG LICENSE
+PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
+
+To protect the Project Gutenberg-tm mission of promoting the free
+distribution of electronic works, by using or distributing this work
+(or any other work associated in any way with the phrase "Project
+Gutenberg"), you agree to comply with all the terms of the Full Project
+Gutenberg-tm License (available with this file or online at
+https://www.gutenberg.org/license).
+
+
+Section 1.  General Terms of Use and Redistributing Project Gutenberg-tm
+electronic works
+
+1.A.  By reading or using any part of this Project Gutenberg-tm
+electronic work, you indicate that you have read, understand, agree to
+and accept all the terms of this license and intellectual property
+(trademark/copyright) agreement.  If you do not agree to abide by all
+the terms of this agreement, you must cease using and return or destroy
+all copies of Project Gutenberg-tm electronic works in your possession.
+If you paid a fee for obtaining a copy of or access to a Project
+Gutenberg-tm electronic work and you do not agree to be bound by the
+terms of this agreement, you may obtain a refund from the person or
+entity to whom you paid the fee as set forth in paragraph 1.E.8.
+
+1.B.  "Project Gutenberg" is a registered trademark.  It may only be
+used on or associated in any way with an electronic work by people who
+agree to be bound by the terms of this agreement.  There are a few
+things that you can do with most Project Gutenberg-tm electronic works
+even without complying with the full terms of this agreement.  See
+paragraph 1.C below.  There are a lot of things you can do with Project
+Gutenberg-tm electronic works if you follow the terms of this agreement
+and help preserve free future access to Project Gutenberg-tm electronic
+works.  See paragraph 1.E below.
+
+1.C.  The Project Gutenberg Literary Archive Foundation ("the Foundation"
+or PGLAF), owns a compilation copyright in the collection of Project
+Gutenberg-tm electronic works.  Nearly all the individual works in the
+collection are in the public domain in the United States.  If an
+individual work is in the public domain in the United States and you are
+located in the United States, we do not claim a right to prevent you from
+copying, distributing, performing, displaying or creating derivative
+works based on the work as long as all references to Project Gutenberg
+are removed.  Of course, we hope that you will support the Project
+Gutenberg-tm mission of promoting free access to electronic works by
+freely sharing Project Gutenberg-tm works in compliance with the terms of
+this agreement for keeping the Project Gutenberg-tm name associated with
+the work.  You can easily comply with the terms of this agreement by
+keeping this work in the same format with its attached full Project
+Gutenberg-tm License when you share it without charge with others.
+
+1.D.  The copyright laws of the place where you are located also govern
+what you can do with this work.  Copyright laws in most countries are in
+a constant state of change.  If you are outside the United States, check
+the laws of your country in addition to the terms of this agreement
+before downloading, copying, displaying, performing, distributing or
+creating derivative works based on this work or any other Project
+Gutenberg-tm work.  The Foundation makes no representations concerning
+the copyright status of any work in any country outside the United
+States.
+
+1.E.  Unless you have removed all references to Project Gutenberg:
+
+1.E.1.  The following sentence, with active links to, or other immediate
+access to, the full Project Gutenberg-tm License must appear prominently
+whenever any copy of a Project Gutenberg-tm work (any work on which the
+phrase "Project Gutenberg" appears, or with which the phrase "Project
+Gutenberg" is associated) is accessed, displayed, performed, viewed,
+copied or distributed:
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
+from the public domain (does not contain a notice indicating that it is
+posted with permission of the copyright holder), the work can be copied
+and distributed to anyone in the United States without paying any fees
+or charges.  If you are redistributing or providing access to a work
+with the phrase "Project Gutenberg" associated with or appearing on the
+work, you must comply either with the requirements of paragraphs 1.E.1
+through 1.E.7 or obtain permission for the use of the work and the
+Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
+1.E.9.
+
+1.E.3.  If an individual Project Gutenberg-tm electronic work is posted
+with the permission of the copyright holder, your use and distribution
+must comply with both paragraphs 1.E.1 through 1.E.7 and any additional
+terms imposed by the copyright holder.  Additional terms will be linked
+to the Project Gutenberg-tm License for all works posted with the
+permission of the copyright holder found at the beginning of this work.
+
+1.E.4.  Do not unlink or detach or remove the full Project Gutenberg-tm
+License terms from this work, or any files containing a part of this
+work or any other work associated with Project Gutenberg-tm.
+
+1.E.5.  Do not copy, display, perform, distribute or redistribute this
+electronic work, or any part of this electronic work, without
+prominently displaying the sentence set forth in paragraph 1.E.1 with
+active links or immediate access to the full terms of the Project
+Gutenberg-tm License.
+
+1.E.6.  You may convert to and distribute this work in any binary,
+compressed, marked up, nonproprietary or proprietary form, including any
+word processing or hypertext form.  However, if you provide access to or
+distribute copies of a Project Gutenberg-tm work in a format other than
+"Plain Vanilla ASCII" or other format used in the official version
+posted on the official Project Gutenberg-tm web site (www.gutenberg.org),
+you must, at no additional cost, fee or expense to the user, provide a
+copy, a means of exporting a copy, or a means of obtaining a copy upon
+request, of the work in its original "Plain Vanilla ASCII" or other
+form.  Any alternate format must include the full Project Gutenberg-tm
+License as specified in paragraph 1.E.1.
+
+1.E.7.  Do not charge a fee for access to, viewing, displaying,
+performing, copying or distributing any Project Gutenberg-tm works
+unless you comply with paragraph 1.E.8 or 1.E.9.
+
+1.E.8.  You may charge a reasonable fee for copies of or providing
+access to or distributing Project Gutenberg-tm electronic works provided
+that
+
+- You pay a royalty fee of 20% of the gross profits you derive from
+     the use of Project Gutenberg-tm works calculated using the method
+     you already use to calculate your applicable taxes.  The fee is
+     owed to the owner of the Project Gutenberg-tm trademark, but he
+     has agreed to donate royalties under this paragraph to the
+     Project Gutenberg Literary Archive Foundation.  Royalty payments
+     must be paid within 60 days following each date on which you
+     prepare (or are legally required to prepare) your periodic tax
+     returns.  Royalty payments should be clearly marked as such and
+     sent to the Project Gutenberg Literary Archive Foundation at the
+     address specified in Section 4, "Information about donations to
+     the Project Gutenberg Literary Archive Foundation."
+
+- You provide a full refund of any money paid by a user who notifies
+     you in writing (or by e-mail) within 30 days of receipt that s/he
+     does not agree to the terms of the full Project Gutenberg-tm
+     License.  You must require such a user to return or
+     destroy all copies of the works possessed in a physical medium
+     and discontinue all use of and all access to other copies of
+     Project Gutenberg-tm works.
+
+- You provide, in accordance with paragraph 1.F.3, a full refund of any
+     money paid for a work or a replacement copy, if a defect in the
+     electronic work is discovered and reported to you within 90 days
+     of receipt of the work.
+
+- You comply with all other terms of this agreement for free
+     distribution of Project Gutenberg-tm works.
+
+1.E.9.  If you wish to charge a fee or distribute a Project Gutenberg-tm
+electronic work or group of works on different terms than are set
+forth in this agreement, you must obtain permission in writing from
+both the Project Gutenberg Literary Archive Foundation and Michael
+Hart, the owner of the Project Gutenberg-tm trademark.  Contact the
+Foundation as set forth in Section 3 below.
+
+1.F.
+
+1.F.1.  Project Gutenberg volunteers and employees expend considerable
+effort to identify, do copyright research on, transcribe and proofread
+public domain works in creating the Project Gutenberg-tm
+collection.  Despite these efforts, Project Gutenberg-tm electronic
+works, and the medium on which they may be stored, may contain
+"Defects," such as, but not limited to, incomplete, inaccurate or
+corrupt data, transcription errors, a copyright or other intellectual
+property infringement, a defective or damaged disk or other medium, a
+computer virus, or computer codes that damage or cannot be read by
+your equipment.
+
+1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
+of Replacement or Refund" described in paragraph 1.F.3, the Project
+Gutenberg Literary Archive Foundation, the owner of the Project
+Gutenberg-tm trademark, and any other party distributing a Project
+Gutenberg-tm electronic work under this agreement, disclaim all
+liability to you for damages, costs and expenses, including legal
+fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
+LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
+PROVIDED IN PARAGRAPH F3.  YOU AGREE THAT THE FOUNDATION, THE
+TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
+LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
+INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
+DAMAGE.
+
+1.F.3.  LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
+defect in this electronic work within 90 days of receiving it, you can
+receive a refund of the money (if any) you paid for it by sending a
+written explanation to the person you received the work from.  If you
+received the work on a physical medium, you must return the medium with
+your written explanation.  The person or entity that provided you with
+the defective work may elect to provide a replacement copy in lieu of a
+refund.  If you received the work electronically, the person or entity
+providing it to you may choose to give you a second opportunity to
+receive the work electronically in lieu of a refund.  If the second copy
+is also defective, you may demand a refund in writing without further
+opportunities to fix the problem.
+
+1.F.4.  Except for the limited right of replacement or refund set forth
+in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO OTHER
+WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
+WARRANTIES OF MERCHANTIBILITY OR FITNESS FOR ANY PURPOSE.
+
+1.F.5.  Some states do not allow disclaimers of certain implied
+warranties or the exclusion or limitation of certain types of damages.
+If any disclaimer or limitation set forth in this agreement violates the
+law of the state applicable to this agreement, the agreement shall be
+interpreted to make the maximum disclaimer or limitation permitted by
+the applicable state law.  The invalidity or unenforceability of any
+provision of this agreement shall not void the remaining provisions.
+
+1.F.6.  INDEMNITY - You agree to indemnify and hold the Foundation, the
+trademark owner, any agent or employee of the Foundation, anyone
+providing copies of Project Gutenberg-tm electronic works in accordance
+with this agreement, and any volunteers associated with the production,
+promotion and distribution of Project Gutenberg-tm electronic works,
+harmless from all liability, costs and expenses, including legal fees,
+that arise directly or indirectly from any of the following which you do
+or cause to occur: (a) distribution of this or any Project Gutenberg-tm
+work, (b) alteration, modification, or additions or deletions to any
+Project Gutenberg-tm work, and (c) any Defect you cause.
+
+
+Section  2.  Information about the Mission of Project Gutenberg-tm
+
+Project Gutenberg-tm is synonymous with the free distribution of
+electronic works in formats readable by the widest variety of computers
+including obsolete, old, middle-aged and new computers.  It exists
+because of the efforts of hundreds of volunteers and donations from
+people in all walks of life.
+
+Volunteers and financial support to provide volunteers with the
+assistance they need, is critical to reaching Project Gutenberg-tm's
+goals and ensuring that the Project Gutenberg-tm collection will
+remain freely available for generations to come.  In 2001, the Project
+Gutenberg Literary Archive Foundation was created to provide a secure
+and permanent future for Project Gutenberg-tm and future generations.
+To learn more about the Project Gutenberg Literary Archive Foundation
+and how your efforts and donations can help, see Sections 3 and 4
+and the Foundation web page at https://www.gutenberg.org/fundraising/pglaf.
+
+
+Section 3.  Information about the Project Gutenberg Literary Archive
+Foundation
+
+The Project Gutenberg Literary Archive Foundation is a non profit
+501(c)(3) educational corporation organized under the laws of the
+state of Mississippi and granted tax exempt status by the Internal
+Revenue Service.  The Foundation's EIN or federal tax identification
+number is 64-6221541.  Contributions to the Project Gutenberg
+Literary Archive Foundation are tax deductible to the full extent
+permitted by U.S. federal laws and your state's laws.
+
+The Foundation's principal office is located at 4557 Melan Dr. S.
+Fairbanks, AK, 99712., but its volunteers and employees are scattered
+throughout numerous locations.  Its business office is located at
+809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887, email
+business@pglaf.org.  Email contact links and up to date contact
+information can be found at the Foundation's web site and official
+page at https://www.gutenberg.org/about/contact
+
+For additional contact information:
+     Dr. Gregory B. Newby
+     Chief Executive and Director
+     gbnewby@pglaf.org
+
+Section 4.  Information about Donations to the Project Gutenberg
+Literary Archive Foundation
+
+Project Gutenberg-tm depends upon and cannot survive without wide
+spread public support and donations to carry out its mission of
+increasing the number of public domain and licensed works that can be
+freely distributed in machine readable form accessible by the widest
+array of equipment including outdated equipment.  Many small donations
+($1 to $5,000) are particularly important to maintaining tax exempt
+status with the IRS.
+
+The Foundation is committed to complying with the laws regulating
+charities and charitable donations in all 50 states of the United
+States.  Compliance requirements are not uniform and it takes a
+considerable effort, much paperwork and many fees to meet and keep up
+with these requirements.  We do not solicit donations in locations
+where we have not received written confirmation of compliance.  To
+SEND DONATIONS or determine the status of compliance for any
+particular state visit https://www.gutenberg.org/fundraising/donate
+
+While we cannot and do not solicit contributions from states where we
+have not met the solicitation requirements, we know of no prohibition
+against accepting unsolicited donations from donors in such states who
+approach us with offers to donate.
+
+International donations are gratefully accepted, but we cannot make
+any statements concerning tax treatment of donations received from
+outside the United States.  U.S. laws alone swamp our small staff.
+
+Please check the Project Gutenberg Web pages for current donation
+methods and addresses.  Donations are accepted in a number of other
+ways including checks, online payments and credit card donations.
+To donate, please visit:
+https://www.gutenberg.org/fundraising/donate
+
+
+Section 5.  General Information About Project Gutenberg-tm electronic
+works.
+
+Professor Michael S. Hart was the originator of the Project Gutenberg-tm
+concept of a library of electronic works that could be freely shared
+with anyone.  For thirty years, he produced and distributed Project
+Gutenberg-tm eBooks with only a loose network of volunteer support.
+
+Project Gutenberg-tm eBooks are often created from several printed
+editions, all of which are confirmed as Public Domain in the U.S.
+unless a copyright notice is included.  Thus, we do not necessarily
+keep eBooks in compliance with any particular paper edition.
+
+Most people start at our Web site which has the main PG search facility:
+
+     https://www.gutenberg.org
+
+This Web site includes information about Project Gutenberg-tm,
+including how to make donations to the Project Gutenberg Literary
+Archive Foundation, how to help produce our new eBooks, and how to
+subscribe to our email newsletter to hear about new eBooks.
+
diff --git a/24564-8.zip b/24564-8.zip
new file mode 100644
index 0000000..574d9d6
--- /dev/null
+++ b/24564-8.zip
diff --git a/24564-h.zip b/24564-h.zip
new file mode 100644
index 0000000..00931b3
--- /dev/null
+++ b/24564-h.zip
diff --git a/24564-h/24564-h.htm b/24564-h/24564-h.htm
new file mode 100644
index 0000000..dd7a9bb
--- /dev/null
+++ b/24564-h/24564-h.htm
@@ -0,0 +1,12532 @@
+<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN"
+    "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">
+<html xmlns="http://www.w3.org/1999/xhtml">
+<head>
+<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1" />
+<title>The Project Gutenberg eBook of A Manual of the Operations of Surgery, by Joseph Bell</title>
+    <style type="text/css">
+/*<![CDATA[  XML blockout */
+<!--
+    p {  text-indent: 2em;
+         margin-top: .75em;
+         text-align: justify;
+         margin-bottom: .75em;}
+    .noind    {text-indent: 0em;}
+    .gap      {margin-top: 2em;}
+    .biggap   {margin-top: 4em;}
+    .sign     {text-align: right; padding-right: 3em;}
+    .bfont    {font-size: 1.1em; font-weight: bold; text-align: center; margin-top: 2em;}
+    .mfont    {font-size: 0.9em; text-align: center;}
+    .ind      {text-indent: 2em;}
+    .smlet    {font-size: 0.9em;}
+    .tog      {white-space: nowrap;}
+
+    h1,h2,h3,h4,h5 { text-align: center; clear: both;}
+
+    hr { width: 33%;
+	 margin-top: 2em;
+	 margin-bottom: 2em;
+         margin-left: auto;
+         margin-right: auto;
+         clear: both;}
+    ins.correction {text-decoration: none; border-bottom: thin dotted red;}
+    .note {
+      margin-left: 15%; margin-right: 15%;
+      font-size: .8em;
+      border-style: dashed;
+      border-width: 1px;
+      background-color: #eeeeee;
+      padding: 10px;}
+
+    body { margin-left: 10%; margin-right: 10%; }
+
+    table {margin-left: auto; margin-right: auto;}
+    .tablenum {float: right; text-align: right; padding-left: 3em;}
+    .tdl  {text-align: justify; padding-left: 2em; text-indent: -2em;}
+    .tdr  {text-align: right; vertical-align: bottom; }
+    .tdn  {text-align: right; vertical-align: top; width: 10%;}
+    .tda  {text-align: left;}
+    .tdiv {margin-left: auto; margin-right: auto; width: 80%; }
+td  .ill      {padding: 1em;}
+
+    ol   { margin-left: 5em; margin-top: 0; list-style-type: upper-roman}
+    li   { margin-top: 0.4em;}
+    ul   { list-style: none; margin-left: 0em; padding-left: 1em; text-indent: -1em; margin-top: 0; }
+
+    .blockquot{margin-left: 10%; margin-right: 10%;}
+    .blockind {margin-left: 20%; margin-right: 20%;}
+    .pagenum  {text-indent: 0em; position: absolute; left: 92%; font-size: 0.7em; text-align: right; color: gray;}
+    .center   {text-align: center;}
+    .smcap    {font-variant: small-caps;}
+    .figcenter {margin: auto; text-align: center;}
+    a img     { border: 0; }
+    .caption  {font-weight: bold;}
+    .figleft     {float: left; clear: left; margin-left: 0; margin-bottom: 1em; margin-top:
+                 1em; margin-right: 1em; padding: 0; text-align: center;}
+    .figright    {float: right; clear: right; margin-left: 1em; margin-bottom: 1em;
+                 margin-top: 1em; margin-right: 0; padding: 0; text-align: center;}
+
+    .footnotes    {border-top: solid 1px; border-bottom: solid 1px;}
+    .footnote         {margin-left: 10%; margin-right: 10%; font-size: 0.9em;}
+    .footnote .label  {position: absolute; right: 84%; text-align: right;}
+    .fnanchor         {vertical-align: 2px; font-size: .8em; text-decoration: none;}
+
+    hr.full { width: 100%;
+              margin-top: 3em;
+              margin-bottom: 0em;
+              margin-left: auto;
+              margin-right: auto;
+              height: 4px;
+              border-width: 4px 0 0 0; /* remove all borders except the top one */
+              border-style: solid;
+              border-color: #000000;
+              clear: both; }
+    pre      {font-size: 85%;}
+    // -->
+    /* XML end  ]]>*/
+    </style>
+</head>
+<body>
+<h1>The Project Gutenberg eBook, A Manual of the Operations of Surgery, by
+Joseph Bell</h1>
+<pre>
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at <a href = "http://www.gutenberg.org">www.gutenberg.org</a></pre>
+<p>Title: A Manual of the Operations of Surgery</p>
+<p>       For the Use of Senior Students, House Surgeons, and Junior Practitioners</p>
+<p>Author: Joseph Bell</p>
+<p>Release Date: February 11, 2008  [eBook #24564]</p>
+<p>Language: English</p>
+<p>Character set encoding: ISO-8859-1</p>
+<p>***START OF THE PROJECT GUTENBERG EBOOK A MANUAL OF THE OPERATIONS OF SURGERY***</p>
+<p>&nbsp;</p>
+<h3>E-text prepared by Michael Ciesielski, Pilar Somoza Fern�ndez,<br />
+    and the Project Gutenberg Online Distributed Proofreading Team<br />
+    (http://www.pgdp.net)</h3>
+<p>&nbsp;</p>
+<div class="note">
+<p class="noind">Transcriber's note:<br />
+<br />
+Spelling mistakes have been left in the text to
+match the original, except for obvious typographical errors,
+marked <ins class="correction" title="text reads 'llike this'">like this</ins>.</p>
+</div>
+<p>&nbsp;</p>
+<hr class="full" />
+<p>&nbsp;</p>
+<p>&nbsp;</p>
+<p>&nbsp;</p>
+
+<h1>A MANUAL</h1>
+<h5 class="gap">OF THE</h5>
+<h1 class="gap">OPERATIONS OF SURGERY</h1>
+<h5 class="gap">FOR THE USE OF</h5>
+<h3 class="gap">SENIOR STUDENTS, HOUSE SURGEONS, AND<br/>
+JUNIOR PRACTITIONERS.</h3>
+
+
+<h4 class="gap">ILLUSTRATED.</h4>
+
+
+<h2 class="biggap">BY JOSEPH BELL, F.R.C.S. <span class="smcap">Edin.</span></h2>
+
+<h5>LECTURER ON CLINICAL SURGERY, SURGEON TO THE ROYAL INFIRMARY AND TO<br/>
+THE EYE INFIRMARY, AND LATE DEMONSTRATOR OF ANATOMY<br/>
+IN THE UNIVERSITY OF EDINBURGH.</h5>
+
+<h4 class="biggap"><i>FIFTH EDITION, REVISED AND ENLARGED.</i></h4>
+
+
+<h3 class="biggap">EDINBURGH: MACLACHLAN &amp; STEWART,</h3>
+<h5>BOOKSELLERS TO THE UNIVERSITY.</h5>
+<h3>LONDON: SIMPKIN, MARSHALL, &amp; CO.</h3>
+
+<h3 class="gap">1883.</h3>
+
+
+
+
+
+<hr style="width: 30%;" />
+
+<p class="center noind">TO THE MEMORY OF</p>
+<h3>JAMES SYME, ESQ., F.R.C.S. AND F.R.S.E.</h3>
+<p class="center noind">SURGEON TO THE QUEEN IN SCOTLAND</p>
+
+<p class="center noind">PROFESSOR OF CLINICAL SURGERY<br/>
+IN THE UNIVERSITY OF EDINBURGH<br/>
+ETC. ETC.</p>
+
+<p class="center noind">THIS BOOK IS DEDICATED<br/>
+BY HIS OLD HOUSE-SURGEON AND ASSISTANT</p>
+
+<p class="sign">THE AUTHOR.</p>
+
+
+
+
+<hr style="width: 30%;" />
+
+<h2>PREFACE TO FIFTH EDITION.</h2>
+
+
+<p class="blockind">To retain the small size of the work and to keep it up to date have been
+the Author's aim in the Fifth Edition.</p>
+
+
+<div class="blockind">20 <span class="smcap">Melville Street, Edinburgh</span>,
+<p><i>August 1883.</i></p></div>
+
+
+
+
+<hr style="width: 30%;" />
+
+<h2>PREFACE TO THE FIRST EDITION.</h2>
+
+
+<p>Having been asked, year after year, by the members of my Class for
+Operative Surgery, to recommend to them some Manual of Surgical
+Operations which might at once guide them in their choice of operations,
+and give minute details as to the mode of performance, I have been
+gradually led to undertake the production of this little work.</p>
+
+<p>My aim has been to describe as simply as possible those operations which
+are most likely to prove useful, and especially those which, from their
+nature, admit of being practised on the dead body.</p>
+
+<p>In accordance with this plan, neither historical completeness of detail,
+nor much variety in the methods of performing any given operation, is to
+be expected. Hence, also, many omissions which would be unpardonable in
+the briefest system of Surgery are unavoidable. For example, excision of
+tumours and operations for necrosis are hardly mentioned, because for
+these no special instructions can well be given; for, while general
+principles may guide us to <i>what</i> should be done, the special
+circumstances of each case must dictate <i>how</i> it is to be done.</p>
+
+<p>In such a work as this, to attempt originality would be undesirable and
+intrusive; a judicious selection, a faithful compilation, are all that
+can be expected.</p>
+
+<p>That the selection of operations may sometimes show "Northern
+Proclivities" is possible; and this is perhaps not unnatural to a
+scholar and teacher in the Edinburgh School.</p>
+
+<p>An earnest endeavour has been used to make the references correct and
+copious: for any mistakes or omissions the author would crave
+indulgence.</p>
+
+<p>The four plates which precede the letterpress were drawn on wood (from
+original photographs) by Mr. D.W. Williamson, Melbourne Place, and the
+lines of incision for the various operations were added by the author.</p>
+
+<p>The rough woodcuts scattered through the work were drawn on wood by the
+author, and for their roughness he, not his engraver, is responsible. He
+also hopes that the references in the letterpress will be accepted as
+sufficient acknowledgment of the true ownership, in those few instances
+in which the idea of the diagram has been borrowed.</p>
+
+<p>It has been thought unnecessary to introduce woodcuts of surgical
+instruments, as the illustrated catalogues lately published by Weiss,
+Maw, and others, are sufficiently accurate.</p>
+
+<p>In excuse of the frequent baldness and brevity of the style, the author
+must point to the size and price of the work. Its composition would have
+been easier had its dimensions been greater.</p>
+
+<p>Though intended chiefly to guide the studies, on the dead subject, of
+students and junior practitioners, the author ventures to hope that the
+Manual may be useful to those who, in the public services, in the
+colonies, or in lonely country districts, find themselves constrained to
+attempt the performance of operations which, in the towns, usually fall
+to the lot of a few Hospital Surgeons.</p>
+
+
+<p class="sign">JOSEPH BELL.</p>
+
+<div class="blockquot">5 <span class="smcap">Castle Terrace, Edinburgh</span>,
+<p><i>July 1866.</i></p></div>
+
+
+
+
+<hr style="width: 30%" />
+
+<h2>CONTENTS.</h2>
+
+
+<table cellspacing="2" cellpadding="2" width="80%" summary="chapters">
+<tr><td colspan="2"><div class="bfont">CHAPTER I.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">LIGATURE OF ARTERIES.</div></td></tr>
+
+
+<tr>
+<td>&nbsp;</td>
+<td class="tdr mfont">PAGE</td>
+</tr>
+<tr>
+<td class="tdl">Ligature of Arteries&mdash;General Maxims&mdash;Ligature of
+Aorta&mdash;Iliacs&mdash;Gluteal&mdash;Femoral&mdash;Popliteal&mdash;Innominate&mdash;Carotids&mdash;
+Lingual&mdash;Subclavian&mdash;Brachial, etc.,</td><td class="tdr"><a href="#Page_1">1</a>-<a href="#Page_45">45</a></td>
+</tr>
+
+
+<tr><td colspan="2"><div class="bfont">CHAPTER II.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">AMPUTATIONS.</div></td></tr>
+
+<tr>
+<td class="tdl">
+Eras of Amputation&mdash;Flap and Circular compared&mdash;Special Amputation of
+Arm and Leg,</td><td class="tdr"><a href="#Page_46">46</a>-<a href="#Page_107">107</a></td>
+</tr>
+
+<tr><td colspan="2"><div class="bfont">CHAPTER III.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">EXCISION OF JOINTS.</div></td></tr>
+
+<tr>
+<td class="tdl">
+Brief Historical Sketch&mdash;Comparison of Excisions with
+Amputations&mdash;Special Excisions of the six larger Joints&mdash;Excisions of
+smaller Joints and Bones,</td><td class="tdr"><a href="#Page_108">108</a>-<a href="#Page_146">146</a></td>
+</tr>
+
+<tr><td colspan="2"><div class="bfont">CHAPTER IV.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">OPERATIONS ON CRANIUM AND SCALP.</div></td></tr>
+
+<tr><td class="tdl">
+Trephining&mdash;Excision of Wens,</td><td class="tdr"><a href="#Page_147">147</a>-<a href="#Page_150">150</a></td></tr>
+
+<tr><td colspan="2"><div class="bfont">CHAPTER V.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">OPERATIONS ON THE EYE AND ITS APPENDAGES.</div></td></tr>
+
+<tr><td class="tdl">Entropium and Ectropium&mdash;Trichiasis&mdash;Tarsal Tumours&mdash;On Lachrymal
+Organs&mdash;Mr. Bowman's Operation&mdash;Pterygium&mdash;Strabismus, convergent and
+divergent&mdash;Paracentesis of the Anterior Chamber&mdash;Operations for Cataract
+by Displacement, Solution, and Extraction&mdash;Various methods of
+Extraction&mdash;Operations for Artificial
+Pupil&mdash;Iridesis&mdash;Corelysis&mdash;Iridectomy&mdash;Excision of Staphyloma&mdash;Excision
+of Eyeball,</td><td class="tdr"><a href="#Page_151">151</a>-<a href="#Page_174">174</a></td></tr>
+
+
+<tr><td colspan="2"><div class="bfont">CHAPTER VI.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">OPERATIONS ON THE NOSE AND LIPS.</div></td></tr>
+
+<tr><td class="tdl">Rhinoplastic Operations from Cheek, Forehead, and elsewhere&mdash;Removal of
+Nasal Polypi&mdash;Excision of Cancers of Lips&mdash;Cheiloplastic
+Operations&mdash;Operations for Harelip,</td><td class="tdr"><a href="#Page_175">175</a>-<a href="#Page_187">187</a></td></tr>
+
+
+<tr><td colspan="2"><div class="bfont">CHAPTER VII.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">OPERATIONS ON THE JAWS.</div></td></tr>
+
+<tr><td class="tdl">Excision of Upper Jaw&mdash;Of Lower Jaw,</td><td class="tdr"><a href="#Page_188">188</a>-<a href="#Page_195">195</a></td></tr>
+
+
+<tr><td colspan="2"><div class="bfont">CHAPTER VIII.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">OPERATIONS ON MOUTH AND THROAT.</div></td></tr>
+
+<tr><td class="tdl">For Salivary Fistula&mdash;Excision of Tongue, complete and partial&mdash;Fissures
+of the Palate, soft and hard&mdash;Excision of Tonsils,</td><td class="tdr"><a href="#Page_196">196</a>-<a href="#Page_205">205</a></td></tr>
+
+
+<tr><td colspan="2"><div class="bfont">CHAPTER IX.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">OPERATIONS ON AIR PASSAGES.</div></td></tr>
+
+<tr><td class="tdl">Larynx and
+Trachea&mdash;Tracheotomy&mdash;Tubes&mdash;Laryngotomy&mdash;&#338;sophagotomy&mdash;[see
+Addendum, p. <a href="#Page_302">302</a>],</td><td class="tdr"><a href="#Page_206">206</a>-<a href="#Page_217">217</a></td></tr>
+
+
+<tr><td colspan="2"><div class="bfont">CHAPTER X.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">OPERATIONS ON THORAX.</div></td></tr>
+
+<tr><td class="tdl">Excision of Mamma&mdash;Paracentesis Thoracis,</td><td class="tdr"><a href="#Page_218">218</a>-<a href="#Page_221">221</a></td></tr>
+
+
+<tr><td colspan="2"><div class="bfont">CHAPTER XI.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">OPERATIONS ON ABDOMEN.</div></td></tr>
+
+<tr><td class="tdl">Paracentesis Abdominis&mdash;Gastrotomy&mdash;Ovariotomy&mdash;Operation for
+Strangulated Hernia&mdash;Inguinal&mdash;Femoral&mdash;Umbilical&mdash;Operations for the
+Radical Cure of Hernia,</td><td class="tdr"><a href="#Page_222">222</a>-<a href="#Page_255">255</a></td></tr>
+
+
+<tr><td colspan="2"><div class="bfont">CHAPTER XII.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">OPERATIONS ON PELVIS.</div></td></tr>
+
+<tr><td class="tdl">Lithotomy&mdash;Varieties&mdash;Lithotrity&mdash;Operations for Stricture&mdash;Puncture of
+the Bladder&mdash;Phymosis&mdash;Amputation of
+Penis&mdash;Hydrocele&mdash;H&aelig;matocele&mdash;Castration&mdash;Operation for
+Fistula&mdash;Fissure&mdash;Polypi of Rectum&mdash;Piles,</td><td class="tdr"><a href="#Page_256">256</a>-<a href="#Page_295">295</a></td></tr>
+
+
+<tr><td colspan="2"><div class="bfont">CHAPTER XIII.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">TENOTOMY.</div></td></tr>
+
+<tr><td class="tdl">On Tenotomy for Wry Neck and Club Foot,</td><td class="tdr"><a href="#Page_296">296</a>-<a href="#Page_298">298</a></td></tr>
+
+
+<tr><td colspan="2"><div class="bfont">CHAPTER XIV.</div></td></tr>
+
+<tr><td colspan="2"><div class="mfont">OPERATIONS ON NERVES.</div></td></tr>
+
+<tr><td class="tdl">Nerve-stretching&mdash;Nerve-cutting&mdash;Nerve suture,</td><td class="tdr"><span class="tog"><a href="#Page_299">299</a>-<a href="#Page_301">301</a></span></td></tr>
+
+
+<tr><td class="tdl"><div class="gap"><span class="smcap">Addendum</span> to Chapter IX.,</div></td><td class="tdr"><a href="#Page_302">302</a></td></tr>
+
+<tr><td class="tdl"><span class="smcap">Index</span>,</td><td class="tdr"><a href="#Page_305">303</a>-<a href="#Page_311">311</a></td></tr>
+</table>
+
+
+
+<hr style="width: 30%;" />
+
+<h2>LIST OF ILLUSTRATIONS.</h2>
+
+<div class="tdiv">
+<p><span class="tablenum smcap">page</span><span class="smcap">&nbsp;</span></p>
+
+<ol>
+<li><span class="tablenum"><a href="#Page_50">50</a></span>Amputations of Fingers,</li>
+
+<li><span class="tablenum"><a href="#Page_50">50</a></span>Diagram of Finger showing Articulations,</li>
+
+<li><span class="tablenum"><a href="#Page_57">57</a></span>Dubrueil's Amputation at Wrist (front view),</li>
+
+<li><span class="tablenum"><a href="#Page_57">57</a></span>&nbsp;&nbsp;&nbsp;&nbsp;"&nbsp;&nbsp;&nbsp;&nbsp;"&nbsp;&nbsp;&nbsp;&nbsp;(dorsal view),</li>
+
+<li><span class="tablenum"><a href="#Page_69">69</a></span>Amputations of Toes,</li>
+
+<li><span class="tablenum"><a href="#Page_126">126</a></span>Excision of Wrist-joint&mdash;Lister's,</li>
+
+<li><span class="tablenum"><a href="#Page_151">151</a></span>Operations for Ectropium and Entropium,</li>
+
+<li><span class="tablenum"><a href="#Page_151">151</a></span>Operation for Trichiasis&mdash;Streatfeild's,</li>
+
+<li><span class="tablenum"><a href="#Page_155">155</a></span>Operation for Epiphora&mdash;Bowman's,</li>
+
+<li><span class="tablenum"><a href="#Page_156">156</a></span>Greenslade's Instrument for above,</li>
+
+<li><span class="tablenum"><a href="#Page_157">157</a></span>Operations for Squint,</li>
+
+<li><span class="tablenum"><a href="#Page_162">162</a></span>Linear Extraction of Cataract,</li>
+
+<li><span class="tablenum"><a href="#Page_162">162</a></span>Flap Extraction of Cataract,</li>
+
+<li><span class="tablenum"><a href="#Page_171">171</a></span>Operation of Corelysis&mdash;Streatfeild's,</li>
+
+<li><span class="tablenum"><a href="#Page_172">172</a></span>Operation for Staphyloma&mdash;Critchett's,</li>
+
+<li><span class="tablenum"><a href="#Page_172">172</a></span>Result of above,</li>
+
+<li><span class="tablenum"><a href="#Page_176">176</a></span>Rhinoplastic Operation from Cheek,</li>
+
+<li><span class="tablenum"><a href="#Page_177">177</a></span>&nbsp;&nbsp;&nbsp;&nbsp;"&nbsp;&nbsp;&nbsp;&nbsp;"&nbsp;&nbsp;&nbsp;&nbsp;Forehead,</li>
+
+<li><span class="tablenum"><a href="#Page_181">181</a></span>Operation on Lip, V-shaped incision,</li>
+
+<li><span class="tablenum"><a href="#Page_181">181</a></span>Operation on Lip, by scissors,</li>
+
+<li><span class="tablenum"><a href="#Page_182">182</a></span>Operation for a new Lip, incisions,</li>
+
+<li><span class="tablenum"><a href="#Page_182">182</a></span>Operation for New Lip sewed up,</li>
+
+<li><span class="tablenum"><a href="#Page_184">184</a></span>Diagram of Partial Fissure (Harelip),</li>
+
+<li><span class="tablenum"><a href="#Page_184">184</a></span>Nelaton's Operation for ditto,</li>
+
+<li><span class="tablenum"><a href="#Page_185">185</a></span>Operation for Double Harelip,</li>
+
+<li><span class="tablenum"><a href="#Page_186">186</a></span>Diagram of Double Harelip,</li>
+
+<li><span class="tablenum"><a href="#Page_189">189</a></span>Excision of Upper and Lower Jaws,</li>
+
+<li><span class="tablenum"><a href="#Page_196">196</a></span>Operation for Salivary Fistula,</li>
+
+<li><span class="tablenum"><a href="#Page_201">201</a></span>Operation for Fissure in Soft Palate,</li>
+
+<li><span class="tablenum"><a href="#Page_203">203</a></span>Operation for Fissure in Hard Palate,</li>
+
+<li><span class="tablenum"><a href="#Page_207">207</a></span>Diagram illustrating Operations on Air Passages,</li>
+
+<li><span class="tablenum"><a href="#Page_241">241</a></span>Diagram illustrating Operations for Hernia,</li>
+
+<li><span class="tablenum"><a href="#Page_253">253</a></span>Diagram of an Artificial Anus,</li>
+
+<li><span class="tablenum"><a href="#Page_257">257</a></span>Diagram of Section of Prostate,</li>
+
+<li><span class="tablenum"><a href="#Page_259">259</a></span>Diagram of Membranous portion of Urethra,</li>
+
+<li><span class="tablenum"><a href="#Page_284">284</a></span>Diagram illustrating Puncture of Bladder,</li>
+
+<li><span class="tablenum"><a href="#Page_286">286</a></span>Diagram of Operation for Phymosis,</li>
+
+<li><span class="tablenum"><a href="#Page_287">287</a></span>Diagram of Amputation of Penis,</li>
+</ol>
+</div>
+
+<hr style="width: 30%;" />
+
+<div class="figcenter" style="width: 436px;">
+<a name="plate_i"><img src="images/f003.jpg" width="436" height="600" alt="Plate I" title="Plate I" /></a>
+</div>
+
+
+<h3>PLATE I.</h3>
+
+<table class="tdiv" summary="plate1">
+<tr><td class="tdn">1.</td>
+<td class="tdl">Ligature of Aorta&mdash;Sir A. Cooper's incision.</td></tr>
+
+<tr><td class="tdn">2.</td>
+<td class="tdl">Ligature of Aorta&mdash;South and Murray's incision.</td></tr>
+
+<tr><td class="tdn">3.</td>
+<td class="tdl">Ligature of Common Iliac.</td></tr>
+
+<tr><td class="tdn">4.</td>
+<td class="tdl">Ligature of External Iliac&mdash;Sir A. Cooper's.</td></tr>
+
+<tr><td class="tdn">5.</td>
+<td class="tdl">Ligature of Femoral in Scarpa's triangle.</td></tr>
+
+<tr><td class="tdn">6.</td>
+<td class="tdl">Ligature of Femoral below Sartorius.<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a></td></tr>
+
+<tr><td class="tdn">7.</td>
+<td class="tdl">Ligature of Innominate.</td></tr>
+
+<tr><td class="tdn">8.</td>
+<td class="tdl">Ligature of third part of Left Subclavian.</td></tr>
+
+<tr><td class="tdn">9.</td>
+<td class="tdl">Ligature of Axillary in its first part.</td></tr>
+
+<tr><td class="tdn">10.</td>
+<td class="tdl">Ligature of Axillary in its third part.</td></tr>
+
+<tr><td class="tdn">11.</td>
+<td class="tdl">Ligature of Brachial.</td></tr>
+
+<tr><td class="tdn">12.</td>
+<td class="tdl">Amputation of Arm by double flaps.</td></tr>
+
+<tr><td class="tdn">13.</td>
+<td class="tdl">Amputation at Shoulder-joint (1st method), showing portion of skin
+left uncut till the conclusion of the disarticulation.</td></tr>
+
+<tr><td class="tdn">14.</td>
+<td class="tdl">Amputation at Ankle-joint by internal flap&mdash;Mackenzie's.</td></tr>
+
+<tr><td class="tdn"><span class="tog">15-16.</span></td>
+<td class="tdl">Amputation of Leg just above the Ankle-joint.</td></tr>
+
+<tr><td class="tdn">17-18.</td>
+<td class="tdl">Amputation below Knee&mdash;modified circular.</td></tr>
+
+<tr><td class="tdn">19.</td>
+<td class="tdl">Amputation through Condyles of Femur&mdash;Syme, and Pl. III. 5.</td></tr>
+
+<tr><td class="tdn">20.</td>
+<td class="tdl">Amputation at lower third of Thigh&mdash;Syme, and Pl. III. 6.</td></tr>
+</table>
+
+<div><br/></div>
+
+<table class="tdiv" summary="plate">
+<tr><td class="tdn">A.</td>
+<td class="tdl">Excision of Head of Humerus.</td></tr>
+
+<tr><td class="tdn">B.</td>
+<td class="tdl">Excision of Knee-joint; semilunar incision.</td></tr>
+</table>
+
+<hr style="width: 30%;" />
+
+<div class="figcenter" style="width: 300px;">
+<a name="plate_ii"><img src="images/f002.jpg" width="300" height="600" alt="Plate II" title="Plate II" /></a>
+</div>
+
+
+<h3>PLATE II.</h3>
+
+<table class="tdiv" summary="Plate II">
+<tr><td class="tdn">1.</td>
+<td class="tdl">Amputation at lower third of Fore-arm&mdash;Teale's.</td></tr>
+
+<tr><td class="tdn">2-2.</td>
+<td class="tdl">Amputation at Shoulder-joint by large postero-external flap&mdash;2d
+method.</td></tr>
+
+<tr><td class="tdn">3-3.</td>
+<td class="tdl">Amputation at Shoulder-joint by triangular flap from deltoid&mdash;3d
+method.</td></tr>
+
+<tr><td class="tdn">4-5.</td>
+<td class="tdl">Amputation through Tarsus&mdash;Chopart's.</td></tr>
+
+<tr><td class="tdn">6-7.</td>
+<td class="tdl">Amputation at Knee-joint.</td></tr>
+
+<tr><td class="tdn">8.</td>
+<td class="tdl">Amputation by Single Flap&mdash;Carden's, and Pl. IV. 16.</td></tr>
+
+<tr><td class="tdn">9-10.</td>
+<td class="tdl">Amputation of Thigh&mdash;Teale's.</td></tr>
+</table>
+
+<div><br/></div>
+
+<table class="tdiv" summary="Plate II-B">
+<tr><td class="tdn">A.</td>
+<td class="tdl">Excision of Hip-joint.</td></tr>
+
+<tr><td class="tdn">B-B.</td>
+<td class="tdl">Excision of Ankle-joint&mdash;Hancock's incisions.</td></tr>
+</table>
+
+<hr style="width: 30%;" />
+
+<div class="figcenter" style="width: 271px;">
+<a name="plate_iii"><img src="images/f001.jpg" width="271" height="600" alt="Plate III" title="Plate III" /></a>
+</div>
+
+
+<h3>PLATE III.</h3>
+
+<table class="tdiv" summary="Plate III">
+<tr><td class="tdn">1.</td>
+<td class="tdl">Ligature of Popliteal.</td></tr>
+
+<tr><td class="tdn">2.</td>
+<td class="tdl">Amputation at Elbow-joint&mdash;posterior flap.</td></tr>
+
+<tr><td class="tdn">3.</td>
+<td class="tdl">Amputation at Shoulder-joint&mdash;posterior incision of first method, and
+Pl. I. 13.</td></tr>
+
+<tr><td class="tdn">4.</td>
+<td class="tdl">Amputation at Ankle-joint&mdash;Mackenzie's, and Pl. I. 14.</td></tr>
+
+<tr><td class="tdn">5.</td>
+<td class="tdl">Amputation through Condyles of Femur&mdash;Syme, and Pl. I. 19.</td></tr>
+
+<tr><td class="tdn">6.</td>
+<td class="tdl">Amputation at lower third of Thigh&mdash;Syme, and Pl. I. 20.</td></tr>
+
+<tr><td class="tdn">7.</td>
+<td class="tdl">Amputation at Knee&mdash;posterior incision.</td></tr>
+
+<tr><td class="tdn">8.</td>
+<td class="tdl">Amputation of Thigh&mdash;Spence's, and at Pl. IV. 18.</td></tr>
+
+<tr><td class="tdn">9.</td>
+<td class="tdl">Amputation at Hip-joint, and Pl. IV. 20.</td></tr>
+</table>
+
+<div><br/></div>
+
+<table class="tdiv" summary="Plate III-B">
+<tr><td class="tdn">A.</td>
+<td class="tdl">Excision of Shoulder-joint&mdash;deltoid flap.</td></tr>
+
+<tr><td class="tdn">B.</td>
+<td class="tdl">Excision of Shoulder-joint by posterior incision.</td></tr>
+
+<tr><td class="tdn">C.</td>
+<td class="tdl">Excision of Elbow-joint&mdash;H-shaped incision.</td></tr>
+
+<tr><td class="tdn">D.</td>
+<td class="tdl">Excision of Elbow-joint&mdash;linear incision.</td></tr>
+
+<tr><td class="tdn">E.</td>
+<td class="tdl">Excision of Hip-joint&mdash;Gross's.</td></tr>
+
+<tr><td class="tdn">F.</td>
+<td class="tdl">Excision of Os Calcis.</td></tr>
+
+<tr><td class="tdn">G.</td>
+<td class="tdl">Excision of Scapula.</td></tr>
+</table>
+
+<hr style="width: 30%;" />
+
+<div class="figcenter" style="width: 441px;">
+<a name="plate_iv"><img src="images/f000.jpg" width="441" height="550" alt="Plate IV" title="Plate IV" /></a>
+</div>
+
+
+<h3>PLATE IV.</h3>
+
+<table class="tdiv" summary="Plate IV">
+<tr><td class="tdn">1.</td>
+<td class="tdl">Ligature of Carotid.</td></tr>
+
+<tr><td class="tdn">2.</td>
+<td class="tdl">Ligature of Subclavian (3d stage)&mdash;Skey's incision.</td></tr>
+
+<tr><td class="tdn">3.</td>
+<td class="tdl">Amputation at Wrist-joint&mdash;dorsal incision.</td></tr>
+
+<tr><td class="tdn">4.</td>
+<td class="tdl">Amputation at Wrist-joint&mdash;palmar incision.</td></tr>
+
+<tr><td class="tdn">5.</td>
+<td class="tdl">Amputation at Fore-arm&mdash;dorsal incision.</td></tr>
+
+<tr><td class="tdn">6.</td>
+<td class="tdl">Amputation at Fore-arm&mdash;palmar incision.</td></tr>
+
+<tr><td class="tdn">7.</td>
+<td class="tdl">Amputation at Elbow-joint&mdash;Anterior flap, and Pl. III. 3.</td></tr>
+
+<tr><td class="tdn">8.</td>
+<td class="tdl">Amputation at Arm&mdash;Teale's method.</td></tr>
+
+<tr><td class="tdn">9.</td>
+<td class="tdl">Amputation at Shoulder-joint&mdash;1st method, and Pl. III. 3.</td></tr>
+
+<tr><td class="tdn">10-11.</td>
+<td class="tdl">Amputation of Metatarsus&mdash;Hey's.</td></tr>
+
+<tr><td class="tdn">12-13.</td>
+<td class="tdl">Amputation at Ankle&mdash;Syme's.</td></tr>
+
+<tr><td class="tdn">14-15.</td>
+<td class="tdl">Amputation of Leg&mdash;posterior flap&mdash;Lee's.</td></tr>
+
+<tr><td class="tdn">16.</td>
+<td class="tdl">Amputation at Knee-joint&mdash;Carden's, and Pl. II. 8.</td></tr>
+
+<tr><td class="tdn">17.</td>
+<td class="tdl">Amputation of Thigh&mdash;B. Bell's.</td></tr>
+
+<tr><td class="tdn">18.</td>
+<td class="tdl">Amputation of Thigh&mdash;Spence's, and Pl. III. 8.</td></tr>
+
+<tr><td class="tdn">19.</td>
+<td class="tdl">Amputation of Thigh in middle third.</td></tr>
+
+<tr><td class="tdn">20-20.</td>
+<td class="tdl">Amputation at Hip-joint, and Pl. III. 9.</td></tr>
+</table>
+
+<div><br/></div>
+
+<table class="tdiv" summary="Plate IV-B">
+<tr><td class="tdn">A.</td>
+<td class="tdl">Excision of Wrist&mdash;radial incision.</td></tr>
+
+<tr><td class="tdn">B.</td>
+<td class="tdl">Excision of Wrist&mdash;ulnar incision.</td></tr>
+</table>
+
+<p class="noind"><span class='pagenum'><a name="Page_1" id="Page_1">{1}</a></span></p>
+
+
+
+<hr style="width: 30%;" />
+
+<h2><a name="CHAPTER_I" id="CHAPTER_I"></a>CHAPTER I.</h2>
+
+<h3>LIGATURE OF ARTERIES.</h3>
+
+
+<p><span class="smcap">Ligature of Arteries.</span>&mdash;In a work of this nature there is no room for any
+discussion of the principles which should guide us in the selection of
+cases, or of the pathology of aneurism, or the local effects of the
+ligature on the vessels. One or two fundamental axioms may be given in a
+few words:&mdash;</p>
+
+<p>1. In selecting the spot for the application of the ligature, avoid as
+far as possible bifurcations, or the neighbourhood of large collateral
+branches.</p>
+
+<p>2. A free incision should be made through the skin and subjacent
+textures, till the sheath of the artery is reached and fairly exposed.</p>
+
+<p>3. The sheath must be opened and the artery cleaned with a sharp knife
+till the white external coat is clearly seen. The portion cleaned
+should, however, be as small as possible, consistent with thorough
+exposure, so that the ligature may be passed round the vessel without
+force.</p>
+
+<p>4. As the artery should never be raised from its bed, it is generally
+advisable to pass the needle only so far as just to permit the eye to be
+seen past the vessel. The ligature should then be seized by a pair of
+forceps and gently pulled through, the needle being cautiously
+withdrawn. When catgut is used, it is better to pass the unarmed needle
+till the eye is visible, then thread and withdraw it, thus pulling the
+catgut through.<span class='pagenum'><a name="Page_2" id="Page_2">{2}</a></span></p>
+
+<p>5. As a rule, the needle should be passed from the side of the vessel at
+which the chief dangers exist. This will generally be in the side at
+which the vein is.</p>
+
+<p>6. The ligature should be single, and consist of strong well-waxed silk,
+and should always be drawn as tight as possible, so as to divide the
+internal and middle coats of the vessel. In cases where the wound is to
+be treated with antiseptic precautions and an attempt at immediate union
+made, the ligature may be of strong catgut properly prepared, and both
+ends of it may be cut off.</p>
+
+<p>7. Before the ligature is tightened, it is well to feel that pressure
+between the ligature and the finger arrests the pulsation of the tumour.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of the Aorta.</span>&mdash;It has been found necessary in a few rare cases
+to place a ligature on the abdominal aorta; no case has as yet survived
+the operation beyond a very few days, but they have in their progress
+sufficiently proved that the circulation can be carried on, and gangrene
+does not necessarily result even after such a decided interference with
+vascular supply.</p>
+
+<p><i>Operation.</i>&mdash;The ligature may be applied in one of two ways, the choice
+being influenced by the nature of the disease for which it is done.</p>
+
+<p>1. A straight incision (<a href="#plate_i">Plate I</a>. fig. 1) in the linea alba, just
+avoiding the umbilicus by a curve, and dividing the peritoneum, allows
+the intestines to be pushed aside, and the aorta exposed still covered
+by the peritoneum, as it lies in front of the lumbar vertebr&aelig;. The
+peritoneum must again be divided very cautiously at the point selected,
+and the aortic plexus of nerves carefully dissected off, in order that
+they may not be interfered with by the ligature. The ligature should
+then be passed round, tied, cut short, and the wound accurately sewed
+up.</p>
+
+<p>2. Without wounding the peritoneum.</p>
+
+<p>A curved incision (<a href="#plate_i">Plate I</a>. fig. 2), with its convexity<span class='pagenum'><a name="Page_3" id="Page_3">{3}</a></span> backwards, from
+the projecting end of the tenth rib to a point a little in front of the
+anterior superior spinous process of the ilium. At first through the
+skin and fascia only, this incision must be continued through the
+muscles of the abdominal wall, one by one, till the transversalis fascia
+is exposed, which must then be scraped through very cautiously, so as
+not to injure the peritoneum, which is to be detached from the fascia
+covering the psoas and iliacus muscles, and must be held inwards and out
+of the way by bent copper spatul&aelig;. The common iliac will then be felt
+pulsating, and on it the finger may easily be guided up until the aorta
+is reached.</p>
+
+<p>The really difficult part of the operation now begins: to isolate the
+vessel from the spine behind, the inferior cava on the right side, and
+the plexus of nerves in the cellular tissue all round. The cleaning of
+the vessel must be done in great measure by the finger-nail, and much
+dexterity will be required to pass the ligature without unnecessarily
+raising the vessel from its bed, especially as the vessel itself may
+very possibly be diseased, and the aneurism of the iliac trunk for which
+the operation is required will displace and confuse the parts, and may
+have set up adhesive inflammation.</p>
+
+<p><i>Results.</i>&mdash;Operation has been performed at least ten times. By the
+first method by Sir Astley Cooper and Mr. James; by the second by Drs.
+Murray and Monteiro, M'Guire, Heron Watson, and Stokes, and Mr. South,
+and Czerny of Heidelberg. All the cases proved fatal; Dr. Monteiro's
+survived for ten days, and eventually perished from h&aelig;morrhage; the rest
+all died at shorter intervals.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of Common Iliac.</span>&mdash;<i>Anatomical Note.</i>&mdash;This short thick trunk
+varies slightly in its relations on the two sides of the body. As the
+aorta bifurcates on the left side of the body of the fourth lumbar
+vertebra,<span class='pagenum'><a name="Page_4" id="Page_4">{4}</a></span> the common iliac of the right side would have a longer course
+to pursue than that on the left, if both ended at corresponding points.
+However, this is not always the case, as has been pointed out by Mr.
+Adams of Dublin, as the right common iliac often bifurcates sooner than
+the left does. With this slight difference, the position of the two
+vessels is precisely similar, each extending along the brim of the
+pelvis from the bifurcation of the aorta towards the sacro-iliac
+synchondrosis for about two inches. Sometimes the division takes place a
+little higher, even at the junction of the last lumbar vertebra and the
+sacrum. This variation depends chiefly on the length of the artery,
+which, as Quain has shown, varies from one inch and a half to more than
+three inches.</p>
+
+<p>The anterior surface of both arteries is covered by the peritoneum, and
+each is crossed by the ureter just as it bifurcates into its branches.</p>
+
+<p>The artery of the right side is in close contact behind with its
+corresponding vein, which at its upper part projects to the outside, and
+below to the inner side. The artery of the left side is less involved
+with its vein, which lies below it, and to the inside. The right is in
+contact with a coil of ileum, the left with the colon. The inferior
+mesenteric artery crosses the left one, while to the outside of both,
+and behind them, lie the sympathetic and obdurator nerves.</p>
+
+<p>There are no named branches from the common iliac.</p>
+
+<p><i>Operation.</i>&mdash;The chief difficulties to be encountered are&mdash;1. The close
+proximity of the peritoneum, and specially the risk there is that it has
+become adherent to the sac of the aneurism; 2. The depth of the parts,
+and tendency of the intestines to roll into the wound; 3. Specially on
+the right side, the proximity of the great veins. With these exceptions
+the passing of the ligature is not so difficult as in some situations,
+the lax cellular tissue in which the vessel lies generally yielding much
+more easily than the tough sheath which<span class='pagenum'><a name="Page_5" id="Page_5">{5}</a></span> elsewhere, as in the femoral,
+requires accurate dissection.</p>
+
+<p><i>Incision.</i>&mdash;(<a href="#plate_i">Plate I.</a> fig. 3.)&mdash;From a point about half an inch above
+the centre of Poupart's ligament, a crescentic incision should be made,
+at first extending upwards and outwards, so as to pass about one inch
+inside of the anterior superior spine of the ilium, and then prolonged
+upwards and inwards, as far as may be rendered necessary by the size of
+the aneurism or the depth of parts. It must extend through skin and
+superficial fascia, exposing the tendon of the external oblique, which
+must then be slit up to the full extent visible. The spermatic cord may
+then be easily exposed under the edge of the internal oblique, and the
+forefinger of the left hand inserted on the cord, and thus beneath the
+internal oblique and transversalis muscles, the peritoneum being quite
+safe below.</p>
+
+<p>On the finger these muscles may be safely divided to the full extent of
+the external incision. The deep circumflex iliac artery if possible
+should not be divided, but may bleed smartly and require a ligature.</p>
+
+<p>The peritoneum must then be very cautiously raised from the tumour, and
+supported, along with the intestines, by copper spatul&aelig;. The surgeon
+will rarely succeed in obtaining anything like a satisfactory view of
+the vessel, but can expose it for the ligature by the aid of his
+finger-nail. An ordinary aneurism-needle will generally suffice for the
+conveyance of the ligature.</p>
+
+<p>The difficulties may occasionally be much increased by special
+circumstances, such as great stoutness of the patient, and consequent
+thickness of the abdominal wall; or large size of the aneurism, which
+may cause alterations in the relation of parts and adhesion of the
+peritoneum. The ureter generally gives no trouble, as in pressing back
+the peritoneum it is adherent to it, and is removed along with it
+towards the middle line.</p>
+
+<p><i>Results.</i>&mdash;Are not by any means satisfactory.<span class='pagenum'><a name="Page_6" id="Page_6">{6}</a></span></p>
+
+<p>Out of twenty-two cases in which the common iliac has been tied for
+aneurism, eight recovered and fourteen died; while out of thirteen cases
+where it required ligature for h&aelig;morrhage after amputation, rupture of
+aneurism, etc., only one recovered.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of Internal Iliac.</span>&mdash;Little need be added to the account just
+given of the operation for ligature of the common iliac, as precisely
+the same incisions are required. The operator having reached the
+bifurcation of the vessel, must, instead of tracing it upwards,
+endeavour to trace it downwards, and the same time inwards, into the
+basin of the pelvis. To do this his finger must cross the external iliac
+artery, which will pulsate under the joint of the ungual phalanx, while
+the pulp of the finger is touching the internal iliac,&mdash;the external
+iliac vein, which occupies the angle formed by the bifurcation of the
+artery, lying between these two points. The ligature should be applied
+within three-quarters of an inch from the bifurcation.</p>
+
+<p><i>Anatomical Note.</i>&mdash;This short thick trunk extends backwards and inwards
+(Ellis); downwards and backwards (Harrison), in front of the sacro-iliac
+synchondrosis, as far as the upper extremity of the great sacro-sciatic
+notch, a distance varying in the adult from one and a half to two inches
+in length. It forms a curve with its concavity forwards, and at its
+termination divides into, rather than gives off, its two or three
+principal branches. Its corresponding vein is in close contact behind,
+as also the lumbo-sacral nerve, the obdurator nerve to its outer side.
+The peritoneum covers it anteriorly, and it is crossed just at its
+commencement by the ureter. On the left side it is covered anteriorly by
+the rectum. Of its anatomical relations, that of the external iliac vein
+is perhaps the most important, as it is apt to interfere with the
+passing of the needle.</p>
+
+<p><i>Results.</i>&mdash;This vessel has been tied for aneurism of one<span class='pagenum'><a name="Page_7" id="Page_7">{7}</a></span> or other of
+its branches, or for wound, about seventeen times.<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a> Of these seven
+recovered; in ten the operation proved fatal, in most of them from
+secondary h&aelig;morrhage. In one case the h&aelig;morrhage occurred within twelve
+hours after the operation. The circulation of the parts supplied after
+the ligature is carried on mainly by the lumbar and lateral sacral
+branches, which become much developed even before the operation, in
+cases of aneurism.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of External Iliac.</span>&mdash;<i>Anatomical Note.</i>&mdash;This artery extends
+from the bifurcation of the common iliac to the centre of Poupart's
+ligament, where it leaves the abdomen, passing under the ligament, and
+becomes the common femoral. Its upper extremity is thus not always
+constant, varying in position from the sacro-lumbar fibro-cartilage to
+the upper end of the sacro-iliac synchondrosis, or even a little lower
+down. Thus, though the position of the lower end is at a fixed point,
+the artery varies in length. In an adult male of moderate stature it is
+from three and a half to four inches in length. On the surface of the
+abdomen the position of this vessel would be indicated by a line drawn
+from about an inch on either side of the umbilicus to the middle of the
+space between the symphysis pubis and the crest of the ilium. Its
+relations to neighbouring parts are as follows:&mdash;The peritoneum lies <i>in
+front</i> of it, separated from it only by a subperitoneal layer of loose
+fascia, in which the artery and vein lie, which varies much in
+consistence and amount, and which occasionally gives a good deal of
+trouble in the operation of ligature. Near its origin it is sometimes
+crossed by the ureter, and near its termination the genito-crural nerve
+lies on it. The spermatic vessels cross it, and occasionally a quantity
+of subperitoneal fat marks its course. <i>Externally.</i>&mdash;The fascia-iliaca
+and some fibres of the psoas<span class='pagenum'><a name="Page_8" id="Page_8">{8}</a></span> muscle separate it from the anterior
+crural nerve, which lies outside of the vessel, and at a somewhat deeper
+level, hidden amid the fibres of psoas and iliacus. <i>Internally.</i>&mdash;The
+external iliac vein lies on the same plane, and to the inner side of the
+artery, at Poupart's ligament, on both sides of the body. As we trace it
+upwards we find that on the left side it lies internal to the artery in
+its whole course, while on the right side it becomes posterior to the
+artery as it approaches the bifurcation of the common iliac. Lastly,
+just before the vessel reaches Poupart, the circumflex iliac vein
+crosses it from within outwards.</p>
+
+<p><i>Branches.</i>&mdash;The two large branches to the wall of the abdomen, the
+epigastric and the circumflex iliac, rise a few lines above Poupart's
+ligament. Their position is unfortunately apt to vary upwards, to the
+extent of an inch and a half or even two inches, and they are important,
+as, besides being liable to be cut during the operation, their position
+very materially modifies the prognosis, as, if too high up, they
+interfere with the proper formation of the coagulum.</p>
+
+<p><i>Operation.</i>&mdash;Various plans of incision through the skin have been
+recommended by various operators, the chief difference being with regard
+to the part of the artery aimed at; the plan known as that of Mr.
+Abernethy, with various modifications, being intended to expose the
+artery pretty high up, and enable the surgeon to reach it from above;
+while the method going by the name of Sir Astley Cooper's exposes the
+lower part of the artery, and enables the surgeon to reach it from
+below. Though the latter is in some respects easier, the former method
+is generally to be preferred, being further from the seat of disease,
+and especially more out of the way of the epigastric and circumflex
+arteries.</p>
+
+<p>The higher operation (<span class="smcap">Abernethy's</span> modified).&mdash;An incision must be made
+through the skin about four inches in length, but longer in proportion
+to the amount of<span class='pagenum'><a name="Page_9" id="Page_9">{9}</a></span> subcutaneous fat, and the depth of the pelvis,
+extending from a point one inch to the inside of the anterior superior
+spine of the ilium, to a point half an inch above the middle line of
+Poupart's ligament. It must be slightly curved, with its convexity
+looking outwards and downwards.<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a></p>
+
+<p>The subcutaneous cellular tissue and the tendon of the external oblique
+may then be divided freely in the same line. Then at some one point or
+other (generally easiest below), the internal oblique and transversalis
+muscles must be cautiously scraped through with the aid of the forceps,
+till the transversalis fascia is reached; they may then be freely
+divided by a probe-pointed bistoury (guarded by the finger pushed up
+below the muscles) to the required extent. The muscles being held aside
+by flat copper spatul&aelig;, the fascia transversalis must be carefully
+scratched through near the crest of the ilium, and thus the operator
+will be enabled to push the peritoneum inwards, and by the forefinger
+will easily recognise the pulsation of the artery lying on the soft brim
+of the pelvis.</p>
+
+<p>A branch of the circumflex iliac artery will very likely be cut in
+dissecting through the muscles, and must be secured, as also any
+branches of the epigastric which may be divided in the incisions through
+the abdominal wall (<i>ut supra</i>, p. <a href="#Page_5">5</a>).</p>
+
+<p>The operator should then, by pressing the peritoneum and its contents
+gently inwards, endeavour to see the vessel; if, from the depth of the
+pelvis, this cannot be done, the sense of touch will be in most cases
+sufficient to enable him to isolate the artery by the point of his
+finger-nail, or by the blunt aneurism-needle, from the vein. The
+ligature should be passed from the inner side to avoid including the
+vein, and thus there will be<span class='pagenum'><a name="Page_10" id="Page_10">{10}</a></span> less chance of wounding the peritoneum
+from the convexity of the needle being applied to it. If possible, the
+genito-crural nerve should not be included in the ligature, but probably
+such an accident would do no great harm.</p>
+
+<p>It is of much more consequence to avoid injuring the peritoneum. This is
+sometimes very difficult, from the adhesions which are set up between
+the peritoneum, the artery, and especially the aneurism, as the result
+of pressure and inflammation. The accident of wounding the peritoneum
+has happened to Keate, Tait, Post, and others, and in some cases with
+perfect impunity. However, the peritoneum should be displaced as little
+as possible from its cellular connections, as such displacement
+increases the risk of diffuse inflammation of that membrane; and the
+vessel itself should be raised and disturbed as little as possible, lest
+destruction of the vasa vasorum cause ulceration of the weak coats and
+secondary h&aelig;morrhage.</p>
+
+<p>The operation from below (<a href="#plate_i">Plate I.</a> fig. 4), <span class="smcap">Sir Astley Cooper's</span>, is thus
+described by Mr. Hodgson:<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a>&mdash;"A semilunar incision is made through the
+integuments in the direction of the fibres of the aponeurosis of the
+external oblique muscle. One extremity of the incision will be situated
+near the spine of the ilium; the other will terminate a little above the
+inner margin of the abdominal ring. The aponeurosis of the external
+oblique muscles will be exposed, and is to be divided throughout the
+extent, and in the direction of the external wound. The flap which is
+thus formed being raised, the spermatic cord will be seen passing under
+the margin of the internal oblique and transverse muscles. The opening
+in the fascia which lines the transverse muscle through which the
+spermatic cord passes, is situated in the mid space between the anterior
+superior spine of the ilium and the symphysis pubis. The epigastric
+artery runs precisely along the inner margin of this opening, beneath
+which<span class='pagenum'><a name="Page_11" id="Page_11">{11}</a></span> the external iliac artery is situated. If the finger therefore be
+passed under the spermatic cord through this opening in the fascia, it
+will come in immediate contact with the artery which lies on the outside
+of the external iliac vein. The artery and vein are connected by dense
+cellular tissue, which must be separated to allow of the ligature being
+passed round the former."</p>
+
+<p>In comparing the two methods of operating, we find that while the latter
+is in some respects easier, and the vessel in it lies more superficial,
+it has certain disadvantages which more than counterbalance its
+advantages. Thus, first, the epigastric artery is very likely to be
+wounded. It may be said, Well, if so, the ends can be tied; but this
+tying is sometimes very difficult; and, as shown in Dupuytren's case of
+this accident, involves considerable interference with the peritoneum,
+and a possibly fatal peritonitis. Besides this, by cutting the
+epigastric you destroy an important agent which would have carried on
+the anastomosing circulation, and thus greatly increase the risk of
+gangrene. By this method, also, the artery is exposed too near to the
+seat of disease; and if found to be enlarged and involved in the
+aneurism, considerable difficulty may be experienced in reaching the
+upper part of the vessel. Again, ligature of the lower third or half of
+the vessel, which this method implies, is dangerous from the occasional
+high origin of the circumflex or epigastric, or both, rendering the
+formation of a clot much more difficult, and secondary h&aelig;morrhage much
+more likely.</p>
+
+<p>The circumflex iliac vein must also be remembered, as it crosses the
+artery from within outwards in the lower end of it, just before it goes
+under Poupart's ligament.</p>
+
+<p>However, the method may occasionally vary with the individual case. In
+every case of ligature of the great vessels of the abdomen, the bowels
+should be carefully evacuated before the operation, and the bladder
+emptied. A properly managed position, with the shoulders raised<span class='pagenum'><a name="Page_12" id="Page_12">{12}</a></span> and the
+knees semiflexed, will greatly facilitate the gaining access to the
+vessel.</p>
+
+<p>In sewing up the wounds in the abdominal walls, advantage will be gained
+by putting in a certain number of stitches so deeply as to include the
+whole thickness of the muscles, and in the intervals between these deep
+ones to insert others less deeply, so as accurately to approximate the
+edges of the skin. This will both facilitate union and also render the
+occurrence of hernia less probable. This latter accident did occur in a
+case, otherwise successful, in which Mr. Kirby tied the external iliac.</p>
+
+<p>Both external iliacs have been tied in the same patient with success, on
+at least two occasions, once by Arendt, with an interval of only eight
+days between the operations; and a second time by Tait, at an interval
+of rather more than eleven months.</p>
+
+<p>This operation is in the great majority of cases performed for femoral
+aneurism, and naturally secondary h&aelig;morrhage is a too frequent result.
+Wounds of these great vessels generally result in so rapid death from
+h&aelig;morrhage as to give no time for surgical interference. One case,
+however, is recorded,<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a> in which the external iliac was cut in a lad of
+seventeen by an accidental stab, and in which Drs. Layraud and Durand,
+who were almost instantly on the spot, succeeded in stopping the
+bleeding by compresses, till Velpeau arrived, who tied the vessel above
+with perfect success.</p>
+
+<p>Of the first twenty-two cases collected by Hodgson, fifteen recovered&mdash;a
+mortality of 31.81 per cent.; and of 153 in Norris's collection,
+including Cutter's cases, forty-seven died&mdash;a mortality of only 32.5 per
+cent.,&mdash;a very satisfactory result, considering the size of the vessel
+and the importance of its relations.</p>
+
+<p><span class="smcap">Ligature of Gluteal.</span>&mdash;This vessel, though one of<span class='pagenum'><a name="Page_13" id="Page_13">{13}</a></span> the branches of the
+internal iliac, approaches the surface so nearly as to be occasionally
+wounded. It is also, though very rarely, the subject of spontaneous
+aneurism. The principle of treatment and the operation to be selected in
+any given case, depends upon its origin, whether traumatic or
+spontaneous. For if traumatic, the wound must almost necessarily be
+accessible from the outside; the neighbouring part of the artery is
+probably healthy, and hence the case can be treated by the old
+operation, slitting up the tumour, and tying the vessel above and below
+the wound. When the aneurism is spontaneous, there is no guide to tell
+us where the aneurism may have first originated; it may be that it is
+high up in the pelvis, and that the visible tumour is only its expansion
+in the direction of least resistance, or the coats of the vessel may be
+extensively diseased. The only chance is ligature of the internal iliac.</p>
+
+<p>1. The old operation, or ligature of the gluteal artery in the hip.</p>
+
+<p><i>Anatomical Note.</i>&mdash;The gluteal is the largest branch of the internal
+iliac, and leaves the pelvis by the great sacro-sciatic notch just at
+the upper edge of the pyriformis muscle. After a very short course, it
+divides into superficial and deep branches opposite the posterior margin
+of the glutens minimus, between it and the pyriformis muscles.</p>
+
+<p>Very precise rules have been given to enable the operator to hit on the
+exact spot where the artery leaves the pelvis. These, though perhaps
+interesting anatomically, are quite useless in a surgical point of view,
+for the only reasons which could possibly induce a surgeon to cut down
+upon the gluteal in the living body, are the existence either of a wound
+of the vessel or an aneurism. In the first the flow of blood, in the
+second the tumour, would give sufficient guidance.</p>
+
+<p>In cases of traumatic aneurism the operation should<span class='pagenum'><a name="Page_14" id="Page_14">{14}</a></span> be something like
+the following:&mdash;A free incision should be made into the tumour, dividing
+it in its long direction; the contents should be rapidly scooped out,
+and a finger placed on the bleeding point, just at the upper corner of
+the sciatic notch. This will at once stop the h&aelig;morrhage till the vessel
+can be secured. This sounds easy enough, and has been done several times
+with success. Thus, John Bell, by an incision two feet long, as he tells
+us in his hyperbolical language, was enabled to tie the vessel in the
+case of the leech-gatherer who had punctured the artery by a pair of
+long scissors. Carmichael of Dublin used a smaller incision, removed one
+or two pounds of clots, and tied the vessel, in a case of wound by a
+penknife.<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a></p>
+
+<p>Now, though both of these cases were eventually successful, both
+patients lost during the operation a very large quantity of blood; John
+Bell's especially could not be removed from the operating-table for a
+considerable time after the operation. The period at which the great
+loss of blood took place was the interval after the incision was made,
+and before the artery was exposed to view, <i>i.e.</i> the interval in which
+the surgeon was busy dislodging the clots from the cellular membrane,
+the sac of the false aneurism. The procedure devised by Mr. Syme to
+obviate this difficulty, and which was put in practice by him in several
+very trying cases, is best given in his own terse description of an
+operation in a case of traumatic gluteal aneurism:&mdash;</p>
+
+<p>"The patient having been rendered unconscious, and placed on his right
+side, I thrust a bistoury into the tumour, over the situation of the
+gluteal artery, and introduced my finger so as to prevent the blood from
+flowing, except by occasional gushes, which showed what would have been
+the effect of neglecting this precaution, while I searched for the
+vessel. Finding it impossible to accomplish the object in this way, I
+enlarged the<span class='pagenum'><a name="Page_15" id="Page_15">{15}</a></span> wound by degrees sufficiently for the introduction of my
+fingers in succession, until the whole hand was admitted into the
+cavity, of which the orifice was still so small as to embrace the wrist
+with a tightness that prevented any continuous h&aelig;morrhage. Being now
+able to explore the state of matters satisfactorily, I found that there
+was a large mass of dense fibrinous coagulum firmly impacted into the
+sciatic notch; and, not without using considerable force, succeeded in
+disengaging the whole of this obstacle to reaching the artery, which
+would have proved very serious if it had been allowed to exist after the
+sac was laid open. The compact mass, which was afterwards found to be
+not less than a pound in weight, having been thus detached, so that it
+moved freely in the fluid contents of the sac, and the gentleman who
+assisted me being prepared for the next step of the process, I ran my
+knife rapidly through the whole extent of the tumour, turned out all
+that was within it, and had the bleeding orifice instantly under
+subjection by the pressure of a finger. Nothing then remained but to
+pass a double thread under the vessel, and tie it on both sides of the
+aperture."</p>
+
+<p>The bleeding in this case was thus rendered comparatively trifling, and
+the patient made a speedy and complete recovery. He returned home within
+six weeks after the operation.<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a></p>
+
+<p>2. In one case, at least, the gluteal artery has been tied with success
+(for traumatic aneurism) just where it leaves the pelvis, without the
+tumour being opened. This was in the practice of Professor Campbell of
+Montreal. The operation was a very difficult one, and while possible
+only in cases seen very early, and where the tumour is very small, does
+not appear to have any advantage over the old method.</p>
+
+<p>Cases of spontaneous aneurism of the gluteal artery should be treated by
+ligature of the internal iliac.<span class='pagenum'><a name="Page_16" id="Page_16">{16}</a></span> Steven's and Syme's cases of ligature
+of the internal iliac were of this nature.</p>
+
+<p>Manuals of operative surgery occasionally devote pages to the
+description of special operations for the ligature of such arteries as
+the sciatic, epigastric, circumflex ilii, and pudic. They do not require
+ligature, except in cases of wound either of the vessels themselves or
+their branches; and, according to the modern principles of surgery in
+such cases, the ligature should be applied to the bleeding point, rather
+than to the vessel at a distance above it.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of Femoral</span>.&mdash;Under this head we practically mean cases of
+ligature of the superficial femoral, for the common femoral, or (as
+called by some anatomists) the femoral, before the profunda is given
+off, very rarely requires to be tied. If it is wounded, of course the
+bleeding point must be sought, and the artery tied above and below it,
+but if an aneurism on the superficial femoral renders ligature of that
+trunk impossible, experience teaches that ligature of the external iliac
+gives better results than ligature of the common femoral. Erichsen
+asserts that out of twelve cases in which the common femoral has been
+tied, only three have succeeded, the others dying from secondary
+h&aelig;morrhage. The experience of the Dublin surgeons, Porter, Smyly, and
+Macnamara, has been more satisfactory, as in eight cases of this
+operation six were successful.<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a> A ninth case was unsuccessful. Reasons
+to explain the danger are not far to seek, for the numerous small
+muscular branches, along with the superficial epigastric, circumflex,
+and pudic trunks, reduce the chances of a good coagulum in the common
+femoral to a minimum, even without taking into consideration the
+shortness of the trunk before the great profunda femoris is given off.
+For the common femoral artery is only from one to two<span class='pagenum'><a name="Page_17" id="Page_17">{17}</a></span> inches in length,
+and if there are some rare cases in which it is a little later in its
+bifurcation, there are others in which it divides nearer to Poupart's
+ligament.</p>
+
+<p>The superficial femoral is the name given to the main trunk between the
+origin of the profunda, and the point at which, passing through the
+tendon of the adductor magnus, it receives the name of popliteal. During
+this long course it gives off no branch large enough or regular enough
+to receive a name, except one, the anastomotica magna, which rises in
+Hunter's canal, close to the end of the vessel, so in that respect it is
+peculiarly suitable for the application of a ligature. Again, in the
+upper part of its course, it is superficial, being covered only by skin
+and fascia. A short notice of its most important anatomical relations is
+necessary.</p>
+
+<p>For the first two inches or two inches and a half of its separate
+existence, the superficial femoral lies in Scarpa's triangle, covered,
+as we said, only by skin and fascia. This triangle is formed by the
+sartorius and adductor longus muscles which meet at its apex, and by
+Poupart's ligament, which defines its base. The artery lies almost
+exactly in the centre of the space, and at the apex is covered by the
+sartorius muscle. The spot where it goes under the sartorius is the one
+selected for the application of the ligature. The femoral vein lies to
+the inner side of the femoral artery in this triangle, but their mutual
+relations vary with the portion of the limb; for, on the level of
+Poupart's ligament, the artery and vein lie side by side on the same
+plane, but in different compartments of their sheath; as the artery
+dives below the sartorius, the vein is still on the inside, but on a
+plane slightly posterior; while, by the time they reach Hunter's canal,
+the vein has got completely behind the artery. The separate compartments
+of the sheath in which the vessels lie are much less marked as the
+vessels go down the limb, the septum between the artery and the vein
+being in most cases very ill marked, even<span class='pagenum'><a name="Page_18" id="Page_18">{18}</a></span> at the level where the
+ligature is applied. The anterior crural nerve, which on the level of
+Poupart's ligament lay outside of the artery and on a plane somewhat
+posterior, has divided into numerous branches before it reaches the
+point of ligature. One of its branches requires to be mentioned, and may
+sometimes be noticed and avoided during the operation, namely the
+internal saphenous nerve, which, first lying external to the artery,
+crosses it in front, reaching its inner side just before it enters
+Hunter's canal, where it leaves the vessel accompanying the anastomotica
+magna branch.</p>
+
+
+<p class="gap"><span class="smcap">Operation of Ligature of the Femoral&mdash;Scarpa's Space</span>.&mdash;The patient being
+placed on his back, and being brought very thoroughly under chloroform,
+the knee of the affected limb should be bent at an angle of about 120&deg;,
+and supported on a pillow. Having previously ascertained the angle of
+junction of the sartorius and adductor, the surgeon should make an
+incision (<a href="#plate_i">Plate I.</a> fig. 5) just over the pulsations of the vessel, in
+the middle line of the space, having its lower end quite over the
+sartorius muscle, and its upper one, at a distance from two and a half
+to three and a half inches, varying according to the amount of fat and
+muscle. The saphena vein can generally be recognised, and is almost
+always safe out of the way of this incision at its inner side.</p>
+
+<p>The first incision should divide the skin, superficial fascia, and fat,
+quite down to the fascia lata. The edges of the wound being held apart,
+the fascia should be carefully divided, and the sartorius exposed; its
+fibres can generally be easily enough recognised by their oblique
+direction; once recognised, the fascia should be dissected from it till
+its inner edge be gained, the corner of which should then be turned so
+that it may be held outwards by an assistant with a blunt hook. The
+sheath of the vessels is now exposed, and after having thoroughly<span class='pagenum'><a name="Page_19" id="Page_19">{19}</a></span>
+satisfied himself of the position of the artery by the pulsation, the
+surgeon should carefully raise a portion of the sheath with the
+dissecting forceps, and open it freely enough to allow the coats of the
+artery to be distinctly seen. If the parts are deep, as in a fat or
+muscular patient, great advantage will be gained by seizing one edge of
+the sheath by a pair of spring forceps, and committing it to the care of
+an assistant, while the operator holds the other in his dissecting
+forceps; there is thus no fear of losing the orifice of the sheath,
+which without this precaution may easily happen, from the parts being
+confused with blood, or the position altered by movements of the
+patient. Now comes the stage of the operation on which, more than on
+anything else, success or failure depends. A <i>small</i> portion of the
+vessel must be cleaned for the reception of the ligature, and it must be
+<i>thoroughly</i> cleaned, so that the needle may be passed round it without
+bruising of the coats, or rupture of an unnecessary number of the vasa
+vasorum by rough attempts to force a passage for it. Hence all
+compromises, such as blunted instruments, silver knives, and the like,
+are dangerous, for in trying to avoid the Scylla of wounding the artery,
+they fall into the Charybdis, on the one hand, of isolating too much of
+the vessel and causing gangrene from want of vascular supply, or, on the
+other, expose the vein to the danger of injury by the aneurism-needle in
+their attempts to force it round an uncleaned vessel.</p>
+
+<p>The needle should in most cases be passed from the inner side, care
+being taken to avoid including the vein which is on the inner side and
+behind the vessel; the internal saphenous nerve, if seen, should be
+avoided. The needle must not be passed quite round the vessel raising it
+up, still less must the vessel be held up on the needle, as used to be
+done, as if the surgeon was surprised at his own success, but the needle
+should be passed just far enough to expose the end of the ligature,<span class='pagenum'><a name="Page_20" id="Page_20">{20}</a></span>
+which must be seized by forceps and cautiously drawn through. It must
+then be tied very firmly and secured with a reef knot.</p>
+
+<p>The edges of the wound must be brought into accurate apposition, and
+secured by one or two stitches. If antiseptics are used, drainage should
+be provided for.</p>
+
+<p>From the very fact that ligature of the superficial femoral is a
+remarkably successful operation in causing consolidation of the aneurism
+and a rapid cure, there is also a corresponding danger that the limb be
+not sufficiently supplied with blood at first. The limb may very
+possibly become cold, and remain so for some hours at least after the
+operation. To avoid this as far as possible, it should be wrapped in
+cotton wadding, and very great care should be taken that it be not
+over-stimulated by hot applications, friction, or the like, any of which
+measures might very likely excite reaction, which would result in
+gangrene.</p>
+
+<p>Complete rest of the limb and of the whole body must be enjoined; the
+food must be nourishing and in moderate quantity. The chief danger is
+from gangrene of the limb, which is especially apt to result when the
+vein is wounded, or even too much handled during the operation.</p>
+
+<p>When properly performed, and in suitable cases, the operation is very
+successful. Mr. Syme tied this artery for aneurism thirty-seven times,
+and of these every one recovered. The statistics of Norris and Porta,
+who collected all the cases in which ligature of the femoral had been
+employed for <i>any</i> cause, show a mortality of somewhat less than one in
+four. Rabe's table up to 1869 with the additional cases collected by Mr.
+Barwell to 1880 gives 297 cases with 53 deaths.<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">[9]</a> Mr. Hutchinson's
+table, again, of fifty cases collected from the records of Metropolitan
+Hospitals, shows the very<span class='pagenum'><a name="Page_21" id="Page_21">{21}</a></span> startling result of sixteen deaths out of the
+fifty cases, or a mortality, in round numbers, of one-third.</p>
+
+<p>Certain anomalies have been observed in the distribution of the femoral
+vessels, of some importance as affecting the possibility of applying,
+and the result of, ligature; such as&mdash;1. A high division of the branches
+which afterwards become posterior tibial and peroneal. 2. A double
+superficial femoral, both branches of which may unite and form the
+popliteal, as in Sir Charles Bell's well-known case. 3. Absence of the
+artery altogether, as in Manec's case, where the popliteal was a
+continuation of an immensely enlarged sciatic.</p>
+
+<p>In such a case the absence of pulsation in front, and the presence of
+increased pulsation behind the limb, ought to prevent any fruitless
+attempt at search.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of the Superficial Femoral below the Sartorius Muscle</span>.&mdash;This
+operation, though once common in France, and though the one recommended
+by Hunter himself, is now comparatively little used in this country; and
+rightly so; for while it has no advantage over the upper position, it is
+at once nearer the seat of disease, and the vessel is more deeply buried
+under muscles, and has a more distinct fibrous sheath, which requires
+division.</p>
+
+<p>It is, however, by no means a difficult operation, and is thus
+performed:&mdash;</p>
+
+<p>The limb being laid as before on the outside, and slightly bent, the
+skin shaved and the pulsation of the artery detected, an incision (<a href="#plate_i">Plate
+I.</a> fig. 6) must be made from the lower edge of the sartorius muscle just
+as it crosses the vessel, along the course of the vessel, avoiding if
+possible the internal saphena vein.</p>
+
+<p>The sartorius when exposed must be drawn inwards. The fibrous canal
+filling the interspace between the abductor magnus and vastus internus
+is then recognised, and must be fairly opened; the artery is now seen
+lying<span class='pagenum'><a name="Page_22" id="Page_22">{22}</a></span> in it, and over the vein which is posterior to it, but projects
+slightly on its outer side; the internal saphenous nerve is lying on the
+artery. The needle is best passed from without inwards so as to avoid
+the vein. The anastomotica magna is sometimes a large trunk, and has
+been mistaken for the femoral in this situation, and tied instead of it.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of the Popliteal</span>.&mdash;This operation is now hardly ever performed
+for aneurism, ligature of the superficial femoral having quite
+superseded it, and it is very rarely required for wounds, from the
+manner in which the vessel is protected by its position.</p>
+
+<p>Before the invention of the Hunterian principle of ligature at a
+distance, the old operation for popliteal aneurism consisted in cutting
+into the space, clearing out the contents of the aneurismal sac, and
+tying both ends of the vessel; from the depth of parts and the close
+connection of the popliteal vein, this operation was very rarely
+successful, and is now quite given up. If the vessel is wounded the
+bleeding point is the object to be aimed at, and is generally sufficient
+guide.</p>
+
+<p>In cases of h&aelig;morrhage for suppuration of an aneurismal sac, it might
+possibly be advisable, and there are certain cases of rupture of the
+artery, without the existence of an external wound, in which attempts
+have been made to save the limb by tying the vessel.<a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">[10]</a> From the
+complexity of the parts, the numerous tendons, veins, and nerves crowded
+together in a narrow hollow, and chiefly from the great depth at which
+the artery lies, any attempt at ligature is very difficult. It is least
+so at the lower angle of the space, where, between the heads of the
+gastrocnemius, the vessel comes more to the surface, but is still
+overlapped by muscle.</p>
+
+<p><i>Operation.</i>&mdash;The patient lying on his face, a straight<span class='pagenum'><a name="Page_23" id="Page_23">{23}</a></span> incision (<a href="#plate_iii">Plate
+III.</a> fig. 1), at least four inches in length, should be made over the
+artery, and thus nearer the inner than the outer hamstring; a strong
+fibrous aponeurosis will require division after the skin and superficial
+fascia are cut through, the limb is then to be flexed, and the tendons
+drawn aside with strong retractors; fat and lymphatic glands must next
+be dissected through, and then the vein and artery, lying on a sort of
+sheath of condensed cellular tissue, are seen, the vein lying above the
+artery and obscuring it. The vein must be drawn to the outside, and the
+thread passed round the artery, which lies close to the bone, on the
+ligamentum posticum of Winslowe.</p>
+
+<p>It is a very difficult subject to decide what operations should be
+described in a work of this character, on the vessels of the leg and
+foot. A very large number of distinct methods of operations on the
+various parts of the three chief arteries of the leg have been described
+by surgeons and anatomists, but specially by the latter.</p>
+
+<p>The fact is, however, that these complicated procedures are rarely
+required, for aneurisms of the arteries of the leg and foot are almost
+unknown, while in cases of wound of the vessel, or rupture resulting in
+traumatic aneurism, the proper treatment is not to tie the vessel higher
+up, but by dilating the wound and clearing out the clots, if required,
+to secure the bleeding point, and tie the vessel above and below.</p>
+
+<p>Again, a wound of the sole of the foot often gives rise to very severe
+and persistent h&aelig;morrhage, while the fasci&aelig; and complicated tendons
+render ligature of the vessel at the spot very difficult; yet ligature
+of either the anterior or posterior tibial would probably be
+insufficient; and to tie both these vessels, with possibly the peroneal
+and interosseous as well, would be a much more severe and dangerous
+procedure than ligature of the superficial femoral; while probably
+careful plugging of<span class='pagenum'><a name="Page_24" id="Page_24">{24}</a></span> the wound, combined with flexion of the knee, will
+be found to stop the h&aelig;morrhage sooner than either of the more
+formidable methods.</p>
+
+<p>A competent knowledge of the anatomy of the part, and of the ordinary
+methods of checking h&aelig;morrhage, such as ligatures, graduated compresses,
+and styptics, aided by position, specially flexion of the knee after Mr.
+Ernest Hart's method, will suffice to enable the surgeon to check any
+h&aelig;morrhage of the foot or leg, without it being necessary to burden the
+memory with the three positions in which to tie the peroneal, or the
+various methods, more or less bloody and tedious, by which the posterior
+tibial in its upper third may be secured.</p>
+
+
+<div class="blockquot smlet"><p><span class="smcap">Note</span>.&mdash;While, as a matter of surgical principle to guide our
+practice on the living, I still hold very strongly the opinions
+here expressed against special operations for ligature of the
+arteries of the leg, and allow the sentences to stand as in the
+first edition of this work, I insert in a note a brief description
+of the more important ones, in deference to the advice of friends
+and the urgent request of pupils, as these operations are used by
+Examining Boards as tests of the operative dexterity of
+candidates:&mdash;</p>
+
+<p>1. <span class="smcap">Anterior Tibial Artery in lower half of Leg</span>.&mdash;<i>Anatomical
+Note.</i>&mdash;This vessel is related on its tibial side to the tibialis
+anticus, and on its fibular, to the extensor longus digitorum
+above, and the extensor pollicis below. The anterior tibial nerve
+lies first on its outer side, then crosses the artery, and
+eventually reaches its inner side near the foot. <i>Operation.</i>&mdash;An
+incision, at least three inches long, parallel with the outer edge
+of the tibia, and about three-quarters of an inch from it, exposes
+the deep fascia. This being divided, the outer edge of the tibialis
+anticus must be found, and will be the guide to the artery, which,
+surrounded by its ven&aelig; comites, lies very deeply between the
+muscles.</p>
+
+<p>2. <span class="smcap">Posterior Tibial</span>.&mdash;<i>A.</i> In middle third of leg. Here the artery
+is separated from the inner border of the tibia, by the flexor
+longus digitorum, and is covered by the soleus. <i>Operation.</i>&mdash;An
+incision at least four inches long, along the inner margin of the
+tibia, exposes the edge of the gastroenemius; then divide the
+tendinous attachment, then expose the soleus,<span class='pagenum'><a name="Page_25" id="Page_25">{25}</a></span> and divide its
+attachment also; the deep fascia will then be seen; slit it up, and
+the vessel will be found about an inch internal to the edge of the
+bone. The nerve is there just crossing it.</p>
+
+<p>Guthrie's, or the direct operation, has the very high authority of
+the late Professor Spence in its favour. An incision through skin
+and fascia in the middle of the back of the leg allows the two
+heads of the gastrocnemius to be separated to the same extent. The
+soleus is then to be scraped through in same direction, and its
+deep aponeurotic surface carefully slit up. The artery and vein are
+then easily seen.</p>
+
+<p>B. In lower third of leg.&mdash;This is an easier and more scientific
+operation, as it does not involve the division of great tendons. An
+incision midway between the internal malleolus and the tendo
+Achillis, parallel with both, will expose the very deep and strong
+fascia in which the tendons lie. The artery, with its ven&aelig; comites,
+occupies a central position, having the tendons of the tibialis
+posticus and flexor communis in front between it and the internal
+malleolus, and the posterior tibial nerve behind it, while the
+flexor longus pollicis lies still nearer the tendo Achillis.</p>
+
+
+<p><span class="smcap">Table</span> illustrating anastomotic circulation after ligature of
+arteries of lower limb.</p>
+
+<p>1. <span class="smcap">Aorta</span>.&mdash;Epigastric and mammary of both sides. H&aelig;morrhoidal and
+spermatic, with branches of pudic both deep and superficial.</p>
+
+<p>2. <span class="smcap">Common Iliac</span>.&mdash;Internal iliac and branches, with those of the
+other side, along with the following:&mdash;</p>
+
+<p>3. <span class="smcap">External Iliac</span>.&mdash;Internal mammary and deep epigastric.</p>
+
+<p>Iliolumbar and lumbar branches of aorta, with deep circumflex ilii.</p>
+
+<p>Pudic from internal iliac, with superficial pudic of common
+femoral.</p>
+
+<p>Gluteal, sciatic, and obturator, with the circumflex and
+perforating branches or deep femoral.</p>
+
+<p>4. <span class="smcap">Femoral</span>.&mdash;External circumflex, with external articular of
+popliteal.</p>
+
+<p>Perforating, with branches of gluteal and sciatic.</p>
+
+<p>Profunda branches with anastomotica and articular branches.</p>
+
+<p>Obturator and internal circumflex with anastomotica and superior
+internal articular.</p>
+
+<p><span class="smcap">Note</span>.&mdash;The importance of the articular branches of the popliteal
+explain the danger of gangrene after a sudden rupture or increase
+in size of a popliteal aneurism. </p></div><p><span class='pagenum'><a name="Page_26" id="Page_26">{26}</a></span></p>
+
+
+<p class="gap"><span class="smcap">Ligature of the Innominate</span>.&mdash;The performance of this extremely
+dangerous, in fact almost hopeless operation, is by no means so
+difficult as might be expected.</p>
+
+<p>The patient lying down with the shoulders raised and head thrown well
+back, the sternal attachment of the right sterno-mastoid must be very
+freely exposed. This may be done by an incision (<a href="#plate_i">Plate I.</a> fig. 7) along
+its anterior edge from the upper edge of the sternum, as far as may be
+necessary; another about the same length along the upper edge of the
+clavicle, will meet the former at an acute angle, and will include a
+triangular flap of skin, which must be carefully dissected up. The
+sternal, and probably a portion of the clavicular attachment of the
+right sterno-mastoid, must then be cautiously divided. This being done,
+the sterno-hyoid and sterno-thyroid muscles require division immediately
+above their sternal attachments.</p>
+
+<p>A dense process of cervical fascia (just becoming thoracic) now covers
+the vessel, binding it on the right side to the right innominate vein,
+and on the left maintaining the relation of the innominate artery to the
+trachea. The inferior thyroid veins lie on this fascia, and must be
+drawn aside, not cut. The fascia is then to be scraped through very
+cautiously, exposing the root of the right carotid, which, being traced
+downwards, will lead to the innominate. The following parts lie in close
+relation to the vessel at the point of ligature, and must be
+avoided:&mdash;1. The left innominate vein crosses the artery in front from
+left to right, and must be drawn down. 2. The right innominate vein and
+right pneumogastric are in close contact with the artery on the right
+side; to avoid them the aneurism-needle must be entered on the outside
+(right of the vessel). 3. The apex of the right pleura and the trachea
+are in close contact behind, requiring the point of the needle to be
+kept close to the artery in bringing the thread round.</p>
+
+<p>It might have been expected that the sudden arrest<span class='pagenum'><a name="Page_27" id="Page_27">{27}</a></span> of so large a
+proportion of the vascular supply of the body, so very near the heart,
+would cause serious, or even fatal symptoms; this, however, is not the
+case, no serious inconvenience of this sort being experienced; yet
+hitherto every case has proved fatal, either from secondary h&aelig;morrhage
+or inflammation of lungs and pleura.</p>
+
+<p>In fifteen well-authenticated, and in three more doubtful cases, the
+ligature has been applied; all of these died at periods varying from
+twelve hours (as in Hutin's case), to forty-two days as in Thomson's,
+and sixty-seven days (Graefe's).<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">[11]</a></p>
+
+<p>A successful case of ligature of the innominate along with the right
+carotid and (after secondary h&aelig;morrhage) the right vertebral, in a
+mulatto aged thirty-two, for a subclavian aneurism, has been put on
+record by Dr. Smyth of New Orleans, in the <i>American Journal of Medical
+Science</i> for July 1866.</p>
+
+<p>And here we may also note that Mr. Heath has lately treated a case of
+innominate aneurism by simultaneous ligature of the third part of the
+subclavian and the carotid. Both ligatures separated on the eighteenth
+day, and the tumour was much smaller some months afterwards.<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">[12]</a></p>
+
+<p>Mr. R. Barwell has reported several most interesting cases in which
+simultaneous ligature of carotid and subclavian have proved of marked
+benefit in aortic as well as in innominate aneurisms.<a name="FNanchor_13_13" id="FNanchor_13_13"></a><a href="#Footnote_13_13" class="fnanchor">[13]</a></p>
+
+<p>In four cases the operation was attempted, but the operators had to
+desist before the application of the ligature, in consequence of the
+diseased state of the arterial coats. Of these, three died, and one
+(Professor Porter's of Dublin) case recovered, the patient leaving the
+hospital with the aneurism nearly consolidated.<span class='pagenum'><a name="Page_28" id="Page_28">{28}</a></span></p>
+
+<p>Dr. Peixotto of Portugal applied a precautionary ligature to the
+innominate in a case where secondary h&aelig;morrhage occurred from the
+carotid. The ligature was not tightened beyond what was necessary merely
+to cause flattening of the vessel. The patient made a good recovery.</p>
+
+<p>Professor George Porter of Dublin records an interesting case of
+subclavian aneurism, in which, after failing to close the axillary
+artery by acupressure, he applied L'Estrange's compressor to the
+innominate itself for three days, with temporary benefit. The patient
+eventually died of h&aelig;morrhage.<a name="FNanchor_14_14" id="FNanchor_14_14"></a><a href="#Footnote_14_14" class="fnanchor">[14]</a></p>
+
+<p>For a very full and interesting account of ligatures of vessels in root
+of neck we may refer to vol. iii. of the 1883 edition of <i>Holmes'
+Surgery</i>, pp. 119-122.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of Common Carotid</span>.&mdash;Though the anatomical relations of the
+right and left carotid are different at their origin, they so precisely
+resemble each other in the whole of that part of their course which is
+at all amenable to surgical treatment, that one description will suffice
+for both, and the necessary anatomy will be brought out quite
+sufficiently in the description of each operation.</p>
+
+<p>From its giving off no collateral branches, the common carotid artery
+may be tied at any part of its course.</p>
+
+<p>It has been tied successfully at the distance of only three-quarters,
+or, in one case by Porter, hardly to be imitated, one-eighth of an inch
+from the innominate, and up to an equal distance from its bifurcation.
+In choosing the part of the vessel for operation, the operator must be
+guided by the position of the aneurism, if on the vessel itself, but if
+the aneurism be distant, as in scalp or orbit, he need have regard to
+position simply as facilitating the operation.<span class='pagenum'><a name="Page_29" id="Page_29">{29}</a></span></p>
+
+<p>The easiest position in which to apply the ligature is just above the
+omohyoid muscle, the vessel being there superficial.</p>
+
+
+<p class="gap"><span class="smcap">Ligature above Omohyoid</span>.&mdash;Using the anterior border of the
+sterno-mastoid as a guide, but leaving it gradually above to a little
+nearer the mesial line, an incision (<a href="#plate_iv">Plate IV.</a> fig. 1), varying in
+length according to the depth of fat and cellular tissue in the neck,
+but with its central point opposite the upper border of the cricoid
+cartilage, must be made through skin, platysma, and superficial fascia.
+While making the incision the head should be held back, and the face
+slightly turned to the opposite side; the parts being now relaxed by
+position, the edges of the wound must be held apart by blunt hooks or
+copper spatul&aelig;, and the deep fascia carefully divided over the vessel,
+which will be recognised by the pulsation. It may be noted here that
+even in thin subjects the sterno-mastoid edge <i>invariably</i> overlaps the
+vessel, though in many anatomical diagrams it would appear to be in part
+subcutaneous.</p>
+
+<p>The descendens noni may possibly be seen, but this is by no means
+invariably the case, crossing the sheath of the vessel very gradually
+from without inwards in its progress down the neck. It must be carefully
+displaced outwards.</p>
+
+<p>The sheath of the vessel is then to be cautiously opened to the extent
+of about half an inch. The internal jugular vein, possibly much
+distended, may overlap the artery on its outer side, and will require to
+be pressed, emptied, and held out of the way. A small portion of the
+artery being thoroughly separated from the sheath, the aneurism-needle
+must be passed from without inwards to avoid the vein, and keep as close
+to the artery as possible to avoid the vagus.</p>
+
+<p>The tendon of the omohyoid muscle, or, in muscular subjects, a portion
+of its anterior fleshy belly, may be<span class='pagenum'><a name="Page_30" id="Page_30">{30}</a></span> seen crossing the vessel from
+above downwards and outwards at the lower angle of the wound.</p>
+
+<p>An enlarged lymphatic gland has occasionally given much trouble, by
+being mistaken for the vessel and cleaned, while the ligature has even
+been placed on a carefully isolated fasciculus of muscular fibres.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of Carotid below the Omohyoid</span>.&mdash;An incision in precisely the
+same direction as the former, but at a slightly lower level, is
+required, but the dissection is rather more difficult. The edge of the
+sterno-mastoid when exposed must be drawn outwards; the sterno-hyoid and
+thyroid inwards; the omohyoid upwards; the sheath opened, and the
+descendens noni or its branches drawn to the tracheal side. The jugular
+vein and vagus are both at the outer side, and must be avoided, while
+the inferior thyroid artery and sympathetic nerve both lie behind the
+vessel, and may be included in the ligature if care be not taken.</p>
+
+<div class="blockquot smlet"><p><span class="smcap">Varieties</span>.&mdash;<i>Sedillot's Operation.</i>&mdash;To secure the artery still
+lower in the neck: An incision two and a half inches long, from the
+inner end of the clavicle obliquely upwards and outwards in the
+interval between the sternal and clavicular attachments of the
+sterno-mastoid; this divides the superficial textures; the two
+portions of muscle must then be drawn apart. The internal jugular
+vein lies in the interval, and must be drawn to the outside before
+the artery can be seen at all, and it is this that makes this
+operation very difficult and dangerous, especially on the left
+side, where the vein is close to the artery, and probably even
+crossing it from left to right. The thoracic duct is behind.</p>
+
+<p><i>Malgaigne's modification of the above</i> is an improvement: to
+expose the external attachment of the muscle, to cut it through and
+turn it to the outside, as in the operation for ligature of the
+innominate, then to divide or pull inwards sterno-hyoid and
+sterno-thyroid, thus exposing the sheath. The needle must be passed
+from without inwards. </p></div>
+
+<p><i>Results.</i>&mdash;Pilz has collected 600 cases, of which 43.16 per cent. died.
+The united tables of Norris and Wood give 188 cases, with a mortality of
+sixty, or nearly one<span class='pagenum'><a name="Page_31" id="Page_31">{31}</a></span> in three. These tables include cases in which the
+vessel was tied for wounds, and as a preparatory step in the operation
+of removal of tumours of the jaw, etc. Later statistics give a very much
+lessened mortality, due chiefly to the use of animal ligatures.</p>
+
+<p>Of thirty-one cases in which it was tied for pulsating tumours of the
+orbit, only two died from the operation.<a name="FNanchor_15_15" id="FNanchor_15_15"></a><a href="#Footnote_15_15" class="fnanchor">[15]</a> Rivington's statistics to a
+later date give forty-six cases on forty-four patients with six deaths.</p>
+
+<p>Both carotids have been tied in the same patient twenty-five times, at
+intervals of less than a year; and it is a very remarkable fact that
+only five of these fifty ligatures proved fatal,&mdash;two in which both were
+tied on the same day, and three in which the operation was performed to
+arrest h&aelig;morrhage from malignant disease of the face and jaws&mdash;from
+gunshot wound,&mdash;and from syphilitic ulceration.</p>
+
+<p>The external carotid, and also most of its principal branches, have been
+tied for aneurisms, wounds, goitres, enlargement of the tongue, vascular
+tumours on occiput and other lesions; also as a first stage in the
+operation of extirpation of the upper jaw, for the purpose of preventing
+h&aelig;morrhage. However, such operations are rare, and will probably become
+rarer still, and it is hardly necessary to describe the operations on
+each <i>seriatim</i>.</p>
+
+<p>Aneurism of the external carotid or branches are rare; if idiopathic,
+ligature of the common carotid will be found at once easier, not more
+dangerous, and more effectual than ligature of the branch; if traumatic,
+the aneurism itself should be attacked, and the bleeding point secured
+by a double ligature. Wounds are common enough, but if accessible at
+all, the injured vessel should be tied at the bleeding point; if
+inaccessible (and under this head we may include wounds of the internal
+carotid), the common carotid must be tied.<span class='pagenum'><a name="Page_32" id="Page_32">{32}</a></span></p>
+
+<p>No one would think of trying the superior thyroids for goitre, unless
+they were so manifestly enlarged, tortuous, and pulsating, as to render
+the operation so simple (from their superficial position) as to require
+no special directions; besides this, the cases in which it has been
+already done have given very little encouragement to repeat it.</p>
+
+<p>As cases may occur in which any diminution of the cerebral supply is
+contra-indicated, and thus the more difficult ligature of the external
+carotid may be preferred to the more simple operation on the common
+trunk, and as the lingual may require ligature near its root, in
+consequence of obstinate h&aelig;morrhage from the tongue, short directions
+are given for the performance of both these operations.</p>
+
+
+<p class="gap">1. <span class="smcap">Ligature of External Carotid</span>.&mdash;Head in same position as for the
+common carotid. A straight incision parallel with the anterior edge of
+sterno-mastoid, but about half an inch in front of it, must begin almost
+at angle of jaw, and extend downwards nearly to the level of the thyroid
+cartilage. Cautiously divide skin, platysma, and fascia; the lower end
+of the parotid must be pulled upwards, and the veins, which are
+numerous, cautiously separated. The anterior border of the
+sterno-mastoid must be pulled backwards, and the digastric and
+stylo-hyoid forwards and inwards. The superior laryngeal nerve which
+lies behind the vessel must be avoided.</p>
+
+
+<p class="gap">2. <span class="smcap">Ligature of Lingual</span>.&mdash;To secure this vessel either before it becomes
+concealed by the hyo-glossus, or after it is under the muscle, a curved
+incision is necessary, following the line of the hyoid bone, and
+especially of its greater cornu, but a line or two above its upper
+border. After the skin and platysma are divided, the posterior belly of
+the digastric must be<span class='pagenum'><a name="Page_33" id="Page_33">{33}</a></span> recognised, which again will guide to the
+posterior edge of the hyo-glossus. The edge of the sub-maxillary gland
+may very probably require to be raised out of the way. The artery can
+then be secured, either before it dips under the hyo-glossus muscle, or
+after it has done so, by the division of a few of its fibres on a
+director. Care is needed to avoid injury of the hypo-glossal nerve,
+which lies above the muscle.</p>
+
+<p>The internal carotid artery occasionally, but very rarely, is the
+subject of aneurism. It may, like any other artery, be wounded,
+especially from the fauces. The treatment of either of these lesions is
+ligature of the common carotid itself, in preference to ligature of the
+internal carotid. Guthrie's operation for securing the bleeding internal
+carotid at the injured spot, by dividing and turning up the ramus of the
+lower jaw, has never been performed in the living body, and is so
+difficult, dangerous, and unnecessary, as not to merit description.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of Subclavian</span>.&mdash;<i>Note.</i>&mdash;In consequence of the difference in
+the origin, and variety in the anatomical relations of the right and
+left subclavian arteries, in so far at least as their first stage is
+concerned, it is necessary to give a very brief separate account of
+each.</p>
+
+<p><i>Right Subclavian.</i>&mdash;The innominate artery divides into the right
+subclavian and right carotid exactly behind the sterno-clavicular
+articulation. The right subclavian extends from this point in an arched
+form across the neck, between the scalene muscles, over the apex of the
+pleura, till, passing under cover of the clavicle, it changes its name
+to axillary at the lower end of the first rib. For convenience of
+description, the artery is divided into three parts, which have very
+various anatomical relations, and differ from each other much in their
+amenability to surgical treatment by ligature. The anterior scalenus
+muscle defines the three parts, the<span class='pagenum'><a name="Page_34" id="Page_34">{34}</a></span> first extending to the inner border
+of the muscle, the second being concealed by the muscle, and the third
+reaching from its outer border to the lower border of the first rib.</p>
+
+<p><i>Branches of the Subclavian.</i>&mdash;While the deep relations of pleura,
+veins, and nerves can be noticed under the head of each operation in
+detail, one anatomical point must never be forgotten as influencing very
+much the success of all surgical interference with the subclavian
+arteries&mdash;<i>i.e.</i> the branches given off. To give any chance of success
+in the application of a ligature to such a large vessel, so near the
+heart, a large portion of artery free from branches is required, that
+the clot may be long, firm, and undisturbed. The first part of the
+subclavian gives off the vertebral, thyroid axis, and internal mammary;
+the second, the superior intercostal; while the third part has in most
+cases no branch whatever. In these anatomical differences we find the
+reason for the almost invariable fatality resulting on any interference
+with the first and second parts, and the comparative safety of ligature
+of the third part, without requiring to account for the difference on
+other grounds, such as depth of part, importance of nervous relations,
+or nearer proximity to the heart.</p>
+
+<p>The second and third parts of both arteries are so similar to each
+other, that a separate account is not required for the two sides.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of Right Subclavian</span>.&mdash;<i>First Part.</i>&mdash;<i>Operation.</i>&mdash;An incision
+just at upper edge of sternum and right clavicle, extending from inner
+edge of <i>left</i> sterno-mastoid transversely to outer border of right
+sterno-mastoid through skin, platysma, and exposing sterno-mastoid, to
+be joined at an angle by a second incision, which, two, three, or even
+four inches long, must extend along inner border of right
+sterno-mastoid. Flap to be raised upwards and outwards. The sternal<span class='pagenum'><a name="Page_35" id="Page_35">{35}</a></span>
+attachment of the sterno-mastoid must then be cautiously divided, as
+also part or the whole of its clavicular attachment, according as room
+is required. The sterno-hyoid and thyroid muscles will then require
+similar division. The internal jugular will then be seen very
+prominent,<a name="FNanchor_16_16" id="FNanchor_16_16"></a><a href="#Footnote_16_16" class="fnanchor">[16]</a> and will require to be drawn inwards or outwards,
+according to circumstances. The carotid and right subclavian arteries
+will then be felt lying close together crossed by the pneumogastric and
+recurrent nerves, the latter turning behind the subclavian. The nerves
+must be drawn inwards; the cardiac filaments of the sympathetic will
+then be observed, and drawn outwards. The subclavian vein lies below,
+concealed by the clavicle, and will probably not be seen during the
+operation. The needle should be passed round the artery from below
+upwards, care being taken not to injure the pleura, which lies beneath
+and behind the artery.</p>
+
+<p><i>Results.</i>&mdash;Twelve cases, all of which died; ten of h&aelig;morrhage, one of
+pleurisy and pericarditis, and one from py&aelig;mia. Attempted in one case by
+Mr. Butcher, but the artery was too much diseased to bear a ligature.
+The patient died on the fourth day.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of Left Subclavian</span>.&mdash;<i>First Part.</i>&mdash;This operation, which has
+been described by some as impossible, has, I believe, been only once
+performed on the living body. <i>Operation.</i>&mdash;Incisions as for the
+preceding operation, except being on the opposite side. After the skin,
+platysma, and muscles have been divided, as already described, the deep
+cervical fascia requires division close to the inner edge of the
+scalenus anticus. The artery lies excessively deep, and great difficulty
+is experienced in avoiding injury to the pleura and the thoracic duct.</p>
+
+<p><i>Results.</i>&mdash;Once performed by Dr. Rodgers of New York; death from
+h&aelig;morrhage on fifteenth day.<span class='pagenum'><a name="Page_36" id="Page_36">{36}</a></span></p>
+
+<p><i>Anatomical Note.</i>&mdash;The course of the left subclavian in its first stage
+is much straighter, as its origin is much deeper, than on the right
+side. The pneumogastric, phrenic, and cardiac nerves lie parallel to its
+course; the &#339;sophagus and thoracic duct lie behind it, and to its
+inner side.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of Subclavian</span>.&mdash;<i>Second Part.</i>&mdash;This very rare operation hardly
+requires a separate description, as the incisions necessary for ligature
+of the artery in its third part will, with very slight modifications, be
+sufficient for the purpose.</p>
+
+<p>It has, however, special elements of danger in it, involved in the
+unavoidable division, of part at least, or probably the whole, of the
+scalenus anticus. The phrenic nerve, from its position on that muscle,
+requires special care to avoid dividing it, and in most cases the
+internal jugular vein is also in the way. The branches of the thyroid
+axis, which cross the neck, are quite in the line of the incision. The
+lowest cord of the brachial plexus lies immediately behind the artery,
+between it and the middle scalenus. The pleura lies just below it. The
+subclavian vein is generally quite safe, running in front of the
+scalenus anticus, and at a lower level.</p>
+
+<p>The presence of the superior intercostal branch adds greatly to the
+danger of ligature of the vessel in this position, from its interfering
+with a proper clot.</p>
+
+<p><i>Results.</i>&mdash;Dupuytren<a name="FNanchor_17_17" id="FNanchor_17_17"></a><a href="#Footnote_17_17" class="fnanchor">[17]</a> performed it successfully for a traumatic
+axillary aneurism. Auchincloss<a name="FNanchor_18_18" id="FNanchor_18_18"></a><a href="#Footnote_18_18" class="fnanchor">[18]</a> did it for a large true aneurism, but
+the patient died sixty-eight and a half hours after the operation.
+Liston cut through the outer portion of the scalenus with success for an
+idiopathic aneurism. Thirteen have been collected by Wyeth with four
+recoveries and nine deaths.<span class='pagenum'><a name="Page_37" id="Page_37">{37}</a></span></p>
+
+
+<p class="gap"><span class="smcap">Ligature of Subclavian</span>.&mdash;<i>Third Part.</i>&mdash;For this comparatively common
+operation, various methods of procedure have been suggested and
+employed.</p>
+
+<p>In the dead body, where the axilla is free from swelling, and in thin
+patients, the artery in this third stage is tolerably superficial, and
+can be secured with ease. But in very muscular men, with short necks and
+well curved clavicles, and specially when the axilla is filled up with
+an aneurism, and the shoulder cannot be depressed, the operation becomes
+very difficult.</p>
+
+<p><i>Operation of Ramsden, Liston, and Syme.</i>&mdash;<i>Position.</i>&mdash;The patient
+lying on his back with his shoulders supported by pillows, and his head
+lying back, and drawn to the opposite side; the shoulder of the affected
+side must be depressed as much as possible.</p>
+
+<p><i>Incisions.</i>&mdash;(<a href="#plate_i">Plate I.</a> fig. 8.)&mdash;One through skin, superficial fascia,
+and platysma, along the upper edge of the clavicle, for at least three
+inches from the anterior edge of the trapezius to the posterior border
+of the sterno-mastoid, and in muscular subjects freely overlapping the
+edges of both muscles. Another two inches in length along posterior
+border of sterno-mastoid meets the first at an angle. On reflecting the
+chief flap thus made upwards and backwards, the external jugular will be
+seen, and, if possible, must be drawn to a side; if not, it must be
+divided, and both ends tied. The lower edge of the posterior belly of
+the omohyoid must then be sought; this leads at once to the posterior or
+outer margin of the scalenus anticus. The connection of the deep fascia
+to that muscle must then be very carefully scraped through, and by
+tracing the muscle to its insertion to the first rib, the artery is at
+once reached, lying behind the insertion. The pulsation of the vessel
+between the forefinger and the first rib will prove a great assistance;
+yet care is required, lest one of the branches of the brachial plexus be
+secured instead of the artery. The lowest cord lies very close to the
+vessel. The subclavian vein is not<span class='pagenum'><a name="Page_38" id="Page_38">{38}</a></span> likely to give much trouble, from
+its being on a lower level, and (unless very much dilated) nearly
+concealed by the clavicle. The suprascapular artery is also hidden, but
+the transverse cervical crosses the very line of incision, and may give
+trouble, being occasionally much enlarged, so much so as even for a time
+to have been mistaken for the subclavian itself. If possible, both these
+branches should be saved, as being important means of carrying on the
+anastomosis for the future support of the limb.</p>
+
+<p>An absorbent gland is occasionally in the way, and has even been
+mistaken for the vessel and carefully cleaned. Such may be removed
+without scruple.</p>
+
+<p>Care must be taken not to injure the pleura, which lies immediately
+behind and below the vessel at the seat of ligature. Various
+instrumental devices have been invented for passing the ligature. The
+simplest seems still to be best, a common aneurism-needle with a
+considerable curve.</p>
+
+<div class="blockquot smlet"><p><i>Other methods of operating.</i>&mdash;A single curved incision above the
+clavicle, with its concavity upwards, of about three or four inches
+long, with its inner end rather higher than the outer (Green,
+Fergusson).</p>
+
+<p>A linear transverse incision in the same situation (Velpeau).</p>
+
+<p>A single linear incision perpendicular to the clavicle (Roux).</p>
+
+<p>An arched incision (<a href="#plate_iv">Plate IV.</a> fig. 2) with its convexity outwards,
+and its base on the posterior edge of the sterno-mastoid, from
+three inches above the clavicle to the clavicular attachment of the
+muscle (Skey). </p></div>
+
+<p><i>Results.</i>&mdash;Dr. Wyeth's Tables in 1877 give 251 cases with 134 or 53 per
+cent. of deaths.</p>
+
+<div class="blockquot smlet"><p>The late Mr. Furner of Brighton reported a most interesting case,
+in which he tied both subclavian arteries at an interval of two
+years in the same patient, for axillary aneurisms, with success. </p></div>
+
+
+<p class="gap"><span class="smcap">Ligature of Axillary.</span>&mdash;<i>Anatomical Note.</i>&mdash;This vessel, the next stage
+in the continuation of the subclavian<span class='pagenum'><a name="Page_39" id="Page_39">{39}</a></span> downwards, may be defined
+surgically as extending from the clavicle to the lower border of the
+teres major. From the depth of the vessel at its upper part, the
+numerous nerves, and the close proximity of the vein, the surgeon has
+carefully to study the anatomical relations. It, like the subclavian, is
+commonly divided into three stages, and, also like the subclavian, these
+stages are defined by the relations of the artery to a muscle, the
+pectoralis minor. Surgically we may draw a very close parallel between
+the two vessels, for we find that in the axillary, as in the subclavian,
+the first stage is very deep, and very rarely amenable to ligature; the
+second, still deeper and more rarely attempted, as in both the operation
+involves division of a deep muscle; while the third stage in each is the
+one most frequently chosen by the surgeon.</p>
+
+<p><i>First Stage.</i>&mdash;Between the lower edge of the first rib and upper border
+of the pectoralis minor the vessel is deeply seated, contained in that
+process of deep fascia called the costo-coracoid membrane, and covered
+above by skin, platysma, and the clavicular portion of the pectoralis
+major. It lies on the first intercostal muscle and the upper digitation
+of the serratus magnus, while the cords of the brachial plexus are on
+its acromial side, and the axillary vein in close contact with it on its
+thoracic side, and frequently overlapping the artery.</p>
+
+<p><i>Operation.</i>&mdash;The great desideratum is free access. An incision (<a href="#plate_i">Plate
+I.</a> fig. 9), semilunar in shape, with its convexity downwards, must
+extend from half an inch outside of the sterno-clavicular articulation
+to very near the coracoid process, stopping just before it arrives at
+the edge of the deltoid, in order to avoid injury of the cephalic vein.
+It must include skin, fascia, and platysma, and the flap must be thrown
+upwards. The clavicular portion of the pectoralis major must then be
+divided right across its fibres, which will retract. The arm must then
+be brought close to the side to relax the<span class='pagenum'><a name="Page_40" id="Page_40">{40}</a></span> pectoralis minor, which must
+be drawn aside. The artery will then be felt pulsating, but hidden by
+the costo-coracoid membrane, which acts as its sheath. This must be
+carefully scratched through, the nerves pulled outwards, the vein
+avoided and pulled downwards and inwards, and the thread passed round
+from within outwards. (Manec, Hodgson, and, with slight modification in
+the incision through the skin, Chamberlaine.)</p>
+
+<div class="blockquot smlet"><p>Ligature has been performed in this position by separating the
+pectoralis and deltoid muscles, without dividing the muscular
+fibres (Roux, Desault).</p>
+
+<p>To attempt to gain access between the clavicular and sternal
+portions of pectoralis major, as has been proposed by some, is
+almost impracticable in the living body, from the position of the
+vein, to which, rather than to the artery, this incision leads. </p></div>
+
+
+<p class="gap"><span class="smcap">Ligature of Axillary</span>, <i>in its second stage</i>, is not an advisable
+operation, when it is merely intended to throw a ligature round the
+artery for an aneurism lower down.</p>
+
+<p>It has been performed at least twice by Delpech, but it is a rude
+procedure; in his cases, after the muscle was cut, a dive with the
+finger was made to collect the whole mass of vessels and nerves, and
+bring them to the surface near the collar-bone; in this position it is
+said the artery was easily isolated and tied.</p>
+
+<p>In Mr. Syme's operation of cutting into large axillary aneurisms, and
+tying both ends of the vessel, the pectoralis minor may, indeed
+generally has, to be divided, and must take its chance without any
+special notice or precaution, in the sweeping, free incisions required.</p>
+
+
+<p class="gap"><span class="smcap">Ligature of Axillary</span> <i>in its third stage</i>.&mdash;This is an operation very
+much more common, more easy of accomplishment, and safer in its results
+than either of the preceding; the artery in this stage being more
+superficial, in fact almost subcutaneous.</p>
+
+<p><i>Operation.</i>&mdash;The arm being extended and supinated, an incision (<a href="#plate_i">Plate
+I.</a> fig. 10) two and a half or three<span class='pagenum'><a name="Page_41" id="Page_41">{41}</a></span> inches long, must be made in the
+base of the axilla over the artery, involving at first skin and
+superficial fascia only; the deep fascia is then exposed and must be
+carefully scraped through, avoiding injury of the basilic vein, if (as
+sometimes occurs) it has not yet dipped through the fascia. The vessel
+can now be felt; the median nerve which lies over the artery, or
+slightly to its outer side, must be drawn outwards, and the axillary
+vein, which lies at the thoracic side, but often overlaps the vessel,
+must be carefully drawn inwards. The ligature must then be passed from
+within outwards.</p>
+
+<p>When the patient is very fat or muscular, the coraco-brachialis muscle
+may be required as a guide to the vessel; but in general its superficial
+position renders any guide quite unnecessary, even in the dead body.</p>
+
+<p><i>Anatomical Note.</i>&mdash;While in each stage the axillary artery gives off
+branches, those arising from the third stage are by far the most
+important, especially the subscapular, which leaves it at the edge of
+the muscle of the same name. To avoid these the ligature should be
+applied as low down on the vessel as possible, and, in point of fact,
+the operation called ligature of the third stage of the axillary is,
+anatomically speaking, really ligature of the brachial high up, and
+where there is room at all, there will be the less chance of secondary
+h&aelig;morrhage, the greater the distance is between the ligature and the
+great subscapular branch.</p>
+
+<p><i>Mr. Syme's Operation for Axillary Aneurism.</i>&mdash;Description of the
+operation in his own words:&mdash;</p>
+
+<p>"Chloroform being administered, I made an incision along the outer edge
+of the sterno-mastoid muscle, through the platysma myoides and fascia of
+the neck, so as to allow a finger to be pushed down to the situation
+where the subclavian artery issues from under the scalenus anticus and
+lies upon the first rib. I then opened the tumour, when a tremendous
+gush of blood showed that the artery was not effectually compressed;<span class='pagenum'><a name="Page_42" id="Page_42">{42}</a></span>
+but while I plugged the aperture with my hand, Mr. Lister, who assisted
+me, by a slight movement of his finger, which had been thrust deeply
+under the upper edge of the tumour, and through the clots contained in
+it, at length succeeded in getting command of the vessel. I then laid
+the cavity freely open, and with both hands scooped out nearly seven
+pounds of coagulated blood, as was ascertained by measurement. The
+axillary artery appeared to have been torn across, and as the lower
+orifice still bled freely, I tied it in the first instance. I next cut
+through the lessor pectoral muscle close up to the clavicle, and holding
+the upper end of the vessel between my finger and thumb, passed an
+aneurism-needle, so as to apply a ligature about half an inch above the
+orifice."<a name="FNanchor_19_19" id="FNanchor_19_19"></a><a href="#Footnote_19_19" class="fnanchor">[19]</a></p>
+
+<p>In a similar operation lately performed by the author for traumatic
+aneurism, the result of a stab, very little blood was lost, though no
+incision was made above the clavicle. The patient made a good
+recovery.<a name="FNanchor_20_20" id="FNanchor_20_20"></a><a href="#Footnote_20_20" class="fnanchor">[20]</a></p>
+
+
+<p class="gap"><span class="smcap">Ligature of Brachial.</span>&mdash;To arrest h&aelig;morrhage from a wound of the artery
+itself, no special directions are required, except to enlarge the wound,
+and secure the vessel above and below the bleeding point. There are,
+however, rare cases in which for bleeding in the palm (after all other
+means have failed), or for aneurism lower down the arm, a ligature may
+be necessary.</p>
+
+<p><i>Operation.</i>&mdash;The biceps muscle, at its inner edge, is the best guide to
+the position of the incision, or if it be obscured by fat or &#339;dema, a
+line extending from the axilla, just over the head of the humerus to the
+middle of the bend of the elbow will define its course. An incision
+(<a href="#plate_i">Plate I.</a>, fig. 11) three inches in length, about the middle of the arm
+(when you have the choice of position), through skin and superficial
+fascia, will expose the deep<span class='pagenum'><a name="Page_43" id="Page_43">{43}</a></span> fascia, and probably the basilic vein.
+Drawing the latter aside, cautiously divide the deep fascia. The artery
+is then exposed, but in close relation to various nerves; of these the
+ones most likely to come in the way are&mdash;1. The median, which lies in
+front of, but a little to the outside of the artery, though in some rare
+cases it lies behind it; 2. The internal cutaneous; 3. The ulnar, both
+of which ought to be rather to the inside of the artery. Two brachial
+veins accompany and wind round the vessel, occasionally interlacing.
+Pulsation will, in the living body, usually suffice to distinguish the
+artery from the other textures, and the ligature may be passed from
+whichever side is most convenient.</p>
+
+<div class="blockquot smlet"><p><i>Note.</i>&mdash;The relation of the median nerve to the vessel varies
+according to the part of the arm&mdash;thus, as low as the insertion of
+the coraco-brachialis it is to the outer side, as has been
+described, it then crosses the vessel obliquely, and two inches
+above the elbow it is on the inner side of the artery. Again, the
+operator must never forget the possibility of there being a high
+division of the artery. This occurs, Mr. Quain has shown, perhaps
+once in every ten or eleven cases, and may necessitate ligature of
+both trunks. </p></div>
+
+<p>In those cases (once much more frequent than at present) where an
+aneurism has formed after a wound of the brachial at the bend of the arm
+in venesection, the aneurism may be either circumscribed or diffuse.</p>
+
+<p>If circumscribed, it is advised by some surgeons, specially by the late
+Professor Colles of Dublin, that the brachial should be tied immediately
+above the tumour. In most cases of circumscribed, and in all such cases
+of diffuse aneurism, the preferable operation is boldly to lay open the
+tumour, turn out all the clots, seek for the wound in the artery, and
+tie the vessel above and below. A tourniquet above, or, better still, a
+trustworthy assistant, prevents all fear of h&aelig;morrhage, and such a
+radical operation exposes the limb to far less chance of gangrene than
+do any attempts at removing or lessening the tumour by pressure (as
+recommended by Cusack, Tyrrell,<span class='pagenum'><a name="Page_44" id="Page_44">{44}</a></span> Harrison), and is much more certain
+than a mere ligature above.<a name="FNanchor_21_21" id="FNanchor_21_21"></a><a href="#Footnote_21_21" class="fnanchor">[21]</a></p>
+
+
+<p class="gap"><span class="smcap">Ligature of Vessels in Fore-arm</span>.&mdash;Here, as also we found is the case in
+the leg, it is almost useless to go on giving exact directions as to the
+method of throwing a ligature round the vessels in all possible
+situations.</p>
+
+<p>For below the elbow spontaneous aneurism is almost unknown, and even
+traumatic aneurisms are extremely rare. It is therefore for h&aelig;morrhage
+only that the vessels are likely to require ligature, and it is a rule
+in surgery that to enlarge the wound and to apply a ligature above and
+below the bleeding point is better practice than to apply a ligature at
+a distance.</p>
+
+<p>In the case of wounds of the palmar arch, it is extremely difficult, and
+very apt to injure the future usefulness of the hand, thus to seek for
+the bleeding point under the palmar fascia, and for <i>these</i>, ligatures
+of radial and ulnar have occasionally been practised. However, as even
+this has proved ineffectual, and the interosseous has proved sufficient
+to continue the bleeding, ligature of the brachial at once is preferable
+to ligature of so many branches in the fore-arm.</p>
+
+<p>The use of graduated compresses, carefully applied, combined with
+flexion of the elbow over a bandage, will generally prove sufficient to
+check such h&aelig;morrhage from the palm, without having recourse to either
+of the above more severe measures.</p>
+
+<div class="blockquot smlet"><p><i>Note.</i>&mdash;As in the lower limb at page 24, and for the same reasons,
+I here insert a brief account of the methods of tying the ulnar and
+radial arteries.</p>
+
+<p>1. <span class="smcap">Ligature of Ulnar</span>.&mdash;Only admissible in the lower half of its
+course. <i>Operation.</i>&mdash;Use the tendon of the flexor carpi ulnaris as
+a guide, and make an incision along its radial edge, at least two
+inches in length; expose the deep fascia of the arm and then
+cautiously divide it; then bending the hand, the flexor carpi
+ulnaris is relaxed, and the artery is found lying pretty<span class='pagenum'><a name="Page_45" id="Page_45">{45}</a></span> deeply
+between it and the flexor sublimis digitorum. The ulnar nerve lies
+at its ulnar side, and the ven&aelig; comites accompany the artery. In a
+tolerably muscular arm, the incision will have to be about an inch
+inside of the ulnar border of the limb.</p>
+
+<p>2. <span class="smcap">Radial</span>.&mdash;This artery lies more superficial than the preceding,
+and may be tied at any part of its course.</p>
+
+<p><i>A.</i> Operation in upper part of fore-arm. Here the artery lies in
+the interval between the supinator longus and the pronator radii
+teres. In a muscular arm, the edge of the former muscle is the best
+guide; in a fat one, the incision may be made in a line extending
+from the centre of the bend of the arm to the inner edge of the
+styloid process of the radius. The deep fascia must be exposed and
+opened, and the muscles relaxed and held aside. The radial nerve
+lies on the radial side of the vessel.</p>
+
+<p><i>B.</i> Operation in lower half of arm. Here the vessel is more
+superficial, lying in the groove between the flexor carpi radialis
+and supinator longus. An incision two inches in length, and
+parallel with these tendons, easily exposes the artery. The nerve
+is still on its radial side.</p>
+
+<p><i>C.</i> Operation at first metacarpal. The artery may be tied easily
+enough in the triangular space bounded by the extensors of the
+thumb, on the dorsum of the proximal end of the first metacarpal
+bone. Skey<a name="FNanchor_22_22" id="FNanchor_22_22"></a><a href="#Footnote_22_22" class="fnanchor">[22]</a> recommends a transverse,&mdash;Stephen Smith<a name="FNanchor_23_23" id="FNanchor_23_23"></a><a href="#Footnote_23_23" class="fnanchor">[23]</a> and
+others, a longitudinal incision. The author had lately to secure
+the radial in its lower third, the superficialis vol&aelig;, and the
+radial again in the triangular space, in a case where division of
+the artery by a transverse cut had caused a large aneurism to form
+close above the annular ligament.</p>
+
+<p><span class="smcap">Table</span> illustrating anastomotic circulation after ligature of
+arteries of neck and upper limb.</p>
+
+<p>1. Common carotid.</p>
+
+<p>(<i>a</i>) Across middle line: thyroids, linguals, facials, occipitals;
+also terminal branches of external carotids; also internal carotids
+by circle of Willis.</p>
+
+<p>(<i>b</i>) Of same side: occipital with vertebral; superior thyroid with
+inferior thyroid, etc.</p>
+
+<p>2. Subclavian, 3d part.</p>
+
+<p>Suprascapular with dorsal branches of subscapular; posterior
+scapular with costal and muscular branches of subscapular. Thoracic
+anastomosis between internal mammary and intercostals, with
+branches of axillary.</p>
+
+<p>3. Axillary and brachial. Anastomosis varies with the position of
+the ligature, but is very free between the various muscular
+branches of these vessels. </p></div>
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_46" id="Page_46">{46}</a></span></p>
+
+<h2><a name="CHAPTER_II" id="CHAPTER_II"></a>CHAPTER II.</h2>
+
+<h3>AMPUTATIONS.</h3>
+
+
+<p>In ordinary surgical language the name Amputation is applied to all
+cases of removal of limbs, or portions of limbs, by the knife, though in
+strict accuracy it should be restricted to those cases in which a limb
+is removed <i>in the continuity of a bone</i>, its removal <i>at a joint</i> being
+called a Disarticulation.</p>
+
+<p>The briefest outline of a history of amputation would fill a work much
+larger than the present. I may be allowed in a few sentences to attempt
+to show the principle on which such a sketch should be written, in
+describing the three great eras of progress in improvement of the
+methods of amputating.<a name="FNanchor_24_24" id="FNanchor_24_24"></a><a href="#Footnote_24_24" class="fnanchor">[24]</a></p>
+
+<p>I. Prior to the invention, or at least prior to the general
+introduction, of the ligature and the tourniquet, the great barrier to
+all improvement in operating was the impossibility of checking
+h&aelig;morrhage during an operation, and after its conclusion. Many surgeons
+would not amputate at all, others only through gangrenous parts; others
+more bold, only at the confines of parts in which gangrene had been
+artificially induced by tight ligatures.</p>
+
+<p>With the exception of Celsus, who in one place recommends a flap to be
+dissected up, and the bone thus<span class='pagenum'><a name="Page_47" id="Page_47">{47}</a></span> divided at a higher level, all were in
+too great a hurry to get the operation completed to think of flaps. Cut
+through all the parts at the same level with a red-hot knife, if you
+will, like Fabricius Hildanus; by a single blow with a chisel and
+mallet, like Scultetus; or by a crushing guillotine, like Purmannus: or
+by two butchers' chopping-knives fixed in heavy blocks of wood, one
+fixed, the other falling in a grove, like Botal; and then try to check
+the bleeding by tying a pig's bladder over the face of the stump, like
+Hans de Gersdorf; or tying it up in the inside of a hen newly killed; or
+by plunging it at once into boiling pitch.</p>
+
+<p>We are the less surprised to read of Celsus's description of a flap
+operation, when we remember that it is almost certain that Celsus <i>was</i>
+acquainted with the ligature as a means of checking h&aelig;morrhage.<a name="FNanchor_25_25" id="FNanchor_25_25"></a><a href="#Footnote_25_25" class="fnanchor">[25]</a></p>
+
+<p>II. A new era was ushered in when, about 1560, Ambrose Par&eacute; invented, or
+re-introduced, the ligature as a means of arresting h&aelig;morrhage, but not
+for more than a century after this did the full benefit of his discovery
+begin to be felt, when the tourniquet was introduced by Morel at
+Besan&ccedil;on in 1674, and James Young of Plymouth in 1678, and improved by
+Petit in 1708-10.</p>
+
+<p><i>Now</i> surgeons had time to look about them during an amputation, and to
+try to get a good covering for the bone, so that the stump might heal
+more rapidly and bear pressure better. Great improvements were rapidly
+made, and any history of these improvements would need to trace two
+great parallel lines, one the circular method, the other the flap
+operation.</p>
+
+<p>1. The old method in which the limb was lopped off by one sweep, all the
+tissues being divided at the same level, might be called the true
+circular. This, however, was soon improved<span class='pagenum'><a name="Page_48" id="Page_48">{48}</a></span>&mdash;</p>
+
+<p><i>A.</i> By Cheselden and Petit, who invented the double circular incision,
+in which first the skin and fat were cut and retracted, and then the
+muscle and bone were divided as high as exposed.</p>
+
+<p><i>B.</i> By Louis, who improved this by making the first incision include
+the muscles also, the bone alone being divided at the higher level.</p>
+
+<p><i>C.</i> By Mynors of Birmingham, who dissected the skin back like the
+sleeve of a coat, and thus gained more covering.</p>
+
+<p><i>D.</i> Then comes the great improvement of Alanson, who first cut through
+skin and fat, and allowing them to retract, next exposed the bone still
+further up by cutting the muscles obliquely so as to leave the cut end
+of the bone in the apex of a conical cavity.</p>
+
+<p><i>E.</i> An easier mode, fulfilling the same indications, is found in the
+triple incision of Benjamin Bell of Edinburgh, who in 1792 taught that
+first the skin and fat should be divided and retracted, next the
+muscles, and lastly the bone.</p>
+
+<p><i>F.</i> A slight improvement on <i>E</i>, made by Hey of Leeds, who advised that
+the posterior muscles of the limb should be divided at a lower level
+than the anterior, to compensate for their greater range of contraction.</p>
+
+<p>2. In the progress of the flap operation fewer stages can be defined.
+Made by cutting from within outwards, after transfixion of the limb, the
+flaps varied in shape, size, position, and numbers, from the single
+posterior one of Verduyn of Amsterdam, to the two equal lateral ones of
+Vermale, and the equal anterior and posterior ones of the Edinburgh
+school.</p>
+
+<p>Then came the battle of the schools: flap or circular.</p>
+
+<p><i>Flap.</i>&mdash;Speedy, easy, and less painful; apt to retract, and that
+unequally.</p>
+
+<p><i>Circular.</i>&mdash;Leaving a smaller wound, but more slow in performance, and
+apt to leave a central adherent cicatrix.<span class='pagenum'><a name="Page_49" id="Page_49">{49}</a></span></p>
+
+<p>3. The last era in amputation began after the introduction of
+an&aelig;sthetics. Now speed in amputation is no object, and the surgeon has
+full time to shape and carve his flaps into the curves most suited for
+accurate apposition, and suitable relation of the cicatrix to the bone.
+It has also been brought clearly out that different methods of operating
+are suitable for different positions, and also that even in the same
+operation it is possible to unite the advantages of both the flap and
+the circular method.</p>
+
+<p>In the modified circular, which is best suited for amputation below the
+knee, in the long anterior flaps of Teale, Spence, and Carden, we have
+illustrations of the manner in which the advantages of both the flap and
+circular methods have been secured, without the disadvantages of either.
+The long anterior flap, not like Teale's to fold upon itself, but like
+Spence's and Carden's to hang over and shield the end of the bones, and
+the face of a transversely-cut short posterior flap, seems to be now the
+typical method for successful amputations. There may be exceptions, as
+when the anterior skin is more injured than the posterior, or where an
+anterior flap would demand too great sacrifice of length of limb, but as
+a rule it will be found the best method for the patient.</p>
+
+
+<div class="figleft" style="width: 150px;">
+<img src="images/050a.jpg" width="150" height="225" alt="Fig. I." title="Fig. I. " />
+<span class="caption smcap">Fig. i.</span>
+</div>
+
+<p class="gap"><span class="smcap">Amputation of the Upper Extremity</span>.&mdash;The extreme importance of the human
+hand, its tactile sensibility, its grasping power, and the irreparable
+loss sustained by its removal, render the greatest caution necessary,
+lest we should remove a single digit or portion of one that might be
+saved. In cases of severe smashing injuries involving the fingers, it is
+the surgeon's bounden duty not recklessly to amputate the limb with neat
+flaps at the wrist-joint, but carefully to endeavour to save even a
+single finger from the wreck, though at the risk of a longer
+convalescence, or even of<span class='pagenum'><a name="Page_50" id="Page_50">{50}</a></span> a profuse suppuration. While a toe or two, or
+a small longitudinal segment of the foot, may be comparatively useless,
+and a good artificial foot, with an ankle-joint stump, certainly
+preferable, a single finger, provided its motions are tolerably intact,
+will prove much more valuable to its possessor than the most ingeniously
+contrived artificial hand.</p>
+
+<p>However, while in cases of extensive smash we endeavour to save anything
+we can, the case is very much altered when it is only one or two fingers
+that are injured. Here we find another principle brought into play, and
+our conservative surgery must be limited by the following consideration.
+In endeavouring to save a portion of the injured finger or fingers, will
+the saved portion interfere with the important movements of the
+uninjured ones? These two principles&mdash;1. Generally to save as much as we
+can; 2. Not to save anything which may be detrimental or in the
+way,&mdash;will guide us in describing the amputations of the upper
+extremity.</p>
+
+<div class="figleft" style="width: 100px;">
+<img src="images/050b.jpg" width="100" height="385" alt="Fig. II." title="Fig. II." />
+<span class="caption smcap">Fig. ii.</span>
+</div>
+
+<p><i>Amputation of a distal phalanx.</i>&mdash;This small operation is not very
+often required. In cases of whitlow in which the distal phalanx alone
+has necrosed, removal of the necrosed bone by forceps is generally all
+that is necessary. In cases of injury, however, in which nail and distal
+phalanx are both reduced to pulp, it will hasten recovery much to remove
+the extremity. There is no choice as to flap, the nail preventing an
+anterior one, so a flap long enough to fold over must be cut from the
+pulp of the finger in either of two ways (Fig. <span class="smcap">i</span>. 1):&mdash;1. Holding the
+fragment to be removed in the left hand, and bending the<span class='pagenum'><a name="Page_51" id="Page_51">{51}</a></span> joint, the
+surgeon makes a transverse cut across the back of the finger, right into
+and through the joint, cutting a long palmar flap from within outwards
+as he withdraws the knife.</p>
+
+<div class="blockquot smlet"><p><i>Note.</i>&mdash;Some difficulty is often felt in making the dorsal
+incision so as exactly and at once to hit the joint; the most
+common mistake being, that the transverse incision is made too
+high, and the knife, instead of striking the joint, only saws
+fruitlessly at the neck of the bone above. To avoid this, the
+surgeon should take as a guide to the joint, not the well-marked
+and tempting-looking <i>dorsal</i> fold in the skin, but the <i>palmar</i>
+one, which exactly corresponds with the joint between the proximal
+and middle phalanges, and is only about a line above the distal
+articulation.&mdash;(Fig. <span class="smcap">ii</span>.) </p></div>
+
+<p>2. Making the long flap by transfixion, it may be held back by an
+assistant, and the joint cut into.</p>
+
+<p><i>Amputation through the second phalanx.</i>&mdash;If the distal phalanx be so
+much crushed that a flap cannot be obtained, two short semilunar lateral
+flaps may be dissected (Fig. <span class="smcap">i</span>. 2) from the sides of the second phalanx,
+which may then be divided by the bone-pliers at the spot required.</p>
+
+<p>In cases of injury which do not admit of either of the preceding
+operations, it is quite possible to amputate either at the first joint,
+or even through the proximal phalanx. Patients are sometimes anxious for
+such operations in preference to amputation of the whole finger. The
+surgeon should, however, never amputate through a finger higher up than
+the distal end of the second phalanx, unless absolutely compelled by the
+patient, for the resulting stump, being no longer commanded by the
+tendons, will prove merely an incumbrance, and may possibly require a
+secondary operation at no distant date for its removal.</p>
+
+<p>This rule is applicable in cases in which a single finger is injured,
+and two or three complete ones are left; in cases where all the fingers
+have been<span class='pagenum'><a name="Page_52" id="Page_52">{52}</a></span> mutilated every morsel should be left, and may be of use.</p>
+
+<p><i>Amputation of a whole finger.</i>&mdash;(Fig. <span class="smcap">i</span>. 3)&mdash;This is an operation of
+great importance, from its frequency.</p>
+
+<p>If the third or fourth digits require amputation, it should be performed
+as follows:&mdash;The vessels of the arm being commanded, an assistant holds
+the hand, separating the fingers at each side of the one to be removed.
+The surgeon holding the finger to be removed, enters the point of a long
+straight bistoury exactly (some authorities say half an inch) above the
+metacarpo-phalangeal joint, and cuts from the prominence of the knuckle
+right into the angle of the web, then, turning inwards there, cuts
+obliquely into the palm to a point nearly opposite the one at which he
+set out.</p>
+
+<div class="blockquot smlet"><p><i>Note.</i>&mdash;While most authorities agree with the direction in the
+text regarding the palmar termination of the incision, I believe,
+in most cases, it is not necessary to go so far, and that the
+incisions may fitly meet in the palm at a point midway between a
+point opposite to the knuckle, and the centre of the well-marked
+"sulcus of flexion." </p></div>
+
+<p>He then repeats this incision on the other side, makes tense the
+ligaments, first at one side and then at the other, by drawing the
+finger to the opposite side, and cuts them. The tendons being cut, the
+finger is detached. The vessels being tied, one point of suture is put
+in on the dorsal aspect, and the fingers on each side tied together at
+their extremities, with a pad of lint between them.</p>
+
+<div class="blockquot smlet"><p><i>Modification.</i>&mdash;Lisfranc's method is too long in its minute
+description to give in detail. The principle is to make a semilunar
+flap at one side (the one opposite the operator's right hand), by
+cutting from without inwards, then to open the joint from this cut,
+and, still keeping the edge of the knife close to the head of the
+phalanx, cutting the other flap from within outwards. This can be
+very rapidly done, but the last flap is apt to be irregular<span class='pagenum'><a name="Page_53" id="Page_53">{53}</a></span> and
+deficient, especially in those common cases, in which, after
+whitlow or the like, the tissues are hard and brawny, and the skin
+does not play freely. </p></div>
+
+<p>It is quite unnecessary to remove the head of the metacarpal, either for
+the sake of appearance, or to render healing more rapid, and its removal
+weakens the arch of the hand; where the cartilage is eroded by disease,
+the cartilage-covered portion can be scooped off by a gouge or removed
+entire by pliers, without interfering with the broad end to which the
+transverse ligament of the palm is attached. If required either for
+injury or disease, the metacarpal head may be easily removed by a single
+straight incision from the knuckle upwards, as far as the point at which
+it may be deemed necessary to saw it through, or better still, divide it
+with the bone-pliers. This incision should be made as a first step in
+the first incision for amputation of the finger, and the finger should
+not be disarticulated, but kept on, to aid by its leverage in separating
+the metacarpal head.</p>
+
+<p><i>Amputation of the index or little fingers.</i>&mdash;This operation differs
+from the preceding only in this, that care must be taken to make a good
+large flap on the free side of each; making the incision, which begins
+at the knuckle (Fig. <span class="smcap">i</span>. 4), enclose a well-rounded flap, and not
+allowing it to enter the palm till it reaches the level of the web
+between the fingers. The metacarpal heads may here be cut obliquely with
+the bone-pliers, to prevent undue projection.</p>
+
+<p><i>Amputation of one or more metacarpals.</i>&mdash;These operations may be
+rendered necessary by disease or injury. If the latter demands their
+performance, no rules can be given for incisions or flaps, they must
+just be obtained where and how they can best be got. If for disease, a
+single dorsal incision (Fig. <span class="smcap">i</span>. 5) over the bone will allow it to be
+dissected out of the hand.</p>
+
+<p><i>N.B.</i>&mdash;In no case, except that of the thumb, should<span class='pagenum'><a name="Page_54" id="Page_54">{54}</a></span> any attempt be
+made to save a finger while its metacarpal is removed. (See <i>Excisions
+of Bones</i>.)</p>
+
+<p><i>Amputation of first and fifth metacarpals.</i>&mdash;Various special operations
+have been devised for speedy and elegant removal of these bones. Their
+disadvantages, etc., are fully detailed under <i>Amputations of the Foot</i>.</p>
+
+<p>The vascularity and consequent vitality of the tissues of the hand and
+arm sometimes afford very encouraging and satisfactory results in
+conservative operations.</p>
+
+<p>The following is an instance of what may be accomplished in a young
+healthy subject.</p>
+
+<p>A. A., &aelig;t. 18, ploughman, was harnessing a vicious horse, when it caught
+his right hand between its teeth, and gave a severe bite. On admission,
+I found the middle and ring fingers completely separated at the
+metacarpal joints, but each hanging on by a portion of skin, the middle
+by the skin on its radial side, the ring by that on its ulnar. The back
+and the palm were both stripped of skin up to the middle of the third
+and fourth metacarpal bones, which were exposed, but not fractured. As
+it was important for him to maintain the transverse arch of the hand
+intact, I determined to make an attempt to save the metacarpals, and
+finding that the skin on the radial side of the middle, and ulnar side
+of the ring fingers, was still warm, and apparently alive, I carefully
+dissected as long a flap as possible from each, and then folded them
+down, one at the front, the other at the back of the hand. The flaps
+survived, and the result was admirable, the patient being able in a very
+few weeks to guide the plough. The sensation in his new palm and back of
+the hand is very peculiar, they being still the fingers, so far as
+nervous supply is concerned.</p>
+
+<p>In amputations involving the metacarpals for injury, it is always
+important to avoid entering the carpo-metacarpal joint, hence if it can
+be done it is best to<span class='pagenum'><a name="Page_55" id="Page_55">{55}</a></span> saw through the bones at the required level,
+rather than disarticulate. This rule should be observed even in those
+cases in which the thumb alone can be saved, for notwithstanding the
+isolation of the joint between the first metacarpal and the trapezium,
+it is very important for the future use of this one digit that the
+motions both of the wrist and carpal joints should be preserved entire.</p>
+
+<p>No exact rules can be given for the performance of these operations, as
+the size and positions of the flaps must be determined by the nature of
+the accident and the amount of skin left uninjured.</p>
+
+<p>In the rare condition where the greater part of the metacarpus is
+destroyed, and yet carpal joints are uninjured, a most useful artificial
+band, preserving the movements of the wrist, may be fitted on; and as
+much as possible should be saved, but in cases of injury, where the
+carpus is opened and the hand irreparably destroyed, the question
+arises, Where ought amputation to be performed? To this we answer that
+there appears no conceivable advantage to be gained by leaving all or
+any of the carpal bones. If successful, it would result only in the
+retention of a flapping joint, unless from there being no tendons to act
+upon it, except the tendon of the flexor carpi ulnaris attached to the
+pisiform, and there are several risks it would run in the inflammation
+of all the carpal joints, and the almost certain spread of this
+inflammation to the bursa underneath the flexor tendons, beyond the
+annular ligament, and up the arm among the muscles.</p>
+
+
+<p class="gap"><span class="smcap">Amputation at the Wrist-Joint.</span>&mdash;This is an operation by no means
+frequent, and it has the advantages of preserving a long stump, and
+retaining the full movements of pronation and supination, in cases where
+the radio-ulnar joint is sound and uninjured,<span class='pagenum'><a name="Page_56" id="Page_56">{56}</a></span> but in practice it is
+often found that fibrous adhesions limit to a great extent the motions
+of the two bones on each other, specially in those cases where the
+radio-ulnar joint has been diseased or injured.</p>
+
+<p>Another advantage is the extreme ease with which disarticulation may be
+performed on emergency, no saw being required, and the ordinary bistoury
+of the pocket-case being quite sufficient for cutting the flaps.</p>
+
+<p><i>Operation.</i>&mdash;By double flap. An incision (<a href="#plate_iv">Plate IV.</a> fig. 3) on the
+dorsal surface, extending in a semilunar direction from one styloid
+process to the other, will define a flap of skin only, which must be
+raised; the joint must then be opened by a transverse incision, and a
+long semilunar flap of skin and fascia should be shaped (<a href="#plate_iv">Plate IV.</a> fig.
+4) from the palm. Disarticulation is facilitated by the surgeon forcibly
+bending the wrist when he makes the transverse cut, and it will be found
+easier to shape the palmar flap from the outside by dissection, than to
+do it by transfixion after disarticulation, on account of the prominence
+of the pisiform on the inner side of the palm.</p>
+
+<div class="blockquot smlet">
+
+<div class="figleft" style="width: 200px;">
+<img src="images/057a.jpg" width="200" height="96" alt="Fig. III." title="Fig. III." />
+<span class="caption smcap">Fig. iii.
+<a name="FNanchor_27_27" id="FNanchor_27_27"></a><a href="#Footnote_27_27" class="fnanchor">[27]</a></span>
+</div>
+
+<div class="figleft" style="width: 250px;">
+<img src="images/057b.jpg" width="250" height="291" alt="Fig. IV." title="Fig. IV." />
+<span class="caption smcap">Fig. iv.
+<a href="#Footnote_27_27" class="fnanchor">[27]</a></span>
+</div>
+
+<p>In the thin wasted wrists of the aged, or in any case where the
+skin is very lax, this amputation may be very easily performed by
+the circular method. While an assistant draws up the skin as much
+as possible, the surgeon makes an accurate circular incision
+through the skin, about an inch below the styloid processes, just
+grazing the thenar and hypothenar eminences. Another circular sweep
+just above the pisiform and unciform bones divides all the soft
+textures, after which the joint may be opened, and, if necessary,
+the styloid processes cut away with saw or pliers.</p>
+
+<p>Amputation by a long single flap, either dorsal or palmar, may be
+rendered necessary by accident. The palmar one of the two is
+preferable; indeed, rather than trust for a covering to the thin
+skin of the back of the hand, with its numerous tendons, it is
+better to amputate an inch or two higher up through the fore arm.<span class='pagenum'><a name="Page_57" id="Page_57">{57}</a></span></p>
+
+<p>The following amputation by external flap has been described (so
+far as I can discover, for the first time) by Dr. Dubrueil, in his
+work on operative Surgery:<a name="FNanchor_26_26" id="FNanchor_26_26"></a><a href="#Footnote_26_26" class="fnanchor">[26]</a>&mdash;"Commencing just below the level of
+the articulation, while the hand is pronated, the surgeon makes a
+convex incision, beginning at the junction of the outer and middle
+thirds of the arm behind, reaching at its summit the middle of the
+dorsal surface of the first metacarpal, and terminating in front
+just below the palmar surface of the joint, again at the junction
+of the outer and middle thirds of the breadth of the arm. This flap
+being raised, the wrist is disarticulated, beginning at the radial
+side. A circular incision finishes the cutting of the skin." (Figs.
+<span class="smcap">iii.</span> and <span class="smcap">iv.</span>) </p></div>
+
+
+<p class="gap"><span class="smcap">Amputation through the Fore-arm.</span>&mdash;The method of operating must, in the
+fore-arm, depend a good deal upon the part of the arm where you require
+to amputate, the muscularity of the limb, and the condition of the skin
+and subcutaneous cellular tissue.</p>
+
+<p>It must be remembered that a section of the fore-arm involves two bones,
+not, like the tibia and fibula, on a constant permanent relation in
+position to each other, but which rotate one upon another to an amount
+which varies with the part of the limb divided, and which rotation is a
+very important element in the future usefulness of the stump; again,
+that two sets of muscles occupy, one the back, the other the front of
+the limb, that these two are unequal in size, and that the outer sides
+or rather edges of each bone are subcutaneous; again, that these sets of
+muscles are comparatively fleshy in the upper<span class='pagenum'><a name="Page_58" id="Page_58">{58}</a></span> two-thirds of the limb,
+and almost entirely tendinous in the lower third.</p>
+
+<p>Remembering these points, we find that certain things require our
+attention, and certain difficulties are present in amputation of the
+fore-arm, from which amputation of the arm, with its single bone and
+copious muscular covering on all sides, is completely free.</p>
+
+<p>Thus our flaps in the fore-arm must be antero-posterior; lateral flaps
+are an impossibility. Great care is requisite to cut them at all equal,
+from the inequality of the muscles on the two sides. In the lower third
+we cannot obtain available muscular flaps. Lastly, care must be taken
+lest, from the ever-varying relations of the two bones to each other in
+the varying positions of the limb, the surgeon mistake their position
+and pass his knife between them.</p>
+
+<p>The next question that arises is, Where are we to operate? In cases
+where we have a choice, is there here, as in the leg, any "point of
+election"? <i>No.</i> As a rule in the fore-arm, the surgeon should endeavour
+to save as much as possible; especially when nearing the middle of the
+fore-arm, he should try to save the insertion of the pronator teres, so
+important in its function of pronating the radius.</p>
+
+
+<p class="gap"><span class="smcap">Amputation in Lower Third of the Fore-arm.</span>&mdash;By two flaps. These
+antero-posterior flaps must consist of skin only, as the tendons are
+only in the way, and thus should be made by dissection from without.<a name="FNanchor_28_28" id="FNanchor_28_28"></a><a href="#Footnote_28_28" class="fnanchor">[28]</a>
+Making the dorsal one first, the surgeon should enter his knife at the
+palmar edge of the bone that is further from him, and cut a semilunar
+flap of skin only, finishing the incision quite on the palmar edge of
+the inner bone. The two ends of this incision must then be<span class='pagenum'><a name="Page_59" id="Page_59">{59}</a></span> united by a
+similar semilunar flap of skin on the palmar side. The two flaps having
+been dissected back, he then clears the bones by a circular incision
+through tendons and muscles, not forgetting to pass the knife between
+the bones, and retracting all the soft parts, saws through the bones, at
+least half or probably three-quarters of an inch higher up. It is
+generally easiest to saw through both bones at once.</p>
+
+<p><i>Long Dorsal Flap.</i>&mdash;Where it is possible from laxity of the soft parts
+and the wrist not being much destroyed, to get a long flap from the back
+of the arm after Mr. Teale's method, a very good stump will result. This
+rule is, "In tracing the long flap a longitudinal line is drawn over the
+radius, so as to leave the radial vessels for the short flap (<a href="#plate_ii">Plate II.</a>
+fig. 1). At a distance equal to half the circumference of the limb,
+another line parallel to the former is drawn along the ulna. These are
+then joined at their lower ends, across the dorsal aspect of the wrist
+or fore-arm, by a transverse line equal in length to half the
+circumference of the fore-arm. The short flap is marked by a transverse
+line on the palmar aspect, uniting the long ones at their upper fourth.</p>
+
+<p>"The operator, in forming the long flap, makes the two longitudinal
+incisions merely through the integuments, but the transverse one is
+carried directly down to the bones. In dissecting the long flap from
+below upwards, the tissues of which it is composed must be separated
+close to the periosteum and interosseous membrane. The short flap is
+made by a transverse incision through all the structures down to the
+bones, care being taken to separate the parts upwards close to the
+periosteum and membrane." The stump must be placed in the prone
+position, "to allow the long dorsal flap to be the superior when the
+patient is recumbent, and thus fall over the ends of the bones."<a name="FNanchor_29_29" id="FNanchor_29_29"></a><a href="#Footnote_29_29" class="fnanchor">[29]</a></p>
+
+<p>The principal objection to the long dorsal rectangular<span class='pagenum'><a name="Page_60" id="Page_60">{60}</a></span> flap (which
+makes an excellent covering) is, that unless it can be obtained from
+over the wrist-joint it requires the bones to be sawn so very high up.
+This may be avoided, to some extent, by making it shorter and rounded
+off, as in Carden's Amputation, <i>q.v.</i></p>
+
+
+<p class="gap"><span class="smcap">Amputation in Upper Two-Thirds</span>.&mdash;Where the fore-arm is very fat or
+fleshy, this amputation can be very easily performed by two equal
+antero-posterior flaps made by transfixion. In most cases, however, from
+the comparative leanness of the dorsal aspect of the limb, the following
+method will have the best result. The surgeon must, as in the former
+case, shape a rounded dorsal flap by dissection from without (<a href="#plate_iv">Plate IV.</a>
+fig. 5), embracing the whole breadth of the limb down to the palmar edge
+of both bones. Then at once he transfixes the two points of this dorsal
+flap, and cuts out an equal one from the anterior aspect of the limb
+(<a href="#plate_iv">Plate IV.</a> fig. 6). Dissecting up the dorsal flap he clears the bones at
+least half an inch above as before, and applies the saw.</p>
+
+<p><i>N.B.</i>&mdash;This operation should be performed even in cases where only an
+inch of radius can be retained, as the attachment of the biceps makes a
+very small stump of fore-arm wonderfully useful.</p>
+
+
+<p class="gap"><span class="smcap">Amputation at Elbow-Joint</span>.&mdash;In cases where it is found impossible to
+save any portion of the fore-arm, disarticulation at the elbow-joint may
+be easily performed. This operation was proposed and performed so long
+ago as the days of Ambrose Par&eacute;,<a name="FNanchor_30_30" id="FNanchor_30_30"></a><a href="#Footnote_30_30" class="fnanchor">[30]</a> was much approved by Dupuytren,
+Baudens, and Velpeau, had fallen into disuse for a time, but is now
+again recommended by some excellent surgeons, especially by Gross<a name="FNanchor_31_31" id="FNanchor_31_31"></a><a href="#Footnote_31_31" class="fnanchor">[31]</a>
+and Ashhurst,<a name="FNanchor_32_32" id="FNanchor_32_32"></a><a href="#Footnote_32_32" class="fnanchor">[32]</a> both of Philadelphia.<span class='pagenum'><a name="Page_61" id="Page_61">{61}</a></span></p>
+
+<p>It is tolerably easy to perform, and does not involve any sawing of
+bones, but the flaps are apt to be cut too short, unless care be taken,
+from the manner in which the trochlea projects downwards beyond the line
+of the condyles, so that if the base of an ordinary-shaped flap be made
+on a level with the condyles, it will prove insufficient to cover the
+bone. It may be performed either by the circular method (Velpeau), oval
+(Baudens), or by a long anterior and short posterior flap (Textor and
+Dupuytren). Probably the best method is by a long anterior flap when it
+can be obtained, thus:&mdash;The arm being placed in a slightly flexed
+position, the surgeon transfixes in front of the joint, in a line
+extending from the level of the external condyle to a point one inch
+below the internal condyle (<a href="#plate_iv">Plate IV.</a> fig. 7); the tissue should be held
+well forward at the moment of transfixion. The flap should be at least
+two and a half inches deep at its apex, which must be rounded off. The
+two ends of this flap may then be united behind by a semilunar incision
+(<a href="#plate_iii">Plate III.</a> fig. 2), which will separate the radial attachments. The
+ulna must then be cleared, and the triceps divided at its insertion.</p>
+
+<div class="blockquot smlet"><p><i>Modifications.</i>&mdash;Dupuytren used to saw through the ulna, leaving
+the olecranon attached. Velpeau opposed this, but it is again
+recommended by Gross, who leaves the olecranon, and at the same
+time improves the shape of the stump by sawing off the "inner
+trochlea" on a level with the general surface. </p></div>
+
+
+<p class="gap"><span class="smcap">Amputation of the Arm</span>.&mdash;This amputation is best performed by double
+flap, and is the typical instance which exhibits all the advantages of
+two equal flaps made by transfixion, without any of the disadvantages of
+that method. These advantages are, easiness of performance, rapidity,
+excellent covering for the bone, with as little sacrifice of tissue as
+is possible, while the fact that the cicatrix is opposite the end of the
+bone<span class='pagenum'><a name="Page_62" id="Page_62">{62}</a></span> is hardly a disadvantage in the arm (as it certainly is in the
+leg), as no weight has to be borne on it. When they can be obtained,
+anterior and posterior flaps are generally considered most satisfactory,
+but Mr. Spence prefers lateral ones, lest the line of union should be
+interfered with by the deltoid raising the bone. If the right arm has to
+be amputated, the operator standing at the inner side raises the
+anterior muscles with his left hand, and enters the knife just in front
+of the brachial vessels (<a href="#plate_i">Plate I.</a> fig. 12); keeping as close as possible
+to the bone, he brings out the knife at a point exactly opposite, then
+with a brisk sawing motion, cuts a semicircular flap, taking care to
+bring out the knife more suddenly just at the end, in order to cut
+through the skin as perpendicularly to the arm as possible. The knife is
+again entered at the same point, carried behind the bone, and brought
+out at the same angle, and an exactly corresponding flap cut from the
+other side of the limb, the flaps are then retracted, the bone cleared
+by circular incision and sawn through as high up as it is exposed. In
+primary cases, where the muscles are firm and developed, the flaps
+should be cut a little concave.</p>
+
+<div class="blockquot smlet"><p><i>Modifications and Varieties.</i>&mdash;Teale's method may of course be
+used here as elsewhere. The internal line of incision (<a href="#plate_iv">Plate IV.</a>
+fig. 8) should be made just in front of the brachial vessels. This
+method requires the amputation to be performed higher up than would
+otherwise be necessary (from the length of the anterior flap), and
+this disadvantage is not counterbalanced by any special advantage
+in the posterior retraction of the cicatrix.</p>
+
+<p>In feeble flabby arms, the true circular operation is very easily
+performed, and with good results. A circular sweep of the knife is
+made through the skin alone, which is drawn up by an assistant,
+while the surgeon separates it from the fascia; another circular
+cut through fascia and muscles exposes the bone, which must then be
+cleared and cut through at a still higher level.</p></div>
+
+<p class="gap"><span class="smcap">Amputation at the Shoulder-Joint</span>.&mdash;This operation,<span class='pagenum'><a name="Page_63" id="Page_63">{63}</a></span> like that at
+the hip joint, can, from the nature of the joint to be covered, and
+the abundant soft parts in the normal state of the tissues, be
+performed on the dead in very various ways, by single, double, or
+triple flaps, by transfixion or dissection, rapidly or slowly.
+Hence manuals of operative surgery might collect at least twenty
+different methods, most of which have some recommendation, and all
+of which are practicable enough.</p>
+
+<p>When, however, we reflect that in the living body, in cases where
+amputation at the shoulder-joint is required at all, the severity
+of the accident, or the urgency of the disease, will, in general,
+leave no room for selection, we shall see how utterly valueless is
+any knowledge of mere methods of operating, and of how much greater
+importance it is that we should be simply thoroughly familiar with
+the anatomy of the joint.</p>
+
+<p>For example, an accident which necessitates amputation so high up
+has, in all probability, opened into the joint and destroyed the
+soft parts on at least one aspect; in such a case the flaps must be
+cut from the uninjured soft parts only. If an aneurism has rendered
+amputation through it and through the joint a last resource, the
+flap must be gained chiefly at least from the outside; a malignant
+tumour of the humerus will almost certainly prevent any
+transfixion, and require flaps to be made by dissection, wherever
+the skin is least likely to be involved. Again, some of the most
+vaunted and most rapid operations almost require for their success
+the integrity of the humerus, which has to make itself useful as a
+lever in disarticulation, while in most cases of accident we are
+amputating for compound injury of the humerus, almost certainly
+implying fracture with comminution.</p>
+
+<p>From its proximity to the trunk, h&aelig;morrhage is one of the chief
+dangers to be apprehended during this operation, especially from
+the axillary artery. As far as possible to obviate this danger,
+most plans of operating<span class='pagenum'><a name="Page_64" id="Page_64">{64}</a></span> are based on the principle that the
+vessels and nerves should be the last tissues to be cut; in some
+they are not divided till after disarticulation.</p>
+
+<p>While a good assistant, to make pressure on the subclavian above
+the clavicle, is a most advisable precaution, too much must not be
+trusted to this pressure above, as the struggles of the patient and
+the spasmodic movements of the limb, which are so apt to occur
+under the stimulus of the knife, are apt to render futile the best
+efforts at compression.</p>
+
+<p>The operator should trust rather to making the incisions in such a
+manner that the great vessel be not divided till the hand of an
+assistant, or in default of a suitable one, his own left hand, is
+able to follow the knife and grasp the flap.</p>
+
+<p>The bleeding from the circumflex, subscapular, and posterior
+scapular arteries can easily be arrested by a dossil of lint till
+the great vessel is tied, and they can be secured.</p>
+
+<p>In cases where proper assistants cannot be had, temporary closure
+of the axillary vessel could easily be made by carrying a strong
+silver wire or silk ligature completely round the vessel by a
+curved needle before the incisions are commenced, and by tying this
+firmly over a pad of lint.</p>
+
+<p>Pressure on the artery above the clavicle is best made by the thumb
+of a strong assistant, who endeavours to compress it against the
+first rib; where the parts are deep and muscular, the padded handle
+of the tourniquet, or of a large door-key, will do as the agent of
+pressure.</p>
+
+<p>A brief notice of three of the best methods of operating will be
+quite sufficient to show what should be aimed at in shoulder-joint
+amputations:&mdash;</p>
+
+<p><b>1.</b> In cases where the surgeon can choose his flaps, the following
+method will be found the most satisfactory, as resulting in the
+smallest possible wound, in having<span class='pagenum'><a name="Page_65" id="Page_65">{65}</a></span> less risk of h&aelig;morrhage during
+the operation than any other method, and in providing excellent
+flaps.</p>
+
+<p>It is Larrey's method slightly modified.</p>
+
+<p><i>Operation.</i>&mdash;With a moderate-sized amputating knife an incision of
+about two inches in length, extending through all the tissues down
+to the bone, should be made from the edge of the acromion process
+to a point about one inch below the top of the humerus; from this
+latter point a curved incision, enclosing a semilunar flap, should
+be made on each side of the limb to the anterior and posterior
+folds of the axilla respectively (<a href="#plate_iv">Plate IV.</a> fig. 9, and <a href="#plate_iii">Plate III.</a>
+fig. 3). These flaps should then be dissected back, including the
+muscles and exposing the joint. When thoroughly exposed, the joint
+must then be opened from above, and the bone separated. One small
+portion of skin lying above the artery, vein, and nerves still
+remains to be divided (<a href="#plate_i">Plate I.</a> fig. 13). This may be done by an
+oblique cut from within outwards, in such a direction as to form
+part of the anterior or internal incision, and with the precaution
+of having an assistant to command the vessels before they are
+divided. The resulting wound is almost perfectly ovoid, the flaps
+come together with great ease in a straight vertical line, which
+admits of easy and thorough drainage. Union is generally rapid.
+Larrey's success by this method was very remarkable: ninety out of
+a hundred cases in military practice were saved, notwithstanding
+the well-known risks of such operations.</p>
+
+<p><b>2.</b> As good as the former, and nearly as universally applicable, is
+the method devised by Professor Spence, and practised by him in
+nearly every case:&mdash;"With a broad strong bistoury I cut down upon
+the inner aspect of the head of the humerus, immediately external
+to the coracoid process, and carry the incision down through the
+clavicular fibres of the deltoid and pectoralis major muscles till
+I reach the humeral attachment of the latter muscle, which I
+divide. I then with a gentle curve<span class='pagenum'><a name="Page_66" id="Page_66">{66}</a></span> carry my incision across and
+fairly through the lower fibres of the deltoid towards, but not
+through, the posterior border of the axilla. Unless the textures be
+much torn, I next mark out the line of the lower part of the inner
+section by carrying an incision through the <i>skin and fat only</i>,
+from the point where my straight incision terminated, across the
+inside of the arm to meet the incision at the outer part. This
+insures accuracy in the line of union, but is not essential. If the
+fibres of the deltoid have been thoroughly divided in the line of
+incision, the flap so marked out, along with the posterior
+circumflex trunk, which enters its deep surface, can be easily
+separated from the bone and joint, and drawn upwards and backwards
+so as to expose the head and tuberosities, by the point of the
+finger without further use of the knife. The tendinous insertions
+of the capsular muscles, the long head of the biceps, and the
+capsule, are next divided by cutting directly upon the tuberosities
+and head of the bone; and the broad subscapular tendon especially,
+being very fully exposed by the incision, can be much more easily
+and completely divided than in the double-flap method. By keeping
+the large posterior flap out of the way by a broad copper spatula
+or the fingers of an assistant, and taking care to keep the edge of
+the knife close to the bone, the trunk of the posterior circumflex
+is protected. In regard to the axillary vessels, they can either be
+compressed by an assistant before completing the division of the
+soft parts on the axillary aspect, or to avoid all risk, the
+axillary artery may be exposed, tied, and divided between two
+ligatures so as to allow it to retract before dividing the other
+textures."<a name="FNanchor_33_33" id="FNanchor_33_33"></a><a href="#Footnote_33_33" class="fnanchor">[33]</a></p>
+
+<div class="blockquot smlet"><p>Another, but not so good method of making an external flap, is the
+following:&mdash;(<i>a.</i>) For the right arm.&mdash;The patient lying well over
+on his left side, the surgeon stands to the inside of the arm to be
+removed. Seizing the deltoid in the left, with<span class='pagenum'><a name="Page_67" id="Page_67">{67}</a></span> the right he passes
+an amputating knife, seven or eight inches in length, from a point
+a little nearer the clavicle than the middle space between the
+acromion and coracoid processes; then, transfixing the base of the
+deltoid, and just grazing the posterior surface of the humerus,
+thrusts the knife downwards and backwards till it protrudes at the
+posterior margin of the axilla. When doing this, it is important
+that the arm be held outwards and backwards, and even upwards, as
+far as possible to relax the deltoid; without this it will be
+impossible to make the flap of the full size. The flap must then be
+cut of as full length as can be obtained, four or five inches at
+least. An assistant then holds it upwards, while the surgeon, or
+(if the arm is very muscular) another assistant, brings the arm
+forwards well across the patient's chest, thus exposing the
+posterior aspect of the joint. This may have very possibly been
+already opened during the transfixion; the attachments of muscles
+must now be divided, the knife passed behind the head of the bone,
+which is dislocated forwards, and a suitable flap of the tissues in
+front cut from within outwards. The assistant is to follow the
+knife with his finger and compress the vessels.</p>
+
+<p>(<i>b.</i>) If the left shoulder is to be amputated, the patient lying
+on his right side, the surgeon stands behind him, and raising the
+elbow of the limb to be removed from the side, and pulling it
+slightly backwards, enters the knife at the posterior fold of the
+axilla (<a href="#plate_ii">Plate II.</a> fig. 2), and passing the posterior aspect of the
+head of the humerus, endeavours to protrude it as near the acromion
+as possible; the flaps must be cut and the rest of the operation
+performed in the manner we have just described for the other arm. </p></div>
+
+<p><b>3.</b> Where the destruction of tissue has been chiefly below the joint, a
+very good flap may be obtained from above, composed chiefly of the
+deltoid muscle, and the skin over it. This may be made by transfixion at
+its base, but is better obtained by dissection from without.</p>
+
+<p>The surgeon cuts (<a href="#plate_ii">Plate II.</a> figs. 3, 3) in a semilunar direction (with
+the convexity downwards) from one side of the deltoid to the other,
+viz., from the root of the acromion to near the coracoid process; he
+then raises the large flap upwards and throws it back, opens the joint,
+disarticulates, passes the knife behind the head of the bone, and cuts
+out without attempting to save any flaps below, in a transverse
+direction. By this means<span class='pagenum'><a name="Page_68" id="Page_68">{68}</a></span> the artery is still almost the last structure
+to be divided, and can be secured by a ready assistant. In cases where
+much injury has been done to the floor of the axilla and wall of chest,
+the deltoid flap must be made large in proportion, and triangular rather
+than semilunar in shape.</p>
+
+<p><i>N.B.</i>&mdash;The statistics of amputation at the shoulder-joint bring out
+some interesting facts: 1. That the primary amputations here are far
+more successful than secondary ones. Guthrie records nineteen cases of
+the former out of which only one died, while out of a similar number in
+which the amputation was secondary, fifteen died. In the Crimea, British
+surgeons had thirty-nine cases, with thirteen deaths; of thirty-three
+primary, nine died; and of six secondary, four were fatal.</p>
+
+<p>S.W. Gross's<a name="FNanchor_34_34" id="FNanchor_34_34"></a><a href="#Footnote_34_34" class="fnanchor">[34]</a> statistics confirm this: of one hundred and
+seventy-eight primary, forty-six died&mdash;25.8 per cent.; ninety-five
+secondary, sixty-one died&mdash;64.2 per cent.</p>
+
+
+<p class="gap"><span class="smcap">Amputations above the Shoulder-Joint</span>.&mdash;Under this head we may group the
+comparatively rare cases in which, from accident or disease, the removal
+of portions of the scapula and clavicle, or even the entire bones, is
+rendered necessary. That it is quite possible to survive such injuries
+has been frequently shown in cases of accident when the scapula along
+with the arm has been torn off, and yet the patient recovered.</p>
+
+<p>Encouraged by such cases, Gaetani Bey of Cairo removed the whole of
+scapula and part of the clavicle in a case where he had amputated at the
+shoulder for smash. The patient recovered. Heron Watson has had a
+similar case. Dr. George M'Lellan amputated arm and scapula in a youth
+of seventeen for an enormous encephaloid tumour. Fifty-one such cases
+are now on record.</p>
+
+<p>Syme amputated with success the arm along with the scapula and outer
+half of clavicle, in a case in which he had previously excised the head
+of the humerus for a tumour.<a name="FNanchor_35_35" id="FNanchor_35_35"></a><a href="#Footnote_35_35" class="fnanchor">[35]</a><span class='pagenum'><a name="Page_69" id="Page_69">{69}</a></span></p>
+
+<p>Gilbert, Mussey, Rigaud, Fergusson, and others have performed similar
+operations, secondary to amputation at the shoulder-joint, for cases of
+caries and malignant tumour. It is impossible to give any exact
+directions for the incisions which must be planned for individual cases,
+with two chief aims, to avoid h&aelig;morrhage as far as possible, and to
+leave abundance of skin. In operations on the scapula, it should be
+freely exposed by large enough incisions. (See <a href="#Page_140"><i>Excisions</i></a>.)</p>
+
+
+<p class="gap"><span class="smcap">Amputations of Lower Extremity</span>.&mdash;Commencing with the most distal, and
+gradually working our way upwards, we find that partial amputations of
+the toes are extremely rare. Only in the case of the great toe is such
+an operation <i>ever</i> admissible, for the other toes are so short, and the
+stumps left by amputation are at once so useless from their shortness,
+and so detrimental from the manner in which they project upwards and rub
+against the shoe, that any injury requiring partial amputation of a
+lesser toe is treated by its complete removal.</p>
+
+<div class="figright" style="width: 193px;">
+<img src="images/069.jpg" width="193" height="300" alt="Fig. V." title="Fig. V." />
+<span class="caption smcap">Fig. v.</span>
+</div>
+
+<p class="gap"><span class="smcap">Amputation of Distal Phalanx of Great Toe</span>.&mdash;This is comparatively rarely
+required now. It used to be thought necessary for the cure of those not
+uncommon cases of exostosis of the distal phalanx, but it is now found
+that most of these can be cured by simply clipping off the exostosis.
+When necessary, however, and when the choice of flaps is possible, the
+best plan is by a long flap from the plantar surface (Fig. <span class="smcap">v</span>. 4), as in
+the similar operation on the thumb; laying the edge of the knife over
+the dorsal aspect of the joint, cutting through it, and turning the edge
+of the knife round close to the bone, so as to cut out a large flap from
+the ball of the toe.<span class='pagenum'><a name="Page_70" id="Page_70">{70}</a></span></p>
+
+
+<p class="gap"><span class="smcap">Amputation of a Single Lesser Toe</span>&mdash;<i>second</i>, <i>third</i>, <i>or fourth</i>.&mdash;This
+operation is on exactly the same principle as that described for the
+corresponding finger; but it must be remembered that the
+metatarso-phalangeal joint is more deeply situated in the soft parts
+than is the metacarpo-phalangeal; and thus the commencement of the
+elliptical incision which is to surround the base of the toe must be
+proportionally higher up (Fig. <span class="smcap">v</span>. 1). On the other hand, as it is very
+important to avoid as much as possible any cicatrix in the sole of the
+foot, the plantar end of the incision need not be carried to a point
+exactly opposite the one from which it set out, but it will be
+sufficient if it reaches the groove between the toe and sole. A little
+more care may thus be required in dissecting out the head of the first
+phalanx, but this is quite repaid by the cicatrix in the sole being
+avoided. Early division of flexor tendons renders disarticulation easy.</p>
+
+
+<p class="gap"><span class="smcap">Amputation of the First and Fifth Toes</span>.&mdash;The incisions are conducted on
+the same principle as in the other operations, the operator being
+careful to preserve as much as possible (Fig. <span class="smcap">v</span>. 2) of the hard useful
+pad of the inner and outer sides respectively.</p>
+
+<p>Most surgeons are now agreed that in these toes it is best not to remove
+the head of the metatarsal bone with the toe. Cutting off the large
+cartilaginous head obliquely with a pair of bone-pliers may prevent an
+awkward unseemly projection, but it does diminish the strength of the
+transverse arch of the foot.</p>
+
+
+<p class="gap"><span class="smcap">Amputation of one or more Toes with their Metatarsals</span>.&mdash;It is not
+necessary to give very particular details regarding such operations, as
+the surgeon must be guided in the individual cases by the specialties of
+accident or disease.<span class='pagenum'><a name="Page_71" id="Page_71">{71}</a></span></p>
+
+<p>One or two guiding principles are important:&mdash;</p>
+
+<p>1. Having made up your mind at what point you are to cut the metatarsal,
+if the amputation be a partial one, or as to the exact position of the
+joint, if you intend to disarticulate, commence your dorsal incision
+(Fig. <span class="smcap">v</span>. 3) at a point fully half an inch higher up than the selected
+spot, as free access is of the very last importance.</p>
+
+<p>2. Whenever it is possible, cut the bone through its continuity rather
+than disarticulate. Specially is this important in the case of the
+metatarsal bone of the great toe, that the insertion of the tendon of
+the peroneus longus may be saved. If, however, the terminal branch of
+the <i>dorsalis pedis</i> artery be wounded, it may be necessary to
+disarticulate the first metatarsal to secure it rather than trust to
+compression to stop the bleeding.</p>
+
+<p>3. In cutting through the first and fifth metatarsals, remember to apply
+the bone-pliers obliquely, not transversely, so as to avoid unseemly
+projection.</p>
+
+<p>4. As far as possible avoid cutting into the sole at all.</p>
+
+<p>The plantar cicatrix is almost a fatal objection to a plan of removing
+the first and fifth toes and their metatarsals which has much otherwise
+in rapidity and elegance to recommend it. In the great toe, for example,
+it is performed as follows:&mdash;Seizing the soft parts of the inner edge of
+the foot in his left hand, the surgeon draws them <i>inwards</i>, transfixes
+just at the tarso-metatarsal joint, and, keeping as close as possible to
+the inner edge of the metatarsal bone, cuts the flap as long as to the
+middle of the first phalanx; then the soft parts of the foot being drawn
+as far <i>outwards</i> as possible by an assistant, the surgeon enters his
+knife between the first and second toes, and succeeds in entering his
+former incision so as to separate the metatarsal bone without removing
+any skin. All that<span class='pagenum'><a name="Page_72" id="Page_72">{72}</a></span> remains is to open the tarso-metatarsal joint. It is
+a very neat-looking operation, leaves a very good covering for the
+parts, and is performed with extreme rapidity. This last is not so much
+required in these days of an&aelig;sthetics, and the cicatrix in the sole is a
+very formidable objection to it.</p>
+
+<p>The simplest and shortest rule that can be given for the amputation of a
+toe, with the part or whole of its metatarsal, is to make one dorsal
+incision, commencing about a quarter of an inch above the spot at which
+you intend to divide the bone or to disarticulate, extending downwards
+in a straight line to the metatarso-phalangeal articulation, and then
+bifurcating so as to surround the base of the toe at the normal fold of
+the skin. The soft parts are then to be cleared from the
+metatarso-phalangeal joint, and the toe still being retained on the
+metatarsal bone, it should be carefully dissected up, avoiding any
+pricking of the soft parts below, till the joint is reached, or the spot
+at which the bone-pliers are to be applied is fully cleared.</p>
+
+
+<p class="gap"><span class="smcap">Amputation of the anterior portion of the Foot at the Tarso-metatarsal
+Joint&mdash;Hey's Operation</span>.&mdash;This operation, which is now comparatively
+rarely performed, has been invested with a halo of difficulty and
+complexity which is to a great extent unnecessary.</p>
+
+<p>There is no doubt that the anatomical conformation of the joints
+involved, especially the manner in which the head of the second
+metatarsal (Fig. <span class="smcap">v.</span> C) projects upwards into the tarsus, and is locked
+between the cuneiform bones, renders disarticulation in the healthy foot
+rather difficult; but it must be remembered that in cases where for
+accident we have to deal with previously healthy tissues, it is quite
+unnecessary to disarticulate, a better result being attained by simply
+sawing the foot across in the line of the articulation; and again, where
+we have to operate for disease, the tissues<span class='pagenum'><a name="Page_73" id="Page_73">{73}</a></span> are so matted, and the
+bones so soft, that complete removal of the metatarsus is much easier
+than it appears when practising on the dead subject.</p>
+
+<p>Very various plans of incision have been proposed. Mr. Hey's original
+procedure has not been much improved upon. His short account of it has
+at once surgical value and historical interest:&mdash;</p>
+
+<p>"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 incision through the integuments and muscles
+covering the metatarsal bones (<a href="#plate_iv">Plate IV.</a> figs. 10, 11). From each
+extremity 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 integuments and
+muscles forming the sole of the foot from the inferior part of the
+metatarsal bones, keeping the edge of my scalpel as near 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
+tarsus, which was easily effected, as the joints lie in a straight line
+across the foot. The projecting part of the first cuneiform bone which
+supports the great toe I was obliged to divide with a saw. The arteries,
+which required a ligature, being tied, I applied the flap which had
+formed the sole of the foot to the integuments which remained on the
+upper part, and retained them in contact by sutures....</p>
+
+<p>"The patient could walk with firmness and ease; she was in no danger of
+hurting the cicatrix by striking the place where the toes had been
+against any hard substance, for this part was covered with the strong
+integuments which had before constituted the sole of<span class='pagenum'><a name="Page_74" id="Page_74">{74}</a></span> the foot. The
+cicatrix was situated upon the upper part of the foot, and had very
+little breadth, as the divided parts had been kept united after being
+brought into close contact."<a name="FNanchor_36_36" id="FNanchor_36_36"></a><a href="#Footnote_36_36" class="fnanchor">[36]</a></p>
+
+<p><i>Lisfranc's method</i> has, briefly, the following modifications.&mdash;Having
+fixed the position of the articulations of the first and fifth
+metatarsals with the tarsus, the operator unites them by a curved
+incision across the dorsum of the foot, with its convexity downwards. He
+then divides the dorsal ligaments over the articulations, opens the
+first from the inside, the fifth, fourth, and third from the outside, he
+then with a strong narrow-bladed knife divides the interosseous
+ligaments between the sides and end of the head of the second metatarsal
+and the cuneiforms, thus completing the disarticulation; bending the
+fore part of the foot downwards, he then keeps the edge of the knife
+close to the lower surface of the bones, separating the plantar
+ligaments, and cutting out a long plantar flap of skin and muscles.</p>
+
+<p>In every case it must be remembered that the upper end of the fifth
+metatarsal projects far up along the outer edge of the foot. Allowance
+must be made for this projection in commencing the incision. A rule
+given by Mr. Syme to guide the disarticulation of the three outer
+metatarsals will often be of service; it is this: "Having once entered
+the joint of the fifth, the knife must be drawn along in a direction of
+a line drawn towards the distal end of the first metatarsal; for the
+fourth, the direction must be changed to the middle of the same bone;
+and to open the third it will be necessary to come across the dorsum of
+the foot as if intending to reach the proximal end."</p>
+
+<p>To avoid the difficulties of disarticulation, Skey recommends cutting
+off the head of the second metatarsal with a pair of pliers. Baudens,
+Gu&eacute;rin, and others<span class='pagenum'><a name="Page_75" id="Page_75">{75}</a></span> approve of sawing all the bones across in the line
+desired.</p>
+
+<p>Most surgeons are now agreed that in this operation it is better to make
+both flaps by cutting from without, in preference to transfixion of the
+plantar one from within. In cases where, from injury and disease, the
+plantar flap is deficient in size, it may be necessary to make the
+dorsal flap longer. However, the long plantar is preferable both from
+its superior hardness, and also because from its length it permits the
+cicatrix to be well on the dorsum of the foot, and therefore less likely
+to be injured by the pressure of the boot in front.</p>
+
+
+<p class="gap"><span class="smcap">Amputations through the Tarsus</span>.&mdash;Various plans of amputating through the
+tarsus have been devised and described at great length. The most
+important of these is the operation of removal of the anterior portion
+of the foot, at the joints between the astragalus and scaphoid, and os
+calcis and cuboid, well known to the profession by the name of its first
+describer, Chopart.</p>
+
+<p>It has been so completely superseded by the infinitely preferable
+amputation at the ankle-joint of Mr. Syme, as rarely, if ever, to be
+practised in this country. Indeed, amputation at the ankle-joint may be
+said to have taken the place of all these amputations through the
+tarsus; for though cases are occasionally met with in which the
+limitation of the disease or injury may render Chopart's possible, and
+though at first sight it appears to have an advantage in removing less
+of the body, still the following objections are nearly fatal to its
+chance of being selected:&mdash;1. In cases of injury, through leaving a long
+stump, and, at first sight, a useful one, experience shows that the
+tendo Achillis sooner or later (being unopposed by the extensors of the
+toes) draws up the heel so as to make the end of the stump point, and
+the cicatrix press on the ground,<span class='pagenum'><a name="Page_76" id="Page_76">{76}</a></span> rendering it unable to bear any
+weight. 2. In cases of removal for disease of the tarsus, the bones left
+behind, though apparently sound at the time, are almost sure to become
+eventually diseased.</p>
+
+<p>As it has an historical interest, and as this operation (defective as it
+is) had been the means of saving many legs prior to the invention of
+amputation at the ankle-joint, a brief description may be appended:&mdash;</p>
+
+<p>Chopart's own manner of operation was briefly somewhat as follows:&mdash;</p>
+
+<p>The tourniquet having been applied, the surgeon is to make a transverse
+incision through the skin which covers the instep, two inches from the
+ankle-joint. He is to divide the skin, and the extensor tendons, and the
+muscles in that situation, so as to expose the convexity of the tarsus.
+He is next to make on each side a small longitudinal incision, which is
+to begin below and a little in front of the malleolus, and is to end at
+one of the extremities of the first incision. After having formed in
+this way a flap of integuments, he is to let it be drawn upwards by the
+assistant who holds the leg. There is no occasion to dissect and reflect
+the flap, for the cellular substance connecting the skin with the
+subjacent aponeurosis is so loose, that it can easily be drawn up above
+the place where the joint of the calcaneum with the cuboides and that
+between the astragalus and scaphoides ought to be opened. The surgeon
+will penetrate the last the most easily, particularly by taking for his
+guide the eminence which indicates the attachment of the tibialis
+anticus muscle to the inside of the os naviculare. The joint of the os
+cuboides and os calcis lies pretty nearly in the same transverse line,
+but rather obliquely forwards. The ligaments having been cut, the foot
+falls back. The bistoury is then to be put down, and the straight knife
+used, with which a flap of the soft parts is to be formed under the
+tarsus and metatarsus, long enough to admit of being applied to<span class='pagenum'><a name="Page_77" id="Page_77">{77}</a></span> the
+naked bones, so as entirely to cover them. It is to be maintained in
+position with three or four straps of adhesive plaster, etc.<a name="FNanchor_37_37" id="FNanchor_37_37"></a><a href="#Footnote_37_37" class="fnanchor">[37]</a></p>
+
+<p>Chopart's amputation, after an interval of comparative neglect, was
+introduced into this country by Mr. Syme in 1829. His method of
+performance is simpler and easier than Chopart's. He thus describes
+it:&mdash;"The blade of the knife employed should be about six inches long,
+and half an inch broad, sharp at the point and blunt on the back. The
+tourniquet ought to be applied immediately above the ankle, having
+compresses placed over the posterior and anterior tibial arteries. The
+surgeon should measure with his eye the middle distance between the
+malleolus externus and the head of the metatarsal bone of the little
+toe, which is the situation of the articulation between the os cuboides
+and os calcis. Placing his forefinger here, he ought to place his thumb
+on the other side of the foot directly opposite, which will show him
+where the os naviculare and astragalus are connected. An incision (<a href="#plate_ii">Plate
+II.</a> figs. 4 and 5) somewhat curved, with its convexity forward, is then
+to be made from one of these points to the other, when, instead of
+proceeding to disarticulate, the operator should transfix the sole of
+the foot from side to side at the extremities of the first incision, and
+carry the knife forwards so as to detach a sufficient flap, which must
+extend the whole length of the metatarsus to the balls of the toes. The
+disarticulation may finally be completed with great ease, as the shape
+of the articular surfaces concerned is very simple, and nearly
+transverse."<a name="FNanchor_38_38" id="FNanchor_38_38"></a><a href="#Footnote_38_38" class="fnanchor">[38]</a> Regarding the method of disarticulating at the
+astragalo-calcaneal joint, and removing all the foot except the
+astragalus, no detail need be given. Malgaigne advises an internal flap,
+thus sacrificing<span class='pagenum'><a name="Page_78" id="Page_78">{78}</a></span> the valuable pad of the heel. Roux, Verneuil, and
+others endeavour to save the pad. This operation, however, has now
+fallen almost completely into disuse.</p>
+
+
+<p class="gap"><span class="smcap">Subastragaloid Amputation</span> has been highly recommended. In it the flap is
+made as in Syme's, then anterior bones removed as in Chopart's, and os
+calcis grasped by lion forceps and twisted off, its attachment and the
+insertion of tendo Achillis being cautiously avoided. If flaps are
+scanty, head of astragulus may be cut off with a small saw.&mdash;Hancock and
+Ashurst.</p>
+
+
+<p class="gap"><span class="smcap">Tripier's Amputation</span><a name="FNanchor_39_39" id="FNanchor_39_39"></a><a href="#Footnote_39_39" class="fnanchor">[39]</a> is a modification of above, the skin incisions
+being made as in Chopart's amputation, and then the calcaneum is sawn
+through on a level with the sustentaculum tali on a plane at right
+angles to the axis of the leg.</p>
+
+
+<p class="gap"><span class="smcap">Amputation at the Ankle-joint, or Syme's Amputation</span>.&mdash;This operation is
+one of much interest and great practical importance. In our cold
+variable climate caries of the bones of the tarsus, and strumous disease
+of the ankle-joint, are very common and very intractable maladies, and
+for both of these, when far advanced, Syme's amputation is the only
+justifiable procedure. When properly done, according to the <i>exact</i> plan
+of its proposer, it removes the whole of the diseased parts and not an
+inch more, is an operation of very slight danger to life, and results
+almost invariably in a thoroughly useful comfortable stump. Much of its
+success depends on the manner in which it is performed, and as many
+surgical manuals are not sufficiently full, some positively in error
+regarding this point, and as very many modifications have been devised
+diminishing in value and applicability very much in proportion as<span class='pagenum'><a name="Page_79" id="Page_79">{79}</a></span> they
+diverge from the original description, I think it advisable to describe
+the operation minutely, and point out in detail the parts of it which
+seem absolutely essential to success.</p>
+
+<p><i>Operation.</i>&mdash;The foot being held at a right angle to the leg, the point
+of a straight bistoury, with a pretty strong blade, should be entered
+just below the centre of the external malleolus (<a href="#plate_iv">Plate IV.</a> figs. 12,
+13), (1.) and then carried right across the integuments of the sole, in
+a straight line (or in the case of a prominent heel, slightly
+backwards), (2.) to a point at the same level on the opposite side. (3.)
+This incision should reach boldly through all the tissues down to the
+bone. Holding the heel in the fingers of his left hand, the operator
+then inserts his left thumb-nail into the incision, and pushes the flap
+downwards, as with the knife kept close to the bone, and cutting on it,
+he frees the flap from its attachments. The thumb-nail guards the knife
+from in any way scoring the flap. (4.) This process is continued till
+the tuberosity of the os calcis is fairly turned, and the tendo Achillis
+nearly reached. Shifting his left hand he then extends the foot, and
+joins the extremities of the first incision by a transverse one right
+across the instep. (5.) Thus he opens the joint between the astragalus
+and tibia, (6.) divides the lateral ligaments, disarticulates, and still
+keeping close to the bone, removes the foot by the division of the tendo
+Achillis.</p>
+
+<p>The lower ends of the tibia and fibula are then to be isolated from the
+soft parts, and a thin slice, including both malleoli, to be removed. If
+the disease of the joint has affected the lower end of the bone, slice
+after slice may be removed, till a healthy surface of cancellated
+texture is obtained. The vessels are then secured.</p>
+
+<p><i>Dressing of the Stump.</i>&mdash;From its peculiar shape and position, the
+escape of any blood into the stump is much<span class='pagenum'><a name="Page_80" id="Page_80">{80}</a></span> to be deprecated, for as it
+cannot easily get out, on the one hand it gives pain, and may cause
+sloughing from its pressure, and on the other it is sure eventually to
+cause suppuration, and delay union. To avoid such results care must be
+taken to secure every vessel that can be seen; if there is any general
+oozing it is best merely to pass the sutures through the edges of the
+flaps, but not bring them together, thus leaving the stump open for some
+hours; then apply cold, and when the surfaces are fairly glazed over,
+remove any clots and bring the flaps together.<a name="FNanchor_40_40" id="FNanchor_40_40"></a><a href="#Footnote_40_40" class="fnanchor">[40]</a></p>
+
+<p>Another plan introduced by Mr. Syme was to make a longitudinal slit in
+the flap, through which all the ligatures are to be drawn; these give a
+dependent drain to any pus that may be formed, and by their presence
+greatly expedite the healing of the wound. Again, in cases where from
+the amount of disease existing before the operation, and the gelatinous
+thickening of the flap and neighbouring parts, much suppuration may be
+looked for, probably it will be found best to keep the flaps quite apart
+for some days, by stuffing the wound with lint, and aiming only at
+secondary union by granulations.</p>
+
+<p>A drainage tube passed through the breadth of the flap, and brought out
+at the angles, and retained for a few days, will do admirably.</p>
+
+<div class="blockquot smlet"><p><i>Notes.</i>&mdash;(1.) If commenced further forward, as in Pirogoff's
+modification, it will be found difficult to turn the corner of the
+heel; if further back, the nutrition of the flap is endangered.</p>
+
+<p>(2.) This is very important. In several well-known text-books, even
+in the last edition of Gross's <i>Surgery</i>, the incision is figured
+passing obliquely <i>forwards</i>. This is a fatal error, for besides
+making a flap far too long, it forces the operator to cut fairly
+into the hollow of the sole, quite off the prominence of the os
+calcis, and he finds that it is utterly impossible to free his flap
+without using great force, and inevitably scoring it in all
+directions. Sloughing is almost inevitably the result.<span class='pagenum'><a name="Page_81" id="Page_81">{81}</a></span></p>
+
+<p>(3.) The incision is to stop at least half-an-inch below the
+internal malleolus. Most surgical manuals, even when they profess
+to describe Mr. Syme's own method of operating, say that the
+incision should extend from malleolus to malleolus. If this is
+done, the flap becomes unsymmetrical, too long, and also the
+posterior tibial artery, on which much of the vascular supply of
+the flap depends, is cut. When the incision is properly made, the
+vessel is not cut till after its division into the plantar
+arteries.</p>
+
+<p>(4.) Scoring the flap. Some may ask, Why do you object to a little
+scoring, the tissues are thick enough, and besides, don't you
+advise a slit in the flap yourself? Yes. One look at an injected
+preparation will show that the vessels supplying this thick flap
+come to it from its inner surface, and are inevitably cut across in
+any scoring of it, and also, that scoring cuts across the vessels,
+and <i>must</i> divide dozens of them; the slit we make is parallel with
+their course, and <i>may</i> not divide one.</p>
+
+<p>(5.) Across the instep. Some authors recommend a semilunar anterior
+flap; this is quite unnecessary, increases bagging and delays
+union. It can be required only in cases where the heel flap has
+been destroyed or lessened by disease, or by operators in whose
+hands the heel flaps occasionally slough.</p>
+
+<p>(6.) It is not impossible that a careless operator may (by cutting
+a little too low) miss the joint and get into the hollow of the
+neck of the astragalus, where he may cut away for a long time
+without making much progress. </p></div>
+
+<p><i>Advantages.</i>&mdash;1. It is wonderfully free of danger to life. It is very
+hard to obtain exact statistical information, but my experience is that
+the mortality is certainly not more than about 10 per cent., a very
+remarkable result when compared with that of amputations through the
+leg, the operation which used to be required for those cases which now
+require only amputation at the ankle-joint.</p>
+
+<p>In the Statistical Report by the Surgeon-General of the United States,
+9705 cases of amputation resulted in death, the proportions being as
+follows:&mdash;</p>
+
+<p><span class='pagenum'><a name="Page_82" id="Page_82">{82}</a></span></p>
+
+<table summary="amputation">
+<tr><td>Amputation of</td><td>hip,</td><td>85</td><td>per cent. died.</td></tr>
+<tr><td class="center">"</td><td>thigh,</td><td>64</td><td class="center">"</td></tr>
+<tr><td class="center">"</td><td>knee,</td><td>55</td><td class="center">"</td></tr>
+<tr><td class="center">"</td><td>leg,</td><td>26</td><td class="center">"</td></tr>
+<tr><td>Amputation of</td><td>ankle-joint,</td><td>13</td><td>per cent. died.</td></tr>
+<tr><td class="center">"</td><td>shoulder,</td><td>39</td><td class="center">"</td></tr>
+<tr><td class="center">"</td><td>arm,</td><td>21</td><td class="center">"</td></tr>
+<tr><td class="center">"</td><td>fore-arm,</td><td>16</td><td class="center">"</td></tr>
+</table>
+
+
+<p>2. It is the most perfect stump that can be made, in fact the only one
+in the lower extremity which can bear pressure enough to support the
+weight of the body; all the others require the weight to be distributed
+over the general surface of the limb by means of apparatus. A good
+ankle-joint stump can bear the whole weight of the body, as when the
+patient hops on it without any artificial aid, or without even the
+interposition of a stocking between the stump and a stone floor. More
+than this, I have seen a patient who had both his feet amputated at the
+ankle-joint run without shoes or stockings on the stone passages,
+without even the aid of a stick, and with very great swiftness.</p>
+
+<p>The reason of this may be found in the nature of the flap itself,
+originally intended to bear the weight of the body, there being no
+cicatrix at the part on which pressure is borne. I have noticed that
+perfection in walking on an ankle-joint stump has a certain relation to
+the freedom of movement which the pad has over the face of the bone.
+This ought to be pretty considerable. It is explained by the new
+attachments formed by the tendons, and is under the control of the
+patient, being elicited when he is told to move his toes.</p>
+
+<p>It has been objected to this operation that the flap is apt to slough.
+When improperly performed, as when the flap is scored transversely in
+its separation, and especially when the flap is cut too long (as has
+been already noticed), this may occur; but that there is nothing
+whatever in the position or condition of the flap itself that at all
+necessitates its sloughing, is thoroughly proved by the following
+remarkable case, given by Mr. Syme in his volume of <i>Observations in
+Clinical Surgery</i>. I quote it entire:<span class='pagenum'><a name="Page_83" id="Page_83">{83}</a></span>&mdash;</p>
+
+<p>"P.C., aged thirty-three, was admitted into the hospital on the 25th
+July 1860, in the following state:&mdash;He had been treated in the
+Manchester Infirmary for popliteal aneurism by pressure, so decidedly
+applied that it had caused an ulcer, of which the cicatrix remained; but
+without producing the effect desired. The femoral artery was then tied
+with success, in so far as the aneurism was concerned, but with the
+unpleasant sequel, some months afterwards, of mortification in the foot,
+which was thrown off, with the exception of the astragalus and os calcis
+with their integuments, a large raw surface being presented in front
+where the bone was bare. Although the patient was extremely weak, and
+the parts concerned might be supposed more than usually disposed to
+slough, I did not hesitate to perform the operation, with the speedy
+result of a most excellent stump and complete restoration to
+health."&mdash;Pp. 49, 50.</p>
+
+<p>The modifications of Mr. Syme's original operation have been very
+various. It will be unnecessary even to name them all. One or two may
+require notice. Retaining Mr. Syme's incisions in their integrity, some
+operators prefer not to disarticulate the foot, but remove it by sawing
+through the tibia and fibula at once, while still in connection with the
+foot. That most excellent surgeon and first-rate operator, Dr. Johnston
+of Montrose, used to prefer this method.</p>
+
+<p>In cases where the pad of the heel has been destroyed by disease or
+accident, so as to be partially or entirely unavailable for the flap,
+the late Dr. Richard Mackenzie<a name="FNanchor_41_41" id="FNanchor_41_41"></a><a href="#Footnote_41_41" class="fnanchor">[41]</a> practised the following operation by
+internal flap:&mdash;With the foot and ankle projecting from the table with
+their internal aspect upwards, he entered the point of the knife (<a href="#plate_i">Plate
+I.</a> fig. 14) in the mesial line of the posterior aspect of the ankle, on
+a level with the articulation, carried it down obliquely across the
+tendo Achillis towards the external border of the plantar<span class='pagenum'><a name="Page_84" id="Page_84">{84}</a></span> aspect of the
+heel, along which it is continued in a semilunar direction. The incision
+is then curved across the sole of the foot, and terminates on the inner
+side of the tendon of the tibialis anticus, about an inch in front of
+the inner malleolus. The second incision (<a href="#plate_iii">Plate III.</a> fig. 4) is carried
+across the outer aspect of the ankle in a semilunar direction, between
+the extremities of the first incisions, the convexity of the incision
+downwards, and passing half an inch below the external malleolus.</p>
+
+<p>Precisely the same principle might supply the flap from the outer side
+in cases where the internal flap as well as the heel was deficient, but
+probably the nutrition of the external flap would be more doubtful.
+Neither the one nor the other is nearly so good as the true heel flap,
+and they are both only very poor substitutes for it when it cannot be
+had.</p>
+
+<p>The modification devised by Dr. Handyside does not seem to have any
+advantages over the original operation, and has not been adopted.</p>
+
+<p>The modification invented by Professor Pirogoff involves a much more
+important principle than any of the preceding. Instead of dissecting the
+flap from the posterior projecting portion of the os calcis, and
+removing the tarsus entire, he sawed off the posterior portion of the os
+calcis obliquely, leaving it in contact with the pad of skin, which is
+retained. Immediately after making the cut which defines the posterior
+flap and divides the tissues down to the bone, he opens the joint in
+front, disarticulates, and then putting on a narrow saw immediately
+behind the astragalus and over the sustentaculum tali, he saws the os
+calcis obliquely downwards and forwards till he reaches the first
+incision; then removes the ends of the tibia and fibula and brings up
+the slice of os calcis into contact with them.</p>
+
+<p><i>Advantages.</i>&mdash;It is easy of performance, saving the dissection from the
+heel, which some find so hard. It<span class='pagenum'><a name="Page_85" id="Page_85">{85}</a></span> leaves a longer limb. It is said to
+bear pressure better, and there is certainly not so much chance of
+bagging of pus, and the mortality is exceedingly small, Hancock's
+collected cases giving only 8.6 per cent.; in cases of injury it is
+quite a warrantable operation.</p>
+
+<p><i>Disadvantages.</i>&mdash;It is contrary to sound principle in cases of disease,
+for it wilfully leaves a portion of the tarsus, in which disease is
+almost certain to return. It leaves too long a limb, for it is found
+that the shortening in Mr Syme's method is just sufficient to admit of a
+properly constructed spring being placed in the boot to make up for the
+loss of the elastic arch of the foot. It brings the firm pad of the heel
+too much forward, thus tending to lean the weight of the body on the
+softer tissues behind the heel. It takes much longer to unite and
+consolidate.</p>
+
+<p>The author has now, in a large number of cases of Syme's amputation for
+disease, found advantage in leaving the periosteum in the heel flap,
+<i>i.e.</i> he cuts fairly into the os calcis when dividing the skin of heel,
+and then using a periosteum scraper instead of the knife, it is quite
+easy to remove the whole of the periosteum from the bone; this results
+in a large and more rounded pad of great strength and thickness.</p>
+
+<p>In cases where from disease or injury it is impossible to obtain either
+a heel flap or a substitute lateral one, the question is, Where should
+amputation be performed?</p>
+
+<p>It was for a long time the opinion of nearly all the best surgeons, and
+still is the opinion of many, that amputation of the leg should be
+performed at what was known as the "seat of election," just below the
+knee, even in cases where abundance of soft parts could be obtained for
+an amputation much lower down. The rule in surgery, to save as much of
+the body as possible in every amputation, was in the leg believed to be
+set aside by objections which militated strongly against all the<span class='pagenum'><a name="Page_86" id="Page_86">{86}</a></span> other
+operations in the leg except the one performed just below the knee. Very
+briefly, these were somewhat as follows:&mdash;1. Just above the ankle you
+have large bones with nothing to cover them except skin and tendons. 2.
+Higher up in the calf you have plenty of muscle, but it is all on one
+side, and that the wrong one; it is very heavy, very difficult to dress
+and keep in position, and then when you have succeeded with it, the
+muscle wastes away and the stump is flabby. 3. And chiefly, as in all
+the amputations of the leg, the cicatrices are so much in the way, and
+the bones are so ill covered, that the patient can never rest his leg on
+the stump itself, but has either to rest his weight on his patella
+impinging on the top of a bottle-shaped leg, or just to stick out his
+stump behind him and kneel on the top of his wooden leg; therefore it is
+no use to have a stump longer than a few inches; in fact, the longer the
+stump is the more it is in the way. And more than this, many of the
+stumps made near the ankle, or through the calf, are not only useless,
+but positively painful. The skin becomes attached to the bones, the
+cicatrix never properly firms at all, the patient can hardly bear the
+pressure of a stocking, far less can he make use of the limb. For these
+reasons, secondary amputations below the knee are of very common
+occurrence.</p>
+
+<p>Now, this idea has been much modified, and a few isolated cases in the
+past, and series of cases considerably more numerous in the present day,
+show that under certain conditions, and as a result of certain
+precautions in their performance, such operations are both warrantable
+and successful.</p>
+
+<p>In the past, as we find in an erudite note in South's Chelius, Dionis,
+White, and Bromfield had each of them many successful cases of
+amputation just above the ankle, successful in so far that artificial
+limbs could be used which preserved the motion of the knee, and gave<span class='pagenum'><a name="Page_87" id="Page_87">{87}</a></span>
+the patient much more command of the limb than is possible with the
+short stump below the knee.</p>
+
+<p>A still more important point to be remembered is, that amputation just
+above the ankle is a much less fatal amputation than that just below the
+knee (Lister in <i>Holmes's Surgery</i>, 3d ed. vol. iii. p. 716; Gross, 6th
+ed. vol. ii. p. 1113; Ben. Bell, 6th edit. vol. vii. p. 312).</p>
+
+<p>There is little doubt, however, that the principle so much in vogue in
+the present day, of one long anterior or posterior flap, instead of two
+equal flaps, or of circular amputations, has done very much to make
+amputations at the ankle or through the calf justifiable and useful in
+bearing the weight of the body.</p>
+
+
+<p class="gap"><span class="smcap">Amputation just above the Ankle.</span>&mdash;Cases admitting of this operation must
+always be rare, for disease of the tarsus or ankle-joint hardly ever
+goes so far as to contra-indicate the performance of Mr. Syme's greatly
+preferable operation; and an accident which would require this operation
+from injury to the ankle would in most cases require an amputation a
+good deal higher up from the splintering of the tibia so apt to occur.</p>
+
+<p>In a suitable case the plan of the operation should be as follows:&mdash;A
+long anterior flap slightly rounded at the end should be cut (<a href="#plate_i">Plate I.</a>
+figs. 15, 16)&mdash;from the outside, not by transfixion,&mdash;and the anterior
+muscles dissected up along with it. It should be long enough to fall
+down over the face of the bones at the point of section, and easily
+cover the point of the posterior flap, which is to be made by cutting
+through all the tissues with one bold transverse stroke of the knife.
+This operation, which is the plan of Mr. Teale of Leeds very slightly
+modified, is equally applicable at any point of the leg, with this
+difference only, that the length of the anterior flap must always be
+carefully proportioned to the mass of the muscular flap behind it has to
+cover in.<span class='pagenum'><a name="Page_88" id="Page_88">{88}</a></span></p>
+
+<p>This operation provides a skin covering, without any danger of the
+cicatrix being pressed on or becoming adherent.</p>
+
+<div class="blockquot smlet"><p>The author has within the last few years operated nine times in
+this manner, in cases of accident in which the heel flaps had been
+completely destroyed; and seen a tenth case in which Mr. Syme did
+so. All ten cases recovered completely and rapidly, and walked on
+useful limbs, with the free movement of the knee-joint. </p></div>
+
+<p>Where from injury in a muscular patient a long anterior flap cannot be
+had, recourse should be had at once to the operation at the seat of
+election, rather than run the risk of pressure on the cicatrix by using
+a double flap operation, or trust that broken reed, the long posterior
+flap from the great muscles of the calf.</p>
+
+<p>In June 1865, Mr. Henry Lee described a method of operating which he
+hoped would unite the benefits of Mr. Teale's method to the ease of
+performance of the old flap from the calf. I append a short account of
+his method. From its position, however, it has the great disadvantage of
+retaining the discharges, and by its weight straining the stitches and
+weighing down the cicatrix:&mdash;</p>
+
+
+<p class="gap"><span class="smcap">Lee's Amputation</span> <i>of the Leg by a long rectangular flap from the
+Calf</i>.&mdash;The operation described was performed according to Mr. Teale's
+method, as far as the external incisions were concerned, but the long
+flap was made from the back instead of from the front of the limb (<a href="#plate_iv">Plate
+IV.</a> figs. 14, 15). Two parallel incisions were made along the sides of
+the leg, these were met by a third transverse incision behind, which
+joined the lower extremities of the first two. These incisions, which
+formed the three sides of the square, extended through the skin and
+cellular tissue only. A fourth incision was made transversely through
+the skin in front of the leg so as to form a flap in this situation,<span class='pagenum'><a name="Page_89" id="Page_89">{89}</a></span>
+one-fourth only of the length of the posterior flap. When the skin had
+somewhat retracted by its natural elasticity, an incision was made
+through the parts situated in front of the bones, which were reflected
+upwards to a level with the upper extremities of the first longitudinal
+incisions. The deeper structures at the back of the leg were then freely
+divided in the situation of the lower transverse incision. The conjoined
+gastrocnemius and soleus muscles were separated from the subjacent
+parts, and reflected as high as the anterior flap. The deeper layer of
+muscles, together with the large vessels and nerves, were divided as
+high as the incision would permit, and the bones sawn through in the
+usual way. The flaps were then adjusted in the manner recommended by Mr.
+Teale.<a name="FNanchor_42_42" id="FNanchor_42_42"></a><a href="#Footnote_42_42" class="fnanchor">[42]</a></p>
+
+<p>The patients were able to bear the weight of the body on the end of the
+stump.</p>
+
+<p>In cases of chronic disease, where the muscles are atrophied and
+condensed, the following posterior flap method may be used with
+advantage. It is approved of by Mr. Spence. An incision is made across
+the front of the leg from the <i>posterior edge</i> of the fibula to the
+<i>posterior edge</i> of the tibia, or <i>vice vers&acirc;</i>, according to the limb.
+The limb is then transfixed behind the bones from the same points, and a
+long and gently rounded posterior flap cut. The bones are then cleaned,
+and cut through at a little higher level.</p>
+
+<p class="gap"><span class="smcap">Amputation immediately below the Knee</span> <i>at the</i> "<i>true seat of
+election</i>."&mdash;The principles on which this operation is founded are&mdash;1.
+That a muscular flap is not necessary, skin being perfectly sufficient;
+2. That as the muscles retract they must be cut at a lower level than
+the bones, and as they retract unequally from their varying length, the
+cuts must be made with due reference to that inequality; 3. That no more
+of the tibia<span class='pagenum'><a name="Page_90" id="Page_90">{90}</a></span> need be retained than what is just sufficient to retain
+the attachment of the ligamentum patell&aelig;, and to insure its vitality; 4.
+That the head of the fibula must be retained in every case, as in a
+certain proportion the tibio-fibular articulation communicates with the
+knee-joint.</p>
+
+<p><i>Operation.</i>&mdash;Two equal semilunar flaps of skin must be cut&mdash;from the
+outside, not by transfixion,&mdash;one anterior and external, the other
+posterior and internal, their extremities meeting at points about two
+inches below the tuberosity of the tibia on either side (<a href="#plate_i">Plate I.</a> figs.
+17, 18). These must be reflected up, and with them a further extent of
+skin, embracing the whole circumference of the limb, must be dissected
+up (as if pulling off the fingers of a glove), so as to expose the bone
+one inch below the tuberosity. The anterior muscles being very close to
+their origin, and consequently being able to retract very slightly, must
+be cut as high as exposed, and the posterior ones about the middle of
+their exposed surface.</p>
+
+<p>The bones must then be sawn as high as exposed, with the following
+precautions:&mdash;1. In order to prevent splintering of the fibula,
+endeavour to saw it along with the tibia, so as to finish it first; 2.
+To prevent projection of a sharp prominence of the edge of the tibia,
+enter the saw obliquely a little higher up than where you intend to
+divide the bone, then withdraw it, and enter the saw again at right
+angles to the bone, and a line or two lower down. Some surgeons prefer
+to make this section afterwards with a finer saw or the bone-pliers.</p>
+
+<p>This operation is very frequently required to remedy painful and
+unhealed stumps, the result of amputations lower down, specially those
+in which the long posterior flap from the muscles of the calf has been
+used. In the above amputation the patient will not be able to rest the
+weight of his body on the <i>face</i> of the stump, but by putting the limb
+into a well-padded case with soft<span class='pagenum'><a name="Page_91" id="Page_91">{91}</a></span> rounded edges, the weight might be
+borne partly on the sides of the stump, and partly on the lower edge of
+the patella; and the patient will be able to walk with great comfort,
+preserving the use of his knee-joint.</p>
+
+
+<p class="gap"><span class="smcap">Amputation at the Knee-joint</span>.&mdash;This "relic of ancient surgery," as Mr.
+Skey calls it, has been revived only of late years, and seems in certain
+cases to be a justifiable and successful operation.</p>
+
+<p>Practised by Fabricius Hildanus and Guillemeau in the sixteenth and
+seventeenth centuries, it had fallen into disuse till revived by Hoin,
+Velpeau, and Baudens, on the Continent, Professor Nathan Smith in
+America, and Mr. Lane in London.</p>
+
+<p>It is not possible that this operation can be at all frequent, since the
+cases in which it is applicable are comparatively rare; for, to be
+successful, the following conditions are essential:&mdash;1. That there be
+abundant skin in front of the knee-joint to make a long anterior flap;
+2. That the patella and articular surface of the femur are healthy.
+These conditions at once exclude nearly every case of disease or
+accident. If the joint is diseased some amputation through the thigh
+must be attempted; if injured, and the front of the knee is safe, it may
+very likely be possible to amputate below the knee. Hence this operation
+may be useful in cases where, for malignant disease, the <i>whole</i> tibia
+requires removal, and yet the knee-joint is sound, or for gunshot
+injuries, in which the tibia is splintered but the soft tissues
+comparatively uninjured.</p>
+
+<p><i>Operation.</i>&mdash;A long anterior flap should be cut with a semilunar end
+(<a href="#plate_ii">Plate II.</a> figs. 6, 7), extending as far as the insertion of the
+ligamentum patell&aelig;. This flap, including the patella, should be thrown
+up, the joint cut into, and a short posterior flap made by transfixion.</p>
+
+<p>It is important to retain the patella, if possible, as it<span class='pagenum'><a name="Page_92" id="Page_92">{92}</a></span> fills up the
+hollow between the condyles; it sometimes becomes anchylosed, but in
+other cases it remains freely mobile, and adds to the value of the
+stump.</p>
+
+<p>Professor Pancoast has practised an amputation at the knee-joint by
+three flaps, performed entirely by the scalpel, which, he says, results
+in a good stump. One flap, the anterior one, is longest and semilunar in
+shape, its convexity passing three inches below the tuberosity of the
+tibia; the other two are much smaller, and postero-lateral.<a name="FNanchor_43_43" id="FNanchor_43_43"></a><a href="#Footnote_43_43" class="fnanchor">[43]</a></p>
+
+<p><i>Advantages.</i>&mdash;The bone is not cut into at all, there is a free drain
+for matter, no tendency to retraction of the flaps, and the weight of
+the body is borne on skin previously habituated to pressure.</p>
+
+<div class="blockquot smlet"><p>The statistics seem to be favourable: out of 55 cases, Continental,
+American, and English, 21 died, a mortality of 38 per cent., while
+in a table of 1055 cases of amputation of the thigh, 464 died,
+being a mortality of 44 per cent. In some of the American cases the
+articulating extremity of the femur seems to have been removed, as
+in the following  operation:&mdash;</p></div>
+
+
+<p class="gap"><span class="smcap">Amputation through the Condyles of the Femur</span>.&mdash;In the <i>London and
+Edinburgh Journal of Medical Science</i> for 1845, Mr. Syme advocated a
+method of amputation through the condyles of the femur as specially
+suitable in case of diseased knee-joint. Amputation at this spot has
+certain advantages:&mdash;1. The shaft of the bone being untouched, there is
+no injury of the medullary cavity, and hence no fear of inflammation of
+its lining membrane. 2. There is less risk of exfoliation, the
+cancellated texture of the epiphysis not being liable to it. 3. Being
+close to the joint, the muscles are cut through where they are
+tendinous, thus very much diminishing the risk of retraction and
+consequent protrusion of the bone. 4. A large broad surface of bone is
+left to bear the weight of the body, and one which, like the ankle-joint
+stump, will round off and<span class='pagenum'><a name="Page_93" id="Page_93">{93}</a></span> afford a comfortable pad over which the skin
+of the flap will freely play.</p>
+
+<p>One objection used to be urged against this mode of operating, the fear
+lest the thickened, brawny, and often ulcerated textures in the
+neighbourhood of a diseased knee-joint, would not make a good covering.
+This, however, is no longer a bugbear, as we see in cases of resection,
+where the diseased joint alone is taken away, how very soon all swelling
+and disease departs, once its cause is removed.</p>
+
+<p>Mr. Syme's original operation was briefly as follows:&mdash;With an ordinary
+amputating-knife make a lunated incision (<a href="#plate_i">Plate I.</a> fig. 19) from one
+condyle to the other, across the front of the joint, on a level with the
+middle of the patella, divide the tissues down to the bones, and then
+draw the flap upwards, then cut the quadriceps extensor immediately
+above the patella. The point of the blade should then be pushed in at
+one end of the wound, thrust behind the femur, and made to appear at the
+other end; it should then be carried downwards (<a href="#plate_iii">Plate III.</a> fig. 5), so
+as to make a flap from the calf of the leg, about six or eight inches in
+length, in proportion to the thickness of the limb; the flap should then
+be slightly retracted, and the knife carried round the bone a little
+above the condyles to clear a way for the saw, which should be applied
+so as to leave the section as horizontal as possible.</p>
+
+<p>This method is now hardly ever used, as the following seems a much
+better one:&mdash;</p>
+
+
+<p class="gap"><span class="smcap">Gritti's<a name="FNanchor_44_44" id="FNanchor_44_44"></a><a href="#Footnote_44_44" class="fnanchor">[44]</a> Amputation</span>.&mdash;In this two flaps are formed&mdash;an anterior long
+one rectangular and a posterior short one. The condyles of the femur are
+divided through their base, and the lower surface of patella is removed
+by a small saw, and then the surfaces of bone approximated.<span class='pagenum'><a name="Page_94" id="Page_94">{94}</a></span></p>
+
+
+<p class="gap"><span class="smcap">Stokes's<a name="FNanchor_45_45" id="FNanchor_45_45"></a><a href="#Footnote_45_45" class="fnanchor">[45]</a> modification of Gritti's amputation</span>.&mdash;In this
+"supracondyloid" amputation, the femur is sawn just above the condyles,
+without going into the medullary canal. The anterior flap is oval, twice
+as long as posterior, and the patella is brought up after denudation
+against end of femur.</p>
+
+
+<p class="gap"><span class="smcap">Carden's Amputation at the Condyles of the Femur</span>.<a name="FNanchor_46_46" id="FNanchor_46_46"></a><a href="#Footnote_46_46" class="fnanchor">[46]</a>&mdash;The operation
+consists in reflecting a rounded or semi-oval flap of skin and fat from
+the front of the knee-joint, dividing everything else straight down to
+the bone, and sawing the bone slightly above the plane of the muscles,
+thus forming a flat-faced stump, with a bonnet of integument to fall
+over it.</p>
+
+<p>The operator standing on the right side of the limb, seizes it between
+his left forefinger and thumb at the spot selected for the base of the
+flap, and enters (<a href="#plate_ii">Plate II.</a> fig. 8) the point of the knife close to his
+finger, bringing it round through skin and fat below the patella to the
+spot pressed by his thumb; then turning the edge downwards at a right
+angle with the line of the limb, he passes it through to the spot where
+it first entered, cutting outwards through everything behind the bone
+(<a href="#plate_iv">Plate IV.</a> fig. 16). The flap is then reflected, and the remainder of
+the soft parts divided straight down to the bone; the muscles are then
+slightly cleared upwards, and I saw it applied.</p>
+
+<p>I have ventured to make a slight change in the method of performing this
+most excellent operation, for having found the posterior flap, as cut in
+the method above described, rather scanty in the earlier cases in which
+I have had occasion to perform it, after dissecting back the anterior
+flap and cutting into the knee-joint, I shape a slightly convex
+posterior flap of skin<span class='pagenum'><a name="Page_95" id="Page_95">{95}</a></span> only, at least one and a half inches in length
+in adult, and allow it to retract before dividing the muscles by a
+circular cut to the bone, and have had every reason to be satisfied with
+the change.</p>
+
+
+<p class="gap"><span class="smcap">Amputation of the Thigh.</span>&mdash;Amputation of the thigh has been the favourite
+battle-ground where flap and circular, antero-posterior and lateral,
+long and short flaps, double, triple, and conical incisions, have
+striven with each other; so were I to attempt to describe one quarter of
+the various methods employed, I should need to rewrite the history of
+Amputation.</p>
+
+<p>It will suffice merely to describe the <i>best</i> modes of amputating the
+thigh through its lower, middle, and upper thirds respectively, and at
+the hip-joint.</p>
+
+<p>In one word, it may be stated that, with the exception of those
+amputations performed through the lower third of the bone, the flap
+method is to be preferred, and the flaps should in almost every case be
+made by transfixion.</p>
+
+<p>In the lower third, however, the flap method, though exceedingly easy,
+and capable of very rapid performance, has certain defects; the chief of
+these being the tendency which the muscular flaps (the necessary result
+of transfixion) have to cause undue retraction, and hence protrusion of
+the bone. This is seen specially in the hamstrings, which from the great
+distance of their origin, and the purely longitudinal direction of their
+fibres, retract to a very great extent, much more than the anterior
+muscles can do from the pennate direction of their fibres, and the
+manner in which they are mutually bound down to each other and to the
+bone.</p>
+
+<p>Even in this one position, the lower third of the thigh, the methods
+that may be needed are various, and require separate notice;&mdash;for
+operations here are extremely frequent from the frequency of strumous
+disease of the knee-joint in our variable climate, and from the<span class='pagenum'><a name="Page_96" id="Page_96">{96}</a></span> fact
+that compound fractures or dislocations of the knee-joint so very often
+necessitate amputation.</p>
+
+<p>In cases where the skin over the patella is uninjured and available, the
+operation by long anterior flap (either by Teale's method, or by Mr.
+Spence's modification of it, which curiously is almost exactly similar
+to the amputation of Benjamin Bell by a single flap) is suitable enough.
+But, I believe, preferable to either of these is the operation of Mr.
+Carden, already described. In cases where the knee-joint is injured, and
+the skin over the patella unavailable, and yet where it is not necessary
+to go higher up the limb, the modified circular amputation of Mr. Syme
+will be found very suitable.</p>
+
+<p>As it is in this lower third of the thigh that a very large proportion
+of the cases requiring a long anterior flap is to be found, it affords
+the best opportunity for comparing in their detail the three almost
+similar plans of B. Bell, Teale, and Spence&mdash;after which Mr. Syme's
+modified circular may be described.</p>
+
+
+<p class="gap"><span class="smcap">Benjamin Bell's Flap Operation above the Knee</span> (reported in his own
+words, slightly abbreviated).&mdash;"When this operation is to be performed
+above the knee, it may be done either with one or two flaps, but it will
+commonly succeed best with one. The flap answers best on the fore part
+of the thigh, for here there is a sufficiency of the parts for covering
+the bones, and the matter passes more freely off than when the flap is
+formed behind.... The extreme point of the flap should reach to the end
+of the limb, unless the teguments are in any part diseased, in which
+case it must terminate where the disease begins, and its base should be
+where the bone is to be sawn. This will determine the length of the
+flap, and we should be directed with respect to the breadth of it by the
+circumference of the limb, for the diameter of a circle being somewhat
+less than a third of its circumference,<span class='pagenum'><a name="Page_97" id="Page_97">{97}</a></span> although a limb may not be
+exactly circular, yet by attention to this we may ascertain with
+sufficient exactness the size of a flap for covering a stump (<a href="#plate_iv">Plate IV.</a>
+fig. 17). Thus a flap of four inches and a quarter in length will reach
+completely across a stump whose circumference is twelve inches; but as
+some allowance must be made for the quantity of skin and muscles that
+may be saved on the opposite side of the limb, by cutting them in the
+manner I have directed, and drawing them up before sawing the bone, and
+as it is a point of importance to leave the limb as long as possible,
+instead of four inches and a quarter, a limb of this size, when the
+first incision is managed in this manner, will not require a flap longer
+than three inches and a quarter, and so in proportion, according to the
+size of the limb. The flap at its base should be as broad as the breadth
+of the limb will permit, and should be continued nearly, although not
+altogether, of the same breadth till within a little of its termination,
+where it should be rounded off so as to correspond as exactly as may be
+with the figure of the sore on the back part of the limb. This being
+marked out, the surgeon, standing on the outside of the limb, should
+push a straight double-edged knife with a sharp point to the depth of
+the bone, by entering the point of it at the outside of the base of the
+intended flap; and carrying the point close to the bone, it must here be
+pushed through the teguments at the mark on the opposite side. The edge
+of the knife must now be carried downwards in such a direction as to
+form the flap, according to the figure marked out; and as it draws
+toward the end, the edge of it should be somewhat raised from the bone,
+so as to make the extremity of the flap thinner than the base, by which
+it will apply with more neatness to the surface of the sore. The flap
+being supported by an assistant, the teguments and muscles of the other
+parts of the limb should, by one stroke of the knife, be cut<span class='pagenum'><a name="Page_98" id="Page_98">{98}</a></span> down to
+the bone, about an inch beneath where the bone is to be sawn; and the
+muscles being separated to this height from the bone with the point of a
+knife, the soft parts must all be supported with the leather retractors
+till the bone is sawn," etc., arteries tied, and dressings applied.<a name="FNanchor_47_47" id="FNanchor_47_47"></a><a href="#Footnote_47_47" class="fnanchor">[47]</a></p>
+
+
+<p class="gap"><span class="smcap">Amputation of Thigh by Rectangular Flap</span>&mdash;(Teale's).&mdash;I take the
+opportunity here of describing fully, and as far as possible in his own
+words, Mr. Teale's method of amputating, this being the situation where
+his method is most frequently available. The same principle may be
+applied to amputations at almost any other part of the body.</p>
+
+<p>After advising the surgeon to mark out the proposed line of incision
+with ink before the operation, he gives the following directions for
+fixing the exact size of the flap:&mdash;"Supposing the amputation to take
+place (<a href="#plate_ii">Plate II.</a> figs. 9, 10) at the lower part of the middle third of
+the thigh, the circumference of the limb is to be measured at the point
+where the bone is to be divided.<a name="FNanchor_48_48" id="FNanchor_48_48"></a><a href="#Footnote_48_48" class="fnanchor">[48]</a> Assuming this to be sixteen inches,
+the long flap is to have its length and breadth each equal to half the
+circumference, namely, eight inches. Two longitudinal lines of this
+extent are then traced on the limb, and are met at their lower points by
+a transverse line of the same length. The inner longitudinal line should
+be first traced in ink as near as practicable to the femoral vessels,
+without including them within the range of the long flap. The outer
+longitudinal line, which is somewhat posterior, is next marked eight
+inches distant from the former and parallel to it. These two lines are
+then joined by a transverse line of the same extent, which falls upon
+the upper border of the patella, or upon some lower portion of this
+bone. The short flap is indicated by a transverse line passing behind
+the<span class='pagenum'><a name="Page_99" id="Page_99">{99}</a></span> thigh, the length of this flap being one-fourth that of the long
+one; or, assuming the circumference of the limb to be sixteen inches,
+and the length of the long flap eight inches, the length of the short
+flap is two inches. The operator begins by making the two lateral
+incisions of the long flap through the <i>integuments only</i>. The
+transverse incision of this flap, supposing it to run along the upper
+edge of the patella, is made by a free sweep of the knife through the
+skin and tendinous structures down to the femur. Should the lower
+transverse line of the flap fall across the middle or lower part of the
+patella, the transverse incision can extend through the skin only, which
+must be dissected up as far as the upper border of the patella, at which
+place the tendinous structures are to be cut direct to the thigh-bone.
+The flap is completed by cutting the fleshy structures from below
+upwards close to the bone. The posterior short flap, containing the
+large vessels and nerves, is made by <i>one sweep</i> of the knife down to
+the bone, the soft parts being afterwards separated from the bone close
+to the periosteum, as far upwards as the intended place of sawing.... In
+adjusting the flaps, the long one is folded over the end of the bone,
+and brought, by its transverse line, into union with the short flap, the
+two corresponding free angles of each being first united by suture. One
+or two additional stitches complete the transverse line of union. Care
+is now required in arranging the two lateral lines of union. As the long
+flap is folded upon itself so as to form a kind of pouch for the end of
+the bone, it is requisite that it should be held in its folded state by
+a point of suture on each side. Another stitch on each side secures the
+lateral line of the short flap to the corresponding part of the long
+one. A longitudinal line of union thus passes at right angles each end
+of the transverse line."<a name="FNanchor_49_49" id="FNanchor_49_49"></a><a href="#Footnote_49_49" class="fnanchor">[49]</a><span class='pagenum'><a name="Page_100" id="Page_100">{100}</a></span></p>
+
+<p>Mr. Teale's account of the resulting stumps is too long to quote entire,
+but in a few words, we find that by retraction of the short posterior
+flap, the cicatrix is drawn up quite behind and out of the way of the
+bone, that a soft mass without any large nerves or vessels is the result
+of the partial atrophy of the long flap, and that the patient is able to
+bear one-half, two-thirds, or even in some cases the entire weight of
+his body on the face of the stump. Such a power of support is to be
+found in no other flap except in Mr. Syme's amputation at the
+ankle-joint.</p>
+
+
+<p class="gap"><span class="smcap">Spence's Amputation by a long Anterior Flap</span>.<a name="FNanchor_50_50" id="FNanchor_50_50"></a><a href="#Footnote_50_50" class="fnanchor">[50]</a>&mdash;The method used by Mr.
+Spence in amputations just above the knee-joint obtains the advantages
+of Teale's method, and avoids many of its disadvantages. He makes two
+flaps. The anterior one, which is to fall loosely over and cover in the
+posterior segment of the stump, must have a breadth fully equal to
+one-half of the circumference of the limb, and must be gently rounded at
+its extremity, so as to adjust itself readily to the curve of the cut
+margin of the posterior half of the stump. He begins the anterior
+incision below, or on a level with, the lower margin of the patella, and
+when the skin is retracted to a little above the patella, cuts down
+<i>obliquely</i> to the bone, so as to divide the soft parts up to the base
+of the flap. For the posterior incision, he begins about two
+fingers'-breadth below the base of the anterior flap, and the assistant
+retracting the skin, the edge of the knife is carried obliquely up to
+the bone (in Alanson's manner) and the posterior soft parts divided, the
+bone is sawn through&mdash;or immediately above&mdash;the condyloid portion. Mr.
+Spence does not advise or practise this method high up. The results are
+good, for by these means the end of the bone has a thick covering,
+including muscular fibres,<span class='pagenum'><a name="Page_101" id="Page_101">{101}</a></span> over it, and the cicatrix is not pressed
+upon in walking. The stump remains full, mobile, and fleshy, as in Mr.
+Teale's method, without the disadvantage which it has, in requiring the
+bone to be divided so far above the seat of injury or disease. This is
+an exceedingly good method of operating in the lower third of the thigh,
+in muscular patients the very best, and in all cases only equalled in
+value by Carden's method.</p>
+
+<p>The next is now hardly ever used here, except in cases where the skin
+over the patella is destroyed.</p>
+
+
+<p class="gap"><span class="smcap">Modified Circular at Lower Third of Thigh</span> (Syme's).&mdash;Two equal semilunar
+flaps of skin should be cut (<a href="#plate_i">Plate I.</a> fig. 20, <a href="#plate_iii">Plate III.</a> fig. 6), one
+anterior, the other posterior, their convexities being towards the knee.
+The skin and subcutaneous cellular tissue should be raised from the
+fascia, and then retracted to a further distance of at least two inches;
+the muscles should then be divided right down to the bone, on a level as
+high as they are exposed in front, and as low as they are exposed
+behind. This allows for the different amount of retraction at the two
+sides of the limb, and leaves the muscles cut on a level; the whole mass
+of muscles should then be drawn well up, and the bone exposed, and sawn
+through at a level about two inches higher than where it was first
+exposed by the anterior incision through the muscles.</p>
+
+<p>In very weak thin flabby limbs this process may be simplified by just at
+once including the muscles in the skin flaps, and carefully exposing the
+bone higher up. In performing the retraction the assistant should be
+cautioned not to overdo it, lest he strip the periosteum from the bone
+higher than is necessary. This is very easy to do in the weak limbs of
+strumous patients, and may cause exfoliation, and greatly delay cure.<span class='pagenum'><a name="Page_102" id="Page_102">{102}</a></span></p>
+
+
+<p class="gap"><span class="smcap">Amputation in the middle third of the Thigh</span>.&mdash;A very short notice will
+suffice here. The exact position, shape, and size of the flaps must in
+every case be modified by the nature of the injury for which the
+operation is performed, taking the flaps where they can be obtained. As
+a general rule, a long anterior flap with a short posterior, on the
+principle described above, should be preferred. In cases where the long
+anterior cannot be obtained, two equal flaps should be made by
+transfixion. The flaps should always be antero-posterior, the lateral
+flaps introduced by Vermale, and indorsed by Chelius and Erichsen,
+having the great disadvantage of allowing the bone, which is drawn up by
+the psoas and iliacus, to project at the upper angle.</p>
+
+<p>Supposing the right thigh is to be amputated, the surgeon, standing on
+the inside of the leg, should raise the skin and muscles of the front of
+the limb in his left hand, and entering the knife just in front of the
+vessels, should transfix the limb, the knife passing in front of the
+bone, and including as nearly as possible an exact half of the limb
+(<a href="#plate_iv">Plate IV.</a> fig. 19); having by a sawing motion brought out the knife and
+cut a flap of the required length, the knife is re-entered at the same
+place, and passing behind the bone, the point must be brought out at the
+angle on the other side. Both flaps being then held back by an
+assistant, the bone is cleared by a circular turn of the knife, and the
+saw applied, the vessels are found cut high up in the inner angle of the
+posterior flap.</p>
+
+<p>In muscular patients it is often better to make the incision through the
+skin first and allow it to retract before transfixing; this is slower
+and not so brilliant looking, but avoids redundancy of muscle.</p>
+
+
+<p class="gap"><span class="smcap">Amputation at the Hip-Joint</span>.&mdash;This operation, exceedingly dangerous from
+the amount of the body removed, the great h&aelig;morrhage, and the risk of<span class='pagenum'><a name="Page_103" id="Page_103">{103}</a></span>
+py&aelig;mia, is of comparatively modern invention. Though the proportion of
+recoveries is at present to that of deaths about one to two or two and a
+half, it is still a perfectly justifiable operation in many cases of
+disease and injury.</p>
+
+<p>Like amputation at the shoulder, amputation at the hip has given rise to
+very many various methods of performance. Under the heads of single
+flap, double flap, oval, circular, and mixed flap and circular, at least
+twenty distinct methods have been put on record, and, including
+modifications, there are thirty-seven or thirty-eight different surgeons
+who have each their own plan of operation.</p>
+
+<p>The reason of this fearful complexity in its literature depends on this
+fact, that this amputation has generally been performed for cases of
+such severe injury of the limb, that no milder amputation was possible,
+and thus the flaps had to be taken just where the surgeon could get them
+best. And this will have to be the guiding principle in most amputations
+at this joint; the surgeon must just cut his coat according to his
+cloth&mdash;get his flaps where and how he can.</p>
+
+<p>In cases, however, where it is possible to have a choice, and to select
+the flaps, the following is, I believe, both the best and quickest
+method:&mdash;</p>
+
+<p>This is one of the very few operations in which quickness of performance
+is a desideratum; the use of an&aelig;sthetics has, in most other cases, given
+time for elaboration of flaps, and careful dissection; here the risk of
+loss of blood, specially from the posterior flap, renders rapid
+disarticulation imperative.</p>
+
+<p><i>Amputation by double flap, anterior the longer.</i>&mdash;In hip-joint
+amputations, besides the ordinary sponge-squeezers, two assistants are
+necessary, whose duties are exceedingly important.</p>
+
+<p>The first is to check h&aelig;morrhage. Pressing with a firm pad on the
+external iliac just as it passes the bone,<span class='pagenum'><a name="Page_104" id="Page_104">{104}</a></span> he must be prepared, the
+instant the anterior flap is cut, to follow the knife and seize flap and
+artery in his hand, and he is to hold it there till all the vessels in
+the posterior flap are first tied.</p>
+
+<p>The second has to manage the limb, and on the manner in which he
+performs his duty much of the success and nearly all the celerity of the
+operation depend. While the surgeon is transfixing the anterior flap,
+this assistant is to support the limb in a slightly flexed position, so
+as to relax the muscles; the instant the flap is cut he is to extend the
+limb forcibly, and at the same time be careful not to abduct it in the
+least, but to turn the toes inward so as to bring the great trochanter
+well forwards on a level with the joint; if this precaution is
+neglected, the operator in making the posterior flap is almost certain
+to lock his knife in the hollow between the head of the bone and the
+great trochanter.</p>
+
+<p>If it is the left side, the operator, standing on the outside of the
+limb, enters the point of a long straight knife midway between the
+anterior superior spinous process of the ilium and the great trochanter,
+and passes it as close to the front of the joint as possible, making the
+point emerge close to the tuberosity of the ischium (<a href="#plate_iv">Plate IV.</a> fig.
+20-20). With a rapid sawing movement he then cuts a long anterior flap,
+avoiding any pointing of it, and endeavouring to make the curve equal.
+The fingers of the assistant must be inserted so as to follow the knife
+and seize the vessel even before it is divided. The flap being raised
+out of the way, the surgeon, without changing his knife (as used to be
+advised), opens the joint, divides the ligaments as they start up on the
+limb being extended and adducted, the round ligament, and the posterior
+part of the capsule; and then getting the knife fairly behind both the
+head of the bone and the trochanter, cuts the posterior flap as rapidly
+as possible. Instantly on the limb being separated, assistants<span class='pagenum'><a name="Page_105" id="Page_105">{105}</a></span> should
+be ready with large dry sponges or pads of dry lint to press against the
+surface of the posterior flap, till the large branches, chiefly of the
+internal iliac, which are cut in it, are tied one by one.</p>
+
+<p>The lever invented by Mr. Richard Davy, by which the common iliac is
+compressed from the rectum, has in many cases proved of great service in
+preventing h&aelig;morrhage, but has dangers of its own in cases of abnormal
+position of rectum, or even in sudden movements of the patient.</p>
+
+<p>In every case the abdominal tourniquet will be found of great service in
+checking h&aelig;morrhage, during the operation of amputation at the
+hip-joint. It consists of an arch of steel fitted with a pad behind,
+which rests against the vertebral column, and a pad in front playing on
+a very fine and long screw, through an opening in the arch. When screwed
+down tightly on the aorta just before the incisions are commenced, it
+checks h&aelig;morrhage admirably without injuring the viscera. When this is
+applied, a method of amputation once practised by Mr. Syme, though not
+so rapid as the double-flap method by transfixion, will be found very
+easy, and to result in most excellent flaps. He cut an anterior flap in
+the usual manner by transfixion, then made a straight incision from its
+outer edge down to about two inches below the great trochanter, thus
+exposing it fully, and from the lower end of this incision transfixed
+again, cutting a posterior flap nearly equal in size to the anterior; a
+few strokes of the knife round the joint finished the disarticulation.
+The resulting flaps came together with great accuracy, and were not
+burdened with the great unequal masses of muscles so often noticed in
+the posterior flaps which are made by cutting from within outwards
+<i>after</i> disarticulation.</p>
+
+<p>In some cases of amputation where the femur has been badly shattered, it
+is a good plan to amputate through the upper third of thigh, tie all the
+vessels, and<span class='pagenum'><a name="Page_106" id="Page_106">{106}</a></span> then, aided by an incision at outer side, dissect out the
+head of the bone.</p>
+
+<p>Mr. Furneaux Jordan of Birmingham carries out this principle by first
+dividing the soft parts in circular direction low down the thigh, and
+then dissecting out the head of the bone from the muscles by a long
+incision on the outer aspect of the limb.</p>
+
+<div class="blockquot smlet"><p><i>Note.</i>&mdash;In severe cases of smash when both lower limbs have
+required amputation, the author has derived much assistance from
+the method of managing the operation detailed below:&mdash;</p>
+
+<p><i>Double Primary Amputation of (both) Thighs from railway
+smash</i>&mdash;<i>Rapid recovery.</i>&mdash;G., a healthy-looking man, aged
+twenty-seven, but looking much older, while driving a horse near
+Granton, caught his foot on the edge of a rail at a point, fell,
+and both his legs were run over by several loaded wagons. A special
+engine was procured, his thighs tightly tied up, and he was sent up
+to hospital at once.</p>
+
+<p>I was in hospital at the time, so with as little delay as possible
+he was placed on the operating table, and the necessity for
+amputation being too evident, I obtained his leave to remove both
+his legs above the knee; but his pulse was very feeble, and he was
+intensely nervous, throwing his arms wildly about, panting for
+breath, and looking very ill, cold, and exhausted.</p>
+
+<p>I determined that by great rapidity he might be got off the table
+alive, so operated in the following manner:&mdash;Fixing the tourniquet
+firmly near both groins, I first amputated the right leg by
+Carden's method, and tied the femoral only, wrapped up the stump in
+a towel wrung out of carbolic solution 1-20, then took off the
+other limb by Mr. Spence's method,&mdash;it had been injured higher than
+the right, so that I could not save the condyles of the
+femur,&mdash;then tied the femoral there, and fixed it up with another
+towel; then returning to the first, I tied one or two large
+branches which spouted, and rolled it up again, then back to the
+left one, doing the same, and getting the tourniquet off both
+limbs. On going back to the right the surface was nearly dry and
+glazed, so, asking Dr. Maclaren, who assisted me, to stitch it up
+and insert a drainage-tube, I did the same for the left, so rapidly
+that the patient was in his bed with his limbs dressed and bandaged
+in 24&#189; minutes from the time he entered the hospital gate.</p>
+
+<p>The strictest antiseptic precautions were observed, two engines
+being used to furnish spray. Of course this great rapidity was due
+to the fact that everything was ready, the<span class='pagenum'><a name="Page_107" id="Page_107">{107}</a></span> assistants all in
+hospital, admirably disciplined, and steam had been up in the spray
+engines. Shock was comparatively trivial; his temperature once, and
+only once, reached 100&deg;. His stumps healed by first intention, and
+he was in the garden on the seventh day after the operation.</p>
+
+<p>I have now in three cases found the benefit of this mode of dealing
+with double primary amputation in avoiding shock, lessening the
+time needed, and greatly diminishing the number of vessels
+requiring to be tied. In a previous case of double amputation for
+railway smash at the knees, the patient was almost pulseless, and
+had he been kept many minutes more on the table would not have left
+it alive. He also rapidly recovered.</p>
+
+<p>The case is interesting also as showing that, when the assistants
+know their work, the strictest adherence to antiseptic precautions
+need not in itself make either the operation or the dressing
+tedious, though it can easily be made an excuse for much fussing
+and many delays.<a name="FNanchor_51_51" id="FNanchor_51_51"></a><a href="#Footnote_51_51" class="fnanchor">[51]</a> </p></div>
+
+
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_108" id="Page_108">{108}</a></span></p>
+
+<h2><a name="CHAPTER_III" id="CHAPTER_III"></a>CHAPTER III.</h2>
+
+<h3>EXCISION OF JOINTS.</h3>
+
+
+<p><i>Historical.</i>&mdash;Beyond a passage ascribed to Hippocrates, but of very
+doubtful authenticity, and slight allusions in the works of Celsus and
+Paulus &AElig;gineta, the ancients give us no information whatever on this
+subject.</p>
+
+<p>Hippocrates says,&mdash;"Complete resections of bones in the neighbourhood of
+joints both in the foot, in the hand, in the tibia up to the malleoli,
+and in the ulna at its junction with the hand, and in many other places,
+are safe operations, if that fatal syncope does not at once occur, and
+continued fever does not attack the patient on the fourth day."</p>
+
+<p>Celsus and &AElig;gineta both advise the removal of protruding ends of bone in
+compound dislocations, but without giving any cases.</p>
+
+<p>From the days of these classic fathers of Surgery, we have hardly an
+indication of any attention whatever having been paid to their hints
+till quite within the last hundred years.</p>
+
+<p>The first distinct publication on the subject was by Henry Park of
+Liverpool, in a letter to Percival Pott in 1783. He proposed the removal
+of the articulating extremities of diseased elbow and knee-joints to
+obtain cures. He says he was led to this by its having been the
+invariable custom, for more than thirty years, at the Liverpool
+Infirmary, to take off the protruded extremities of bones in cases of
+compound dislocation.<span class='pagenum'><a name="Page_109" id="Page_109">{109}</a></span></p>
+
+<p>The chief credit, however, in practically elevating excisions into the
+catalogue of recognised surgical operations, is owing, British surgeons
+most cordially own, to two provincial surgeons of France, the Moreaus
+(father and son) of Bar-sur-Ornain. They took the lead in the most
+marked manner, having excised the shoulder in 1786, the wrist and elbow
+in 1794, knee and ankle in 1792, and had followed this up so well that,
+in 1803, the younger Moreau could boast, "the town has become in some
+sort the refuge of the unfortunate afflicted with carious joints, after
+they have tried all the means usually recommended by professional men,
+or have had recourse to empirical nostrums, or when amputation seemed to
+them the last resource."</p>
+
+<p>Moreau's papers and cases, which, between 1786 and 1789, he frequently
+read to the French Academy, were, some violently opposed, others utterly
+neglected by his compatriots, and many of them lost and buried in the
+unpublished papers of that body.</p>
+
+<p>And though diseased joints did not decline in frequency, and though
+injured ones were extremely numerous during these long years of European
+war, excisions were but rarely performed.</p>
+
+<p>With the exception of the removal of head of humerus after gunshot
+injury, hardly any British, and but very few French, limbs were saved by
+excision taking the place of amputation.</p>
+
+<p>The limbs that were saved by Percy by excision of the head of the
+humerus really owe their recovery and safety to the elder Moreau; for an
+operation of his, at which he was assisted by that distinguished
+military surgeon, gave the latter the hint, which he followed so
+successfully, that by 1795 he had performed it nineteen times, and had
+indoctrinated Sabatier, Larrey, and others, and elevated it into a
+recognised operation of military surgery.</p>
+
+<p>So far, however, as the application of the great improvement<span class='pagenum'><a name="Page_110" id="Page_110">{110}</a></span> of the
+Moreaus to disease went, the French surgeons have little reason to
+boast, for it is to English surgery, and especially to one Edinburgh
+surgeon, that this class of operations owes nearly all its improvement
+in methods and frequency of performance.</p>
+
+<p>For though (as we shall see under the special heads) here and there one
+or two cases were performed, it was not till the publication of Mr.
+Syme's monograph on the excision of diseased joints, in 1831, that the
+importance and value of the discovery were fairly brought before the
+profession; and the conservative surgery, of which excision as preferred
+to amputation is the great type, must ever be associated with British
+surgeons&mdash;Syme, Fergusson, Mackenzie, Jones of Jersey, Butcher of
+Dublin.</p>
+
+<p>On the Continent&mdash;Langenbeck, Stromeyer, Heyfelder, Ollier, Esmarch of
+Kiel, specially in the surgical history of the first Schleswig-Holstein
+war, have <ins class="correction" title="text reads 'fol-folowed'">followed</ins> up the example set them here.</p>
+
+<p>Before proceeding to describe the operations on the various joints, one
+or two questions may be briefly asked and answered by way of
+introduction.</p>
+
+<p>In what cases, or sorts of cases, are excisions suitable?</p>
+
+<p>1. In cases of compound injury or dislocation of a large joint, as used
+by Filkin, Park, White, and other English surgeons long ago. In hospital
+practice, or in private, where there is every advantage of rest, food,
+and appliances, such operations will frequently be found suitable where
+the joint is alone or chiefly the seat of injury, and where the general
+health seems fit to bear a prolonged suppuration. But long and sad
+experience has shown that, as a general rule in military practice, with
+the difficulties of transport, the generally bad sanitary state of the
+hospitals, and the want often of adequate dressings and attention,
+excisions are much more fatal than amputations, and, except in elbow and
+shoulder (<i>q.v.</i>), should be as a general rule avoided.<span class='pagenum'><a name="Page_111" id="Page_111">{111}</a></span></p>
+
+<p>2. Excision for deformity (generally speaking for bony anchylosis) will
+require for decision the consideration of many points, <i>i.e.</i> the joint
+affected, the nature of the disease or injury which has caused the
+anchylosis: and in each case&mdash;(1.) the state of health of the patient;
+and (2.) his occupation, and the consequent position of limb which would
+suit him best. As a general rule, I believe, experience will prove that
+such operations on the lower extremity are almost absolutely
+inadmissible, except under very special urgency on the part of the
+patient, and a very high condition of health&mdash;while in the upper, the
+elbow-joint is the only one which you will ever be likely to be asked to
+remedy, or should comply with the request if asked; as the shoulder,
+even if anchylosed, will (1.) from its own weight generally become so in
+the most favourable position; and (2.) from the extreme mobility which
+the scapula can acquire, its anchylosis will not be so much felt.</p>
+
+<p>The elbow, however, from the frequency of fractures of the condyles of
+the humerus obliquely into the joint, and from the manner in which these
+are so often neither recognised nor properly treated, very often becomes
+anchylosed in the most awkward possible position, <i>i.e.</i> nearly
+straight; and operations undertaken for such deformities are in general
+both quite safe and very satisfactory. Mr. Syme had one case (resulting
+from a fall, causing a double fracture), in which both arms were thus
+firmly anchylosed in such a position that the sufferer could absolutely
+perform none of the commonest duties of life without assistance.
+Excision of both joints cured him.</p>
+
+<p>The author excised with success for disease the elbow-joint of a patient
+whose other arm had required the same operation.</p>
+
+<p>The occupation of the patient must always be taken into consideration
+when settling the position of an anchylosis, or the necessity or
+advantage of a resection.<span class='pagenum'><a name="Page_112" id="Page_112">{112}</a></span></p>
+
+<p>Thus, Bryant<a name="FNanchor_52_52" id="FNanchor_52_52"></a><a href="#Footnote_52_52" class="fnanchor">[52]</a> tells of a painter who wished his arm to be fixed in a
+straight position, and of a turner whose knee at his own request was
+permitted to stiffen at a right angle, as that position allowed him to
+turn his wheel.</p>
+
+<p>3. <i>Excision for Disease of the Joint.</i>&mdash;In our cold climate, so cursed
+by scrofula, and specially among the children of the labouring poor,
+such joint diseases are very prevalent, and whether the disease
+commences in the synovial membrane, the articular cartilages, or the
+heads of the bones, it frequently so disorganises the joint as to make
+it a question whether something must not be done to preserve the very
+life of the patient.</p>
+
+<p>The difficulty of diagnosing the cases in which excisions are suitable
+or necessary is often very great; and we must balance its
+performance&mdash;(1.) against the possibly good results of an expectant
+treatment; (2.) against amputation of the limb.</p>
+
+<p>(1.) <i>Against expectant Treatment.</i>&mdash;The patient has youth on his side,
+could we give him fresh sea air, good diet, cod oil, etc., we might very
+likely obtain anchylosis; true, but he may die while trying for this
+anchylosis, and also this anchylosis, when got, may so lame or deform
+him that resection may still be required.</p>
+
+<p>These points must all be considered, but as a general rule, I would say
+that such attempts at preservation of the limb are much more
+justifiable, and longer justifiable in the hip and knee-joints than in
+the elbow or shoulder; for the results in the lower limb will probably
+be as good, if the patient survive, if not better, than those obtained
+by excision, while the danger of the operation is greater; while in the
+upper limb, the danger to life in operating is less than that of leaving
+the limb on, and the results obtained by a successful operation, with
+well-managed after treatment, are far more satisfactory than the best
+possible anchylosis.<span class='pagenum'><a name="Page_113" id="Page_113">{113}</a></span></p>
+
+<p>Another point bearing on this, of very great importance: In children,
+the most frequent subjects of such disease, excision of the lower limb
+may, by removing the epiphyses, cause to a very considerable degree
+disparity in their length, thus rendering them nearly useless, while in
+the upper such disparity is neither so extensive nor so injurious to the
+usefulness of the limb, which is not required for purposes of
+progression.</p>
+
+<p>In the hip-joint especially, all the resources of the art should be
+tried in the expectant treatment, for amputation at the hip-joint is
+hardly ever admissible for disease of the joint, while excision has
+anything but satisfactory statistics.</p>
+
+<p>(2.) <i>Against Amputation.</i>&mdash;Many questions must be considered, chiefly
+under the heads of the separate joints:&mdash;</p>
+
+<p>1. As to the difficulties and dangers of the operations contrasted.</p>
+
+<p>Such as the following:&mdash;</p>
+
+<p>Excisions give the surgeon more trouble, require more manual dexterity;
+take longer to perform; are very painful operations. Not valid
+objections in these days of chloroform and operative surgery on the dead
+body.</p>
+
+<p>Excisions have the special peculiarity and danger of dealing chiefly
+with cancellated bone, broadened out, open, with numerous patulous
+canals for large veins, tending on any irritation or inflammation to set
+up a diffuse suppuration, and to culminate in phlebitis, myelitis, and
+other py&aelig;mic conditions.</p>
+
+<p>Excisions are performed through degenerate or disorganised, amputations
+through healthy, tissue.</p>
+
+<p>Excisions require extreme care and absolute rest (<i>i.e.</i> in lower limb)
+for many weeks and months after the operation.</p>
+
+<p>But, on the other hand,&mdash;</p>
+
+<p>Amputations remove a portion of the body; excisions a much less one.
+Amputations are always necessarily<span class='pagenum'><a name="Page_114" id="Page_114">{114}</a></span> nearer the centre than the
+corresponding excisions, and statistics show that the fatality of
+operations increases in exact proportion as they approach the centre.</p>
+
+<p>A successful excision, especially in arm, saves a limb nearly perfect;
+an amputation at best is only the stump for a wooden one.</p>
+
+<p>On the whole, there is actually very little difference in the mortality
+of excisions and amputations.</p>
+
+<p>2. As to the results of the operation on the usefulness of the limb,
+depending on joint involved, age of patient, and amount of bone
+removed:&mdash;</p>
+
+<p>A. <i>Joint involved.</i>&mdash;These must be noticed separately, but one thing is
+absolutely certain, that a much higher standard of usefulness, both in
+equality of length, amount of anchylosis, and position, is needed in the
+lower than in the upper limb. For a leg hanging like a flail, or
+shortened by some inches, is not so good for purposes of locomotion as a
+wooden leg is, while an arm, even though powerless at the elbow, and
+perhaps much shortened, can be so strengthened and supported by slings
+and bandages as to give a most useful hand, the complex movements and
+uses of the fingers of which no mechanism can at all imitate.</p>
+
+<p>B. <i>Age of Patient.</i>&mdash;It must be remembered that excision in a child
+removes the epiphyses by which in great measure the growth of the bone
+is to be managed, and the stunted limb, especially in the leg, will
+eventually be of little advantage, though after the operation it looked
+excellently well, if a few years later it be found to be seven or eight
+inches shorter than its neighbour.</p>
+
+<p>C. <i>Amount of Bone removed.</i>&mdash;From an erroneous view of the pathological
+changes in the bone affected, far too much was removed by many of the
+earlier operators, especially Moreau and Crampton.</p>
+
+<p>The reason that this is often still the case, is well seen in many
+preparations. The bones are thickened to a considerable distance, and
+covered with irregular warty<span class='pagenum'><a name="Page_115" id="Page_115">{115}</a></span> excrescences. These, which used to be
+considered evidences of disease, are only compact new healthy bone,
+thrown out like the callus of a fracture in consequence of the
+irritation.</p>
+
+<p>In a word, what we require to remove is the following:&mdash;</p>
+
+<p>1. All the cartilage, dead or alive, healthy or diseased.</p>
+
+<p>2. Only the bone involving the articular extremities, in thin slices, or
+with the occasional use of the gouge, till a healthy bleeding surface is
+obtained.</p>
+
+<p>3. The synovial membrane, however gelatinous or thickened looking,
+really requires very little care or notice; it will disappear of itself,
+partly by sloughing, partly by absorption during the profuse
+suppuration.<a name="FNanchor_53_53" id="FNanchor_53_53"></a><a href="#Footnote_53_53" class="fnanchor">[53]</a></p>
+
+
+<p class="gap"><span class="smcap">Excision of the Shoulder-Joint.</span>&mdash;Before considering the method of
+operating, a word or two is required on the subject of how much is to be
+removed, and in what cases the operation should be performed. The
+shoulder and hip joints are the only ones in which partial excision is
+ever admissible, indeed, in the shoulder excision of the head of the
+humerus only is in many cases found to be all that is necessary, while
+in all it is much less dangerous to life than when the glenoid cavity
+also requires to be interfered with.</p>
+
+<p>It is rarely necessary to remove more of the bone than merely its
+articular extremity (when performed for disease of the joint), and if
+possible this should be done inside the capsule, <i>i.e.</i> through an
+incision in the capsule, but without involving its attachment to the
+neck of the bone. When the glenoid is also diseased, mere gouging or
+scraping the cartilaginous surface will not suffice, but the neck must
+be thoroughly exposed,<span class='pagenum'><a name="Page_116" id="Page_116">{116}</a></span> so that the whole cup of the glenoid may be
+removed by powerful forceps.</p>
+
+<p><i>Cases suitable for Excision.</i>&mdash;Cases of chronic disease of the head of
+the humerus (generally tubercular), or of chronic ulceration of the
+cartilages which has resisted counter-irritation. Cases of gunshot
+injury of the joint, or of compound dislocation, or fracture involving
+the joint. Cases of limited tumours affecting merely the head and upper
+third of the bone, and non-malignant in character. Anchylosis very
+rarely requires and would not be much benefited by such an operation.</p>
+
+<p><i>Operation.</i>&mdash;Though perhaps not the easiest, the following method is
+the one followed by the best results. It is suited especially for cases
+of caries or other disease of the joint, where the head of the humerus
+is either alone or chiefly affected:&mdash;</p>
+
+<p>A single straight incision (<a href="#plate_i">Plate I.</a> fig. <span class="smcap">a</span>.) is made from a point just
+external to the coracoid process downwards along the humerus for at
+least three inches. It corresponds almost exactly to the bicipital
+groove, and has the advantage of avoiding the great vessels and nerves.
+The long head of the biceps may then be raised from its groove, and
+drawn to a side so as to be preserved. This is deemed of importance by
+Langenbeck and others. Mr. Syme, however, did not attach much value to
+its preservation, as it is often diseased. The capsule, which is often
+much altered, perhaps in part destroyed, is then opened, and the tendons
+of the muscles which rotate the head of the humerus divided in
+succession, while the elbow is rotated first inwards and then outwards
+by an assistant so as to put them on the stretch. The arm being then
+forced backwards, the head of the bone can be protruded through the
+wound, and sawn off at the necessary distance down the shaft. The
+glenoid must then be carefully examined, and any diseased bone removed
+by the cutting pliers. One or two small branches supplying the anterior
+fold<span class='pagenum'><a name="Page_117" id="Page_117">{117}</a></span> of the axilla are the only vessels divided, and may not even
+require ligature, unless, indeed, from necrosis, or to remove a tumour,
+a larger portion of the humerus than usual has been removed. If the
+limit of capsule has been infringed on below, the circumflex vessels may
+probably be cut, in which case the bleeding may be considerable.</p>
+
+<p><i>N.B.</i>&mdash;In cases of fracture of neck of humerus, or of compound gunshot
+injury, or where the head has been separated by necrosis from the shaft,
+or where, as has happened to Stanley and others, the bone broke in the
+endeavour to tilt the head out, the surgeon will require to seize the
+detached head with strong forceps, and dissect it out with care.</p>
+
+<p><i>Other methods of Resection.</i>&mdash;When from great thickening and induration
+of the soft parts, enlargement of the head of the bone, or other reason,
+the straight incision may be deemed insufficient for the purpose (and we
+may remark that there are comparatively few cases in which it is
+insufficient), access may be obtained to the joint by raising a flap
+from the deltoid (<a href="#plate_iii">Plate III.</a> fig. <span class="smcap">a</span>). Its shape&mdash;V-shaped, semilunar, or
+ovoid&mdash;is not of much consequence, for there are no great nerves or
+vessels to wound on the outside of the joint, and the surgeon should be
+guided, as in all other operations on the joint, very much by the
+position of any pre-existing sinuses. This flap being raised upwards
+towards its base, very free access is gained to the joint.</p>
+
+<p>In these cases, fortunately comparatively rare, in which there is reason
+to believe that the glenoid is chiefly involved in disease, and yet that
+the disease can be removed without amputation, access will be gained
+most easily by an incision (<a href="#plate_iii">Plate III.</a> fig. <span class="smcap">b</span>.) on the posterior surface
+of the joint, corresponding in size and direction to the linear incision
+in front. This gives a much easier mode of access to the glenoid. I have
+seen this practised in one very remarkable case by Mr. Syme, in which
+the glenoid cavity and neck of the<span class='pagenum'><a name="Page_118" id="Page_118">{118}</a></span> scapula were extensively diseased,
+while the head of the bone was quite sound.</p>
+
+<p><i>After-treatment</i> is exceedingly simple; for the first day or two the
+shoulder is to be supported on a pillow with a simple pad in the axilla,
+if there is any tendency for the arm to drag inwards; after this the
+patient should be encouraged to sit up and move about with his arm in a
+sling, the elbow hanging freely down.</p>
+
+<p><i>Results.</i>&mdash;Hodge records ninety-six cases in which this excision was
+performed for gunshot injury, of which twenty-five proved fatal, and
+fifty for disease, of which only eight died,&mdash;results which are more
+encouraging than those of amputation at the shoulder-joint for disease;
+though for injury the mortality is much greater than Larrey's famous
+Statistics of Amputation, <i>q.v.</i> p. 65.</p>
+
+<p>Spence had thirty-three cases, with three deaths. He generally made a
+counter-opening behind to get rid of discharges, and inserted a
+drainage-tube.</p>
+
+<p>Gurlt's statistics of excision for gunshot injury give of 1661 cases
+1067 recoveries, 27 doubtful results, and 567 deaths, the mortality
+being 34.70 per cent.</p>
+
+<p class="gap"><span class="smcap">Excision of the Elbow-Joint</span>&mdash;<i>In what cases should it be performed?</i>&mdash;1.
+For disease of the elbow-joint which has resisted ordinary remedies, and
+is wearing down the patient's strength, including caries, ulceration of
+cartilages, and gelatinous synovial degeneration.</p>
+
+<p>2. For wounds of the elbow penetrating the joint, the prognosis both as
+to the patient's life and the usefulness of his arm is much better after
+excision than after endeavours to save the joint without excision. This
+is especially the case when the wound of the joint is small and
+punctured, but if the case is seen early and treated by free drainage,
+with antiseptic precautions, excision may not be required.</p>
+
+<p>3. For anchylosis, in cases where after disease or injury the limb has
+stiffened in a bad position, especially<span class='pagenum'><a name="Page_119" id="Page_119">{119}</a></span> when, with a straight elbow,
+the hand is rendered almost perfectly useless.</p>
+
+<p><i>How much should be removed?</i>&mdash;In the elbow-joint, more than any other
+joint in the body, complete excision is absolutely necessary; any
+portion of the articular surface being left proves a source of
+unfavourable result.</p>
+
+<p>The surgeon is apt to err rather in removing too little than too much.
+For the removal of too little bone is, on the one hand, apt to result in
+long-standing sinuses, on the other, to induce anchylosis.</p>
+
+<p>In making the section of the bones, the saw ought to be applied to the
+humerus transversely just at the commencement of its condyloid
+projections, and to the radius and ulna, at least at a level with the
+base of the coronoid process of the ulna.</p>
+
+<p>But while removing enough, we must not be led into the error of removing
+too much. If this is done, as was done by Sir Philip Crampton in his
+first case, and as happens occasionally of necessity in cases of
+excision for gunshot wounds or other accidents, much of the power of the
+arm is lost as a consequence of the shortening and excessive mobility.</p>
+
+<p>A mistaken pathology sometimes deceives in the examination of the state
+of the bones, and causes an unnecessary amount to be removed. For in
+many cases of disease the bones in the neighbourhood of the joint are
+stimulated to an excessive amount of what is in reality Nature's effort
+at repair, and while the cartilaginous surfaces are denuded of
+cartilage, soft, and porous, the bones close by are roughened with a
+stalactitic-looking growth, projecting in knobs and angles. Now, if this
+be mistaken for disease and removed, too much will almost certainly be
+taken away, and the result will be unsatisfactory.</p>
+
+<p>Much less care need be taken exactly to discriminate and remove the
+diseased soft parts; indeed they may be left alone; the synovial
+membrane in a state of<span class='pagenum'><a name="Page_120" id="Page_120">{120}</a></span> gelatinous degeneration sometimes presents a
+very formidable appearance of disease, but if the bones be properly
+removed, all this swelling will soon go down, and a healthy condition of
+parts succeed, without any clipping or paring on the surgeon's part.</p>
+
+<p><i>Operation.</i>&mdash;The back of the joint is of course chosen for the seat of
+the incisions, both because the bones are there just under the skin, and
+because the great vessels and nerves lie in front of the joint. The form
+and number of the incisions vary considerably, and ought to vary
+according to the nature of the case and the amount of disease or injury.</p>
+
+<p>Though it is now little used, for historical interest I retain the
+description of the H-shaped incision (<a href="#plate_iii">Plate III.</a> fig. <span class="smcap">c</span>.),
+used first by Moreau, and re-introduced by Mr. Syme, and used by him for
+most of his very numerous cases.</p>
+
+<p>The posterior surface of the joint being exposed, the surgeon, with a
+strong straight bistoury, makes a transverse incision into the joint
+just above the olecranon. It should begin just far enough outside of the
+internal condyle to avoid the ulnar nerve, which the surgeon should
+protect by the forefinger of his left hand, and should extend
+transversely across to the outer condyle. From each end of this incision
+the surgeon should next make at a right angle two incisions, each about
+one inch and a half or two inches long, right down to the bone, thus
+marking out two quadrilateral flaps. These should next be raised from
+the bones, up and down, as much of the soft parts being retained in them
+as possible, so as to add to their thickness. The olecranon is thus
+exposed, and should be removed by saw or pliers by cutting into the
+greater sigmoid notch; the lateral ligaments must then be cut, if they
+are not already destroyed by the disease, and the humerus protruded, a
+proper amount of which is then to be sawn off in a transverse direction.
+The head of the radius is then<span class='pagenum'><a name="Page_121" id="Page_121">{121}</a></span> easily removed by the bone-pliers, and
+the ulna also protruded, the attachment of the brachialis anticus to the
+coronoid process divided, and the bone sawn across just at the base of
+that process.</p>
+
+<p>Few vessels, if any, will require ligature, and the arm being bent to
+nearly a right angle, the transverse incision must be very carefully
+sewed up with silver sutures closely set and deeply placed, as much of
+the future success of the joint depends on the completeness of the
+primary union of this incision. The external incision may also be
+accurately adjusted, the internal one not so completely, to allow free
+vent for the discharge, which is aided by the ligatures, if any are
+required, being brought out at its lower angle. A figure-of-8 bandage
+should be applied over pads of dry lint, and the limb laid on a pillow.
+No splint is necessary; in a few days the patient will be able to rise
+and walk about.</p>
+
+<p>Passive motion should be begun so soon as the first inflammatory
+symptoms have passed off.</p>
+
+<p>If properly performed, in a tolerably healthy subject, the surgeon
+should not be satisfied with any results short of almost perfect
+restoration of motion in the joint. Flexion and extension to their full
+extent, with a very considerable amount of pronation and supination, are
+to be expected, with proper care, in a patient of average intelligence.</p>
+
+<p>Numerous cases are now on record where almost perfect performance of all
+the duties of life was retained after excision of the elbow-joint.<a name="FNanchor_54_54" id="FNanchor_54_54"></a><a href="#Footnote_54_54" class="fnanchor">[54]</a></p>
+
+<p>In most cases it is possible, and in nearly all advisable, to excise the
+joint by means of a less complicated incision. Thus one long vertical
+incision at the posterior surface, with its centre about midway between
+the ulna and the external condyle, with a transverse<span class='pagenum'><a name="Page_122" id="Page_122">{122}</a></span> incision at right
+angles to it, and reaching almost to the internal condyle, has been
+often practised with a very good result.</p>
+
+<p>By nearly universal consent this single straight incision is now used,
+and when it is properly dressed and <i>drained</i> gives admirable results.</p>
+
+<p>A single vertical incision (<a href="#plate_iii">Plate III.</a> fig. <span class="smcap">d.</span>) without any transverse
+one, as long ago recommended by Chassaignac, is, in most cases, quite
+sufficient to give access. It is most suitable in cases of anchylosis,
+where there is little deposit of new bone, or in cases of disease of the
+joint, accompanied with little swelling or thickening of surrounding
+tissues. It has the advantage of avoiding the cicatrix of a transverse
+incision, which doubtless may, if at all a broad one, somewhat interfere
+with the future flexion of the limb, but, on the other hand, unless care
+is taken, it does <i>not</i> give such free egress for the discharge, and
+when there is much delay in healing, the vertical incision may leave a
+cicatrix nearly as troublesome as the other.</p>
+
+<div class="blockquot smlet"><p>The following modification, suggested and practised by the late Mr.
+Maunder, seems to be a step in the right direction when it is
+practicable. "After a longitudinal incision crossing the point of
+the olecranon I next let the knife sink into the triceps muscle,
+and divide it longitudinally into two portions, the inner one of
+which is the more firmly attached to the ulna, while the outer
+portion is continuous with the anconeus muscle, and sends some
+tendinous fibres to blend with the fascia of the fore-arm. It is
+these latter fibres that are to be scrupulously preserved.</p>
+
+<p>"Two points have to be remembered: first, the ulnar nerve, often
+unseen, must be lifted from its bed, and carried over the internal
+condyle to a safe place, and then the outer portion of the triceps
+muscle with its tendinous prolongation, the fascia of the fore-arm
+and the anconeus muscle must be dissected up, as it were, in one
+piece, sufficiently to allow of its being temporarily carried out
+over the external condyle of the humerus."<a name="FNanchor_55_55" id="FNanchor_55_55"></a><a href="#Footnote_55_55" class="fnanchor">[55]</a></p>
+
+<p>This method aids in retaining the power of <i>active</i> extension of
+the elbow-joint. </p></div><p><span class='pagenum'><a name="Page_123" id="Page_123">{123}</a></span></p>
+
+<p>Excision for osseous anchylosis in the extended position of the joint
+may be sometimes rendered very difficult by the density, firmness, and
+extensive hypertrophy of the bones, which become fused into one solid
+mass. Any attempt to isolate the bones, and remove the anchylosed joint
+entire, by incising the bones as if for disease, will both prove very
+laborious, and also probably end in doing some damage to the vessels and
+nerves in front. But by sawing through the anchylosis about its centre,
+as was pointed out many years ago by Mr. Syme, the fore-arm may be
+flexed, and the bones as easily displayed, cleaned, and removed, as in
+the operation for disease. In this operation, as there is less
+thickening of the skin and subjacent textures, and in consequence more
+risk of deficiency and even sloughing of the flaps made by the H-shaped
+incision, a single straight incision will serve the
+purpose admirably.</p>
+
+<p>Partial incisions of the elbow-joint are, as a rule, less successful and
+more dangerous to life than complete ones, except in cases of excision
+for anchylosis. Even in gunshot wounds, where the bones were previously
+healthy, and where uninjured portions might have been left with some
+hopes of success, this is the case.</p>
+
+<div class="blockquot smlet"><p>Dr. Heron Watson has devised the following operation for cases of
+anchylosis the result of injury:&mdash;(1.) A linear incision over ulnar
+nerve at inner side of olecranon. (2.) The ulnar nerve to be
+carefully turned over the inner condyle. (3.) A probe-pointed
+bistoury to be introduced into the elbow-joint in front of the
+humerus, and then behind and carried upwards, so as to divide the
+upper capsular attachments in front and behind. (4.) A pair of
+bone-forceps to be next employed to cut off the entire inner
+condyle and trochlea of the humerus, and then introduced in the
+opposite diagonal direction so as to detach the external condyle
+and capitulum of the humerus from the shaft. (5.) The truncated and
+angular end of the humerus to be divided, turned out through the
+incision, and smoothed across at right angles to the line of the
+shaft by means of the saw, whereby (6.) room might be afforded, so
+that partly by twisting and partly by dissection the external
+condyle and capitulum are<span class='pagenum'><a name="Page_124" id="Page_124">{124}</a></span> removed without any division of the skin
+on the outer side of the arm.<a name="FNanchor_56_56" id="FNanchor_56_56"></a><a href="#Footnote_56_56" class="fnanchor">[56]</a> Six cases have had satisfactory
+results. </p></div>
+
+<p>The mortality from this operation is considerably less than that from
+amputation of the arm. Of a series of excisions for disease, injury, and
+anchylosis, 22.15 per cent. died, while out of a similar series of
+amputations of the arm the mortality was 33.4 per cent.<a name="FNanchor_57_57" id="FNanchor_57_57"></a><a href="#Footnote_57_57" class="fnanchor">[57]</a> Our
+mortality of excision of the elbow here is certainly much less than the
+above. All of the cases, between thirty and forty, in which I have done
+it have recovered with but one exception, and Mr. Syme lost only one
+during the time I was his assistant.</p>
+
+<p>Professor Spence lost only 16 in 189 cases, or 8.3 per cent.</p>
+
+<p>Gurlt's statistics for gunshot injury give a mortality of over 24 per
+cent.</p>
+
+<p>Out of 82 cases where the joint was excised for injury in the
+Schleswig-Holstein and Crimean campaigns, only 16 died; and out of 115
+cases in which the joint was excised for disease, only 15 died.</p>
+
+<p>The period after the injury at which the excision is performed seems to
+be important.</p>
+
+
+<table summary="numbers">
+<tr><td>&nbsp;</td><td class="center">&nbsp;</td><td class="center">&nbsp;</td><td class="center">&nbsp;</td><td class="center">&nbsp;</td><td>Deaths.</td><td class="center">&nbsp;</td></tr>
+<tr><td>Thus of</td><td>11</td><td>cases</td><td>within</td><td>first twenty-four hours,</td><td>1</td><td>= 1-11</td></tr>
+<tr><td class="center">"</td><td>20</td><td class="center">"</td><td>between</td><td>second and fourth days,</td><td>4</td><td>= 1-5</td></tr>
+<tr><td class="center">"</td><td>9</td><td class="center">"</td><td class="center">"</td><td>eighth and thirty-seventh,</td><td>1</td><td>= 1-9</td></tr>
+<tr><td class="center">&nbsp;</td><td>&mdash;</td><td class="center">&nbsp;</td><td class="center">&nbsp;</td><td class="center">&nbsp;</td><td>&mdash;</td><td class="center">&nbsp;</td></tr>
+<tr><td class="center">&nbsp;</td><td>40</td><td class="center">&nbsp;</td><td class="center">&nbsp;</td><td class="center">&nbsp;</td><td>6</td><td class="center">&nbsp;</td></tr>
+</table>
+
+
+<p class="gap"><span class="smcap">Excision of the Wrist</span>.&mdash;Very various methods have been proposed and
+executed for the purpose of excising this joint. These vary much in
+difficulty and complexity, in proportion to the endeavours made to save
+the tendons from being cut.</p>
+
+<p>The principles which must guide all attempts at operative interference
+with this joint are<span class='pagenum'><a name="Page_125" id="Page_125">{125}</a></span>&mdash;</p>
+
+<p>1. To remove all the diseased bone, including the cartilage-covered
+portions of the radius, ulna, and of the metacarpal bones, as little of
+these bones being removed as possible, beyond the cartilage-covered
+portions.</p>
+
+<p>2. To disturb the tendons as little as possible, especially to avoid
+isolating them from the cellular sheath.</p>
+
+<p>3. To commence passive motion of the fingers very soon after the
+operation.</p>
+
+<p>It is rarely possible to remove the carpal bones as a whole, from the
+diseased condition which renders the operation necessary, and the
+digging out of the various bones piecemeal renders the operation very
+tedious, especially if the proximal ends of the metacarpal bones are
+involved and require to be removed, hence this operation was practically
+impossible till after the discovery of an&aelig;sthesia.</p>
+
+<p>In describing the operation elaborated and described by Professor
+Lister, the type of the various plans in which the tendons are saved is
+given, while a very few words descriptive of the incisions used by
+others who cut the tendons will suffice.</p>
+
+
+<p class="gap"><span class="smcap">Lister's Operation of Excision of the Wrist-Joint.</span>&mdash;Even an abridgment
+of Mr. Lister's account of his operation must necessarily be long,
+because the operation itself is so complicated and prolonged, and guided
+by such precise principles, as to render much abridgment almost
+impossible.</p>
+
+<p>A tourniquet is put on, to prevent oozing, which would conceal the state
+of the bones; any adhesions of the tendons must be then broken down by
+free movement of all the joints.</p>
+
+<p><i>The radial incision</i> (<a href="#plate_iv">Plate IV.</a> fig. <span class="smcap">a</span>.) is then made. It commences at
+the middle of the dorsal aspect of the radius, on a level with the
+styloid process, passes as if going towards the inner side of the
+metacarpo-phalangeal joint of the thumb, in a line parallel to the
+extensor<span class='pagenum'><a name="Page_126" id="Page_126">{126}</a></span> secundi internodii, but turns off at an angle as it passes the
+radial border of the second metacarpal, and then longitudinally
+downwards for half the length of that bone. The extensor carpi radialis
+brevior tendon is divided in the incision. The soft parts at the radial
+side are to be carefully dissected up, and the tendon of the extensor
+carpi radialis longior divided at its insertion. The cut tendons, and
+the extensor secundi internodii tendon and the radial artery can thus be
+pushed outwards, enabling the trapezium to be separated from the carpus
+by cutting-pliers. The extensor tendons being relaxed by bending back
+the hand, the soft parts must be cleared from the carpus as far as
+possible towards the ulnar side.</p>
+
+<div class="figleft" style="width: 279px;">
+<img src="images/126.jpg" width="279" height="350" alt="Fig. VI." title="Fig. VI." />
+<span class="caption smcap">Fig. vi.<a name="FNanchor_58_58" id="FNanchor_58_58"></a><a href="#Footnote_58_58" class="fnanchor">[58]</a></span>
+</div>
+
+<p><i>The ulnar incision</i> (<a href="#plate_iv">Plate IV.</a> fig. <span class="smcap">b</span>.) extends from two inches above
+the end of the ulna, in a line between the bone and the flexor carpi
+ulnaris, straight down as far as the middle of the palmar aspect of the
+fifth metacarpal. The dorsal lip of this incision is then raised, and
+the tendon of the extensor carpi ulnaris cut at its insertion, and
+reflected up out of its groove in the ulna along with the skin. The
+extensor tendons are then raised from the carpus, and the dorsal and
+lateral ligaments of the wrist divided, the tendons still being left as
+far as possible undisturbed in their relation to the radius. In front
+the flexor tendons are cleared from the carpus, the pisiform bone
+separated from the others though not removed, and the hook of<span class='pagenum'><a name="Page_127" id="Page_127">{127}</a></span> the
+unciform divided by pliers. The knife must not go further down than the
+base of the metacarpal bones, in case of dividing the deep palmar arch.
+The anterior ligament of the wrist being now divided, the carpus and
+metacarpus are to be separated by cutting-pliers, and the carpus
+extracted by strong sequestrum forceps. By forcible eversion of the
+hand, the ends of radius and ulna can be protruded at the ulnar
+incision; as little as possible should be removed, consistent with
+removing all the disease. The ulna should be cut obliquely, leaving the
+base of the styloid process, and removing all the cartilage-covered
+portion. A thin slice of the radius is then to be cut also with the saw,
+so thin as to remove only the bevelled ungrooved portion, and leaving
+the tendons as far as possible undisturbed in their grooves. The ulnar
+articular facet is to be snipped off with bone-pliers. If the bones are
+more deeply carious, the diseased parts must at all hazards be removed
+with pliers or gouge. The metacarpal bones must then be treated in
+precisely the same way, their ends sawn off and their articular facets
+snipped off with the bone-pliers longitudinally. The trapezium is then
+to be seized by forceps and carefully dissected out, the metacarpal bone
+of the thumb pared like the others, the articular surface of the
+pisiform removed, the rest of the bone being left if it is sound. The
+radial incision is stitched closely throughout, and also the ends of the
+ulnar incision, any ligature being brought out through the centre of the
+ulnar incision, which is kept open with a piece of lint, which also
+gives support to the extensor tendons.</p>
+
+<p>The after-treatment is important, the principal specialities being&mdash;(1.)
+early and free movement of the fingers; (2.) secure fixing of the wrist
+to procure consolidation. (1.) By passive motion of the joints of the
+knuckles and fingers, commenced on the second day, and continued daily
+after the operation; (2.) By a splint supporting the fore-arm and hand,
+the fingers being held in a semiflexed<span class='pagenum'><a name="Page_128" id="Page_128">{128}</a></span> position by a large pad of cork
+fastened firmly on to the splint and made to fit the palm; this prevents
+the splint from slipping up the arm, and by a turn of a bandage insures
+fixation of the wrist-joint. The anterior part of this splint below the
+fingers may be gradually shortened, allowing more and more passive
+motion of the fingers, but the patient must wear it for months, indeed,
+till he finds his wrist as strong without it as with it.</p>
+
+<p>Among the various operations that have been devised, the following
+require notice:&mdash;Mr. Spence, Dr. Gillespie, Dr. Watson, and the author,
+use a single dorsal incision with excellent results, and find it quite
+easy to remove all the bones from it. Mr. Spence had sixteen cases
+without a death.</p>
+
+<div class="blockquot smlet"><p><span class="smcap">Posterior Semilunar Flap</span>, from carpal attachment of metacarpal of
+index finger round to styloid process of ulna; dividing integuments
+only, then separating the tendons of the common extensor
+longitudinally, and drawing them aside by blunt hooks, the diseased
+bones are removed piecemeal by curved parrot-bill forceps.<a name="FNanchor_59_59" id="FNanchor_59_59"></a><a href="#Footnote_59_59" class="fnanchor">[59]</a></p>
+
+<p><span class="smcap">Posterior Curved Flap.</span>&mdash;An incision down to the carpal bones,
+extended from a point two lines to the ulnar side of the extensor
+secundi internodii pollicis, and from a quarter to half an inch
+below the radio-carpal articulation, swept in a curvilinear
+direction downwards, close to the carpal extremities of the
+metacarpal bones, to a point just below the end of the ulna. The
+flap thus marked out was dissected up, and consisted of the
+integuments, areolar tissue, and extensor tendons of the four
+fingers, together with large deposits of fibrine, the products of
+repeated and prolonged inflammatory action. The tendon of the
+second extensor and its soft parts around were separated from the
+bones. The remains of the ligaments were cut, flexion of the hand
+protruded the carious ends of radius and ulna. The bones were then
+dissected out, leaving the trapezium, which was not diseased, and
+hand placed on a splint.<a name="FNanchor_60_60" id="FNanchor_60_60"></a><a href="#Footnote_60_60" class="fnanchor">[60]</a></p></div>
+
+
+<p class="gap"><span class="smcap">Excision of the Hip-Joint.</span>&mdash;The question as to<span class='pagenum'><a name="Page_129" id="Page_129">{129}</a></span> the propriety of
+performing this operation in any case is still debated by some surgeons,
+and the selection of suitable cases for the operation is greatly
+modified by the varying opinions of the different schools of surgery.
+Enough here to describe the method of operating, and the amount of the
+bone which is to be removed.</p>
+
+<p>As in the shoulder-joint, the head of the femur is much more liable to
+disease, and, as a rule, much earlier attacked than is the acetabulum,
+but unfortunately the acetabulum does eventually become affected also in
+probably a much larger proportionate number of cases than the glenoid.
+Caries of the head, neck, and trochanters of the femur is a very common
+disease in this variable climate, and frequently connected with the
+strumous taint. After much suffering, abscesses form and discharge,
+giving considerable pain, and often end by carrying off the patient. As
+a result of the abscess and destruction of the ligaments, the head of
+the bone is apt to be displaced, and under some sudden muscular exertion
+or involuntary spasm, consecutive dislocation of the femur (generally on
+to the dorsum ilii) very often occurs.</p>
+
+<p>In such a case the operation of excision of the head of the femur is by
+no means difficult, and not excessively dangerous, especially in young
+children.</p>
+
+<p><i>Operation.</i>&mdash;It is hardly necessary, or indeed possible, to lay down
+exact rules for the performance of this operation, in so far as the
+external incisions are concerned, for the sinuses which exist ought in
+general to be made use of.</p>
+
+<p>When the surgeon has his choice, a straight incision (<a href="#plate_ii">Plate II.</a> fig.
+<span class="smcap">a</span>.), parallel with the bone, extending from the top of the great
+trochanter downwards for about two inches, and also from the same point
+in a curved direction with the concavity forwards, upwards towards the
+position of the head of the bone (see diagram), will be found most
+convenient. The incisions should be<span class='pagenum'><a name="Page_130" id="Page_130">{130}</a></span> carried boldly down to the bone,
+which will often be felt exposed and bathed in pus, any remains of the
+ligamentous structures must be cautiously divided with a probe-pointed
+bistoury, and then by bringing the knee of the affected side forcibly
+across the opposite thigh, with the toes everted, the head of the bone
+is forced out of the wound. The head, neck, and great trochanter should
+be fully exposed, and the saw applied transversely below the level of
+the trochanter, so as to remove it entire. If this is not done, it
+prevents discharge, protrudes at the wound, and besides this it is
+almost invariably diseased along with the head. Chain saws are quite
+unnecessary, it being in most cases easy to apply an ordinary one to the
+bone, if it is properly everted.</p>
+
+<p>Great care in the after-treatment is required to prevent undue
+shortening of the limb, or in the event of a cure to secure the most
+favourable position for the anchylosis. The femur occasionally tends to
+protrude at the wound, and hence may require to be counter-extended by
+splints. If required at all, the splint should be made with an iron
+elbow opposite the wound to admit of its being easily dressed. In most
+cases counter-extension may be best managed by a weight and pulley.</p>
+
+<p>Various forms of hammock swings to support the whole body, and slings of
+leather or canvas to support the limb only, have been found to aid
+recovery, and render the patient much more comfortable.</p>
+
+<p>When the acetabulum is also diseased the prognosis is much more
+unfavourable than when it is sound.</p>
+
+<p>The experiments of Heine and J&auml;ger on the dead body, and operations by
+Hancock, Erichsen, and Holmes, on patients, have shown that in cases of
+extensive disease of the acetabulum it is quite possible by a prolonged
+and careful dissection to remove it all without injury of the pelvic
+viscera.<span class='pagenum'><a name="Page_131" id="Page_131">{131}</a></span></p>
+
+<p>The details of incisions for such an operation need scarcely be given,
+as they must vary in each case with the amount of bone diseased, and the
+position of the already existing sinuses. The amount of bone that <i>may</i>
+be removed varies much. Erichsen in one case excised "the upper end of
+the femur, the acetabulum, the rami of the pubis, and of the ischium, a
+portion of the tuber ischii, and part of the dorsum ilii."<a name="FNanchor_61_61" id="FNanchor_61_61"></a><a href="#Footnote_61_61" class="fnanchor">[61]</a></p>
+
+<p>A less formidable proceeding may be useful in cases where the acetabulum
+is diseased, but not deeply. The moderate use of an ordinary gouge may
+succeed in removing the diseased bone.</p>
+
+<p>Experience and the cold evidence of statistics prove, however, that the
+prognosis in any case is modified very much for the worse by the
+presence of any disease of the acetabulum, more than one-half of the
+cases proving fatal in which it is diseased, whether attempts to remove
+the disease of the acetabulum be made or not, and that those cases do
+best in which the head of the femur has been displaced, and lies outside
+the joint almost like a loose sequestrum among the soft parts.</p>
+
+<p>The results of excision of the hip have as yet been very discouraging,
+the mortality of the whole series of published cases being, according to
+Dr. Hodge's careful table, very little under 1 in every 2 cases, viz., 1
+in 2-5/53. Later statistics are however more favourable.</p>
+
+<p>Like all other excisions, the mortality increases very much with the
+patient's age.</p>
+
+<p>Thus of 103 completed cases in which the age is given, 53 recovered and
+50 died, but dividing the cases at the end of the sixteenth year, we
+find that of the children below this age 43 recovered and 29 died, a
+mortality of 40.2 per cent.; of the adults, 10 recovered, and 21 died,
+or a mortality of 67.6 per cent.</p>
+
+<p>If we remember the marvellous power of recovery from joint diseases we
+find in childhood, under the<span class='pagenum'><a name="Page_132" id="Page_132">{132}</a></span> influence of good diet, cod-liver oil, and
+fresh air, we cannot shut our eyes to the fact that such results and
+such a mortality are by no means encouraging.</p>
+
+<p>From an extensive experience in a special hospital for hip-disease,
+where fresh air, abundant nourishment, and very excellent nursing are
+provided, the author is learning more and more to trust to the power of
+nature in the cure of even very advanced cases of hip-disease in
+children, and he believes that operation is rarely necessary, or even
+warrantable, except for the removal of sequestra.</p>
+
+<div class="blockquot smlet"><p>Mr. Holmes's<a name="FNanchor_62_62" id="FNanchor_62_62"></a><a href="#Footnote_62_62" class="fnanchor">[62]</a> statistics are interesting. He has operated on no
+fewer than nineteen cases. Of these seven died, one after secondary
+amputation at the hip. Another required amputation and recovered.
+Two others died of other diseases without having used their limb.
+Of the remaining nine, three were perfectly successful, four were
+promising cases, and two unpromising.</p>
+
+<p>Professor Spence in 19 cases had 6 deaths, or a mortality of 31.6
+per cent.</p>
+
+<p>Culbertson's collection gives out of 426 cases, 192 deaths, or 45
+per cent.</p>
+
+<p>Mr. Croft, whose skill and success as an operator are well known,
+has recorded 45 cases of excision of hip in his own practice; of
+these 16 died, 11 were under treatment, 18 had recovered, of which
+16 had moveable joints and useful limb; the other two are
+"potentially cured."<a name="FNanchor_63_63" id="FNanchor_63_63"></a><a href="#Footnote_63_63" class="fnanchor">[63]</a></p>
+
+<p>Various other incisions have been devised for gaining access to the
+joint. The most noticeable are those in which a flap is made
+instead of a linear incision. Sedillot makes a semilunar or ovoid
+flap, the base of which is just below the great trochanter, and
+which includes it, the convexity being upwards and the flap being
+turned down. Gross's modification of this is preferable, being
+turned the opposite way, the convexity being downwards (<a href="#plate_iii">Plate III.</a>
+fig. <span class="smcap">e</span>.), and the flap thus being turned up.</p></div>
+
+<p><i>Results in successful cases.</i>&mdash;Of fifty-two in Hodge's table,
+thirty-one had useful limbs, six indifferent, three<span class='pagenum'><a name="Page_133" id="Page_133">{133}</a></span> decidedly useless,
+four died within three years, and of the remaining eight no details are
+given.</p>
+
+<p>The shortening is always considerable, a high-heeled shoe being required
+in most cases; a stick is indispensable; in many, crutches are
+necessary.</p>
+
+<div class="blockquot smlet"><p>Various operations have been devised for the treatment of osseous
+anchylosis of the hip-joint when in a bad position. All are more or
+less dangerous. Perhaps one of the least dangerous is the plan of
+subcutaneous division of the neck of the femur by a narrow saw,
+proposed by Mr. Adams of London. It is sometimes a very laborious
+operation. </p></div>
+
+
+<p class="gap"><span class="smcap">Excision of Knee-Joint</span>.&mdash;<i>Removal of Bone.</i>&mdash;In every case the excision
+of the joint ought to be complete. Some attempts have been made to save
+one or other of the articular surfaces, but they have proved failures.
+The patella has frequently been left when it was not diseased, as is
+often the case, but the results have not been such as to recommend such
+a practice.</p>
+
+<p><i>Direction of Section of the Bones.</i>&mdash;The bones should be cut
+transversely, and, as far as possible, be in accurate and complete
+apposition. A slight bevelling at the expense of the posterior margin
+will produce an anchylosis of the limb in a very slightly flexed
+position, which is found to aid the patient in walking.</p>
+
+<p>It has been proposed by some<a name="FNanchor_64_64" id="FNanchor_64_64"></a><a href="#Footnote_64_64" class="fnanchor">[64]</a> to cut both bones obliquely, so as to
+obviate the difficulty of making the transverse surfaces parallel. This
+involves a still greater practical difficulty in keeping these oblique
+surfaces in position during the after-treatment.</p>
+
+<p>This plan might possibly be valuable in cases where the disease was
+limited to one or other edge of the bone.</p>
+
+<p>Among the various incisions recommended, the best seems to be the
+<i>Semilunar Incision</i>.</p>
+
+<p><i>Operation.</i>&mdash;The limb being held in an extended position, a single
+semilunar incision (<a href="#plate_i">Plate I.</a> fig. <span class="smcap">b</span>.) is<span class='pagenum'><a name="Page_134" id="Page_134">{134}</a></span> made, entering the joint at
+once, and dividing the ligamentum patell&aelig;. It should extend from the
+inner side of the inner condyle of the femur to a corresponding point
+over the outer one, passing in front of the joint midway between the
+lower edge of the patella and tuberosity of the tibia. The flap is then
+dissected back, the ligaments divided, when by extreme flexion of the
+limb the articular surface of the tibia and femur are thoroughly
+exposed. The crucial ligaments must then be divided cautiously, and the
+articular portion of the femur cleaned anteriorly by the knife,
+posteriorly by the operator's finger, so far as possible to avoid injury
+of the artery. The whole articular surface of the femur must then be
+removed by a transverse cut with the saw as exactly as possible at a
+right angle with the axis of the bone. The amount of the femur which
+will require removal will in the adult vary from an inch to an inch and
+a half or even more. It <i>must</i> involve all the bone normally covered by
+cartilage; and this being removed, if the section shows evidence of
+disease, slice after slice may require removal till a healthy surface is
+obtained. Occasionally, if the diseased portion appears limited, though
+deep, the application of a gouge may succeed in removing disease without
+involving too great shortening of the limb. Specially in children, it is
+of great importance to avoid removing the whole epiphysis. The tibia
+must then be exposed in a similar manner, and a thin slice removed; if
+the bone be tolerably healthy, even less than half an inch will prove
+quite sufficient.</p>
+
+<p>This method has an immense advantage in that it provides an excellent
+anterior flap for the amputation, which may be required in cases where
+the disease of bone is found too extensive to admit of the excision
+being practised.</p>
+
+<p>This method, with slight deviations, is substantially that of Richard
+Mackenzie of Edinburgh, Wood of New York, Jones of Jersey.<span class='pagenum'><a name="Page_135" id="Page_135">{135}</a></span></p>
+
+<p>H&aelig;morrhage must then be stopped, and that as thoroughly as possible, by
+torsion, cold, and pressure, and the flap brought accurately together
+with sutures.</p>
+
+<p>In some rare cases, it may be found necessary to divide the hamstring
+tendons to rectify spastic contraction of the muscles; but this can
+generally be done quite well from the original wound.</p>
+
+<p>Holt makes a dependent opening in the popliteal space for drainage. This
+is unnecessary if the incisions are made sufficiently far back, and if
+the wound is properly drained. It is unsafe, as approaching so close to
+the artery and veins. If much bagging takes place, the use of a
+drainage-tube will prove quite sufficient.</p>
+
+<p><i>After-treatment.</i>&mdash;Wire splints lined with leather and provided with a
+foot-piece; special box-splints with moveable sides, as Butcher's;<a name="FNanchor_65_65" id="FNanchor_65_65"></a><a href="#Footnote_65_65" class="fnanchor">[65]</a>
+plaster-of-Paris moulds are used by Dr. P.H. Watson<a name="FNanchor_66_66" id="FNanchor_66_66"></a><a href="#Footnote_66_66" class="fnanchor">[66]</a> of Edinburgh and
+others; this last form of dressing is the best, and allows the limb to
+be suspended from a Salter's swing.</p>
+
+<p>H-<i>shaped incision.</i>&mdash;The internal incision should commence at
+a point about two inches below the articular surface of the tibia, and
+in a line with its inner edge; it should then be carried up along the
+femur in a direction parallel to the axis of the extended limb, so as to
+pass in front of the saphena vein, and thus avoid it, for a distance of
+five inches. The external incision, commencing just below the head of
+the fibula, must be carried upwards parallel to the preceding for the
+same distance. Both incisions must be made by a heavy scalpel with a
+firm hand, so as to divide all the tissues down to the bone. The
+vertical incisions are then united by a transverse one passing across
+just below the lower angle of the patella. The flaps thus formed must
+then be dissected up and down, and the internal and external lateral
+ligaments divided, thus thoroughly opening<span class='pagenum'><a name="Page_136" id="Page_136">{136}</a></span> the joint and exposing the
+crucial ligaments. These must be divided carefully, remembering the
+position of the artery. The bones are then to be cleared and divided, as
+in the operation already described. This is the method of Moreau and
+Butcher.<a name="FNanchor_67_67" id="FNanchor_67_67"></a><a href="#Footnote_67_67" class="fnanchor">[67]</a></p>
+
+<p><i>Patella and Ligamentum Patell&aelig; retained.</i>&mdash;"A longitudinal incision,
+full four inches in extent, was made on each side of the knee-joint,
+midway between the vasti and flexors of the leg; these two cuts were
+down to the bones, they were connected by a transverse one just over the
+prominence of the tubercle of the tibia, <i>care being taken to avoid
+cutting by this incision the ligamentum patell&aelig;</i>; the flap thus defined
+was reflected upwards, the patella and the ligament were then freed and
+drawn over the internal condyle, and kept there by means of a broad,
+flat, and turned-up spatula; the joint was thus exposed, and after the
+synovial capsule had been cut through as far as could be seen, the leg
+was forcibly flexed, the crucial ligaments, almost breaking in the act,
+only required a slight touch of the knife to divide them completely. The
+articular surfaces of the bones were now completely brought to view, and
+the diseased portions removed by means of suitable saws, the soft parts
+being hold aside by assistants."<a name="FNanchor_68_68" id="FNanchor_68_68"></a><a href="#Footnote_68_68" class="fnanchor">[68]</a></p>
+
+<p>Results of Excision of Knee-joint:&mdash;Holmes's Table of recent cases from
+1873-1878&mdash;</p>
+
+<table summary="numbers">
+<tr><td>&nbsp;</td><td class="tdr">245 cases;</td><td>25 deaths, and 47 failures.</td></tr>
+<tr><td>Spence's</td><td class="tdr">33 cases;</td><td>22 recovered, 11 died.</td></tr>
+</table>
+
+
+<p class="gap"><span class="smcap">Buck's Operation for Anchylosed Knee-Joint</span>.&mdash;The principle of this
+operation is to remove a triangular portion of bone, which is to include
+the surfaces of the femur and tibia, which have anchylosed in an awkward
+position, and by this means to set the bones free, and enable the limb
+to be straightened. Access<span class='pagenum'><a name="Page_137" id="Page_137">{137}</a></span> to the joint may be obtained by either of
+the two methods already described. Sections of the bones are then to be
+made with the saw, so as to meet posteriorly a little in front of the
+posterior surface of the anchylosed joint, and thus remove a triangular
+portion of bone; the portion still remaining, and which still keeps up
+the deformity, is then to be broken through as best you can, either by a
+chisel, or a saw, or forced flexion. The ends are to be pared off by
+bone-pliers, and the surfaces brought into as close apposition as
+possible. The operation is a difficult one, a gap being generally left
+between the anterior edges of the bones, from the unyielding nature of
+the integuments behind, and the difficulty of removing the posterior
+projecting edges from their close proximity to the artery. Of twenty
+cases on record, eight died, and two required amputation.</p>
+
+<p><i>Relation of Age to result in Excision of Knee-Joint from Hodge's
+Tables.</i></p>
+
+<p>Of 182 complete cases:&mdash;</p>
+
+
+<table summary="numbers">
+<tr><td class="center">68 below 16 years: 50 recovered&mdash;18 died; or 26 per cent. died.</td></tr>
+<tr><td class="center">114 above 16 years: 55 recovered&mdash;59 died; or 51.7 per cent. died.</td></tr>
+</table>
+
+
+<p><span class="smcap">Excision of the Ankle-Joint</span>.&mdash;<i>In what cases is it to be done, and how
+much bone is to be removed?</i></p>
+
+<p>In cases of compound dislocation of the ankle-joint, the tibia and
+fibula are apt to be protruded either in front or behind. When this
+happens it is a dislocation generally very difficult to reduce, and when
+reduced to retain in position. In such cases, if there seems to be any
+chance of retaining the foot, excision of the articular ends of tibia
+and fibula greatly add to the probabilities in its favour. It may be
+done without any new wound, and, in general, by an ordinary surgeon's
+saw.</p>
+
+<p>When the astragalus does not protrude, it seems to matter little for the
+future result whether its articular surface be removed or not. When, on
+the other hand, it protrudes, as a result either of the displacement of<span class='pagenum'><a name="Page_138" id="Page_138">{138}</a></span>
+the entire foot, or of a dislocation complete or partial of the
+astragalus itself, there is no doubt that excision either of its
+articular surface or of the entire bone will give very excellent
+results. J&auml;ger reports twenty-seven such cases, with only one fatal, and
+one doubtful result.</p>
+
+<p><i>In cases of disease of the Ankle-joint.</i>&mdash;Excision has been performed a
+good many times, and should in most cases be complete. A work like this
+is not the place to discuss the propriety of operations so much as the
+method of performing them, but one remark may be permitted. Few points
+of surgical diagnosis are more difficult than it is to tell whether in
+any given case disease is confined to the ankle-joint, and whether or
+not the bones of the tarsus participate. If they do even to a slight
+extent, no operation which attacks the ankle-joint only has any
+reasonable chance of success. It may look well for a time, but sinuses
+remain, the irritation of the operation only hastens the progress of the
+disease of the bone, and the result will almost certainly be
+disappointing, amputation being almost the inevitable <i>dernier ressort</i>.</p>
+
+<p><i>Methods of Operating</i>:&mdash;</p>
+
+<p><i>Mr. Hancock</i> has been very successful by the following method:&mdash;</p>
+
+<p>Commence the incision (<a href="#plate_ii">Plate II.</a> figs. <span class="smcap">B.B.</span>) about two inches above and
+behind the external malleolus, and carry it across the instep to about
+two inches above and behind the internal malleolus. Take care that this
+incision merely divides the skin, and does not penetrate beyond the
+fascia. Reflect the flap so made, and next cut down upon the external
+malleolus, carrying your knife close to the edge of the bone, both
+behind and below the process, dislodge the peronei tendons, and divide
+the external lateral ligaments of the joint. Having done this, with the
+bone-nippers cut through the fibula, about an inch above the malleolus,
+remove<span class='pagenum'><a name="Page_139" id="Page_139">{139}</a></span> this piece of bone, dividing the inferior tibio-fibular
+ligament, and then turn the leg and foot on the outside. Now carefully
+dissect the tendons of the tibialis posticus and flexor communis
+digitorum from behind the internal malleolus. Carry your knife close
+round the edge of this process, and detach the internal lateral
+ligament, then grasping the heel with one hand, and the front of the
+foot with the other, forcibly turn the sole of the foot downwards, by
+which the lower end of the tibia is dislocated and protruded through the
+wound. This done, remove the diseased end of the tibia with the common
+amputating saw, and afterwards with a small metacarpal saw placed upon
+the back of the upper articulating process of the astragalus, between
+that process and the tendo Achillis, remove the former by cutting from
+behind forwards. Replace the parts <i>in situ</i>; close the wound carefully
+on the inner side and front of the ankle; but leave the outside open,
+that there may be a free exit for discharge, apply water-dressing, place
+the limb on its outer side on a splint, and the operation is completed.</p>
+
+<p>Skin, external, and internal ligaments, and the bones are the only parts
+divided, no tendons and no arteries of any size.<a name="FNanchor_69_69" id="FNanchor_69_69"></a><a href="#Footnote_69_69" class="fnanchor">[69]</a></p>
+
+<p><i>Barwell's</i> method by <i>lateral incisions</i> is briefly as follows:&mdash;</p>
+
+<p>On the outer side, an incision over the lower three inches of the fibula
+turns forward at the malleolus at an angle, and ends about half an inch
+above the base of the outer metatarsal. The flap is to be reflected,
+fibula divided about two inches from its lower end by the forceps, and
+dissected out, leaving peronei tendons uncut. A similar incision on the
+inner side terminates over the projection of the internal cuneiform
+bone; the sheaths of the tendons under inner angle are then to be
+divided, and the artery and nerve avoided; the internal<span class='pagenum'><a name="Page_140" id="Page_140">{140}</a></span> lateral
+ligament is then to be divided, the foot twisted outwards, so as to
+protrude the astragalus and tibia at the inner wound. The lower end of
+the tibia and top of the astragalus are to be sawn off by a
+narrow-bladed saw passing from one wound to the other.<a name="FNanchor_70_70" id="FNanchor_70_70"></a><a href="#Footnote_70_70" class="fnanchor">[70]</a></p>
+
+<p>Dr. M. Buchanan of Glasgow has described an operation by which the joint
+can be excised through a single incision over the external malleolus.</p>
+
+<p><i>Results.</i>&mdash;So far as can be gathered from cases already published, the
+results are very often (at least in one out of every two cases)
+unsatisfactory. Sinuses remain, which do not heal, the limbs are
+useless, and amputation is in the end necessary.</p>
+
+<p>Langenbeck has performed it sixteen times during the last
+Schleswig-Holstein war (in 1864), and the Bohemian war in 1866, with
+only three deaths. In these cases the operation was subperiosteal.</p>
+
+
+<p class="gap"><span class="smcap">Excision of the Scapula.</span>&mdash;More or less of the scapula has in many cases
+been removed along with the arm, and even with the addition of portion
+of the clavicle.</p>
+
+<p>Excision of the entire bone, leaving the arm, has been performed in two
+instances by Mr. Syme. The procedure must vary according to the nature
+and shape of the tumour on account of which the operation is performed.
+Mr. Syme operated as follows:&mdash;</p>
+
+<p>In the first case, one of cerebriform tumour of the bone, he "made an
+incision from the acromion process transversely to the posterior edge of
+the scapula, and another from the centre of this one directly downwards
+to the lower margin of the tumour. The flaps thus formed being reflected
+without much h&aelig;morrhage, I separated the scapular attachment of the
+deltoid, and divided the connections of the acromial extremity of the
+clavicle. Then, wishing to command the subscapular artery, I<span class='pagenum'><a name="Page_141" id="Page_141">{141}</a></span> divided
+it, with the effect of giving issue to a fearful gush of blood, but
+fortunately caught the vessel and tied it without any delay. I next cut
+into the joint and round the glenoid cavity, hooked my finger under the
+coracoid process, so as to facilitate the division of its muscular and
+ligamentous attachments, and then pulling back the bone with all the
+force of my left hand, separated its remaining attachments with rapid
+sweeps of the knife." (<a href="#plate_iii">Plate III.</a> fig. <span class="smcap">g.</span>)</p>
+
+<p>Mr. Syme's second case was also one of tumour of the scapula; the head
+of the humerus had been excised two years before.</p>
+
+<p>He removed it by two incisions, one from the clavicle a little to the
+sternal side of the coracoid, directed downwards to the lower boundary
+of the tumour, another transversely from the shoulder to the posterior
+edge of the scapula. The clavicle was divided at the spot where it was
+exposed, and the outer portion removed along with the scapula.<a name="FNanchor_71_71" id="FNanchor_71_71"></a><a href="#Footnote_71_71" class="fnanchor">[71]</a></p>
+
+<p>The author has in a case of osseous tumour removed the whole body of the
+scapula, leaving glenoid, spine, acromion and anterior margin with
+excellent result and a useful arm.</p>
+
+<p>Large portions of the shafts of the humerus, radius, and ulna have been
+removed for disease or accident, and useful arms have resulted; but as
+the operative procedures must vary in every case, according to the
+amount of bone to be removed, and the number and position of the
+sinuses, no exact directions can be given.</p>
+
+<p>For very interesting cases of such resections reference may be made to
+Wagner's treatise on the subject, translated and enlarged by Mr. Holmes,
+and to Williamson's <i>Military Surgery</i>, p. 227.</p>
+
+
+<p class="gap"><span class="smcap">Excision of Metacarpals and Phalanges</span>.&mdash;To <i>excise</i> the metacarpal
+implies that the corresponding<span class='pagenum'><a name="Page_142" id="Page_142">{142}</a></span> finger is left. Except in cases of
+necrosis, where abundance of new bone has formed in the detached
+periosteum, the results of such excisions do not encourage repetition,
+the digits which remain being generally very useless. It is quite
+different, however, if it is the thumb that is involved; and every
+effort should, in every case, be made to retain the thumb, even in the
+complete absence of its metacarpal bone. For the good results of a case
+in which Mr. Syme excised the whole metacarpal bone for a tumour, see
+his <i>Observations in Clinical Surgery</i>, p. 38.</p>
+
+<p>The operation is not difficult, and requires merely a straight incision
+over the dorsum, extending the whole length of the bone.</p>
+
+<p>In the same way the proximal phalanx of the thumb may be excised, and
+yet, if proper care be taken, a very useful limb be left. I quote entire
+the following case by Mr. Butcher of Dublin:&mdash;</p>
+
+
+<p class="gap"><span class="smcap">Excision of Proximal Phalanx of the Thumb</span>.&mdash;The
+thumb of the right hand was crushed by the crank of a steam-engine.
+The proximal phalanx was completely shivered; its fragments were
+removed, the cartilage of the proximal end of the distal phalanx, and
+also of the head of the metacarpal bone, were pared off with a strong
+knife. The digit was put up on a splint fully extended. In about a month
+cure was nearly complete, a firm dense tissue took the place of the
+removed phalanx, and the power of flexing the unguinal was nearly
+complete.<a name="FNanchor_72_72" id="FNanchor_72_72"></a><a href="#Footnote_72_72" class="fnanchor">[72]</a></p>
+
+
+<p class="gap"><span class="smcap">Excision of the Joints of the Fingers</span>.&mdash;These operations may be
+performed for compound dislocation, specially when the thumb is injured;
+no directions can be given for the incisions.<a name="FNanchor_73_73" id="FNanchor_73_73"></a><a href="#Footnote_73_73" class="fnanchor">[73]</a><span class='pagenum'><a name="Page_143" id="Page_143">{143}</a></span></p>
+
+<p>In cases of disease it is rarely necessary or advisable to attempt to
+save a finger, but if the metacarpo-phalangeal joint of the thumb be
+affected, excision should be performed with the hope of saving the
+thumb. A single free incision on the radial side of the joint will give
+sufficient access.</p>
+
+
+<p class="gap"><span class="smcap">Excision of the Os Calcis</span>.&mdash;In those comparatively rare cases in which
+the os calcis is alone affected, the rest of the tarsus and the
+ankle-joint being healthy, a considerable difference of opinion exists
+as to the proper course to be followed. By some surgeons it is
+considered best merely to gain free access to the diseased bone, and
+then remove by a gouge all the softened and altered portions, leaving a
+shell of bone all round, of course saving the periosteum and avoiding
+interference with the joint. This operation requires no special detailed
+instruction. We find many surgeons, among them Fergusson and Hodge,
+supporters of this comparatively modest operation. The author has many
+times performed this operation with excellent results. Even when nothing
+but periosteum is left, the new bone becomes strong and of full size.</p>
+
+<p>Excision of the whole of the diseased bone at its joints, with or
+without an attempt to leave some of the periosteum, has been deemed
+necessary by others. Holmes, who has had considerable experience,
+removes the bone at once by the following incisions, without paying any
+reference to the periosteum:&mdash;</p>
+
+<p><i>Operation.</i>&mdash;An incision (<a href="#plate_iii">Plate III.</a> fig. <span class="smcap">f.</span>) is commenced at the inner
+edge of the tendo Achillis, and drawn horizontally forwards along the
+outer side of the foot, somewhat in front of the calcaneo-cuboid joint,
+which lies midway between the outer malleolus and the end of the fifth
+metatarsal bone. This incision should go down at once upon the bone, so
+that the tendon should be felt to snap as the incision is commenced. It<span class='pagenum'><a name="Page_144" id="Page_144">{144}</a></span>
+should be as nearly as possible on a level with the upper border of the
+os calcis, a point which the surgeon can determine, if the dorsum of the
+foot is in a natural state, by feeling the pit in which the extensor
+brevis digitorum arises. Another incision is then to be drawn vertically
+across the sole, commencing near the anterior end of the former
+incision, and terminating at the outer border of the grooved or internal
+surface of the os calcis, beyond which point it should not extend, for
+fear of wounding the posterior tibial vessels. If more room be required,
+this vertical incision may be prolonged a little upwards, so as to form
+a crucial incision. The bone being now denuded by throwing back the
+flaps, the first point is to find and lay open the calcaneo-cuboid
+joint, and then the joints with the astragalus. The close connections
+between these two bones constitute the principal difficulty in the
+operation on the dead subject; but these joints will frequently be found
+to have been destroyed in cases of disease. The calcaneum having been
+separated thus from its bony connections by the free use of the knife,
+aided, if necessary, by the lever, lion-forceps, etc., the soft parts
+are next to be cleaned off its inner side with care, in order to avoid
+the vessels, and the bone will then come away.<a name="FNanchor_74_74" id="FNanchor_74_74"></a><a href="#Footnote_74_74" class="fnanchor">[74]</a></p>
+
+<p>Attempts may occasionally be made in such an operation to save a portion
+of periosteum in attachment to the soft parts, but success or failure in
+this seems to have very little effect on the future result.</p>
+
+<div class="blockquot smlet"><p><i>Hancock's Method.</i>&mdash;A single flap was formed in the sole, with the
+convexity looking forwards, by an incision from one malleolus to
+the other.</p>
+
+<p><i>Greenhow's Method.</i>&mdash;Incisions made from the inner and outer
+ankles, meeting at the apex of the heel, and then others extending
+along the sides of the foot, the flaps being dissected back so as
+to expose the bone and its connections.<a name="FNanchor_75_75" id="FNanchor_75_75"></a><a href="#Footnote_75_75" class="fnanchor">[75]</a> </p></div>
+
+<p><span class='pagenum'><a name="Page_145" id="Page_145">{145}</a></span></p>
+
+<p class="gap"><span class="smcap">Excision of Astragalus</span>.&mdash;A curved incision on the dorsum of the foot
+extending from one malleolus to the other, and as far forwards as the
+front of the scaphoid. The chief caution required is to divide all
+ligaments which hold the bone in place, and dissect it clean on all
+other parts before meddling with its posterior surface where the groove
+exists for the flexor longus pollicis tendon near which the posterior
+tibial vessels and nerve lie.<a name="FNanchor_76_76" id="FNanchor_76_76"></a><a href="#Footnote_76_76" class="fnanchor">[76]</a></p>
+
+
+<p class="gap"><span class="smcap">Excision of Astragalus and Scaphoid</span>.&mdash;An incision similar to the
+anterior one in Syme's amputation at the ankle. The flap was then turned
+back from the dorsum of the foot. The joint was then opened, the lateral
+ligaments of the ankle-joint divided, the foot dislocated so as to show
+the astragalo-calcanean ligaments, and allow them to be divided. The
+bones were then grasped with the lion-forceps and pulled forwards, while
+the posterior surface of the astragalus was very cautiously cleaned, so
+as to avoid the posterior tibial artery.<a name="FNanchor_77_77" id="FNanchor_77_77"></a><a href="#Footnote_77_77" class="fnanchor">[77]</a></p>
+
+
+<p class="gap"><span class="smcap">Excision of Metatarso-Phalangeal Joint of Great Toe</span>.&mdash;Butcher performs
+it by splitting up the sinuses leading to the carious joint, exposing it
+and cutting off with bone-pliers the anterior third of the metatarsal
+bone, and the proximal end of the first phalanx. He also cuts
+subcutaneously the extensor tendons to prevent them from cocking up the
+toe.<a name="FNanchor_78_78" id="FNanchor_78_78"></a><a href="#Footnote_78_78" class="fnanchor">[78]</a> Pancoast prefers a semilunar incision. A lateral incision is
+usually to be preferred.</p>
+
+<p>The author has performed this excision frequently for disease; when the
+whole cartilages are removed and the wound is freely drained, an
+admirable result is obtained.<span class='pagenum'><a name="Page_146" id="Page_146">{146}</a></span></p>
+
+<p>In cases of compound dislocation of the head of the metatarsal bone, it
+will occasionally be found necessary to excise it either by the
+original, or a slightly enlarged wound.</p>
+
+<p>The author lately excised one-half of shaft of metatarsal and the
+corresponding half of proximal phalanx of great toe for exostosis, with
+antiseptic precautions. The result was a useful toe with a <i>mobile
+joint</i>.</p>
+
+
+<p class="gap"><span class="smcap">Excision of Metatarsal Bone of Great Toe</span>.&mdash;For this operation a
+quadrilateral flap has been recommended, but this is quite unnecessary.
+A single straight incision along the inner border of the foot, extending
+the whole length of the bone, renders it very easy to remove the whole
+bone from joint to joint. This is an operation, however, which is rarely
+needed, and which would leave a very useless flail of a toe. The
+operation, which is at once more commonly required, and also gives
+promise of a more satisfactory result, is the one performed for
+cario-necrosis of the shaft only, and in the following manner:&mdash;</p>
+
+<p>A straight incision through all the tissues, including the periosteum,
+right down to the bone; then with nail or handle of the knife to
+separate the periosteum from the bone; then with a pair of bone-pliers
+or a fine saw to divide the shaft from both its extremities and remove
+it entire.<a name="FNanchor_79_79" id="FNanchor_79_79"></a><a href="#Footnote_79_79" class="fnanchor">[79]</a></p>
+
+
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_147" id="Page_147">{147}</a></span></p>
+
+<h2><a name="CHAPTER_IV" id="CHAPTER_IV"></a>CHAPTER IV.</h2>
+
+<h3>OPERATIONS ON CRANIUM AND SCALP.</h3>
+
+
+<p><span class="smcap">Trephining and Trepanning</span> are the names given to operations for the
+removal of portions of the cranium by circular saws which play on a
+centre pivot. When the motion is given to the saw simply by rotation of
+the hand of the operator, as is common in this country, it is called
+<i>trephining</i>; when (as used to be the case in this country, and still is
+on the Continent) the motion is given by an instrument like a
+carpenter's brace, the operation is called <i>trepanning</i>.</p>
+
+<p>The nature of the operation varies according to the nature of the case
+for which it is performed. Thus (1.) it may be performed through the
+uninjured cranium in the hope of evacuating an abscess of the diploe or
+dura mater, or of relieving pressure caused by suppuration in the brain
+itself, or by extravasation into the brain or membranes; or (2.) it may
+be required in cases of punctured and depressed fracture for the purpose
+of removing projecting corners of bone and allowing elevation of the
+depressed portions; or (3.) it is sometimes used to remove a circular
+portion of bone in cases of epilepsy in which pain or tenderness is felt
+at some limited portion of the cranium.</p>
+
+<p>1. <i>In cases where the cranium and its coverings are entire.</i>&mdash;There are
+certain positions where, if it is possible, the trephine should <i>not</i> be
+applied. These are<span class='pagenum'><a name="Page_148" id="Page_148">{148}</a></span> the longitudinal sinus, the anterior inferior angle
+of the parietal bone, where the middle meningeal artery is in the way,
+the occipital protuberance, and the various sutures. These being
+avoided, a crucial incision is to be made through the skin, and its
+flaps reflected. The pericranium should then be raised from the centre,
+for a space large enough to hold the crown of the trephine. The
+pericranium should never be removed, but carefully raised and preserved,
+as its presence will greatly aid in the restoration of bone.<a name="FNanchor_80_80" id="FNanchor_80_80"></a><a href="#Footnote_80_80" class="fnanchor">[80]</a> The
+centre pin should then be projected for about the eighth of an inch and
+bored into the bone. On it as a centre the saw is then worked by
+semicircular sweeps in both directions alternately, till it forms a
+groove for itself. Whenever this groove is deep enough the pin should be
+retracted, lest from its projection it pierce the dura mater before the
+tables of the skull are cut through. Were the cranium always of the same
+thickness, and even of similar consistence, the operation would always
+be exceedingly easy; but in both these particulars different skulls vary
+much from each other, and thus by a rash use of the instrument the dura
+mater may possibly be injured. The tough outer table is more difficult
+to cut than the softer and more vascular diploe, and the inner table is
+denser than either, but more brittle. In many old skulls, however, the
+diploe is wanting altogether, and the two tables are amalgamated, and
+often very thin.</p>
+
+<p>Great care must be taken in every case to saw slowly, to remove the
+sawdust, and examine the track of the saw by a probe or quill, lest one
+part should be cut through quicker than another. The last turns of the
+instrument must specially be cautious ones. When the disk of bone does
+not at once come away in the trephine, the elevator or the special
+forceps for the purpose will easily remove it. If the abscess,
+extravasation, or exostosis be then discovered and removed, all that
+remains<span class='pagenum'><a name="Page_149" id="Page_149">{149}</a></span> is to remove any sawdust or loose pieces of bone, and possibly
+to smooth off any sharp edges of the orifice by an instrument called the
+lenticular. This is very seldom required, and now hardly ever used.</p>
+
+<p>2. <i>In cases of depressed or punctured fracture</i> the trephine is
+occasionally required (when symptoms of compression are present) for the
+purpose of enabling the depressed portion to be elevated. It is unsafe
+to apply it to the depressed or fractured bone, lest the additional
+pressure of the instrument should cause wound of the dura mater or
+brain. It is generally applied on some projecting corner of sound bone
+under which the depressed portion is locked, and hence it is rarely
+necessary to remove a complete circular portion. In fact very many cases
+of such displacement may be remedied more easily by a pair of strong
+bone-forceps, or a Hey's saw, applied to remove the projecting portion
+of sound bone. The same precautions must be used as in the operation
+already described, and the sawing must be done even more cautiously, as
+it is rarely more than a semicircle that requires cutting.</p>
+
+<p>In former days trephining was a much more frequent operation than it is
+now, and apparently more successful. The reason of the greater apparent
+success can easily be found in the fact that it was performed in many
+cases merely as a precautionary measure against dreaded inflammation of
+the brain, which probably never would have appeared at all, and that the
+operation itself is one by no means dangerous. Very numerous
+applications of the trephine have been made in the same individual&mdash;two,
+four, six, and even in one case twenty-seven disks having been removed
+from the same skull, and yet the patients have survived.</p>
+
+
+<p class="gap"><span class="smcap">Tumours of the Scalp</span>, <i>Removal of</i>.&mdash;By far the most frequent are the
+encysted tumours, or wens. These consist of a thick firm cyst-wall,
+which contains soft,<span class='pagenum'><a name="Page_150" id="Page_150">{150}</a></span> curdy, or pultaceous matter, sometimes almost
+fluid, at others dry and gritty. They are loosely attached in the
+subcutaneous cellular tissue, and unless they have become very large, or
+have been much pressed on, are non-adherent to the skin.</p>
+
+<p>The treatment is thus very simple. They should merely be transfixed by a
+sharp knife, the contents evacuated, and the cyst seized by strong
+dissecting forceps and twisted out.</p>
+
+<p>If they have once become adherent, they must be dissected out in the
+usual manner, after the adherent portion of skin has been defined by
+elliptical incisions.</p>
+
+<p>In the case of large wens on visible parts of scalp or face, the author
+avoids scar, by the following plan:&mdash;</p>
+
+<p>Make a small incision, two lines at most, through skin only, then with a
+blunt probe separate the cyst from the skin subcutaneously; then,
+pulling it to the wound with catch-forceps, empty the cyst and gradually
+pull it out, as if taking out an ovarian cyst. No scar but a dimple will
+remain.</p>
+
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_151" id="Page_151">{151}</a></span></p>
+
+<h2><a name="CHAPTER_V" id="CHAPTER_V"></a>CHAPTER V.</h2>
+
+<h3>OPERATIONS ON EYE.</h3>
+
+<p class="center noind"><i>Operations on the Eye and its Appendages.</i></p>
+
+
+<p class="gap"><span class="smcap">Operations on the Lids</span>.&mdash;</p>
+
+<div class="figright" style="width: 150px;">
+<img src="images/000a.jpg" width="150" height="128" alt="Fig. vii." title="Fig. vii." />
+<span class="caption"><span class="smcap">Fig. vii.</span>
+<a name="FNanchor_81_81" id="FNanchor_81_81"></a><a href="#Footnote_81_81" class="fnanchor">[81]</a></span>
+</div>
+
+
+<p>1. <span class="smcap">For Entropium or Inversion of the Lids, often Combined with
+Trichiasis, irregularity of the Cili&aelig;</span>.&mdash;As in many cases the entropium
+seems to depend partly on a too great laxity of the skin of the lid,
+combined occasionally with spasm of the orbicularis, the simplest and
+most natural plan of operation is (<i>a</i>) to remove (Fig. <span class="smcap">vii</span>. <i>a</i>) an
+elliptical portion of skin, extending transversely along the whole
+length of the affected lid, including the fibres of the orbicularis
+lying below it, and then to unite the edges with several points of fine
+suture. (<i>b</i>) An improvement on this in obstinate cases is proposed by
+Mr. Streatfeild (Fig. <span class="smcap">viii</span>.) He continues the same incision, but in
+addition removes a long narrow wedge-shaped<span class='pagenum'><a name="Page_152" id="Page_152">{152}</a></span> portion of the tarsal
+cartilage, grooving it without entirely cutting it through, in such a
+manner that the retraction of the skin bends the cartilage backwards,
+thus everting to a very considerable extent the previously inverted
+cili&aelig;.<a name="FNanchor_83_83" id="FNanchor_83_83"></a><a href="#Footnote_83_83" class="fnanchor">[83]</a></p>
+
+<div class="figright" style="width: 300px;">
+<img src="images/000b.jpg" width="300" height="175" alt="Fig. viii." title="Fig. viii." />
+<span class="caption"><span class="smcap">Fig. viii.</span>
+<a name="FNanchor_82_82" id="FNanchor_82_82"></a><a href="#Footnote_82_82" class="fnanchor">[82]</a></span>
+</div>
+
+<p>2. <span class="smcap">Ectropium</span> is the opposite condition from entropium; in it the eyelids
+are everted and the palpebral conjunctiva is exposed.</p>
+
+<p>If the result of cicatrix, of a burn, or of disease of bone, the
+treatment must be varied according to circumstances, and in many cases,
+skin must be transplanted to fill the gap.</p>
+
+<p>In the more usual cases resulting from chronic inflammation the
+following simple operations are required:&mdash;1. In mild cases the excision
+of an elliptical portion of conjunctiva may suffice, the edges must not
+be left to contract, but should be brought carefully together. 2. In
+more chronic cases, where all the tissues of the lid are very lax, it is
+necessary to remove (Fig. <span class="smcap">vii</span>. <i>b</i>) a V-shaped portion of lid and skin,
+and then stitch it very carefully up with interrupted sutures.</p>
+
+
+<p class="gap"><span class="smcap">Tumours of Eyelids</span>.&mdash;1. <i>Encysted tumours; cysts of the lids; tarsal
+tumour.</i>&mdash;Under these and similar names are recognised a very frequent
+form of disease, chiefly in the upper lid: small tumours which rarely
+exceed half a pea in size, convex towards the skin, which is freely
+moveable over them; they give no pain, and are annoying only from their
+bulk and deformity.</p>
+
+<p><i>Operation.</i>&mdash;Evert the lid, incise the conjunctiva freely over the
+tumour, insert the blunt end of a probe and roughly stir up the contents
+of the cyst, thus evacuating it. If the tumour is large and of old
+standing it may be requisite to cut out an elliptical or circular
+portion of its conjunctival wall. The probe may require to be reapplied
+once or twice at intervals<span class='pagenum'><a name="Page_153" id="Page_153">{153}</a></span> of two or three days, and in certain rare
+cases it may be necessary as a last resource freely to cauterise the
+inside of the cyst with the solid nitrate of silver.</p>
+
+<p>In <i>no</i> case is it ever necessary to excise the tumour from the outside
+of the eyelid; when this has been done in error there frequently remains
+an awkward and unsightly scar.</p>
+
+<p>2. <i>Fibrous cysts</i>, frequently congenital, are met with in one
+situation, just over the external angular process of the frontal bone.
+These are larger in size than the preceding, ranging from the size of a
+barley pickle to that of an almond. Their treatment is excision by a
+prolonged and careful dissection from the periosteum, to which they
+almost invariably are adherent.</p>
+
+
+<p class="gap"><span class="smcap">Operations on the Lachrymal Organs</span>.&mdash;In a system of ophthalmic surgery,
+various operative procedures might be detailed under this head,
+authorised and sanctioned by old custom. Excision of a diseased
+lachrymal gland, and removal of stones in the gland or ducts, need no
+special directions for their performance, and the operation immediately
+to be described, under the head of Mr. Bowman's operation, is applicable
+in almost every one of the diseased conditions of the lachrymal canal,
+sac, and nasal duct, to the exclusion of all the older methods.</p>
+
+<p><i>Mr. Bowman's Operation.</i>&mdash;In cases of obstruction of the punctum,
+canaliculus, and nasal duct, resulting in watery eye, accumulation of
+mucus in the canal, and dryness of the nose, great difficulty used to be
+experienced in the treatment. To pass a probe along the punctum was
+extremely difficult, in fact, possible only with a very small one, while
+the common operation of opening the dilated sac, through the skin, and
+then passing probes through this artificial opening, was found quite
+useless from the rapid closure of the wound, unless the treatment was
+followed up by the insertion and retention<span class='pagenum'><a name="Page_154" id="Page_154">{154}</a></span> of a style in the nasal
+duct. This was painful, unsightly, often unsuccessful; and even in some
+cases dangerous, from the amount of irritation, suppuration, and even
+caries of the nasal bones which is set up.</p>
+
+<p>The principle of Mr. Bowman's most excellent operation is, that the
+punctum, canaliculus, and nasal duct resemble in many respects the
+urethral passage, and in cases of stricture require to be treated on the
+same principle. If, then, it were possible to pass instruments gradually
+increasing in size through the seat of stricture, it would be gradually
+dilated. It is, however, in the normal state of parts, impossible to
+pass any instrument beyond the size of a human hair past the curve which
+the canaliculus makes on its entrance to the duct, hence the proper
+dilatation cannot be performed. Again, it is found that the puncta,
+specially the lower one, are themselves very often to blame, in cases of
+watery eye, sometimes because they are inverted or everted, more often
+because, sympathising with the lid, they are turgid, angry, and
+inflamed, pouting and closed like the orifice of the urethra in a
+gonorrh&#339;a.</p>
+
+<p>Mr. Bowman found that by slitting up the inferior punctum and
+canaliculus as far as the caruncula, several advantages were
+gained:&mdash;(1.) The swollen, angry, displaced punctum no longer impeded
+the entrance of the tears; (2.) and chiefly when the canaliculus was
+slit up, the curve, or rather angle, which impeded the passage of
+probes, was done away with, and the nasal duct could be readily and
+thoroughly dilated.</p>
+
+<p><i>Operation.</i>&mdash;The surgeon stands behind the patient, who is seated, and
+leans his head on the surgeon's chest. The affected lid is then drawn
+gently downwards on the cheek, so as to evert and thoroughly expose the
+lower punctum. Into this the surgeon introduces a fine probe of steel
+gilt, the first inch of which is very thin, especially at the point, and
+deeply grooved on one side, exactly like a small (and straight) Syme's
+stricture director.<span class='pagenum'><a name="Page_155" id="Page_155">{155}</a></span></p>
+
+<p>Keeping the canal relaxed by relaxing his hold on the lid, the surgeon
+now gently wriggles the probe along the canaliculus, gradually
+stretching it as the probe advances, so as to avoid catching of the
+sides of the canal before the point of the instrument, till he is
+satisfied that it has fairly entered the nasal duct. He then stretches
+the eyelid, brings the handle of the probe out over the cheek so as to
+evert the punctum as much as possible, and then with a fine
+sharp-pointed knife enters the groove (Fig. <span class="smcap">ix</span>.), and fairly slits up
+the punctum and the canal to the full extent. The incision should be as
+straight as possible, and through the upper wall of the canaliculus. A
+dexterous turn of the instrument upwards on the forehead will generally
+enable it to be passed at once fairly into the nose through the nasal
+duct, the usual rule being observed of passing it downwards and slightly
+backwards, the handle of the probe passing just over the supraorbital
+notch.</p>
+
+<div class="figcenter" style="width: 450px;">
+<img src="images/155.jpg" width="450" height="231" alt="Fig. ix." title="Fig. ix." />
+<span class="caption"><span class="smcap">Fig. ix.</span>
+<a name="FNanchor_84_84" id="FNanchor_84_84"></a><a href="#Footnote_84_84" class="fnanchor">[84]</a></span>
+</div>
+
+<p>For several days after the operation the probe will have to be passed,
+both to prevent the wound in the canaliculus from healing up, which it
+is too apt to do, and also to gradually dilate the nasal duct if it has
+been previously strictured. Probes and directors of various sizes are
+required; in fact very much the same instruments<span class='pagenum'><a name="Page_156" id="Page_156">{156}</a></span> (in miniature) as are
+required for the treatment of stricture of the urethra.</p>
+
+<p>Mr. Greenslade has invented a very ingenious little instrument, of
+which, through his kindness, I am able to show a woodcut (Fig. <span class="smcap">x</span>.), for
+slitting up the canaliculus without having to fit the knife in the
+groove.</p>
+
+<div class="figcenter" style="width: 550px;">
+<img src="images/156.jpg" width="550" height="163" alt="Fig. x." title="Fig. x." />
+<span class="caption"><span class="smcap">Fig. x.</span></span>
+</div>
+
+<p><span class="smcap">Pterygium</span>, the reddish fleshy triangular growth, with its base at the
+inner canthus, and its apex spreading to and often over the cornea,
+requires invariably a small operation for its removal. In most cases it
+will be found sufficient merely to raise the lax portion over the
+sclerotic with forceps, and divide it freely, removing a transverse
+portion. If it has encroached upon the cornea, the portion interfering
+with vision must be dissected off with great care and removed.</p>
+
+<p>In some cases, however, it has been found that after removal of a large
+pterygium, a retraction of the caruncle and the semilunar fold is apt to
+take place, which renders the eyeball unpleasantly prominent. To avoid
+this the pterygium may be carefully dissected up from its apex to near
+its base, and then displaced laterally either upwards or downwards, its
+apex and sides being stitched to a previously prepared site of
+conjunctiva.</p>
+
+
+<p class="gap"><span class="smcap">Operation for Convergent Strabismus.</span>&mdash;<i>Division of the internal
+rectus.</i>&mdash;<i>Subconjunctival operation.</i>&mdash;The spring-wire speculum (C)
+separating the lids, the surgeon divides the conjunctiva by a pair of
+scissors in a horizontal line (Fig. <span class="smcap">xi. A A</span>) from the inner margin of
+the<span class='pagenum'><a name="Page_157" id="Page_157">{157}</a></span> cornea, a little below its transverse diameter to the caruncle,
+then snipping through the sub-conjunctival tissue, he passes a blunt
+hook bent at an obtuse angle under the tendon of the internal rectus,
+and endeavours by depressing the handle to project the point of the hook
+at the wound. Then with successive snips of the scissors he divides the
+tendon on the hook, close to its sclerotic margin. Lest it should not be
+freely divided, various dips with the hook may be made to catch any
+stray fibres left untouched; but very great care should be taken not to
+wound the conjunctiva beyond the first horizontal cut in it. The tendon
+being divided satisfactorily, the edges of conjunctiva should be
+replaced, and the eye closed for a few hours.</p>
+
+<div class="figright" style="width: 250px;">
+<img src="images/157.jpg" width="250" height="99" alt="Fig. xi." title="" />
+<span class="caption"><span class="smcap">Fig. xi.</span>
+<a name="FNanchor_85_85" id="FNanchor_85_85"></a><a href="#Footnote_85_85" class="fnanchor">[85]</a></span>
+</div>
+
+
+<p>The original operation of Dieffenbach, now rarely practised, consisted
+in making an incision, <span class="smcap">b b</span>, across the tendon, then, by cutting the
+areolar tissue exposing the insertion of the tendon, and dividing it
+freely; after which the sclerotic in the neighbourhood was to be cleaned
+and any band of fibres divided. There are risks on the one hand of a
+most unseemly exophthalmos with divergent squint, and on the other of a
+retraction of the semilunar fold, so that the sub-conjunctival operation
+is always preferable.</p>
+
+
+<p class="gap"><span class="smcap">Operations for Divergent Squint</span>.&mdash;This very serious deformity is often
+the result of the operation for convergent squint, and is associated
+with a fixed, leering, and prominent eye, and frequently with most
+annoying double vision.</p>
+
+<p>1. In a simple case of primary divergent strabismus<span class='pagenum'><a name="Page_158" id="Page_158">{158}</a></span> (very rare) it is
+sufficient simply to divide the external rectus in the manner already
+described for division of the internal.</p>
+
+<p>2. If secondary to an operation for convergent squint, the indication is
+to restore the cut internal rectus to a position on the sclerotic a
+little behind its previous one, as the cause of the divergence is found
+in a complete detachment of the internal rectus. This is attempted in
+various ways.</p>
+
+<p>(1.) <i>Jules Gu&eacute;rin</i> carefully divided the conjunctiva over it, and
+sought for the remains of the internal rectus, freeing it from its
+attachments. He then passed a thread through the sclerotic on the
+<i>outer</i> side of the globe, and by pulling on it and fixing it across the
+nose, rotated the eye inwards, in the hope that the remains of the
+internal rectus would secure a new attachment.</p>
+
+<p>(2.) <i>Graefe's modification</i> of this is more certain. Without any minute
+dissection he merely separated the internal rectus, along with the
+conjunctiva, and fascia over it, so that it can be pulled forwards, then
+cut the external rectus, and inverted the eyeball to a sufficient extent
+by means of a thread passed through the portion of the tendon of the
+external rectus, which remains attached to the sclerotic. The risk of
+all these operations, in which both muscles are divided, is protrusion
+of the eyeball from the removal of muscular tension.</p>
+
+<p>(3.) <i>Solomon's operation for the radical cure of extreme divergent
+strabismus</i>,<a name="FNanchor_86_86" id="FNanchor_86_86"></a><a href="#Footnote_86_86" class="fnanchor">[86]</a> is at first sight a very curious one. Without going
+into all the details, the steps are as follows:&mdash;</p>
+
+<p><i>a.</i> A square-shaped flap, with its attached base at the nasal side, is
+raised, containing the remains of the inner rectus and its adjacent
+parts.</p>
+
+<p><i>b.</i> A flap similar in shape and size, but different in the position of
+its attached base, is made on the other<span class='pagenum'><a name="Page_159" id="Page_159">{159}</a></span> side of the cornea. It is made
+by dividing the external rectus just behind its tendon, and then
+reflecting forwards the tendon with its conjunctiva.</p>
+
+<p><i>c.</i> These two flaps are united over the vertical meridian of the cornea
+by sutures, three generally being sufficient. This entirely hides the
+cornea for a time, but eventually shrivels and contracts, and the
+remnants are to be cut off with scissors three weeks after the
+operation.</p>
+
+
+<p class="gap"><span class="smcap">Puncture of the Cornea</span>.&mdash;<i>Paracentesis of the Anterior
+Chamber.</i>&mdash;<i>Tapping of the Aqueous Humour.</i>&mdash;This very simple operation
+is in many cases extremely useful. In cases of corneal ulcer, the result
+either of injury or disease, where there is much pain in the bone, and
+evidence of tension of the globe, it gives great relief, and when
+repeated at short intervals greatly hastens a cure. Sperino of Turin
+recommends its frequent use in cases of chronic glaucoma.</p>
+
+<p><i>Operation.</i>&mdash;The surgeon stands behind the patient, who is seated; the
+lids being fixed, the upper by the surgeon's left hand, and the lower by
+an assistant, the cornea is punctured a little in front of the sclerotic
+margin, either with a broad needle, or, what is as good, a well-worn
+Beer's knife. Care must be taken on entering the knife, on the one hand,
+not to wound the iris, which is sometimes arched forwards in the cases
+of commencing glaucoma, and, on the other, fairly to enter the anterior
+chamber, not merely split up the layers of the cornea. On withdrawing
+the cataract knife, the aqueous humour gets out by its side, aided by a
+slight turn of the knife, sometimes with great force, and in much larger
+quantity than usual. If the operation has been done by a needle, a blunt
+probe requires to be introduced on the removal of the needle. Once
+punctured, the remarkable fact is that the same wound suffices for many
+succeeding tappings, which are effected by pressing the probe into the
+wound day after day, sometimes<span class='pagenum'><a name="Page_160" id="Page_160">{160}</a></span> several times a day, with great relief
+to the symptoms. If the probe is to be used for succeeding evacuations,
+the operator must be careful to remember the exact spot at which the
+needle or knife was entered. To facilitate remembering it, it is best,
+when nothing prevents it, to operate always in the same spot. Sperino
+chooses the horizontal meridian of the cornea at the temporal side, at
+the junction of the cornea and sclerotic.</p>
+
+
+<p class="gap"><span class="smcap">Cataract Operations.</span>&mdash;Here we cannot enter into any discussion of the
+pathology of cataract and the varieties of it. Enough for our purpose to
+know that the lens is in some cases hard, in others soft, and that thus
+in the latter it may be removed piecemeal, and by a small incision,
+while in the former, removal must be almost entire, and by a larger
+opening.</p>
+
+<p>In cataract, the lens, which should be transparent, has become opaque,
+and the object of treatment is to get it out of the line of sight, to
+prevent it from obstructing, now that it can no longer assist sight.</p>
+
+<p>The operations used for this end may be classed under three heads:&mdash;</p>
+
+<p>1. <i>Operations for the removal of the lens out of the way without its
+removal from the eye.</i>&mdash;These used to be extensively practised under the
+name couching, and are of two kinds,&mdash;<i>Depression</i>, where the lens is
+simply pushed down from its place by a needle; <i>Reclination</i>, in which
+it is shoved backwards (turning on its transverse axis) as well as
+downwards. These are relics of old surgery, and very rarely practised by
+any oculists of eminence, as, though easy to perform, and with very
+flattering immediate results, the risks of chronic inflammation of the
+whole globe and injury to the retina are very great.</p>
+
+<p>2. <i>For solution.</i>&mdash;<span class="smcap">The Needle Operation</span>.&mdash;Suitable<span class='pagenum'><a name="Page_161" id="Page_161">{161}</a></span> (among other cases)
+especially in congenital cataracts in infants, and in cases of diabetic
+cataract.</p>
+
+<p>The principle of this operation is that the lens, once the capsule is
+freely opened in front and the aqueous humour admitted, is found rapidly
+to become absorbed and disappear, if the cataract has been a soft one.</p>
+
+<p><i>Operation.</i>&mdash;A needle with a lance-shaped head is to be used. It should
+be so made that the rounded shaft of the needle is just large enough to
+play freely in the wound made by the broader point, and yet not so small
+as to allow the aqueous humour to escape rapidly. The pupil has been
+dilated, the patient is lying on his back, and the globe is fixed by
+forceps attached to the conjunctiva of the inner side of the eye, and
+held by an assistant. The surgeon then enters the needle close to the
+sclerotic margin of the cornea, carries it fairly on in the anterior
+chamber, till the centre of the pupil is reached. He then, by bringing
+forward the handle, projects the point backwards against the anterior
+capsule, which he freely lacerates with the point and edge in several
+directions.</p>
+
+<p>In infants, where processes of repair go on very rapidly, the whole lens
+may be freely broken up. In diabetic cataract, or indeed in all cases of
+solution, where the patient is adolescent or adult, or the eye at all
+weak, only a small portion of the lens should be attacked at one
+sitting.</p>
+
+<p>The needle should then be withdrawn gradually and with great care, that
+the broad axis of the blade be in exactly the same position in which it
+entered, <i>i.e.</i> flat and parallel with the iris, lest the iris be
+wounded, entangled, or prolapsed.</p>
+
+<p>The eye is then to be closed for twenty-four hours; if there is much
+pain, atropia must be freely used.</p>
+
+<p><i>Varieties in the Operation.</i>&mdash;Some use two needles at once for breaking
+up the lens. Some surgeons prefer<span class='pagenum'><a name="Page_162" id="Page_162">{162}</a></span> to enter the needle through the
+sclerotic; this complicates the operation and renders it less certain,
+as the point of the needle is of course out of sight in its progress
+between the iris and the lens.</p>
+
+<p>Even in children this operation requires in most cases to be repeated at
+least once, while in adults it may be required at short intervals for
+many months.</p>
+
+<p>3. <i>By Extraction.</i>&mdash;In these operations the lens is at once removed
+from the eye&mdash;</p>
+
+<p>(1.) By linear, or perhaps, more correctly, rectilinear incision. This
+method is specially suited for cases of soft cataract.</p>
+
+<p><i>Operation.</i>&mdash;A fine spear-shaped needle is very cautiously introduced
+through the cornea, about a line from its outer margin, and the anterior
+capsule lacerated, and the lens broken up, great care being taken not to
+injure the posterior capsule. The pupil must then be kept freely
+dilated, the wound heals at once, and the aqueous humour reaccumulates.</p>
+
+<div class="figcenter" style="width: 400px;">
+<img src="images/162a.jpg" width="400" height="126" alt="Fig. xii." title="Fig. xii." />
+<span class="caption"><span class="smcap">Fig. xii.</span></span>
+</div>
+
+<div class="figcenter" style="width: 400px;">
+<img src="images/162b.jpg" width="400" height="125" alt="Fig. xiii." title="Fig. xiii." />
+<span class="caption"><span class="smcap">Fig. xiii.</span></span>
+</div>
+
+<p>From three to six days after this first operation, a linear incision
+(Fig. <span class="smcap">xii</span>.) is made in the outer side of the cornea by a straight stab
+from a double-edged knife, or rather spear. The size of the incision
+must vary with the size and consistence of the lens, and can be
+regulated<span class='pagenum'><a name="Page_163" id="Page_163">{163}</a></span> by the breadth of the knife and the distance to which it is
+entered. By careful withdrawal of the knife, in many cases a large
+portion of the soft lens can be removed along with it, and then what
+remains must be cautiously lifted out by a flat spoon introduced through
+the wound, and behind the remains of the lens.</p>
+
+<p>Care must be taken lest any of the lens substance remain in the wound;
+with this precaution the incision generally heals rapidly, and with much
+less risk of general inflammation of the ball than in the ordinary flap
+operation of extraction.</p>
+
+<div class="blockquot smlet"><p><span class="smcap">Extraction of Soft Cataract by Suction.</span>&mdash;Mr. T. P. Teale, of
+Leeds,<a name="FNanchor_87_87" id="FNanchor_87_87"></a><a href="#Footnote_87_87" class="fnanchor">[87]</a> has invented an instrument by which the removal of soft
+cataract is made more easy, through a linear incision by suction,
+applied through the medium of a hollow curette furnished with an
+india-rubber tube and mouth-piece.</p>
+
+<p>The curette is of the usual size, but is roofed in (instead of
+being merely grooved) to within one line of its extremity, thus
+forming a tube flattened above, but terminating in a small cup.
+This is screwed into an ordinary straight handle, which is hollow
+for a short distance, far enough to join with a second tube fixed
+at right angles to the handle, and into which the india-rubber pipe
+and mouth-piece, through which suction is to be made, is attached.
+In many cases it seems to serve its purpose extremely well.</p>
+
+<p>Certain points require attention:&mdash;1. That the puncture to admit
+the curette is large enough; 2. That its end be sufficiently
+rounded; 3. Its open end must be held in the area of the pupil, and
+not allowed to pass behind the iris, else there is great risk of
+the iris being drawn in. Among other advantages claimed by its
+inventor, the chief seems to be a more thorough removal of the lens
+than by the ordinary means, and consequently less risk of opaque
+deposit in the posterior capsule. </p></div>
+
+<p>(2.) <span class="smcap">Extraction by Flap.</span>&mdash;When properly performed in a suitable subject,
+and when free from accident, this operation is one of the most
+thoroughly beautiful and satisfactory in the whole domain of surgery;
+but it is difficult, and liable to many risks<span class='pagenum'><a name="Page_164" id="Page_164">{164}</a></span> which neither skill nor
+caution can completely guard against.</p>
+
+<p>It is required in many cases of hard cataract, which are amenable
+neither to solution nor linear extraction.</p>
+
+<p><i>Operation</i> must be considered in various stages:&mdash;</p>
+
+<p><i>a.</i> To make a flap of cornea large enough to permit of the removal of
+the entire lens without pressure or bruising. To make it of cornea only,
+to prevent the escape of the vitreous, and to avoid injury of the iris.</p>
+
+<p>The great difficulty in making the required section of the cornea is,
+that we are debarred from using scissors or any ordinary knife or
+scalpel in making it, for this reason, that the sawing movements
+required in all ordinary cutting are inadmissible here, as any
+withdrawal of the blade, however slight, would permit evacuation of the
+aqueous humour, and at once be followed by prolapse of the iris before
+the knife. Hence we are compelled to make the requisite flap by one
+steady push of a knife, which, too, must be of such a shape as in its
+entrance constantly to fill up the wound it makes. Very various shapes
+and sizes of knives have been proposed, the one called Beer's knife
+being the sort of model or common parent from which all the others are
+derived. It is triangular in shape, with a straight back, about 12-10ths
+of an inch in length, and 4-10ths broad at the base of the blade,
+tapering at a straight edge from its base to its point, and also
+diminishing in thickness to the point.</p>
+
+<p>Considerable difference of opinion exists as to the relative merits of
+an upper or lower section of the cornea. The general view at present
+seems to be that an upper section is to be preferred; but in cases where
+the surgeon is not ambidexterous, it is better that he should make the
+section which lies easiest to his hand than attempt an upper section in
+a less favourable position.</p>
+
+<p>The patient should be placed flat on his back, the lids should be gently
+opened, the upper one by the surgeon,<span class='pagenum'><a name="Page_165" id="Page_165">{165}</a></span> the lower one by his assistant,
+who is to press the lid downwards against the malar bone without
+exercising any pressure on the ball. The eye should be still further
+steadied by the conjunctiva and subjacent cellular tissue on the inner
+side being seized by a pair of catch-forceps, still with no downward
+pressure on the ball. The point of the knife must then be introduced
+about a line from the outer sclerotic margin of the transverse diameter
+of the cornea (Fig. <span class="smcap">xiii.</span>), the blade being held parallel with the
+fibres of the iris, pushed steadily across the anterior chamber, and
+protruded as nearly as possible at the corresponding spot at the inner
+side of the cornea. The aqueous humour should not escape till the
+section is completed. If it does, the iris is almost certainly projected
+forwards and entangled in the blade of the knife, a most annoying
+accident, and one which is not easily remedied. The books tell us of
+various man&#339;uvres by pressure or otherwise, by which the iris may be
+pushed back. Practically, however, if it has once occurred it is not
+easily saved from being cut. If a small portion only is involved, it is
+not of much consequence; if a large portion be in danger, it is
+sometimes necessary to withdraw the knife before the section is
+completed, and finish it with a probe-pointed, curved bistoury.</p>
+
+<p>If, however, the flap is safely finished, the lids should be gently
+allowed to close for a few seconds.</p>
+
+<p>On opening them again the surgeon must decide whether the corneal flap
+is sufficiently large to allow the lens to come out without force; if
+not, he must enlarge it either by the narrow probe-pointed "secondary
+knife" or by a pair of sharp scissors. Occasionally the lens, and even a
+little vitreous humour, may escape at once on the section being
+completed, but this is not to be desired.</p>
+
+<p><i>b.</i> <i>Laceration of the Capsule of the Lens.</i>&mdash;This is performed by
+insinuating a sharp curved needle under the corneal flap, avoiding the
+iris, and then tearing up the anterior capsule through the dilated
+pupil, the chief point<span class='pagenum'><a name="Page_166" id="Page_166">{166}</a></span> to be attended to being that the capsule be
+lacerated in its entire length.</p>
+
+<p><i>c.</i> <i>Removal of the Lens.</i>&mdash;This must be done with the most extreme
+caution and gentleness, lest the vitreous humour be also evacuated. The
+surgeon's object is to tilt the lens so as to turn it slightly on its
+transverse axis, and cause the edge nearest the section to rise out of
+the capsule and appear at the wound. This is best done by gentle
+pressure at the required spot by the back of the needle, or by a common
+probe. When the lens begins to protrude the pressure must be very,
+gentle, lest it be forced out suddenly and the vitreous follow it.</p>
+
+<p>Soft portions of the lens are apt to remain adherent to the wound in the
+cornea. These must be removed by scoop or probe.</p>
+
+<p><i>Varieties in the method of Flap Extraction.</i>&mdash;Jacobsen of K&ouml;nigsberg in
+every case gives chloroform. He always makes his flap in the boundary
+line of the cornea and the sclerotic, through a vascular structure, and
+he believes that union is on this account more rapid, and after
+extraction removes that portion of the iris which appears to have been
+most exposed to bruising during the exit of the lens.</p>
+
+<p>The operation of extraction may in many cases be either preceded or
+followed by iridectomy, as proposed by Mooren, Von Graefe, and others.
+The following operation seems to diminish the risks to a very great
+extent:&mdash;</p>
+
+<div class="blockquot smlet"><p><i>Professor Von Graefe's Operation.</i>&mdash;The lids are separated by a
+speculum, and the eyeball is drawn down by forceps placed
+immediately below the cornea. The point of a small knife, of which
+the edge is directed upwards, is inserted at a point fully half a
+line from the margin of the cornea near its upper part, so as to
+enter the anterior chamber as peripherally as possible. The point
+should not be directed at first towards the spot for
+counterpuncture; nor till the knife has advanced fully three and a
+half lines within the visible portion of the anterior chamber,
+should the handle be lowered and the point directed so as to make
+a<span class='pagenum'><a name="Page_167" id="Page_167">{167}</a></span> symmetrical counterpuncture, which will give the external wound
+a length of four and a half or five lines. As soon as the
+resistance to the point is felt to be overcome, showing that the
+counterpuncture is effected, the knife must at once be turned
+forward, so that its back is directed almost to the centre of the
+ideal sphere of the cornea, whether the conjunctiva is transfixed
+or not, and the scleral border is divided by boldly pushing the
+knife onwards and again drawing it backwards. This portion of the
+operation is concluded by the formation of a conjunctival flap a
+line and a half or two lines in length. A section thus made is
+almost perpendicular to the cornea, a circumstance much
+facilitating the passage of the lens, and the line of incision is
+nearly straight, so that the wound does not gape. The iris should
+be excised to the very end of the wound, and the capsule most
+freely opened by a V-shaped laceration. Any lens, even the hardest,
+may then be removed without the introduction of an instrument into
+the eye, but Von Graefe's experience shows it to be advisable to
+assist the evacuation by the hook in about one case in eight. In a
+certain number of cases the lens will escape without difficulty
+when the operator presses on the posterior lip of the wound,
+especially when the back of the spoon is made to glide along the
+sclera; should this not occur, Von Graefe uses a peculiar blunt
+hook, or occasionally, though rarely, a spoon. A compressing
+bandage is applied, and replaced at intervals.<a name="FNanchor_88_88" id="FNanchor_88_88"></a><a href="#Footnote_88_88" class="fnanchor">[88]</a> </p></div>
+
+<p>We are recommended to perform it in two sets of cases:&mdash;</p>
+
+<p>1. Those in which the eye is known to be unhealthy and liable to
+inflammations, specially of iris, retina, or choroid. In cases where the
+patient has already lost an eye, Von Graefe thinks iridectomy should
+always precede extraction. In the above, then, it is a precautionary
+measure, and, if convenient, should be performed three, four, or even
+six weeks before the extraction.</p>
+
+<p>2. It is recommended to be performed at the same time as extraction in
+all cases in which the operation has presented any special difficulties,
+or has not gone smoothly, <i>e.g.</i> in cases where the lens has required
+much force to<span class='pagenum'><a name="Page_168" id="Page_168">{168}</a></span> expel it, either from the flap of cornea being too small,
+or from adhesions between the lens and capsule; or, again, in cases in
+which there is a tendency to prolapse of the iris, in which any of the
+cortical substance has been necessarily left behind, or in which old
+adhesions had existed between the iris and capsule, or between the
+cornea and iris.</p>
+
+
+<p class="gap"><span class="smcap">Operations for Artificial Pupil.</span>&mdash;The cases are by no means unfrequent
+in which it is necessary to remove or destroy a portion of the iris to
+admit light to the retina. In cases of excessive prolapse of the iris
+after extraction of the lens, where the iris has formed adhesions to the
+wound, and still more frequently in cases where central opacities of the
+cornea have fairly occluded the natural pupil, the only chance for
+vision is to enlarge the old one, or make a new pupil by removal of the
+iris.</p>
+
+<p>Very various operations have been proposed, and exceedingly numerous and
+complicated instruments invented for this purpose. We can notice here
+only one or two of the most approved procedures:&mdash;</p>
+
+<p>1. <i>Incision</i> is the simplest.</p>
+
+<p>This is practicable and effectual only in cases where the iris is so far
+healthy as still to retain its contractile power, and so far free from
+adhesions as to be able to make use of it. The best example of such a
+case is that of a cataract, in which after extraction a prolapse of the
+iris has occurred to such an extent as to obliterate the pupil, and
+where, at the same time, the only adhesions are to the wound, none to
+the cornea.</p>
+
+<p><i>Operation.</i>&mdash;A double-edged needle is introduced through the cornea
+near its margin; on arriving at the place where the pupil ought to be,
+one edge is drawn against the iris, and divides it transversely, if
+possible, without injuring the lens; the fibres of the iris start back,
+contract, so that a sufficiently large central pupil may be obtained.<span class='pagenum'><a name="Page_169" id="Page_169">{169}</a></span></p>
+
+<p>2. <i>Excision.</i>&mdash;In the far more frequent cases in which there exist
+adhesions between iris and cornea, or iris and anterior capsule,
+incision is not sufficient, and it is necessary to excise a portion of
+the iris.</p>
+
+<p>The simplest and safest operation is the following:&mdash;</p>
+
+<p>The patient recumbent, and the lids held apart by a speculum, the
+eyeball should be steadied by the forceps of an assistant. A broad
+cutting needle should then be introduced at the lower or outer edge of
+the corneal margin. This must be very gently withdrawn so as to retain
+as much aqueous humour as possible. Into the wound thus made the surgeon
+must introduce the blunt hook (known as Tyrrell's) at first with its
+point forwards, then, on arriving opposite the edge of the pupil, which
+it is intended to enlarge or replace, with its point turned backwards,
+so as to hook over the edge of the iris and thus drag on it. Once the
+hook has fairly got hold, it must again be rotated forwards, and
+withdrawn in the same direction as it was put in. The iris thus pulled
+out of the wound is to be cut off with a pair of fine scissors, so as to
+remove a sufficient amount to make a new pupil of the required size.</p>
+
+<p>But in those cases in which the whole or greater part of the pupillary
+margin is adherent, the blunt hook will not do, because there exists no
+edge round which to hook it. One of two plans is generally chosen to
+remedy this:&mdash;</p>
+
+<p>(1.) A free incision made with a double-edged needle; through this a
+pair of canula forceps is introduced, with which a portion of iris is
+seized and dragged to the external wound; it can then either be cut off
+or tied (see <i>Iridesis</i>); or,</p>
+
+<p>(2.) A previous attempt may be made to free a portion to form an edge to
+catch hold of, either by incision or by <i>Corelysis</i> (<i>q.v.</i>)</p>
+
+<p class="gap"><span class="smcap">Iridesis.</span>&mdash;<i>Critchett's Operation of Ligature.</i><a name="FNanchor_89_89" id="FNanchor_89_89"></a><a href="#Footnote_89_89" class="fnanchor">[89]</a>&mdash;Patient<span class='pagenum'><a name="Page_170" id="Page_170">{170}</a></span> being put
+under chloroform, the ball is fixed by the wire speculum, and also by a
+fold of conjunctiva being seized by forceps. An opening is then made
+with a broad needle through the margin of the cornea, <i>close</i> to the
+sclerotic, just large enough to admit the canula forceps, with which a
+small portion of iris close to its ciliary attachment is seized and
+drawn out; a piece of fine floss silk, previously tied in a small loop
+round the canula forceps, is slipped down and carefully tightened round
+the prolapsed portion. This speedily shrinks, and the loop may generally
+be removed about the second day. The chief advantage claimed for this
+method is the ease with which the size of the new pupil can be
+regulated. It is also suitable in cases of conical cornea, where it is
+wished to change the form of the pupil into a narrow slit.</p>
+
+<p><i>N.B.</i>&mdash;The ends of the ligature must be left sufficiently long to avoid
+any risk of their being drawn out of sight into the substance of the
+cornea, or even into the ball, by retraction of the fibres of the iris.</p>
+
+
+<p class="gap"><span class="smcap">Corelysis</span>.&mdash;<i>Freeing of the Pupil.</i>&mdash;An operative procedure for
+separating posterior adhesions of the iris to the lens. In it the
+surgeon hopes to act, not on the iris, as in the operations for
+artificial pupil, but only on the bands of false membrane which distort
+the pupil.</p>
+
+<p>The operation is briefly as follows:&mdash;The eye being firmly held by a
+wire speculum, and forceps pinching up the conjunctiva, a broad needle
+is passed rapidly through the cornea at a point which may give easy
+access to the adhesion to be torn through. This point is generally at
+the opposite margin of the irregular pupil, so that the needle may pass
+through the cornea in front of the one side of the iris, then through
+the orifice of the pupil, so as to reach the back of the other side. The
+needle is withdrawn gradually, so as to lose as little of<span class='pagenum'><a name="Page_171" id="Page_171">{171}</a></span> the aqueous
+humour as possible, and then the spatula hook, called after the inventor
+of the operation, Mr. Streatfeild, is introduced. It is used first as a
+spatula, that is, with its blunt, though polished edge, to separate the
+adhesions, and if this is unsuccessful, as a hook (<span class="smcap">Fig. xiv.</span>), so as to
+catch and tear them. In cases which resist the instrument used in both
+of these ways, Mr. Streatfeild has used very fine canula-scissors to cut
+the adhesions.<a name="FNanchor_90_90" id="FNanchor_90_90"></a><a href="#Footnote_90_90" class="fnanchor">[90]</a> Such a further complication of the operation
+practically alters its character into an operation for artificial pupil,
+<i>q.v.</i></p>
+
+<div class="figright" style="width: 200px;">
+<img src="images/171.jpg" width="200" height="143" alt="Fig. xiv." title="Fig. xiv." />
+<span class="caption"><span class="smcap">Fig. xiv.</span>
+<a name="FNanchor_91_91" id="FNanchor_91_91"></a><a href="#Footnote_91_91" class="fnanchor">[91]</a></span>
+</div>
+
+
+<p class="gap"><span class="smcap">Iridectomy.</span>&mdash;In cases of acute glaucoma, irido-choroiditis, and all deep
+inflammations of the eye in which the ocular tension is increased, also
+in certain cases of flap extraction already alluded to, the operation of
+iridectomy as originally proposed by Von Graefe will be found of use.</p>
+
+<p><i>Operation.</i>&mdash;The patient recumbent, and the eye absolutely fixed by
+speculum and forceps, a linear incision, varying in length from
+one-sixth to one-fourth of an inch, is made just at the margin of the
+cornea. The point of election is the upper pole of the cornea. The lens
+must not be wounded. The best instrument for making the section is an
+ordinary linear extraction knife, bent at an angle to admit of its being
+introduced from above. The iris will protrude through the wound, or, if
+adherent, must be drawn out by forceps, and then is to be cut off with
+scissors. The operation is rarely successful, unless a third, or at
+least a fourth, of the iris be removed.<span class='pagenum'><a name="Page_172" id="Page_172">{172}</a></span></p>
+
+
+<p class="gap"><span class="smcap">Excision of a Staphylomatous Cornea.</span>&mdash;There are certain cases in which
+the whole or greater part of the cornea bulges forward in a great blue
+projecting tumour. It is very ugly as it protrudes between the lids and
+prevents their closure; besides this, from its exposure it frequently
+inflames, even ulcerates, and has a most injurious effect on the other
+eye. In the cases suitable for operation vision is completely gone,
+without hope of its restoration by any operative procedure.</p>
+
+<p>The best thing for the patient is to have just enough of the staphyloma
+removed to enable the remains of the eyeball to form a good stump for an
+artificial eye. Various means have been suggested for doing this,
+varying in extent and severity from a mere shaving off the apex of the
+staphyloma to excision of the whole eyeball.</p>
+
+<p>By far the best method of operating is the one proposed and practised by
+Mr. Critchett.</p>
+
+<table summary="figdob">
+<tr><td>
+<div class="center ill">
+<img src="images/172a.jpg" width="400" height="239" alt="Fig. xv." title="Fig. xv." />
+<br/><span class="caption"><span class="smcap">Fig. xv.</span>
+<a name="FNanchor_92_92" id="FNanchor_92_92"></a><a href="#Footnote_92_92" class="fnanchor">[92]</a></span>
+</div>
+</td><td>
+<div class="center ill">
+<img src="images/172b.jpg" width="200" height="148" alt="Fig. xvi." title="Fig. xvi." />
+<br/><span class="caption"><span class="smcap">Fig. xvi.</span>
+<a name="FNanchor_93_93" id="FNanchor_93_93"></a><a href="#Footnote_93_93" class="fnanchor">[93]</a></span>
+</div>
+</td></tr>
+</table>
+
+
+<p>The object of it is to remove an elliptical portion of the front of the
+staphyloma, or the whole staphyloma, when it is possible, and at the
+same time to prevent as far as possible the escape of the vitreous.<span class='pagenum'><a name="Page_173" id="Page_173">{173}</a></span></p>
+
+<p><i>Operation.</i>&mdash;Three, four, or five small curved needles armed with
+thread are passed through the staphyloma from above downwards, being
+each entered a little above the line of the intended upper incision, and
+brought out a little below the line of the intended lower one (Fig. <span class="smcap">xv.</span>)</p>
+
+<p>To remove the included elliptical portion, Mr. Critchett pierces the
+sclerotic with a Beer's knife, just in front of the tendinous insertion
+of the external rectus. Through this incision a pair of probe-pointed
+scissors is introduced, and the piece cut just within the points of the
+needles. On the removal, the needles, which have retained the vitreous
+by their pressure, are drawn through and the threads cautiously tied.</p>
+
+<p>Union by first intention very often occurs, and an excellent stump is
+left with a narrow depressed transverse cicatrix<a name="FNanchor_94_94" id="FNanchor_94_94"></a><a href="#Footnote_94_94" class="fnanchor">[94]</a> (Fig. <span class="smcap">xvi.</span>)</p>
+
+
+<p class="gap"><span class="smcap">Extirpation of the Eyeball.</span>&mdash;1. <i>Of the Eyeball only.</i>&mdash;A circular
+incision should be made with curved scissors through the conjunctiva, a
+little beyond the corneal margin, then, beginning with the external
+rectus, muscle after muscle should be raised with the forceps, and
+divided, after which the optic nerve is cut through with the scissors. A
+slight preliminary extension outwards of the optic commissure will
+facilitate the dissection, and must be secured with metallic sutures;
+any vessels should be tied, and the orbit filled up with a light
+compress of charpie secured with a bandage.</p>
+
+<p>2. <i>Of the contents of the Orbit.</i>&mdash;This may be required for malignant
+disease, but with a very poor prognosis. The optic commissure should be
+freely divided, and then, by bold strokes of curved scissors, or curved
+probe-pointed bistoury, the orbit may be fairly emptied by scooping out
+its contents. Even the periosteum may require to be scraped off, and the
+optic nerve<span class='pagenum'><a name="Page_174" id="Page_174">{174}</a></span> divided as far back as possible. The h&aelig;morrhage may be
+pretty smart, but can generally be easily checked by compresses; if
+necessary, these can be soaked in the solution of the perchloride of
+iron.</p>
+
+<p>The author has done this operation many times, in cases extensive and of
+old standing, for malignant disease, melanotic and encephaloid. All have
+recovered, and in no instance has there been any trouble in stopping the
+bleeding.</p>
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_175" id="Page_175">{175}</a></span></p>
+
+<h2><a name="CHAPTER_VI" id="CHAPTER_VI"></a>CHAPTER VI.</h2>
+
+<h3>OPERATIONS ON THE NOSE AND LIPS.</h3>
+
+
+<p class="gap"><span class="smcap">Rhinoplastic Operations.</span>&mdash;The operations for the restoration or repair
+of lost or mutilated noses are so various, and the minuteness of detail
+necessary for full description of them so great, that a complete account
+in a manual such as this is impossible; a brief notice of some of the
+most important varieties of the operation is all that can be given.</p>
+
+<p><i>Principles.</i>&mdash;1. It is necessary in every case that a suitable edge be
+prepared on which to fix the flap of skin, however obtained. To be
+suitable, this edge, should be (<i>a</i>) made in healthy skin, not in old or
+weak cicatrices; hence no trace of the original disease should be left;
+(<i>b</i>) it should be made thoroughly raw, by the removal of an appreciable
+amount of its edge; it should be pared, not merely scraped.</p>
+
+<p>2. It is useless to attempt to restore a nose unless the patient is in
+good general health, well nourished, and perfectly free from all remains
+of disease in the nose or its neighbourhood. The flaps which are to form
+the new nose may be obtained either from (1.) the cheeks; (2.) the
+forehead; (3.) a distant part either of the patient or of another
+person.</p>
+
+<p>(1.) <i>From the Cheeks.</i>&mdash;When the cheeks are healthy, and specially if
+they are tolerably full and lax, the flaps from the cheeks produce much
+the most satisfactory result. As performed by Mr. Syme, the operation<span class='pagenum'><a name="Page_176" id="Page_176">{176}</a></span>
+consists in the shaping of two equal flaps (<span class="smcap">a, a</span>) from the skin of the
+cheek at each side, having the attachment above. A site for each flap is
+formed by the careful paring away of the whole thickness of the edge of
+the cavity of the lost organ (see Fig. <span class="smcap">xvii</span>.)</p>
+
+<div class="figleft" style="width: 200px;">
+<img src="images/176.jpg" width="200" height="169" alt="Fig. xvii." title="Fig. xvii." />
+<span class="caption"><span class="smcap">Fig. xvii.</span>
+<a name="FNanchor_95_95" id="FNanchor_95_95"></a><a href="#Footnote_95_95" class="fnanchor">[95]</a></span>
+</div>
+
+<p>The flaps are then raised from their attachments to the upper jaw-bone,
+and approximated in the middle line by several points of metallic suture
+and the outer edges stitched to the raw surface on each side at a proper
+distance from the nasal orifice. If any septum remains of the old nose,
+it may be made very useful as a fixed point, a straight needle being
+thrust through one flap close to its outer lower edge, then through the
+septum, and out at a corresponding point of the other flap. The edges of
+the wound left in the cheek at each side can generally be, to a certain
+extent, approximated by silver stitches (<span class="smcap">b, b</span>) and the triangular
+portion (<span class="smcap">c, c</span>), which is necessarily left to heal by granulation, proves
+an advantage, as by its depression it enhances the apparent height and
+prominence of the new organ. The cavity should be very gently distended
+with lint, and may be supported by the blades of a small pair of
+forceps, applied so as to embrace the nose.</p>
+
+<p>(2.) <i>From the Forehead.</i>&mdash;The Indian operation may be used as a last
+resource, in cases where, from disease, the cheeks also have suffered,
+and are not to be trusted to for flaps.</p>
+
+<p><i>Operation.</i>&mdash;1. It should be decided as to the shape and size of the
+portion of skin necessary, by fitting on pieces of soft leather or
+moulding wax. To allow for<span class='pagenum'><a name="Page_177" id="Page_177">{177}</a></span> shrinking, the flap should be made at least
+one-third larger than is at first apparently necessary. The exact
+boundaries of the flap to be raised should then be marked out on the
+forehead by lightly pencilling it with nitrate of silver, the mark from
+which is not effaced by blood, as is sure to be the case with an ink
+line. Various shapes have been proposed for the flap varying in length
+of neck, in the shape of the angles, and especially in the arrangements
+made for the formation of a columna. Some (as Liston) prefer afterwards
+to provide for the columns separately, by a flap raised from the upper
+lip in a subsequent operation. The flap is then to be raised from the
+forehead, care being taken not to injure the periosteum. The incision is
+to be carried lower down on the side (generally the left), to which the
+flap is to be twisted. The flap is then to be brought round (Fig.
+<span class="smcap">xviii</span>.) and carefully fitted on to the edges previously prepared for its
+reception. The neck must be left as lax as possible, lest by tight
+twisting the supply of blood be cut off, and the flaps thus deprived of
+nourishment. Both silk and metallic sutures are recommended. Hamilton of
+Dublin,<a name="FNanchor_96_96" id="FNanchor_96_96"></a><a href="#Footnote_96_96" class="fnanchor">[96]</a> after a large experience of both, prefers the former.</p>
+
+<div class="figright" style="width: 279px;">
+<img src="images/177.jpg" width="279" height="400" alt="Fig. xviii." title="Fig. xviii." />
+<span class="caption"><span class="smcap">Fig. xviii.</span>
+<a name="FNanchor_97_97" id="FNanchor_97_97"></a><a href="#Footnote_97_97" class="fnanchor">[97]</a></span>
+</div>
+
+<p>There are various risks; sloughing of the whole flap at once, shrinking
+of it after weeks or even months;<span class='pagenum'><a name="Page_178" id="Page_178">{178}</a></span> certain inevitable drawbacks, as the
+cicatrix on the forehead, the very various and ludicrous changes of
+colour to which the new organ is subject,&mdash;these cannot be remedied by
+further operation. Two points generally require a second use of the
+knife a few weeks after:&mdash;(1.) The neck of the flap is sure to be
+redundant and prominent, but can be pared. (2.) The columna almost
+always requires improving, and, in Liston's method, to be made. He pared
+the inner surface of the apex of the nose, and then raised a central
+flap of the lip in the middle line, about a quarter of an inch broad,
+and extending from the remains of the old septum to the free border,
+raising it from the gum, and stitched the free end of it to the prepared
+apex, bringing together the two divided portions of the lip by ordinary
+harelip sutures. Tho columna, if redundant, could be shaved down, and it
+was found that the mucous surface very quickly became like skin on
+exposure.</p>
+
+<p>For other points with regard to the operation, reference may be made to
+the works of Liston and Skey, and Hamilton's monograph, referred to
+above.</p>
+
+<p><i>Note.</i>&mdash;The tongue and groove suture proposed by Professor Pancoast,
+and recommended by Professor Gross, is said to be specially suitable for
+such plastic operations. It is very complicated, as it requires one edge
+to be bevelled to a wedge shape, the other being grooved to include the
+wedge, thus opposing four raw surfaces, which are retained in contact by
+being transfixed by fine silk sutures.</p>
+
+<p>(3.) There are certain cases in which neither cheeks nor forehead are
+available for flaps, and yet the patients press very much for some
+operation. If they have patience and determination, the Taliacotian or
+Italian operation may be attempted.</p>
+
+<p>Without going into detail, the principle of it is as follows:&mdash;1. A
+piece of skin of suitable size was marked out over the left biceps, and
+defined by two longitudinal<span class='pagenum'><a name="Page_179" id="Page_179">{179}</a></span> incisions, and raised from the subcutaneous
+cellular tissue, thus being left attached by its two ends only; a piece
+of linen was pulled below it. 2. After a few days the upper end was also
+divided, and the flap thus contracted. In a few days more the sides of
+the old nose were made raw, and the upper free surface of the flap also
+made raw and stitched to them, the arm being fastened up by a most
+elaborate series of bandages. 3. After a fortnight in this position, the
+last attachment of the flap to the arm was severed, and the new nose
+could then be modelled at pleasure.</p>
+
+<p>The literature of the subject is exceedingly curious, especially the
+cases in which the new material was obtained from an accommodating
+friend or servant.</p>
+
+
+<p class="gap"><span class="smcap">Operative Treatment of Lupus.</span>&mdash;We may here notice a mode of treatment
+which has admirable results. The patient being put deeply under an
+an&aelig;sthetic, the surgeon with a sharp spoon carefully pares away all the
+diseased tissues, and then destroys the base either by nitric acid or a
+strong solution of chloride of zinc. The author has done this in a great
+number of cases with excellent effect.</p>
+
+
+<p class="gap"><span class="smcap">Nasal Polypi,</span> <i>Removal of.</i>&mdash;Of these there are different kinds.</p>
+
+<p>1. <span class="smcap">Ordinary Mucous Polypi.</span>&mdash;These grow from the spongy bones, generally
+the superior one, are non-malignant in their character, soft and
+vascular, often fill up the whole of both nasal cavities, and frequently
+hang down behind into the pharynx. The practical point to remember is
+that, however large and numerous they may be, they <i>invariably</i> have
+their origin from a comparatively limited spot, the edge of the spongy
+bone, and <i>always</i> hang from a narrow neck. Hence the treatment is easy
+and satisfactory, if the neck be attacked, and not the body of the
+tumour.<span class='pagenum'><a name="Page_180" id="Page_180">{180}</a></span></p>
+
+<p>Slightly curved, narrow-bladed forceps should be passed along by the
+side of the superior spongy bone, with their blades open, till the neck
+of the polypus is seized. Holding it firmly, the forceps should then be
+slowly twisted round till the neck is destroyed and the polypus
+detached. This should be repeated till the patient can blow freely
+through both nostrils. If attempts are made to seize the body of the
+polypus, it will break down under the forceps, bleed, and give much
+trouble.</p>
+
+<p>2. <span class="smcap">The Fibrous Polypus.</span>&mdash;This form is fortunately much more rare than
+the other. It is almost invariably single, is attached to the posterior
+margin of the nares by a narrow but very strong root, is extremely firm
+in consistence, may grow to a large size so as to obstruct both
+nostrils, generally gives rise to severe and frequent h&aelig;morrhages. The
+h&aelig;morrhage <i>during</i> any attempt to remove it is generally of the most
+severe character, but ceases <i>immediately</i> on its complete detachment.</p>
+
+<p>We owe nearly all that we do know about the treatment of this form of
+polypus to Mr. Syme. His method is&mdash;By the ordinary polypus forceps
+described already, he seized the tumour through the nostril, and then
+with the fore and middle fingers of the left hand introduced behind the
+soft palate, he attacked the point of attachment, and by his nails,
+aided by the forceps, detached it from its narrow base.<a name="FNanchor_98_98" id="FNanchor_98_98"></a><a href="#Footnote_98_98" class="fnanchor">[98]</a></p>
+
+<p>3. <span class="smcap">Malignant Polypi</span> should not be meddled with unless it is absolutely
+certain that the whole of the bone from which they grow can be removed
+also. This is very rarely the case. (See <i>Excision of Superior
+Maxilla</i>.)</p>
+
+
+<p class="gap"><span class="smcap">Operations on the Lips.</span>&mdash;1. Epithelial cancers of the lower lip are very
+frequent, and require removal.<span class='pagenum'><a name="Page_181" id="Page_181">{181}</a></span></p>
+
+<div class="figright" style="width: 350px;">
+<img src="images/181a.jpg" width="350" height="217" alt="Fig. xix." title="Fig. xix." />
+<span class="caption"><span class="smcap">Fig. xix.</span>
+<a name="FNanchor_99_99" id="FNanchor_99_99"></a><a href="#Footnote_99_99" class="fnanchor">[99]</a></span>
+</div>
+
+<p>If the tumour or ulcer is small, and involves a considerable thickness
+of the lip, it is most easily removed by a V-shaped incision
+(Fig. <span class="smcap">xix. A B A</span>). Its shape permits the most accurate apposition of the
+cut surfaces; and if the lips are full and the tumour small, very slight
+trace of the operation will remain.</p>
+
+<p>Again, if the tumour be more extensive, involving a large portion of the
+prolabium, and yet not extending deeply into the substance of the lip,
+it may be very easily removed by a pair of curved scissors, applied in
+the direction shown in the diagram (Fig. <span class="smcap">xx. A B</span>). The skin must then be
+stitched to the mucous membrane by numerous points of interrupted
+suture.</p>
+
+<p>But if the tumour be at once extensive and deep, mere removal is not
+sufficient, but some provision must be made for supplying the blank left
+by the operation.</p>
+
+<div class="figright" style="width: 350px;">
+<img src="images/181b.jpg" width="350" height="213" alt="Fig. xx." title="Fig. xx." />
+<span class="caption"><span class="smcap">Fig. xx.</span>
+<a name="FNanchor_100_100" id="FNanchor_100_100"></a><a href="#Footnote_100_100" class="fnanchor">[100]</a></span>
+</div>
+
+<p>In cases where a third, or even a half, of the lower lip has thus been
+removed, it may be found sufficient freely to dissect what is left of
+the lip from the gums, and thus approximate the cut surfaces in the
+middle line.</p>
+
+<p>This alone, however, would so much diminish the buccal orifice, and
+twist its corners, as to cause great deformity. The addition of an
+incision horizontally outwards, at one or both angles of the mouth,
+will<span class='pagenum'><a name="Page_182" id="Page_182">{182}</a></span> do away with such risk, and allow the surfaces to come together
+without puckering; while by stitching the skin and mucous membrane
+together in the course of these horizontal incisions, we can increase
+the size of the buccal orifice almost <i>ad libitum</i>.</p>
+
+<p>Lastly, when the lower lip has been entirely removed, it is still
+possible to supply its place in the following manner, which was devised
+by Mr. Syme: The tumour being fairly isolated by a V-shaped
+incision (Fig. <span class="smcap">xxi.</span>) <span class="smcap">C A C</span> including the whole thickness of the lip,
+each of the incisions should be prolonged downwards and outwards, as
+shown by the dotted lines <span class="smcap">A D</span>, <span class="smcap">A D</span>. The flaps thus marked out must be
+separated from the bone, brought upwards, and approximated in the middle
+line. Possibly it may be necessary still further to enlarge the buccal
+orifice by short lateral incisions, <span class="smcap">C C</span>. Whether these are required<span class='pagenum'><a name="Page_183" id="Page_183">{183}</a></span> or
+not, silk stitches are to be introduced to unite the skin and mucous
+membrane along the lines <span class="smcap">a c</span>. The gap left between <span class="smcap">D B D</span> must be left to
+granulate, but in most cases may be very much diminished in size by
+additional sutures at its outer corners, near <span class="smcap">d</span>. The granulating surface
+<span class="smcap">E E</span> very rapidly heals up, leaving a dimple on each side, which rather
+improves the appearance, by adding to the prominence of the chin, <span class="smcap">b</span>.</p>
+
+<div class="figleft" style="width: 350px;">
+<img src="images/182.jpg" width="350" height="292" alt="Fig. xxi." title="Fig. xxi." />
+<span class="caption"><span class="smcap">Fig. xxi.</span>
+<a name="FNanchor_101_101" id="FNanchor_101_101"></a><a href="#Footnote_101_101" class="fnanchor">[101]</a></span>
+</div>
+
+<div class="figleft" style="width: 350px;">
+<img src="images/182b.jpg" width="350" height="296" alt="Fig. xxii." title="Fig. xxii." />
+<span class="caption"><span class="smcap">Fig. xxii.</span>
+<a name="FNanchor_102_102" id="FNanchor_102_102"></a><a href="#Footnote_102_102" class="fnanchor">[102]</a></span>
+</div>
+
+<p><span class="smcap">The Operations for Harelip</span>, though all conducted on the same general
+principles, vary considerably in extent required according to the
+position and size of the fissure or fissures to be remedied.</p>
+
+<p>1. <i>For Single Harelip.</i>&mdash;Where the fissure extends only from the
+prolabium up to the attachment of the lip to the gums: this is very
+easily remedied, the chief risk being lest the surgeon should not remove
+enough of the edges of the fissure.</p>
+
+<p><i>Operation.</i>&mdash;Bleeding being controlled by an assistant, the surgeon
+fixes a pair of spring artery forceps into the mucous membrane and skin
+at the salient angle at each side of the fissure. Taking one of these in
+his left hand, he puts the edge to be pared on the stretch, and then
+with a sharp narrow straight bistoury he transfixes the lip at the point
+just beyond the upper angle of the fissure, and cuts outwards, being
+careful to remove the whole thinner part of the lip, and to leave the
+edge rather concave than convex. If left convex, or even quite straight,
+there is a risk that, after union has taken place, an angle remain
+showing the position of the cleft. The same is then to be done on the
+other side. The bleeding is then to be controlled by twisting the larger
+vessels, and if oozing still continues from the smaller ones, a pad of
+lint should be placed in the wound, and a few minutes' delay given, as,
+to facilitate immediate union, it is of the greatest importance that all
+h&aelig;morrhage should have ceased before the edges are brought together.<span class='pagenum'><a name="Page_184" id="Page_184">{184}</a></span></p>
+
+<p>When the bleeding has ceased, the edges should be approximated by two or
+more points of interrupted metallic suture inserted very deeply through
+the tissues, and taking a good hold of the edges of the wound. If the
+edges do not fit accurately, one or two horse-hair sutures will help.
+Some surgeons still prefer the old harelip needles secured by a
+figure-of-eight suture. A silk suture inserted through the prolabium is
+of great advantage, as it keeps the inner surface of the wound closed,
+which without it is very apt to be kept open by the pressure of the
+teeth or gums, and in infants by the movements of the tip of the tongue.</p>
+
+<div class="blockquot smlet"><p>Various methods have been devised to utilise, if possible, the
+portion of the edge of the lip which is separated during the
+operation of refreshing the edges, for the purpose of filling up
+the sort of cleft or gap which is apt to be noticed at the edge of
+the prolabium. The most ingenious and simplest of these is that
+proposed by M. Nelaton, for use in cases where the fissure does not
+extend so far up as the nose. It consists in leaving the two
+portions which are pared off (Fig. <span class="smcap">xxiii.</span>) the sides of the cleft
+attached to each other as well as to the free edge of the lip, then
+pulling them down, so as to bring their bleeding surfaces into
+apposition, and make a diamond-shaped wound instead of a triangular
+cleft (Fig. <span class="smcap">xxiv.</span>) When brought together by sutures a projection is
+left at the edge of the lip; this, in most cases, disappears; if it
+does not, it can easily be pared down. </p></div>
+
+<table summary="figdob">
+<tr><td>
+<div class="center ill">
+<img src="images/184a.jpg" width="200" height="163" alt="Fig. xxiii." title="Fig. xxiii." />
+<br/><span class="caption"><span class="smcap">Fig. xxiii.</span>
+<a name="FNanchor_103_103" id="FNanchor_103_103"></a><a href="#Footnote_103_103" class="fnanchor">[103]</a></span>
+</div>
+</td><td>
+<div class="center ill">
+<img src="images/184b.jpg" width="220" height="206" alt="Fig. xxiv." title="Fig. xxiv." />
+<br/><span class="caption"><span class="smcap">Fig. xxiv.</span>
+<a name="FNanchor_104_104" id="FNanchor_104_104"></a><a href="#Footnote_104_104" class="fnanchor">[104]</a></span>
+</div>
+</td></tr>
+</table>
+
+<p><span class='pagenum'><a name="Page_185" id="Page_185">{185}</a></span></p>
+
+<p>2. When the fissure, though single, extends upwards into the nose, the
+operation is more difficult, and the result frequently less
+satisfactory. The first thing to be done is to separate the lips from
+the gums, so as to make them more freely mobile. The whole edges of the
+cleft require refreshing.</p>
+
+<p>3. <i>Double Harelip</i>, without bony deformity, and where the intervening
+portion of the skin is vertical, does not project, and can be made
+useful for the new lip. Such cases are not very common, but when they do
+occur the question arises, How are they to be managed&mdash;in two separate
+operations or at once? I believe, in every case, at once. The central
+wedge-shaped portion is not large enough to extend downwards as far as
+the prolabium, but still should not be removed altogether, as it may be
+of great use, especially in bearing the columna nasi, and allowing its
+full development. The edges should be pared in the same way, and to the
+same extent as in single harelip, with the addition that the intervening
+portion should have its edges completely removed, and be left in the
+form of a wedge, with its apex downwards. The highest suture should be
+passed through first one side, then the base of the wedge, and then the
+other side; the second one through both, and the apex of the wedge; and
+a third should unite the prolabium, not including the wedge.</p>
+
+<div class="figright" style="width: 150px;">
+<img src="images/185.jpg" width="150" height="129" alt="Fig. xxv." title="Fig. xxv." />
+<span class="caption"><span class="smcap">Fig. xxv.</span>
+<a name="FNanchor_105_105" id="FNanchor_105_105"></a><a href="#Footnote_105_105" class="fnanchor">[105]</a></span>
+</div>
+
+<p>4. <i>Double Harelip</i> combined with fissures of the hard palate, and
+projection of a central bone. This is the analogue of the
+inter-maxillary bone in the lower animals, and bears the two middle
+incisor teeth, and projects very variously in different cases. In some
+it projects horizontally forwards in the most<span class='pagenum'><a name="Page_186" id="Page_186">{186}</a></span> hideous manner, in others
+it lies at an angle more or less oblique; in very few does it maintain
+its proper position; when projecting forwards, and as the teeth also
+share in its projection, it entirely prevents approximation of the edges
+of the fissures by operation, so it must first be dealt with in one of
+two ways, either&mdash;</p>
+
+<div class="figleft" style="width: 200px;">
+<img src="images/186.jpg" width="200" height="123" alt="Fig. xxvi." title="Fig. xxvi." />
+<span class="caption"><span class="smcap">Fig. xxvi.</span>
+<a name="FNanchor_106_106" id="FNanchor_106_106"></a><a href="#Footnote_106_106" class="fnanchor">[106]</a></span>
+</div>
+
+<p>(1.) It may be at once removed with bone-pliers, the piece of skin over
+it being saved. This is the best that can be done in cases of old
+standing after the first year or two, though attempts have been made to
+break the neck of the projecting portion, and thus permit of its being
+shoved back.</p>
+
+<p>(2.) By gradual pressure by a spring truss, strapping, or a bandage, it
+may be forced back. This is possible only in cases where the deformity
+has been comparatively slight, and the patient has been seen early. The
+edges must then be pared and approximated as directed above.</p>
+
+<p>One or two points about the operation for harelip require a special
+notice:&mdash;</p>
+
+<p>1. <i>When to operate.</i>&mdash;Great differences in opinion exist. Some say not
+before two or three years, others within two or three days, or even
+<i>hours</i>, after birth.</p>
+
+<p>Probably the safest time is not much earlier than the second month in
+very strong children, the fifth in weakly ones, up to the commencement
+of the first dentition; and when once dentition has commenced it is not
+so safe to operate till it is over.</p>
+
+<p>Prior to dentition the operation is attended with rather more risk, but
+again, if delayed, there is great risk that the teeth do not come in
+properly.<span class='pagenum'><a name="Page_187" id="Page_187">{187}</a></span></p>
+
+<p>2. With regard to the most delicate part of the operation, <i>the
+management of the prolabium</i>.&mdash;Some are satisfied, and I believe
+rightly, with careful apposition by a silk suture after a <i>sufficient</i>
+amount of the edges has been removed; others have proposed various plans
+to obviate any risk of an angle remaining.</p>
+
+<p>Malgaigne proposes to retain a small portion of the parings of the edge
+to make small flap at each side; Lloyd a single one from the long half
+of the lip, and brings it up under the opposite one, securing it with a
+stitch.<span class='pagenum'><a name="Page_188" id="Page_188">{188}</a></span></p>
+
+
+
+<hr style="width: 30%;" />
+
+<h2><a name="CHAPTER_VII" id="CHAPTER_VII"></a>CHAPTER VII.</h2>
+
+<h3>OPERATIONS ON THE JAWS.</h3>
+
+
+<p class="gap">1. <span class="smcap">Excision of the Upper Jaw.</span>&mdash;With regard to the morbid conditions for
+which this operation is undertaken, it may be sufficient here to
+observe, that in no case can the operation be called justifiable in
+which the disease extends beyond the upper jaw-bone and the
+corresponding palate-bone, for unless the morbid growth be entirely
+removed, recurrence is inevitable, and no advantage is gained by the
+operation. It is undertaken for the removal of tumours of the antrum and
+of the alveolar margins, in all which cases the section for its removal
+must be made through healthy bone, and wide of the disease, so as to
+insure that the whole is removed. There are other cases in which the
+whole or part of the upper jaw has been removed for the purpose of
+giving access to disease behind, for example, to naso-pharyngeal polypi
+with extensive attachments.</p>
+
+<p>In describing the operation for the excision of the entire upper jaw, we
+have to consider&mdash;(1.) what incisions through the soft parts will expose
+the tumour best, and with least deformity; (2.) what bony processes
+require to be divided, and where. Very various incisions have been
+recommended by various authors; some describing three, in various
+directions, forming flaps of different sizes, while others, again, are
+satisfied with a very small division of the upper lip into the nose, or<span class='pagenum'><a name="Page_189" id="Page_189">{189}</a></span>
+even attempt removal of the bone without any incision through the skin
+at all. These discrepancies depend in great measure on different views
+of what constitutes excision of the upper jaw, the more complicated ones
+contemplating removal of the whole bone anatomically so called,
+including the floor of the orbit, while the less complicated ones are
+suitable for cases in which a much less extensive removal is required.</p>
+
+<p>To remove the whole bone, an incision (Fig. <span class="smcap">xxvii. A</span>) of the skin must
+extend from the angle of the mouth upwards and outwards in a slightly
+curved direction with its convexity downwards, as far on the malar bone
+as half an inch outside of the outer angle of the eye. The flaps must
+then be raised in both directions, the inner one specially dissected off
+the bones, so as to expose thoroughly the nasal cavity. It is of great
+importance thoroughly to display the floor of the orbit, so that the
+attachment of the orbital fascia may be accurately cut through, the
+inferior oblique muscle divided at its origin, and the eye and the fat
+of the orbit cautiously raised from its floor.</p>
+
+<div class="figright" style="width: 150px;">
+<img src="images/189.jpg" width="150" height="189" alt="Fig. xxvii." title="Fig. xxvii." />
+<span class="caption"><span class="smcap">Fig. xxvii.</span>
+<a name="FNanchor_107_107" id="FNanchor_107_107"></a><a href="#Footnote_107_107" class="fnanchor">[107]</a></span>
+</div>
+
+<p>Three processes of bone then require attention and division.</p>
+
+<p>(1.) The articulation with the opposite bone in the hard palate. To
+divide this, one incisor tooth at least must be drawn, the soft palate
+divided by a knife to prevent laceration, and the thick alveolar portion
+sawn through in a longitudinal direction from before backwards.</p>
+
+<p>(2.) The articulation with the malar bone at the<span class='pagenum'><a name="Page_190" id="Page_190">{190}</a></span> upper angle of the
+incision through the skin. This must be notched with a small saw in a
+direction corresponding to the articulation, and then wrenched asunder
+by a pair of strong bone-pliers.</p>
+
+<p>(3.) The nasal process of the upper jaw must now be divided by the
+pliers, one limb of which is cautiously inserted into the orbit, the
+other into the nose. If the disease extends high up in this process, it
+may be necessary partially to separate the corresponding nasal bone, and
+thus reach the suture between the nasal process and the frontal bone.
+The pliers must now be inserted into the groove already made by the saw
+on the hard palate, and the separation continued to the full extent
+backwards. A comparatively slight force exerted on the tumour either by
+the hand, or (when the tumour is small) by a pair of strong claw
+forceps, will suffice to break down the posterior attachments of the
+bone and remove it entire. The necessary laceration of the soft parts
+behind is so far an advantage, as it lessens the risk of h&aelig;morrhage from
+the posterior palatine vessels.</p>
+
+<p>The h&aelig;morrhage from this operation was at one time much dreaded, but is
+rarely excessive; very few vessels require ligature, except those
+divided in the early stages in making the skin flaps; the hollow left
+should be stuffed with lint, which may be soaked in the perchloride of
+iron should there be any oozing.</p>
+
+<p>The incisions recommended for this operation have been very various, and
+a knowledge of some of them may occasionally be useful, on account of
+specialities in the shape and size of the tumour. Liston "entered the
+bistoury over the external angular process of the frontal bone, and
+carried it down through the cheek to the corner of the mouth. Then the
+knife is to be pushed through the integument to the nasal process of the
+maxilla, the cartilage of the ala is detached from the bone, and lip cut
+through in the mesial line; the flap<span class='pagenum'><a name="Page_191" id="Page_191">{191}</a></span> thus formed is to be dissected up
+and the bones divided."<a name="FNanchor_108_108" id="FNanchor_108_108"></a><a href="#Footnote_108_108" class="fnanchor">[108]</a> Dieffenbach made an incision through the
+upper lip and along the back or prominent part of the nose, up towards
+the inner canthus, from whence he carried the knife along the lower
+eyelid, at a right angle to the first incision as far as the malar bone.</p>
+
+<p>In cases where the tumour is of moderate size, Sir W. Fergusson
+found<a name="FNanchor_109_109" id="FNanchor_109_109"></a><a href="#Footnote_109_109" class="fnanchor">[109]</a> it sufficient to divide the upper lip by a single incision
+exactly in the middle line, this incision to be continued into one or
+both nostrils, if required. The ala of the nose is so easily raised, and
+the tip so moveable as to give great facilities to the operator for
+clearing the bone even to the floor of the orbit.</p>
+
+<p>In cases where the tumour is larger, or the bones more extensively
+affected, Sir W. Fergusson preferred an extension of the foregoing
+incision (Fig. <span class="smcap">xxvii. B</span>) upwards along the edge of the nose almost to
+the angle of the eye, and thence at a right angle along the lower
+eyelid, as far as may be necessary, even to the zygoma. The advantages
+claimed for such procedures are that the deformity is less and the
+vessels are divided at their terminal extremities.</p>
+
+
+<p class="gap">2. <span class="smcap">Excision of the Lower Jaw.</span>&mdash;Removal of portions, greater or smaller,
+of the lower jaw, for tumours, simple or malignant, are now operations
+of very frequent occurrence, while in some few cases the whole bone has
+been removed at both its articulations.</p>
+
+<p>The operative procedures vary much, according to the amount of bone
+requiring removal, and also the position of the portion to be excised.</p>
+
+<p>(1.) <i>Of a portion only of one side of the body of the bone.</i>&mdash;This is
+perhaps the simplest form of operation, and is frequently required for
+tumours, specially for epulis.</p>
+
+<p><i>Incision.</i>&mdash;If the parts are tolerably lax and the<span class='pagenum'><a name="Page_192" id="Page_192">{192}</a></span> tumour small, a
+single incision just at the lower edge of the bone, of a length rather
+greater than the piece of bone to be removed, will suffice; this will
+divide the facial artery, which must be tied or compressed,<a name="FNanchor_110_110" id="FNanchor_110_110"></a><a href="#Footnote_110_110" class="fnanchor">[110]</a> while
+the surgeon, dissecting on the tumour, separates the flaps in front,
+cutting upwards into the mouth, and then detaches the mylohyoid below,
+and clears the bone freely from mucous membrane. He then, with a narrow
+saw, notches the bone beyond the tumour at each side, and, introducing
+strong bone-pliers into the notches, is enabled to separate the required
+portion. The wound is then stitched up, and a very rapid cure generally
+results with very little deformity, as the cicatrix is in shadow. If
+from the size of the tumour more room is needed, it can easily be got by
+an additional incision from the angle of the mouth joining the former.</p>
+
+<p>To prevent deformity, which is apt to result from the centre of the chin
+crossing the middle line, it is often a wise precaution to have a silver
+plate prepared fitting the molar teeth of both jaws on the sound side,
+and thus acting as a splint. Such a precaution may be required in any
+operation in which the lower jaw is sawn through.</p>
+
+<p><i>N.B.</i>&mdash;There are certain cases in which the epulis is small and
+confined to the alveolar margin, in which an attempt may be made to
+retain the base of the jaw entire, and remove the tumour without any
+incision of the skin. The mucous membrane on both sides being carefully
+dissected from the affected part, the bone may be sawn as before, but
+only through the alveolar portion, the groves of the saw converging as
+they penetrate, then by a pair of strong curved bone-pliers, the<span class='pagenum'><a name="Page_193" id="Page_193">{193}</a></span>
+affected alveolar portion is to be scooped out without injuring the
+base. This proceeding, which has been practised by Syme, Fergusson,
+Pollock, the author in many cases, and others, leaves no deformity, but,
+it must be owned, is much more liable to the risk of recurrence of the
+disease, and for this reason is strongly condemned by Gross.</p>
+
+<p><i>Note.</i>&mdash;In this, as in all other operations on the jaws, the very first
+thing to be done is to draw the teeth at the spots at which the saw is
+to be applied.</p>
+
+<p>(2.) <i>Excision of a portion involving the Symphysis.</i>&mdash;Free access is of
+importance. The best incision is probably one which (Fig. <span class="smcap">xxvii. C</span>)
+commences at the angle of the mouth opposite the healthy portion of jaw,
+extends down to the place at which the saw is to be applied and then
+along the base of the jaw past the middle line to the other point of
+section. The flap is to be thrown up and the bone cleared. The next
+point to be noticed is, that when, in clearing the bone behind, the
+muscles attached to the symphysis are divided, the tongue loses its
+support, and unless watched may tend to fall backwards, embarrassing
+respiration and even perhaps choking the patient. The tongue, being
+confided to a special assistant, must be drawn well forwards. Various
+plans have been devised for keeping it in position, as stitching it to
+the point of the patient's nose; putting a ligature into its apex, and
+fastening it to the cheek by a piece of strapping, and transfixing its
+roots with a harelip needle, used to stitch up a central incision in the
+chin. The tendency to retraction very soon ceases, new attachments are
+formed by the muscles, and after the first five or six days there is
+very little risk of the tongue giving rise to any untoward consequences
+by its displacement.</p>
+
+<p>(3.) <i>Disarticulation of one, or both Joints.</i>&mdash;When the portion of bone
+implicated involves disarticulation for its complete removal, the
+difficulty of the operation is<span class='pagenum'><a name="Page_194" id="Page_194">{194}</a></span> much increased. The remarkably strong
+attachments of the joint, especially the relation of the temporal muscle
+to the coronoid process, and the close proximity of large arteries and
+nerves, especially the internal maxillary artery and the lingual nerve,
+render this disarticulation very difficult.</p>
+
+<p>The chief points to be attended to seem to be (1.) that the incision
+through the skin should extend quite up to the level of the
+articulation; (2.) that the bone should be sawn through at the other
+side of the tumour, and freely cleared from all its attachments, before
+any attempt be made at disarticulation, for by means of the tumour great
+leverage can be attained, so as to put the muscles on the stretch, and
+allow them to be safely divided; (3.) that the articulation should
+always be entered from the front, not from behind, and the inner side of
+the condyle should be very carefully cleaned, the surgeon cutting on the
+bone so as to avoid, if possible, the internal maxillary artery; (4.)
+free and early division of the attachment of the temporal muscle to the
+coronoid process.</p>
+
+<p>Disarticulation of the entire bone has been very rarely performed.<a name="FNanchor_111_111" id="FNanchor_111_111"></a><a href="#Footnote_111_111" class="fnanchor">[111]</a>
+If necessary, it can be performed without any incision into the mouth,
+by one semilunar sweep from one articulation to the other, passing along
+the lower margin of each side of the body, and just below the symphysis
+of the chin.</p>
+
+<p><i>Disarticulation of the Ramus without opening into the cavity of the
+Mouth.</i>&mdash;That this operation is possible, though it may not be often
+required, is shown by the following case by Mr. Syme. It was a tumour of
+the ramus, extending only as far forwards as the wisdom-tooth:&mdash;</p>
+
+<p>"An incision was made from the zygomatic arch down along the posterior
+margin of the ramus, slightly<span class='pagenum'><a name="Page_195" id="Page_195">{195}</a></span> curved with its convexity towards the
+ear, to a little way beyond the base of the jaw. The parotid gland and
+masseter muscle being dissected off the jaw, it was divided by
+cutting-pliers immediately behind the wisdom-tooth, after being notched
+with a saw. The ramus was then seized by a strong pair of tooth-forceps,
+and notwithstanding strong posterior attachments, was drawn outwards,
+its muscular connections divided and turned out entire. There was thus
+no wound of the mucous membrane of the mouth, the masseter and pterygoid
+muscles were not completely divided, and the facial artery was
+intact."<a name="FNanchor_112_112" id="FNanchor_112_112"></a><a href="#Footnote_112_112" class="fnanchor">[112]</a></p>
+
+<p>Fergusson<a name="FNanchor_113_113" id="FNanchor_113_113"></a><a href="#Footnote_113_113" class="fnanchor">[113]</a> holds that even the very largest tumours of the lower jaw
+may be successfully removed without opening into the orifice of the
+mouth at all by division of the lips. A large lunated incision below the
+lower margin of the bone, with its ends extending upwards to within half
+an inch of the lips, will give free access, and yet avoid both
+h&aelig;morrhage and deformity, as the labial artery and vein are not cut, and
+there is no trouble in readjusting the lips. Some tumours of lower jaw
+can be removed without any wound of skin.</p>
+
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_196" id="Page_196">{196}</a></span></p>
+
+<h2><a name="CHAPTER_VIII" id="CHAPTER_VIII"></a>CHAPTER VIII.</h2>
+
+<h3>OPERATIONS ON MOUTH AND THROAT.</h3>
+
+
+<p class="gap"><span class="smcap">Salivary Fistula</span>, <i>Operation for.</i>&mdash;After a wound or abscess of the
+cheek, in which the parotid duct is implicated, a salivary fistula is
+very apt to remain. The saliva thus discharges in the cheek, giving rise
+to considerable annoyance, as well as injury to the digestion. It is by
+no means easy to cure this. Perhaps the best operation is the one of
+which a rude diagram is given (Fig. <span class="smcap">xxviii.</span>). The duct (<span class="smcap">c</span>) communicates
+with the fistula (<span class="smcap">d</span>). One end of a thread, either silken or metallic,
+should be passed through the fistula, and then as far backwards as
+convenient through the cheek into the mouth; the needle should then be
+withdrawn, the thread being left in. The other end being threaded should
+then be re-inserted at the fistula, and carried forwards in a similar
+manner; the needle should be again unthreaded in the mouth and
+withdrawn; the two ends should then be tied pretty tightly inside, and
+allowed to make their way by ulceration<span class='pagenum'><a name="Page_197" id="Page_197">{197}</a></span> into the cavity of the mouth. A
+passage will thus be obtained for the saliva into the mouth, and every
+possible precaution should be taken to enable the external wound to
+close.</p>
+
+<div class="figleft" style="width: 250px;">
+<img src="images/196.jpg" width="250" height="275" alt="Fig. xxviii." title="Fig. xxviii." />
+<span class="caption"><span class="smcap">Fig. xxviii.</span>
+<a name="FNanchor_114_114" id="FNanchor_114_114"></a><a href="#Footnote_114_114" class="fnanchor">[114]</a></span>
+</div>
+
+
+<p class="gap"><span class="smcap">Excision of the Tongue</span>, for malignant disease of the organ, may be
+either complete or partial. Complete excision affords a hope of
+permanent and complete relief from the disease, but it is an operation
+of extreme difficulty and danger. It may be performed in either of the
+following methods. The first is the only one in which absolute
+completeness of removal is insured.</p>
+
+<p>1. <i>Syme's method of excision.</i>&mdash;The patient being seated on a chair,
+chloroform was not administered, so that the blood might escape
+forwards, and not pass into the pharynx. The operation is thus
+described:<a name="FNanchor_115_115" id="FNanchor_115_115"></a><a href="#Footnote_115_115" class="fnanchor">[115]</a>&mdash;</p>
+
+<p>"Having extracted one of the front incisors, I cut through the middle of
+the lip and continued the incision down to the os hyoides, then sawed
+through the jaw in the same line, and insinuating my finger under the
+tongue as a guide to the knife, divided the mucous lining of the mouth,
+together with the attachment of the genio-hyoglossi. While the two
+halves of the bone were held apart, I dissected backwards, and cut
+through the hyoglossi, along with the mucous membrane covering them, so
+as to allow the tongue to be pulled forward, and bring into view the
+situation of the lingual arteries, which were cut and tied, first on one
+side, and then on the other. The process might now have been at once
+completed, had I not feared that the epiglottis might be implicated in
+the disease, which extended beyond the reach of my finger, and thus
+suffer injury from the knife if used without a guide. I therefore cut
+away about two-thirds of the tongue, and then being able to reach the os
+hyoides with my finger, retained it there while the remaining
+attachments were divided by the knife in<span class='pagenum'><a name="Page_198" id="Page_198">{198}</a></span> my other hand close to the
+bone. Some small arterial branches having been tied, the edges of the
+wound were brought together and retained by silver sutures, except at
+the lowest part, where the ligatures were allowed to maintain a drain
+for the discharge of fluids from the cavity." The patient was able to
+swallow from a drinking-cup with a spout on the day following the
+operation, and was able to travel upwards of 200 miles within four weeks
+of the operation.</p>
+
+<p>2. <i>By the &Eacute;craseur.</i>&mdash;Nunneley of Leeds has recorded cases in which he
+made a small incision through the skin, and mylohyoid and geniohyoid
+muscles, and through this passed a curved needle bearing the chain of
+the &eacute;craseur completely round the base of the tongue. In one case the
+chain was unsatisfactory, but strong whipcord was introduced as it was
+withdrawn, and tied with all possible force. The organ eventually
+sloughed away, with a cure which lasted at least for some months.</p>
+
+<p>Sir James Paget operates as follows:&mdash;</p>
+
+<p>The patient is placed under the influence of chloroform, and the mouth
+held widely open. The tongue is then drawn forwards, the mucous membrane
+and soft parts of the floor of the mouth, including the attachment of
+the genio-hyoglossi to the symphysis being divided close to the bone.
+The steel wire of an &eacute;craseur is then passed round its root as low down
+as possible, slowly tightened, and the tongue thus divided through its
+whole thickness in a very few minutes. The bleeding is slight, being
+almost entirely from the parts cut with the knife. Recovery has been
+rapid in the recorded cases.<a name="FNanchor_116_116" id="FNanchor_116_116"></a><a href="#Footnote_116_116" class="fnanchor">[116]</a></p>
+
+<p>To Dr. George Buchanan of Glasgow the credit is due of the invention of
+the operation of removal of the half of the tongue in the median line.
+In at least one instance the cure after five years is still permanent.</p>
+
+<p>Partial excisions of the tongue are as unsatisfactory<span class='pagenum'><a name="Page_199" id="Page_199">{199}</a></span> in their results
+as they are unsound in principle, yet many cases present themselves, in
+which, while the patient urges some operative measure for his relief,
+the tumour is so limited as not to warrant the exceedingly dangerous
+operation of complete excision.</p>
+
+<p>Portions may be removed in various ways:&mdash;</p>
+
+<p>1. By the knife. If in the apex, by a V-shaped incision; if in the
+lateral regions, by a bold free incision with a probe-pointed bistoury
+round the tumour.</p>
+
+<p>2. By ligature, drawn as tightly as possible, and, if the portion
+included be large, in successive portions.</p>
+
+<p>3. By the &eacute;craseur.</p>
+
+<p>Mr. Furneaux Jordan has removed the whole tongue with success by means
+of two &eacute;craseurs worked at the same time.<a name="FNanchor_117_117" id="FNanchor_117_117"></a><a href="#Footnote_117_117" class="fnanchor">[117]</a></p>
+
+<p>4. By the galvano-caustic wire.</p>
+
+<p>5. The author has in nine cases removed the affected half of the tongue
+by means of the thermo-cautery, first splitting it in the middle line
+and then cutting through the base with a curved platinum knife at a low
+red heat. In one only was there any trouble from h&aelig;morrhage, and all
+made good recoveries.</p>
+
+<p>Mr. Barwell has recorded (<i>Lancet</i>, 1879, vol. i.) an easy, safe, and
+comparatively painless mode of removing the tongue by &eacute;craseurs.</p>
+
+<p>Mr. Walter Whitehead,<a name="FNanchor_118_118" id="FNanchor_118_118"></a><a href="#Footnote_118_118" class="fnanchor">[118]</a> of Manchester, has had a very large
+experience of an operation devised by himself, in which, after pulling
+the tongue well forward by a string previously introduced near its apex,
+and the mouth being held open by a gag, he detaches the organ from jaw
+and fauces by successive short snips with scissors, and then in same
+manner divides the muscles, tying or twisting the vessels as they bleed.
+His success has been very great by this method, though others who have
+tried it have sometimes found bleeding troublesome.<span class='pagenum'><a name="Page_200" id="Page_200">{200}</a></span></p>
+
+<p>It is comparatively seldom now necessary to split the jaw and perform
+Syme's operation, and in all operations on the tongue the thermocautory
+(Paquelin's) is of great use.</p>
+
+<p>Regnoli's method<a name="FNanchor_119_119" id="FNanchor_119_119"></a><a href="#Footnote_119_119" class="fnanchor">[119]</a> may deserve a brief notice. A semilunar incision
+along the base of the jaw, from one angle to the other, detaches the
+muscles and soft structures, and is thrown down; the tongue is then
+drawn through the opening, and can be freely dealt with either by knife
+or ligature. After removal the flap is replaced.</p>
+
+
+<p class="gap"><span class="smcap">Fissures in the Palate.</span>&mdash;The operations requisite for the cure of
+fissures in the soft and hard palates are so complicated in their
+details, that a small treatise would be required thoroughly to describe
+the various procedures.</p>
+
+<p>Different cases vary so much in the nature and amount of their
+deformity, that at least five different sets of cases have been
+described. It is sufficient here merely to describe the absolutely
+essential principles of the operations for the cure of fissures of the
+hard and soft palate respectively.</p>
+
+<p>In all operations on the palate, two conditions used to be considered
+requisite for success:&mdash;1. That the patient should have arrived at years
+of discretion, at twelve or fourteen years at least; that he be
+possessed of considerable firmness, and be extremely anxious for a cure,
+so as to give full and intelligent co-operation. 2. That for some days
+or weeks prior to the operation the mouth and palate should have been
+trained to open widely and to bear manipulation, without reflex action
+being excited. Professor Billroth of Vienna,<a name="FNanchor_120_120" id="FNanchor_120_120"></a><a href="#Footnote_120_120" class="fnanchor">[120]</a> and Mr. Thomas
+Smith<a name="FNanchor_121_121" id="FNanchor_121_121"></a><a href="#Footnote_121_121" class="fnanchor">[121]</a> of London, have had cases which prove the possibility of
+performing this operation in childhood, under chloroform, with the
+assistance, in the<span class='pagenum'><a name="Page_201" id="Page_201">{201}</a></span> English cases, of a suitable gag, invented by Mr.
+Smith. The effect of the operation on the voice of the child has been
+very encouraging, as much more improvement takes place than in cases
+where the operation is performed late in life.</p>
+
+<p><i>Fissure in the soft palate only</i> appears as a triangular cleft, the
+apex of which is above, the base being a line between the points of the
+bifid uvula, which are widely separated. To cure this it is required&mdash;</p>
+
+<p>1. That the edges of the fissure should be brought together without
+strain or tightness. In small fissures this can generally be done easily
+enough; but where the fissure is extensive, some means must be used to
+relieve tension. For this, Sir William Fergusson long ago proposed the
+division of the palatal muscles, the levator, tensor, and
+palato-pharyngeus muscle of each side. The incisions in the palate for
+this purpose certainly aid apposition, but many surgeons entertain
+doubts whether the division of the muscles has much to do with the good
+result, and believe that the simple incisions in the mucous membrane, in
+a proper direction, are all that is required (see Fig. <span class="smcap">xxix.</span>).</p>
+
+<div class="figright" style="width: 300px;">
+<img src="images/201.jpg" width="300" height="224" alt="Fig. xxix." title="Fig. xxix." />
+<span class="caption"><span class="smcap">Fig. xxix.</span>
+<a name="FNanchor_122_122" id="FNanchor_122_122"></a><a href="#Footnote_122_122" class="fnanchor">[122]</a></span>
+</div>
+
+<p>2. That the edges of the fissure be made raw, so as to afford surfaces
+which will readily unite. Complicated instruments, such as knives of
+various strange shapes, have been devised for this purpose; an ordinary
+cataract knife, very sharp, and set on a long handle is perhaps the
+best. It greatly facilitates the section if the parts are tense, so the
+point of the uvula should be seized by<span class='pagenum'><a name="Page_202" id="Page_202">{202}</a></span> an ordinary pair of spring
+forceps, and drawn across the roof of the mouth, while the knife should
+enter in the middle line, a little above the apex of the fissure, and
+make the cut downwards as in harelip.</p>
+
+<p>3. That sutures should be inserted to keep the edges in apposition, yet
+not so tightly as to cause ulceration. They may be either of metal,
+silver being preferable, or of fine silk well waxed. The metallic
+sutures are now generally preferred. Some dexterity is required in their
+introduction, and various instruments have been devised; the best seems
+to be a needle with a short curve fixed on a long handle, which should
+be entered on the (patient's) left side of the fissure in front, and
+brought out on the right side.</p>
+
+<p>If silk sutures be used, the chief difficulty, that of passing the
+thread through the second side from behind forwards, can be avoided in
+the following manner.<a name="FNanchor_123_123" id="FNanchor_123_123"></a><a href="#Footnote_123_123" class="fnanchor">[123]</a> A curved needle is passed through one side of
+the fissure, and then towards the middle line, till its point is seen
+through the cleft. One of the ends of the thread is then seized by a
+long pair of forceps, and drawn through the cleft; the needle is then
+withdrawn, leaving the thread through the palate, and both ends are
+brought outside at the angle of the mouth. Another needle is then passed
+through a corresponding point at the opposite side of the palate, till
+its point again appears at the cleft; this time a double loop of the
+thread is also brought out through the cleft by the forceps into the
+mouth. If then the single thread of the first ligature which is in the
+cleft be passed through the loop of the second one also in the cleft, it
+is easy, by withdrawing the loop through the palate, to finish the
+stitch (see Fig. <span class="smcap">xxix.</span>). All the stitches should be passed and their
+position approved before any one be tied, and it is most convenient to
+secure them from above downwards. To prevent confusion, each pair of
+threads after being inserted<span class='pagenum'><a name="Page_203" id="Page_203">{203}</a></span> should be left very long, and brought up
+to a coronet fixed on the brow, which is fitted with several pairs of
+hooks numbered for easy reference. This will prevent twisting of the
+threads or any mistake in tying.</p>
+
+
+<p class="gap"><span class="smcap">Fissure of the Hard Palate.</span>&mdash;This may vary in extent from a very slight
+cleft in the middle line behind, up to a complete separation of the two
+halves of the jaw, including even the alveolar process in front, and
+sometimes complicated with harelip.</p>
+
+<p>To close such fissures by operation is difficult, as the breadth of the
+cleft is so great as to prevent the apposition of the edges when
+prepared, without such extreme tension as quite prevents any hope of
+union. Through the researches of Avery, Warren, Langenbeck, and others,
+a method has been discovered of closing such fissures by operation,
+which, though certainly not easy, is, when properly performed, generally
+successful.</p>
+
+<p><i>Operation.</i>&mdash;In addition to the usual paring of the edges of the cleft,
+an incision is made on each side of the palate, extending "from the
+canine tooth in front to the last molar behind,"<a name="FNanchor_124_124" id="FNanchor_124_124"></a><a href="#Footnote_124_124" class="fnanchor">[124]</a> along the alveolar
+ridge (Fig. <span class="smcap">xxx.</span>). The whole flap between the cleft and this incision on
+each side is then to be raised from the bone by a blunt rounded
+instrument slightly curved. With this the whole mucous membrane and as
+much of the periosteum as possible should be completely raised from the
+bone, attachments for nourishment of the flap being left in front and
+behind where the vessels enter.</p>
+
+<div class="figright" style="width: 185px;">
+<img src="images/203.jpg" width="185" height="200" alt="Fig. xxx." title="Fig. xxx." />
+<span class="caption"><span class="smcap">Fig. xxx.</span>
+<a name="FNanchor_125_125" id="FNanchor_125_125"></a><a href="#Footnote_125_125" class="fnanchor">[125]</a></span>
+</div>
+
+<p>The flaps thus raised will be found to come together in the middle line,
+sometimes even to overlap, and,<span class='pagenum'><a name="Page_204" id="Page_204">{204}</a></span> when united by suture, form a new
+palate at a lower level than the fissure, experience having shown that
+in cases of fissure the arch of the palate is always much higher than
+usual. The flaps do not slough, being well supplied with blood, unless
+they have been injured in their separation.</p>
+
+<p>The edges must be carefully united by various points of metallic suture,
+and the fissure of the soft palate closed at the same sitting, unless
+the patient has lost much blood, or is very much exhausted with the
+pain. The stitches may be left in for a week, or even ten days, unless
+they are exciting much irritation. The patient must exercise great
+self-control and caution in the character of his food and his manner of
+eating for ten days or a fortnight after the operation.</p>
+
+
+<p class="gap"><span class="smcap">Excision of Tonsils.</span>&mdash;To remove the whole tonsil is of course impossible
+in the living body, the operation to which the name of excision is given
+being only the shaving off of a redundant and projecting portion. When
+properly performed it is a very safe, and in adults a very easy
+operation, but in children it is sometimes rendered exceedingly
+difficult by their struggles, combined with the movements of the tongue
+and the insufficient access through the small mouth. Many instruments
+have been devised for the purpose of at once transfixing and excising
+the projecting portion; some of them are very ingenious and complicated.
+By far the best and safest method of removing the redundant portion is
+to seize it with a volsellum, and then cut it off by a single stroke of
+a probe-pointed curved bistoury; cutting from above downwards, and being
+careful to cut parallel with the great vessels.</p>
+
+<p>The ordinary volsellum is much improved for this purpose by the addition
+of a third hook in each tonsil placed between the others, with a shorter
+curve, and slightly shorter; this ensures the safe holding of the<span class='pagenum'><a name="Page_205" id="Page_205">{205}</a></span>
+fragment removed, and prevents the risk of its falling down the throat
+of the patient.</p>
+
+<p>If both tonsils are enlarged they should both be operated on at the same
+sitting, and the pain is so slight that even children frequently make
+little objection to the second operation. Bleeding is rarely troublesome
+if the portion be at once fairly removed, but if in the patient's
+struggles the hook should slip before the cut is complete, the partially
+detached portion will irritate the fauces, cause coughing and attempts
+to vomit, and sometimes a troublesome h&aelig;morrhage.</p>
+
+<p>The plentiful use of cold water will generally be sufficient to stop the
+bleeding, though cases are on record in which the use of styptics, or
+even the temporary closure of a bleeding point by pressure, has been
+necessary.</p>
+
+<p>M. Guersant has operated on more than one thousand children, with only
+three cases of any trouble from h&aelig;morrhage, while four or five out of
+fifteen adults required either the actual cautery or the sesqui-chloride
+of iron.<a name="FNanchor_126_126" id="FNanchor_126_126"></a><a href="#Footnote_126_126" class="fnanchor">[126]</a></p>
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_206" id="Page_206">{206}</a></span></p>
+
+<h2><a name="CHAPTER_IX" id="CHAPTER_IX"></a>CHAPTER IX.</h2>
+
+<h3>OPERATIONS ON AIR PASSAGES.</h3>
+
+
+<p class="gap"><span class="smcap">Operations on the Larynx and Trachea.</span>&mdash;The great air passage may be
+opened at three different situations, and to the operations at these
+different places the following names have been given:&mdash;</p>
+
+<p><i>Laryngotomy</i>, when the opening is made in the interval between the
+cricoid and thyroid cartilages, through the crico-thyroid membrane.</p>
+
+<p><i>Laryngo-tracheotomy</i>, when the cricoid cartilage and the upper ring of
+the trachea are divided.</p>
+
+<p><i>Tracheotomy</i>, when the trachea itself is opened by the division of two,
+three, or more rings.</p>
+
+<p>Of these the last, <i>tracheotomy</i>, is by far the most frequent,
+important, difficult, and dangerous, and requires a very detailed
+description. Chassaignac<a name="FNanchor_127_127" id="FNanchor_127_127"></a><a href="#Footnote_127_127" class="fnanchor">[127]</a> says "the only really rational operation
+for the opening of the air passages by the surgeon is tracheotomy."</p>
+
+<p class="gap"><span class="smcap">Tracheotomy.</span>&mdash;<i>Anatomy.</i>&mdash;Between the cricoid cartilage and the level of
+the upper border of the sternum, the middle line of the neck is occupied
+by the upper portion of the trachea. Its depth from the surface varies,
+gradually increasing as the trachea descends, and varying very much
+according to the fatness, muscularity, and length of the neck. It is,
+however, almost<span class='pagenum'><a name="Page_207" id="Page_207">{207}</a></span> subcutaneous at the commencement below the cricoid, and
+on the level of the sternum it is in most cases at least an inch from
+the surface, in many much deeper. Again, its length varies, even in the
+adult, from two and a half to three, or even four inches. This is
+important, as affecting the simplicity of the operation, which, as a
+rule, is easier the longer the neck is.</p>
+
+<p>The trachea has most important and complicated anatomical
+relations&mdash;some constant, others irregular.</p>
+
+<p>1. The carotid arteries and jugular veins lie at either side, but, where
+these are regular in their distribution, do not practically interfere in
+a well-conducted operation.</p>
+
+<p>2. The thyroid gland lies in close relation to the trachea, one lobe
+being at each side (Fig. <span class="smcap">xxxi.</span> B B), and the isthmus of the thyroid
+crosses the trachea just over the second and third cartilaginous rings.
+In fat vascular necks, or where the thyroid is enlarged it may occupy a
+much larger portion of the trachea. The position of the isthmus
+practically divides the trachea into two portions in which it is
+possible to perform tracheotomy. Both have their advocates, but the
+balance of authority tends to support the operation below the thyroid. A
+separate notice of each will be required immediately.</p>
+
+<div class="figright" style="width: 142px;">
+<img src="images/207.jpg" width="142" height="350" alt="Fig. xxxi." title="Fig. xxxi." />
+<span class="caption"><span class="smcap">Fig. xxxi.</span>
+<a name="FNanchor_128_128" id="FNanchor_128_128"></a><a href="#Footnote_128_128" class="fnanchor">[128]</a></span>
+</div>
+
+<p>3. The <i>muscles</i> in relation to the trachea are the sterno-hyoid and
+sterno-thyroid of each side. The latter are the broadest, are in close
+contact across the trachea by the inner edges below, but gradually
+diverge as they ascend the neck. In thick-set, muscular necks, however,
+they are in<span class='pagenum'><a name="Page_208" id="Page_208">{208}</a></span> close contact for a considerable distance, and require to
+be separated to give access to the trachea.</p>
+
+<p>The <i>arteries</i> are in most cases unimportant; no named branch of any
+size ought to be divided in the operation. However, occasionally very
+free bleeding may result from the division of an abnormal <i>thyroidea
+ima</i> running up the trachea to the thyroid body from the innominate, or
+even from the aorta itself.</p>
+
+<p>The <i>veins</i> are very numerous and irregularly distributed. There is
+generally a large transverse communicating branch between the superior
+thyroid veins just above the isthmus. The isthmus itself has a large
+venous plexus over it. Below the isthmus the veins converge into one
+trunk (or sometimes two parallel ones) lying right in front of the
+trachea.</p>
+
+<p>4. The last anatomical point which may give trouble in normal necks is
+the thymus, which is present in children below the age of two, and
+covers the lower end of the trachea just above the level of the sternum.
+Where this is not only not diminished, but enlarged, as it sometimes is
+in unhealthy children, it may give a very great deal of trouble, rolling
+out at the wound and greatly embarrassing proceedings.</p>
+
+<p>Abnormalities are very various and sometimes very dangerous: vessels
+crossing the trachea, as the innominate did in Macilwain's case,<a name="FNanchor_129_129" id="FNanchor_129_129"></a><a href="#Footnote_129_129" class="fnanchor">[129]</a> or
+where two brachiocephalic trunks are present, as recorded by
+Chassaignac.<a name="FNanchor_130_130" id="FNanchor_130_130"></a><a href="#Footnote_130_130" class="fnanchor">[130]</a> One of the most frequent dangers to be guarded against
+is a possible dilatation of the aorta or aneurism of the arch. This may
+very possibly, as happened in one case to the author, give rise to
+suffocative paroxysms from its pressure on the recurrent laryngeal
+nerves. Tracheotomy may be deemed necessary, and there is a great risk,
+unless proper precautions<span class='pagenum'><a name="Page_209" id="Page_209">{209}</a></span> be taken, of wounding the aorta, where it
+passes upwards in the jugular fossa. In the author's case the vessel had
+actually to be pushed downwards by the pulp of the forefinger while the
+trachea was opened, the knife being guided on the back of the nail of
+the same finger.</p>
+
+<p class="gap"><span class="smcap">The Operation.</span>&mdash;In a work of this kind it would be utterly impossible to
+go at all into the subject of what diseases, injuries, etc., warrant or
+require the operation. It is enough to describe the various methods of
+operating, their dangers and difficulties.</p>
+
+<p>1. <i>The operation above the isthmus of the thyroid.</i>&mdash;A spot about a
+quarter or half of an inch in vertical diameter between the cricoid
+cartilage (Fig. <span class="smcap">xxxi.</span>) and thyroid isthmus.</p>
+
+<p><i>Advantages.</i>&mdash;It is near the surface, the vessels are few and
+comparatively small. It is most suitable in cases of aneurism.</p>
+
+<p>Professor Spence<a name="FNanchor_131_131" id="FNanchor_131_131"></a><a href="#Footnote_131_131" class="fnanchor">[131]</a> gives his sanction to the high operation in adults
+with thick short necks when the operation is performed for ulceration or
+papilloma of larynx or for spasm from aneurism, the low operation being
+still best in cases of croup or diphtheria.</p>
+
+<p><i>Disadvantages.</i>&mdash;The space is too small, requires very considerable
+disturbance of the thyroid isthmus, or actual division of it. It is too
+near the point where the disease is; so much so, that in most cases of
+croup or diphtheria it would be perfectly useless. However, if required,
+or if the operation lower down be contra-indicated, this may be
+performed easily enough. A straight incision being made in the middle
+line about one inch and a half in length, expose the upper ring by
+careful dissection, if possible draw aside the veins, and depress the
+thyroid isthmus, divide the rings thus exposed, and introduce the tube.<span class='pagenum'><a name="Page_210" id="Page_210">{210}</a></span></p>
+
+<p><i>The operation below the isthmus.</i>&mdash;This, though more difficult in its
+performance, is a much more scientific and satisfactory operation.
+Considerable coolness and a thorough knowledge of the anatomy of the
+part are absolutely required.</p>
+
+<p>The patient being in the recumbent posture, the shoulders should be well
+raised, and the head held back so as to extend the windpipe, and thus
+bring it as near as possible to the surface. A pillow, or the arm of an
+assistant, behind the neck will be of service.</p>
+
+<p><i>N.B.</i>&mdash;Be careful lest too great extension by an anxious assistant,
+accompanied by closure of the mouth, should choke the patient (whose
+breathing is of course already much embarrassed) before the operation be
+begun.</p>
+
+<p>Chloroform may occasionally be given, and, if well borne, renders the
+operation very much easier than it would otherwise be. An incision must
+then be made exactly in the median line of the neck, from a little below
+the cricoid cartilage, almost to the upper edge of the sternum; at first
+it should be through skin only, then the veins will be seen, probably
+turgid with dark blood; the larger ones should be drawn aside, if
+necessary divided, the bleeding stopped by gentle pressure. The deep
+fascia must then be cautiously divided, great care being taken to keep
+exactly in the middle line, and the contiguous edges of sterno-thyroid
+muscles separated from each other by the handle of the knife. A quantity
+of loose connective tissue, containing numerous small veins, must now be
+pushed aside, the thyroid isthmus pressed upwards, still with the handle
+of the knife. The forefinger must then be used to distinguish the rings
+of the trachea. If there is much convulsive movement of the larynx and
+trachea, they should be fixed by the insertion of a small sharp hook
+with a short curve, just below the cricoid cartilage, and this should be
+confided to an assistant. The surgeon should then, with the forefinger
+of his left hand, fix the<span class='pagenum'><a name="Page_211" id="Page_211">{211}</a></span> trachea, and open it by a straight
+sharp-pointed scalpel, boldly thrusting it through the rings with a jerk
+or stab, the back of the knife being below, and divide two or three of
+the rings from below upwards. Any attempt to enter the trachea slowly
+with a blunt knife or trocar will probably be unsuccessful, as the
+rings, especially in children, give way before the knife, which merely
+approximates the sides of the trachea without opening it.</p>
+
+<p><i>Question of H&aelig;morrhage.</i>&mdash;It is often a question of some importance,
+and one which sometimes it is not easy to settle, how far attempts
+should be made completely to arrest the venous h&aelig;morrhage before opening
+the trachea.</p>
+
+<p><i>On the one hand</i>, if not arrested, besides the risk of weakening the
+patient, we have to dread the much more serious complication of the
+admission of blood into the wound. And this is very serious in a patient
+whose respiration has already been much impeded, whose lungs are
+probably engorged, and who has certainly, by the mere existence of a
+wound in his trachea, lost the power of coughing properly; it must never
+be forgotten that a quantity of blood so trifling as to be at once
+ejected by a single cough in the case of a healthy chest, may be a fatal
+obstacle to respiration in one already weakened by disease. Thus any
+well-marked arterial h&aelig;morrhage from cut branches, or from the isthmus
+of the thyroid, must certainly be arrested prior to opening the trachea.
+Besides this, blood once having entered the bronchi is apt to extend
+into their smaller ramifications and prove a cause of death, by acting
+as a local irritation, and setting up intra-lobular suppurative
+pneumonia. The author has found this to be the case both after
+tracheotomy and still more frequently in suicide by cut throat.</p>
+
+<p>But, <i>on the other hand</i>, it is equally true that there is almost always
+a considerable amount of oozing from<span class='pagenum'><a name="Page_212" id="Page_212">{212}</a></span> small venous radicles divided
+during the operation, which depends simply on the great venous
+engorgement resulting from the obstruction to the respiration, so that
+while to attempt to tie every point would be simply endless, we may be
+almost certain that the oozing will cease whenever the trachea is
+opened, and respiration fairly improved. Slight pressure on the wound is
+generally sufficient to stop the bleeding till the venous engorgement
+has disappeared.</p>
+
+<p>Of late years many tracheotomies have been done bloodlessly by use of
+the thermo-cautery, for division of the soft parts, but the subsequent
+sloughing of the wound is a great objection to this method.</p>
+
+<p>In cases of extreme urgency, all such minor considerations as
+suppression of venous oozing must be ignored, and the trachea simply
+opened as rapidly as possible. I had once to perform the operation after
+respiration had entirely ceased, and no pulse could be felt at the
+wrist, with no assistance except that of a female attendant. Merely
+feeling that no large arterial branch was in the way, I cut straight
+through all the tissues, opened the trachea, and commenced artificial
+respiration. The patient eventually recovered.</p>
+
+<p><i>Question of Tubes, etc.</i>&mdash;Once the trachea is opened, the next question
+is, How is the opening to be kept pervious? For the moment the handle of
+the scalpel is to be inserted in the wound, so as to stretch it
+transversely; this will probably suffice to allow of the escape of any
+foreign body. But where, to admit air, the wound is to be <i>kept</i> open,
+how is this to be done? It used to be advised that an elliptical portion
+of the wall of the trachea be removed; this, though succeeding well
+enough for a time, was unscientific, as the wound always tended to
+cicatrise, and ended of course in permanent narrowing of the canal of
+the trachea. It may be necessary thus to excise a portion of the
+trachea, in cases where it is very intolerant of the presence of a<span class='pagenum'><a name="Page_213" id="Page_213">{213}</a></span>
+tube. Such a case is recorded by Sir J. Fayrer of Calcutta.<a name="FNanchor_132_132" id="FNanchor_132_132"></a><a href="#Footnote_132_132" class="fnanchor">[132]</a> Not
+much better is the proposal to insert a silk ligature in each side of
+the wound, and by pulling these apart thus mechanically to open the
+wound. This also is evidently a merely temporary expedient.</p>
+
+<p>Various canul&aelig; and tubes have been proposed. The ones recommended by the
+older surgeons had all one great fault; they were much too small, and
+were many of them straight, and thus liable to displacement. The
+smallness of their bore was their greatest objection, and Mr. Liston
+conferred a great benefit on surgery by his insisting upon the
+introduction of tubes with a larger bore, and with a proper curve, so as
+thoroughly to enter the trachea. The tube ought to be large enough to
+admit all the air required by the lungs, without hurrying the
+respiration in the least.</p>
+
+<p>There is a mistake made in the construction of many of the tubes even of
+the present day; the outer opening is large and full, while for
+convenience of insertion the tube tapers down to an inner opening,
+admitting perhaps not one-half as much air as the outer one does.</p>
+
+<p>It must be remembered that for some days there is great risk of the tube
+becoming occluded, by frothy blood or mucus, especially in cases of
+croup, and in children. To prevent this a double canula will be found of
+great service, providing only that it be remembered that the inner
+canula, not the outer merely, is to be made large enough to breathe
+through, and that the inner should project slightly beyond the outer
+one.</p>
+
+<p>The inner one can thus be removed at intervals and cleansed, by the
+nurse, without any risk of exciting spasm or dyspn&#339;a by its absence
+and reintroduction.</p>
+
+<p><i>After-treatment.</i>&mdash;The after-treatment of a case in which tracheotomy
+has been performed demands great care and many precautions. For the
+first day or two the constant presence of an experienced nurse or
+student<span class='pagenum'><a name="Page_214" id="Page_214">{214}</a></span> is always necessary to insure the patency of the tube. The
+temperature of the room should be equable and high, and it seems of
+importance that the air should be kept moist as well as warm by the use
+of abundance of steam.</p>
+
+<p>A piece of thin gauze, or other light protective material, should be
+placed over the mouth of the tube, to prevent the entrance of foreign
+bodies.</p>
+
+<p>In cases where the operation has been performed for some temporary
+inflammatory closure of the air passage, retention of the tube for a few
+days may suffice. It may then be removed, but it must be remembered that
+the wound will generally close with great rapidity, so that it is as
+well to be quite sure of the patency of the natural passage before the
+artificial one is allowed to close by the removal of the tube.</p>
+
+<p>In cases where from long-standing disease or severe accident the larynx
+is rendered totally unfit for work, and the tube has to be worn during
+the rest of the patient's life, care must be taken (1.) lest the tube do
+not fit accurately, in which case it may ulcerate in various directions,
+even into the great vessels;<a name="FNanchor_133_133" id="FNanchor_133_133"></a><a href="#Footnote_133_133" class="fnanchor">[133]</a> (2.) lest the tube become worn, and
+lest the part within the windpipe fall into the trachea and suffocate
+the patient.<a name="FNanchor_134_134" id="FNanchor_134_134"></a><a href="#Footnote_134_134" class="fnanchor">[134]</a></p>
+
+
+<p class="gap"><span class="smcap">Laryngotomy.</span>&mdash;As a temporary expedient in cases of great urgency, where
+proper instruments and assistants are not at hand, laryngotomy is
+occasionally useful, though from the want of space without encroaching
+on the cartilages of the larynx, and from its close proximity to the
+disease, laryngotomy is by no means a suitable or permanently successful
+operation.</p>
+
+<p>In the adult, especially in males with long spare necks, the operation
+itself is exceedingly easy to perform. The<span class='pagenum'><a name="Page_215" id="Page_215">{215}</a></span> crico-thyroid space (Fig.
+<span class="smcap">xxxi. a</span>) is so distinctly shown by the prominence of the thyroid
+cartilage, and is so superficial that it is quite easy to open it in the
+middle line with a common penknife, there being merely the skin and the
+crico-thyroid membrane to be cut through, with very rarely any vessel of
+any size. The opening can then be kept patent by a quill or a small
+piece of flat wood. This simple operation has in many cases, where a
+foreign body has filled up the box of the larynx, succeeded in saving
+life, and even in cases of disease I have known it useful in giving time
+for the subsequent performance of tracheotomy.</p>
+
+<p>Easy as it appears and really is, cases are on record in which the
+thyro-hyoid space has been opened instead of the crico-thyroid, such
+operations being of course perfectly useless.</p>
+
+<p>The incision is best made transversely.</p>
+
+
+<p class="gap"><span class="smcap">Laryngo-Tracheotomy.</span>&mdash;This modification consists in opening the air
+passage by the division of the cricoid cartilage vertically in the
+middle line, along with one or two of the upper rings of the trachea.</p>
+
+<p>It seems to combine all the dangers with none of the advantages of the
+other methods of operating. It is close to the disease, involves cutting
+a cartilage of the larynx, and almost certain wounding of the isthmus of
+the thyroid; and it is not easy to see what corresponding advantages it
+has over tracheotomy in the usual position.</p>
+
+
+<p class="gap"><span class="smcap">Thyrotomy</span> is an operation by which the larynx is opened in the middle
+line by a vertical incision, and its halves separated, while any morbid
+growths are excised from the cords or ventricles. The merits and dangers
+of this operation have been discussed at length by Mr. Durham<a name="FNanchor_135_135" id="FNanchor_135_135"></a><a href="#Footnote_135_135" class="fnanchor">[135]</a> and
+Dr. Morell Mackenzie.<a name="FNanchor_136_136" id="FNanchor_136_136"></a><a href="#Footnote_136_136" class="fnanchor">[136]</a><span class='pagenum'><a name="Page_216" id="Page_216">{216}</a></span></p>
+
+
+<p class="gap"><span class="smcap">Laryngectomy or Excision of the Larynx</span>, first performed by Dr. Heron
+Watson in 1866, has been lately frequently performed for carcinoma and
+sarcoma. Each case presents its own difficulties, which vary according
+to the amount and extent of the disease for which it is done.</p>
+
+<p>The trachea must be divided and tamponed by a Trendelenburg canula,
+after which the larynx must be carefully dissected out. The immediate
+mortality, <i>i.e.</i> in first ten days, is fifty per cent., and Dr. Gross
+holds that life has not been prolonged by the operation.<a name="FNanchor_137_137" id="FNanchor_137_137"></a><a href="#Footnote_137_137" class="fnanchor">[137]</a></p>
+
+
+<p class="gap"><span class="smcap">&#338;sophagotomy.</span>&mdash;This operation is very rarely required, and has as yet
+been performed only for the removal of foreign bodies impacted in the
+&#339;sophagus, and interfering with respiration and deglutition. To cut
+upon the flaccid empty &#339;sophagus in the living body would be an
+extremely difficult and dangerous operation, from the manner in which it
+lies concealed behind the larynx, and in close contact with the great
+vessels. When it is distended by a foreign body, and specially if the
+foreign body has well-marked angles, the operation is not nearly so
+difficult. It has now been performed in forty-three cases at least, of
+which eight or nine have proved fatal. Seven, along with another in
+which he himself performed it with success, were recorded by Mr. Cock of
+Guy's Hospital.<a name="FNanchor_138_138" id="FNanchor_138_138"></a><a href="#Footnote_138_138" class="fnanchor">[138]</a> Three others were performed by Mr. Syme, with a
+successful result. Of the seven cases collected by Mr. Cock only two
+died, one of pneumonia, the other of gangrene of the pharynx.</p>
+
+<p><i>Operation.</i>&mdash;Unless there is a very decided projection of the foreign
+body on the right, the left side of the neck should be chosen, as the
+&#339;sophagus normally lies rather on the left of the middle line. An
+incision similar to<span class='pagenum'><a name="Page_217" id="Page_217">{217}</a></span> that required for ligature of the carotid above the
+omohyoid should be made over the inner edge of the sterno-mastoid
+muscle; with it as a guide, the omohyoid may be sought and drawn
+downwards and inwards, the sheath of the vessels exposed and drawn
+outwards, the larynx slightly pushed across to the right, the thyroid
+gland drawn out of the way by a blunt hook, the superior thyroid either
+avoided or tied. The &#339;sophagus is then exposed, and if the foreign
+body is large, it is easily recognised; if the foreign body be small, a
+large probang with a globular ivory head should then be passed from the
+fauces down to the obstruction; this will distend the walls of the
+&#339;sophagus, and make it a much more easy and safe business to divide
+them to the required extent. The wound in the &#339;sophagus should be
+longitudinal, and at first not larger than is required to admit the
+finger, on which as a guide the forceps may be introduced to remove the
+foreign body, or, if necessary, a probe-pointed bistoury still further
+to dilate the wound.</p>
+
+<p>For some days or even weeks the patient must be fed through an elastic
+catheter introduced through the nose and retained, or by an ordinary
+stomach-tube through the mouth. In introducing the latter there is
+always a risk of opening the wound. No special sutures for the wound in
+the &#339;sophagus are required, nor is it advisable too closely to sew up
+the external wound.</p>
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_218" id="Page_218">{218}</a></span></p>
+
+<h2><a name="CHAPTER_X" id="CHAPTER_X"></a>CHAPTER X.</h2>
+
+<h3>OPERATIONS ON THORAX.</h3>
+
+
+<p class="gap"><span class="smcap">Excision of Mamma.</span>&mdash;When the whole breast is to be removed, two
+incisions, inclosing an elliptical portion of skin along with the
+nipple, must be made in the direction of the fibres of the pectoralis
+muscle. The distance between the incisions at their broadest must depend
+upon the nature of the disease for which the operation is performed, and
+the extent to which the skin is involved; in every case the whole nipple
+should be removed. The incisions should, if possible, be parallel with
+the fibres of the pectoralis major, and extend across the full diameter
+of the breast. During the operation the arm should be extended so as to
+stretch both skin and muscle. The lower flap should be first raised and
+dissected downwards, with care that the cuts are made in the
+subcutaneous fat, and wide of the disease; the upper flap is then thrown
+open, and the edge of the gland raised, so that the fibres of the
+pectoralis are exposed below it. These should be cleanly dissected, so
+as to insure removal of the whole gland.</p>
+
+<p>Any bleeding during the operation can easily be checked by the fingers
+of an assistant, and if the arteries entering the gland from the axilla
+be divided last, they can be at once secured. If there are many bleeding
+points, the application of cold for a few hours before the wound is
+finally closed is a wise precaution.</p>
+
+<p>The requisite stitches may be inserted while the<span class='pagenum'><a name="Page_219" id="Page_219">{219}</a></span> patient is under
+chloroform, but not tightened. The arm should then be brought down to
+the side, and a folded towel laid over the wound after it is finally
+closed. Great benefit results from the free use of drainage-tubes in
+most cases; for this purpose a dependent opening in the lower flap is
+often made.</p>
+
+<p>Surgeons now operate even when the axillary glands are diseased, and by
+a very free dissection and removal, even in hopeless-looking cases, life
+may be prolonged. To insure the removal of the lymphatic vessels as well
+as the glands, it is best not to separate the breast at its axillary
+margin, but keep it attached by the tail of lymphatics surrounded by
+fat, which will lead up to the glands. Section of the great pectoral
+muscle will aid the dissection.</p>
+
+<div class="blockquot smlet"><p>When the tumour is very large, and the skin has been much stretched
+and undermined, more complicated incisions may be necessary; these
+must be governed a good deal by the presence and positions of
+adhesions or ulcerations of the skin. The best direction, when the
+surgeon has his choice, that these incisions can take, is that of
+radii from the nipple, bisecting the flaps made by the original
+elliptical incision. </p></div>
+
+<p><i>N.B.</i>&mdash;In operating for malignant disease, the one paramount
+consideration is that <i>all</i> the disease be excised, however curious,
+inconvenient, or awkward, even insufficient, the flaps may look. Partial
+excisions are worse than useless.</p>
+
+
+<p class="gap"><span class="smcap">Paracentesis Thoracis</span>, for the relief of pleurisy, acute and chronic,
+and empyema, is an operation of extreme simplicity.</p>
+
+<p>The proper selection of cases, the settling of the suitable position for
+the tapping, and the choosing of the suitable time for it, are more
+difficult, and not within the scope of the present work. On these
+subjects much information may be obtained from the papers of Dr.
+Bowditch of Boston, of Dr. Hughes and Mr. Cock,<a name="FNanchor_139_139" id="FNanchor_139_139"></a><a href="#Footnote_139_139" class="fnanchor">[139]</a> and<span class='pagenum'><a name="Page_220" id="Page_220">{220}</a></span> an exceedingly
+interesting and valuable paper by Dr. Warburton Begbie.<a name="FNanchor_140_140" id="FNanchor_140_140"></a><a href="#Footnote_140_140" class="fnanchor">[140]</a></p>
+
+<p><i>Where</i> is it to be performed? Not <i>above</i> the sixth rib, else the
+opening is not sufficiently dependent; very rarely <i>below</i> the eighth on
+the right side, and the ninth on the left. The intercostal space
+generally bulges outwards if fluid is present, and this bulging acts as
+an aid to diagnosis. As the intercostal artery lies under the lower edge
+of the upper rib in each space, the trocar should be entered not higher
+than the middle of the space; and because the artery is largest near the
+spine, and also the space is there deeply covered with muscle, the
+tapping should never be <i>behind</i> the angle of the rib. In most of the
+manuals we are told to select a spot midway between the sternum and
+spine for the puncture; but Bowditch, Cock, and Begbie, who have had
+large experience, prefer, and I believe rightly, a position considerably
+behind this, <i>an inch</i> or two below the angle of the scapula, between
+the seventh and eighth, or between the eighth and ninth ribs.</p>
+
+<p>The operation may be performed with a simple trocar and canula, round,
+about an eighth of an inch in diameter, and at least two inches in
+length. The point must be sharp, and it must be pushed in with
+considerable quickness, so as to penetrate, not merely push forwards,
+the pleura, which may be tough, and thicker than usual. Once the skin is
+pierced, the instrument must be directed obliquely upwards, so as to
+make the opening and position of the trocar dependent. When the trocar
+is withdrawn the fluid may be allowed to flow so long as it keeps in a
+full equable stream; whenever it becomes jerky and spasmodic, the canula
+should be removed <i>before</i> the sucking noise of air entering the chest
+is heard.</p>
+
+<p>In more chronic cases, where the quantity of fluid is large, and
+especially if it is thick and curdy, the<span class='pagenum'><a name="Page_221" id="Page_221">{221}</a></span> exhausting syringe of Mr.
+Bowditch is an improvement on the simple trocar and canula.</p>
+
+<p>It consists of a powerful syringe, which fits accurately to the trocar
+with which the puncture is made. There is a stop-cock between the trocar
+and syringe, and another at right angles to the syringe. The trocar
+being introduced, it is held firmly in position by an assistant, by
+means of a strong cross handle; the first stop-cock is then opened, and
+the syringe worked slowly till it is filled with fluid through the
+trocar, the other delivery stop-cock being closed. The first is then
+closed, and the second opened; the syringe is then emptied through the
+second into a basin. By a repetition of this process, the fluid can be
+removed at pleasure, without any risk of the entrance of air.</p>
+
+<div class="blockquot smlet"><p>Dieulafoy's aspirateur, which the author has now used in a very
+large number of cases, will be found the best method yet devised of
+safely removing the fluid in cases of serous effusion. But in
+severe cases of empyema the pus is sure to be reproduced in the
+great majority, and then a free incision, with strict antiseptic
+precautions, will be needed, and subsequent free drainage.</p>
+
+<p>The author has used with great benefit silver tubes, like long
+narrow trachea-tubes, with broad shields, to insure free drain. </p></div>
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_222" id="Page_222">{222}</a></span></p>
+
+<h2><a name="CHAPTER_XI" id="CHAPTER_XI"></a>CHAPTER XI.</h2>
+
+<h3>OPERATIONS ON ABDOMEN.</h3>
+
+
+<p class="gap"><span class="smcap">Paracentesis Abdominis.</span>&mdash;To withdraw fluid from the abdominal cavity is
+an exceedingly simple operation in itself, though certain precautions
+are necessary to render it safe.</p>
+
+<p><i>Trocar.</i>&mdash;The usual instrument used to be a simple round canula with a
+trocar, the point of which should be very sharp, and in the shape of a
+three-sided pyramid. It should be about three inches in length, and a
+quarter of an inch in diameter. It may for convenience have an
+india-rubber tube fixed to its side or end, for the purpose of conveying
+the fluid to the pail or basin, but any other additions or alterations
+have not been improvements. Lately surgeons have been diminishing the
+size of the tube so as to withdraw the fluid more slowly, and taking
+many precautions to insure the wound being kept aseptic.</p>
+
+<p><i>Where to tap.</i>&mdash;In the linea alba, midway between the umbilicus and
+pubes, or rather nearer the umbilicus. Here, there are no muscles nor
+vessels, the opening is a dependent one, and the bladder is quite out of
+the way of injury.</p>
+
+<p><i>N.B.</i>&mdash;It is a wise precaution, in every case where there is a
+possibility of doubt as to the state of the bladder, to pass a catheter.
+I have myself known at least one case in which a surgeon was asked to
+tap an over-distended bladder, as a case of ascites.<span class='pagenum'><a name="Page_223" id="Page_223">{223}</a></span></p>
+
+<p><i>The Operation.</i>&mdash;As there is great risk of syncope coming on during the
+operation, from the sudden relief to the pressure on the organs, a broad
+flannel bandage should be applied to the belly, the ends of which are
+split into three at each side, and crossed and interlaced behind. An
+assistant should stand at each side to make gradual pressure by pulling
+on the ends of the bandage, thus assisting the flow, and maintaining the
+pressure. A hole should be cut in the bandage at the spot where the
+puncture is to be made, and the trocar inserted by one firm push,
+without any preliminary incision, unless the patient is inordinately
+fat. As the trocar is withdrawn, the canula should be pushed still
+further in. The surgeon should be ready at once to close the canula with
+his thumb, if the flow begins to cease, lest air should be admitted. If
+the flow ceases from any cause before all the fluid seems to be
+evacuated, the trocar should <i>not</i> be re-introduced, lest the intestines
+be wounded, but a blunt-headed perforated instrument fitting the canula
+should be inserted.</p>
+
+<p>When all the fluid that can be easily obtained is evacuated, the canula
+may be withdrawn, and a pad of lint secured over the wound by strapping.</p>
+
+
+<p class="gap"><span class="smcap">Gastrotomy.</span>&mdash;Cutting into the stomach for the extraction of a foreign
+body has now been performed at least ten times, and all but one
+recovered. A typical example is that by Dr. Bell of Davenport, who
+removed a bar of lead one pound in weight and ten inches in length, by
+an incision four inches in length from the umbilicus to the false ribs.
+The opening into the stomach was as small as possible, and required no
+sutures.</p>
+
+
+<p class="gap"><span class="smcap">Gastrostomy</span> has within the last few years been practised very
+frequently. Gross has collected 79 cases, 57 of which were for carcinoma
+of &#339;sophagus, all of<span class='pagenum'><a name="Page_224" id="Page_224">{224}</a></span> which died within a few weeks, except eight who
+survived for periods varying from three to seven months. The results in
+cases of cicatricial and syphilitic strictures are more
+favourable.&mdash;Howse's method seems the best, consisting of two stages.</p>
+
+<p>1. A curved incision is made through the parietes parallel with, and a
+finger-breadth below, the lower margin of chest wall on left side, the
+peritoneum should be opened at the linea semilunaris, the stomach sought
+for, and then attached to the abdominal wall by an outer ring of sutures
+and to the edge of the wound by an inner ring. It should then be dressed
+with carbolised lint and supported by a bandage.</p>
+
+<p>2. A small opening should be made four or five days after the first
+stage and the patient should be fed through this opening.</p>
+
+<p>For full details, see Mr. Durham's paper in vol. i. of Holmes's Surgery,
+edition of 1883, pp. 801-4.</p>
+
+
+<p class="gap"><span class="smcap">Gastrectomy.</span>&mdash;Excision of whole or part of the stomach is one of the
+latest developments of operative daring, first done as a regular
+operation by Pean in 1879, it has now been repeated sixteen times; four
+cases have survived the operation for more than ten days. The chief
+points to be attended to are prevention of death from shock and
+h&aelig;morrhage, and very careful stitching up of the wound. Considering the
+difficulty of the diagnosis, the danger of the operation, and the almost
+certain recurrence of the disease, the propriety of such operation seems
+very doubtful.</p>
+
+
+<p class="gap"><span class="smcap">Ovariotomy.</span>&mdash;For the pathology of ovarian disease we must refer to Sir
+Spencer Wells's work on the subject, and to the smaller Monograph on
+Ovarian Pathology, by the late lamented Dr. Charles Ritchie, junior.</p>
+
+<p>Even the modifications in the method of operating which have been
+devised are so various and numerous,<span class='pagenum'><a name="Page_225" id="Page_225">{225}</a></span> that if collected from the medical
+journals of the last ten years they would fill a large volume. Besides
+this, the operation of ovariotomy is one attended by so many
+complications, that individual cases vary from each other as much as do
+individual cases of hernia and tracheotomy; and as the specialities of
+each case require to be met by specialities of treatment, there is
+hardly any operation in surgery which requires greater readiness of
+invention, or more individual sagacity in the operator.</p>
+
+<p>To lay open the abdominal cavity from the sternum to the pubes, and
+rapidly dissect out of this cavity an enormous tumour with a narrow
+neck, the operator's only embarrassment being the peristaltic movements
+of the bowels, and his only care being to tie the neck of the tumour
+firmly with strong string, sew up the wound, and trust to nature, was an
+operation very easy to perform, and requiring free cutting rather than
+dexterity, and rashness more than true surgical insight.</p>
+
+<p>Such were the ovariotomies prior to 1857.</p>
+
+<p>An ovariotomy in 1883 is a very different business, varying in certain
+important particulars.</p>
+
+<p>(1.) Instead of the incision extending from sternum to pubes, it is now
+made as short as possible.</p>
+
+<p>(2.) Instead of being removed entire, the cyst is now emptied with the
+greatest possible care (prior to its removal), and none of the contents
+allowed to enter the peritoneal cavity.</p>
+
+<p>(3.) The pedicle is brought to the surface, and in every case where it
+is possible is secured outside the wound.</p>
+
+<p>Besides these three important and cardinal points, there are other minor
+matters almost equally essential; these are&mdash;(1.) The proper management
+of the adhesions and the thorough prevention of all h&aelig;morrhage from
+them; (2.) the stitching up of the external wound, including the
+peritoneum; (3.) the treatment of the patient during the first few days
+of convalescence.<span class='pagenum'><a name="Page_226" id="Page_226">{226}</a></span></p>
+
+<p><i>Operation</i> in a typical case, after the method of Sir Spencer Wells and
+Dr. Thomas Keith.&mdash;The patient having had her bowels gently opened on
+the previous day, and being as far as possible in her usual state of
+health, should be warmly clad in flannel, both in body and limb, and
+laid on an operating table of convenient height, in or near the room she
+is to occupy. No carrying from ward to operating theatre and back again
+is admissible. It will be found both cleanly and convenient to have a
+large india-rubber cloth over the whole abdomen, cut out in the centre
+so as to expose so much of the tumour as is necessary, but gummed on or
+otherwise secured to the sides of the abdomen, and thus protecting the
+clothes, and hanging down over the edge of the table; this will prevent
+all wetting of the clothes and unnecessary exposure of the patient's
+person, and can be easily removed after the operation. Chloroform being
+administered, the bladder is evacuated by means of a catheter, and the
+patient's head and shoulders are elevated on pillows. An incision is
+then made in the linea alba, between the umbilicus and pubes, for about
+four inches in length at first, so as to be large enough to admit the
+hand, through all the tissues down to and through the peritoneum. Care
+is necessary in dividing the peritoneum, on the one hand, not to divide
+too much, in which case the cyst-wall will be penetrated, and the
+contents effused into the peritoneal cavity; or, on the other hand, too
+little, in which case the peritoneum may be mistaken for the cyst, and
+separated from the transversalis fascia under the idea that adhesions
+exist. Once the peritoneal cavity is opened, the incision through the
+peritoneum must be extended to the full length of the external wound by
+a probe-pointed bistoury.</p>
+
+<p>The operator's hand must now be passed into the abdomen, and the tumour
+isolated from its connections as far as possible. When no adhesions
+exist it is<span class='pagenum'><a name="Page_227" id="Page_227">{227}</a></span> extremely easy to pass the hand quite round the tumour,
+ascertain its relations to the uterus and Fallopian tubes, and the
+length and thickness of its pedicle. The presence of adhesions adds very
+seriously to the danger and duration of the operation. We will suppose
+at present that none exist in this typical case, and that the pedicle is
+found of a satisfactory size and shape. The surgeon now protrudes the
+anterior portion of the cyst-wall through the wound, and pierces it with
+a large trocar,<a name="FNanchor_141_141" id="FNanchor_141_141"></a><a href="#Footnote_141_141" class="fnanchor">[141]</a> to which is attached an india-rubber tube, by means
+of which the effused fluid can be easily got rid of in any direction.
+During the escape of the fluid from the cyst a special assistant keeps
+up the tension by careful pressure on the abdomen. In cases where the
+cyst is multilocular, and thus only a portion of the contents of the
+tumour is at first evaluated, the operator should, by partially
+withdrawing the trocar, without removing it entirely from the cyst,
+endeavour to pierce and evacuate the other cysts, still through the
+original opening in the first one.</p>
+
+<p>While doing this, great care must be taken lest he pierce the external
+wall of the tumour, and let any of the contents escape into the
+abdominal cavity; to guard<span class='pagenum'><a name="Page_228" id="Page_228">{228}</a></span> against this, the punctures should be made
+by the right hand, while the left, re-inserted into the abdomen,
+supports the cyst-wall.</p>
+
+<p>The tumour having been as far as possible emptied of its fluid contents,
+must now be dragged out of the wound, care being still taken lest any of
+its fluid contents escape into the peritoneal cavity. In favourable
+cases the pedicle is now brought easily into view. This may vary very
+much in length and thickness. It is sometimes entirely absent, the
+tumour being sessile on the broad ligament of the uterus; sometimes it
+is thick and strong, sometimes long and slender. The manner in which it
+is to be managed depends on its length and thickness. Varieties in
+treatment will be noticed immediately. We will suppose that it is four
+inches in length and one or two fingers in breadth. This is quite a
+suitable case for the use of the clamp, the principle involved in the
+use of which is, that the pedicle should be brought quite out of the
+abdomen through the wound and secured on the surface. The best form
+seems to be one made like a carpenter's callipers, with long but
+removable handles, and a very powerful fixing-screw.</p>
+
+<p>The blades of this clamp being protected by pads of lint should be made
+to embrace the pedicle close to the cyst, in a direction at right angles
+to the abdominal wound, and lying across it, the handles should then be
+removed, and pads of lint placed below the clamp to protect the skin.
+The cyst may now be cut away at some little distance above the clamp,
+enough being left to prevent all danger of its slipping. Further to
+avoid this danger, the pedicle may be transfixed by one or two needles
+above the clamp.</p>
+
+<p>The wound is now to be sewed up by several points of interrupted suture,
+some inserted very deeply through all the tissues, including even the
+peritoneum, others in the intervals of the first, including little more
+than the<span class='pagenum'><a name="Page_229" id="Page_229">{229}</a></span> skin. They may be either of iron, silver, platinum,
+telegraph-wire (Mr. Clover's copper, coated with gutta-percha), or silk.
+It seems of very little consequence which is used. Sir Spencer Wells,
+after many trials, uses silk, as being removed with least pain to the
+patient, and really causing no more suppuration than the metallic ones
+do, if only removed early enough, viz., about the second or third day,
+by which time the union of the wound should be firm.</p>
+
+<p>The after-treatment should be very simple. Except under special
+circumstances, stimulants are rarely necessary, and indeed, to avoid
+vomiting, as little as possible should be given by the mouth during the
+first twenty-four hours. The patient should be allowed to suck a little
+ice to allay thirst, and opiate and nutritive enemata will be found
+quite sufficient to keep up the strength in ordinary cases. The urine
+should be drawn off by the catheter every six hours. The room should be
+kept quiet, and the temperature equable, so long as there is no
+interference with a plentiful supply of fresh air.</p>
+
+<p>Some of the specialities and abnormalities involving special risks may
+now be briefly noticed:&mdash;</p>
+
+<p>1. <i>Adhesions.</i>&mdash;These vary much in amount, in position, in
+organisation, and danger.</p>
+
+<p><i>a.</i> <i>In amount.</i>&mdash;In certain cases no adhesions exist, while in others,
+omentum, intestines, tumour, uterus, and abdominal wall may be all
+matted together in one common mass.</p>
+
+<p><i>b.</i> <i>In organisation.</i>&mdash;Occasionally they are so soft and friable as to
+break down under the finger with ease, and so slightly organised as not
+to bleed at all in the process, while again they may be so firm and
+close as to require a careful and prolonged dissection, and so vascular
+as to require many points of ligature to be applied to large active
+vessels.</p>
+
+<p><i>c.</i> There are special <i>dangers</i> connected with the presence of these
+adhesions, and varying much in different<span class='pagenum'><a name="Page_230" id="Page_230">{230}</a></span> cases. Thus adhesions to the
+intestines can generally be separated with comparative ease, and seem,
+as a rule, to require the application of fewer ligatures than those
+which unite the tumour to the abdominal wall. Adhesions to the wall are
+sometimes so firm as to be quite inseparable, and thus to necessitate
+some of the cyst-wall being left adherent. In Sir Spencer Wells's cases,
+adhesions to the liver and gall-bladder occasionally occurred, requiring
+careful dissection to separate them, and yet the patients all survived,
+while pelvic adhesions, especially to the bladder and uterus, on more
+than one occasion prevented the completion of the operation.</p>
+
+<p>Vascular adhesions to the wall which require many ligatures certainly
+add to the dangers of the case, while adhesions to the anterior wall of
+the abdomen render the operation, especially its first stages, much more
+difficult, preventing the cyst from being recognised.</p>
+
+<p>2. <i>The condition of the pedicle</i> is of great importance. If it is too
+short, it prevents the use of the clamp, as if applied it is apt either
+to pull the uterus up, or, pulling the clamp down, to make undue
+traction on the wound, and rupture any adhesions. This is especially the
+case where much flatus is generated, or where the patient is naturally
+stout.</p>
+
+<p><i>Treatment.</i>&mdash;Where the pedicle is just long enough to allow the clamp
+to be applied, and yet too short to leave room for any distension of the
+abdomen without undue tension, the best plan is to transfix it with a
+stout double thread just below the clamp, tie it in two halves, and
+bring the threads out past the clamp, so that, if tension does occur,
+the clamp may be removed, the part beyond it cut off, and the rest
+allowed to slip back into the pelvis, the ligatures being kept out at
+the mouth of the wound.</p>
+
+<p>Or again, it is sometimes possible, after applying one clamp firmly as
+near the tumour as possible, to apply another above it when the greater
+part of the tumour<span class='pagenum'><a name="Page_231" id="Page_231">{231}</a></span> has been cut away; when the second is firmly fixed
+it may then be safe to remove the first, and thus an artificially
+elongated pedicle is obtained.</p>
+
+<p>When still shorter, two plans remain for selection&mdash;(1.) to transfix the
+pedicle in one or more points, then, securing it in two, three, or more
+portions, cut it off above the ligatures and return it, leaving the
+ligatures at the lower end of the wound. This gives a free drain for
+pus, but theoretically the sloughing pedicle might be expected to set up
+peritonitis; (2.) to transfix and tie the pedicle with one or more loops
+of stout string, cut the ends off short, and return the whole affair,
+closing the external wound at once. Theoretically there are grave
+objections to this plan, but it has proved very successful, especially
+in the hands of Dr. Tyler Smith.</p>
+
+<p>Another ingenious modification, sometimes useful in a short narrow
+pedicle, is to tie it as close to the cyst as possible, bring the
+ligature out at the wound, and then with a strong harelip needle
+transfix the pedicle, along with both sides of the wound, just below the
+ligature.</p>
+
+<p>When the pedicle is excessively broad and stout, it should be transfixed
+by strong needles and double threads in various places, and thus tied in
+several portions. Absence of the pedicle greatly adds to the danger in
+any given case. Various plans have been tried, as cutting the attachment
+through slowly by the &eacute;craseur, ligature of each vessel separately, so
+many as twelve being sometimes required, and cauterising the stump. The
+latter, as used by Mr. Baker Brown, has met with a large measure of
+success, and is much used now.<a name="FNanchor_142_142" id="FNanchor_142_142"></a><a href="#Footnote_142_142" class="fnanchor">[142]</a></p>
+
+<p>Dr. Keith for a time operated with antiseptic precautions,<span class='pagenum'><a name="Page_232" id="Page_232">{232}</a></span> but has now
+(1883) entirely given up the use of the spray, which he believes has
+especial dangers in abdominal surgery.</p>
+
+
+<p class="gap"><span class="smcap">Operation for Strangulated Inguinal Hernia.</span>&mdash;The great rule to be
+remembered with regard to this, as well as all other operations for
+hernia, is, that the earlier it is performed the better chance the
+patient has. Once a fair trial has been given to the taxis, aided by
+proper position of the patient, the warm bath, and specially chloroform,
+the operation should be performed.</p>
+
+<p>The patient should be placed on his back with his shoulders elevated,
+and the knee of the affected side slightly bent. The groin should then
+be shaved, and the shape and size of the tumour, with the position of
+the inguinal canal, carefully studied. The surgeon should then lift up a
+fold of skin and cellular tissue, in a direction at right angles to the
+long axis of the tumour, and holding one side of this raised fold in his
+own left hand, commit the other to an assistant. He then transfixes this
+fold with a sharp straight bistoury, with its back towards the sac, and
+cuts outwards, thus at once making an incision along the axis of the
+hernia without any risk of wounding the sac or bowel. Any vessel that
+bleeds may now be tied. This incision will be found sufficiently large
+for most cases; if not, however, it can easily be prolonged either
+upwards or downwards. The surgeon must now devote his attention to
+exposing the neck of the sac, and in so doing, defining the external
+inguinal ring. The safest method of doing so is carefully to pinch up,
+with dissecting forceps, layer after layer of connective tissue,
+dividing each separately by the knife held with its flat side, not its
+edge, on the sac, and then by means of the finger or forceps raising
+each layer in succession and dividing it to the full extent of the
+external incision. It is not<span class='pagenum'><a name="Page_233" id="Page_233">{233}</a></span> always an easy matter to recognise the
+sac, especially as the number of layers above it, which are described in
+the anatomical text-books, are often not at all distinct.</p>
+
+<p>The thickness of the connective tissue of the part varies immensely;
+sometimes six layers or even more can be separately dissected, while,
+again, one only may be found before the sac is exposed.</p>
+
+<p>If small and recent, the sac may be recognised by its bluish colour, and
+by the fact that it is possible to pinch up a portion of it between the
+finger and thumb, and thus to rub its opposed surfaces against each
+other.</p>
+
+<p>If large and of old standing, it is sometimes so thin as not to be
+recognisable, or again so enormously thickened, and so adherent, as to
+be defined with great difficulty.</p>
+
+<p>If it is small, <i>i.e.</i> when the whole tumour is under the size of an
+egg, it ought to be thoroughly isolated, and its boundaries everywhere
+defined. If large, and specially if adherent, the neck alone should be
+cleared.</p>
+
+<p>The sac thus being reached, the external abdominal ring should be
+clearly defined, and the finger passed into it so as if possible to
+determine the presence or absence of any constriction in it. If it feels
+tight, the internal pillar of the ring should then be cautiously divided
+on the finger by a probe-pointed narrow bistoury, in a direction
+parallel to the linea alba.</p>
+
+<p>At this stage the question comes to be considered as to whether the sac
+should or should not be opened. Much has been said and written on both
+sides.</p>
+
+<p>Not to open the sac avoids the risk of peritonitis, and of injury to the
+bowel; but, on the other hand, exposes the patient to the danger of the
+hernia being returned unreduced; for in many cases the stricture is to
+be found in the sac itself, and adhesions very rapidly form between
+coils of intestine in the sac and the inner wall. Again, not to open the
+sac prevents us from discovering the<span class='pagenum'><a name="Page_234" id="Page_234">{234}</a></span>
+condition in which the <ins class="correction" title="text reads 'bowl'">bowel</ins> is; it
+may possibly be gangrenous, in which case such a return <i>en masse</i> would
+be almost necessarily fatal.</p>
+
+<p>A general rule or two may be given here:&mdash;</p>
+
+<p>1. The sac should be opened in every case where there is any reason for
+doubt about the condition of the bowel, where there has been
+long-continued vomiting, or much tenderness on pressure.</p>
+
+<p>2. Even in cases in which there is every reason to believe the bowel is
+perfectly sound, the sac should be opened, unless the whole contents can
+be easily and completely reduced out of the sac into the belly, as in
+cases where this cannot be done there probably exist either a stricture
+in the neck of the sac itself, or adhesions of the bowel to the sac. We
+should endeavour to avoid opening the sac in cases of old scrotal hernia
+of large size, where the symptoms have not been urgent, especially in
+large unhealthy hospitals, as the risk of peritonitis is so great.
+Antiseptic precautions seem considerably to diminish the risk of opening
+the sac.</p>
+
+<p>If the sac then is not to be opened, the rest of the operation is very
+simple. Endeavour to reduce the bowel out of the sac, and then return
+the sac itself, unless the hernia is of old standing, and adhesions
+prevent its reduction. A few silver stitches to close the wound and a
+carefully adjusted pad are now all that is requisite.</p>
+
+<p>If the sac is to be opened, how can it be done with least danger to the
+bowel?</p>
+
+<p>If the hernia is small, and it is possible to define it all, the sac
+should be opened at its lower end, as <i>there</i> a small quantity of serous
+fluid which intervenes between the sac and the bowel will be found.
+Where this is present, there is no danger of wounding the bowel, as the
+sac can be easily pinched up; but this is by no means invariably the
+case, so great care should always be taken. A small portion of the wall
+being thus<span class='pagenum'><a name="Page_235" id="Page_235">{235}</a></span> pinched up should be divided in the same manner as the
+layers of cellular tissue were divided in exposing the sac. A few drops
+of serum will then escape, and the glistening surface of the bowel be
+exposed; the finger should then be introduced at the opening, and the
+incision enlarged by a probe-pointed bistoury. If the hernia is small
+the sac should be slit up to its full extent; if large, only a
+sufficient portion of the neck should be opened. As soon as the opening
+in the sac is large enough to admit the point of the operator's
+forefinger, it should be inserted so as to protect the intestines, and
+the remainder of the sac slit up on it as a guide.</p>
+
+<p>The sac thus opened, the next step is to divide the constriction,
+wherever it be. It is most likely to be found at the neck of the sac,
+just where it protrudes through the internal ring in an oblique hernia,
+or through the tendons of the transversalis and internal oblique, where
+the hernia is direct. Now, this constriction might be divided in any
+direction were it not for the risk of wounding the epigastric artery,
+and also of injuring the spermatic cord, which is in close relation to
+the neck of the sac of an oblique hernia.</p>
+
+<p>Wound of the epigastric artery is the chief danger, for in <i>all</i> cases
+it is close to the neck of the sac. Were its position in relation to the
+neck of the sac constant, it might be easily avoided by an incision in
+the opposite direction; but as this relation varies according to the
+nature of the hernia, an element of danger is introduced. Thus, in
+oblique inguinal ruptures, where the sac passes out through the internal
+ring (Fig. <span class="smcap">xxxii. ir</span>), the artery will always be found to the inside of
+the neck of the sac; while in direct herni&aelig;, where the bowel has made
+its escape through the triangle of Hesselbach (Fig. <span class="smcap">xxxii.</span> +), and
+passed through the conjoint tendon straight to the external ring, the
+epigastric artery will be found on the outside of the neck of the sac.
+In recent herni&aelig; the differential diagnosis is comparatively easy, but
+in those<span class='pagenum'><a name="Page_236" id="Page_236">{236}</a></span> of old standing and large size, in which the obliquity of the
+canal has been much diminished, it is almost impossible to tell of what
+kind the hernia originally was, and consequently to determine in which
+direction it is safe to incise the neck of the sac.</p>
+
+<p>Such being the case, the best rule is to incise the neck of the sac
+directly upwards, <i>i.e.</i> in a line parallel with the linea alba, and
+also to cut it very cautiously bit by bit, in every case, if possible,
+with the finger inserted as a guide to the position of a vessel and a
+protection to the gut.</p>
+
+<p>The spermatic vessels lie sometimes behind, sometimes on either side of
+the sac, and in very old herni&aelig; may be separated from each other so as
+really to surround the sac. The cut directly upwards is also the safest
+for them.</p>
+
+<p>All constrictions being overcome, it is not sufficient merely to push
+back the gut into the belly. Its condition must be carefully examined,
+and it must be decided whether the constriction has caused gangrene or
+not. To examine this properly, it is generally best to pull down an inch
+or two more of the gut, so as thoroughly to bring into view the
+constricted portion, as <i>it</i> is most likely to be fatally nipped.</p>
+
+<p>It is not always easy to decide as to the condition of the bowel.
+Certain points must be observed:&mdash;</p>
+
+<p>(1.) <i>Colour.</i>&mdash;There may be very great alteration in the colour of the
+bowel from congestion, and yet no gangrene. It may be dark red, claret,
+purple, or even have a brownish tint, and yet recover; where it is
+black, or a deep brown, the prognosis is unfavourable.</p>
+
+<p>(2.) <i>Glistening.</i>&mdash;So long as the proper glistening appearance of the
+bowel remains, there is hope for it, even when the colour is bad; if it
+has lost it, and especially if, instead of being tense and shining, it
+is dull and flaccid and in wrinkles, the bowel is almost certainly
+gangrenous.<span class='pagenum'><a name="Page_237" id="Page_237">{237}</a></span></p>
+
+<p>(3.) <i>Thickness.</i>&mdash;If much thickened, and especially if rough on the
+surface, the bowel has probably been forming adhesions to the sac, or to
+contiguous coils, and the prognosis is less favourable.</p>
+
+<p>(4.) <i>Smell.</i>&mdash;The peculiar gangrenous odour on opening the sac is very
+characteristic. In cases where ulceration and perforation have occurred,
+the odour is f&aelig;cal.</p>
+
+<p>1. If, then, the bowel is tolerably healthy-looking, though discoloured,
+it should be returned gradually, not <i>en masse</i>, into the abdomen, the
+wound sewed up, and a pad of lint put on, with a bandage.</p>
+
+<p>2. If there are adhesions of bowel to sac or to a neighbouring coil, or
+of omentum to sac, the stricture should be freely divided, the
+protruding coils of intestine should be emptied of their contents, but
+no rash attempt made to force their return. Especially is this rule to
+be observed with protruded, swollen, or adherent omentum, for
+considerable risks attend any attempt at excision of the protruded
+portion&mdash;risks of h&aelig;morrhage, peritonitis, and ulceration of the
+contiguous bowel.</p>
+
+<p>If the bowel be returned, or even the continuity of the canal restored
+by the cutting of the stricture, though the bowel be not returned, no
+great risks accrue from the retention of a piece of omentum in the sac,
+in a position which it may possibly have already occupied for years.</p>
+
+<p>3. If the bowel is absolutely gangrenous, even in a very small portion
+of its length, no reduction should be attempted, but the gangrenous
+portion should be kept outside, with the hope that adhesive inflammation
+may be set up, so as to glue the bowel to the abdominal wall, prevent
+f&aelig;cal extravasation, and form a temporary artificial anus. If the
+gangrenous portion be very full of f&aelig;ces or flatus, incisions may be
+made into it. This should be avoided in cases where the patient is
+already much prostrated, as I have seen cases in which the opening of
+the bowel seemed to inflict a fatal shock.<span class='pagenum'><a name="Page_238" id="Page_238">{238}</a></span></p>
+
+<p>Enterectomy or excision of the gangrenous portion has recently been
+recommended and performed by some surgeons. The very high authority of
+the late Professor Spence is against such procedure.<a name="FNanchor_143_143" id="FNanchor_143_143"></a><a href="#Footnote_143_143" class="fnanchor">[143]</a></p>
+
+<p>Cases of gangrene of even large portions of bowel are by no means
+necessarily fatal. They may recover with an artificial anus, the remedy
+of which by surgical means we must notice in its proper place.</p>
+
+
+<p class="gap"><span class="smcap">Operation for Strangulated Femoral Hernia.</span>&mdash;While the general principles
+guiding treatment and ruling the conduct of the operation are the same
+as in inguinal, there are some differences in points of detail which
+render a brief separate description necessary.</p>
+
+<div class="blockquot smlet"><p>A single word on the anatomy. Tracing a femoral rupture from within
+outwards, we find that its first stage is to push its way through
+the weak point of the arch formed by Poupart's ligament, that is,
+the spot called the crural arch, bounded on its outer side by the
+sheath of fascia which surrounds the femoral vein; above by
+Poupart's ligament; on its inner side by the curved fibres of
+Poupart's ligament, which, curving backwards, are inserted into the
+ilio-pectineal line, have a sharp falciform edge, and have been
+dignified by the special name of Gimbernat's ligament (Fig. <span class="smcap">xxxii.
+g</span>); and below by the os pubis itself. This arch or ring thus
+bounded is, in the normal state of parts, filled by a layer of
+fibrous texture, a little fat, and occasionally a small gland.
+These parts are pushed forwards in the descent of the hernia, and
+in a small recent one may be said to form a sort of inner covering;
+in a larger and older one they are split by the hernia, and, while
+forming a constriction round its neck, leave the fundus of the sac,
+so far as they are concerned, quite uncovered.</p>
+
+<p>A femoral hernia may stop there, satisfied with merely coming
+through the ring, and, if sudden and recent in a healthy, well-knit
+subject, such a rupture is exceedingly dangerous, the constriction
+being very severe, and the consequent gangrene of the bowel very
+rapid if unrelieved. In most cases, however, it makes its way still
+further out, and the next covering it gains is from the cribriform
+fascia. This is the layer of fibres, pierced (as its name implies)
+with orifices for the passage of veins and<span class='pagenum'><a name="Page_239" id="Page_239">{239}</a></span> lymphatics, which
+stretches between the two curved edges of the saphenous opening. It
+varies much in strength; when the rupture has been slow and
+gradual, it will certainly add a covering of greater or less
+thickness, but where the hernia is large and old we must not expect
+to find many traces of the cribriform fascia, at least over the
+fundus of the tumour.</p>
+
+<p>The ordinary superficial fascia of the part, with its fat, nerves,
+veins, and lymphatics, and the thin skin of the groin, are the only
+remaining coverings. It is very remarkable how exceedingly thin all
+the so-called coats become in large femoral herni&aelig; of long
+standing, especially in thin old people. </p></div>
+
+<p><i>Operation.</i>&mdash;Various incisions are recommended. The one which gives
+freest access and exposes the sac best, is shaped like a T, the
+horizontal limb of which is oblique, the direction of the obliquity
+varying on the two sides. The horizontal incision should be made just
+over Poupart's ligament, and parallel to it, the centre of the incision
+corresponding to the neck of the sac, and its length varying according
+to the size of the tumour and the depth of the parts; the other should
+extend downwards from the centre of the former, as far as is necessary
+to display the whole sac. The first should be made by pinching up and
+transfixing the skin, the second by ordinary incision, to the same depth
+as the first. The small flaps thus made must now be thrown back; any
+vessels that have been divided are to be tied. Now, with great care and
+caution the surgeon is to pinch up and divide any layers of condensed
+cellular tissue which may still cover the sac, till it is thoroughly
+exposed to its full extent, and remove any glands which may intervene.</p>
+
+<p>The neck of the sac being exposed, it may be possible in some very
+exceptional cases to give the patient the benefit of the minor
+operation, which consists in leaving the sac unopened. In such a case
+(to be described immediately), the surgeon passes his finger along the
+neck of the sac as far as possible into the ring, and then with a
+probe-pointed bistoury very cautiously nicks the<span class='pagenum'><a name="Page_240" id="Page_240">{240}</a></span> upper edge of
+Gimbernat's ligament, in one or more places, being careful to feel for
+any pulsation before dividing a single fibre. He may then be able to
+empty the sac of its contents, and return the bowel and omentum, still
+retaining the sac outside.</p>
+
+<p>On the other hand, where it is determined to open the sac, the pinching
+up of the sac must be managed with great care, to avoid injury of the
+bowel. There is generally a little fluid to be found at the fundus,
+which will protect the bowel. In one case in which Liston operated, he
+tells us, "there was no possibility of pinching up the sac, either with
+the fingers or forceps; it contained no fluid, and was impacted most
+firmly with bowel; very luckily the membrane was thin; and, observing a
+pelleton of fat underneath, I scratched very cautiously with the point
+of the knife in the unsupported hand, until a trifling puncture was
+made, sufficient to admit the blunt point of a narrow bistoury."<a name="FNanchor_144_144" id="FNanchor_144_144"></a><a href="#Footnote_144_144" class="fnanchor">[144]</a> If
+the sac contains bowel and omentum, it is safer to open it over the
+omentum than over the bowel. When a small opening is made, an escape of
+the contained fluid takes place, and then the sac should be slit up as
+far as its neck by a probe-pointed bistoury, guided by the finger,
+introduced to protect the bowel, whenever the opening is sufficiently
+large. The forefinger must now be cautiously insinuated into the neck of
+the sac, the nail being directed to the bowel, the pulp to the
+crescentic margin of Gimbernat's ligament, and any constriction very
+cautiously divided. The bowel should then be drawn down a little, the
+constricted point carefully examined, and then returned or not,
+according to its condition.</p>
+
+<p>Two points require a brief separate notice:&mdash;</p>
+
+<p>1. In what direction is the crural arch to be divided? Not outwards
+certainly, on account of the vein, nor downwards, as the bone prevents
+that direction. Is it<span class='pagenum'><a name="Page_241" id="Page_241">{241}</a></span> to be upwards or inwards? Not upwards, for such
+an incision would endanger the spermatic cord or round ligament, besides
+greatly weakening the abdominal wall by the division, partial or
+complete, of Poupart's ligament. Inwards then it must be; and little
+more need be said about it, were it not for the occasional existence of
+an abnormal course and distribution of the obturator artery.</p>
+
+<div class="figcenter" style="width: 550px;">
+<img src="images/241.jpg" width="550" height="437" alt="Fig. xxxii." title="Fig. xxxii." />
+<span class="caption"><span class="smcap">Fig. xxxii.</span>
+<a name="FNanchor_145_145" id="FNanchor_145_145"></a><a href="#Footnote_145_145" class="fnanchor">[145]</a></span>
+</div>
+
+<p>The usual origin of this vessel is from the internal iliac, in which
+case (Fig. <span class="smcap">xxxii. n o</span>) it never comes near the sac at all. In certain
+cases (1 in 3&#189;) it rises from the epigastric, and in a very few (1 in
+72) from the external iliac. If rising from either of the two last, it<span class='pagenum'><a name="Page_242" id="Page_242">{242}</a></span>
+most commonly passes downwards at the outer side of the hernia, in which
+case (Fig. <span class="smcap">xxxii. s o</span>) no harm can possibly result; but in a few rare
+cases, perhaps 1 in every 60 of those operated on, the vessel winds
+round the hernia (Fig. <span class="smcap">xxxii. o</span>), crossing at its inner side, and thus
+may be (and has actually been) divided by a rash incision. With due
+care, however, and by cutting a very little at a time, even this danger
+may be avoided.</p>
+
+<p>2. Under what circumstances is it possible or justifiable to reduce a
+femoral hernia, without previously opening the sac? Only in certain very
+select cases, where the hernia is recent, the constricting parts lax,
+the general symptoms very mild, and where there is reason to believe the
+bowel has completely escaped injury by compression or the taxis. There
+are both difficulties and dangers in this so-called minor operation:&mdash;1.
+<i>Difficulties</i>, For it is not easy to divide the constriction without
+the assistance of the finger in the sac, and it is not easy to reduce
+the contents with the sac unopened, except through a much freer opening
+than is necessary when the <ins class="correction" title="text reads 'bowl'">bowel</ins> has been fairly exposed. 2.
+<i>Dangers</i>, Of reducing sac and viscera, together with the strangulation
+still kept up by tightness in the neck of the sac; or of supposing the
+sac is emptied while a knuckle of bowel still remains in it, and is
+strangulated; or, lastly, of reducing the intestine which has already
+become gangrenous. It is very remarkable how very soon gangrene may come
+on, in a case of a small recent femoral hernia, in which the fibrous
+tissues constricting the neck of the sac are tense and undilatable. A
+protrusion for eight hours has been sufficient to destroy the life of a
+knuckle of bowel.</p>
+
+<div class="blockquot smlet"><p>A note here on a certain condition very frequent in femoral herni&aelig;,
+which may occasionally give a good deal of trouble. Symptoms of
+strangulation have been well marked, yet when the sac is opened
+nothing is to be seen except a mass of omentum, perhaps tolerably
+healthy-looking. To reduce this <i>en</i><span class='pagenum'><a name="Page_243" id="Page_243">{243}</a></span><i> masse</i> would be very unsafe;
+it is necessary carefully to unravel it, and disengage the knuckle
+of bowel which is almost certainly included in it, and which has
+given rise to the symptoms of strangulation. </p></div>
+
+
+<p class="gap"><span class="smcap">Operation for Strangulated Umbilical Hernia.</span>&mdash;The operation is
+practically the same, whether the hernia is a true umbilical one, or one
+which with more strict accuracy might be called ventral. True umbilical
+hernia is a disease of infancy and childhood, being almost always
+congenital, and the viscera protrude through the umbilical aperture.
+This rarely requires operation, as it may generally be returned with
+ease, and even cured by a proper bandage and compress. Ventral hernia,
+commonly called <i>umbilical</i>, is generally a protrusion of viscera
+through a new preternatural aperture in the fibrous tissues close to the
+navel, may often attain a large size, is liable to strangulation, and is
+not easily palliated or cured.</p>
+
+<p>In either case the operation requires a very brief description. If the
+hernia is small, under the size of a hen's egg, a crucial incision
+through the thin skin which covers it will thoroughly expose the sac
+when the flaps are dissected back. The forefinger should then be
+inserted in the round opening, and the edges cautiously incised in
+several directions, each incision however being very small.</p>
+
+<p>If the rupture is large, a single linear, or a T-shaped incision,
+exposing the base of the tumour, will be sufficient to allow the
+requisite dilatation of the opening to be made. It is not at all
+necessary in every case to open the sac of the peritoneum. If required,
+it must be done with great caution, as the sac is generally very thin.
+In cases where the hernia is chiefly omental, the sac should be opened,
+lest a knuckle of bowel be inclosed and strangulated in the omentum.</p>
+
+
+<p class="gap"><span class="smcap">Obturator Hernia</span> is an extremely rare lesion, and<span class='pagenum'><a name="Page_244" id="Page_244">{244}</a></span> a large proportion of
+the recorded cases were discovered only after death. When diagnosed
+during life and strangulated, some have been reduced by taxis, and only
+a very few cases have been operated on, some with success. It is not
+likely that a diagnosis could be made, except in very emaciated
+patients, in whom pain at the obturator foramen was a prominent symptom,
+and in whom it could be ascertained positively that the crural ring was
+empty. An incision over the tumour, sufficient to allow the pectineus
+muscle to be exposed and divided, is necessary. The hernia may then be
+reduced without opening the sac, if recent; if of long standing, the sac
+must be opened. One case is recorded by Dr. Lorinzer, in which, after
+strangulation for eleven days, he opened the sac and found the bowel
+gangrenous. The patient had a f&aelig;cal fistula; but survived the operation
+for eleven months. Nuttel, Obr&egrave;, and Bransby Cooper have each diagnosed
+and treated such cases.<a name="FNanchor_146_146" id="FNanchor_146_146"></a><a href="#Footnote_146_146" class="fnanchor">[146]</a></p>
+
+<p>Other forms of hernia are so rare, and the treatment of each case must
+necessarily vary so much in its circumstances, as not to require or
+admit of any detailed account of the operations requisite for their
+relief.</p>
+
+
+<p class="gap"><span class="smcap">Operations for the Radical Cure of Hernia.</span>&mdash;The inconveniences and
+discomfort caused by even the best-adjusted trusses or bandages, the
+unsatisfactory support they afford, and the risk of their slipping and
+allowing the hernia to escape, have given rise to many attempts to cure
+hernia by operation.</p>
+
+<p>Even to enumerate these would be quite beyond the limits of the present
+volume; suffice it to classify a few of the most important of them
+according to the principle involved in each, and then give a very brief
+account of the method of operating which seems to be at once the most
+scientific, least dangerous, and most permanently useful.<span class='pagenum'><a name="Page_245" id="Page_245">{245}</a></span></p>
+
+<p>The question at issue is briefly this. We have, in a hernia, the
+following condition:&mdash;The walls of a great cavity are at one or more
+points specially weak, the contained viscera have protruded, either by
+extension and stretching of a natural opening, or by the formation of a
+new breach in the walls, and, in protruding, they have brought with them
+as a covering a serous membrane, extremely extensible, highly sensitive
+to injury, and, when injured, certain to resent it by severe, spreading,
+and dangerous inflammation.</p>
+
+<p>Do we desire to remedy this protrusion, we may act&mdash;</p>
+
+<p>1. On the intestines themselves; but for all surgical purposes, they are
+out of our reach. We cannot do more than, by diminishing their contents,
+diminish their volume, and by position and rest reduce to the utmost
+their tendency to protrude. This includes the medical and prophylactic
+treatment of hernia, or rather of the tendency to hernia.</p>
+
+<p>2. We may try what can be done with the <i>sac</i> which the intestines have
+pushed down before them. Can it be obliterated? If it can, perhaps the
+intestines may be retained in their cavity. Very many plans of dealing
+with the sac have been tried.</p>
+
+<p>To cause obliteration of its cavity many methods have been proposed:&mdash;by
+ligature of it along with the spermatic cord, involving loss of the
+testicle, either by gradual separation, by sloughing, or by immediate
+removal;&mdash;by cutting into it, and then stitching it up;&mdash;by constricting
+it with wire, as in the <i>punctum aureum</i>; by pinching sac and coverings
+up, by passing needles under them as they emerge from the external ring,
+as Bonnet of Lyons did; by constricting sac alone with a double wire, by
+subcutaneous puncture, as Dr. Morton of Glasgow has done;&mdash;by severe
+pressure from the outside with a strong tight truss and a pad of wood,
+as proposed by Richter; by setons of threads or candlewicks, as proposed
+by Schuh of Vienna;&mdash;by injection<span class='pagenum'><a name="Page_246" id="Page_246">{246}</a></span> of tincture of iodine or cantharides,
+as by Velpeau and Pancoast;&mdash;by the introduction into the sac of thin
+bladders of goldbeaters' skin, which were then filled with air, and were
+intended to excite inflammation, as in the radical cure of hydrocele; or
+by the still more severe method of Langenbeck, consisting in exposing
+the sac by a free incision at the superficial ring, separating it from
+the cord, and passing a ligature round the sac alone, leaving the
+ligatured portion in the scrotum either to become obliterated or to
+slough out. Schmucker of Berlin varied this, by cutting away the
+constricted portion below the ligature.</p>
+
+<p>The objections to these methods are various: the more gentle are
+uncertain and inefficient; of the more severe, some involve mutilation,
+by the loss or removal of the testicle; others, as those of Langenbeck
+and Schmucker, are very dangerous and fatal, by the inflammation
+spreading to the peritoneal cavity (20 to 30 per cent. died); while all
+of these methods afford at best only temporary relief. And this is only
+what might have been expected, for the sac was only a <i>result</i> of the
+protrusion, not a <i>cause</i>; and so long as the weakness and insufficiency
+of the parietes of the abdomen remain, so long will the extensible
+loosely-attached peritoneum continue to furnish new sacs for visceral
+protrusions.</p>
+
+<p>3. We have now only the canal left to act upon; and the operations on
+the canal may be divided into two great classes:&mdash;</p>
+
+<p>(<i>a.</i>) Those in which the operator attempts to plug up the dilated
+canal. (<i>b.</i>) Those in which he tries to constrict it, by reuniting its
+separated sides.</p>
+
+<p>(<i>a.</i>) Attempts to plug the canal have, in most cases, been made by
+invagination of the skin of the scrotum and its fascia. These have been
+very numerous and various in their adaptation of mechanical appliances,
+but have all been designed with the same object. Dzondi of Halle, and
+Jameson of Baltimore, incised<span class='pagenum'><a name="Page_247" id="Page_247">{247}</a></span> lancet-shaped flaps of skin, and
+endeavoured to fix them by displacement over the ring. Gerdy invaginated
+a portion of scrotum and fascia into the enlarged canal, by the
+forefinger pushed it up, and secured it in its place by a thread passed
+from the point of his finger first through the invaginated skin, then
+through the abdominal walls, endeavouring to include the walls of the
+inguinal canal, causing the point of the needle to project some lines
+above the inguinal ring; the same process being effected with the other
+end of the thread on the other side of the finger, and the two ends
+which have been brought out near each other on the abdominal wall, being
+tied tightly over a cylinder of plaster. The ensheathed sac was then
+painted with caustic ammonia to excite inflammation, and a pad put on
+over all.</p>
+
+<p>Signoroni modified this by fixing the invaginated skin by a piece of
+female catheter, retained in its place by transfixion by three harelip
+needles, tied by twisted sutures.</p>
+
+<p>W&uuml;tzer of Bonn, again, modified this, by substituting a complicated
+instrument, consisting of a stout plug in the inguinal canal, held in
+position by needles which are passed through the anterior wall of the
+canal in the groin. Compression between plug and compress, with the
+intention of causing adhesion between skin, fascia, and sac, is then
+managed by means of a screw. The plug is retained for about seven days.</p>
+
+<p>Modifications of this method have been tried by Wells, Rothmund, and
+Redfern Davies, all aiming in the direction of simplicity; but by far
+the most simple and efficacious method on the W&uuml;tzer principle yet
+devised is that of Professor Syme, which he described in the pages of
+the <i>Edinburgh Medical Journal</i> for May 1861, in which the invagination
+of integument is both simply and securely managed by strong threads, as
+in Gerdy's method, while a piece of bougie or gutta-percha,<span class='pagenum'><a name="Page_248" id="Page_248">{248}</a></span> to which
+the threads are fixed, replaces W&uuml;tzer's expensive and complicated
+apparatus. Sir J. Fayrer of Calcutta has had a very large experience of
+W&uuml;tzer's method, and also of a plan of his own. Out of 102 cases by the
+latter method, 77 were cured, 9 relieved, 14 failed, and 2 died.<a name="FNanchor_147_147" id="FNanchor_147_147"></a><a href="#Footnote_147_147" class="fnanchor">[147]</a></p>
+
+<p>Mr. Pritchard of Bristol has proposed an additional step in operations
+on the invagination principle, consisting in the stripping of a thin
+slip of skin from the orifice of the cutaneous canal, and then putting a
+pin through the parts to get them to unite, and thus close the aperture
+completely.</p>
+
+<p>Now, what results follow these operations? At first they are almost
+invariably successful, but the complaint is that, in most cases, the
+rupture recurs. The principle is to plug up the passage by the
+mechanical presence of the invaginated skin, the plug being retained in
+position by adhesive inflammation between it and the edges of the
+dilated ring. But the ring is left dilated, or, indeed, generally its
+dilatation is increased; and as, on continued pressure from within, the
+new adhesions give way, or, as often happens, a new protrusion takes
+place in the circular <i>cul-de-sac</i> necessarily left all round the apex
+of the invagination, the still lax ring and canal offer no resistance to
+the protrusion.</p>
+
+<p>(<i>b.</i>) The principle of constriction of the canal by reuniting its
+separated sides. This is the principle of the various methods introduced
+by Mr. Wood of King's College, and described by him in his most able and
+exhaustive work.<a name="FNanchor_148_148" id="FNanchor_148_148"></a><a href="#Footnote_148_148" class="fnanchor">[148]</a></p>
+
+<p>He applies sutures through the sides of the dilated inguinal or crural
+canals, or umbilical openings, in such a manner as to insure their
+complete closure.</p>
+
+<p>1. <i>For inguinal hernia.</i>&mdash;To stitch together the two sides of the canal
+with safety requires attention to<span class='pagenum'><a name="Page_249" id="Page_249">{249}</a></span> several points&mdash;(1.) That it be done
+nearly, if not entirely, subcutaneously. (2.) That the protruding bowel
+should be kept out of the way, and not be transfixed by the needle. (3.)
+That the spermatic cord should be protected from injurious pressure.</p>
+
+<p>These different indications are attained by Mr. Wood by a very ingenious
+mode of operating, which I can describe here only briefly, and for a
+full description of which I must refer to Mr. Wood's own monograph
+already alluded to.</p>
+
+<p>For his first twenty cases Mr. Wood used strong hempen thread for the
+stitches; of late, however, he has proved the greater advantage of
+strong wire.</p>
+
+<p>When a large old hernia in an adult is the subject of operation, it is
+thus performed by Mr. Wood:&mdash;The pubes being shaved, and the patient put
+thoroughly under the influence of chloroform, the rupture is reduced,
+and the operator's forefinger forced up the canal so as to push every
+morsel of bowel fairly into the abdomen. An assistant then commands the
+internal ring by pressure, to prevent return of the rupture.</p>
+
+<p>An incision is made in the scrotum over the fundus of the sac, large
+enough to admit a forefinger and the large needle used in the operation;
+the edges of the skin are to be separated from the fascia below for
+about one inch all round. The forefinger is then to be passed in at the
+aperture and pushed upwards, invaginating the detached fascia before it,
+and it must be made to enter the inguinal canal far enough to define the
+lower border of the internal oblique muscle stretched over it. A large
+curved needle (unarmed) is then passed on the finger as a guide, through
+the internal oblique tendon, the internal portion of the ring, and the
+skin of the abdomen; it is then threaded and withdrawn. Again, the
+needle (now with a thread) is guided by the finger and pushed through
+Poupart's ligament and the external pillar of the ring as before; while
+by a little manipulation its<span class='pagenum'><a name="Page_250" id="Page_250">{250}</a></span> point is made to protrude through the same
+opening in the skin as before, a loop of thread is now left there, and
+the needle, still threaded, is again withdrawn. The next stitch, still
+guided on the finger, takes up the tendinous layer of the triangular
+aponeurosis covering the outer border of the rectus tendon close to the
+pubic spine; the point of the needle is then turned obliquely, so as to
+protrude through the original puncture in the skin a third time, the
+needle is then freed from the thread and withdrawn, thus leaving two
+ends and one intermediate loop of thread all at the one opening. These
+are so arranged that when they are tightened they draw together the
+sides of the canal; they are then secured over a compress of lint. The
+compress is removed and the stitches loosened, at dates varying from the
+third to the seventh day.</p>
+
+<p>Mr. Wood now uses wire instead of thread. It has the advantage of
+greater firmness, excites less suppuration, and may be left much longer
+<i>in situ</i>, in consequence of which there is less risk of suppuration or
+py&aelig;mia, and more chance of a good consolidation of the parts.</p>
+
+<div class="blockquot smlet"><p>In congenital herni&aelig;, and small ruptures in children and young
+boys, Mr. Wood uses rectangular pins in the following manner:&mdash;The
+scrotum being invaginated (without any incision through the skin)
+as far as possible up the canal, a rectangular pin, with a
+slightly-curved spear-pointed head, is passed through the skin of
+the groin to the operator's forefinger; guided by it, it is brought
+safely down the canal, and brought out through the skin of the
+scrotum just over the fundus of the hernial sac. A second pin is
+passed from the lower opening (still guided by the finger) in an
+upward direction, transfixing in its course the posterior surface
+of the outer pillar of the superficial ring, its point being
+brought out through, or at least close to, the first puncture made
+by the first pin. The pins are then locked in each other's
+loops&mdash;the punctures and skin protected by lint or adhesive
+plaster,&mdash;and the whole is retained by lint and a spica bandage.
+The pins should generally be withdrawn about the tenth day. </p></div>
+
+<p>The author has now in many cases stitched with catgut<span class='pagenum'><a name="Page_251" id="Page_251">{251}</a></span> the edges of the
+ring after the ordinary operation for hernia with the best effect.</p>
+
+<p>2. <i>For Femoral Rupture.</i>&mdash;Cases suitable for operation are very
+infrequent; but should such a one be met with, Mr. Wood proposes the
+following operation on the same plan as the preceding. The hernia being
+fully reduced and the parts relaxed by position, an incision about an
+inch long should be made over the fundus of the tumour, and its edges
+raised so as to admit the finger fairly into the crural opening. The
+vein is then to be pushed inwards, and the needle passed through the
+pubic portion of the fascia lata of the thigh, and then through
+Poupart's ligament, appearing on the skin of the abdomen, a wire is then
+passed through the eye of the needle and hooked down, appearing through
+the wound, it is then withdrawn, and the needle again passed through the
+pubic portion of the fascia lata, but about three-quarters of an inch to
+the inside of the first puncture, then through Poupart's ligament again,
+and protruded through the same orifice in the skin; the other end of the
+wire is then hooked down as before, leaving a loop above, at the needle
+orifice, and two ends at the wound in the skin below. Both loops and
+ends must be managed as before.</p>
+
+<div class="blockquot smlet"><p>The author after operating for the relief of strangulation in a
+case of very large femoral hernia in a girl aged 23, stitched up
+the neck of the sac, and also stitched it to Gimbernat's ligament.
+The result for some months was admirable, though the hernia had
+been a very difficult one to replace from its size, and had been
+long in the habit of coming down. Eventually protrusion occurred to
+a very slight extent, but a truss keeps it completely up. </p></div>
+
+<p>3. <i>For Umbilical Rupture.</i>&mdash;The principle involved in Mr. Wood's
+operation for umbilical rupture is precisely the same as for inguinal
+and crural. It consists in stitching the two edges of the tendinous
+aperture by wire; the needle is passed on a sort of small scoop or<span class='pagenum'><a name="Page_252" id="Page_252">{252}</a></span>
+broad grooved director, which at once invaginates the skin and protects
+the bowel. Two stitches are thus inserted on each side. For the
+ingenious method by which they are introduced subcutaneously, I must
+refer to the detailed description in Mr. Wood's monograph. The wires are
+thus twisted and tightened over a pad of lint or wood, drawing together
+the edges of the opening in the tendon.</p>
+
+
+<p class="gap"><span class="smcap">Operations for Artificial Anus.</span>&mdash;In children the condition known as
+imperforate anus may sometimes be remedied by exploratory operations in
+the perineum, guided by the protrusion caused by the distended
+intestine. There are other cases, however, in which the rectum, as well
+as the anus, seems to be deficient, and in which, from the want of
+protrusion, there is no warrant for attempting an operation there; in
+these the only chance of life that remains is in an attempt to open the
+bowel higher up.</p>
+
+<p>In adults, again, absolute closure of the rectum and anus, and complete
+obstruction, may be the result of malignant disease, or even, very
+rarely, of simple organic stricture.</p>
+
+<p>In such cases, where the patient is tolerably strong and yet evidently
+doomed from the complete obstruction, an attempt at the formation of an
+artificial anus is warrantable, and in many cases afford great relief,
+and prolongs life for months.</p>
+
+<p>Without going into all the various positions proposed for such
+operations, I select the two most warrantable, which have borne the test
+of experience. These are&mdash;1. Colotomy in the left loin. This is
+applicable in the case of adults with rectal obstruction. 2. Colotomy in
+the left groin applicable in cases of imperforate anus and deficiency of
+rectum in infants.</p>
+
+<p>1. <i>Colotomy in the left loin</i>, generally known by the name of
+<i>Amussat's operation</i>.&mdash;The patient is laid upon<span class='pagenum'><a name="Page_253" id="Page_253">{253}</a></span> his face, a pillow
+placed under the abdomen, rendering the left flank prominent. A
+transverse incision should then be made at a level about two
+finger-breadths above the crest of the ilium, extending from the outer
+edge of the erector spin&aelig; muscle forward for four or five inches,
+according to the fatness of the patient; the muscles must then be
+carefully divided till the transversalis fascia is exposed. It is then
+to be pinched up and divided, as in the operation for strangulated
+hernia. The muscular wall of the colon uncovered by peritoneum is then
+in most cases very easily recognised from its immense distension. The
+bowel should then be hooked up by a curved needle, two or three points
+at least secured to the margins of the wounds by stitches, and then the
+bowel should be opened by a longitudinal incision of at least an inch in
+length. When the distension has been great, there is generally a rush of
+fluid f&aelig;ces, which must be provided for, special care being taken lest
+any get into the cavity of the peritoneum.</p>
+
+<div class="figright" style="width: 250px;">
+<img src="images/253.jpg" width="250" height="171" alt="Fig. xxxiii." title="Fig. xxxiii." />
+<span class="caption"><span class="smcap">Fig. xxxiii.</span>
+<a name="FNanchor_149_149" id="FNanchor_149_149"></a><a href="#Footnote_149_149" class="fnanchor">[149]</a></span>
+</div>
+
+<p>2. <i>Colotomy in the left groin</i>, for absence of anus and deficiency of
+rectum in newly born infants.&mdash;The dissections of Curling, Gosselin, and
+others have shown that in infants the operation of lumbar colotomy is
+very difficult, and its results uncertain, while it is comparatively
+easy to open the colon in the left groin. Huguier, again, has shown that
+in certain cases the colon is not to be found in the left groin, but is
+accessible in the right groin. This abnormality seems, as shown by
+Curling, to occur not oftener than once in every ten cases.<span class='pagenum'><a name="Page_254" id="Page_254">{254}</a></span></p>
+
+<p><i>Operation.</i>&mdash;An oblique incision from an inch and a half to two inches
+in length should be made in the left iliac region above Poupart's
+ligament, extending a little above the anterior-superior spinous process
+of the ilium. The fibres of the abdominal muscles should be divided on a
+director passed beneath them, and the peritoneum should next be
+cautiously opened to a sufficient extent. The colon will most likely
+protrude, but if small intestine appear the colon must be sought for
+higher up. A curved needle armed with a silk ligature should be passed
+lengthways through the coats of the upper part of the colon, and another
+inserted in the same way below, and the bowel, being drawn forwards,
+should then be opened by a longitudinal incision. The colon must
+afterwards be attached to the skin forming the margin of the wound by
+four sutures at the points of entry and exit of the needles.</p>
+
+
+<p class="gap"><span class="smcap">Operation for the Removal of an Artificial Anus</span>, in cases where the
+bowel is patent below.&mdash;After the operation for hernia in a case where
+the bowel is gangrenous, the only hope of the patient's recovery
+consists in the formation of adhesions between the bowel and the
+external wound, and the presence, for a time at least, of an artificial
+anus. If adhesions do form, and the patient recovers, it becomes a
+matter of great importance for his future comfort that the canal of the
+intestine should be re-established, and the fistulous opening allowed to
+close. This, however, is by no means easy, as even when the portion of
+intestine destroyed has been very small, a septum or valve remains which
+directs the contents of the bowel outwards, and so long as it exists is
+an effectual obstacle to any of the f&aelig;cal contents passing into the
+distal portion of the bowel. This septum or &eacute;peron is formed by the
+mesenteric side of the two ends of the bowel. To destroy this without
+causing peritonitis is the aim of the surgeon,<span class='pagenum'><a name="Page_255" id="Page_255">{255}</a></span> and it is not an easy
+matter to accomplish. To cut it away would at once open the peritoneal
+cavity, so the mode of treatment now adopted in the rare cases where it
+is necessary is that recommended by Dupuytren. The principle of it is to
+destroy the &eacute;peron by pressure so gradual as to cause adhesive
+inflammation between the two surfaces, and thus seal up the cavity of
+the peritoneum, before the continuance of the same pressure shall have
+caused sloughing of the septum. This is managed by the gradual
+approximation by a screw of the blades of a pair of forceps, to which
+Dupuytren gave the name Enterotome. The process, which extends over days
+and weeks, must be carefully watched lest the inflammation go too far.</p>
+
+<p>Plastic operations are occasionally required to close the opening after
+the passage is restored. For a good example of such an operation see
+<i>Edin. Med. Journal</i> for August 1873, in which Mr. John Duncan describes
+a case.</p>
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_256" id="Page_256">{256}</a></span></p>
+
+<h2><a name="CHAPTER_XII" id="CHAPTER_XII"></a>CHAPTER XII.</h2>
+
+<h3>OPERATIONS ON PELVIS.</h3>
+
+
+<p class="gap"><span class="smcap">Lithotomy.</span>&mdash;However interesting and even instructive it might be, any
+history of the various operations for the removal of calculi from the
+bladder would be quite out of place in a manual such as this. It will be
+sufficient here to describe the operations recommended and practised in
+the present day.</p>
+
+<p>There are three different situations in which the bladder may be entered
+for the purpose of removing a calculus:&mdash;</p>
+
+<p>1. The perineum, where access is gained through the urethra, prostate,
+and neck of the bladder.</p>
+
+<p>2. Above the pubes, where the portion of bladder not covered by
+peritoneum is opened from above.</p>
+
+<p>3. From the rectum.</p>
+
+
+<p class="gap">1. <span class="smcap">Lithotomy through the Perineum</span>, by far the most frequent position for
+the operation.&mdash;Very various methods for its performance have been
+devised, differing in the nature and shape of the instruments employed,
+the direction and size of the incisions, the nature of the wound; but
+all resemble each other in certain very cardinal and important
+particulars. Thus all agree that it is absolutely necessary to enter the
+bladder at <i>one</i> spot&mdash;the neck of the bladder; and that to do this
+safely the urethra must be opened, and some instrument<span class='pagenum'><a name="Page_257" id="Page_257">{257}</a></span> previously
+introduced by the urethra is to be used as a guide for the knife. But an
+instrument in the urethra and bladder is surrounded for at least an inch
+of its course by the prostate; and thus the knife, gorget, or finger,
+which, guided by the instrument in the urethra, is intended to cut or
+dilate the entrance to the bladder for the purpose of allowing the
+calculus to be removed, cannot do this without also cutting or dilating
+this prostate gland. Experience has proved that much of the success of
+the operation depends upon the position and amount of incision made in
+this prostate gland. But it might be asked, Why can we not enter the
+bladder by one side, avoiding altogether its neck and this prostate
+gland? For this, among other reasons, that the bladder normally
+contains, and so long as the patient lives must contain, a certain
+quantity of a very irritating fluid. It is surrounded by the loose
+areolar tissue of the pelvis, into which, if any of this fluid escapes,
+abcesses will form and death probably ensue; this result will almost
+certainly follow any opening made into the bladder except at one spot.
+This spot is the neck of the bladder. Why does urinary infiltration not
+occur there? Because the fascia of the pelvis (which when entire can
+resist infiltration) is prolonged forwards at the neck of the bladder,
+over the prostate (Fig. <span class="smcap">xxxiv. pf</span>), for which it forms a very strong
+funnel-like sheath. So long as this sheath is not cut where it covers
+the sides of the prostate, urinary infiltration of the pelvis<span class='pagenum'><a name="Page_258" id="Page_258">{258}</a></span> is
+impossible, the urine being carried forwards and fairly out of the
+pelvis in this urine-tight funnel.</p>
+
+<div class="figright" style="width: 350px;">
+<img src="images/257.jpg" width="350" height="197" alt="Fig. xxxiv." title="Fig. xxxiv." />
+<span class="caption"><span class="smcap">Fig. xxxiv.</span>
+<a name="FNanchor_150_150" id="FNanchor_150_150"></a><a href="#Footnote_150_150" class="fnanchor">[150]</a></span>
+</div>
+
+<p>But it may now be said, If this be the case, we are very much limited in
+the size of the incision we may make into the bladder. We cannot remove
+a large stone, for the prostate ought not to be larger than a good-sized
+chestnut, and any cut we might make through a chestnut without cutting
+out of its side must be very small. Very true; but fortunately the
+sheath of the prostate, unlike the rind of the chestnut, is very freely
+dilatable, and will allow the passage of a very considerable stone.</p>
+
+<p>Again, an inquirer might ask, If it is so dilatable, why should we run
+the risk of cutting the prostate at all? Why should we not introduce
+instruments gradually increasing in size into the membranous portion of
+the urethra, and thus dilate prostate and neck of bladder? For this
+reason, that the urethral canal passing through the prostate is itself
+lined immediately outside of the mucous membrane by a firm membranous
+sheath (Fig. <span class="smcap">xxxiv. rr</span>), which resists dilatation to the utmost.
+Experience tells us that any attempts to dilate or even forcibly to tear
+this ring of fibrous texture are both ineffectual and dangerous, while a
+clean cut into it and through it into the substance of the prostate is
+at once effectual and comparatively safe.</p>
+
+<p>In a word, we can describe the relation of the prostate to the operation
+of lithotomy somewhat in this manner:&mdash;Its fibrous sheath surrounding
+the urethra must be cut freely. The gland substance may be cut and
+freely dilated by the finger. Its fibrous envelope must, as far as
+possible, be preserved intact, but this interferes the less with the
+operation, as it is comparatively freely dilatable.</p>
+
+<p>The firm lining of the urethra, which must be cut, is specially strong
+at its base, forming a tough resisting band just at the aperture of the
+bladder, which, unfortunately,<span class='pagenum'><a name="Page_259" id="Page_259">{259}</a></span> is often so high up in the pelvis in
+tall patients, or in cases in which the prostate is much enlarged, as to
+be almost out of reach of the finger, and so far up the staff as perhaps
+to escape division. You will be warned of such an occurrence by the
+urine in the bladder failing to make its appearance; and if any attempt
+be made to dilate the opening and introduce the forceps without further
+incision of the base of the prostate, the result will very likely be
+fatal, generally from py&aelig;mic symptoms depending on a suppurative
+inflammation of the prostatic plexus of veins (Fig. <span class="smcap">xxxiv</span>.). In fact,
+upon a recognition of this fact is founded the aphorism, "that cases in
+which the forceps have been introduced before the bladder fairly begins
+to empty its contents are generally fatal."</p>
+
+<div class="figright" style="width: 350px;">
+<img src="images/259.jpg" width="350" height="206" alt="Fig. xxxv." title="Fig. xxxv." />
+<span class="caption"><span class="smcap">Fig. xxxv.</span>
+<a name="FNanchor_151_151" id="FNanchor_151_151"></a><a href="#Footnote_151_151" class="fnanchor">[151]</a></span>
+</div>
+
+<p>We have thus traced the necessary guiding principles as to our incisions
+from the bladder outwards through the prostatic portion of the urethra.
+We have next to discover what sort of an opening is necessary in the
+membranous portion of the urethra consistent with the fulfilment of the
+same conditions, namely, freedom of escape for the urine, and room
+enough to remove the stone. Both of these are gained at once by a free
+incision of the membranous portion, dividing especially those anterior
+fibres of the great sphincter muscle of the pelvis, the levator ani,
+which embrace the membranous portion, under the special names of
+compressor (Fig.<span class='pagenum'><a name="Page_260" id="Page_260">{260}</a></span> <span class="smcap">xxv.</span>) and levator urethr&aelig; (Guthrie's and Wilson's
+muscles).</p>
+
+<p>The principles which guide the position and size of the preliminary
+incisions which enable the urethra to be opened are very simple:&mdash;(1.)
+The wound in the perineum should be large enough to give free access to
+the urethra, and easy egress to the stone; (2.) It should be conical,
+with its base outwards, so as to favour escape of urine and prevent
+infiltration; (3.) It should not wound any important organ or vessel;
+that is, it must avoid the rectum, the corpus spongiosum, especially the
+bulb, if possible, the artery of the bulb, and in every case should
+leave the pudic artery intact.</p>
+
+<p>So far for broad general principles, which must guide all methods of
+successful lithotomy.</p>
+
+
+<p class="gap"><span class="smcap">The Lateral Operation.</span>&mdash;<i>Operation of Cheselden.</i>&mdash;(1.) <i>Instruments
+required.</i>&mdash;A staff with a broad substantial handle, and a longer curve
+than the ordinary catheter requires, furnished with a very deep and wide
+groove, which occupies the space midway between its convexity and its
+left side. The one used should invariably be large enough to dilate
+fully the urethra.</p>
+
+<p>A knife, with its blade three or four inches in length, but sharp only
+for an inch and a half from its point, its back straight up to within a
+sixth of an inch of its point, and there deflected at an angle to the
+point, which again curves to the edge. The angle from the back to the
+point permits the knife to run more freely along the groove in the
+staff.</p>
+
+<p>A probe-pointed straight knife with a narrow blade may occasionally be
+useful in enlarging the incision in the prostate, when this is required
+by the size of the stone.</p>
+
+<p>Forceps of various sizes and shapes, some with the blades curved at an
+angle to reach stones lying behind an enlarged prostate, all with broad
+blades as thin as is consistent with perfect inflexibility, the blades
+hollowed<span class='pagenum'><a name="Page_261" id="Page_261">{261}</a></span> and roughened in the inside, but without the projecting teeth
+sometimes recommended, which are dangerous from being apt to break the
+stone.</p>
+
+<p>A scoop to remove fragments or small stones, sometimes useful with the
+aid of the forefinger in lifting out a large one.</p>
+
+<p>A flexible tube of at least half an inch calibre, and about six inches
+long, rounded off and fenestrated above, fitted at its outer end with a
+ring and two eyelet-holes for the tapes, with which it is tied into the
+bladder.</p>
+
+<p>Prior to the operation the patient's health should be attended to, the
+stomach and bowels regulated, and any disorder of the kidneys or bladder
+as far as possible alleviated. If his health has been good and habits
+active, three or four days' confinement to his room on low diet, with a
+full purge the evening before the operation, is all the preparatory
+treatment that is necessary.</p>
+
+<p>It is of the utmost importance for the safety of the operation and the
+patient's comfort after it, that the rectum be completely unloaded
+before the operation, and the bowels so far emptied as to permit three
+or four days after the operation to elapse without any movement of the
+bowels being necessary. If there is any doubt as to the effect of the
+laxative, a large stimulant enema should be administered on the morning
+of the operation.</p>
+
+<p><i>Position.</i>&mdash;Much depends on the proper tying up of the patient. He
+should be placed with his breech projecting over the edge of a narrow
+table, with head slightly raised on a pillow, but the shoulders low. The
+hands are then to be secured each to its corresponding foot, by a strong
+bandage passing round wrist and instep, or by suitable leather anklets,
+the knees should be wide apart, and on exactly the same level, so that
+the pelvis may be quite straight. An assistant should be placed to take
+charge of each leg.</p>
+
+<p>The staff is next introduced and the stone felt; if there is little
+water in the bladder a few ounces may be<span class='pagenum'><a name="Page_262" id="Page_262">{262}</a></span> injected, but this is rarely
+necessary, for the patient should be ordered to retain as much water as
+possible, and when he cannot retain it, injection of water may do harm,
+and will probably not be retained, but at once come away along the
+groove in the staff. The staff is then committed to a special assistant,
+who must be thoroughly up to his duty, and attend to the staff alone.</p>
+
+<p>Some surgeons direct the assistant to make the convexity of the staff
+bulge in the perineum, to enable the groove to be struck more easily. It
+will be, however, safer both for the rectum and the bulb, if the staff
+be hooked firmly up against the symphysis pubis, as advised by Liston.
+The same assistant can also keep the scrotum up out of the way.</p>
+
+<p>If the perineum has not been previously shaved, this is now done.</p>
+
+<p>The operator sits down on a low stool in front of the patient's breech,
+his instruments being ready to his hand, and then steadying the skin of
+the perineum with the fingers of his left hand, enters the point of the
+knife in the raphe of the perineum, midway between the anus and scrotum
+(one inch in front of anus&mdash;<i>Cheselden</i>, <i>Crichton</i>; one and a
+quarter&mdash;<i>Gross</i>, <i>Skey</i>, and <i>Brodie</i>; one and
+three-quarters&mdash;<i>Fergusson</i>; one inch behind the scrotum&mdash;<i>Liston</i>), and
+carries the incision obliquely downwards and outwards, in a line midway
+between the anus and tuberosity of the ischium. The length of the
+incision must vary with the size of the perineum, and the supposed size
+of the stone, but there is less risk in its being too large, so long as
+the rectum is safe, than in its being too small. Its depth should be
+greatest at its upper angle, where it has to divide the parts to the
+depth of the transverse muscle of the perineum, and least at its lower
+angle, where a deep incision is not required, and would be almost sure
+to wound the rectum.<span class='pagenum'><a name="Page_263" id="Page_263">{263}</a></span></p>
+
+<p>The forefinger of the left hand is now to be deeply inserted into the
+wound, and any remaining fibres of the levator ani in front are to be
+divided, the edge of the knife being directed from above downwards. The
+left forefinger being still used to push its way through the cellular
+tissue, the groove in the staff is now felt in the membranous portion of
+the urethra covered by the deep fascia of the perineum. Now comes the
+deeper part of the incision. Guided by the finger-nail of the left hand,
+the surgeon introduces the point of the knife into the groove of the
+staff. He then takes hold of the staff for a moment to feel that it is
+held up properly against the pubis, and in the middle line, and also
+that the knife is fairly in the groove. Giving the staff back again to
+the assistant, and keeping the rectum well out of the way by the left
+hand, he now steadily directs the knife along the groove of the staff
+till the bladder is fairly entered, and the ring at the base of the
+prostate completely divided. When this is the case a gush of urine takes
+place, following the withdrawal of the knife.</p>
+
+<p>When making the deep incision, and in the groove of the staff, the blade
+of the knife should lie neither vertical nor horizontal, but midway
+between the two, so as to make the section of the left lobe of the
+prostate in its longest diameter, that is, in a direction downwards and
+backwards (Fig. <span class="smcap">xxxiv.</span> L).</p>
+
+<p>The knife is now withdrawn, and the left forefinger inserted. In most
+cases it will be long enough to reach the bladder and touch the stone,
+and may then be freely used by gradual pressure to dilate the wound;
+this may be done very freely when necessary for a large stone, if only
+the ring of fibrous tissue surrounding the urethra be first cut and the
+bladder fairly entered. Whenever the stone is felt by the finger, the
+assistant may withdraw the staff.</p>
+
+<p>When the operator has thus felt the stone and sufficiently dilated the
+wound, the next step is to introduce<span class='pagenum'><a name="Page_264" id="Page_264">{264}</a></span> the forceps; this should be done
+under the guidance of the finger, and with the blades closed. When the
+stone is felt the blades should be opened very widely, slightly
+withdrawn, and then pushed in again, the lower one, if possible, being
+insinuated under the stone. The blades must be made fairly to grasp and
+contain the stone in their hollow, for if they only nibble at the end of
+an oval stone, extraction is impossible. Extraction should then be
+performed slowly, with alternate wrigglings of the forceps from side to
+side, so as gradually to dilate, not to tear, the prostate, and the
+operator must remember to pull in the axis of the pelvis, not against
+the os pubis or the promontory of the sacrum.</p>
+
+<p>If there is much resistance, it may possibly be caused by the stone
+having been caught in its longer axis, and this may be remedied by
+careful manipulation by means of the finger and forceps. If the stone is
+still too large to be extracted without greater force than is
+warrantable, there are still various expedients (see <i>infra</i>, pp. 265,
+270).</p>
+
+<p>In most cases, however, the stone is removed rapidly enough by the
+single incision. The finger, or a sound, must then be introduced to feel
+if any more stones are present. The closed forceps make a very effectual
+instrument for this purpose. Much information may be gained from the
+appearance of the first stone, the presence or absence of facets. Its
+smoothness or roughness enables us to form a pretty certain opinion; yet
+the bladder should always be carefully searched; and if the stone has
+been friable or broken in extraction, should be washed out by a current
+of water. Where the calculi are very numerous, or where many fragments
+have separated, the scoop will be found useful, both for detecting and
+removing them. All the stones being extracted, there is in most cases
+little or no bleeding (see <i>infra</i>, H&aelig;morrhage). The tube already
+described may now be inserted and tied into the bladder. It may be<span class='pagenum'><a name="Page_265" id="Page_265">{265}</a></span>
+retained for forty-eight or seventy-two hours, according to
+circumstances. Care must be taken lest it be closed up by coagula during
+the first hour or two after the operation. In children the tube is not
+necessary, and from their restlessness might possibly do harm, but in
+adults (though neglected by some surgeons) experience shows it is a
+valuable adjunct in the after-treatment.</p>
+
+<p>Having thus traced the course of an ordinary uncomplicated case of
+lithotomy by the lateral operation, a brief notice is suitable of some
+of the obstacles and difficulties, some of the dangers and bad results
+which may be met with, and the best methods of overcoming them.</p>
+
+<p>1. <i>Large size of the stone</i>, as an obstacle to extraction. When, either
+from the enormous size of the stone, generally to be made out before the
+operation, or from some congenital or acquired deformity of the pelvis,
+it is obvious beforehand that the calculus cannot pass through the bony
+pelvis entire, a choice of two courses remains, either&mdash;</p>
+
+<p>(1.) The high or supra-pubic operation (<i>q.v. infra</i>); or (2.) Crushing
+of the calculus in the bladder, and removal piecemeal. Instruments of
+great strength have been devised for this latter operation. The risk to
+the bladder is very great, and fragments are apt to be left behind;
+these are sure to form nuclei of new calculi.</p>
+
+<p>2. <i>Peculiarities in the position or relations of the stone</i> in the
+bladder:&mdash;</p>
+
+<p>(1.) It may lie in a sort of pouch behind the prostate, and thus be out
+of the reach of the forceps. This may be remedied by the use of curved
+forceps, or, better still, by the finger in the rectum to tilt up the
+stone into the bladder.</p>
+
+<p>(2.) It may lie above the pubis in the anterior wall of the bladder.
+Pressure on the hypogastrium, or the use of a strong probe as a hook,
+will generally suffice to dislodge it.<span class='pagenum'><a name="Page_266" id="Page_266">{266}</a></span></p>
+
+<p>(3.) The stone may be encysted. This is extremely rare, and, as
+Fergusson says, we hear more of these from bunglers who have operated
+only several times, than from those who have had large experience.</p>
+
+<p>3. <i>An enlarged prostate</i> is at once a source of difficulty and of some
+danger.</p>
+
+<p>The distance of the bladder from the surface may be so very much
+increased by enlargement of the prostate as to render even the longest
+forefinger too short to reach the stone or even the bladder. This
+renders the introduction of the forceps more difficult and uncertain,
+the dilatation more prolonged, and the extraction more dangerous. If
+very large, the groove of the staff may not reach the bladder, and thus
+the deep incision may fail of cutting the ring at the base of the gland,
+and the urine may thus not escape, and all the dangers of laceration of
+the ring may result. Such cases may be well managed by the insertion of
+a straight deeply grooved staff into the insufficient incision, and
+fairly into the bladder, and on this, pushing a cutting gorget through
+the uncut portion of the gland. This insures a sufficient yet not
+dangerous incision, which we cannot so safely perform with the knife, as
+the parts are so far beyond the reach of the guiding forefinger.</p>
+
+<p>Under the head of risks after lithotomy we may class the following:&mdash;</p>
+
+<p>1. Sinking, or shock. In the very aged or very young, or after a very
+prolonged or painful operation, shock may now and then kill the patient
+within a few hours. Since the days of chloroform this result is
+extremely rare.</p>
+
+<p>2. H&aelig;morrhage seems to be a very infrequent risk. The transverse
+perineal artery, which is always cut in the operation, is small, and
+rarely bleeds much. If the bulb is wounded, as no doubt frequently
+occurs, the flow from it can easily be checked. The pudic is so well
+protected from any ordinary incision as to be practically<span class='pagenum'><a name="Page_267" id="Page_267">{267}</a></span> safe; and if
+wounded by some frightfully extensive incision, it can be compressed
+against the tuberosity of the ischium.</p>
+
+<p>There is an abnormal distribution of the dorsal artery of the penis, in
+which, rising higher up than it ought, and coursing along the neck of
+the bladder, and the lateral lobe of the prostate, it may be divided.
+This may give trouble, and even result in fatal h&aelig;morrhage. Fortunately
+it is rare. The author has met with one case in a boy of eleven, in whom
+a very severe h&aelig;morrhage was not to be explained. The patient recovered
+without another bad symptom.</p>
+
+<p>Again, a general oozing may often appear a few hours after the
+operation, when the patient is warm in bed, apparently from the
+substance of the prostate. If raising the breech and the application of
+cold fail to arrest it, it may be necessary to plug the wound. This is
+done by stuffing it with long strips of lint round the tube. Great care
+must be then taken lest the tube become occluded.</p>
+
+<p>3. Infiltration of urine may occur as a result of a too free incision of
+the vesical fascia (in adults), and still more frequently of a too small
+external wound.</p>
+
+<p>Here it should be noticed that in children it is fortunately of very
+little consequence to preserve the integrity of the prostatic sheath of
+vesical fascia. In them the prostate is so exceedingly small and
+undeveloped, that even the forefinger could not be introduced into the
+bladder without a complete section of the prostate. Probably from the
+blander nature of their urine, and the greater vitality of their
+tissues, this is of less consequence, as it is rarely found that any bad
+effects result from this section.</p>
+
+<p>Among other risks we find peritonitis, inflammation of neck of bladder,
+inflammation of prostatic plexus of veins, resulting in py&aelig;mia,
+suppression of urine, and other kidney complications. For the symptoms
+and<span class='pagenum'><a name="Page_268" id="Page_268">{268}</a></span> treatment of these there is no place in a mere manual of surgical
+operations.</p>
+
+<p><i>Wound of rectum and recto-vesical fistula.</i>&mdash;Such wounds were not
+uncommon, and in many cases unavoidable, before the days of chloroform,
+from the struggles of the patient; now they are comparatively rare, and
+should be still rarer. They probably occur in more cases than the
+surgeon is aware of, and heal up without his knowledge; we may arrive at
+this conclusion from the fact that small wounds are found in
+<i>post-mortem</i> examinations of cases in which no such complication has
+been thought of.</p>
+
+<p>They occasionally heal without giving any trouble, but, at other times,
+as the external wound contracts, a communication forms between rectum
+and the urethra, in which the contents are apt to be interchanged in a
+most disagreeable manner, flatus passing per urethram, and urine per
+rectum.</p>
+
+<p>When it is evidently not going to heal spontaneously, the septum between
+the external orifice of the wound and the communication with the gut
+should be laid open, as in the operation for fistula <i>in ano</i>.</p>
+
+<div class="blockquot smlet"><p>There are certain modifications and varieties in the method of
+operating for stone through the perineum, which deserve at least a
+brief notice:&mdash;</p>
+
+<p>1. <i>The bilateral operation.</i>&mdash;Though he was not the inventor,
+Dupuytren's name is justly associated with this operation. The
+principle of it is to divide both sides of the prostate equally, so
+as to give more room for extraction of a large stone, without the
+necessity of much laceration, or the risk of cutting through the
+prostatic sheath of fascia.</p>
+
+<p><i>The operation.</i>&mdash;A semilunar incision is made transversely across
+the perineum, extending from a point midway between the right tuber
+ischii and the anus, upwards, crossing the raphe nearly an inch
+above the anus, and then curving downwards to a corresponding point
+on the opposite side. The skin, superficial fascia, and a few of
+the anterior fibres of the external sphincter, are thus divided,
+and the groove of the staff sought by the forefinger. The
+membranous portion of the urethra is then laid open<span class='pagenum'><a name="Page_269" id="Page_269">{269}</a></span> in the middle
+line, and the beak of a double lithotome cach&eacute; securely lodged in
+the groove. It is then pushed into the bladder with its concavity
+upwards, and when fairly in it is turned round, its blades
+protruded to the required extent, and withdrawn with its concavity
+downwards, thus dividing both lobes of the prostate in a direction
+downwards and outwards (Fig. <span class="smcap">xxiv.</span> D D). The operation is finished
+in the usual manner. Though it is a comparatively easy operation,
+and theoretically may be proved to have many advantages, experience
+has shown that the results are not so favourable as those of the
+ordinary lateral operation.</p>
+
+<p>2. <i>Buchanan's medio-lateral operation</i> on a rectangular
+staff.&mdash;The staff is bent at a right angle three inches from the
+end, and deeply grooved on its left side. This is introduced into
+the urethra so that the angle projects the membranous portion of
+the urethra close to the apex of the prostate and the terminal
+straight portion enters the bladder parallel to the rectum. The
+angle projects in the perineum, so that the operator with his left
+forefinger in the rectum is enabled, by a stab with a long straight
+bistoury (held horizontally and with the cutting edge to the left
+side), at once to enter the groove, and, by following the groove,
+the bladder. Whenever the escape of urine shows that the bladder is
+fairly reached, the knife is withdrawn so as to make a lateral
+section of the prostate, and then, with the finger still in the
+rectum, to make an incision in the ischio-rectal fossa, of
+<ins class="correction" title="text reads 'sufficent'">sufficient</ins> size to allow the stone to be easily
+withdrawn.</p>
+
+<p>The inventor claims for this method that it is easier, that there
+is less risk of h&aelig;morrhage, wound of the rectum, and infiltration
+of urine.</p>
+
+<p>3. <i>Allarton's operation of median lithotomy</i> suits admirably for
+stones known to be small, but is quite unsuitable for large ones.
+Probably in most cases it should be superseded by lithotrity.</p>
+
+<p><i>Operation.</i>&mdash;A large curved staff with a central groove is to be
+held firmly hooked up against the symphysis pubis, and then
+steadied by the left forefinger in the rectum. The operator pierces
+the raphe of the perineum with a long straight bistoury about half
+an inch above the verge of the anus, enters the groove of the
+staff, and cuts inwards, almost, but not quite, into the bladder.
+In withdrawing the knife the wound in the urethra is enlarged
+upwards towards the scrotum. A ball-pointed probe is then passed on
+the staff into the bladder, the staff is withdrawn, and the finger,
+guided by the probe, is used to dilate the neck of the bladder, to
+an extent sufficient for the removal of the stone by a small pair
+of forceps.</p>
+
+<p>In this operation the prostate is hardly incised at all. The
+results are not better than those of the lateral operation. </p></div><p><span class='pagenum'><a name="Page_270" id="Page_270">{270}</a></span></p>
+
+<p class="gap">2. <span class="smcap">Lithotomy above the Pubes</span>, <i>or the High Operation</i>.&mdash;In cases where,
+from the known size of the stone, or from the deformity of the bones of
+the pelvis, it is impossible that the stone can be extracted entire in
+the usual manner; in cases where the prostate is very much enlarged, or
+where there is any real or supposed likelihood of inflammation of the
+neck of the bladder, the supra-pubic operation <i>may</i> be warrantable. Its
+performance is easy, it does not involve any wound of the peritoneum if
+properly performed, and there is no risk of h&aelig;morrhage. There are
+certainly great risks attending it of peritonitis and urinary
+infiltration.</p>
+
+<p>In more than one case this operation has been attended by wound of
+peritoneum and subsequent escape of intestines through the wound, even
+when dressed antiseptically and performed under spray.</p>
+
+<p><i>Operation.</i>&mdash;The patient lies on his back, with his head and shoulders
+slightly raised, so as to relax the abdominal muscles, and his legs
+hanging down over the edge of the table. If his bladder can bear it, it
+should be fully distended, either by voluntary retention of the urine,
+or by injection with tepid water. A vertical incision is then made in
+the middle line, separating the recti muscles from below upwards, care
+being taken to push the peritoneum well out of the way, which is easily
+done by the finger in the loose cellular tissue of the part. The
+anterior wall of the bladder is then exposed, uncovered by peritoneum;
+it must be opened with great care, also in the middle line, while the
+wound in the parietes is held aside by retractors. The wall of the
+bladder should be transfixed by a curved needle, and thus held in
+position before it is opened. The stone is then removed by a pair of
+straight forceps, generally with great ease. Attempts used to be made to
+leave a catheter or canula in the bladder wound to prevent infiltration.
+Probably the safest method now will be to close the bladder wound at
+once by metallic<span class='pagenum'><a name="Page_271" id="Page_271">{271}</a></span> stitches, and stitching the abdominal wound carefully
+with deeply entered wires, to leave the patient on his back. When
+compared with the lateral operations the statistics of the supra-pubic
+operation are discouraging, the mortality being one in three and a half
+to one in four. But in cases where the stone is known to be very large
+and of firm consistence, the risks are probably less from this method
+than from lateral lithotomy, followed by efforts to crush the stone
+through the wound prior to its removal.</p>
+
+<p>The late Mr. George Bell, a most successful lithotomist, proposed to
+perform this operation in two stages. In a case of greatly enlarged
+prostate, where the bladder had been punctured above the pubes by a
+country surgeon for retention of urine, he dilated the track of the
+canula by means of sponge-tents gradually increased in size, and then
+succeeded in extracting through the dilated opening several large
+calculi. The case recovered, and may encourage similar attempts.</p>
+
+<p class="gap">3. <span class="smcap">Operations through the Rectum.</span>&mdash;(<i>a.</i>) <i>Sanson's Recto-vesical
+Operation.</i>&mdash;The principle of this operation consisted in laying the two
+canals, the rectum and the urethra, into one. A large staff, grooved on
+its convexity, being inserted into the urethra, the operator, with the
+forefinger of his left hand in the rectum as a guide to the knife,
+pierces the anterior wall of the rectum, reaches the groove of the staff
+just in front of the prostate, and cutting outwards divides the rectum,
+the anterior fibres of levator ani, and the sphincter, as well as the
+skin of the perineum in the middle line. Entering the knife again into
+the groove of the staff, it is to be pushed right onwards into the
+bladder, dividing the prostate, and avoiding if possible the seminal
+vesicles and ducts; the stone is then very easily removed.</p>
+
+<p>Though this operation was supposed to lessen the risk of pelvic
+infiltration it is <i>not</i> found to do so, and<span class='pagenum'><a name="Page_272" id="Page_272">{272}</a></span> it adds the additional
+inconvenience of almost inevitable rectal fistula, through which the
+urine escapes. It is certainly a very easy operation, but the mortality
+is found to be greater than in the ordinary lateral operation.</p>
+
+<p>(<i>b.</i>) <i>Lithotomy through the rectum above the prostate.</i>&mdash;The presence
+of a small portion of bladder beyond the prostate in close relation to
+the rectum renders it possible, in cases where the prostate is not
+enlarged, to enter the bladder and remove a stone of moderate size,
+without interfering with the peritoneum, prostate, or neck of the
+bladder.</p>
+
+<p>This ingenious but difficult operation was performed for the first time
+by Drs. Sims and Bauer in 1859.</p>
+
+<p>I quote the brief notice of the operation by Dr. Sims from the <i>Lancet</i>
+of 1864 (vol. i. p. 111):&mdash;</p>
+
+<p>"The patient was placed on the left side, and my speculum was introduced
+into the rectum, exposing the anterior wall of the rectum, just as it
+would the vagina in the female. A sound was passed into the bladder. The
+doctor entered the blade of a bistoury in the triangular space bounded
+by the prostate, the vesicul&aelig; seminales, and the peritoneal
+reduplication. He passed the finger through this opening, felt the
+stone, and removed it with the forceps without the least trouble. The
+operation was done as quickly and as easily as it would have been in a
+female through the vaginal septum. After the removal of the stone, Dr.
+Bauer kindly asked me to close the wound with silver sutures, which I
+did, introducing some five or six wires, with the same facility as in
+the vagina. There was no leakage of urine. The patient recovered without
+the least trouble of any sort. The wires were removed on the eighth day,
+and on the ninth day the patient rode in a carriage with Dr. Bauer a
+distance of four or five miles, to call on, and report himself to, our
+distinguished countryman, Dr. Mott."</p>
+
+<p>The chief risks in this operation seem to be the<span class='pagenum'><a name="Page_273" id="Page_273">{273}</a></span> chance of wounding the
+peritoneal <i>cul-de-sac</i>, as the amount of free space between it and the
+prostate seems to vary much in individuals and in races. Dr. Marion Sims
+mentioned to me in conversation that he believed this operation
+impossible in the negro race, from the greater projection downwards of
+the peritoneal reduplication. An enlarged prostate would be an
+insuperable objection. The use of silver wire, to close up the wound at
+once, diminishes very much any risk of recto-vesical fistula.</p>
+
+
+<p class="gap"><span class="smcap">Lithotrity or Lithotripsy.</span>&mdash;There exist cases of stone in the bladder,
+which, under certain conditions, may be relieved without lithotomy, by
+an operation which crushes the stone into fragments small enough to be
+discharged through the urethra.</p>
+
+<p>To enter with any fulness into the history, literature, and varieties of
+this operation, and the instruments required, would in itself require a
+large volume. Suffice it here to describe the case suitable for the
+operation, the essentials required in the instrument, and the method of
+performance.</p>
+
+<p>1. <i>For a case to be suitable</i> the <i>stone</i> should not be too large, and
+especially not too hard, also there should not be too many of them.</p>
+
+<p>The <i>urethra</i> should be capacious enough to let the instrument pass
+easily and painlessly.</p>
+
+<p>The <i>bladder</i> should be large enough to contain four ounces of water at
+least, should not be much inflamed, and, on the other hand, should not
+be paralysed. Paralysis or want of tone in the bladder prevents the
+thorough evacuation of its contents, and still more the expulsion of the
+fragments of stone.</p>
+
+<p>2. <i>A good instrument</i> should, as far as possible, combine strength with
+lightness. The curved portion of the fixed blade should be fenestrated
+to allow escape of the fragments and thorough closure of the
+instrument.<span class='pagenum'><a name="Page_274" id="Page_274">{274}</a></span></p>
+
+<p>The movable blade must be so arranged as to combine perfect ease of
+movement up and down in seeking for the stone, with a powerful, slow,
+and gradual approximation in crushing it. This can be managed by an
+ingenious arrangement, which leaves the movable blade under the control
+only of the operator's thumb till the stone is found, and yet, by
+touching a spring, gives him the advantage either of a fine screw or of
+a rack and pinion movement for crushing the stone.</p>
+
+<p>3. <i>Operation.</i>&mdash;The patient being prepared by a free evacuation of the
+bowels, and the urethra having been previously fairly dilated, he is
+asked to retain his urine as long as possible, or, if he cannot do so, a
+few ounces of tepid water may be injected per urethram.</p>
+
+<p>He is then laid on a sofa or table, the breech being well raised by
+pillows, the shoulders low, the thighs and knees bent up and separated.
+The instrument, well warmed and oiled, is then introduced with the
+blades closed. When fairly into the bladder the search for the stone
+begins.</p>
+
+<p>There are differences of opinion regarding the best method of fishing
+for the stone; great patience and gentleness, with a thorough previous
+acquaintance with bladder manipulation, are required, whichever method
+be chosen.</p>
+
+<p>The two chief methods may be described as the English and the French,
+the latter, Civiale's, being now used by Sir Henry Thompson, and other
+English operators. Briefly, the two are:&mdash;</p>
+
+<p>(1.) <i>Heurteloup's and Sir B. C. Brodie's.</i>&mdash;In this, after the
+instrument is fairly entered, its handle is elevated, thus depressing
+the curved extremity, the forceps are then opened, and, by being kept as
+low as possible in the bladder, it is hoped that the calculus will fall
+into the opened blades by its own weight. In this method<span class='pagenum'><a name="Page_275" id="Page_275">{275}</a></span> the fundus is
+the scene of crushing, and there is a risk of injuring the sensitive
+neck of the bladder, especially at the moment of opening the blades.</p>
+
+<p>(2.) <i>Civiale's&mdash;Thompson's.</i>&mdash;In this the pelvis is to be so elevated
+that the centre of the bladder and space beneath it give plenty of room
+for seizing the stone, and all contact with the wall of the bladder is
+(as far as possible) avoided.</p>
+
+<p>The instrument is introduced closed, and carried fairly away in to the
+posterior part of the bladder before it is opened at all. It probably
+grazes the stone in passing, and, if so, is directed to the side of the
+bladder in which the stone is <i>not</i> lying. Then when nearly touching the
+posterior wall, the movable blade is withdrawn, the instrument inclined
+towards the stone lying unmoved in the most dependent part, and there
+seizes it generally with ease.</p>
+
+<p>If not felt, the blades are again to be opened, turned a little to the
+other side of the bladder, and then closed. Sir H. Thompson lays the
+greatest stress on the importance of always having the blades fairly
+opened before shifting their position, for if moved when closed, the
+very opening of the movable blade is certain to drive the stone out of
+the way and prevent its seizure.</p>
+
+<p>Certain rules are useful:&mdash;Move the axis of the instrument as little as
+possible; it should be kept in the centre of the bladder, so far in,
+that the movements of the male blade are quite free from the neck of the
+bladder and prostate, and the blades only should be moved in the bladder
+on the centre of the shaft as an axis. There should be no jerking once
+the stone is caught, and the crushing should be done as far as possible
+in the very centre of the bladder, the blades not touching any of the
+walls.</p>
+
+<p>After the stone is seized, do not crush till, by a turn of the blades
+from side to side, you discover that none<span class='pagenum'><a name="Page_276" id="Page_276">{276}</a></span> of the mucous membrane of the
+bladder is caught in the instrument.</p>
+
+<p>The lithotrite is not meant to extract stones, but to crush them, hence
+never attempt to withdraw it unless the blades are in absolute
+apposition.</p>
+
+<p>Never attempt too much at one time. Sir H. Thompson holds that five
+minutes is the longest time that should be given, perhaps in most cases
+three minutes being long enough.</p>
+
+<p>While many surgeons will still agree with the above advice, Dr. Bigelow
+of Boston has lately been highly commending a method which he has called
+Litholapaxy, in which, at one sitting under chloroform, the stone is
+crushed and aspirated, or sucked out of the bladder at once.<a name="FNanchor_152_152" id="FNanchor_152_152"></a><a href="#Footnote_152_152" class="fnanchor">[152]</a></p>
+
+<div class="blockquot smlet"><p>Since the above was written the operation of Litholapaxy has made
+great strides in the favour of surgeons, and many stones that would
+have been removed by lithotomy are now broken down by powerful
+instruments at a single sitting, and removed piecemeal by the
+suction apparatus.</p>
+
+<p>S. W. Gross has collected 312 cases, of which 17 died or 5.45 per
+cent., but of 180 done by experienced surgeons, Thompson, Bigelow,
+Van Buren, Weir, and Stevenson only five died, or 3.33 per cent.,
+while of 1470 cases of lithotrity, as formerly practised, 159, or
+10.81, per cent. died.<a name="FNanchor_153_153" id="FNanchor_153_153"></a><a href="#Footnote_153_153" class="fnanchor">[153]</a> </p></div>
+
+
+<p class="gap"><span class="smcap">Operations for Stricture of Urethra.</span>&mdash;Under this head many manipulations
+and operations might be described; the very instruments devised being
+exceedingly numerous and complicated. Enough here to detail a few of the
+more simple and practical procedures under the different heads of&mdash;1.
+<i>Dilatation</i> gradual and forced. 2. <i>Internal Division.</i> 3. <i>External
+Division.</i></p>
+
+<p class="gap">1. <span class="smcap">Dilatation.</span>&mdash;Under this head we have&mdash;</p>
+
+<p><i>a.</i> <i>Vital dilatation.</i>&mdash;The passing of a succession of bougies,
+gradually increasing in diameter, at intervals of<span class='pagenum'><a name="Page_277" id="Page_277">{277}</a></span> three or four days,
+for the purpose of exciting an amount of interstitial absorption in the
+new material constituting the stricture, sufficient to remove it.
+Passing a bougie, though certainly often very difficult, perhaps should
+hardly come into the category of surgical operations, yet to preserve a
+certain completeness in the account of stricture, a very brief
+description may be here inserted.</p>
+
+<p>The recumbent posture is in most cases to be preferred. The patient
+should lie flat on his back, with the knees slightly bent and separated,
+and the head and shoulders slightly raised on a pillow. The operator
+standing on the patient's left side, raises the penis in his left hand,
+and with the right introduces the instrument, previously warmed and
+oiled, into the meatus. He then pushes it very gently onwards, at the
+same time stretching the penis with the left hand, just so far as to
+efface any wrinkles in the mucous membrane, till the point reaches the
+bulbous portion. The axis of the instrument, which at first for
+convenience was over the left groin, has now gradually been approaching
+the middle line. When this is reached, the instrument should be raised
+from the abdomen, and the handle cautiously carried in the arc of a
+circle first upwards and then downwards, till, when the instrument is
+fairly into the bladder, the handle is depressed between the patient's
+thighs. While this is being done the operator's left hand should be
+withdrawn from the penis, and the points of the fingers applied to the
+perineum.</p>
+
+<p>In cases of difficulty certain points may be remembered:&mdash;</p>
+
+<p>(1.) That the point of the instrument may in the first inch or two be
+occasionally entangled in a lacuna in the roof, especially when a small
+instrument is used; hence the beak should be at first maintained against
+the inferior wall of the canal.<a name="FNanchor_154_154" id="FNanchor_154_154"></a><a href="#Footnote_154_154" class="fnanchor">[154]</a><span class='pagenum'><a name="Page_278" id="Page_278">{278}</a></span></p>
+
+<p>(2.) That the handle should not be depressed too soon; if it is, there
+is a risk of a false passage being made through the upper wall.</p>
+
+<p>(3.) The opposite error may force the point out of the urethra between
+the membranous portion and the rectum, and onwards into the substance of
+the prostate gland.</p>
+
+<p>And certain cautions may be given:&mdash;</p>
+
+<p>(1.) In every exploration of an unknown urethra the surgeon should
+commence with an instrument of medium size, certainly not less than No.
+7 or 8.</p>
+
+<p>(2.) In cases of difficulty occurring in the urethra behind the scrotum,
+invariably use the forefinger of the left hand in the rectum as a guide.</p>
+
+<p>(3.) Expression of pain on the part of the patient is no indication that
+a false passage is being made, nor its absence that the instrument is in
+the passage, for it is a remark of Mr. Syme, that passing an instrument
+through a stricture is generally more painful than making a false
+passage through the walls of the urethra.</p>
+
+<div class="blockquot smlet"><p>An instrument may be passed, while the patient is erect, with the
+following precautions:&mdash;The patient should stand with his back
+against a wall, his arms supported on the back of a chair on each
+side, heels eight or ten inches apart, and four or five inches from
+the wall; his clothes thoroughly down, not merely opened. The
+bougie should then be held nearly horizontal, with its concavity
+over the left groin of the patient, the penis being raised in the
+surgeon's left hand. Introduced thus for four or five inches, the
+handle is gradually raised into the middle line of the abdomen, and
+to the perpendicular; it is then to be lightly depressed, and, as
+the point enters the bladder, brought down towards the operator
+until it sinks beneath the horizontal line. </p></div>
+
+<p><i>b.</i> <i>Mechanical dilatation</i> is of two kinds, both very rarely
+used:&mdash;(1.) When an instrument cannot be passed, it consists of passing
+down day after day the point of an instrument (sometimes armed with
+caustic, sometimes not), and pressing it against the stricture<span class='pagenum'><a name="Page_279" id="Page_279">{279}</a></span> till it
+is overcome.<a name="FNanchor_155_155" id="FNanchor_155_155"></a><a href="#Footnote_155_155" class="fnanchor">[155]</a> (2.) When an instrument is introduced through an
+intractable stricture, and is left there either for some hours, or for
+some days, to excite what is called "suppuration" of the stricture.<a name="FNanchor_156_156" id="FNanchor_156_156"></a><a href="#Footnote_156_156" class="fnanchor">[156]</a></p>
+
+<p><i>c.</i> <i>Forced dilatation.</i>&mdash;Under this head we might describe at great
+length mechanical contrivances to force or rupture a stricture. A word
+or two on a few of the most important:&mdash;</p>
+
+<p>(1.) Conical bougies of steel or silver.</p>
+
+<p>(2.) Mr. Wakley's method, on which many others have been founded. He
+passed a small bougie or wire into the bladder, over which were slipped
+straight tubes of varying size, with perfect certainty that they could
+not leave the urethra.</p>
+
+<p>(3.) Mr. Holt's method.<a name="FNanchor_157_157" id="FNanchor_157_157"></a><a href="#Footnote_157_157" class="fnanchor">[157]</a>&mdash;The principle of it is to rupture the
+stricture at once, so that a No. 12 catheter can immediately be passed
+into the bladder.</p>
+
+<p>He attains this object by means of an instrument composed of two grooved
+blades, united about one inch from their apex, into a conical sound,
+which at its apex is about the size of a No. 2 bougie. This is passed
+into the bladder, and the grooved blades are separated to any extent
+that is desired by passing down between them a straight rod equal in
+size of a No. 8, 10, or 12, bougie. To guide this properly it is made
+hollow, and it is passed down over a central wire which lies between the
+grooved blades of the instrument and is welded to the apex. A great
+improvement is effected on Mr. Holt's later instruments by this wire
+being made hollow, and fitted with a stilette, for by this means we can
+with certainty ascertain whether or not the instrument has been passed
+into the bladder. This instrument, which is an improvement upon one
+invented<span class='pagenum'><a name="Page_280" id="Page_280">{280}</a></span> by Perr&egrave;ve nearly forty years ago, has been used on very many
+occasions by Mr. Holt and others with success. The risk to life, if the
+case be properly managed, is trifling, but, like every other means of
+treating stricture, it has the objection that the stricture is liable to
+recur, unless bougies be passed at intervals for months and years.</p>
+
+<p>Sir Henry Thompson has introduced and described another very ingenious
+instrument for the same purpose, constructed on somewhat similar
+principles. His account of it, to which I must refer, will be found in
+Holmes's <i>System of Surgery</i>, 1st ed. vol. iv. p. 399.</p>
+
+<p class="gap">2. <span class="smcap">Internal Division of Stricture</span> is a mode of treatment which by many
+surgeons is highly disapproved, yet of late years it has been more used
+than formerly, especially in resilient strictures. It may be done in two
+ways:&mdash;</p>
+
+<p>(1.) <i>From before backwards.</i>&mdash;This method, to be at all admissible,
+requires a guide to be previously passed; a lancet-shaped blade may then
+be slipped down a groove in this guide till the stricture is divided.
+This is least objectionable in cases of stricture close to the meatus.</p>
+
+<p>(2.) <i>From behind forwards.</i>&mdash;To make the incision thus, it is of course
+necessary that the stricture should be so far dilatable as to admit an
+instrument the point of which is large enough to contain the blade by
+which the stricture is to be divided. This will be found to be at least
+equal in size to a No. 3 or No. 4 catheter. In many instruments it is
+much larger.</p>
+
+<p><i>Civiale's</i> instrument for internal incision of the urethra from behind
+forwards has the very high recommendation of Sir H. Thompson.<a name="FNanchor_158_158" id="FNanchor_158_158"></a><a href="#Footnote_158_158" class="fnanchor">[158]</a> It
+consists of a sound with a bulbous extremity (as large as a No. 5
+bougie) which contains a small blade, which can be made to project<span class='pagenum'><a name="Page_281" id="Page_281">{281}</a></span> for
+such a distance as the operator wishes. It is passed through the
+stricture with the blade concealed, till the bulb is carried about
+one-third of an inch or more beyond the stricture; the blade is then
+projected, and the incision made by drawing it slowly but firmly
+outwards towards the meatus, with the blade towards the floor of the
+urethra, till the stricture is divided in its whole extent. Sir H.
+Thompson recommends this to be used in cases <i>where it is not that the
+stricture is of very small calibre, but that it is undilatable</i>, that
+prevents the cure. Many modifications of above have been devised by
+Lund, Teevan, and other surgeons, on similar principles.</p>
+
+<p class="gap">3. <span class="smcap">Mr. Syme's Operation of External Division.</span>&mdash;Mr. Syme held that no
+stricture through which the water can escape should be called
+<i>impermeable</i>, for by patience and care the surgeon should always be
+able to pass a slender director through the stricture on which it may be
+divided with ease and certainty. The old operation of "perineal section"
+for so-called impermeable stricture is very different, being difficult,
+dangerous, and uncertain in its results.</p>
+
+<p><i>Operation.</i>&mdash;A director is passed into the stricture. Mr. Syme's
+directors are of different sizes, the smallest being in diameter less
+than an ordinary surgical probe. They are made of steel, are grooved on
+the convexity, and have this peculiarity, that while the lower half is
+small, the upper is of full size (No. 8 or 10), the difference in
+calibre occurring quite abruptly. The presence of this "shoulder" on the
+staff enables the operator to ascertain exactly the position of the
+stricture, and also to tell when it is fully divided without the
+necessity of withdrawing the instrument.</p>
+
+<p>This being fairly in the stricture, the patient is put in the position
+for lithotomy, an assistant holds the staff in his right hand, drawing
+up the scrotum with his left.</p>
+
+<p>The surgeon then makes an incision in the middle<span class='pagenum'><a name="Page_282" id="Page_282">{282}</a></span> line over the
+stricture for the necessary distance, from above downwards, till he
+exposes the urethra, and feels exactly the shoulder of the staff. Care
+must be taken not to go past the urethra at either side. When he
+distinctly feels the outline of the staff, he takes it in his left hand,
+and a short sharp-pointed bistoury in his right. It should be held
+firmly in the palm of the hand, with the back of the blade resting on
+the forefinger, the pulp of which guides the point to the groove, and
+guards it when making the incision; the knife is to be placed on the
+groove beyond (<i>on the bladder side</i>) of the stricture, and brought
+forwards, slowly cutting through <i>the whole</i> stricture; till the
+shoulder of the staff is reached. It requires strength and precision to
+divide thoroughly the indurated stricture, which is apt to elude the
+knife.</p>
+
+<p>The shoulder of the staff can now be passed through the stricture if the
+operation is complete; if not, the incision must be extended, always in
+the middle line, and guided by the groove. When thoroughly divided, the
+staff is now to be withdrawn, and a full-sized catheter with a double
+curve passed into the bladder. This should <i>not</i> be furnished with a
+stop-cock or plug, lest the bladder should by inadvertence be allowed to
+be too full, and extravasation into the cellular tissue of the urethra
+take place along the side of the instrument.</p>
+
+<p>The catheter should be tied in, and left for two, sometimes for three
+days, when it can generally be removed with safety, and a bougie should
+be passed at intervals of three or four, till the wound is healed. To
+prevent recurrence of the stricture, it is a wise precaution to pass an
+instrument at intervals for many months after the cure is apparently
+complete.</p>
+
+<p>In certain cases, where the stricture is far back and the urinary
+symptoms severe, Mr. Syme found advantage from the introduction of a
+shorter double-curved catheter (only about nine inches long) through
+the<span class='pagenum'><a name="Page_283" id="Page_283">{283}</a></span> wound into the bladder, where it should be left for three days.
+This seems to diminish the risk of rigors, and other symptoms of fever,
+which are apt to occur when the urine is allowed for the first time to
+pass over the wound.</p>
+
+<p><i>Perineal Section</i> is an operation both dangerous and difficult; as Sir
+Astley Cooper used to say, "the surgeon who performs it requires to have
+a long summer's day before him."</p>
+
+<p>No director or guide can be passed. A full-sized catheter must be passed
+as far as possible <i>up</i> to the stricture, and held firmly in the middle
+line. The patient must be tied up in lithotomy position on a table in
+the very best light that can be obtained. The perineum being shaved, an
+incision must be made in the middle line from over the point of the
+catheter to the verge of the anus, if the stricture extends far back.</p>
+
+<p>The urethra should then be opened over the catheter, the edges of the
+mucous membrane held to each side by silk threads passed through them;
+and the surgeon must endeavour to pass a fine probe into the opening of
+the stricture; if this can be done, it is comparatively easy to slit the
+stricture up. If not, the surgeon must simply seek for the remains of
+the urethra by slow, cautious dissection in the middle line. If
+successful, a catheter must be secured in the bladder in the usual way.</p>
+
+<p>A stricture near the orifice, or, as it is not uncommon, involving
+merely the meatus, can be treated with great ease in the above manner by
+division on a grooved probe. When quite close to the orifice, with a
+well-defined hardness, as of a ring round the urethra, it may be divided
+subcutaneously by a tenotomy knife or other narrow-bladed instrument. It
+is not necessary to keep a catheter in the bladder in cases where the
+stricture has been in front of the scrotum.</p>
+
+
+<p class="gap"><span class="smcap">Puncture of the Bladder.</span>&mdash;A patient and dexterous<span class='pagenum'><a name="Page_284" id="Page_284">{284}</a></span> use of the catheter
+prevents this operation from being often required; still, circumstances
+may arise in which it is found impossible to enter the bladder <i>per vias
+naturales</i>. In such a case the bladder may be punctured from the outside
+by a curved trocar and canula, in either of two situations.</p>
+
+<p>1. <i>From above the pubis.</i>&mdash;This operation is a very simple one, and
+when the bladder is distended need not imply a wound of the peritoneum.</p>
+
+<p><i>Operation.</i>&mdash;A preliminary incision, varying in length according to the
+amount of fat, should be made above the pubis exactly in the middle
+line; the edges of the recti should be separated, the peritoneum pushed
+out of the way and upwards by the finger, and a curved trocar plunged
+into the distended bladder obliquely backwards. The canula should be
+retained for a day or two, and then a flexible catheter with a shield
+inserted instead. Such instruments have been worn for years. The
+aspirateur pneumatique of Dr. Dieulafoy will be found an exceedingly
+useful instrument for puncture of bladder and removal of urine. The
+author has now used it very frequently with the best results. Its
+advantage is that the urine is removed through an aperture so small as
+to allow of the withdrawal and reintroduction of the canula as often as
+is necessary.</p>
+
+<div class="figleft" style="width: 289px;">
+<img src="images/284.jpg" width="289" height="350" alt="Fig. xxxvi." title="Fig. xxxvi." />
+<span class="caption"><span class="smcap">Fig. xxxvi.</span>
+<a name="FNanchor_159_159" id="FNanchor_159_159"></a><a href="#Footnote_159_159" class="fnanchor">[159]</a></span>
+</div>
+
+<p><span class='pagenum'><a name="Page_285" id="Page_285">{285}</a></span></p>
+
+<p>2. <i>From the Rectum.</i>&mdash;Except in cases of enlargement of the prostate,
+it is at once easier and safer to puncture the bladder from the rectum.
+The well-known triangular space uncovered by peritoneum, with its apex
+in front close to the prostate, and bounded on either side by the vasa
+deferentia and vesicul&aelig; seminales, can be easily reached by a curved
+trocar. This should be guided by one, or, still better, by two fingers,
+into the rectum, with its concavity upwards, and the point should be
+pushed upwards by depression of the handle, whenever it is fairly behind
+the prostate. The trocar may then be withdrawn, and the canula retained
+for at least forty-eight hours by a suitable bandage. Mr. Cock, of Guy's
+Hospital, had a special canula for the purpose, which expands at its
+extremity after its introduction, and thus is not apt to slip.<a name="FNanchor_160_160" id="FNanchor_160_160"></a><a href="#Footnote_160_160" class="fnanchor">[160]</a> Some
+surgeons insist that the surgeon should be able to ascertain the
+existence of fluctuation between the finger in the rectum, and the other
+hand above the pubes. This is exceedingly difficult to elicit when the
+bladder is very much distended, and from the constrained position of the
+finger in the bowel.</p>
+
+
+<p class="gap"><span class="smcap">Phymosis.</span>&mdash;Elongation of the prepuce, with contraction of its orifice,
+in most cases congenital, sometimes so extreme as to cause difficulty in
+micturition, and frequently preventing the uncovering of the glans.</p>
+
+<p><i>Operation.</i>&mdash;In all well-marked cases, the following is required:&mdash;The
+elongated prepuce should be pulled forwards by a pair of catch-forceps,
+and a circle of skin and mucous membrane removed by a single stroke of a
+bistoury, or by sharp scissors. Care should be taken lest the glans be
+included in the incision, as has happened in <i>at least</i> one instance.
+The skin will then be found to retract very freely beyond the glans, but
+the mucous membrane is found still to cover the glans, and<span class='pagenum'><a name="Page_286" id="Page_286">{286}</a></span> its orifice
+is still constricted. It must then be slit up (Fig. <span class="smcap">xxxvii.</span> <i>b b</i>) on
+the dorsum of the glans, with probe-pointed scissors, as far as the
+corona, and the glans will then be thoroughly exposed. The edges of
+mucous membrane and skin should then be stitched to each other by at
+least five or six fine silk sutures, any bleeding points having been
+first carefully secured. The angles will in time round off, and a
+wonderfully seemly prepuce be obtained. This operation may be done as a
+method of cure for obstinate enuresis in cases in which the prepuce is
+very long and redundant, even when it is not too tight. The author has
+done this in more than twenty cases with excellent results.</p>
+
+<div class="figleft" style="width: 250px;">
+<img src="images/286.jpg" width="250" height="242" alt="Fig. xxxvii." title="Fig. xxxvii." />
+<span class="caption"><span class="smcap">Fig. xxxvii.</span>
+<a name="FNanchor_161_161" id="FNanchor_161_161"></a><a href="#Footnote_161_161" class="fnanchor">[161]</a></span>
+</div>
+
+<div class="blockquot smlet"><p><i>Varieties.</i>&mdash;When the prepuce is narrowed at its orifice without
+being redundant in length, a milder operation will prove
+sufficient. The principle is the same as in the former, but the
+amount of incision is less, and nothing is removed. Two methods are
+possible:&mdash;</p>
+
+<p>1. <i>By scissors.</i>&mdash;The blunt point of a pair of scissors is
+introduced through the preputial orifice, the other blade being
+outside, and the skin and mucous membrane are divided for about
+half an inch; the skin being then retracted, the mucous membrane is
+still further divided by one or two additional snips, and then the
+edges of skin and mucous membrane are stitched together by one or
+two points of suture.</p>
+
+<p>2. <i>By knife.</i>&mdash;A director being introduced within the prepuce, a
+narrow-bladed knife is guided along it, and pushed through the
+prepuce from within, and then made to divide skin and mucous
+membrane from within outwards. Stitches as before.</p>
+
+<p><i>N.B.</i>&mdash;Be careful lest the director pass into the meatus
+urinarius, and the glans be split up.<span class='pagenum'><a name="Page_287" id="Page_287">{287}</a></span></p>
+
+<p>Again, some surgeons prefer two lateral incisions instead of one
+dorsal one. In this case skin and mucous membrane should be divided
+by scissors for about a quarter of an inch, and then a single
+stitch inserted in the angle of junction. This has been further
+modified by Cullerier, who proposed the division of the tight
+mucous membrane only, in three or four points. He used a pair of
+scissors with one sharp and one probe-pointed blade, the sharp one
+thrust in between skin and mucous membrane, the blunt one between
+the mucous membrane and the glans. </p></div>
+
+
+<p class="gap"><span class="smcap">Amputation of the Penis.</span>&mdash;This exceedingly simple operation is performed
+by a single stroke of an amputating knife, drawn along from heel to
+point, while the penis is stretched in the operator's left hand. As
+there is more risk of redundancy than of deficiency of the skin, no
+attempt is made to save it. Numerous vessels in the corpora cavernosa
+require ligature. Amputation of the penis may be done bloodlessly by the
+thermo-cautery even close to its root. Transfix the root of corpora
+cavernosa by a needle; above this pass two or three turns of an elastic
+ligature; then slowly divide at a low red heat the skin and corpora
+cavernosa below the needles; split the urethra after dividing its mucous
+membrane with a knife. The author has done this several times with ease
+and rapid healing.</p>
+
+<div class="figright" style="width: 150px;">
+<img src="images/287.jpg" width="150" height="165" alt="Fig. xxxviii." title="Fig. xxxviii." />
+<span class="caption"><span class="smcap">Fig. xxxviii.</span>
+<a name="FNanchor_162_162" id="FNanchor_162_162"></a><a href="#Footnote_162_162" class="fnanchor">[162]</a></span>
+</div>
+
+<p>The chief risk is stricture of the orifice of the urethra. To prevent
+this, several modifications of the operation have been introduced.</p>
+
+<p>1. <i>Ricord's method.</i><a name="FNanchor_163_163" id="FNanchor_163_163"></a><a href="#Footnote_163_163" class="fnanchor">[163]</a>&mdash;After the amputation the surgeon seizes with
+forceps the mucous membrane of the urethra, and with a pair of scissors
+makes four slits in it, so as to form four equal flaps, and with a silk
+ligature stitches each of these to the skin. Contraction of the
+cicatrix<span class='pagenum'><a name="Page_288" id="Page_288">{288}</a></span> will thus tend to open rather than close the urethral orifice.</p>
+
+<p>2. <i>Teale's method.</i><a name="FNanchor_164_164" id="FNanchor_164_164"></a><a href="#Footnote_164_164" class="fnanchor">[164]</a>&mdash;He slits up, by a bistoury on a director, the
+urethra and skin over it for about two-thirds of an inch, and then
+stitches the one to the other, thus making it a long oval dependent
+orifice (Fig. <span class="smcap">xxxviii.</span>).</p>
+
+<p>3. <i>Miller's proposed method.</i><a name="FNanchor_165_165" id="FNanchor_165_165"></a><a href="#Footnote_165_165" class="fnanchor">[165]</a>&mdash;"A narrow-bladed knife is first
+used to transfix the penis between the spongy and cavernous bodies close
+to the root; the knife having been carried forwards for an inch and a
+half, its edge is turned perpendicularly downwards, and the urethra and
+skin flap are divided, the cavernous bodies and dorsal integument being
+then cut perpendicularly upwards where the knife was originally entered
+for transfixion. A button-hole is afterwards made in the lower flap,
+though which the corpus spongiosum and urethra protrude, while the flap
+itself is turned upwards, and attached dorsally and laterally, so as to
+cover in the exposed cavernous structure."</p>
+
+<p><span class="smcap">Hydrocele.</span>&mdash;The very simple operation necessary for hydrocele is thus
+performed:&mdash;The surgeon supports the tumour in his left hand so as to
+project it forwards, and make the scrotum as tense as possible in front.
+Having carefully ascertained the exact position of the testicle, which
+can generally be easily enough done by a finger accustomed to
+discriminate the difference between a soft solid, and a bag tensely
+filled with fluid, aided by the peculiar sensation of the testicle when
+squeezed, the surgeon enters a trocar and canula about an eighth of an
+inch in diameter into the distended cavity of the tunica vaginalis, near
+the fundus of the swelling. When it is evident the instrument is fairly
+entered, and not till then, the trocar is withdrawn, and the fluid
+allowed completely to drain off. When it<span class='pagenum'><a name="Page_289" id="Page_289">{289}</a></span> ceases to flow the surgeon
+places his forefinger over the end of the canula to prevent the entrance
+of air, till he fits into its orifice a suitable syringe containing two
+drachms of the tincture of iodine, made according to the Edinburgh
+Pharmacop&#339;ia: the tincture of the British Pharmacop&#339;ia is not
+sufficiently strong. Having injected this cautiously into the cavity,
+the canula is withdrawn, and the surgeon, seizing the now flaccid
+scrotum in his right hand, gives it a thorough shake, so as to spread
+the iodine over as much as possible of the inner wall. When properly
+performed this very simple procedure very rarely fails to produce a
+radical cure; though less thorough operations, such as mere evacuation
+of the fluid, less stimulating injections, unguents introduced on
+probes, and the like, often fail of success, and thus give encouragement
+to absurdities, such as wire-setons, or to more severe operations, such
+as laying open the sac.</p>
+
+
+<p class="gap"><span class="smcap">H&aelig;matocele.</span>&mdash;When the contents of the sac of the tunica vaginalis are
+found to be grumous instead of simply serous, or when, as often happens,
+only pure blood escapes when the fluid is nearly evacuated, it is found
+that simple evacuation and injection are very rarely sufficient to
+effect a cure.</p>
+
+<p>After they have been fairly tried, the sac of the h&aelig;matocele should be
+laid open in its full extent; any large vessels which bleed should be
+tied, and the cavity then stuffed with lint. When the lint can be
+removed, which will be after two or three days, the edges of the wound
+should be brought closely together, and the cavity will then rapidly
+heal up from the bottom, and be obliterated by secondary union of
+granulations.</p>
+
+<p>In cases where the walls of the cavity are enormously thickened, or
+even, as sometimes happens, almost bony in consistence, an elliptical
+portion may be removed with advantage.<span class='pagenum'><a name="Page_290" id="Page_290">{290}</a></span></p>
+
+
+<p><span class="smcap">Excision of Testicle.</span>&mdash;This operation is rarely required except for
+tumours of the testicle. Hence the size of the incision necessary must
+vary much with the size of the tumour; and the amount of skin to be
+removed (if any) on the amount of adhesions it has formed to the tumour.</p>
+
+<p>One or two points must be attended to in every case of extirpation of a
+testicle:&mdash;</p>
+
+<p>1. The incision should commence over the cord just outside of the
+external ring, and be continued fairly over the tumour to its base.</p>
+
+<p>2. As to removal of skin, some surgeons advise that none should be taken
+away, others that a considerable quantity can be spared. There is
+certainly less risk of secondary h&aelig;morrhage if a portion be removed,
+than when a flaccid empty bag is left. The author invariably removes a
+very large quantity of skin if the tumour is large, as there is much
+more rapid healing, and the resulting scrotum is much more comfortable
+for the patient.</p>
+
+<p>3. The cord should be exposed at the beginning of the operation, raised
+from its bed and given to an assistant, who should compress it gently,
+not from any fear of its escape into the abdomen, but to prevent
+h&aelig;morrhage. If the tumour has been very large and heavy, the cord will
+have been much stretched, and if divided too high up, may really give
+trouble by its elasticity, unless the above precaution is taken. The
+cord then having been divided close to the tumour, the latter is
+removed, care being taken not to include the sound testicle in the
+removal. All the vessels are then to be tied or twisted, and the
+spermatic artery is to be secured alone, not, as used to be the case,
+included in a common ligature with the other constituents of the cord.
+Secondary h&aelig;morrhage is very apt to occur from small scrotal branches
+which may have escaped notice during the operation.<span class='pagenum'><a name="Page_291" id="Page_291">{291}</a></span></p>
+
+
+<p class="gap"><span class="smcap">Operations on the Anus and its Neighbourhood.</span>&mdash;<span class="smcap">Fistula in Ano.</span>&mdash;While
+much might be written on the pathology of fistula, and a good deal even
+on its diagnosis, a very few words will suffice to describe the simple
+and effectual operation for its relief.</p>
+
+<p>Dismissing at once all so-called palliatives, drugs, unguents, pressure,
+and injections, as mere waste of time, and holding that the only method
+of cure consists in laying the fistula fairly open, the question narrows
+itself into this: What is the best method of laying it open? Prior to
+the discovery by Ribes of the great principle that the internal orifice
+of the sinus is always within an inch or an inch and a half of the
+orifice of the anus, the operations for fistula were most unnecessarily
+severe; the gut used to be divided as far up as the sinuses extended;
+and large portions of the anus used to be excised bodily along with the
+sinuses. It is now a much simpler and more satisfactory operation.</p>
+
+<p><i>Operation.</i>&mdash;A common silver probe bent to the required shape is passed
+into the external opening, or, if there are more than one, into the
+largest and oldest one. The forefinger of the left hand being introduced
+into the rectum, the probe is passed through the internal orifice, and
+its point brought out by the anus. The portion of tissue raised by the
+probe can then be easily divided with the certainty that the fistula is
+laid fully open. Anal fistul&aelig; have been divided by the elastic ligature,
+but it seems slower in action and more painful, with no counterbalancing
+advantages.</p>
+
+<div class="blockquot smlet"><p>The author has for last few years operated almost exclusively by a
+long knife which is continued into a steel probe. The probe is
+passed up the fistula, then into the bowel, and is hooked out at
+the anus, and in being simply pushed on the knife cuts the
+fistula&mdash;tuto, cito, et jucunde, the patient rarely knowing that
+more has been done than an exploration.</p>
+
+<p>In cases where, from the hardness and density of the parts it is
+impossible to pass the probe and bring it out at the anus, a strong
+probe-pointed bistoury may be passed in by the external<span class='pagenum'><a name="Page_292" id="Page_292">{292}</a></span> orifice
+till its probe-point can be felt by the finger in the bowel at the
+internal opening. Supported by the finger it can then be made to
+cut outwards till the whole septum is divided. </p></div>
+
+
+<p class="gap"><span class="smcap">Fissure of the Anus, Ulcer of the Anus</span>, resemble each other alike in the
+exceeding annoyance which they give to the sufferer, and in the
+simplicity of the treatment needed.</p>
+
+<p><i>Operation.</i>&mdash;Once the presence of either is determined by the finger in
+the anus, a sharp-pointed curved bistoury should be introduced,
+transfixing the base of the fissure or ulcer, and then guided on the
+finger, completely dividing it, so as to change the ragged ulceration
+into a simple wound which will rapidly heal.</p>
+
+<p class="gap"><span class="smcap">Prolapsus Ani</span>, <i>Operation for</i>.&mdash;Complete prolapsus in which the whole
+gut is involved, as seen in the very young and the very aged, is suited
+for palliative rather than radical treatment.</p>
+
+<p>Cases of prolapsus of the mucous membrane only, as is not uncommon in
+connection with or as a result of h&aelig;morrhoids in adults, give
+opportunity for operative interference.</p>
+
+<p>We may act on either the skin or mucous membrane, or both at once.</p>
+
+<p class="gap">1. <i>The skin</i> is often found loose, and arranged in radiating folds
+round the anus. In such cases, as recommended first by Dupuytren, some
+of these projecting folds may be removed. Again it may be prolapsed in a
+great loose ring or circular fold round the margin, forming an
+exaggerated external pile; in such a case the loose fold may be fairly
+excised with curved scissors, as recommended by Hey of Leeds.</p>
+
+<p>The first of these methods is apt to be insufficient, the second again
+has the risk of removing too much.</p>
+
+<p class="gap">2. If the protrusion is chiefly mucous membrane exposed<span class='pagenum'><a name="Page_293" id="Page_293">{293}</a></span> in folds, or a
+ring, which is generally outside, one of two methods of treatment may be
+tried:&mdash;</p>
+
+<p><i>a.</i> By ligature, as recommended by Mr. Copeland. Raising a longitudinal
+fold of the mucous membrane, he passed a ligature round it as if it were
+a pile. There is less chance of the ligature slipping if a double thread
+be used and its base thus transfixed. Three, four, or even more folds
+may be thus treated.</p>
+
+<p><i>b.</i> When the mucous membrane has been so long exposed as to have lost
+many of its characters, and to resemble leather in its toughness,
+excision will be found less painful and much more rapid than ligature.</p>
+
+<p>A longitudinal fold at each side of the anus should be pinched up and
+excised by a pair of probe-pointed curved scissors. There is always a
+certain amount of risk of h&aelig;morrhage following such an operation. The
+risk is lessened and the result improved by stitching up the wound in
+the mucous membrane before the protruded portion of bowel is returned.</p>
+
+
+<p class="gap"><span class="smcap">Polypi of the Rectum.</span>&mdash;Pedunculated growths varying in consistence,
+shape, and size, but resembling each other in having a distinct stalk,
+and in frequently being protruded at stool.</p>
+
+<p><i>Operation.</i>&mdash;Invariably by ligature, which may be single round the
+stalk, if the tumour be globular and with a distinct narrow stalk, or by
+transfixion, if (as sometimes happens) the tumour be of uniform
+thickness throughout, like a worm.</p>
+
+
+<p class="gap"><span class="smcap">H&aelig;morrhoids Or Piles.</span>&mdash;In the treatment of piles it is the differential
+diagnosis that is troublesome and occasionally difficult; the operative
+interference required is generally very simple, if the nature of the
+case be rightly determined.</p>
+
+<p><i>External piles.</i>&mdash;<i>Operation.</i>&mdash;The apex of the soft flabby excrescence
+should be seized by a pair of catch-forceps,<span class='pagenum'><a name="Page_294" id="Page_294">{294}</a></span> and it should be cut off
+close to its base with a knife, or, what is better, a pair of curved
+scissors. Any little vessel which jets may then be secured. If, instead
+of numerous individual tumours, a ring of skin round the anus be
+involved, the whole of it should be shaved off, but not very close to
+its base, lest too great contraction of the anal orifice should ensue.</p>
+
+<div class="blockquot smlet"><p>If the surgeon, after excising a pile or piles, will take the
+trouble to stitch up the wound with catgut, he will find the cure
+much more rapid and less painful than when this is omitted. </p></div>
+
+<p><i>Internal piles.</i>&mdash;Incision is extremely dangerous, from the vascularity
+of the parts, and their being so inaccessible from their position within
+the sphincter ani. Hence ligature is safer and equally effectual. The
+patient should be directed to sit over hot water, and strain till the
+whole of his piles are fairly protruded. The surgeon should then
+transfix the base of each separately with a curved needle bearing a
+strong double thread. The needle being cut off, the threads should be
+very firmly tied, each isolating its own half of the pile. The tying
+should be exceedingly tight, so as to cause instant and complete
+strangulation and death of the tumours. All the piles should be tied at
+the same sitting. If the piles are very small they may be secured
+without transfixion in a single noose after being seized by a hook or
+forceps. There is greater risk of the noose slipping than when the base
+has been transfixed.</p>
+
+<p>The strangulated masses must then be returned into the bowel, and the
+patient kept in bed or on a sofa till the ligatures separate, which is
+generally not till the fourth or fifth day. A certain amount of urinary
+irritation, showing itself sometimes in strangury, sometimes in complete
+retention, occasionally follows this operation.</p>
+
+<p>Mr. Smith of King's College, and many other surgeons, treat internal
+piles by means of an ivory clamp to hold<span class='pagenum'><a name="Page_295" id="Page_295">{295}</a></span> them tight, while they are
+burned off by the actual cautery or the thermo-cautery at a low red
+heat. They claim that py&aelig;mia more rarely follows this mode.</p>
+
+<div class="blockquot smlet"><p>There are certain cases in which the lower inch or two of the
+rectum are found red and congested, and in which every stool is
+followed by the loss of a certain quantity of florid arterial
+blood, and yet no distinct h&aelig;morrhoidal tumour is to be seen. In
+such cases the ligature is not applicable, and relief is obtained
+by the application of pure nitric acid, or other potential caustics
+to the bleeding surface, as recommended by Houston, Lee, Smith,
+Ashton, and others. These cases are comparatively rare, and
+whenever they can be applied, the ligature is much simpler, safer,
+and more certain. </p></div>
+
+<p><i>Venous piles.</i>&mdash;When a sudden effusion of blood has occurred into one
+of the varicose veins or sinuses of a congested anus, an oval or rounded
+tumour is felt, very tense, shining, and painful. To slit it freely up
+with an abscess lancet, and evert the clot inside, at once relieves all
+the symptoms.</p>
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_296" id="Page_296">{296}</a></span></p>
+
+<h2><a name="CHAPTER_XIII" id="CHAPTER_XIII"></a>CHAPTER XIII.</h2>
+
+<h3>TENOTOMY.</h3>
+
+
+<p>For convenience' sake I group under this one head certain operations
+used for the relief of distortion, in which muscles or tendons are
+divided subcutaneously. Since the discovery of the principle by Delpech,
+and the application of it by Stromeyer, Dieffenbach, Little, and
+countless successors, it has been used for very many cases for which it
+is totally inapplicable, <i>e.g.</i> for the division of the muscles of the
+back in spinal curvature. Still there remain several deformities for the
+relief of which subcutaneous tenotomy is a most important remedy; chief
+among these are Wry Neck and Club-foot.</p>
+
+
+<p class="gap"><span class="smcap">Operation for Wry Neck.</span>&mdash;<i>Subcutaneous section of the
+sterno-mastoid.</i>&mdash;In what cases of wry neck is this operation suitable?
+In those only in which the muscles are the starting-point of the
+mischief. These are sometimes congenital, more frequently they commence
+in childhood. In cases where the distortion depends on disease of the
+cervical vertebr&aelig;, or is secondary to curvature of the spine, division
+of the muscle is worse than useless.</p>
+
+<p><i>Operation.</i>&mdash;A tenotomy knife, which should be sharp-pointed, narrow in
+the blade, with a blunt back, should be introduced through the skin a
+little to one side of the sternal portion of the affected muscle, passed
+along<span class='pagenum'><a name="Page_297" id="Page_297">{297}</a></span> with its flat edge between the skin and the tendon, till it has
+fairly crossed the tendon; the blade should then be turned so that by a
+gradual sawing motion the edge may be made to divide the tendon about an
+inch above the sternum. A distinct snap will then be felt or heard, and
+the position of the head will be at once much improved. Exercise, warm
+bathing, and rubbing, will generally suffice to complete the cure,
+without it being necessary to call in the aid of the instrument-maker
+with his expensive apparatus.<a name="FNanchor_166_166" id="FNanchor_166_166"></a><a href="#Footnote_166_166" class="fnanchor">[166]</a></p>
+
+
+<p class="gap"><span class="smcap">Operations for Club-Foot.</span>&mdash;The following are the tendons which <i>may</i>
+require division in the cure of club-foot, and the operations for their
+division.</p>
+
+<p>1. <i>The tendo Achillis.</i>&mdash;There are very few cases of true club-foot
+which can be successfully treated without division of the tendo
+Achillis. While in talipes equinis it is generally the only disturbing
+agent, in talipes varus and valgus it invariably increases and maintains
+the deformity, which the tibiales or peronei seem to originate.</p>
+
+<p><i>Operation.</i>&mdash;The foot being held at about a right angle with the leg,
+the operator should pinch up the skin over the tendon, introduce the
+knife flatwise, a little to one side of the tendon, till its point is
+nearly projecting at the other, then turn the edge on the tendon and cut
+inwards with a sawing motion till the tendon gives way with a distinct
+snap, and the foot can be completely flexed with ease.</p>
+
+<div class="blockquot smlet"><p>Dr. Little<a name="FNanchor_167_167" id="FNanchor_167_167"></a><a href="#Footnote_167_167" class="fnanchor">[167]</a> recommends that the tendon should be divided from
+before backwards. There is more risk by this method of wounding the
+skin, and thus losing the subcutaneous character of the operation.</p>
+
+<p>Professor Pancoast<a name="FNanchor_168_168" id="FNanchor_168_168"></a><a href="#Footnote_168_168" class="fnanchor">[168]</a> divides the inferior portion of the soleus
+muscle instead of the tendo Achillis. </p></div><p><span class='pagenum'><a name="Page_298" id="Page_298">{298}</a></span></p>
+
+<p>2. <i>Tibialis posticus.</i>&mdash;Next in frequency and importance to that of the
+tendo Achillis, division of this tendon is much more difficult to
+perform. It may be performed either above or below the ankle.</p>
+
+<p>(<i>a.</i>) <i>Above the ankle.</i>&mdash;The blade of a tenotomy knife should be
+entered perpendicularly at the posterior margin of the tibia, half an
+inch or an inch above the internal malleolus, so as to pass between the
+bone and the tendon of the tibialis posticus, the blade directed towards
+the latter; the assistant should now evert the foot, the operator
+pressing the blade against the tendon.<a name="FNanchor_169_169" id="FNanchor_169_169"></a><a href="#Footnote_169_169" class="fnanchor">[169]</a></p>
+
+<p>(<i>b.</i>) <i>Below the ankle, close to the attachment to the scaphoid.</i> This
+is the better position of the two when the position of the tendon can be
+made out, which is not always the case, especially in cases of old
+standing.</p>
+
+<p>Raising the skin just over the astragalo-scaphoid joint, the knife
+should be entered with its blade downwards, and across the tendon, and
+should be made to cut on the bone, while an assistant everts the foot
+till the tendon gives way with a distinct snap.</p>
+
+<p>3. <i>Tibialis anticus</i> may in like manner be divided either just above
+the ankle, or at its insertion. When it requires division it can
+generally be made so prominent as to render its division comparatively
+easy.</p>
+
+<p>4. <i>Peronei.</i>&mdash;These do not often require division, cases of talipes
+valgus being usually paralytic in character. If necessary they can be
+cut as they cross the fibula.</p>
+
+<p>5. <i>The plantar fascia</i>, may require division; when this is the case, it
+is so prominent as to render the operation very easy, if conducted on
+the principles mentioned above.</p>
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_299" id="Page_299">{299}</a></span></p>
+
+<h2><a name="CHAPTER_XIV" id="CHAPTER_XIV"></a>CHAPTER XIV.</h2>
+
+<h3>OPERATIONS ON NERVES.</h3>
+
+
+<p class="gap"><span class="smcap">Nerve-stretching.</span>&mdash;Surgical literature in last ten years is full of
+cases in which nerves have been stretched for all manner of diseases
+with varying success: an example of the operative procedure may
+suffice:&mdash;</p>
+
+<p>1. Stretching of the great sciatic either for sciatica, sclerosis, or
+locomotor ataxia.</p>
+
+<p><i>Operation.</i>&mdash;A line drawn from the centre of the space between the
+tuberosity of the ischium or the great trochanter to a corresponding
+point between the condyles of the femur will give the direction. A free
+incision in this line three or four inches in length&mdash;the nerve lies
+just below the the femoral aponeurosis, beneath the edge of gluteal
+fold, requiring no muscular fibres to be divided. It must be raised from
+its bed and boldly stretched or elongated into a loop. Symington's
+experiments have shown that in the average adult 130 lb. are required to
+break the nerve.</p>
+
+<p>2. The facial has been stretched for spasm. The trunk is easily reached
+by an incision extending from near the external auditory meatus to the
+angle of the jaw, which enables the parotid to be pushed forward and the
+edge of the sterno-mastoid pulled backwards.</p>
+
+
+<p class="gap"><span class="smcap">Neurotomy and Neurectomy.</span>&mdash;Chiefly performed for neuralgia of the fifth
+nerve.<span class='pagenum'><a name="Page_300" id="Page_300">{300}</a></span></p>
+
+<p><i>a.</i> This is a very easy operation if directed at the terminal branches
+only of the nerve, where they make their exit from the frontal,
+supraorbital, and mental foramina. The author has done it in very
+numerous cases, and with great relief, if care be taken to destroy the
+nerve in the foramen to some extent&mdash;a sharp-pointed thermo-cautery does
+this easily and safely.</p>
+
+<p><i>b.</i> The more severe and radical operation of cutting out a portion of
+the trunk of the fifth nerve just after it has left the skull, and
+destroying Meckel's ganglion, has been done pretty frequently, chiefly
+by American surgeons&mdash;in various ways.</p>
+
+<p>1. <i>Carnochan's Operation.</i>&mdash;Exposing the whole front wall of antrum,
+its cavity is opened into from the front by a large trephine. The lower
+wall of the infra-orbital canal is cut away by a chisel, the posterior
+wall of the antrum by a smaller trephine, the nerve thus isolated is
+traced up to and past Meckel's ganglion, which is removed close to the
+foramen rotundum by cutting the nerve by curved blunt-pointed scissors.</p>
+
+<p>2. <i>Pancoast's Operation.</i>&mdash;Expose the coronoid process by a free
+incision, divide it at its root and throw it up, then expose and tie
+internal maxillary artery, after which the upper portion of the external
+pterygoid is to be detached from the sphenoid, thus exposing the nerve
+leaving foramen ovale; the second portion is deeper and not so easily
+got at.</p>
+
+<p>3. The spinal accessory occasionally may be divided before it enters the
+sterno-mastoid in cases of spasmodic wry neck, with great advantage.
+This operation is an easy one; the sterno-mastoid edge being once fairly
+exposed, the nerve is easily seen, and a piece should be cut out at
+least half an inch in length.</p>
+
+
+<p class="gap"><span class="smcap">Nerve Suture</span> is occasionally practised with great advantage in cases
+where nerves have been divided<span class='pagenum'><a name="Page_301" id="Page_301">{301}</a></span> either by accident or in operation.
+Catgut seems to be the best medium, and cases are on record in which,
+even after months of separation and subsequent paralysis, improvement
+has followed an operation for refreshing and joining the divided ends.</p>
+
+
+
+<hr style="width: 30%;" />
+
+<p><span class='pagenum'><a name="Page_302" id="Page_302">{302}</a></span></p>
+
+<h2><a name="ADDENDUM_TO_CHAPTER_IX" id="ADDENDUM_TO_CHAPTER_IX"></a>ADDENDUM TO CHAPTER IX.</h2>
+
+
+<p><span class="smcap">Dr. Solis Cohen</span> has recently (in a paper read before the Philadelphia
+College of Physicians, April 4, 1883) collected the notes of sixty-five
+cases of excision of the entire larynx. Fifty-six of these were done for
+cancer, and the remainder for sarcomata, papillomata, etc. Of the
+fifty-six done for cancer, forty are reported as having died, either
+shortly after the operation from shock or pneumonia, or a few months
+later from recurrence of the disease. In two instances the disease had
+recurred, but death had not been reported when the paper was read.
+Fourteen remain in which neither death nor recurrence had been reported.
+Dr. Cohen's conclusion is that laryngectomy does not tend to the
+prolongation of life, and thinks that the greatest good to the greater
+number appears better secured by dependence on the palliative operation
+of tracheotomy.</p>
+
+<!-- <span class='pagenum'><a name="Page_303" id="Page_303">{303}</a></span> -->
+
+
+
+<hr style="width: 30%;" />
+<!-- <span class='pagenum'><a name="Page_304" id="Page_304">{304}</a></span></p> -->
+
+
+
+<p><span class='pagenum'><a name="Page_305" id="Page_305">{305}</a></span></p>
+
+<h2><a name="INDEX" id="INDEX"></a>INDEX.</h2>
+
+<div class="blockquot">
+
+
+<ul>
+<li><span class="smcap">Abdomen</span>, operations on, <a href="#Page_222">222</a>.</li>
+
+<li>Abernethy on ligature of external iliac, <a href="#Page_8">8</a>.</li>
+
+<li>Adams on anatomy of common iliac, <a href="#Page_4">4</a>.</li>
+<li class="ind">on hip deformity, <a href="#Page_133">133</a>.</li>
+
+<li>&AElig;gineta, Paulus, on excision of joints, <a href="#Page_108">108</a>.</li>
+
+<li>Allarton on median lithotomy, <a href="#Page_269">269</a>.</li>
+
+<li>Amputation and excision contrasted, <a href="#Page_113">113</a>.</li>
+
+<li>Amputation at ankle-joint (Syme's), <a href="#Page_78">78</a>.</li>
+<li class="ind">of anterior portion of foot (Hey's), <a href="#Page_73">73</a>.</li>
+<li class="ind">of arm, <a href="#Page_62">62</a>.</li>
+<li class="ind">at elbow-joint, <a href="#Page_61">61</a>.</li>
+<li class="ind">through femur, condyles of, <a href="#Page_92">92</a>.</li>
+<li class="ind">of fingers, <a href="#Page_51">51</a>-54.</li>
+<li class="ind">of fore-arm, <a href="#Page_58">58</a>.</li>
+<li class="ind">at hip-joint, <a href="#Page_102">102</a>.</li>
+<li class="ind">at knee-joint, <a href="#Page_92">92</a>.</li>
+<li class="ind">of penis, <a href="#Page_286">286</a>.</li>
+<li class="ind">at shoulder-joint, <a href="#Page_63">63</a>.</li>
+<li class="ind">at tarsus (Chopart's), <a href="#Page_75">75</a>.</li>
+<li class="ind">at thigh, <a href="#Page_94">94</a>.</li>
+<li class="ind">double primary of thigh, <a href="#Page_106">106</a>.</li>
+<li class="ind">of toes, <a href="#Page_69">69</a>.</li>
+<li class="ind">at wrist-joint, <a href="#Page_56">56</a>.</li>
+
+<li>Amussat's operation, <a href="#Page_252">252</a>.</li>
+
+<li>Anchylosis of elbow, excision for, <a href="#Page_122">122</a>.</li>
+
+<li>Ankle-joint, excision of, <a href="#Page_137">137</a>.</li>
+
+<li>Annandale on staphyloraphy, <a href="#Page_203">203</a>.</li>
+
+<li>Anus, artificial, operation for, <a href="#Page_252">252</a>.</li>
+<li class="ind">artificial, removal of, <a href="#Page_254">254</a>.</li>
+
+<li>Arendt, ligature of external iliac, <a href="#Page_12">12</a>.</li>
+
+<li>Astragalus, excision of, <a href="#Page_145">145</a>.</li>
+
+<li>Auchincloss on ligature of subclavian, <a href="#Page_36">36</a>.</li>
+
+<li>Avery, hard palate, fissures of, <a href="#Page_203">203</a>.</li>
+
+
+<li class="gap"><span class="smcap">Barwell</span> on excision of ankle-joint, <a href="#Page_139">139</a>.</li>
+<li class="ind">on excision of tongue, <a href="#Page_199">199</a>.</li>
+
+<li>Baudens on amputation at elbow-joint, <a href="#Page_61">61</a>.</li>
+<li class="ind">on amputation of anterior portion of foot, <a href="#Page_75">75</a>.</li>
+<li class="ind">on amputation at knee-joint, <a href="#Page_92">92</a>.</li>
+
+<li>Bauer on recto-vesical lithotomy, <a href="#Page_272">272</a>.</li>
+
+<li>Begbie, Dr. Warburton, on paracentesis thoracis, <a href="#Page_220">220</a>.</li>
+
+<li>Bell, Benjamin, on amputation, <a href="#Page_49">49</a>.</li>
+<li class="ind">on amputation of ankle, <a href="#Page_86">86</a>.</li>
+<li class="ind">on amputation of thigh, <a href="#Page_96">96</a>.</li>
+
+<li>Bell, Sir Charles, on ligature of femoral, <a href="#Page_22">22</a>.</li>
+
+<li>Bell, George, on supra-pubic lithotomy, <a href="#Page_271">271</a>.</li>
+
+<li>Bell, John, on ligature of gluteal, <a href="#Page_14">14</a>.</li>
+
+<li>Bey, Gaetani, on amputation above the shoulder-joint, <a href="#Page_70">70</a>.</li>
+
+<li>Bigelow, Dr., on litholapaxy, <a href="#Page_276">276</a>.</li>
+
+<li>Billroth, Dr., on fissure of palate, <a href="#Page_200">200</a>.</li>
+
+<li>Bladder, puncture of, <a href="#Page_284">284</a>.</li>
+
+<li>Bonnet on radical cure of hernia, <a href="#Page_245">245</a>.</li>
+
+<li>Botal on amputation, <a href="#Page_47">47</a>.</li>
+
+<li>Bowditch on paracentesis thoracis, <a href="#Page_221">221</a>.</li>
+
+<li>Bowman's operation, lachrymal canal, <a href="#Page_153">153</a>.</li>
+
+<li>Brachial, ligature of, <a href="#Page_242">242</a>.</li>
+
+<li>Brodie, Sir B. C., on lithotomy, <a href="#Page_262">262</a>.</li>
+<li class="ind">on lithotrity, <a href="#Page_274">274</a>.</li>
+
+<li>Bromfield, amputation of leg, <a href="#Page_86">86</a>.</li>
+
+<li>Brown, Baker, ovariotomy, <a href="#Page_231">231</a>.</li>
+
+<li>Bryant, on excision of joints, <a href="#Page_112">112</a>.</li>
+
+<li>Buchanan, Dr. A., on lithotomy, <a href="#Page_269">269</a>.</li>
+
+<li>Buchanan, Dr. G., on excision of tongue, <a href="#Page_198">198</a>.</li>
+
+<li>Buchanan, Dr. M., on excision of ankle, <a href="#Page_140">140</a>.<span class='pagenum'><a name="Page_306" id="Page_306">{306}</a></span></li>
+
+<li>Buck's operation for anchylosis, <a href="#Page_136">136</a>.</li>
+
+<li>Butcher, ligature of subclavian, <a href="#Page_35">35</a>.</li>
+<li class="ind">excision of joints, <a href="#Page_110">110</a>.</li>
+<li class="ind">excision of wrist-joint, <a href="#Page_128">128</a>.</li>
+<li class="ind">excision of knee-joint, <a href="#Page_135">135</a>.</li>
+<li class="ind">excision of metacarpals. <a href="#Page_142">142</a>.</li>
+
+<li class="gap"><span class="smcap">Campbell</span>, Professor, on ligature of gluteal, <a href="#Page_15">15</a>.</li>
+
+<li>Carden's amputation at condyles of femur, <a href="#Page_50">50</a>, <a href="#Page_94">94</a>.</li>
+
+<li>Carmichael on ligature of gluteal, <a href="#Page_14">14</a>.</li>
+
+<li>Carnochan on neurectomy, <a href="#Page_300">300</a>.</li>
+
+<li>Carotid, ligature of common, <a href="#Page_28">28</a>.</li>
+<li class="ind">ligature of external, <a href="#Page_32">32</a>.</li>
+
+<li>Cataract operations, <a href="#Page_160">160</a>.</li>
+
+<li>Celsus on amputation, <a href="#Page_48">48</a>.</li>
+<li class="ind">on excision of joints, <a href="#Page_108">108</a>.</li>
+
+<li>Chamberlaine, on ligature of axillary, <a href="#Page_40">40</a>.</li>
+
+<li>Chassaignac on tracheotomy, <a href="#Page_206">206</a>.</li>
+
+<li>Cheiloplastics, Syme on, <a href="#Page_178">178</a>.</li>
+
+<li>Cheselden on amputation, <a href="#Page_49">49</a>.</li>
+<li class="ind">on lithotomy, <a href="#Page_260">260</a>.</li>
+
+<li>Chopart's amputation, <a href="#Page_75">75</a>.</li>
+
+<li>Civiale on lithotrity, <a href="#Page_275">275</a>.</li>
+
+<li>Club-foot, operations for, <a href="#Page_297">297</a>.</li>
+
+<li>Cock on &#339;sophagotomy, <a href="#Page_216">216</a>.</li>
+<li class="ind">paracentesis thoracis, <a href="#Page_220">220</a>.</li>
+<li class="ind">on puncture of bladder, <a href="#Page_285">285</a>.</li>
+
+<li>Colles on ligature of brachial, <a href="#Page_44">44</a>.</li>
+
+<li>Cooper, Sir Astley, on ligature of aorta and iliacs, <a href="#Page_3">3</a>, <a href="#Page_10">10</a>.</li>
+<li class="ind">on perineal section. <a href="#Page_276">276</a>.</li>
+
+<li>Cornea, puncture of, <a href="#Page_159">159</a>.</li>
+<li class="ind">staphylomatous, excision of a, <a href="#Page_168">168</a>.</li>
+
+<li>Corelysis, <a href="#Page_170">170</a>.</li>
+
+<li>Crampton, Sir Philip, on excision, <a href="#Page_119">119</a>.</li>
+
+<li>Crichton on lithotomy, <a href="#Page_262">262</a>.</li>
+
+<li>Critchett's operation of iridesis, <a href="#Page_169">169</a>.</li>
+<li class="ind">operation for staphyloma, <a href="#Page_172">172</a>.</li>
+
+<li>Croft, Mr., on hip disease, <a href="#Page_132">132</a>.</li>
+
+<li>Culbertson on excision of hip, <a href="#Page_132">132</a>.</li>
+
+<li>Cullerier on phymosis, <a href="#Page_287">287</a>.</li>
+
+<li>Curling on operation for artificial anus, <a href="#Page_253">253</a>.</li>
+
+<li>Cusack on treatment of brachial aneurism, <a href="#Page_43">43</a>.</li>
+
+<li class="gap"><span class="smcap">Davies, Redfern</span>, on radical cure of hernia, <a href="#Page_244">244</a>.</li>
+
+<li>Davy's (Mr. Richard), lever, <a href="#Page_105">105</a>.</li>
+
+<li>Desault on ligature of axillary, <a href="#Page_40">40</a>.</li>
+
+<li>Dieffenbach on excision of upper jaw, <a href="#Page_191">191</a>.</li>
+
+<li>Dieulafoy's aspirateur, <a href="#Page_284">284</a>.</li>
+
+<li>Dionis' amputation of leg, <a href="#Page_87">87</a>.</li>
+
+<li>Dubrueil, amputation at wrist, <a href="#Page_57">57</a>.</li>
+
+<li>Duncan, Mr. J., on artificial anus, <a href="#Page_254">254</a>.</li>
+
+<li>Dupuytren on ligature of iliac, <a href="#Page_11">11</a>.</li>
+<li class="ind">on ligature of subclavian, <a href="#Page_36">36</a>.</li>
+<li class="ind">amputation at elbow-joint, <a href="#Page_62">62</a>.</li>
+<li class="ind">removal of artificial anus, <a href="#Page_254">254</a>.</li>
+<li class="ind">on bilateral lithotomy, <a href="#Page_268">268</a>.</li>
+
+<li>Durand, case of h&aelig;morrhage from iliac, <a href="#Page_12">12</a>.</li>
+
+<li>Durham on thyrotomy, <a href="#Page_215">215</a>.</li>
+
+<li>Dzondi on radical cure of hernia, <a href="#Page_246">246</a>.</li>
+
+<li class="gap"><span class="smcap">Elbow-Joint</span>, amputation at, <a href="#Page_62">62</a>.</li>
+
+<li>Ellis on anatomy of iliac arteries, <a href="#Page_6">6</a>.</li>
+
+<li>Ectropium, <a href="#Page_152">152</a>.</li>
+
+<li>Entropium, <a href="#Page_151">151</a>.</li>
+
+<li>Erichsen on excision of hip, <a href="#Page_130">130</a>.</li>
+
+<li>Esmarch on excision of joints, <a href="#Page_110">110</a>.</li>
+
+<li>Excision and amputation contrasted, <a href="#Page_112">112</a>.</li>
+
+<li>Excision of ankle-joint, <a href="#Page_138">138</a>.</li>
+<li class="ind">of astragalus, <a href="#Page_145">145</a>.</li>
+<li class="ind">of elbow-joint, <a href="#Page_118">118</a>.</li>
+<li class="ind">of hip-joint, <a href="#Page_128">128</a>.</li>
+<li class="ind">of jaw, upper, <a href="#Page_188">188</a>.</li>
+<li class="ind">of jaw, lower, <a href="#Page_191">191</a>.</li>
+<li class="ind">of knee-joint, <a href="#Page_133">133</a>.</li>
+<li class="ind">of mamma, <a href="#Page_216">216</a>.</li>
+<li class="ind">of scapula, <a href="#Page_139">139</a>.</li>
+<li class="ind">of shoulder-joint, <a href="#Page_115">115</a>.</li>
+<li class="ind">of testicle, <a href="#Page_290">290</a>.</li>
+<li class="ind">of tongue, <a href="#Page_197">197</a>.</li>
+<li class="ind">of tonsils, <a href="#Page_203">203</a>.</li>
+<li class="ind">of wrist-joint, <a href="#Page_125">125</a>.</li>
+
+<li>Eye, operations on, <a href="#Page_151">151</a>.</li>
+
+<li>Eyeball, extirpation of the, <a href="#Page_173">173</a>.</li>
+
+<li>Eyelid, tumours on the, <a href="#Page_152">152</a>.</li>
+
+<li class="gap"><span class="smcap">Fayrer</span>, Sir J., on tracheotomy, <a href="#Page_212">212</a>.</li>
+<li class="ind">on radical cure of hernia, <a href="#Page_248">248</a>.</li>
+
+<li>Femoral, ligature of, <a href="#Page_18">18</a>.</li>
+<li class="ind">superficial, ligature of, in Scarpa's space, <a href="#Page_19">19</a>.</li>
+<li><span class='pagenum'><a name="Page_307" id="Page_307">{307}</a></span></li><li class="ind">in Hunter's canal, <a href="#Page_21">21</a>.</li>
+
+<li>Femur, amputation through condyles of, <a href="#Page_92">92</a>.</li>
+
+<li>Fergusson, Sir W., on ligature of subclavian, <a href="#Page_38">38</a>.</li>
+<li class="ind">on amputation at shoulder-joint, <a href="#Page_70">70</a>.</li>
+<li class="ind">on excision of joints, <a href="#Page_110">110</a>.</li>
+<li class="ind">on excision of upper jaw, <a href="#Page_191">191</a>.</li>
+<li class="ind">on excision of lower jaw, <a href="#Page_195">195</a>.</li>
+<li class="ind">on fissures of palate, <a href="#Page_201">201</a>.</li>
+<li class="ind">on lithotomy, <a href="#Page_262">262</a>.</li>
+
+<li>Filkin on excision of joints, <a href="#Page_110">110</a>.</li>
+
+<li>Fingers, amputation of, <a href="#Page_51">51</a>.</li>
+
+<li>Fissures in the palate, soft, <a href="#Page_200">200</a>.</li>
+<li class="ind">in the palate, hard, <a href="#Page_202">202</a>.</li>
+<li class="ind">of anus, <a href="#Page_292">292</a>.</li>
+
+<li>Fistula, salivary, operations for, <a href="#Page_192">192</a>.</li>
+<li class="ind">in ano, operation for, <a href="#Page_291">291</a>.</li>
+
+<li>Fore-arm, amputation through the, <a href="#Page_58">58</a>.</li>
+<li class="ind">ligature of vessels in, <a href="#Page_44">44</a>.</li>
+
+<li>Forster, Mr. Cooper, on gastrotomy, <a href="#Page_224">224</a>.</li>
+
+<li>Furner, ligature of both subclavians, <a href="#Page_38">38</a>.</li>
+
+<li class="gap"><span class="smcap">Gastrectomy</span>, <a href="#Page_224">224</a>.</li>
+
+<li>Gastrostomy, <a href="#Page_223">223</a>.</li>
+
+<li>Gastrotomy, <a href="#Page_223">223</a>.</li>
+
+<li>Gersdorf, Hans de, on amputation, <a href="#Page_48">48</a>.</li>
+
+<li>Gerdy on radical cure of hernia, <a href="#Page_246">246</a>.</li>
+
+<li>Gilbert, amputation above the shoulder-joint, <a href="#Page_68">68</a>.</li>
+
+<li>Gillespie on excision of wrist-joint, <a href="#Page_128">128</a>.</li>
+
+<li>Gluteal, ligature of, <a href="#Page_12">12</a>.</li>
+
+<li>Gosselin on colotomy, <a href="#Page_253">253</a>.</li>
+
+<li>Graefe on strabismus, <a href="#Page_158">158</a>.</li>
+<li class="ind">on cataract operations, <a href="#Page_166">166</a>.</li>
+<li class="ind">or iridectomy, <a href="#Page_171">171</a>.</li>
+
+<li>Green on ligature of subclavian, <a href="#Page_38">38</a>.</li>
+
+<li>Greenhow on excision of os calcis, <a href="#Page_144">144</a>.</li>
+
+<li>Greenslade on Bowman's operation, <a href="#Page_156">156</a>.</li>
+
+<li>Gritti's amputation, <a href="#Page_93">93</a></li>
+
+<li>Gross on amputation at elbow-joint, <a href="#Page_61">61</a>.</li>
+<li class="ind">on amputation, <a href="#Page_81">81</a>-87.</li>
+<li class="ind">on excision of hip, <a href="#Page_132">132</a>.</li>
+<li class="ind">on lithotomy, <a href="#Page_262">262</a>.</li>
+<li class="ind">on rhinoplastic operation, <a href="#Page_178">178</a>.</li>
+<li class="ind">on excision of lower jaw, <a href="#Page_192">192</a>.</li>
+
+<li>Gu&eacute;rin, Jules, on amputation of toes, <a href="#Page_76">76</a>.</li>
+<li class="ind">on operation for strabismus, <a href="#Page_158">158</a>.</li>
+
+<li>Guersant on excision of tonsils, <a href="#Page_205">205</a>.</li>
+
+<li>Guillemeau on amputation at knee-joint, <a href="#Page_91">91</a>.</li>
+
+<li>Gurlt's statistics, <a href="#Page_118">118</a>, <a href="#Page_124">124</a>.</li>
+
+<li class="gap"><span class="smcap">H&aelig;morrhoids</span>, operations for, <a href="#Page_294">294</a>.</li>
+
+<li>H&aelig;matocele, operation for, <a href="#Page_289">289</a>.</li>
+
+<li>Hamilton on rhinoplastic operations, <a href="#Page_177">177</a>.</li>
+
+<li>Hancock on excision of hip, <a href="#Page_130">130</a>.</li>
+<li class="ind">on excision of ankle, <a href="#Page_138">138</a>.</li>
+<li class="ind">on excision of os calcis, <a href="#Page_144">144</a>.</li>
+
+<li>Harelip, operations for, <a href="#Page_183">183</a>.</li>
+
+<li>Harrison on anatomy of iliac, <a href="#Page_6">6</a>.</li>
+<li class="ind">on brachial aneurism, <a href="#Page_44">44</a>.</li>
+
+<li>Hart, Mr. Ernest, on flexion of limbs, <a href="#Page_24">24</a>.</li>
+
+<li>Heath's case of aneurism of innominate, <a href="#Page_28">28</a>.</li>
+
+<li>Heine on excision of hip, <a href="#Page_130">130</a>.</li>
+
+<li>Hernia, strangulated inguinal, <a href="#Page_232">232</a>.</li>
+<li class="ind">strangulated femoral, <a href="#Page_237">237</a>.</li>
+<li class="ind">strangulated umbilical, <a href="#Page_242">242</a>.</li>
+<li class="ind">strangulated obturator, <a href="#Page_243">243</a>.</li>
+<li class="ind">radical cure of, <a href="#Page_244">244</a>.</li>
+
+<li>Heurtloup on lithotrity, <a href="#Page_274">274</a>.</li>
+
+<li>Hey on amputation, <a href="#Page_48">48</a>, <a href="#Page_73">73</a>.</li>
+
+<li>Heyfelder on excisions, <a href="#Page_110">110</a>, <a href="#Page_130">130</a>.</li>
+
+<li>Hildanus, Fabricius, on amputation, <a href="#Page_47">47</a>, <a href="#Page_91">91</a>.</li>
+
+<li>Hip-joint, amputation at the, <a href="#Page_102">102</a>.</li>
+<li class="ind">excision of, <a href="#Page_128">128</a>.</li>
+
+<li>Hippocrates on excision of joints, <a href="#Page_108">108</a>.</li>
+
+<li>Hodgson, statistics of aneurism, <a href="#Page_12">12</a>.</li>
+<li class="ind">ligature of axillary, <a href="#Page_40">40</a>.</li>
+
+<li>Hodge on excisions <a href="#Page_112">112</a>, <a href="#Page_132">132</a>.</li>
+
+<li>Hoin on amputation at knee-joint, <a href="#Page_92">92</a>.</li>
+
+<li>Holmes on excision of hip, <a href="#Page_130">130</a>, <a href="#Page_132">132</a>, <a href="#Page_144">144</a>.</li>
+
+<li>Holt's operation for stricture, <a href="#Page_279">279</a>.</li>
+
+<li>Howse, Mr., on gastrotomy, <a href="#Page_224">224</a>.</li>
+
+<li>Hughes, Dr. on paracentesis thoracis, <a href="#Page_220">220</a>.</li>
+
+<li>Huguier on colotomy, <a href="#Page_253">253</a>.</li>
+
+<li>Hunter on ligature of femoral, <a href="#Page_21">21</a>.</li>
+
+<li>Hutchinson's statistics, <a href="#Page_20">20</a>.</li>
+
+<li>Hydrocele, operation for, <a href="#Page_288">288</a>.</li>
+
+<li class="gap"><span class="smcap">Iliac</span>, ligature of common, <a href="#Page_3">3</a>.</li>
+<li><span class='pagenum'><a name="Page_308" id="Page_308">{308}</a></span></li><li class="ind">ligature of external, <a href="#Page_7">7</a>.</li>
+
+<li>Iliac, ligature of internal, <a href="#Page_6">6</a>.</li>
+
+<li>Innominate, ligature of the, <a href="#Page_26">26</a>.</li>
+
+<li>Iridectomy, <a href="#Page_171">171</a>.</li>
+
+<li>Iridesis, <a href="#Page_169">169</a>.</li>
+
+<li class="gap"><span class="smcap">Jacobson</span> on cataract operations, <a href="#Page_166">166</a>.</li>
+
+<li>J&auml;ger on excision of hip, <a href="#Page_130">130</a>.</li>
+
+<li>James, Mr., on ligature of aorta, <a href="#Page_3">3</a>.</li>
+
+<li>Jameson on radical cure of hernia, <a href="#Page_246">246</a>.</li>
+
+<li>Jaw, excision of upper, <a href="#Page_188">188</a>.</li>
+<li class="ind">excision of lower, <a href="#Page_191">191</a>.</li>
+
+<li>Johnston, Dr., on amputation at ankle-joint, <a href="#Page_84">84</a>.</li>
+
+<li>Joints, excision of, <a href="#Page_108">108</a>.</li>
+
+<li>Jones on excision of joints, <a href="#Page_110">110</a>, <a href="#Page_134">134</a>, <a href="#Page_136">136</a>.</li>
+
+<li>Jordan, Mr. F., on amputation, <a href="#Page_106">106</a>;</li>
+<li class="ind">on excision of tongue, <a href="#Page_199">199</a>.</li>
+
+<li class="gap"><span class="smcap">Keith</span>, Dr. Thomas, on ovariotomy, <a href="#Page_224">224</a>-227.</li>
+
+<li>Kirby, Mr., on ligature of iliac, <a href="#Page_12">12</a>.</li>
+
+<li>Knife, Beer's description of, <a href="#Page_164">164</a>.</li>
+
+<li>Knee, amputation below and above, <a href="#Page_90">90</a>, <a href="#Page_91">91</a>.</li>
+<li class="ind">amputation at, <a href="#Page_91">91</a>.</li>
+<li class="ind">joint, excision of, <a href="#Page_132">132</a>.</li>
+
+<li class="gap"><span class="smcap">Lachrymal</span> organs, operations on the, <a href="#Page_153">153</a>.</li>
+
+<li>Lane, Mr., on amputation at knee-joint, <a href="#Page_91">91</a>.</li>
+
+<li>Langenbeck on excision of joints, <a href="#Page_110">110</a>, <a href="#Page_140">140</a>.</li>
+<li class="ind">on fissure in hard palate, <a href="#Page_203">203</a>.</li>
+<li class="ind">on radical cure of hernia, <a href="#Page_245">245</a>.</li>
+
+<li>Larrey on amputation at shoulder, <a href="#Page_64">64</a>.</li>
+<li class="ind">on excision of joints, <a href="#Page_109">109</a>.</li>
+
+<li>Larynx, operations on the, <a href="#Page_206">206</a>.</li>
+
+<li>Laryngectomy, <a href="#Page_216">216</a>.</li>
+<li class="ind">Dr. Solis Cohen on, <a href="#Page_302">302</a>.</li>
+
+<li>Laryngotomy, <a href="#Page_214">214</a>.</li>
+
+<li>Laryngo-tracheotomy, <a href="#Page_215">215</a>.</li>
+
+<li>Layraud, Dr., case of h&aelig;morrhage from iliac, <a href="#Page_12">12</a>.</li>
+
+<li>Lee, Mr. Henry, amputation of leg, <a href="#Page_88">88</a>.</li>
+
+<li>Ligature of the aorta, <a href="#Page_2">2</a>.</li>
+<li class="ind">of the axillary, <a href="#Page_38">38</a>, <a href="#Page_39">39</a>, <a href="#Page_40">40</a>.</li>
+<li class="ind">of the brachial, <a href="#Page_42">42</a>.</li>
+<li class="ind">of the carotid, common, <a href="#Page_29">29</a>, <a href="#Page_30">30</a>.</li>
+<li class="ind">of the carotid, external, <a href="#Page_32">32</a>.</li>
+<li class="ind">of the femoral, <a href="#Page_18">18</a>, <a href="#Page_21">21</a>.</li>
+<li class="ind">of the gluteal, <a href="#Page_12">12</a>.</li>
+<li class="ind">of the iliac, <a href="#Page_3">3</a>.</li>
+<li class="ind">of the iliac, external, <a href="#Page_7">7</a>.</li>
+<li class="ind">of the iliac, internal, <a href="#Page_6">6</a>.</li>
+<li class="ind">of the innominate, <a href="#Page_26">26</a>.</li>
+<li class="ind">of the lingual, <a href="#Page_32">32</a>.</li>
+<li class="ind">of the popliteal, <a href="#Page_22">22</a>.</li>
+<li class="ind">of the subclavian, <a href="#Page_33">33</a>-37.</li>
+<li class="ind">of the vessels in fore-arm, <a href="#Page_45">45</a>.</li>
+
+<li>Lips, operations on the, <a href="#Page_180">180</a>.</li>
+
+<li>Lisfranc on amputation, <a href="#Page_52">52</a>, <a href="#Page_74">74</a>.</li>
+
+<li>Lister, Professor, on Syme's amputation, <a href="#Page_87">87</a>.</li>
+<li class="ind">on excision of wrist, <a href="#Page_125">125</a>.</li>
+
+<li>Liston, Mr., on ligature of subclavian, <a href="#Page_36">36</a>, <a href="#Page_37">37</a>.</li>
+<li class="ind">on rhinoplastic operations, <a href="#Page_177">177</a>.</li>
+<li class="ind">on excision of upper jaw, <a href="#Page_186">186</a>.</li>
+<li class="ind">tracheotomy, <a href="#Page_213">213</a>.</li>
+<li class="ind">on femoral hernia, <a href="#Page_240">240</a>.</li>
+<li class="ind">on lithotomy, <a href="#Page_262">262</a>.</li>
+
+<li>Litholapaxy, Dr. Bigelow on, <a href="#Page_276">276</a>.</li>
+
+<li>Lithotomy, <a href="#Page_255">255</a>.</li>
+
+<li>Lithotrity, <a href="#Page_278">278</a>.</li>
+
+<li>Little on club-foot, <a href="#Page_297">297</a>.</li>
+
+<li>Lloyd on harelip, <a href="#Page_187">187</a>.</li>
+
+<li>Lorinzer on obturator hernia, <a href="#Page_244">244</a>.</li>
+
+<li>Louis on amputation, <a href="#Page_48">48</a>.</li>
+
+<li>Lower extremity, amputations of, <a href="#Page_68">68</a>.</li>
+
+<li>Lupus, operative treatment of, <a href="#Page_179">179</a>.</li>
+
+<li class="gap"><span class="smcap">Macilwain</span> on tracheotomy, <a href="#Page_208">208</a>.</li>
+
+<li>Mackenzie, Dr. Morell, on thyrotomy, <a href="#Page_215">215</a>.</li>
+
+<li>Mackenzie, Dr. R., on modification of Syme's amputation, <a href="#Page_83">83</a>.</li>
+<li class="ind">on excision of joints, <a href="#Page_110">110</a>, <a href="#Page_134">134</a>.</li>
+
+<li>Malgaigne on Chopart's amputation, <a href="#Page_77">77</a>.</li>
+<li class="ind">on harelip, <a href="#Page_187">187</a>.</li>
+
+<li>Mamma, excision of, <a href="#Page_218">218</a>.</li>
+
+<li>Manec on ligature of axillary, <a href="#Page_40">40</a>.</li>
+
+<li>Maunder on excision of the elbow-joint, <a href="#Page_122">122</a>.<span class='pagenum'><a name="Page_309" id="Page_309">{309}</a></span></li>
+
+<li>Maclennan, Dr. G., on amputation above the shoulder-joint, <a href="#Page_69">69</a>.</li>
+
+<li>Metacarpals, amputation of, <a href="#Page_54">54</a>.</li>
+<li class="ind">excision of, <a href="#Page_141">141</a>.</li>
+
+<li>Metatarsals, amputation of, <a href="#Page_72">72</a>.</li>
+
+<li>Miller on amputation of penis, <a href="#Page_288">288</a>.</li>
+
+<li>Monteiro, Dr., on ligature of aorta, <a href="#Page_3">3</a>.</li>
+
+<li>Mooren on cataract operations, <a href="#Page_166">166</a>.</li>
+
+<li>Moreaus, the, on excision of joints, <a href="#Page_109">109</a>, <a href="#Page_114">114</a>, <a href="#Page_120">120</a>, <a href="#Page_132">132</a>, <a href="#Page_134">134</a>.</li>
+
+<li>Morel, tourniquet invented by, <a href="#Page_47">47</a>.</li>
+
+<li>Morton, Dr., on radical cure of hernia, <a href="#Page_245">245</a>.</li>
+
+<li>Murray, Dr., on ligature of aorta, <a href="#Page_3">3</a>.</li>
+
+<li>Mussey, case of amputation, <a href="#Page_70">70</a>.</li>
+
+<li>Mynors on amputation, <a href="#Page_48">48</a>.</li>
+
+<li class="gap"><span class="smcap">Nasal polypi</span>, removal of, <a href="#Page_179">179</a>.</li>
+
+<li>Needle operation for cataract, <a href="#Page_160">160</a>.</li>
+
+<li>Nelaton on harelip, <a href="#Page_184">184</a>.</li>
+
+<li>Nerve-stretching, <a href="#Page_299">299</a>.</li>
+
+<li>Nerve suture, <a href="#Page_300">300</a>.</li>
+
+<li>Neurectomy, <a href="#Page_299">299</a>.</li>
+
+<li>Neurotomy, <a href="#Page_299">299</a>.</li>
+
+<li>Norris's statistics, <a href="#Page_12">12</a>, <a href="#Page_20">20</a>, <a href="#Page_31">31</a>.</li>
+
+<li>Nunneley on excision of tongue, <a href="#Page_198">198</a>.</li>
+
+<li class="gap"><span class="smcap">&#338;sophagotomy</span>, <a href="#Page_216">216</a>.</li>
+
+<li>Ollier on excision of joints, <a href="#Page_110">110</a>.</li>
+
+<li>Os calcis, excision of, <a href="#Page_143">143</a>.</li>
+
+<li>Ovariotomy, <a href="#Page_224">224</a>.</li>
+
+<li class="gap"><span class="smcap">Paget</span> on excision of tongue, <a href="#Page_198">198</a>.</li>
+
+<li>Palate, fissures in soft, <a href="#Page_200">200</a>.</li>
+<li class="ind">fissures in hard, <a href="#Page_202">202</a>.</li>
+
+<li>Pancoast, Professor, on rhinoplastic operations, <a href="#Page_178">178</a>.</li>
+<li class="ind">on radical cure of hernia, <a href="#Page_245">245</a>.</li>
+<li class="ind">on neurectomy, <a href="#Page_300">300</a>.</li>
+<li class="ind">on club-foot, <a href="#Page_297">297</a>.</li>
+
+<li>Paracentesis thoracis, <a href="#Page_219">219</a>.</li>
+<li class="ind">abdominis, <a href="#Page_222">222</a>.</li>
+
+<li>Par&eacute;, Ambrose, on amputation, <a href="#Page_47">47</a>.</li>
+<li class="ind">on amputation at elbow-joint, <a href="#Page_60">60</a>.</li>
+
+<li>Park on excision of joints, <a href="#Page_110">110</a>.</li>
+
+<li>Peixotto, Dr., on ligature of innominate, <a href="#Page_27">27</a>.</li>
+
+<li>Penis, amputation of, <a href="#Page_287">287</a>.</li>
+
+<li>Perineal section, operation of, <a href="#Page_273">273</a>.</li>
+
+<li>Percy on excision of joints, <a href="#Page_109">109</a>.</li>
+
+<li>Phymosis, operation for, <a href="#Page_285">285</a>.</li>
+
+<li>Pirogoff's modification of Syme's amputation, <a href="#Page_80">80</a>, <a href="#Page_84">84</a>.</li>
+
+<li>Pollock on excision of lower jaw, <a href="#Page_193">193</a>.</li>
+
+<li>Polypi, nasal, removal of, <a href="#Page_179">179</a>.</li>
+<li class="ind">anal, removal of, <a href="#Page_293">293</a>.</li>
+
+<li>Popliteal, ligature of, <a href="#Page_22">22</a>.</li>
+
+<li>Porta's statistics, <a href="#Page_20">20</a>.</li>
+
+<li>Porter, Professor, on ligature of innominate, <a href="#Page_27">27</a>.</li>
+<li class="ind">on ligature of common carotid, <a href="#Page_28">28</a>.</li>
+<li class="ind">statistics of amputation, <a href="#Page_122">122</a>.</li>
+
+<li>Post on ligature of iliac, <a href="#Page_10">10</a>.</li>
+
+<li>Pritchard, Mr., radical cure of hernia, <a href="#Page_248">248</a>.</li>
+
+<li>Prolapsus ani, <a href="#Page_292">292</a>.</li>
+
+<li>Pterygium, operation for, <a href="#Page_156">156</a>.</li>
+
+<li>Puncture of bladder, <a href="#Page_284">284</a>.</li>
+
+<li>Pupil, operations for artificial, <a href="#Page_168">168</a>.</li>
+
+<li>Purmannus on amputation, <a href="#Page_48">48</a>.</li>
+
+<li class="gap"><span class="smcap">Quain</span> on anatomy of iliac, <a href="#Page_4">4</a>.</li>
+<li class="ind">on anatomy of brachial, <a href="#Page_43">43</a>.</li>
+
+<li class="gap"><span class="smcap">Regnoli</span> on excision of tongue, <a href="#Page_199">199</a>.</li>
+
+<li>Rhinoplastic operations, <a href="#Page_175">175</a>.</li>
+
+<li>Richter on radical cure of hernia, <a href="#Page_245">245</a>.</li>
+
+<li>Ricord on amputation of penis, <a href="#Page_287">287</a>.</li>
+
+<li>Rigaud on amputation above the shoulder-joint, <a href="#Page_67">67</a>.</li>
+
+<li>Ritchie, Dr. Charles, on ovariotomy, <a href="#Page_224">224</a>.</li>
+
+<li>Rodgers, Dr., on ligature of subclavian, <a href="#Page_36">36</a>.</li>
+
+<li>Rothmund on radical cure of hernia, <a href="#Page_247">247</a>.</li>
+
+<li>Roux on ligature of subclavian, <a href="#Page_38">38</a>.</li>
+<li class="ind">on ligature of axillary, <a href="#Page_40">40</a>,</li>
+<li class="ind">on Chopart's amputation, <a href="#Page_77">77</a>, <a href="#Page_78">78</a>.</li>
+
+<li class="gap"><span class="smcap">Sabatier</span> on excision of joints, <a href="#Page_109">109</a>.</li>
+
+<li>Salivary fistula, operation for, <a href="#Page_196">196</a>.</li>
+
+<li>Sanson on recto-vesical lithotomy, <a href="#Page_271">271</a>.</li>
+
+<li>Scalp, tumours of the, removal of <a href="#Page_149">149</a>.</li>
+
+<li>Scapula, excision of (Syme), <a href="#Page_140">140</a>.<span class='pagenum'><a name="Page_310" id="Page_310">{310}</a></span></li>
+
+<li>Schuh on radical cure of hernia, <a href="#Page_245">245</a>.</li>
+
+<li>Schmucker on radical cure of hernia, <a href="#Page_246">246</a>.</li>
+
+<li>Scultetus on amputation, <a href="#Page_46">46</a>.</li>
+
+<li>Sedillot's operation for ligature of carotid, <a href="#Page_30">30</a>.</li>
+<li class="ind">on excision of hip, <a href="#Page_132">132</a>.</li>
+
+<li>Shoulder-joint, amputation at the, <a href="#Page_66">66</a>.</li>
+<li class="ind">excision of, <a href="#Page_115">115</a>.</li>
+
+<li>Signoroni on radical cure of hernia, <a href="#Page_247">247</a>.</li>
+
+<li>Sims, Dr. M., on lithotomy, <a href="#Page_272">272</a>.</li>
+
+<li>Smith, Dr. Nathan, on amputation at knee-joint, <a href="#Page_91">91</a>.</li>
+
+<li>Smith, Thomas, on staphyloraphy, <a href="#Page_200">200</a>.</li>
+
+<li>Smith, Dr. Tyler, on ovariotomy, <a href="#Page_231">231</a>.</li>
+
+<li>Smyth on subclavian aneurism, <a href="#Page_27">27</a>.</li>
+
+<li>Skey on ligature of subclavian, <a href="#Page_38">38</a>.</li>
+<li class="ind">on amputation, <a href="#Page_74">74</a>, <a href="#Page_91">91</a>.</li>
+<li class="ind">on excision of wrist, <a href="#Page_127">127</a>.</li>
+<li class="ind">on rhinoplastic operation, <a href="#Page_178">178</a>.</li>
+<li class="ind">on lithotomy, <a href="#Page_262">262</a>.</li>
+
+<li>Solis Cohen, Dr., on laryngectomy, <a href="#Page_302">302</a>.</li>
+
+<li>Solomon on strabismus, <a href="#Page_158">158</a>.</li>
+
+<li>South on ligature of aorta, <a href="#Page_3">3</a>.</li>
+
+<li>Spence, Professor, on amputation, <a href="#Page_50">50</a>, <a href="#Page_66">66</a>, <a href="#Page_89">89</a>, <a href="#Page_100">100</a>.</li>
+<li class="ind">on excision of shoulder, elbow, and wrist joints, <a href="#Page_118">118</a>, <a href="#Page_124">124</a>, <a href="#Page_128">128</a>, <a href="#Page_136">136</a>.</li>
+
+<li>Sperino on puncture of cornea, <a href="#Page_159">159</a>.</li>
+
+<li>Stanley on excision of shoulder, <a href="#Page_117">117</a>.</li>
+
+<li>Steven, Professor, on ligature of internal iliac, <a href="#Page_15">15</a>.</li>
+
+<li>Strabismus, convergent, <a href="#Page_156">156</a>.</li>
+<li class="ind">divergent, <a href="#Page_157">157</a>.</li>
+
+<li>Streatfeild on entropium, <a href="#Page_151">151</a>.</li>
+<li class="ind">on corelysis, <a href="#Page_170">170</a>.</li>
+
+<li>Stricture, operation for, <a href="#Page_276">276</a>.</li>
+
+<li>Stokes's amputation, <a href="#Page_94">94</a>.</li>
+
+<li>Stromeyer on excision of joints, <a href="#Page_110">110</a>.</li>
+
+<li>Subclavian, ligature of right, <a href="#Page_34">34</a>.</li>
+<li class="ind">ligature of left, <a href="#Page_35">35</a>.</li>
+
+<li>Surgeon-General, United States, statistical report by, <a href="#Page_82">82</a>.</li>
+
+<li>Syme, Mr., on amputation at ankle-joint, <a href="#Page_78">78</a>.</li>
+<li class="ind">on amputation through condyles of femur, <a href="#Page_92">92</a>.</li>
+<li class="ind">on amputation at hip-joint, <a href="#Page_106">106</a>.</li>
+<li class="ind">on amputation above the shoulder-joint, <a href="#Page_73">73</a>.</li>
+<li class="ind">on modified circular amputation, <a href="#Page_101">101</a>.</li>
+<li class="ind">on axillary aneurism, operation for, <a href="#Page_41">41</a>.</li>
+<li class="ind">on cheiloplastic operation, <a href="#Page_181">181</a>.</li>
+<li class="ind">Chopart's amputation introduced by, <a href="#Page_77">77</a>.</li>
+<li class="ind">on excision of lower jaw, <a href="#Page_191">191</a>.</li>
+<li class="ind">on excision of joints, <a href="#Page_111">111</a>-120.</li>
+<li class="ind">on excision of scapula, <a href="#Page_140">140</a>.</li>
+<li class="ind">on excision of tongue, <a href="#Page_197">197</a>.</li>
+<li class="ind">on ligature of femoral, <a href="#Page_20">20</a>.</li>
+<li class="ind">on ligature of gluteal, <a href="#Page_14">14</a>, <a href="#Page_15">15</a>.</li>
+<li class="ind">on radical cure of hernia, <a href="#Page_247">247</a>.</li>
+<li class="ind">on Hey's operation, <a href="#Page_73">73</a>.</li>
+<li class="ind">on &#339;sophagotomy, <a href="#Page_216">216</a>.</li>
+<li class="ind">on removal of polypi, <a href="#Page_180">180</a>.</li>
+<li class="ind">on rhinoplastic operation, <a href="#Page_175">175</a>.</li>
+<li class="ind">on stricture, <a href="#Page_278">278</a>-282.</li>
+
+<li class="gap"><span class="smcap">Tait</span> on ligature of iliac, <a href="#Page_10">10</a>, <a href="#Page_12">12</a>.</li>
+
+<li>Taliacotian operation, <a href="#Page_178">178</a>.</li>
+
+<li>Tarso-metatarsal joint, amputation at, <a href="#Page_72">72</a>.</li>
+
+<li>Tarsus, amputation through the, <a href="#Page_75">75</a>.</li>
+
+<li>Teale on amputation, <a href="#Page_50">50</a>.</li>
+<li class="ind">on amputation of fore-arm, <a href="#Page_59">59</a>.</li>
+<li class="ind">on amputation of arm, <a href="#Page_63">63</a>.</li>
+<li class="ind">on amputation of leg, <a href="#Page_89">89</a>.</li>
+<li class="ind">on amputation of thigh, <a href="#Page_98">98</a>.</li>
+<li class="ind">on amputation of penis, <a href="#Page_288">288</a>.</li>
+
+<li>Teale, T. P., on cataract, <a href="#Page_163">163</a>.</li>
+
+<li>Tenotomy, <a href="#Page_296">296</a>.</li>
+
+<li>Testicle, excision of, <a href="#Page_290">290</a>.</li>
+
+<li>Textor on amputation at elbow-joint, <a href="#Page_60">60</a>.</li>
+
+<li>Thigh, amputations of, <a href="#Page_96">96</a>.</li>
+
+<li>Thompson on lithotrity, <a href="#Page_275">275</a>.</li>
+<li class="ind">on stricture, <a href="#Page_277">277</a>.</li>
+
+<li>Thorax, operations on the, <a href="#Page_218">218</a>.</li>
+
+<li>Thyrotomy, <a href="#Page_215">215</a>.</li>
+
+<li>Toes, amputations of, <a href="#Page_68">68</a>.</li>
+
+<li>Tongue, excision of, <a href="#Page_197">197</a>.</li>
+
+<li>Tonsils, excision of, <a href="#Page_203">203</a>.</li>
+
+<li>Tracheotomy, <a href="#Page_206">206</a>-214.</li>
+
+<li>Trephining and trepanning, <a href="#Page_147">147</a>.</li>
+
+<li>Trichiasis, <a href="#Page_151">151</a>.</li>
+
+<li>Tripier's amputation, <a href="#Page_78">78</a>.</li>
+
+<li>Trocar of Sir S. Wells described, <a href="#Page_227">227</a>.</li>
+
+<li>Tumours of scalp, removal of, <a href="#Page_149">149</a>.</li>
+<li><span class='pagenum'><a name="Page_311" id="Page_311">{311}</a></span></li><li class="ind">of eyelids, removal of, <a href="#Page_152">152</a>.</li>
+
+<li>Tyrrell on treatment of brachial aneurism, <a href="#Page_43">43</a>.</li>
+
+<li class="gap"><span class="smcap">Upper extremity</span>, amputation of, <a href="#Page_50">50</a>.</li>
+
+<li>Urethra, stricture of, <a href="#Page_276">276</a>.</li>
+
+<li class="gap"><span class="smcap">Velpeau</span> on ligature of iliac, <a href="#Page_12">12</a>.</li>
+<li class="ind">on ligature of subclavian, <a href="#Page_38">38</a>.</li>
+<li class="ind">on amputation at elbow-joint, <a href="#Page_60">60</a>.</li>
+<li class="ind">on amputation at knee-joint, <a href="#Page_91">91</a>.</li>
+<li class="ind">on radical cure of hernia, <a href="#Page_245">245</a>.</li>
+
+<li>Vermale on amputation of thigh, <a href="#Page_102">102</a>.</li>
+
+<li>Verneuil on Chopart's amputation, <a href="#Page_78">78</a>.</li>
+
+<li>Vessels of fore-arm, ligature of, <a href="#Page_44">44</a>.</li>
+
+<li class="gap"><span class="smcap">Wakley</span> on stricture, <a href="#Page_279">279</a>.</li>
+
+<li>Warren on fissure of hard palate, <a href="#Page_203">203</a>.</li>
+
+<li>Watson, Dr. P. H., on excision, <a href="#Page_135">135</a>.</li>
+<li class="ind">on excision of elbow-joint, <a href="#Page_123">123</a>.</li>
+<li class="ind">on laryngectomy, <a href="#Page_216">216</a>.</li>
+
+<li>Wells, Sir Spencer, on ovariotomy, <a href="#Page_224">224</a>-229.</li>
+<li class="ind">trocar, <a href="#Page_227">227</a>.</li>
+<li class="ind">hernia, radical cure of, <a href="#Page_247">247</a>.</li>
+
+<li>White on amputation of leg, <a href="#Page_86">86</a>.</li>
+<li class="ind">on excision of joints, <a href="#Page_110">110</a>.</li>
+
+<li>Whitehead, Mr. W., on excision of tongue, <a href="#Page_199">199</a>.</li>
+
+<li>Willet on &#339;sophagotomy, <a href="#Page_216">216</a>.</li>
+
+<li>Wood's statistics, <a href="#Page_30">30</a>.</li>
+<li class="ind">on joints, <a href="#Page_134">134</a>.</li>
+<li class="ind">on radical cure of hernia, <a href="#Page_248">248</a>-251.</li>
+
+<li>Wry neck, operation for, <a href="#Page_296">296</a>.</li>
+
+<li>Wrist-joint, amputation at, <a href="#Page_55">55</a>.</li>
+<li class="ind">excision of, <a href="#Page_124">124</a>.</li>
+
+<li>W&uuml;tzer on radical cure of hernia, <a href="#Page_247">247</a>.</li>
+
+<li>Wyeth, Dr., statistics, <a href="#Page_36">36</a>, <a href="#Page_38">38</a>.</li>
+
+<li class="gap"><span class="smcap">Young, James</span>, tourniquet introduced by, <a href="#Page_47">47</a>.</li>
+
+<li class="gap"><span class="smcap">Zehender</span>'s statistics, <a href="#Page_30">30</a>.</li>
+</ul>
+
+</div>
+
+<!-- {312} -->
+
+<!-- {313} -->
+
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> This line is placed too low down; it should be in the
+middle third of the thigh.</p></div>
+
+<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> Erichsen, <i>Surgery</i>. Sixth edition, vol. ii. p. 121.</p></div>
+
+<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> The line 3 in <a href="#plate_i">Plate I.</a> shows the direction required. It
+will not be necessary to carry the incision so far up for the external
+as for the common iliac.</p></div>
+
+<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> <i>On the Arteries and Veins</i>, p. 421.</p></div>
+
+<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> <i>Cyclop&aelig;dia of Practical Surgery</i>, vol. i. p. 277.</p></div>
+
+<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> John Bell's <i>Prin. of Surg.</i>, vol. i. 421; <i>Dublin Jour.</i>,
+vol. iv. 321.</p></div>
+
+<div class="footnote"><p><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a> <i>Observations in Clinical Surgery</i>, Syme, pp. 171-3.</p></div>
+
+<div class="footnote"><p><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">[8]</span></a> <i>Brit. Med. Jour.</i> 1867, Oct. 5.</p></div>
+
+<div class="footnote"><p><a name="Footnote_9_9" id="Footnote_9_9"></a><a href="#FNanchor_9_9"><span class="label">[9]</span></a> <i>International Encyclop&aelig;dia of Surgery</i>, vol. iii. p. 466.</p></div>
+
+<div class="footnote"><p><a name="Footnote_10_10" id="Footnote_10_10"></a><a href="#FNanchor_10_10"><span class="label">[10]</span></a> Poland, <i>Guy's Hosp. Report</i>, ser. iii. vol. vi.</p></div>
+
+<div class="footnote"><p><a name="Footnote_11_11" id="Footnote_11_11"></a><a href="#FNanchor_11_11"><span class="label">[11]</span></a> Mr. W. Thomson's most interesting paper on this subject is
+full of information down to the latest date.</p></div>
+
+<div class="footnote"><p><a name="Footnote_12_12" id="Footnote_12_12"></a><a href="#FNanchor_12_12"><span class="label">[12]</span></a> <i>Lancet</i>, Jan. 5, 1867.</p></div>
+
+<div class="footnote"><p><a name="Footnote_13_13" id="Footnote_13_13"></a><a href="#FNanchor_13_13"><span class="label">[13]</span></a> <i>Lancet</i>, May 1879.</p></div>
+
+<div class="footnote"><p><a name="Footnote_14_14" id="Footnote_14_14"></a><a href="#FNanchor_14_14"><span class="label">[14]</span></a> <i>Dublin Quarterly Journal</i>, Nov. 1867.</p></div>
+
+<div class="footnote"><p><a name="Footnote_15_15" id="Footnote_15_15"></a><a href="#FNanchor_15_15"><span class="label">[15]</span></a> W. Zehender&mdash;Monatsbl. f&uuml;r Augenheilkunde. 1868.</p></div>
+
+<div class="footnote"><p><a name="Footnote_16_16" id="Footnote_16_16"></a><a href="#FNanchor_16_16"><span class="label">[16]</span></a> Butcher, <i>Op. and Cons. Surgery</i>, p. 861.</p></div>
+
+<div class="footnote"><p><a name="Footnote_17_17" id="Footnote_17_17"></a><a href="#FNanchor_17_17"><span class="label">[17]</span></a> <i>Le&ccedil;ons Orales</i>, iv. 530.</p></div>
+
+<div class="footnote"><p><a name="Footnote_18_18" id="Footnote_18_18"></a><a href="#FNanchor_18_18"><span class="label">[18]</span></a> <i>Ed. Med. and Surg. Journ.</i> vol. xlv.</p></div>
+
+<div class="footnote"><p><a name="Footnote_19_19" id="Footnote_19_19"></a><a href="#FNanchor_19_19"><span class="label">[19]</span></a> <i>Observations in Clinical Surgery</i>, pp. 148, 149.</p></div>
+
+<div class="footnote"><p><a name="Footnote_20_20" id="Footnote_20_20"></a><a href="#FNanchor_20_20"><span class="label">[20]</span></a> <i>Edin. Med. Journal</i>, March 1879.</p></div>
+
+<div class="footnote"><p><a name="Footnote_21_21" id="Footnote_21_21"></a><a href="#FNanchor_21_21"><span class="label">[21]</span></a> See case of recurrence, Fergusson's <i>Practical Surgery</i>
+1st ed. p. 222.</p></div>
+
+<div class="footnote"><p><a name="Footnote_22_22" id="Footnote_22_22"></a><a href="#FNanchor_22_22"><span class="label">[22]</span></a> <i>Operative Surgery</i>, p. 279.</p></div>
+
+<div class="footnote"><p><a name="Footnote_23_23" id="Footnote_23_23"></a><a href="#FNanchor_23_23"><span class="label">[23]</span></a> <i>Surgical Operations</i>, p. 50.</p></div>
+
+<div class="footnote"><p><a name="Footnote_24_24" id="Footnote_24_24"></a><a href="#FNanchor_24_24"><span class="label">[24]</span></a> For details see article "Amputation" in Cooper's <i>Surgical
+Dictionary</i>, and the short sketch of the history in Mr. Lister's paper
+in the third volume of Holmes's <i>System of Surgery</i>.</p></div>
+
+<div class="footnote"><p><a name="Footnote_25_25" id="Footnote_25_25"></a><a href="#FNanchor_25_25"><span class="label">[25]</span></a> See a most interesting foot-note to Professor Lister's
+paper on "Amputation," in Holmes's <i>System of Surgery</i>, vol. iii. pp.
+52, 53.</p></div>
+
+<div class="footnote"><p><a name="Footnote_26_26" id="Footnote_26_26"></a><a href="#FNanchor_26_26"><span class="label">[26]</span></a> <i>Manuel d'Op&eacute;rations chirurgicales.</i></p></div>
+
+<div class="footnote"><p><a name="Footnote_27_27" id="Footnote_27_27"></a><a href="#FNanchor_27_27"><span class="label">[27]</span></a> <span class="smcap">Fig. <span class="smcap">iv</span>.</span> shows dorsal view of incision. <span class="smcap">Fig. <span class="smcap">iii</span>.</span> showsface of completed stump; R, radial; U, ulnar.</p></div>
+
+<div class="footnote"><p><a name="Footnote_28_28" id="Footnote_28_28"></a><a href="#FNanchor_28_28"><span class="label">[28]</span></a> As the surgeon will find it most convenient to stand on
+his own right side of the limb to be removed, the knife will be entered
+on the palmar side of the radius of the right arm, of the ulna of the
+left.</p></div>
+
+<div class="footnote"><p><a name="Footnote_29_29" id="Footnote_29_29"></a><a href="#FNanchor_29_29"><span class="label">[29]</span></a> Teale, <i>On Amputation by Rectangular Flaps</i>, pp. 46-48.</p></div>
+
+<div class="footnote"><p><a name="Footnote_30_30" id="Footnote_30_30"></a><a href="#FNanchor_30_30"><span class="label">[30]</span></a> Johnson's folio ed., p. 342.</p></div>
+
+<div class="footnote"><p><a name="Footnote_31_31" id="Footnote_31_31"></a><a href="#FNanchor_31_31"><span class="label">[31]</span></a> Gross's <i>Surgery</i>, 6th ed. vol. ii. p. 1103.</p></div>
+
+<div class="footnote"><p><a name="Footnote_32_32" id="Footnote_32_32"></a><a href="#FNanchor_32_32"><span class="label">[32]</span></a> <i>International Encyclop&aelig;dia of Surgery</i>, vol. i. p. 641.</p></div>
+
+<div class="footnote"><p><a name="Footnote_33_33" id="Footnote_33_33"></a><a href="#FNanchor_33_33"><span class="label">[33]</span></a> Spence's <i>Surgery</i>, pp. 800, 801.</p></div>
+
+<div class="footnote"><p><a name="Footnote_34_34" id="Footnote_34_34"></a><a href="#FNanchor_34_34"><span class="label">[34]</span></a> Gross's <i>Surgery</i>, 8vo., 6th ed., vol. ii., p. 1106.</p></div>
+
+<div class="footnote"><p><a name="Footnote_35_35" id="Footnote_35_35"></a><a href="#FNanchor_35_35"><span class="label">[35]</span></a> <i>Excision of Scapula</i>, p. 33.</p></div>
+
+<div class="footnote"><p><a name="Footnote_36_36" id="Footnote_36_36"></a><a href="#FNanchor_36_36"><span class="label">[36]</span></a> Hey's <i>Observations</i>, 3d ed. pp. 552, 556.</p></div>
+
+<div class="footnote"><p><a name="Footnote_37_37" id="Footnote_37_37"></a><a href="#FNanchor_37_37"><span class="label">[37]</span></a> Roux's <i>Parallel between English and French Surgery</i>.
+Translation abridged from Cooper's <i>Surgical Dictionary</i>, p. 106.</p></div>
+
+<div class="footnote"><p><a name="Footnote_38_38" id="Footnote_38_38"></a><a href="#FNanchor_38_38"><span class="label">[38]</span></a> Syme's <i>Principles</i>, 4th edit. p. 145.</p></div>
+
+<div class="footnote"><p><a name="Footnote_39_39" id="Footnote_39_39"></a><a href="#FNanchor_39_39"><span class="label">[39]</span></a> <i>International Encyclop&aelig;dia</i>, vol. 1. p. 655.</p></div>
+
+<div class="footnote"><p><a name="Footnote_40_40" id="Footnote_40_40"></a><a href="#FNanchor_40_40"><span class="label">[40]</span></a> <i>Observations in Clin. Surgery</i>, p. 48.</p></div>
+
+<div class="footnote"><p><a name="Footnote_41_41" id="Footnote_41_41"></a><a href="#FNanchor_41_41"><span class="label">[41]</span></a> <i>Monthly Journal of Medical Science for 1849</i>, vol. ix. p.
+951.</p></div>
+
+<div class="footnote"><p><a name="Footnote_42_42" id="Footnote_42_42"></a><a href="#FNanchor_42_42"><span class="label">[42]</span></a> <i>Med. Times and Gazette</i>, June 3, 1865.</p></div>
+
+<div class="footnote"><p><a name="Footnote_43_43" id="Footnote_43_43"></a><a href="#FNanchor_43_43"><span class="label">[43]</span></a> <i>Operative Surgery</i>, p. 170.</p></div>
+
+<div class="footnote"><p><a name="Footnote_44_44" id="Footnote_44_44"></a><a href="#FNanchor_44_44"><span class="label">[44]</span></a> <i>Annali Universali de Medicina</i>, Milano, 1857.</p></div>
+
+<div class="footnote"><p><a name="Footnote_45_45" id="Footnote_45_45"></a><a href="#FNanchor_45_45"><span class="label">[45]</span></a> <i>Med. Chir. Transactions of London</i>, vol. liii., p. 175.</p></div>
+
+<div class="footnote"><p><a name="Footnote_46_46" id="Footnote_46_46"></a><a href="#FNanchor_46_46"><span class="label">[46]</span></a> Carden's (of Worcester) Pamphlet, pp. 5, 6; and <i>British
+Medical Journal</i>, 1864.</p></div>
+
+<div class="footnote"><p><a name="Footnote_47_47" id="Footnote_47_47"></a><a href="#FNanchor_47_47"><span class="label">[47]</span></a> B. Bell's <i>Surgery</i>, 6th ed. vol. vii. pp. 336-339.</p></div>
+
+<div class="footnote"><p><a name="Footnote_48_48" id="Footnote_48_48"></a><a href="#FNanchor_48_48"><span class="label">[48]</span></a> In diagram the amputation is drawn as if for middle third
+of thigh.</p></div>
+
+<div class="footnote"><p><a name="Footnote_49_49" id="Footnote_49_49"></a><a href="#FNanchor_49_49"><span class="label">[49]</span></a> Teale, <i>op. cit.</i>, pp. 34, 39.</p></div>
+
+<div class="footnote"><p><a name="Footnote_50_50" id="Footnote_50_50"></a><a href="#FNanchor_50_50"><span class="label">[50]</span></a> <i>Edin. Med. Journal</i>, for April 1863.</p></div>
+
+<div class="footnote"><p><a name="Footnote_51_51" id="Footnote_51_51"></a><a href="#FNanchor_51_51"><span class="label">[51]</span></a> <i>Edin. Medical Journal</i>, March 1879.</p></div>
+
+<div class="footnote"><p><a name="Footnote_52_52" id="Footnote_52_52"></a><a href="#FNanchor_52_52"><span class="label">[52]</span></a> <i>On Diseases and Injuries of Joints</i>, p. 121.</p></div>
+
+<div class="footnote"><p><a name="Footnote_53_53" id="Footnote_53_53"></a><a href="#FNanchor_53_53"><span class="label">[53]</span></a> For a very large amount of most interesting and valuable
+information on the whole subject of excisions of joints, I would refer
+to Dr. Hodge's most excellent work on this subject&mdash;<i>On Excisions of
+Joints</i>. By Richard M. Hodge, M.D., Boston, Massachusetts.</p></div>
+
+<div class="footnote"><p><a name="Footnote_54_54" id="Footnote_54_54"></a><a href="#FNanchor_54_54"><span class="label">[54]</span></a> See Syme's <i>Observations on Clinical Surgery</i>, pp. 55, 57;
+Hodge <i>on Excision of Joints</i>, p. 63.</p></div>
+
+<div class="footnote"><p><a name="Footnote_55_55" id="Footnote_55_55"></a><a href="#FNanchor_55_55"><span class="label">[55]</span></a> Maunder's <i>Operative Surgery</i>, 2d ed. p. 123.</p></div>
+
+<div class="footnote"><p><a name="Footnote_56_56" id="Footnote_56_56"></a><a href="#FNanchor_56_56"><span class="label">[56]</span></a> <i>Edin. Med. Journal</i>, May 1873.</p></div>
+
+<div class="footnote"><p><a name="Footnote_57_57" id="Footnote_57_57"></a><a href="#FNanchor_57_57"><span class="label">[57]</span></a> Quoted by Mr. Porter. <i>Dublin Quarterly Journal</i> for May
+1867, p. 264.</p></div>
+
+<div class="footnote"><p><a name="Footnote_58_58" id="Footnote_58_58"></a><a href="#FNanchor_58_58"><span class="label">[58]</span></a> A-A. Deep palmar arch; B. Trapezium; C. Articular surface
+of ulna; Dotted lines include the amount removed in Lister's earlier
+operations; Unshaded portions are those removed by Lister in cases where
+the disease is limited to the carpus. (Reduced from Lister's diagram in
+<i>Lancet</i>, 1865.)</p></div>
+
+<div class="footnote"><p><a name="Footnote_59_59" id="Footnote_59_59"></a><a href="#FNanchor_59_59"><span class="label">[59]</span></a> Skey, <i>Op. Surg.</i>, 2d ed. p. 438.</p></div>
+
+<div class="footnote"><p><a name="Footnote_60_60" id="Footnote_60_60"></a><a href="#FNanchor_60_60"><span class="label">[60]</span></a> Abridged from Butcher, <i>Op. and Con. Surgery</i>, p. 208.</p></div>
+
+<div class="footnote"><p><a name="Footnote_61_61" id="Footnote_61_61"></a><a href="#FNanchor_61_61"><span class="label">[61]</span></a> <i>Science and Art of Surgery</i>, 3d ed. p. 745.</p></div>
+
+<div class="footnote"><p><a name="Footnote_62_62" id="Footnote_62_62"></a><a href="#FNanchor_62_62"><span class="label">[62]</span></a> <i>On the Surgical Treatment of Children's Diseases</i>, pp.
+454-6.</p></div>
+
+<div class="footnote"><p><a name="Footnote_63_63" id="Footnote_63_63"></a><a href="#FNanchor_63_63"><span class="label">[63]</span></a> <i>Clinical Society's Transactions</i>, vol. xiii. p. 71.</p></div>
+
+<div class="footnote"><p><a name="Footnote_64_64" id="Footnote_64_64"></a><a href="#FNanchor_64_64"><span class="label">[64]</span></a> Billroth of Vienna and Pelikan of St. Petersburg, quoted
+from Heyfelder by Hodge <i>on Excision of Joints</i>, p. 161.</p></div>
+
+<div class="footnote"><p><a name="Footnote_65_65" id="Footnote_65_65"></a><a href="#FNanchor_65_65"><span class="label">[65]</span></a> <i>Operative and Conservative Surgery</i>, pp. 28, 138.</p></div>
+
+<div class="footnote"><p><a name="Footnote_66_66" id="Footnote_66_66"></a><a href="#FNanchor_66_66"><span class="label">[66]</span></a> <i>On Excision of Knee-Joint</i>, pp. 18, 20.</p></div>
+
+<div class="footnote"><p><a name="Footnote_67_67" id="Footnote_67_67"></a><a href="#FNanchor_67_67"><span class="label">[67]</span></a> <i>Operative and Conservative Surgery</i>, p. 169.</p></div>
+
+<div class="footnote"><p><a name="Footnote_68_68" id="Footnote_68_68"></a><a href="#FNanchor_68_68"><span class="label">[68]</span></a> Mr. Jones of Jersey, <i>Med. Chir. Trans.</i>, vol. xxxvii. p.
+68.</p></div>
+
+<div class="footnote"><p><a name="Footnote_69_69" id="Footnote_69_69"></a><a href="#FNanchor_69_69"><span class="label">[69]</span></a> <i>Lancet</i>, Oct. 1, 1859.</p></div>
+
+<div class="footnote"><p><a name="Footnote_70_70" id="Footnote_70_70"></a><a href="#FNanchor_70_70"><span class="label">[70]</span></a> Barwell <i>On Diseased Joints</i>, p. 464.</p></div>
+
+<div class="footnote"><p><a name="Footnote_71_71" id="Footnote_71_71"></a><a href="#FNanchor_71_71"><span class="label">[71]</span></a> Syme <i>On Excision of the Scapula</i>, pp. 13-26, 1864.</p></div>
+
+<div class="footnote"><p><a name="Footnote_72_72" id="Footnote_72_72"></a><a href="#FNanchor_72_72"><span class="label">[72]</span></a> Butcher's <i>Operative and Conservative Surgery</i>, p. 225.</p></div>
+
+<div class="footnote"><p><a name="Footnote_73_73" id="Footnote_73_73"></a><a href="#FNanchor_73_73"><span class="label">[73]</span></a> For an excellent case, see Annandale on <i>Diseases of the
+Finger and Toes</i>, p. 261.</p></div>
+
+<div class="footnote"><p><a name="Footnote_74_74" id="Footnote_74_74"></a><a href="#FNanchor_74_74"><span class="label">[74]</span></a> Holmes's <i>Surgery</i>, 3d edition, vol. iii. p. 771.</p></div>
+
+<div class="footnote"><p><a name="Footnote_75_75" id="Footnote_75_75"></a><a href="#FNanchor_75_75"><span class="label">[75]</span></a> <i>Brit. and Foreign Med. Chir. Review</i> for July 1853.</p></div>
+
+<div class="footnote"><p><a name="Footnote_76_76" id="Footnote_76_76"></a><a href="#FNanchor_76_76"><span class="label">[76]</span></a> Mr. Holmes in <i>Lancet</i> for February 18, 1856.</p></div>
+
+<div class="footnote"><p><a name="Footnote_77_77" id="Footnote_77_77"></a><a href="#FNanchor_77_77"><span class="label">[77]</span></a> <i>Ibid.</i> for May 1865.</p></div>
+
+<div class="footnote"><p><a name="Footnote_78_78" id="Footnote_78_78"></a><a href="#FNanchor_78_78"><span class="label">[78]</span></a> Butcher, <i>Operative and Conservative Surgery</i>, p. 354.</p></div>
+
+<div class="footnote"><p><a name="Footnote_79_79" id="Footnote_79_79"></a><a href="#FNanchor_79_79"><span class="label">[79]</span></a> See Butcher, <i>Operative and Conservative Surgery</i>, p.
+356.</p></div>
+
+<div class="footnote"><p><a name="Footnote_80_80" id="Footnote_80_80"></a><a href="#FNanchor_80_80"><span class="label">[80]</span></a> See case by the author in the <i>Edin. Med. Jour.</i> for June
+1868.</p></div>
+
+<div class="footnote"><p><a name="Footnote_81_81" id="Footnote_81_81"></a><a href="#FNanchor_81_81"><span class="label">[81]</span></a> <i>a.</i> Elliptical incision for entropium; <i>b.</i> wedge-shaped
+incision for ectropium.</p></div>
+
+<div class="footnote"><p><a name="Footnote_82_82" id="Footnote_82_82"></a><a href="#FNanchor_82_82"><span class="label">[82]</span></a> Fig. <span class="smcap">viii</span>. illustrates Streatfeild's operation for
+entropium.&mdash;<i>a.</i> section of skin; <i>b.</i> section of levator palpebrae;
+<i>c.</i> section of cartilage of lid; <i>d.</i> section of conjunctiva; <i>e.</i>
+wedge-shaped portion excised.</p></div>
+
+<div class="footnote"><p><a name="Footnote_83_83" id="Footnote_83_83"></a><a href="#FNanchor_83_83"><span class="label">[83]</span></a> <i>Ophthalmic Hospital Reports</i>, vol. i. p. 121.</p></div>
+
+<div class="footnote"><p><a name="Footnote_84_84" id="Footnote_84_84"></a><a href="#FNanchor_84_84"><span class="label">[84]</span></a> Rough diagram of Bowman's operation, showing the grooved
+director in the punctum, and the knife in the groove just before it
+slits up the canaliculus.</p></div>
+
+<div class="footnote"><p><a name="Footnote_85_85" id="Footnote_85_85"></a><a href="#FNanchor_85_85"><span class="label">[85]</span></a> Diagram of operations for convergent squint&mdash;<span class="smcap">A A</span>, line of
+sub-conjunctival incision; <span class="smcap">B B</span>, line of Dieffenbach's operation; <span class="smcap">c</span>, wire
+speculum.</p></div>
+
+<div class="footnote"><p><a name="Footnote_86_86" id="Footnote_86_86"></a><a href="#FNanchor_86_86"><span class="label">[86]</span></a> <i>The Radical Cure of Extreme Divergent Strabismus.</i> J.
+Vose Solomon, F.R.C.S., 1864.</p></div>
+
+<div class="footnote"><p><a name="Footnote_87_87" id="Footnote_87_87"></a><a href="#FNanchor_87_87"><span class="label">[87]</span></a> <i>Ophthalmic Hospital Reports</i>, vol. iv. part ii. p. 197.</p></div>
+
+<div class="footnote"><p><a name="Footnote_88_88" id="Footnote_88_88"></a><a href="#FNanchor_88_88"><span class="label">[88]</span></a> <i>Biennial Retrospect</i> for 1865-66. Syd. Soc. pp. 363-4.
+For a thorough discussion of the merits of this operation, see papers by
+Von Graefe in <i>Brit. Med. Jour.</i> for 1867, vol. i. pp. 379, 446, 499,
+657, 765.</p></div>
+
+<div class="footnote"><p><a name="Footnote_89_89" id="Footnote_89_89"></a><a href="#FNanchor_89_89"><span class="label">[89]</span></a> <i>Ophthalmic Hospital Reports</i>, vol. i. p. 224.</p></div>
+
+<div class="footnote"><p><a name="Footnote_90_90" id="Footnote_90_90"></a><a href="#FNanchor_90_90"><span class="label">[90]</span></a> Streatfeild on Corelysis. <i>Ophthalmic Hospital Reports</i>,
+vol. ii. p. 309.</p></div>
+
+<div class="footnote"><p><a name="Footnote_91_91" id="Footnote_91_91"></a><a href="#FNanchor_91_91"><span class="label">[91]</span></a> <i>a</i> iris; <i>b</i> lens; <i>c</i> cornea. The hook is seen applied
+to the adhesion between lens and iris.</p></div>
+
+<div class="footnote"><p><a name="Footnote_92_92" id="Footnote_92_92"></a><a href="#FNanchor_92_92"><span class="label">[92]</span></a> The staphyloma with the needles inserted, the lids held
+asunder by a spring speculum. The elliptical dotted line shows the
+amount to be removed; the vertical one, the position of the preliminary
+incision with the Beer's knife.</p></div>
+
+<div class="footnote"><p><a name="Footnote_93_93" id="Footnote_93_93"></a><a href="#FNanchor_93_93"><span class="label">[93]</span></a> Resulting stump after the stitches are inserted.</p></div>
+
+<div class="footnote"><p><a name="Footnote_94_94" id="Footnote_94_94"></a><a href="#FNanchor_94_94"><span class="label">[94]</span></a> <i>Ophthalmic Hospital Reports</i>, vol. iv. part 1.</p></div>
+
+<div class="footnote"><p><a name="Footnote_95_95" id="Footnote_95_95"></a><a href="#FNanchor_95_95"><span class="label">[95]</span></a> Operation for formation of a new nose from the cheeks; <span class="smcap">a
+a</span>, flaps approximated in middle line; <span class="smcap">B B</span>, outer part of bed of flaps
+stitched up; <span class="smcap">C C</span>, triangle at each side left to granulate.</p></div>
+
+<div class="footnote"><p><a name="Footnote_96_96" id="Footnote_96_96"></a><a href="#FNanchor_96_96"><span class="label">[96]</span></a> <i>The Restoration of a Lost Nose by Operation</i>, p. 57; an
+excellent monograph on the subject.</p></div>
+
+<div class="footnote"><p><a name="Footnote_97_97" id="Footnote_97_97"></a><a href="#FNanchor_97_97"><span class="label">[97]</span></a> Operation for formation of a new nose from the
+forehead:&mdash;<i>a</i>, prominence of flap which is to be used as septum; <i>b</i>,
+left-hand corner of flap, which is twisted and fastened at <i>c</i>; <i>d</i>, one
+of the tubes or quills over which the nose is moulded.&mdash;(<i>Modified from
+Bernard and Huette.</i>)</p></div>
+
+<div class="footnote"><p><a name="Footnote_98_98" id="Footnote_98_98"></a><a href="#FNanchor_98_98"><span class="label">[98]</span></a> Syme's <i>Observations in Clinical Surgery</i>, p. 132.</p></div>
+
+<div class="footnote"><p><a name="Footnote_99_99" id="Footnote_99_99"></a><a href="#FNanchor_99_99"><span class="label">[99]</span></a> Diagram of V-shaped incision; <span class="smcap">A B A</span>, dots showing points
+for sutures.</p></div>
+
+<div class="footnote"><p><a name="Footnote_100_100" id="Footnote_100_100"></a><a href="#FNanchor_100_100"><span class="label">[100]</span></a> Diagram of incision for scooping out a shallow tumour by
+scissors.</p></div>
+
+<div class="footnote"><p><a name="Footnote_101_101" id="Footnote_101_101"></a><a href="#FNanchor_101_101"><span class="label">[101]</span></a> Diagram of incisions:&mdash;<span class="smcap">C A C</span>, outline of incision for
+removal; <span class="smcap">C A D</span>, outline of flap on each side; <span class="smcap">b</span>, prominence of chin; <span class="smcap">C
+C</span>, dotted lines, showing incisions to enlarge mouth, if required.</p></div>
+
+<div class="footnote"><p><a name="Footnote_102_102" id="Footnote_102_102"></a><a href="#FNanchor_102_102"><span class="label">[102]</span></a> Diagram of flaps in position:&mdash;<span class="smcap">A A</span>, corners of flaps
+brought up and approximated by <i>silver</i> sutures; <span class="smcap">C C</span>, new lip got by
+lateral incisions, skin and mucous membrane being united by <i>silk</i>
+threads; <span class="smcap">E E</span>, gap left to granulate.</p></div>
+
+<div class="footnote"><p><a name="Footnote_103_103" id="Footnote_103_103"></a><a href="#FNanchor_103_103"><span class="label">[103]</span></a> Fig. <span class="smcap">xxiii.</span> shows the incision bounding the cleft.</p></div>
+
+<div class="footnote"><p><a name="Footnote_104_104" id="Footnote_104_104"></a><a href="#FNanchor_104_104"><span class="label">[104]</span></a> Fig. <span class="smcap">xxiv.</span> shows the diamond-shaped wound before the
+sutures are applied.</p></div>
+
+<div class="footnote"><p><a name="Footnote_105_105" id="Footnote_105_105"></a><a href="#FNanchor_105_105"><span class="label">[105]</span></a> Diagram of operation for double harelip:&mdash;<i>a</i>, stitch
+through both sides and wedge-shaped portion, which also aids the septum;
+<i>b</i>, other stitches approximating edges.</p></div>
+
+<div class="footnote"><p><a name="Footnote_106_106" id="Footnote_106_106"></a><a href="#FNanchor_106_106"><span class="label">[106]</span></a> Diagram of double harelip, with projecting bone:&mdash;<i>a</i>,
+central piece of lip, dotted lines showing incision; <i>b</i>, projecting
+bone bearing teeth, which are generally small and stunted.</p></div>
+
+<div class="footnote"><p><a name="Footnote_107_107" id="Footnote_107_107"></a><a href="#FNanchor_107_107"><span class="label">[107]</span></a> Diagram of operations on the jaws:&mdash;<span class="smcap">a</span>, incision for
+removal of the whole upper jaw; <span class="smcap">b</span>, incision for removal of alveolar
+portion and antrum; <span class="smcap">c</span>, incision for removing the larger half of lower
+jaw; the opposite side is the one supposed to be operated on, and the
+incision is crossing the symphysis and turning up at a right angle.</p></div>
+
+<div class="footnote"><p><a name="Footnote_108_108" id="Footnote_108_108"></a><a href="#FNanchor_108_108"><span class="label">[108]</span></a> <i>Operative Surgery</i>, p. 265.</p></div>
+
+<div class="footnote"><p><a name="Footnote_109_109" id="Footnote_109_109"></a><a href="#FNanchor_109_109"><span class="label">[109]</span></a> <i>Lancet</i>, July 1, 1865.</p></div>
+
+<div class="footnote"><p><a name="Footnote_110_110" id="Footnote_110_110"></a><a href="#FNanchor_110_110"><span class="label">[110]</span></a> Temporary compression of the facial can be easily
+managed, in cases where it is of much importance to avoid loss of blood,
+by passing a needle from the outside through the skin above the vessel,
+then under the vessel, and out again through the skin below. A
+figure-of-eight suture can then be thrown round both ends of the needle,
+and the artery thus thoroughly compressed.</p></div>
+
+<div class="footnote"><p><a name="Footnote_111_111" id="Footnote_111_111"></a><a href="#FNanchor_111_111"><span class="label">[111]</span></a> Syme, <i>Contributions to the Path. and Practice of
+Surgery</i>, p. 21; Carnochan of New York, <i>Cases in Surgery</i>.</p></div>
+
+<div class="footnote"><p><a name="Footnote_112_112" id="Footnote_112_112"></a><a href="#FNanchor_112_112"><span class="label">[112]</span></a> <i>Contributions to the Path. and Prac. of Surgery</i>, pp.
+23, 24.</p></div>
+
+<div class="footnote"><p><a name="Footnote_113_113" id="Footnote_113_113"></a><a href="#FNanchor_113_113"><span class="label">[113]</span></a> <i>Lancet</i>, July 1, 1865.</p></div>
+
+<div class="footnote"><p><a name="Footnote_114_114" id="Footnote_114_114"></a><a href="#FNanchor_114_114"><span class="label">[114]</span></a> Rough diagram of operation for salivary fistula:&mdash;<span class="smcap">a</span>,
+section of cheek close to buccal orifice; <span class="smcap">b</span>, section of zygoma, muscles,
+etc.; <span class="smcap">c</span>, the duct of the parotid; <span class="smcap">d</span>, the fistulous opening of the cheek;
+<span class="smcap">E E</span>, the thread knotted inside the mouth; <span class="smcap">f</span>, the palate.</p></div>
+
+<div class="footnote"><p><a name="Footnote_115_115" id="Footnote_115_115"></a><a href="#FNanchor_115_115"><span class="label">[115]</span></a> <i>Lancet</i>, Feb. 4, 1865.</p></div>
+
+<div class="footnote"><p><a name="Footnote_116_116" id="Footnote_116_116"></a><a href="#FNanchor_116_116"><span class="label">[116]</span></a> <i>Med. Times and Gazette</i> for Feb. 10, 1866.</p></div>
+
+<div class="footnote"><p><a name="Footnote_117_117" id="Footnote_117_117"></a><a href="#FNanchor_117_117"><span class="label">[117]</span></a> <i>Lancet</i>, April 20, 1872.</p></div>
+
+<div class="footnote"><p><a name="Footnote_118_118" id="Footnote_118_118"></a><a href="#FNanchor_118_118"><span class="label">[118]</span></a> <i>Transactions International Medical Congress</i>, 1881, vol.
+ii. p. 460.</p></div>
+
+<div class="footnote"><p><a name="Footnote_119_119" id="Footnote_119_119"></a><a href="#FNanchor_119_119"><span class="label">[119]</span></a> Gross's <i>Surgery</i>, vol. ii. p. 472.</p></div>
+
+<div class="footnote"><p><a name="Footnote_120_120" id="Footnote_120_120"></a><a href="#FNanchor_120_120"><span class="label">[120]</span></a> Langenbeck, <i>Archiv</i>, ii. p. 657.</p></div>
+
+<div class="footnote"><p><a name="Footnote_121_121" id="Footnote_121_121"></a><a href="#FNanchor_121_121"><span class="label">[121]</span></a> <i>Med. Chir. Trans.</i> for 1867-8.</p></div>
+
+<div class="footnote"><p><a name="Footnote_122_122" id="Footnote_122_122"></a><a href="#FNanchor_122_122"><span class="label">[122]</span></a> Diagram of staphyloraphy, chiefly to illustrate the
+passing of the threads:&mdash;<i>a</i>, the first thread; <i>b</i>, the second. The
+dotted line at edge of fissure shows amount to be removed; the other
+dotted lines showing size and position of the incision through the
+mucous membrane above.</p></div>
+
+<div class="footnote"><p><a name="Footnote_123_123" id="Footnote_123_123"></a><a href="#FNanchor_123_123"><span class="label">[123]</span></a> Holmes's <i>Surgery</i>, vol. ii. pp. 504-513.</p></div>
+
+<div class="footnote"><p><a name="Footnote_124_124" id="Footnote_124_124"></a><a href="#FNanchor_124_124"><span class="label">[124]</span></a> <i>Edinburgh Medical Journal</i> for Jan. 1865, Mr.
+Annandale's instructive paper on "Cleft Palate."</p></div>
+
+<div class="footnote"><p><a name="Footnote_125_125" id="Footnote_125_125"></a><a href="#FNanchor_125_125"><span class="label">[125]</span></a> Diagram of fissure of hard palate:&mdash;<i>a</i>, anterior
+palatine foramina; <i>b</i>, posterior palatine foramina with groove for
+artery; <i>c</i>, incisions requisite to free the soft structures.</p></div>
+
+<div class="footnote"><p><a name="Footnote_126_126" id="Footnote_126_126"></a><a href="#FNanchor_126_126"><span class="label">[126]</span></a> Holmes's <i>Diseases of Children</i>, p. 555.</p></div>
+
+<div class="footnote"><p><a name="Footnote_127_127" id="Footnote_127_127"></a><a href="#FNanchor_127_127"><span class="label">[127]</span></a> <i>Le&ccedil;ons sur la Trach&eacute;otomie</i>, p. 10.</p></div>
+
+<div class="footnote"><p><a name="Footnote_128_128" id="Footnote_128_128"></a><a href="#FNanchor_128_128"><span class="label">[128]</span></a> Rough diagram of larynx and trachea:&mdash;A, crico-thyroid
+space, <i>laryngotomy</i>; B B, dotted outline of thyroid isthmus and lobes,
+defines the upper and lower positions for <i>tracheotomy</i>; C, thyroid&mdash;D,
+cricoid cartilages; E, dotted outline of thymus gland in child of two
+years; F F, outline of clavicles and jugular fossa.</p></div>
+
+<div class="footnote"><p><a name="Footnote_129_129" id="Footnote_129_129"></a><a href="#FNanchor_129_129"><span class="label">[129]</span></a> <i>Surgical Observations</i>, p. 335. See also Harrison <i>On
+the Arteries</i>, vol. i. p. 16.</p></div>
+
+<div class="footnote"><p><a name="Footnote_130_130" id="Footnote_130_130"></a><a href="#FNanchor_130_130"><span class="label">[130]</span></a> <i>Le&ccedil;ons sur la Trach&eacute;otomie</i>, p. 9.</p></div>
+
+<div class="footnote"><p><a name="Footnote_131_131" id="Footnote_131_131"></a><a href="#FNanchor_131_131"><span class="label">[131]</span></a> <i>Lectures on Surgery</i>, 3d ed., vol. ii. p. 900.</p></div>
+
+<div class="footnote"><p><a name="Footnote_132_132" id="Footnote_132_132"></a><a href="#FNanchor_132_132"><span class="label">[132]</span></a> <i>Clinical Surgery in India</i> (1866), p. 143.</p></div>
+
+<div class="footnote"><p><a name="Footnote_133_133" id="Footnote_133_133"></a><a href="#FNanchor_133_133"><span class="label">[133]</span></a> Mr. John Wood, <i>Path. Soc. Trans.</i>, vol. xi. p. 20.</p></div>
+
+<div class="footnote"><p><a name="Footnote_134_134" id="Footnote_134_134"></a><a href="#FNanchor_134_134"><span class="label">[134]</span></a> South's <i>Chelius</i>, vol. ii. p. 400; and case recorded by
+Spence, in <i>Ed. Med. Journal</i>, for August 1862.</p></div>
+
+<div class="footnote"><p><a name="Footnote_135_135" id="Footnote_135_135"></a><a href="#FNanchor_135_135"><span class="label">[135]</span></a> <i>Med. Chir. Transactions of London</i>, 1872.</p></div>
+
+<div class="footnote"><p><a name="Footnote_136_136" id="Footnote_136_136"></a><a href="#FNanchor_136_136"><span class="label">[136]</span></a> <i>British Med. Journal</i> (Nos. 643, 644), 1873.</p></div>
+
+<div class="footnote"><p><a name="Footnote_137_137" id="Footnote_137_137"></a><a href="#FNanchor_137_137"><span class="label">[137]</span></a> Gross's <i>Surgery</i>, 6th ed., vol. ii. p. 342.</p></div>
+
+<div class="footnote"><p><a name="Footnote_138_138" id="Footnote_138_138"></a><a href="#FNanchor_138_138"><span class="label">[138]</span></a> <i>Guy's Hospital Reports</i> for 1858.</p></div>
+
+<div class="footnote"><p><a name="Footnote_139_139" id="Footnote_139_139"></a><a href="#FNanchor_139_139"><span class="label">[139]</span></a> Both in <i>Guy's Hospital Reports</i>, second series, vol.
+ii.</p></div>
+
+<div class="footnote"><p><a name="Footnote_140_140" id="Footnote_140_140"></a><a href="#FNanchor_140_140"><span class="label">[140]</span></a> <i>Edinburgh Medical Journal</i> for June 1866.</p></div>
+
+<div class="footnote"><p><a name="Footnote_141_141" id="Footnote_141_141"></a><a href="#FNanchor_141_141"><span class="label">[141]</span></a> <i>Description of Sir Spencer Wells's Trocar.</i>&mdash;"It
+consists of a hollow cylinder six inches long, and half an inch in
+diameter, within which another cylinder fitting it tightly plays. The
+inner one is cut off at its extremity, somewhat in the form of a pen,
+and is sharp. The sharp end is kept retracted within the outer cylinder
+by a spiral spring in the handle at the other end, but can be protruded
+by pressing on this handle when required for use. When thus protruded it
+is plunged into the cyst up to its middle; the pressure on the handle is
+taken off, and the cutting edge is retracted within its sheath. The
+fluid rushes into the tube, and escapes by an aperture in the side, to
+which an india-rubber tube is attached, the end of which drops into a
+bucket under the table. The instrument is furnished at its middle with
+two semicircular bars, carrying each four or five long curved teeth like
+a vulsellum. These teeth lie in contact with the outer surface of the
+cylinder, but can be raised from it by pressing two handles. When the
+cyst begins to be flaccid by the escape of the fluid, these side
+vulsellums are raised, and the adjoining part of the cyst is drawn up
+under the teeth, where it is firmly caught and compressed against the
+side of the tube."</p></div>
+
+<div class="footnote"><p><a name="Footnote_142_142" id="Footnote_142_142"></a><a href="#FNanchor_142_142"><span class="label">[142]</span></a> For further details on the operations described above,
+reference may be made to Sir Spencer Wells's work on ovarian disease,
+and to the very valuable papers contributed by Dr. Thomas Keith to the
+<i>Edinburgh Medical Journal</i>. To the latter especially the author is
+indebted for much oral instruction, and for the opportunity of seeing
+his careful and dexterous mode of operating.</p></div>
+
+<div class="footnote"><p><a name="Footnote_143_143" id="Footnote_143_143"></a><a href="#FNanchor_143_143"><span class="label">[143]</span></a> <i>Lect. on Surgery</i>, 3d ed., vol. ii. p. 998.</p></div>
+
+<div class="footnote"><p><a name="Footnote_144_144" id="Footnote_144_144"></a><a href="#FNanchor_144_144"><span class="label">[144]</span></a> <i>Operative Surgery</i>, p. 462.</p></div>
+
+<div class="footnote"><p><a name="Footnote_145_145" id="Footnote_145_145"></a><a href="#FNanchor_145_145"><span class="label">[145]</span></a> Rough diagram of abnormal course of obturator and its
+relation to the neck of a hernia. Parts seen from the inside: <span class="smcap">h</span>, femoral
+hernia; <span class="smcap">a</span>, femoral artery; <span class="smcap">v</span>, femoral vein; <span class="smcap">e</span>, epigastric artery; <span class="smcap">o</span>,
+obturator from epigastric (dangerous); <span class="smcap">s o</span>, obturator from epigastric
+(safe); <span class="smcap">n o</span>, normal course of obturator; <span class="smcap">i r</span>, internal inguinal ring; Sp
+<span class="smcap">c</span>, spermatic chord and its vessels; <span class="smcap">g</span>, Gimbernat's ligament; +, in
+triangle of Hesselbach.</p></div>
+
+<div class="footnote"><p><a name="Footnote_146_146" id="Footnote_146_146"></a><a href="#FNanchor_146_146"><span class="label">[146]</span></a> Holmes's <i>Surgery</i>, 3d ed., 1883, vol. ii. p. 837.</p></div>
+
+<div class="footnote"><p><a name="Footnote_147_147" id="Footnote_147_147"></a><a href="#FNanchor_147_147"><span class="label">[147]</span></a> <i>Clinical and Pathological Observations in India</i>, pp.
+44, 325.</p></div>
+
+<div class="footnote"><p><a name="Footnote_148_148" id="Footnote_148_148"></a><a href="#FNanchor_148_148"><span class="label">[148]</span></a> Wood <i>On Rupture</i>, 1863.</p></div>
+
+<div class="footnote"><p><a name="Footnote_149_149" id="Footnote_149_149"></a><a href="#FNanchor_149_149"><span class="label">[149]</span></a> Diagram of an artificial anus, showing small sutures
+which unite the edges of the gut and the skin, and the large ones
+stitching up the wound beyond.</p></div>
+
+<div class="footnote"><p><a name="Footnote_150_150" id="Footnote_150_150"></a><a href="#FNanchor_150_150"><span class="label">[150]</span></a> Diagram of section of prostate seen from the inside:&mdash;<span class="smcap">pf</span>,
+pelvic fascia or prostatic sheath; <span class="smcap">rr</span>, ring which must be cut; <span class="smcap">l</span>,
+position of incision in the lateral operation; <span class="smcap">dd</span>, position of incisions
+in the bilateral operation.</p></div>
+
+<div class="footnote"><p><a name="Footnote_151_151" id="Footnote_151_151"></a><a href="#FNanchor_151_151"><span class="label">[151]</span></a> Diagram of muscles of membranous portion of urethra seen
+from the inside:&mdash;<span class="smcap">ss</span>, section of os pubis; <span class="smcap">u</span>, urethra; <span class="smcap">g</span>, Guthrie's
+muscle, compressor urethr&aelig;; <span class="smcap">w</span>, Wilson's muscle, levator urethr&aelig;.</p></div>
+
+<div class="footnote"><p><a name="Footnote_152_152" id="Footnote_152_152"></a><a href="#FNanchor_152_152"><span class="label">[152]</span></a> <i>Boston Medical and Surgical Journal</i>, May 29, 1879.</p></div>
+
+<div class="footnote"><p><a name="Footnote_153_153" id="Footnote_153_153"></a><a href="#FNanchor_153_153"><span class="label">[153]</span></a> Gross, <i>Surgery</i>, 6th ed. vol. ii. p. 736.</p></div>
+
+<div class="footnote"><p><a name="Footnote_154_154" id="Footnote_154_154"></a><a href="#FNanchor_154_154"><span class="label">[154]</span></a> Holmes's <i>Surgery</i>, vol. iv. p. 392.</p></div>
+
+<div class="footnote"><p><a name="Footnote_155_155" id="Footnote_155_155"></a><a href="#FNanchor_155_155"><span class="label">[155]</span></a> See Miller's <i>Practice of Surgery</i>, p. 212.</p></div>
+
+<div class="footnote"><p><a name="Footnote_156_156" id="Footnote_156_156"></a><a href="#FNanchor_156_156"><span class="label">[156]</span></a> Solly's <i>Surgical Experiences</i>, pp. 537, 538, etc.</p></div>
+
+<div class="footnote"><p><a name="Footnote_157_157" id="Footnote_157_157"></a><a href="#FNanchor_157_157"><span class="label">[157]</span></a> <i>The Immediate Treatment of Stricture.</i> By Bernard Holt,
+F.R.C.S. London. Third Edition, 1868.</p></div>
+
+<div class="footnote"><p><a name="Footnote_158_158" id="Footnote_158_158"></a><a href="#FNanchor_158_158"><span class="label">[158]</span></a> Holmes's <i>System of Surgery</i>, 1st ed. vol. iv. p. 403.</p></div>
+
+<div class="footnote"><p><a name="Footnote_159_159" id="Footnote_159_159"></a><a href="#FNanchor_159_159"><span class="label">[159]</span></a> Diagram of puncture of the bladder:&mdash;<span class="smcap">b</span>, bladder; <span class="smcap">sp</span>,
+symphysis pubis; <span class="smcap">sc</span>, scrotum; <i>b</i>, bulb; <i>pr</i>, peritoneum; <span class="smcap">p</span>, prostate;
+<span class="smcap">r</span>, rectum; <span class="smcap">s</span>, sacrum and coccyx.</p></div>
+
+<div class="footnote"><p><a name="Footnote_160_160" id="Footnote_160_160"></a><a href="#FNanchor_160_160"><span class="label">[160]</span></a> <i>Med. Chir. Trans.</i>, vol. <span class="smcap">xxxv</span>.</p></div>
+
+<div class="footnote"><p><a name="Footnote_161_161" id="Footnote_161_161"></a><a href="#FNanchor_161_161"><span class="label">[161]</span></a> Diagram of operation for phymosis:&mdash;<i>a</i>, glans penis; <i>b
+b</i>, mucous membrane exposed by retraction of the skin, and slit up; <i>c
+d</i>, sutures introduced and ready to be tied, uniting the skin and mucous
+membrane.</p></div>
+
+<div class="footnote"><p><a name="Footnote_162_162" id="Footnote_162_162"></a><a href="#FNanchor_162_162"><span class="label">[162]</span></a> To illustrate Teale's operation:&mdash;<i>c</i>, section of penis
+<i>b</i>, thread inserted uniting mucous membrane and skin; <i>a</i>, thread
+tied.</p></div>
+
+<div class="footnote"><p><a name="Footnote_163_163" id="Footnote_163_163"></a><a href="#FNanchor_163_163"><span class="label">[163]</span></a> <i>Med. Times and Gazette</i>, vol. xix. p. 354.</p></div>
+
+<div class="footnote"><p><a name="Footnote_164_164" id="Footnote_164_164"></a><a href="#FNanchor_164_164"><span class="label">[164]</span></a> Miller's <i>System of Surgery</i>, p. 1255.</p></div>
+
+<div class="footnote"><p><a name="Footnote_165_165" id="Footnote_165_165"></a><a href="#FNanchor_165_165"><span class="label">[165]</span></a> Miller's <i>System of Surgery</i>, p. 1256.</p></div>
+
+<div class="footnote"><p><a name="Footnote_166_166" id="Footnote_166_166"></a><a href="#FNanchor_166_166"><span class="label">[166]</span></a> Syme's <i>Pathology and Practice of Surgery</i>, p. 220.</p></div>
+
+<div class="footnote"><p><a name="Footnote_167_167" id="Footnote_167_167"></a><a href="#FNanchor_167_167"><span class="label">[167]</span></a> Holmes's <i>Surgery</i>, vol. iii. p. 573.</p></div>
+
+<div class="footnote"><p><a name="Footnote_168_168" id="Footnote_168_168"></a><a href="#FNanchor_168_168"><span class="label">[168]</span></a> Cross's <i>Surgery</i>, vol. ii. p. 273, 3d ed.</p></div>
+
+<div class="footnote"><p><a name="Footnote_169_169" id="Footnote_169_169"></a><a href="#FNanchor_169_169"><span class="label">[169]</span></a> Miller's <i>System of Surgery</i>, p. 1339; Holmes's
+<i>Surgery</i>, vol. iii. p. 571.</p></div>
+
+</div>
+
+<p>&nbsp;</p>
+<p>&nbsp;</p>
+<hr class="full" />
+<p>***END OF THE PROJECT GUTENBERG EBOOK A MANUAL OF THE OPERATIONS OF SURGERY***</p>
+<p>******* This file should be named 24564-h.txt or 24564-h.zip *******</p>
+<p>This and all associated files of various formats will be found in:<br />
+<a href="http://www.gutenberg.org/dirs/2/4/5/6/24564">http://www.gutenberg.org/2/4/5/6/24564</a></p>
+<p>Updated editions will replace the previous one--the old editions
+will be renamed.</p>
+
+<p>Creating the works from public domain print editions means that no
+one owns a United States copyright in these works, so the Foundation
+(and you!) can copy and distribute it in the United States without
+permission and without paying copyright royalties.  Special rules,
+set forth in the General Terms of Use part of this license, apply to
+copying and distributing Project Gutenberg-tm electronic works to
+protect the PROJECT GUTENBERG-tm concept and trademark.  Project
+Gutenberg is a registered trademark, and may not be used if you
+charge for the eBooks, unless you receive specific permission.  If you
+do not charge anything for copies of this eBook, complying with the
+rules is very easy.  You may use this eBook for nearly any purpose
+such as creation of derivative works, reports, performances and
+research.  They may be modified and printed and given away--you may do
+practically ANYTHING with public domain eBooks.  Redistribution is
+subject to the trademark license, especially commercial
+redistribution.</p>
+
+
+
+<pre>
+*** START: FULL LICENSE ***
+
+THE FULL PROJECT GUTENBERG LICENSE
+PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
+
+To protect the Project Gutenberg-tm mission of promoting the free
+distribution of electronic works, by using or distributing this work
+(or any other work associated in any way with the phrase "Project
+Gutenberg"), you agree to comply with all the terms of the Full Project
+Gutenberg-tm License (available with this file or online at
+<a href="http://www.gutenberg.org/license">http://www.gutenberg.org/license)</a>.
+
+
+Section 1.  General Terms of Use and Redistributing Project Gutenberg-tm
+electronic works
+
+1.A.  By reading or using any part of this Project Gutenberg-tm
+electronic work, you indicate that you have read, understand, agree to
+and accept all the terms of this license and intellectual property
+(trademark/copyright) agreement.  If you do not agree to abide by all
+the terms of this agreement, you must cease using and return or destroy
+all copies of Project Gutenberg-tm electronic works in your possession.
+If you paid a fee for obtaining a copy of or access to a Project
+Gutenberg-tm electronic work and you do not agree to be bound by the
+terms of this agreement, you may obtain a refund from the person or
+entity to whom you paid the fee as set forth in paragraph 1.E.8.
+
+1.B.  "Project Gutenberg" is a registered trademark.  It may only be
+used on or associated in any way with an electronic work by people who
+agree to be bound by the terms of this agreement.  There are a few
+things that you can do with most Project Gutenberg-tm electronic works
+even without complying with the full terms of this agreement.  See
+paragraph 1.C below.  There are a lot of things you can do with Project
+Gutenberg-tm electronic works if you follow the terms of this agreement
+and help preserve free future access to Project Gutenberg-tm electronic
+works.  See paragraph 1.E below.
+
+1.C.  The Project Gutenberg Literary Archive Foundation ("the Foundation"
+or PGLAF), owns a compilation copyright in the collection of Project
+Gutenberg-tm electronic works.  Nearly all the individual works in the
+collection are in the public domain in the United States.  If an
+individual work is in the public domain in the United States and you are
+located in the United States, we do not claim a right to prevent you from
+copying, distributing, performing, displaying or creating derivative
+works based on the work as long as all references to Project Gutenberg
+are removed.  Of course, we hope that you will support the Project
+Gutenberg-tm mission of promoting free access to electronic works by
+freely sharing Project Gutenberg-tm works in compliance with the terms of
+this agreement for keeping the Project Gutenberg-tm name associated with
+the work.  You can easily comply with the terms of this agreement by
+keeping this work in the same format with its attached full Project
+Gutenberg-tm License when you share it without charge with others.
+
+1.D.  The copyright laws of the place where you are located also govern
+what you can do with this work.  Copyright laws in most countries are in
+a constant state of change.  If you are outside the United States, check
+the laws of your country in addition to the terms of this agreement
+before downloading, copying, displaying, performing, distributing or
+creating derivative works based on this work or any other Project
+Gutenberg-tm work.  The Foundation makes no representations concerning
+the copyright status of any work in any country outside the United
+States.
+
+1.E.  Unless you have removed all references to Project Gutenberg:
+
+1.E.1.  The following sentence, with active links to, or other immediate
+access to, the full Project Gutenberg-tm License must appear prominently
+whenever any copy of a Project Gutenberg-tm work (any work on which the
+phrase "Project Gutenberg" appears, or with which the phrase "Project
+Gutenberg" is associated) is accessed, displayed, performed, viewed,
+copied or distributed:
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
+from the public domain (does not contain a notice indicating that it is
+posted with permission of the copyright holder), the work can be copied
+and distributed to anyone in the United States without paying any fees
+or charges.  If you are redistributing or providing access to a work
+with the phrase "Project Gutenberg" associated with or appearing on the
+work, you must comply either with the requirements of paragraphs 1.E.1
+through 1.E.7 or obtain permission for the use of the work and the
+Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
+1.E.9.
+
+1.E.3.  If an individual Project Gutenberg-tm electronic work is posted
+with the permission of the copyright holder, your use and distribution
+must comply with both paragraphs 1.E.1 through 1.E.7 and any additional
+terms imposed by the copyright holder.  Additional terms will be linked
+to the Project Gutenberg-tm License for all works posted with the
+permission of the copyright holder found at the beginning of this work.
+
+1.E.4.  Do not unlink or detach or remove the full Project Gutenberg-tm
+License terms from this work, or any files containing a part of this
+work or any other work associated with Project Gutenberg-tm.
+
+1.E.5.  Do not copy, display, perform, distribute or redistribute this
+electronic work, or any part of this electronic work, without
+prominently displaying the sentence set forth in paragraph 1.E.1 with
+active links or immediate access to the full terms of the Project
+Gutenberg-tm License.
+
+1.E.6.  You may convert to and distribute this work in any binary,
+compressed, marked up, nonproprietary or proprietary form, including any
+word processing or hypertext form.  However, if you provide access to or
+distribute copies of a Project Gutenberg-tm work in a format other than
+"Plain Vanilla ASCII" or other format used in the official version
+posted on the official Project Gutenberg-tm web site (www.gutenberg.org),
+you must, at no additional cost, fee or expense to the user, provide a
+copy, a means of exporting a copy, or a means of obtaining a copy upon
+request, of the work in its original "Plain Vanilla ASCII" or other
+form.  Any alternate format must include the full Project Gutenberg-tm
+License as specified in paragraph 1.E.1.
+
+1.E.7.  Do not charge a fee for access to, viewing, displaying,
+performing, copying or distributing any Project Gutenberg-tm works
+unless you comply with paragraph 1.E.8 or 1.E.9.
+
+1.E.8.  You may charge a reasonable fee for copies of or providing
+access to or distributing Project Gutenberg-tm electronic works provided
+that
+
+- You pay a royalty fee of 20% of the gross profits you derive from
+     the use of Project Gutenberg-tm works calculated using the method
+     you already use to calculate your applicable taxes.  The fee is
+     owed to the owner of the Project Gutenberg-tm trademark, but he
+     has agreed to donate royalties under this paragraph to the
+     Project Gutenberg Literary Archive Foundation.  Royalty payments
+     must be paid within 60 days following each date on which you
+     prepare (or are legally required to prepare) your periodic tax
+     returns.  Royalty payments should be clearly marked as such and
+     sent to the Project Gutenberg Literary Archive Foundation at the
+     address specified in Section 4, "Information about donations to
+     the Project Gutenberg Literary Archive Foundation."
+
+- You provide a full refund of any money paid by a user who notifies
+     you in writing (or by e-mail) within 30 days of receipt that s/he
+     does not agree to the terms of the full Project Gutenberg-tm
+     License.  You must require such a user to return or
+     destroy all copies of the works possessed in a physical medium
+     and discontinue all use of and all access to other copies of
+     Project Gutenberg-tm works.
+
+- You provide, in accordance with paragraph 1.F.3, a full refund of any
+     money paid for a work or a replacement copy, if a defect in the
+     electronic work is discovered and reported to you within 90 days
+     of receipt of the work.
+
+- You comply with all other terms of this agreement for free
+     distribution of Project Gutenberg-tm works.
+
+1.E.9.  If you wish to charge a fee or distribute a Project Gutenberg-tm
+electronic work or group of works on different terms than are set
+forth in this agreement, you must obtain permission in writing from
+both the Project Gutenberg Literary Archive Foundation and Michael
+Hart, the owner of the Project Gutenberg-tm trademark.  Contact the
+Foundation as set forth in Section 3 below.
+
+1.F.
+
+1.F.1.  Project Gutenberg volunteers and employees expend considerable
+effort to identify, do copyright research on, transcribe and proofread
+public domain works in creating the Project Gutenberg-tm
+collection.  Despite these efforts, Project Gutenberg-tm electronic
+works, and the medium on which they may be stored, may contain
+"Defects," such as, but not limited to, incomplete, inaccurate or
+corrupt data, transcription errors, a copyright or other intellectual
+property infringement, a defective or damaged disk or other medium, a
+computer virus, or computer codes that damage or cannot be read by
+your equipment.
+
+1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
+of Replacement or Refund" described in paragraph 1.F.3, the Project
+Gutenberg Literary Archive Foundation, the owner of the Project
+Gutenberg-tm trademark, and any other party distributing a Project
+Gutenberg-tm electronic work under this agreement, disclaim all
+liability to you for damages, costs and expenses, including legal
+fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
+LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
+PROVIDED IN PARAGRAPH F3.  YOU AGREE THAT THE FOUNDATION, THE
+TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
+LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
+INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
+DAMAGE.
+
+1.F.3.  LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
+defect in this electronic work within 90 days of receiving it, you can
+receive a refund of the money (if any) you paid for it by sending a
+written explanation to the person you received the work from.  If you
+received the work on a physical medium, you must return the medium with
+your written explanation.  The person or entity that provided you with
+the defective work may elect to provide a replacement copy in lieu of a
+refund.  If you received the work electronically, the person or entity
+providing it to you may choose to give you a second opportunity to
+receive the work electronically in lieu of a refund.  If the second copy
+is also defective, you may demand a refund in writing without further
+opportunities to fix the problem.
+
+1.F.4.  Except for the limited right of replacement or refund set forth
+in paragraph 1.F.3, this work is provided to you 'AS-IS,' WITH NO OTHER
+WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
+WARRANTIES OF MERCHANTIBILITY OR FITNESS FOR ANY PURPOSE.
+
+1.F.5.  Some states do not allow disclaimers of certain implied
+warranties or the exclusion or limitation of certain types of damages.
+If any disclaimer or limitation set forth in this agreement violates the
+law of the state applicable to this agreement, the agreement shall be
+interpreted to make the maximum disclaimer or limitation permitted by
+the applicable state law.  The invalidity or unenforceability of any
+provision of this agreement shall not void the remaining provisions.
+
+1.F.6.  INDEMNITY - You agree to indemnify and hold the Foundation, the
+trademark owner, any agent or employee of the Foundation, anyone
+providing copies of Project Gutenberg-tm electronic works in accordance
+with this agreement, and any volunteers associated with the production,
+promotion and distribution of Project Gutenberg-tm electronic works,
+harmless from all liability, costs and expenses, including legal fees,
+that arise directly or indirectly from any of the following which you do
+or cause to occur: (a) distribution of this or any Project Gutenberg-tm
+work, (b) alteration, modification, or additions or deletions to any
+Project Gutenberg-tm work, and (c) any Defect you cause.
+
+
+Section  2.  Information about the Mission of Project Gutenberg-tm
+
+Project Gutenberg-tm is synonymous with the free distribution of
+electronic works in formats readable by the widest variety of computers
+including obsolete, old, middle-aged and new computers.  It exists
+because of the efforts of hundreds of volunteers and donations from
+people in all walks of life.
+
+Volunteers and financial support to provide volunteers with the
+assistance they need, is critical to reaching Project Gutenberg-tm's
+goals and ensuring that the Project Gutenberg-tm collection will
+remain freely available for generations to come.  In 2001, the Project
+Gutenberg Literary Archive Foundation was created to provide a secure
+and permanent future for Project Gutenberg-tm and future generations.
+To learn more about the Project Gutenberg Literary Archive Foundation
+and how your efforts and donations can help, see Sections 3 and 4
+and the Foundation web page at http://www.gutenberg.org/fundraising/pglaf.
+
+
+Section 3.  Information about the Project Gutenberg Literary Archive
+Foundation
+
+The Project Gutenberg Literary Archive Foundation is a non profit
+501(c)(3) educational corporation organized under the laws of the
+state of Mississippi and granted tax exempt status by the Internal
+Revenue Service.  The Foundation's EIN or federal tax identification
+number is 64-6221541.  Contributions to the Project Gutenberg
+Literary Archive Foundation are tax deductible to the full extent
+permitted by U.S. federal laws and your state's laws.
+
+The Foundation's principal office is located at 4557 Melan Dr. S.
+Fairbanks, AK, 99712., but its volunteers and employees are scattered
+throughout numerous locations.  Its business office is located at
+809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887, email
+business@pglaf.org.  Email contact links and up to date contact
+information can be found at the Foundation's web site and official
+page at http://www.gutenberg.org/about/contact
+
+For additional contact information:
+     Dr. Gregory B. Newby
+     Chief Executive and Director
+     gbnewby@pglaf.org
+
+Section 4.  Information about Donations to the Project Gutenberg
+Literary Archive Foundation
+
+Project Gutenberg-tm depends upon and cannot survive without wide
+spread public support and donations to carry out its mission of
+increasing the number of public domain and licensed works that can be
+freely distributed in machine readable form accessible by the widest
+array of equipment including outdated equipment.  Many small donations
+($1 to $5,000) are particularly important to maintaining tax exempt
+status with the IRS.
+
+The Foundation is committed to complying with the laws regulating
+charities and charitable donations in all 50 states of the United
+States.  Compliance requirements are not uniform and it takes a
+considerable effort, much paperwork and many fees to meet and keep up
+with these requirements.  We do not solicit donations in locations
+where we have not received written confirmation of compliance.  To
+SEND DONATIONS or determine the status of compliance for any
+particular state visit http://www.gutenberg.org/fundraising/pglaf
+
+While we cannot and do not solicit contributions from states where we
+have not met the solicitation requirements, we know of no prohibition
+against accepting unsolicited donations from donors in such states who
+approach us with offers to donate.
+
+International donations are gratefully accepted, but we cannot make
+any statements concerning tax treatment of donations received from
+outside the United States.  U.S. laws alone swamp our small staff.
+
+Please check the Project Gutenberg Web pages for current donation
+methods and addresses.  Donations are accepted in a number of other
+ways including checks, online payments and credit card donations.
+To donate, please visit: http://www.gutenberg.org/fundraising/donate
+
+
+Section 5.  General Information About Project Gutenberg-tm electronic
+works.
+
+Professor Michael S. Hart is the originator of the Project Gutenberg-tm
+concept of a library of electronic works that could be freely shared
+with anyone.  For thirty years, he produced and distributed Project
+Gutenberg-tm eBooks with only a loose network of volunteer support.
+
+Project Gutenberg-tm eBooks are often created from several printed
+editions, all of which are confirmed as Public Domain in the U.S.
+unless a copyright notice is included.  Thus, we do not necessarily
+keep eBooks in compliance with any particular paper edition.
+
+Each eBook is in a subdirectory of the same number as the eBook's
+eBook number, often in several formats including plain vanilla ASCII,
+compressed (zipped), HTML and others.
+
+Corrected EDITIONS of our eBooks replace the old file and take over
+the old filename and etext number.  The replaced older file is renamed.
+VERSIONS based on separate sources are treated as new eBooks receiving
+new filenames and etext numbers.
+
+Most people start at our Web site which has the main PG search facility:
+
+<a href="http://www.gutenberg.org">http://www.gutenberg.org</a>
+
+This Web site includes information about Project Gutenberg-tm,
+including how to make donations to the Project Gutenberg Literary
+Archive Foundation, how to help produce our new eBooks, and how to
+subscribe to our email newsletter to hear about new eBooks.
+
+EBooks posted prior to November 2003, with eBook numbers BELOW #10000,
+are filed in directories based on their release date.  If you want to
+download any of these eBooks directly, rather than using the regular
+search system you may utilize the following addresses and just
+download by the etext year.
+
+<a href="http://www.gutenberg.org/dirs/etext06/">http://www.gutenberg.org/dirs/etext06/</a>
+
+    (Or /etext 05, 04, 03, 02, 01, 00, 99,
+     98, 97, 96, 95, 94, 93, 92, 92, 91 or 90)
+
+EBooks posted since November 2003, with etext numbers OVER #10000, are
+filed in a different way.  The year of a release date is no longer part
+of the directory path.  The path is based on the etext number (which is
+identical to the filename).  The path to the file is made up of single
+digits corresponding to all but the last digit in the filename.  For
+example an eBook of filename 10234 would be found at:
+
+http://www.gutenberg.org/dirs/1/0/2/3/10234
+
+or filename 24689 would be found at:
+http://www.gutenberg.org/dirs/2/4/6/8/24689
+
+An alternative method of locating eBooks:
+<a href="http://www.gutenberg.org/dirs/GUTINDEX.ALL">http://www.gutenberg.org/dirs/GUTINDEX.ALL</a>
+
+*** END: FULL LICENSE ***
+</pre>
+</body>
+</html>
diff --git a/24564-h/images/000.jpg b/24564-h/images/000.jpg
new file mode 100644
index 0000000..92de94e
--- /dev/null
+++ b/24564-h/images/000.jpg
diff --git a/24564-h/images/000a.jpg b/24564-h/images/000a.jpg
new file mode 100644
index 0000000..51f6289
--- /dev/null
+++ b/24564-h/images/000a.jpg
diff --git a/24564-h/images/000b.jpg b/24564-h/images/000b.jpg
new file mode 100644
index 0000000..2baee24
--- /dev/null
+++ b/24564-h/images/000b.jpg
diff --git a/24564-h/images/050a.jpg b/24564-h/images/050a.jpg
new file mode 100644
index 0000000..2b4c64f
--- /dev/null
+++ b/24564-h/images/050a.jpg
diff --git a/24564-h/images/050b.jpg b/24564-h/images/050b.jpg
new file mode 100644
index 0000000..af5d308
--- /dev/null
+++ b/24564-h/images/050b.jpg
diff --git a/24564-h/images/057a.jpg b/24564-h/images/057a.jpg
new file mode 100644
index 0000000..5a43198
--- /dev/null
+++ b/24564-h/images/057a.jpg
diff --git a/24564-h/images/057b.jpg b/24564-h/images/057b.jpg
new file mode 100644
index 0000000..e4b0973
--- /dev/null
+++ b/24564-h/images/057b.jpg
diff --git a/24564-h/images/069.jpg b/24564-h/images/069.jpg
new file mode 100644
index 0000000..2d99da2
--- /dev/null
+++ b/24564-h/images/069.jpg
diff --git a/24564-h/images/126.jpg b/24564-h/images/126.jpg
new file mode 100644
index 0000000..a8c0148
--- /dev/null
+++ b/24564-h/images/126.jpg
diff --git a/24564-h/images/155.jpg b/24564-h/images/155.jpg
new file mode 100644
index 0000000..a1307d6
--- /dev/null
+++ b/24564-h/images/155.jpg
diff --git a/24564-h/images/156.jpg b/24564-h/images/156.jpg
new file mode 100644
index 0000000..df9e31d
--- /dev/null
+++ b/24564-h/images/156.jpg
diff --git a/24564-h/images/157.jpg b/24564-h/images/157.jpg
new file mode 100644
index 0000000..6bc4edd
--- /dev/null
+++ b/24564-h/images/157.jpg
diff --git a/24564-h/images/162a.jpg b/24564-h/images/162a.jpg
new file mode 100644
index 0000000..5c9eb00
--- /dev/null
+++ b/24564-h/images/162a.jpg
diff --git a/24564-h/images/162b.jpg b/24564-h/images/162b.jpg
new file mode 100644
index 0000000..11508ce
--- /dev/null
+++ b/24564-h/images/162b.jpg
diff --git a/24564-h/images/171.jpg b/24564-h/images/171.jpg
new file mode 100644
index 0000000..7e59da9
--- /dev/null
+++ b/24564-h/images/171.jpg
diff --git a/24564-h/images/172a.jpg b/24564-h/images/172a.jpg
new file mode 100644
index 0000000..4962450
--- /dev/null
+++ b/24564-h/images/172a.jpg
diff --git a/24564-h/images/172b.jpg b/24564-h/images/172b.jpg
new file mode 100644
index 0000000..7167bda
--- /dev/null
+++ b/24564-h/images/172b.jpg
diff --git a/24564-h/images/176.jpg b/24564-h/images/176.jpg
new file mode 100644
index 0000000..f0d564c
--- /dev/null
+++ b/24564-h/images/176.jpg
diff --git a/24564-h/images/177.jpg b/24564-h/images/177.jpg
new file mode 100644
index 0000000..7f2044b
--- /dev/null
+++ b/24564-h/images/177.jpg
diff --git a/24564-h/images/181a.jpg b/24564-h/images/181a.jpg
new file mode 100644
index 0000000..2d2bce1
--- /dev/null
+++ b/24564-h/images/181a.jpg
diff --git a/24564-h/images/181b.jpg b/24564-h/images/181b.jpg
new file mode 100644
index 0000000..8edccb5
--- /dev/null
+++ b/24564-h/images/181b.jpg
diff --git a/24564-h/images/182.jpg b/24564-h/images/182.jpg
new file mode 100644
index 0000000..2c79091
--- /dev/null
+++ b/24564-h/images/182.jpg
diff --git a/24564-h/images/182b.jpg b/24564-h/images/182b.jpg
new file mode 100644
index 0000000..121bd4b
--- /dev/null
+++ b/24564-h/images/182b.jpg
diff --git a/24564-h/images/184a.jpg b/24564-h/images/184a.jpg
new file mode 100644
index 0000000..69d2268
--- /dev/null
+++ b/24564-h/images/184a.jpg
diff --git a/24564-h/images/184b.jpg b/24564-h/images/184b.jpg
new file mode 100644
index 0000000..265ca85
--- /dev/null
+++ b/24564-h/images/184b.jpg
diff --git a/24564-h/images/185.jpg b/24564-h/images/185.jpg
new file mode 100644
index 0000000..8ad20d1
--- /dev/null
+++ b/24564-h/images/185.jpg
diff --git a/24564-h/images/186.jpg b/24564-h/images/186.jpg
new file mode 100644
index 0000000..dccc42c
--- /dev/null
+++ b/24564-h/images/186.jpg
diff --git a/24564-h/images/189.jpg b/24564-h/images/189.jpg
new file mode 100644
index 0000000..0e356bd
--- /dev/null
+++ b/24564-h/images/189.jpg
diff --git a/24564-h/images/196.jpg b/24564-h/images/196.jpg
new file mode 100644
index 0000000..7d34244
--- /dev/null
+++ b/24564-h/images/196.jpg
diff --git a/24564-h/images/201.jpg b/24564-h/images/201.jpg
new file mode 100644
index 0000000..3a98e19
--- /dev/null
+++ b/24564-h/images/201.jpg
diff --git a/24564-h/images/203.jpg b/24564-h/images/203.jpg
new file mode 100644
index 0000000..1a0e7b3
--- /dev/null
+++ b/24564-h/images/203.jpg
diff --git a/24564-h/images/207.jpg b/24564-h/images/207.jpg
new file mode 100644
index 0000000..b38ec10
--- /dev/null
+++ b/24564-h/images/207.jpg
diff --git a/24564-h/images/241.jpg b/24564-h/images/241.jpg
new file mode 100644
index 0000000..40fb500
--- /dev/null
+++ b/24564-h/images/241.jpg
diff --git a/24564-h/images/253.jpg b/24564-h/images/253.jpg
new file mode 100644
index 0000000..b4dafd5
--- /dev/null
+++ b/24564-h/images/253.jpg
diff --git a/24564-h/images/257.jpg b/24564-h/images/257.jpg
new file mode 100644
index 0000000..57d10c9
--- /dev/null
+++ b/24564-h/images/257.jpg
diff --git a/24564-h/images/259.jpg b/24564-h/images/259.jpg
new file mode 100644
index 0000000..d4350b3
--- /dev/null
+++ b/24564-h/images/259.jpg
diff --git a/24564-h/images/284.jpg b/24564-h/images/284.jpg
new file mode 100644
index 0000000..e79c9b0
--- /dev/null
+++ b/24564-h/images/284.jpg
diff --git a/24564-h/images/286.jpg b/24564-h/images/286.jpg
new file mode 100644
index 0000000..a994e80
--- /dev/null
+++ b/24564-h/images/286.jpg
diff --git a/24564-h/images/287.jpg b/24564-h/images/287.jpg
new file mode 100644
index 0000000..c8e327c
--- /dev/null
+++ b/24564-h/images/287.jpg
diff --git a/24564-h/images/f000.jpg b/24564-h/images/f000.jpg
new file mode 100644
index 0000000..c9c2bad
--- /dev/null
+++ b/24564-h/images/f000.jpg
diff --git a/24564-h/images/f001.jpg b/24564-h/images/f001.jpg
new file mode 100644
index 0000000..fbc0e1f
--- /dev/null
+++ b/24564-h/images/f001.jpg
diff --git a/24564-h/images/f002.jpg b/24564-h/images/f002.jpg
new file mode 100644
index 0000000..8bde4a9
--- /dev/null
+++ b/24564-h/images/f002.jpg
diff --git a/24564-h/images/f003.jpg b/24564-h/images/f003.jpg
new file mode 100644
index 0000000..897df21
--- /dev/null
+++ b/24564-h/images/f003.jpg
diff --git a/24564.txt b/24564.txt
new file mode 100644
index 0000000..0b8e4eb
--- /dev/null
+++ b/24564.txt
@@ -0,0 +1,12116 @@
+The Project Gutenberg eBook, A Manual of the Operations of Surgery, by
+Joseph Bell
+
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+
+
+
+Title: A Manual of the Operations of Surgery
+       For the Use of Senior Students, House Surgeons, and Junior Practitioners
+
+
+Author: Joseph Bell
+
+
+
+Release Date: February 11, 2008  [eBook #24564]
+
+Language: English
+
+Character set encoding: ISO-646-US (US-ASCII)
+
+
+***START OF THE PROJECT GUTENBERG EBOOK A MANUAL OF THE OPERATIONS OF
+SURGERY***
+
+
+E-text prepared by Michael Ciesielski, Pilar Somoza Fern�ndez, and the
+Project Gutenberg Online Distributed Proofreading Team
+(https://www.pgdp.net)
+
+
+
+Note: Project Gutenberg also has an HTML version of this
+      file which includes the original illustrations.
+      See 24564-h.htm or 24564-h.zip:
+      (https://www.gutenberg.org/dirs/2/4/5/6/24564/24564-h/24564-h.htm)
+      or
+      (https://www.gutenberg.org/dirs/2/4/5/6/24564/24564-h.zip)
+
+
+Transcriber's note:
+
+      Spelling mistakes have been left in the text to match the original,
+      except for obvious typographical errors.
+
+
+
+
+
+A MANUAL OF THE OPERATIONS OF SURGERY
+
+For the Use of Senior Students, House Surgeons, and
+Junior Practitioners.
+
+Illustrated.
+
+by
+
+JOSEPH BELL, F.R.C.S. EDIN.
+
+Lecturer on Clinical Surgery, Surgeon to the Royal Infirmary and to
+the Eye Infirmary, and Late Demonstrator of Anatomy
+in the University of Edinburgh.
+
+FIFTH EDITION, REVISED AND ENLARGED.
+
+
+
+
+
+
+
+Edinburgh: Maclachlan & Stewart,
+Booksellers to the University.
+London: Simpkin, Marshall, & Co.
+1883.
+
+
+
+
+TO THE MEMORY OF
+JAMES SYME, ESQ., F.R.C.S. AND F.R.S.E.
+SURGEON TO THE QUEEN IN SCOTLAND
+
+PROFESSOR OF CLINICAL SURGERY
+IN THE UNIVERSITY OF EDINBURGH
+ETC. ETC.
+
+THIS BOOK IS DEDICATED
+BY HIS OLD HOUSE-SURGEON AND ASSISTANT
+
+THE AUTHOR.
+
+
+
+
+PREFACE TO FIFTH EDITION.
+
+
+To retain the small size of the work and to keep it up to date have been
+the Author's aim in the Fifth Edition.
+
+
+20 MELVILLE STREET, EDINBURGH,
+_August 1883._
+
+
+
+
+PREFACE TO THE FIRST EDITION.
+
+
+Having been asked, year after year, by the members of my Class for
+Operative Surgery, to recommend to them some Manual of Surgical
+Operations which might at once guide them in their choice of operations,
+and give minute details as to the mode of performance, I have been
+gradually led to undertake the production of this little work.
+
+My aim has been to describe as simply as possible those operations which
+are most likely to prove useful, and especially those which, from their
+nature, admit of being practised on the dead body.
+
+In accordance with this plan, neither historical completeness of detail,
+nor much variety in the methods of performing any given operation, is to
+be expected. Hence, also, many omissions which would be unpardonable in
+the briefest system of Surgery are unavoidable. For example, excision of
+tumours and operations for necrosis are hardly mentioned, because for
+these no special instructions can well be given; for, while general
+principles may guide us to _what_ should be done, the special
+circumstances of each case must dictate _how_ it is to be done.
+
+In such a work as this, to attempt originality would be undesirable and
+intrusive; a judicious selection, a faithful compilation, are all that
+can be expected.
+
+That the selection of operations may sometimes show "Northern
+Proclivities" is possible; and this is perhaps not unnatural to a
+scholar and teacher in the Edinburgh School.
+
+An earnest endeavour has been used to make the references correct and
+copious: for any mistakes or omissions the author would crave
+indulgence.
+
+The four plates which precede the letterpress were drawn on wood (from
+original photographs) by Mr. D.W. Williamson, Melbourne Place, and the
+lines of incision for the various operations were added by the author.
+
+The rough woodcuts scattered through the work were drawn on wood by the
+author, and for their roughness he, not his engraver, is responsible. He
+also hopes that the references in the letterpress will be accepted as
+sufficient acknowledgment of the true ownership, in those few instances
+in which the idea of the diagram has been borrowed.
+
+It has been thought unnecessary to introduce woodcuts of surgical
+instruments, as the illustrated catalogues lately published by Weiss,
+Maw, and others, are sufficiently accurate.
+
+In excuse of the frequent baldness and brevity of the style, the author
+must point to the size and price of the work. Its composition would have
+been easier had its dimensions been greater.
+
+Though intended chiefly to guide the studies, on the dead subject, of
+students and junior practitioners, the author ventures to hope that the
+Manual may be useful to those who, in the public services, in the
+colonies, or in lonely country districts, find themselves constrained to
+attempt the performance of operations which, in the towns, usually fall
+to the lot of a few Hospital Surgeons.
+
+
+                                                     JOSEPH BELL.
+
+5 CASTLE TERRACE, EDINBURGH,
+       _July 1866._
+
+
+
+
+CONTENTS.
+
+
+CHAPTER I.
+
+LIGATURE OF ARTERIES.
+
+                                                                    PAGE
+
+Ligature of Arteries--General Maxims--Ligature of
+Aorta--Iliacs--Gluteal--Femoral--Popliteal--Innominate--Carotids--
+Lingual--Subclavian--Brachial, etc.,                                1-45
+
+
+CHAPTER II.
+
+AMPUTATIONS.
+
+Eras of Amputation--Flap and Circular compared--Special Amputation of
+Arm and Leg,                                                      46-107
+
+
+CHAPTER III.
+
+EXCISION OF JOINTS.
+
+Brief Historical Sketch--Comparison of Excisions with
+Amputations--Special Excisions of the six larger Joints--Excisions of
+smaller Joints and Bones,                                        108-146
+
+
+CHAPTER IV.
+
+OPERATIONS ON CRANIUM AND SCALP.
+
+Trephining--Excision of Wens,                                    147-150
+
+
+CHAPTER V.
+
+OPERATIONS ON THE EYE AND ITS APPENDAGES.
+
+Entropium and Ectropium--Trichiasis--Tarsal Tumours--On Lachrymal
+Organs--Mr. Bowman's Operation--Pterygium--Strabismus, convergent
+and divergent--Paracentesis of the Anterior Chamber--Operations
+for Cataract by Displacement, Solution, and Extraction--Various
+methods of Extraction--Operations for Artificial
+Pupil--Iridesis--Corelysis--Iridectomy--Excision of Staphyloma--Excision
+of Eyeball,                                                      151-174
+
+
+CHAPTER VI.
+
+OPERATIONS ON THE NOSE AND LIPS.
+
+Rhinoplastic Operations from Cheek, Forehead, and elsewhere--Removal of
+Nasal Polypi--Excision of Cancers of Lips--Cheiloplastic
+Operations--Operations for Harelip,                              175-187
+
+
+CHAPTER VII.
+
+OPERATIONS ON THE JAWS.
+
+Excision of Upper Jaw--Of Lower Jaw,                             188-195
+
+
+CHAPTER VIII.
+
+OPERATIONS ON MOUTH AND THROAT.
+
+For Salivary Fistula--Excision of Tongue, complete and partial--Fissures
+of the Palate, soft and hard--Excision of Tonsils,               196-205
+
+
+CHAPTER IX.
+
+OPERATIONS ON AIR PASSAGES.
+
+Larynx and
+Trachea--Tracheotomy--Tubes--Laryngotomy--OEsophagotomy--[see
+Addendum, p. 302],                                               206-217
+
+
+CHAPTER X.
+
+OPERATIONS ON THORAX.
+                                                                    PAGE
+Excision of Mamma--Paracentesis Thoracis,                        218-221
+
+
+CHAPTER XI.
+
+OPERATIONS ON ABDOMEN.
+
+Paracentesis Abdominis--Gastrotomy--Ovariotomy--Operation for
+Strangulated Hernia--Inguinal--Femoral--Umbilical--Operations for the
+Radical Cure of Hernia,                                          222-255
+
+
+CHAPTER XII.
+
+OPERATIONS ON PELVIS.
+
+Lithotomy--Varieties--Lithotrity--Operations for Stricture--Puncture of
+the Bladder--Phymosis--Amputation of
+Penis--Hydrocele--Haematocele--Castration--Operation for
+Fistula--Fissure--Polypi of Rectum--Piles,                       256-295
+
+
+CHAPTER XIII.
+
+TENOTOMY.
+
+On Tenotomy for Wry Neck and Club Foot,                          296-298
+
+
+CHAPTER XIV.
+
+OPERATIONS ON NERVES.
+
+Nerve-stretching--Nerve-cutting--Nerve suture,                   299-301
+
+
+ADDENDUM to Chapter IX.,                                             302
+
+INDEX,                                                           303-311
+
+
+
+
+LIST OF ILLUSTRATIONS.
+
+
+FIG.                                                                PAGE
+
+I.       Amputations of Fingers,                                      50
+
+II.      Diagram of Finger showing Articulations,                     50
+
+III.     Dubrueil's Amputation at Wrist (front view),                 57
+
+IV.       "             "             (dorsal view),                  57
+
+V.       Amputations of Toes,                                         69
+
+VI.      Excision of Wrist-joint--Lister's,                          126
+
+VII.     Operations for Ectropium and Entropium,                     151
+
+VIII.    Operation for Trichiasis--Streatfeild's,                    151
+
+IX.      Operation for Epiphora--Bowman's,                           155
+
+X.       Greenslade's Instrument for above,                          156
+
+XI.      Operations for Squint,                                      157
+
+XII.     Linear Extraction of Cataract,                              162
+
+XIII.    Flap Extraction of Cataract,                                162
+
+XIV.     Operation of Corelysis--Streatfeild's,                      171
+
+XV.      Operation for Staphyloma--Critchett's,                      172
+
+XVI.     Result of above,                                            172
+
+XVII.    Rhinoplastic Operation from Cheek,                          176
+
+XVIII.     "              "       Forehead,                          177
+
+XIX.     Operation on Lip, V-shaped incision,                        181
+
+XX.      Operation on Lip, by scissors,                              181
+
+XXI.     Operation for a new Lip, incisions,                         182
+
+XXII.    Operation for New Lip sewed up,                             182
+
+XXIII.   Diagram of Partial Fissure (Harelip),                       184
+
+XXIV.    Nelaton's Operation for ditto,                              184
+
+XXV.     Operation for Double Harelip,                               185
+
+XXVI.    Diagram of Double Harelip,                                  186
+
+XXVII.   Excision of Upper and Lower Jaws,                           189
+
+XXVIII.  Operation for Salivary Fistula,                             196
+
+XXIX.    Operation for Fissure in Soft Palate,                       201
+
+XXX.     Operation for Fissure in Hard Palate,                       203
+
+XXXI.    Diagram illustrating Operations on Air Passages,            207
+
+XXXII.   Diagram illustrating Operations for Hernia,                 241
+
+XXXIII.  Diagram of an Artificial Anus,                              253
+
+XXXIV.   Diagram of Section of Prostate,                             257
+
+XXXV.    Diagram of Membranous portion of Urethra,                   259
+
+XXXVI.   Diagram illustrating Puncture of Bladder,                   284
+
+XXXVII.  Diagram of Operation for Phymosis,                          286
+
+XXXVIII. Diagram of Amputation of Penis,                             287
+
+
+[Illustration]
+
+
+PLATE I.
+
+1. Ligature of Aorta--Sir A. Cooper's incision.
+
+2. Ligature of Aorta--South and Murray's incision.
+
+3. Ligature of Common Iliac.
+
+4. Ligature of External Iliac--Sir A. Cooper's.
+
+5. Ligature of Femoral in Scarpa's triangle.
+
+6. Ligature of Femoral below Sartorius.[1]
+
+7. Ligature of Innominate.
+
+8. Ligature of third part of Left Subclavian.
+
+9. Ligature of Axillary in its first part.
+
+10. Ligature of Axillary in its third part.
+
+11. Ligature of Brachial.
+
+12. Amputation of Arm by double flaps.
+
+13. Amputation at Shoulder-joint (1st method), showing portion of skin
+left uncut till the conclusion of the disarticulation.
+
+14. Amputation at Ankle-joint by internal flap--Mackenzie's.
+
+15-16. Amputation of Leg just above the Ankle-joint.
+
+17-18. Amputation below Knee--modified circular.
+
+19. Amputation through Condyles of Femur--Syme, and Pl. III. 5.
+
+20. Amputation at lower third of Thigh--Syme, and Pl. III. 6.
+
+
+A. Excision of Head of Humerus.
+
+B. Excision of Knee-joint; semilunar incision.
+
+
+FOOTNOTES:
+
+[1] This line is placed too low down; it should be in the middle third
+of the thigh.
+
+
+[Illustration]
+
+
+PLATE II.
+
+1. Amputation at lower third of Fore-arm--Teale's.
+
+2-2. Amputation at Shoulder-joint by large postero-external flap--2d
+method.
+
+3-3. Amputation at Shoulder-joint by triangular flap from deltoid--3d
+method.
+
+4-5. Amputation through Tarsus--Chopart's.
+
+6-7. Amputation at Knee-joint.
+
+8. Amputation by Single Flap--Carden's, and Pl. IV. 16.
+
+9-10. Amputation of Thigh--Teale's.
+
+
+A. Excision of Hip-joint.
+
+B-B. Excision of Ankle-joint--Hancock's incisions.
+
+
+[Illustration]
+
+
+PLATE III.
+
+1. Ligature of Popliteal.
+
+2. Amputation at Elbow-joint--posterior flap.
+
+3. Amputation at Shoulder-joint--posterior incision of first method, and
+Pl. I. 13.
+
+4. Amputation at Ankle-joint--Mackenzie's, and Pl. I. 14.
+
+5. Amputation through Condyles of Femur--Syme, and Pl. I. 19.
+
+6. Amputation at lower third of Thigh--Syme, and Pl. I. 20.
+
+7. Amputation at Knee--posterior incision.
+
+8. Amputation of Thigh--Spence's, and at Pl. IV. 18.
+
+9. Amputation at Hip-joint, and Pl. IV. 20.
+
+
+A. Excision of Shoulder-joint--deltoid flap.
+
+B. Excision of Shoulder-joint by posterior incision.
+
+C. Excision of Elbow-joint--H-shaped incision.
+
+D. Excision of Elbow-joint--linear incision.
+
+E. Excision of Hip-joint--Gross's.
+
+F. Excision of Os Calcis.
+
+G. Excision of Scapula.
+
+
+[Illustration]
+
+
+PLATE IV.
+
+1. Ligature of Carotid.
+
+2. Ligature of Subclavian (3d stage)--Skey's incision.
+
+3. Amputation at Wrist-joint--dorsal incision.
+
+4. Amputation at Wrist-joint--palmar incision.
+
+5. Amputation at Fore-arm--dorsal incision.
+
+6. Amputation at Fore-arm--palmar incision.
+
+7. Amputation at Elbow-joint--Anterior flap, and Pl. III. 3.
+
+8. Amputation at Arm--Teale's method.
+
+9. Amputation at Shoulder-joint--1st method, and Pl. III. 3.
+
+10-11. Amputation of Metatarsus--Hey's.
+
+12-13. Amputation at Ankle--Syme's.
+
+14-15. Amputation of Leg--posterior flap--Lee's.
+
+16. Amputation at Knee-joint--Carden's, and Pl. II. 8.
+
+17. Amputation of Thigh--B. Bell's.
+
+18. Amputation of Thigh--Spence's, and Pl. III. 8.
+
+19. Amputation of Thigh in middle third.
+
+20-20. Amputation at Hip-joint, and Pl. III. 9.
+
+
+A. Excision of Wrist--radial incision.
+
+B. Excision of Wrist--ulnar incision.
+
+
+
+
+CHAPTER I.
+
+LIGATURE OF ARTERIES.
+
+
+LIGATURE OF ARTERIES.--In a work of this nature there is no room for any
+discussion of the principles which should guide us in the selection of
+cases, or of the pathology of aneurism, or the local effects of the
+ligature on the vessels. One or two fundamental axioms may be given in a
+few words:--
+
+1. In selecting the spot for the application of the ligature, avoid as
+far as possible bifurcations, or the neighbourhood of large collateral
+branches.
+
+2. A free incision should be made through the skin and subjacent
+textures, till the sheath of the artery is reached and fairly exposed.
+
+3. The sheath must be opened and the artery cleaned with a sharp knife
+till the white external coat is clearly seen. The portion cleaned
+should, however, be as small as possible, consistent with thorough
+exposure, so that the ligature may be passed round the vessel without
+force.
+
+4. As the artery should never be raised from its bed, it is generally
+advisable to pass the needle only so far as just to permit the eye to be
+seen past the vessel. The ligature should then be seized by a pair of
+forceps and gently pulled through, the needle being cautiously
+withdrawn. When catgut is used, it is better to pass the unarmed needle
+till the eye is visible, then thread and withdraw it, thus pulling the
+catgut through.
+
+5. As a rule, the needle should be passed from the side of the vessel at
+which the chief dangers exist. This will generally be in the side at
+which the vein is.
+
+6. The ligature should be single, and consist of strong well-waxed silk,
+and should always be drawn as tight as possible, so as to divide the
+internal and middle coats of the vessel. In cases where the wound is to
+be treated with antiseptic precautions and an attempt at immediate union
+made, the ligature may be of strong catgut properly prepared, and both
+ends of it may be cut off.
+
+7. Before the ligature is tightened, it is well to feel that pressure
+between the ligature and the finger arrests the pulsation of the tumour.
+
+
+LIGATURE OF THE AORTA.--It has been found necessary in a few rare cases
+to place a ligature on the abdominal aorta; no case has as yet survived
+the operation beyond a very few days, but they have in their progress
+sufficiently proved that the circulation can be carried on, and gangrene
+does not necessarily result even after such a decided interference with
+vascular supply.
+
+_Operation._--The ligature may be applied in one of two ways, the choice
+being influenced by the nature of the disease for which it is done.
+
+1. A straight incision (Plate I. fig. 1) in the linea alba, just
+avoiding the umbilicus by a curve, and dividing the peritoneum, allows
+the intestines to be pushed aside, and the aorta exposed still covered
+by the peritoneum, as it lies in front of the lumbar vertebrae. The
+peritoneum must again be divided very cautiously at the point selected,
+and the aortic plexus of nerves carefully dissected off, in order that
+they may not be interfered with by the ligature. The ligature should
+then be passed round, tied, cut short, and the wound accurately sewed
+up.
+
+2. Without wounding the peritoneum.
+
+A curved incision (Plate I. fig. 2), with its convexity backwards, from
+the projecting end of the tenth rib to a point a little in front of the
+anterior superior spinous process of the ilium. At first through the
+skin and fascia only, this incision must be continued through the
+muscles of the abdominal wall, one by one, till the transversalis fascia
+is exposed, which must then be scraped through very cautiously, so as
+not to injure the peritoneum, which is to be detached from the fascia
+covering the psoas and iliacus muscles, and must be held inwards and out
+of the way by bent copper spatulae. The common iliac will then be felt
+pulsating, and on it the finger may easily be guided up until the aorta
+is reached.
+
+The really difficult part of the operation now begins: to isolate the
+vessel from the spine behind, the inferior cava on the right side, and
+the plexus of nerves in the cellular tissue all round. The cleaning of
+the vessel must be done in great measure by the finger-nail, and much
+dexterity will be required to pass the ligature without unnecessarily
+raising the vessel from its bed, especially as the vessel itself may
+very possibly be diseased, and the aneurism of the iliac trunk for which
+the operation is required will displace and confuse the parts, and may
+have set up adhesive inflammation.
+
+_Results._--Operation has been performed at least ten times. By the
+first method by Sir Astley Cooper and Mr. James; by the second by Drs.
+Murray and Monteiro, M'Guire, Heron Watson, and Stokes, and Mr. South,
+and Czerny of Heidelberg. All the cases proved fatal; Dr. Monteiro's
+survived for ten days, and eventually perished from haemorrhage; the rest
+all died at shorter intervals.
+
+
+LIGATURE OF COMMON ILIAC.--_Anatomical Note._--This short thick trunk
+varies slightly in its relations on the two sides of the body. As the
+aorta bifurcates on the left side of the body of the fourth lumbar
+vertebra, the common iliac of the right side would have a longer course
+to pursue than that on the left, if both ended at corresponding points.
+However, this is not always the case, as has been pointed out by Mr.
+Adams of Dublin, as the right common iliac often bifurcates sooner than
+the left does. With this slight difference, the position of the two
+vessels is precisely similar, each extending along the brim of the
+pelvis from the bifurcation of the aorta towards the sacro-iliac
+synchondrosis for about two inches. Sometimes the division takes place a
+little higher, even at the junction of the last lumbar vertebra and the
+sacrum. This variation depends chiefly on the length of the artery,
+which, as Quain has shown, varies from one inch and a half to more than
+three inches.
+
+The anterior surface of both arteries is covered by the peritoneum, and
+each is crossed by the ureter just as it bifurcates into its branches.
+
+The artery of the right side is in close contact behind with its
+corresponding vein, which at its upper part projects to the outside, and
+below to the inner side. The artery of the left side is less involved
+with its vein, which lies below it, and to the inside. The right is in
+contact with a coil of ileum, the left with the colon. The inferior
+mesenteric artery crosses the left one, while to the outside of both,
+and behind them, lie the sympathetic and obdurator nerves.
+
+There are no named branches from the common iliac.
+
+_Operation._--The chief difficulties to be encountered are--1. The close
+proximity of the peritoneum, and specially the risk there is that it has
+become adherent to the sac of the aneurism; 2. The depth of the parts,
+and tendency of the intestines to roll into the wound; 3. Specially on
+the right side, the proximity of the great veins. With these exceptions
+the passing of the ligature is not so difficult as in some situations,
+the lax cellular tissue in which the vessel lies generally yielding much
+more easily than the tough sheath which elsewhere, as in the femoral,
+requires accurate dissection.
+
+_Incision._--(Plate I. fig. 3.)--From a point about half an inch above
+the centre of Poupart's ligament, a crescentic incision should be made,
+at first extending upwards and outwards, so as to pass about one inch
+inside of the anterior superior spine of the ilium, and then prolonged
+upwards and inwards, as far as may be rendered necessary by the size of
+the aneurism or the depth of parts. It must extend through skin and
+superficial fascia, exposing the tendon of the external oblique, which
+must then be slit up to the full extent visible. The spermatic cord may
+then be easily exposed under the edge of the internal oblique, and the
+forefinger of the left hand inserted on the cord, and thus beneath the
+internal oblique and transversalis muscles, the peritoneum being quite
+safe below.
+
+On the finger these muscles may be safely divided to the full extent of
+the external incision. The deep circumflex iliac artery if possible
+should not be divided, but may bleed smartly and require a ligature.
+
+The peritoneum must then be very cautiously raised from the tumour, and
+supported, along with the intestines, by copper spatulae. The surgeon
+will rarely succeed in obtaining anything like a satisfactory view of
+the vessel, but can expose it for the ligature by the aid of his
+finger-nail. An ordinary aneurism-needle will generally suffice for the
+conveyance of the ligature.
+
+The difficulties may occasionally be much increased by special
+circumstances, such as great stoutness of the patient, and consequent
+thickness of the abdominal wall; or large size of the aneurism, which
+may cause alterations in the relation of parts and adhesion of the
+peritoneum. The ureter generally gives no trouble, as in pressing back
+the peritoneum it is adherent to it, and is removed along with it
+towards the middle line.
+
+_Results._--Are not by any means satisfactory.
+
+Out of twenty-two cases in which the common iliac has been tied for
+aneurism, eight recovered and fourteen died; while out of thirteen cases
+where it required ligature for haemorrhage after amputation, rupture of
+aneurism, etc., only one recovered.
+
+
+LIGATURE OF INTERNAL ILIAC.--Little need be added to the account just
+given of the operation for ligature of the common iliac, as precisely
+the same incisions are required. The operator having reached the
+bifurcation of the vessel, must, instead of tracing it upwards,
+endeavour to trace it downwards, and the same time inwards, into the
+basin of the pelvis. To do this his finger must cross the external iliac
+artery, which will pulsate under the joint of the ungual phalanx, while
+the pulp of the finger is touching the internal iliac,--the external
+iliac vein, which occupies the angle formed by the bifurcation of the
+artery, lying between these two points. The ligature should be applied
+within three-quarters of an inch from the bifurcation.
+
+_Anatomical Note._--This short thick trunk extends backwards and inwards
+(Ellis); downwards and backwards (Harrison), in front of the sacro-iliac
+synchondrosis, as far as the upper extremity of the great sacro-sciatic
+notch, a distance varying in the adult from one and a half to two inches
+in length. It forms a curve with its concavity forwards, and at its
+termination divides into, rather than gives off, its two or three
+principal branches. Its corresponding vein is in close contact behind,
+as also the lumbo-sacral nerve, the obdurator nerve to its outer side.
+The peritoneum covers it anteriorly, and it is crossed just at its
+commencement by the ureter. On the left side it is covered anteriorly by
+the rectum. Of its anatomical relations, that of the external iliac vein
+is perhaps the most important, as it is apt to interfere with the
+passing of the needle.
+
+_Results._--This vessel has been tied for aneurism of one or other of
+its branches, or for wound, about seventeen times.[2] Of these seven
+recovered; in ten the operation proved fatal, in most of them from
+secondary haemorrhage. In one case the haemorrhage occurred within twelve
+hours after the operation. The circulation of the parts supplied after
+the ligature is carried on mainly by the lumbar and lateral sacral
+branches, which become much developed even before the operation, in
+cases of aneurism.
+
+
+LIGATURE OF EXTERNAL ILIAC.--_Anatomical Note._--This artery extends
+from the bifurcation of the common iliac to the centre of Poupart's
+ligament, where it leaves the abdomen, passing under the ligament, and
+becomes the common femoral. Its upper extremity is thus not always
+constant, varying in position from the sacro-lumbar fibro-cartilage to
+the upper end of the sacro-iliac synchondrosis, or even a little lower
+down. Thus, though the position of the lower end is at a fixed point,
+the artery varies in length. In an adult male of moderate stature it is
+from three and a half to four inches in length. On the surface of the
+abdomen the position of this vessel would be indicated by a line drawn
+from about an inch on either side of the umbilicus to the middle of the
+space between the symphysis pubis and the crest of the ilium. Its
+relations to neighbouring parts are as follows:--The peritoneum lies _in
+front_ of it, separated from it only by a subperitoneal layer of loose
+fascia, in which the artery and vein lie, which varies much in
+consistence and amount, and which occasionally gives a good deal of
+trouble in the operation of ligature. Near its origin it is sometimes
+crossed by the ureter, and near its termination the genito-crural nerve
+lies on it. The spermatic vessels cross it, and occasionally a quantity
+of subperitoneal fat marks its course. _Externally._--The fascia-iliaca
+and some fibres of the psoas muscle separate it from the anterior
+crural nerve, which lies outside of the vessel, and at a somewhat deeper
+level, hidden amid the fibres of psoas and iliacus. _Internally._--The
+external iliac vein lies on the same plane, and to the inner side of the
+artery, at Poupart's ligament, on both sides of the body. As we trace it
+upwards we find that on the left side it lies internal to the artery in
+its whole course, while on the right side it becomes posterior to the
+artery as it approaches the bifurcation of the common iliac. Lastly,
+just before the vessel reaches Poupart, the circumflex iliac vein
+crosses it from within outwards.
+
+_Branches._--The two large branches to the wall of the abdomen, the
+epigastric and the circumflex iliac, rise a few lines above Poupart's
+ligament. Their position is unfortunately apt to vary upwards, to the
+extent of an inch and a half or even two inches, and they are important,
+as, besides being liable to be cut during the operation, their position
+very materially modifies the prognosis, as, if too high up, they
+interfere with the proper formation of the coagulum.
+
+_Operation._--Various plans of incision through the skin have been
+recommended by various operators, the chief difference being with regard
+to the part of the artery aimed at; the plan known as that of Mr.
+Abernethy, with various modifications, being intended to expose the
+artery pretty high up, and enable the surgeon to reach it from above;
+while the method going by the name of Sir Astley Cooper's exposes the
+lower part of the artery, and enables the surgeon to reach it from
+below. Though the latter is in some respects easier, the former method
+is generally to be preferred, being further from the seat of disease,
+and especially more out of the way of the epigastric and circumflex
+arteries.
+
+The higher operation (ABERNETHY'S modified).--An incision must be made
+through the skin about four inches in length, but longer in proportion
+to the amount of subcutaneous fat, and the depth of the pelvis,
+extending from a point one inch to the inside of the anterior superior
+spine of the ilium, to a point half an inch above the middle line of
+Poupart's ligament. It must be slightly curved, with its convexity
+looking outwards and downwards.[3]
+
+The subcutaneous cellular tissue and the tendon of the external oblique
+may then be divided freely in the same line. Then at some one point or
+other (generally easiest below), the internal oblique and transversalis
+muscles must be cautiously scraped through with the aid of the forceps,
+till the transversalis fascia is reached; they may then be freely
+divided by a probe-pointed bistoury (guarded by the finger pushed up
+below the muscles) to the required extent. The muscles being held aside
+by flat copper spatulae, the fascia transversalis must be carefully
+scratched through near the crest of the ilium, and thus the operator
+will be enabled to push the peritoneum inwards, and by the forefinger
+will easily recognise the pulsation of the artery lying on the soft brim
+of the pelvis.
+
+A branch of the circumflex iliac artery will very likely be cut in
+dissecting through the muscles, and must be secured, as also any
+branches of the epigastric which may be divided in the incisions through
+the abdominal wall (_ut supra_, p. 5).
+
+The operator should then, by pressing the peritoneum and its contents
+gently inwards, endeavour to see the vessel; if, from the depth of the
+pelvis, this cannot be done, the sense of touch will be in most cases
+sufficient to enable him to isolate the artery by the point of his
+finger-nail, or by the blunt aneurism-needle, from the vein. The
+ligature should be passed from the inner side to avoid including the
+vein, and thus there will be less chance of wounding the peritoneum
+from the convexity of the needle being applied to it. If possible, the
+genito-crural nerve should not be included in the ligature, but probably
+such an accident would do no great harm.
+
+It is of much more consequence to avoid injuring the peritoneum. This is
+sometimes very difficult, from the adhesions which are set up between
+the peritoneum, the artery, and especially the aneurism, as the result
+of pressure and inflammation. The accident of wounding the peritoneum
+has happened to Keate, Tait, Post, and others, and in some cases with
+perfect impunity. However, the peritoneum should be displaced as little
+as possible from its cellular connections, as such displacement
+increases the risk of diffuse inflammation of that membrane; and the
+vessel itself should be raised and disturbed as little as possible, lest
+destruction of the vasa vasorum cause ulceration of the weak coats and
+secondary haemorrhage.
+
+The operation from below (Plate I. fig. 4), SIR ASTLEY COOPER'S, is thus
+described by Mr. Hodgson:[4]--"A semilunar incision is made through the
+integuments in the direction of the fibres of the aponeurosis of the
+external oblique muscle. One extremity of the incision will be situated
+near the spine of the ilium; the other will terminate a little above the
+inner margin of the abdominal ring. The aponeurosis of the external
+oblique muscles will be exposed, and is to be divided throughout the
+extent, and in the direction of the external wound. The flap which is
+thus formed being raised, the spermatic cord will be seen passing under
+the margin of the internal oblique and transverse muscles. The opening
+in the fascia which lines the transverse muscle through which the
+spermatic cord passes, is situated in the mid space between the anterior
+superior spine of the ilium and the symphysis pubis. The epigastric
+artery runs precisely along the inner margin of this opening, beneath
+which the external iliac artery is situated. If the finger therefore be
+passed under the spermatic cord through this opening in the fascia, it
+will come in immediate contact with the artery which lies on the outside
+of the external iliac vein. The artery and vein are connected by dense
+cellular tissue, which must be separated to allow of the ligature being
+passed round the former."
+
+In comparing the two methods of operating, we find that while the latter
+is in some respects easier, and the vessel in it lies more superficial,
+it has certain disadvantages which more than counterbalance its
+advantages. Thus, first, the epigastric artery is very likely to be
+wounded. It may be said, Well, if so, the ends can be tied; but this
+tying is sometimes very difficult; and, as shown in Dupuytren's case of
+this accident, involves considerable interference with the peritoneum,
+and a possibly fatal peritonitis. Besides this, by cutting the
+epigastric you destroy an important agent which would have carried on
+the anastomosing circulation, and thus greatly increase the risk of
+gangrene. By this method, also, the artery is exposed too near to the
+seat of disease; and if found to be enlarged and involved in the
+aneurism, considerable difficulty may be experienced in reaching the
+upper part of the vessel. Again, ligature of the lower third or half of
+the vessel, which this method implies, is dangerous from the occasional
+high origin of the circumflex or epigastric, or both, rendering the
+formation of a clot much more difficult, and secondary haemorrhage much
+more likely.
+
+The circumflex iliac vein must also be remembered, as it crosses the
+artery from within outwards in the lower end of it, just before it goes
+under Poupart's ligament.
+
+However, the method may occasionally vary with the individual case. In
+every case of ligature of the great vessels of the abdomen, the bowels
+should be carefully evacuated before the operation, and the bladder
+emptied. A properly managed position, with the shoulders raised and the
+knees semiflexed, will greatly facilitate the gaining access to the
+vessel.
+
+In sewing up the wounds in the abdominal walls, advantage will be gained
+by putting in a certain number of stitches so deeply as to include the
+whole thickness of the muscles, and in the intervals between these deep
+ones to insert others less deeply, so as accurately to approximate the
+edges of the skin. This will both facilitate union and also render the
+occurrence of hernia less probable. This latter accident did occur in a
+case, otherwise successful, in which Mr. Kirby tied the external iliac.
+
+Both external iliacs have been tied in the same patient with success, on
+at least two occasions, once by Arendt, with an interval of only eight
+days between the operations; and a second time by Tait, at an interval
+of rather more than eleven months.
+
+This operation is in the great majority of cases performed for femoral
+aneurism, and naturally secondary haemorrhage is a too frequent result.
+Wounds of these great vessels generally result in so rapid death from
+haemorrhage as to give no time for surgical interference. One case,
+however, is recorded,[5] in which the external iliac was cut in a lad of
+seventeen by an accidental stab, and in which Drs. Layraud and Durand,
+who were almost instantly on the spot, succeeded in stopping the
+bleeding by compresses, till Velpeau arrived, who tied the vessel above
+with perfect success.
+
+Of the first twenty-two cases collected by Hodgson, fifteen recovered--a
+mortality of 31.81 per cent.; and of 153 in Norris's collection,
+including Cutter's cases, forty-seven died--a mortality of only 32.5 per
+cent.,--a very satisfactory result, considering the size of the vessel
+and the importance of its relations.
+
+
+LIGATURE OF GLUTEAL.--This vessel, though one of the branches of the
+internal iliac, approaches the surface so nearly as to be occasionally
+wounded. It is also, though very rarely, the subject of spontaneous
+aneurism. The principle of treatment and the operation to be selected in
+any given case, depends upon its origin, whether traumatic or
+spontaneous. For if traumatic, the wound must almost necessarily be
+accessible from the outside; the neighbouring part of the artery is
+probably healthy, and hence the case can be treated by the old
+operation, slitting up the tumour, and tying the vessel above and below
+the wound. When the aneurism is spontaneous, there is no guide to tell
+us where the aneurism may have first originated; it may be that it is
+high up in the pelvis, and that the visible tumour is only its expansion
+in the direction of least resistance, or the coats of the vessel may be
+extensively diseased. The only chance is ligature of the internal iliac.
+
+1. The old operation, or ligature of the gluteal artery in the hip.
+
+_Anatomical Note._--The gluteal is the largest branch of the internal
+iliac, and leaves the pelvis by the great sacro-sciatic notch just at
+the upper edge of the pyriformis muscle. After a very short course, it
+divides into superficial and deep branches opposite the posterior margin
+of the glutens minimus, between it and the pyriformis muscles.
+
+Very precise rules have been given to enable the operator to hit on the
+exact spot where the artery leaves the pelvis. These, though perhaps
+interesting anatomically, are quite useless in a surgical point of view,
+for the only reasons which could possibly induce a surgeon to cut down
+upon the gluteal in the living body, are the existence either of a wound
+of the vessel or an aneurism. In the first the flow of blood, in the
+second the tumour, would give sufficient guidance.
+
+In cases of traumatic aneurism the operation should be something like
+the following:--A free incision should be made into the tumour, dividing
+it in its long direction; the contents should be rapidly scooped out,
+and a finger placed on the bleeding point, just at the upper corner of
+the sciatic notch. This will at once stop the haemorrhage till the vessel
+can be secured. This sounds easy enough, and has been done several times
+with success. Thus, John Bell, by an incision two feet long, as he tells
+us in his hyperbolical language, was enabled to tie the vessel in the
+case of the leech-gatherer who had punctured the artery by a pair of
+long scissors. Carmichael of Dublin used a smaller incision, removed one
+or two pounds of clots, and tied the vessel, in a case of wound by a
+penknife.[6]
+
+Now, though both of these cases were eventually successful, both
+patients lost during the operation a very large quantity of blood; John
+Bell's especially could not be removed from the operating-table for a
+considerable time after the operation. The period at which the great
+loss of blood took place was the interval after the incision was made,
+and before the artery was exposed to view, _i.e._ the interval in which
+the surgeon was busy dislodging the clots from the cellular membrane,
+the sac of the false aneurism. The procedure devised by Mr. Syme to
+obviate this difficulty, and which was put in practice by him in several
+very trying cases, is best given in his own terse description of an
+operation in a case of traumatic gluteal aneurism:--
+
+"The patient having been rendered unconscious, and placed on his right
+side, I thrust a bistoury into the tumour, over the situation of the
+gluteal artery, and introduced my finger so as to prevent the blood from
+flowing, except by occasional gushes, which showed what would have been
+the effect of neglecting this precaution, while I searched for the
+vessel. Finding it impossible to accomplish the object in this way, I
+enlarged the wound by degrees sufficiently for the introduction of my
+fingers in succession, until the whole hand was admitted into the
+cavity, of which the orifice was still so small as to embrace the wrist
+with a tightness that prevented any continuous haemorrhage. Being now
+able to explore the state of matters satisfactorily, I found that there
+was a large mass of dense fibrinous coagulum firmly impacted into the
+sciatic notch; and, not without using considerable force, succeeded in
+disengaging the whole of this obstacle to reaching the artery, which
+would have proved very serious if it had been allowed to exist after the
+sac was laid open. The compact mass, which was afterwards found to be
+not less than a pound in weight, having been thus detached, so that it
+moved freely in the fluid contents of the sac, and the gentleman who
+assisted me being prepared for the next step of the process, I ran my
+knife rapidly through the whole extent of the tumour, turned out all
+that was within it, and had the bleeding orifice instantly under
+subjection by the pressure of a finger. Nothing then remained but to
+pass a double thread under the vessel, and tie it on both sides of the
+aperture."
+
+The bleeding in this case was thus rendered comparatively trifling, and
+the patient made a speedy and complete recovery. He returned home within
+six weeks after the operation.[7]
+
+2. In one case, at least, the gluteal artery has been tied with success
+(for traumatic aneurism) just where it leaves the pelvis, without the
+tumour being opened. This was in the practice of Professor Campbell of
+Montreal. The operation was a very difficult one, and while possible
+only in cases seen very early, and where the tumour is very small, does
+not appear to have any advantage over the old method.
+
+Cases of spontaneous aneurism of the gluteal artery should be treated by
+ligature of the internal iliac. Steven's and Syme's cases of ligature
+of the internal iliac were of this nature.
+
+Manuals of operative surgery occasionally devote pages to the
+description of special operations for the ligature of such arteries as
+the sciatic, epigastric, circumflex ilii, and pudic. They do not require
+ligature, except in cases of wound either of the vessels themselves or
+their branches; and, according to the modern principles of surgery in
+such cases, the ligature should be applied to the bleeding point, rather
+than to the vessel at a distance above it.
+
+
+LIGATURE OF FEMORAL.--Under this head we practically mean cases of
+ligature of the superficial femoral, for the common femoral, or (as
+called by some anatomists) the femoral, before the profunda is given
+off, very rarely requires to be tied. If it is wounded, of course the
+bleeding point must be sought, and the artery tied above and below it,
+but if an aneurism on the superficial femoral renders ligature of that
+trunk impossible, experience teaches that ligature of the external iliac
+gives better results than ligature of the common femoral. Erichsen
+asserts that out of twelve cases in which the common femoral has been
+tied, only three have succeeded, the others dying from secondary
+haemorrhage. The experience of the Dublin surgeons, Porter, Smyly, and
+Macnamara, has been more satisfactory, as in eight cases of this
+operation six were successful.[8] A ninth case was unsuccessful. Reasons
+to explain the danger are not far to seek, for the numerous small
+muscular branches, along with the superficial epigastric, circumflex,
+and pudic trunks, reduce the chances of a good coagulum in the common
+femoral to a minimum, even without taking into consideration the
+shortness of the trunk before the great profunda femoris is given off.
+For the common femoral artery is only from one to two inches in length,
+and if there are some rare cases in which it is a little later in its
+bifurcation, there are others in which it divides nearer to Poupart's
+ligament.
+
+The superficial femoral is the name given to the main trunk between the
+origin of the profunda, and the point at which, passing through the
+tendon of the adductor magnus, it receives the name of popliteal. During
+this long course it gives off no branch large enough or regular enough
+to receive a name, except one, the anastomotica magna, which rises in
+Hunter's canal, close to the end of the vessel, so in that respect it is
+peculiarly suitable for the application of a ligature. Again, in the
+upper part of its course, it is superficial, being covered only by skin
+and fascia. A short notice of its most important anatomical relations is
+necessary.
+
+For the first two inches or two inches and a half of its separate
+existence, the superficial femoral lies in Scarpa's triangle, covered,
+as we said, only by skin and fascia. This triangle is formed by the
+sartorius and adductor longus muscles which meet at its apex, and by
+Poupart's ligament, which defines its base. The artery lies almost
+exactly in the centre of the space, and at the apex is covered by the
+sartorius muscle. The spot where it goes under the sartorius is the one
+selected for the application of the ligature. The femoral vein lies to
+the inner side of the femoral artery in this triangle, but their mutual
+relations vary with the portion of the limb; for, on the level of
+Poupart's ligament, the artery and vein lie side by side on the same
+plane, but in different compartments of their sheath; as the artery
+dives below the sartorius, the vein is still on the inside, but on a
+plane slightly posterior; while, by the time they reach Hunter's canal,
+the vein has got completely behind the artery. The separate compartments
+of the sheath in which the vessels lie are much less marked as the
+vessels go down the limb, the septum between the artery and the vein
+being in most cases very ill marked, even at the level where the
+ligature is applied. The anterior crural nerve, which on the level of
+Poupart's ligament lay outside of the artery and on a plane somewhat
+posterior, has divided into numerous branches before it reaches the
+point of ligature. One of its branches requires to be mentioned, and may
+sometimes be noticed and avoided during the operation, namely the
+internal saphenous nerve, which, first lying external to the artery,
+crosses it in front, reaching its inner side just before it enters
+Hunter's canal, where it leaves the vessel accompanying the anastomotica
+magna branch.
+
+
+OPERATION OF LIGATURE OF THE FEMORAL--SCARPA'S SPACE.--The patient being
+placed on his back, and being brought very thoroughly under chloroform,
+the knee of the affected limb should be bent at an angle of about 120 deg.,
+and supported on a pillow. Having previously ascertained the angle of
+junction of the sartorius and adductor, the surgeon should make an
+incision (Plate I. fig. 5) just over the pulsations of the vessel, in
+the middle line of the space, having its lower end quite over the
+sartorius muscle, and its upper one, at a distance from two and a half
+to three and a half inches, varying according to the amount of fat and
+muscle. The saphena vein can generally be recognised, and is almost
+always safe out of the way of this incision at its inner side.
+
+The first incision should divide the skin, superficial fascia, and fat,
+quite down to the fascia lata. The edges of the wound being held apart,
+the fascia should be carefully divided, and the sartorius exposed; its
+fibres can generally be easily enough recognised by their oblique
+direction; once recognised, the fascia should be dissected from it till
+its inner edge be gained, the corner of which should then be turned so
+that it may be held outwards by an assistant with a blunt hook. The
+sheath of the vessels is now exposed, and after having thoroughly
+satisfied himself of the position of the artery by the pulsation, the
+surgeon should carefully raise a portion of the sheath with the
+dissecting forceps, and open it freely enough to allow the coats of the
+artery to be distinctly seen. If the parts are deep, as in a fat or
+muscular patient, great advantage will be gained by seizing one edge of
+the sheath by a pair of spring forceps, and committing it to the care of
+an assistant, while the operator holds the other in his dissecting
+forceps; there is thus no fear of losing the orifice of the sheath,
+which without this precaution may easily happen, from the parts being
+confused with blood, or the position altered by movements of the
+patient. Now comes the stage of the operation on which, more than on
+anything else, success or failure depends. A _small_ portion of the
+vessel must be cleaned for the reception of the ligature, and it must be
+_thoroughly_ cleaned, so that the needle may be passed round it without
+bruising of the coats, or rupture of an unnecessary number of the vasa
+vasorum by rough attempts to force a passage for it. Hence all
+compromises, such as blunted instruments, silver knives, and the like,
+are dangerous, for in trying to avoid the Scylla of wounding the artery,
+they fall into the Charybdis, on the one hand, of isolating too much of
+the vessel and causing gangrene from want of vascular supply, or, on the
+other, expose the vein to the danger of injury by the aneurism-needle in
+their attempts to force it round an uncleaned vessel.
+
+The needle should in most cases be passed from the inner side, care
+being taken to avoid including the vein which is on the inner side and
+behind the vessel; the internal saphenous nerve, if seen, should be
+avoided. The needle must not be passed quite round the vessel raising it
+up, still less must the vessel be held up on the needle, as used to be
+done, as if the surgeon was surprised at his own success, but the needle
+should be passed just far enough to expose the end of the ligature,
+which must be seized by forceps and cautiously drawn through. It must
+then be tied very firmly and secured with a reef knot.
+
+The edges of the wound must be brought into accurate apposition, and
+secured by one or two stitches. If antiseptics are used, drainage should
+be provided for.
+
+From the very fact that ligature of the superficial femoral is a
+remarkably successful operation in causing consolidation of the aneurism
+and a rapid cure, there is also a corresponding danger that the limb be
+not sufficiently supplied with blood at first. The limb may very
+possibly become cold, and remain so for some hours at least after the
+operation. To avoid this as far as possible, it should be wrapped in
+cotton wadding, and very great care should be taken that it be not
+over-stimulated by hot applications, friction, or the like, any of which
+measures might very likely excite reaction, which would result in
+gangrene.
+
+Complete rest of the limb and of the whole body must be enjoined; the
+food must be nourishing and in moderate quantity. The chief danger is
+from gangrene of the limb, which is especially apt to result when the
+vein is wounded, or even too much handled during the operation.
+
+When properly performed, and in suitable cases, the operation is very
+successful. Mr. Syme tied this artery for aneurism thirty-seven times,
+and of these every one recovered. The statistics of Norris and Porta,
+who collected all the cases in which ligature of the femoral had been
+employed for _any_ cause, show a mortality of somewhat less than one in
+four. Rabe's table up to 1869 with the additional cases collected by Mr.
+Barwell to 1880 gives 297 cases with 53 deaths.[9] Mr. Hutchinson's
+table, again, of fifty cases collected from the records of Metropolitan
+Hospitals, shows the very startling result of sixteen deaths out of the
+fifty cases, or a mortality, in round numbers, of one-third.
+
+Certain anomalies have been observed in the distribution of the femoral
+vessels, of some importance as affecting the possibility of applying,
+and the result of, ligature; such as--1. A high division of the branches
+which afterwards become posterior tibial and peroneal. 2. A double
+superficial femoral, both branches of which may unite and form the
+popliteal, as in Sir Charles Bell's well-known case. 3. Absence of the
+artery altogether, as in Manec's case, where the popliteal was a
+continuation of an immensely enlarged sciatic.
+
+In such a case the absence of pulsation in front, and the presence of
+increased pulsation behind the limb, ought to prevent any fruitless
+attempt at search.
+
+
+LIGATURE OF THE SUPERFICIAL FEMORAL BELOW THE SARTORIUS MUSCLE.--This
+operation, though once common in France, and though the one recommended
+by Hunter himself, is now comparatively little used in this country; and
+rightly so; for while it has no advantage over the upper position, it is
+at once nearer the seat of disease, and the vessel is more deeply buried
+under muscles, and has a more distinct fibrous sheath, which requires
+division.
+
+It is, however, by no means a difficult operation, and is thus
+performed:--
+
+The limb being laid as before on the outside, and slightly bent, the
+skin shaved and the pulsation of the artery detected, an incision (Plate
+I. fig. 6) must be made from the lower edge of the sartorius muscle just
+as it crosses the vessel, along the course of the vessel, avoiding if
+possible the internal saphena vein.
+
+The sartorius when exposed must be drawn inwards. The fibrous canal
+filling the interspace between the abductor magnus and vastus internus
+is then recognised, and must be fairly opened; the artery is now seen
+lying in it, and over the vein which is posterior to it, but projects
+slightly on its outer side; the internal saphenous nerve is lying on the
+artery. The needle is best passed from without inwards so as to avoid
+the vein. The anastomotica magna is sometimes a large trunk, and has
+been mistaken for the femoral in this situation, and tied instead of it.
+
+
+LIGATURE OF THE POPLITEAL.--This operation is now hardly ever performed
+for aneurism, ligature of the superficial femoral having quite
+superseded it, and it is very rarely required for wounds, from the
+manner in which the vessel is protected by its position.
+
+Before the invention of the Hunterian principle of ligature at a
+distance, the old operation for popliteal aneurism consisted in cutting
+into the space, clearing out the contents of the aneurismal sac, and
+tying both ends of the vessel; from the depth of parts and the close
+connection of the popliteal vein, this operation was very rarely
+successful, and is now quite given up. If the vessel is wounded the
+bleeding point is the object to be aimed at, and is generally sufficient
+guide.
+
+In cases of haemorrhage for suppuration of an aneurismal sac, it might
+possibly be advisable, and there are certain cases of rupture of the
+artery, without the existence of an external wound, in which attempts
+have been made to save the limb by tying the vessel.[10] From the
+complexity of the parts, the numerous tendons, veins, and nerves crowded
+together in a narrow hollow, and chiefly from the great depth at which
+the artery lies, any attempt at ligature is very difficult. It is least
+so at the lower angle of the space, where, between the heads of the
+gastrocnemius, the vessel comes more to the surface, but is still
+overlapped by muscle.
+
+_Operation._--The patient lying on his face, a straight incision (Plate
+III. fig. 1), at least four inches in length, should be made over the
+artery, and thus nearer the inner than the outer hamstring; a strong
+fibrous aponeurosis will require division after the skin and superficial
+fascia are cut through, the limb is then to be flexed, and the tendons
+drawn aside with strong retractors; fat and lymphatic glands must next
+be dissected through, and then the vein and artery, lying on a sort of
+sheath of condensed cellular tissue, are seen, the vein lying above the
+artery and obscuring it. The vein must be drawn to the outside, and the
+thread passed round the artery, which lies close to the bone, on the
+ligamentum posticum of Winslowe.
+
+It is a very difficult subject to decide what operations should be
+described in a work of this character, on the vessels of the leg and
+foot. A very large number of distinct methods of operations on the
+various parts of the three chief arteries of the leg have been described
+by surgeons and anatomists, but specially by the latter.
+
+The fact is, however, that these complicated procedures are rarely
+required, for aneurisms of the arteries of the leg and foot are almost
+unknown, while in cases of wound of the vessel, or rupture resulting in
+traumatic aneurism, the proper treatment is not to tie the vessel higher
+up, but by dilating the wound and clearing out the clots, if required,
+to secure the bleeding point, and tie the vessel above and below.
+
+Again, a wound of the sole of the foot often gives rise to very severe
+and persistent haemorrhage, while the fasciae and complicated tendons
+render ligature of the vessel at the spot very difficult; yet ligature
+of either the anterior or posterior tibial would probably be
+insufficient; and to tie both these vessels, with possibly the peroneal
+and interosseous as well, would be a much more severe and dangerous
+procedure than ligature of the superficial femoral; while probably
+careful plugging of the wound, combined with flexion of the knee, will
+be found to stop the haemorrhage sooner than either of the more
+formidable methods.
+
+A competent knowledge of the anatomy of the part, and of the ordinary
+methods of checking haemorrhage, such as ligatures, graduated compresses,
+and styptics, aided by position, specially flexion of the knee after Mr.
+Ernest Hart's method, will suffice to enable the surgeon to check any
+haemorrhage of the foot or leg, without it being necessary to burden the
+memory with the three positions in which to tie the peroneal, or the
+various methods, more or less bloody and tedious, by which the posterior
+tibial in its upper third may be secured.
+
+     NOTE.--While, as a matter of surgical principle to guide our
+     practice on the living, I still hold very strongly the opinions
+     here expressed against special operations for ligature of the
+     arteries of the leg, and allow the sentences to stand as in the
+     first edition of this work, I insert in a note a brief description
+     of the more important ones, in deference to the advice of friends
+     and the urgent request of pupils, as these operations are used by
+     Examining Boards as tests of the operative dexterity of
+     candidates:--
+
+     1. ANTERIOR TIBIAL ARTERY IN LOWER HALF OF LEG.--_Anatomical
+     Note._--This vessel is related on its tibial side to the tibialis
+     anticus, and on its fibular, to the extensor longus digitorum
+     above, and the extensor pollicis below. The anterior tibial nerve
+     lies first on its outer side, then crosses the artery, and
+     eventually reaches its inner side near the foot. _Operation._--An
+     incision, at least three inches long, parallel with the outer edge
+     of the tibia, and about three-quarters of an inch from it, exposes
+     the deep fascia. This being divided, the outer edge of the tibialis
+     anticus must be found, and will be the guide to the artery, which,
+     surrounded by its venae comites, lies very deeply between the
+     muscles.
+
+     2. Posterior Tibial.--_A._ In middle third of leg. Here the artery
+     is separated from the inner border of the tibia, by the flexor
+     longus digitorum, and is covered by the soleus. _Operation._--An
+     incision at least four inches long, along the inner margin of the
+     tibia, exposes the edge of the gastroenemius; then divide the
+     tendinous attachment, then expose the soleus, and divide its
+     attachment also; the deep fascia will then be seen; slit it up, and
+     the vessel will be found about an inch internal to the edge of the
+     bone. The nerve is there just crossing it.
+
+     Guthrie's, or the direct operation, has the very high authority of
+     the late Professor Spence in its favour. An incision through skin
+     and fascia in the middle of the back of the leg allows the two
+     heads of the gastrocnemius to be separated to the same extent. The
+     soleus is then to be scraped through in same direction, and its
+     deep aponeurotic surface carefully slit up. The artery and vein are
+     then easily seen.
+
+     B. In lower third of leg.--This is an easier and more scientific
+     operation, as it does not involve the division of great tendons. An
+     incision midway between the internal malleolus and the tendo
+     Achillis, parallel with both, will expose the very deep and strong
+     fascia in which the tendons lie. The artery, with its venae comites,
+     occupies a central position, having the tendons of the tibialis
+     posticus and flexor communis in front between it and the internal
+     malleolus, and the posterior tibial nerve behind it, while the
+     flexor longus pollicis lies still nearer the tendo Achillis.
+
+
+     TABLE illustrating anastomotic circulation after ligature of
+     arteries of lower limb.
+
+     1. AORTA.--Epigastric and mammary of both sides. Haemorrhoidal and
+     spermatic, with branches of pudic both deep and superficial.
+
+     2. COMMON ILIAC.--Internal iliac and branches, with those of the
+     other side, along with the following:--
+
+     3. EXTERNAL ILIAC.--Internal mammary and deep epigastric.
+
+     Iliolumbar and lumbar branches of aorta, with deep circumflex ilii.
+
+     Pudic from internal iliac, with superficial pudic of common
+     femoral.
+
+     Gluteal, sciatic, and obturator, with the circumflex and
+     perforating branches or deep femoral.
+
+     4. FEMORAL.--External circumflex, with external articular of
+     popliteal.
+
+     Perforating, with branches of gluteal and sciatic.
+
+     Profunda branches with anastomotica and articular branches.
+
+     Obturator and internal circumflex with anastomotica and superior
+     internal articular.
+
+     NOTE.--The importance of the articular branches of the popliteal
+     explain the danger of gangrene after a sudden rupture or increase
+     in size of a popliteal aneurism.
+
+
+LIGATURE OF THE INNOMINATE.--The performance of this extremely
+dangerous, in fact almost hopeless operation, is by no means so
+difficult as might be expected.
+
+The patient lying down with the shoulders raised and head thrown well
+back, the sternal attachment of the right sterno-mastoid must be very
+freely exposed. This may be done by an incision (Plate I. fig. 7) along
+its anterior edge from the upper edge of the sternum, as far as may be
+necessary; another about the same length along the upper edge of the
+clavicle, will meet the former at an acute angle, and will include a
+triangular flap of skin, which must be carefully dissected up. The
+sternal, and probably a portion of the clavicular attachment of the
+right sterno-mastoid, must then be cautiously divided. This being done,
+the sterno-hyoid and sterno-thyroid muscles require division immediately
+above their sternal attachments.
+
+A dense process of cervical fascia (just becoming thoracic) now covers
+the vessel, binding it on the right side to the right innominate vein,
+and on the left maintaining the relation of the innominate artery to the
+trachea. The inferior thyroid veins lie on this fascia, and must be
+drawn aside, not cut. The fascia is then to be scraped through very
+cautiously, exposing the root of the right carotid, which, being traced
+downwards, will lead to the innominate. The following parts lie in close
+relation to the vessel at the point of ligature, and must be
+avoided:--1. The left innominate vein crosses the artery in front from
+left to right, and must be drawn down. 2. The right innominate vein and
+right pneumogastric are in close contact with the artery on the right
+side; to avoid them the aneurism-needle must be entered on the outside
+(right of the vessel). 3. The apex of the right pleura and the trachea
+are in close contact behind, requiring the point of the needle to be
+kept close to the artery in bringing the thread round.
+
+It might have been expected that the sudden arrest of so large a
+proportion of the vascular supply of the body, so very near the heart,
+would cause serious, or even fatal symptoms; this, however, is not the
+case, no serious inconvenience of this sort being experienced; yet
+hitherto every case has proved fatal, either from secondary haemorrhage
+or inflammation of lungs and pleura.
+
+In fifteen well-authenticated, and in three more doubtful cases, the
+ligature has been applied; all of these died at periods varying from
+twelve hours (as in Hutin's case), to forty-two days as in Thomson's,
+and sixty-seven days (Graefe's).[11]
+
+A successful case of ligature of the innominate along with the right
+carotid and (after secondary haemorrhage) the right vertebral, in a
+mulatto aged thirty-two, for a subclavian aneurism, has been put on
+record by Dr. Smyth of New Orleans, in the _American Journal of Medical
+Science_ for July 1866.
+
+And here we may also note that Mr. Heath has lately treated a case of
+innominate aneurism by simultaneous ligature of the third part of the
+subclavian and the carotid. Both ligatures separated on the eighteenth
+day, and the tumour was much smaller some months afterwards.[12]
+
+Mr. R. Barwell has reported several most interesting cases in which
+simultaneous ligature of carotid and subclavian have proved of marked
+benefit in aortic as well as in innominate aneurisms.[13]
+
+In four cases the operation was attempted, but the operators had to
+desist before the application of the ligature, in consequence of the
+diseased state of the arterial coats. Of these, three died, and one
+(Professor Porter's of Dublin) case recovered, the patient leaving the
+hospital with the aneurism nearly consolidated.
+
+Dr. Peixotto of Portugal applied a precautionary ligature to the
+innominate in a case where secondary haemorrhage occurred from the
+carotid. The ligature was not tightened beyond what was necessary merely
+to cause flattening of the vessel. The patient made a good recovery.
+
+Professor George Porter of Dublin records an interesting case of
+subclavian aneurism, in which, after failing to close the axillary
+artery by acupressure, he applied L'Estrange's compressor to the
+innominate itself for three days, with temporary benefit. The patient
+eventually died of haemorrhage.[14]
+
+For a very full and interesting account of ligatures of vessels in root
+of neck we may refer to vol. iii. of the 1883 edition of _Holmes'
+Surgery_, pp. 119-122.
+
+
+LIGATURE OF COMMON CAROTID.--Though the anatomical relations of the
+right and left carotid are different at their origin, they so precisely
+resemble each other in the whole of that part of their course which is
+at all amenable to surgical treatment, that one description will suffice
+for both, and the necessary anatomy will be brought out quite
+sufficiently in the description of each operation.
+
+From its giving off no collateral branches, the common carotid artery
+may be tied at any part of its course.
+
+It has been tied successfully at the distance of only three-quarters,
+or, in one case by Porter, hardly to be imitated, one-eighth of an inch
+from the innominate, and up to an equal distance from its bifurcation.
+In choosing the part of the vessel for operation, the operator must be
+guided by the position of the aneurism, if on the vessel itself, but if
+the aneurism be distant, as in scalp or orbit, he need have regard to
+position simply as facilitating the operation.
+
+The easiest position in which to apply the ligature is just above the
+omohyoid muscle, the vessel being there superficial.
+
+
+LIGATURE ABOVE OMOHYOID.--Using the anterior border of the
+sterno-mastoid as a guide, but leaving it gradually above to a little
+nearer the mesial line, an incision (Plate IV. fig. 1), varying in
+length according to the depth of fat and cellular tissue in the neck,
+but with its central point opposite the upper border of the cricoid
+cartilage, must be made through skin, platysma, and superficial fascia.
+While making the incision the head should be held back, and the face
+slightly turned to the opposite side; the parts being now relaxed by
+position, the edges of the wound must be held apart by blunt hooks or
+copper spatulae, and the deep fascia carefully divided over the vessel,
+which will be recognised by the pulsation. It may be noted here that
+even in thin subjects the sterno-mastoid edge _invariably_ overlaps the
+vessel, though in many anatomical diagrams it would appear to be in part
+subcutaneous.
+
+The descendens noni may possibly be seen, but this is by no means
+invariably the case, crossing the sheath of the vessel very gradually
+from without inwards in its progress down the neck. It must be carefully
+displaced outwards.
+
+The sheath of the vessel is then to be cautiously opened to the extent
+of about half an inch. The internal jugular vein, possibly much
+distended, may overlap the artery on its outer side, and will require to
+be pressed, emptied, and held out of the way. A small portion of the
+artery being thoroughly separated from the sheath, the aneurism-needle
+must be passed from without inwards to avoid the vein, and keep as close
+to the artery as possible to avoid the vagus.
+
+The tendon of the omohyoid muscle, or, in muscular subjects, a portion
+of its anterior fleshy belly, may be seen crossing the vessel from
+above downwards and outwards at the lower angle of the wound.
+
+An enlarged lymphatic gland has occasionally given much trouble, by
+being mistaken for the vessel and cleaned, while the ligature has even
+been placed on a carefully isolated fasciculus of muscular fibres.
+
+
+LIGATURE OF CAROTID BELOW THE OMOHYOID.--An incision in precisely the
+same direction as the former, but at a slightly lower level, is
+required, but the dissection is rather more difficult. The edge of the
+sterno-mastoid when exposed must be drawn outwards; the sterno-hyoid and
+thyroid inwards; the omohyoid upwards; the sheath opened, and the
+descendens noni or its branches drawn to the tracheal side. The jugular
+vein and vagus are both at the outer side, and must be avoided, while
+the inferior thyroid artery and sympathetic nerve both lie behind the
+vessel, and may be included in the ligature if care be not taken.
+
+     VARIETIES.--_Sedillot's Operation._--To secure the artery still
+     lower in the neck: An incision two and a half inches long, from the
+     inner end of the clavicle obliquely upwards and outwards in the
+     interval between the sternal and clavicular attachments of the
+     sterno-mastoid; this divides the superficial textures; the two
+     portions of muscle must then be drawn apart. The internal jugular
+     vein lies in the interval, and must be drawn to the outside before
+     the artery can be seen at all, and it is this that makes this
+     operation very difficult and dangerous, especially on the left
+     side, where the vein is close to the artery, and probably even
+     crossing it from left to right. The thoracic duct is behind.
+
+     _Malgaigne's modification of the above_ is an improvement: to
+     expose the external attachment of the muscle, to cut it through and
+     turn it to the outside, as in the operation for ligature of the
+     innominate, then to divide or pull inwards sterno-hyoid and
+     sterno-thyroid, thus exposing the sheath. The needle must be passed
+     from without inwards.
+
+_Results._--Pilz has collected 600 cases, of which 43.16 per cent. died.
+The united tables of Norris and Wood give 188 cases, with a mortality of
+sixty, or nearly one in three. These tables include cases in which the
+vessel was tied for wounds, and as a preparatory step in the operation
+of removal of tumours of the jaw, etc. Later statistics give a very much
+lessened mortality, due chiefly to the use of animal ligatures.
+
+Of thirty-one cases in which it was tied for pulsating tumours of the
+orbit, only two died from the operation.[15] Rivington's statistics to a
+later date give forty-six cases on forty-four patients with six deaths.
+
+Both carotids have been tied in the same patient twenty-five times, at
+intervals of less than a year; and it is a very remarkable fact that
+only five of these fifty ligatures proved fatal,--two in which both were
+tied on the same day, and three in which the operation was performed to
+arrest haemorrhage from malignant disease of the face and jaws--from
+gunshot wound,--and from syphilitic ulceration.
+
+The external carotid, and also most of its principal branches, have been
+tied for aneurisms, wounds, goitres, enlargement of the tongue, vascular
+tumours on occiput and other lesions; also as a first stage in the
+operation of extirpation of the upper jaw, for the purpose of preventing
+haemorrhage. However, such operations are rare, and will probably become
+rarer still, and it is hardly necessary to describe the operations on
+each _seriatim_.
+
+Aneurism of the external carotid or branches are rare; if idiopathic,
+ligature of the common carotid will be found at once easier, not more
+dangerous, and more effectual than ligature of the branch; if traumatic,
+the aneurism itself should be attacked, and the bleeding point secured
+by a double ligature. Wounds are common enough, but if accessible at
+all, the injured vessel should be tied at the bleeding point; if
+inaccessible (and under this head we may include wounds of the internal
+carotid), the common carotid must be tied.
+
+No one would think of trying the superior thyroids for goitre, unless
+they were so manifestly enlarged, tortuous, and pulsating, as to render
+the operation so simple (from their superficial position) as to require
+no special directions; besides this, the cases in which it has been
+already done have given very little encouragement to repeat it.
+
+As cases may occur in which any diminution of the cerebral supply is
+contra-indicated, and thus the more difficult ligature of the external
+carotid may be preferred to the more simple operation on the common
+trunk, and as the lingual may require ligature near its root, in
+consequence of obstinate haemorrhage from the tongue, short directions
+are given for the performance of both these operations.
+
+
+1. LIGATURE OF EXTERNAL CAROTID.--Head in same position as for the
+common carotid. A straight incision parallel with the anterior edge of
+sterno-mastoid, but about half an inch in front of it, must begin almost
+at angle of jaw, and extend downwards nearly to the level of the thyroid
+cartilage. Cautiously divide skin, platysma, and fascia; the lower end
+of the parotid must be pulled upwards, and the veins, which are
+numerous, cautiously separated. The anterior border of the
+sterno-mastoid must be pulled backwards, and the digastric and
+stylo-hyoid forwards and inwards. The superior laryngeal nerve which
+lies behind the vessel must be avoided.
+
+
+2. LIGATURE OF LINGUAL.--To secure this vessel either before it becomes
+concealed by the hyo-glossus, or after it is under the muscle, a curved
+incision is necessary, following the line of the hyoid bone, and
+especially of its greater cornu, but a line or two above its upper
+border. After the skin and platysma are divided, the posterior belly of
+the digastric must be recognised, which again will guide to the
+posterior edge of the hyo-glossus. The edge of the sub-maxillary gland
+may very probably require to be raised out of the way. The artery can
+then be secured, either before it dips under the hyo-glossus muscle, or
+after it has done so, by the division of a few of its fibres on a
+director. Care is needed to avoid injury of the hypo-glossal nerve,
+which lies above the muscle.
+
+The internal carotid artery occasionally, but very rarely, is the
+subject of aneurism. It may, like any other artery, be wounded,
+especially from the fauces. The treatment of either of these lesions is
+ligature of the common carotid itself, in preference to ligature of the
+internal carotid. Guthrie's operation for securing the bleeding internal
+carotid at the injured spot, by dividing and turning up the ramus of the
+lower jaw, has never been performed in the living body, and is so
+difficult, dangerous, and unnecessary, as not to merit description.
+
+
+LIGATURE OF SUBCLAVIAN.--_Note._--In consequence of the difference in
+the origin, and variety in the anatomical relations of the right and
+left subclavian arteries, in so far at least as their first stage is
+concerned, it is necessary to give a very brief separate account of
+each.
+
+_Right Subclavian._--The innominate artery divides into the right
+subclavian and right carotid exactly behind the sterno-clavicular
+articulation. The right subclavian extends from this point in an arched
+form across the neck, between the scalene muscles, over the apex of the
+pleura, till, passing under cover of the clavicle, it changes its name
+to axillary at the lower end of the first rib. For convenience of
+description, the artery is divided into three parts, which have very
+various anatomical relations, and differ from each other much in their
+amenability to surgical treatment by ligature. The anterior scalenus
+muscle defines the three parts, the first extending to the inner border
+of the muscle, the second being concealed by the muscle, and the third
+reaching from its outer border to the lower border of the first rib.
+
+_Branches of the Subclavian._--While the deep relations of pleura,
+veins, and nerves can be noticed under the head of each operation in
+detail, one anatomical point must never be forgotten as influencing very
+much the success of all surgical interference with the subclavian
+arteries--_i.e._ the branches given off. To give any chance of success
+in the application of a ligature to such a large vessel, so near the
+heart, a large portion of artery free from branches is required, that
+the clot may be long, firm, and undisturbed. The first part of the
+subclavian gives off the vertebral, thyroid axis, and internal mammary;
+the second, the superior intercostal; while the third part has in most
+cases no branch whatever. In these anatomical differences we find the
+reason for the almost invariable fatality resulting on any interference
+with the first and second parts, and the comparative safety of ligature
+of the third part, without requiring to account for the difference on
+other grounds, such as depth of part, importance of nervous relations,
+or nearer proximity to the heart.
+
+The second and third parts of both arteries are so similar to each
+other, that a separate account is not required for the two sides.
+
+
+LIGATURE OF RIGHT SUBCLAVIAN.--_First Part._--_Operation._--An incision
+just at upper edge of sternum and right clavicle, extending from inner
+edge of _left_ sterno-mastoid transversely to outer border of right
+sterno-mastoid through skin, platysma, and exposing sterno-mastoid, to
+be joined at an angle by a second incision, which, two, three, or even
+four inches long, must extend along inner border of right
+sterno-mastoid. Flap to be raised upwards and outwards. The sternal
+attachment of the sterno-mastoid must then be cautiously divided, as
+also part or the whole of its clavicular attachment, according as room
+is required. The sterno-hyoid and thyroid muscles will then require
+similar division. The internal jugular will then be seen very
+prominent,[16] and will require to be drawn inwards or outwards,
+according to circumstances. The carotid and right subclavian arteries
+will then be felt lying close together crossed by the pneumogastric and
+recurrent nerves, the latter turning behind the subclavian. The nerves
+must be drawn inwards; the cardiac filaments of the sympathetic will
+then be observed, and drawn outwards. The subclavian vein lies below,
+concealed by the clavicle, and will probably not be seen during the
+operation. The needle should be passed round the artery from below
+upwards, care being taken not to injure the pleura, which lies beneath
+and behind the artery.
+
+_Results._--Twelve cases, all of which died; ten of haemorrhage, one of
+pleurisy and pericarditis, and one from pyaemia. Attempted in one case by
+Mr. Butcher, but the artery was too much diseased to bear a ligature.
+The patient died on the fourth day.
+
+
+LIGATURE OF LEFT SUBCLAVIAN.--_First Part._--This operation, which has
+been described by some as impossible, has, I believe, been only once
+performed on the living body. _Operation._--Incisions as for the
+preceding operation, except being on the opposite side. After the skin,
+platysma, and muscles have been divided, as already described, the deep
+cervical fascia requires division close to the inner edge of the
+scalenus anticus. The artery lies excessively deep, and great difficulty
+is experienced in avoiding injury to the pleura and the thoracic duct.
+
+_Results._--Once performed by Dr. Rodgers of New York; death from
+haemorrhage on fifteenth day.
+
+_Anatomical Note._--The course of the left subclavian in its first stage
+is much straighter, as its origin is much deeper, than on the right
+side. The pneumogastric, phrenic, and cardiac nerves lie parallel to its
+course; the oesophagus and thoracic duct lie behind it, and to its inner
+side.
+
+
+LIGATURE OF SUBCLAVIAN.--_Second Part._--This very rare operation hardly
+requires a separate description, as the incisions necessary for ligature
+of the artery in its third part will, with very slight modifications, be
+sufficient for the purpose.
+
+It has, however, special elements of danger in it, involved in the
+unavoidable division, of part at least, or probably the whole, of the
+scalenus anticus. The phrenic nerve, from its position on that muscle,
+requires special care to avoid dividing it, and in most cases the
+internal jugular vein is also in the way. The branches of the thyroid
+axis, which cross the neck, are quite in the line of the incision. The
+lowest cord of the brachial plexus lies immediately behind the artery,
+between it and the middle scalenus. The pleura lies just below it. The
+subclavian vein is generally quite safe, running in front of the
+scalenus anticus, and at a lower level.
+
+The presence of the superior intercostal branch adds greatly to the
+danger of ligature of the vessel in this position, from its interfering
+with a proper clot.
+
+_Results._--Dupuytren[17] performed it successfully for a traumatic
+axillary aneurism. Auchincloss[18] did it for a large true aneurism, but
+the patient died sixty-eight and a half hours after the operation.
+Liston cut through the outer portion of the scalenus with success for an
+idiopathic aneurism. Thirteen have been collected by Wyeth with four
+recoveries and nine deaths.
+
+
+LIGATURE OF SUBCLAVIAN.--_Third Part._--For this comparatively common
+operation, various methods of procedure have been suggested and
+employed.
+
+In the dead body, where the axilla is free from swelling, and in thin
+patients, the artery in this third stage is tolerably superficial, and
+can be secured with ease. But in very muscular men, with short necks and
+well curved clavicles, and specially when the axilla is filled up with
+an aneurism, and the shoulder cannot be depressed, the operation becomes
+very difficult.
+
+_Operation of Ramsden, Liston, and Syme._--_Position._--The patient
+lying on his back with his shoulders supported by pillows, and his head
+lying back, and drawn to the opposite side; the shoulder of the affected
+side must be depressed as much as possible.
+
+_Incisions._--(Plate I. fig. 8.)--One through skin, superficial fascia,
+and platysma, along the upper edge of the clavicle, for at least three
+inches from the anterior edge of the trapezius to the posterior border
+of the sterno-mastoid, and in muscular subjects freely overlapping the
+edges of both muscles. Another two inches in length along posterior
+border of sterno-mastoid meets the first at an angle. On reflecting the
+chief flap thus made upwards and backwards, the external jugular will be
+seen, and, if possible, must be drawn to a side; if not, it must be
+divided, and both ends tied. The lower edge of the posterior belly of
+the omohyoid must then be sought; this leads at once to the posterior or
+outer margin of the scalenus anticus. The connection of the deep fascia
+to that muscle must then be very carefully scraped through, and by
+tracing the muscle to its insertion to the first rib, the artery is at
+once reached, lying behind the insertion. The pulsation of the vessel
+between the forefinger and the first rib will prove a great assistance;
+yet care is required, lest one of the branches of the brachial plexus be
+secured instead of the artery. The lowest cord lies very close to the
+vessel. The subclavian vein is not likely to give much trouble, from
+its being on a lower level, and (unless very much dilated) nearly
+concealed by the clavicle. The suprascapular artery is also hidden, but
+the transverse cervical crosses the very line of incision, and may give
+trouble, being occasionally much enlarged, so much so as even for a time
+to have been mistaken for the subclavian itself. If possible, both these
+branches should be saved, as being important means of carrying on the
+anastomosis for the future support of the limb.
+
+An absorbent gland is occasionally in the way, and has even been
+mistaken for the vessel and carefully cleaned. Such may be removed
+without scruple.
+
+Care must be taken not to injure the pleura, which lies immediately
+behind and below the vessel at the seat of ligature. Various
+instrumental devices have been invented for passing the ligature. The
+simplest seems still to be best, a common aneurism-needle with a
+considerable curve.
+
+     _Other methods of operating._--A single curved incision above the
+     clavicle, with its concavity upwards, of about three or four inches
+     long, with its inner end rather higher than the outer (Green,
+     Fergusson).
+
+     A linear transverse incision in the same situation (Velpeau).
+
+     A single linear incision perpendicular to the clavicle (Roux).
+
+     An arched incision (Plate IV. fig. 2) with its convexity outwards,
+     and its base on the posterior edge of the sterno-mastoid, from
+     three inches above the clavicle to the clavicular attachment of the
+     muscle (Skey).
+
+_Results._--Dr. Wyeth's Tables in 1877 give 251 cases with 134 or 53 per
+cent. of deaths.
+
+     The late Mr. Furner of Brighton reported a most interesting case,
+     in which he tied both subclavian arteries at an interval of two
+     years in the same patient, for axillary aneurisms, with success.
+
+
+LIGATURE OF AXILLARY.--_Anatomical Note._--This vessel, the next stage
+in the continuation of the subclavian downwards, may be defined
+surgically as extending from the clavicle to the lower border of the
+teres major. From the depth of the vessel at its upper part, the
+numerous nerves, and the close proximity of the vein, the surgeon has
+carefully to study the anatomical relations. It, like the subclavian, is
+commonly divided into three stages, and, also like the subclavian, these
+stages are defined by the relations of the artery to a muscle, the
+pectoralis minor. Surgically we may draw a very close parallel between
+the two vessels, for we find that in the axillary, as in the subclavian,
+the first stage is very deep, and very rarely amenable to ligature; the
+second, still deeper and more rarely attempted, as in both the operation
+involves division of a deep muscle; while the third stage in each is the
+one most frequently chosen by the surgeon.
+
+_First Stage._--Between the lower edge of the first rib and upper border
+of the pectoralis minor the vessel is deeply seated, contained in that
+process of deep fascia called the costo-coracoid membrane, and covered
+above by skin, platysma, and the clavicular portion of the pectoralis
+major. It lies on the first intercostal muscle and the upper digitation
+of the serratus magnus, while the cords of the brachial plexus are on
+its acromial side, and the axillary vein in close contact with it on its
+thoracic side, and frequently overlapping the artery.
+
+_Operation._--The great desideratum is free access. An incision (Plate
+I. fig. 9), semilunar in shape, with its convexity downwards, must
+extend from half an inch outside of the sterno-clavicular articulation
+to very near the coracoid process, stopping just before it arrives at
+the edge of the deltoid, in order to avoid injury of the cephalic vein.
+It must include skin, fascia, and platysma, and the flap must be thrown
+upwards. The clavicular portion of the pectoralis major must then be
+divided right across its fibres, which will retract. The arm must then
+be brought close to the side to relax the pectoralis minor, which must
+be drawn aside. The artery will then be felt pulsating, but hidden by
+the costo-coracoid membrane, which acts as its sheath. This must be
+carefully scratched through, the nerves pulled outwards, the vein
+avoided and pulled downwards and inwards, and the thread passed round
+from within outwards. (Manec, Hodgson, and, with slight modification in
+the incision through the skin, Chamberlaine.)
+
+     Ligature has been performed in this position by separating the
+     pectoralis and deltoid muscles, without dividing the muscular
+     fibres (Roux, Desault).
+
+     To attempt to gain access between the clavicular and sternal
+     portions of pectoralis major, as has been proposed by some, is
+     almost impracticable in the living body, from the position of the
+     vein, to which, rather than to the artery, this incision leads.
+
+
+LIGATURE OF AXILLARY, _in its second stage_, is not an advisable
+operation, when it is merely intended to throw a ligature round the
+artery for an aneurism lower down.
+
+It has been performed at least twice by Delpech, but it is a rude
+procedure; in his cases, after the muscle was cut, a dive with the
+finger was made to collect the whole mass of vessels and nerves, and
+bring them to the surface near the collar-bone; in this position it is
+said the artery was easily isolated and tied.
+
+In Mr. Syme's operation of cutting into large axillary aneurisms, and
+tying both ends of the vessel, the pectoralis minor may, indeed
+generally has, to be divided, and must take its chance without any
+special notice or precaution, in the sweeping, free incisions required.
+
+
+LIGATURE OF AXILLARY _in its third stage_.--This is an operation very
+much more common, more easy of accomplishment, and safer in its results
+than either of the preceding; the artery in this stage being more
+superficial, in fact almost subcutaneous.
+
+_Operation._--The arm being extended and supinated, an incision (Plate
+I. fig. 10) two and a half or three inches long, must be made in the
+base of the axilla over the artery, involving at first skin and
+superficial fascia only; the deep fascia is then exposed and must be
+carefully scraped through, avoiding injury of the basilic vein, if (as
+sometimes occurs) it has not yet dipped through the fascia. The vessel
+can now be felt; the median nerve which lies over the artery, or
+slightly to its outer side, must be drawn outwards, and the axillary
+vein, which lies at the thoracic side, but often overlaps the vessel,
+must be carefully drawn inwards. The ligature must then be passed from
+within outwards.
+
+When the patient is very fat or muscular, the coraco-brachialis muscle
+may be required as a guide to the vessel; but in general its superficial
+position renders any guide quite unnecessary, even in the dead body.
+
+_Anatomical Note._--While in each stage the axillary artery gives off
+branches, those arising from the third stage are by far the most
+important, especially the subscapular, which leaves it at the edge of
+the muscle of the same name. To avoid these the ligature should be
+applied as low down on the vessel as possible, and, in point of fact,
+the operation called ligature of the third stage of the axillary is,
+anatomically speaking, really ligature of the brachial high up, and
+where there is room at all, there will be the less chance of secondary
+haemorrhage, the greater the distance is between the ligature and the
+great subscapular branch.
+
+_Mr. Syme's Operation for Axillary Aneurism._--Description of the
+operation in his own words:--
+
+"Chloroform being administered, I made an incision along the outer edge
+of the sterno-mastoid muscle, through the platysma myoides and fascia of
+the neck, so as to allow a finger to be pushed down to the situation
+where the subclavian artery issues from under the scalenus anticus and
+lies upon the first rib. I then opened the tumour, when a tremendous
+gush of blood showed that the artery was not effectually compressed;
+but while I plugged the aperture with my hand, Mr. Lister, who assisted
+me, by a slight movement of his finger, which had been thrust deeply
+under the upper edge of the tumour, and through the clots contained in
+it, at length succeeded in getting command of the vessel. I then laid
+the cavity freely open, and with both hands scooped out nearly seven
+pounds of coagulated blood, as was ascertained by measurement. The
+axillary artery appeared to have been torn across, and as the lower
+orifice still bled freely, I tied it in the first instance. I next cut
+through the lessor pectoral muscle close up to the clavicle, and holding
+the upper end of the vessel between my finger and thumb, passed an
+aneurism-needle, so as to apply a ligature about half an inch above the
+orifice."[19]
+
+In a similar operation lately performed by the author for traumatic
+aneurism, the result of a stab, very little blood was lost, though no
+incision was made above the clavicle. The patient made a good
+recovery.[20]
+
+
+LIGATURE OF BRACHIAL.--To arrest haemorrhage from a wound of the artery
+itself, no special directions are required, except to enlarge the wound,
+and secure the vessel above and below the bleeding point. There are,
+however, rare cases in which for bleeding in the palm (after all other
+means have failed), or for aneurism lower down the arm, a ligature may
+be necessary.
+
+_Operation._--The biceps muscle, at its inner edge, is the best guide to
+the position of the incision, or if it be obscured by fat or oedema, a
+line extending from the axilla, just over the head of the humerus to the
+middle of the bend of the elbow will define its course. An incision
+(Plate I., fig. 11) three inches in length, about the middle of the arm
+(when you have the choice of position), through skin and superficial
+fascia, will expose the deep fascia, and probably the basilic vein.
+Drawing the latter aside, cautiously divide the deep fascia. The artery
+is then exposed, but in close relation to various nerves; of these the
+ones most likely to come in the way are--1. The median, which lies in
+front of, but a little to the outside of the artery, though in some rare
+cases it lies behind it; 2. The internal cutaneous; 3. The ulnar, both
+of which ought to be rather to the inside of the artery. Two brachial
+veins accompany and wind round the vessel, occasionally interlacing.
+Pulsation will, in the living body, usually suffice to distinguish the
+artery from the other textures, and the ligature may be passed from
+whichever side is most convenient.
+
+     _Note._--The relation of the median nerve to the vessel varies
+     according to the part of the arm--thus, as low as the insertion of
+     the coraco-brachialis it is to the outer side, as has been
+     described, it then crosses the vessel obliquely, and two inches
+     above the elbow it is on the inner side of the artery. Again, the
+     operator must never forget the possibility of there being a high
+     division of the artery. This occurs, Mr. Quain has shown, perhaps
+     once in every ten or eleven cases, and may necessitate ligature of
+     both trunks.
+
+In those cases (once much more frequent than at present) where an
+aneurism has formed after a wound of the brachial at the bend of the arm
+in venesection, the aneurism may be either circumscribed or diffuse.
+
+If circumscribed, it is advised by some surgeons, specially by the late
+Professor Colles of Dublin, that the brachial should be tied immediately
+above the tumour. In most cases of circumscribed, and in all such cases
+of diffuse aneurism, the preferable operation is boldly to lay open the
+tumour, turn out all the clots, seek for the wound in the artery, and
+tie the vessel above and below. A tourniquet above, or, better still, a
+trustworthy assistant, prevents all fear of haemorrhage, and such a
+radical operation exposes the limb to far less chance of gangrene than
+do any attempts at removing or lessening the tumour by pressure (as
+recommended by Cusack, Tyrrell, Harrison), and is much more certain
+than a mere ligature above.[21]
+
+
+LIGATURE OF VESSELS IN FORE-ARM.--Here, as also we found is the case in
+the leg, it is almost useless to go on giving exact directions as to the
+method of throwing a ligature round the vessels in all possible
+situations.
+
+For below the elbow spontaneous aneurism is almost unknown, and even
+traumatic aneurisms are extremely rare. It is therefore for haemorrhage
+only that the vessels are likely to require ligature, and it is a rule
+in surgery that to enlarge the wound and to apply a ligature above and
+below the bleeding point is better practice than to apply a ligature at
+a distance.
+
+In the case of wounds of the palmar arch, it is extremely difficult, and
+very apt to injure the future usefulness of the hand, thus to seek for
+the bleeding point under the palmar fascia, and for _these_, ligatures
+of radial and ulnar have occasionally been practised. However, as even
+this has proved ineffectual, and the interosseous has proved sufficient
+to continue the bleeding, ligature of the brachial at once is preferable
+to ligature of so many branches in the fore-arm.
+
+The use of graduated compresses, carefully applied, combined with
+flexion of the elbow over a bandage, will generally prove sufficient to
+check such haemorrhage from the palm, without having recourse to either
+of the above more severe measures.
+
+     _Note._--As in the lower limb at page 24, and for the same reasons,
+     I here insert a brief account of the methods of tying the ulnar and
+     radial arteries.
+
+     1. LIGATURE OF ULNAR.--Only admissible in the lower half of its
+     course. _Operation._--Use the tendon of the flexor carpi ulnaris as
+     a guide, and make an incision along its radial edge, at least two
+     inches in length; expose the deep fascia of the arm and then
+     cautiously divide it; then bending the hand, the flexor carpi
+     ulnaris is relaxed, and the artery is found lying pretty deeply
+     between it and the flexor sublimis digitorum. The ulnar nerve lies
+     at its ulnar side, and the venae comites accompany the artery. In a
+     tolerably muscular arm, the incision will have to be about an inch
+     inside of the ulnar border of the limb.
+
+     2. RADIAL.--This artery lies more superficial than the preceding,
+     and may be tied at any part of its course.
+
+     _A._ Operation in upper part of fore-arm. Here the artery lies in
+     the interval between the supinator longus and the pronator radii
+     teres. In a muscular arm, the edge of the former muscle is the best
+     guide; in a fat one, the incision may be made in a line extending
+     from the centre of the bend of the arm to the inner edge of the
+     styloid process of the radius. The deep fascia must be exposed and
+     opened, and the muscles relaxed and held aside. The radial nerve
+     lies on the radial side of the vessel.
+
+     _B._ Operation in lower half of arm. Here the vessel is more
+     superficial, lying in the groove between the flexor carpi radialis
+     and supinator longus. An incision two inches in length, and
+     parallel with these tendons, easily exposes the artery. The nerve
+     is still on its radial side.
+
+     _C._ Operation at first metacarpal. The artery may be tied easily
+     enough in the triangular space bounded by the extensors of the
+     thumb, on the dorsum of the proximal end of the first metacarpal
+     bone. Skey[22] recommends a transverse,--Stephen Smith[23] and
+     others, a longitudinal incision. The author had lately to secure
+     the radial in its lower third, the superficialis volae, and the
+     radial again in the triangular space, in a case where division of
+     the artery by a transverse cut had caused a large aneurism to form
+     close above the annular ligament.
+
+     TABLE illustrating anastomotic circulation after ligature of
+     arteries of neck and upper limb.
+
+     1. Common carotid.
+
+     (_a_) Across middle line: thyroids, linguals, facials, occipitals;
+     also terminal branches of external carotids; also internal carotids
+     by circle of Willis.
+
+     (_b_) Of same side: occipital with vertebral; superior thyroid with
+     inferior thyroid, etc.
+
+     2. Subclavian, 3d part.
+
+     Suprascapular with dorsal branches of subscapular; posterior
+     scapular with costal and muscular branches of subscapular. Thoracic
+     anastomosis between internal mammary and intercostals, with
+     branches of axillary.
+
+     3. Axillary and brachial. Anastomosis varies with the position of
+     the ligature, but is very free between the various muscular
+     branches of these vessels.
+
+
+FOOTNOTES:
+
+[2] Erichsen, _Surgery_. Sixth edition, vol. ii. p. 121.
+
+[3] The line 3 in Plate I. shows the direction required. It
+will not be necessary to carry the incision so far up for the external
+as for the common iliac.
+
+[4] _On the Arteries and Veins_, p. 421.
+
+[5] _Cyclopaedia of Practical Surgery_, vol. i. p. 277.
+
+[6] John Bell's _Prin. of Surg._, vol. i. 421; _Dublin Jour._,
+vol. iv. 321.
+
+[7] _Observations in Clinical Surgery_, Syme, pp. 171-3.
+
+[8] _Brit. Med. Jour._ 1867, Oct. 5.
+
+[9] _International Encyclopaedia of Surgery_, vol. iii. p. 466.
+
+[10] Poland, _Guy's Hosp. Report_, ser. iii. vol. vi.
+
+[11] Mr. W. Thomson's most interesting paper on this subject is
+full of information down to the latest date.
+
+[12] _Lancet_, Jan. 5, 1867.
+
+[13] _Lancet_, May 1879.
+
+[14] _Dublin Quarterly Journal_, Nov. 1867.
+
+[15] W. Zehender--Monatsbl. fuer Augenheilkunde. 1868.
+
+[16] Butcher, _Op. and Cons. Surgery_, p. 861.
+
+[17] _Lecons Orales_, iv. 530.
+
+[18] _Ed. Med. and Surg. Journ._ vol. xlv.
+
+[19] _Observations in Clinical Surgery_, pp. 148, 149.
+
+[20] _Edin. Med. Journal_, March 1879.
+
+[21] See case of recurrence, Fergusson's _Practical Surgery_
+1st ed. p. 222.
+
+[22] _Operative Surgery_, p. 279.
+
+[23] _Surgical Operations_, p. 50.
+
+
+
+
+CHAPTER II.
+
+AMPUTATIONS.
+
+
+In ordinary surgical language the name Amputation is applied to all
+cases of removal of limbs, or portions of limbs, by the knife, though in
+strict accuracy it should be restricted to those cases in which a limb
+is removed _in the continuity of a bone_, its removal _at a joint_ being
+called a Disarticulation.
+
+The briefest outline of a history of amputation would fill a work much
+larger than the present. I may be allowed in a few sentences to attempt
+to show the principle on which such a sketch should be written, in
+describing the three great eras of progress in improvement of the
+methods of amputating.[24]
+
+I. Prior to the invention, or at least prior to the general
+introduction, of the ligature and the tourniquet, the great barrier to
+all improvement in operating was the impossibility of checking
+haemorrhage during an operation, and after its conclusion. Many surgeons
+would not amputate at all, others only through gangrenous parts; others
+more bold, only at the confines of parts in which gangrene had been
+artificially induced by tight ligatures.
+
+With the exception of Celsus, who in one place recommends a flap to be
+dissected up, and the bone thus divided at a higher level, all were in
+too great a hurry to get the operation completed to think of flaps. Cut
+through all the parts at the same level with a red-hot knife, if you
+will, like Fabricius Hildanus; by a single blow with a chisel and
+mallet, like Scultetus; or by a crushing guillotine, like Purmannus: or
+by two butchers' chopping-knives fixed in heavy blocks of wood, one
+fixed, the other falling in a grove, like Botal; and then try to check
+the bleeding by tying a pig's bladder over the face of the stump, like
+Hans de Gersdorf; or tying it up in the inside of a hen newly killed; or
+by plunging it at once into boiling pitch.
+
+We are the less surprised to read of Celsus's description of a flap
+operation, when we remember that it is almost certain that Celsus _was_
+acquainted with the ligature as a means of checking haemorrhage.[25]
+
+II. A new era was ushered in when, about 1560, Ambrose Pare invented, or
+re-introduced, the ligature as a means of arresting haemorrhage, but not
+for more than a century after this did the full benefit of his discovery
+begin to be felt, when the tourniquet was introduced by Morel at
+Besancon in 1674, and James Young of Plymouth in 1678, and improved by
+Petit in 1708-10.
+
+_Now_ surgeons had time to look about them during an amputation, and to
+try to get a good covering for the bone, so that the stump might heal
+more rapidly and bear pressure better. Great improvements were rapidly
+made, and any history of these improvements would need to trace two
+great parallel lines, one the circular method, the other the flap
+operation.
+
+1. The old method in which the limb was lopped off by one sweep, all the
+tissues being divided at the same level, might be called the true
+circular. This, however, was soon improved--
+
+_A._ By Cheselden and Petit, who invented the double circular incision,
+in which first the skin and fat were cut and retracted, and then the
+muscle and bone were divided as high as exposed.
+
+_B._ By Louis, who improved this by making the first incision include
+the muscles also, the bone alone being divided at the higher level.
+
+_C._ By Mynors of Birmingham, who dissected the skin back like the
+sleeve of a coat, and thus gained more covering.
+
+_D._ Then comes the great improvement of Alanson, who first cut through
+skin and fat, and allowing them to retract, next exposed the bone still
+further up by cutting the muscles obliquely so as to leave the cut end
+of the bone in the apex of a conical cavity.
+
+_E._ An easier mode, fulfilling the same indications, is found in the
+triple incision of Benjamin Bell of Edinburgh, who in 1792 taught that
+first the skin and fat should be divided and retracted, next the
+muscles, and lastly the bone.
+
+_F._ A slight improvement on _E_, made by Hey of Leeds, who advised that
+the posterior muscles of the limb should be divided at a lower level
+than the anterior, to compensate for their greater range of contraction.
+
+2. In the progress of the flap operation fewer stages can be defined.
+Made by cutting from within outwards, after transfixion of the limb, the
+flaps varied in shape, size, position, and numbers, from the single
+posterior one of Verduyn of Amsterdam, to the two equal lateral ones of
+Vermale, and the equal anterior and posterior ones of the Edinburgh
+school.
+
+Then came the battle of the schools: flap or circular.
+
+_Flap._--Speedy, easy, and less painful; apt to retract, and that
+unequally.
+
+_Circular._--Leaving a smaller wound, but more slow in performance, and
+apt to leave a central adherent cicatrix.
+
+3. The last era in amputation began after the introduction of
+anaesthetics. Now speed in amputation is no object, and the surgeon has
+full time to shape and carve his flaps into the curves most suited for
+accurate apposition, and suitable relation of the cicatrix to the bone.
+It has also been brought clearly out that different methods of operating
+are suitable for different positions, and also that even in the same
+operation it is possible to unite the advantages of both the flap and
+the circular method.
+
+In the modified circular, which is best suited for amputation below the
+knee, in the long anterior flaps of Teale, Spence, and Carden, we have
+illustrations of the manner in which the advantages of both the flap and
+circular methods have been secured, without the disadvantages of either.
+The long anterior flap, not like Teale's to fold upon itself, but like
+Spence's and Carden's to hang over and shield the end of the bones, and
+the face of a transversely-cut short posterior flap, seems to be now the
+typical method for successful amputations. There may be exceptions, as
+when the anterior skin is more injured than the posterior, or where an
+anterior flap would demand too great sacrifice of length of limb, but as
+a rule it will be found the best method for the patient.
+
+
+AMPUTATION OF THE UPPER EXTREMITY.--The extreme importance of the human
+hand, its tactile sensibility, its grasping power, and the irreparable
+loss sustained by its removal, render the greatest caution necessary,
+lest we should remove a single digit or portion of one that might be
+saved. In cases of severe smashing injuries involving the fingers, it is
+the surgeon's bounden duty not recklessly to amputate the limb with neat
+flaps at the wrist-joint, but carefully to endeavour to save even a
+single finger from the wreck, though at the risk of a longer
+convalescence, or even of a profuse suppuration. While a toe or two, or
+a small longitudinal segment of the foot, may be comparatively useless,
+and a good artificial foot, with an ankle-joint stump, certainly
+preferable, a single finger, provided its motions are tolerably intact,
+will prove much more valuable to its possessor than the most ingeniously
+contrived artificial hand.
+
+[Illustration: FIG. I.]
+
+However, while in cases of extensive smash we endeavour to save anything
+we can, the case is very much altered when it is only one or two fingers
+that are injured. Here we find another principle brought into play, and
+our conservative surgery must be limited by the following consideration.
+In endeavouring to save a portion of the injured finger or fingers, will
+the saved portion interfere with the important movements of the
+uninjured ones? These two principles--1. Generally to save as much as we
+can; 2. Not to save anything which may be detrimental or in the
+way,--will guide us in describing the amputations of the upper
+extremity.
+
+[Illustration: FIG. II.]
+
+_Amputation of a distal phalanx._--This small operation is not very
+often required. In cases of whitlow in which the distal phalanx alone
+has necrosed, removal of the necrosed bone by forceps is generally all
+that is necessary. In cases of injury, however, in which nail and distal
+phalanx are both reduced to pulp, it will hasten recovery much to remove
+the extremity. There is no choice as to flap, the nail preventing an
+anterior one, so a flap long enough to fold over must be cut from the
+pulp of the finger in either of two ways (Fig. I. 1):--1. Holding the
+fragment to be removed in the left hand, and bending the joint, the
+surgeon makes a transverse cut across the back of the finger, right into
+and through the joint, cutting a long palmar flap from within outwards
+as he withdraws the knife.
+
+     _Note._--Some difficulty is often felt in making the dorsal
+     incision so as exactly and at once to hit the joint; the most
+     common mistake being, that the transverse incision is made too
+     high, and the knife, instead of striking the joint, only saws
+     fruitlessly at the neck of the bone above. To avoid this, the
+     surgeon should take as a guide to the joint, not the well-marked
+     and tempting-looking _dorsal_ fold in the skin, but the _palmar_
+     one, which exactly corresponds with the joint between the proximal
+     and middle phalanges, and is only about a line above the distal
+     articulation.--(Fig. II.)
+
+2. Making the long flap by transfixion, it may be held back by an
+assistant, and the joint cut into.
+
+_Amputation through the second phalanx._--If the distal phalanx be so
+much crushed that a flap cannot be obtained, two short semilunar lateral
+flaps may be dissected (Fig. I. 2) from the sides of the second phalanx,
+which may then be divided by the bone-pliers at the spot required.
+
+In cases of injury which do not admit of either of the preceding
+operations, it is quite possible to amputate either at the first joint,
+or even through the proximal phalanx. Patients are sometimes anxious for
+such operations in preference to amputation of the whole finger. The
+surgeon should, however, never amputate through a finger higher up than
+the distal end of the second phalanx, unless absolutely compelled by the
+patient, for the resulting stump, being no longer commanded by the
+tendons, will prove merely an incumbrance, and may possibly require a
+secondary operation at no distant date for its removal.
+
+This rule is applicable in cases in which a single finger is injured,
+and two or three complete ones are left; in cases where all the fingers
+have been mutilated every morsel should be left, and may be of use.
+
+_Amputation of a whole finger._--(Fig. I. 3)--This is an operation of
+great importance, from its frequency.
+
+If the third or fourth digits require amputation, it should be performed
+as follows:--The vessels of the arm being commanded, an assistant holds
+the hand, separating the fingers at each side of the one to be removed.
+The surgeon holding the finger to be removed, enters the point of a long
+straight bistoury exactly (some authorities say half an inch) above the
+metacarpo-phalangeal joint, and cuts from the prominence of the knuckle
+right into the angle of the web, then, turning inwards there, cuts
+obliquely into the palm to a point nearly opposite the one at which he
+set out.
+
+     _Note._--While most authorities agree with the direction in the
+     text regarding the palmar termination of the incision, I believe,
+     in most cases, it is not necessary to go so far, and that the
+     incisions may fitly meet in the palm at a point midway between a
+     point opposite to the knuckle, and the centre of the well-marked
+     "sulcus of flexion."
+
+He then repeats this incision on the other side, makes tense the
+ligaments, first at one side and then at the other, by drawing the
+finger to the opposite side, and cuts them. The tendons being cut, the
+finger is detached. The vessels being tied, one point of suture is put
+in on the dorsal aspect, and the fingers on each side tied together at
+their extremities, with a pad of lint between them.
+
+     _Modification._--Lisfranc's method is too long in its minute
+     description to give in detail. The principle is to make a semilunar
+     flap at one side (the one opposite the operator's right hand), by
+     cutting from without inwards, then to open the joint from this cut,
+     and, still keeping the edge of the knife close to the head of the
+     phalanx, cutting the other flap from within outwards. This can be
+     very rapidly done, but the last flap is apt to be irregular and
+     deficient, especially in those common cases, in which, after
+     whitlow or the like, the tissues are hard and brawny, and the skin
+     does not play freely.
+
+It is quite unnecessary to remove the head of the metacarpal, either for
+the sake of appearance, or to render healing more rapid, and its removal
+weakens the arch of the hand; where the cartilage is eroded by disease,
+the cartilage-covered portion can be scooped off by a gouge or removed
+entire by pliers, without interfering with the broad end to which the
+transverse ligament of the palm is attached. If required either for
+injury or disease, the metacarpal head may be easily removed by a single
+straight incision from the knuckle upwards, as far as the point at which
+it may be deemed necessary to saw it through, or better still, divide it
+with the bone-pliers. This incision should be made as a first step in
+the first incision for amputation of the finger, and the finger should
+not be disarticulated, but kept on, to aid by its leverage in separating
+the metacarpal head.
+
+_Amputation of the index or little fingers._--This operation differs
+from the preceding only in this, that care must be taken to make a good
+large flap on the free side of each; making the incision, which begins
+at the knuckle (Fig. I. 4), enclose a well-rounded flap, and not
+allowing it to enter the palm till it reaches the level of the web
+between the fingers. The metacarpal heads may here be cut obliquely with
+the bone-pliers, to prevent undue projection.
+
+_Amputation of one or more metacarpals._--These operations may be
+rendered necessary by disease or injury. If the latter demands their
+performance, no rules can be given for incisions or flaps, they must
+just be obtained where and how they can best be got. If for disease, a
+single dorsal incision (Fig. I. 5) over the bone will allow it to be
+dissected out of the hand.
+
+_N.B._--In no case, except that of the thumb, should any attempt be
+made to save a finger while its metacarpal is removed. (See _Excisions
+of Bones_.)
+
+_Amputation of first and fifth metacarpals._--Various special operations
+have been devised for speedy and elegant removal of these bones. Their
+disadvantages, etc., are fully detailed under _Amputations of the Foot_.
+
+The vascularity and consequent vitality of the tissues of the hand and
+arm sometimes afford very encouraging and satisfactory results in
+conservative operations.
+
+The following is an instance of what may be accomplished in a young
+healthy subject.
+
+A. A., aet. 18, ploughman, was harnessing a vicious horse, when it caught
+his right hand between its teeth, and gave a severe bite. On admission,
+I found the middle and ring fingers completely separated at the
+metacarpal joints, but each hanging on by a portion of skin, the middle
+by the skin on its radial side, the ring by that on its ulnar. The back
+and the palm were both stripped of skin up to the middle of the third
+and fourth metacarpal bones, which were exposed, but not fractured. As
+it was important for him to maintain the transverse arch of the hand
+intact, I determined to make an attempt to save the metacarpals, and
+finding that the skin on the radial side of the middle, and ulnar side
+of the ring fingers, was still warm, and apparently alive, I carefully
+dissected as long a flap as possible from each, and then folded them
+down, one at the front, the other at the back of the hand. The flaps
+survived, and the result was admirable, the patient being able in a very
+few weeks to guide the plough. The sensation in his new palm and back of
+the hand is very peculiar, they being still the fingers, so far as
+nervous supply is concerned.
+
+In amputations involving the metacarpals for injury, it is always
+important to avoid entering the carpo-metacarpal joint, hence if it can
+be done it is best to saw through the bones at the required level,
+rather than disarticulate. This rule should be observed even in those
+cases in which the thumb alone can be saved, for notwithstanding the
+isolation of the joint between the first metacarpal and the trapezium,
+it is very important for the future use of this one digit that the
+motions both of the wrist and carpal joints should be preserved entire.
+
+No exact rules can be given for the performance of these operations, as
+the size and positions of the flaps must be determined by the nature of
+the accident and the amount of skin left uninjured.
+
+In the rare condition where the greater part of the metacarpus is
+destroyed, and yet carpal joints are uninjured, a most useful artificial
+band, preserving the movements of the wrist, may be fitted on; and as
+much as possible should be saved, but in cases of injury, where the
+carpus is opened and the hand irreparably destroyed, the question
+arises, Where ought amputation to be performed? To this we answer that
+there appears no conceivable advantage to be gained by leaving all or
+any of the carpal bones. If successful, it would result only in the
+retention of a flapping joint, unless from there being no tendons to act
+upon it, except the tendon of the flexor carpi ulnaris attached to the
+pisiform, and there are several risks it would run in the inflammation
+of all the carpal joints, and the almost certain spread of this
+inflammation to the bursa underneath the flexor tendons, beyond the
+annular ligament, and up the arm among the muscles.
+
+
+AMPUTATION AT THE WRIST-JOINT.--This is an operation by no means
+frequent, and it has the advantages of preserving a long stump, and
+retaining the full movements of pronation and supination, in cases where
+the radio-ulnar joint is sound and uninjured, but in practice it is
+often found that fibrous adhesions limit to a great extent the motions
+of the two bones on each other, specially in those cases where the
+radio-ulnar joint has been diseased or injured.
+
+Another advantage is the extreme ease with which disarticulation may be
+performed on emergency, no saw being required, and the ordinary bistoury
+of the pocket-case being quite sufficient for cutting the flaps.
+
+_Operation._--By double flap. An incision (Plate IV. fig. 3) on the
+dorsal surface, extending in a semilunar direction from one styloid
+process to the other, will define a flap of skin only, which must be
+raised; the joint must then be opened by a transverse incision, and a
+long semilunar flap of skin and fascia should be shaped (Plate IV. fig.
+4) from the palm. Disarticulation is facilitated by the surgeon forcibly
+bending the wrist when he makes the transverse cut, and it will be found
+easier to shape the palmar flap from the outside by dissection, than to
+do it by transfixion after disarticulation, on account of the prominence
+of the pisiform on the inner side of the palm.
+
+     In the thin wasted wrists of the aged, or in any case where the
+     skin is very lax, this amputation may be very easily performed by
+     the circular method. While an assistant draws up the skin as much
+     as possible, the surgeon makes an accurate circular incision
+     through the skin, about an inch below the styloid processes, just
+     grazing the thenar and hypothenar eminences. Another circular sweep
+     just above the pisiform and unciform bones divides all the soft
+     textures, after which the joint may be opened, and, if necessary,
+     the styloid processes cut away with saw or pliers.
+
+     Amputation by a long single flap, either dorsal or palmar, may be
+     rendered necessary by accident. The palmar one of the two is
+     preferable; indeed, rather than trust for a covering to the thin
+     skin of the back of the hand, with its numerous tendons, it is
+     better to amputate an inch or two higher up through the fore arm.
+
+     The following amputation by external flap has been described (so
+     far as I can discover, for the first time) by Dr. Dubrueil, in his
+     work on operative Surgery:[26]--"Commencing just below the level of
+     the articulation, while the hand is pronated, the surgeon makes a
+     convex incision, beginning at the junction of the outer and middle
+     thirds of the arm behind, reaching at its summit the middle of the
+     dorsal surface of the first metacarpal, and terminating in front
+     just below the palmar surface of the joint, again at the junction
+     of the outer and middle thirds of the breadth of the arm. This flap
+     being raised, the wrist is disarticulated, beginning at the radial
+     side. A circular incision finishes the cutting of the skin." (Figs.
+     III. and IV.)
+
+[Illustration: FIG. III.[27]]
+
+[Illustration: FIG. IV.[27]]
+
+
+AMPUTATION THROUGH THE FORE-ARM.--The method of operating must, in the
+fore-arm, depend a good deal upon the part of the arm where you require
+to amputate, the muscularity of the limb, and the condition of the skin
+and subcutaneous cellular tissue.
+
+It must be remembered that a section of the fore-arm involves two bones,
+not, like the tibia and fibula, on a constant permanent relation in
+position to each other, but which rotate one upon another to an amount
+which varies with the part of the limb divided, and which rotation is a
+very important element in the future usefulness of the stump; again,
+that two sets of muscles occupy, one the back, the other the front of
+the limb, that these two are unequal in size, and that the outer sides
+or rather edges of each bone are subcutaneous; again, that these sets of
+muscles are comparatively fleshy in the upper two-thirds of the limb,
+and almost entirely tendinous in the lower third.
+
+Remembering these points, we find that certain things require our
+attention, and certain difficulties are present in amputation of the
+fore-arm, from which amputation of the arm, with its single bone and
+copious muscular covering on all sides, is completely free.
+
+Thus our flaps in the fore-arm must be antero-posterior; lateral flaps
+are an impossibility. Great care is requisite to cut them at all equal,
+from the inequality of the muscles on the two sides. In the lower third
+we cannot obtain available muscular flaps. Lastly, care must be taken
+lest, from the ever-varying relations of the two bones to each other in
+the varying positions of the limb, the surgeon mistake their position
+and pass his knife between them.
+
+The next question that arises is, Where are we to operate? In cases
+where we have a choice, is there here, as in the leg, any "point of
+election"? _No._ As a rule in the fore-arm, the surgeon should endeavour
+to save as much as possible; especially when nearing the middle of the
+fore-arm, he should try to save the insertion of the pronator teres, so
+important in its function of pronating the radius.
+
+
+AMPUTATION IN LOWER THIRD OF THE FORE-ARM.--By two flaps. These
+antero-posterior flaps must consist of skin only, as the tendons are
+only in the way, and thus should be made by dissection from without.[28]
+Making the dorsal one first, the surgeon should enter his knife at the
+palmar edge of the bone that is further from him, and cut a semilunar
+flap of skin only, finishing the incision quite on the palmar edge of
+the inner bone. The two ends of this incision must then be united by a
+similar semilunar flap of skin on the palmar side. The two flaps having
+been dissected back, he then clears the bones by a circular incision
+through tendons and muscles, not forgetting to pass the knife between
+the bones, and retracting all the soft parts, saws through the bones, at
+least half or probably three-quarters of an inch higher up. It is
+generally easiest to saw through both bones at once.
+
+_Long Dorsal Flap._--Where it is possible from laxity of the soft parts
+and the wrist not being much destroyed, to get a long flap from the back
+of the arm after Mr. Teale's method, a very good stump will result. This
+rule is, "In tracing the long flap a longitudinal line is drawn over the
+radius, so as to leave the radial vessels for the short flap (Plate II.
+fig. 1). At a distance equal to half the circumference of the limb,
+another line parallel to the former is drawn along the ulna. These are
+then joined at their lower ends, across the dorsal aspect of the wrist
+or fore-arm, by a transverse line equal in length to half the
+circumference of the fore-arm. The short flap is marked by a transverse
+line on the palmar aspect, uniting the long ones at their upper fourth.
+
+"The operator, in forming the long flap, makes the two longitudinal
+incisions merely through the integuments, but the transverse one is
+carried directly down to the bones. In dissecting the long flap from
+below upwards, the tissues of which it is composed must be separated
+close to the periosteum and interosseous membrane. The short flap is
+made by a transverse incision through all the structures down to the
+bones, care being taken to separate the parts upwards close to the
+periosteum and membrane." The stump must be placed in the prone
+position, "to allow the long dorsal flap to be the superior when the
+patient is recumbent, and thus fall over the ends of the bones."[29]
+
+The principal objection to the long dorsal rectangular flap (which
+makes an excellent covering) is, that unless it can be obtained from
+over the wrist-joint it requires the bones to be sawn so very high up.
+This may be avoided, to some extent, by making it shorter and rounded
+off, as in Carden's Amputation, _q.v._
+
+
+AMPUTATION IN UPPER TWO-THIRDS.--Where the fore-arm is very fat or
+fleshy, this amputation can be very easily performed by two equal
+antero-posterior flaps made by transfixion. In most cases, however, from
+the comparative leanness of the dorsal aspect of the limb, the following
+method will have the best result. The surgeon must, as in the former
+case, shape a rounded dorsal flap by dissection from without (Plate IV.
+fig. 5), embracing the whole breadth of the limb down to the palmar edge
+of both bones. Then at once he transfixes the two points of this dorsal
+flap, and cuts out an equal one from the anterior aspect of the limb
+(Plate IV. fig. 6). Dissecting up the dorsal flap he clears the bones at
+least half an inch above as before, and applies the saw.
+
+_N.B._--This operation should be performed even in cases where only an
+inch of radius can be retained, as the attachment of the biceps makes a
+very small stump of fore-arm wonderfully useful.
+
+
+AMPUTATION AT ELBOW-JOINT.--In cases where it is found impossible to
+save any portion of the fore-arm, disarticulation at the elbow-joint may
+be easily performed. This operation was proposed and performed so long
+ago as the days of Ambrose Pare,[30] was much approved by Dupuytren,
+Baudens, and Velpeau, had fallen into disuse for a time, but is now
+again recommended by some excellent surgeons, especially by Gross[31]
+and Ashhurst,[32] both of Philadelphia.
+
+It is tolerably easy to perform, and does not involve any sawing of
+bones, but the flaps are apt to be cut too short, unless care be taken,
+from the manner in which the trochlea projects downwards beyond the line
+of the condyles, so that if the base of an ordinary-shaped flap be made
+on a level with the condyles, it will prove insufficient to cover the
+bone. It may be performed either by the circular method (Velpeau), oval
+(Baudens), or by a long anterior and short posterior flap (Textor and
+Dupuytren). Probably the best method is by a long anterior flap when it
+can be obtained, thus:--The arm being placed in a slightly flexed
+position, the surgeon transfixes in front of the joint, in a line
+extending from the level of the external condyle to a point one inch
+below the internal condyle (Plate IV. fig. 7); the tissue should be held
+well forward at the moment of transfixion. The flap should be at least
+two and a half inches deep at its apex, which must be rounded off. The
+two ends of this flap may then be united behind by a semilunar incision
+(Plate III. fig. 2), which will separate the radial attachments. The
+ulna must then be cleared, and the triceps divided at its insertion.
+
+     _Modifications._--Dupuytren used to saw through the ulna, leaving
+     the olecranon attached. Velpeau opposed this, but it is again
+     recommended by Gross, who leaves the olecranon, and at the same
+     time improves the shape of the stump by sawing off the "inner
+     trochlea" on a level with the general surface.
+
+
+AMPUTATION OF THE ARM.--This amputation is best performed by double
+flap, and is the typical instance which exhibits all the advantages of
+two equal flaps made by transfixion, without any of the disadvantages of
+that method. These advantages are, easiness of performance, rapidity,
+excellent covering for the bone, with as little sacrifice of tissue as
+is possible, while the fact that the cicatrix is opposite the end of the
+bone is hardly a disadvantage in the arm (as it certainly is in the
+leg), as no weight has to be borne on it. When they can be obtained,
+anterior and posterior flaps are generally considered most satisfactory,
+but Mr. Spence prefers lateral ones, lest the line of union should be
+interfered with by the deltoid raising the bone. If the right arm has to
+be amputated, the operator standing at the inner side raises the
+anterior muscles with his left hand, and enters the knife just in front
+of the brachial vessels (Plate I. fig. 12); keeping as close as possible
+to the bone, he brings out the knife at a point exactly opposite, then
+with a brisk sawing motion, cuts a semicircular flap, taking care to
+bring out the knife more suddenly just at the end, in order to cut
+through the skin as perpendicularly to the arm as possible. The knife is
+again entered at the same point, carried behind the bone, and brought
+out at the same angle, and an exactly corresponding flap cut from the
+other side of the limb, the flaps are then retracted, the bone cleared
+by circular incision and sawn through as high up as it is exposed. In
+primary cases, where the muscles are firm and developed, the flaps
+should be cut a little concave.
+
+     _Modifications and Varieties._--Teale's method may of course be
+     used here as elsewhere. The internal line of incision (Plate IV.
+     fig. 8) should be made just in front of the brachial vessels. This
+     method requires the amputation to be performed higher up than would
+     otherwise be necessary (from the length of the anterior flap), and
+     this disadvantage is not counterbalanced by any special advantage
+     in the posterior retraction of the cicatrix.
+
+     In feeble flabby arms, the true circular operation is very easily
+     performed, and with good results. A circular sweep of the knife is
+     made through the skin alone, which is drawn up by an assistant,
+     while the surgeon separates it from the fascia; another circular
+     cut through fascia and muscles exposes the bone, which must then be
+     cleared and cut through at a still higher level.
+
+
+AMPUTATION AT THE SHOULDER-JOINT.--This operation, like that at the hip
+joint, can, from the nature of the joint to be covered, and the abundant
+soft parts in the normal state of the tissues, be performed on the dead
+in very various ways, by single, double, or triple flaps, by transfixion
+or dissection, rapidly or slowly. Hence manuals of operative surgery
+might collect at least twenty different methods, most of which have some
+recommendation, and all of which are practicable enough.
+
+When, however, we reflect that in the living body, in cases where
+amputation at the shoulder-joint is required at all, the severity of the
+accident, or the urgency of the disease, will, in general, leave no room
+for selection, we shall see how utterly valueless is any knowledge of
+mere methods of operating, and of how much greater importance it is that
+we should be simply thoroughly familiar with the anatomy of the joint.
+
+For example, an accident which necessitates amputation so high up has,
+in all probability, opened into the joint and destroyed the soft parts
+on at least one aspect; in such a case the flaps must be cut from the
+uninjured soft parts only. If an aneurism has rendered amputation
+through it and through the joint a last resource, the flap must be
+gained chiefly at least from the outside; a malignant tumour of the
+humerus will almost certainly prevent any transfixion, and require flaps
+to be made by dissection, wherever the skin is least likely to be
+involved. Again, some of the most vaunted and most rapid operations
+almost require for their success the integrity of the humerus, which has
+to make itself useful as a lever in disarticulation, while in most cases
+of accident we are amputating for compound injury of the humerus, almost
+certainly implying fracture with comminution.
+
+From its proximity to the trunk, haemorrhage is one of the chief dangers
+to be apprehended during this operation, especially from the axillary
+artery. As far as possible to obviate this danger, most plans of
+operating are based on the principle that the vessels and nerves should
+be the last tissues to be cut; in some they are not divided till after
+disarticulation.
+
+While a good assistant, to make pressure on the subclavian above the
+clavicle, is a most advisable precaution, too much must not be trusted
+to this pressure above, as the struggles of the patient and the
+spasmodic movements of the limb, which are so apt to occur under the
+stimulus of the knife, are apt to render futile the best efforts at
+compression.
+
+The operator should trust rather to making the incisions in such a
+manner that the great vessel be not divided till the hand of an
+assistant, or in default of a suitable one, his own left hand, is able
+to follow the knife and grasp the flap.
+
+The bleeding from the circumflex, subscapular, and posterior scapular
+arteries can easily be arrested by a dossil of lint till the great
+vessel is tied, and they can be secured.
+
+In cases where proper assistants cannot be had, temporary closure of the
+axillary vessel could easily be made by carrying a strong silver wire or
+silk ligature completely round the vessel by a curved needle before the
+incisions are commenced, and by tying this firmly over a pad of lint.
+
+Pressure on the artery above the clavicle is best made by the thumb of a
+strong assistant, who endeavours to compress it against the first rib;
+where the parts are deep and muscular, the padded handle of the
+tourniquet, or of a large door-key, will do as the agent of pressure.
+
+A brief notice of three of the best methods of operating will be quite
+sufficient to show what should be aimed at in shoulder-joint
+amputations:--
+
+#1.# In cases where the surgeon can choose his flaps, the following
+method will be found the most satisfactory, as resulting in the smallest
+possible wound, in having less risk of haemorrhage during the operation
+than any other method, and in providing excellent flaps.
+
+It is Larrey's method slightly modified.
+
+_Operation._--With a moderate-sized amputating knife an incision of
+about two inches in length, extending through all the tissues down to
+the bone, should be made from the edge of the acromion process to a
+point about one inch below the top of the humerus; from this latter
+point a curved incision, enclosing a semilunar flap, should be made on
+each side of the limb to the anterior and posterior folds of the axilla
+respectively (Plate IV. fig. 9, and Plate III. fig. 3). These flaps
+should then be dissected back, including the muscles and exposing the
+joint. When thoroughly exposed, the joint must then be opened from
+above, and the bone separated. One small portion of skin lying above the
+artery, vein, and nerves still remains to be divided (Plate I. fig. 13).
+This may be done by an oblique cut from within outwards, in such a
+direction as to form part of the anterior or internal incision, and with
+the precaution of having an assistant to command the vessels before they
+are divided. The resulting wound is almost perfectly ovoid, the flaps
+come together with great ease in a straight vertical line, which admits
+of easy and thorough drainage. Union is generally rapid. Larrey's
+success by this method was very remarkable: ninety out of a hundred
+cases in military practice were saved, notwithstanding the well-known
+risks of such operations.
+
+#2.# As good as the former, and nearly as universally applicable, is the
+method devised by Professor Spence, and practised by him in nearly every
+case:--"With a broad strong bistoury I cut down upon the inner aspect of
+the head of the humerus, immediately external to the coracoid process,
+and carry the incision down through the clavicular fibres of the deltoid
+and pectoralis major muscles till I reach the humeral attachment of the
+latter muscle, which I divide. I then with a gentle curve carry my
+incision across and fairly through the lower fibres of the deltoid
+towards, but not through, the posterior border of the axilla. Unless the
+textures be much torn, I next mark out the line of the lower part of the
+inner section by carrying an incision through the _skin and fat only_,
+from the point where my straight incision terminated, across the inside
+of the arm to meet the incision at the outer part. This insures accuracy
+in the line of union, but is not essential. If the fibres of the deltoid
+have been thoroughly divided in the line of incision, the flap so marked
+out, along with the posterior circumflex trunk, which enters its deep
+surface, can be easily separated from the bone and joint, and drawn
+upwards and backwards so as to expose the head and tuberosities, by the
+point of the finger without further use of the knife. The tendinous
+insertions of the capsular muscles, the long head of the biceps, and the
+capsule, are next divided by cutting directly upon the tuberosities and
+head of the bone; and the broad subscapular tendon especially, being
+very fully exposed by the incision, can be much more easily and
+completely divided than in the double-flap method. By keeping the large
+posterior flap out of the way by a broad copper spatula or the fingers
+of an assistant, and taking care to keep the edge of the knife close to
+the bone, the trunk of the posterior circumflex is protected. In regard
+to the axillary vessels, they can either be compressed by an assistant
+before completing the division of the soft parts on the axillary aspect,
+or to avoid all risk, the axillary artery may be exposed, tied, and
+divided between two ligatures so as to allow it to retract before
+dividing the other textures."[33]
+
+     Another, but not so good method of making an external flap, is the
+     following:--(_a._) For the right arm.--The patient lying well over
+     on his left side, the surgeon stands to the inside of the arm to be
+     removed. Seizing the deltoid in the left, with the right he passes
+     an amputating knife, seven or eight inches in length, from a point
+     a little nearer the clavicle than the middle space between the
+     acromion and coracoid processes; then, transfixing the base of the
+     deltoid, and just grazing the posterior surface of the humerus,
+     thrusts the knife downwards and backwards till it protrudes at the
+     posterior margin of the axilla. When doing this, it is important
+     that the arm be held outwards and backwards, and even upwards, as
+     far as possible to relax the deltoid; without this it will be
+     impossible to make the flap of the full size. The flap must then be
+     cut of as full length as can be obtained, four or five inches at
+     least. An assistant then holds it upwards, while the surgeon, or
+     (if the arm is very muscular) another assistant, brings the arm
+     forwards well across the patient's chest, thus exposing the
+     posterior aspect of the joint. This may have very possibly been
+     already opened during the transfixion; the attachments of muscles
+     must now be divided, the knife passed behind the head of the bone,
+     which is dislocated forwards, and a suitable flap of the tissues in
+     front cut from within outwards. The assistant is to follow the
+     knife with his finger and compress the vessels.
+
+     (_b._) If the left shoulder is to be amputated, the patient lying
+     on his right side, the surgeon stands behind him, and raising the
+     elbow of the limb to be removed from the side, and pulling it
+     slightly backwards, enters the knife at the posterior fold of the
+     axilla (Plate II. fig. 2), and passing the posterior aspect of the
+     head of the humerus, endeavours to protrude it as near the acromion
+     as possible; the flaps must be cut and the rest of the operation
+     performed in the manner we have just described for the other arm.
+
+#3.# Where the destruction of tissue has been chiefly below the joint, a
+very good flap may be obtained from above, composed chiefly of the
+deltoid muscle, and the skin over it. This may be made by transfixion at
+its base, but is better obtained by dissection from without.
+
+The surgeon cuts (Plate II. figs. 3, 3) in a semilunar direction (with
+the convexity downwards) from one side of the deltoid to the other,
+viz., from the root of the acromion to near the coracoid process; he
+then raises the large flap upwards and throws it back, opens the joint,
+disarticulates, passes the knife behind the head of the bone, and cuts
+out without attempting to save any flaps below, in a transverse
+direction. By this means the artery is still almost the last structure
+to be divided, and can be secured by a ready assistant. In cases where
+much injury has been done to the floor of the axilla and wall of chest,
+the deltoid flap must be made large in proportion, and triangular rather
+than semilunar in shape.
+
+_N.B._--The statistics of amputation at the shoulder-joint bring out
+some interesting facts: 1. That the primary amputations here are far
+more successful than secondary ones. Guthrie records nineteen cases of
+the former out of which only one died, while out of a similar number in
+which the amputation was secondary, fifteen died. In the Crimea, British
+surgeons had thirty-nine cases, with thirteen deaths; of thirty-three
+primary, nine died; and of six secondary, four were fatal.
+
+S.W. Gross's[34] statistics confirm this: of one hundred and
+seventy-eight primary, forty-six died--25.8 per cent.; ninety-five
+secondary, sixty-one died--64.2 per cent.
+
+
+AMPUTATIONS ABOVE THE SHOULDER-JOINT.--Under this head we may group the
+comparatively rare cases in which, from accident or disease, the removal
+of portions of the scapula and clavicle, or even the entire bones, is
+rendered necessary. That it is quite possible to survive such injuries
+has been frequently shown in cases of accident when the scapula along
+with the arm has been torn off, and yet the patient recovered.
+
+Encouraged by such cases, Gaetani Bey of Cairo removed the whole of
+scapula and part of the clavicle in a case where he had amputated at the
+shoulder for smash. The patient recovered. Heron Watson has had a
+similar case. Dr. George M'Lellan amputated arm and scapula in a youth
+of seventeen for an enormous encephaloid tumour. Fifty-one such cases
+are now on record.
+
+Syme amputated with success the arm along with the scapula and outer
+half of clavicle, in a case in which he had previously excised the head
+of the humerus for a tumour.[35]
+
+Gilbert, Mussey, Rigaud, Fergusson, and others have performed similar
+operations, secondary to amputation at the shoulder-joint, for cases of
+caries and malignant tumour. It is impossible to give any exact
+directions for the incisions which must be planned for individual cases,
+with two chief aims, to avoid haemorrhage as far as possible, and to
+leave abundance of skin. In operations on the scapula, it should be
+freely exposed by large enough incisions. (See _Excisions_.)
+
+
+AMPUTATIONS OF LOWER EXTREMITY.--Commencing with the most distal, and
+gradually working our way upwards, we find that partial amputations of
+the toes are extremely rare. Only in the case of the great toe is such
+an operation _ever_ admissible, for the other toes are so short, and the
+stumps left by amputation are at once so useless from their shortness,
+and so detrimental from the manner in which they project upwards and rub
+against the shoe, that any injury requiring partial amputation of a
+lesser toe is treated by its complete removal.
+
+[Illustration: FIG. V.]
+
+
+AMPUTATION OF DISTAL PHALANX OF GREAT TOE.--This is comparatively rarely
+required now. It used to be thought necessary for the cure of those not
+uncommon cases of exostosis of the distal phalanx, but it is now found
+that most of these can be cured by simply clipping off the exostosis.
+When necessary, however, and when the choice of flaps is possible, the
+best plan is by a long flap from the plantar surface (Fig. V. 4), as in
+the similar operation on the thumb; laying the edge of the knife over
+the dorsal aspect of the joint, cutting through it, and turning the edge
+of the knife round close to the bone, so as to cut out a large flap from
+the ball of the toe.
+
+
+AMPUTATION OF A SINGLE LESSER TOE--_second_, _third_, _or fourth_.--This
+operation is on exactly the same principle as that described for the
+corresponding finger; but it must be remembered that the
+metatarso-phalangeal joint is more deeply situated in the soft parts
+than is the metacarpo-phalangeal; and thus the commencement of the
+elliptical incision which is to surround the base of the toe must be
+proportionally higher up (Fig. V. 1). On the other hand, as it is very
+important to avoid as much as possible any cicatrix in the sole of the
+foot, the plantar end of the incision need not be carried to a point
+exactly opposite the one from which it set out, but it will be
+sufficient if it reaches the groove between the toe and sole. A little
+more care may thus be required in dissecting out the head of the first
+phalanx, but this is quite repaid by the cicatrix in the sole being
+avoided. Early division of flexor tendons renders disarticulation easy.
+
+
+AMPUTATION OF THE FIRST AND FIFTH TOES.--The incisions are conducted on
+the same principle as in the other operations, the operator being
+careful to preserve as much as possible (Fig. V. 2) of the hard useful
+pad of the inner and outer sides respectively.
+
+Most surgeons are now agreed that in these toes it is best not to remove
+the head of the metatarsal bone with the toe. Cutting off the large
+cartilaginous head obliquely with a pair of bone-pliers may prevent an
+awkward unseemly projection, but it does diminish the strength of the
+transverse arch of the foot.
+
+
+AMPUTATION OF ONE OR MORE TOES WITH THEIR METATARSALS.--It is not
+necessary to give very particular details regarding such operations, as
+the surgeon must be guided in the individual cases by the specialties of
+accident or disease.
+
+One or two guiding principles are important:--
+
+1. Having made up your mind at what point you are to cut the metatarsal,
+if the amputation be a partial one, or as to the exact position of the
+joint, if you intend to disarticulate, commence your dorsal incision
+(Fig. V. 3) at a point fully half an inch higher up than the selected
+spot, as free access is of the very last importance.
+
+2. Whenever it is possible, cut the bone through its continuity rather
+than disarticulate. Specially is this important in the case of the
+metatarsal bone of the great toe, that the insertion of the tendon of
+the peroneus longus may be saved. If, however, the terminal branch of
+the _dorsalis pedis_ artery be wounded, it may be necessary to
+disarticulate the first metatarsal to secure it rather than trust to
+compression to stop the bleeding.
+
+3. In cutting through the first and fifth metatarsals, remember to apply
+the bone-pliers obliquely, not transversely, so as to avoid unseemly
+projection.
+
+4. As far as possible avoid cutting into the sole at all.
+
+The plantar cicatrix is almost a fatal objection to a plan of removing
+the first and fifth toes and their metatarsals which has much otherwise
+in rapidity and elegance to recommend it. In the great toe, for example,
+it is performed as follows:--Seizing the soft parts of the inner edge of
+the foot in his left hand, the surgeon draws them _inwards_, transfixes
+just at the tarso-metatarsal joint, and, keeping as close as possible to
+the inner edge of the metatarsal bone, cuts the flap as long as to the
+middle of the first phalanx; then the soft parts of the foot being drawn
+as far _outwards_ as possible by an assistant, the surgeon enters his
+knife between the first and second toes, and succeeds in entering his
+former incision so as to separate the metatarsal bone without removing
+any skin. All that remains is to open the tarso-metatarsal joint. It is
+a very neat-looking operation, leaves a very good covering for the
+parts, and is performed with extreme rapidity. This last is not so much
+required in these days of anaesthetics, and the cicatrix in the sole is a
+very formidable objection to it.
+
+The simplest and shortest rule that can be given for the amputation of a
+toe, with the part or whole of its metatarsal, is to make one dorsal
+incision, commencing about a quarter of an inch above the spot at which
+you intend to divide the bone or to disarticulate, extending downwards
+in a straight line to the metatarso-phalangeal articulation, and then
+bifurcating so as to surround the base of the toe at the normal fold of
+the skin. The soft parts are then to be cleared from the
+metatarso-phalangeal joint, and the toe still being retained on the
+metatarsal bone, it should be carefully dissected up, avoiding any
+pricking of the soft parts below, till the joint is reached, or the spot
+at which the bone-pliers are to be applied is fully cleared.
+
+
+AMPUTATION OF THE ANTERIOR PORTION OF THE FOOT AT THE TARSO-METATARSAL
+JOINT--HEY'S OPERATION.--This operation, which is now comparatively
+rarely performed, has been invested with a halo of difficulty and
+complexity which is to a great extent unnecessary.
+
+There is no doubt that the anatomical conformation of the joints
+involved, especially the manner in which the head of the second
+metatarsal (Fig. V. C) projects upwards into the tarsus, and is locked
+between the cuneiform bones, renders disarticulation in the healthy foot
+rather difficult; but it must be remembered that in cases where for
+accident we have to deal with previously healthy tissues, it is quite
+unnecessary to disarticulate, a better result being attained by simply
+sawing the foot across in the line of the articulation; and again, where
+we have to operate for disease, the tissues are so matted, and the
+bones so soft, that complete removal of the metatarsus is much easier
+than it appears when practising on the dead subject.
+
+Very various plans of incision have been proposed. Mr. Hey's original
+procedure has not been much improved upon. His short account of it has
+at once surgical value and historical interest:--
+
+"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 incision through the integuments and muscles
+covering the metatarsal bones (Plate IV. figs. 10, 11). From each
+extremity 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 integuments and
+muscles forming the sole of the foot from the inferior part of the
+metatarsal bones, keeping the edge of my scalpel as near 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
+tarsus, which was easily effected, as the joints lie in a straight line
+across the foot. The projecting part of the first cuneiform bone which
+supports the great toe I was obliged to divide with a saw. The arteries,
+which required a ligature, being tied, I applied the flap which had
+formed the sole of the foot to the integuments which remained on the
+upper part, and retained them in contact by sutures....
+
+"The patient could walk with firmness and ease; she was in no danger of
+hurting the cicatrix by striking the place where the toes had been
+against any hard substance, for this part was covered with the strong
+integuments which had before constituted the sole of the foot. The
+cicatrix was situated upon the upper part of the foot, and had very
+little breadth, as the divided parts had been kept united after being
+brought into close contact."[36]
+
+_Lisfranc's method_ has, briefly, the following modifications.--Having
+fixed the position of the articulations of the first and fifth
+metatarsals with the tarsus, the operator unites them by a curved
+incision across the dorsum of the foot, with its convexity downwards. He
+then divides the dorsal ligaments over the articulations, opens the
+first from the inside, the fifth, fourth, and third from the outside, he
+then with a strong narrow-bladed knife divides the interosseous
+ligaments between the sides and end of the head of the second metatarsal
+and the cuneiforms, thus completing the disarticulation; bending the
+fore part of the foot downwards, he then keeps the edge of the knife
+close to the lower surface of the bones, separating the plantar
+ligaments, and cutting out a long plantar flap of skin and muscles.
+
+In every case it must be remembered that the upper end of the fifth
+metatarsal projects far up along the outer edge of the foot. Allowance
+must be made for this projection in commencing the incision. A rule
+given by Mr. Syme to guide the disarticulation of the three outer
+metatarsals will often be of service; it is this: "Having once entered
+the joint of the fifth, the knife must be drawn along in a direction of
+a line drawn towards the distal end of the first metatarsal; for the
+fourth, the direction must be changed to the middle of the same bone;
+and to open the third it will be necessary to come across the dorsum of
+the foot as if intending to reach the proximal end."
+
+To avoid the difficulties of disarticulation, Skey recommends cutting
+off the head of the second metatarsal with a pair of pliers. Baudens,
+Guerin, and others approve of sawing all the bones across in the line
+desired.
+
+Most surgeons are now agreed that in this operation it is better to make
+both flaps by cutting from without, in preference to transfixion of the
+plantar one from within. In cases where, from injury and disease, the
+plantar flap is deficient in size, it may be necessary to make the
+dorsal flap longer. However, the long plantar is preferable both from
+its superior hardness, and also because from its length it permits the
+cicatrix to be well on the dorsum of the foot, and therefore less likely
+to be injured by the pressure of the boot in front.
+
+
+AMPUTATIONS THROUGH THE TARSUS.--Various plans of amputating through the
+tarsus have been devised and described at great length. The most
+important of these is the operation of removal of the anterior portion
+of the foot, at the joints between the astragalus and scaphoid, and os
+calcis and cuboid, well known to the profession by the name of its first
+describer, Chopart.
+
+It has been so completely superseded by the infinitely preferable
+amputation at the ankle-joint of Mr. Syme, as rarely, if ever, to be
+practised in this country. Indeed, amputation at the ankle-joint may be
+said to have taken the place of all these amputations through the
+tarsus; for though cases are occasionally met with in which the
+limitation of the disease or injury may render Chopart's possible, and
+though at first sight it appears to have an advantage in removing less
+of the body, still the following objections are nearly fatal to its
+chance of being selected:--1. In cases of injury, through leaving a long
+stump, and, at first sight, a useful one, experience shows that the
+tendo Achillis sooner or later (being unopposed by the extensors of the
+toes) draws up the heel so as to make the end of the stump point, and
+the cicatrix press on the ground, rendering it unable to bear any
+weight. 2. In cases of removal for disease of the tarsus, the bones left
+behind, though apparently sound at the time, are almost sure to become
+eventually diseased.
+
+As it has an historical interest, and as this operation (defective as it
+is) had been the means of saving many legs prior to the invention of
+amputation at the ankle-joint, a brief description may be appended:--
+
+Chopart's own manner of operation was briefly somewhat as follows:--
+
+The tourniquet having been applied, the surgeon is to make a transverse
+incision through the skin which covers the instep, two inches from the
+ankle-joint. He is to divide the skin, and the extensor tendons, and the
+muscles in that situation, so as to expose the convexity of the tarsus.
+He is next to make on each side a small longitudinal incision, which is
+to begin below and a little in front of the malleolus, and is to end at
+one of the extremities of the first incision. After having formed in
+this way a flap of integuments, he is to let it be drawn upwards by the
+assistant who holds the leg. There is no occasion to dissect and reflect
+the flap, for the cellular substance connecting the skin with the
+subjacent aponeurosis is so loose, that it can easily be drawn up above
+the place where the joint of the calcaneum with the cuboides and that
+between the astragalus and scaphoides ought to be opened. The surgeon
+will penetrate the last the most easily, particularly by taking for his
+guide the eminence which indicates the attachment of the tibialis
+anticus muscle to the inside of the os naviculare. The joint of the os
+cuboides and os calcis lies pretty nearly in the same transverse line,
+but rather obliquely forwards. The ligaments having been cut, the foot
+falls back. The bistoury is then to be put down, and the straight knife
+used, with which a flap of the soft parts is to be formed under the
+tarsus and metatarsus, long enough to admit of being applied to the
+naked bones, so as entirely to cover them. It is to be maintained in
+position with three or four straps of adhesive plaster, etc.[37]
+
+Chopart's amputation, after an interval of comparative neglect, was
+introduced into this country by Mr. Syme in 1829. His method of
+performance is simpler and easier than Chopart's. He thus describes
+it:--"The blade of the knife employed should be about six inches long,
+and half an inch broad, sharp at the point and blunt on the back. The
+tourniquet ought to be applied immediately above the ankle, having
+compresses placed over the posterior and anterior tibial arteries. The
+surgeon should measure with his eye the middle distance between the
+malleolus externus and the head of the metatarsal bone of the little
+toe, which is the situation of the articulation between the os cuboides
+and os calcis. Placing his forefinger here, he ought to place his thumb
+on the other side of the foot directly opposite, which will show him
+where the os naviculare and astragalus are connected. An incision (Plate
+II. figs. 4 and 5) somewhat curved, with its convexity forward, is then
+to be made from one of these points to the other, when, instead of
+proceeding to disarticulate, the operator should transfix the sole of
+the foot from side to side at the extremities of the first incision, and
+carry the knife forwards so as to detach a sufficient flap, which must
+extend the whole length of the metatarsus to the balls of the toes. The
+disarticulation may finally be completed with great ease, as the shape
+of the articular surfaces concerned is very simple, and nearly
+transverse."[38] Regarding the method of disarticulating at the
+astragalo-calcaneal joint, and removing all the foot except the
+astragalus, no detail need be given. Malgaigne advises an internal flap,
+thus sacrificing the valuable pad of the heel. Roux, Verneuil, and
+others endeavour to save the pad. This operation, however, has now
+fallen almost completely into disuse.
+
+
+SUBASTRAGALOID AMPUTATION has been highly recommended. In it the flap is
+made as in Syme's, then anterior bones removed as in Chopart's, and os
+calcis grasped by lion forceps and twisted off, its attachment and the
+insertion of tendo Achillis being cautiously avoided. If flaps are
+scanty, head of astragulus may be cut off with a small saw.--Hancock and
+Ashurst.
+
+
+TRIPIER'S AMPUTATION[39] is a modification of above, the skin incisions
+being made as in Chopart's amputation, and then the calcaneum is sawn
+through on a level with the sustentaculum tali on a plane at right
+angles to the axis of the leg.
+
+
+AMPUTATION AT THE ANKLE-JOINT, OR SYME'S AMPUTATION.--This operation is
+one of much interest and great practical importance. In our cold
+variable climate caries of the bones of the tarsus, and strumous disease
+of the ankle-joint, are very common and very intractable maladies, and
+for both of these, when far advanced, Syme's amputation is the only
+justifiable procedure. When properly done, according to the _exact_ plan
+of its proposer, it removes the whole of the diseased parts and not an
+inch more, is an operation of very slight danger to life, and results
+almost invariably in a thoroughly useful comfortable stump. Much of its
+success depends on the manner in which it is performed, and as many
+surgical manuals are not sufficiently full, some positively in error
+regarding this point, and as very many modifications have been devised
+diminishing in value and applicability very much in proportion as they
+diverge from the original description, I think it advisable to describe
+the operation minutely, and point out in detail the parts of it which
+seem absolutely essential to success.
+
+_Operation._--The foot being held at a right angle to the leg, the point
+of a straight bistoury, with a pretty strong blade, should be entered
+just below the centre of the external malleolus (Plate IV. figs. 12,
+13), (1.) and then carried right across the integuments of the sole, in
+a straight line (or in the case of a prominent heel, slightly
+backwards), (2.) to a point at the same level on the opposite side. (3.)
+This incision should reach boldly through all the tissues down to the
+bone. Holding the heel in the fingers of his left hand, the operator
+then inserts his left thumb-nail into the incision, and pushes the flap
+downwards, as with the knife kept close to the bone, and cutting on it,
+he frees the flap from its attachments. The thumb-nail guards the knife
+from in any way scoring the flap. (4.) This process is continued till
+the tuberosity of the os calcis is fairly turned, and the tendo Achillis
+nearly reached. Shifting his left hand he then extends the foot, and
+joins the extremities of the first incision by a transverse one right
+across the instep. (5.) Thus he opens the joint between the astragalus
+and tibia, (6.) divides the lateral ligaments, disarticulates, and still
+keeping close to the bone, removes the foot by the division of the tendo
+Achillis.
+
+The lower ends of the tibia and fibula are then to be isolated from the
+soft parts, and a thin slice, including both malleoli, to be removed. If
+the disease of the joint has affected the lower end of the bone, slice
+after slice may be removed, till a healthy surface of cancellated
+texture is obtained. The vessels are then secured.
+
+_Dressing of the Stump._--From its peculiar shape and position, the
+escape of any blood into the stump is much to be deprecated, for as it
+cannot easily get out, on the one hand it gives pain, and may cause
+sloughing from its pressure, and on the other it is sure eventually to
+cause suppuration, and delay union. To avoid such results care must be
+taken to secure every vessel that can be seen; if there is any general
+oozing it is best merely to pass the sutures through the edges of the
+flaps, but not bring them together, thus leaving the stump open for some
+hours; then apply cold, and when the surfaces are fairly glazed over,
+remove any clots and bring the flaps together.[40]
+
+Another plan introduced by Mr. Syme was to make a longitudinal slit in
+the flap, through which all the ligatures are to be drawn; these give a
+dependent drain to any pus that may be formed, and by their presence
+greatly expedite the healing of the wound. Again, in cases where from
+the amount of disease existing before the operation, and the gelatinous
+thickening of the flap and neighbouring parts, much suppuration may be
+looked for, probably it will be found best to keep the flaps quite apart
+for some days, by stuffing the wound with lint, and aiming only at
+secondary union by granulations.
+
+A drainage tube passed through the breadth of the flap, and brought out
+at the angles, and retained for a few days, will do admirably.
+
+     _Notes._--(1.) If commenced further forward, as in Pirogoff's
+     modification, it will be found difficult to turn the corner of the
+     heel; if further back, the nutrition of the flap is endangered.
+
+     (2.) This is very important. In several well-known text-books, even
+     in the last edition of Gross's _Surgery_, the incision is figured
+     passing obliquely _forwards_. This is a fatal error, for besides
+     making a flap far too long, it forces the operator to cut fairly
+     into the hollow of the sole, quite off the prominence of the os
+     calcis, and he finds that it is utterly impossible to free his flap
+     without using great force, and inevitably scoring it in all
+     directions. Sloughing is almost inevitably the result.
+
+     (3.) The incision is to stop at least half-an-inch below the
+     internal malleolus. Most surgical manuals, even when they profess
+     to describe Mr. Syme's own method of operating, say that the
+     incision should extend from malleolus to malleolus. If this is
+     done, the flap becomes unsymmetrical, too long, and also the
+     posterior tibial artery, on which much of the vascular supply of
+     the flap depends, is cut. When the incision is properly made, the
+     vessel is not cut till after its division into the plantar
+     arteries.
+
+     (4.) Scoring the flap. Some may ask, Why do you object to a little
+     scoring, the tissues are thick enough, and besides, don't you
+     advise a slit in the flap yourself? Yes. One look at an injected
+     preparation will show that the vessels supplying this thick flap
+     come to it from its inner surface, and are inevitably cut across in
+     any scoring of it, and also, that scoring cuts across the vessels,
+     and _must_ divide dozens of them; the slit we make is parallel with
+     their course, and _may_ not divide one.
+
+     (5.) Across the instep. Some authors recommend a semilunar anterior
+     flap; this is quite unnecessary, increases bagging and delays
+     union. It can be required only in cases where the heel flap has
+     been destroyed or lessened by disease, or by operators in whose
+     hands the heel flaps occasionally slough.
+
+     (6.) It is not impossible that a careless operator may (by cutting
+     a little too low) miss the joint and get into the hollow of the
+     neck of the astragalus, where he may cut away for a long time
+     without making much progress.
+
+_Advantages._--1. It is wonderfully free of danger to life. It is very
+hard to obtain exact statistical information, but my experience is that
+the mortality is certainly not more than about 10 per cent., a very
+remarkable result when compared with that of amputations through the
+leg, the operation which used to be required for those cases which now
+require only amputation at the ankle-joint.
+
+In the Statistical Report by the Surgeon-General of the United States,
+9705 cases of amputation resulted in death, the proportions being as
+follows:--
+
+    Amputation of hip,         85 per cent. died.
+        "         thigh,       64        "
+        "         knee,        55        "
+        "         leg,         26        "
+    Amputation of ankle-joint, 13 per cent. died.
+        "         shoulder,    39        "
+        "         arm,         21        "
+        "         fore-arm,    16        "
+
+2. It is the most perfect stump that can be made, in fact the only one
+in the lower extremity which can bear pressure enough to support the
+weight of the body; all the others require the weight to be distributed
+over the general surface of the limb by means of apparatus. A good
+ankle-joint stump can bear the whole weight of the body, as when the
+patient hops on it without any artificial aid, or without even the
+interposition of a stocking between the stump and a stone floor. More
+than this, I have seen a patient who had both his feet amputated at the
+ankle-joint run without shoes or stockings on the stone passages,
+without even the aid of a stick, and with very great swiftness.
+
+The reason of this may be found in the nature of the flap itself,
+originally intended to bear the weight of the body, there being no
+cicatrix at the part on which pressure is borne. I have noticed that
+perfection in walking on an ankle-joint stump has a certain relation to
+the freedom of movement which the pad has over the face of the bone.
+This ought to be pretty considerable. It is explained by the new
+attachments formed by the tendons, and is under the control of the
+patient, being elicited when he is told to move his toes.
+
+It has been objected to this operation that the flap is apt to slough.
+When improperly performed, as when the flap is scored transversely in
+its separation, and especially when the flap is cut too long (as has
+been already noticed), this may occur; but that there is nothing
+whatever in the position or condition of the flap itself that at all
+necessitates its sloughing, is thoroughly proved by the following
+remarkable case, given by Mr. Syme in his volume of _Observations in
+Clinical Surgery_. I quote it entire:--
+
+"P.C., aged thirty-three, was admitted into the hospital on the 25th
+July 1860, in the following state:--He had been treated in the
+Manchester Infirmary for popliteal aneurism by pressure, so decidedly
+applied that it had caused an ulcer, of which the cicatrix remained; but
+without producing the effect desired. The femoral artery was then tied
+with success, in so far as the aneurism was concerned, but with the
+unpleasant sequel, some months afterwards, of mortification in the foot,
+which was thrown off, with the exception of the astragalus and os calcis
+with their integuments, a large raw surface being presented in front
+where the bone was bare. Although the patient was extremely weak, and
+the parts concerned might be supposed more than usually disposed to
+slough, I did not hesitate to perform the operation, with the speedy
+result of a most excellent stump and complete restoration to
+health."--Pp. 49, 50.
+
+The modifications of Mr. Syme's original operation have been very
+various. It will be unnecessary even to name them all. One or two may
+require notice. Retaining Mr. Syme's incisions in their integrity, some
+operators prefer not to disarticulate the foot, but remove it by sawing
+through the tibia and fibula at once, while still in connection with the
+foot. That most excellent surgeon and first-rate operator, Dr. Johnston
+of Montrose, used to prefer this method.
+
+In cases where the pad of the heel has been destroyed by disease or
+accident, so as to be partially or entirely unavailable for the flap,
+the late Dr. Richard Mackenzie[41] practised the following operation by
+internal flap:--With the foot and ankle projecting from the table with
+their internal aspect upwards, he entered the point of the knife (Plate
+I. fig. 14) in the mesial line of the posterior aspect of the ankle, on
+a level with the articulation, carried it down obliquely across the
+tendo Achillis towards the external border of the plantar aspect of the
+heel, along which it is continued in a semilunar direction. The incision
+is then curved across the sole of the foot, and terminates on the inner
+side of the tendon of the tibialis anticus, about an inch in front of
+the inner malleolus. The second incision (Plate III. fig. 4) is carried
+across the outer aspect of the ankle in a semilunar direction, between
+the extremities of the first incisions, the convexity of the incision
+downwards, and passing half an inch below the external malleolus.
+
+Precisely the same principle might supply the flap from the outer side
+in cases where the internal flap as well as the heel was deficient, but
+probably the nutrition of the external flap would be more doubtful.
+Neither the one nor the other is nearly so good as the true heel flap,
+and they are both only very poor substitutes for it when it cannot be
+had.
+
+The modification devised by Dr. Handyside does not seem to have any
+advantages over the original operation, and has not been adopted.
+
+The modification invented by Professor Pirogoff involves a much more
+important principle than any of the preceding. Instead of dissecting the
+flap from the posterior projecting portion of the os calcis, and
+removing the tarsus entire, he sawed off the posterior portion of the os
+calcis obliquely, leaving it in contact with the pad of skin, which is
+retained. Immediately after making the cut which defines the posterior
+flap and divides the tissues down to the bone, he opens the joint in
+front, disarticulates, and then putting on a narrow saw immediately
+behind the astragalus and over the sustentaculum tali, he saws the os
+calcis obliquely downwards and forwards till he reaches the first
+incision; then removes the ends of the tibia and fibula and brings up
+the slice of os calcis into contact with them.
+
+_Advantages._--It is easy of performance, saving the dissection from the
+heel, which some find so hard. It leaves a longer limb. It is said to
+bear pressure better, and there is certainly not so much chance of
+bagging of pus, and the mortality is exceedingly small, Hancock's
+collected cases giving only 8.6 per cent.; in cases of injury it is
+quite a warrantable operation.
+
+_Disadvantages._--It is contrary to sound principle in cases of disease,
+for it wilfully leaves a portion of the tarsus, in which disease is
+almost certain to return. It leaves too long a limb, for it is found
+that the shortening in Mr Syme's method is just sufficient to admit of a
+properly constructed spring being placed in the boot to make up for the
+loss of the elastic arch of the foot. It brings the firm pad of the heel
+too much forward, thus tending to lean the weight of the body on the
+softer tissues behind the heel. It takes much longer to unite and
+consolidate.
+
+The author has now, in a large number of cases of Syme's amputation for
+disease, found advantage in leaving the periosteum in the heel flap,
+_i.e._ he cuts fairly into the os calcis when dividing the skin of heel,
+and then using a periosteum scraper instead of the knife, it is quite
+easy to remove the whole of the periosteum from the bone; this results
+in a large and more rounded pad of great strength and thickness.
+
+In cases where from disease or injury it is impossible to obtain either
+a heel flap or a substitute lateral one, the question is, Where should
+amputation be performed?
+
+It was for a long time the opinion of nearly all the best surgeons, and
+still is the opinion of many, that amputation of the leg should be
+performed at what was known as the "seat of election," just below the
+knee, even in cases where abundance of soft parts could be obtained for
+an amputation much lower down. The rule in surgery, to save as much of
+the body as possible in every amputation, was in the leg believed to be
+set aside by objections which militated strongly against all the other
+operations in the leg except the one performed just below the knee. Very
+briefly, these were somewhat as follows:--1. Just above the ankle you
+have large bones with nothing to cover them except skin and tendons. 2.
+Higher up in the calf you have plenty of muscle, but it is all on one
+side, and that the wrong one; it is very heavy, very difficult to dress
+and keep in position, and then when you have succeeded with it, the
+muscle wastes away and the stump is flabby. 3. And chiefly, as in all
+the amputations of the leg, the cicatrices are so much in the way, and
+the bones are so ill covered, that the patient can never rest his leg on
+the stump itself, but has either to rest his weight on his patella
+impinging on the top of a bottle-shaped leg, or just to stick out his
+stump behind him and kneel on the top of his wooden leg; therefore it is
+no use to have a stump longer than a few inches; in fact, the longer the
+stump is the more it is in the way. And more than this, many of the
+stumps made near the ankle, or through the calf, are not only useless,
+but positively painful. The skin becomes attached to the bones, the
+cicatrix never properly firms at all, the patient can hardly bear the
+pressure of a stocking, far less can he make use of the limb. For these
+reasons, secondary amputations below the knee are of very common
+occurrence.
+
+Now, this idea has been much modified, and a few isolated cases in the
+past, and series of cases considerably more numerous in the present day,
+show that under certain conditions, and as a result of certain
+precautions in their performance, such operations are both warrantable
+and successful.
+
+In the past, as we find in an erudite note in South's Chelius, Dionis,
+White, and Bromfield had each of them many successful cases of
+amputation just above the ankle, successful in so far that artificial
+limbs could be used which preserved the motion of the knee, and gave
+the patient much more command of the limb than is possible with the
+short stump below the knee.
+
+A still more important point to be remembered is, that amputation just
+above the ankle is a much less fatal amputation than that just below the
+knee (Lister in _Holmes's Surgery_, 3d ed. vol. iii. p. 716; Gross, 6th
+ed. vol. ii. p. 1113; Ben. Bell, 6th edit. vol. vii. p. 312).
+
+There is little doubt, however, that the principle so much in vogue in
+the present day, of one long anterior or posterior flap, instead of two
+equal flaps, or of circular amputations, has done very much to make
+amputations at the ankle or through the calf justifiable and useful in
+bearing the weight of the body.
+
+
+AMPUTATION JUST ABOVE THE ANKLE.--Cases admitting of this operation must
+always be rare, for disease of the tarsus or ankle-joint hardly ever
+goes so far as to contra-indicate the performance of Mr. Syme's greatly
+preferable operation; and an accident which would require this operation
+from injury to the ankle would in most cases require an amputation a
+good deal higher up from the splintering of the tibia so apt to occur.
+
+In a suitable case the plan of the operation should be as follows:--A
+long anterior flap slightly rounded at the end should be cut (Plate I.
+figs. 15, 16)--from the outside, not by transfixion,--and the anterior
+muscles dissected up along with it. It should be long enough to fall
+down over the face of the bones at the point of section, and easily
+cover the point of the posterior flap, which is to be made by cutting
+through all the tissues with one bold transverse stroke of the knife.
+This operation, which is the plan of Mr. Teale of Leeds very slightly
+modified, is equally applicable at any point of the leg, with this
+difference only, that the length of the anterior flap must always be
+carefully proportioned to the mass of the muscular flap behind it has to
+cover in.
+
+This operation provides a skin covering, without any danger of the
+cicatrix being pressed on or becoming adherent.
+
+     The author has within the last few years operated nine times in
+     this manner, in cases of accident in which the heel flaps had been
+     completely destroyed; and seen a tenth case in which Mr. Syme did
+     so. All ten cases recovered completely and rapidly, and walked on
+     useful limbs, with the free movement of the knee-joint.
+
+Where from injury in a muscular patient a long anterior flap cannot be
+had, recourse should be had at once to the operation at the seat of
+election, rather than run the risk of pressure on the cicatrix by using
+a double flap operation, or trust that broken reed, the long posterior
+flap from the great muscles of the calf.
+
+In June 1865, Mr. Henry Lee described a method of operating which he
+hoped would unite the benefits of Mr. Teale's method to the ease of
+performance of the old flap from the calf. I append a short account of
+his method. From its position, however, it has the great disadvantage of
+retaining the discharges, and by its weight straining the stitches and
+weighing down the cicatrix:--
+
+
+LEE'S AMPUTATION _of the Leg by a long rectangular flap from the
+Calf_.--The operation described was performed according to Mr. Teale's
+method, as far as the external incisions were concerned, but the long
+flap was made from the back instead of from the front of the limb (Plate
+IV. figs. 14, 15). Two parallel incisions were made along the sides of
+the leg, these were met by a third transverse incision behind, which
+joined the lower extremities of the first two. These incisions, which
+formed the three sides of the square, extended through the skin and
+cellular tissue only. A fourth incision was made transversely through
+the skin in front of the leg so as to form a flap in this situation,
+one-fourth only of the length of the posterior flap. When the skin had
+somewhat retracted by its natural elasticity, an incision was made
+through the parts situated in front of the bones, which were reflected
+upwards to a level with the upper extremities of the first longitudinal
+incisions. The deeper structures at the back of the leg were then freely
+divided in the situation of the lower transverse incision. The conjoined
+gastrocnemius and soleus muscles were separated from the subjacent
+parts, and reflected as high as the anterior flap. The deeper layer of
+muscles, together with the large vessels and nerves, were divided as
+high as the incision would permit, and the bones sawn through in the
+usual way. The flaps were then adjusted in the manner recommended by Mr.
+Teale.[42]
+
+The patients were able to bear the weight of the body on the end of the
+stump.
+
+In cases of chronic disease, where the muscles are atrophied and
+condensed, the following posterior flap method may be used with
+advantage. It is approved of by Mr. Spence. An incision is made across
+the front of the leg from the _posterior edge_ of the fibula to the
+_posterior edge_ of the tibia, or _vice versa_, according to the limb.
+The limb is then transfixed behind the bones from the same points, and a
+long and gently rounded posterior flap cut. The bones are then cleaned,
+and cut through at a little higher level.
+
+
+AMPUTATION IMMEDIATELY BELOW THE KNEE _at the_ "_true seat of
+election_."--The principles on which this operation is founded are--1.
+That a muscular flap is not necessary, skin being perfectly sufficient;
+2. That as the muscles retract they must be cut at a lower level than
+the bones, and as they retract unequally from their varying length, the
+cuts must be made with due reference to that inequality; 3. That no more
+of the tibia need be retained than what is just sufficient to retain
+the attachment of the ligamentum patellae, and to insure its vitality; 4.
+That the head of the fibula must be retained in every case, as in a
+certain proportion the tibio-fibular articulation communicates with the
+knee-joint.
+
+_Operation._--Two equal semilunar flaps of skin must be cut--from the
+outside, not by transfixion,--one anterior and external, the other
+posterior and internal, their extremities meeting at points about two
+inches below the tuberosity of the tibia on either side (Plate I. figs.
+17, 18). These must be reflected up, and with them a further extent of
+skin, embracing the whole circumference of the limb, must be dissected
+up (as if pulling off the fingers of a glove), so as to expose the bone
+one inch below the tuberosity. The anterior muscles being very close to
+their origin, and consequently being able to retract very slightly, must
+be cut as high as exposed, and the posterior ones about the middle of
+their exposed surface.
+
+The bones must then be sawn as high as exposed, with the following
+precautions:--1. In order to prevent splintering of the fibula,
+endeavour to saw it along with the tibia, so as to finish it first; 2.
+To prevent projection of a sharp prominence of the edge of the tibia,
+enter the saw obliquely a little higher up than where you intend to
+divide the bone, then withdraw it, and enter the saw again at right
+angles to the bone, and a line or two lower down. Some surgeons prefer
+to make this section afterwards with a finer saw or the bone-pliers.
+
+This operation is very frequently required to remedy painful and
+unhealed stumps, the result of amputations lower down, specially those
+in which the long posterior flap from the muscles of the calf has been
+used. In the above amputation the patient will not be able to rest the
+weight of his body on the _face_ of the stump, but by putting the limb
+into a well-padded case with soft rounded edges, the weight might be
+borne partly on the sides of the stump, and partly on the lower edge of
+the patella; and the patient will be able to walk with great comfort,
+preserving the use of his knee-joint.
+
+
+AMPUTATION AT THE KNEE-JOINT.--This "relic of ancient surgery," as Mr.
+Skey calls it, has been revived only of late years, and seems in certain
+cases to be a justifiable and successful operation.
+
+Practised by Fabricius Hildanus and Guillemeau in the sixteenth and
+seventeenth centuries, it had fallen into disuse till revived by Hoin,
+Velpeau, and Baudens, on the Continent, Professor Nathan Smith in
+America, and Mr. Lane in London.
+
+It is not possible that this operation can be at all frequent, since the
+cases in which it is applicable are comparatively rare; for, to be
+successful, the following conditions are essential:--1. That there be
+abundant skin in front of the knee-joint to make a long anterior flap;
+2. That the patella and articular surface of the femur are healthy.
+These conditions at once exclude nearly every case of disease or
+accident. If the joint is diseased some amputation through the thigh
+must be attempted; if injured, and the front of the knee is safe, it may
+very likely be possible to amputate below the knee. Hence this operation
+may be useful in cases where, for malignant disease, the _whole_ tibia
+requires removal, and yet the knee-joint is sound, or for gunshot
+injuries, in which the tibia is splintered but the soft tissues
+comparatively uninjured.
+
+_Operation._--A long anterior flap should be cut with a semilunar end
+(Plate II. figs. 6, 7), extending as far as the insertion of the
+ligamentum patellae. This flap, including the patella, should be thrown
+up, the joint cut into, and a short posterior flap made by transfixion.
+
+It is important to retain the patella, if possible, as it fills up the
+hollow between the condyles; it sometimes becomes anchylosed, but in
+other cases it remains freely mobile, and adds to the value of the
+stump.
+
+Professor Pancoast has practised an amputation at the knee-joint by
+three flaps, performed entirely by the scalpel, which, he says, results
+in a good stump. One flap, the anterior one, is longest and semilunar in
+shape, its convexity passing three inches below the tuberosity of the
+tibia; the other two are much smaller, and postero-lateral.[43]
+
+_Advantages._--The bone is not cut into at all, there is a free drain
+for matter, no tendency to retraction of the flaps, and the weight of
+the body is borne on skin previously habituated to pressure.
+
+     The statistics seem to be favourable: out of 55 cases, Continental,
+     American, and English, 21 died, a mortality of 38 per cent., while
+     in a table of 1055 cases of amputation of the thigh, 464 died,
+     being a mortality of 44 per cent. In some of the American cases the
+     articulating extremity of the femur seems to have been removed, as
+     in the following  operation:--
+
+
+AMPUTATION THROUGH THE CONDYLES OF THE FEMUR.--In the _London and
+Edinburgh Journal of Medical Science_ for 1845, Mr. Syme advocated a
+method of amputation through the condyles of the femur as specially
+suitable in case of diseased knee-joint. Amputation at this spot has
+certain advantages:--1. The shaft of the bone being untouched, there is
+no injury of the medullary cavity, and hence no fear of inflammation of
+its lining membrane. 2. There is less risk of exfoliation, the
+cancellated texture of the epiphysis not being liable to it. 3. Being
+close to the joint, the muscles are cut through where they are
+tendinous, thus very much diminishing the risk of retraction and
+consequent protrusion of the bone. 4. A large broad surface of bone is
+left to bear the weight of the body, and one which, like the ankle-joint
+stump, will round off and afford a comfortable pad over which the skin
+of the flap will freely play.
+
+One objection used to be urged against this mode of operating, the fear
+lest the thickened, brawny, and often ulcerated textures in the
+neighbourhood of a diseased knee-joint, would not make a good covering.
+This, however, is no longer a bugbear, as we see in cases of resection,
+where the diseased joint alone is taken away, how very soon all swelling
+and disease departs, once its cause is removed.
+
+Mr. Syme's original operation was briefly as follows:--With an ordinary
+amputating-knife make a lunated incision (Plate I. fig. 19) from one
+condyle to the other, across the front of the joint, on a level with the
+middle of the patella, divide the tissues down to the bones, and then
+draw the flap upwards, then cut the quadriceps extensor immediately
+above the patella. The point of the blade should then be pushed in at
+one end of the wound, thrust behind the femur, and made to appear at the
+other end; it should then be carried downwards (Plate III. fig. 5), so
+as to make a flap from the calf of the leg, about six or eight inches in
+length, in proportion to the thickness of the limb; the flap should then
+be slightly retracted, and the knife carried round the bone a little
+above the condyles to clear a way for the saw, which should be applied
+so as to leave the section as horizontal as possible.
+
+This method is now hardly ever used, as the following seems a much
+better one:--
+
+
+GRITTI'S[44] AMPUTATION.--In this two flaps are formed--an anterior long
+one rectangular and a posterior short one. The condyles of the femur are
+divided through their base, and the lower surface of patella is removed
+by a small saw, and then the surfaces of bone approximated.
+
+
+STOKES'S[45] MODIFICATION OF GRITTI'S AMPUTATION.--In this
+"supracondyloid" amputation, the femur is sawn just above the condyles,
+without going into the medullary canal. The anterior flap is oval, twice
+as long as posterior, and the patella is brought up after denudation
+against end of femur.
+
+
+CARDEN'S AMPUTATION AT THE CONDYLES OF THE FEMUR.[46]--The operation
+consists in reflecting a rounded or semi-oval flap of skin and fat from
+the front of the knee-joint, dividing everything else straight down to
+the bone, and sawing the bone slightly above the plane of the muscles,
+thus forming a flat-faced stump, with a bonnet of integument to fall
+over it.
+
+The operator standing on the right side of the limb, seizes it between
+his left forefinger and thumb at the spot selected for the base of the
+flap, and enters (Plate II. fig. 8) the point of the knife close to his
+finger, bringing it round through skin and fat below the patella to the
+spot pressed by his thumb; then turning the edge downwards at a right
+angle with the line of the limb, he passes it through to the spot where
+it first entered, cutting outwards through everything behind the bone
+(Plate IV. fig. 16). The flap is then reflected, and the remainder of
+the soft parts divided straight down to the bone; the muscles are then
+slightly cleared upwards, and I saw it applied.
+
+I have ventured to make a slight change in the method of performing this
+most excellent operation, for having found the posterior flap, as cut in
+the method above described, rather scanty in the earlier cases in which
+I have had occasion to perform it, after dissecting back the anterior
+flap and cutting into the knee-joint, I shape a slightly convex
+posterior flap of skin only, at least one and a half inches in length
+in adult, and allow it to retract before dividing the muscles by a
+circular cut to the bone, and have had every reason to be satisfied with
+the change.
+
+
+AMPUTATION OF THE THIGH.--Amputation of the thigh has been the favourite
+battle-ground where flap and circular, antero-posterior and lateral,
+long and short flaps, double, triple, and conical incisions, have
+striven with each other; so were I to attempt to describe one quarter of
+the various methods employed, I should need to rewrite the history of
+Amputation.
+
+It will suffice merely to describe the _best_ modes of amputating the
+thigh through its lower, middle, and upper thirds respectively, and at
+the hip-joint.
+
+In one word, it may be stated that, with the exception of those
+amputations performed through the lower third of the bone, the flap
+method is to be preferred, and the flaps should in almost every case be
+made by transfixion.
+
+In the lower third, however, the flap method, though exceedingly easy,
+and capable of very rapid performance, has certain defects; the chief of
+these being the tendency which the muscular flaps (the necessary result
+of transfixion) have to cause undue retraction, and hence protrusion of
+the bone. This is seen specially in the hamstrings, which from the great
+distance of their origin, and the purely longitudinal direction of their
+fibres, retract to a very great extent, much more than the anterior
+muscles can do from the pennate direction of their fibres, and the
+manner in which they are mutually bound down to each other and to the
+bone.
+
+Even in this one position, the lower third of the thigh, the methods
+that may be needed are various, and require separate notice;--for
+operations here are extremely frequent from the frequency of strumous
+disease of the knee-joint in our variable climate, and from the fact
+that compound fractures or dislocations of the knee-joint so very often
+necessitate amputation.
+
+In cases where the skin over the patella is uninjured and available, the
+operation by long anterior flap (either by Teale's method, or by Mr.
+Spence's modification of it, which curiously is almost exactly similar
+to the amputation of Benjamin Bell by a single flap) is suitable enough.
+But, I believe, preferable to either of these is the operation of Mr.
+Carden, already described. In cases where the knee-joint is injured, and
+the skin over the patella unavailable, and yet where it is not necessary
+to go higher up the limb, the modified circular amputation of Mr. Syme
+will be found very suitable.
+
+As it is in this lower third of the thigh that a very large proportion
+of the cases requiring a long anterior flap is to be found, it affords
+the best opportunity for comparing in their detail the three almost
+similar plans of B. Bell, Teale, and Spence--after which Mr. Syme's
+modified circular may be described.
+
+
+BENJAMIN BELL'S FLAP OPERATION ABOVE THE KNEE (reported in his own
+words, slightly abbreviated).--"When this operation is to be performed
+above the knee, it may be done either with one or two flaps, but it will
+commonly succeed best with one. The flap answers best on the fore part
+of the thigh, for here there is a sufficiency of the parts for covering
+the bones, and the matter passes more freely off than when the flap is
+formed behind.... The extreme point of the flap should reach to the end
+of the limb, unless the teguments are in any part diseased, in which
+case it must terminate where the disease begins, and its base should be
+where the bone is to be sawn. This will determine the length of the
+flap, and we should be directed with respect to the breadth of it by the
+circumference of the limb, for the diameter of a circle being somewhat
+less than a third of its circumference, although a limb may not be
+exactly circular, yet by attention to this we may ascertain with
+sufficient exactness the size of a flap for covering a stump (Plate IV.
+fig. 17). Thus a flap of four inches and a quarter in length will reach
+completely across a stump whose circumference is twelve inches; but as
+some allowance must be made for the quantity of skin and muscles that
+may be saved on the opposite side of the limb, by cutting them in the
+manner I have directed, and drawing them up before sawing the bone, and
+as it is a point of importance to leave the limb as long as possible,
+instead of four inches and a quarter, a limb of this size, when the
+first incision is managed in this manner, will not require a flap longer
+than three inches and a quarter, and so in proportion, according to the
+size of the limb. The flap at its base should be as broad as the breadth
+of the limb will permit, and should be continued nearly, although not
+altogether, of the same breadth till within a little of its termination,
+where it should be rounded off so as to correspond as exactly as may be
+with the figure of the sore on the back part of the limb. This being
+marked out, the surgeon, standing on the outside of the limb, should
+push a straight double-edged knife with a sharp point to the depth of
+the bone, by entering the point of it at the outside of the base of the
+intended flap; and carrying the point close to the bone, it must here be
+pushed through the teguments at the mark on the opposite side. The edge
+of the knife must now be carried downwards in such a direction as to
+form the flap, according to the figure marked out; and as it draws
+toward the end, the edge of it should be somewhat raised from the bone,
+so as to make the extremity of the flap thinner than the base, by which
+it will apply with more neatness to the surface of the sore. The flap
+being supported by an assistant, the teguments and muscles of the other
+parts of the limb should, by one stroke of the knife, be cut down to
+the bone, about an inch beneath where the bone is to be sawn; and the
+muscles being separated to this height from the bone with the point of a
+knife, the soft parts must all be supported with the leather retractors
+till the bone is sawn," etc., arteries tied, and dressings applied.[47]
+
+
+AMPUTATION OF THIGH BY RECTANGULAR FLAP--(Teale's).--I take the
+opportunity here of describing fully, and as far as possible in his own
+words, Mr. Teale's method of amputating, this being the situation where
+his method is most frequently available. The same principle may be
+applied to amputations at almost any other part of the body.
+
+After advising the surgeon to mark out the proposed line of incision
+with ink before the operation, he gives the following directions for
+fixing the exact size of the flap:--"Supposing the amputation to take
+place (Plate II. figs. 9, 10) at the lower part of the middle third of
+the thigh, the circumference of the limb is to be measured at the point
+where the bone is to be divided.[48] Assuming this to be sixteen inches,
+the long flap is to have its length and breadth each equal to half the
+circumference, namely, eight inches. Two longitudinal lines of this
+extent are then traced on the limb, and are met at their lower points by
+a transverse line of the same length. The inner longitudinal line should
+be first traced in ink as near as practicable to the femoral vessels,
+without including them within the range of the long flap. The outer
+longitudinal line, which is somewhat posterior, is next marked eight
+inches distant from the former and parallel to it. These two lines are
+then joined by a transverse line of the same extent, which falls upon
+the upper border of the patella, or upon some lower portion of this
+bone. The short flap is indicated by a transverse line passing behind
+the thigh, the length of this flap being one-fourth that of the long
+one; or, assuming the circumference of the limb to be sixteen inches,
+and the length of the long flap eight inches, the length of the short
+flap is two inches. The operator begins by making the two lateral
+incisions of the long flap through the _integuments only_. The
+transverse incision of this flap, supposing it to run along the upper
+edge of the patella, is made by a free sweep of the knife through the
+skin and tendinous structures down to the femur. Should the lower
+transverse line of the flap fall across the middle or lower part of the
+patella, the transverse incision can extend through the skin only, which
+must be dissected up as far as the upper border of the patella, at which
+place the tendinous structures are to be cut direct to the thigh-bone.
+The flap is completed by cutting the fleshy structures from below
+upwards close to the bone. The posterior short flap, containing the
+large vessels and nerves, is made by _one sweep_ of the knife down to
+the bone, the soft parts being afterwards separated from the bone close
+to the periosteum, as far upwards as the intended place of sawing.... In
+adjusting the flaps, the long one is folded over the end of the bone,
+and brought, by its transverse line, into union with the short flap, the
+two corresponding free angles of each being first united by suture. One
+or two additional stitches complete the transverse line of union. Care
+is now required in arranging the two lateral lines of union. As the long
+flap is folded upon itself so as to form a kind of pouch for the end of
+the bone, it is requisite that it should be held in its folded state by
+a point of suture on each side. Another stitch on each side secures the
+lateral line of the short flap to the corresponding part of the long
+one. A longitudinal line of union thus passes at right angles each end
+of the transverse line."[49]
+
+Mr. Teale's account of the resulting stumps is too long to quote entire,
+but in a few words, we find that by retraction of the short posterior
+flap, the cicatrix is drawn up quite behind and out of the way of the
+bone, that a soft mass without any large nerves or vessels is the result
+of the partial atrophy of the long flap, and that the patient is able to
+bear one-half, two-thirds, or even in some cases the entire weight of
+his body on the face of the stump. Such a power of support is to be
+found in no other flap except in Mr. Syme's amputation at the
+ankle-joint.
+
+
+SPENCE'S AMPUTATION BY A LONG ANTERIOR FLAP.[50]--The method used by Mr.
+Spence in amputations just above the knee-joint obtains the advantages
+of Teale's method, and avoids many of its disadvantages. He makes two
+flaps. The anterior one, which is to fall loosely over and cover in the
+posterior segment of the stump, must have a breadth fully equal to
+one-half of the circumference of the limb, and must be gently rounded at
+its extremity, so as to adjust itself readily to the curve of the cut
+margin of the posterior half of the stump. He begins the anterior
+incision below, or on a level with, the lower margin of the patella, and
+when the skin is retracted to a little above the patella, cuts down
+_obliquely_ to the bone, so as to divide the soft parts up to the base
+of the flap. For the posterior incision, he begins about two
+fingers'-breadth below the base of the anterior flap, and the assistant
+retracting the skin, the edge of the knife is carried obliquely up to
+the bone (in Alanson's manner) and the posterior soft parts divided, the
+bone is sawn through--or immediately above--the condyloid portion. Mr.
+Spence does not advise or practise this method high up. The results are
+good, for by these means the end of the bone has a thick covering,
+including muscular fibres, over it, and the cicatrix is not pressed
+upon in walking. The stump remains full, mobile, and fleshy, as in Mr.
+Teale's method, without the disadvantage which it has, in requiring the
+bone to be divided so far above the seat of injury or disease. This is
+an exceedingly good method of operating in the lower third of the thigh,
+in muscular patients the very best, and in all cases only equalled in
+value by Carden's method.
+
+The next is now hardly ever used here, except in cases where the skin
+over the patella is destroyed.
+
+
+MODIFIED CIRCULAR AT LOWER THIRD OF THIGH (Syme's).--Two equal semilunar
+flaps of skin should be cut (Plate I. fig. 20, Plate III. fig. 6), one
+anterior, the other posterior, their convexities being towards the knee.
+The skin and subcutaneous cellular tissue should be raised from the
+fascia, and then retracted to a further distance of at least two inches;
+the muscles should then be divided right down to the bone, on a level as
+high as they are exposed in front, and as low as they are exposed
+behind. This allows for the different amount of retraction at the two
+sides of the limb, and leaves the muscles cut on a level; the whole mass
+of muscles should then be drawn well up, and the bone exposed, and sawn
+through at a level about two inches higher than where it was first
+exposed by the anterior incision through the muscles.
+
+In very weak thin flabby limbs this process may be simplified by just at
+once including the muscles in the skin flaps, and carefully exposing the
+bone higher up. In performing the retraction the assistant should be
+cautioned not to overdo it, lest he strip the periosteum from the bone
+higher than is necessary. This is very easy to do in the weak limbs of
+strumous patients, and may cause exfoliation, and greatly delay cure.
+
+
+AMPUTATION IN THE MIDDLE THIRD OF THE THIGH.--A very short notice will
+suffice here. The exact position, shape, and size of the flaps must in
+every case be modified by the nature of the injury for which the
+operation is performed, taking the flaps where they can be obtained. As
+a general rule, a long anterior flap with a short posterior, on the
+principle described above, should be preferred. In cases where the long
+anterior cannot be obtained, two equal flaps should be made by
+transfixion. The flaps should always be antero-posterior, the lateral
+flaps introduced by Vermale, and indorsed by Chelius and Erichsen,
+having the great disadvantage of allowing the bone, which is drawn up by
+the psoas and iliacus, to project at the upper angle.
+
+Supposing the right thigh is to be amputated, the surgeon, standing on
+the inside of the leg, should raise the skin and muscles of the front of
+the limb in his left hand, and entering the knife just in front of the
+vessels, should transfix the limb, the knife passing in front of the
+bone, and including as nearly as possible an exact half of the limb
+(Plate IV. fig. 19); having by a sawing motion brought out the knife and
+cut a flap of the required length, the knife is re-entered at the same
+place, and passing behind the bone, the point must be brought out at the
+angle on the other side. Both flaps being then held back by an
+assistant, the bone is cleared by a circular turn of the knife, and the
+saw applied, the vessels are found cut high up in the inner angle of the
+posterior flap.
+
+In muscular patients it is often better to make the incision through the
+skin first and allow it to retract before transfixing; this is slower
+and not so brilliant looking, but avoids redundancy of muscle.
+
+
+AMPUTATION AT THE HIP-JOINT.--This operation, exceedingly dangerous from
+the amount of the body removed, the great haemorrhage, and the risk of
+pyaemia, is of comparatively modern invention. Though the proportion of
+recoveries is at present to that of deaths about one to two or two and a
+half, it is still a perfectly justifiable operation in many cases of
+disease and injury.
+
+Like amputation at the shoulder, amputation at the hip has given rise to
+very many various methods of performance. Under the heads of single
+flap, double flap, oval, circular, and mixed flap and circular, at least
+twenty distinct methods have been put on record, and, including
+modifications, there are thirty-seven or thirty-eight different surgeons
+who have each their own plan of operation.
+
+The reason of this fearful complexity in its literature depends on this
+fact, that this amputation has generally been performed for cases of
+such severe injury of the limb, that no milder amputation was possible,
+and thus the flaps had to be taken just where the surgeon could get them
+best. And this will have to be the guiding principle in most amputations
+at this joint; the surgeon must just cut his coat according to his
+cloth--get his flaps where and how he can.
+
+In cases, however, where it is possible to have a choice, and to select
+the flaps, the following is, I believe, both the best and quickest
+method:--
+
+This is one of the very few operations in which quickness of performance
+is a desideratum; the use of anaesthetics has, in most other cases, given
+time for elaboration of flaps, and careful dissection; here the risk of
+loss of blood, specially from the posterior flap, renders rapid
+disarticulation imperative.
+
+_Amputation by double flap, anterior the longer._--In hip-joint
+amputations, besides the ordinary sponge-squeezers, two assistants are
+necessary, whose duties are exceedingly important.
+
+The first is to check haemorrhage. Pressing with a firm pad on the
+external iliac just as it passes the bone, he must be prepared, the
+instant the anterior flap is cut, to follow the knife and seize flap and
+artery in his hand, and he is to hold it there till all the vessels in
+the posterior flap are first tied.
+
+The second has to manage the limb, and on the manner in which he
+performs his duty much of the success and nearly all the celerity of the
+operation depend. While the surgeon is transfixing the anterior flap,
+this assistant is to support the limb in a slightly flexed position, so
+as to relax the muscles; the instant the flap is cut he is to extend the
+limb forcibly, and at the same time be careful not to abduct it in the
+least, but to turn the toes inward so as to bring the great trochanter
+well forwards on a level with the joint; if this precaution is
+neglected, the operator in making the posterior flap is almost certain
+to lock his knife in the hollow between the head of the bone and the
+great trochanter.
+
+If it is the left side, the operator, standing on the outside of the
+limb, enters the point of a long straight knife midway between the
+anterior superior spinous process of the ilium and the great trochanter,
+and passes it as close to the front of the joint as possible, making the
+point emerge close to the tuberosity of the ischium (Plate IV. fig.
+20-20). With a rapid sawing movement he then cuts a long anterior flap,
+avoiding any pointing of it, and endeavouring to make the curve equal.
+The fingers of the assistant must be inserted so as to follow the knife
+and seize the vessel even before it is divided. The flap being raised
+out of the way, the surgeon, without changing his knife (as used to be
+advised), opens the joint, divides the ligaments as they start up on the
+limb being extended and adducted, the round ligament, and the posterior
+part of the capsule; and then getting the knife fairly behind both the
+head of the bone and the trochanter, cuts the posterior flap as rapidly
+as possible. Instantly on the limb being separated, assistants should
+be ready with large dry sponges or pads of dry lint to press against the
+surface of the posterior flap, till the large branches, chiefly of the
+internal iliac, which are cut in it, are tied one by one.
+
+The lever invented by Mr. Richard Davy, by which the common iliac is
+compressed from the rectum, has in many cases proved of great service in
+preventing haemorrhage, but has dangers of its own in cases of abnormal
+position of rectum, or even in sudden movements of the patient.
+
+In every case the abdominal tourniquet will be found of great service in
+checking haemorrhage, during the operation of amputation at the
+hip-joint. It consists of an arch of steel fitted with a pad behind,
+which rests against the vertebral column, and a pad in front playing on
+a very fine and long screw, through an opening in the arch. When screwed
+down tightly on the aorta just before the incisions are commenced, it
+checks haemorrhage admirably without injuring the viscera. When this is
+applied, a method of amputation once practised by Mr. Syme, though not
+so rapid as the double-flap method by transfixion, will be found very
+easy, and to result in most excellent flaps. He cut an anterior flap in
+the usual manner by transfixion, then made a straight incision from its
+outer edge down to about two inches below the great trochanter, thus
+exposing it fully, and from the lower end of this incision transfixed
+again, cutting a posterior flap nearly equal in size to the anterior; a
+few strokes of the knife round the joint finished the disarticulation.
+The resulting flaps came together with great accuracy, and were not
+burdened with the great unequal masses of muscles so often noticed in
+the posterior flaps which are made by cutting from within outwards
+_after_ disarticulation.
+
+In some cases of amputation where the femur has been badly shattered, it
+is a good plan to amputate through the upper third of thigh, tie all the
+vessels, and then, aided by an incision at outer side, dissect out the
+head of the bone.
+
+Mr. Furneaux Jordan of Birmingham carries out this principle by first
+dividing the soft parts in circular direction low down the thigh, and
+then dissecting out the head of the bone from the muscles by a long
+incision on the outer aspect of the limb.
+
+     _Note._--In severe cases of smash when both lower limbs have
+     required amputation, the author has derived much assistance from
+     the method of managing the operation detailed below:--
+
+     _Double Primary Amputation of (both) Thighs from railway
+     smash_--_Rapid recovery._--G., a healthy-looking man, aged
+     twenty-seven, but looking much older, while driving a horse near
+     Granton, caught his foot on the edge of a rail at a point, fell,
+     and both his legs were run over by several loaded wagons. A special
+     engine was procured, his thighs tightly tied up, and he was sent up
+     to hospital at once.
+
+     I was in hospital at the time, so with as little delay as possible
+     he was placed on the operating table, and the necessity for
+     amputation being too evident, I obtained his leave to remove both
+     his legs above the knee; but his pulse was very feeble, and he was
+     intensely nervous, throwing his arms wildly about, panting for
+     breath, and looking very ill, cold, and exhausted.
+
+     I determined that by great rapidity he might be got off the table
+     alive, so operated in the following manner:--Fixing the tourniquet
+     firmly near both groins, I first amputated the right leg by
+     Carden's method, and tied the femoral only, wrapped up the stump in
+     a towel wrung out of carbolic solution 1-20, then took off the
+     other limb by Mr. Spence's method,--it had been injured higher than
+     the right, so that I could not save the condyles of the
+     femur,--then tied the femoral there, and fixed it up with another
+     towel; then returning to the first, I tied one or two large
+     branches which spouted, and rolled it up again, then back to the
+     left one, doing the same, and getting the tourniquet off both
+     limbs. On going back to the right the surface was nearly dry and
+     glazed, so, asking Dr. Maclaren, who assisted me, to stitch it up
+     and insert a drainage-tube, I did the same for the left, so rapidly
+     that the patient was in his bed with his limbs dressed and bandaged
+     in 24-1/2 minutes from the time he entered the hospital gate.
+
+     The strictest antiseptic precautions were observed, two engines
+     being used to furnish spray. Of course this great rapidity was due
+     to the fact that everything was ready, the assistants all in
+     hospital, admirably disciplined, and steam had been up in the spray
+     engines. Shock was comparatively trivial; his temperature once, and
+     only once, reached 100 deg.. His stumps healed by first intention, and
+     he was in the garden on the seventh day after the operation.
+
+     I have now in three cases found the benefit of this mode of dealing
+     with double primary amputation in avoiding shock, lessening the
+     time needed, and greatly diminishing the number of vessels
+     requiring to be tied. In a previous case of double amputation for
+     railway smash at the knees, the patient was almost pulseless, and
+     had he been kept many minutes more on the table would not have left
+     it alive. He also rapidly recovered.
+
+     The case is interesting also as showing that, when the assistants
+     know their work, the strictest adherence to antiseptic precautions
+     need not in itself make either the operation or the dressing
+     tedious, though it can easily be made an excuse for much fussing
+     and many delays.[51]
+
+
+FOOTNOTES:
+
+[24] For details see article "Amputation" in Cooper's _Surgical
+Dictionary_, and the short sketch of the history in Mr. Lister's paper
+in the third volume of Holmes's _System of Surgery_.
+
+[25] See a most interesting foot-note to Professor Lister's paper on
+"Amputation," in Holmes's _System of Surgery_, vol. iii. pp. 52, 53.
+
+[26] _Manuel d'Operations chirurgicales._
+
+[27] FIG. IV. shows dorsal view of incision. FIG. III. shows face of
+completed stump; R, radial; U, ulnar.
+
+[28] As the surgeon will find it most convenient to stand on his own
+right side of the limb to be removed, the knife will be entered on the
+palmar side of the radius of the right arm, of the ulna of the left.
+
+[29] Teale, _On Amputation by Rectangular Flaps_, pp. 46-48.
+
+[30] Johnson's folio ed., p. 342.
+
+[31] Gross's _Surgery_, 6th ed. vol. ii. p. 1103.
+
+[32] _International Encyclopaedia of Surgery_, vol. i. p. 641.
+
+[33] Spence's _Surgery_, pp. 800, 801.
+
+[34] Gross's _Surgery_, 8vo., 6th ed., vol. ii., p. 1106.
+
+[35] _Excision of Scapula_, p. 33.
+
+[36] Hey's _Observations_, 3d ed. pp. 552, 556.
+
+[37] Roux's _Parallel between English and French Surgery_. Translation
+abridged from Cooper's _Surgical Dictionary_, p. 106.
+
+[38] Syme's _Principles_, 4th edit. p. 145.
+
+[39] _International Encyclopaedia_, vol. 1. p. 655.
+
+[40] _Observations in Clin. Surgery_, p. 48.
+
+[41] _Monthly Journal of Medical Science for 1849_, vol. ix. p. 951.
+
+[42] _Med. Times and Gazette_, June 3, 1865.
+
+[43] _Operative Surgery_, p. 170.
+
+[44] _Annali Universali de Medicina_, Milano, 1857.
+
+[45] _Med. Chir. Transactions of London_, vol. liii., p. 175.
+
+[46] Carden's (of Worcester) Pamphlet, pp. 5, 6; and _British Medical
+Journal_, 1864.
+
+[47] B. Bell's _Surgery_, 6th ed. vol. vii. pp. 336-339.
+
+[48] In diagram the amputation is drawn as if for middle third of thigh.
+
+[49] Teale, _op. cit._, pp. 34, 39.
+
+[50] _Edin. Med. Journal_, for April 1863.
+
+[51] _Edin. Medical Journal_, March 1879.
+
+
+
+
+CHAPTER III.
+
+EXCISION OF JOINTS.
+
+
+_Historical._--Beyond a passage ascribed to Hippocrates, but of very
+doubtful authenticity, and slight allusions in the works of Celsus and
+Paulus AEgineta, the ancients give us no information whatever on this
+subject.
+
+Hippocrates says,--"Complete resections of bones in the neighbourhood of
+joints both in the foot, in the hand, in the tibia up to the malleoli,
+and in the ulna at its junction with the hand, and in many other places,
+are safe operations, if that fatal syncope does not at once occur, and
+continued fever does not attack the patient on the fourth day."
+
+Celsus and AEgineta both advise the removal of protruding ends of bone in
+compound dislocations, but without giving any cases.
+
+From the days of these classic fathers of Surgery, we have hardly an
+indication of any attention whatever having been paid to their hints
+till quite within the last hundred years.
+
+The first distinct publication on the subject was by Henry Park of
+Liverpool, in a letter to Percival Pott in 1783. He proposed the removal
+of the articulating extremities of diseased elbow and knee-joints to
+obtain cures. He says he was led to this by its having been the
+invariable custom, for more than thirty years, at the Liverpool
+Infirmary, to take off the protruded extremities of bones in cases of
+compound dislocation.
+
+The chief credit, however, in practically elevating excisions into the
+catalogue of recognised surgical operations, is owing, British surgeons
+most cordially own, to two provincial surgeons of France, the Moreaus
+(father and son) of Bar-sur-Ornain. They took the lead in the most
+marked manner, having excised the shoulder in 1786, the wrist and elbow
+in 1794, knee and ankle in 1792, and had followed this up so well that,
+in 1803, the younger Moreau could boast, "the town has become in some
+sort the refuge of the unfortunate afflicted with carious joints, after
+they have tried all the means usually recommended by professional men,
+or have had recourse to empirical nostrums, or when amputation seemed to
+them the last resource."
+
+Moreau's papers and cases, which, between 1786 and 1789, he frequently
+read to the French Academy, were, some violently opposed, others utterly
+neglected by his compatriots, and many of them lost and buried in the
+unpublished papers of that body.
+
+And though diseased joints did not decline in frequency, and though
+injured ones were extremely numerous during these long years of European
+war, excisions were but rarely performed.
+
+With the exception of the removal of head of humerus after gunshot
+injury, hardly any British, and but very few French, limbs were saved by
+excision taking the place of amputation.
+
+The limbs that were saved by Percy by excision of the head of the
+humerus really owe their recovery and safety to the elder Moreau; for an
+operation of his, at which he was assisted by that distinguished
+military surgeon, gave the latter the hint, which he followed so
+successfully, that by 1795 he had performed it nineteen times, and had
+indoctrinated Sabatier, Larrey, and others, and elevated it into a
+recognised operation of military surgery.
+
+So far, however, as the application of the great improvement of the
+Moreaus to disease went, the French surgeons have little reason to
+boast, for it is to English surgery, and especially to one Edinburgh
+surgeon, that this class of operations owes nearly all its improvement
+in methods and frequency of performance.
+
+For though (as we shall see under the special heads) here and there one
+or two cases were performed, it was not till the publication of Mr.
+Syme's monograph on the excision of diseased joints, in 1831, that the
+importance and value of the discovery were fairly brought before the
+profession; and the conservative surgery, of which excision as preferred
+to amputation is the great type, must ever be associated with British
+surgeons--Syme, Fergusson, Mackenzie, Jones of Jersey, Butcher of
+Dublin.
+
+On the Continent--Langenbeck, Stromeyer, Heyfelder, Ollier, Esmarch of
+Kiel, specially in the surgical history of the first Schleswig-Holstein
+war, have followed up the example set them here.
+
+Before proceeding to describe the operations on the various joints, one
+or two questions may be briefly asked and answered by way of
+introduction.
+
+In what cases, or sorts of cases, are excisions suitable?
+
+1. In cases of compound injury or dislocation of a large joint, as used
+by Filkin, Park, White, and other English surgeons long ago. In hospital
+practice, or in private, where there is every advantage of rest, food,
+and appliances, such operations will frequently be found suitable where
+the joint is alone or chiefly the seat of injury, and where the general
+health seems fit to bear a prolonged suppuration. But long and sad
+experience has shown that, as a general rule in military practice, with
+the difficulties of transport, the generally bad sanitary state of the
+hospitals, and the want often of adequate dressings and attention,
+excisions are much more fatal than amputations, and, except in elbow and
+shoulder (_q.v._), should be as a general rule avoided.
+
+2. Excision for deformity (generally speaking for bony anchylosis) will
+require for decision the consideration of many points, _i.e._ the joint
+affected, the nature of the disease or injury which has caused the
+anchylosis: and in each case--(1.) the state of health of the patient;
+and (2.) his occupation, and the consequent position of limb which would
+suit him best. As a general rule, I believe, experience will prove that
+such operations on the lower extremity are almost absolutely
+inadmissible, except under very special urgency on the part of the
+patient, and a very high condition of health--while in the upper, the
+elbow-joint is the only one which you will ever be likely to be asked to
+remedy, or should comply with the request if asked; as the shoulder,
+even if anchylosed, will (1.) from its own weight generally become so in
+the most favourable position; and (2.) from the extreme mobility which
+the scapula can acquire, its anchylosis will not be so much felt.
+
+The elbow, however, from the frequency of fractures of the condyles of
+the humerus obliquely into the joint, and from the manner in which these
+are so often neither recognised nor properly treated, very often becomes
+anchylosed in the most awkward possible position, _i.e._ nearly
+straight; and operations undertaken for such deformities are in general
+both quite safe and very satisfactory. Mr. Syme had one case (resulting
+from a fall, causing a double fracture), in which both arms were thus
+firmly anchylosed in such a position that the sufferer could absolutely
+perform none of the commonest duties of life without assistance.
+Excision of both joints cured him.
+
+The author excised with success for disease the elbow-joint of a patient
+whose other arm had required the same operation.
+
+The occupation of the patient must always be taken into consideration
+when settling the position of an anchylosis, or the necessity or
+advantage of a resection.
+
+Thus, Bryant[52] tells of a painter who wished his arm to be fixed in a
+straight position, and of a turner whose knee at his own request was
+permitted to stiffen at a right angle, as that position allowed him to
+turn his wheel.
+
+3. _Excision for Disease of the Joint._--In our cold climate, so cursed
+by scrofula, and specially among the children of the labouring poor,
+such joint diseases are very prevalent, and whether the disease
+commences in the synovial membrane, the articular cartilages, or the
+heads of the bones, it frequently so disorganises the joint as to make
+it a question whether something must not be done to preserve the very
+life of the patient.
+
+The difficulty of diagnosing the cases in which excisions are suitable
+or necessary is often very great; and we must balance its
+performance--(1.) against the possibly good results of an expectant
+treatment; (2.) against amputation of the limb.
+
+(1.) _Against expectant Treatment._--The patient has youth on his side,
+could we give him fresh sea air, good diet, cod oil, etc., we might very
+likely obtain anchylosis; true, but he may die while trying for this
+anchylosis, and also this anchylosis, when got, may so lame or deform
+him that resection may still be required.
+
+These points must all be considered, but as a general rule, I would say
+that such attempts at preservation of the limb are much more
+justifiable, and longer justifiable in the hip and knee-joints than in
+the elbow or shoulder; for the results in the lower limb will probably
+be as good, if the patient survive, if not better, than those obtained
+by excision, while the danger of the operation is greater; while in the
+upper limb, the danger to life in operating is less than that of leaving
+the limb on, and the results obtained by a successful operation, with
+well-managed after treatment, are far more satisfactory than the best
+possible anchylosis.
+
+Another point bearing on this, of very great importance: In children,
+the most frequent subjects of such disease, excision of the lower limb
+may, by removing the epiphyses, cause to a very considerable degree
+disparity in their length, thus rendering them nearly useless, while in
+the upper such disparity is neither so extensive nor so injurious to the
+usefulness of the limb, which is not required for purposes of
+progression.
+
+In the hip-joint especially, all the resources of the art should be
+tried in the expectant treatment, for amputation at the hip-joint is
+hardly ever admissible for disease of the joint, while excision has
+anything but satisfactory statistics.
+
+(2.) _Against Amputation._--Many questions must be considered, chiefly
+under the heads of the separate joints:--
+
+1. As to the difficulties and dangers of the operations contrasted.
+
+Such as the following:--
+
+Excisions give the surgeon more trouble, require more manual dexterity;
+take longer to perform; are very painful operations. Not valid
+objections in these days of chloroform and operative surgery on the dead
+body.
+
+Excisions have the special peculiarity and danger of dealing chiefly
+with cancellated bone, broadened out, open, with numerous patulous
+canals for large veins, tending on any irritation or inflammation to set
+up a diffuse suppuration, and to culminate in phlebitis, myelitis, and
+other pyaemic conditions.
+
+Excisions are performed through degenerate or disorganised, amputations
+through healthy, tissue.
+
+Excisions require extreme care and absolute rest (_i.e._ in lower limb)
+for many weeks and months after the operation.
+
+But, on the other hand,--
+
+Amputations remove a portion of the body; excisions a much less one.
+Amputations are always necessarily nearer the centre than the
+corresponding excisions, and statistics show that the fatality of
+operations increases in exact proportion as they approach the centre.
+
+A successful excision, especially in arm, saves a limb nearly perfect;
+an amputation at best is only the stump for a wooden one.
+
+On the whole, there is actually very little difference in the mortality
+of excisions and amputations.
+
+2. As to the results of the operation on the usefulness of the limb,
+depending on joint involved, age of patient, and amount of bone
+removed:--
+
+A. _Joint involved._--These must be noticed separately, but one thing is
+absolutely certain, that a much higher standard of usefulness, both in
+equality of length, amount of anchylosis, and position, is needed in the
+lower than in the upper limb. For a leg hanging like a flail, or
+shortened by some inches, is not so good for purposes of locomotion as a
+wooden leg is, while an arm, even though powerless at the elbow, and
+perhaps much shortened, can be so strengthened and supported by slings
+and bandages as to give a most useful hand, the complex movements and
+uses of the fingers of which no mechanism can at all imitate.
+
+B. _Age of Patient._--It must be remembered that excision in a child
+removes the epiphyses by which in great measure the growth of the bone
+is to be managed, and the stunted limb, especially in the leg, will
+eventually be of little advantage, though after the operation it looked
+excellently well, if a few years later it be found to be seven or eight
+inches shorter than its neighbour.
+
+C. _Amount of Bone removed._--From an erroneous view of the pathological
+changes in the bone affected, far too much was removed by many of the
+earlier operators, especially Moreau and Crampton.
+
+The reason that this is often still the case, is well seen in many
+preparations. The bones are thickened to a considerable distance, and
+covered with irregular warty excrescences. These, which used to be
+considered evidences of disease, are only compact new healthy bone,
+thrown out like the callus of a fracture in consequence of the
+irritation.
+
+In a word, what we require to remove is the following:--
+
+1. All the cartilage, dead or alive, healthy or diseased.
+
+2. Only the bone involving the articular extremities, in thin slices, or
+with the occasional use of the gouge, till a healthy bleeding surface is
+obtained.
+
+3. The synovial membrane, however gelatinous or thickened looking,
+really requires very little care or notice; it will disappear of itself,
+partly by sloughing, partly by absorption during the profuse
+suppuration.[53]
+
+
+EXCISION OF THE SHOULDER-JOINT.--Before considering the method of
+operating, a word or two is required on the subject of how much is to be
+removed, and in what cases the operation should be performed. The
+shoulder and hip joints are the only ones in which partial excision is
+ever admissible, indeed, in the shoulder excision of the head of the
+humerus only is in many cases found to be all that is necessary, while
+in all it is much less dangerous to life than when the glenoid cavity
+also requires to be interfered with.
+
+It is rarely necessary to remove more of the bone than merely its
+articular extremity (when performed for disease of the joint), and if
+possible this should be done inside the capsule, _i.e._ through an
+incision in the capsule, but without involving its attachment to the
+neck of the bone. When the glenoid is also diseased, mere gouging or
+scraping the cartilaginous surface will not suffice, but the neck must
+be thoroughly exposed, so that the whole cup of the glenoid may be
+removed by powerful forceps.
+
+_Cases suitable for Excision._--Cases of chronic disease of the head of
+the humerus (generally tubercular), or of chronic ulceration of the
+cartilages which has resisted counter-irritation. Cases of gunshot
+injury of the joint, or of compound dislocation, or fracture involving
+the joint. Cases of limited tumours affecting merely the head and upper
+third of the bone, and non-malignant in character. Anchylosis very
+rarely requires and would not be much benefited by such an operation.
+
+_Operation._--Though perhaps not the easiest, the following method is
+the one followed by the best results. It is suited especially for cases
+of caries or other disease of the joint, where the head of the humerus
+is either alone or chiefly affected:--
+
+A single straight incision (Plate I. fig. A.) is made from a point just
+external to the coracoid process downwards along the humerus for at
+least three inches. It corresponds almost exactly to the bicipital
+groove, and has the advantage of avoiding the great vessels and nerves.
+The long head of the biceps may then be raised from its groove, and
+drawn to a side so as to be preserved. This is deemed of importance by
+Langenbeck and others. Mr. Syme, however, did not attach much value to
+its preservation, as it is often diseased. The capsule, which is often
+much altered, perhaps in part destroyed, is then opened, and the tendons
+of the muscles which rotate the head of the humerus divided in
+succession, while the elbow is rotated first inwards and then outwards
+by an assistant so as to put them on the stretch. The arm being then
+forced backwards, the head of the bone can be protruded through the
+wound, and sawn off at the necessary distance down the shaft. The
+glenoid must then be carefully examined, and any diseased bone removed
+by the cutting pliers. One or two small branches supplying the anterior
+fold of the axilla are the only vessels divided, and may not even
+require ligature, unless, indeed, from necrosis, or to remove a tumour,
+a larger portion of the humerus than usual has been removed. If the
+limit of capsule has been infringed on below, the circumflex vessels may
+probably be cut, in which case the bleeding may be considerable.
+
+_N.B._--In cases of fracture of neck of humerus, or of compound gunshot
+injury, or where the head has been separated by necrosis from the shaft,
+or where, as has happened to Stanley and others, the bone broke in the
+endeavour to tilt the head out, the surgeon will require to seize the
+detached head with strong forceps, and dissect it out with care.
+
+_Other methods of Resection._--When from great thickening and induration
+of the soft parts, enlargement of the head of the bone, or other reason,
+the straight incision may be deemed insufficient for the purpose (and we
+may remark that there are comparatively few cases in which it is
+insufficient), access may be obtained to the joint by raising a flap
+from the deltoid (Plate III. fig. A). Its shape--V-shaped, semilunar, or
+ovoid--is not of much consequence, for there are no great nerves or
+vessels to wound on the outside of the joint, and the surgeon should be
+guided, as in all other operations on the joint, very much by the
+position of any pre-existing sinuses. This flap being raised upwards
+towards its base, very free access is gained to the joint.
+
+In these cases, fortunately comparatively rare, in which there is reason
+to believe that the glenoid is chiefly involved in disease, and yet that
+the disease can be removed without amputation, access will be gained
+most easily by an incision (Plate III. fig. B.) on the posterior surface
+of the joint, corresponding in size and direction to the linear incision
+in front. This gives a much easier mode of access to the glenoid. I have
+seen this practised in one very remarkable case by Mr. Syme, in which
+the glenoid cavity and neck of the scapula were extensively diseased,
+while the head of the bone was quite sound.
+
+_After-treatment_ is exceedingly simple; for the first day or two the
+shoulder is to be supported on a pillow with a simple pad in the axilla,
+if there is any tendency for the arm to drag inwards; after this the
+patient should be encouraged to sit up and move about with his arm in a
+sling, the elbow hanging freely down.
+
+_Results._--Hodge records ninety-six cases in which this excision was
+performed for gunshot injury, of which twenty-five proved fatal, and
+fifty for disease, of which only eight died,--results which are more
+encouraging than those of amputation at the shoulder-joint for disease;
+though for injury the mortality is much greater than Larrey's famous
+Statistics of Amputation, _q.v._ p. 65.
+
+Spence had thirty-three cases, with three deaths. He generally made a
+counter-opening behind to get rid of discharges, and inserted a
+drainage-tube.
+
+Gurlt's statistics of excision for gunshot injury give of 1661 cases
+1067 recoveries, 27 doubtful results, and 567 deaths, the mortality
+being 34.70 per cent.
+
+EXCISION OF THE ELBOW-JOINT--_In what cases should it be performed?_--1.
+For disease of the elbow-joint which has resisted ordinary remedies, and
+is wearing down the patient's strength, including caries, ulceration of
+cartilages, and gelatinous synovial degeneration.
+
+2. For wounds of the elbow penetrating the joint, the prognosis both as
+to the patient's life and the usefulness of his arm is much better after
+excision than after endeavours to save the joint without excision. This
+is especially the case when the wound of the joint is small and
+punctured, but if the case is seen early and treated by free drainage,
+with antiseptic precautions, excision may not be required.
+
+3. For anchylosis, in cases where after disease or injury the limb has
+stiffened in a bad position, especially when, with a straight elbow,
+the hand is rendered almost perfectly useless.
+
+_How much should be removed?_--In the elbow-joint, more than any other
+joint in the body, complete excision is absolutely necessary; any
+portion of the articular surface being left proves a source of
+unfavourable result.
+
+The surgeon is apt to err rather in removing too little than too much.
+For the removal of too little bone is, on the one hand, apt to result in
+long-standing sinuses, on the other, to induce anchylosis.
+
+In making the section of the bones, the saw ought to be applied to the
+humerus transversely just at the commencement of its condyloid
+projections, and to the radius and ulna, at least at a level with the
+base of the coronoid process of the ulna.
+
+But while removing enough, we must not be led into the error of removing
+too much. If this is done, as was done by Sir Philip Crampton in his
+first case, and as happens occasionally of necessity in cases of
+excision for gunshot wounds or other accidents, much of the power of the
+arm is lost as a consequence of the shortening and excessive mobility.
+
+A mistaken pathology sometimes deceives in the examination of the state
+of the bones, and causes an unnecessary amount to be removed. For in
+many cases of disease the bones in the neighbourhood of the joint are
+stimulated to an excessive amount of what is in reality Nature's effort
+at repair, and while the cartilaginous surfaces are denuded of
+cartilage, soft, and porous, the bones close by are roughened with a
+stalactitic-looking growth, projecting in knobs and angles. Now, if this
+be mistaken for disease and removed, too much will almost certainly be
+taken away, and the result will be unsatisfactory.
+
+Much less care need be taken exactly to discriminate and remove the
+diseased soft parts; indeed they may be left alone; the synovial
+membrane in a state of gelatinous degeneration sometimes presents a
+very formidable appearance of disease, but if the bones be properly
+removed, all this swelling will soon go down, and a healthy condition of
+parts succeed, without any clipping or paring on the surgeon's part.
+
+_Operation._--The back of the joint is of course chosen for the seat of
+the incisions, both because the bones are there just under the skin, and
+because the great vessels and nerves lie in front of the joint. The form
+and number of the incisions vary considerably, and ought to vary
+according to the nature of the case and the amount of disease or injury.
+
+Though it is now little used, for historical interest I retain the
+description of the H-shaped incision (Plate III. fig. C.), used first by
+Moreau, and re-introduced by Mr. Syme, and used by him for most of his
+very numerous cases.
+
+The posterior surface of the joint being exposed, the surgeon, with a
+strong straight bistoury, makes a transverse incision into the joint
+just above the olecranon. It should begin just far enough outside of the
+internal condyle to avoid the ulnar nerve, which the surgeon should
+protect by the forefinger of his left hand, and should extend
+transversely across to the outer condyle. From each end of this incision
+the surgeon should next make at a right angle two incisions, each about
+one inch and a half or two inches long, right down to the bone, thus
+marking out two quadrilateral flaps. These should next be raised from
+the bones, up and down, as much of the soft parts being retained in them
+as possible, so as to add to their thickness. The olecranon is thus
+exposed, and should be removed by saw or pliers by cutting into the
+greater sigmoid notch; the lateral ligaments must then be cut, if they
+are not already destroyed by the disease, and the humerus protruded, a
+proper amount of which is then to be sawn off in a transverse direction.
+The head of the radius is then easily removed by the bone-pliers, and
+the ulna also protruded, the attachment of the brachialis anticus to the
+coronoid process divided, and the bone sawn across just at the base of
+that process.
+
+Few vessels, if any, will require ligature, and the arm being bent to
+nearly a right angle, the transverse incision must be very carefully
+sewed up with silver sutures closely set and deeply placed, as much of
+the future success of the joint depends on the completeness of the
+primary union of this incision. The external incision may also be
+accurately adjusted, the internal one not so completely, to allow free
+vent for the discharge, which is aided by the ligatures, if any are
+required, being brought out at its lower angle. A figure-of-8 bandage
+should be applied over pads of dry lint, and the limb laid on a pillow.
+No splint is necessary; in a few days the patient will be able to rise
+and walk about.
+
+Passive motion should be begun so soon as the first inflammatory
+symptoms have passed off.
+
+If properly performed, in a tolerably healthy subject, the surgeon
+should not be satisfied with any results short of almost perfect
+restoration of motion in the joint. Flexion and extension to their full
+extent, with a very considerable amount of pronation and supination, are
+to be expected, with proper care, in a patient of average intelligence.
+
+Numerous cases are now on record where almost perfect performance of all
+the duties of life was retained after excision of the elbow-joint.[54]
+
+In most cases it is possible, and in nearly all advisable, to excise the
+joint by means of a less complicated incision. Thus one long vertical
+incision at the posterior surface, with its centre about midway between
+the ulna and the external condyle, with a transverse incision at right
+angles to it, and reaching almost to the internal condyle, has been
+often practised with a very good result.
+
+By nearly universal consent this single straight incision is now used,
+and when it is properly dressed and _drained_ gives admirable results.
+
+A single vertical incision (Plate III. fig. D.) without any transverse
+one, as long ago recommended by Chassaignac, is, in most cases, quite
+sufficient to give access. It is most suitable in cases of anchylosis,
+where there is little deposit of new bone, or in cases of disease of the
+joint, accompanied with little swelling or thickening of surrounding
+tissues. It has the advantage of avoiding the cicatrix of a transverse
+incision, which doubtless may, if at all a broad one, somewhat interfere
+with the future flexion of the limb, but, on the other hand, unless care
+is taken, it does _not_ give such free egress for the discharge, and
+when there is much delay in healing, the vertical incision may leave a
+cicatrix nearly as troublesome as the other.
+
+     The following modification, suggested and practised by the late Mr.
+     Maunder, seems to be a step in the right direction when it is
+     practicable. "After a longitudinal incision crossing the point of
+     the olecranon I next let the knife sink into the triceps muscle,
+     and divide it longitudinally into two portions, the inner one of
+     which is the more firmly attached to the ulna, while the outer
+     portion is continuous with the anconeus muscle, and sends some
+     tendinous fibres to blend with the fascia of the fore-arm. It is
+     these latter fibres that are to be scrupulously preserved.
+
+     "Two points have to be remembered: first, the ulnar nerve, often
+     unseen, must be lifted from its bed, and carried over the internal
+     condyle to a safe place, and then the outer portion of the triceps
+     muscle with its tendinous prolongation, the fascia of the fore-arm
+     and the anconeus muscle must be dissected up, as it were, in one
+     piece, sufficiently to allow of its being temporarily carried out
+     over the external condyle of the humerus."[55]
+
+     This method aids in retaining the power of _active_ extension of
+     the elbow-joint.
+
+Excision for osseous anchylosis in the extended position of the joint
+may be sometimes rendered very difficult by the density, firmness, and
+extensive hypertrophy of the bones, which become fused into one solid
+mass. Any attempt to isolate the bones, and remove the anchylosed joint
+entire, by incising the bones as if for disease, will both prove very
+laborious, and also probably end in doing some damage to the vessels and
+nerves in front. But by sawing through the anchylosis about its centre,
+as was pointed out many years ago by Mr. Syme, the fore-arm may be
+flexed, and the bones as easily displayed, cleaned, and removed, as in
+the operation for disease. In this operation, as there is less
+thickening of the skin and subjacent textures, and in consequence more
+risk of deficiency and even sloughing of the flaps made by the H-shaped
+incision, a single straight incision will serve the purpose admirably.
+
+Partial incisions of the elbow-joint are, as a rule, less successful and
+more dangerous to life than complete ones, except in cases of excision
+for anchylosis. Even in gunshot wounds, where the bones were previously
+healthy, and where uninjured portions might have been left with some
+hopes of success, this is the case.
+
+     Dr. Heron Watson has devised the following operation for cases of
+     anchylosis the result of injury:--(1.) A linear incision over ulnar
+     nerve at inner side of olecranon. (2.) The ulnar nerve to be
+     carefully turned over the inner condyle. (3.) A probe-pointed
+     bistoury to be introduced into the elbow-joint in front of the
+     humerus, and then behind and carried upwards, so as to divide the
+     upper capsular attachments in front and behind. (4.) A pair of
+     bone-forceps to be next employed to cut off the entire inner
+     condyle and trochlea of the humerus, and then introduced in the
+     opposite diagonal direction so as to detach the external condyle
+     and capitulum of the humerus from the shaft. (5.) The truncated and
+     angular end of the humerus to be divided, turned out through the
+     incision, and smoothed across at right angles to the line of the
+     shaft by means of the saw, whereby (6.) room might be afforded, so
+     that partly by twisting and partly by dissection the external
+     condyle and capitulum are removed without any division of the skin
+     on the outer side of the arm.[56] Six cases have had satisfactory
+     results.
+
+The mortality from this operation is considerably less than that from
+amputation of the arm. Of a series of excisions for disease, injury, and
+anchylosis, 22.15 per cent. died, while out of a similar series of
+amputations of the arm the mortality was 33.4 per cent.[57] Our
+mortality of excision of the elbow here is certainly much less than the
+above. All of the cases, between thirty and forty, in which I have done
+it have recovered with but one exception, and Mr. Syme lost only one
+during the time I was his assistant.
+
+Professor Spence lost only 16 in 189 cases, or 8.3 per cent.
+
+Gurlt's statistics for gunshot injury give a mortality of over 24 per
+cent.
+
+Out of 82 cases where the joint was excised for injury in the
+Schleswig-Holstein and Crimean campaigns, only 16 died; and out of 115
+cases in which the joint was excised for disease, only 15 died.
+
+The period after the injury at which the excision is performed seems to
+be important.
+
+                                                        Deaths.
+    Thus of 11 cases within first twenty-four hours,    1 = 1-11
+      "     20   "   between second and fourth days,    4 = 1-5
+      "      9   "      "    eighth and thirty-seventh, 1 = 1-9
+            --                                         --
+            40                                          6
+
+
+EXCISION OF THE WRIST.--Very various methods have been proposed and
+executed for the purpose of excising this joint. These vary much in
+difficulty and complexity, in proportion to the endeavours made to save
+the tendons from being cut.
+
+The principles which must guide all attempts at operative interference
+with this joint are--
+
+1. To remove all the diseased bone, including the cartilage-covered
+portions of the radius, ulna, and of the metacarpal bones, as little of
+these bones being removed as possible, beyond the cartilage-covered
+portions.
+
+2. To disturb the tendons as little as possible, especially to avoid
+isolating them from the cellular sheath.
+
+3. To commence passive motion of the fingers very soon after the
+operation.
+
+It is rarely possible to remove the carpal bones as a whole, from the
+diseased condition which renders the operation necessary, and the
+digging out of the various bones piecemeal renders the operation very
+tedious, especially if the proximal ends of the metacarpal bones are
+involved and require to be removed, hence this operation was practically
+impossible till after the discovery of anaesthesia.
+
+In describing the operation elaborated and described by Professor
+Lister, the type of the various plans in which the tendons are saved is
+given, while a very few words descriptive of the incisions used by
+others who cut the tendons will suffice.
+
+
+LISTER'S OPERATION OF EXCISION OF THE WRIST-JOINT.--Even an abridgment
+of Mr. Lister's account of his operation must necessarily be long,
+because the operation itself is so complicated and prolonged, and guided
+by such precise principles, as to render much abridgment almost
+impossible.
+
+A tourniquet is put on, to prevent oozing, which would conceal the state
+of the bones; any adhesions of the tendons must be then broken down by
+free movement of all the joints.
+
+_The radial incision_ (Plate IV. fig. A.) is then made. It commences at
+the middle of the dorsal aspect of the radius, on a level with the
+styloid process, passes as if going towards the inner side of the
+metacarpo-phalangeal joint of the thumb, in a line parallel to the
+extensor secundi internodii, but turns off at an angle as it passes the
+radial border of the second metacarpal, and then longitudinally
+downwards for half the length of that bone. The extensor carpi radialis
+brevior tendon is divided in the incision. The soft parts at the radial
+side are to be carefully dissected up, and the tendon of the extensor
+carpi radialis longior divided at its insertion. The cut tendons, and
+the extensor secundi internodii tendon and the radial artery can thus be
+pushed outwards, enabling the trapezium to be separated from the carpus
+by cutting-pliers. The extensor tendons being relaxed by bending back
+the hand, the soft parts must be cleared from the carpus as far as
+possible towards the ulnar side.
+
+[Illustration: FIG. VI.[58]]
+
+_The ulnar incision_ (Plate IV. fig. B.) extends from two inches above
+the end of the ulna, in a line between the bone and the flexor carpi
+ulnaris, straight down as far as the middle of the palmar aspect of the
+fifth metacarpal. The dorsal lip of this incision is then raised, and
+the tendon of the extensor carpi ulnaris cut at its insertion, and
+reflected up out of its groove in the ulna along with the skin. The
+extensor tendons are then raised from the carpus, and the dorsal and
+lateral ligaments of the wrist divided, the tendons still being left as
+far as possible undisturbed in their relation to the radius. In front
+the flexor tendons are cleared from the carpus, the pisiform bone
+separated from the others though not removed, and the hook of the
+unciform divided by pliers. The knife must not go further down than the
+base of the metacarpal bones, in case of dividing the deep palmar arch.
+The anterior ligament of the wrist being now divided, the carpus and
+metacarpus are to be separated by cutting-pliers, and the carpus
+extracted by strong sequestrum forceps. By forcible eversion of the
+hand, the ends of radius and ulna can be protruded at the ulnar
+incision; as little as possible should be removed, consistent with
+removing all the disease. The ulna should be cut obliquely, leaving the
+base of the styloid process, and removing all the cartilage-covered
+portion. A thin slice of the radius is then to be cut also with the saw,
+so thin as to remove only the bevelled ungrooved portion, and leaving
+the tendons as far as possible undisturbed in their grooves. The ulnar
+articular facet is to be snipped off with bone-pliers. If the bones are
+more deeply carious, the diseased parts must at all hazards be removed
+with pliers or gouge. The metacarpal bones must then be treated in
+precisely the same way, their ends sawn off and their articular facets
+snipped off with the bone-pliers longitudinally. The trapezium is then
+to be seized by forceps and carefully dissected out, the metacarpal bone
+of the thumb pared like the others, the articular surface of the
+pisiform removed, the rest of the bone being left if it is sound. The
+radial incision is stitched closely throughout, and also the ends of the
+ulnar incision, any ligature being brought out through the centre of the
+ulnar incision, which is kept open with a piece of lint, which also
+gives support to the extensor tendons.
+
+The after-treatment is important, the principal specialities being--(1.)
+early and free movement of the fingers; (2.) secure fixing of the wrist
+to procure consolidation. (1.) By passive motion of the joints of the
+knuckles and fingers, commenced on the second day, and continued daily
+after the operation; (2.) By a splint supporting the fore-arm and hand,
+the fingers being held in a semiflexed position by a large pad of cork
+fastened firmly on to the splint and made to fit the palm; this prevents
+the splint from slipping up the arm, and by a turn of a bandage insures
+fixation of the wrist-joint. The anterior part of this splint below the
+fingers may be gradually shortened, allowing more and more passive
+motion of the fingers, but the patient must wear it for months, indeed,
+till he finds his wrist as strong without it as with it.
+
+Among the various operations that have been devised, the following
+require notice:--Mr. Spence, Dr. Gillespie, Dr. Watson, and the author,
+use a single dorsal incision with excellent results, and find it quite
+easy to remove all the bones from it. Mr. Spence had sixteen cases
+without a death.
+
+     POSTERIOR SEMILUNAR FLAP, from carpal attachment of metacarpal of
+     index finger round to styloid process of ulna; dividing integuments
+     only, then separating the tendons of the common extensor
+     longitudinally, and drawing them aside by blunt hooks, the diseased
+     bones are removed piecemeal by curved parrot-bill forceps.[59]
+
+     POSTERIOR CURVED FLAP.--An incision down to the carpal bones,
+     extended from a point two lines to the ulnar side of the extensor
+     secundi internodii pollicis, and from a quarter to half an inch
+     below the radio-carpal articulation, swept in a curvilinear
+     direction downwards, close to the carpal extremities of the
+     metacarpal bones, to a point just below the end of the ulna. The
+     flap thus marked out was dissected up, and consisted of the
+     integuments, areolar tissue, and extensor tendons of the four
+     fingers, together with large deposits of fibrine, the products of
+     repeated and prolonged inflammatory action. The tendon of the
+     second extensor and its soft parts around were separated from the
+     bones. The remains of the ligaments were cut, flexion of the hand
+     protruded the carious ends of radius and ulna. The bones were then
+     dissected out, leaving the trapezium, which was not diseased, and
+     hand placed on a splint.[60]
+
+
+EXCISION OF THE HIP-JOINT.--The question as to the propriety of
+performing this operation in any case is still debated by some surgeons,
+and the selection of suitable cases for the operation is greatly
+modified by the varying opinions of the different schools of surgery.
+Enough here to describe the method of operating, and the amount of the
+bone which is to be removed.
+
+As in the shoulder-joint, the head of the femur is much more liable to
+disease, and, as a rule, much earlier attacked than is the acetabulum,
+but unfortunately the acetabulum does eventually become affected also in
+probably a much larger proportionate number of cases than the glenoid.
+Caries of the head, neck, and trochanters of the femur is a very common
+disease in this variable climate, and frequently connected with the
+strumous taint. After much suffering, abscesses form and discharge,
+giving considerable pain, and often end by carrying off the patient. As
+a result of the abscess and destruction of the ligaments, the head of
+the bone is apt to be displaced, and under some sudden muscular exertion
+or involuntary spasm, consecutive dislocation of the femur (generally on
+to the dorsum ilii) very often occurs.
+
+In such a case the operation of excision of the head of the femur is by
+no means difficult, and not excessively dangerous, especially in young
+children.
+
+_Operation._--It is hardly necessary, or indeed possible, to lay down
+exact rules for the performance of this operation, in so far as the
+external incisions are concerned, for the sinuses which exist ought in
+general to be made use of.
+
+When the surgeon has his choice, a straight incision (Plate II. fig.
+A.), parallel with the bone, extending from the top of the great
+trochanter downwards for about two inches, and also from the same point
+in a curved direction with the concavity forwards, upwards towards the
+position of the head of the bone (see diagram), will be found most
+convenient. The incisions should be carried boldly down to the bone,
+which will often be felt exposed and bathed in pus, any remains of the
+ligamentous structures must be cautiously divided with a probe-pointed
+bistoury, and then by bringing the knee of the affected side forcibly
+across the opposite thigh, with the toes everted, the head of the bone
+is forced out of the wound. The head, neck, and great trochanter should
+be fully exposed, and the saw applied transversely below the level of
+the trochanter, so as to remove it entire. If this is not done, it
+prevents discharge, protrudes at the wound, and besides this it is
+almost invariably diseased along with the head. Chain saws are quite
+unnecessary, it being in most cases easy to apply an ordinary one to the
+bone, if it is properly everted.
+
+Great care in the after-treatment is required to prevent undue
+shortening of the limb, or in the event of a cure to secure the most
+favourable position for the anchylosis. The femur occasionally tends to
+protrude at the wound, and hence may require to be counter-extended by
+splints. If required at all, the splint should be made with an iron
+elbow opposite the wound to admit of its being easily dressed. In most
+cases counter-extension may be best managed by a weight and pulley.
+
+Various forms of hammock swings to support the whole body, and slings of
+leather or canvas to support the limb only, have been found to aid
+recovery, and render the patient much more comfortable.
+
+When the acetabulum is also diseased the prognosis is much more
+unfavourable than when it is sound.
+
+The experiments of Heine and Jaeger on the dead body, and operations by
+Hancock, Erichsen, and Holmes, on patients, have shown that in cases of
+extensive disease of the acetabulum it is quite possible by a prolonged
+and careful dissection to remove it all without injury of the pelvic
+viscera.
+
+The details of incisions for such an operation need scarcely be given,
+as they must vary in each case with the amount of bone diseased, and the
+position of the already existing sinuses. The amount of bone that _may_
+be removed varies much. Erichsen in one case excised "the upper end of
+the femur, the acetabulum, the rami of the pubis, and of the ischium, a
+portion of the tuber ischii, and part of the dorsum ilii."[61]
+
+A less formidable proceeding may be useful in cases where the acetabulum
+is diseased, but not deeply. The moderate use of an ordinary gouge may
+succeed in removing the diseased bone.
+
+Experience and the cold evidence of statistics prove, however, that the
+prognosis in any case is modified very much for the worse by the
+presence of any disease of the acetabulum, more than one-half of the
+cases proving fatal in which it is diseased, whether attempts to remove
+the disease of the acetabulum be made or not, and that those cases do
+best in which the head of the femur has been displaced, and lies outside
+the joint almost like a loose sequestrum among the soft parts.
+
+The results of excision of the hip have as yet been very discouraging,
+the mortality of the whole series of published cases being, according to
+Dr. Hodge's careful table, very little under 1 in every 2 cases, viz., 1
+in 2-5/53. Later statistics are however more favourable.
+
+Like all other excisions, the mortality increases very much with the
+patient's age.
+
+Thus of 103 completed cases in which the age is given, 53 recovered and
+50 died, but dividing the cases at the end of the sixteenth year, we
+find that of the children below this age 43 recovered and 29 died, a
+mortality of 40.2 per cent.; of the adults, 10 recovered, and 21 died,
+or a mortality of 67.6 per cent.
+
+If we remember the marvellous power of recovery from joint diseases we
+find in childhood, under the influence of good diet, cod-liver oil, and
+fresh air, we cannot shut our eyes to the fact that such results and
+such a mortality are by no means encouraging.
+
+From an extensive experience in a special hospital for hip-disease,
+where fresh air, abundant nourishment, and very excellent nursing are
+provided, the author is learning more and more to trust to the power of
+nature in the cure of even very advanced cases of hip-disease in
+children, and he believes that operation is rarely necessary, or even
+warrantable, except for the removal of sequestra.
+
+     Mr. Holmes's[62] statistics are interesting. He has operated on no
+     fewer than nineteen cases. Of these seven died, one after secondary
+     amputation at the hip. Another required amputation and recovered.
+     Two others died of other diseases without having used their limb.
+     Of the remaining nine, three were perfectly successful, four were
+     promising cases, and two unpromising.
+
+     Professor Spence in 19 cases had 6 deaths, or a mortality of 31.6
+     per cent.
+
+     Culbertson's collection gives out of 426 cases, 192 deaths, or 45
+     per cent.
+
+     Mr. Croft, whose skill and success as an operator are well known,
+     has recorded 45 cases of excision of hip in his own practice; of
+     these 16 died, 11 were under treatment, 18 had recovered, of which
+     16 had moveable joints and useful limb; the other two are
+     "potentially cured."[63]
+
+     Various other incisions have been devised for gaining access to the
+     joint. The most noticeable are those in which a flap is made
+     instead of a linear incision. Sedillot makes a semilunar or ovoid
+     flap, the base of which is just below the great trochanter, and
+     which includes it, the convexity being upwards and the flap being
+     turned down. Gross's modification of this is preferable, being
+     turned the opposite way, the convexity being downwards (Plate III.
+     fig. E.), and the flap thus being turned up.
+
+_Results in successful cases._--Of fifty-two in Hodge's table,
+thirty-one had useful limbs, six indifferent, three decidedly useless,
+four died within three years, and of the remaining eight no details are
+given.
+
+The shortening is always considerable, a high-heeled shoe being required
+in most cases; a stick is indispensable; in many, crutches are
+necessary.
+
+     Various operations have been devised for the treatment of osseous
+     anchylosis of the hip-joint when in a bad position. All are more or
+     less dangerous. Perhaps one of the least dangerous is the plan of
+     subcutaneous division of the neck of the femur by a narrow saw,
+     proposed by Mr. Adams of London. It is sometimes a very laborious
+     operation.
+
+
+EXCISION OF KNEE-JOINT.--_Removal of Bone._--In every case the excision
+of the joint ought to be complete. Some attempts have been made to save
+one or other of the articular surfaces, but they have proved failures.
+The patella has frequently been left when it was not diseased, as is
+often the case, but the results have not been such as to recommend such
+a practice.
+
+_Direction of Section of the Bones._--The bones should be cut
+transversely, and, as far as possible, be in accurate and complete
+apposition. A slight bevelling at the expense of the posterior margin
+will produce an anchylosis of the limb in a very slightly flexed
+position, which is found to aid the patient in walking.
+
+It has been proposed by some[64] to cut both bones obliquely, so as to
+obviate the difficulty of making the transverse surfaces parallel. This
+involves a still greater practical difficulty in keeping these oblique
+surfaces in position during the after-treatment.
+
+This plan might possibly be valuable in cases where the disease was
+limited to one or other edge of the bone.
+
+Among the various incisions recommended, the best seems to be the
+_Semilunar Incision_.
+
+_Operation._--The limb being held in an extended position, a single
+semilunar incision (Plate I. fig. B.) is made, entering the joint at
+once, and dividing the ligamentum patellae. It should extend from the
+inner side of the inner condyle of the femur to a corresponding point
+over the outer one, passing in front of the joint midway between the
+lower edge of the patella and tuberosity of the tibia. The flap is then
+dissected back, the ligaments divided, when by extreme flexion of the
+limb the articular surface of the tibia and femur are thoroughly
+exposed. The crucial ligaments must then be divided cautiously, and the
+articular portion of the femur cleaned anteriorly by the knife,
+posteriorly by the operator's finger, so far as possible to avoid injury
+of the artery. The whole articular surface of the femur must then be
+removed by a transverse cut with the saw as exactly as possible at a
+right angle with the axis of the bone. The amount of the femur which
+will require removal will in the adult vary from an inch to an inch and
+a half or even more. It _must_ involve all the bone normally covered by
+cartilage; and this being removed, if the section shows evidence of
+disease, slice after slice may require removal till a healthy surface is
+obtained. Occasionally, if the diseased portion appears limited, though
+deep, the application of a gouge may succeed in removing disease without
+involving too great shortening of the limb. Specially in children, it is
+of great importance to avoid removing the whole epiphysis. The tibia
+must then be exposed in a similar manner, and a thin slice removed; if
+the bone be tolerably healthy, even less than half an inch will prove
+quite sufficient.
+
+This method has an immense advantage in that it provides an excellent
+anterior flap for the amputation, which may be required in cases where
+the disease of bone is found too extensive to admit of the excision
+being practised.
+
+This method, with slight deviations, is substantially that of Richard
+Mackenzie of Edinburgh, Wood of New York, Jones of Jersey.
+
+Haemorrhage must then be stopped, and that as thoroughly as possible, by
+torsion, cold, and pressure, and the flap brought accurately together
+with sutures.
+
+In some rare cases, it may be found necessary to divide the hamstring
+tendons to rectify spastic contraction of the muscles; but this can
+generally be done quite well from the original wound.
+
+Holt makes a dependent opening in the popliteal space for drainage. This
+is unnecessary if the incisions are made sufficiently far back, and if
+the wound is properly drained. It is unsafe, as approaching so close to
+the artery and veins. If much bagging takes place, the use of a
+drainage-tube will prove quite sufficient.
+
+_After-treatment._--Wire splints lined with leather and provided with a
+foot-piece; special box-splints with moveable sides, as Butcher's;[65]
+plaster-of-Paris moulds are used by Dr. P.H. Watson[66] of Edinburgh and
+others; this last form of dressing is the best, and allows the limb to
+be suspended from a Salter's swing.
+
+H-_shaped incision._--The internal incision should commence at
+a point about two inches below the articular surface of the tibia, and
+in a line with its inner edge; it should then be carried up along the
+femur in a direction parallel to the axis of the extended limb, so as to
+pass in front of the saphena vein, and thus avoid it, for a distance of
+five inches. The external incision, commencing just below the head of
+the fibula, must be carried upwards parallel to the preceding for the
+same distance. Both incisions must be made by a heavy scalpel with a
+firm hand, so as to divide all the tissues down to the bone. The
+vertical incisions are then united by a transverse one passing across
+just below the lower angle of the patella. The flaps thus formed must
+then be dissected up and down, and the internal and external lateral
+ligaments divided, thus thoroughly opening the joint and exposing the
+crucial ligaments. These must be divided carefully, remembering the
+position of the artery. The bones are then to be cleared and divided, as
+in the operation already described. This is the method of Moreau and
+Butcher.[67]
+
+_Patella and Ligamentum Patellae retained._--"A longitudinal incision,
+full four inches in extent, was made on each side of the knee-joint,
+midway between the vasti and flexors of the leg; these two cuts were
+down to the bones, they were connected by a transverse one just over the
+prominence of the tubercle of the tibia, _care being taken to avoid
+cutting by this incision the ligamentum patellae_; the flap thus defined
+was reflected upwards, the patella and the ligament were then freed and
+drawn over the internal condyle, and kept there by means of a broad,
+flat, and turned-up spatula; the joint was thus exposed, and after the
+synovial capsule had been cut through as far as could be seen, the leg
+was forcibly flexed, the crucial ligaments, almost breaking in the act,
+only required a slight touch of the knife to divide them completely. The
+articular surfaces of the bones were now completely brought to view, and
+the diseased portions removed by means of suitable saws, the soft parts
+being hold aside by assistants."[68]
+
+Results of Excision of Knee-joint:--Holmes's Table of recent cases from
+1873-1878--
+
+             245 cases; 25 deaths, and 47 failures.
+    Spence's--33 cases; 22 recovered, 11 died.
+
+
+BUCK'S OPERATION FOR ANCHYLOSED KNEE-JOINT.--The principle of this
+operation is to remove a triangular portion of bone, which is to include
+the surfaces of the femur and tibia, which have anchylosed in an awkward
+position, and by this means to set the bones free, and enable the limb
+to be straightened. Access to the joint may be obtained by either of
+the two methods already described. Sections of the bones are then to be
+made with the saw, so as to meet posteriorly a little in front of the
+posterior surface of the anchylosed joint, and thus remove a triangular
+portion of bone; the portion still remaining, and which still keeps up
+the deformity, is then to be broken through as best you can, either by a
+chisel, or a saw, or forced flexion. The ends are to be pared off by
+bone-pliers, and the surfaces brought into as close apposition as
+possible. The operation is a difficult one, a gap being generally left
+between the anterior edges of the bones, from the unyielding nature of
+the integuments behind, and the difficulty of removing the posterior
+projecting edges from their close proximity to the artery. Of twenty
+cases on record, eight died, and two required amputation.
+
+_Relation of Age to result in Excision of Knee-Joint from Hodge's
+Tables._
+
+Of 182 complete cases:--
+
+     68 below 16 years: 50 recovered--18 died; or 26 per cent. died.
+    114 above 16 years: 55 recovered--59 died; or 51.7 per cent. died.
+
+
+EXCISION OF THE ANKLE-JOINT.--_In what cases is it to be done, and how
+much bone is to be removed?_
+
+In cases of compound dislocation of the ankle-joint, the tibia and
+fibula are apt to be protruded either in front or behind. When this
+happens it is a dislocation generally very difficult to reduce, and when
+reduced to retain in position. In such cases, if there seems to be any
+chance of retaining the foot, excision of the articular ends of tibia
+and fibula greatly add to the probabilities in its favour. It may be
+done without any new wound, and, in general, by an ordinary surgeon's
+saw.
+
+When the astragalus does not protrude, it seems to matter little for the
+future result whether its articular surface be removed or not. When, on
+the other hand, it protrudes, as a result either of the displacement of
+the entire foot, or of a dislocation complete or partial of the
+astragalus itself, there is no doubt that excision either of its
+articular surface or of the entire bone will give very excellent
+results. Jaeger reports twenty-seven such cases, with only one fatal, and
+one doubtful result.
+
+_In cases of disease of the Ankle-joint._--Excision has been performed a
+good many times, and should in most cases be complete. A work like this
+is not the place to discuss the propriety of operations so much as the
+method of performing them, but one remark may be permitted. Few points
+of surgical diagnosis are more difficult than it is to tell whether in
+any given case disease is confined to the ankle-joint, and whether or
+not the bones of the tarsus participate. If they do even to a slight
+extent, no operation which attacks the ankle-joint only has any
+reasonable chance of success. It may look well for a time, but sinuses
+remain, the irritation of the operation only hastens the progress of the
+disease of the bone, and the result will almost certainly be
+disappointing, amputation being almost the inevitable _dernier ressort_.
+
+_Methods of Operating_:--
+
+_Mr. Hancock_ has been very successful by the following method:--
+
+Commence the incision (Plate II. figs. B.B.) about two inches above and
+behind the external malleolus, and carry it across the instep to about
+two inches above and behind the internal malleolus. Take care that this
+incision merely divides the skin, and does not penetrate beyond the
+fascia. Reflect the flap so made, and next cut down upon the external
+malleolus, carrying your knife close to the edge of the bone, both
+behind and below the process, dislodge the peronei tendons, and divide
+the external lateral ligaments of the joint. Having done this, with the
+bone-nippers cut through the fibula, about an inch above the malleolus,
+remove this piece of bone, dividing the inferior tibio-fibular
+ligament, and then turn the leg and foot on the outside. Now carefully
+dissect the tendons of the tibialis posticus and flexor communis
+digitorum from behind the internal malleolus. Carry your knife close
+round the edge of this process, and detach the internal lateral
+ligament, then grasping the heel with one hand, and the front of the
+foot with the other, forcibly turn the sole of the foot downwards, by
+which the lower end of the tibia is dislocated and protruded through the
+wound. This done, remove the diseased end of the tibia with the common
+amputating saw, and afterwards with a small metacarpal saw placed upon
+the back of the upper articulating process of the astragalus, between
+that process and the tendo Achillis, remove the former by cutting from
+behind forwards. Replace the parts _in situ_; close the wound carefully
+on the inner side and front of the ankle; but leave the outside open,
+that there may be a free exit for discharge, apply water-dressing, place
+the limb on its outer side on a splint, and the operation is completed.
+
+Skin, external, and internal ligaments, and the bones are the only parts
+divided, no tendons and no arteries of any size.[69]
+
+_Barwell's_ method by _lateral incisions_ is briefly as follows:--
+
+On the outer side, an incision over the lower three inches of the fibula
+turns forward at the malleolus at an angle, and ends about half an inch
+above the base of the outer metatarsal. The flap is to be reflected,
+fibula divided about two inches from its lower end by the forceps, and
+dissected out, leaving peronei tendons uncut. A similar incision on the
+inner side terminates over the projection of the internal cuneiform
+bone; the sheaths of the tendons under inner angle are then to be
+divided, and the artery and nerve avoided; the internal lateral
+ligament is then to be divided, the foot twisted outwards, so as to
+protrude the astragalus and tibia at the inner wound. The lower end of
+the tibia and top of the astragalus are to be sawn off by a
+narrow-bladed saw passing from one wound to the other.[70]
+
+Dr. M. Buchanan of Glasgow has described an operation by which the joint
+can be excised through a single incision over the external malleolus.
+
+_Results._--So far as can be gathered from cases already published, the
+results are very often (at least in one out of every two cases)
+unsatisfactory. Sinuses remain, which do not heal, the limbs are
+useless, and amputation is in the end necessary.
+
+Langenbeck has performed it sixteen times during the last
+Schleswig-Holstein war (in 1864), and the Bohemian war in 1866, with
+only three deaths. In these cases the operation was subperiosteal.
+
+
+EXCISION OF THE SCAPULA.--More or less of the scapula has in many cases
+been removed along with the arm, and even with the addition of portion
+of the clavicle.
+
+Excision of the entire bone, leaving the arm, has been performed in two
+instances by Mr. Syme. The procedure must vary according to the nature
+and shape of the tumour on account of which the operation is performed.
+Mr. Syme operated as follows:--
+
+In the first case, one of cerebriform tumour of the bone, he "made an
+incision from the acromion process transversely to the posterior edge of
+the scapula, and another from the centre of this one directly downwards
+to the lower margin of the tumour. The flaps thus formed being reflected
+without much haemorrhage, I separated the scapular attachment of the
+deltoid, and divided the connections of the acromial extremity of the
+clavicle. Then, wishing to command the subscapular artery, I divided
+it, with the effect of giving issue to a fearful gush of blood, but
+fortunately caught the vessel and tied it without any delay. I next cut
+into the joint and round the glenoid cavity, hooked my finger under the
+coracoid process, so as to facilitate the division of its muscular and
+ligamentous attachments, and then pulling back the bone with all the
+force of my left hand, separated its remaining attachments with rapid
+sweeps of the knife." (Plate III. fig. G.)
+
+Mr. Syme's second case was also one of tumour of the scapula; the head
+of the humerus had been excised two years before.
+
+He removed it by two incisions, one from the clavicle a little to the
+sternal side of the coracoid, directed downwards to the lower boundary
+of the tumour, another transversely from the shoulder to the posterior
+edge of the scapula. The clavicle was divided at the spot where it was
+exposed, and the outer portion removed along with the scapula.[71]
+
+The author has in a case of osseous tumour removed the whole body of the
+scapula, leaving glenoid, spine, acromion and anterior margin with
+excellent result and a useful arm.
+
+Large portions of the shafts of the humerus, radius, and ulna have been
+removed for disease or accident, and useful arms have resulted; but as
+the operative procedures must vary in every case, according to the
+amount of bone to be removed, and the number and position of the
+sinuses, no exact directions can be given.
+
+For very interesting cases of such resections reference may be made to
+Wagner's treatise on the subject, translated and enlarged by Mr. Holmes,
+and to Williamson's _Military Surgery_, p. 227.
+
+
+EXCISION OF METACARPALS AND PHALANGES.--To _excise_ the metacarpal
+implies that the corresponding finger is left. Except in cases of
+necrosis, where abundance of new bone has formed in the detached
+periosteum, the results of such excisions do not encourage repetition,
+the digits which remain being generally very useless. It is quite
+different, however, if it is the thumb that is involved; and every
+effort should, in every case, be made to retain the thumb, even in the
+complete absence of its metacarpal bone. For the good results of a case
+in which Mr. Syme excised the whole metacarpal bone for a tumour, see
+his _Observations in Clinical Surgery_, p. 38.
+
+The operation is not difficult, and requires merely a straight incision
+over the dorsum, extending the whole length of the bone.
+
+In the same way the proximal phalanx of the thumb may be excised, and
+yet, if proper care be taken, a very useful limb be left. I quote entire
+the following case by Mr. Butcher of Dublin:--
+
+
+EXCISION OF PROXIMAL PHALANX OF THE THUMB.--
+
+The thumb of the right hand was crushed by the crank of a steam-engine.
+The proximal phalanx was completely shivered; its fragments were
+removed, the cartilage of the proximal end of the distal phalanx, and
+also of the head of the metacarpal bone, were pared off with a strong
+knife. The digit was put up on a splint fully extended. In about a month
+cure was nearly complete, a firm dense tissue took the place of the
+removed phalanx, and the power of flexing the unguinal was nearly
+complete.[72]
+
+
+EXCISION OF THE JOINTS OF THE FINGERS.--These operations may be
+performed for compound dislocation, specially when the thumb is injured;
+no directions can be given for the incisions.[73]
+
+In cases of disease it is rarely necessary or advisable to attempt to
+save a finger, but if the metacarpo-phalangeal joint of the thumb be
+affected, excision should be performed with the hope of saving the
+thumb. A single free incision on the radial side of the joint will give
+sufficient access.
+
+
+EXCISION OF THE OS CALCIS.--In those comparatively rare cases in which
+the os calcis is alone affected, the rest of the tarsus and the
+ankle-joint being healthy, a considerable difference of opinion exists
+as to the proper course to be followed. By some surgeons it is
+considered best merely to gain free access to the diseased bone, and
+then remove by a gouge all the softened and altered portions, leaving a
+shell of bone all round, of course saving the periosteum and avoiding
+interference with the joint. This operation requires no special detailed
+instruction. We find many surgeons, among them Fergusson and Hodge,
+supporters of this comparatively modest operation. The author has many
+times performed this operation with excellent results. Even when nothing
+but periosteum is left, the new bone becomes strong and of full size.
+
+Excision of the whole of the diseased bone at its joints, with or
+without an attempt to leave some of the periosteum, has been deemed
+necessary by others. Holmes, who has had considerable experience,
+removes the bone at once by the following incisions, without paying any
+reference to the periosteum:--
+
+_Operation._--An incision (Plate III. fig. F.) is commenced at the inner
+edge of the tendo Achillis, and drawn horizontally forwards along the
+outer side of the foot, somewhat in front of the calcaneo-cuboid joint,
+which lies midway between the outer malleolus and the end of the fifth
+metatarsal bone. This incision should go down at once upon the bone, so
+that the tendon should be felt to snap as the incision is commenced. It
+should be as nearly as possible on a level with the upper border of the
+os calcis, a point which the surgeon can determine, if the dorsum of the
+foot is in a natural state, by feeling the pit in which the extensor
+brevis digitorum arises. Another incision is then to be drawn vertically
+across the sole, commencing near the anterior end of the former
+incision, and terminating at the outer border of the grooved or internal
+surface of the os calcis, beyond which point it should not extend, for
+fear of wounding the posterior tibial vessels. If more room be required,
+this vertical incision may be prolonged a little upwards, so as to form
+a crucial incision. The bone being now denuded by throwing back the
+flaps, the first point is to find and lay open the calcaneo-cuboid
+joint, and then the joints with the astragalus. The close connections
+between these two bones constitute the principal difficulty in the
+operation on the dead subject; but these joints will frequently be found
+to have been destroyed in cases of disease. The calcaneum having been
+separated thus from its bony connections by the free use of the knife,
+aided, if necessary, by the lever, lion-forceps, etc., the soft parts
+are next to be cleaned off its inner side with care, in order to avoid
+the vessels, and the bone will then come away.[74]
+
+Attempts may occasionally be made in such an operation to save a portion
+of periosteum in attachment to the soft parts, but success or failure in
+this seems to have very little effect on the future result.
+
+     _Hancock's Method._--A single flap was formed in the sole, with the
+     convexity looking forwards, by an incision from one malleolus to
+     the other.
+
+     _Greenhow's Method._--Incisions made from the inner and outer
+     ankles, meeting at the apex of the heel, and then others extending
+     along the sides of the foot, the flaps being dissected back so as
+     to expose the bone and its connections.[75]
+
+
+EXCISION OF ASTRAGALUS.--A curved incision on the dorsum of the foot
+extending from one malleolus to the other, and as far forwards as the
+front of the scaphoid. The chief caution required is to divide all
+ligaments which hold the bone in place, and dissect it clean on all
+other parts before meddling with its posterior surface where the groove
+exists for the flexor longus pollicis tendon near which the posterior
+tibial vessels and nerve lie.[76]
+
+
+EXCISION OF ASTRAGALUS AND SCAPHOID.--An incision similar to the
+anterior one in Syme's amputation at the ankle. The flap was then turned
+back from the dorsum of the foot. The joint was then opened, the lateral
+ligaments of the ankle-joint divided, the foot dislocated so as to show
+the astragalo-calcanean ligaments, and allow them to be divided. The
+bones were then grasped with the lion-forceps and pulled forwards, while
+the posterior surface of the astragalus was very cautiously cleaned, so
+as to avoid the posterior tibial artery.[77]
+
+
+EXCISION OF METATARSO-PHALANGEAL JOINT OF GREAT TOE.--Butcher performs
+it by splitting up the sinuses leading to the carious joint, exposing it
+and cutting off with bone-pliers the anterior third of the metatarsal
+bone, and the proximal end of the first phalanx. He also cuts
+subcutaneously the extensor tendons to prevent them from cocking up the
+toe.[78] Pancoast prefers a semilunar incision. A lateral incision is
+usually to be preferred.
+
+The author has performed this excision frequently for disease; when the
+whole cartilages are removed and the wound is freely drained, an
+admirable result is obtained.
+
+In cases of compound dislocation of the head of the metatarsal bone, it
+will occasionally be found necessary to excise it either by the
+original, or a slightly enlarged wound.
+
+The author lately excised one-half of shaft of metatarsal and the
+corresponding half of proximal phalanx of great toe for exostosis, with
+antiseptic precautions. The result was a useful toe with a _mobile
+joint_.
+
+
+EXCISION OF METATARSAL BONE OF GREAT TOE.--For this operation a
+quadrilateral flap has been recommended, but this is quite unnecessary.
+A single straight incision along the inner border of the foot, extending
+the whole length of the bone, renders it very easy to remove the whole
+bone from joint to joint. This is an operation, however, which is rarely
+needed, and which would leave a very useless flail of a toe. The
+operation, which is at once more commonly required, and also gives
+promise of a more satisfactory result, is the one performed for
+cario-necrosis of the shaft only, and in the following manner:--
+
+A straight incision through all the tissues, including the periosteum,
+right down to the bone; then with nail or handle of the knife to
+separate the periosteum from the bone; then with a pair of bone-pliers
+or a fine saw to divide the shaft from both its extremities and remove
+it entire.[79]
+
+
+FOOTNOTES:
+
+[52] _On Diseases and Injuries of Joints_, p. 121.
+
+[53] For a very large amount of most interesting and valuable
+information on the whole subject of excisions of joints, I would refer
+to Dr. Hodge's most excellent work on this subject--_On Excisions of
+Joints_. By Richard M. Hodge, M.D., Boston, Massachusetts.
+
+[54] See Syme's _Observations on Clinical Surgery_, pp. 55, 57; Hodge
+_on Excision of Joints_, p. 63.
+
+[55] Maunder's _Operative Surgery_, 2d ed. p. 123.
+
+[56] _Edin. Med. Journal_, May 1873.
+
+[57] Quoted by Mr. Porter. _Dublin Quarterly Journal_ for May 1867, p.
+264.
+
+[58] A-A. Deep palmar arch; B. Trapezium; C. Articular surface of ulna;
+Dotted lines include the amount removed in Lister's earlier operations;
+Unshaded portions are those removed by Lister in cases where the disease
+is limited to the carpus. (Reduced from Lister's diagram in _Lancet_,
+1865.)
+
+[59] Skey, _Op. Surg._, 2d ed. p. 438.
+
+[60] Abridged from Butcher, _Op. and Con. Surgery_, p. 208.
+
+[61] _Science and Art of Surgery_, 3d ed. p. 745.
+
+[62] _On the Surgical Treatment of Children's Diseases_, pp. 454-6.
+
+[63] _Clinical Society's Transactions_, vol. xiii. p. 71.
+
+[64] Billroth of Vienna and Pelikan of St. Petersburg, quoted from
+Heyfelder by Hodge _on Excision of Joints_, p. 161.
+
+[65] _Operative and Conservative Surgery_, pp. 28, 138.
+
+[66] _On Excision of Knee-Joint_, pp. 18, 20.
+
+[67] _Operative and Conservative Surgery_, p. 169.
+
+[68] Mr. Jones of Jersey, _Med. Chir. Trans._, vol. xxxvii. p. 68.
+
+[69] _Lancet_, Oct. 1, 1859.
+
+[70] Barwell _On Diseased Joints_, p. 464.
+
+[71] Syme _On Excision of the Scapula_, pp. 13-26, 1864.
+
+[72] Butcher's _Operative and Conservative Surgery_, p. 225.
+
+[73] For an excellent case, see Annandale on _Diseases of the Finger and
+Toes_, p. 261.
+
+[74] Holmes's _Surgery_, 3d edition, vol. iii. p. 771.
+
+[75] _Brit. and Foreign Med. Chir. Review_ for July 1853.
+
+[76] Mr. Holmes in _Lancet_ for February 18, 1856.
+
+[77] _Ibid._ for May 1865.
+
+[78] Butcher, _Operative and Conservative Surgery_, p. 354.
+
+[79] See Butcher, _Operative and Conservative Surgery_, p. 356.
+
+
+
+
+CHAPTER IV.
+
+OPERATIONS ON CRANIUM AND SCALP.
+
+
+TREPHINING AND TREPANNING are the names given to operations for the
+removal of portions of the cranium by circular saws which play on a
+centre pivot. When the motion is given to the saw simply by rotation of
+the hand of the operator, as is common in this country, it is called
+_trephining_; when (as used to be the case in this country, and still is
+on the Continent) the motion is given by an instrument like a
+carpenter's brace, the operation is called _trepanning_.
+
+The nature of the operation varies according to the nature of the case
+for which it is performed. Thus (1.) it may be performed through the
+uninjured cranium in the hope of evacuating an abscess of the diploe or
+dura mater, or of relieving pressure caused by suppuration in the brain
+itself, or by extravasation into the brain or membranes; or (2.) it may
+be required in cases of punctured and depressed fracture for the purpose
+of removing projecting corners of bone and allowing elevation of the
+depressed portions; or (3.) it is sometimes used to remove a circular
+portion of bone in cases of epilepsy in which pain or tenderness is felt
+at some limited portion of the cranium.
+
+1. _In cases where the cranium and its coverings are entire._--There are
+certain positions where, if it is possible, the trephine should _not_ be
+applied. These are the longitudinal sinus, the anterior inferior angle
+of the parietal bone, where the middle meningeal artery is in the way,
+the occipital protuberance, and the various sutures. These being
+avoided, a crucial incision is to be made through the skin, and its
+flaps reflected. The pericranium should then be raised from the centre,
+for a space large enough to hold the crown of the trephine. The
+pericranium should never be removed, but carefully raised and preserved,
+as its presence will greatly aid in the restoration of bone.[80] The
+centre pin should then be projected for about the eighth of an inch and
+bored into the bone. On it as a centre the saw is then worked by
+semicircular sweeps in both directions alternately, till it forms a
+groove for itself. Whenever this groove is deep enough the pin should be
+retracted, lest from its projection it pierce the dura mater before the
+tables of the skull are cut through. Were the cranium always of the same
+thickness, and even of similar consistence, the operation would always
+be exceedingly easy; but in both these particulars different skulls vary
+much from each other, and thus by a rash use of the instrument the dura
+mater may possibly be injured. The tough outer table is more difficult
+to cut than the softer and more vascular diploe, and the inner table is
+denser than either, but more brittle. In many old skulls, however, the
+diploe is wanting altogether, and the two tables are amalgamated, and
+often very thin.
+
+Great care must be taken in every case to saw slowly, to remove the
+sawdust, and examine the track of the saw by a probe or quill, lest one
+part should be cut through quicker than another. The last turns of the
+instrument must specially be cautious ones. When the disk of bone does
+not at once come away in the trephine, the elevator or the special
+forceps for the purpose will easily remove it. If the abscess,
+extravasation, or exostosis be then discovered and removed, all that
+remains is to remove any sawdust or loose pieces of bone, and possibly
+to smooth off any sharp edges of the orifice by an instrument called the
+lenticular. This is very seldom required, and now hardly ever used.
+
+2. _In cases of depressed or punctured fracture_ the trephine is
+occasionally required (when symptoms of compression are present) for the
+purpose of enabling the depressed portion to be elevated. It is unsafe
+to apply it to the depressed or fractured bone, lest the additional
+pressure of the instrument should cause wound of the dura mater or
+brain. It is generally applied on some projecting corner of sound bone
+under which the depressed portion is locked, and hence it is rarely
+necessary to remove a complete circular portion. In fact very many cases
+of such displacement may be remedied more easily by a pair of strong
+bone-forceps, or a Hey's saw, applied to remove the projecting portion
+of sound bone. The same precautions must be used as in the operation
+already described, and the sawing must be done even more cautiously, as
+it is rarely more than a semicircle that requires cutting.
+
+In former days trephining was a much more frequent operation than it is
+now, and apparently more successful. The reason of the greater apparent
+success can easily be found in the fact that it was performed in many
+cases merely as a precautionary measure against dreaded inflammation of
+the brain, which probably never would have appeared at all, and that the
+operation itself is one by no means dangerous. Very numerous
+applications of the trephine have been made in the same individual--two,
+four, six, and even in one case twenty-seven disks having been removed
+from the same skull, and yet the patients have survived.
+
+
+TUMOURS OF THE SCALP, _Removal of_.--By far the most frequent are the
+encysted tumours, or wens. These consist of a thick firm cyst-wall,
+which contains soft, curdy, or pultaceous matter, sometimes almost
+fluid, at others dry and gritty. They are loosely attached in the
+subcutaneous cellular tissue, and unless they have become very large, or
+have been much pressed on, are non-adherent to the skin.
+
+The treatment is thus very simple. They should merely be transfixed by a
+sharp knife, the contents evacuated, and the cyst seized by strong
+dissecting forceps and twisted out.
+
+If they have once become adherent, they must be dissected out in the
+usual manner, after the adherent portion of skin has been defined by
+elliptical incisions.
+
+In the case of large wens on visible parts of scalp or face, the author
+avoids scar, by the following plan:--
+
+Make a small incision, two lines at most, through skin only, then with a
+blunt probe separate the cyst from the skin subcutaneously; then,
+pulling it to the wound with catch-forceps, empty the cyst and gradually
+pull it out, as if taking out an ovarian cyst. No scar but a dimple will
+remain.
+
+
+FOOTNOTES:
+
+[80] See case by the author in the _Edin. Med. Jour._ for June 1868.
+
+
+
+
+CHAPTER V.
+
+OPERATIONS ON EYE.
+
+_Operations on the Eye and its Appendages._
+
+
+OPERATIONS ON THE LIDS.--
+
+[Illustration: FIG. VII.[81]]
+
+[Illustration: FIG. VIII.[82]]
+
+1. FOR ENTROPIUM OR INVERSION OF THE LIDS, OFTEN COMBINED WITH
+TRICHIASIS, IRREGULARITY OF THE CILIAE.--As in many cases the entropium
+seems to depend partly on a too great laxity of the skin of the lid,
+combined occasionally with spasm of the orbicularis, the simplest and
+most natural plan of operation is (_a_) to remove (Fig. VII. _a_) an
+elliptical portion of skin, extending transversely along the whole
+length of the affected lid, including the fibres of the orbicularis
+lying below it, and then to unite the edges with several points of fine
+suture. (_b_) An improvement on this in obstinate cases is proposed by
+Mr. Streatfeild (Fig. VIII.) He continues the same incision, but in
+addition removes a long narrow wedge-shaped portion of the tarsal
+cartilage, grooving it without entirely cutting it through, in such a
+manner that the retraction of the skin bends the cartilage backwards,
+thus everting to a very considerable extent the previously inverted
+ciliae.[83]
+
+2. ECTROPIUM is the opposite condition from entropium; in it the eyelids
+are everted and the palpebral conjunctiva is exposed.
+
+If the result of cicatrix, of a burn, or of disease of bone, the
+treatment must be varied according to circumstances, and in many cases,
+skin must be transplanted to fill the gap.
+
+In the more usual cases resulting from chronic inflammation the
+following simple operations are required:--1. In mild cases the excision
+of an elliptical portion of conjunctiva may suffice, the edges must not
+be left to contract, but should be brought carefully together. 2. In
+more chronic cases, where all the tissues of the lid are very lax, it is
+necessary to remove (Fig. VII. _b_) a V-shaped portion of lid and skin,
+and then stitch it very carefully up with interrupted sutures.
+
+
+TUMOURS OF EYELIDS.--1. _Encysted tumours; cysts of the lids; tarsal
+tumour._--Under these and similar names are recognised a very frequent
+form of disease, chiefly in the upper lid: small tumours which rarely
+exceed half a pea in size, convex towards the skin, which is freely
+moveable over them; they give no pain, and are annoying only from their
+bulk and deformity.
+
+_Operation._--Evert the lid, incise the conjunctiva freely over the
+tumour, insert the blunt end of a probe and roughly stir up the contents
+of the cyst, thus evacuating it. If the tumour is large and of old
+standing it may be requisite to cut out an elliptical or circular
+portion of its conjunctival wall. The probe may require to be reapplied
+once or twice at intervals of two or three days, and in certain rare
+cases it may be necessary as a last resource freely to cauterise the
+inside of the cyst with the solid nitrate of silver.
+
+In _no_ case is it ever necessary to excise the tumour from the outside
+of the eyelid; when this has been done in error there frequently remains
+an awkward and unsightly scar.
+
+2. _Fibrous cysts_, frequently congenital, are met with in one
+situation, just over the external angular process of the frontal bone.
+These are larger in size than the preceding, ranging from the size of a
+barley pickle to that of an almond. Their treatment is excision by a
+prolonged and careful dissection from the periosteum, to which they
+almost invariably are adherent.
+
+
+OPERATIONS ON THE LACHRYMAL ORGANS.--In a system of ophthalmic surgery,
+various operative procedures might be detailed under this head,
+authorised and sanctioned by old custom. Excision of a diseased
+lachrymal gland, and removal of stones in the gland or ducts, need no
+special directions for their performance, and the operation immediately
+to be described, under the head of Mr. Bowman's operation, is applicable
+in almost every one of the diseased conditions of the lachrymal canal,
+sac, and nasal duct, to the exclusion of all the older methods.
+
+_Mr. Bowman's Operation._--In cases of obstruction of the punctum,
+canaliculus, and nasal duct, resulting in watery eye, accumulation of
+mucus in the canal, and dryness of the nose, great difficulty used to be
+experienced in the treatment. To pass a probe along the punctum was
+extremely difficult, in fact, possible only with a very small one, while
+the common operation of opening the dilated sac, through the skin, and
+then passing probes through this artificial opening, was found quite
+useless from the rapid closure of the wound, unless the treatment was
+followed up by the insertion and retention of a style in the nasal
+duct. This was painful, unsightly, often unsuccessful; and even in some
+cases dangerous, from the amount of irritation, suppuration, and even
+caries of the nasal bones which is set up.
+
+The principle of Mr. Bowman's most excellent operation is, that the
+punctum, canaliculus, and nasal duct resemble in many respects the
+urethral passage, and in cases of stricture require to be treated on the
+same principle. If, then, it were possible to pass instruments gradually
+increasing in size through the seat of stricture, it would be gradually
+dilated. It is, however, in the normal state of parts, impossible to
+pass any instrument beyond the size of a human hair past the curve which
+the canaliculus makes on its entrance to the duct, hence the proper
+dilatation cannot be performed. Again, it is found that the puncta,
+specially the lower one, are themselves very often to blame, in cases of
+watery eye, sometimes because they are inverted or everted, more often
+because, sympathising with the lid, they are turgid, angry, and
+inflamed, pouting and closed like the orifice of the urethra in a
+gonorrhoea.
+
+Mr. Bowman found that by slitting up the inferior punctum and
+canaliculus as far as the caruncula, several advantages were
+gained:--(1.) The swollen, angry, displaced punctum no longer impeded
+the entrance of the tears; (2.) and chiefly when the canaliculus was
+slit up, the curve, or rather angle, which impeded the passage of
+probes, was done away with, and the nasal duct could be readily and
+thoroughly dilated.
+
+_Operation._--The surgeon stands behind the patient, who is seated, and
+leans his head on the surgeon's chest. The affected lid is then drawn
+gently downwards on the cheek, so as to evert and thoroughly expose the
+lower punctum. Into this the surgeon introduces a fine probe of steel
+gilt, the first inch of which is very thin, especially at the point, and
+deeply grooved on one side, exactly like a small (and straight) Syme's
+stricture director.
+
+Keeping the canal relaxed by relaxing his hold on the lid, the surgeon
+now gently wriggles the probe along the canaliculus, gradually
+stretching it as the probe advances, so as to avoid catching of the
+sides of the canal before the point of the instrument, till he is
+satisfied that it has fairly entered the nasal duct. He then stretches
+the eyelid, brings the handle of the probe out over the cheek so as to
+evert the punctum as much as possible, and then with a fine
+sharp-pointed knife enters the groove (Fig. IX.), and fairly slits up
+the punctum and the canal to the full extent. The incision should be as
+straight as possible, and through the upper wall of the canaliculus. A
+dexterous turn of the instrument upwards on the forehead will generally
+enable it to be passed at once fairly into the nose through the nasal
+duct, the usual rule being observed of passing it downwards and slightly
+backwards, the handle of the probe passing just over the supraorbital
+notch.
+
+[Illustration: FIG. IX.[84]]
+
+For several days after the operation the probe will have to be passed,
+both to prevent the wound in the canaliculus from healing up, which it
+is too apt to do, and also to gradually dilate the nasal duct if it has
+been previously strictured. Probes and directors of various sizes are
+required; in fact very much the same instruments (in miniature) as are
+required for the treatment of stricture of the urethra.
+
+Mr. Greenslade has invented a very ingenious little instrument, of
+which, through his kindness, I am able to show a woodcut (Fig. X.), for
+slitting up the canaliculus without having to fit the knife in the
+groove.
+
+[Illustration: FIG. X.]
+
+PTERYGIUM, the reddish fleshy triangular growth, with its base at the
+inner canthus, and its apex spreading to and often over the cornea,
+requires invariably a small operation for its removal. In most cases it
+will be found sufficient merely to raise the lax portion over the
+sclerotic with forceps, and divide it freely, removing a transverse
+portion. If it has encroached upon the cornea, the portion interfering
+with vision must be dissected off with great care and removed.
+
+In some cases, however, it has been found that after removal of a large
+pterygium, a retraction of the caruncle and the semilunar fold is apt to
+take place, which renders the eyeball unpleasantly prominent. To avoid
+this the pterygium may be carefully dissected up from its apex to near
+its base, and then displaced laterally either upwards or downwards, its
+apex and sides being stitched to a previously prepared site of
+conjunctiva.
+
+
+OPERATION FOR CONVERGENT STRABISMUS.--_Division of the internal
+rectus._--_Subconjunctival operation._--The spring-wire speculum (C)
+separating the lids, the surgeon divides the conjunctiva by a pair of
+scissors in a horizontal line (Fig. XI. A A) from the inner margin of
+the cornea, a little below its transverse diameter to the caruncle,
+then snipping through the sub-conjunctival tissue, he passes a blunt
+hook bent at an obtuse angle under the tendon of the internal rectus,
+and endeavours by depressing the handle to project the point of the hook
+at the wound. Then with successive snips of the scissors he divides the
+tendon on the hook, close to its sclerotic margin. Lest it should not be
+freely divided, various dips with the hook may be made to catch any
+stray fibres left untouched; but very great care should be taken not to
+wound the conjunctiva beyond the first horizontal cut in it. The tendon
+being divided satisfactorily, the edges of conjunctiva should be
+replaced, and the eye closed for a few hours.
+
+[Illustration: FIG. XI.[85]]
+
+The original operation of Dieffenbach, now rarely practised, consisted
+in making an incision, B B, across the tendon, then, by cutting the
+areolar tissue exposing the insertion of the tendon, and dividing it
+freely; after which the sclerotic in the neighbourhood was to be cleaned
+and any band of fibres divided. There are risks on the one hand of a
+most unseemly exophthalmos with divergent squint, and on the other of a
+retraction of the semilunar fold, so that the sub-conjunctival operation
+is always preferable.
+
+
+OPERATIONS FOR DIVERGENT SQUINT.--This very serious deformity is often
+the result of the operation for convergent squint, and is associated
+with a fixed, leering, and prominent eye, and frequently with most
+annoying double vision.
+
+1. In a simple case of primary divergent strabismus (very rare) it is
+sufficient simply to divide the external rectus in the manner already
+described for division of the internal.
+
+2. If secondary to an operation for convergent squint, the indication is
+to restore the cut internal rectus to a position on the sclerotic a
+little behind its previous one, as the cause of the divergence is found
+in a complete detachment of the internal rectus. This is attempted in
+various ways.
+
+(1.) _Jules Guerin_ carefully divided the conjunctiva over it, and
+sought for the remains of the internal rectus, freeing it from its
+attachments. He then passed a thread through the sclerotic on the
+_outer_ side of the globe, and by pulling on it and fixing it across the
+nose, rotated the eye inwards, in the hope that the remains of the
+internal rectus would secure a new attachment.
+
+(2.) _Graefe's modification_ of this is more certain. Without any minute
+dissection he merely separated the internal rectus, along with the
+conjunctiva, and fascia over it, so that it can be pulled forwards, then
+cut the external rectus, and inverted the eyeball to a sufficient extent
+by means of a thread passed through the portion of the tendon of the
+external rectus, which remains attached to the sclerotic. The risk of
+all these operations, in which both muscles are divided, is protrusion
+of the eyeball from the removal of muscular tension.
+
+(3.) _Solomon's operation for the radical cure of extreme divergent
+strabismus_,[86] is at first sight a very curious one. Without going
+into all the details, the steps are as follows:--
+
+_a._ A square-shaped flap, with its attached base at the nasal side, is
+raised, containing the remains of the inner rectus and its adjacent
+parts.
+
+_b._ A flap similar in shape and size, but different in the position of
+its attached base, is made on the other side of the cornea. It is made
+by dividing the external rectus just behind its tendon, and then
+reflecting forwards the tendon with its conjunctiva.
+
+_c._ These two flaps are united over the vertical meridian of the cornea
+by sutures, three generally being sufficient. This entirely hides the
+cornea for a time, but eventually shrivels and contracts, and the
+remnants are to be cut off with scissors three weeks after the
+operation.
+
+
+PUNCTURE OF THE CORNEA.--_Paracentesis of the Anterior
+Chamber._--_Tapping of the Aqueous Humour._--This very simple operation
+is in many cases extremely useful. In cases of corneal ulcer, the result
+either of injury or disease, where there is much pain in the bone, and
+evidence of tension of the globe, it gives great relief, and when
+repeated at short intervals greatly hastens a cure. Sperino of Turin
+recommends its frequent use in cases of chronic glaucoma.
+
+_Operation._--The surgeon stands behind the patient, who is seated; the
+lids being fixed, the upper by the surgeon's left hand, and the lower by
+an assistant, the cornea is punctured a little in front of the sclerotic
+margin, either with a broad needle, or, what is as good, a well-worn
+Beer's knife. Care must be taken on entering the knife, on the one hand,
+not to wound the iris, which is sometimes arched forwards in the cases
+of commencing glaucoma, and, on the other, fairly to enter the anterior
+chamber, not merely split up the layers of the cornea. On withdrawing
+the cataract knife, the aqueous humour gets out by its side, aided by a
+slight turn of the knife, sometimes with great force, and in much larger
+quantity than usual. If the operation has been done by a needle, a blunt
+probe requires to be introduced on the removal of the needle. Once
+punctured, the remarkable fact is that the same wound suffices for many
+succeeding tappings, which are effected by pressing the probe into the
+wound day after day, sometimes several times a day, with great relief
+to the symptoms. If the probe is to be used for succeeding evacuations,
+the operator must be careful to remember the exact spot at which the
+needle or knife was entered. To facilitate remembering it, it is best,
+when nothing prevents it, to operate always in the same spot. Sperino
+chooses the horizontal meridian of the cornea at the temporal side, at
+the junction of the cornea and sclerotic.
+
+
+CATARACT OPERATIONS.--Here we cannot enter into any discussion of the
+pathology of cataract and the varieties of it. Enough for our purpose to
+know that the lens is in some cases hard, in others soft, and that thus
+in the latter it may be removed piecemeal, and by a small incision,
+while in the former, removal must be almost entire, and by a larger
+opening.
+
+In cataract, the lens, which should be transparent, has become opaque,
+and the object of treatment is to get it out of the line of sight, to
+prevent it from obstructing, now that it can no longer assist sight.
+
+The operations used for this end may be classed under three heads:--
+
+1. _Operations for the removal of the lens out of the way without its
+removal from the eye._--These used to be extensively practised under the
+name couching, and are of two kinds,--_Depression_, where the lens is
+simply pushed down from its place by a needle; _Reclination_, in which
+it is shoved backwards (turning on its transverse axis) as well as
+downwards. These are relics of old surgery, and very rarely practised by
+any oculists of eminence, as, though easy to perform, and with very
+flattering immediate results, the risks of chronic inflammation of the
+whole globe and injury to the retina are very great.
+
+2. _For solution._--THE NEEDLE OPERATION.--Suitable (among other cases)
+especially in congenital cataracts in infants, and in cases of diabetic
+cataract.
+
+The principle of this operation is that the lens, once the capsule is
+freely opened in front and the aqueous humour admitted, is found rapidly
+to become absorbed and disappear, if the cataract has been a soft one.
+
+_Operation._--A needle with a lance-shaped head is to be used. It should
+be so made that the rounded shaft of the needle is just large enough to
+play freely in the wound made by the broader point, and yet not so small
+as to allow the aqueous humour to escape rapidly. The pupil has been
+dilated, the patient is lying on his back, and the globe is fixed by
+forceps attached to the conjunctiva of the inner side of the eye, and
+held by an assistant. The surgeon then enters the needle close to the
+sclerotic margin of the cornea, carries it fairly on in the anterior
+chamber, till the centre of the pupil is reached. He then, by bringing
+forward the handle, projects the point backwards against the anterior
+capsule, which he freely lacerates with the point and edge in several
+directions.
+
+In infants, where processes of repair go on very rapidly, the whole lens
+may be freely broken up. In diabetic cataract, or indeed in all cases of
+solution, where the patient is adolescent or adult, or the eye at all
+weak, only a small portion of the lens should be attacked at one
+sitting.
+
+The needle should then be withdrawn gradually and with great care, that
+the broad axis of the blade be in exactly the same position in which it
+entered, _i.e._ flat and parallel with the iris, lest the iris be
+wounded, entangled, or prolapsed.
+
+The eye is then to be closed for twenty-four hours; if there is much
+pain, atropia must be freely used.
+
+_Varieties in the Operation._--Some use two needles at once for breaking
+up the lens. Some surgeons prefer to enter the needle through the
+sclerotic; this complicates the operation and renders it less certain,
+as the point of the needle is of course out of sight in its progress
+between the iris and the lens.
+
+Even in children this operation requires in most cases to be repeated at
+least once, while in adults it may be required at short intervals for
+many months.
+
+3. _By Extraction._--In these operations the lens is at once removed
+from the eye--
+
+(1.) By linear, or perhaps, more correctly, rectilinear incision. This
+method is specially suited for cases of soft cataract.
+
+_Operation._--A fine spear-shaped needle is very cautiously introduced
+through the cornea, about a line from its outer margin, and the anterior
+capsule lacerated, and the lens broken up, great care being taken not to
+injure the posterior capsule. The pupil must then be kept freely
+dilated, the wound heals at once, and the aqueous humour reaccumulates.
+
+[Illustration: FIG. XII.]
+
+[Illustration: FIG. XIII.]
+
+From three to six days after this first operation, a linear incision
+(Fig. XII.) is made in the outer side of the cornea by a straight stab
+from a double-edged knife, or rather spear. The size of the incision
+must vary with the size and consistence of the lens, and can be
+regulated by the breadth of the knife and the distance to which it is
+entered. By careful withdrawal of the knife, in many cases a large
+portion of the soft lens can be removed along with it, and then what
+remains must be cautiously lifted out by a flat spoon introduced through
+the wound, and behind the remains of the lens.
+
+Care must be taken lest any of the lens substance remain in the wound;
+with this precaution the incision generally heals rapidly, and with much
+less risk of general inflammation of the ball than in the ordinary flap
+operation of extraction.
+
+     EXTRACTION OF SOFT CATARACT BY SUCTION.--Mr. T. P. Teale, of
+     Leeds,[87] has invented an instrument by which the removal of soft
+     cataract is made more easy, through a linear incision by suction,
+     applied through the medium of a hollow curette furnished with an
+     india-rubber tube and mouth-piece.
+
+     The curette is of the usual size, but is roofed in (instead of
+     being merely grooved) to within one line of its extremity, thus
+     forming a tube flattened above, but terminating in a small cup.
+     This is screwed into an ordinary straight handle, which is hollow
+     for a short distance, far enough to join with a second tube fixed
+     at right angles to the handle, and into which the india-rubber pipe
+     and mouth-piece, through which suction is to be made, is attached.
+     In many cases it seems to serve its purpose extremely well.
+
+     Certain points require attention:--1. That the puncture to admit
+     the curette is large enough; 2. That its end be sufficiently
+     rounded; 3. Its open end must be held in the area of the pupil, and
+     not allowed to pass behind the iris, else there is great risk of
+     the iris being drawn in. Among other advantages claimed by its
+     inventor, the chief seems to be a more thorough removal of the lens
+     than by the ordinary means, and consequently less risk of opaque
+     deposit in the posterior capsule.
+
+(2.) EXTRACTION BY FLAP.--When properly performed in a suitable subject,
+and when free from accident, this operation is one of the most
+thoroughly beautiful and satisfactory in the whole domain of surgery;
+but it is difficult, and liable to many risks which neither skill nor
+caution can completely guard against.
+
+It is required in many cases of hard cataract, which are amenable
+neither to solution nor linear extraction.
+
+_Operation_ must be considered in various stages:--
+
+_a._ To make a flap of cornea large enough to permit of the removal of
+the entire lens without pressure or bruising. To make it of cornea only,
+to prevent the escape of the vitreous, and to avoid injury of the iris.
+
+The great difficulty in making the required section of the cornea is,
+that we are debarred from using scissors or any ordinary knife or
+scalpel in making it, for this reason, that the sawing movements
+required in all ordinary cutting are inadmissible here, as any
+withdrawal of the blade, however slight, would permit evacuation of the
+aqueous humour, and at once be followed by prolapse of the iris before
+the knife. Hence we are compelled to make the requisite flap by one
+steady push of a knife, which, too, must be of such a shape as in its
+entrance constantly to fill up the wound it makes. Very various shapes
+and sizes of knives have been proposed, the one called Beer's knife
+being the sort of model or common parent from which all the others are
+derived. It is triangular in shape, with a straight back, about 12-10ths
+of an inch in length, and 4-10ths broad at the base of the blade,
+tapering at a straight edge from its base to its point, and also
+diminishing in thickness to the point.
+
+Considerable difference of opinion exists as to the relative merits of
+an upper or lower section of the cornea. The general view at present
+seems to be that an upper section is to be preferred; but in cases where
+the surgeon is not ambidexterous, it is better that he should make the
+section which lies easiest to his hand than attempt an upper section in
+a less favourable position.
+
+The patient should be placed flat on his back, the lids should be gently
+opened, the upper one by the surgeon, the lower one by his assistant,
+who is to press the lid downwards against the malar bone without
+exercising any pressure on the ball. The eye should be still further
+steadied by the conjunctiva and subjacent cellular tissue on the inner
+side being seized by a pair of catch-forceps, still with no downward
+pressure on the ball. The point of the knife must then be introduced
+about a line from the outer sclerotic margin of the transverse diameter
+of the cornea (Fig. XIII.), the blade being held parallel with the
+fibres of the iris, pushed steadily across the anterior chamber, and
+protruded as nearly as possible at the corresponding spot at the inner
+side of the cornea. The aqueous humour should not escape till the
+section is completed. If it does, the iris is almost certainly projected
+forwards and entangled in the blade of the knife, a most annoying
+accident, and one which is not easily remedied. The books tell us of
+various manoeuvres by pressure or otherwise, by which the iris may be
+pushed back. Practically, however, if it has once occurred it is not
+easily saved from being cut. If a small portion only is involved, it is
+not of much consequence; if a large portion be in danger, it is
+sometimes necessary to withdraw the knife before the section is
+completed, and finish it with a probe-pointed, curved bistoury.
+
+If, however, the flap is safely finished, the lids should be gently
+allowed to close for a few seconds.
+
+On opening them again the surgeon must decide whether the corneal flap
+is sufficiently large to allow the lens to come out without force; if
+not, he must enlarge it either by the narrow probe-pointed "secondary
+knife" or by a pair of sharp scissors. Occasionally the lens, and even a
+little vitreous humour, may escape at once on the section being
+completed, but this is not to be desired.
+
+_b._ _Laceration of the Capsule of the Lens._--This is performed by
+insinuating a sharp curved needle under the corneal flap, avoiding the
+iris, and then tearing up the anterior capsule through the dilated
+pupil, the chief point to be attended to being that the capsule be
+lacerated in its entire length.
+
+_c._ _Removal of the Lens._--This must be done with the most extreme
+caution and gentleness, lest the vitreous humour be also evacuated. The
+surgeon's object is to tilt the lens so as to turn it slightly on its
+transverse axis, and cause the edge nearest the section to rise out of
+the capsule and appear at the wound. This is best done by gentle
+pressure at the required spot by the back of the needle, or by a common
+probe. When the lens begins to protrude the pressure must be very,
+gentle, lest it be forced out suddenly and the vitreous follow it.
+
+Soft portions of the lens are apt to remain adherent to the wound in the
+cornea. These must be removed by scoop or probe.
+
+_Varieties in the method of Flap Extraction._--Jacobsen of Koenigsberg in
+every case gives chloroform. He always makes his flap in the boundary
+line of the cornea and the sclerotic, through a vascular structure, and
+he believes that union is on this account more rapid, and after
+extraction removes that portion of the iris which appears to have been
+most exposed to bruising during the exit of the lens.
+
+The operation of extraction may in many cases be either preceded or
+followed by iridectomy, as proposed by Mooren, Von Graefe, and others.
+The following operation seems to diminish the risks to a very great
+extent:--
+
+     _Professor Von Graefe's Operation._--The lids are separated by a
+     speculum, and the eyeball is drawn down by forceps placed
+     immediately below the cornea. The point of a small knife, of which
+     the edge is directed upwards, is inserted at a point fully half a
+     line from the margin of the cornea near its upper part, so as to
+     enter the anterior chamber as peripherally as possible. The point
+     should not be directed at first towards the spot for
+     counterpuncture; nor till the knife has advanced fully three and a
+     half lines within the visible portion of the anterior chamber,
+     should the handle be lowered and the point directed so as to make
+     a symmetrical counterpuncture, which will give the external wound
+     a length of four and a half or five lines. As soon as the
+     resistance to the point is felt to be overcome, showing that the
+     counterpuncture is effected, the knife must at once be turned
+     forward, so that its back is directed almost to the centre of the
+     ideal sphere of the cornea, whether the conjunctiva is transfixed
+     or not, and the scleral border is divided by boldly pushing the
+     knife onwards and again drawing it backwards. This portion of the
+     operation is concluded by the formation of a conjunctival flap a
+     line and a half or two lines in length. A section thus made is
+     almost perpendicular to the cornea, a circumstance much
+     facilitating the passage of the lens, and the line of incision is
+     nearly straight, so that the wound does not gape. The iris should
+     be excised to the very end of the wound, and the capsule most
+     freely opened by a V-shaped laceration. Any lens, even the hardest,
+     may then be removed without the introduction of an instrument into
+     the eye, but Von Graefe's experience shows it to be advisable to
+     assist the evacuation by the hook in about one case in eight. In a
+     certain number of cases the lens will escape without difficulty
+     when the operator presses on the posterior lip of the wound,
+     especially when the back of the spoon is made to glide along the
+     sclera; should this not occur, Von Graefe uses a peculiar blunt
+     hook, or occasionally, though rarely, a spoon. A compressing
+     bandage is applied, and replaced at intervals.[88]
+
+We are recommended to perform it in two sets of cases:--
+
+1. Those in which the eye is known to be unhealthy and liable to
+inflammations, specially of iris, retina, or choroid. In cases where the
+patient has already lost an eye, Von Graefe thinks iridectomy should
+always precede extraction. In the above, then, it is a precautionary
+measure, and, if convenient, should be performed three, four, or even
+six weeks before the extraction.
+
+2. It is recommended to be performed at the same time as extraction in
+all cases in which the operation has presented any special difficulties,
+or has not gone smoothly, _e.g._ in cases where the lens has required
+much force to expel it, either from the flap of cornea being too small,
+or from adhesions between the lens and capsule; or, again, in cases in
+which there is a tendency to prolapse of the iris, in which any of the
+cortical substance has been necessarily left behind, or in which old
+adhesions had existed between the iris and capsule, or between the
+cornea and iris.
+
+
+OPERATIONS FOR ARTIFICIAL PUPIL.--The cases are by no means unfrequent
+in which it is necessary to remove or destroy a portion of the iris to
+admit light to the retina. In cases of excessive prolapse of the iris
+after extraction of the lens, where the iris has formed adhesions to the
+wound, and still more frequently in cases where central opacities of the
+cornea have fairly occluded the natural pupil, the only chance for
+vision is to enlarge the old one, or make a new pupil by removal of the
+iris.
+
+Very various operations have been proposed, and exceedingly numerous and
+complicated instruments invented for this purpose. We can notice here
+only one or two of the most approved procedures:--
+
+1. _Incision_ is the simplest.
+
+This is practicable and effectual only in cases where the iris is so far
+healthy as still to retain its contractile power, and so far free from
+adhesions as to be able to make use of it. The best example of such a
+case is that of a cataract, in which after extraction a prolapse of the
+iris has occurred to such an extent as to obliterate the pupil, and
+where, at the same time, the only adhesions are to the wound, none to
+the cornea.
+
+_Operation._--A double-edged needle is introduced through the cornea
+near its margin; on arriving at the place where the pupil ought to be,
+one edge is drawn against the iris, and divides it transversely, if
+possible, without injuring the lens; the fibres of the iris start back,
+contract, so that a sufficiently large central pupil may be obtained.
+
+2. _Excision._--In the far more frequent cases in which there exist
+adhesions between iris and cornea, or iris and anterior capsule,
+incision is not sufficient, and it is necessary to excise a portion of
+the iris.
+
+The simplest and safest operation is the following:--
+
+The patient recumbent, and the lids held apart by a speculum, the
+eyeball should be steadied by the forceps of an assistant. A broad
+cutting needle should then be introduced at the lower or outer edge of
+the corneal margin. This must be very gently withdrawn so as to retain
+as much aqueous humour as possible. Into the wound thus made the surgeon
+must introduce the blunt hook (known as Tyrrell's) at first with its
+point forwards, then, on arriving opposite the edge of the pupil, which
+it is intended to enlarge or replace, with its point turned backwards,
+so as to hook over the edge of the iris and thus drag on it. Once the
+hook has fairly got hold, it must again be rotated forwards, and
+withdrawn in the same direction as it was put in. The iris thus pulled
+out of the wound is to be cut off with a pair of fine scissors, so as to
+remove a sufficient amount to make a new pupil of the required size.
+
+But in those cases in which the whole or greater part of the pupillary
+margin is adherent, the blunt hook will not do, because there exists no
+edge round which to hook it. One of two plans is generally chosen to
+remedy this:--
+
+(1.) A free incision made with a double-edged needle; through this a
+pair of canula forceps is introduced, with which a portion of iris is
+seized and dragged to the external wound; it can then either be cut off
+or tied (see _Iridesis_); or,
+
+(2.) A previous attempt may be made to free a portion to form an edge to
+catch hold of, either by incision or by _Corelysis_ (_q.v._)
+
+
+IRIDESIS.--_Critchett's Operation of Ligature._[89]--Patient being put
+under chloroform, the ball is fixed by the wire speculum, and also by a
+fold of conjunctiva being seized by forceps. An opening is then made
+with a broad needle through the margin of the cornea, _close_ to the
+sclerotic, just large enough to admit the canula forceps, with which a
+small portion of iris close to its ciliary attachment is seized and
+drawn out; a piece of fine floss silk, previously tied in a small loop
+round the canula forceps, is slipped down and carefully tightened round
+the prolapsed portion. This speedily shrinks, and the loop may generally
+be removed about the second day. The chief advantage claimed for this
+method is the ease with which the size of the new pupil can be
+regulated. It is also suitable in cases of conical cornea, where it is
+wished to change the form of the pupil into a narrow slit.
+
+_N.B._--The ends of the ligature must be left sufficiently long to avoid
+any risk of their being drawn out of sight into the substance of the
+cornea, or even into the ball, by retraction of the fibres of the iris.
+
+
+CORELYSIS.--_Freeing of the Pupil._--An operative procedure for
+separating posterior adhesions of the iris to the lens. In it the
+surgeon hopes to act, not on the iris, as in the operations for
+artificial pupil, but only on the bands of false membrane which distort
+the pupil.
+
+The operation is briefly as follows:--The eye being firmly held by a
+wire speculum, and forceps pinching up the conjunctiva, a broad needle
+is passed rapidly through the cornea at a point which may give easy
+access to the adhesion to be torn through. This point is generally at
+the opposite margin of the irregular pupil, so that the needle may pass
+through the cornea in front of the one side of the iris, then through
+the orifice of the pupil, so as to reach the back of the other side. The
+needle is withdrawn gradually, so as to lose as little of the aqueous
+humour as possible, and then the spatula hook, called after the inventor
+of the operation, Mr. Streatfeild, is introduced. It is used first as a
+spatula, that is, with its blunt, though polished edge, to separate the
+adhesions, and if this is unsuccessful, as a hook (FIG. XIV.), so as to
+catch and tear them. In cases which resist the instrument used in both
+of these ways, Mr. Streatfeild has used very fine canula-scissors to cut
+the adhesions.[90] Such a further complication of the operation
+practically alters its character into an operation for artificial pupil,
+_q.v._
+
+[Illustration: FIG. XIV.[91]]
+
+
+IRIDECTOMY.--In cases of acute glaucoma, irido-choroiditis, and all deep
+inflammations of the eye in which the ocular tension is increased, also
+in certain cases of flap extraction already alluded to, the operation of
+iridectomy as originally proposed by Von Graefe will be found of use.
+
+_Operation._--The patient recumbent, and the eye absolutely fixed by
+speculum and forceps, a linear incision, varying in length from
+one-sixth to one-fourth of an inch, is made just at the margin of the
+cornea. The point of election is the upper pole of the cornea. The lens
+must not be wounded. The best instrument for making the section is an
+ordinary linear extraction knife, bent at an angle to admit of its being
+introduced from above. The iris will protrude through the wound, or, if
+adherent, must be drawn out by forceps, and then is to be cut off with
+scissors. The operation is rarely successful, unless a third, or at
+least a fourth, of the iris be removed.
+
+
+EXCISION OF A STAPHYLOMATOUS CORNEA.--There are certain cases in which
+the whole or greater part of the cornea bulges forward in a great blue
+projecting tumour. It is very ugly as it protrudes between the lids and
+prevents their closure; besides this, from its exposure it frequently
+inflames, even ulcerates, and has a most injurious effect on the other
+eye. In the cases suitable for operation vision is completely gone,
+without hope of its restoration by any operative procedure.
+
+The best thing for the patient is to have just enough of the staphyloma
+removed to enable the remains of the eyeball to form a good stump for an
+artificial eye. Various means have been suggested for doing this,
+varying in extent and severity from a mere shaving off the apex of the
+staphyloma to excision of the whole eyeball.
+
+By far the best method of operating is the one proposed and practised by
+Mr. Critchett.
+
+[Illustration: FIG. XV.[92]]
+
+[Illustration: FIG. XVI.[93]]
+
+The object of it is to remove an elliptical portion of the front of the
+staphyloma, or the whole staphyloma, when it is possible, and at the
+same time to prevent as far as possible the escape of the vitreous.
+
+_Operation._--Three, four, or five small curved needles armed with
+thread are passed through the staphyloma from above downwards, being
+each entered a little above the line of the intended upper incision, and
+brought out a little below the line of the intended lower one (Fig. XV.)
+
+To remove the included elliptical portion, Mr. Critchett pierces the
+sclerotic with a Beer's knife, just in front of the tendinous insertion
+of the external rectus. Through this incision a pair of probe-pointed
+scissors is introduced, and the piece cut just within the points of the
+needles. On the removal, the needles, which have retained the vitreous
+by their pressure, are drawn through and the threads cautiously tied.
+
+Union by first intention very often occurs, and an excellent stump is
+left with a narrow depressed transverse cicatrix[94] (Fig. XVI.)
+
+
+EXTIRPATION OF THE EYEBALL.--1. _Of the Eyeball only._--A circular
+incision should be made with curved scissors through the conjunctiva, a
+little beyond the corneal margin, then, beginning with the external
+rectus, muscle after muscle should be raised with the forceps, and
+divided, after which the optic nerve is cut through with the scissors. A
+slight preliminary extension outwards of the optic commissure will
+facilitate the dissection, and must be secured with metallic sutures;
+any vessels should be tied, and the orbit filled up with a light
+compress of charpie secured with a bandage.
+
+2. _Of the contents of the Orbit._--This may be required for malignant
+disease, but with a very poor prognosis. The optic commissure should be
+freely divided, and then, by bold strokes of curved scissors, or curved
+probe-pointed bistoury, the orbit may be fairly emptied by scooping out
+its contents. Even the periosteum may require to be scraped off, and the
+optic nerve divided as far back as possible. The haemorrhage may be
+pretty smart, but can generally be easily checked by compresses; if
+necessary, these can be soaked in the solution of the perchloride of
+iron.
+
+The author has done this operation many times, in cases extensive and of
+old standing, for malignant disease, melanotic and encephaloid. All have
+recovered, and in no instance has there been any trouble in stopping the
+bleeding.
+
+
+FOOTNOTES:
+
+[81] _a._ Elliptical incision for entropium; _b._ wedge-shaped incision
+for ectropium.
+
+[82] Fig. VIII. illustrates Streatfeild's operation for entropium.--_a._
+section of skin; _b._ section of levator palpebrae; _c._ section of
+cartilage of lid; _d._ section of conjunctiva; _e._ wedge-shaped portion
+excised.
+
+[83] _Ophthalmic Hospital Reports_, vol. i. p. 121.
+
+[84] Rough diagram of Bowman's operation, showing the grooved director
+in the punctum, and the knife in the groove just before it slits up the
+canaliculus.
+
+[85] Diagram of operations for convergent squint--A A, line of
+sub-conjunctival incision; B B, line of Dieffenbach's operation; C, wire
+speculum.
+
+[86] _The Radical Cure of Extreme Divergent Strabismus._ J. Vose
+Solomon, F.R.C.S., 1864.
+
+[87] _Ophthalmic Hospital Reports_, vol. iv. part ii. p. 197.
+
+[88] _Biennial Retrospect_ for 1865-66. Syd. Soc. pp. 363-4. For a
+thorough discussion of the merits of this operation, see papers by Von
+Graefe in _Brit. Med. Jour._ for 1867, vol. i. pp. 379, 446, 499, 657,
+765.
+
+[89] _Ophthalmic Hospital Reports_, vol. i. p. 224.
+
+[90] Streatfeild on Corelysis. _Ophthalmic Hospital Reports_, vol. ii.
+p. 309.
+
+[91] _a_ iris; _b_ lens; _c_ cornea. The hook is seen applied to the
+adhesion between lens and iris.
+
+[92] The staphyloma with the needles inserted, the lids held asunder by
+a spring speculum. The elliptical dotted line shows the amount to be
+removed; the vertical one, the position of the preliminary incision with
+the Beer's knife.
+
+[93] Resulting stump after the stitches are inserted.
+
+[94] _Ophthalmic Hospital Reports_, vol. iv. part 1.
+
+
+
+
+CHAPTER VI.
+
+OPERATIONS ON THE NOSE AND LIPS.
+
+
+RHINOPLASTIC OPERATIONS.--The operations for the restoration or repair
+of lost or mutilated noses are so various, and the minuteness of detail
+necessary for full description of them so great, that a complete account
+in a manual such as this is impossible; a brief notice of some of the
+most important varieties of the operation is all that can be given.
+
+_Principles._--1. It is necessary in every case that a suitable edge be
+prepared on which to fix the flap of skin, however obtained. To be
+suitable, this edge, should be (_a_) made in healthy skin, not in old or
+weak cicatrices; hence no trace of the original disease should be left;
+(_b_) it should be made thoroughly raw, by the removal of an appreciable
+amount of its edge; it should be pared, not merely scraped.
+
+2. It is useless to attempt to restore a nose unless the patient is in
+good general health, well nourished, and perfectly free from all remains
+of disease in the nose or its neighbourhood. The flaps which are to form
+the new nose may be obtained either from (1.) the cheeks; (2.) the
+forehead; (3.) a distant part either of the patient or of another
+person.
+
+(1.) _From the Cheeks._--When the cheeks are healthy, and specially if
+they are tolerably full and lax, the flaps from the cheeks produce much
+the most satisfactory result. As performed by Mr. Syme, the operation
+consists in the shaping of two equal flaps (A, A) from the skin of the
+cheek at each side, having the attachment above. A site for each flap is
+formed by the careful paring away of the whole thickness of the edge of
+the cavity of the lost organ (see Fig. XVII.)
+
+[Illustration: FIG. XVII.[95]]
+
+The flaps are then raised from their attachments to the upper jaw-bone,
+and approximated in the middle line by several points of metallic suture
+and the outer edges stitched to the raw surface on each side at a proper
+distance from the nasal orifice. If any septum remains of the old nose,
+it may be made very useful as a fixed point, a straight needle being
+thrust through one flap close to its outer lower edge, then through the
+septum, and out at a corresponding point of the other flap. The edges of
+the wound left in the cheek at each side can generally be, to a certain
+extent, approximated by silver stitches (B, B) and the triangular
+portion (C, C), which is necessarily left to heal by granulation, proves
+an advantage, as by its depression it enhances the apparent height and
+prominence of the new organ. The cavity should be very gently distended
+with lint, and may be supported by the blades of a small pair of
+forceps, applied so as to embrace the nose.
+
+(2.) _From the Forehead._--The Indian operation may be used as a last
+resource, in cases where, from disease, the cheeks also have suffered,
+and are not to be trusted to for flaps.
+
+_Operation._--1. It should be decided as to the shape and size of the
+portion of skin necessary, by fitting on pieces of soft leather or
+moulding wax. To allow for shrinking, the flap should be made at least
+one-third larger than is at first apparently necessary. The exact
+boundaries of the flap to be raised should then be marked out on the
+forehead by lightly pencilling it with nitrate of silver, the mark from
+which is not effaced by blood, as is sure to be the case with an ink
+line. Various shapes have been proposed for the flap varying in length
+of neck, in the shape of the angles, and especially in the arrangements
+made for the formation of a columna. Some (as Liston) prefer afterwards
+to provide for the columns separately, by a flap raised from the upper
+lip in a subsequent operation. The flap is then to be raised from the
+forehead, care being taken not to injure the periosteum. The incision is
+to be carried lower down on the side (generally the left), to which the
+flap is to be twisted. The flap is then to be brought round (Fig.
+XVIII.) and carefully fitted on to the edges previously prepared for its
+reception. The neck must be left as lax as possible, lest by tight
+twisting the supply of blood be cut off, and the flaps thus deprived of
+nourishment. Both silk and metallic sutures are recommended. Hamilton of
+Dublin,[96] after a large experience of both, prefers the former.
+
+[Illustration: FIG. XVIII.[97]]
+
+There are various risks; sloughing of the whole flap at once, shrinking
+of it after weeks or even months; certain inevitable drawbacks, as the
+cicatrix on the forehead, the very various and ludicrous changes of
+colour to which the new organ is subject,--these cannot be remedied by
+further operation. Two points generally require a second use of the
+knife a few weeks after:--(1.) The neck of the flap is sure to be
+redundant and prominent, but can be pared. (2.) The columna almost
+always requires improving, and, in Liston's method, to be made. He pared
+the inner surface of the apex of the nose, and then raised a central
+flap of the lip in the middle line, about a quarter of an inch broad,
+and extending from the remains of the old septum to the free border,
+raising it from the gum, and stitched the free end of it to the prepared
+apex, bringing together the two divided portions of the lip by ordinary
+harelip sutures. Tho columna, if redundant, could be shaved down, and it
+was found that the mucous surface very quickly became like skin on
+exposure.
+
+For other points with regard to the operation, reference may be made to
+the works of Liston and Skey, and Hamilton's monograph, referred to
+above.
+
+_Note._--The tongue and groove suture proposed by Professor Pancoast,
+and recommended by Professor Gross, is said to be specially suitable for
+such plastic operations. It is very complicated, as it requires one edge
+to be bevelled to a wedge shape, the other being grooved to include the
+wedge, thus opposing four raw surfaces, which are retained in contact by
+being transfixed by fine silk sutures.
+
+(3.) There are certain cases in which neither cheeks nor forehead are
+available for flaps, and yet the patients press very much for some
+operation. If they have patience and determination, the Taliacotian or
+Italian operation may be attempted.
+
+Without going into detail, the principle of it is as follows:--1. A
+piece of skin of suitable size was marked out over the left biceps, and
+defined by two longitudinal incisions, and raised from the subcutaneous
+cellular tissue, thus being left attached by its two ends only; a piece
+of linen was pulled below it. 2. After a few days the upper end was also
+divided, and the flap thus contracted. In a few days more the sides of
+the old nose were made raw, and the upper free surface of the flap also
+made raw and stitched to them, the arm being fastened up by a most
+elaborate series of bandages. 3. After a fortnight in this position, the
+last attachment of the flap to the arm was severed, and the new nose
+could then be modelled at pleasure.
+
+The literature of the subject is exceedingly curious, especially the
+cases in which the new material was obtained from an accommodating
+friend or servant.
+
+
+OPERATIVE TREATMENT OF LUPUS.--We may here notice a mode of treatment
+which has admirable results. The patient being put deeply under an
+anaesthetic, the surgeon with a sharp spoon carefully pares away all the
+diseased tissues, and then destroys the base either by nitric acid or a
+strong solution of chloride of zinc. The author has done this in a great
+number of cases with excellent effect.
+
+
+NASAL POLYPI, _Removal of._--Of these there are different kinds.
+
+1. ORDINARY MUCOUS POLYPI.--These grow from the spongy bones, generally
+the superior one, are non-malignant in their character, soft and
+vascular, often fill up the whole of both nasal cavities, and frequently
+hang down behind into the pharynx. The practical point to remember is
+that, however large and numerous they may be, they _invariably_ have
+their origin from a comparatively limited spot, the edge of the spongy
+bone, and _always_ hang from a narrow neck. Hence the treatment is easy
+and satisfactory, if the neck be attacked, and not the body of the
+tumour.
+
+Slightly curved, narrow-bladed forceps should be passed along by the
+side of the superior spongy bone, with their blades open, till the neck
+of the polypus is seized. Holding it firmly, the forceps should then be
+slowly twisted round till the neck is destroyed and the polypus
+detached. This should be repeated till the patient can blow freely
+through both nostrils. If attempts are made to seize the body of the
+polypus, it will break down under the forceps, bleed, and give much
+trouble.
+
+2. THE FIBROUS POLYPUS.--This form is fortunately much more rare than
+the other. It is almost invariably single, is attached to the posterior
+margin of the nares by a narrow but very strong root, is extremely firm
+in consistence, may grow to a large size so as to obstruct both
+nostrils, generally gives rise to severe and frequent haemorrhages. The
+haemorrhage _during_ any attempt to remove it is generally of the most
+severe character, but ceases _immediately_ on its complete detachment.
+
+We owe nearly all that we do know about the treatment of this form of
+polypus to Mr. Syme. His method is--By the ordinary polypus forceps
+described already, he seized the tumour through the nostril, and then
+with the fore and middle fingers of the left hand introduced behind the
+soft palate, he attacked the point of attachment, and by his nails,
+aided by the forceps, detached it from its narrow base.[98]
+
+3. MALIGNANT POLYPI should not be meddled with unless it is absolutely
+certain that the whole of the bone from which they grow can be removed
+also. This is very rarely the case. (See _Excision of Superior
+Maxilla_.)
+
+
+OPERATIONS ON THE LIPS.--1. Epithelial cancers of the lower lip are very
+frequent, and require removal.
+
+If the tumour or ulcer is small, and involves a considerable thickness
+of the lip, it is most easily removed by a V-shaped incision (Fig. XIX.
+A B A). Its shape permits the most accurate apposition of the cut
+surfaces; and if the lips are full and the tumour small, very slight
+trace of the operation will remain.
+
+[Illustration: FIG. XIX.[99]]
+
+Again, if the tumour be more extensive, involving a large portion of the
+prolabium, and yet not extending deeply into the substance of the lip,
+it may be very easily removed by a pair of curved scissors, applied in
+the direction shown in the diagram (Fig. XX. A B). The skin must then be
+stitched to the mucous membrane by numerous points of interrupted
+suture.
+
+[Illustration: FIG. XX.[100]]
+
+But if the tumour be at once extensive and deep, mere removal is not
+sufficient, but some provision must be made for supplying the blank left
+by the operation.
+
+In cases where a third, or even a half, of the lower lip has thus been
+removed, it may be found sufficient freely to dissect what is left of
+the lip from the gums, and thus approximate the cut surfaces in the
+middle line.
+
+This alone, however, would so much diminish the buccal orifice, and
+twist its corners, as to cause great deformity. The addition of an
+incision horizontally outwards, at one or both angles of the mouth,
+will do away with such risk, and allow the surfaces to come together
+without puckering; while by stitching the skin and mucous membrane
+together in the course of these horizontal incisions, we can increase
+the size of the buccal orifice almost _ad libitum_.
+
+Lastly, when the lower lip has been entirely removed, it is still
+possible to supply its place in the following manner, which was devised
+by Mr. Syme: The tumour being fairly isolated by a V-shaped incision
+(Fig. XXI.) C A C including the whole thickness of the lip, each of the
+incisions should be prolonged downwards and outwards, as shown by the
+dotted lines A D, A D. The flaps thus marked out must be separated from
+the bone, brought upwards, and approximated in the middle line. Possibly
+it may be necessary still further to enlarge the buccal orifice by short
+lateral incisions, C C. Whether these are required or not, silk
+stitches are to be introduced to unite the skin and mucous membrane
+along the lines A C. The gap left between D B D must be left to
+granulate, but in most cases may be very much diminished in size by
+additional sutures at its outer corners, near D. The granulating surface
+E E very rapidly heals up, leaving a dimple on each side, which rather
+improves the appearance, by adding to the prominence of the chin, B.
+
+[Illustration: FIG. XXI.[101]]
+
+[Illustration: FIG. XXII.[102]]
+
+THE OPERATIONS FOR HARELIP, though all conducted on the same general
+principles, vary considerably in extent required according to the
+position and size of the fissure or fissures to be remedied.
+
+1. _For Single Harelip._--Where the fissure extends only from the
+prolabium up to the attachment of the lip to the gums: this is very
+easily remedied, the chief risk being lest the surgeon should not remove
+enough of the edges of the fissure.
+
+_Operation._--Bleeding being controlled by an assistant, the surgeon
+fixes a pair of spring artery forceps into the mucous membrane and skin
+at the salient angle at each side of the fissure. Taking one of these in
+his left hand, he puts the edge to be pared on the stretch, and then
+with a sharp narrow straight bistoury he transfixes the lip at the point
+just beyond the upper angle of the fissure, and cuts outwards, being
+careful to remove the whole thinner part of the lip, and to leave the
+edge rather concave than convex. If left convex, or even quite straight,
+there is a risk that, after union has taken place, an angle remain
+showing the position of the cleft. The same is then to be done on the
+other side. The bleeding is then to be controlled by twisting the larger
+vessels, and if oozing still continues from the smaller ones, a pad of
+lint should be placed in the wound, and a few minutes' delay given, as,
+to facilitate immediate union, it is of the greatest importance that all
+haemorrhage should have ceased before the edges are brought together.
+
+When the bleeding has ceased, the edges should be approximated by two or
+more points of interrupted metallic suture inserted very deeply through
+the tissues, and taking a good hold of the edges of the wound. If the
+edges do not fit accurately, one or two horse-hair sutures will help.
+Some surgeons still prefer the old harelip needles secured by a
+figure-of-eight suture. A silk suture inserted through the prolabium is
+of great advantage, as it keeps the inner surface of the wound closed,
+which without it is very apt to be kept open by the pressure of the
+teeth or gums, and in infants by the movements of the tip of the tongue.
+
+     Various methods have been devised to utilise, if possible, the
+     portion of the edge of the lip which is separated during the
+     operation of refreshing the edges, for the purpose of filling up
+     the sort of cleft or gap which is apt to be noticed at the edge of
+     the prolabium. The most ingenious and simplest of these is that
+     proposed by M. Nelaton, for use in cases where the fissure does not
+     extend so far up as the nose. It consists in leaving the two
+     portions which are pared off (Fig. XXIII.) the sides of the cleft
+     attached to each other as well as to the free edge of the lip, then
+     pulling them down, so as to bring their bleeding surfaces into
+     apposition, and make a diamond-shaped wound instead of a triangular
+     cleft (Fig. XXIV.) When brought together by sutures a projection is
+     left at the edge of the lip; this, in most cases, disappears; if it
+     does not, it can easily be pared down.
+
+[Illustration: FIG. XXIII.[103]]
+
+[Illustration: FIG. XXIV.[104]]
+
+2. When the fissure, though single, extends upwards into the nose, the
+operation is more difficult, and the result frequently less
+satisfactory. The first thing to be done is to separate the lips from
+the gums, so as to make them more freely mobile. The whole edges of the
+cleft require refreshing.
+
+3. _Double Harelip_, without bony deformity, and where the intervening
+portion of the skin is vertical, does not project, and can be made
+useful for the new lip. Such cases are not very common, but when they do
+occur the question arises, How are they to be managed--in two separate
+operations or at once? I believe, in every case, at once. The central
+wedge-shaped portion is not large enough to extend downwards as far as
+the prolabium, but still should not be removed altogether, as it may be
+of great use, especially in bearing the columna nasi, and allowing its
+full development. The edges should be pared in the same way, and to the
+same extent as in single harelip, with the addition that the intervening
+portion should have its edges completely removed, and be left in the
+form of a wedge, with its apex downwards. The highest suture should be
+passed through first one side, then the base of the wedge, and then the
+other side; the second one through both, and the apex of the wedge; and
+a third should unite the prolabium, not including the wedge.
+
+[Illustration: FIG. XXV.[105]]
+
+4. _Double Harelip_ combined with fissures of the hard palate, and
+projection of a central bone. This is the analogue of the
+inter-maxillary bone in the lower animals, and bears the two middle
+incisor teeth, and projects very variously in different cases. In some
+it projects horizontally forwards in the most hideous manner, in others
+it lies at an angle more or less oblique; in very few does it maintain
+its proper position; when projecting forwards, and as the teeth also
+share in its projection, it entirely prevents approximation of the edges
+of the fissures by operation, so it must first be dealt with in one of
+two ways, either--
+
+[Illustration: FIG. XXVI.[106]]
+
+(1.) It may be at once removed with bone-pliers, the piece of skin over
+it being saved. This is the best that can be done in cases of old
+standing after the first year or two, though attempts have been made to
+break the neck of the projecting portion, and thus permit of its being
+shoved back.
+
+(2.) By gradual pressure by a spring truss, strapping, or a bandage, it
+may be forced back. This is possible only in cases where the deformity
+has been comparatively slight, and the patient has been seen early. The
+edges must then be pared and approximated as directed above.
+
+One or two points about the operation for harelip require a special
+notice:--
+
+1. _When to operate._--Great differences in opinion exist. Some say not
+before two or three years, others within two or three days, or even
+_hours_, after birth.
+
+Probably the safest time is not much earlier than the second month in
+very strong children, the fifth in weakly ones, up to the commencement
+of the first dentition; and when once dentition has commenced it is not
+so safe to operate till it is over.
+
+Prior to dentition the operation is attended with rather more risk, but
+again, if delayed, there is great risk that the teeth do not come in
+properly.
+
+2. With regard to the most delicate part of the operation, _the
+management of the prolabium_.--Some are satisfied, and I believe
+rightly, with careful apposition by a silk suture after a _sufficient_
+amount of the edges has been removed; others have proposed various plans
+to obviate any risk of an angle remaining.
+
+Malgaigne proposes to retain a small portion of the parings of the edge
+to make small flap at each side; Lloyd a single one from the long half
+of the lip, and brings it up under the opposite one, securing it with a
+stitch.
+
+
+FOOTNOTES:
+
+[95] Operation for formation of a new nose from the cheeks; A A, flaps
+approximated in middle line; B B, outer part of bed of flaps stitched
+up; C C, triangle at each side left to granulate.
+
+[96] _The Restoration of a Lost Nose by Operation_, p. 57; an excellent
+monograph on the subject.
+
+[97] Operation for formation of a new nose from the forehead:--_a_,
+prominence of flap which is to be used as septum; _b_, left-hand corner
+of flap, which is twisted and fastened at _c_; _d_, one of the tubes or
+quills over which the nose is moulded.--(_Modified from Bernard and
+Huette._)
+
+[98] Syme's _Observations in Clinical Surgery_, p. 132.
+
+[99] Diagram of V-shaped incision; A B A, dots showing points for
+sutures.
+
+[100] Diagram of incision for scooping out a shallow tumour by scissors.
+
+[101] Diagram of incisions:--C A C, outline of incision for removal; C A
+D, outline of flap on each side; B, prominence of chin; C C, dotted
+lines, showing incisions to enlarge mouth, if required.
+
+[102] Diagram of flaps in position:--A A, corners of flaps brought up
+and approximated by _silver_ sutures; C C, new lip got by lateral
+incisions, skin and mucous membrane being united by _silk_ threads; E E,
+gap left to granulate.
+
+[103] Fig. XXIII. shows the incision bounding the cleft.
+
+[104] Fig. XXIV. shows the diamond-shaped wound before the sutures are
+applied.
+
+[105] Diagram of operation for double harelip:--_a_, stitch through both
+sides and wedge-shaped portion, which also aids the septum; _b_, other
+stitches approximating edges.
+
+[106] Diagram of double harelip, with projecting bone:--_a_, central
+piece of lip, dotted lines showing incision; _b_, projecting bone
+bearing teeth, which are generally small and stunted.
+
+
+
+
+CHAPTER VII.
+
+OPERATIONS ON THE JAWS.
+
+
+1. EXCISION OF THE UPPER JAW.--With regard to the morbid conditions for
+which this operation is undertaken, it may be sufficient here to
+observe, that in no case can the operation be called justifiable in
+which the disease extends beyond the upper jaw-bone and the
+corresponding palate-bone, for unless the morbid growth be entirely
+removed, recurrence is inevitable, and no advantage is gained by the
+operation. It is undertaken for the removal of tumours of the antrum and
+of the alveolar margins, in all which cases the section for its removal
+must be made through healthy bone, and wide of the disease, so as to
+insure that the whole is removed. There are other cases in which the
+whole or part of the upper jaw has been removed for the purpose of
+giving access to disease behind, for example, to naso-pharyngeal polypi
+with extensive attachments.
+
+In describing the operation for the excision of the entire upper jaw, we
+have to consider--(1.) what incisions through the soft parts will expose
+the tumour best, and with least deformity; (2.) what bony processes
+require to be divided, and where. Very various incisions have been
+recommended by various authors; some describing three, in various
+directions, forming flaps of different sizes, while others, again, are
+satisfied with a very small division of the upper lip into the nose, or
+even attempt removal of the bone without any incision through the skin
+at all. These discrepancies depend in great measure on different views
+of what constitutes excision of the upper jaw, the more complicated ones
+contemplating removal of the whole bone anatomically so called,
+including the floor of the orbit, while the less complicated ones are
+suitable for cases in which a much less extensive removal is required.
+
+To remove the whole bone, an incision (Fig. XXVII. A) of the skin must
+extend from the angle of the mouth upwards and outwards in a slightly
+curved direction with its convexity downwards, as far on the malar bone
+as half an inch outside of the outer angle of the eye. The flaps must
+then be raised in both directions, the inner one specially dissected off
+the bones, so as to expose thoroughly the nasal cavity. It is of great
+importance thoroughly to display the floor of the orbit, so that the
+attachment of the orbital fascia may be accurately cut through, the
+inferior oblique muscle divided at its origin, and the eye and the fat
+of the orbit cautiously raised from its floor.
+
+[Illustration: FIG. XXVII.[107]]
+
+Three processes of bone then require attention and division.
+
+(1.) The articulation with the opposite bone in the hard palate. To
+divide this, one incisor tooth at least must be drawn, the soft palate
+divided by a knife to prevent laceration, and the thick alveolar portion
+sawn through in a longitudinal direction from before backwards.
+
+(2.) The articulation with the malar bone at the upper angle of the
+incision through the skin. This must be notched with a small saw in a
+direction corresponding to the articulation, and then wrenched asunder
+by a pair of strong bone-pliers.
+
+(3.) The nasal process of the upper jaw must now be divided by the
+pliers, one limb of which is cautiously inserted into the orbit, the
+other into the nose. If the disease extends high up in this process, it
+may be necessary partially to separate the corresponding nasal bone, and
+thus reach the suture between the nasal process and the frontal bone.
+The pliers must now be inserted into the groove already made by the saw
+on the hard palate, and the separation continued to the full extent
+backwards. A comparatively slight force exerted on the tumour either by
+the hand, or (when the tumour is small) by a pair of strong claw
+forceps, will suffice to break down the posterior attachments of the
+bone and remove it entire. The necessary laceration of the soft parts
+behind is so far an advantage, as it lessens the risk of haemorrhage from
+the posterior palatine vessels.
+
+The haemorrhage from this operation was at one time much dreaded, but is
+rarely excessive; very few vessels require ligature, except those
+divided in the early stages in making the skin flaps; the hollow left
+should be stuffed with lint, which may be soaked in the perchloride of
+iron should there be any oozing.
+
+The incisions recommended for this operation have been very various, and
+a knowledge of some of them may occasionally be useful, on account of
+specialities in the shape and size of the tumour. Liston "entered the
+bistoury over the external angular process of the frontal bone, and
+carried it down through the cheek to the corner of the mouth. Then the
+knife is to be pushed through the integument to the nasal process of the
+maxilla, the cartilage of the ala is detached from the bone, and lip cut
+through in the mesial line; the flap thus formed is to be dissected up
+and the bones divided."[108] Dieffenbach made an incision through the
+upper lip and along the back or prominent part of the nose, up towards
+the inner canthus, from whence he carried the knife along the lower
+eyelid, at a right angle to the first incision as far as the malar bone.
+
+In cases where the tumour is of moderate size, Sir W. Fergusson
+found[109] it sufficient to divide the upper lip by a single incision
+exactly in the middle line, this incision to be continued into one or
+both nostrils, if required. The ala of the nose is so easily raised, and
+the tip so moveable as to give great facilities to the operator for
+clearing the bone even to the floor of the orbit.
+
+In cases where the tumour is larger, or the bones more extensively
+affected, Sir W. Fergusson preferred an extension of the foregoing
+incision (Fig. XXVII. B) upwards along the edge of the nose almost to
+the angle of the eye, and thence at a right angle along the lower
+eyelid, as far as may be necessary, even to the zygoma. The advantages
+claimed for such procedures are that the deformity is less and the
+vessels are divided at their terminal extremities.
+
+
+2. EXCISION OF THE LOWER JAW.--Removal of portions, greater or smaller,
+of the lower jaw, for tumours, simple or malignant, are now operations
+of very frequent occurrence, while in some few cases the whole bone has
+been removed at both its articulations.
+
+The operative procedures vary much, according to the amount of bone
+requiring removal, and also the position of the portion to be excised.
+
+(1.) _Of a portion only of one side of the body of the bone._--This is
+perhaps the simplest form of operation, and is frequently required for
+tumours, specially for epulis.
+
+_Incision._--If the parts are tolerably lax and the tumour small, a
+single incision just at the lower edge of the bone, of a length rather
+greater than the piece of bone to be removed, will suffice; this will
+divide the facial artery, which must be tied or compressed,[110] while
+the surgeon, dissecting on the tumour, separates the flaps in front,
+cutting upwards into the mouth, and then detaches the mylohyoid below,
+and clears the bone freely from mucous membrane. He then, with a narrow
+saw, notches the bone beyond the tumour at each side, and, introducing
+strong bone-pliers into the notches, is enabled to separate the required
+portion. The wound is then stitched up, and a very rapid cure generally
+results with very little deformity, as the cicatrix is in shadow. If
+from the size of the tumour more room is needed, it can easily be got by
+an additional incision from the angle of the mouth joining the former.
+
+To prevent deformity, which is apt to result from the centre of the chin
+crossing the middle line, it is often a wise precaution to have a silver
+plate prepared fitting the molar teeth of both jaws on the sound side,
+and thus acting as a splint. Such a precaution may be required in any
+operation in which the lower jaw is sawn through.
+
+_N.B._--There are certain cases in which the epulis is small and
+confined to the alveolar margin, in which an attempt may be made to
+retain the base of the jaw entire, and remove the tumour without any
+incision of the skin. The mucous membrane on both sides being carefully
+dissected from the affected part, the bone may be sawn as before, but
+only through the alveolar portion, the groves of the saw converging as
+they penetrate, then by a pair of strong curved bone-pliers, the
+affected alveolar portion is to be scooped out without injuring the
+base. This proceeding, which has been practised by Syme, Fergusson,
+Pollock, the author in many cases, and others, leaves no deformity, but,
+it must be owned, is much more liable to the risk of recurrence of the
+disease, and for this reason is strongly condemned by Gross.
+
+_Note._--In this, as in all other operations on the jaws, the very first
+thing to be done is to draw the teeth at the spots at which the saw is
+to be applied.
+
+(2.) _Excision of a portion involving the Symphysis._--Free access is of
+importance. The best incision is probably one which (Fig. XXVII. C)
+commences at the angle of the mouth opposite the healthy portion of jaw,
+extends down to the place at which the saw is to be applied and then
+along the base of the jaw past the middle line to the other point of
+section. The flap is to be thrown up and the bone cleared. The next
+point to be noticed is, that when, in clearing the bone behind, the
+muscles attached to the symphysis are divided, the tongue loses its
+support, and unless watched may tend to fall backwards, embarrassing
+respiration and even perhaps choking the patient. The tongue, being
+confided to a special assistant, must be drawn well forwards. Various
+plans have been devised for keeping it in position, as stitching it to
+the point of the patient's nose; putting a ligature into its apex, and
+fastening it to the cheek by a piece of strapping, and transfixing its
+roots with a harelip needle, used to stitch up a central incision in the
+chin. The tendency to retraction very soon ceases, new attachments are
+formed by the muscles, and after the first five or six days there is
+very little risk of the tongue giving rise to any untoward consequences
+by its displacement.
+
+(3.) _Disarticulation of one, or both Joints._--When the portion of bone
+implicated involves disarticulation for its complete removal, the
+difficulty of the operation is much increased. The remarkably strong
+attachments of the joint, especially the relation of the temporal muscle
+to the coronoid process, and the close proximity of large arteries and
+nerves, especially the internal maxillary artery and the lingual nerve,
+render this disarticulation very difficult.
+
+The chief points to be attended to seem to be (1.) that the incision
+through the skin should extend quite up to the level of the
+articulation; (2.) that the bone should be sawn through at the other
+side of the tumour, and freely cleared from all its attachments, before
+any attempt be made at disarticulation, for by means of the tumour great
+leverage can be attained, so as to put the muscles on the stretch, and
+allow them to be safely divided; (3.) that the articulation should
+always be entered from the front, not from behind, and the inner side of
+the condyle should be very carefully cleaned, the surgeon cutting on the
+bone so as to avoid, if possible, the internal maxillary artery; (4.)
+free and early division of the attachment of the temporal muscle to the
+coronoid process.
+
+Disarticulation of the entire bone has been very rarely performed.[111]
+If necessary, it can be performed without any incision into the mouth,
+by one semilunar sweep from one articulation to the other, passing along
+the lower margin of each side of the body, and just below the symphysis
+of the chin.
+
+_Disarticulation of the Ramus without opening into the cavity of the
+Mouth._--That this operation is possible, though it may not be often
+required, is shown by the following case by Mr. Syme. It was a tumour of
+the ramus, extending only as far forwards as the wisdom-tooth:--
+
+"An incision was made from the zygomatic arch down along the posterior
+margin of the ramus, slightly curved with its convexity towards the
+ear, to a little way beyond the base of the jaw. The parotid gland and
+masseter muscle being dissected off the jaw, it was divided by
+cutting-pliers immediately behind the wisdom-tooth, after being notched
+with a saw. The ramus was then seized by a strong pair of tooth-forceps,
+and notwithstanding strong posterior attachments, was drawn outwards,
+its muscular connections divided and turned out entire. There was thus
+no wound of the mucous membrane of the mouth, the masseter and pterygoid
+muscles were not completely divided, and the facial artery was
+intact."[112]
+
+Fergusson[113] holds that even the very largest tumours of the lower jaw
+may be successfully removed without opening into the orifice of the
+mouth at all by division of the lips. A large lunated incision below the
+lower margin of the bone, with its ends extending upwards to within half
+an inch of the lips, will give free access, and yet avoid both
+haemorrhage and deformity, as the labial artery and vein are not cut, and
+there is no trouble in readjusting the lips. Some tumours of lower jaw
+can be removed without any wound of skin.
+
+
+FOOTNOTES:
+
+[107] Diagram of operations on the jaws:--A, incision for removal of the
+whole upper jaw; B, incision for removal of alveolar portion and antrum;
+C, incision for removing the larger half of lower jaw; the opposite side
+is the one supposed to be operated on, and the incision is crossing the
+symphysis and turning up at a right angle.
+
+[108] _Operative Surgery_, p. 265.
+
+[109] _Lancet_, July 1, 1865.
+
+[110] Temporary compression of the facial can be easily managed, in
+cases where it is of much importance to avoid loss of blood, by passing
+a needle from the outside through the skin above the vessel, then under
+the vessel, and out again through the skin below. A figure-of-eight
+suture can then be thrown round both ends of the needle, and the artery
+thus thoroughly compressed.
+
+[111] Syme, _Contributions to the Path. and Practice of Surgery_, p. 21;
+Carnochan of New York, _Cases in Surgery_.
+
+[112] _Contributions to the Path. and Prac. of Surgery_, pp. 23, 24.
+
+[113] _Lancet_, July 1, 1865.
+
+
+
+
+CHAPTER VIII.
+
+OPERATIONS ON MOUTH AND THROAT.
+
+
+SALIVARY FISTULA, _Operation for._--After a wound or abscess of the
+cheek, in which the parotid duct is implicated, a salivary fistula is
+very apt to remain. The saliva thus discharges in the cheek, giving rise
+to considerable annoyance, as well as injury to the digestion. It is by
+no means easy to cure this. Perhaps the best operation is the one of
+which a rude diagram is given (Fig. XXVIII.). The duct (C) communicates
+with the fistula (D). One end of a thread, either silken or metallic,
+should be passed through the fistula, and then as far backwards as
+convenient through the cheek into the mouth; the needle should then be
+withdrawn, the thread being left in. The other end being threaded should
+then be re-inserted at the fistula, and carried forwards in a similar
+manner; the needle should be again unthreaded in the mouth and
+withdrawn; the two ends should then be tied pretty tightly inside, and
+allowed to make their way by ulceration into the cavity of the mouth. A
+passage will thus be obtained for the saliva into the mouth, and every
+possible precaution should be taken to enable the external wound to
+close.
+
+[Illustration: FIG. XXVIII.[114]]
+
+
+EXCISION OF THE TONGUE, for malignant disease of the organ, may be
+either complete or partial. Complete excision affords a hope of
+permanent and complete relief from the disease, but it is an operation
+of extreme difficulty and danger. It may be performed in either of the
+following methods. The first is the only one in which absolute
+completeness of removal is insured.
+
+1. _Syme's method of excision._--The patient being seated on a chair,
+chloroform was not administered, so that the blood might escape
+forwards, and not pass into the pharynx. The operation is thus
+described:[115]--
+
+"Having extracted one of the front incisors, I cut through the middle of
+the lip and continued the incision down to the os hyoides, then sawed
+through the jaw in the same line, and insinuating my finger under the
+tongue as a guide to the knife, divided the mucous lining of the mouth,
+together with the attachment of the genio-hyoglossi. While the two
+halves of the bone were held apart, I dissected backwards, and cut
+through the hyoglossi, along with the mucous membrane covering them, so
+as to allow the tongue to be pulled forward, and bring into view the
+situation of the lingual arteries, which were cut and tied, first on one
+side, and then on the other. The process might now have been at once
+completed, had I not feared that the epiglottis might be implicated in
+the disease, which extended beyond the reach of my finger, and thus
+suffer injury from the knife if used without a guide. I therefore cut
+away about two-thirds of the tongue, and then being able to reach the os
+hyoides with my finger, retained it there while the remaining
+attachments were divided by the knife in my other hand close to the
+bone. Some small arterial branches having been tied, the edges of the
+wound were brought together and retained by silver sutures, except at
+the lowest part, where the ligatures were allowed to maintain a drain
+for the discharge of fluids from the cavity." The patient was able to
+swallow from a drinking-cup with a spout on the day following the
+operation, and was able to travel upwards of 200 miles within four weeks
+of the operation.
+
+2. _By the Ecraseur._--Nunneley of Leeds has recorded cases in which he
+made a small incision through the skin, and mylohyoid and geniohyoid
+muscles, and through this passed a curved needle bearing the chain of
+the ecraseur completely round the base of the tongue. In one case the
+chain was unsatisfactory, but strong whipcord was introduced as it was
+withdrawn, and tied with all possible force. The organ eventually
+sloughed away, with a cure which lasted at least for some months.
+
+Sir James Paget operates as follows:--
+
+The patient is placed under the influence of chloroform, and the mouth
+held widely open. The tongue is then drawn forwards, the mucous membrane
+and soft parts of the floor of the mouth, including the attachment of
+the genio-hyoglossi to the symphysis being divided close to the bone.
+The steel wire of an ecraseur is then passed round its root as low down
+as possible, slowly tightened, and the tongue thus divided through its
+whole thickness in a very few minutes. The bleeding is slight, being
+almost entirely from the parts cut with the knife. Recovery has been
+rapid in the recorded cases.[116]
+
+To Dr. George Buchanan of Glasgow the credit is due of the invention of
+the operation of removal of the half of the tongue in the median line.
+In at least one instance the cure after five years is still permanent.
+
+Partial excisions of the tongue are as unsatisfactory in their results
+as they are unsound in principle, yet many cases present themselves, in
+which, while the patient urges some operative measure for his relief,
+the tumour is so limited as not to warrant the exceedingly dangerous
+operation of complete excision.
+
+Portions may be removed in various ways:--
+
+1. By the knife. If in the apex, by a V-shaped incision; if in the
+lateral regions, by a bold free incision with a probe-pointed bistoury
+round the tumour.
+
+2. By ligature, drawn as tightly as possible, and, if the portion
+included be large, in successive portions.
+
+3. By the ecraseur.
+
+Mr. Furneaux Jordan has removed the whole tongue with success by means
+of two ecraseurs worked at the same time.[117]
+
+4. By the galvano-caustic wire.
+
+5. The author has in nine cases removed the affected half of the tongue
+by means of the thermo-cautery, first splitting it in the middle line
+and then cutting through the base with a curved platinum knife at a low
+red heat. In one only was there any trouble from haemorrhage, and all
+made good recoveries.
+
+Mr. Barwell has recorded (_Lancet_, 1879, vol. i.) an easy, safe, and
+comparatively painless mode of removing the tongue by ecraseurs.
+
+Mr. Walter Whitehead,[118] of Manchester, has had a very large
+experience of an operation devised by himself, in which, after pulling
+the tongue well forward by a string previously introduced near its apex,
+and the mouth being held open by a gag, he detaches the organ from jaw
+and fauces by successive short snips with scissors, and then in same
+manner divides the muscles, tying or twisting the vessels as they bleed.
+His success has been very great by this method, though others who have
+tried it have sometimes found bleeding troublesome.
+
+It is comparatively seldom now necessary to split the jaw and perform
+Syme's operation, and in all operations on the tongue the thermocautory
+(Paquelin's) is of great use.
+
+Regnoli's method[119] may deserve a brief notice. A semilunar incision
+along the base of the jaw, from one angle to the other, detaches the
+muscles and soft structures, and is thrown down; the tongue is then
+drawn through the opening, and can be freely dealt with either by knife
+or ligature. After removal the flap is replaced.
+
+
+FISSURES IN THE PALATE.--The operations requisite for the cure of
+fissures in the soft and hard palates are so complicated in their
+details, that a small treatise would be required thoroughly to describe
+the various procedures.
+
+Different cases vary so much in the nature and amount of their
+deformity, that at least five different sets of cases have been
+described. It is sufficient here merely to describe the absolutely
+essential principles of the operations for the cure of fissures of the
+hard and soft palate respectively.
+
+In all operations on the palate, two conditions used to be considered
+requisite for success:--1. That the patient should have arrived at years
+of discretion, at twelve or fourteen years at least; that he be
+possessed of considerable firmness, and be extremely anxious for a cure,
+so as to give full and intelligent co-operation. 2. That for some days
+or weeks prior to the operation the mouth and palate should have been
+trained to open widely and to bear manipulation, without reflex action
+being excited. Professor Billroth of Vienna,[120] and Mr. Thomas
+Smith[121] of London, have had cases which prove the possibility of
+performing this operation in childhood, under chloroform, with the
+assistance, in the English cases, of a suitable gag, invented by Mr.
+Smith. The effect of the operation on the voice of the child has been
+very encouraging, as much more improvement takes place than in cases
+where the operation is performed late in life.
+
+_Fissure in the soft palate only_ appears as a triangular cleft, the
+apex of which is above, the base being a line between the points of the
+bifid uvula, which are widely separated. To cure this it is required--
+
+1. That the edges of the fissure should be brought together without
+strain or tightness. In small fissures this can generally be done easily
+enough; but where the fissure is extensive, some means must be used to
+relieve tension. For this, Sir William Fergusson long ago proposed the
+division of the palatal muscles, the levator, tensor, and
+palato-pharyngeus muscle of each side. The incisions in the palate for
+this purpose certainly aid apposition, but many surgeons entertain
+doubts whether the division of the muscles has much to do with the good
+result, and believe that the simple incisions in the mucous membrane, in
+a proper direction, are all that is required (see Fig. XXIX.).
+
+[Illustration: FIG. XXIX.[122]]
+
+2. That the edges of the fissure be made raw, so as to afford surfaces
+which will readily unite. Complicated instruments, such as knives of
+various strange shapes, have been devised for this purpose; an ordinary
+cataract knife, very sharp, and set on a long handle is perhaps the
+best. It greatly facilitates the section if the parts are tense, so the
+point of the uvula should be seized by an ordinary pair of spring
+forceps, and drawn across the roof of the mouth, while the knife should
+enter in the middle line, a little above the apex of the fissure, and
+make the cut downwards as in harelip.
+
+3. That sutures should be inserted to keep the edges in apposition, yet
+not so tightly as to cause ulceration. They may be either of metal,
+silver being preferable, or of fine silk well waxed. The metallic
+sutures are now generally preferred. Some dexterity is required in their
+introduction, and various instruments have been devised; the best seems
+to be a needle with a short curve fixed on a long handle, which should
+be entered on the (patient's) left side of the fissure in front, and
+brought out on the right side.
+
+If silk sutures be used, the chief difficulty, that of passing the
+thread through the second side from behind forwards, can be avoided in
+the following manner.[123] A curved needle is passed through one side of
+the fissure, and then towards the middle line, till its point is seen
+through the cleft. One of the ends of the thread is then seized by a
+long pair of forceps, and drawn through the cleft; the needle is then
+withdrawn, leaving the thread through the palate, and both ends are
+brought outside at the angle of the mouth. Another needle is then passed
+through a corresponding point at the opposite side of the palate, till
+its point again appears at the cleft; this time a double loop of the
+thread is also brought out through the cleft by the forceps into the
+mouth. If then the single thread of the first ligature which is in the
+cleft be passed through the loop of the second one also in the cleft, it
+is easy, by withdrawing the loop through the palate, to finish the
+stitch (see Fig. XXIX.). All the stitches should be passed and their
+position approved before any one be tied, and it is most convenient to
+secure them from above downwards. To prevent confusion, each pair of
+threads after being inserted should be left very long, and brought up
+to a coronet fixed on the brow, which is fitted with several pairs of
+hooks numbered for easy reference. This will prevent twisting of the
+threads or any mistake in tying.
+
+
+FISSURE OF THE HARD PALATE.--This may vary in extent from a very slight
+cleft in the middle line behind, up to a complete separation of the two
+halves of the jaw, including even the alveolar process in front, and
+sometimes complicated with harelip.
+
+To close such fissures by operation is difficult, as the breadth of the
+cleft is so great as to prevent the apposition of the edges when
+prepared, without such extreme tension as quite prevents any hope of
+union. Through the researches of Avery, Warren, Langenbeck, and others,
+a method has been discovered of closing such fissures by operation,
+which, though certainly not easy, is, when properly performed, generally
+successful.
+
+_Operation._--In addition to the usual paring of the edges of the cleft,
+an incision is made on each side of the palate, extending "from the
+canine tooth in front to the last molar behind,"[124] along the alveolar
+ridge (Fig. XXX.). The whole flap between the cleft and this incision on
+each side is then to be raised from the bone by a blunt rounded
+instrument slightly curved. With this the whole mucous membrane and as
+much of the periosteum as possible should be completely raised from the
+bone, attachments for nourishment of the flap being left in front and
+behind where the vessels enter.
+
+[Illustration: FIG. XXX.[125]]
+
+The flaps thus raised will be found to come together in the middle line,
+sometimes even to overlap, and, when united by suture, form a new
+palate at a lower level than the fissure, experience having shown that
+in cases of fissure the arch of the palate is always much higher than
+usual. The flaps do not slough, being well supplied with blood, unless
+they have been injured in their separation.
+
+The edges must be carefully united by various points of metallic suture,
+and the fissure of the soft palate closed at the same sitting, unless
+the patient has lost much blood, or is very much exhausted with the
+pain. The stitches may be left in for a week, or even ten days, unless
+they are exciting much irritation. The patient must exercise great
+self-control and caution in the character of his food and his manner of
+eating for ten days or a fortnight after the operation.
+
+
+EXCISION OF TONSILS.--To remove the whole tonsil is of course impossible
+in the living body, the operation to which the name of excision is given
+being only the shaving off of a redundant and projecting portion. When
+properly performed it is a very safe, and in adults a very easy
+operation, but in children it is sometimes rendered exceedingly
+difficult by their struggles, combined with the movements of the tongue
+and the insufficient access through the small mouth. Many instruments
+have been devised for the purpose of at once transfixing and excising
+the projecting portion; some of them are very ingenious and complicated.
+By far the best and safest method of removing the redundant portion is
+to seize it with a volsellum, and then cut it off by a single stroke of
+a probe-pointed curved bistoury; cutting from above downwards, and being
+careful to cut parallel with the great vessels.
+
+The ordinary volsellum is much improved for this purpose by the addition
+of a third hook in each tonsil placed between the others, with a shorter
+curve, and slightly shorter; this ensures the safe holding of the
+fragment removed, and prevents the risk of its falling down the throat
+of the patient.
+
+If both tonsils are enlarged they should both be operated on at the same
+sitting, and the pain is so slight that even children frequently make
+little objection to the second operation. Bleeding is rarely troublesome
+if the portion be at once fairly removed, but if in the patient's
+struggles the hook should slip before the cut is complete, the partially
+detached portion will irritate the fauces, cause coughing and attempts
+to vomit, and sometimes a troublesome haemorrhage.
+
+The plentiful use of cold water will generally be sufficient to stop the
+bleeding, though cases are on record in which the use of styptics, or
+even the temporary closure of a bleeding point by pressure, has been
+necessary.
+
+M. Guersant has operated on more than one thousand children, with only
+three cases of any trouble from haemorrhage, while four or five out of
+fifteen adults required either the actual cautery or the sesqui-chloride
+of iron.[126]
+
+
+FOOTNOTES:
+
+[114] Rough diagram of operation for salivary fistula:--A, section of
+cheek close to buccal orifice; B, section of zygoma, muscles, etc.; C,
+the duct of the parotid; D, the fistulous opening of the cheek; E E, the
+thread knotted inside the mouth; F, the palate.
+
+[115] _Lancet_, Feb. 4, 1865.
+
+[116] _Med. Times and Gazette_ for Feb. 10, 1866.
+
+[117] _Lancet_, April 20, 1872.
+
+[118] _Transactions International Medical Congress_, 1881, vol. ii. p.
+460.
+
+[119] Gross's _Surgery_, vol. ii. p. 472.
+
+[120] Langenbeck, _Archiv_, ii. p. 657.
+
+[121] _Med. Chir. Trans._ for 1867-8.
+
+[122] Diagram of staphyloraphy, chiefly to illustrate the passing of the
+threads:--_a_, the first thread; _b_, the second. The dotted line at
+edge of fissure shows amount to be removed; the other dotted lines
+showing size and position of the incision through the mucous membrane
+above.
+
+[123] Holmes's _Surgery_, vol. ii. pp. 504-513.
+
+[124] _Edinburgh Medical Journal_ for Jan. 1865, Mr. Annandale's
+instructive paper on "Cleft Palate."
+
+[125] Diagram of fissure of hard palate:--_a_, anterior palatine
+foramina; _b_, posterior palatine foramina with groove for artery; _c_,
+incisions requisite to free the soft structures.
+
+[126] Holmes's _Diseases of Children_, p. 555.
+
+
+
+
+CHAPTER IX.
+
+OPERATIONS ON AIR PASSAGES.
+
+
+OPERATIONS ON THE LARYNX AND TRACHEA.--The great air passage may be
+opened at three different situations, and to the operations at these
+different places the following names have been given:--
+
+_Laryngotomy_, when the opening is made in the interval between the
+cricoid and thyroid cartilages, through the crico-thyroid membrane.
+
+_Laryngo-tracheotomy_, when the cricoid cartilage and the upper ring of
+the trachea are divided.
+
+_Tracheotomy_, when the trachea itself is opened by the division of two,
+three, or more rings.
+
+Of these the last, _tracheotomy_, is by far the most frequent,
+important, difficult, and dangerous, and requires a very detailed
+description. Chassaignac[127] says "the only really rational operation
+for the opening of the air passages by the surgeon is tracheotomy."
+
+
+TRACHEOTOMY.--_Anatomy._--Between the cricoid cartilage and the level of
+the upper border of the sternum, the middle line of the neck is occupied
+by the upper portion of the trachea. Its depth from the surface varies,
+gradually increasing as the trachea descends, and varying very much
+according to the fatness, muscularity, and length of the neck. It is,
+however, almost subcutaneous at the commencement below the cricoid, and
+on the level of the sternum it is in most cases at least an inch from
+the surface, in many much deeper. Again, its length varies, even in the
+adult, from two and a half to three, or even four inches. This is
+important, as affecting the simplicity of the operation, which, as a
+rule, is easier the longer the neck is.
+
+The trachea has most important and complicated anatomical
+relations--some constant, others irregular.
+
+1. The carotid arteries and jugular veins lie at either side, but, where
+these are regular in their distribution, do not practically interfere in
+a well-conducted operation.
+
+2. The thyroid gland lies in close relation to the trachea, one lobe
+being at each side (Fig. XXXI. B B), and the isthmus of the thyroid
+crosses the trachea just over the second and third cartilaginous rings.
+In fat vascular necks, or where the thyroid is enlarged it may occupy a
+much larger portion of the trachea. The position of the isthmus
+practically divides the trachea into two portions in which it is
+possible to perform tracheotomy. Both have their advocates, but the
+balance of authority tends to support the operation below the thyroid. A
+separate notice of each will be required immediately.
+
+[Illustration: FIG. XXXI.[128]]
+
+3. The _muscles_ in relation to the trachea are the sterno-hyoid and
+sterno-thyroid of each side. The latter are the broadest, are in close
+contact across the trachea by the inner edges below, but gradually
+diverge as they ascend the neck. In thick-set, muscular necks, however,
+they are in close contact for a considerable distance, and require to
+be separated to give access to the trachea.
+
+The _arteries_ are in most cases unimportant; no named branch of any
+size ought to be divided in the operation. However, occasionally very
+free bleeding may result from the division of an abnormal _thyroidea
+ima_ running up the trachea to the thyroid body from the innominate, or
+even from the aorta itself.
+
+The _veins_ are very numerous and irregularly distributed. There is
+generally a large transverse communicating branch between the superior
+thyroid veins just above the isthmus. The isthmus itself has a large
+venous plexus over it. Below the isthmus the veins converge into one
+trunk (or sometimes two parallel ones) lying right in front of the
+trachea.
+
+4. The last anatomical point which may give trouble in normal necks is
+the thymus, which is present in children below the age of two, and
+covers the lower end of the trachea just above the level of the sternum.
+Where this is not only not diminished, but enlarged, as it sometimes is
+in unhealthy children, it may give a very great deal of trouble, rolling
+out at the wound and greatly embarrassing proceedings.
+
+Abnormalities are very various and sometimes very dangerous: vessels
+crossing the trachea, as the innominate did in Macilwain's case,[129] or
+where two brachiocephalic trunks are present, as recorded by
+Chassaignac.[130] One of the most frequent dangers to be guarded against
+is a possible dilatation of the aorta or aneurism of the arch. This may
+very possibly, as happened in one case to the author, give rise to
+suffocative paroxysms from its pressure on the recurrent laryngeal
+nerves. Tracheotomy may be deemed necessary, and there is a great risk,
+unless proper precautions be taken, of wounding the aorta, where it
+passes upwards in the jugular fossa. In the author's case the vessel had
+actually to be pushed downwards by the pulp of the forefinger while the
+trachea was opened, the knife being guided on the back of the nail of
+the same finger.
+
+
+THE OPERATION.--In a work of this kind it would be utterly impossible to
+go at all into the subject of what diseases, injuries, etc., warrant or
+require the operation. It is enough to describe the various methods of
+operating, their dangers and difficulties.
+
+1. _The operation above the isthmus of the thyroid._--A spot about a
+quarter or half of an inch in vertical diameter between the cricoid
+cartilage (Fig. XXXI.) and thyroid isthmus.
+
+_Advantages._--It is near the surface, the vessels are few and
+comparatively small. It is most suitable in cases of aneurism.
+
+Professor Spence[131] gives his sanction to the high operation in adults
+with thick short necks when the operation is performed for ulceration or
+papilloma of larynx or for spasm from aneurism, the low operation being
+still best in cases of croup or diphtheria.
+
+_Disadvantages._--The space is too small, requires very considerable
+disturbance of the thyroid isthmus, or actual division of it. It is too
+near the point where the disease is; so much so, that in most cases of
+croup or diphtheria it would be perfectly useless. However, if required,
+or if the operation lower down be contra-indicated, this may be
+performed easily enough. A straight incision being made in the middle
+line about one inch and a half in length, expose the upper ring by
+careful dissection, if possible draw aside the veins, and depress the
+thyroid isthmus, divide the rings thus exposed, and introduce the tube.
+
+_The operation below the isthmus._--This, though more difficult in its
+performance, is a much more scientific and satisfactory operation.
+Considerable coolness and a thorough knowledge of the anatomy of the
+part are absolutely required.
+
+The patient being in the recumbent posture, the shoulders should be well
+raised, and the head held back so as to extend the windpipe, and thus
+bring it as near as possible to the surface. A pillow, or the arm of an
+assistant, behind the neck will be of service.
+
+_N.B._--Be careful lest too great extension by an anxious assistant,
+accompanied by closure of the mouth, should choke the patient (whose
+breathing is of course already much embarrassed) before the operation be
+begun.
+
+Chloroform may occasionally be given, and, if well borne, renders the
+operation very much easier than it would otherwise be. An incision must
+then be made exactly in the median line of the neck, from a little below
+the cricoid cartilage, almost to the upper edge of the sternum; at first
+it should be through skin only, then the veins will be seen, probably
+turgid with dark blood; the larger ones should be drawn aside, if
+necessary divided, the bleeding stopped by gentle pressure. The deep
+fascia must then be cautiously divided, great care being taken to keep
+exactly in the middle line, and the contiguous edges of sterno-thyroid
+muscles separated from each other by the handle of the knife. A quantity
+of loose connective tissue, containing numerous small veins, must now be
+pushed aside, the thyroid isthmus pressed upwards, still with the handle
+of the knife. The forefinger must then be used to distinguish the rings
+of the trachea. If there is much convulsive movement of the larynx and
+trachea, they should be fixed by the insertion of a small sharp hook
+with a short curve, just below the cricoid cartilage, and this should be
+confided to an assistant. The surgeon should then, with the forefinger
+of his left hand, fix the trachea, and open it by a straight
+sharp-pointed scalpel, boldly thrusting it through the rings with a jerk
+or stab, the back of the knife being below, and divide two or three of
+the rings from below upwards. Any attempt to enter the trachea slowly
+with a blunt knife or trocar will probably be unsuccessful, as the
+rings, especially in children, give way before the knife, which merely
+approximates the sides of the trachea without opening it.
+
+_Question of Haemorrhage._--It is often a question of some importance,
+and one which sometimes it is not easy to settle, how far attempts
+should be made completely to arrest the venous haemorrhage before opening
+the trachea.
+
+_On the one hand_, if not arrested, besides the risk of weakening the
+patient, we have to dread the much more serious complication of the
+admission of blood into the wound. And this is very serious in a patient
+whose respiration has already been much impeded, whose lungs are
+probably engorged, and who has certainly, by the mere existence of a
+wound in his trachea, lost the power of coughing properly; it must never
+be forgotten that a quantity of blood so trifling as to be at once
+ejected by a single cough in the case of a healthy chest, may be a fatal
+obstacle to respiration in one already weakened by disease. Thus any
+well-marked arterial haemorrhage from cut branches, or from the isthmus
+of the thyroid, must certainly be arrested prior to opening the trachea.
+Besides this, blood once having entered the bronchi is apt to extend
+into their smaller ramifications and prove a cause of death, by acting
+as a local irritation, and setting up intra-lobular suppurative
+pneumonia. The author has found this to be the case both after
+tracheotomy and still more frequently in suicide by cut throat.
+
+But, _on the other hand_, it is equally true that there is almost always
+a considerable amount of oozing from small venous radicles divided
+during the operation, which depends simply on the great venous
+engorgement resulting from the obstruction to the respiration, so that
+while to attempt to tie every point would be simply endless, we may be
+almost certain that the oozing will cease whenever the trachea is
+opened, and respiration fairly improved. Slight pressure on the wound is
+generally sufficient to stop the bleeding till the venous engorgement
+has disappeared.
+
+Of late years many tracheotomies have been done bloodlessly by use of
+the thermo-cautery, for division of the soft parts, but the subsequent
+sloughing of the wound is a great objection to this method.
+
+In cases of extreme urgency, all such minor considerations as
+suppression of venous oozing must be ignored, and the trachea simply
+opened as rapidly as possible. I had once to perform the operation after
+respiration had entirely ceased, and no pulse could be felt at the
+wrist, with no assistance except that of a female attendant. Merely
+feeling that no large arterial branch was in the way, I cut straight
+through all the tissues, opened the trachea, and commenced artificial
+respiration. The patient eventually recovered.
+
+_Question of Tubes, etc._--Once the trachea is opened, the next question
+is, How is the opening to be kept pervious? For the moment the handle of
+the scalpel is to be inserted in the wound, so as to stretch it
+transversely; this will probably suffice to allow of the escape of any
+foreign body. But where, to admit air, the wound is to be _kept_ open,
+how is this to be done? It used to be advised that an elliptical portion
+of the wall of the trachea be removed; this, though succeeding well
+enough for a time, was unscientific, as the wound always tended to
+cicatrise, and ended of course in permanent narrowing of the canal of
+the trachea. It may be necessary thus to excise a portion of the
+trachea, in cases where it is very intolerant of the presence of a
+tube. Such a case is recorded by Sir J. Fayrer of Calcutta.[132] Not
+much better is the proposal to insert a silk ligature in each side of
+the wound, and by pulling these apart thus mechanically to open the
+wound. This also is evidently a merely temporary expedient.
+
+Various canulae and tubes have been proposed. The ones recommended by the
+older surgeons had all one great fault; they were much too small, and
+were many of them straight, and thus liable to displacement. The
+smallness of their bore was their greatest objection, and Mr. Liston
+conferred a great benefit on surgery by his insisting upon the
+introduction of tubes with a larger bore, and with a proper curve, so as
+thoroughly to enter the trachea. The tube ought to be large enough to
+admit all the air required by the lungs, without hurrying the
+respiration in the least.
+
+There is a mistake made in the construction of many of the tubes even of
+the present day; the outer opening is large and full, while for
+convenience of insertion the tube tapers down to an inner opening,
+admitting perhaps not one-half as much air as the outer one does.
+
+It must be remembered that for some days there is great risk of the tube
+becoming occluded, by frothy blood or mucus, especially in cases of
+croup, and in children. To prevent this a double canula will be found of
+great service, providing only that it be remembered that the inner
+canula, not the outer merely, is to be made large enough to breathe
+through, and that the inner should project slightly beyond the outer
+one.
+
+The inner one can thus be removed at intervals and cleansed, by the
+nurse, without any risk of exciting spasm or dyspnoea by its absence
+and reintroduction.
+
+_After-treatment._--The after-treatment of a case in which tracheotomy
+has been performed demands great care and many precautions. For the
+first day or two the constant presence of an experienced nurse or
+student is always necessary to insure the patency of the tube. The
+temperature of the room should be equable and high, and it seems of
+importance that the air should be kept moist as well as warm by the use
+of abundance of steam.
+
+A piece of thin gauze, or other light protective material, should be
+placed over the mouth of the tube, to prevent the entrance of foreign
+bodies.
+
+In cases where the operation has been performed for some temporary
+inflammatory closure of the air passage, retention of the tube for a few
+days may suffice. It may then be removed, but it must be remembered that
+the wound will generally close with great rapidity, so that it is as
+well to be quite sure of the patency of the natural passage before the
+artificial one is allowed to close by the removal of the tube.
+
+In cases where from long-standing disease or severe accident the larynx
+is rendered totally unfit for work, and the tube has to be worn during
+the rest of the patient's life, care must be taken (1.) lest the tube do
+not fit accurately, in which case it may ulcerate in various directions,
+even into the great vessels;[133] (2.) lest the tube become worn, and
+lest the part within the windpipe fall into the trachea and suffocate
+the patient.[134]
+
+
+LARYNGOTOMY.--As a temporary expedient in cases of great urgency, where
+proper instruments and assistants are not at hand, laryngotomy is
+occasionally useful, though from the want of space without encroaching
+on the cartilages of the larynx, and from its close proximity to the
+disease, laryngotomy is by no means a suitable or permanently successful
+operation.
+
+In the adult, especially in males with long spare necks, the operation
+itself is exceedingly easy to perform. The crico-thyroid space (Fig.
+XXXI. A) is so distinctly shown by the prominence of the thyroid
+cartilage, and is so superficial that it is quite easy to open it in the
+middle line with a common penknife, there being merely the skin and the
+crico-thyroid membrane to be cut through, with very rarely any vessel of
+any size. The opening can then be kept patent by a quill or a small
+piece of flat wood. This simple operation has in many cases, where a
+foreign body has filled up the box of the larynx, succeeded in saving
+life, and even in cases of disease I have known it useful in giving time
+for the subsequent performance of tracheotomy.
+
+Easy as it appears and really is, cases are on record in which the
+thyro-hyoid space has been opened instead of the crico-thyroid, such
+operations being of course perfectly useless.
+
+The incision is best made transversely.
+
+
+LARYNGO-TRACHEOTOMY.--This modification consists in opening the air
+passage by the division of the cricoid cartilage vertically in the
+middle line, along with one or two of the upper rings of the trachea.
+
+It seems to combine all the dangers with none of the advantages of the
+other methods of operating. It is close to the disease, involves cutting
+a cartilage of the larynx, and almost certain wounding of the isthmus of
+the thyroid; and it is not easy to see what corresponding advantages it
+has over tracheotomy in the usual position.
+
+
+THYROTOMY is an operation by which the larynx is opened in the middle
+line by a vertical incision, and its halves separated, while any morbid
+growths are excised from the cords or ventricles. The merits and dangers
+of this operation have been discussed at length by Mr. Durham[135] and
+Dr. Morell Mackenzie.[136]
+
+
+LARYNGECTOMY OR EXCISION OF THE LARYNX, first performed by Dr. Heron
+Watson in 1866, has been lately frequently performed for carcinoma and
+sarcoma. Each case presents its own difficulties, which vary according
+to the amount and extent of the disease for which it is done.
+
+The trachea must be divided and tamponed by a Trendelenburg canula,
+after which the larynx must be carefully dissected out. The immediate
+mortality, _i.e._ in first ten days, is fifty per cent., and Dr. Gross
+holds that life has not been prolonged by the operation.[137]
+
+
+OESOPHAGOTOMY.--This operation is very rarely required, and has as yet
+been performed only for the removal of foreign bodies impacted in the
+oesophagus, and interfering with respiration and deglutition. To cut
+upon the flaccid empty oesophagus in the living body would be an
+extremely difficult and dangerous operation, from the manner in which it
+lies concealed behind the larynx, and in close contact with the great
+vessels. When it is distended by a foreign body, and specially if the
+foreign body has well-marked angles, the operation is not nearly so
+difficult. It has now been performed in forty-three cases at least, of
+which eight or nine have proved fatal. Seven, along with another in
+which he himself performed it with success, were recorded by Mr. Cock of
+Guy's Hospital.[138] Three others were performed by Mr. Syme, with a
+successful result. Of the seven cases collected by Mr. Cock only two
+died, one of pneumonia, the other of gangrene of the pharynx.
+
+_Operation._--Unless there is a very decided projection of the foreign
+body on the right, the left side of the neck should be chosen, as the
+oesophagus normally lies rather on the left of the middle line. An
+incision similar to that required for ligature of the carotid above the
+omohyoid should be made over the inner edge of the sterno-mastoid
+muscle; with it as a guide, the omohyoid may be sought and drawn
+downwards and inwards, the sheath of the vessels exposed and drawn
+outwards, the larynx slightly pushed across to the right, the thyroid
+gland drawn out of the way by a blunt hook, the superior thyroid either
+avoided or tied. The oesophagus is then exposed, and if the foreign
+body is large, it is easily recognised; if the foreign body be small, a
+large probang with a globular ivory head should then be passed from the
+fauces down to the obstruction; this will distend the walls of the
+oesophagus, and make it a much more easy and safe business to divide
+them to the required extent. The wound in the oesophagus should be
+longitudinal, and at first not larger than is required to admit the
+finger, on which as a guide the forceps may be introduced to remove the
+foreign body, or, if necessary, a probe-pointed bistoury still further
+to dilate the wound.
+
+For some days or even weeks the patient must be fed through an elastic
+catheter introduced through the nose and retained, or by an ordinary
+stomach-tube through the mouth. In introducing the latter there is
+always a risk of opening the wound. No special sutures for the wound in
+the oesophagus are required, nor is it advisable too closely to sew up
+the external wound.
+
+
+FOOTNOTES:
+
+[127] _Lecons sur la Tracheotomie_, p. 10.
+
+[128] Rough diagram of larynx and trachea:--A, crico-thyroid space,
+_laryngotomy_; B B, dotted outline of thyroid isthmus and lobes, defines
+the upper and lower positions for _tracheotomy_; C, thyroid--D, cricoid
+cartilages; E, dotted outline of thymus gland in child of two years; F
+F, outline of clavicles and jugular fossa.
+
+[129] _Surgical Observations_, p. 335. See also Harrison _On the
+Arteries_, vol. i. p. 16.
+
+[130] _Lecons sur la Tracheotomie_, p. 9.
+
+[131] _Lectures on Surgery_, 3d ed., vol. ii. p. 900.
+
+[132] _Clinical Surgery in India_ (1866), p. 143.
+
+[133] Mr. John Wood, _Path. Soc. Trans._, vol. xi. p. 20.
+
+[134] South's _Chelius_, vol. ii. p. 400; and case recorded by Spence,
+in _Ed. Med. Journal_, for August 1862.
+
+[135] _Med. Chir. Transactions of London_, 1872.
+
+[136] _British Med. Journal_ (Nos. 643, 644), 1873.
+
+[137] Gross's _Surgery_, 6th ed., vol. ii. p. 342.
+
+[138] _Guy's Hospital Reports_ for 1858.
+
+
+
+
+CHAPTER X.
+
+OPERATIONS ON THORAX.
+
+
+EXCISION OF MAMMA.--When the whole breast is to be removed, two
+incisions, inclosing an elliptical portion of skin along with the
+nipple, must be made in the direction of the fibres of the pectoralis
+muscle. The distance between the incisions at their broadest must depend
+upon the nature of the disease for which the operation is performed, and
+the extent to which the skin is involved; in every case the whole nipple
+should be removed. The incisions should, if possible, be parallel with
+the fibres of the pectoralis major, and extend across the full diameter
+of the breast. During the operation the arm should be extended so as to
+stretch both skin and muscle. The lower flap should be first raised and
+dissected downwards, with care that the cuts are made in the
+subcutaneous fat, and wide of the disease; the upper flap is then thrown
+open, and the edge of the gland raised, so that the fibres of the
+pectoralis are exposed below it. These should be cleanly dissected, so
+as to insure removal of the whole gland.
+
+Any bleeding during the operation can easily be checked by the fingers
+of an assistant, and if the arteries entering the gland from the axilla
+be divided last, they can be at once secured. If there are many bleeding
+points, the application of cold for a few hours before the wound is
+finally closed is a wise precaution.
+
+The requisite stitches may be inserted while the patient is under
+chloroform, but not tightened. The arm should then be brought down to
+the side, and a folded towel laid over the wound after it is finally
+closed. Great benefit results from the free use of drainage-tubes in
+most cases; for this purpose a dependent opening in the lower flap is
+often made.
+
+Surgeons now operate even when the axillary glands are diseased, and by
+a very free dissection and removal, even in hopeless-looking cases, life
+may be prolonged. To insure the removal of the lymphatic vessels as well
+as the glands, it is best not to separate the breast at its axillary
+margin, but keep it attached by the tail of lymphatics surrounded by
+fat, which will lead up to the glands. Section of the great pectoral
+muscle will aid the dissection.
+
+     When the tumour is very large, and the skin has been much stretched
+     and undermined, more complicated incisions may be necessary; these
+     must be governed a good deal by the presence and positions of
+     adhesions or ulcerations of the skin. The best direction, when the
+     surgeon has his choice, that these incisions can take, is that of
+     radii from the nipple, bisecting the flaps made by the original
+     elliptical incision.
+
+_N.B._--In operating for malignant disease, the one paramount
+consideration is that _all_ the disease be excised, however curious,
+inconvenient, or awkward, even insufficient, the flaps may look. Partial
+excisions are worse than useless.
+
+
+PARACENTESIS THORACIS, for the relief of pleurisy, acute and chronic,
+and empyema, is an operation of extreme simplicity.
+
+The proper selection of cases, the settling of the suitable position for
+the tapping, and the choosing of the suitable time for it, are more
+difficult, and not within the scope of the present work. On these
+subjects much information may be obtained from the papers of Dr.
+Bowditch of Boston, of Dr. Hughes and Mr. Cock,[139] and an exceedingly
+interesting and valuable paper by Dr. Warburton Begbie.[140]
+
+_Where_ is it to be performed? Not _above_ the sixth rib, else the
+opening is not sufficiently dependent; very rarely _below_ the eighth on
+the right side, and the ninth on the left. The intercostal space
+generally bulges outwards if fluid is present, and this bulging acts as
+an aid to diagnosis. As the intercostal artery lies under the lower edge
+of the upper rib in each space, the trocar should be entered not higher
+than the middle of the space; and because the artery is largest near the
+spine, and also the space is there deeply covered with muscle, the
+tapping should never be _behind_ the angle of the rib. In most of the
+manuals we are told to select a spot midway between the sternum and
+spine for the puncture; but Bowditch, Cock, and Begbie, who have had
+large experience, prefer, and I believe rightly, a position considerably
+behind this, _an inch_ or two below the angle of the scapula, between
+the seventh and eighth, or between the eighth and ninth ribs.
+
+The operation may be performed with a simple trocar and canula, round,
+about an eighth of an inch in diameter, and at least two inches in
+length. The point must be sharp, and it must be pushed in with
+considerable quickness, so as to penetrate, not merely push forwards,
+the pleura, which may be tough, and thicker than usual. Once the skin is
+pierced, the instrument must be directed obliquely upwards, so as to
+make the opening and position of the trocar dependent. When the trocar
+is withdrawn the fluid may be allowed to flow so long as it keeps in a
+full equable stream; whenever it becomes jerky and spasmodic, the canula
+should be removed _before_ the sucking noise of air entering the chest
+is heard.
+
+In more chronic cases, where the quantity of fluid is large, and
+especially if it is thick and curdy, the exhausting syringe of Mr.
+Bowditch is an improvement on the simple trocar and canula.
+
+It consists of a powerful syringe, which fits accurately to the trocar
+with which the puncture is made. There is a stop-cock between the trocar
+and syringe, and another at right angles to the syringe. The trocar
+being introduced, it is held firmly in position by an assistant, by
+means of a strong cross handle; the first stop-cock is then opened, and
+the syringe worked slowly till it is filled with fluid through the
+trocar, the other delivery stop-cock being closed. The first is then
+closed, and the second opened; the syringe is then emptied through the
+second into a basin. By a repetition of this process, the fluid can be
+removed at pleasure, without any risk of the entrance of air.
+
+     Dieulafoy's aspirateur, which the author has now used in a very
+     large number of cases, will be found the best method yet devised of
+     safely removing the fluid in cases of serous effusion. But in
+     severe cases of empyema the pus is sure to be reproduced in the
+     great majority, and then a free incision, with strict antiseptic
+     precautions, will be needed, and subsequent free drainage.
+
+     The author has used with great benefit silver tubes, like long
+     narrow trachea-tubes, with broad shields, to insure free drain.
+
+
+FOOTNOTES:
+
+[139] Both in _Guy's Hospital Reports_, second series, vol. ii.
+
+[140] _Edinburgh Medical Journal_ for June 1866.
+
+
+
+
+CHAPTER XI.
+
+OPERATIONS ON ABDOMEN.
+
+
+PARACENTESIS ABDOMINIS.--To withdraw fluid from the abdominal cavity is
+an exceedingly simple operation in itself, though certain precautions
+are necessary to render it safe.
+
+_Trocar._--The usual instrument used to be a simple round canula with a
+trocar, the point of which should be very sharp, and in the shape of a
+three-sided pyramid. It should be about three inches in length, and a
+quarter of an inch in diameter. It may for convenience have an
+india-rubber tube fixed to its side or end, for the purpose of conveying
+the fluid to the pail or basin, but any other additions or alterations
+have not been improvements. Lately surgeons have been diminishing the
+size of the tube so as to withdraw the fluid more slowly, and taking
+many precautions to insure the wound being kept aseptic.
+
+_Where to tap._--In the linea alba, midway between the umbilicus and
+pubes, or rather nearer the umbilicus. Here, there are no muscles nor
+vessels, the opening is a dependent one, and the bladder is quite out of
+the way of injury.
+
+_N.B._--It is a wise precaution, in every case where there is a
+possibility of doubt as to the state of the bladder, to pass a catheter.
+I have myself known at least one case in which a surgeon was asked to
+tap an over-distended bladder, as a case of ascites.
+
+_The Operation._--As there is great risk of syncope coming on during the
+operation, from the sudden relief to the pressure on the organs, a broad
+flannel bandage should be applied to the belly, the ends of which are
+split into three at each side, and crossed and interlaced behind. An
+assistant should stand at each side to make gradual pressure by pulling
+on the ends of the bandage, thus assisting the flow, and maintaining the
+pressure. A hole should be cut in the bandage at the spot where the
+puncture is to be made, and the trocar inserted by one firm push,
+without any preliminary incision, unless the patient is inordinately
+fat. As the trocar is withdrawn, the canula should be pushed still
+further in. The surgeon should be ready at once to close the canula with
+his thumb, if the flow begins to cease, lest air should be admitted. If
+the flow ceases from any cause before all the fluid seems to be
+evacuated, the trocar should _not_ be re-introduced, lest the intestines
+be wounded, but a blunt-headed perforated instrument fitting the canula
+should be inserted.
+
+When all the fluid that can be easily obtained is evacuated, the canula
+may be withdrawn, and a pad of lint secured over the wound by strapping.
+
+
+GASTROTOMY.--Cutting into the stomach for the extraction of a foreign
+body has now been performed at least ten times, and all but one
+recovered. A typical example is that by Dr. Bell of Davenport, who
+removed a bar of lead one pound in weight and ten inches in length, by
+an incision four inches in length from the umbilicus to the false ribs.
+The opening into the stomach was as small as possible, and required no
+sutures.
+
+
+GASTROSTOMY has within the last few years been practised very
+frequently. Gross has collected 79 cases, 57 of which were for carcinoma
+of oesophagus, all of which died within a few weeks, except eight who
+survived for periods varying from three to seven months. The results in
+cases of cicatricial and syphilitic strictures are more
+favourable.--Howse's method seems the best, consisting of two stages.
+
+1. A curved incision is made through the parietes parallel with, and a
+finger-breadth below, the lower margin of chest wall on left side, the
+peritoneum should be opened at the linea semilunaris, the stomach sought
+for, and then attached to the abdominal wall by an outer ring of sutures
+and to the edge of the wound by an inner ring. It should then be dressed
+with carbolised lint and supported by a bandage.
+
+2. A small opening should be made four or five days after the first
+stage and the patient should be fed through this opening.
+
+For full details, see Mr. Durham's paper in vol. i. of Holmes's Surgery,
+edition of 1883, pp. 801-4.
+
+
+GASTRECTOMY.--Excision of whole or part of the stomach is one of the
+latest developments of operative daring, first done as a regular
+operation by Pean in 1879, it has now been repeated sixteen times; four
+cases have survived the operation for more than ten days. The chief
+points to be attended to are prevention of death from shock and
+haemorrhage, and very careful stitching up of the wound. Considering the
+difficulty of the diagnosis, the danger of the operation, and the almost
+certain recurrence of the disease, the propriety of such operation seems
+very doubtful.
+
+
+OVARIOTOMY.--For the pathology of ovarian disease we must refer to Sir
+Spencer Wells's work on the subject, and to the smaller Monograph on
+Ovarian Pathology, by the late lamented Dr. Charles Ritchie, junior.
+
+Even the modifications in the method of operating which have been
+devised are so various and numerous, that if collected from the medical
+journals of the last ten years they would fill a large volume. Besides
+this, the operation of ovariotomy is one attended by so many
+complications, that individual cases vary from each other as much as do
+individual cases of hernia and tracheotomy; and as the specialities of
+each case require to be met by specialities of treatment, there is
+hardly any operation in surgery which requires greater readiness of
+invention, or more individual sagacity in the operator.
+
+To lay open the abdominal cavity from the sternum to the pubes, and
+rapidly dissect out of this cavity an enormous tumour with a narrow
+neck, the operator's only embarrassment being the peristaltic movements
+of the bowels, and his only care being to tie the neck of the tumour
+firmly with strong string, sew up the wound, and trust to nature, was an
+operation very easy to perform, and requiring free cutting rather than
+dexterity, and rashness more than true surgical insight.
+
+Such were the ovariotomies prior to 1857.
+
+An ovariotomy in 1883 is a very different business, varying in certain
+important particulars.
+
+(1.) Instead of the incision extending from sternum to pubes, it is now
+made as short as possible.
+
+(2.) Instead of being removed entire, the cyst is now emptied with the
+greatest possible care (prior to its removal), and none of the contents
+allowed to enter the peritoneal cavity.
+
+(3.) The pedicle is brought to the surface, and in every case where it
+is possible is secured outside the wound.
+
+Besides these three important and cardinal points, there are other minor
+matters almost equally essential; these are--(1.) The proper management
+of the adhesions and the thorough prevention of all haemorrhage from
+them; (2.) the stitching up of the external wound, including the
+peritoneum; (3.) the treatment of the patient during the first few days
+of convalescence.
+
+_Operation_ in a typical case, after the method of Sir Spencer Wells and
+Dr. Thomas Keith.--The patient having had her bowels gently opened on
+the previous day, and being as far as possible in her usual state of
+health, should be warmly clad in flannel, both in body and limb, and
+laid on an operating table of convenient height, in or near the room she
+is to occupy. No carrying from ward to operating theatre and back again
+is admissible. It will be found both cleanly and convenient to have a
+large india-rubber cloth over the whole abdomen, cut out in the centre
+so as to expose so much of the tumour as is necessary, but gummed on or
+otherwise secured to the sides of the abdomen, and thus protecting the
+clothes, and hanging down over the edge of the table; this will prevent
+all wetting of the clothes and unnecessary exposure of the patient's
+person, and can be easily removed after the operation. Chloroform being
+administered, the bladder is evacuated by means of a catheter, and the
+patient's head and shoulders are elevated on pillows. An incision is
+then made in the linea alba, between the umbilicus and pubes, for about
+four inches in length at first, so as to be large enough to admit the
+hand, through all the tissues down to and through the peritoneum. Care
+is necessary in dividing the peritoneum, on the one hand, not to divide
+too much, in which case the cyst-wall will be penetrated, and the
+contents effused into the peritoneal cavity; or, on the other hand, too
+little, in which case the peritoneum may be mistaken for the cyst, and
+separated from the transversalis fascia under the idea that adhesions
+exist. Once the peritoneal cavity is opened, the incision through the
+peritoneum must be extended to the full length of the external wound by
+a probe-pointed bistoury.
+
+The operator's hand must now be passed into the abdomen, and the tumour
+isolated from its connections as far as possible. When no adhesions
+exist it is extremely easy to pass the hand quite round the tumour,
+ascertain its relations to the uterus and Fallopian tubes, and the
+length and thickness of its pedicle. The presence of adhesions adds very
+seriously to the danger and duration of the operation. We will suppose
+at present that none exist in this typical case, and that the pedicle is
+found of a satisfactory size and shape. The surgeon now protrudes the
+anterior portion of the cyst-wall through the wound, and pierces it with
+a large trocar,[141] to which is attached an india-rubber tube, by means
+of which the effused fluid can be easily got rid of in any direction.
+During the escape of the fluid from the cyst a special assistant keeps
+up the tension by careful pressure on the abdomen. In cases where the
+cyst is multilocular, and thus only a portion of the contents of the
+tumour is at first evaluated, the operator should, by partially
+withdrawing the trocar, without removing it entirely from the cyst,
+endeavour to pierce and evacuate the other cysts, still through the
+original opening in the first one.
+
+While doing this, great care must be taken lest he pierce the external
+wall of the tumour, and let any of the contents escape into the
+abdominal cavity; to guard against this, the punctures should be made
+by the right hand, while the left, re-inserted into the abdomen,
+supports the cyst-wall.
+
+The tumour having been as far as possible emptied of its fluid contents,
+must now be dragged out of the wound, care being still taken lest any of
+its fluid contents escape into the peritoneal cavity. In favourable
+cases the pedicle is now brought easily into view. This may vary very
+much in length and thickness. It is sometimes entirely absent, the
+tumour being sessile on the broad ligament of the uterus; sometimes it
+is thick and strong, sometimes long and slender. The manner in which it
+is to be managed depends on its length and thickness. Varieties in
+treatment will be noticed immediately. We will suppose that it is four
+inches in length and one or two fingers in breadth. This is quite a
+suitable case for the use of the clamp, the principle involved in the
+use of which is, that the pedicle should be brought quite out of the
+abdomen through the wound and secured on the surface. The best form
+seems to be one made like a carpenter's callipers, with long but
+removable handles, and a very powerful fixing-screw.
+
+The blades of this clamp being protected by pads of lint should be made
+to embrace the pedicle close to the cyst, in a direction at right angles
+to the abdominal wound, and lying across it, the handles should then be
+removed, and pads of lint placed below the clamp to protect the skin.
+The cyst may now be cut away at some little distance above the clamp,
+enough being left to prevent all danger of its slipping. Further to
+avoid this danger, the pedicle may be transfixed by one or two needles
+above the clamp.
+
+The wound is now to be sewed up by several points of interrupted suture,
+some inserted very deeply through all the tissues, including even the
+peritoneum, others in the intervals of the first, including little more
+than the skin. They may be either of iron, silver, platinum,
+telegraph-wire (Mr. Clover's copper, coated with gutta-percha), or silk.
+It seems of very little consequence which is used. Sir Spencer Wells,
+after many trials, uses silk, as being removed with least pain to the
+patient, and really causing no more suppuration than the metallic ones
+do, if only removed early enough, viz., about the second or third day,
+by which time the union of the wound should be firm.
+
+The after-treatment should be very simple. Except under special
+circumstances, stimulants are rarely necessary, and indeed, to avoid
+vomiting, as little as possible should be given by the mouth during the
+first twenty-four hours. The patient should be allowed to suck a little
+ice to allay thirst, and opiate and nutritive enemata will be found
+quite sufficient to keep up the strength in ordinary cases. The urine
+should be drawn off by the catheter every six hours. The room should be
+kept quiet, and the temperature equable, so long as there is no
+interference with a plentiful supply of fresh air.
+
+Some of the specialities and abnormalities involving special risks may
+now be briefly noticed:--
+
+1. _Adhesions._--These vary much in amount, in position, in
+organisation, and danger.
+
+_a._ _In amount._--In certain cases no adhesions exist, while in others,
+omentum, intestines, tumour, uterus, and abdominal wall may be all
+matted together in one common mass.
+
+_b._ _In organisation._--Occasionally they are so soft and friable as to
+break down under the finger with ease, and so slightly organised as not
+to bleed at all in the process, while again they may be so firm and
+close as to require a careful and prolonged dissection, and so vascular
+as to require many points of ligature to be applied to large active
+vessels.
+
+_c._ There are special _dangers_ connected with the presence of these
+adhesions, and varying much in different cases. Thus adhesions to the
+intestines can generally be separated with comparative ease, and seem,
+as a rule, to require the application of fewer ligatures than those
+which unite the tumour to the abdominal wall. Adhesions to the wall are
+sometimes so firm as to be quite inseparable, and thus to necessitate
+some of the cyst-wall being left adherent. In Sir Spencer Wells's cases,
+adhesions to the liver and gall-bladder occasionally occurred, requiring
+careful dissection to separate them, and yet the patients all survived,
+while pelvic adhesions, especially to the bladder and uterus, on more
+than one occasion prevented the completion of the operation.
+
+Vascular adhesions to the wall which require many ligatures certainly
+add to the dangers of the case, while adhesions to the anterior wall of
+the abdomen render the operation, especially its first stages, much more
+difficult, preventing the cyst from being recognised.
+
+2. _The condition of the pedicle_ is of great importance. If it is too
+short, it prevents the use of the clamp, as if applied it is apt either
+to pull the uterus up, or, pulling the clamp down, to make undue
+traction on the wound, and rupture any adhesions. This is especially the
+case where much flatus is generated, or where the patient is naturally
+stout.
+
+_Treatment._--Where the pedicle is just long enough to allow the clamp
+to be applied, and yet too short to leave room for any distension of the
+abdomen without undue tension, the best plan is to transfix it with a
+stout double thread just below the clamp, tie it in two halves, and
+bring the threads out past the clamp, so that, if tension does occur,
+the clamp may be removed, the part beyond it cut off, and the rest
+allowed to slip back into the pelvis, the ligatures being kept out at
+the mouth of the wound.
+
+Or again, it is sometimes possible, after applying one clamp firmly as
+near the tumour as possible, to apply another above it when the greater
+part of the tumour has been cut away; when the second is firmly fixed
+it may then be safe to remove the first, and thus an artificially
+elongated pedicle is obtained.
+
+When still shorter, two plans remain for selection--(1.) to transfix the
+pedicle in one or more points, then, securing it in two, three, or more
+portions, cut it off above the ligatures and return it, leaving the
+ligatures at the lower end of the wound. This gives a free drain for
+pus, but theoretically the sloughing pedicle might be expected to set up
+peritonitis; (2.) to transfix and tie the pedicle with one or more loops
+of stout string, cut the ends off short, and return the whole affair,
+closing the external wound at once. Theoretically there are grave
+objections to this plan, but it has proved very successful, especially
+in the hands of Dr. Tyler Smith.
+
+Another ingenious modification, sometimes useful in a short narrow
+pedicle, is to tie it as close to the cyst as possible, bring the
+ligature out at the wound, and then with a strong harelip needle
+transfix the pedicle, along with both sides of the wound, just below the
+ligature.
+
+When the pedicle is excessively broad and stout, it should be transfixed
+by strong needles and double threads in various places, and thus tied in
+several portions. Absence of the pedicle greatly adds to the danger in
+any given case. Various plans have been tried, as cutting the attachment
+through slowly by the ecraseur, ligature of each vessel separately, so
+many as twelve being sometimes required, and cauterising the stump. The
+latter, as used by Mr. Baker Brown, has met with a large measure of
+success, and is much used now.[142]
+
+Dr. Keith for a time operated with antiseptic precautions, but has now
+(1883) entirely given up the use of the spray, which he believes has
+especial dangers in abdominal surgery.
+
+
+OPERATION FOR STRANGULATED INGUINAL HERNIA.--The great rule to be
+remembered with regard to this, as well as all other operations for
+hernia, is, that the earlier it is performed the better chance the
+patient has. Once a fair trial has been given to the taxis, aided by
+proper position of the patient, the warm bath, and specially chloroform,
+the operation should be performed.
+
+The patient should be placed on his back with his shoulders elevated,
+and the knee of the affected side slightly bent. The groin should then
+be shaved, and the shape and size of the tumour, with the position of
+the inguinal canal, carefully studied. The surgeon should then lift up a
+fold of skin and cellular tissue, in a direction at right angles to the
+long axis of the tumour, and holding one side of this raised fold in his
+own left hand, commit the other to an assistant. He then transfixes this
+fold with a sharp straight bistoury, with its back towards the sac, and
+cuts outwards, thus at once making an incision along the axis of the
+hernia without any risk of wounding the sac or bowel. Any vessel that
+bleeds may now be tied. This incision will be found sufficiently large
+for most cases; if not, however, it can easily be prolonged either
+upwards or downwards. The surgeon must now devote his attention to
+exposing the neck of the sac, and in so doing, defining the external
+inguinal ring. The safest method of doing so is carefully to pinch up,
+with dissecting forceps, layer after layer of connective tissue,
+dividing each separately by the knife held with its flat side, not its
+edge, on the sac, and then by means of the finger or forceps raising
+each layer in succession and dividing it to the full extent of the
+external incision. It is not always an easy matter to recognise the
+sac, especially as the number of layers above it, which are described in
+the anatomical text-books, are often not at all distinct.
+
+The thickness of the connective tissue of the part varies immensely;
+sometimes six layers or even more can be separately dissected, while,
+again, one only may be found before the sac is exposed.
+
+If small and recent, the sac may be recognised by its bluish colour, and
+by the fact that it is possible to pinch up a portion of it between the
+finger and thumb, and thus to rub its opposed surfaces against each
+other.
+
+If large and of old standing, it is sometimes so thin as not to be
+recognisable, or again so enormously thickened, and so adherent, as to
+be defined with great difficulty.
+
+If it is small, _i.e._ when the whole tumour is under the size of an
+egg, it ought to be thoroughly isolated, and its boundaries everywhere
+defined. If large, and specially if adherent, the neck alone should be
+cleared.
+
+The sac thus being reached, the external abdominal ring should be
+clearly defined, and the finger passed into it so as if possible to
+determine the presence or absence of any constriction in it. If it feels
+tight, the internal pillar of the ring should then be cautiously divided
+on the finger by a probe-pointed narrow bistoury, in a direction
+parallel to the linea alba.
+
+At this stage the question comes to be considered as to whether the sac
+should or should not be opened. Much has been said and written on both
+sides.
+
+Not to open the sac avoids the risk of peritonitis, and of injury to the
+bowel; but, on the other hand, exposes the patient to the danger of the
+hernia being returned unreduced; for in many cases the stricture is to
+be found in the sac itself, and adhesions very rapidly form between
+coils of intestine in the sac and the inner wall. Again, not to open the
+sac prevents us from discovering the condition in which the bowl is; it
+may possibly be gangrenous, in which case such a return _en masse_ would
+be almost necessarily fatal.
+
+A general rule or two may be given here:--
+
+1. The sac should be opened in every case where there is any reason for
+doubt about the condition of the bowel, where there has been
+long-continued vomiting, or much tenderness on pressure.
+
+2. Even in cases in which there is every reason to believe the bowel is
+perfectly sound, the sac should be opened, unless the whole contents can
+be easily and completely reduced out of the sac into the belly, as in
+cases where this cannot be done there probably exist either a stricture
+in the neck of the sac itself, or adhesions of the bowel to the sac. We
+should endeavour to avoid opening the sac in cases of old scrotal hernia
+of large size, where the symptoms have not been urgent, especially in
+large unhealthy hospitals, as the risk of peritonitis is so great.
+Antiseptic precautions seem considerably to diminish the risk of opening
+the sac.
+
+If the sac then is not to be opened, the rest of the operation is very
+simple. Endeavour to reduce the bowel out of the sac, and then return
+the sac itself, unless the hernia is of old standing, and adhesions
+prevent its reduction. A few silver stitches to close the wound and a
+carefully adjusted pad are now all that is requisite.
+
+If the sac is to be opened, how can it be done with least danger to the
+bowel?
+
+If the hernia is small, and it is possible to define it all, the sac
+should be opened at its lower end, as _there_ a small quantity of serous
+fluid which intervenes between the sac and the bowel will be found.
+Where this is present, there is no danger of wounding the bowel, as the
+sac can be easily pinched up; but this is by no means invariably the
+case, so great care should always be taken. A small portion of the wall
+being thus pinched up should be divided in the same manner as the
+layers of cellular tissue were divided in exposing the sac. A few drops
+of serum will then escape, and the glistening surface of the bowel be
+exposed; the finger should then be introduced at the opening, and the
+incision enlarged by a probe-pointed bistoury. If the hernia is small
+the sac should be slit up to its full extent; if large, only a
+sufficient portion of the neck should be opened. As soon as the opening
+in the sac is large enough to admit the point of the operator's
+forefinger, it should be inserted so as to protect the intestines, and
+the remainder of the sac slit up on it as a guide.
+
+The sac thus opened, the next step is to divide the constriction,
+wherever it be. It is most likely to be found at the neck of the sac,
+just where it protrudes through the internal ring in an oblique hernia,
+or through the tendons of the transversalis and internal oblique, where
+the hernia is direct. Now, this constriction might be divided in any
+direction were it not for the risk of wounding the epigastric artery,
+and also of injuring the spermatic cord, which is in close relation to
+the neck of the sac of an oblique hernia.
+
+Wound of the epigastric artery is the chief danger, for in _all_ cases
+it is close to the neck of the sac. Were its position in relation to the
+neck of the sac constant, it might be easily avoided by an incision in
+the opposite direction; but as this relation varies according to the
+nature of the hernia, an element of danger is introduced. Thus, in
+oblique inguinal ruptures, where the sac passes out through the internal
+ring (Fig. XXXII. IR), the artery will always be found to the inside of
+the neck of the sac; while in direct herniae, where the bowel has made
+its escape through the triangle of Hesselbach (Fig. XXXII. +), and
+passed through the conjoint tendon straight to the external ring, the
+epigastric artery will be found on the outside of the neck of the sac.
+In recent herniae the differential diagnosis is comparatively easy, but
+in those of old standing and large size, in which the obliquity of the
+canal has been much diminished, it is almost impossible to tell of what
+kind the hernia originally was, and consequently to determine in which
+direction it is safe to incise the neck of the sac.
+
+Such being the case, the best rule is to incise the neck of the sac
+directly upwards, _i.e._ in a line parallel with the linea alba, and
+also to cut it very cautiously bit by bit, in every case, if possible,
+with the finger inserted as a guide to the position of a vessel and a
+protection to the gut.
+
+The spermatic vessels lie sometimes behind, sometimes on either side of
+the sac, and in very old herniae may be separated from each other so as
+really to surround the sac. The cut directly upwards is also the safest
+for them.
+
+All constrictions being overcome, it is not sufficient merely to push
+back the gut into the belly. Its condition must be carefully examined,
+and it must be decided whether the constriction has caused gangrene or
+not. To examine this properly, it is generally best to pull down an inch
+or two more of the gut, so as thoroughly to bring into view the
+constricted portion, as _it_ is most likely to be fatally nipped.
+
+It is not always easy to decide as to the condition of the bowel.
+Certain points must be observed:--
+
+(1.) _Colour._--There may be very great alteration in the colour of the
+bowel from congestion, and yet no gangrene. It may be dark red, claret,
+purple, or even have a brownish tint, and yet recover; where it is
+black, or a deep brown, the prognosis is unfavourable.
+
+(2.) _Glistening._--So long as the proper glistening appearance of the
+bowel remains, there is hope for it, even when the colour is bad; if it
+has lost it, and especially if, instead of being tense and shining, it
+is dull and flaccid and in wrinkles, the bowel is almost certainly
+gangrenous.
+
+(3.) _Thickness._--If much thickened, and especially if rough on the
+surface, the bowel has probably been forming adhesions to the sac, or to
+contiguous coils, and the prognosis is less favourable.
+
+(4.) _Smell._--The peculiar gangrenous odour on opening the sac is very
+characteristic. In cases where ulceration and perforation have occurred,
+the odour is faecal.
+
+1. If, then, the bowel is tolerably healthy-looking, though discoloured,
+it should be returned gradually, not _en masse_, into the abdomen, the
+wound sewed up, and a pad of lint put on, with a bandage.
+
+2. If there are adhesions of bowel to sac or to a neighbouring coil, or
+of omentum to sac, the stricture should be freely divided, the
+protruding coils of intestine should be emptied of their contents, but
+no rash attempt made to force their return. Especially is this rule to
+be observed with protruded, swollen, or adherent omentum, for
+considerable risks attend any attempt at excision of the protruded
+portion--risks of haemorrhage, peritonitis, and ulceration of the
+contiguous bowel.
+
+If the bowel be returned, or even the continuity of the canal restored
+by the cutting of the stricture, though the bowel be not returned, no
+great risks accrue from the retention of a piece of omentum in the sac,
+in a position which it may possibly have already occupied for years.
+
+3. If the bowel is absolutely gangrenous, even in a very small portion
+of its length, no reduction should be attempted, but the gangrenous
+portion should be kept outside, with the hope that adhesive inflammation
+may be set up, so as to glue the bowel to the abdominal wall, prevent
+faecal extravasation, and form a temporary artificial anus. If the
+gangrenous portion be very full of faeces or flatus, incisions may be
+made into it. This should be avoided in cases where the patient is
+already much prostrated, as I have seen cases in which the opening of
+the bowel seemed to inflict a fatal shock.
+
+Enterectomy or excision of the gangrenous portion has recently been
+recommended and performed by some surgeons. The very high authority of
+the late Professor Spence is against such procedure.[143]
+
+Cases of gangrene of even large portions of bowel are by no means
+necessarily fatal. They may recover with an artificial anus, the remedy
+of which by surgical means we must notice in its proper place.
+
+
+OPERATION FOR STRANGULATED FEMORAL HERNIA.--While the general principles
+guiding treatment and ruling the conduct of the operation are the same
+as in inguinal, there are some differences in points of detail which
+render a brief separate description necessary.
+
+     A single word on the anatomy. Tracing a femoral rupture from within
+     outwards, we find that its first stage is to push its way through
+     the weak point of the arch formed by Poupart's ligament, that is,
+     the spot called the crural arch, bounded on its outer side by the
+     sheath of fascia which surrounds the femoral vein; above by
+     Poupart's ligament; on its inner side by the curved fibres of
+     Poupart's ligament, which, curving backwards, are inserted into the
+     ilio-pectineal line, have a sharp falciform edge, and have been
+     dignified by the special name of Gimbernat's ligament (Fig. XXXII.
+     G); and below by the os pubis itself. This arch or ring thus
+     bounded is, in the normal state of parts, filled by a layer of
+     fibrous texture, a little fat, and occasionally a small gland.
+     These parts are pushed forwards in the descent of the hernia, and
+     in a small recent one may be said to form a sort of inner covering;
+     in a larger and older one they are split by the hernia, and, while
+     forming a constriction round its neck, leave the fundus of the sac,
+     so far as they are concerned, quite uncovered.
+
+     A femoral hernia may stop there, satisfied with merely coming
+     through the ring, and, if sudden and recent in a healthy, well-knit
+     subject, such a rupture is exceedingly dangerous, the constriction
+     being very severe, and the consequent gangrene of the bowel very
+     rapid if unrelieved. In most cases, however, it makes its way still
+     further out, and the next covering it gains is from the cribriform
+     fascia. This is the layer of fibres, pierced (as its name implies)
+     with orifices for the passage of veins and lymphatics, which
+     stretches between the two curved edges of the saphenous opening. It
+     varies much in strength; when the rupture has been slow and
+     gradual, it will certainly add a covering of greater or less
+     thickness, but where the hernia is large and old we must not expect
+     to find many traces of the cribriform fascia, at least over the
+     fundus of the tumour.
+
+     The ordinary superficial fascia of the part, with its fat, nerves,
+     veins, and lymphatics, and the thin skin of the groin, are the only
+     remaining coverings. It is very remarkable how exceedingly thin all
+     the so-called coats become in large femoral herniae of long
+     standing, especially in thin old people.
+
+_Operation._--Various incisions are recommended. The one which gives
+freest access and exposes the sac best, is shaped like a T, the
+horizontal limb of which is oblique, the direction of the obliquity
+varying on the two sides. The horizontal incision should be made just
+over Poupart's ligament, and parallel to it, the centre of the incision
+corresponding to the neck of the sac, and its length varying according
+to the size of the tumour and the depth of the parts; the other should
+extend downwards from the centre of the former, as far as is necessary
+to display the whole sac. The first should be made by pinching up and
+transfixing the skin, the second by ordinary incision, to the same depth
+as the first. The small flaps thus made must now be thrown back; any
+vessels that have been divided are to be tied. Now, with great care and
+caution the surgeon is to pinch up and divide any layers of condensed
+cellular tissue which may still cover the sac, till it is thoroughly
+exposed to its full extent, and remove any glands which may intervene.
+
+The neck of the sac being exposed, it may be possible in some very
+exceptional cases to give the patient the benefit of the minor
+operation, which consists in leaving the sac unopened. In such a case
+(to be described immediately), the surgeon passes his finger along the
+neck of the sac as far as possible into the ring, and then with a
+probe-pointed bistoury very cautiously nicks the upper edge of
+Gimbernat's ligament, in one or more places, being careful to feel for
+any pulsation before dividing a single fibre. He may then be able to
+empty the sac of its contents, and return the bowel and omentum, still
+retaining the sac outside.
+
+On the other hand, where it is determined to open the sac, the pinching
+up of the sac must be managed with great care, to avoid injury of the
+bowel. There is generally a little fluid to be found at the fundus,
+which will protect the bowel. In one case in which Liston operated, he
+tells us, "there was no possibility of pinching up the sac, either with
+the fingers or forceps; it contained no fluid, and was impacted most
+firmly with bowel; very luckily the membrane was thin; and, observing a
+pelleton of fat underneath, I scratched very cautiously with the point
+of the knife in the unsupported hand, until a trifling puncture was
+made, sufficient to admit the blunt point of a narrow bistoury."[144] If
+the sac contains bowel and omentum, it is safer to open it over the
+omentum than over the bowel. When a small opening is made, an escape of
+the contained fluid takes place, and then the sac should be slit up as
+far as its neck by a probe-pointed bistoury, guided by the finger,
+introduced to protect the bowel, whenever the opening is sufficiently
+large. The forefinger must now be cautiously insinuated into the neck of
+the sac, the nail being directed to the bowel, the pulp to the
+crescentic margin of Gimbernat's ligament, and any constriction very
+cautiously divided. The bowel should then be drawn down a little, the
+constricted point carefully examined, and then returned or not,
+according to its condition.
+
+Two points require a brief separate notice:--
+
+1. In what direction is the crural arch to be divided? Not outwards
+certainly, on account of the vein, nor downwards, as the bone prevents
+that direction. Is it to be upwards or inwards? Not upwards, for such
+an incision would endanger the spermatic cord or round ligament, besides
+greatly weakening the abdominal wall by the division, partial or
+complete, of Poupart's ligament. Inwards then it must be; and little
+more need be said about it, were it not for the occasional existence of
+an abnormal course and distribution of the obturator artery.
+
+[Illustration: FIG. XXXII.[145]]
+
+The usual origin of this vessel is from the internal iliac, in which
+case (Fig. XXXII. N O) it never comes near the sac at all. In certain
+cases (1 in 3-1/2) it rises from the epigastric, and in a very few (1 in
+72) from the external iliac. If rising from either of the two last, it
+most commonly passes downwards at the outer side of the hernia, in which
+case (Fig. XXXII. S O) no harm can possibly result; but in a few rare
+cases, perhaps 1 in every 60 of those operated on, the vessel winds
+round the hernia (Fig. XXXII. O), crossing at its inner side, and thus
+may be (and has actually been) divided by a rash incision. With due
+care, however, and by cutting a very little at a time, even this danger
+may be avoided.
+
+2. Under what circumstances is it possible or justifiable to reduce a
+femoral hernia, without previously opening the sac? Only in certain very
+select cases, where the hernia is recent, the constricting parts lax,
+the general symptoms very mild, and where there is reason to believe the
+bowel has completely escaped injury by compression or the taxis. There
+are both difficulties and dangers in this so-called minor operation:--1.
+_Difficulties_, For it is not easy to divide the constriction without
+the assistance of the finger in the sac, and it is not easy to reduce
+the contents with the sac unopened, except through a much freer opening
+than is necessary when the bowel has been fairly exposed. 2. _Dangers_,
+Of reducing sac and viscera, together with the strangulation still kept
+up by tightness in the neck of the sac; or of supposing the sac is
+emptied while a knuckle of bowel still remains in it, and is
+strangulated; or, lastly, of reducing the intestine which has already
+become gangrenous. It is very remarkable how very soon gangrene may come
+on, in a case of a small recent femoral hernia, in which the fibrous
+tissues constricting the neck of the sac are tense and undilatable. A
+protrusion for eight hours has been sufficient to destroy the life of a
+knuckle of bowel.
+
+     A note here on a certain condition very frequent in femoral herniae,
+     which may occasionally give a good deal of trouble. Symptoms of
+     strangulation have been well marked, yet when the sac is opened
+     nothing is to be seen except a mass of omentum, perhaps tolerably
+     healthy-looking. To reduce this _en masse_ would be very unsafe;
+     it is necessary carefully to unravel it, and disengage the knuckle
+     of bowel which is almost certainly included in it, and which has
+     given rise to the symptoms of strangulation.
+
+
+OPERATION FOR STRANGULATED UMBILICAL HERNIA.--The operation is
+practically the same, whether the hernia is a true umbilical one, or one
+which with more strict accuracy might be called ventral. True umbilical
+hernia is a disease of infancy and childhood, being almost always
+congenital, and the viscera protrude through the umbilical aperture.
+This rarely requires operation, as it may generally be returned with
+ease, and even cured by a proper bandage and compress. Ventral hernia,
+commonly called _umbilical_, is generally a protrusion of viscera
+through a new preternatural aperture in the fibrous tissues close to the
+navel, may often attain a large size, is liable to strangulation, and is
+not easily palliated or cured.
+
+In either case the operation requires a very brief description. If the
+hernia is small, under the size of a hen's egg, a crucial incision
+through the thin skin which covers it will thoroughly expose the sac
+when the flaps are dissected back. The forefinger should then be
+inserted in the round opening, and the edges cautiously incised in
+several directions, each incision however being very small.
+
+If the rupture is large, a single linear, or a T-shaped incision,
+exposing the base of the tumour, will be sufficient to allow the
+requisite dilatation of the opening to be made. It is not at all
+necessary in every case to open the sac of the peritoneum. If required,
+it must be done with great caution, as the sac is generally very thin.
+In cases where the hernia is chiefly omental, the sac should be opened,
+lest a knuckle of bowel be inclosed and strangulated in the omentum.
+
+
+OBTURATOR HERNIA is an extremely rare lesion, and a large proportion of
+the recorded cases were discovered only after death. When diagnosed
+during life and strangulated, some have been reduced by taxis, and only
+a very few cases have been operated on, some with success. It is not
+likely that a diagnosis could be made, except in very emaciated
+patients, in whom pain at the obturator foramen was a prominent symptom,
+and in whom it could be ascertained positively that the crural ring was
+empty. An incision over the tumour, sufficient to allow the pectineus
+muscle to be exposed and divided, is necessary. The hernia may then be
+reduced without opening the sac, if recent; if of long standing, the sac
+must be opened. One case is recorded by Dr. Lorinzer, in which, after
+strangulation for eleven days, he opened the sac and found the bowel
+gangrenous. The patient had a faecal fistula; but survived the operation
+for eleven months. Nuttel, Obre, and Bransby Cooper have each diagnosed
+and treated such cases.[146]
+
+Other forms of hernia are so rare, and the treatment of each case must
+necessarily vary so much in its circumstances, as not to require or
+admit of any detailed account of the operations requisite for their
+relief.
+
+
+OPERATIONS FOR THE RADICAL CURE OF HERNIA.--The inconveniences and
+discomfort caused by even the best-adjusted trusses or bandages, the
+unsatisfactory support they afford, and the risk of their slipping and
+allowing the hernia to escape, have given rise to many attempts to cure
+hernia by operation.
+
+Even to enumerate these would be quite beyond the limits of the present
+volume; suffice it to classify a few of the most important of them
+according to the principle involved in each, and then give a very brief
+account of the method of operating which seems to be at once the most
+scientific, least dangerous, and most permanently useful.
+
+The question at issue is briefly this. We have, in a hernia, the
+following condition:--The walls of a great cavity are at one or more
+points specially weak, the contained viscera have protruded, either by
+extension and stretching of a natural opening, or by the formation of a
+new breach in the walls, and, in protruding, they have brought with them
+as a covering a serous membrane, extremely extensible, highly sensitive
+to injury, and, when injured, certain to resent it by severe, spreading,
+and dangerous inflammation.
+
+Do we desire to remedy this protrusion, we may act--
+
+1. On the intestines themselves; but for all surgical purposes, they are
+out of our reach. We cannot do more than, by diminishing their contents,
+diminish their volume, and by position and rest reduce to the utmost
+their tendency to protrude. This includes the medical and prophylactic
+treatment of hernia, or rather of the tendency to hernia.
+
+2. We may try what can be done with the _sac_ which the intestines have
+pushed down before them. Can it be obliterated? If it can, perhaps the
+intestines may be retained in their cavity. Very many plans of dealing
+with the sac have been tried.
+
+To cause obliteration of its cavity many methods have been proposed:--by
+ligature of it along with the spermatic cord, involving loss of the
+testicle, either by gradual separation, by sloughing, or by immediate
+removal;--by cutting into it, and then stitching it up;--by constricting
+it with wire, as in the _punctum aureum_; by pinching sac and coverings
+up, by passing needles under them as they emerge from the external ring,
+as Bonnet of Lyons did; by constricting sac alone with a double wire, by
+subcutaneous puncture, as Dr. Morton of Glasgow has done;--by severe
+pressure from the outside with a strong tight truss and a pad of wood,
+as proposed by Richter; by setons of threads or candlewicks, as proposed
+by Schuh of Vienna;--by injection of tincture of iodine or cantharides,
+as by Velpeau and Pancoast;--by the introduction into the sac of thin
+bladders of goldbeaters' skin, which were then filled with air, and were
+intended to excite inflammation, as in the radical cure of hydrocele; or
+by the still more severe method of Langenbeck, consisting in exposing
+the sac by a free incision at the superficial ring, separating it from
+the cord, and passing a ligature round the sac alone, leaving the
+ligatured portion in the scrotum either to become obliterated or to
+slough out. Schmucker of Berlin varied this, by cutting away the
+constricted portion below the ligature.
+
+The objections to these methods are various: the more gentle are
+uncertain and inefficient; of the more severe, some involve mutilation,
+by the loss or removal of the testicle; others, as those of Langenbeck
+and Schmucker, are very dangerous and fatal, by the inflammation
+spreading to the peritoneal cavity (20 to 30 per cent. died); while all
+of these methods afford at best only temporary relief. And this is only
+what might have been expected, for the sac was only a _result_ of the
+protrusion, not a _cause_; and so long as the weakness and insufficiency
+of the parietes of the abdomen remain, so long will the extensible
+loosely-attached peritoneum continue to furnish new sacs for visceral
+protrusions.
+
+3. We have now only the canal left to act upon; and the operations on
+the canal may be divided into two great classes:--
+
+(_a._) Those in which the operator attempts to plug up the dilated
+canal. (_b._) Those in which he tries to constrict it, by reuniting its
+separated sides.
+
+(_a._) Attempts to plug the canal have, in most cases, been made by
+invagination of the skin of the scrotum and its fascia. These have been
+very numerous and various in their adaptation of mechanical appliances,
+but have all been designed with the same object. Dzondi of Halle, and
+Jameson of Baltimore, incised lancet-shaped flaps of skin, and
+endeavoured to fix them by displacement over the ring. Gerdy invaginated
+a portion of scrotum and fascia into the enlarged canal, by the
+forefinger pushed it up, and secured it in its place by a thread passed
+from the point of his finger first through the invaginated skin, then
+through the abdominal walls, endeavouring to include the walls of the
+inguinal canal, causing the point of the needle to project some lines
+above the inguinal ring; the same process being effected with the other
+end of the thread on the other side of the finger, and the two ends
+which have been brought out near each other on the abdominal wall, being
+tied tightly over a cylinder of plaster. The ensheathed sac was then
+painted with caustic ammonia to excite inflammation, and a pad put on
+over all.
+
+Signoroni modified this by fixing the invaginated skin by a piece of
+female catheter, retained in its place by transfixion by three harelip
+needles, tied by twisted sutures.
+
+Wuetzer of Bonn, again, modified this, by substituting a complicated
+instrument, consisting of a stout plug in the inguinal canal, held in
+position by needles which are passed through the anterior wall of the
+canal in the groin. Compression between plug and compress, with the
+intention of causing adhesion between skin, fascia, and sac, is then
+managed by means of a screw. The plug is retained for about seven days.
+
+Modifications of this method have been tried by Wells, Rothmund, and
+Redfern Davies, all aiming in the direction of simplicity; but by far
+the most simple and efficacious method on the Wuetzer principle yet
+devised is that of Professor Syme, which he described in the pages of
+the _Edinburgh Medical Journal_ for May 1861, in which the invagination
+of integument is both simply and securely managed by strong threads, as
+in Gerdy's method, while a piece of bougie or gutta-percha, to which
+the threads are fixed, replaces Wuetzer's expensive and complicated
+apparatus. Sir J. Fayrer of Calcutta has had a very large experience of
+Wuetzer's method, and also of a plan of his own. Out of 102 cases by the
+latter method, 77 were cured, 9 relieved, 14 failed, and 2 died.[147]
+
+Mr. Pritchard of Bristol has proposed an additional step in operations
+on the invagination principle, consisting in the stripping of a thin
+slip of skin from the orifice of the cutaneous canal, and then putting a
+pin through the parts to get them to unite, and thus close the aperture
+completely.
+
+Now, what results follow these operations? At first they are almost
+invariably successful, but the complaint is that, in most cases, the
+rupture recurs. The principle is to plug up the passage by the
+mechanical presence of the invaginated skin, the plug being retained in
+position by adhesive inflammation between it and the edges of the
+dilated ring. But the ring is left dilated, or, indeed, generally its
+dilatation is increased; and as, on continued pressure from within, the
+new adhesions give way, or, as often happens, a new protrusion takes
+place in the circular _cul-de-sac_ necessarily left all round the apex
+of the invagination, the still lax ring and canal offer no resistance to
+the protrusion.
+
+(_b._) The principle of constriction of the canal by reuniting its
+separated sides. This is the principle of the various methods introduced
+by Mr. Wood of King's College, and described by him in his most able and
+exhaustive work.[148]
+
+He applies sutures through the sides of the dilated inguinal or crural
+canals, or umbilical openings, in such a manner as to insure their
+complete closure.
+
+1. _For inguinal hernia._--To stitch together the two sides of the canal
+with safety requires attention to several points--(1.) That it be done
+nearly, if not entirely, subcutaneously. (2.) That the protruding bowel
+should be kept out of the way, and not be transfixed by the needle. (3.)
+That the spermatic cord should be protected from injurious pressure.
+
+These different indications are attained by Mr. Wood by a very ingenious
+mode of operating, which I can describe here only briefly, and for a
+full description of which I must refer to Mr. Wood's own monograph
+already alluded to.
+
+For his first twenty cases Mr. Wood used strong hempen thread for the
+stitches; of late, however, he has proved the greater advantage of
+strong wire.
+
+When a large old hernia in an adult is the subject of operation, it is
+thus performed by Mr. Wood:--The pubes being shaved, and the patient put
+thoroughly under the influence of chloroform, the rupture is reduced,
+and the operator's forefinger forced up the canal so as to push every
+morsel of bowel fairly into the abdomen. An assistant then commands the
+internal ring by pressure, to prevent return of the rupture.
+
+An incision is made in the scrotum over the fundus of the sac, large
+enough to admit a forefinger and the large needle used in the operation;
+the edges of the skin are to be separated from the fascia below for
+about one inch all round. The forefinger is then to be passed in at the
+aperture and pushed upwards, invaginating the detached fascia before it,
+and it must be made to enter the inguinal canal far enough to define the
+lower border of the internal oblique muscle stretched over it. A large
+curved needle (unarmed) is then passed on the finger as a guide, through
+the internal oblique tendon, the internal portion of the ring, and the
+skin of the abdomen; it is then threaded and withdrawn. Again, the
+needle (now with a thread) is guided by the finger and pushed through
+Poupart's ligament and the external pillar of the ring as before; while
+by a little manipulation its point is made to protrude through the same
+opening in the skin as before, a loop of thread is now left there, and
+the needle, still threaded, is again withdrawn. The next stitch, still
+guided on the finger, takes up the tendinous layer of the triangular
+aponeurosis covering the outer border of the rectus tendon close to the
+pubic spine; the point of the needle is then turned obliquely, so as to
+protrude through the original puncture in the skin a third time, the
+needle is then freed from the thread and withdrawn, thus leaving two
+ends and one intermediate loop of thread all at the one opening. These
+are so arranged that when they are tightened they draw together the
+sides of the canal; they are then secured over a compress of lint. The
+compress is removed and the stitches loosened, at dates varying from the
+third to the seventh day.
+
+Mr. Wood now uses wire instead of thread. It has the advantage of
+greater firmness, excites less suppuration, and may be left much longer
+_in situ_, in consequence of which there is less risk of suppuration or
+pyaemia, and more chance of a good consolidation of the parts.
+
+     In congenital herniae, and small ruptures in children and young
+     boys, Mr. Wood uses rectangular pins in the following manner:--The
+     scrotum being invaginated (without any incision through the skin)
+     as far as possible up the canal, a rectangular pin, with a
+     slightly-curved spear-pointed head, is passed through the skin of
+     the groin to the operator's forefinger; guided by it, it is brought
+     safely down the canal, and brought out through the skin of the
+     scrotum just over the fundus of the hernial sac. A second pin is
+     passed from the lower opening (still guided by the finger) in an
+     upward direction, transfixing in its course the posterior surface
+     of the outer pillar of the superficial ring, its point being
+     brought out through, or at least close to, the first puncture made
+     by the first pin. The pins are then locked in each other's
+     loops--the punctures and skin protected by lint or adhesive
+     plaster,--and the whole is retained by lint and a spica bandage.
+     The pins should generally be withdrawn about the tenth day.
+
+The author has now in many cases stitched with catgut the edges of the
+ring after the ordinary operation for hernia with the best effect.
+
+2. _For Femoral Rupture._--Cases suitable for operation are very
+infrequent; but should such a one be met with, Mr. Wood proposes the
+following operation on the same plan as the preceding. The hernia being
+fully reduced and the parts relaxed by position, an incision about an
+inch long should be made over the fundus of the tumour, and its edges
+raised so as to admit the finger fairly into the crural opening. The
+vein is then to be pushed inwards, and the needle passed through the
+pubic portion of the fascia lata of the thigh, and then through
+Poupart's ligament, appearing on the skin of the abdomen, a wire is then
+passed through the eye of the needle and hooked down, appearing through
+the wound, it is then withdrawn, and the needle again passed through the
+pubic portion of the fascia lata, but about three-quarters of an inch to
+the inside of the first puncture, then through Poupart's ligament again,
+and protruded through the same orifice in the skin; the other end of the
+wire is then hooked down as before, leaving a loop above, at the needle
+orifice, and two ends at the wound in the skin below. Both loops and
+ends must be managed as before.
+
+     The author after operating for the relief of strangulation in a
+     case of very large femoral hernia in a girl aged 23, stitched up
+     the neck of the sac, and also stitched it to Gimbernat's ligament.
+     The result for some months was admirable, though the hernia had
+     been a very difficult one to replace from its size, and had been
+     long in the habit of coming down. Eventually protrusion occurred to
+     a very slight extent, but a truss keeps it completely up.
+
+3. _For Umbilical Rupture._--The principle involved in Mr. Wood's
+operation for umbilical rupture is precisely the same as for inguinal
+and crural. It consists in stitching the two edges of the tendinous
+aperture by wire; the needle is passed on a sort of small scoop or
+broad grooved director, which at once invaginates the skin and protects
+the bowel. Two stitches are thus inserted on each side. For the
+ingenious method by which they are introduced subcutaneously, I must
+refer to the detailed description in Mr. Wood's monograph. The wires are
+thus twisted and tightened over a pad of lint or wood, drawing together
+the edges of the opening in the tendon.
+
+
+OPERATIONS FOR ARTIFICIAL ANUS.--In children the condition known as
+imperforate anus may sometimes be remedied by exploratory operations in
+the perineum, guided by the protrusion caused by the distended
+intestine. There are other cases, however, in which the rectum, as well
+as the anus, seems to be deficient, and in which, from the want of
+protrusion, there is no warrant for attempting an operation there; in
+these the only chance of life that remains is in an attempt to open the
+bowel higher up.
+
+In adults, again, absolute closure of the rectum and anus, and complete
+obstruction, may be the result of malignant disease, or even, very
+rarely, of simple organic stricture.
+
+In such cases, where the patient is tolerably strong and yet evidently
+doomed from the complete obstruction, an attempt at the formation of an
+artificial anus is warrantable, and in many cases afford great relief,
+and prolongs life for months.
+
+Without going into all the various positions proposed for such
+operations, I select the two most warrantable, which have borne the test
+of experience. These are--1. Colotomy in the left loin. This is
+applicable in the case of adults with rectal obstruction. 2. Colotomy in
+the left groin applicable in cases of imperforate anus and deficiency of
+rectum in infants.
+
+1. _Colotomy in the left loin_, generally known by the name of
+_Amussat's operation_.--The patient is laid upon his face, a pillow
+placed under the abdomen, rendering the left flank prominent. A
+transverse incision should then be made at a level about two
+finger-breadths above the crest of the ilium, extending from the outer
+edge of the erector spinae muscle forward for four or five inches,
+according to the fatness of the patient; the muscles must then be
+carefully divided till the transversalis fascia is exposed. It is then
+to be pinched up and divided, as in the operation for strangulated
+hernia. The muscular wall of the colon uncovered by peritoneum is then
+in most cases very easily recognised from its immense distension. The
+bowel should then be hooked up by a curved needle, two or three points
+at least secured to the margins of the wounds by stitches, and then the
+bowel should be opened by a longitudinal incision of at least an inch in
+length. When the distension has been great, there is generally a rush of
+fluid faeces, which must be provided for, special care being taken lest
+any get into the cavity of the peritoneum.
+
+[Illustration: FIG. XXXIII.[149]]
+
+2. _Colotomy in the left groin_, for absence of anus and deficiency of
+rectum in newly born infants.--The dissections of Curling, Gosselin, and
+others have shown that in infants the operation of lumbar colotomy is
+very difficult, and its results uncertain, while it is comparatively
+easy to open the colon in the left groin. Huguier, again, has shown that
+in certain cases the colon is not to be found in the left groin, but is
+accessible in the right groin. This abnormality seems, as shown by
+Curling, to occur not oftener than once in every ten cases.
+
+_Operation._--An oblique incision from an inch and a half to two inches
+in length should be made in the left iliac region above Poupart's
+ligament, extending a little above the anterior-superior spinous process
+of the ilium. The fibres of the abdominal muscles should be divided on a
+director passed beneath them, and the peritoneum should next be
+cautiously opened to a sufficient extent. The colon will most likely
+protrude, but if small intestine appear the colon must be sought for
+higher up. A curved needle armed with a silk ligature should be passed
+lengthways through the coats of the upper part of the colon, and another
+inserted in the same way below, and the bowel, being drawn forwards,
+should then be opened by a longitudinal incision. The colon must
+afterwards be attached to the skin forming the margin of the wound by
+four sutures at the points of entry and exit of the needles.
+
+
+OPERATION FOR THE REMOVAL OF AN ARTIFICIAL ANUS, in cases where the
+bowel is patent below.--After the operation for hernia in a case where
+the bowel is gangrenous, the only hope of the patient's recovery
+consists in the formation of adhesions between the bowel and the
+external wound, and the presence, for a time at least, of an artificial
+anus. If adhesions do form, and the patient recovers, it becomes a
+matter of great importance for his future comfort that the canal of the
+intestine should be re-established, and the fistulous opening allowed to
+close. This, however, is by no means easy, as even when the portion of
+intestine destroyed has been very small, a septum or valve remains which
+directs the contents of the bowel outwards, and so long as it exists is
+an effectual obstacle to any of the faecal contents passing into the
+distal portion of the bowel. This septum or eperon is formed by the
+mesenteric side of the two ends of the bowel. To destroy this without
+causing peritonitis is the aim of the surgeon, and it is not an easy
+matter to accomplish. To cut it away would at once open the peritoneal
+cavity, so the mode of treatment now adopted in the rare cases where it
+is necessary is that recommended by Dupuytren. The principle of it is to
+destroy the eperon by pressure so gradual as to cause adhesive
+inflammation between the two surfaces, and thus seal up the cavity of
+the peritoneum, before the continuance of the same pressure shall have
+caused sloughing of the septum. This is managed by the gradual
+approximation by a screw of the blades of a pair of forceps, to which
+Dupuytren gave the name Enterotome. The process, which extends over days
+and weeks, must be carefully watched lest the inflammation go too far.
+
+Plastic operations are occasionally required to close the opening after
+the passage is restored. For a good example of such an operation see
+_Edin. Med. Journal_ for August 1873, in which Mr. John Duncan describes
+a case.
+
+
+FOOTNOTES:
+
+[141] _Description of Sir Spencer Wells's Trocar._--"It consists of a
+hollow cylinder six inches long, and half an inch in diameter, within
+which another cylinder fitting it tightly plays. The inner one is cut
+off at its extremity, somewhat in the form of a pen, and is sharp. The
+sharp end is kept retracted within the outer cylinder by a spiral spring
+in the handle at the other end, but can be protruded by pressing on this
+handle when required for use. When thus protruded it is plunged into the
+cyst up to its middle; the pressure on the handle is taken off, and the
+cutting edge is retracted within its sheath. The fluid rushes into the
+tube, and escapes by an aperture in the side, to which an india-rubber
+tube is attached, the end of which drops into a bucket under the table.
+The instrument is furnished at its middle with two semicircular bars,
+carrying each four or five long curved teeth like a vulsellum. These
+teeth lie in contact with the outer surface of the cylinder, but can be
+raised from it by pressing two handles. When the cyst begins to be
+flaccid by the escape of the fluid, these side vulsellums are raised,
+and the adjoining part of the cyst is drawn up under the teeth, where it
+is firmly caught and compressed against the side of the tube."
+
+[142] For further details on the operations described above, reference
+may be made to Sir Spencer Wells's work on ovarian disease, and to the
+very valuable papers contributed by Dr. Thomas Keith to the _Edinburgh
+Medical Journal_. To the latter especially the author is indebted for
+much oral instruction, and for the opportunity of seeing his careful and
+dexterous mode of operating.
+
+[143] _Lect. on Surgery_, 3d ed., vol. ii. p. 998.
+
+[144] _Operative Surgery_, p. 462.
+
+[145] Rough diagram of abnormal course of obturator and its relation to
+the neck of a hernia. Parts seen from the inside: H, femoral hernia; A,
+femoral artery; V, femoral vein; E, epigastric artery; O, obturator from
+epigastric (dangerous); S O, obturator from epigastric (safe); N O,
+normal course of obturator; I R, internal inguinal ring; Sp C, spermatic
+chord and its vessels; G, Gimbernat's ligament; +, in triangle of
+Hesselbach.
+
+[146] Holmes's _Surgery_, 3d ed., 1883, vol. ii. p. 837.
+
+[147] _Clinical and Pathological Observations in India_, pp. 44, 325.
+
+[148] Wood _On Rupture_, 1863.
+
+[149] Diagram of an artificial anus, showing small sutures which unite
+the edges of the gut and the skin, and the large ones stitching up the
+wound beyond.
+
+
+
+
+CHAPTER XII.
+
+OPERATIONS ON PELVIS.
+
+
+LITHOTOMY.--However interesting and even instructive it might be, any
+history of the various operations for the removal of calculi from the
+bladder would be quite out of place in a manual such as this. It will be
+sufficient here to describe the operations recommended and practised in
+the present day.
+
+There are three different situations in which the bladder may be entered
+for the purpose of removing a calculus:--
+
+1. The perineum, where access is gained through the urethra, prostate,
+and neck of the bladder.
+
+2. Above the pubes, where the portion of bladder not covered by
+peritoneum is opened from above.
+
+3. From the rectum.
+
+
+1. LITHOTOMY THROUGH THE PERINEUM, by far the most frequent position for
+the operation.--Very various methods for its performance have been
+devised, differing in the nature and shape of the instruments employed,
+the direction and size of the incisions, the nature of the wound; but
+all resemble each other in certain very cardinal and important
+particulars. Thus all agree that it is absolutely necessary to enter the
+bladder at _one_ spot--the neck of the bladder; and that to do this
+safely the urethra must be opened, and some instrument previously
+introduced by the urethra is to be used as a guide for the knife. But an
+instrument in the urethra and bladder is surrounded for at least an inch
+of its course by the prostate; and thus the knife, gorget, or finger,
+which, guided by the instrument in the urethra, is intended to cut or
+dilate the entrance to the bladder for the purpose of allowing the
+calculus to be removed, cannot do this without also cutting or dilating
+this prostate gland. Experience has proved that much of the success of
+the operation depends upon the position and amount of incision made in
+this prostate gland. But it might be asked, Why can we not enter the
+bladder by one side, avoiding altogether its neck and this prostate
+gland? For this, among other reasons, that the bladder normally
+contains, and so long as the patient lives must contain, a certain
+quantity of a very irritating fluid. It is surrounded by the loose
+areolar tissue of the pelvis, into which, if any of this fluid escapes,
+abcesses will form and death probably ensue; this result will almost
+certainly follow any opening made into the bladder except at one spot.
+This spot is the neck of the bladder. Why does urinary infiltration not
+occur there? Because the fascia of the pelvis (which when entire can
+resist infiltration) is prolonged forwards at the neck of the bladder,
+over the prostate (Fig. XXXIV. PF), for which it forms a very strong
+funnel-like sheath. So long as this sheath is not cut where it covers
+the sides of the prostate, urinary infiltration of the pelvis is
+impossible, the urine being carried forwards and fairly out of the
+pelvis in this urine-tight funnel.
+
+[Illustration: FIG. XXXIV.[150]]
+
+But it may now be said, If this be the case, we are very much limited in
+the size of the incision we may make into the bladder. We cannot remove
+a large stone, for the prostate ought not to be larger than a good-sized
+chestnut, and any cut we might make through a chestnut without cutting
+out of its side must be very small. Very true; but fortunately the
+sheath of the prostate, unlike the rind of the chestnut, is very freely
+dilatable, and will allow the passage of a very considerable stone.
+
+Again, an inquirer might ask, If it is so dilatable, why should we run
+the risk of cutting the prostate at all? Why should we not introduce
+instruments gradually increasing in size into the membranous portion of
+the urethra, and thus dilate prostate and neck of bladder? For this
+reason, that the urethral canal passing through the prostate is itself
+lined immediately outside of the mucous membrane by a firm membranous
+sheath (Fig. XXXIV. RR), which resists dilatation to the utmost.
+Experience tells us that any attempts to dilate or even forcibly to tear
+this ring of fibrous texture are both ineffectual and dangerous, while a
+clean cut into it and through it into the substance of the prostate is
+at once effectual and comparatively safe.
+
+In a word, we can describe the relation of the prostate to the operation
+of lithotomy somewhat in this manner:--Its fibrous sheath surrounding
+the urethra must be cut freely. The gland substance may be cut and
+freely dilated by the finger. Its fibrous envelope must, as far as
+possible, be preserved intact, but this interferes the less with the
+operation, as it is comparatively freely dilatable.
+
+The firm lining of the urethra, which must be cut, is specially strong
+at its base, forming a tough resisting band just at the aperture of the
+bladder, which, unfortunately, is often so high up in the pelvis in
+tall patients, or in cases in which the prostate is much enlarged, as to
+be almost out of reach of the finger, and so far up the staff as perhaps
+to escape division. You will be warned of such an occurrence by the
+urine in the bladder failing to make its appearance; and if any attempt
+be made to dilate the opening and introduce the forceps without further
+incision of the base of the prostate, the result will very likely be
+fatal, generally from pyaemic symptoms depending on a suppurative
+inflammation of the prostatic plexus of veins (Fig. XXXIV.). In fact,
+upon a recognition of this fact is founded the aphorism, "that cases in
+which the forceps have been introduced before the bladder fairly begins
+to empty its contents are generally fatal."
+
+[Illustration: FIG. XXXV.[151]]
+
+We have thus traced the necessary guiding principles as to our incisions
+from the bladder outwards through the prostatic portion of the urethra.
+We have next to discover what sort of an opening is necessary in the
+membranous portion of the urethra consistent with the fulfilment of the
+same conditions, namely, freedom of escape for the urine, and room
+enough to remove the stone. Both of these are gained at once by a free
+incision of the membranous portion, dividing especially those anterior
+fibres of the great sphincter muscle of the pelvis, the levator ani,
+which embrace the membranous portion, under the special names of
+compressor (Fig. XXV.) and levator urethrae (Guthrie's and Wilson's
+muscles).
+
+The principles which guide the position and size of the preliminary
+incisions which enable the urethra to be opened are very simple:--(1.)
+The wound in the perineum should be large enough to give free access to
+the urethra, and easy egress to the stone; (2.) It should be conical,
+with its base outwards, so as to favour escape of urine and prevent
+infiltration; (3.) It should not wound any important organ or vessel;
+that is, it must avoid the rectum, the corpus spongiosum, especially the
+bulb, if possible, the artery of the bulb, and in every case should
+leave the pudic artery intact.
+
+So far for broad general principles, which must guide all methods of
+successful lithotomy.
+
+
+THE LATERAL OPERATION.--_Operation of Cheselden._--(1.) _Instruments
+required._--A staff with a broad substantial handle, and a longer curve
+than the ordinary catheter requires, furnished with a very deep and wide
+groove, which occupies the space midway between its convexity and its
+left side. The one used should invariably be large enough to dilate
+fully the urethra.
+
+A knife, with its blade three or four inches in length, but sharp only
+for an inch and a half from its point, its back straight up to within a
+sixth of an inch of its point, and there deflected at an angle to the
+point, which again curves to the edge. The angle from the back to the
+point permits the knife to run more freely along the groove in the
+staff.
+
+A probe-pointed straight knife with a narrow blade may occasionally be
+useful in enlarging the incision in the prostate, when this is required
+by the size of the stone.
+
+Forceps of various sizes and shapes, some with the blades curved at an
+angle to reach stones lying behind an enlarged prostate, all with broad
+blades as thin as is consistent with perfect inflexibility, the blades
+hollowed and roughened in the inside, but without the projecting teeth
+sometimes recommended, which are dangerous from being apt to break the
+stone.
+
+A scoop to remove fragments or small stones, sometimes useful with the
+aid of the forefinger in lifting out a large one.
+
+A flexible tube of at least half an inch calibre, and about six inches
+long, rounded off and fenestrated above, fitted at its outer end with a
+ring and two eyelet-holes for the tapes, with which it is tied into the
+bladder.
+
+Prior to the operation the patient's health should be attended to, the
+stomach and bowels regulated, and any disorder of the kidneys or bladder
+as far as possible alleviated. If his health has been good and habits
+active, three or four days' confinement to his room on low diet, with a
+full purge the evening before the operation, is all the preparatory
+treatment that is necessary.
+
+It is of the utmost importance for the safety of the operation and the
+patient's comfort after it, that the rectum be completely unloaded
+before the operation, and the bowels so far emptied as to permit three
+or four days after the operation to elapse without any movement of the
+bowels being necessary. If there is any doubt as to the effect of the
+laxative, a large stimulant enema should be administered on the morning
+of the operation.
+
+_Position._--Much depends on the proper tying up of the patient. He
+should be placed with his breech projecting over the edge of a narrow
+table, with head slightly raised on a pillow, but the shoulders low. The
+hands are then to be secured each to its corresponding foot, by a strong
+bandage passing round wrist and instep, or by suitable leather anklets,
+the knees should be wide apart, and on exactly the same level, so that
+the pelvis may be quite straight. An assistant should be placed to take
+charge of each leg.
+
+The staff is next introduced and the stone felt; if there is little
+water in the bladder a few ounces may be injected, but this is rarely
+necessary, for the patient should be ordered to retain as much water as
+possible, and when he cannot retain it, injection of water may do harm,
+and will probably not be retained, but at once come away along the
+groove in the staff. The staff is then committed to a special assistant,
+who must be thoroughly up to his duty, and attend to the staff alone.
+
+Some surgeons direct the assistant to make the convexity of the staff
+bulge in the perineum, to enable the groove to be struck more easily. It
+will be, however, safer both for the rectum and the bulb, if the staff
+be hooked firmly up against the symphysis pubis, as advised by Liston.
+The same assistant can also keep the scrotum up out of the way.
+
+If the perineum has not been previously shaved, this is now done.
+
+The operator sits down on a low stool in front of the patient's
+breech, his instruments being ready to his hand, and then steadying
+the skin of the perineum with the fingers of his left hand, enters
+the point of the knife in the raphe of the perineum, midway between
+the anus and scrotum (one inch in front of anus--_Cheselden_,
+_Crichton_; one and a quarter--_Gross_, _Skey_, and _Brodie_; one
+and three-quarters--_Fergusson_; one inch behind the scrotum--_Liston_),
+and carries the incision obliquely downwards and outwards, in a line
+midway between the anus and tuberosity of the ischium. The length of the
+incision must vary with the size of the perineum, and the supposed size
+of the stone, but there is less risk in its being too large, so long as
+the rectum is safe, than in its being too small. Its depth should be
+greatest at its upper angle, where it has to divide the parts to the
+depth of the transverse muscle of the perineum, and least at its lower
+angle, where a deep incision is not required, and would be almost sure
+to wound the rectum.
+
+The forefinger of the left hand is now to be deeply inserted into the
+wound, and any remaining fibres of the levator ani in front are to be
+divided, the edge of the knife being directed from above downwards. The
+left forefinger being still used to push its way through the cellular
+tissue, the groove in the staff is now felt in the membranous portion of
+the urethra covered by the deep fascia of the perineum. Now comes the
+deeper part of the incision. Guided by the finger-nail of the left hand,
+the surgeon introduces the point of the knife into the groove of the
+staff. He then takes hold of the staff for a moment to feel that it is
+held up properly against the pubis, and in the middle line, and also
+that the knife is fairly in the groove. Giving the staff back again to
+the assistant, and keeping the rectum well out of the way by the left
+hand, he now steadily directs the knife along the groove of the staff
+till the bladder is fairly entered, and the ring at the base of the
+prostate completely divided. When this is the case a gush of urine takes
+place, following the withdrawal of the knife.
+
+When making the deep incision, and in the groove of the staff, the blade
+of the knife should lie neither vertical nor horizontal, but midway
+between the two, so as to make the section of the left lobe of the
+prostate in its longest diameter, that is, in a direction downwards and
+backwards (Fig. XXXIV. L).
+
+The knife is now withdrawn, and the left forefinger inserted. In most
+cases it will be long enough to reach the bladder and touch the stone,
+and may then be freely used by gradual pressure to dilate the wound;
+this may be done very freely when necessary for a large stone, if only
+the ring of fibrous tissue surrounding the urethra be first cut and the
+bladder fairly entered. Whenever the stone is felt by the finger, the
+assistant may withdraw the staff.
+
+When the operator has thus felt the stone and sufficiently dilated the
+wound, the next step is to introduce the forceps; this should be done
+under the guidance of the finger, and with the blades closed. When the
+stone is felt the blades should be opened very widely, slightly
+withdrawn, and then pushed in again, the lower one, if possible, being
+insinuated under the stone. The blades must be made fairly to grasp and
+contain the stone in their hollow, for if they only nibble at the end of
+an oval stone, extraction is impossible. Extraction should then be
+performed slowly, with alternate wrigglings of the forceps from side to
+side, so as gradually to dilate, not to tear, the prostate, and the
+operator must remember to pull in the axis of the pelvis, not against
+the os pubis or the promontory of the sacrum.
+
+If there is much resistance, it may possibly be caused by the stone
+having been caught in its longer axis, and this may be remedied by
+careful manipulation by means of the finger and forceps. If the stone is
+still too large to be extracted without greater force than is
+warrantable, there are still various expedients (see _infra_, pp. 265,
+270).
+
+In most cases, however, the stone is removed rapidly enough by the
+single incision. The finger, or a sound, must then be introduced to feel
+if any more stones are present. The closed forceps make a very effectual
+instrument for this purpose. Much information may be gained from the
+appearance of the first stone, the presence or absence of facets. Its
+smoothness or roughness enables us to form a pretty certain opinion; yet
+the bladder should always be carefully searched; and if the stone has
+been friable or broken in extraction, should be washed out by a current
+of water. Where the calculi are very numerous, or where many fragments
+have separated, the scoop will be found useful, both for detecting and
+removing them. All the stones being extracted, there is in most cases
+little or no bleeding (see _infra_, Haemorrhage). The tube already
+described may now be inserted and tied into the bladder. It may be
+retained for forty-eight or seventy-two hours, according to
+circumstances. Care must be taken lest it be closed up by coagula during
+the first hour or two after the operation. In children the tube is not
+necessary, and from their restlessness might possibly do harm, but in
+adults (though neglected by some surgeons) experience shows it is a
+valuable adjunct in the after-treatment.
+
+Having thus traced the course of an ordinary uncomplicated case of
+lithotomy by the lateral operation, a brief notice is suitable of some
+of the obstacles and difficulties, some of the dangers and bad results
+which may be met with, and the best methods of overcoming them.
+
+1. _Large size of the stone_, as an obstacle to extraction. When, either
+from the enormous size of the stone, generally to be made out before the
+operation, or from some congenital or acquired deformity of the pelvis,
+it is obvious beforehand that the calculus cannot pass through the bony
+pelvis entire, a choice of two courses remains, either--
+
+(1.) The high or supra-pubic operation (_q.v. infra_); or (2.) Crushing
+of the calculus in the bladder, and removal piecemeal. Instruments of
+great strength have been devised for this latter operation. The risk to
+the bladder is very great, and fragments are apt to be left behind;
+these are sure to form nuclei of new calculi.
+
+2. _Peculiarities in the position or relations of the stone_ in the
+bladder:--
+
+(1.) It may lie in a sort of pouch behind the prostate, and thus be out
+of the reach of the forceps. This may be remedied by the use of curved
+forceps, or, better still, by the finger in the rectum to tilt up the
+stone into the bladder.
+
+(2.) It may lie above the pubis in the anterior wall of the bladder.
+Pressure on the hypogastrium, or the use of a strong probe as a hook,
+will generally suffice to dislodge it.
+
+(3.) The stone may be encysted. This is extremely rare, and, as
+Fergusson says, we hear more of these from bunglers who have operated
+only several times, than from those who have had large experience.
+
+3. _An enlarged prostate_ is at once a source of difficulty and of some
+danger.
+
+The distance of the bladder from the surface may be so very much
+increased by enlargement of the prostate as to render even the longest
+forefinger too short to reach the stone or even the bladder. This
+renders the introduction of the forceps more difficult and uncertain,
+the dilatation more prolonged, and the extraction more dangerous. If
+very large, the groove of the staff may not reach the bladder, and thus
+the deep incision may fail of cutting the ring at the base of the gland,
+and the urine may thus not escape, and all the dangers of laceration of
+the ring may result. Such cases may be well managed by the insertion of
+a straight deeply grooved staff into the insufficient incision, and
+fairly into the bladder, and on this, pushing a cutting gorget through
+the uncut portion of the gland. This insures a sufficient yet not
+dangerous incision, which we cannot so safely perform with the knife, as
+the parts are so far beyond the reach of the guiding forefinger.
+
+Under the head of risks after lithotomy we may class the following:--
+
+1. Sinking, or shock. In the very aged or very young, or after a very
+prolonged or painful operation, shock may now and then kill the patient
+within a few hours. Since the days of chloroform this result is
+extremely rare.
+
+2. Haemorrhage seems to be a very infrequent risk. The transverse
+perineal artery, which is always cut in the operation, is small, and
+rarely bleeds much. If the bulb is wounded, as no doubt frequently
+occurs, the flow from it can easily be checked. The pudic is so well
+protected from any ordinary incision as to be practically safe; and if
+wounded by some frightfully extensive incision, it can be compressed
+against the tuberosity of the ischium.
+
+There is an abnormal distribution of the dorsal artery of the penis, in
+which, rising higher up than it ought, and coursing along the neck of
+the bladder, and the lateral lobe of the prostate, it may be divided.
+This may give trouble, and even result in fatal haemorrhage. Fortunately
+it is rare. The author has met with one case in a boy of eleven, in whom
+a very severe haemorrhage was not to be explained. The patient recovered
+without another bad symptom.
+
+Again, a general oozing may often appear a few hours after the
+operation, when the patient is warm in bed, apparently from the
+substance of the prostate. If raising the breech and the application of
+cold fail to arrest it, it may be necessary to plug the wound. This is
+done by stuffing it with long strips of lint round the tube. Great care
+must be then taken lest the tube become occluded.
+
+3. Infiltration of urine may occur as a result of a too free incision of
+the vesical fascia (in adults), and still more frequently of a too small
+external wound.
+
+Here it should be noticed that in children it is fortunately of very
+little consequence to preserve the integrity of the prostatic sheath of
+vesical fascia. In them the prostate is so exceedingly small and
+undeveloped, that even the forefinger could not be introduced into the
+bladder without a complete section of the prostate. Probably from the
+blander nature of their urine, and the greater vitality of their
+tissues, this is of less consequence, as it is rarely found that any bad
+effects result from this section.
+
+Among other risks we find peritonitis, inflammation of neck of bladder,
+inflammation of prostatic plexus of veins, resulting in pyaemia,
+suppression of urine, and other kidney complications. For the symptoms
+and treatment of these there is no place in a mere manual of surgical
+operations.
+
+_Wound of rectum and recto-vesical fistula._--Such wounds were not
+uncommon, and in many cases unavoidable, before the days of chloroform,
+from the struggles of the patient; now they are comparatively rare, and
+should be still rarer. They probably occur in more cases than the
+surgeon is aware of, and heal up without his knowledge; we may arrive at
+this conclusion from the fact that small wounds are found in
+_post-mortem_ examinations of cases in which no such complication has
+been thought of.
+
+They occasionally heal without giving any trouble, but, at other times,
+as the external wound contracts, a communication forms between rectum
+and the urethra, in which the contents are apt to be interchanged in a
+most disagreeable manner, flatus passing per urethram, and urine per
+rectum.
+
+When it is evidently not going to heal spontaneously, the septum between
+the external orifice of the wound and the communication with the gut
+should be laid open, as in the operation for fistula _in ano_.
+
+     There are certain modifications and varieties in the method of
+     operating for stone through the perineum, which deserve at least a
+     brief notice:--
+
+     1. _The bilateral operation._--Though he was not the inventor,
+     Dupuytren's name is justly associated with this operation. The
+     principle of it is to divide both sides of the prostate equally, so
+     as to give more room for extraction of a large stone, without the
+     necessity of much laceration, or the risk of cutting through the
+     prostatic sheath of fascia.
+
+     _The operation._--A semilunar incision is made transversely across
+     the perineum, extending from a point midway between the right tuber
+     ischii and the anus, upwards, crossing the raphe nearly an inch
+     above the anus, and then curving downwards to a corresponding point
+     on the opposite side. The skin, superficial fascia, and a few of
+     the anterior fibres of the external sphincter, are thus divided,
+     and the groove of the staff sought by the forefinger. The
+     membranous portion of the urethra is then laid open in the middle
+     line, and the beak of a double lithotome cache securely lodged in
+     the groove. It is then pushed into the bladder with its concavity
+     upwards, and when fairly in it is turned round, its blades
+     protruded to the required extent, and withdrawn with its concavity
+     downwards, thus dividing both lobes of the prostate in a direction
+     downwards and outwards (Fig. XXIV. D D). The operation is finished
+     in the usual manner. Though it is a comparatively easy operation,
+     and theoretically may be proved to have many advantages, experience
+     has shown that the results are not so favourable as those of the
+     ordinary lateral operation.
+
+     2. _Buchanan's medio-lateral operation_ on a rectangular
+     staff.--The staff is bent at a right angle three inches from the
+     end, and deeply grooved on its left side. This is introduced into
+     the urethra so that the angle projects the membranous portion of
+     the urethra close to the apex of the prostate and the terminal
+     straight portion enters the bladder parallel to the rectum. The
+     angle projects in the perineum, so that the operator with his left
+     forefinger in the rectum is enabled, by a stab with a long straight
+     bistoury (held horizontally and with the cutting edge to the left
+     side), at once to enter the groove, and, by following the groove,
+     the bladder. Whenever the escape of urine shows that the bladder is
+     fairly reached, the knife is withdrawn so as to make a lateral
+     section of the prostate, and then, with the finger still in the
+     rectum, to make an incision in the ischio-rectal fossa, of
+     sufficient size to allow the stone to be easily withdrawn.
+
+     The inventor claims for this method that it is easier, that there
+     is less risk of haemorrhage, wound of the rectum, and infiltration
+     of urine.
+
+     3. _Allarton's operation of median lithotomy_ suits admirably for
+     stones known to be small, but is quite unsuitable for large ones.
+     Probably in most cases it should be superseded by lithotrity.
+
+     _Operation._--A large curved staff with a central groove is to be
+     held firmly hooked up against the symphysis pubis, and then
+     steadied by the left forefinger in the rectum. The operator pierces
+     the raphe of the perineum with a long straight bistoury about half
+     an inch above the verge of the anus, enters the groove of the
+     staff, and cuts inwards, almost, but not quite, into the bladder.
+     In withdrawing the knife the wound in the urethra is enlarged
+     upwards towards the scrotum. A ball-pointed probe is then passed on
+     the staff into the bladder, the staff is withdrawn, and the finger,
+     guided by the probe, is used to dilate the neck of the bladder, to
+     an extent sufficient for the removal of the stone by a small pair
+     of forceps.
+
+     In this operation the prostate is hardly incised at all. The
+     results are not better than those of the lateral operation.
+
+2. LITHOTOMY ABOVE THE PUBES, _or the High Operation_.--In cases where,
+from the known size of the stone, or from the deformity of the bones of
+the pelvis, it is impossible that the stone can be extracted entire in
+the usual manner; in cases where the prostate is very much enlarged, or
+where there is any real or supposed likelihood of inflammation of the
+neck of the bladder, the supra-pubic operation _may_ be warrantable. Its
+performance is easy, it does not involve any wound of the peritoneum if
+properly performed, and there is no risk of haemorrhage. There are
+certainly great risks attending it of peritonitis and urinary
+infiltration.
+
+In more than one case this operation has been attended by wound of
+peritoneum and subsequent escape of intestines through the wound, even
+when dressed antiseptically and performed under spray.
+
+_Operation._--The patient lies on his back, with his head and shoulders
+slightly raised, so as to relax the abdominal muscles, and his legs
+hanging down over the edge of the table. If his bladder can bear it, it
+should be fully distended, either by voluntary retention of the urine,
+or by injection with tepid water. A vertical incision is then made in
+the middle line, separating the recti muscles from below upwards, care
+being taken to push the peritoneum well out of the way, which is easily
+done by the finger in the loose cellular tissue of the part. The
+anterior wall of the bladder is then exposed, uncovered by peritoneum;
+it must be opened with great care, also in the middle line, while the
+wound in the parietes is held aside by retractors. The wall of the
+bladder should be transfixed by a curved needle, and thus held in
+position before it is opened. The stone is then removed by a pair of
+straight forceps, generally with great ease. Attempts used to be made to
+leave a catheter or canula in the bladder wound to prevent infiltration.
+Probably the safest method now will be to close the bladder wound at
+once by metallic stitches, and stitching the abdominal wound carefully
+with deeply entered wires, to leave the patient on his back. When
+compared with the lateral operations the statistics of the supra-pubic
+operation are discouraging, the mortality being one in three and a half
+to one in four. But in cases where the stone is known to be very large
+and of firm consistence, the risks are probably less from this method
+than from lateral lithotomy, followed by efforts to crush the stone
+through the wound prior to its removal.
+
+The late Mr. George Bell, a most successful lithotomist, proposed to
+perform this operation in two stages. In a case of greatly enlarged
+prostate, where the bladder had been punctured above the pubes by a
+country surgeon for retention of urine, he dilated the track of the
+canula by means of sponge-tents gradually increased in size, and then
+succeeded in extracting through the dilated opening several large
+calculi. The case recovered, and may encourage similar attempts.
+
+3. OPERATIONS THROUGH THE RECTUM.--(_a._) _Sanson's Recto-vesical
+Operation._--The principle of this operation consisted in laying the two
+canals, the rectum and the urethra, into one. A large staff, grooved on
+its convexity, being inserted into the urethra, the operator, with the
+forefinger of his left hand in the rectum as a guide to the knife,
+pierces the anterior wall of the rectum, reaches the groove of the staff
+just in front of the prostate, and cutting outwards divides the rectum,
+the anterior fibres of levator ani, and the sphincter, as well as the
+skin of the perineum in the middle line. Entering the knife again into
+the groove of the staff, it is to be pushed right onwards into the
+bladder, dividing the prostate, and avoiding if possible the seminal
+vesicles and ducts; the stone is then very easily removed.
+
+Though this operation was supposed to lessen the risk of pelvic
+infiltration it is _not_ found to do so, and it adds the additional
+inconvenience of almost inevitable rectal fistula, through which the
+urine escapes. It is certainly a very easy operation, but the mortality
+is found to be greater than in the ordinary lateral operation.
+
+(_b._) _Lithotomy through the rectum above the prostate._--The presence
+of a small portion of bladder beyond the prostate in close relation to
+the rectum renders it possible, in cases where the prostate is not
+enlarged, to enter the bladder and remove a stone of moderate size,
+without interfering with the peritoneum, prostate, or neck of the
+bladder.
+
+This ingenious but difficult operation was performed for the first time
+by Drs. Sims and Bauer in 1859.
+
+I quote the brief notice of the operation by Dr. Sims from the _Lancet_
+of 1864 (vol. i. p. 111):--
+
+"The patient was placed on the left side, and my speculum was introduced
+into the rectum, exposing the anterior wall of the rectum, just as it
+would the vagina in the female. A sound was passed into the bladder. The
+doctor entered the blade of a bistoury in the triangular space bounded
+by the prostate, the vesiculae seminales, and the peritoneal
+reduplication. He passed the finger through this opening, felt the
+stone, and removed it with the forceps without the least trouble. The
+operation was done as quickly and as easily as it would have been in a
+female through the vaginal septum. After the removal of the stone, Dr.
+Bauer kindly asked me to close the wound with silver sutures, which I
+did, introducing some five or six wires, with the same facility as in
+the vagina. There was no leakage of urine. The patient recovered without
+the least trouble of any sort. The wires were removed on the eighth day,
+and on the ninth day the patient rode in a carriage with Dr. Bauer a
+distance of four or five miles, to call on, and report himself to, our
+distinguished countryman, Dr. Mott."
+
+The chief risks in this operation seem to be the chance of wounding the
+peritoneal _cul-de-sac_, as the amount of free space between it and the
+prostate seems to vary much in individuals and in races. Dr. Marion Sims
+mentioned to me in conversation that he believed this operation
+impossible in the negro race, from the greater projection downwards of
+the peritoneal reduplication. An enlarged prostate would be an
+insuperable objection. The use of silver wire, to close up the wound at
+once, diminishes very much any risk of recto-vesical fistula.
+
+
+LITHOTRITY OR LITHOTRIPSY.--There exist cases of stone in the bladder,
+which, under certain conditions, may be relieved without lithotomy, by
+an operation which crushes the stone into fragments small enough to be
+discharged through the urethra.
+
+To enter with any fulness into the history, literature, and varieties of
+this operation, and the instruments required, would in itself require a
+large volume. Suffice it here to describe the case suitable for the
+operation, the essentials required in the instrument, and the method of
+performance.
+
+1. _For a case to be suitable_ the _stone_ should not be too large, and
+especially not too hard, also there should not be too many of them.
+
+The _urethra_ should be capacious enough to let the instrument pass
+easily and painlessly.
+
+The _bladder_ should be large enough to contain four ounces of water at
+least, should not be much inflamed, and, on the other hand, should not
+be paralysed. Paralysis or want of tone in the bladder prevents the
+thorough evacuation of its contents, and still more the expulsion of the
+fragments of stone.
+
+2. _A good instrument_ should, as far as possible, combine strength with
+lightness. The curved portion of the fixed blade should be fenestrated
+to allow escape of the fragments and thorough closure of the
+instrument.
+
+The movable blade must be so arranged as to combine perfect ease of
+movement up and down in seeking for the stone, with a powerful, slow,
+and gradual approximation in crushing it. This can be managed by an
+ingenious arrangement, which leaves the movable blade under the control
+only of the operator's thumb till the stone is found, and yet, by
+touching a spring, gives him the advantage either of a fine screw or of
+a rack and pinion movement for crushing the stone.
+
+3. _Operation._--The patient being prepared by a free evacuation of the
+bowels, and the urethra having been previously fairly dilated, he is
+asked to retain his urine as long as possible, or, if he cannot do so, a
+few ounces of tepid water may be injected per urethram.
+
+He is then laid on a sofa or table, the breech being well raised by
+pillows, the shoulders low, the thighs and knees bent up and separated.
+The instrument, well warmed and oiled, is then introduced with the
+blades closed. When fairly into the bladder the search for the stone
+begins.
+
+There are differences of opinion regarding the best method of fishing
+for the stone; great patience and gentleness, with a thorough previous
+acquaintance with bladder manipulation, are required, whichever method
+be chosen.
+
+The two chief methods may be described as the English and the French,
+the latter, Civiale's, being now used by Sir Henry Thompson, and other
+English operators. Briefly, the two are:--
+
+(1.) _Heurteloup's and Sir B. C. Brodie's._--In this, after the
+instrument is fairly entered, its handle is elevated, thus depressing
+the curved extremity, the forceps are then opened, and, by being kept as
+low as possible in the bladder, it is hoped that the calculus will fall
+into the opened blades by its own weight. In this method the fundus is
+the scene of crushing, and there is a risk of injuring the sensitive
+neck of the bladder, especially at the moment of opening the blades.
+
+(2.) _Civiale's--Thompson's._--In this the pelvis is to be so elevated
+that the centre of the bladder and space beneath it give plenty of room
+for seizing the stone, and all contact with the wall of the bladder is
+(as far as possible) avoided.
+
+The instrument is introduced closed, and carried fairly away in to the
+posterior part of the bladder before it is opened at all. It probably
+grazes the stone in passing, and, if so, is directed to the side of the
+bladder in which the stone is _not_ lying. Then when nearly touching the
+posterior wall, the movable blade is withdrawn, the instrument inclined
+towards the stone lying unmoved in the most dependent part, and there
+seizes it generally with ease.
+
+If not felt, the blades are again to be opened, turned a little to the
+other side of the bladder, and then closed. Sir H. Thompson lays the
+greatest stress on the importance of always having the blades fairly
+opened before shifting their position, for if moved when closed, the
+very opening of the movable blade is certain to drive the stone out of
+the way and prevent its seizure.
+
+Certain rules are useful:--Move the axis of the instrument as little as
+possible; it should be kept in the centre of the bladder, so far in,
+that the movements of the male blade are quite free from the neck of the
+bladder and prostate, and the blades only should be moved in the bladder
+on the centre of the shaft as an axis. There should be no jerking once
+the stone is caught, and the crushing should be done as far as possible
+in the very centre of the bladder, the blades not touching any of the
+walls.
+
+After the stone is seized, do not crush till, by a turn of the blades
+from side to side, you discover that none of the mucous membrane of the
+bladder is caught in the instrument.
+
+The lithotrite is not meant to extract stones, but to crush them, hence
+never attempt to withdraw it unless the blades are in absolute
+apposition.
+
+Never attempt too much at one time. Sir H. Thompson holds that five
+minutes is the longest time that should be given, perhaps in most cases
+three minutes being long enough.
+
+While many surgeons will still agree with the above advice, Dr. Bigelow
+of Boston has lately been highly commending a method which he has called
+Litholapaxy, in which, at one sitting under chloroform, the stone is
+crushed and aspirated, or sucked out of the bladder at once.[152]
+
+     Since the above was written the operation of Litholapaxy has made
+     great strides in the favour of surgeons, and many stones that would
+     have been removed by lithotomy are now broken down by powerful
+     instruments at a single sitting, and removed piecemeal by the
+     suction apparatus.
+
+     S. W. Gross has collected 312 cases, of which 17 died or 5.45 per
+     cent., but of 180 done by experienced surgeons, Thompson, Bigelow,
+     Van Buren, Weir, and Stevenson only five died, or 3.33 per cent.,
+     while of 1470 cases of lithotrity, as formerly practised, 159, or
+     10.81, per cent. died.[153]
+
+
+OPERATIONS FOR STRICTURE OF URETHRA.--Under this head many manipulations
+and operations might be described; the very instruments devised being
+exceedingly numerous and complicated. Enough here to detail a few of the
+more simple and practical procedures under the different heads of--1.
+_Dilatation_ gradual and forced. 2. _Internal Division._ 3. _External
+Division._
+
+1. DILATATION.--Under this head we have--
+
+_a._ _Vital dilatation._--The passing of a succession of bougies,
+gradually increasing in diameter, at intervals of three or four days,
+for the purpose of exciting an amount of interstitial absorption in the
+new material constituting the stricture, sufficient to remove it.
+Passing a bougie, though certainly often very difficult, perhaps should
+hardly come into the category of surgical operations, yet to preserve a
+certain completeness in the account of stricture, a very brief
+description may be here inserted.
+
+The recumbent posture is in most cases to be preferred. The patient
+should lie flat on his back, with the knees slightly bent and separated,
+and the head and shoulders slightly raised on a pillow. The operator
+standing on the patient's left side, raises the penis in his left hand,
+and with the right introduces the instrument, previously warmed and
+oiled, into the meatus. He then pushes it very gently onwards, at the
+same time stretching the penis with the left hand, just so far as to
+efface any wrinkles in the mucous membrane, till the point reaches the
+bulbous portion. The axis of the instrument, which at first for
+convenience was over the left groin, has now gradually been approaching
+the middle line. When this is reached, the instrument should be raised
+from the abdomen, and the handle cautiously carried in the arc of a
+circle first upwards and then downwards, till, when the instrument is
+fairly into the bladder, the handle is depressed between the patient's
+thighs. While this is being done the operator's left hand should be
+withdrawn from the penis, and the points of the fingers applied to the
+perineum.
+
+In cases of difficulty certain points may be remembered:--
+
+(1.) That the point of the instrument may in the first inch or two be
+occasionally entangled in a lacuna in the roof, especially when a small
+instrument is used; hence the beak should be at first maintained against
+the inferior wall of the canal.[154]
+
+(2.) That the handle should not be depressed too soon; if it is, there
+is a risk of a false passage being made through the upper wall.
+
+(3.) The opposite error may force the point out of the urethra between
+the membranous portion and the rectum, and onwards into the substance of
+the prostate gland.
+
+And certain cautions may be given:--
+
+(1.) In every exploration of an unknown urethra the surgeon should
+commence with an instrument of medium size, certainly not less than No.
+7 or 8.
+
+(2.) In cases of difficulty occurring in the urethra behind the scrotum,
+invariably use the forefinger of the left hand in the rectum as a guide.
+
+(3.) Expression of pain on the part of the patient is no indication that
+a false passage is being made, nor its absence that the instrument is in
+the passage, for it is a remark of Mr. Syme, that passing an instrument
+through a stricture is generally more painful than making a false
+passage through the walls of the urethra.
+
+     An instrument may be passed, while the patient is erect, with the
+     following precautions:--The patient should stand with his back
+     against a wall, his arms supported on the back of a chair on each
+     side, heels eight or ten inches apart, and four or five inches from
+     the wall; his clothes thoroughly down, not merely opened. The
+     bougie should then be held nearly horizontal, with its concavity
+     over the left groin of the patient, the penis being raised in the
+     surgeon's left hand. Introduced thus for four or five inches, the
+     handle is gradually raised into the middle line of the abdomen, and
+     to the perpendicular; it is then to be lightly depressed, and, as
+     the point enters the bladder, brought down towards the operator
+     until it sinks beneath the horizontal line.
+
+_b._ _Mechanical dilatation_ is of two kinds, both very rarely
+used:--(1.) When an instrument cannot be passed, it consists of passing
+down day after day the point of an instrument (sometimes armed with
+caustic, sometimes not), and pressing it against the stricture till it
+is overcome.[155] (2.) When an instrument is introduced through an
+intractable stricture, and is left there either for some hours, or for
+some days, to excite what is called "suppuration" of the stricture.[156]
+
+_c._ _Forced dilatation._--Under this head we might describe at great
+length mechanical contrivances to force or rupture a stricture. A word
+or two on a few of the most important:--
+
+(1.) Conical bougies of steel or silver.
+
+(2.) Mr. Wakley's method, on which many others have been founded. He
+passed a small bougie or wire into the bladder, over which were slipped
+straight tubes of varying size, with perfect certainty that they could
+not leave the urethra.
+
+(3.) Mr. Holt's method.[157]--The principle of it is to rupture the
+stricture at once, so that a No. 12 catheter can immediately be passed
+into the bladder.
+
+He attains this object by means of an instrument composed of two grooved
+blades, united about one inch from their apex, into a conical sound,
+which at its apex is about the size of a No. 2 bougie. This is passed
+into the bladder, and the grooved blades are separated to any extent
+that is desired by passing down between them a straight rod equal in
+size of a No. 8, 10, or 12, bougie. To guide this properly it is made
+hollow, and it is passed down over a central wire which lies between the
+grooved blades of the instrument and is welded to the apex. A great
+improvement is effected on Mr. Holt's later instruments by this wire
+being made hollow, and fitted with a stilette, for by this means we can
+with certainty ascertain whether or not the instrument has been passed
+into the bladder. This instrument, which is an improvement upon one
+invented by Perreve nearly forty years ago, has been used on very many
+occasions by Mr. Holt and others with success. The risk to life, if the
+case be properly managed, is trifling, but, like every other means of
+treating stricture, it has the objection that the stricture is liable to
+recur, unless bougies be passed at intervals for months and years.
+
+Sir Henry Thompson has introduced and described another very ingenious
+instrument for the same purpose, constructed on somewhat similar
+principles. His account of it, to which I must refer, will be found in
+Holmes's _System of Surgery_, 1st ed. vol. iv. p. 399.
+
+2. INTERNAL DIVISION OF STRICTURE is a mode of treatment which by many
+surgeons is highly disapproved, yet of late years it has been more used
+than formerly, especially in resilient strictures. It may be done in two
+ways:--
+
+(1.) _From before backwards._--This method, to be at all admissible,
+requires a guide to be previously passed; a lancet-shaped blade may then
+be slipped down a groove in this guide till the stricture is divided.
+This is least objectionable in cases of stricture close to the meatus.
+
+(2.) _From behind forwards._--To make the incision thus, it is of course
+necessary that the stricture should be so far dilatable as to admit an
+instrument the point of which is large enough to contain the blade by
+which the stricture is to be divided. This will be found to be at least
+equal in size to a No. 3 or No. 4 catheter. In many instruments it is
+much larger.
+
+_Civiale's_ instrument for internal incision of the urethra from behind
+forwards has the very high recommendation of Sir H. Thompson.[158] It
+consists of a sound with a bulbous extremity (as large as a No. 5
+bougie) which contains a small blade, which can be made to project for
+such a distance as the operator wishes. It is passed through the
+stricture with the blade concealed, till the bulb is carried about
+one-third of an inch or more beyond the stricture; the blade is then
+projected, and the incision made by drawing it slowly but firmly
+outwards towards the meatus, with the blade towards the floor of the
+urethra, till the stricture is divided in its whole extent. Sir H.
+Thompson recommends this to be used in cases _where it is not that the
+stricture is of very small calibre, but that it is undilatable_, that
+prevents the cure. Many modifications of above have been devised by
+Lund, Teevan, and other surgeons, on similar principles.
+
+3. MR. SYME'S OPERATION OF EXTERNAL DIVISION.--Mr. Syme held that no
+stricture through which the water can escape should be called
+_impermeable_, for by patience and care the surgeon should always be
+able to pass a slender director through the stricture on which it may be
+divided with ease and certainty. The old operation of "perineal section"
+for so-called impermeable stricture is very different, being difficult,
+dangerous, and uncertain in its results.
+
+_Operation._--A director is passed into the stricture. Mr. Syme's
+directors are of different sizes, the smallest being in diameter less
+than an ordinary surgical probe. They are made of steel, are grooved on
+the convexity, and have this peculiarity, that while the lower half is
+small, the upper is of full size (No. 8 or 10), the difference in
+calibre occurring quite abruptly. The presence of this "shoulder" on the
+staff enables the operator to ascertain exactly the position of the
+stricture, and also to tell when it is fully divided without the
+necessity of withdrawing the instrument.
+
+This being fairly in the stricture, the patient is put in the position
+for lithotomy, an assistant holds the staff in his right hand, drawing
+up the scrotum with his left.
+
+The surgeon then makes an incision in the middle line over the
+stricture for the necessary distance, from above downwards, till he
+exposes the urethra, and feels exactly the shoulder of the staff. Care
+must be taken not to go past the urethra at either side. When he
+distinctly feels the outline of the staff, he takes it in his left hand,
+and a short sharp-pointed bistoury in his right. It should be held
+firmly in the palm of the hand, with the back of the blade resting on
+the forefinger, the pulp of which guides the point to the groove, and
+guards it when making the incision; the knife is to be placed on the
+groove beyond (_on the bladder side_) of the stricture, and brought
+forwards, slowly cutting through _the whole_ stricture; till the
+shoulder of the staff is reached. It requires strength and precision to
+divide thoroughly the indurated stricture, which is apt to elude the
+knife.
+
+The shoulder of the staff can now be passed through the stricture if the
+operation is complete; if not, the incision must be extended, always in
+the middle line, and guided by the groove. When thoroughly divided, the
+staff is now to be withdrawn, and a full-sized catheter with a double
+curve passed into the bladder. This should _not_ be furnished with a
+stop-cock or plug, lest the bladder should by inadvertence be allowed to
+be too full, and extravasation into the cellular tissue of the urethra
+take place along the side of the instrument.
+
+The catheter should be tied in, and left for two, sometimes for three
+days, when it can generally be removed with safety, and a bougie should
+be passed at intervals of three or four, till the wound is healed. To
+prevent recurrence of the stricture, it is a wise precaution to pass an
+instrument at intervals for many months after the cure is apparently
+complete.
+
+In certain cases, where the stricture is far back and the urinary
+symptoms severe, Mr. Syme found advantage from the introduction of a
+shorter double-curved catheter (only about nine inches long) through
+the wound into the bladder, where it should be left for three days.
+This seems to diminish the risk of rigors, and other symptoms of fever,
+which are apt to occur when the urine is allowed for the first time to
+pass over the wound.
+
+_Perineal Section_ is an operation both dangerous and difficult; as Sir
+Astley Cooper used to say, "the surgeon who performs it requires to have
+a long summer's day before him."
+
+No director or guide can be passed. A full-sized catheter must be passed
+as far as possible _up_ to the stricture, and held firmly in the middle
+line. The patient must be tied up in lithotomy position on a table in
+the very best light that can be obtained. The perineum being shaved, an
+incision must be made in the middle line from over the point of the
+catheter to the verge of the anus, if the stricture extends far back.
+
+The urethra should then be opened over the catheter, the edges of the
+mucous membrane held to each side by silk threads passed through them;
+and the surgeon must endeavour to pass a fine probe into the opening of
+the stricture; if this can be done, it is comparatively easy to slit the
+stricture up. If not, the surgeon must simply seek for the remains of
+the urethra by slow, cautious dissection in the middle line. If
+successful, a catheter must be secured in the bladder in the usual way.
+
+A stricture near the orifice, or, as it is not uncommon, involving
+merely the meatus, can be treated with great ease in the above manner by
+division on a grooved probe. When quite close to the orifice, with a
+well-defined hardness, as of a ring round the urethra, it may be divided
+subcutaneously by a tenotomy knife or other narrow-bladed instrument. It
+is not necessary to keep a catheter in the bladder in cases where the
+stricture has been in front of the scrotum.
+
+
+PUNCTURE OF THE BLADDER.--A patient and dexterous use of the catheter
+prevents this operation from being often required; still, circumstances
+may arise in which it is found impossible to enter the bladder _per vias
+naturales_. In such a case the bladder may be punctured from the outside
+by a curved trocar and canula, in either of two situations.
+
+1. _From above the pubis._--This operation is a very simple one, and
+when the bladder is distended need not imply a wound of the peritoneum.
+
+_Operation._--A preliminary incision, varying in length according to the
+amount of fat, should be made above the pubis exactly in the middle
+line; the edges of the recti should be separated, the peritoneum pushed
+out of the way and upwards by the finger, and a curved trocar plunged
+into the distended bladder obliquely backwards. The canula should be
+retained for a day or two, and then a flexible catheter with a shield
+inserted instead. Such instruments have been worn for years. The
+aspirateur pneumatique of Dr. Dieulafoy will be found an exceedingly
+useful instrument for puncture of bladder and removal of urine. The
+author has now used it very frequently with the best results. Its
+advantage is that the urine is removed through an aperture so small as
+to allow of the withdrawal and reintroduction of the canula as often as
+is necessary.
+
+[Illustration: FIG. XXXVI.[159]]
+
+2. _From the Rectum._--Except in cases of enlargement of the prostate,
+it is at once easier and safer to puncture the bladder from the rectum.
+The well-known triangular space uncovered by peritoneum, with its apex
+in front close to the prostate, and bounded on either side by the vasa
+deferentia and vesiculae seminales, can be easily reached by a curved
+trocar. This should be guided by one, or, still better, by two fingers,
+into the rectum, with its concavity upwards, and the point should be
+pushed upwards by depression of the handle, whenever it is fairly behind
+the prostate. The trocar may then be withdrawn, and the canula retained
+for at least forty-eight hours by a suitable bandage. Mr. Cock, of Guy's
+Hospital, had a special canula for the purpose, which expands at its
+extremity after its introduction, and thus is not apt to slip.[160] Some
+surgeons insist that the surgeon should be able to ascertain the
+existence of fluctuation between the finger in the rectum, and the other
+hand above the pubes. This is exceedingly difficult to elicit when the
+bladder is very much distended, and from the constrained position of the
+finger in the bowel.
+
+
+PHYMOSIS.--Elongation of the prepuce, with contraction of its orifice,
+in most cases congenital, sometimes so extreme as to cause difficulty in
+micturition, and frequently preventing the uncovering of the glans.
+
+_Operation._--In all well-marked cases, the following is required:--The
+elongated prepuce should be pulled forwards by a pair of catch-forceps,
+and a circle of skin and mucous membrane removed by a single stroke of a
+bistoury, or by sharp scissors. Care should be taken lest the glans be
+included in the incision, as has happened in _at least_ one instance.
+The skin will then be found to retract very freely beyond the glans, but
+the mucous membrane is found still to cover the glans, and its orifice
+is still constricted. It must then be slit up (Fig. XXXVII. _b b_) on
+the dorsum of the glans, with probe-pointed scissors, as far as the
+corona, and the glans will then be thoroughly exposed. The edges of
+mucous membrane and skin should then be stitched to each other by at
+least five or six fine silk sutures, any bleeding points having been
+first carefully secured. The angles will in time round off, and a
+wonderfully seemly prepuce be obtained. This operation may be done as a
+method of cure for obstinate enuresis in cases in which the prepuce is
+very long and redundant, even when it is not too tight. The author has
+done this in more than twenty cases with excellent results.
+
+[Illustration: FIG. XXXVII.[161]]
+
+     _Varieties._--When the prepuce is narrowed at its orifice without
+     being redundant in length, a milder operation will prove
+     sufficient. The principle is the same as in the former, but the
+     amount of incision is less, and nothing is removed. Two methods are
+     possible:--
+
+     1. _By scissors._--The blunt point of a pair of scissors is
+     introduced through the preputial orifice, the other blade being
+     outside, and the skin and mucous membrane are divided for about
+     half an inch; the skin being then retracted, the mucous membrane is
+     still further divided by one or two additional snips, and then the
+     edges of skin and mucous membrane are stitched together by one or
+     two points of suture.
+
+     2. _By knife._--A director being introduced within the prepuce, a
+     narrow-bladed knife is guided along it, and pushed through the
+     prepuce from within, and then made to divide skin and mucous
+     membrane from within outwards. Stitches as before.
+
+     _N.B._--Be careful lest the director pass into the meatus
+     urinarius, and the glans be split up.
+
+     Again, some surgeons prefer two lateral incisions instead of one
+     dorsal one. In this case skin and mucous membrane should be divided
+     by scissors for about a quarter of an inch, and then a single
+     stitch inserted in the angle of junction. This has been further
+     modified by Cullerier, who proposed the division of the tight
+     mucous membrane only, in three or four points. He used a pair of
+     scissors with one sharp and one probe-pointed blade, the sharp one
+     thrust in between skin and mucous membrane, the blunt one between
+     the mucous membrane and the glans.
+
+
+AMPUTATION OF THE PENIS.--This exceedingly simple operation is performed
+by a single stroke of an amputating knife, drawn along from heel to
+point, while the penis is stretched in the operator's left hand. As
+there is more risk of redundancy than of deficiency of the skin, no
+attempt is made to save it. Numerous vessels in the corpora cavernosa
+require ligature. Amputation of the penis may be done bloodlessly by the
+thermo-cautery even close to its root. Transfix the root of corpora
+cavernosa by a needle; above this pass two or three turns of an elastic
+ligature; then slowly divide at a low red heat the skin and corpora
+cavernosa below the needles; split the urethra after dividing its mucous
+membrane with a knife. The author has done this several times with ease
+and rapid healing.
+
+[Illustration: FIG. XXXVIII.[162]]
+
+The chief risk is stricture of the orifice of the urethra. To prevent
+this, several modifications of the operation have been introduced.
+
+1. _Ricord's method._[163]--After the amputation the surgeon seizes with
+forceps the mucous membrane of the urethra, and with a pair of scissors
+makes four slits in it, so as to form four equal flaps, and with a silk
+ligature stitches each of these to the skin. Contraction of the
+cicatrix will thus tend to open rather than close the urethral orifice.
+
+2. _Teale's method._[164]--He slits up, by a bistoury on a director, the
+urethra and skin over it for about two-thirds of an inch, and then
+stitches the one to the other, thus making it a long oval dependent
+orifice (Fig. XXXVIII.).
+
+3. _Miller's proposed method._[165]--"A narrow-bladed knife is first
+used to transfix the penis between the spongy and cavernous bodies close
+to the root; the knife having been carried forwards for an inch and a
+half, its edge is turned perpendicularly downwards, and the urethra and
+skin flap are divided, the cavernous bodies and dorsal integument being
+then cut perpendicularly upwards where the knife was originally entered
+for transfixion. A button-hole is afterwards made in the lower flap,
+though which the corpus spongiosum and urethra protrude, while the flap
+itself is turned upwards, and attached dorsally and laterally, so as to
+cover in the exposed cavernous structure."
+
+
+HYDROCELE.--The very simple operation necessary for hydrocele is thus
+performed:--The surgeon supports the tumour in his left hand so as to
+project it forwards, and make the scrotum as tense as possible in front.
+Having carefully ascertained the exact position of the testicle, which
+can generally be easily enough done by a finger accustomed to
+discriminate the difference between a soft solid, and a bag tensely
+filled with fluid, aided by the peculiar sensation of the testicle when
+squeezed, the surgeon enters a trocar and canula about an eighth of an
+inch in diameter into the distended cavity of the tunica vaginalis, near
+the fundus of the swelling. When it is evident the instrument is fairly
+entered, and not till then, the trocar is withdrawn, and the fluid
+allowed completely to drain off. When it ceases to flow the surgeon
+places his forefinger over the end of the canula to prevent the entrance
+of air, till he fits into its orifice a suitable syringe containing two
+drachms of the tincture of iodine, made according to the Edinburgh
+Pharmacopoeia: the tincture of the British Pharmacopoeia is not
+sufficiently strong. Having injected this cautiously into the cavity,
+the canula is withdrawn, and the surgeon, seizing the now flaccid
+scrotum in his right hand, gives it a thorough shake, so as to spread
+the iodine over as much as possible of the inner wall. When properly
+performed this very simple procedure very rarely fails to produce a
+radical cure; though less thorough operations, such as mere evacuation
+of the fluid, less stimulating injections, unguents introduced on
+probes, and the like, often fail of success, and thus give encouragement
+to absurdities, such as wire-setons, or to more severe operations, such
+as laying open the sac.
+
+
+HAEMATOCELE.--When the contents of the sac of the tunica vaginalis are
+found to be grumous instead of simply serous, or when, as often happens,
+only pure blood escapes when the fluid is nearly evacuated, it is found
+that simple evacuation and injection are very rarely sufficient to
+effect a cure.
+
+After they have been fairly tried, the sac of the haematocele should be
+laid open in its full extent; any large vessels which bleed should be
+tied, and the cavity then stuffed with lint. When the lint can be
+removed, which will be after two or three days, the edges of the wound
+should be brought closely together, and the cavity will then rapidly
+heal up from the bottom, and be obliterated by secondary union of
+granulations.
+
+In cases where the walls of the cavity are enormously thickened, or
+even, as sometimes happens, almost bony in consistence, an elliptical
+portion may be removed with advantage.
+
+
+EXCISION OF TESTICLE.--This operation is rarely required except for
+tumours of the testicle. Hence the size of the incision necessary must
+vary much with the size of the tumour; and the amount of skin to be
+removed (if any) on the amount of adhesions it has formed to the tumour.
+
+One or two points must be attended to in every case of extirpation of a
+testicle:--
+
+1. The incision should commence over the cord just outside of the
+external ring, and be continued fairly over the tumour to its base.
+
+2. As to removal of skin, some surgeons advise that none should be taken
+away, others that a considerable quantity can be spared. There is
+certainly less risk of secondary haemorrhage if a portion be removed,
+than when a flaccid empty bag is left. The author invariably removes a
+very large quantity of skin if the tumour is large, as there is much
+more rapid healing, and the resulting scrotum is much more comfortable
+for the patient.
+
+3. The cord should be exposed at the beginning of the operation, raised
+from its bed and given to an assistant, who should compress it gently,
+not from any fear of its escape into the abdomen, but to prevent
+haemorrhage. If the tumour has been very large and heavy, the cord will
+have been much stretched, and if divided too high up, may really give
+trouble by its elasticity, unless the above precaution is taken. The
+cord then having been divided close to the tumour, the latter is
+removed, care being taken not to include the sound testicle in the
+removal. All the vessels are then to be tied or twisted, and the
+spermatic artery is to be secured alone, not, as used to be the case,
+included in a common ligature with the other constituents of the cord.
+Secondary haemorrhage is very apt to occur from small scrotal branches
+which may have escaped notice during the operation.
+
+
+OPERATIONS ON THE ANUS AND ITS NEIGHBOURHOOD.--FISTULA IN ANO.--While
+much might be written on the pathology of fistula, and a good deal even
+on its diagnosis, a very few words will suffice to describe the simple
+and effectual operation for its relief.
+
+Dismissing at once all so-called palliatives, drugs, unguents, pressure,
+and injections, as mere waste of time, and holding that the only method
+of cure consists in laying the fistula fairly open, the question narrows
+itself into this: What is the best method of laying it open? Prior to
+the discovery by Ribes of the great principle that the internal orifice
+of the sinus is always within an inch or an inch and a half of the
+orifice of the anus, the operations for fistula were most unnecessarily
+severe; the gut used to be divided as far up as the sinuses extended;
+and large portions of the anus used to be excised bodily along with the
+sinuses. It is now a much simpler and more satisfactory operation.
+
+_Operation._--A common silver probe bent to the required shape is passed
+into the external opening, or, if there are more than one, into the
+largest and oldest one. The forefinger of the left hand being introduced
+into the rectum, the probe is passed through the internal orifice, and
+its point brought out by the anus. The portion of tissue raised by the
+probe can then be easily divided with the certainty that the fistula is
+laid fully open. Anal fistulae have been divided by the elastic ligature,
+but it seems slower in action and more painful, with no counterbalancing
+advantages.
+
+     The author has for last few years operated almost exclusively by a
+     long knife which is continued into a steel probe. The probe is
+     passed up the fistula, then into the bowel, and is hooked out at
+     the anus, and in being simply pushed on the knife cuts the
+     fistula--tuto, cito, et jucunde, the patient rarely knowing that
+     more has been done than an exploration.
+
+     In cases where, from the hardness and density of the parts it is
+     impossible to pass the probe and bring it out at the anus, a strong
+     probe-pointed bistoury may be passed in by the external orifice
+     till its probe-point can be felt by the finger in the bowel at the
+     internal opening. Supported by the finger it can then be made to
+     cut outwards till the whole septum is divided.
+
+
+FISSURE OF THE ANUS, ULCER OF THE ANUS, resemble each other alike in the
+exceeding annoyance which they give to the sufferer, and in the
+simplicity of the treatment needed.
+
+_Operation._--Once the presence of either is determined by the finger in
+the anus, a sharp-pointed curved bistoury should be introduced,
+transfixing the base of the fissure or ulcer, and then guided on the
+finger, completely dividing it, so as to change the ragged ulceration
+into a simple wound which will rapidly heal.
+
+
+PROLAPSUS ANI, _Operation for_.--Complete prolapsus in which the whole
+gut is involved, as seen in the very young and the very aged, is suited
+for palliative rather than radical treatment.
+
+Cases of prolapsus of the mucous membrane only, as is not uncommon in
+connection with or as a result of haemorrhoids in adults, give
+opportunity for operative interference.
+
+We may act on either the skin or mucous membrane, or both at once.
+
+1. _The skin_ is often found loose, and arranged in radiating folds
+round the anus. In such cases, as recommended first by Dupuytren, some
+of these projecting folds may be removed. Again it may be prolapsed in a
+great loose ring or circular fold round the margin, forming an
+exaggerated external pile; in such a case the loose fold may be fairly
+excised with curved scissors, as recommended by Hey of Leeds.
+
+The first of these methods is apt to be insufficient, the second again
+has the risk of removing too much.
+
+2. If the protrusion is chiefly mucous membrane exposed in folds, or a
+ring, which is generally outside, one of two methods of treatment may be
+tried:--
+
+_a._ By ligature, as recommended by Mr. Copeland. Raising a longitudinal
+fold of the mucous membrane, he passed a ligature round it as if it were
+a pile. There is less chance of the ligature slipping if a double thread
+be used and its base thus transfixed. Three, four, or even more folds
+may be thus treated.
+
+_b._ When the mucous membrane has been so long exposed as to have lost
+many of its characters, and to resemble leather in its toughness,
+excision will be found less painful and much more rapid than ligature.
+
+A longitudinal fold at each side of the anus should be pinched up and
+excised by a pair of probe-pointed curved scissors. There is always a
+certain amount of risk of haemorrhage following such an operation. The
+risk is lessened and the result improved by stitching up the wound in
+the mucous membrane before the protruded portion of bowel is returned.
+
+
+POLYPI OF THE RECTUM.--Pedunculated growths varying in consistence,
+shape, and size, but resembling each other in having a distinct stalk,
+and in frequently being protruded at stool.
+
+_Operation._--Invariably by ligature, which may be single round the
+stalk, if the tumour be globular and with a distinct narrow stalk, or by
+transfixion, if (as sometimes happens) the tumour be of uniform
+thickness throughout, like a worm.
+
+
+HAEMORRHOIDS OR PILES.--In the treatment of piles it is the differential
+diagnosis that is troublesome and occasionally difficult; the operative
+interference required is generally very simple, if the nature of the
+case be rightly determined.
+
+_External piles._--_Operation._--The apex of the soft flabby excrescence
+should be seized by a pair of catch-forceps, and it should be cut off
+close to its base with a knife, or, what is better, a pair of curved
+scissors. Any little vessel which jets may then be secured. If, instead
+of numerous individual tumours, a ring of skin round the anus be
+involved, the whole of it should be shaved off, but not very close to
+its base, lest too great contraction of the anal orifice should ensue.
+
+     If the surgeon, after excising a pile or piles, will take the
+     trouble to stitch up the wound with catgut, he will find the cure
+     much more rapid and less painful than when this is omitted.
+
+_Internal piles._--Incision is extremely dangerous, from the vascularity
+of the parts, and their being so inaccessible from their position within
+the sphincter ani. Hence ligature is safer and equally effectual. The
+patient should be directed to sit over hot water, and strain till the
+whole of his piles are fairly protruded. The surgeon should then
+transfix the base of each separately with a curved needle bearing a
+strong double thread. The needle being cut off, the threads should be
+very firmly tied, each isolating its own half of the pile. The tying
+should be exceedingly tight, so as to cause instant and complete
+strangulation and death of the tumours. All the piles should be tied at
+the same sitting. If the piles are very small they may be secured
+without transfixion in a single noose after being seized by a hook or
+forceps. There is greater risk of the noose slipping than when the base
+has been transfixed.
+
+The strangulated masses must then be returned into the bowel, and the
+patient kept in bed or on a sofa till the ligatures separate, which is
+generally not till the fourth or fifth day. A certain amount of urinary
+irritation, showing itself sometimes in strangury, sometimes in complete
+retention, occasionally follows this operation.
+
+Mr. Smith of King's College, and many other surgeons, treat internal
+piles by means of an ivory clamp to hold them tight, while they are
+burned off by the actual cautery or the thermo-cautery at a low red
+heat. They claim that pyaemia more rarely follows this mode.
+
+     There are certain cases in which the lower inch or two of the
+     rectum are found red and congested, and in which every stool is
+     followed by the loss of a certain quantity of florid arterial
+     blood, and yet no distinct haemorrhoidal tumour is to be seen. In
+     such cases the ligature is not applicable, and relief is obtained
+     by the application of pure nitric acid, or other potential caustics
+     to the bleeding surface, as recommended by Houston, Lee, Smith,
+     Ashton, and others. These cases are comparatively rare, and
+     whenever they can be applied, the ligature is much simpler, safer,
+     and more certain.
+
+_Venous piles._--When a sudden effusion of blood has occurred into one
+of the varicose veins or sinuses of a congested anus, an oval or rounded
+tumour is felt, very tense, shining, and painful. To slit it freely up
+with an abscess lancet, and evert the clot inside, at once relieves all
+the symptoms.
+
+
+FOOTNOTES:
+
+[150] Diagram of section of prostate seen from the inside:--PF, pelvic
+fascia or prostatic sheath; RR, ring which must be cut; L, position of
+incision in the lateral operation; DD, position of incisions in the
+bilateral operation.
+
+[151] Diagram of muscles of membranous portion of urethra seen from the
+inside:--SS, section of os pubis; U, urethra; G, Guthrie's muscle,
+compressor urethrae; W, Wilson's muscle, levator urethrae.
+
+[152] _Boston Medical and Surgical Journal_, May 29, 1879.
+
+[153] Gross, _Surgery_, 6th ed. vol. ii. p. 736.
+
+[154] Holmes's _Surgery_, vol. iv. p. 392.
+
+[155] See Miller's _Practice of Surgery_, p. 212.
+
+[156] Solly's _Surgical Experiences_, pp. 537, 538, etc.
+
+[157] _The Immediate Treatment of Stricture._ By Bernard Holt, F.R.C.S.
+London. Third Edition, 1868.
+
+[158] Holmes's _System of Surgery_, 1st ed. vol. iv. p. 403.
+
+[159] Diagram of puncture of the bladder:--B, bladder; SP, symphysis
+pubis; SC, scrotum; _b_, bulb; _pr_, peritoneum; P, prostate; R, rectum;
+S, sacrum and coccyx.
+
+[160] _Med. Chir. Trans._, vol. XXXV.
+
+[161] Diagram of operation for phymosis:--_a_, glans penis; _b b_,
+mucous membrane exposed by retraction of the skin, and slit up; _c d_,
+sutures introduced and ready to be tied, uniting the skin and mucous
+membrane.
+
+[162] To illustrate Teale's operation:--_c_, section of penis _b_,
+thread inserted uniting mucous membrane and skin; _a_, thread tied.
+
+[163] _Med. Times and Gazette_, vol. xix. p. 354.
+
+[164] Miller's _System of Surgery_, p. 1255.
+
+[165] Miller's _System of Surgery_, p. 1256.
+
+
+
+
+CHAPTER XIII.
+
+TENOTOMY.
+
+
+For convenience' sake I group under this one head certain operations
+used for the relief of distortion, in which muscles or tendons are
+divided subcutaneously. Since the discovery of the principle by Delpech,
+and the application of it by Stromeyer, Dieffenbach, Little, and
+countless successors, it has been used for very many cases for which it
+is totally inapplicable, _e.g._ for the division of the muscles of the
+back in spinal curvature. Still there remain several deformities for the
+relief of which subcutaneous tenotomy is a most important remedy; chief
+among these are Wry Neck and Club-foot.
+
+
+OPERATION FOR WRY NECK.--_Subcutaneous section of the
+sterno-mastoid._--In what cases of wry neck is this operation suitable?
+In those only in which the muscles are the starting-point of the
+mischief. These are sometimes congenital, more frequently they commence
+in childhood. In cases where the distortion depends on disease of the
+cervical vertebrae, or is secondary to curvature of the spine, division
+of the muscle is worse than useless.
+
+_Operation._--A tenotomy knife, which should be sharp-pointed, narrow in
+the blade, with a blunt back, should be introduced through the skin a
+little to one side of the sternal portion of the affected muscle, passed
+along with its flat edge between the skin and the tendon, till it has
+fairly crossed the tendon; the blade should then be turned so that by a
+gradual sawing motion the edge may be made to divide the tendon about an
+inch above the sternum. A distinct snap will then be felt or heard, and
+the position of the head will be at once much improved. Exercise, warm
+bathing, and rubbing, will generally suffice to complete the cure,
+without it being necessary to call in the aid of the instrument-maker
+with his expensive apparatus.[166]
+
+
+OPERATIONS FOR CLUB-FOOT.--The following are the tendons which _may_
+require division in the cure of club-foot, and the operations for their
+division.
+
+1. _The tendo Achillis._--There are very few cases of true club-foot
+which can be successfully treated without division of the tendo
+Achillis. While in talipes equinis it is generally the only disturbing
+agent, in talipes varus and valgus it invariably increases and maintains
+the deformity, which the tibiales or peronei seem to originate.
+
+_Operation._--The foot being held at about a right angle with the leg,
+the operator should pinch up the skin over the tendon, introduce the
+knife flatwise, a little to one side of the tendon, till its point is
+nearly projecting at the other, then turn the edge on the tendon and cut
+inwards with a sawing motion till the tendon gives way with a distinct
+snap, and the foot can be completely flexed with ease.
+
+     Dr. Little[167] recommends that the tendon should be divided from
+     before backwards. There is more risk by this method of wounding the
+     skin, and thus losing the subcutaneous character of the operation.
+
+     Professor Pancoast[168] divides the inferior portion of the soleus
+     muscle instead of the tendo Achillis.
+
+2. _Tibialis posticus._--Next in frequency and importance to that of the
+tendo Achillis, division of this tendon is much more difficult to
+perform. It may be performed either above or below the ankle.
+
+(_a._) _Above the ankle._--The blade of a tenotomy knife should be
+entered perpendicularly at the posterior margin of the tibia, half an
+inch or an inch above the internal malleolus, so as to pass between the
+bone and the tendon of the tibialis posticus, the blade directed towards
+the latter; the assistant should now evert the foot, the operator
+pressing the blade against the tendon.[169]
+
+(_b._) _Below the ankle, close to the attachment to the scaphoid._ This
+is the better position of the two when the position of the tendon can be
+made out, which is not always the case, especially in cases of old
+standing.
+
+Raising the skin just over the astragalo-scaphoid joint, the knife
+should be entered with its blade downwards, and across the tendon, and
+should be made to cut on the bone, while an assistant everts the foot
+till the tendon gives way with a distinct snap.
+
+3. _Tibialis anticus_ may in like manner be divided either just above
+the ankle, or at its insertion. When it requires division it can
+generally be made so prominent as to render its division comparatively
+easy.
+
+4. _Peronei._--These do not often require division, cases of talipes
+valgus being usually paralytic in character. If necessary they can be
+cut as they cross the fibula.
+
+5. _The plantar fascia_, may require division; when this is the case, it
+is so prominent as to render the operation very easy, if conducted on
+the principles mentioned above.
+
+
+FOOTNOTES:
+
+[166] Syme's _Pathology and Practice of Surgery_, p. 220.
+
+[167] Holmes's _Surgery_, vol. iii. p. 573.
+
+[168] Cross's _Surgery_, vol. ii. p. 273, 3d ed.
+
+[169] Miller's _System of Surgery_, p. 1339; Holmes's _Surgery_, vol.
+iii. p. 571.
+
+
+
+
+CHAPTER XIV.
+
+OPERATIONS ON NERVES.
+
+
+NERVE-STRETCHING.--Surgical literature in last ten years is full of
+cases in which nerves have been stretched for all manner of diseases
+with varying success: an example of the operative procedure may
+suffice:--
+
+1. Stretching of the great sciatic either for sciatica, sclerosis, or
+locomotor ataxia.
+
+_Operation._--A line drawn from the centre of the space between the
+tuberosity of the ischium or the great trochanter to a corresponding
+point between the condyles of the femur will give the direction. A free
+incision in this line three or four inches in length--the nerve lies
+just below the the femoral aponeurosis, beneath the edge of gluteal
+fold, requiring no muscular fibres to be divided. It must be raised from
+its bed and boldly stretched or elongated into a loop. Symington's
+experiments have shown that in the average adult 130 lb. are required to
+break the nerve.
+
+2. The facial has been stretched for spasm. The trunk is easily reached
+by an incision extending from near the external auditory meatus to the
+angle of the jaw, which enables the parotid to be pushed forward and the
+edge of the sterno-mastoid pulled backwards.
+
+
+NEUROTOMY AND NEURECTOMY.--Chiefly performed for neuralgia of the fifth
+nerve.
+
+_a._ This is a very easy operation if directed at the terminal branches
+only of the nerve, where they make their exit from the frontal,
+supraorbital, and mental foramina. The author has done it in very
+numerous cases, and with great relief, if care be taken to destroy the
+nerve in the foramen to some extent--a sharp-pointed thermo-cautery does
+this easily and safely.
+
+_b._ The more severe and radical operation of cutting out a portion of
+the trunk of the fifth nerve just after it has left the skull, and
+destroying Meckel's ganglion, has been done pretty frequently, chiefly
+by American surgeons--in various ways.
+
+1. _Carnochan's Operation._--Exposing the whole front wall of antrum,
+its cavity is opened into from the front by a large trephine. The lower
+wall of the infra-orbital canal is cut away by a chisel, the posterior
+wall of the antrum by a smaller trephine, the nerve thus isolated is
+traced up to and past Meckel's ganglion, which is removed close to the
+foramen rotundum by cutting the nerve by curved blunt-pointed scissors.
+
+2. _Pancoast's Operation._--Expose the coronoid process by a free
+incision, divide it at its root and throw it up, then expose and tie
+internal maxillary artery, after which the upper portion of the external
+pterygoid is to be detached from the sphenoid, thus exposing the nerve
+leaving foramen ovale; the second portion is deeper and not so easily
+got at.
+
+3. The spinal accessory occasionally may be divided before it enters the
+sterno-mastoid in cases of spasmodic wry neck, with great advantage.
+This operation is an easy one; the sterno-mastoid edge being once fairly
+exposed, the nerve is easily seen, and a piece should be cut out at
+least half an inch in length.
+
+
+NERVE SUTURE is occasionally practised with great advantage in cases
+where nerves have been divided either by accident or in operation.
+Catgut seems to be the best medium, and cases are on record in which,
+even after months of separation and subsequent paralysis, improvement
+has followed an operation for refreshing and joining the divided ends.
+
+
+
+
+ADDENDUM TO CHAPTER IX.
+
+
+DR. SOLIS COHEN has recently (in a paper read before the Philadelphia
+College of Physicians, April 4, 1883) collected the notes of sixty-five
+cases of excision of the entire larynx. Fifty-six of these were done for
+cancer, and the remainder for sarcomata, papillomata, etc. Of the
+fifty-six done for cancer, forty are reported as having died, either
+shortly after the operation from shock or pneumonia, or a few months
+later from recurrence of the disease. In two instances the disease had
+recurred, but death had not been reported when the paper was read.
+Fourteen remain in which neither death nor recurrence had been reported.
+Dr. Cohen's conclusion is that laryngectomy does not tend to the
+prolongation of life, and thinks that the greatest good to the greater
+number appears better secured by dependence on the palliative operation
+of tracheotomy.
+
+
+
+
+INDEX.
+
+
+Abdomen, operations on, 222.
+
+Abernethy on ligature of external iliac, 8.
+
+Adams on anatomy of common iliac, 4.
+  on hip deformity, 133.
+
+AEgineta, Paulus, on excision of joints, 108.
+
+Allarton on median lithotomy, 269.
+
+Amputation and excision contrasted, 113.
+
+Amputation at ankle-joint (Syme's), 78.
+  of anterior portion of foot (Hey's), 73.
+  of arm, 62.
+  at elbow-joint, 61.
+  through femur, condyles of, 92.
+  of fingers, 51-54.
+  of fore-arm, 58.
+  at hip-joint, 102.
+  at knee-joint, 92.
+  of penis, 286.
+  at shoulder-joint, 63.
+  at tarsus (Chopart's), 75.
+  at thigh, 94.
+  double primary of thigh, 106.
+  of toes, 69.
+  at wrist-joint, 56.
+
+Amussat's operation, 252.
+
+Anchylosis of elbow, excision for, 122.
+
+Ankle-joint, excision of, 137.
+
+Annandale on staphyloraphy, 203.
+
+Anus, artificial, operation for, 252.
+  artificial, removal of, 254.
+
+Arendt, ligature of external iliac, 12.
+
+Astragalus, excision of, 145.
+
+Auchincloss on ligature of subclavian, 36.
+
+Avery, hard palate, fissures of, 203.
+
+
+Barwell on excision of ankle-joint, 139.
+  on excision of tongue, 199.
+
+Baudens on amputation at elbow-joint, 61.
+  on amputation of anterior portion of foot, 75.
+  on amputation at knee-joint, 92.
+
+Bauer on recto-vesical lithotomy, 272.
+
+Begbie, Dr. Warburton, on paracentesis thoracis, 220.
+
+Bell, Benjamin, on amputation, 49.
+  on amputation of ankle, 86.
+  on amputation of thigh, 96.
+
+Bell, Sir Charles, on ligature of femoral, 22.
+
+Bell, George, on supra-pubic lithotomy, 271.
+
+Bell, John, on ligature of gluteal, 14.
+
+Bey, Gaetani, on amputation above the shoulder-joint, 70.
+
+Bigelow, Dr., on litholapaxy, 276.
+
+Billroth, Dr., on fissure of palate, 200.
+
+Bladder, puncture of, 284.
+
+Bonnet on radical cure of hernia, 245.
+
+Botal on amputation, 47.
+
+Bowditch on paracentesis thoracis, 221.
+
+Bowman's operation, lachrymal canal, 153.
+
+Brachial, ligature of, 242.
+
+Brodie, Sir B. C., on lithotomy, 262.
+  on lithotrity, 274.
+
+Bromfield, amputation of leg, 86.
+
+Brown, Baker, ovariotomy, 231.
+
+Bryant, on excision of joints, 112.
+
+Buchanan, Dr. A., on lithotomy, 269.
+
+Buchanan, Dr. G., on excision of tongue, 198.
+
+Buchanan, Dr. M., on excision of ankle, 140.
+
+Buck's operation for anchylosis, 136.
+
+Butcher, ligature of subclavian, 35.
+  excision of joints, 110.
+  excision of wrist-joint, 128.
+  excision of knee-joint, 135.
+  excision of metacarpals. 142.
+
+
+Campbell, Professor, on ligature of gluteal, 15.
+
+Carden's amputation at condyles of femur, 50, 94.
+
+Carmichael on ligature of gluteal, 14.
+
+Carnochan on neurectomy, 300.
+
+Carotid, ligature of common, 28.
+  ligature of external, 32.
+
+Cataract operations, 160.
+
+Celsus on amputation, 48.
+  on excision of joints, 108.
+
+Chamberlaine, on ligature of axillary, 40.
+
+Chassaignac on tracheotomy, 206.
+
+Cheiloplastics, Syme on, 178.
+
+Cheselden on amputation, 49.
+  on lithotomy, 260.
+
+Chopart's amputation, 75.
+
+Civiale on lithotrity, 275.
+
+Club-foot, operations for, 297.
+
+Cock on oesophagotomy, 216.
+  paracentesis thoracis, 220.
+  on puncture of bladder, 285.
+
+Colles on ligature of brachial, 44.
+
+Cooper, Sir Astley, on ligature of aorta and iliacs, 3, 10.
+  on perineal section. 276.
+
+Cornea, puncture of, 159.
+  staphylomatous, excision of a, 168.
+
+Corelysis, 170.
+
+Crampton, Sir Philip, on excision, 119.
+
+Crichton on lithotomy, 262.
+
+Critchett's operation of iridesis, 169.
+  operation for staphyloma, 172.
+
+Croft, Mr., on hip disease, 132.
+
+Culbertson on excision of hip, 132.
+
+Cullerier on phymosis, 287.
+
+Curling on operation for artificial anus, 253.
+
+Cusack on treatment of brachial aneurism, 43.
+
+
+Davies, Redfern, on radical cure of hernia, 244.
+
+Davy's (Mr. Richard), lever, 105.
+
+Desault on ligature of axillary, 40.
+
+Dieffenbach on excision of upper jaw, 191.
+
+Dieulafoy's aspirateur, 284.
+
+Dionis' amputation of leg, 87.
+
+Dubrueil, amputation at wrist, 57.
+
+Duncan, Mr. J., on artificial anus, 254.
+
+Dupuytren on ligature of iliac, 11.
+  on ligature of subclavian, 36.
+  amputation at elbow-joint, 62.
+  removal of artificial anus, 254.
+  on bilateral lithotomy, 268.
+
+Durand, case of haemorrhage from iliac, 12.
+
+Durham on thyrotomy, 215.
+
+Dzondi on radical cure of hernia, 246.
+
+
+Elbow-Joint, amputation at, 62.
+
+Ellis on anatomy of iliac arteries, 6.
+
+Ectropium, 152.
+
+Entropium, 151.
+
+Erichsen on excision of hip, 130.
+
+Esmarch on excision of joints, 110.
+
+Excision and amputation contrasted, 112.
+
+Excision of ankle-joint, 138.
+  of astragalus, 145.
+  of elbow-joint, 118.
+  of hip-joint, 128.
+  of jaw, upper, 188.
+  of jaw, lower, 191.
+  of knee-joint, 133.
+  of mamma, 216.
+  of scapula, 139.
+  of shoulder-joint, 115.
+  of testicle, 290.
+  of tongue, 197.
+  of tonsils, 203.
+  of wrist-joint, 125.
+
+Eye, operations on, 151.
+
+Eyeball, extirpation of the, 173.
+
+Eyelid, tumours on the, 152.
+
+
+Fayrer, Sir J., on tracheotomy, 212.
+  on radical cure of hernia, 248.
+
+Femoral, ligature of, 18.
+  superficial, ligature of, in Scarpa's space, 19.
+  in Hunter's canal, 21.
+
+Femur, amputation through condyles of, 92.
+
+Fergusson, Sir W., on ligature of subclavian, 38.
+  on amputation at shoulder-joint, 70.
+  on excision of joints, 110.
+  on excision of upper jaw, 191.
+  on excision of lower jaw, 195.
+  on fissures of palate, 201.
+  on lithotomy, 262.
+
+Filkin on excision of joints, 110.
+
+Fingers, amputation of, 51.
+
+Fissures in the palate, soft, 200.
+  in the palate, hard, 202.
+  of anus, 292.
+
+Fistula, salivary, operations for, 192.
+  in ano, operation for, 291.
+
+Fore-arm, amputation through the, 58.
+  ligature of vessels in, 44.
+
+Forster, Mr. Cooper, on gastrotomy, 224.
+
+Furner, ligature of both subclavians, 38.
+
+
+Gastrectomy, 224.
+
+Gastrostomy, 223.
+
+Gastrotomy, 223.
+
+Gersdorf, Hans de, on amputation, 48.
+
+Gerdy on radical cure of hernia, 246.
+
+Gilbert, amputation above the shoulder-joint, 68.
+
+Gillespie on excision of wrist-joint, 128.
+
+Gluteal, ligature of, 12.
+
+Gosselin on colotomy, 253.
+
+Graefe on strabismus, 158.
+  on cataract operations, 166.
+  or iridectomy, 171.
+
+Green on ligature of subclavian, 38.
+
+Greenhow on excision of os calcis, 144.
+
+Greenslade on Bowman's operation, 156.
+
+Gritti's amputation, 93
+
+Gross on amputation at elbow-joint, 61.
+  on amputation, 81-87.
+  on excision of hip, 132.
+  on lithotomy, 262.
+  on rhinoplastic operation, 178.
+  on excision of lower jaw, 192.
+
+Guerin, Jules, on amputation of toes, 76.
+  on operation for strabismus, 158.
+
+Guersant on excision of tonsils, 205.
+
+Guillemeau on amputation at knee-joint, 91.
+
+Gurlt's statistics, 118, 124.
+
+
+Haemorrhoids, operations for, 294.
+
+Haematocele, operation for, 289.
+
+Hamilton on rhinoplastic operations, 177.
+
+Hancock on excision of hip, 130.
+  on excision of ankle, 138.
+  on excision of os calcis, 144.
+
+Harelip, operations for, 183.
+
+Harrison on anatomy of iliac, 6.
+  on brachial aneurism, 44.
+
+Hart, Mr. Ernest, on flexion of limbs, 24.
+
+Heath's case of aneurism of innominate, 28.
+
+Heine on excision of hip, 130.
+
+Hernia, strangulated inguinal, 232.
+  strangulated femoral, 237.
+  strangulated umbilical, 242.
+  strangulated obturator, 243.
+  radical cure of, 244.
+
+Heurtloup on lithotrity, 274.
+
+Hey on amputation, 48, 73.
+
+Heyfelder on excisions, 110, 130.
+
+Hildanus, Fabricius, on amputation, 47, 91.
+
+Hip-joint, amputation at the, 102.
+  excision of, 128.
+
+Hippocrates on excision of joints, 108.
+
+Hodgson, statistics of aneurism, 12.
+  ligature of axillary, 40.
+
+Hodge on excisions 112, 132.
+
+Hoin on amputation at knee-joint, 92.
+
+Holmes on excision of hip, 130, 132, 144.
+
+Holt's operation for stricture, 279.
+
+Howse, Mr., on gastrotomy, 224.
+
+Hughes, Dr. on paracentesis thoracis, 220.
+
+Huguier on colotomy, 253.
+
+Hunter on ligature of femoral, 21.
+
+Hutchinson's statistics, 20.
+
+Hydrocele, operation for, 288.
+
+
+Iliac, ligature of common, 3.
+  ligature of external, 7.
+
+Iliac, ligature of internal, 6.
+
+Innominate, ligature of the, 26.
+
+Iridectomy, 171.
+
+Iridesis, 169.
+
+
+Jacobson on cataract operations, 166.
+
+Jaeger on excision of hip, 130.
+
+James, Mr., on ligature of aorta, 3.
+
+Jameson on radical cure of hernia, 246.
+
+Jaw, excision of upper, 188.
+  excision of lower, 191.
+
+Johnston, Dr., on amputation at ankle-joint, 84.
+
+Joints, excision of, 108.
+
+Jones on excision of joints, 110, 134, 136.
+
+Jordan, Mr. F., on amputation, 106;
+  on excision of tongue, 199.
+
+
+Keith, Dr. Thomas, on ovariotomy, 224-227.
+
+Kirby, Mr., on ligature of iliac, 12.
+
+Knife, Beer's description of, 164.
+
+Knee, amputation below and above, 90, 91.
+  amputation at, 91.
+  joint, excision of, 132.
+
+
+Lachrymal organs, operations on the, 153.
+
+Lane, Mr., on amputation at knee-joint, 91.
+
+Langenbeck on excision of joints, 110, 140.
+  on fissure in hard palate, 203.
+  on radical cure of hernia, 245.
+
+Larrey on amputation at shoulder, 64.
+  on excision of joints, 109.
+
+Larynx, operations on the, 206.
+
+Laryngectomy, 216.
+  Dr. Solis Cohen on, 302.
+
+Laryngotomy, 214.
+
+Laryngo-tracheotomy, 215.
+
+Layraud, Dr., case of haemorrhage from iliac, 12.
+
+Lee, Mr. Henry, amputation of leg, 88.
+
+Ligature of the aorta, 2.
+  of the axillary, 38, 39, 40.
+  of the brachial, 42.
+  of the carotid, common, 29, 30.
+  of the carotid, external, 32.
+  of the femoral, 18, 21.
+  of the gluteal, 12.
+  of the iliac, 3.
+  of the iliac, external, 7.
+  of the iliac, internal, 6.
+  of the innominate, 26.
+  of the lingual, 32.
+  of the popliteal, 22.
+  of the subclavian, 33-37.
+  of the vessels in fore-arm, 45.
+
+Lips, operations on the, 180.
+
+Lisfranc on amputation, 52, 74.
+
+Lister, Professor, on Syme's amputation, 87.
+  on excision of wrist, 125.
+
+Liston, Mr., on ligature of subclavian, 36, 37.
+  on rhinoplastic operations, 177.
+  on excision of upper jaw, 186.
+  tracheotomy, 213.
+  on femoral hernia, 240.
+  on lithotomy, 262.
+
+Litholapaxy, Dr. Bigelow on, 276.
+
+Lithotomy, 255.
+
+Lithotrity, 278.
+
+Little on club-foot, 297.
+
+Lloyd on harelip, 187.
+
+Lorinzer on obturator hernia, 244.
+
+Louis on amputation, 48.
+
+Lower extremity, amputations of, 68.
+
+Lupus, operative treatment of, 179.
+
+
+Macilwain on tracheotomy, 208.
+
+Mackenzie, Dr. Morell, on thyrotomy, 215.
+
+Mackenzie, Dr. R., on modification of Syme's amputation, 83.
+  on excision of joints, 110, 134.
+
+Malgaigne on Chopart's amputation, 77.
+  on harelip, 187.
+
+Mamma, excision of, 218.
+
+Manec on ligature of axillary, 40.
+
+Maunder on excision of the elbow-joint, 122.
+
+Maclennan, Dr. G., on amputation above the shoulder-joint, 69.
+
+Metacarpals, amputation of, 54.
+  excision of, 141.
+
+Metatarsals, amputation of, 72.
+
+Miller on amputation of penis, 288.
+
+Monteiro, Dr., on ligature of aorta, 3.
+
+Mooren on cataract operations, 166.
+
+Moreaus, the, on excision of joints, 109, 114, 120, 132, 134.
+
+Morel, tourniquet invented by, 47.
+
+Morton, Dr., on radical cure of hernia, 245.
+
+Murray, Dr., on ligature of aorta, 3.
+
+Mussey, case of amputation, 70.
+
+Mynors on amputation, 48.
+
+
+Nasal polypi, removal of, 179.
+
+Needle operation for cataract, 160.
+
+Nelaton on harelip, 184.
+
+Nerve-stretching, 299.
+
+Nerve suture, 300.
+
+Neurectomy, 299.
+
+Neurotomy, 299.
+
+Norris's statistics, 12, 20, 31.
+
+Nunneley on excision of tongue, 198.
+
+
+Oesophagotomy, 216.
+
+Ollier on excision of joints, 110.
+
+Os calcis, excision of, 143.
+
+Ovariotomy, 224.
+
+
+Paget on excision of tongue, 198.
+
+Palate, fissures in soft, 200.
+  fissures in hard, 202.
+
+Pancoast, Professor, on rhinoplastic operations, 178.
+  on radical cure of hernia, 245.
+  on neurectomy, 300.
+  on club-foot, 297.
+
+Paracentesis thoracis, 219.
+  abdominis, 222.
+
+Pare, Ambrose, on amputation, 47.
+  on amputation at elbow-joint, 60.
+
+Park on excision of joints, 110.
+
+Peixotto, Dr., on ligature of innominate, 27.
+
+Penis, amputation of, 287.
+
+Perineal section, operation of, 273.
+
+Percy on excision of joints, 109.
+
+Phymosis, operation for, 285.
+
+Pirogoff's modification of Syme's amputation, 80, 84.
+
+Pollock on excision of lower jaw, 193.
+
+Polypi, nasal, removal of, 179.
+  anal, removal of, 293.
+
+Popliteal, ligature of, 22.
+
+Porta's statistics, 20.
+
+Porter, Professor, on ligature of innominate, 27.
+  on ligature of common carotid, 28.
+  statistics of amputation, 122.
+
+Post on ligature of iliac, 10.
+
+Pritchard, Mr., radical cure of hernia, 248.
+
+Prolapsus ani, 292.
+
+Pterygium, operation for, 156.
+
+Puncture of bladder, 284.
+
+Pupil, operations for artificial, 168.
+
+Purmannus on amputation, 48.
+
+
+Quain on anatomy of iliac, 4.
+  on anatomy of brachial, 43.
+
+
+Regnoli on excision of tongue, 199.
+
+Rhinoplastic operations, 175.
+
+Richter on radical cure of hernia, 245.
+
+Ricord on amputation of penis, 287.
+
+Rigaud on amputation above the shoulder-joint, 67.
+
+Ritchie, Dr. Charles, on ovariotomy, 224.
+
+Rodgers, Dr., on ligature of subclavian, 36.
+
+Rothmund on radical cure of hernia, 247.
+
+Roux on ligature of subclavian, 38.
+  on ligature of axillary, 40,
+  on Chopart's amputation, 77, 78.
+
+
+Sabatier on excision of joints, 109.
+
+Salivary fistula, operation for, 196.
+
+Sanson on recto-vesical lithotomy, 271.
+
+Scalp, tumours of the, removal of 149.
+
+Scapula, excision of (Syme), 140.
+
+Schuh on radical cure of hernia, 245.
+
+Schmucker on radical cure of hernia, 246.
+
+Scultetus on amputation, 46.
+
+Sedillot's operation for ligature of carotid, 30.
+  on excision of hip, 132.
+
+Shoulder-joint, amputation at the, 66.
+  excision of, 115.
+
+Signoroni on radical cure of hernia, 247.
+
+Sims, Dr. M., on lithotomy, 272.
+
+Smith, Dr. Nathan, on amputation at knee-joint, 91.
+
+Smith, Thomas, on staphyloraphy, 200.
+
+Smith, Dr. Tyler, on ovariotomy, 231.
+
+Smyth on subclavian aneurism, 27.
+
+Skey on ligature of subclavian, 38.
+  on amputation, 74, 91.
+  on excision of wrist, 127.
+  on rhinoplastic operation, 178.
+  on lithotomy, 262.
+
+Solis Cohen, Dr., on laryngectomy, 302.
+
+Solomon on strabismus, 158.
+
+South on ligature of aorta, 3.
+
+Spence, Professor, on amputation, 50, 66, 89, 100.
+  on excision of shoulder, elbow, and wrist joints, 118, 124, 128, 136.
+
+Sperino on puncture of cornea, 159.
+
+Stanley on excision of shoulder, 117.
+
+Steven, Professor, on ligature of internal iliac, 15.
+
+Strabismus, convergent, 156.
+  divergent, 157.
+
+Streatfeild on entropium, 151.
+  on corelysis, 170.
+
+Stricture, operation for, 276.
+
+Stokes's amputation, 94.
+
+Stromeyer on excision of joints, 110.
+
+Subclavian, ligature of right, 34.
+  ligature of left, 35.
+
+Surgeon-General, United States, statistical report by, 82.
+
+Syme, Mr., on amputation at ankle-joint, 78.
+  on amputation through condyles of femur, 92.
+  on amputation at hip-joint, 106.
+  on amputation above the shoulder-joint, 73.
+  on modified circular amputation, 101.
+  on axillary aneurism, operation for, 41.
+  on cheiloplastic operation, 181.
+  Chopart's amputation introduced by, 77.
+  on excision of lower jaw, 191.
+  on excision of joints, 111-120.
+  on excision of scapula, 140.
+  on excision of tongue, 197.
+  on ligature of femoral, 20.
+  on ligature of gluteal, 14, 15.
+  on radical cure of hernia, 247.
+  on Hey's operation, 73.
+  on oesophagotomy, 216.
+  on removal of polypi, 180.
+  on rhinoplastic operation, 175.
+  on stricture, 278-282.
+
+
+Tait on ligature of iliac, 10, 12.
+
+Taliacotian operation, 178.
+
+Tarso-metatarsal joint, amputation at, 72.
+
+Tarsus, amputation through the, 75.
+
+Teale on amputation, 50.
+  on amputation of fore-arm, 59.
+  on amputation of arm, 63.
+  on amputation of leg, 89.
+  on amputation of thigh, 98.
+  on amputation of penis, 288.
+
+Teale, T. P., on cataract, 163.
+
+Tenotomy, 296.
+
+Testicle, excision of, 290.
+
+Textor on amputation at elbow-joint, 60.
+
+Thigh, amputations of, 96.
+
+Thompson on lithotrity, 275.
+  on stricture, 277.
+
+Thorax, operations on the, 218.
+
+Thyrotomy, 215.
+
+Toes, amputations of, 68.
+
+Tongue, excision of, 197.
+
+Tonsils, excision of, 203.
+
+Tracheotomy, 206-214.
+
+Trephining and trepanning, 147.
+
+Trichiasis, 151.
+
+Tripier's amputation, 78.
+
+Trocar of Sir S. Wells described, 227.
+
+Tumours of scalp, removal of, 149.
+  of eyelids, removal of, 152.
+
+Tyrrell on treatment of brachial aneurism, 43.
+
+
+Upper extremity, amputation of, 50.
+
+Urethra, stricture of, 276.
+
+
+Velpeau on ligature of iliac, 12.
+  on ligature of subclavian, 38.
+  on amputation at elbow-joint, 60.
+  on amputation at knee-joint, 91.
+  on radical cure of hernia, 245.
+
+Vermale on amputation of thigh, 102.
+
+Verneuil on Chopart's amputation, 78.
+
+Vessels of fore-arm, ligature of, 44.
+
+
+Wakley on stricture, 279.
+
+Warren on fissure of hard palate, 203.
+
+Watson, Dr. P. H., on excision, 135.
+  on excision of elbow-joint, 123.
+  on laryngectomy, 216.
+
+Wells, Sir Spencer, on ovariotomy, 224-229.
+  trocar, 227.
+  hernia, radical cure of, 247.
+
+White on amputation of leg, 86.
+ on excision of joints, 110.
+
+Whitehead, Mr. W., on excision of tongue, 199.
+
+Willet on oesophagotomy, 216.
+
+Wood's statistics, 30.
+  on joints, 134.
+  on radical cure of hernia, 248-251.
+
+Wry neck, operation for, 296.
+
+Wrist-joint, amputation at, 55.
+  excision of, 124.
+
+Wuetzer on radical cure of hernia, 247.
+
+Wyeth, Dr., statistics, 36, 38.
+
+
+Young, James, tourniquet introduced by, 47.
+
+
+Zehender's statistics, 30.
+
+
+
+***END OF THE PROJECT GUTENBERG EBOOK A MANUAL OF THE OPERATIONS OF
+SURGERY***
+
+
+******* This file should be named 24564.txt or 24564.zip *******
+
+
+This and all associated files of various formats will be found in:
+https://www.gutenberg.org/dirs/2/4/5/6/24564
+
+
+
+Updated editions will replace the previous one--the old editions
+will be renamed.
+
+Creating the works from public domain print editions means that no
+one owns a United States copyright in these works, so the Foundation
+(and you!) can copy and distribute it in the United States without
+permission and without paying copyright royalties.  Special rules,
+set forth in the General Terms of Use part of this license, apply to
+copying and distributing Project Gutenberg-tm electronic works to
+protect the PROJECT GUTENBERG-tm concept and trademark.  Project
+Gutenberg is a registered trademark, and may not be used if you
+charge for the eBooks, unless you receive specific permission.  If you
+do not charge anything for copies of this eBook, complying with the
+rules is very easy.  You may use this eBook for nearly any purpose
+such as creation of derivative works, reports, performances and
+research.  They may be modified and printed and given away--you may do
+practically ANYTHING with public domain eBooks.  Redistribution is
+subject to the trademark license, especially commercial
+redistribution.
+
+
+
+*** START: FULL LICENSE ***
+
+THE FULL PROJECT GUTENBERG LICENSE
+PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
+
+To protect the Project Gutenberg-tm mission of promoting the free
+distribution of electronic works, by using or distributing this work
+(or any other work associated in any way with the phrase "Project
+Gutenberg"), you agree to comply with all the terms of the Full Project
+Gutenberg-tm License (available with this file or online at
+https://www.gutenberg.org/license).
+
+
+Section 1.  General Terms of Use and Redistributing Project Gutenberg-tm
+electronic works
+
+1.A.  By reading or using any part of this Project Gutenberg-tm
+electronic work, you indicate that you have read, understand, agree to
+and accept all the terms of this license and intellectual property
+(trademark/copyright) agreement.  If you do not agree to abide by all
+the terms of this agreement, you must cease using and return or destroy
+all copies of Project Gutenberg-tm electronic works in your possession.
+If you paid a fee for obtaining a copy of or access to a Project
+Gutenberg-tm electronic work and you do not agree to be bound by the
+terms of this agreement, you may obtain a refund from the person or
+entity to whom you paid the fee as set forth in paragraph 1.E.8.
+
+1.B.  "Project Gutenberg" is a registered trademark.  It may only be
+used on or associated in any way with an electronic work by people who
+agree to be bound by the terms of this agreement.  There are a few
+things that you can do with most Project Gutenberg-tm electronic works
+even without complying with the full terms of this agreement.  See
+paragraph 1.C below.  There are a lot of things you can do with Project
+Gutenberg-tm electronic works if you follow the terms of this agreement
+and help preserve free future access to Project Gutenberg-tm electronic
+works.  See paragraph 1.E below.
+
+1.C.  The Project Gutenberg Literary Archive Foundation ("the Foundation"
+or PGLAF), owns a compilation copyright in the collection of Project
+Gutenberg-tm electronic works.  Nearly all the individual works in the
+collection are in the public domain in the United States.  If an
+individual work is in the public domain in the United States and you are
+located in the United States, we do not claim a right to prevent you from
+copying, distributing, performing, displaying or creating derivative
+works based on the work as long as all references to Project Gutenberg
+are removed.  Of course, we hope that you will support the Project
+Gutenberg-tm mission of promoting free access to electronic works by
+freely sharing Project Gutenberg-tm works in compliance with the terms of
+this agreement for keeping the Project Gutenberg-tm name associated with
+the work.  You can easily comply with the terms of this agreement by
+keeping this work in the same format with its attached full Project
+Gutenberg-tm License when you share it without charge with others.
+
+1.D.  The copyright laws of the place where you are located also govern
+what you can do with this work.  Copyright laws in most countries are in
+a constant state of change.  If you are outside the United States, check
+the laws of your country in addition to the terms of this agreement
+before downloading, copying, displaying, performing, distributing or
+creating derivative works based on this work or any other Project
+Gutenberg-tm work.  The Foundation makes no representations concerning
+the copyright status of any work in any country outside the United
+States.
+
+1.E.  Unless you have removed all references to Project Gutenberg:
+
+1.E.1.  The following sentence, with active links to, or other immediate
+access to, the full Project Gutenberg-tm License must appear prominently
+whenever any copy of a Project Gutenberg-tm work (any work on which the
+phrase "Project Gutenberg" appears, or with which the phrase "Project
+Gutenberg" is associated) is accessed, displayed, performed, viewed,
+copied or distributed:
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
+from the public domain (does not contain a notice indicating that it is
+posted with permission of the copyright holder), the work can be copied
+and distributed to anyone in the United States without paying any fees
+or charges.  If you are redistributing or providing access to a work
+with the phrase "Project Gutenberg" associated with or appearing on the
+work, you must comply either with the requirements of paragraphs 1.E.1
+through 1.E.7 or obtain permission for the use of the work and the
+Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
+1.E.9.
+
+1.E.3.  If an individual Project Gutenberg-tm electronic work is posted
+with the permission of the copyright holder, your use and distribution
+must comply with both paragraphs 1.E.1 through 1.E.7 and any additional
+terms imposed by the copyright holder.  Additional terms will be linked
+to the Project Gutenberg-tm License for all works posted with the
+permission of the copyright holder found at the beginning of this work.
+
+1.E.4.  Do not unlink or detach or remove the full Project Gutenberg-tm
+License terms from this work, or any files containing a part of this
+work or any other work associated with Project Gutenberg-tm.
+
+1.E.5.  Do not copy, display, perform, distribute or redistribute this
+electronic work, or any part of this electronic work, without
+prominently displaying the sentence set forth in paragraph 1.E.1 with
+active links or immediate access to the full terms of the Project
+Gutenberg-tm License.
+
+1.E.6.  You may convert to and distribute this work in any binary,
+compressed, marked up, nonproprietary or proprietary form, including any
+word processing or hypertext form.  However, if you provide access to or
+distribute copies of a Project Gutenberg-tm work in a format other than
+"Plain Vanilla ASCII" or other format used in the official version
+posted on the official Project Gutenberg-tm web site (www.gutenberg.org),
+you must, at no additional cost, fee or expense to the user, provide a
+copy, a means of exporting a copy, or a means of obtaining a copy upon
+request, of the work in its original "Plain Vanilla ASCII" or other
+form.  Any alternate format must include the full Project Gutenberg-tm
+License as specified in paragraph 1.E.1.
+
+1.E.7.  Do not charge a fee for access to, viewing, displaying,
+performing, copying or distributing any Project Gutenberg-tm works
+unless you comply with paragraph 1.E.8 or 1.E.9.
+
+1.E.8.  You may charge a reasonable fee for copies of or providing
+access to or distributing Project Gutenberg-tm electronic works provided
+that
+
+- You pay a royalty fee of 20% of the gross profits you derive from
+     the use of Project Gutenberg-tm works calculated using the method
+     you already use to calculate your applicable taxes.  The fee is
+     owed to the owner of the Project Gutenberg-tm trademark, but he
+     has agreed to donate royalties under this paragraph to the
+     Project Gutenberg Literary Archive Foundation.  Royalty payments
+     must be paid within 60 days following each date on which you
+     prepare (or are legally required to prepare) your periodic tax
+     returns.  Royalty payments should be clearly marked as such and
+     sent to the Project Gutenberg Literary Archive Foundation at the
+     address specified in Section 4, "Information about donations to
+     the Project Gutenberg Literary Archive Foundation."
+
+- You provide a full refund of any money paid by a user who notifies
+     you in writing (or by e-mail) within 30 days of receipt that s/he
+     does not agree to the terms of the full Project Gutenberg-tm
+     License.  You must require such a user to return or
+     destroy all copies of the works possessed in a physical medium
+     and discontinue all use of and all access to other copies of
+     Project Gutenberg-tm works.
+
+- You provide, in accordance with paragraph 1.F.3, a full refund of any
+     money paid for a work or a replacement copy, if a defect in the
+     electronic work is discovered and reported to you within 90 days
+     of receipt of the work.
+
+- You comply with all other terms of this agreement for free
+     distribution of Project Gutenberg-tm works.
+
+1.E.9.  If you wish to charge a fee or distribute a Project Gutenberg-tm
+electronic work or group of works on different terms than are set
+forth in this agreement, you must obtain permission in writing from
+both the Project Gutenberg Literary Archive Foundation and Michael
+Hart, the owner of the Project Gutenberg-tm trademark.  Contact the
+Foundation as set forth in Section 3 below.
+
+1.F.
+
+1.F.1.  Project Gutenberg volunteers and employees expend considerable
+effort to identify, do copyright research on, transcribe and proofread
+public domain works in creating the Project Gutenberg-tm
+collection.  Despite these efforts, Project Gutenberg-tm electronic
+works, and the medium on which they may be stored, may contain
+"Defects," such as, but not limited to, incomplete, inaccurate or
+corrupt data, transcription errors, a copyright or other intellectual
+property infringement, a defective or damaged disk or other medium, a
+computer virus, or computer codes that damage or cannot be read by
+your equipment.
+
+1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
+of Replacement or Refund" described in paragraph 1.F.3, the Project
+Gutenberg Literary Archive Foundation, the owner of the Project
+Gutenberg-tm trademark, and any other party distributing a Project
+Gutenberg-tm electronic work under this agreement, disclaim all
+liability to you for damages, costs and expenses, including legal
+fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
+LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
+PROVIDED IN PARAGRAPH F3.  YOU AGREE THAT THE FOUNDATION, THE
+TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
+LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
+INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
+DAMAGE.
+
+1.F.3.  LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
+defect in this electronic work within 90 days of receiving it, you can
+receive a refund of the money (if any) you paid for it by sending a
+written explanation to the person you received the work from.  If you
+received the work on a physical medium, you must return the medium with
+your written explanation.  The person or entity that provided you with
+the defective work may elect to provide a replacement copy in lieu of a
+refund.  If you received the work electronically, the person or entity
+providing it to you may choose to give you a second opportunity to
+receive the work electronically in lieu of a refund.  If the second copy
+is also defective, you may demand a refund in writing without further
+opportunities to fix the problem.
+
+1.F.4.  Except for the limited right of replacement or refund set forth
+in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO OTHER
+WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
+WARRANTIES OF MERCHANTIBILITY OR FITNESS FOR ANY PURPOSE.
+
+1.F.5.  Some states do not allow disclaimers of certain implied
+warranties or the exclusion or limitation of certain types of damages.
+If any disclaimer or limitation set forth in this agreement violates the
+law of the state applicable to this agreement, the agreement shall be
+interpreted to make the maximum disclaimer or limitation permitted by
+the applicable state law.  The invalidity or unenforceability of any
+provision of this agreement shall not void the remaining provisions.
+
+1.F.6.  INDEMNITY - You agree to indemnify and hold the Foundation, the
+trademark owner, any agent or employee of the Foundation, anyone
+providing copies of Project Gutenberg-tm electronic works in accordance
+with this agreement, and any volunteers associated with the production,
+promotion and distribution of Project Gutenberg-tm electronic works,
+harmless from all liability, costs and expenses, including legal fees,
+that arise directly or indirectly from any of the following which you do
+or cause to occur: (a) distribution of this or any Project Gutenberg-tm
+work, (b) alteration, modification, or additions or deletions to any
+Project Gutenberg-tm work, and (c) any Defect you cause.
+
+
+Section  2.  Information about the Mission of Project Gutenberg-tm
+
+Project Gutenberg-tm is synonymous with the free distribution of
+electronic works in formats readable by the widest variety of computers
+including obsolete, old, middle-aged and new computers.  It exists
+because of the efforts of hundreds of volunteers and donations from
+people in all walks of life.
+
+Volunteers and financial support to provide volunteers with the
+assistance they need, is critical to reaching Project Gutenberg-tm's
+goals and ensuring that the Project Gutenberg-tm collection will
+remain freely available for generations to come.  In 2001, the Project
+Gutenberg Literary Archive Foundation was created to provide a secure
+and permanent future for Project Gutenberg-tm and future generations.
+To learn more about the Project Gutenberg Literary Archive Foundation
+and how your efforts and donations can help, see Sections 3 and 4
+and the Foundation web page at https://www.gutenberg.org/fundraising/pglaf.
+
+
+Section 3.  Information about the Project Gutenberg Literary Archive
+Foundation
+
+The Project Gutenberg Literary Archive Foundation is a non profit
+501(c)(3) educational corporation organized under the laws of the
+state of Mississippi and granted tax exempt status by the Internal
+Revenue Service.  The Foundation's EIN or federal tax identification
+number is 64-6221541.  Contributions to the Project Gutenberg
+Literary Archive Foundation are tax deductible to the full extent
+permitted by U.S. federal laws and your state's laws.
+
+The Foundation's principal office is located at 4557 Melan Dr. S.
+Fairbanks, AK, 99712., but its volunteers and employees are scattered
+throughout numerous locations.  Its business office is located at
+809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887, email
+business@pglaf.org.  Email contact links and up to date contact
+information can be found at the Foundation's web site and official
+page at https://www.gutenberg.org/about/contact
+
+For additional contact information:
+     Dr. Gregory B. Newby
+     Chief Executive and Director
+     gbnewby@pglaf.org
+
+Section 4.  Information about Donations to the Project Gutenberg
+Literary Archive Foundation
+
+Project Gutenberg-tm depends upon and cannot survive without wide
+spread public support and donations to carry out its mission of
+increasing the number of public domain and licensed works that can be
+freely distributed in machine readable form accessible by the widest
+array of equipment including outdated equipment.  Many small donations
+($1 to $5,000) are particularly important to maintaining tax exempt
+status with the IRS.
+
+The Foundation is committed to complying with the laws regulating
+charities and charitable donations in all 50 states of the United
+States.  Compliance requirements are not uniform and it takes a
+considerable effort, much paperwork and many fees to meet and keep up
+with these requirements.  We do not solicit donations in locations
+where we have not received written confirmation of compliance.  To
+SEND DONATIONS or determine the status of compliance for any
+particular state visit https://www.gutenberg.org/fundraising/donate
+
+While we cannot and do not solicit contributions from states where we
+have not met the solicitation requirements, we know of no prohibition
+against accepting unsolicited donations from donors in such states who
+approach us with offers to donate.
+
+International donations are gratefully accepted, but we cannot make
+any statements concerning tax treatment of donations received from
+outside the United States.  U.S. laws alone swamp our small staff.
+
+Please check the Project Gutenberg Web pages for current donation
+methods and addresses.  Donations are accepted in a number of other
+ways including checks, online payments and credit card donations.
+To donate, please visit:
+https://www.gutenberg.org/fundraising/donate
+
+
+Section 5.  General Information About Project Gutenberg-tm electronic
+works.
+
+Professor Michael S. Hart was the originator of the Project Gutenberg-tm
+concept of a library of electronic works that could be freely shared
+with anyone.  For thirty years, he produced and distributed Project
+Gutenberg-tm eBooks with only a loose network of volunteer support.
+
+Project Gutenberg-tm eBooks are often created from several printed
+editions, all of which are confirmed as Public Domain in the U.S.
+unless a copyright notice is included.  Thus, we do not necessarily
+keep eBooks in compliance with any particular paper edition.
+
+Most people start at our Web site which has the main PG search facility:
+
+     https://www.gutenberg.org
+
+This Web site includes information about Project Gutenberg-tm,
+including how to make donations to the Project Gutenberg Literary
+Archive Foundation, how to help produce our new eBooks, and how to
+subscribe to our email newsletter to hear about new eBooks.
+
diff --git a/24564.zip b/24564.zip
new file mode 100644
index 0000000..34e3628
--- /dev/null
+++ b/24564.zip
diff --git a/LICENSE.txt b/LICENSE.txt
new file mode 100644
index 0000000..6312041
--- /dev/null
+++ b/LICENSE.txt
@@ -0,0 +1,11 @@
+This eBook, including all associated images, markup, improvements,
+metadata, and any other content or labor, has been confirmed to be
+in the PUBLIC DOMAIN IN THE UNITED STATES.
+
+Procedures for determining public domain status are described in
+the "Copyright How-To" at https://www.gutenberg.org.
+
+No investigation has been made concerning possible copyrights in
+jurisdictions other than the United States. Anyone seeking to utilize
+this eBook outside of the United States should confirm copyright
+status under the laws that apply to them.
diff --git a/README.md b/README.md
new file mode 100644
index 0000000..47e0c6c
--- /dev/null
+++ b/README.md
@@ -0,0 +1,2 @@
+Project Gutenberg (https://www.gutenberg.org) public repository for
+eBook #24564 (https://www.gutenberg.org/ebooks/24564)