file which includes the original illustrations4 ,see #bdefd-;h4htm or #bdefd-;h4zip3 7https3_/_/www4gutenberg4org_/dirs_/#b_/ d_/e_/f_/bdefd_/bdefd-;h_/#bdefd-;h4htm7 or 7https3_/_/www4gutenberg4org_/dirs_/#b_/ d_/e_/f_/bdefd_/bdefd-;h4zip7 ,transcriber's note3 ,spelling mistakes have been left in the text to match the original1 except for obvious typographical errors4 ,a ,,manual ,,of ,,the ,,operations ,,of ,,surgery ,for the ,use of ,senior ,students1 ,house ,surgeons1 and ,junior ,practitioners4 ,illustrated4 by ,,joseph ,,bell1 ,f4,r4,c4,s4 ,,edin4 ,lecturer on ,clinical ,surgery1 ,surgeon to the ,royal ,infirmary and to the ,eye ,infirmary1 and ,late ,demonstrator of ,anatomy in the ,university of ,edinburgh4 ,,fifth ,,edition1 ,,revised ,,and ,,enlarged4 ,edinburgh3 ,maclachlan ,stewart1 ,booksellers to the ,university4 ,london3 ,simpkin1 ,marshall1 ,co4 #ahhc4 ,,to ,,the ,,memory ,,of ,,james ,,syme1 ,,esq41 ,f4,r4,c4,s4 ,,and ,f4,r4,s4,e4 ,,surgeon ,,to ,,the ,,queen ,,in ,,scotland ,,professor ,,of ,,clinical ,,surgery ,,in ,,the ,,university ,,of ,,edinburgh ,,etc4 ,,etc4 ,,this ,,book ,,is ,,dedicated ,,by ,,his ,,old ,,house-,,surgeon ,,and ,,assistant ,,the ,,author4 ,,preface ,,to ,,fifth ,,edition4 ,to retain the small size of the work and to keep it up to date have been the ,author's aim in the ,fifth ,edition4 #bj ,,melville ,,street1 ,,edinburgh1 ,august #ahhc4 ,,preface ,,to ,,the ,,first ,,edition4 ,having been asked1 year after year1 by the members of my ,class for ,operative ,surgery1 to recommend to them some ,manual of ,surgical ,operations which might at once guide them in their choice of operations1 and give minute details as to the mode of performance1 ,i have been gradually led to undertake the production of this little work4 ,my aim has been to describe as simply as possible those operations which are most likely to prove useful1 and especially those which1 from their nature1 admit of being practised on the dead body4 ,in accordance with this plan1 neither historical completeness of detail1 nor much variety in the methods of performing any given operation1 is to be expected4 ,hence1 also1 many omissions which would be unpardonable in the briefest system of ,surgery are unavoidable4 ,for example1 excision of tumours and operations for necrosis are hardly mentioned1 because for these no special instructions can well be given2 for1 while general principles may guide us to what should be done1 the special circumstances of each case must dictate how it is to be done4 ,in such a work as this1 to attempt originality would be undesirable and intrusive2 a judicious selection1 a faithful compilation1 are all that can be expected4 ,that the selection of operations may sometimes show ,northern ,proclivities is possible2 and this is perhaps not unnatural to a scholar and teacher in the ,edinburgh ,school4 ,an earnest endeavour has been used to make the references correct and copious3 for any mistakes or omissions the author would crave indulgence4 ,the four plates which precede the letterpress were drawn on wood 7from original photographs7 by ,mr4 ,d4,w4 ,williamson1 ,melbourne ,place1 and the lines of incision for the various operations were added by the author4 ,the rough woodcuts scattered through the work were drawn on wood by the author1 and for their roughness he1 not his engraver1 is responsible4 ,he also hopes that the references in the letterpress will be accepted as sufficient acknowledgment of the true ownership1 in those few instances in which the idea of the diagram has been borrowed4 ,it has been thought unnecessary to introduce woodcuts of surgical instruments1 as the illustrated catalogues lately published by ,weiss1 ,maw1 and others1 are sufficiently accurate4 ,in excuse of the frequent baldness and brevity of the style1 the author must point to the size and price of the work4 ,its composition would have been easier had its dimensions been greater4 ,though intended chiefly to guide the studies1 on the dead subject1 of students and junior practitioners1 the author ventures to hope that the ,manual may be useful to those who1 in the public services1 in the colonies1 or in lonely country districts1 find themselves constrained to attempt the performance of operations which1 in the towns1 usually fall to the lot of a few ,hospital ,surgeons4 ,,joseph ,,bell4 #e ,,castle ,,terrace1 ,,edinburgh1 ,july #ahff4 ,,contents4 ,,chapter ,i4 ,,ligature ,,of ,,arteries4 ,,page ,ligature of ,arteries--,general ,maxims--,ligature of ,aorta--,iliacs--,gluteal--,femoral--,po pliteal--,innominate--,carotids-- ,lingual--,subclavian--,brachial1 etc41 #a-de ,,chapter ,,ii4 ,,amputations4 ,eras of ,amputation--,flap and ,circular compared--,special ,amputation of ,arm and ,leg1 #df-ajg ,,chapter ,,iii4 ,,excision ,,of ,,joints4 ,brief ,historical ,sketch--,comparison of ,excisions with ,amputations--,special ,excisions of the six larger ,joints--,excisions of smaller ,joints and ,bones1 #ajh-adf ,,chapter ,,iv4 ,,operations ,,on ,,cranium ,,and ,,scalp4 ,trephining--,excision of ,wens1 #adg-aej ,,chapter ,v4 ,,operations ,,on ,,the ,,eye ,,and ,,its ,,appendages4 ,entropium and ,ectropium--,trichiasis--,tarsal ,tumours--,on ,lachrymal ,organs--,mr4 ,bowman's ,operation--,pterygium--,strabismus1 convergent and divergent--,paracentesis of the ,anterior ,chamber--,operations for ,cataract by ,displacement1 ,solution1 and ,extraction--,various methods of ,extraction--,operations for ,artificial ,pupil--,iridesis--,corelysis--,iridecto my--,excision of ,staphyloma--,excision of ,eyeball1 #aea-agd ,,chapter ,,vi4 ,,operations ,,on ,,the ,,nose ,,and ,,lips4 ,rhinoplastic ,operations from ,cheek1 ,forehead1 and elsewhere--,removal of ,nasal ,polypi--,excision of ,cancers of ,lips--,cheiloplastic ,operations--,operations for ,harelip1 #age-ahg ,,chapter ,,vii4 ,,operations ,,on ,,the ,,jaws4 ,excision of ,upper ,jaw--,of ,lower ,jaw1 #ahh-aie ,,chapter ,,viii4 ,,operations ,,on ,,mouth ,,and ,,throat4 ,for ,salivary ,fistula--,excision of ,tongue1 complete and partial--,fissures of the ,palate1 soft and hard--,excision of ,tonsils1 #aif-bje ,,chapter ,,ix4 ,,operations ,,on ,,air ,,passages4 ,larynx and ,trachea--,tracheotomy--,tubes--,laryngo tomy--,o,esophagotomy--see ,addendum1 p4 #cjb1 #bjf-bag ,,chapter ,x4 ,,operations ,,on ,,thorax4 ,,page ,excision of ,mamma--,paracentesis ,thoracis1 #bah-bba ,,chapter ,,xi4 ,,operations ,,on ,,abdomen4 ,paracentesis ,abdominis--,gastrotomy--,ovariotomy--,o peration for ,strangulated ,hernia--,inguinal--,femoral--,umbilical --,operations for the ,radical ,cure of ,hernia1 #bbb-bee ,,chapter ,,xii4 ,,operations ,,on ,,pelvis4 ,lithotomy--,varieties--,lithotrity--,op erations for ,stricture--,puncture of the ,bladder--,phymosis--,amputation of ,penis--,hydrocele--,hmatocele--,castrat ion--,operation for ,fistula--,fissure--,polypi of ,rectum--,piles1 #bef-bie ,,chapter ,,xiii4 ,,tenotomy4 ,on ,tenotomy for ,wry ,neck and ,club ,foot1 #bif-bih ,,chapter ,,xiv4 ,,operations ,,on ,,nerves4 ,nerve-stretching--,nerve-cutting--,nerv e suture1 #bii-cja ,,addendum to ,chapter ,,ix41 #cjb ,,index1 #cjc-caa ,,list ,,of ,,illustrations4 ,,fig4 ,,page ,i4 ,amputations of ,fingers1 #ej ,,ii4 ,diagram of ,finger showing ,articulations1 #ej ,,iii4 ,dubrueil's ,amputation at ,wrist 7front view71 #eg ,,iv4 7dorsal view71 #eg ,v4 ,amputations of ,toes1 #fi ,,vi4 ,excision of ,wrist-joint--,lister's1 #abf ,,vii4 ,operations for ,ectropium and ,entropium1 #aea ,,viii4 ,operation for ,trichiasis--,streatfeild's1 #aea ,,ix4 ,operation for ,epiphora--,bowman's1 #aee ,x4 ,greenslade's ,instrument for above1 #aef ,,xi4 ,operations for ,squint1 #aeg ,,xii4 ,linear ,extraction of ,cataract1 #afb ,,xiii4 ,flap ,extraction of ,cataract1 #afb ,,xiv4 ,operation of ,corelysis--,streatfeild's1 #aga ,,xv4 ,operation for ,staphyloma--,critchett's1 #agb ,,xvi4 ,result of above1 #agb ,,xvii4 ,rhinoplastic ,operation from ,cheek1 #agf ,,xviii4 ,forehead1 #agg ,,xix4 ,operation on ,lip1 ,v-shaped incision1 #aha ,,xx4 ,operation on ,lip1 by scissors1 #aha ,,xxi4 ,operation for a new ,lip1 incisions1 #ahb ,,xxii4 ,operation for ,new ,lip sewed up1 #ahb ,,xxiii4 ,diagram of ,partial ,fissure 7,harelip71 #ahd ,,xxiv4 ,nelaton's ,operation for ditto1 #ahd ,,xxv4 ,operation for ,double ,harelip1 #ahe ,,xxvi4 ,diagram of ,double ,harelip1 #ahf ,,xxvii4 ,excision of ,upper and ,lower ,jaws1 #ahi ,,xxviii4 ,operation for ,salivary ,fistula1 #aif ,,xxix4 ,operation for ,fissure in ,soft ,palate1 #bja ,,xxx4 ,operation for ,fissure in ,hard ,palate1 #bjc ,,xxxi4 ,diagram illustrating ,operations on ,air ,passages1 #bjg ,,xxxii4 ,diagram illustrating ,operations for ,hernia1 #bda ,,xxxiii4 ,diagram of an ,artificial ,anus1 #bec ,,xxxiv4 ,diagram of ,section of ,prostate1 #beg ,,xxxv4 ,diagram of ,membranous portion of ,urethra1 #bei ,,xxxvi4 ,diagram illustrating ,puncture of ,bladder1 #bhd ,,xxxvii4 ,diagram of ,operation for ,phymosis1 #bhf ,,xxxviii4 ,diagram of ,amputation of ,penis1 #bhg ,illustration ,,plate ,i4 #a4 ,ligature of ,aorta--,sir ,a4 ,cooper's incision4 #b4 ,ligature of ,aorta--,south and ,murray's incision4 #c4 ,ligature of ,common ,iliac4 #d4 ,ligature of ,external ,iliac--,sir ,a4 ,cooper's4 #e4 ,ligature of ,femoral in ,scarpa's triangle4 #f4 ,ligature of ,femoral below ,sartorius4#a #g4 ,ligature of ,innominate4 #h4 ,ligature of third part of ,left ,subclavian4 #i4 ,ligature of ,axillary in its first part4 #aj4 ,ligature of ,axillary in its third part4 #aa4 ,ligature of ,brachial4 #ab4 ,amputation of ,arm by double flaps4 #ac4 ,amputation at ,shoulder-joint 7#ast method71 showing portion of skin left uncut till the conclusion of the disarticulation4 #ad4 ,amputation at ,ankle-joint by internal flap--,mackenzie's4 #ae-af4 ,amputation of ,leg just above the ,ankle-joint4 #ag-ah4 ,amputation below ,knee--modified circular4 #ai4 ,amputation through ,condyles of ,femur--,syme1 and ,pl4 ,,iii4 #e4 #bj4 ,amputation at lower third of ,thigh--,syme1 and ,pl4 ,,iii4 #f4 ,a4 ,excision of ,head of ,humerus4 ,b4 ,excision of ,knee-joint2 semilunar incision4 ,,footnotes3 #a ,this line is placed too low down2 it should be in the middle third of the thigh4 ,illustration ,,plate ,,ii4 #a4 ,amputation at lower third of ,fore-arm--,teale's4 #b-b4 ,amputation at ,shoulder-joint by large postero-external flap--#b;d method4 #c-c4 ,amputation at ,shoulder-joint by triangular flap from deltoid--#c;d method4 #d-e4 ,amputation through ,tarsus--,chopart's4 #f-g4 ,amputation at ,knee-joint4 #h4 ,amputation by ,single ,flap--,carden's1 and ,pl4 ,,iv4 #af4 #i-aj4 ,amputation of ,thigh--,teale's4 ,a4 ,excision of ,hip-joint4 ,b-,b4 ,excision of ,ankle-joint--,hancock's incisions4 ,illustration ,,plate ,,iii4 #a4 ,ligature of ,popliteal4 #b4 ,amputation at ,elbow-joint--posterior flap4 #c4 ,amputation at ,shoulder-joint--posterior incision of first method1 and ,pl4 ,i4 #ac4 #d4 ,amputation at ,ankle-joint--,mackenzie's1 and ,pl4 ,i4 #ad4 #e4 ,amputation through ,condyles of ,femur--,syme1 and ,pl4 ,i4 #ai4 #f4 ,amputation at lower third of ,thigh--,syme1 and ,pl4 ,i4 #bj4 #g4 ,amputation at ,knee--posterior incision4 #h4 ,amputation of ,thigh--,spence's1 and at ,pl4 ,,iv4 #ah4 #i4 ,amputation at ,hip-joint1 and ,pl4 ,,iv4 #bj4 ,a4 ,excision of ,shoulder-joint--deltoid flap4 ,b4 ,excision of ,shoulder-joint by posterior incision4 ,c4 ,excision of ,elbow-joint--,h-shaped incision4 ,d4 ,excision of ,elbow-joint--linear incision4 ,e4 ,excision of ,hip-joint--,gross's4 ,f4 ,excision of ,os ,calcis4 ,g4 ,excision of ,scapula4 ,illustration ,,plate ,,iv4 #a4 ,ligature of ,carotid4 #b4 ,ligature of ,subclavian 7#c;d stage7--,skey's incision4 #c4 ,amputation at ,wrist-joint--dorsal incision4 #d4 ,amputation at ,wrist-joint--palmar incision4 #e4 ,amputation at ,fore-arm--dorsal incision4 #f4 ,amputation at ,fore-arm--palmar incision4 #g4 ,amputation at ,elbow-joint--,anterior flap1 and ,pl4 ,,iii4 #c4 #h4 ,amputation at ,arm--,teale's method4 #i4 ,amputation at ,shoulder-joint--#ast method1 and ,pl4 ,,iii4 #c4 #aj-aa4 ,amputation of ,metatarsus--,hey's4 #ab-ac4 ,amputation at ,ankle--,syme's4 #ad-ae4 ,amputation of ,leg--posterior flap--,lee's4 #af4 ,amputation at ,knee-joint--,carden's1 and ,pl4 ,,ii4 #h4 #ag4 ,amputation of ,thigh--,b4 ,bell's4 #ah4 ,amputation of ,thigh--,spence's1 and ,pl4 ,,iii4 #h4 #ai4 ,amputation of ,thigh in middle third4 #bj-bj4 ,amputation at ,hip-joint1 and ,pl4 ,,iii4 #i4 ,a4 ,excision of ,wrist--radial incision4 ,b4 ,excision of ,wrist--ulnar incision4 ,,chapter ,i4 ,,ligature ,,of ,,arteries4 ,,ligature ,,of ,,arteries4--,in a work of this nature there is no room for any discussion of the principles which should guide us in the selection of cases1 or of the pathology of aneurism1 or the local effects of the ligature on the vessels4 ,one or two fundamental axioms may be given in a few words3-- #a4 ,in selecting the spot for the application of the ligature1 avoid as far as possible bifurcations1 or the neighbourhood of large collateral branches4 #b4 ,a free incision should be made through the skin and subjacent textures1 till the sheath of the artery is reached and fairly exposed4 #c4 ,the sheath must be opened and the artery cleaned with a sharp knife till the white external coat is clearly seen4 ,the portion cleaned should1 however1 be as small as possible1 consistent with thorough exposure1 so that the ligature may be passed round the vessel without force4 #d4 ,as the artery should never be raised from its bed1 it is generally advisable to pass the needle only so far as just to permit the eye to be seen past the vessel4 ,the ligature should then be seized by a pair of forceps and gently pulled through1 the needle being cautiously withdrawn4 ,when catgut is used1 it is better to pass the unarmed needle till the eye is visible1 then thread and withdraw it1 thus pulling the catgut through4 #e4 ,as a rule1 the needle should be passed from the side of the vessel at which the chief dangers exist4 ,this will generally be in the side at which the vein is4 #f4 ,the ligature should be single1 and consist of strong well-waxed silk1 and should always be drawn as tight as possible1 so as to divide the internal and middle coats of the vessel4 ,in cases where the wound is to be treated with antiseptic precautions and an attempt at immediate union made1 the ligature may be of strong catgut properly prepared1 and both ends of it may be cut off4 #g4 ,before the ligature is tightened1 it is well to feel that pressure between the ligature and the finger arrests the pulsation of the tumour4 ,,ligature ,,of ,,the ,,aorta4--,it has been found necessary in a few rare cases to place a ligature on the abdominal aorta2 no case has as yet survived the operation beyond a very few days1 but they have in their progress sufficiently proved that the circulation can be carried on1 and gangrene does not necessarily result even after such a decided interference with vascular supply4 ,operation4--,the ligature may be applied in one of two ways1 the choice being influenced by the nature of the disease for which it is done4 #a4 ,a straight incision 7,plate ,i4 fig4 #a7 in the linea alba1 just avoiding the umbilicus by a curve1 and dividing the peritoneum1 allows the intestines to be pushed aside1 and the aorta exposed still covered by the peritoneum1 as it lies in front of the lumbar vertebr4 ,the peritoneum must again be divided very cautiously at the point selected1 and the aortic plexus of nerves carefully dissected off1 in order that they may not be interfered with by the ligature4 ,the ligature should then be passed round1 tied1 cut short1 and the wound accurately sewed up4 #b4 ,without wounding the peritoneum4 ,a curved incision 7,plate ,i4 fig4 #b71 with its convexity backwards1 from the projecting end of the tenth rib to a point a little in front of the anterior superior spinous process of the ilium4 ,at first through the skin and fascia only1 this incision must be continued through the muscles of the abdominal wall1 one by one1 till the transversalis fascia is exposed1 which must then be scraped through very cautiously1 so as not to injure the peritoneum1 which is to be detached from the fascia covering the psoas and iliacus muscles1 and must be held inwards and out of the way by bent copper spatul4 ,the common iliac will then be felt pulsating1 and on it the finger may easily be guided up until the aorta is reached4 ,the really difficult part of the operation now begins3 to isolate the vessel from the spine behind1 the inferior cava on the right side1 and the plexus of nerves in the cellular tissue all round4 ,the cleaning of the vessel must be done in great measure by the finger-nail1 and much dexterity will be required to pass the ligature without unnecessarily raising the vessel from its bed1 especially as the vessel itself may very possibly be diseased1 and the aneurism of the iliac trunk for which the operation is required will displace and confuse the parts1 and may have set up adhesive inflammation4 ,results4--,operation has been performed at least ten times4 ,by the first method by ,sir ,astley ,cooper and ,mr4 ,james2 by the second by ,drs4 ,murray and ,monteiro1 ,m',guire1 ,heron ,watson1 and ,stokes1 and ,mr4 ,south1 and ,czerny of ,heidelberg4 ,all the cases proved fatal2 ,dr4 ,monteiro's survived for ten days1 and eventually perished from hmorrhage2 the rest all died at shorter intervals4 ,,ligature ,,of ,,common ,,iliac4--,anatomical ,note4--,this short thick trunk varies slightly in its relations on the two sides of the body4 ,as the aorta bifurcates on the left side of the body of the fourth lumbar vertebra1 the common iliac of the right side would have a longer course to pursue than that on the left1 if both ended at corresponding points4 ,however1 this is not always the case1 as has been pointed out by ,mr4 ,adams of ,dublin1 as the right common iliac often bifurcates sooner than the left does4 ,with this slight difference1 the position of the two vessels is precisely similar1 each extending along the brim of the pelvis from the bifurcation of the aorta towards the sacro-iliac synchondrosis for about two inches4 ,sometimes the division takes place a little higher1 even at the junction of the last lumbar vertebra and the sacrum4 ,this variation depends chiefly on the length of the artery1 which1 as ,quain has shown1 varies from one inch and a half to more than three inches4 ,the anterior surface of both arteries is covered by the peritoneum1 and each is crossed by the ureter just as it bifurcates into its branches4 ,the artery of the right side is in close contact behind with its corresponding vein1 which at its upper part projects to the outside1 and below to the inner side4 ,the artery of the left side is less involved with its vein1 which lies below it1 and to the inside4 ,the right is in contact with a coil of ileum1 the left with the colon4 ,the inferior mesenteric artery crosses the left one1 while to the outside of both1 and behind them1 lie the sympathetic and obdurator nerves4 ,there are no named branches from the common iliac4 ,operation4--,the chief difficulties to be encountered are--#a4 ,the close proximity of the peritoneum1 and specially the risk there is that it has become adherent to the sac of the aneurism2 #b4 ,the depth of the parts1 and tendency of the intestines to roll into the wound2 #c4 ,specially on the right side1 the proximity of the great veins4 ,with these exceptions the passing of the ligature is not so difficult as in some situations1 the lax cellular tissue in which the vessel lies generally yielding much more easily than the tough sheath which elsewhere1 as in the femoral1 requires accurate dissection4 ,incision4--7,plate ,i4 fig4 #c47--;,from a point about half an inch above the centre of ,poupart's ligament1 a crescentic incision should be made1 at first extending upwards and outwards1 so as to pass about one inch inside of the anterior superior spine of the ilium1 and then prolonged upwards and inwards1 as far as may be rendered necessary by the size of the aneurism or the depth of parts4 ,it must extend through skin and superficial fascia1 exposing the tendon of the external oblique1 which must then be slit up to the full extent visible4 ,the spermatic cord may then be easily exposed under the edge of the internal oblique1 and the forefinger of the left hand inserted on the cord1 and thus beneath the internal oblique and transversalis muscles1 the peritoneum being quite safe below4 ,on the finger these muscles may be safely divided to the full extent of the external incision4 ,the deep circumflex iliac artery if possible should not be divided1 but may bleed smartly and require a ligature4 ,the peritoneum must then be very cautiously raised from the tumour1 and supported1 along with the intestines1 by copper spatul4 ,the surgeon will rarely succeed in obtaining anything like a satisfactory view of the vessel1 but can expose it for the ligature by the aid of his finger-nail4 ,an ordinary aneurism-needle will generally suffice for the conveyance of the ligature4 ,the difficulties may occasionally be much increased by special circumstances1 such as great stoutness of the patient1 and consequent thickness of the abdominal wall2 or large size of the aneurism1 which may cause alterations in the relation of parts and adhesion of the peritoneum4 ,the ureter generally gives no trouble1 as in pressing back the peritoneum it is adherent to it1 and is removed along with it towards the middle line4 ,results4--,are not by any means satisfactory4 ,out of twenty-two cases in which the common iliac has been tied for aneurism1 eight recovered and fourteen died2 while out of thirteen cases where it required ligature for hmorrhage after amputation1 rupture of aneurism1 etc41 only one recovered4 ,,ligature ,,of ,,internal ,,iliac4--,little need be added to the account just given of the operation for ligature of the common iliac1 as precisely the same incisions are required4 ,the operator having reached the bifurcation of the vessel1 must1 instead of tracing it upwards1 endeavour to trace it downwards1 and the same time inwards1 into the basin of the pelvis4 ,to do this his finger must cross the external iliac artery1 which will pulsate under the joint of the ungual phalanx1 while the pulp of the finger is touching the internal iliac1--the external iliac vein1 which occupies the angle formed by the bifurcation of the artery1 lying between these two points4 ,the ligature should be applied within three-quarters of an inch from the bifurcation4 ,anatomical ,note4--,this short thick trunk extends backwards and inwards 7,ellis72 downwards and backwards 7,harrison71 in front of the sacro-iliac synchondrosis1 as far as the upper extremity of the great sacro-sciatic notch1 a distance varying in the adult from one and a half to two inches in length4 ,it forms a curve with its concavity forwards1 and at its termination divides into1 rather than gives off1 its two or three principal branches4 ,its corresponding vein is in close contact behind1 as also the lumbo-sacral nerve1 the obdurator nerve to its outer side4 ,the peritoneum covers it anteriorly1 and it is crossed just at its commencement by the ureter4 ,on the left side it is covered anteriorly by the rectum4 ,of its anatomical relations1 that of the external iliac vein is perhaps the most important1 as it is apt to interfere with the passing of the needle4 ,results4--,this vessel has been tied for aneurism of one or other of its branches1 or for wound1 about seventeen times4#b ,of these seven recovered2 in ten the operation proved fatal1 in most of them from secondary hmorrhage4 ,in one case the hmorrhage occurred within twelve hours after the operation4 ,the circulation of the parts supplied after the ligature is carried on mainly by the lumbar and lateral sacral branches1 which become much developed even before the operation1 in cases of aneurism4 ,,ligature ,,of ,,external ,,iliac4--,anatomical ,note4--,this artery extends from the bifurcation of the common iliac to the centre of ,poupart's ligament1 where it leaves the abdomen1 passing under the ligament1 and becomes the common femoral4 ,its upper extremity is thus not always constant1 varying in position from the sacro-lumbar fibro-cartilage to the upper end of the sacro-iliac synchondrosis1 or even a little lower down4 ,thus1 though the position of the lower end is at a fixed point1 the artery varies in length4 ,in an adult male of moderate stature it is from three and a half to four inches in length4 ,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 ilium4 ,its relations to neighbouring parts are as follows3--,the peritoneum lies in front of it1 separated from it only by a subperitoneal layer of loose fascia1 in which the artery and vein lie1 which varies much in consistence and amount1 and which occasionally gives a good deal of trouble in the operation of ligature4 ,near its origin it is sometimes crossed by the ureter1 and near its termination the genito-crural nerve lies on it4 ,the spermatic vessels cross it1 and occasionally a quantity of subperitoneal fat marks its course4 ,externally4--,the fascia-iliaca and some fibres of the psoas muscle separate it from the anterior crural nerve1 which lies outside of the vessel1 and at a somewhat deeper level1 hidden amid the fibres of psoas and iliacus4 ,internally4--,the external iliac vein lies on the same plane1 and to the inner side of the artery1 at ,poupart's ligament1 on both sides of the body4 ,as we trace it upwards we find that on the left side it lies internal to the artery in its whole course1 while on the right side it becomes posterior to the artery as it approaches the bifurcation of the common iliac4 ,lastly1 just before the vessel reaches ,poupart1 the circumflex iliac vein crosses it from within outwards4 ,branches4--,the two large branches to the wall of the abdomen1 the epigastric and the circumflex iliac1 rise a few lines above ,poupart's ligament4 ,their position is unfortunately apt to vary upwards1 to the extent of an inch and a half or even two inches1 and they are important1 as1 besides being liable to be cut during the operation1 their position very materially modifies the prognosis1 as1 if too high up1 they interfere with the proper formation of the coagulum4 ,operation4--,various plans of incision through the skin have been recommended by various operators1 the chief difference being with regard to the part of the artery aimed at2 the plan known as that of ,mr4 ,abernethy1 with various modifications1 being intended to expose the artery pretty high up1 and enable the surgeon to reach it from above2 while the method going by the name of ,sir ,astley ,cooper's exposes the lower part of the artery1 and enables the surgeon to reach it from below4 ,though the latter is in some respects easier1 the former method is generally to be preferred1 being further from the seat of disease1 and especially more out of the way of the epigastric and circumflex arteries4 ,the higher operation 7,,abernethy',s modified74--,an incision must be made through the skin about four inches in length1 but longer in proportion to the amount of subcutaneous fat1 and the depth of the pelvis1 extending from a point one inch to the inside of the anterior superior spine of the ilium1 to a point half an inch above the middle line of ,poupart's ligament4 ,it must be slightly curved1 with its convexity looking outwards and downwards4#c ,the subcutaneous cellular tissue and the tendon of the external oblique may then be divided freely in the same line4 ,then at some one point or other 7generally easiest below71 the internal oblique and transversalis muscles must be cautiously scraped through with the aid of the forceps1 till the transversalis fascia is reached2 they may then be freely divided by a probe-pointed bistoury 7guarded by the finger pushed up below the muscles7 to the required extent4 ,the muscles being held aside by flat copper spatul1 the fascia transversalis must be carefully scratched through near the crest of the ilium1 and thus the operator will be enabled to push the peritoneum inwards1 and by the forefinger will easily recognise the pulsation of the artery lying on the soft brim of the pelvis4 ,a branch of the circumflex iliac artery will very likely be cut in dissecting through the muscles1 and must be secured1 as also any branches of the epigastric which may be divided in the incisions through the abdominal wall 7ut supra1 p4 #e74 ,the operator should then1 by pressing the peritoneum and its contents gently inwards1 endeavour to see the vessel2 if1 from the depth of the pelvis1 this cannot be done1 the sense of touch will be in most cases sufficient to enable him to isolate the artery by the point of his finger-nail1 or by the blunt aneurism-needle1 from the vein4 ,the ligature should be passed from the inner side to avoid including the vein1 and thus there will be less chance of wounding the peritoneum from the convexity of the needle being applied to it4 ,if possible1 the genito-crural nerve should not be included in the ligature1 but probably such an accident would do no great harm4 ,it is of much more consequence to avoid injuring the peritoneum4 ,this is sometimes very difficult1 from the adhesions which are set up between the peritoneum1 the artery1 and especially the aneurism1 as the result of pressure and inflammation4 ,the accident of wounding the peritoneum has happened to ,keate1 ,tait1 ,post1 and others1 and in some cases with perfect impunity4 ,however1 the peritoneum should be displaced as little as possible from its cellular connections1 as such displacement increases the risk of diffuse inflammation of that membrane2 and the vessel itself should be raised and disturbed as little as possible1 lest destruction of the vasa vasorum cause ulceration of the weak coats and secondary hmorrhage4 ,the operation from below 7,plate ,i4 fig4 #d71 ,,sir ,,astley ,,cooper',s1 is thus described by ,mr4 ,hodgson3#d--;,a semilunar incision is made through the integuments in the direction of the fibres of the aponeurosis of the external oblique muscle4 ,one extremity of the incision will be situated near the spine of the ilium2 the other will terminate a little above the inner margin of the abdominal ring4 ,the aponeurosis of the external oblique muscles will be exposed1 and is to be divided throughout the extent1 and in the direction of the external wound4 ,the flap which is thus formed being raised1 the spermatic cord will be seen passing under the margin of the internal oblique and transverse muscles4 ,the opening in the fascia which lines the transverse muscle through which the spermatic cord passes1 is situated in the mid space between the anterior superior spine of the ilium and the symphysis pubis4 ,the epigastric artery runs precisely along the inner margin of this opening1 beneath which the external iliac artery is situated4 ,if the finger therefore be passed under the spermatic cord through this opening in the fascia1 it will come in immediate contact with the artery which lies on the outside of the external iliac vein4 ,the artery and vein are connected by dense cellular tissue1 which must be separated to allow of the ligature being passed round the former4 ,in comparing the two methods of operating1 we find that while the latter is in some respects easier1 and the vessel in it lies more superficial1 it has certain disadvantages which more than counterbalance its advantages4 ,thus1 first1 the epigastric artery is very likely to be wounded4 ,it may be said1 ,well1 if so1 the ends can be tied2 but this tying is sometimes very difficult2 and1 as shown in ,dupuytren's case of this accident1 involves considerable interference with the peritoneum1 and a possibly fatal peritonitis4 ,besides this1 by cutting the epigastric you destroy an important agent which would have carried on the anastomosing circulation1 and thus greatly increase the risk of gangrene4 ,by this method1 also1 the artery is exposed too near to the seat of disease2 and if found to be enlarged and involved in the aneurism1 considerable difficulty may be experienced in reaching the upper part of the vessel4 ,again1 ligature of the lower third or half of the vessel1 which this method implies1 is dangerous from the occasional high origin of the circumflex or epigastric1 or both1 rendering the formation of a clot much more difficult1 and secondary hmorrhage much more likely4 ,the circumflex iliac vein must also be remembered1 as it crosses the artery from within outwards in the lower end of it1 just before it goes under ,poupart's ligament4 ,however1 the method may occasionally vary with the individual case4 ,in every case of ligature of the great vessels of the abdomen1 the bowels should be carefully evacuated before the operation1 and the bladder emptied4 ,a properly managed position1 with the shoulders raised and the knees semiflexed1 will greatly facilitate the gaining access to the vessel4 ,in sewing up the wounds in the abdominal walls1 advantage will be gained by putting in a certain number of stitches so deeply as to include the whole thickness of the muscles1 and in the intervals between these deep ones to insert others less deeply1 so as accurately to approximate the edges of the skin4 ,this will both facilitate union and also render the occurrence of hernia less probable4 ,this latter accident did occur in a case1 otherwise successful1 in which ,mr4 ,kirby tied the external iliac4 ,both external iliacs have been tied in the same patient with success1 on at least two occasions1 once by ,arendt1 with an interval of only eight days between the operations2 and a second time by ,tait1 at an interval of rather more than eleven months4 ,this operation is in the great majority of cases performed for femoral aneurism1 and naturally secondary hmorrhage is a too frequent result4 ,wounds of these great vessels generally result in so rapid death from hmorrhage as to give no time for surgical interference4 ,one case1 however1 is recorded1#e in which the external iliac was cut in a lad of seventeen by an accidental stab1 and in which ,drs4 ,layraud and ,durand1 who were almost instantly on the spot1 succeeded in stopping the bleeding by compresses1 till ,velpeau arrived1 who tied the vessel above with perfect success4 ,of the first twenty-two cases collected by ,hodgson1 fifteen recovered--a mortality of #ca4ha per cent42 and of #aec in ,norris's collection1 including ,cutter's cases1 forty-seven died--a mortality of only #cb4e per cent41--a very satisfactory result1 considering the size of the vessel and the importance of its relations4 ,,ligature ,,of ,,gluteal4--,this vessel1 though one of the branches of the internal iliac1 approaches the surface so nearly as to be occasionally wounded4 ,it is also1 though very rarely1 the subject of spontaneous aneurism4 ,the principle of treatment and the operation to be selected in any given case1 depends upon its origin1 whether traumatic or spontaneous4 ,for if traumatic1 the wound must almost necessarily be accessible from the outside2 the neighbouring part of the artery is probably healthy1 and hence the case can be treated by the old operation1 slitting up the tumour1 and tying the vessel above and below the wound4 ,when the aneurism is spontaneous1 there is no guide to tell us where the aneurism may have first originated2 it may be that it is high up in the pelvis1 and that the visible tumour is only its expansion in the direction of least resistance1 or the coats of the vessel may be extensively diseased4 ,the only chance is ligature of the internal iliac4 #a4 ,the old operation1 or ligature of the gluteal artery in the hip4 ,anatomical ,note4--,the gluteal is the largest branch of the internal iliac1 and leaves the pelvis by the great sacro-sciatic notch just at the upper edge of the pyriformis muscle4 ,after a very short course1 it divides into superficial and deep branches opposite the posterior margin of the glutens minimus1 between it and the pyriformis muscles4 ,very precise rules have been given to enable the operator to hit on the exact spot where the artery leaves the pelvis4 ,these1 though perhaps interesting anatomically1 are quite useless in a surgical point of view1 for the only reasons which could possibly induce a surgeon to cut down upon the gluteal in the living body1 are the existence either of a wound of the vessel or an aneurism4 ,in the first the flow of blood1 in the second the tumour1 would give sufficient guidance4 ,in cases of traumatic aneurism the operation should be something like the following3--,a free incision should be made into the tumour1 dividing it in its long direction2 the contents should be rapidly scooped out1 and a finger placed on the bleeding point1 just at the upper corner of the sciatic notch4 ,this will at once stop the hmorrhage till the vessel can be secured4 ,this sounds easy enough1 and has been done several times with success4 ,thus1 ,john ,bell1 by an incision two feet long1 as he tells us in his hyperbolical language1 was enabled to tie the vessel in the case of the leech-gatherer who had punctured the artery by a pair of long scissors4 ,carmichael of ,dublin used a smaller incision1 removed one or two pounds of clots1 and tied the vessel1 in a case of wound by a penknife4#f ,now1 though both of these cases were eventually successful1 both patients lost during the operation a very large quantity of blood2 ,john ,bell's especially could not be removed from the operating-table for a considerable time after the operation4 ,the period at which the great loss of blood took place was the interval after the incision was made1 and before the artery was exposed to view1 i4e4 the interval in which the surgeon was busy dislodging the clots from the cellular membrane1 the sac of the false aneurism4 ,the procedure devised by ,mr4 ,syme to obviate this difficulty1 and which was put in practice by him in several very trying cases1 is best given in his own terse description of an operation in a case of traumatic gluteal aneurism3-- ,the patient having been rendered unconscious1 and placed on his right side1 ,i thrust a bistoury into the tumour1 over the situation of the gluteal artery1 and introduced my finger so as to prevent the blood from flowing1 except by occasional gushes1 which showed what would have been the effect of neglecting this precaution1 while ,i searched for the vessel4 ,finding it impossible to accomplish the object in this way1 ,i enlarged the wound by degrees sufficiently for the introduction of my fingers in succession1 until the whole hand was admitted into the cavity1 of which the orifice was still so small as to embrace the wrist with a tightness that prevented any continuous hmorrhage4 ,being now able to explore the state of matters satisfactorily1 ,i found that there was a large mass of dense fibrinous coagulum firmly impacted into the sciatic notch2 and1 not without using considerable force1 succeeded in disengaging the whole of this obstacle to reaching the artery1 which would have proved very serious if it had been allowed to exist after the sac was laid open4 ,the compact mass1 which was afterwards found to be not less than a pound in weight1 having been thus detached1 so that it moved freely in the fluid contents of the sac1 and the gentleman who assisted me being prepared for the next step of the process1 ,i ran my knife rapidly through the whole extent of the tumour1 turned out all that was within it1 and had the bleeding orifice instantly under subjection by the pressure of a finger4 ,nothing then remained but to pass a double thread under the vessel1 and tie it on both sides of the aperture4 ,the bleeding in this case was thus rendered comparatively trifling1 and the patient made a speedy and complete recovery4 ,he returned home within six weeks after the operation4#g #b4 ,in one case1 at least1 the gluteal artery has been tied with success 7for traumatic aneurism7 just where it leaves the pelvis1 without the tumour being opened4 ,this was in the practice of ,professor ,campbell of ,montreal4 ,the operation was a very difficult one1 and while possible only in cases seen very early1 and where the tumour is very small1 does not appear to have any advantage over the old method4 ,cases of spontaneous aneurism of the gluteal artery should be treated by ligature of the internal iliac4 ,steven's and ,syme's cases of ligature of the internal iliac were of this nature4 ,manuals of operative surgery occasionally devote pages to the description of special operations for the ligature of such arteries as the sciatic1 epigastric1 circumflex ilii1 and pudic4 ,they do not require ligature1 except in cases of wound either of the vessels themselves or their branches2 and1 according to the modern principles of surgery in such cases1 the ligature should be applied to the bleeding point1 rather than to the vessel at a distance above it4 ,,ligature ,,of ,,femoral4--,under this head we practically mean cases of ligature of the superficial femoral1 for the common femoral1 or 7as called by some anatomists7 the femoral1 before the profunda is given off1 very rarely requires to be tied4 ,if it is wounded1 of course the bleeding point must be sought1 and the artery tied above and below it1 but if an aneurism on the superficial femoral renders ligature of that trunk impossible1 experience teaches that ligature of the external iliac gives better results than ligature of the common femoral4 ,erichsen asserts that out of twelve cases in which the common femoral has been tied1 only three have succeeded1 the others dying from secondary hmorrhage4 ,the experience of the ,dublin surgeons1 ,porter1 ,smyly1 and ,macnamara1 has been more satisfactory1 as in eight cases of this operation six were successful4#h ,a ninth case was unsuccessful4 ,reasons to explain the danger are not far to seek1 for the numerous small muscular branches1 along with the superficial epigastric1 circumflex1 and pudic trunks1 reduce the chances of a good coagulum in the common femoral to a minimum1 even without taking into consideration the shortness of the trunk before the great profunda femoris is given off4 ,for the common femoral artery is only from one to two inches in length1 and if there are some rare cases in which it is a little later in its bifurcation1 there are others in which it divides nearer to ,poupart's ligament4 ,the superficial femoral is the name given to the main trunk between the origin of the profunda1 and the point at which1 passing through the tendon of the adductor magnus1 it receives the name of popliteal4 ,during this long course it gives off no branch large enough or regular enough to receive a name1 except one1 the anastomotica magna1 which rises in ,hunter's canal1 close to the end of the vessel1 so in that respect it is peculiarly suitable for the application of a ligature4 ,again1 in the upper part of its course1 it is superficial1 being covered only by skin and fascia4 ,a short notice of its most important anatomical relations is necessary4 ,for the first two inches or two inches and a half of its separate existence1 the superficial femoral lies in ,scarpa's triangle1 covered1 as we said1 only by skin and fascia4 ,this triangle is formed by the sartorius and adductor longus muscles which meet at its apex1 and by ,poupart's ligament1 which defines its base4 ,the artery lies almost exactly in the centre of the space1 and at the apex is covered by the sartorius muscle4 ,the spot where it goes under the sartorius is the one selected for the application of the ligature4 ,the femoral vein lies to the inner side of the femoral artery in this triangle1 but their mutual relations vary with the portion of the limb2 for1 on the level of ,poupart's ligament1 the artery and vein lie side by side on the same plane1 but in different compartments of their sheath2 as the artery dives below the sartorius1 the vein is still on the inside1 but on a plane slightly posterior2 while1 by the time they reach ,hunter's canal1 the vein has got completely behind the artery4 ,the separate compartments of the sheath in which the vessels lie are much less marked as the vessels go down the limb1 the septum between the artery and the vein being in most cases very ill marked1 even at the level where the ligature is applied4 ,the anterior crural nerve1 which on the level of ,poupart's ligament lay outside of the artery and on a plane somewhat posterior1 has divided into numerous branches before it reaches the point of ligature4 ,one of its branches requires to be mentioned1 and may sometimes be noticed and avoided during the operation1 namely the internal saphenous nerve1 which1 first lying external to the artery1 crosses it in front1 reaching its inner side just before it enters ,hunter's canal1 where it leaves the vessel accompanying the anastomotica magna branch4 ,,operation ,,of ,,ligature ,,of ,,the ,,femoral--,,scarpa',s ,,space4--,the patient being placed on his back1 and being brought very thoroughly under chloroform1 the knee of the affected limb should be bent at an angle of about #abj1 and supported on a pillow4 ,having previously ascertained the angle of junction of the sartorius and adductor1 the surgeon should make an incision 7,plate ,i4 fig4 #e7 just over the pulsations of the vessel1 in the middle line of the space1 having its lower end quite over the sartorius muscle1 and its upper one1 at a distance from two and a half to three and a half inches1 varying according to the amount of fat and muscle4 ,the saphena vein can generally be recognised1 and is almost always safe out of the way of this incision at its inner side4 ,the first incision should divide the skin1 superficial fascia1 and fat1 quite down to the fascia lata4 ,the edges of the wound being held apart1 the fascia should be carefully divided1 and the sartorius exposed2 its fibres can generally be easily enough recognised by their oblique direction2 once recognised1 the fascia should be dissected from it till its inner edge be gained1 the corner of which should then be turned so that it may be held outwards by an assistant with a blunt hook4 ,the sheath of the vessels is now exposed1 and after having thoroughly satisfied himself of the position of the artery by the pulsation1 the surgeon should carefully raise a portion of the sheath with the dissecting forceps1 and open it freely enough to allow the coats of the artery to be distinctly seen4 ,if the parts are deep1 as in a fat or muscular patient1 great advantage will be gained by seizing one edge of the sheath by a pair of spring forceps1 and committing it to the care of an assistant1 while the operator holds the other in his dissecting forceps2 there is thus no fear of losing the orifice of the sheath1 which without this precaution may easily happen1 from the parts being confused with blood1 or the position altered by movements of the patient4 ,now comes the stage of the operation on which1 more than on anything else1 success or failure depends4 ,a small portion of the vessel must be cleaned for the reception of the ligature1 and it must be thoroughly cleaned1 so that the needle may be passed round it without bruising of the coats1 or rupture of an unnecessary number of the vasa vasorum by rough attempts to force a passage for it4 ,hence all compromises1 such as blunted instruments1 silver knives1 and the like1 are dangerous1 for in trying to avoid the ,scylla of wounding the artery1 they fall into the ,charybdis1 on the one hand1 of isolating too much of the vessel and causing gangrene from want of vascular supply1 or1 on the other1 expose the vein to the danger of injury by the aneurism-needle in their attempts to force it round an uncleaned vessel4 ,the needle should in most cases be passed from the inner side1 care being taken to avoid including the vein which is on the inner side and behind the vessel2 the internal saphenous nerve1 if seen1 should be avoided4 ,the needle must not be passed quite round the vessel raising it up1 still less must the vessel be held up on the needle1 as used to be done1 as if the surgeon was surprised at his own success1 but the needle should be passed just far enough to expose the end of the ligature1 which must be seized by forceps and cautiously drawn through4 ,it must then be tied very firmly and secured with a reef knot4 ,the edges of the wound must be brought into accurate apposition1 and secured by one or two stitches4 ,if antiseptics are used1 drainage should be provided for4 ,from the very fact that ligature of the superficial femoral is a remarkably successful operation in causing consolidation of the aneurism and a rapid cure1 there is also a corresponding danger that the limb be not sufficiently supplied with blood at first4 ,the limb may very possibly become cold1 and remain so for some hours at least after the operation4 ,to avoid this as far as possible1 it should be wrapped in cotton wadding1 and very great care should be taken that it be not over-stimulated by hot applications1 friction1 or the like1 any of which measures might very likely excite reaction1 which would result in gangrene4 ,complete rest of the limb and of the whole body must be enjoined2 the food must be nourishing and in moderate quantity4 ,the chief danger is from gangrene of the limb1 which is especially apt to result when the vein is wounded1 or even too much handled during the operation4 ,when properly performed1 and in suitable cases1 the operation is very successful4 ,mr4 ,syme tied this artery for aneurism thirty-seven times1 and of these every one recovered4 ,the statistics of ,norris and ,porta1 who collected all the cases in which ligature of the femoral had been employed for any cause1 show a mortality of somewhat less than one in four4 ,rabe's table up to #ahfi with the additional cases collected by ,mr4 ,barwell to #ahhj gives #big cases with #ec deaths4#i ,mr4 ,hutchinson's table1 again1 of fifty cases collected from the records of ,metropolitan ,hospitals1 shows the very startling result of sixteen deaths out of the fifty cases1 or a mortality1 in round numbers1 of one-third4 ,certain anomalies have been observed in the distribution of the femoral vessels1 of some importance as affecting the possibility of applying1 and the result of1 ligature2 such as--#a4 ,a high division of the branches which afterwards become posterior tibial and peroneal4 #b4 ,a double superficial femoral1 both branches of which may unite and form the popliteal1 as in ,sir ,charles ,bell's well-known case4 #c4 ,absence of the artery altogether1 as in ,manec's case1 where the popliteal was a continuation of an immensely enlarged sciatic4 ,in such a case the absence of pulsation in front1 and the presence of increased pulsation behind the limb1 ought to prevent any fruitless attempt at search4 ,,ligature ,,of ,,the ,,superficial ,,femoral ,,below ,,the ,,sartorius ,,muscle4--,this operation1 though once common in ,france1 and though the one recommended by ,hunter himself1 is now comparatively little used in this country2 and rightly so2 for while it has no advantage over the upper position1 it is at once nearer the seat of disease1 and the vessel is more deeply buried under muscles1 and has a more distinct fibrous sheath1 which requires division4 ,it is1 however1 by no means a difficult operation1 and is thus performed3-- ,the limb being laid as before on the outside1 and slightly bent1 the skin shaved and the pulsation of the artery detected1 an incision 7,plate ,i4 fig4 #f7 must be made from the lower edge of the sartorius muscle just as it crosses the vessel1 along the course of the vessel1 avoiding if possible the internal saphena vein4 ,the sartorius when exposed must be drawn inwards4 ,the fibrous canal filling the interspace between the abductor magnus and vastus internus is then recognised1 and must be fairly opened2 the artery is now seen lying in it1 and over the vein which is posterior to it1 but projects slightly on its outer side2 the internal saphenous nerve is lying on the artery4 ,the needle is best passed from without inwards so as to avoid the vein4 ,the anastomotica magna is sometimes a large trunk1 and has been mistaken for the femoral in this situation1 and tied instead of it4 ,,ligature ,,of ,,the ,,popliteal4--,this operation is now hardly ever performed for aneurism1 ligature of the superficial femoral having quite superseded it1 and it is very rarely required for wounds1 from the manner in which the vessel is protected by its position4 ,before the invention of the ,hunterian principle of ligature at a distance1 the old operation for popliteal aneurism consisted in cutting into the space1 clearing out the contents of the aneurismal sac1 and tying both ends of the vessel2 from the depth of parts and the close connection of the popliteal vein1 this operation was very rarely successful1 and is now quite given up4 ,if the vessel is wounded the bleeding point is the object to be aimed at1 and is generally sufficient guide4 ,in cases of hmorrhage for suppuration of an aneurismal sac1 it might possibly be advisable1 and there are certain cases of rupture of the artery1 without the existence of an external wound1 in which attempts have been made to save the limb by tying the vessel4#aj ,from the complexity of the parts1 the numerous tendons1 veins1 and nerves crowded together in a narrow hollow1 and chiefly from the great depth at which the artery lies1 any attempt at ligature is very difficult4 ,it is least so at the lower angle of the space1 where1 between the heads of the gastrocnemius1 the vessel comes more to the surface1 but is still overlapped by muscle4 ,operation4--,the patient lying on his face1 a straight incision 7,plate ,,iii4 fig4 #a71 at least four inches in length1 should be made over the artery1 and thus nearer the inner than the outer hamstring2 a strong fibrous aponeurosis will require division after the skin and superficial fascia are cut through1 the limb is then to be flexed1 and the tendons drawn aside with strong retractors2 fat and lymphatic glands must next be dissected through1 and then the vein and artery1 lying on a sort of sheath of condensed cellular tissue1 are seen1 the vein lying above the artery and obscuring it4 ,the vein must be drawn to the outside1 and the thread passed round the artery1 which lies close to the bone1 on the ligamentum posticum of ,winslowe4 ,it is a very difficult subject to decide what operations should be described in a work of this character1 on the vessels of the leg and foot4 ,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 anatomists1 but specially by the latter4 ,the fact is1 however1 that these complicated procedures are rarely required1 for aneurisms of the arteries of the leg and foot are almost unknown1 while in cases of wound of the vessel1 or rupture resulting in traumatic aneurism1 the proper treatment is not to tie the vessel higher up1 but by dilating the wound and clearing out the clots1 if required1 to secure the bleeding point1 and tie the vessel above and below4 ,again1 a wound of the sole of the foot often gives rise to very severe and persistent hmorrhage1 while the fasci and complicated tendons render ligature of the vessel at the spot very difficult2 yet ligature of either the anterior or posterior tibial would probably be insufficient2 and to tie both these vessels1 with possibly the peroneal and interosseous as well1 would be a much more severe and dangerous procedure than ligature of the superficial femoral2 while probably careful plugging of the wound1 combined with flexion of the knee1 will be found to stop the hmorrhage sooner than either of the more formidable methods4 ,a competent knowledge of the anatomy of the part1 and of the ordinary methods of checking hmorrhage1 such as ligatures1 graduated compresses1 and styptics1 aided by position1 specially flexion of the knee after ,mr4 ,ernest ,hart's method1 will suffice to enable the surgeon to check any hmorrhage of the foot or leg1 without it being necessary to burden the memory with the three positions in which to tie the peroneal1 or the various methods1 more or less bloody and tedious1 by which the posterior tibial in its upper third may be secured4 ,,note4--,while1 as a matter of surgical principle to guide our practice on the living1 ,i still hold very strongly the opinions here expressed against special operations for ligature of the arteries of the leg1 and allow the sentences to stand as in the first edition of this work1 ,i insert in a note a brief description of the more important ones1 in deference to the advice of friends and the urgent request of pupils1 as these operations are used by ,examining ,boards as tests of the operative dexterity of candidates3-- #a4 ,,anterior ,,tibial ,,artery ,,in ,,lower ,,half ,,of ,,leg4--,anatomical ,note4--,this vessel is related on its tibial side to the tibialis anticus1 and on its fibular1 to the extensor longus digitorum above1 and the extensor pollicis below4 ,the anterior tibial nerve lies first on its outer side1 then crosses the artery1 and eventually reaches its inner side near the foot4 ,operation4--,an incision1 at least three inches long1 parallel with the outer edge of the tibia1 and about three-quarters of an inch from it1 exposes the deep fascia4 ,this being divided1 the outer edge of the tibialis anticus must be found1 and will be the guide to the artery1 which1 surrounded by its ven comites1 lies very deeply between the muscles4 #b4 ,posterior ,tibial4--,a4 ,in middle third of leg4 ,here the artery is separated from the inner border of the tibia1 by the flexor longus digitorum1 and is covered by the soleus4 ,operation4--,an incision at least four inches long1 along the inner margin of the tibia1 exposes the edge of the gastroenemius2 then divide the tendinous attachment1 then expose the soleus1 and divide its attachment also2 the deep fascia will then be seen2 slit it up1 and the vessel will be found about an inch internal to the edge of the bone4 ,the nerve is there just crossing it4 ,guthrie's1 or the direct operation1 has the very high authority of the late ,professor ,spence in its favour4 ,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 extent4 ,the soleus is then to be scraped through in same direction1 and its deep aponeurotic surface carefully slit up4 ,the artery and vein are then easily seen4 ,b4 ,in lower third of leg4--,this is an easier and more scientific operation1 as it does not involve the division of great tendons4 ,an incision midway between the internal malleolus and the tendo ,achillis1 parallel with both1 will expose the very deep and strong fascia in which the tendons lie4 ,the artery1 with its ven comites1 occupies a central position1 having the tendons of the tibialis posticus and flexor communis in front between it and the internal malleolus1 and the posterior tibial nerve behind it1 while the flexor longus pollicis lies still nearer the tendo ,achillis4 ,,table illustrating anastomotic circulation after ligature of arteries of lower limb4 #a4 ,,aorta4--,epigastric and mammary of both sides4 ,hmorrhoidal and spermatic1 with branches of pudic both deep and superficial4 #b4 ,,common ,,iliac4--,internal iliac and branches1 with those of the other side1 along with the following3-- #c4 ,,external ,,iliac4--,internal mammary and deep epigastric4 ,iliolumbar and lumbar branches of aorta1 with deep circumflex ilii4 ,pudic from internal iliac1 with superficial pudic of common femoral4 ,gluteal1 sciatic1 and obturator1 with the circumflex and perforating branches or deep femoral4 #d4 ,,femoral4--,external circumflex1 with external articular of popliteal4 ,perforating1 with branches of gluteal and sciatic4 ,profunda branches with anastomotica and articular branches4 ,obturator and internal circumflex with anastomotica and superior internal articular4 ,,note4--,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 aneurism4 ,,ligature ,,of ,,the ,,innominate4--,the performance of this extremely dangerous1 in fact almost hopeless operation1 is by no means so difficult as might be expected4 ,the patient lying down with the shoulders raised and head thrown well back1 the sternal attachment of the right sterno-mastoid must be very freely exposed4 ,this may be done by an incision 7,plate ,i4 fig4 #g7 along its anterior edge from the upper edge of the sternum1 as far as may be necessary2 another about the same length along the upper edge of the clavicle1 will meet the former at an acute angle1 and will include a triangular flap of skin1 which must be carefully dissected up4 ,the sternal1 and probably a portion of the clavicular attachment of the right sterno-mastoid1 must then be cautiously divided4 ,this being done1 the sterno-hyoid and sterno-thyroid muscles require division immediately above their sternal attachments4 ,a dense process of cervical fascia 7just becoming thoracic7 now covers the vessel1 binding it on the right side to the right innominate vein1 and on the left maintaining the relation of the innominate artery to the trachea4 ,the inferior thyroid veins lie on this fascia1 and must be drawn aside1 not cut4 ,the fascia is then to be scraped through very cautiously1 exposing the root of the right carotid1 which1 being traced downwards1 will lead to the innominate4 ,the following parts lie in close relation to the vessel at the point of ligature1 and must be avoided3--#a4 ,the left innominate vein crosses the artery in front from left to right1 and must be drawn down4 #b4 ,the right innominate vein and right pneumogastric are in close contact with the artery on the right side2 to avoid them the aneurism-needle must be entered on the outside 7right of the vessel74 #c4 ,the apex of the right pleura and the trachea are in close contact behind1 requiring the point of the needle to be kept close to the artery in bringing the thread round4 ,it might have been expected that the sudden arrest of so large a proportion of the vascular supply of the body1 so very near the heart1 would cause serious1 or even fatal symptoms2 this1 however1 is not the case1 no serious inconvenience of this sort being experienced2 yet hitherto every case has proved fatal1 either from secondary hmorrhage or inflammation of lungs and pleura4 ,in fifteen well-authenticated1 and in three more doubtful cases1 the ligature has been applied2 all of these died at periods varying from twelve hours 7as in ,hutin's case71 to forty-two days as in ,thomson's1 and sixty-seven days 7,graefe's74#aa ,a successful case of ligature of the innominate along with the right carotid and 7after secondary hmorrhage7 the right vertebral1 in a mulatto aged thirty-two1 for a subclavian aneurism1 has been put on record by ,dr4 ,smyth of ,new ,orleans1 in the ,american ,journal of ,medical ,science for ,july #ahff4 ,and here we may also note that ,mr4 ,heath has lately treated a case of innominate aneurism by simultaneous ligature of the third part of the subclavian and the carotid4 ,both ligatures separated on the eighteenth day1 and the tumour was much smaller some months afterwards4#ab ,mr4 ,r4 ,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 aneurisms4#ac ,in four cases the operation was attempted1 but the operators had to desist before the application of the ligature1 in consequence of the diseased state of the arterial coats4 ,of these1 three died1 and one 7,professor ,porter's of ,dublin7 case recovered1 the patient leaving the hospital with the aneurism nearly consolidated4 ,dr4 ,peixotto of ,portugal applied a precautionary ligature to the innominate in a case where secondary hmorrhage occurred from the carotid4 ,the ligature was not tightened beyond what was necessary merely to cause flattening of the vessel4 ,the patient made a good recovery4 ,professor ,george ,porter of ,dublin records an interesting case of subclavian aneurism1 in which1 after failing to close the axillary artery by acupressure1 he applied ,l',estrange's compressor to the innominate itself for three days1 with temporary benefit4 ,the patient eventually died of hmorrhage4#ad ,for a very full and interesting account of ligatures of vessels in root of neck we may refer to vol4 iii4 of the #ahhc edition of ,holmes' ,surgery1 pp4 #aai-abb4 ,,ligature ,,of ,,common ,,carotid4--,though the anatomical relations of the right and left carotid are different at their origin1 they so precisely resemble each other in the whole of that part of their course which is at all amenable to surgical treatment1 that one description will suffice for both1 and the necessary anatomy will be brought out quite sufficiently in the description of each operation4 ,from its giving off no collateral branches1 the common carotid artery may be tied at any part of its course4 ,it has been tied successfully at the distance of only three-quarters1 or1 in one case by ,porter1 hardly to be imitated1 one-eighth of an inch from the innominate1 and up to an equal distance from its bifurcation4 ,in choosing the part of the vessel for operation1 the operator must be guided by the position of the aneurism1 if on the vessel itself1 but if the aneurism be distant1 as in scalp or orbit1 he need have regard to position simply as facilitating the operation4 ,the easiest position in which to apply the ligature is just above the omohyoid muscle1 the vessel being there superficial4 ,,ligature ,,above ,,omohyoid4--,using the anterior border of the sterno-mastoid as a guide1 but leaving it gradually above to a little nearer the mesial line1 an incision 7,plate ,,iv4 fig4 #a71 varying in length according to the depth of fat and cellular tissue in the neck1 but with its central point opposite the upper border of the cricoid cartilage1 must be made through skin1 platysma1 and superficial fascia4 ,while making the incision the head should be held back1 and the face slightly turned to the opposite side2 the parts being now relaxed by position1 the edges of the wound must be held apart by blunt hooks or copper spatul1 and the deep fascia carefully divided over the vessel1 which will be recognised by the pulsation4 ,it may be noted here that even in thin subjects the sterno-mastoid edge invariably overlaps the vessel1 though in many anatomical diagrams it would appear to be in part subcutaneous4 ,the descendens noni may possibly be seen1 but this is by no means invariably the case1 crossing the sheath of the vessel very gradually from without inwards in its progress down the neck4 ,it must be carefully displaced outwards4 ,the sheath of the vessel is then to be cautiously opened to the extent of about half an inch4 ,the internal jugular vein1 possibly much distended1 may overlap the artery on its outer side1 and will require to be pressed1 emptied1 and held out of the way4 ,a small portion of the artery being thoroughly separated from the sheath1 the aneurism-needle must be passed from without inwards to avoid the vein1 and keep as close to the artery as possible to avoid the vagus4 ,the tendon of the omohyoid muscle1 or1 in muscular subjects1 a portion of its anterior fleshy belly1 may be seen crossing the vessel from above downwards and outwards at the lower angle of the wound4 ,an enlarged lymphatic gland has occasionally given much trouble1 by being mistaken for the vessel and cleaned1 while the ligature has even been placed on a carefully isolated fasciculus of muscular fibres4 ,,ligature ,,of ,,carotid ,,below ,,the ,,omohyoid4--,an incision in precisely the same direction as the former1 but at a slightly lower level1 is required1 but the dissection is rather more difficult4 ,the edge of the sterno-mastoid when exposed must be drawn outwards2 the sterno-hyoid and thyroid inwards2 the omohyoid upwards2 the sheath opened1 and the descendens noni or its branches drawn to the tracheal side4 ,the jugular vein and vagus are both at the outer side1 and must be avoided1 while the inferior thyroid artery and sympathetic nerve both lie behind the vessel1 and may be included in the ligature if care be not taken4 ,,varieties4--,sedillot's ,operation4--,to secure the artery still lower in the neck3 ,an incision two and a half inches long1 from the inner end of the clavicle obliquely upwards and outwards in the interval between the sternal and clavicular attachments of the sterno-mastoid2 this divides the superficial textures2 the two portions of muscle must then be drawn apart4 ,the internal jugular vein lies in the interval1 and must be drawn to the outside before the artery can be seen at all1 and it is this that makes this operation very difficult and dangerous1 especially on the left side1 where the vein is close to the artery1 and probably even crossing it from left to right4 ,the thoracic duct is behind4 ,malgaigne's modification of the above is an improvement3 to expose the external attachment of the muscle1 to cut it through and turn it to the outside1 as in the operation for ligature of the innominate1 then to divide or pull inwards sterno-hyoid and sterno-thyroid1 thus exposing the sheath4 ,the needle must be passed from without inwards4 ,results4--,pilz has collected #fjj cases1 of which #dc4af per cent4 died4 ,the united tables of ,norris and ,wood give #ahh cases1 with a mortality of sixty1 or nearly one in three4 ,these tables include cases in which the vessel was tied for wounds1 and as a preparatory step in the operation of removal of tumours of the jaw1 etc4 ,later statistics give a very much lessened mortality1 due chiefly to the use of animal ligatures4 ,of thirty-one cases in which it was tied for pulsating tumours of the orbit1 only two died from the operation4#ae ,rivington's statistics to a later date give forty-six cases on forty-four patients with six deaths4 ,both carotids have been tied in the same patient twenty-five times1 at intervals of less than a year2 and it is a very remarkable fact that only five of these fifty ligatures proved fatal1--two in which both were tied on the same day1 and three in which the operation was performed to arrest hmorrhage from malignant disease of the face and jaws--from gunshot wound1--and from syphilitic ulceration4 ,the external carotid1 and also most of its principal branches1 have been tied for aneurisms1 wounds1 goitres1 enlargement of the tongue1 vascular tumours on occiput and other lesions2 also as a first stage in the operation of extirpation of the upper jaw1 for the purpose of preventing hmorrhage4 ,however1 such operations are rare1 and will probably become rarer still1 and it is hardly necessary to describe the operations on each seriatim4 ,aneurism of the external carotid or branches are rare2 if idiopathic1 ligature of the common carotid will be found at once easier1 not more dangerous1 and more effectual than ligature of the branch2 if traumatic1 the aneurism itself should be attacked1 and the bleeding point secured by a double ligature4 ,wounds are common enough1 but if accessible at all1 the injured vessel should be tied at the bleeding point2 if inaccessible 7and under this head we may include wounds of the internal carotid71 the common carotid must be tied4 ,no one would think of trying the superior thyroids for goitre1 unless they were so manifestly enlarged1 tortuous1 and pulsating1 as to render the operation so simple 7from their superficial position7 as to require no special directions2 besides this1 the cases in which it has been already done have given very little encouragement to repeat it4 ,as cases may occur in which any diminution of the cerebral supply is contra-indicated1 and thus the more difficult ligature of the external carotid may be preferred to the more simple operation on the common trunk1 and as the lingual may require ligature near its root1 in consequence of obstinate hmorrhage from the tongue1 short directions are given for the performance of both these operations4 #a4 ,,ligature ,,of ,,external ,,carotid4--,head in same position as for the common carotid4 ,a straight incision parallel with the anterior edge of sterno-mastoid1 but about half an inch in front of it1 must begin almost at angle of jaw1 and extend downwards nearly to the level of the thyroid cartilage4 ,cautiously divide skin1 platysma1 and fascia2 the lower end of the parotid must be pulled upwards1 and the veins1 which are numerous1 cautiously separated4 ,the anterior border of the sterno-mastoid must be pulled backwards1 and the digastric and stylo-hyoid forwards and inwards4 ,the superior laryngeal nerve which lies behind the vessel must be avoided4 #b4 ,,ligature ,,of ,,lingual4--,to secure this vessel either before it becomes concealed by the hyo-glossus1 or after it is under the muscle1 a curved incision is necessary1 following the line of the hyoid bone1 and especially of its greater cornu1 but a line or two above its upper border4 ,after the skin and platysma are divided1 the posterior belly of the digastric must be recognised1 which again will guide to the posterior edge of the hyo-glossus4 ,the edge of the sub-maxillary gland may very probably require to be raised out of the way4 ,the artery can then be secured1 either before it dips under the hyo-glossus muscle1 or after it has done so1 by the division of a few of its fibres on a director4 ,care is needed to avoid injury of the hypo-glossal nerve1 which lies above the muscle4 ,the internal carotid artery occasionally1 but very rarely1 is the subject of aneurism4 ,it may1 like any other artery1 be wounded1 especially from the fauces4 ,the treatment of either of these lesions is ligature of the common carotid itself1 in preference to ligature of the internal carotid4 ,guthrie's operation for securing the bleeding internal carotid at the injured spot1 by dividing and turning up the ramus of the lower jaw1 has never been performed in the living body1 and is so difficult1 dangerous1 and unnecessary1 as not to merit description4 ,,ligature ,,of ,,subclavian4--,note4--,in consequence of the difference in the origin1 and variety in the anatomical relations of the right and left subclavian arteries1 in so far at least as their first stage is concerned1 it is necessary to give a very brief separate account of each4 ,right ,subclavian4--,the innominate artery divides into the right subclavian and right carotid exactly behind the sterno-clavicular articulation4 ,the right subclavian extends from this point in an arched form across the neck1 between the scalene muscles1 over the apex of the pleura1 till1 passing under cover of the clavicle1 it changes its name to axillary at the lower end of the first rib4 ,for convenience of description1 the artery is divided into three parts1 which have very various anatomical relations1 and differ from each other much in their amenability to surgical treatment by ligature4 ,the anterior scalenus muscle defines the three parts1 the first extending to the inner border of the muscle1 the second being concealed by the muscle1 and the third reaching from its outer border to the lower border of the first rib4 ,branches of the ,subclavian4--,while the deep relations of pleura1 veins1 and nerves can be noticed under the head of each operation in detail1 one anatomical point must never be forgotten as influencing very much the success of all surgical interference with the subclavian arteries--i4e4 the branches given off4 ,to give any chance of success in the application of a ligature to such a large vessel1 so near the heart1 a large portion of artery free from branches is required1 that the clot may be long1 firm1 and undisturbed4 ,the first part of the subclavian gives off the vertebral1 thyroid axis1 and internal mammary2 the second1 the superior intercostal2 while the third part has in most cases no branch whatever4 ,in these anatomical differences we find the reason for the almost invariable fatality resulting on any interference with the first and second parts1 and the comparative safety of ligature of the third part1 without requiring to account for the difference on other grounds1 such as depth of part1 importance of nervous relations1 or nearer proximity to the heart4 ,the second and third parts of both arteries are so similar to each other1 that a separate account is not required for the two sides4 ,,ligature ,,of ,,right ,,subclavian4--,first ,part4--,operation4--,an incision just at upper edge of sternum and right clavicle1 extending from inner edge of left sterno-mastoid transversely to outer border of right sterno-mastoid through skin1 platysma1 and exposing sterno-mastoid1 to be joined at an angle by a second incision1 which1 two1 three1 or even four inches long1 must extend along inner border of right sterno-mastoid4 ,flap to be raised upwards and outwards4 ,the sternal attachment of the sterno-mastoid must then be cautiously divided1 as also part or the whole of its clavicular attachment1 according as room is required4 ,the sterno-hyoid and thyroid muscles will then require similar division4 ,the internal jugular will then be seen very prominent1#af and will require to be drawn inwards or outwards1 according to circumstances4 ,the carotid and right subclavian arteries will then be felt lying close together crossed by the pneumogastric and recurrent nerves1 the latter turning behind the subclavian4 ,the nerves must be drawn inwards2 the cardiac filaments of the sympathetic will then be observed1 and drawn outwards4 ,the subclavian vein lies below1 concealed by the clavicle1 and will probably not be seen during the operation4 ,the needle should be passed round the artery from below upwards1 care being taken not to injure the pleura1 which lies beneath and behind the artery4 ,results4--,twelve cases1 all of which died2 ten of hmorrhage1 one of pleurisy and pericarditis1 and one from pymia4 ,attempted in one case by ,mr4 ,butcher1 but the artery was too much diseased to bear a ligature4 ,the patient died on the fourth day4 ,,ligature ,,of ,,left ,,subclavian4--,first ,part4--,this operation1 which has been described by some as impossible1 has1 ,i believe1 been only once performed on the living body4 ,operation4--,incisions as for the preceding operation1 except being on the opposite side4 ,after the skin1 platysma1 and muscles have been divided1 as already described1 the deep cervical fascia requires division close to the inner edge of the scalenus anticus4 ,the artery lies excessively deep1 and great difficulty is experienced in avoiding injury to the pleura and the thoracic duct4 ,results4--,once performed by ,dr4 ,rodgers of ,new ,york2 death from hmorrhage on fifteenth day4 ,anatomical ,note4--,the course of the left subclavian in its first stage is much straighter1 as its origin is much deeper1 than on the right side4 ,the pneumogastric1 phrenic1 and cardiac nerves lie parallel to its course2 the oesophagus and thoracic duct lie behind it1 and to its inner side4 ,,ligature ,,of ,,subclavian4--,second ,part4--,this very rare operation hardly requires a separate description1 as the incisions necessary for ligature of the artery in its third part will1 with very slight modifications1 be sufficient for the purpose4 ,it has1 however1 special elements of danger in it1 involved in the unavoidable division1 of part at least1 or probably the whole1 of the scalenus anticus4 ,the phrenic nerve1 from its position on that muscle1 requires special care to avoid dividing it1 and in most cases the internal jugular vein is also in the way4 ,the branches of the thyroid axis1 which cross the neck1 are quite in the line of the incision4 ,the lowest cord of the brachial plexus lies immediately behind the artery1 between it and the middle scalenus4 ,the pleura lies just below it4 ,the subclavian vein is generally quite safe1 running in front of the scalenus anticus1 and at a lower level4 ,the presence of the superior intercostal branch adds greatly to the danger of ligature of the vessel in this position1 from its interfering with a proper clot4 ,results4--,dupuytren#ag performed it successfully for a traumatic axillary aneurism4 ,auchincloss#ah did it for a large true aneurism1 but the patient died sixty-eight and a half hours after the operation4 ,liston cut through the outer portion of the scalenus with success for an idiopathic aneurism4 ,thirteen have been collected by ,wyeth with four recoveries and nine deaths4 ,,ligature ,,of ,,subclavian4--,third ,part4--,for this comparatively common operation1 various methods of procedure have been suggested and employed4 ,in the dead body1 where the axilla is free from swelling1 and in thin patients1 the artery in this third stage is tolerably superficial1 and can be secured with ease4 ,but in very muscular men1 with short necks and well curved clavicles1 and specially when the axilla is filled up with an aneurism1 and the shoulder cannot be depressed1 the operation becomes very difficult4 ,operation of ,ramsden1 ,liston1 and ,syme4--,position4--,the patient lying on his back with his shoulders supported by pillows1 and his head lying back1 and drawn to the opposite side2 the shoulder of the affected side must be depressed as much as possible4 ,incisions4--7,plate ,i4 fig4 #h47--,one through skin1 superficial fascia1 and platysma1 along the upper edge of the clavicle1 for at least three inches from the anterior edge of the trapezius to the posterior border of the sterno-mastoid1 and in muscular subjects freely overlapping the edges of both muscles4 ,another two inches in length along posterior border of sterno-mastoid meets the first at an angle4 ,on reflecting the chief flap thus made upwards and backwards1 the external jugular will be seen1 and1 if possible1 must be drawn to a side2 if not1 it must be divided1 and both ends tied4 ,the lower edge of the posterior belly of the omohyoid must then be sought2 this leads at once to the posterior or outer margin of the scalenus anticus4 ,the connection of the deep fascia to that muscle must then be very carefully scraped through1 and by tracing the muscle to its insertion to the first rib1 the artery is at once reached1 lying behind the insertion4 ,the pulsation of the vessel between the forefinger and the first rib will prove a great assistance2 yet care is required1 lest one of the branches of the brachial plexus be secured instead of the artery4 ,the lowest cord lies very close to the vessel4 ,the subclavian vein is not likely to give much trouble1 from its being on a lower level1 and 7unless very much dilated7 nearly concealed by the clavicle4 ,the suprascapular artery is also hidden1 but the transverse cervical crosses the very line of incision1 and may give trouble1 being occasionally much enlarged1 so much so as even for a time to have been mistaken for the subclavian itself4 ,if possible1 both these branches should be saved1 as being important means of carrying on the anastomosis for the future support of the limb4 ,an absorbent gland is occasionally in the way1 and has even been mistaken for the vessel and carefully cleaned4 ,such may be removed without scruple4 ,care must be taken not to injure the pleura1 which lies immediately behind and below the vessel at the seat of ligature4 ,various instrumental devices have been invented for passing the ligature4 ,the simplest seems still to be best1 a common aneurism-needle with a considerable curve4 ,other methods of operating4--,a single curved incision above the clavicle1 with its concavity upwards1 of about three or four inches long1 with its inner end rather higher than the outer 7,green1 ,fergusson74 ,a linear transverse incision in the same situation 7,velpeau74 ,a single linear incision perpendicular to the clavicle 7,roux74 ,an arched incision 7,plate ,,iv4 fig4 #b7 with its convexity outwards1 and its base on the posterior edge of the sterno-mastoid1 from three inches above the clavicle to the clavicular attachment of the muscle 7,skey74 ,results4--,dr4 ,wyeth's ,tables in #ahgg give #bea cases with #acd or #ec per cent4 of deaths4 ,the late ,mr4 ,furner of ,brighton reported a most interesting case1 in which he tied both subclavian arteries at an interval of two years in the same patient1 for axillary aneurisms1 with success4 ,,ligature ,,of ,,axillary4--,anatomical ,note4--,this vessel1 the next stage in the continuation of the subclavian downwards1 may be defined surgically as extending from the clavicle to the lower border of the teres major4 ,from the depth of the vessel at its upper part1 the numerous nerves1 and the close proximity of the vein1 the surgeon has carefully to study the anatomical relations4 ,it1 like the subclavian1 is commonly divided into three stages1 and1 also like the subclavian1 these stages are defined by the relations of the artery to a muscle1 the pectoralis minor4 ,surgically we may draw a very close parallel between the two vessels1 for we find that in the axillary1 as in the subclavian1 the first stage is very deep1 and very rarely amenable to ligature2 the second1 still deeper and more rarely attempted1 as in both the operation involves division of a deep muscle2 while the third stage in each is the one most frequently chosen by the surgeon4 ,first ,stage4--,between the lower edge of the first rib and upper border of the pectoralis minor the vessel is deeply seated1 contained in that process of deep fascia called the costo-coracoid membrane1 and covered above by skin1 platysma1 and the clavicular portion of the pectoralis major4 ,it lies on the first intercostal muscle and the upper digitation of the serratus magnus1 while the cords of the brachial plexus are on its acromial side1 and the axillary vein in close contact with it on its thoracic side1 and frequently overlapping the artery4 ,operation4--,the great desideratum is free access4 ,an incision 7,plate ,i4 fig4 #i71 semilunar in shape1 with its convexity downwards1 must extend from half an inch outside of the sterno-clavicular articulation to very near the coracoid process1 stopping just before it arrives at the edge of the deltoid1 in order to avoid injury of the cephalic vein4 ,it must include skin1 fascia1 and platysma1 and the flap must be thrown upwards4 ,the clavicular portion of the pectoralis major must then be divided right across its fibres1 which will retract4 ,the arm must then be brought close to the side to relax the pectoralis minor1 which must be drawn aside4 ,the artery will then be felt pulsating1 but hidden by the costo-coracoid membrane1 which acts as its sheath4 ,this must be carefully scratched through1 the nerves pulled outwards1 the vein avoided and pulled downwards and inwards1 and the thread passed round from within outwards4 7,manec1 ,hodgson1 and1 with slight modification in the incision through the skin1 ,chamberlaine47 ,ligature has been performed in this position by separating the pectoralis and deltoid muscles1 without dividing the muscular fibres 7,roux1 ,desault74 ,to attempt to gain access between the clavicular and sternal portions of pectoralis major1 as has been proposed by some1 is almost impracticable in the living body1 from the position of the vein1 to which1 rather than to the artery1 this incision leads4 ,,ligature ,,of ,,axillary1 in its second stage1 is not an advisable operation1 when it is merely intended to throw a ligature round the artery for an aneurism lower down4 ,it has been performed at least twice by ,delpech1 but it is a rude procedure2 in his cases1 after the muscle was cut1 a dive with the finger was made to collect the whole mass of vessels and nerves1 and bring them to the surface near the collar-bone2 in this position it is said the artery was easily isolated and tied4 ,in ,mr4 ,syme's operation of cutting into large axillary aneurisms1 and tying both ends of the vessel1 the pectoralis minor may1 indeed generally has1 to be divided1 and must take its chance without any special notice or precaution1 in the sweeping1 free incisions required4 ,,ligature ,,of ,,axillary in its third stage4--,this is an operation very much more common1 more easy of accomplishment1 and safer in its results than either of the preceding2 the artery in this stage being more superficial1 in fact almost subcutaneous4 ,operation4--,the arm being extended and supinated1 an incision 7,plate ,i4 fig4 #aj7 two and a half or three inches long1 must be made in the base of the axilla over the artery1 involving at first skin and superficial fascia only2 the deep fascia is then exposed and must be carefully scraped through1 avoiding injury of the basilic vein1 if 7as sometimes occurs7 it has not yet dipped through the fascia4 ,the vessel can now be felt2 the median nerve which lies over the artery1 or slightly to its outer side1 must be drawn outwards1 and the axillary vein1 which lies at the thoracic side1 but often overlaps the vessel1 must be carefully drawn inwards4 ,the ligature must then be passed from within outwards4 ,when the patient is very fat or muscular1 the coraco-brachialis muscle may be required as a guide to the vessel2 but in general its superficial position renders any guide quite unnecessary1 even in the dead body4 ,anatomical ,note4--,while in each stage the axillary artery gives off branches1 those arising from the third stage are by far the most important1 especially the subscapular1 which leaves it at the edge of the muscle of the same name4 ,to avoid these the ligature should be applied as low down on the vessel as possible1 and1 in point of fact1 the operation called ligature of the third stage of the axillary is1 anatomically speaking1 really ligature of the brachial high up1 and where there is room at all1 there will be the less chance of secondary hmorrhage1 the greater the distance is between the ligature and the great subscapular branch4 ,mr4 ,syme's ,operation for ,axillary ,aneurism4--,description of the operation in his own words3-- ,chloroform being administered1 ,i made an incision along the outer edge of the sterno-mastoid muscle1 through the platysma myoides and fascia of the neck1 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 rib4 ,i then opened the tumour1 when a tremendous gush of blood showed that the artery was not effectually compressed2 but while ,i plugged the aperture with my hand1 ,mr4 ,lister1 who assisted me1 by a slight movement of his finger1 which had been thrust deeply under the upper edge of the tumour1 and through the clots contained in it1 at length succeeded in getting command of the vessel4 ,i then laid the cavity freely open1 and with both hands scooped out nearly seven pounds of coagulated blood1 as was ascertained by measurement4 ,the axillary artery appeared to have been torn across1 and as the lower orifice still bled freely1 ,i tied it in the first instance4 ,i next cut through the lessor pectoral muscle close up to the clavicle1 and holding the upper end of the vessel between my finger and thumb1 passed an aneurism-needle1 so as to apply a ligature about half an inch above the orifice4#ai ,in a similar operation lately performed by the author for traumatic aneurism1 the result of a stab1 very little blood was lost1 though no incision was made above the clavicle4 ,the patient made a good recovery4#bj ,,ligature ,,of ,,brachial4--,to arrest hmorrhage from a wound of the artery itself1 no special directions are required1 except to enlarge the wound1 and secure the vessel above and below the bleeding point4 ,there are1 however1 rare cases in which for bleeding in the palm 7after all other means have failed71 or for aneurism lower down the arm1 a ligature may be necessary4 ,operation4--,the biceps muscle1 at its inner edge1 is the best guide to the position of the incision1 or if it be obscured by fat or oedema1 a line extending from the axilla1 just over the head of the humerus to the middle of the bend of the elbow will define its course4 ,an incision 7,plate ,i41 fig4 #aa7 three inches in length1 about the middle of the arm 7when you have the choice of position71 through skin and superficial fascia1 will expose the deep fascia1 and probably the basilic vein4 ,drawing the latter aside1 cautiously divide the deep fascia4 ,the artery is then exposed1 but in close relation to various nerves2 of these the ones most likely to come in the way are--#a4 ,the median1 which lies in front of1 but a little to the outside of the artery1 though in some rare cases it lies behind it2 #b4 ,the internal cutaneous2 #c4 ,the ulnar1 both of which ought to be rather to the inside of the artery4 ,two brachial veins accompany and wind round the vessel1 occasionally interlacing4 ,pulsation will1 in the living body1 usually suffice to distinguish the artery from the other textures1 and the ligature may be passed from whichever side is most convenient4 ,note4--,the relation of the median nerve to the vessel varies according to the part of the arm--thus1 as low as the insertion of the coraco-brachialis it is to the outer side1 as has been described1 it then crosses the vessel obliquely1 and two inches above the elbow it is on the inner side of the artery4 ,again1 the operator must never forget the possibility of there being a high division of the artery4 ,this occurs1 ,mr4 ,quain has shown1 perhaps once in every ten or eleven cases1 and may necessitate ligature of both trunks4 ,in those cases 7once much more frequent than at present7 where an aneurism has formed after a wound of the brachial at the bend of the arm in venesection1 the aneurism may be either circumscribed or diffuse4 ,if circumscribed1 it is advised by some surgeons1 specially by the late ,professor ,colles of ,dublin1 that the brachial should be tied immediately above the tumour4 ,in most cases of circumscribed1 and in all such cases of diffuse aneurism1 the preferable operation is boldly to lay open the tumour1 turn out all the clots1 seek for the wound in the artery1 and tie the vessel above and below4 ,a tourniquet above1 or1 better still1 a trustworthy assistant1 prevents all fear of hmorrhage1 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 7as recommended by ,cusack1 ,tyrrell1 ,harrison71 and is much more certain than a mere ligature above4#ba ,,ligature ,,of ,,vessels ,,in ,,fore-,,arm4--,here1 as also we found is the case in the leg1 it is almost useless to go on giving exact directions as to the method of throwing a ligature round the vessels in all possible situations4 ,for below the elbow spontaneous aneurism is almost unknown1 and even traumatic aneurisms are extremely rare4 ,it is therefore for hmorrhage only that the vessels are likely to require ligature1 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 distance4 ,in the case of wounds of the palmar arch1 it is extremely difficult1 and very apt to injure the future usefulness of the hand1 thus to seek for the bleeding point under the palmar fascia1 and for these1 ligatures of radial and ulnar have occasionally been practised4 ,however1 as even this has proved ineffectual1 and the interosseous has proved sufficient to continue the bleeding1 ligature of the brachial at once is preferable to ligature of so many branches in the fore-arm4 ,the use of graduated compresses1 carefully applied1 combined with flexion of the elbow over a bandage1 will generally prove sufficient to check such hmorrhage from the palm1 without having recourse to either of the above more severe measures4 ,note4--,as in the lower limb at page #bd1 and for the same reasons1 ,i here insert a brief account of the methods of tying the ulnar and radial arteries4 #a4 ,,ligature ,,of ,,ulnar4--,only admissible in the lower half of its course4 ,operation4--,use the tendon of the flexor carpi ulnaris as a guide1 and make an incision along its radial edge1 at least two inches in length2 expose the deep fascia of the arm and then cautiously divide it2 then bending the hand1 the flexor carpi ulnaris is relaxed1 and the artery is found lying pretty deeply between it and the flexor sublimis digitorum4 ,the ulnar nerve lies at its ulnar side1 and the ven comites accompany the artery4 ,in a tolerably muscular arm1 the incision will have to be about an inch inside of the ulnar border of the limb4 #b4 ,,radial4--,this artery lies more superficial than the preceding1 and may be tied at any part of its course4 ,a4 ,operation in upper part of fore-arm4 ,here the artery lies in the interval between the supinator longus and the pronator radii teres4 ,in a muscular arm1 the edge of the former muscle is the best guide2 in a fat one1 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 radius4 ,the deep fascia must be exposed and opened1 and the muscles relaxed and held aside4 ,the radial nerve lies on the radial side of the vessel4 ,b4 ,operation in lower half of arm4 ,here the vessel is more superficial1 lying in the groove between the flexor carpi radialis and supinator longus4 ,an incision two inches in length1 and parallel with these tendons1 easily exposes the artery4 ,the nerve is still on its radial side4 ,c4 ,operation at first metacarpal4 ,the artery may be tied easily enough in the triangular space bounded by the extensors of the thumb1 on the dorsum of the proximal end of the first metacarpal bone4 ,skey#bb recommends a transverse1--,stephen ,smith#bc and others1 a longitudinal incision4 ,the author had lately to secure the radial in its lower third1 the superficialis vol1 and the radial again in the triangular space1 in a case where division of the artery by a transverse cut had caused a large aneurism to form close above the annular ligament4 ,,table illustrating anastomotic circulation after ligature of arteries of neck and upper limb4 #a4 ,common carotid4 7a7 ,across middle line3 thyroids1 linguals1 facials1 occipitals2 also terminal branches of external carotids2 also internal carotids by circle of ,willis4 7b7 ,of same side3 occipital with vertebral2 superior thyroid with inferior thyroid1 etc4 #b4 ,subclavian1 #c;d part4 ,suprascapular with dorsal branches of subscapular2 posterior scapular with costal and muscular branches of subscapular4 ,thoracic anastomosis between internal mammary and intercostals1 with branches of axillary4 #c4 ,axillary and brachial4 ,anastomosis varies with the position of the ligature1 but is very free between the various muscular branches of these vessels4 ,,footnotes3 #b ,erichsen1 ,surgery4 ,sixth edition1 vol4 ii4 p4 #aba4 #c ,the line #c in ,plate ,i4 shows the direction required4 ,it will not be necessary to carry the incision so far up for the external as for the common iliac4 #d ,on the ,arteries and ,veins1 p4 #dba4 #e ,cyclopdia of ,practical ,surgery1 vol4 i4 p4 #bgg4 #f ,john ,bell's ,prin4 of ,surg41 vol4 i4 #dba2 ,dublin ,jour41 vol4 iv4 #cba4 #g ,observations in ,clinical ,surgery1 ,syme1 pp4 #aga-c4 #h ,brit4 ,med4 ,jour4 #ahfg1 ,oct4 #e4 #i ,international ,encyclopdia of ,surgery1 vol4 iii4 p4 #dff4 #aj ,poland1 ,guy's ,hosp4 ,report1 ser4 iii4 vol4 vi4 #aa ,mr4 ,w4 ,thomson's most interesting paper on this subject is full of information down to the latest date4 #ab ,lancet1 ,jan4 #e1 #ahfg4 #ac ,lancet1 ,may #ahgi4 #ad ,dublin ,quarterly ,journal1 ,nov4 #ahfg4 #ae ,w4 ,zehender--,monatsbl4 fr ,augenheilkunde4 #ahfh4 #af ,butcher1 ,op4 and ,cons4 ,surgery1 p4 #hfa4 #ag ,leons ,orales1 iv4 #ecj4 #ah ,ed4 ,med4 and ,surg4 ,journ4 vol4 xlv4 #ai ,observations in ,clinical ,surgery1 pp4 #adh1 #adi4 #bj ,edin4 ,med4 ,journal1 ,march #ahgi4 #ba ,see case of recurrence1 ,fergusson's ,practical ,surgery #ast ed4 p4 #bbb4 #bb ,operative ,surgery1 p4 #bgi4 #bc ,surgical ,operations1 p4 #ej4 ,,chapter ,,ii4 ,,amputations4 ,in ordinary surgical language the name ,amputation is applied to all cases of removal of limbs1 or portions of limbs1 by the knife1 though in strict accuracy it should be restricted to those cases in which a limb is removed in the continuity of a bone1 its removal at a joint being called a ,disarticulation4 ,the briefest outline of a history of amputation would fill a work much larger than the present4 ,i may be allowed in a few sentences to attempt to show the principle on which such a sketch should be written1 in describing the three great eras of progress in improvement of the methods of amputating4#bd ,i4 ,prior to the invention1 or at least prior to the general introduction1 of the ligature and the tourniquet1 the great barrier to all improvement in operating was the impossibility of checking hmorrhage during an operation1 and after its conclusion4 ,many surgeons would not amputate at all1 others only through gangrenous parts2 others more bold1 only at the confines of parts in which gangrene had been artificially induced by tight ligatures4 ,with the exception of ,celsus1 who in one place recommends a flap to be dissected up1 and the bone thus divided at a higher level1 all were in too great a hurry to get the operation completed to think of flaps4 ,cut through all the parts at the same level with a red-hot knife1 if you will1 like ,fabricius ,hildanus2 by a single blow with a chisel and mallet1 like ,scultetus2 or by a crushing guillotine1 like ,purmannus3 or by two butchers' chopping-knives fixed in heavy blocks of wood1 one fixed1 the other falling in a grove1 like ,botal2 and then try to check the bleeding by tying a pig's bladder over the face of the stump1 like ,hans de ,gersdorf2 or tying it up in the inside of a hen newly killed2 or by plunging it at once into boiling pitch4 ,we are the less surprised to read of ,celsus's description of a flap operation1 when we remember that it is almost certain that ,celsus was acquainted with the ligature as a means of checking hmorrhage4#be ,,ii4 ,a new era was ushered in when1 about #aefj1 ,ambrose ,par invented1 or re-introduced1 the ligature as a means of arresting hmorrhage1 but not for more than a century after this did the full benefit of his discovery begin to be felt1 when the tourniquet was introduced by ,morel at ,besanon in #afgd1 and ,james ,young of ,plymouth in #afgh1 and improved by ,petit in #agjh-aj4 ,now surgeons had time to look about them during an amputation1 and to try to get a good covering for the bone1 so that the stump might heal more rapidly and bear pressure better4 ,great improvements were rapidly made1 and any history of these improvements would need to trace two great parallel lines1 one the circular method1 the other the flap operation4 #a4 ,the old method in which the limb was lopped off by one sweep1 all the tissues being divided at the same level1 might be called the true circular4 ,this1 however1 was soon improved-- ,a4 ,by ,cheselden and ,petit1 who invented the double circular incision1 in which first the skin and fat were cut and retracted1 and then the muscle and bone were divided as high as exposed4 ,b4 ,by ,louis1 who improved this by making the first incision include the muscles also1 the bone alone being divided at the higher level4 ,c4 ,by ,mynors of ,birmingham1 who dissected the skin back like the sleeve of a coat1 and thus gained more covering4 ,d4 ,then comes the great improvement of ,alanson1 who first cut through skin and fat1 and allowing them to retract1 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 cavity4 ,e4 ,an easier mode1 fulfilling the same indications1 is found in the triple incision of ,benjamin ,bell of ,edinburgh1 who in #agib taught that first the skin and fat should be divided and retracted1 next the muscles1 and lastly the bone4 ,f4 ,a slight improvement on ,e1 made by ,hey of ,leeds1 who advised that the posterior muscles of the limb should be divided at a lower level than the anterior1 to compensate for their greater range of contraction4 #b4 ,in the progress of the flap operation fewer stages can be defined4 ,made by cutting from within outwards1 after transfixion of the limb1 the flaps varied in shape1 size1 position1 and numbers1 from the single posterior one of ,verduyn of ,amsterdam1 to the two equal lateral ones of ,vermale1 and the equal anterior and posterior ones of the ,edinburgh school4 ,then came the battle of the schools3 flap or circular4 ,flap4--,speedy1 easy1 and less painful2 apt to retract1 and that unequally4 ,circular4--,leaving a smaller wound1 but more slow in performance1 and apt to leave a central adherent cicatrix4 #c4 ,the last era in amputation began after the introduction of ansthetics4 ,now speed in amputation is no object1 and the surgeon has full time to shape and carve his flaps into the curves most suited for accurate apposition1 and suitable relation of the cicatrix to the bone4 ,it has also been brought clearly out that different methods of operating are suitable for different positions1 and also that even in the same operation it is possible to unite the advantages of both the flap and the circular method4 ,in the modified circular1 which is best suited for amputation below the knee1 in the long anterior flaps of ,teale1 ,spence1 and ,carden1 we have illustrations of the manner in which the advantages of both the flap and circular methods have been secured1 without the disadvantages of either4 ,the long anterior flap1 not like ,teale's to fold upon itself1 but like ,spence's and ,carden's to hang over and shield the end of the bones1 and the face of a transversely-cut short posterior flap1 seems to be now the typical method for successful amputations4 ,there may be exceptions1 as when the anterior skin is more injured than the posterior1 or where an anterior flap would demand too great sacrifice of length of limb1 but as a rule it will be found the best method for the patient4 ,,amputation ,,of ,,the ,,upper ,,extremity4--,the extreme importance of the human hand1 its tactile sensibility1 its grasping power1 and the irreparable loss sustained by its removal1 render the greatest caution necessary1 lest we should remove a single digit or portion of one that might be saved4 ,in cases of severe smashing injuries involving the fingers1 it is the surgeon's bounden duty not recklessly to amputate the limb with neat flaps at the wrist-joint1 but carefully to endeavour to save even a single finger from the wreck1 though at the risk of a longer convalescence1 or even of a profuse suppuration4 ,while a toe or two1 or a small longitudinal segment of the foot1 may be comparatively useless1 and a good artificial foot1 with an ankle-joint stump1 certainly preferable1 a single finger1 provided its motions are tolerably intact1 will prove much more valuable to its possessor than the most ingeniously contrived artificial hand4 ,illustration3 ,,fig4 ,i4 ,however1 while in cases of extensive smash we endeavour to save anything we can1 the case is very much altered when it is only one or two fingers that are injured4 ,here we find another principle brought into play1 and our conservative surgery must be limited by the following consideration4 ,in endeavouring to save a portion of the injured finger or fingers1 will the saved portion interfere with the important movements of the uninjured ones8 ,these two principles--#a4 ,generally to save as much as we can2 #b4 ,not to save anything which may be detrimental or in the way1--will guide us in describing the amputations of the upper extremity4 ,illustration3 ,,fig4 ,,ii4 ,amputation of a distal phalanx4--,this small operation is not very often required4 ,in cases of whitlow in which the distal phalanx alone has necrosed1 removal of the necrosed bone by forceps is generally all that is necessary4 ,in cases of injury1 however1 in which nail and distal phalanx are both reduced to pulp1 it will hasten recovery much to remove the extremity4 ,there is no choice as to flap1 the nail preventing an anterior one1 so a flap long enough to fold over must be cut from the pulp of the finger in either of two ways 7,fig4 ,i4 #a73--a4 ,holding the fragment to be removed in the left hand1 and bending the joint1 the surgeon makes a transverse cut across the back of the finger1 right into and through the joint1 cutting a long palmar flap from within outwards as he withdraws the knife4 ,note4--,some difficulty is often felt in making the dorsal incision so as exactly and at once to hit the joint2 the most common mistake being1 that the transverse incision is made too high1 and the knife1 instead of striking the joint1 only saws fruitlessly at the neck of the bone above4 ,to avoid this1 the surgeon should take as a guide to the joint1 not the well-marked and tempting-looking dorsal fold in the skin1 but the palmar one1 which exactly corresponds with the joint between the proximal and middle phalanges1 and is only about a line above the distal articulation4--7,fig4 ,,ii47 #b4 ,making the long flap by transfixion1 it may be held back by an assistant1 and the joint cut into4 ,amputation through the second phalanx4--,if the distal phalanx be so much crushed that a flap cannot be obtained1 two short semilunar lateral flaps may be dissected 7,fig4 ,i4 #b7 from the sides of the second phalanx1 which may then be divided by the bone-pliers at the spot required4 ,in cases of injury which do not admit of either of the preceding operations1 it is quite possible to amputate either at the first joint1 or even through the proximal phalanx4 ,patients are sometimes anxious for such operations in preference to amputation of the whole finger4 ,the surgeon should1 however1 never amputate through a finger higher up than the distal end of the second phalanx1 unless absolutely compelled by the patient1 for the resulting stump1 being no longer commanded by the tendons1 will prove merely an incumbrance1 and may possibly require a secondary operation at no distant date for its removal4 ,this rule is applicable in cases in which a single finger is injured1 and two or three complete ones are left2 in cases where all the fingers have been mutilated every morsel should be left1 and may be of use4 ,amputation of a whole finger4--7,fig4 ,i4 #c7--,this is an operation of great importance1 from its frequency4 ,if the third or fourth digits require amputation1 it should be performed as follows3--,the vessels of the arm being commanded1 an assistant holds the hand1 separating the fingers at each side of the one to be removed4 ,the surgeon holding the finger to be removed1 enters the point of a long straight bistoury exactly 7some authorities say half an inch7 above the metacarpo-phalangeal joint1 and cuts from the prominence of the knuckle right into the angle of the web1 then1 turning inwards there1 cuts obliquely into the palm to a point nearly opposite the one at which he set out4 ,note4--,while most authorities agree with the direction in the text regarding the palmar termination of the incision1 ,i believe1 in most cases1 it is not necessary to go so far1 and that the incisions may fitly meet in the palm at a point midway between a point opposite to the knuckle1 and the centre of the well-marked sulcus of flexion4 ,he then repeats this incision on the other side1 makes tense the ligaments1 first at one side and then at the other1 by drawing the finger to the opposite side1 and cuts them4 ,the tendons being cut1 the finger is detached4 ,the vessels being tied1 one point of suture is put in on the dorsal aspect1 and the fingers on each side tied together at their extremities1 with a pad of lint between them4 ,modification4--,lisfranc's method is too long in its minute description to give in detail4 ,the principle is to make a semilunar flap at one side 7the one opposite the operator's right hand71 by cutting from without inwards1 then to open the joint from this cut1 and1 still keeping the edge of the knife close to the head of the phalanx1 cutting the other flap from within outwards4 ,this can be very rapidly done1 but the last flap is apt to be irregular and deficient1 especially in those common cases1 in which1 after whitlow or the like1 the tissues are hard and brawny1 and the skin does not play freely4 ,it is quite unnecessary to remove the head of the metacarpal1 either for the sake of appearance1 or to render healing more rapid1 and its removal weakens the arch of the hand2 where the cartilage is eroded by disease1 the cartilage-covered portion can be scooped off by a gouge or removed entire by pliers1 without interfering with the broad end to which the transverse ligament of the palm is attached4 ,if required either for injury or disease1 the metacarpal head may be easily removed by a single straight incision from the knuckle upwards1 as far as the point at which it may be deemed necessary to saw it through1 or better still1 divide it with the bone-pliers4 ,this incision should be made as a first step in the first incision for amputation of the finger1 and the finger should not be disarticulated1 but kept on1 to aid by its leverage in separating the metacarpal head4 ,amputation of the index or little fingers4--,this operation differs from the preceding only in this1 that care must be taken to make a good large flap on the free side of each2 making the incision1 which begins at the knuckle 7,fig4 ,i4 #d71 enclose a well-rounded flap1 and not allowing it to enter the palm till it reaches the level of the web between the fingers4 ,the metacarpal heads may here be cut obliquely with the bone-pliers1 to prevent undue projection4 ,amputation of one or more metacarpals4--,these operations may be rendered necessary by disease or injury4 ,if the latter demands their performance1 no rules can be given for incisions or flaps1 they must just be obtained where and how they can best be got4 ,if for disease1 a single dorsal incision 7,fig4 ,i4 #e7 over the bone will allow it to be dissected out of the hand4 ,n4,b4--,in no case1 except that of the thumb1 should any attempt be made to save a finger while its metacarpal is removed4 7,see ,excisions of ,bones47 ,amputation of first and fifth metacarpals4--,various special operations have been devised for speedy and elegant removal of these bones4 ,their disadvantages1 etc41 are fully detailed under ,amputations of the ,foot4 ,the vascularity and consequent vitality of the tissues of the hand and arm sometimes afford very encouraging and satisfactory results in conservative operations4 ,the following is an instance of what may be accomplished in a young healthy subject4 ,a4 ,a41 t4 #ah1 ploughman1 was harnessing a vicious horse1 when it caught his right hand between its teeth1 and gave a severe bite4 ,on admission1 ,i found the middle and ring fingers completely separated at the metacarpal joints1 but each hanging on by a portion of skin1 the middle by the skin on its radial side1 the ring by that on its ulnar4 ,the back and the palm were both stripped of skin up to the middle of the third and fourth metacarpal bones1 which were exposed1 but not fractured4 ,as it was important for him to maintain the transverse arch of the hand intact1 ,i determined to make an attempt to save the metacarpals1 and finding that the skin on the radial side of the middle1 and ulnar side of the ring fingers1 was still warm1 and apparently alive1 ,i carefully dissected as long a flap as possible from each1 and then folded them down1 one at the front1 the other at the back of the hand4 ,the flaps survived1 and the result was admirable1 the patient being able in a very few weeks to guide the plough4 ,the sensation in his new palm and back of the hand is very peculiar1 they being still the fingers1 so far as nervous supply is concerned4 ,in amputations involving the metacarpals for injury1 it is always important to avoid entering the carpo-metacarpal joint1 hence if it can be done it is best to saw through the bones at the required level1 rather than disarticulate4 ,this rule should be observed even in those cases in which the thumb alone can be saved1 for notwithstanding the isolation of the joint between the first metacarpal and the trapezium1 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 entire4 ,no exact rules can be given for the performance of these operations1 as the size and positions of the flaps must be determined by the nature of the accident and the amount of skin left uninjured4 ,in the rare condition where the greater part of the metacarpus is destroyed1 and yet carpal joints are uninjured1 a most useful artificial band1 preserving the movements of the wrist1 may be fitted on2 and as much as possible should be saved1 but in cases of injury1 where the carpus is opened and the hand irreparably destroyed1 the question arises1 ,where ought amputation to be performed8 ,to this we answer that there appears no conceivable advantage to be gained by leaving all or any of the carpal bones4 ,if successful1 it would result only in the retention of a flapping joint1 unless from there being no tendons to act upon it1 except the tendon of the flexor carpi ulnaris attached to the pisiform1 and there are several risks it would run in the inflammation of all the carpal joints1 and the almost certain spread of this inflammation to the bursa underneath the flexor tendons1 beyond the annular ligament1 and up the arm among the muscles4 ,,amputation ,,at ,,the ,,wrist-,,joint4--,this is an operation by no means frequent1 and it has the advantages of preserving a long stump1 and retaining the full movements of pronation and supination1 in cases where the radio-ulnar joint is sound and uninjured1 but in practice it is often found that fibrous adhesions limit to a great extent the motions of the two bones on each other1 specially in those cases where the radio-ulnar joint has been diseased or injured4 ,another advantage is the extreme ease with which disarticulation may be performed on emergency1 no saw being required1 and the ordinary bistoury of the pocket-case being quite sufficient for cutting the flaps4 ,operation4--,by double flap4 ,an incision 7,plate ,,iv4 fig4 #c7 on the dorsal surface1 extending in a semilunar direction from one styloid process to the other1 will define a flap of skin only1 which must be raised2 the joint must then be opened by a transverse incision1 and a long semilunar flap of skin and fascia should be shaped 7,plate ,,iv4 fig4 #d7 from the palm4 ,disarticulation is facilitated by the surgeon forcibly bending the wrist when he makes the transverse cut1 and it will be found easier to shape the palmar flap from the outside by dissection1 than to do it by transfixion after disarticulation1 on account of the prominence of the pisiform on the inner side of the palm4 ,in the thin wasted wrists of the aged1 or in any case where the skin is very lax1 this amputation may be very easily performed by the circular method4 ,while an assistant draws up the skin as much as possible1 the surgeon makes an accurate circular incision through the skin1 about an inch below the styloid processes1 just grazing the thenar and hypothenar eminences4 ,another circular sweep just above the pisiform and unciform bones divides all the soft textures1 after which the joint may be opened1 and1 if necessary1 the styloid processes cut away with saw or pliers4 ,amputation by a long single flap1 either dorsal or palmar1 may be rendered necessary by accident4 ,the palmar one of the two is preferable2 indeed1 rather than trust for a covering to the thin skin of the back of the hand1 with its numerous tendons1 it is better to amputate an inch or two higher up through the fore arm4 ,the following amputation by external flap has been described 7so far as ,i can discover1 for the first time7 by ,dr4 ,dubrueil1 in his work on operative ,surgery3#bf--;,commencing just below the level of the articulation1 while the hand is pronated1 the surgeon makes a convex incision1 beginning at the junction of the outer and middle thirds of the arm behind1 reaching at its summit the middle of the dorsal surface of the first metacarpal1 and terminating in front just below the palmar surface of the joint1 again at the junction of the outer and middle thirds of the breadth of the arm4 ,this flap being raised1 the wrist is disarticulated1 beginning at the radial side4 ,a circular incision finishes the cutting of the skin4 7,figs4 ,,iii4 and ,,iv47 ,illustration3 ,,fig4 ,,iii4#bg ,illustration3 ,,fig4 ,,iv4#bg ,,amputation ,,through ,,the ,,fore-,,arm4--,the method of operating must1 in the fore-arm1 depend a good deal upon the part of the arm where you require to amputate1 the muscularity of the limb1 and the condition of the skin and subcutaneous cellular tissue4 ,it must be remembered that a section of the fore-arm involves two bones1 not1 like the tibia and fibula1 on a constant permanent relation in position to each other1 but which rotate one upon another to an amount which varies with the part of the limb divided1 and which rotation is a very important element in the future usefulness of the stump2 again1 that two sets of muscles occupy1 one the back1 the other the front of the limb1 that these two are unequal in size1 and that the outer sides or rather edges of each bone are subcutaneous2 again1 that these sets of muscles are comparatively fleshy in the upper two-thirds of the limb1 and almost entirely tendinous in the lower third4 ,remembering these points1 we find that certain things require our attention1 and certain difficulties are present in amputation of the fore-arm1 from which amputation of the arm1 with its single bone and copious muscular covering on all sides1 is completely free4 ,thus our flaps in the fore-arm must be antero-posterior2 lateral flaps are an impossibility4 ,great care is requisite to cut them at all equal1 from the inequality of the muscles on the two sides4 ,in the lower third we cannot obtain available muscular flaps4 ,lastly1 care must be taken lest1 from the ever-varying relations of the two bones to each other in the varying positions of the limb1 the surgeon mistake their position and pass his knife between them4 ,the next question that arises is1 ,where are we to operate8 ,in cases where we have a choice1 is there here1 as in the leg1 any point of election8 ,no4 ,as a rule in the fore-arm1 the surgeon should endeavour to save as much as possible2 especially when nearing the middle of the fore-arm1 he should try to save the insertion of the pronator teres1 so important in its function of pronating the radius4 ,,amputation ,,in ,,lower ,,third ,,of ,,the ,,fore-,,arm4--,by two flaps4 ,these antero-posterior flaps must consist of skin only1 as the tendons are only in the way1 and thus should be made by dissection from without4#bh ,making the dorsal one first1 the surgeon should enter his knife at the palmar edge of the bone that is further from him1 and cut a semilunar flap of skin only1 finishing the incision quite on the palmar edge of the inner bone4 ,the two ends of this incision must then be united by a similar semilunar flap of skin on the palmar side4 ,the two flaps having been dissected back1 he then clears the bones by a circular incision through tendons and muscles1 not forgetting to pass the knife between the bones1 and retracting all the soft parts1 saws through the bones1 at least half or probably three-quarters of an inch higher up4 ,it is generally easiest to saw through both bones at once4 ,long ,dorsal ,flap4--,where it is possible from laxity of the soft parts and the wrist not being much destroyed1 to get a long flap from the back of the arm after ,mr4 ,teale's method1 a very good stump will result4 ,this rule is1 ,in tracing the long flap a longitudinal line is drawn over the radius1 so as to leave the radial vessels for the short flap 7,plate ,,ii4 fig4 #a74 ,at a distance equal to half the circumference of the limb1 another line parallel to the former is drawn along the ulna4 ,these are then joined at their lower ends1 across the dorsal aspect of the wrist or fore-arm1 by a transverse line equal in length to half the circumference of the fore-arm4 ,the short flap is marked by a transverse line on the palmar aspect1 uniting the long ones at their upper fourth4 ,the operator1 in forming the long flap1 makes the two longitudinal incisions merely through the integuments1 but the transverse one is carried directly down to the bones4 ,in dissecting the long flap from below upwards1 the tissues of which it is composed must be separated close to the periosteum and interosseous membrane4 ,the short flap is made by a transverse incision through all the structures down to the bones1 care being taken to separate the parts upwards close to the periosteum and membrane4 ,the stump must be placed in the prone position1 to allow the long dorsal flap to be the superior when the patient is recumbent1 and thus fall over the ends of the bones4#bi ,the principal objection to the long dorsal rectangular flap 7which makes an excellent covering7 is1 that unless it can be obtained from over the wrist-joint it requires the bones to be sawn so very high up4 ,this may be avoided1 to some extent1 by making it shorter and rounded off1 as in ,carden's ,amputation1 q4v4 ,,amputation ,,in ,,upper ,,two-,,thirds4--,where the fore-arm is very fat or fleshy1 this amputation can be very easily performed by two equal antero-posterior flaps made by transfixion4 ,in most cases1 however1 from the comparative leanness of the dorsal aspect of the limb1 the following method will have the best result4 ,the surgeon must1 as in the former case1 shape a rounded dorsal flap by dissection from without 7,plate ,,iv4 fig4 #e71 embracing the whole breadth of the limb down to the palmar edge of both bones4 ,then at once he transfixes the two points of this dorsal flap1 and cuts out an equal one from the anterior aspect of the limb 7,plate ,,iv4 fig4 #f74 ,dissecting up the dorsal flap he clears the bones at least half an inch above as before1 and applies the saw4 ,n4,b4--,this operation should be performed even in cases where only an inch of radius can be retained1 as the attachment of the biceps makes a very small stump of fore-arm wonderfully useful4 ,,amputation ,,at ,,elbow-,,joint4--,in cases where it is found impossible to save any portion of the fore-arm1 disarticulation at the elbow-joint may be easily performed4 ,this operation was proposed and performed so long ago as the days of ,ambrose ,par1#cj was much approved by ,dupuytren1 ,baudens1 and ,velpeau1 had fallen into disuse for a time1 but is now again recommended by some excellent surgeons1 especially by ,gross#ca and ,ashhurst1#cb both of ,philadelphia4 ,it is tolerably easy to perform1 and does not involve any sawing of bones1 but the flaps are apt to be cut too short1 unless care be taken1 from the manner in which the trochlea projects downwards beyond the line of the condyles1 so that if the base of an ordinary-shaped flap be made on a level with the condyles1 it will prove insufficient to cover the bone4 ,it may be performed either by the circular method 7,velpeau71 oval 7,baudens71 or by a long anterior and short posterior flap 7,textor and ,dupuytren74 ,probably the best method is by a long anterior flap when it can be obtained1 thus3--,the arm being placed in a slightly flexed position1 the surgeon transfixes in front of the joint1 in a line extending from the level of the external condyle to a point one inch below the internal condyle 7,plate ,,iv4 fig4 #g72 the tissue should be held well forward at the moment of transfixion4 ,the flap should be at least two and a half inches deep at its apex1 which must be rounded off4 ,the two ends of this flap may then be united behind by a semilunar incision 7,plate ,,iii4 fig4 #b71 which will separate the radial attachments4 ,the ulna must then be cleared1 and the triceps divided at its insertion4 ,modifications4--,dupuytren used to saw through the ulna1 leaving the olecranon attached4 ,velpeau opposed this1 but it is again recommended by ,gross1 who leaves the olecranon1 and at the same time improves the shape of the stump by sawing off the inner trochlea on a level with the general surface4 ,,amputation ,,of ,,the ,,arm4--,this amputation is best performed by double flap1 and is the typical instance which exhibits all the advantages of two equal flaps made by transfixion1 without any of the disadvantages of that method4 ,these advantages are1 easiness of performance1 rapidity1 excellent covering for the bone1 with as little sacrifice of tissue as is possible1 while the fact that the cicatrix is opposite the end of the bone is hardly a disadvantage in the arm 7as it certainly is in the leg71 as no weight has to be borne on it4 ,when they can be obtained1 anterior and posterior flaps are generally considered most satisfactory1 but ,mr4 ,spence prefers lateral ones1 lest the line of union should be interfered with by the deltoid raising the bone4 ,if the right arm has to be amputated1 the operator standing at the inner side raises the anterior muscles with his left hand1 and enters the knife just in front of the brachial vessels 7,plate ,i4 fig4 #ab72 keeping as close as possible to the bone1 he brings out the knife at a point exactly opposite1 then with a brisk sawing motion1 cuts a semicircular flap1 taking care to bring out the knife more suddenly just at the end1 in order to cut through the skin as perpendicularly to the arm as possible4 ,the knife is again entered at the same point1 carried behind the bone1 and brought out at the same angle1 and an exactly corresponding flap cut from the other side of the limb1 the flaps are then retracted1 the bone cleared by circular incision and sawn through as high up as it is exposed4 ,in primary cases1 where the muscles are firm and developed1 the flaps should be cut a little concave4 ,modifications and ,varieties4--,teale's method may of course be used here as elsewhere4 ,the internal line of incision 7,plate ,,iv4 fig4 #h7 should be made just in front of the brachial vessels4 ,this method requires the amputation to be performed higher up than would otherwise be necessary 7from the length of the anterior flap71 and this disadvantage is not counterbalanced by any special advantage in the posterior retraction of the cicatrix4 ,in feeble flabby arms1 the true circular operation is very easily performed1 and with good results4 ,a circular sweep of the knife is made through the skin alone1 which is drawn up by an assistant1 while the surgeon separates it from the fascia2 another circular cut through fascia and muscles exposes the bone1 which must then be cleared and cut through at a still higher level4 ,,amputation ,,at ,,the ,,shoulder-,,joint4--,this operation1 like that at the hip joint1 can1 from the nature of the joint to be covered1 and the abundant soft parts in the normal state of the tissues1 be performed on the dead in very various ways1 by single1 double1 or triple flaps1 by transfixion or dissection1 rapidly or slowly4 ,hence manuals of operative surgery might collect at least twenty different methods1 most of which have some recommendation1 and all of which are practicable enough4 ,when1 however1 we reflect that in the living body1 in cases where amputation at the shoulder-joint is required at all1 the severity of the accident1 or the urgency of the disease1 will1 in general1 leave no room for selection1 we shall see how utterly valueless is any knowledge of mere methods of operating1 and of how much greater importance it is that we should be simply thoroughly familiar with the anatomy of the joint4 ,for example1 an accident which necessitates amputation so high up has1 in all probability1 opened into the joint and destroyed the soft parts on at least one aspect2 in such a case the flaps must be cut from the uninjured soft parts only4 ,if an aneurism has rendered amputation through it and through the joint a last resource1 the flap must be gained chiefly at least from the outside2 a malignant tumour of the humerus will almost certainly prevent any transfixion1 and require flaps to be made by dissection1 wherever the skin is least likely to be involved4 ,again1 some of the most vaunted and most rapid operations almost require for their success the integrity of the humerus1 which has to make itself useful as a lever in disarticulation1 while in most cases of accident we are amputating for compound injury of the humerus1 almost certainly implying fracture with comminution4 ,from its proximity to the trunk1 hmorrhage is one of the chief dangers to be apprehended during this operation1 especially from the axillary artery4 ,as far as possible to obviate this danger1 most plans of operating are based on the principle that the vessels and nerves should be the last tissues to be cut2 in some they are not divided till after disarticulation4 ,while a good assistant1 to make pressure on the subclavian above the clavicle1 is a most advisable precaution1 too much must not be trusted to this pressure above1 as the struggles of the patient and the spasmodic movements of the limb1 which are so apt to occur under the stimulus of the knife1 are apt to render futile the best efforts at compression4 ,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 assistant1 or in default of a suitable one1 his own left hand1 is able to follow the knife and grasp the flap4 ,the bleeding from the circumflex1 subscapular1 and posterior scapular arteries can easily be arrested by a dossil of lint till the great vessel is tied1 and they can be secured4 ,in cases where proper assistants cannot be had1 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 commenced1 and by tying this firmly over a pad of lint4 ,pressure on the artery above the clavicle is best made by the thumb of a strong assistant1 who endeavours to compress it against the first rib2 where the parts are deep and muscular1 the padded handle of the tourniquet1 or of a large door-key1 will do as the agent of pressure4 ,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 amputations3-- #a4 ,in cases where the surgeon can choose his flaps1 the following method will be found the most satisfactory1 as resulting in the smallest possible wound1 in having less risk of hmorrhage during the operation than any other method1 and in providing excellent flaps4 ,it is ,larrey's method slightly modified4 ,operation4--,with a moderate-sized amputating knife an incision of about two inches in length1 extending through all the tissues down to the bone1 should be made from the edge of the acromion process to a point about one inch below the top of the humerus2 from this latter point a curved incision1 enclosing a semilunar flap1 should be made on each side of the limb to the anterior and posterior folds of the axilla respectively 7,plate ,,iv4 fig4 #i1 and ,plate ,,iii4 fig4 #c74 ,these flaps should then be dissected back1 including the muscles and exposing the joint4 ,when thoroughly exposed1 the joint must then be opened from above1 and the bone separated4 ,one small portion of skin lying above the artery1 vein1 and nerves still remains to be divided 7,plate ,i4 fig4 #ac74 ,this may be done by an oblique cut from within outwards1 in such a direction as to form part of the anterior or internal incision1 and with the precaution of having an assistant to command the vessels before they are divided4 ,the resulting wound is almost perfectly ovoid1 the flaps come together with great ease in a straight vertical line1 which admits of easy and thorough drainage4 ,union is generally rapid4 ,larrey's success by this method was very remarkable3 ninety out of a hundred cases in military practice were saved1 notwithstanding the well-known risks of such operations4 #b4 ,as good as the former1 and nearly as universally applicable1 is the method devised by ,professor ,spence1 and practised by him in nearly every case3--,with a broad strong bistoury ,i cut down upon the inner aspect of the head of the humerus1 immediately external to the coracoid process1 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 muscle1 which ,i divide4 ,i then with a gentle curve carry my incision across and fairly through the lower fibres of the deltoid towards1 but not through1 the posterior border of the axilla4 ,unless the textures be much torn1 ,i next mark out the line of the lower part of the inner section by carrying an incision through the skin and fat only1 from the point where my straight incision terminated1 across the inside of the arm to meet the incision at the outer part4 ,this insures accuracy in the line of union1 but is not essential4 ,if the fibres of the deltoid have been thoroughly divided in the line of incision1 the flap so marked out1 along with the posterior circumflex trunk1 which enters its deep surface1 can be easily separated from the bone and joint1 and drawn upwards and backwards so as to expose the head and tuberosities1 by the point of the finger without further use of the knife4 ,the tendinous insertions of the capsular muscles1 the long head of the biceps1 and the capsule1 are next divided by cutting directly upon the tuberosities and head of the bone2 and the broad subscapular tendon especially1 being very fully exposed by the incision1 can be much more easily and completely divided than in the double-flap method4 ,by keeping the large posterior flap out of the way by a broad copper spatula or the fingers of an assistant1 and taking care to keep the edge of the knife close to the bone1 the trunk of the posterior circumflex is protected4 ,in regard to the axillary vessels1 they can either be compressed by an assistant before completing the division of the soft parts on the axillary aspect1 or to avoid all risk1 the axillary artery may be exposed1 tied1 and divided between two ligatures so as to allow it to retract before dividing the other textures4#cc ,another1 but not so good method of making an external flap1 is the following3--7a47 ,for the right arm4--,the patient lying well over on his left side1 the surgeon stands to the inside of the arm to be removed4 ,seizing the deltoid in the left1 with the right he passes an amputating knife1 seven or eight inches in length1 from a point a little nearer the clavicle than the middle space between the acromion and coracoid processes2 then1 transfixing the base of the deltoid1 and just grazing the posterior surface of the humerus1 thrusts the knife downwards and backwards till it protrudes at the posterior margin of the axilla4 ,when doing this1 it is important that the arm be held outwards and backwards1 and even upwards1 as far as possible to relax the deltoid2 without this it will be impossible to make the flap of the full size4 ,the flap must then be cut of as full length as can be obtained1 four or five inches at least4 ,an assistant then holds it upwards1 while the surgeon1 or 7if the arm is very muscular7 another assistant1 brings the arm forwards well across the patient's chest1 thus exposing the posterior aspect of the joint4 ,this may have very possibly been already opened during the transfixion2 the attachments of muscles must now be divided1 the knife passed behind the head of the bone1 which is dislocated forwards1 and a suitable flap of the tissues in front cut from within outwards4 ,the assistant is to follow the knife with his finger and compress the vessels4 7b47 ,if the left shoulder is to be amputated1 the patient lying on his right side1 the surgeon stands behind him1 and raising the elbow of the limb to be removed from the side1 and pulling it slightly backwards1 enters the knife at the posterior fold of the axilla 7,plate ,,ii4 fig4 #b71 and passing the posterior aspect of the head of the humerus1 endeavours to protrude it as near the acromion as possible2 the flaps must be cut and the rest of the operation performed in the manner we have just described for the other arm4 #c4 ,where the destruction of tissue has been chiefly below the joint1 a very good flap may be obtained from above1 composed chiefly of the deltoid muscle1 and the skin over it4 ,this may be made by transfixion at its base1 but is better obtained by dissection from without4 ,the surgeon cuts 7,plate ,,ii4 figs4 #c1 #c7 in a semilunar direction 7with the convexity downwards7 from one side of the deltoid to the other1 viz41 from the root of the acromion to near the coracoid process2 he then raises the large flap upwards and throws it back1 opens the joint1 disarticulates1 passes the knife behind the head of the bone1 and cuts out without attempting to save any flaps below1 in a transverse direction4 ,by this means the artery is still almost the last structure to be divided1 and can be secured by a ready assistant4 ,in cases where much injury has been done to the floor of the axilla and wall of chest1 the deltoid flap must be made large in proportion1 and triangular rather than semilunar in shape4 ,n4,b4--,the statistics of amputation at the shoulder-joint bring out some interesting facts3 #a4 ,that the primary amputations here are far more successful than secondary ones4 ,guthrie records nineteen cases of the former out of which only one died1 while out of a similar number in which the amputation was secondary1 fifteen died4 ,in the ,crimea1 ,british surgeons had thirty-nine cases1 with thirteen deaths2 of thirty-three primary1 nine died2 and of six secondary1 four were fatal4 ,s4,w4 ,gross's#cd statistics confirm this3 of one hundred and seventy-eight primary1 forty-six died--#be4h per cent42 ninety-five secondary1 sixty-one died--#fd4b per cent4 ,,amputations ,,above ,,the ,,shoulder-,,joint4--,under this head we may group the comparatively rare cases in which1 from accident or disease1 the removal of portions of the scapula and clavicle1 or even the entire bones1 is rendered necessary4 ,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 off1 and yet the patient recovered4 ,encouraged by such cases1 ,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 smash4 ,the patient recovered4 ,heron ,watson has had a similar case4 ,dr4 ,george ,m',lellan amputated arm and scapula in a youth of seventeen for an enormous encephaloid tumour4 ,fifty-one such cases are now on record4 ,syme amputated with success the arm along with the scapula and outer half of clavicle1 in a case in which he had previously excised the head of the humerus for a tumour4#ce ,gilbert1 ,mussey1 ,rigaud1 ,fergusson1 and others have performed similar operations1 secondary to amputation at the shoulder-joint1 for cases of caries and malignant tumour4 ,it is impossible to give any exact directions for the incisions which must be planned for individual cases1 with two chief aims1 to avoid hmorrhage as far as possible1 and to leave abundance of skin4 ,in operations on the scapula1 it should be freely exposed by large enough incisions4 7,see ,excisions47 ,,amputations ,,of ,,lower ,,extremity4--,commencing with the most distal1 and gradually working our way upwards1 we find that partial amputations of the toes are extremely rare4 ,only in the case of the great toe is such an operation ever admissible1 for the other toes are so short1 and the stumps left by amputation are at once so useless from their shortness1 and so detrimental from the manner in which they project upwards and rub against the shoe1 that any injury requiring partial amputation of a lesser toe is treated by its complete removal4 ,illustration3 ,,fig4 ,v4 ,,amputation ,,of ,,distal ,,phalanx ,,of ,,great ,,toe4--,this is comparatively rarely required now4 ,it used to be thought necessary for the cure of those not uncommon cases of exostosis of the distal phalanx1 but it is now found that most of these can be cured by simply clipping off the exostosis4 ,when necessary1 however1 and when the choice of flaps is possible1 the best plan is by a long flap from the plantar surface 7,fig4 ,v4 #d71 as in the similar operation on the thumb2 laying the edge of the knife over the dorsal aspect of the joint1 cutting through it1 and turning the edge of the knife round close to the bone1 so as to cut out a large flap from the ball of the toe4 ,,amputation ,,of ,a ,,single ,,lesser ,,toe--second1 third1 or fourth4--,this operation is on exactly the same principle as that described for the corresponding finger2 but it must be remembered that the metatarso-phalangeal joint is more deeply situated in the soft parts than is the metacarpo-phalangeal2 and thus the commencement of the elliptical incision which is to surround the base of the toe must be proportionally higher up 7,fig4 ,v4 #a74 ,on the other hand1 as it is very important to avoid as much as possible any cicatrix in the sole of the foot1 the plantar end of the incision need not be carried to a point exactly opposite the one from which it set out1 but it will be sufficient if it reaches the groove between the toe and sole4 ,a little more care may thus be required in dissecting out the head of the first phalanx1 but this is quite repaid by the cicatrix in the sole being avoided4 ,early division of flexor tendons renders disarticulation easy4 ,,amputation ,,of ,,the ,,first ,,and ,,fifth ,,toes4--,the incisions are conducted on the same principle as in the other operations1 the operator being careful to preserve as much as possible 7,fig4 ,v4 #b7 of the hard useful pad of the inner and outer sides respectively4 ,most surgeons are now agreed that in these toes it is best not to remove the head of the metatarsal bone with the toe4 ,cutting off the large cartilaginous head obliquely with a pair of bone-pliers may prevent an awkward unseemly projection1 but it does diminish the strength of the transverse arch of the foot4 ,,amputation ,,of ,,one ,,or ,,more ,,toes ,,with ,,their ,,metatarsals4--,it is not necessary to give very particular details regarding such operations1 as the surgeon must be guided in the individual cases by the specialties of accident or disease4 ,one or two guiding principles are important3-- #a4 ,having made up your mind at what point you are to cut the metatarsal1 if the amputation be a partial one1 or as to the exact position of the joint1 if you intend to disarticulate1 commence your dorsal incision 7,fig4 ,v4 #c7 at a point fully half an inch higher up than the selected spot1 as free access is of the very last importance4 #b4 ,whenever it is possible1 cut the bone through its continuity rather than disarticulate4 ,specially is this important in the case of the metatarsal bone of the great toe1 that the insertion of the tendon of the peroneus longus may be saved4 ,if1 however1 the terminal branch of the dorsalis pedis artery be wounded1 it may be necessary to disarticulate the first metatarsal to secure it rather than trust to compression to stop the bleeding4 #c4 ,in cutting through the first and fifth metatarsals1 remember to apply the bone-pliers obliquely1 not transversely1 so as to avoid unseemly projection4 #d4 ,as far as possible avoid cutting into the sole at all4 ,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 it4 ,in the great toe1 for example1 it is performed as follows3--,seizing the soft parts of the inner edge of the foot in his left hand1 the surgeon draws them inwards1 transfixes just at the tarso-metatarsal joint1 and1 keeping as close as possible to the inner edge of the metatarsal bone1 cuts the flap as long as to the middle of the first phalanx2 then the soft parts of the foot being drawn as far outwards as possible by an assistant1 the surgeon enters his knife between the first and second toes1 and succeeds in entering his former incision so as to separate the metatarsal bone without removing any skin4 ,all that remains is to open the tarso-metatarsal joint4 ,it is a very neat-looking operation1 leaves a very good covering for the parts1 and is performed with extreme rapidity4 ,this last is not so much required in these days of ansthetics1 and the cicatrix in the sole is a very formidable objection to it4 ,the simplest and shortest rule that can be given for the amputation of a toe1 with the part or whole of its metatarsal1 is to make one dorsal incision1 commencing about a quarter of an inch above the spot at which you intend to divide the bone or to disarticulate1 extending downwards in a straight line to the metatarso-phalangeal articulation1 and then bifurcating so as to surround the base of the toe at the normal fold of the skin4 ,the soft parts are then to be cleared from the metatarso-phalangeal joint1 and the toe still being retained on the metatarsal bone1 it should be carefully dissected up1 avoiding any pricking of the soft parts below1 till the joint is reached1 or the spot at which the bone-pliers are to be applied is fully cleared4 ,,amputation ,,of ,,the ,,anterior ,,portion ,,of ,,the ,,foot ,,at ,,the ,,tarso-,,metatarsal ,,joint--,,hey',s ,,operation4--,this operation1 which is now comparatively rarely performed1 has been invested with a halo of difficulty and complexity which is to a great extent unnecessary4 ,there is no doubt that the anatomical conformation of the joints involved1 especially the manner in which the head of the second metatarsal 7,fig4 ,v4 ,c7 projects upwards into the tarsus1 and is locked between the cuneiform bones1 renders disarticulation in the healthy foot rather difficult2 but it must be remembered that in cases where for accident we have to deal with previously healthy tissues1 it is quite unnecessary to disarticulate1 a better result being attained by simply sawing the foot across in the line of the articulation2 and again1 where we have to operate for disease1 the tissues are so matted1 and the bones so soft1 that complete removal of the metatarsus is much easier than it appears when practising on the dead subject4 ,very various plans of incision have been proposed4 ,mr4 ,hey's original procedure has not been much improved upon4 ,his short account of it has at once surgical value and historical interest3-- ,i made a mark across the upper part of the foot1 to point out as exactly as ,i could the place where the metatarsal bones were joined to those of the tarsus4 ,about half an inch from this mark1 nearer the toes1 ,i made a transverse incision through the integuments and muscles covering the metatarsal bones 7,plate ,,iv4 figs4 #aj1 #aa74 ,from each extremity of this wound ,i made an incision 7along the inner and outer side of the foot7 to the toes4 ,i removed all the toes at their junction with the metatarsal bones1 and then separated the integuments and muscles forming the sole of the foot from the inferior part of the metatarsal bones1 keeping the edge of my scalpel as near the bones as ,i could1 that ,i might both expedite the operation and preserve as much muscular flesh in the flap as possible4 ,i then separated with the scalpel the four smaller metatarsal bones at their junction with the tarsus1 which was easily effected1 as the joints lie in a straight line across the foot4 ,the projecting part of the first cuneiform bone which supports the great toe ,i was obliged to divide with a saw4 ,the arteries1 which required a ligature1 being tied1 ,i applied the flap which had formed the sole of the foot to the integuments which remained on the upper part1 and retained them in contact by sutures4444 ,the patient could walk with firmness and ease2 she was in no danger of hurting the cicatrix by striking the place where the toes had been against any hard substance1 for this part was covered with the strong integuments which had before constituted the sole of the foot4 ,the cicatrix was situated upon the upper part of the foot1 and had very little breadth1 as the divided parts had been kept united after being brought into close contact4#cf ,lisfranc's method has1 briefly1 the following modifications4--,having fixed the position of the articulations of the first and fifth metatarsals with the tarsus1 the operator unites them by a curved incision across the dorsum of the foot1 with its convexity downwards4 ,he then divides the dorsal ligaments over the articulations1 opens the first from the inside1 the fifth1 fourth1 and third from the outside1 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 cuneiforms1 thus completing the disarticulation2 bending the fore part of the foot downwards1 he then keeps the edge of the knife close to the lower surface of the bones1 separating the plantar ligaments1 and cutting out a long plantar flap of skin and muscles4 ,in every case it must be remembered that the upper end of the fifth metatarsal projects far up along the outer edge of the foot4 ,allowance must be made for this projection in commencing the incision4 ,a rule given by ,mr4 ,syme to guide the disarticulation of the three outer metatarsals will often be of service2 it is this3 ,having once entered the joint of the fifth1 the knife must be drawn along in a direction of a line drawn towards the distal end of the first metatarsal2 for the fourth1 the direction must be changed to the middle of the same bone2 and to open the third it will be necessary to come across the dorsum of the foot as if intending to reach the proximal end4 ,to avoid the difficulties of disarticulation1 ,skey recommends cutting off the head of the second metatarsal with a pair of pliers4 ,baudens1 ,gurin1 and others approve of sawing all the bones across in the line desired4 ,most surgeons are now agreed that in this operation it is better to make both flaps by cutting from without1 in preference to transfixion of the plantar one from within4 ,in cases where1 from injury and disease1 the plantar flap is deficient in size1 it may be necessary to make the dorsal flap longer4 ,however1 the long plantar is preferable both from its superior hardness1 and also because from its length it permits the cicatrix to be well on the dorsum of the foot1 and therefore less likely to be injured by the pressure of the boot in front4 ,,amputations ,,through ,,the ,,tarsus4--,various plans of amputating through the tarsus have been devised and described at great length4 ,the most important of these is the operation of removal of the anterior portion of the foot1 at the joints between the astragalus and scaphoid1 and os calcis and cuboid1 well known to the profession by the name of its first describer1 ,chopart4 ,it has been so completely superseded by the infinitely preferable amputation at the ankle-joint of ,mr4 ,syme1 as rarely1 if ever1 to be practised in this country4 ,indeed1 amputation at the ankle-joint may be said to have taken the place of all these amputations through the tarsus2 for though cases are occasionally met with in which the limitation of the disease or injury may render ,chopart's possible1 and though at first sight it appears to have an advantage in removing less of the body1 still the following objections are nearly fatal to its chance of being selected3--#a4 ,in cases of injury1 through leaving a long stump1 and1 at first sight1 a useful one1 experience shows that the tendo ,achillis sooner or later 7being unopposed by the extensors of the toes7 draws up the heel so as to make the end of the stump point1 and the cicatrix press on the ground1 rendering it unable to bear any weight4 #b4 ,in cases of removal for disease of the tarsus1 the bones left behind1 though apparently sound at the time1 are almost sure to become eventually diseased4 ,as it has an historical interest1 and as this operation 7defective as it is7 had been the means of saving many legs prior to the invention of amputation at the ankle-joint1 a brief description may be appended3-- ,chopart's own manner of operation was briefly somewhat as follows3-- ,the tourniquet having been applied1 the surgeon is to make a transverse incision through the skin which covers the instep1 two inches from the ankle-joint4 ,he is to divide the skin1 and the extensor tendons1 and the muscles in that situation1 so as to expose the convexity of the tarsus4 ,he is next to make on each side a small longitudinal incision1 which is to begin below and a little in front of the malleolus1 and is to end at one of the extremities of the first incision4 ,after having formed in this way a flap of integuments1 he is to let it be drawn upwards by the assistant who holds the leg4 ,there is no occasion to dissect and reflect the flap1 for the cellular substance connecting the skin with the subjacent aponeurosis is so loose1 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 opened4 ,the surgeon will penetrate the last the most easily1 particularly by taking for his guide the eminence which indicates the attachment of the tibialis anticus muscle to the inside of the os naviculare4 ,the joint of the os cuboides and os calcis lies pretty nearly in the same transverse line1 but rather obliquely forwards4 ,the ligaments having been cut1 the foot falls back4 ,the bistoury is then to be put down1 and the straight knife used1 with which a flap of the soft parts is to be formed under the tarsus and metatarsus1 long enough to admit of being applied to the naked bones1 so as entirely to cover them4 ,it is to be maintained in position with three or four straps of adhesive plaster1 etc4#cg ,chopart's amputation1 after an interval of comparative neglect1 was introduced into this country by ,mr4 ,syme in #ahbi4 ,his method of performance is simpler and easier than ,chopart's4 ,he thus describes it3--,the blade of the knife employed should be about six inches long1 and half an inch broad1 sharp at the point and blunt on the back4 ,the tourniquet ought to be applied immediately above the ankle1 having compresses placed over the posterior and anterior tibial arteries4 ,the surgeon should measure with his eye the middle distance between the malleolus externus and the head of the metatarsal bone of the little toe1 which is the situation of the articulation between the os cuboides and os calcis4 ,placing his forefinger here1 he ought to place his thumb on the other side of the foot directly opposite1 which will show him where the os naviculare and astragalus are connected4 ,an incision 7,plate ,,ii4 figs4 #d and #e7 somewhat curved1 with its convexity forward1 is then to be made from one of these points to the other1 when1 instead of proceeding to disarticulate1 the operator should transfix the sole of the foot from side to side at the extremities of the first incision1 and carry the knife forwards so as to detach a sufficient flap1 which must extend the whole length of the metatarsus to the balls of the toes4 ,the disarticulation may finally be completed with great ease1 as the shape of the articular surfaces concerned is very simple1 and nearly transverse4#ch ,regarding the method of disarticulating at the astragalo-calcaneal joint1 and removing all the foot except the astragalus1 no detail need be given4 ,malgaigne advises an internal flap1 thus sacrificing the valuable pad of the heel4 ,roux1 ,verneuil1 and others endeavour to save the pad4 ,this operation1 however1 has now fallen almost completely into disuse4 ,,subastragaloid ,,amputation has been highly recommended4 ,in it the flap is made as in ,syme's1 then anterior bones removed as in ,chopart's1 and os calcis grasped by lion forceps and twisted off1 its attachment and the insertion of tendo ,achillis being cautiously avoided4 ,if flaps are scanty1 head of astragulus may be cut off with a small saw4--,hancock and ,ashurst4 ,,tripier',s ,,amputation#ci is a modification of above1 the skin incisions being made as in ,chopart's amputation1 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 leg4 ,,amputation ,,at ,,the ,,ankle-,,joint1 ,,or ,,syme',s ,,amputation4--,this operation is one of much interest and great practical importance4 ,in our cold variable climate caries of the bones of the tarsus1 and strumous disease of the ankle-joint1 are very common and very intractable maladies1 and for both of these1 when far advanced1 ,syme's amputation is the only justifiable procedure4 ,when properly done1 according to the exact plan of its proposer1 it removes the whole of the diseased parts and not an inch more1 is an operation of very slight danger to life1 and results almost invariably in a thoroughly useful comfortable stump4 ,much of its success depends on the manner in which it is performed1 and as many surgical manuals are not sufficiently full1 some positively in error regarding this point1 and as very many modifications have been devised diminishing in value and applicability very much in proportion as they diverge from the original description1 ,i think it advisable to describe the operation minutely1 and point out in detail the parts of it which seem absolutely essential to success4 ,operation4--,the foot being held at a right angle to the leg1 the point of a straight bistoury1 with a pretty strong blade1 should be entered just below the centre of the external malleolus 7,plate ,,iv4 figs4 #ab1 #ac71 7#a47 and then carried right across the integuments of the sole1 in a straight line 7or in the case of a prominent heel1 slightly backwards71 7#b47 to a point at the same level on the opposite side4 7#c47 ,this incision should reach boldly through all the tissues down to the bone4 ,holding the heel in the fingers of his left hand1 the operator then inserts his left thumb-nail into the incision1 and pushes the flap downwards1 as with the knife kept close to the bone1 and cutting on it1 he frees the flap from its attachments4 ,the thumb-nail guards the knife from in any way scoring the flap4 7#d47 ,this process is continued till the tuberosity of the os calcis is fairly turned1 and the tendo ,achillis nearly reached4 ,shifting his left hand he then extends the foot1 and joins the extremities of the first incision by a transverse one right across the instep4 7#e47 ,thus he opens the joint between the astragalus and tibia1 7#f47 divides the lateral ligaments1 disarticulates1 and still keeping close to the bone1 removes the foot by the division of the tendo ,achillis4 ,the lower ends of the tibia and fibula are then to be isolated from the soft parts1 and a thin slice1 including both malleoli1 to be removed4 ,if the disease of the joint has affected the lower end of the bone1 slice after slice may be removed1 till a healthy surface of cancellated texture is obtained4 ,the vessels are then secured4 ,dressing of the ,stump4--,from its peculiar shape and position1 the escape of any blood into the stump is much to be deprecated1 for as it cannot easily get out1 on the one hand it gives pain1 and may cause sloughing from its pressure1 and on the other it is sure eventually to cause suppuration1 and delay union4 ,to avoid such results care must be taken to secure every vessel that can be seen2 if there is any general oozing it is best merely to pass the sutures through the edges of the flaps1 but not bring them together1 thus leaving the stump open for some hours2 then apply cold1 and when the surfaces are fairly glazed over1 remove any clots and bring the flaps together4#dj ,another plan introduced by ,mr4 ,syme was to make a longitudinal slit in the flap1 through which all the ligatures are to be drawn2 these give a dependent drain to any pus that may be formed1 and by their presence greatly expedite the healing of the wound4 ,again1 in cases where from the amount of disease existing before the operation1 and the gelatinous thickening of the flap and neighbouring parts1 much suppuration may be looked for1 probably it will be found best to keep the flaps quite apart for some days1 by stuffing the wound with lint1 and aiming only at secondary union by granulations4 ,a drainage tube passed through the breadth of the flap1 and brought out at the angles1 and retained for a few days1 will do admirably4 ,notes4--7#a47 ,if commenced further forward1 as in ,pirogoff's modification1 it will be found difficult to turn the corner of the heel2 if further back1 the nutrition of the flap is endangered4 7#b47 ,this is very important4 ,in several well-known text-books1 even in the last edition of ,gross's ,surgery1 the incision is figured passing obliquely forwards4 ,this is a fatal error1 for besides making a flap far too long1 it forces the operator to cut fairly into the hollow of the sole1 quite off the prominence of the os calcis1 and he finds that it is utterly impossible to free his flap without using great force1 and inevitably scoring it in all directions4 ,sloughing is almost inevitably the result4 7#c47 ,the incision is to stop at least half-an-inch below the internal malleolus4 ,most surgical manuals1 even when they profess to describe ,mr4 ,syme's own method of operating1 say that the incision should extend from malleolus to malleolus4 ,if this is done1 the flap becomes unsymmetrical1 too long1 and also the posterior tibial artery1 on which much of the vascular supply of the flap depends1 is cut4 ,when the incision is properly made1 the vessel is not cut till after its division into the plantar arteries4 7#d47 ,scoring the flap4 ,some may ask1 ,why do you object to a little scoring1 the tissues are thick enough1 and besides1 don't you advise a slit in the flap yourself8 ,yes4 ,one look at an injected preparation will show that the vessels supplying this thick flap come to it from its inner surface1 and are inevitably cut across in any scoring of it1 and also1 that scoring cuts across the vessels1 and must divide dozens of them2 the slit we make is parallel with their course1 and may not divide one4 7#e47 ,across the instep4 ,some authors recommend a semilunar anterior flap2 this is quite unnecessary1 increases bagging and delays union4 ,it can be required only in cases where the heel flap has been destroyed or lessened by disease1 or by operators in whose hands the heel flaps occasionally slough4 7#f47 ,it is not impossible that a careless operator may 7by cutting a little too low7 miss the joint and get into the hollow of the neck of the astragalus1 where he may cut away for a long time without making much progress4 ,advantages4--#a4 ,it is wonderfully free of danger to life4 ,it is very hard to obtain exact statistical information1 but my experience is that the mortality is certainly not more than about #aj per cent41 a very remarkable result when compared with that of amputations through the leg1 the operation which used to be required for those cases which now require only amputation at the ankle-joint4 ,in the ,statistical ,report by the ,surgeon-,general of the ,united ,states1 #igje cases of amputation resulted in death1 the proportions being as follows3-- ,amputation of hip1 #he per cent4 died4 thigh1 #fd knee1 #ee leg1 #bf ,amputation of ankle-joint1 #ac per cent4 died4 shoulder1 #ci arm1 #ba fore-arm1 #af #b4 ,it is the most perfect stump that can be made1 in fact the only one in the lower extremity which can bear pressure enough to support the weight of the body2 all the others require the weight to be distributed over the general surface of the limb by means of apparatus4 ,a good ankle-joint stump can bear the whole weight of the body1 as when the patient hops on it without any artificial aid1 or without even the interposition of a stocking between the stump and a stone floor4 ,more than this1 ,i have seen a patient who had both his feet amputated at the ankle-joint run without shoes or stockings on the stone passages1 without even the aid of a stick1 and with very great swiftness4 ,the reason of this may be found in the nature of the flap itself1 originally intended to bear the weight of the body1 there being no cicatrix at the part on which pressure is borne4 ,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 bone4 ,this ought to be pretty considerable4 ,it is explained by the new attachments formed by the tendons1 and is under the control of the patient1 being elicited when he is told to move his toes4 ,it has been objected to this operation that the flap is apt to slough4 ,when improperly performed1 as when the flap is scored transversely in its separation1 and especially when the flap is cut too long 7as has been already noticed71 this may occur2 but that there is nothing whatever in the position or condition of the flap itself that at all necessitates its sloughing1 is thoroughly proved by the following remarkable case1 given by ,mr4 ,syme in his volume of ,observations in ,clinical ,surgery4 ,i quote it entire3-- ,p4,c41 aged thirty-three1 was admitted into the hospital on the #beth ,july #ahfj1 in the following state3--,he had been treated in the ,manchester ,infirmary for popliteal aneurism by pressure1 so decidedly applied that it had caused an ulcer1 of which the cicatrix remained2 but without producing the effect desired4 ,the femoral artery was then tied with success1 in so far as the aneurism was concerned1 but with the unpleasant sequel1 some months afterwards1 of mortification in the foot1 which was thrown off1 with the exception of the astragalus and os calcis with their integuments1 a large raw surface being presented in front where the bone was bare4 ,although the patient was extremely weak1 and the parts concerned might be supposed more than usually disposed to slough1 ,i did not hesitate to perform the operation1 with the speedy result of a most excellent stump and complete restoration to health4--,pp4 #di1 #ej4 ,the modifications of ,mr4 ,syme's original operation have been very various4 ,it will be unnecessary even to name them all4 ,one or two may require notice4 ,retaining ,mr4 ,syme's incisions in their integrity1 some operators prefer not to disarticulate the foot1 but remove it by sawing through the tibia and fibula at once1 while still in connection with the foot4 ,that most excellent surgeon and first-rate operator1 ,dr4 ,johnston of ,montrose1 used to prefer this method4 ,in cases where the pad of the heel has been destroyed by disease or accident1 so as to be partially or entirely unavailable for the flap1 the late ,dr4 ,richard ,mackenzie#da practised the following operation by internal flap3--,with the foot and ankle projecting from the table with their internal aspect upwards1 he entered the point of the knife 7,plate ,i4 fig4 #ad7 in the mesial line of the posterior aspect of the ankle1 on a level with the articulation1 carried it down obliquely across the tendo ,achillis towards the external border of the plantar aspect of the heel1 along which it is continued in a semilunar direction4 ,the incision is then curved across the sole of the foot1 and terminates on the inner side of the tendon of the tibialis anticus1 about an inch in front of the inner malleolus4 ,the second incision 7,plate ,,iii4 fig4 #d7 is carried across the outer aspect of the ankle in a semilunar direction1 between the extremities of the first incisions1 the convexity of the incision downwards1 and passing half an inch below the external malleolus4 ,precisely the same principle might supply the flap from the outer side in cases where the internal flap as well as the heel was deficient1 but probably the nutrition of the external flap would be more doubtful4 ,neither the one nor the other is nearly so good as the true heel flap1 and they are both only very poor substitutes for it when it cannot be had4 ,the modification devised by ,dr4 ,handyside does not seem to have any advantages over the original operation1 and has not been adopted4 ,the modification invented by ,professor ,pirogoff involves a much more important principle than any of the preceding4 ,instead of dissecting the flap from the posterior projecting portion of the os calcis1 and removing the tarsus entire1 he sawed off the posterior portion of the os calcis obliquely1 leaving it in contact with the pad of skin1 which is retained4 ,immediately after making the cut which defines the posterior flap and divides the tissues down to the bone1 he opens the joint in front1 disarticulates1 and then putting on a narrow saw immediately behind the astragalus and over the sustentaculum tali1 he saws the os calcis obliquely downwards and forwards till he reaches the first incision2 then removes the ends of the tibia and fibula and brings up the slice of os calcis into contact with them4 ,advantages4--,it is easy of performance1 saving the dissection from the heel1 which some find so hard4 ,it leaves a longer limb4 ,it is said to bear pressure better1 and there is certainly not so much chance of bagging of pus1 and the mortality is exceedingly small1 ,hancock's collected cases giving only #h4f per cent42 in cases of injury it is quite a warrantable operation4 ,disadvantages4--,it is contrary to sound principle in cases of disease1 for it wilfully leaves a portion of the tarsus1 in which disease is almost certain to return4 ,it leaves too long a limb1 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 foot4 ,it brings the firm pad of the heel too much forward1 thus tending to lean the weight of the body on the softer tissues behind the heel4 ,it takes much longer to unite and consolidate4 ,the author has now1 in a large number of cases of ,syme's amputation for disease1 found advantage in leaving the periosteum in the heel flap1 i4e4 he cuts fairly into the os calcis when dividing the skin of heel1 and then using a periosteum scraper instead of the knife1 it is quite easy to remove the whole of the periosteum from the bone2 this results in a large and more rounded pad of great strength and thickness4 ,in cases where from disease or injury it is impossible to obtain either a heel flap or a substitute lateral one1 the question is1 ,where should amputation be performed8 ,it was for a long time the opinion of nearly all the best surgeons1 and still is the opinion of many1 that amputation of the leg should be performed at what was known as the seat of election1 just below the knee1 even in cases where abundance of soft parts could be obtained for an amputation much lower down4 ,the rule in surgery1 to save as much of the body as possible in every amputation1 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 knee4 ,very briefly1 these were somewhat as follows3--#a4 ,just above the ankle you have large bones with nothing to cover them except skin and tendons4 #b4 ,higher up in the calf you have plenty of muscle1 but it is all on one side1 and that the wrong one2 it is very heavy1 very difficult to dress and keep in position1 and then when you have succeeded with it1 the muscle wastes away and the stump is flabby4 #c4 ,and chiefly1 as in all the amputations of the leg1 the cicatrices are so much in the way1 and the bones are so ill covered1 that the patient can never rest his leg on the stump itself1 but has either to rest his weight on his patella impinging on the top of a bottle-shaped leg1 or just to stick out his stump behind him and kneel on the top of his wooden leg2 therefore it is no use to have a stump longer than a few inches2 in fact1 the longer the stump is the more it is in the way4 ,and more than this1 many of the stumps made near the ankle1 or through the calf1 are not only useless1 but positively painful4 ,the skin becomes attached to the bones1 the cicatrix never properly firms at all1 the patient can hardly bear the pressure of a stocking1 far less can he make use of the limb4 ,for these reasons1 secondary amputations below the knee are of very common occurrence4 ,now1 this idea has been much modified1 and a few isolated cases in the past1 and series of cases considerably more numerous in the present day1 show that under certain conditions1 and as a result of certain precautions in their performance1 such operations are both warrantable and successful4 ,in the past1 as we find in an erudite note in ,south's ,chelius1 ,dionis1 ,white1 and ,bromfield had each of them many successful cases of amputation just above the ankle1 successful in so far that artificial limbs could be used which preserved the motion of the knee1 and gave the patient much more command of the limb than is possible with the short stump below the knee4 ,a still more important point to be remembered is1 that amputation just above the ankle is a much less fatal amputation than that just below the knee 7,lister in ,holmes's ,surgery1 #c;d ed4 vol4 iii4 p4 #gaf2 ,gross1 #fth ed4 vol4 ii4 p4 #aaac2 ,ben4 ,bell1 #fth edit4 vol4 vii4 p4 #cab74 ,there is little doubt1 however1 that the principle so much in vogue in the present day1 of one long anterior or posterior flap1 instead of two equal flaps1 or of circular amputations1 has done very much to make amputations at the ankle or through the calf justifiable and useful in bearing the weight of the body4 ,,amputation ,,just ,,above ,,the ,,ankle4--,cases admitting of this operation must always be rare1 for disease of the tarsus or ankle-joint hardly ever goes so far as to contra-indicate the performance of ,mr4 ,syme's greatly preferable operation2 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 occur4 ,in a suitable case the plan of the operation should be as follows3--,a long anterior flap slightly rounded at the end should be cut 7,plate ,i4 figs4 #ae1 #af7--;from the outside1 not by transfixion1--and the anterior muscles dissected up along with it4 ,it should be long enough to fall down over the face of the bones at the point of section1 and easily cover the point of the posterior flap1 which is to be made by cutting through all the tissues with one bold transverse stroke of the knife4 ,this operation1 which is the plan of ,mr4 ,teale of ,leeds very slightly modified1 is equally applicable at any point of the leg1 with this difference only1 that the length of the anterior flap must always be carefully proportioned to the mass of the muscular flap behind it has to cover in4 ,this operation provides a skin covering1 without any danger of the cicatrix being pressed on or becoming adherent4 ,the author has within the last few years operated nine times in this manner1 in cases of accident in which the heel flaps had been completely destroyed2 and seen a tenth case in which ,mr4 ,syme did so4 ,all ten cases recovered completely and rapidly1 and walked on useful limbs1 with the free movement of the knee-joint4 ,where from injury in a muscular patient a long anterior flap cannot be had1 recourse should be had at once to the operation at the seat of election1 rather than run the risk of pressure on the cicatrix by using a double flap operation1 or trust that broken reed1 the long posterior flap from the great muscles of the calf4 ,in ,june #ahfe1 ,mr4 ,henry ,lee described a method of operating which he hoped would unite the benefits of ,mr4 ,teale's method to the ease of performance of the old flap from the calf4 ,i append a short account of his method4 ,from its position1 however1 it has the great disadvantage of retaining the discharges1 and by its weight straining the stitches and weighing down the cicatrix3-- ,,lee',s ,,amputation of the ,leg by a long rectangular flap from the ,calf4--,the operation described was performed according to ,mr4 ,teale's method1 as far as the external incisions were concerned1 but the long flap was made from the back instead of from the front of the limb 7,plate ,,iv4 figs4 #ad1 #ae74 ,two parallel incisions were made along the sides of the leg1 these were met by a third transverse incision behind1 which joined the lower extremities of the first two4 ,these incisions1 which formed the three sides of the square1 extended through the skin and cellular tissue only4 ,a fourth incision was made transversely through the skin in front of the leg so as to form a flap in this situation1 one-fourth only of the length of the posterior flap4 ,when the skin had somewhat retracted by its natural elasticity1 an incision was made through the parts situated in front of the bones1 which were reflected upwards to a level with the upper extremities of the first longitudinal incisions4 ,the deeper structures at the back of the leg were then freely divided in the situation of the lower transverse incision4 ,the conjoined gastrocnemius and soleus muscles were separated from the subjacent parts1 and reflected as high as the anterior flap4 ,the deeper layer of muscles1 together with the large vessels and nerves1 were divided as high as the incision would permit1 and the bones sawn through in the usual way4 ,the flaps were then adjusted in the manner recommended by ,mr4 ,teale4#db ,the patients were able to bear the weight of the body on the end of the stump4 ,in cases of chronic disease1 where the muscles are atrophied and condensed1 the following posterior flap method may be used with advantage4 ,it is approved of by ,mr4 ,spence4 ,an incision is made across the front of the leg from the posterior edge of the fibula to the posterior edge of the tibia1 or vice vers1 according to the limb4 ,the limb is then transfixed behind the bones from the same points1 and a long and gently rounded posterior flap cut4 ,the bones are then cleaned1 and cut through at a little higher level4 ,,amputation ,,immediately ,,below ,,the ,,knee at the true seat of election4--,the principles on which this operation is founded are--#a4 ,that a muscular flap is not necessary1 skin being perfectly sufficient2 #b4 ,that as the muscles retract they must be cut at a lower level than the bones1 and as they retract unequally from their varying length1 the cuts must be made with due reference to that inequality2 #c4 ,that no more of the tibia need be retained than what is just sufficient to retain the attachment of the ligamentum patell1 and to insure its vitality2 #d4 ,that the head of the fibula must be retained in every case1 as in a certain proportion the tibio-fibular articulation communicates with the knee-joint4 ,operation4--,two equal semilunar flaps of skin must be cut--from the outside1 not by transfixion1--one anterior and external1 the other posterior and internal1 their extremities meeting at points about two inches below the tuberosity of the tibia on either side 7,plate ,i4 figs4 #ag1 #ah74 ,these must be reflected up1 and with them a further extent of skin1 embracing the whole circumference of the limb1 must be dissected up 7as if pulling off the fingers of a glove71 so as to expose the bone one inch below the tuberosity4 ,the anterior muscles being very close to their origin1 and consequently being able to retract very slightly1 must be cut as high as exposed1 and the posterior ones about the middle of their exposed surface4 ,the bones must then be sawn as high as exposed1 with the following precautions3--#a4 ,in order to prevent splintering of the fibula1 endeavour to saw it along with the tibia1 so as to finish it first2 #b4 ,to prevent projection of a sharp prominence of the edge of the tibia1 enter the saw obliquely a little higher up than where you intend to divide the bone1 then withdraw it1 and enter the saw again at right angles to the bone1 and a line or two lower down4 ,some surgeons prefer to make this section afterwards with a finer saw or the bone-pliers4 ,this operation is very frequently required to remedy painful and unhealed stumps1 the result of amputations lower down1 specially those in which the long posterior flap from the muscles of the calf has been used4 ,in the above amputation the patient will not be able to rest the weight of his body on the face of the stump1 but by putting the limb into a well-padded case with soft rounded edges1 the weight might be borne partly on the sides of the stump1 and partly on the lower edge of the patella2 and the patient will be able to walk with great comfort1 preserving the use of his knee-joint4 ,,amputation ,,at ,,the ,,knee-,,joint4--,this relic of ancient surgery1 as ,mr4 ,skey calls it1 has been revived only of late years1 and seems in certain cases to be a justifiable and successful operation4 ,practised by ,fabricius ,hildanus and ,guillemeau in the sixteenth and seventeenth centuries1 it had fallen into disuse till revived by ,hoin1 ,velpeau1 and ,baudens1 on the ,continent1 ,professor ,nathan ,smith in ,america1 and ,mr4 ,lane in ,london4 ,it is not possible that this operation can be at all frequent1 since the cases in which it is applicable are comparatively rare2 for1 to be successful1 the following conditions are essential3--#a4 ,that there be abundant skin in front of the knee-joint to make a long anterior flap2 #b4 ,that the patella and articular surface of the femur are healthy4 ,these conditions at once exclude nearly every case of disease or accident4 ,if the joint is diseased some amputation through the thigh must be attempted2 if injured1 and the front of the knee is safe1 it may very likely be possible to amputate below the knee4 ,hence this operation may be useful in cases where1 for malignant disease1 the whole tibia requires removal1 and yet the knee-joint is sound1 or for gunshot injuries1 in which the tibia is splintered but the soft tissues comparatively uninjured4 ,operation4--,a long anterior flap should be cut with a semilunar end 7,plate ,,ii4 figs4 #f1 #g71 extending as far as the insertion of the ligamentum patell4 ,this flap1 including the patella1 should be thrown up1 the joint cut into1 and a short posterior flap made by transfixion4 ,it is important to retain the patella1 if possible1 as it fills up the hollow between the condyles2 it sometimes becomes anchylosed1 but in other cases it remains freely mobile1 and adds to the value of the stump4 ,professor ,pancoast has practised an amputation at the knee-joint by three flaps1 performed entirely by the scalpel1 which1 he says1 results in a good stump4 ,one flap1 the anterior one1 is longest and semilunar in shape1 its convexity passing three inches below the tuberosity of the tibia2 the other two are much smaller1 and postero-lateral4#dc ,advantages4--,the bone is not cut into at all1 there is a free drain for matter1 no tendency to retraction of the flaps1 and the weight of the body is borne on skin previously habituated to pressure4 ,the statistics seem to be favourable3 out of #ee cases1 ,continental1 ,american1 and ,english1 #ba died1 a mortality of #ch per cent41 while in a table of #ajee cases of amputation of the thigh1 #dfd died1 being a mortality of #dd per cent4 ,in some of the ,american cases the articulating extremity of the femur seems to have been removed1 as in the following operation3-- ,,amputation ,,through ,,the ,,condyles ,,of ,,the ,,femur4--,in the ,london and ,edinburgh ,journal of ,medical ,science for #ahde1 ,mr4 ,syme advocated a method of amputation through the condyles of the femur as specially suitable in case of diseased knee-joint4 ,amputation at this spot has certain advantages3--#a4 ,the shaft of the bone being untouched1 there is no injury of the medullary cavity1 and hence no fear of inflammation of its lining membrane4 #b4 ,there is less risk of exfoliation1 the cancellated texture of the epiphysis not being liable to it4 #c4 ,being close to the joint1 the muscles are cut through where they are tendinous1 thus very much diminishing the risk of retraction and consequent protrusion of the bone4 #d4 ,a large broad surface of bone is left to bear the weight of the body1 and one which1 like the ankle-joint stump1 will round off and afford a comfortable pad over which the skin of the flap will freely play4 ,one objection used to be urged against this mode of operating1 the fear lest the thickened1 brawny1 and often ulcerated textures in the neighbourhood of a diseased knee-joint1 would not make a good covering4 ,this1 however1 is no longer a bugbear1 as we see in cases of resection1 where the diseased joint alone is taken away1 how very soon all swelling and disease departs1 once its cause is removed4 ,mr4 ,syme's original operation was briefly as follows3--,with an ordinary amputating-knife make a lunated incision 7,plate ,i4 fig4 #ai7 from one condyle to the other1 across the front of the joint1 on a level with the middle of the patella1 divide the tissues down to the bones1 and then draw the flap upwards1 then cut the quadriceps extensor immediately above the patella4 ,the point of the blade should then be pushed in at one end of the wound1 thrust behind the femur1 and made to appear at the other end2 it should then be carried downwards 7,plate ,,iii4 fig4 #e71 so as to make a flap from the calf of the leg1 about six or eight inches in length1 in proportion to the thickness of the limb2 the flap should then be slightly retracted1 and the knife carried round the bone a little above the condyles to clear a way for the saw1 which should be applied so as to leave the section as horizontal as possible4 ,this method is now hardly ever used1 as the following seems a much better one3-- ,,gritti',s#dd ,,amputation4--,in this two flaps are formed--an anterior long one rectangular and a posterior short one4 ,the condyles of the femur are divided through their base1 and the lower surface of patella is removed by a small saw1 and then the surfaces of bone approximated4 ,,stokes',s#de ,,modification ,,of ,,gritti',s ,,amputation4--,in this supracondyloid amputation1 the femur is sawn just above the condyles1 without going into the medullary canal4 ,the anterior flap is oval1 twice as long as posterior1 and the patella is brought up after denudation against end of femur4 ,,carden',s ,,amputation ,,at ,,the ,,condyles ,,of ,,the ,,femur4#df--,the operation consists in reflecting a rounded or semi-oval flap of skin and fat from the front of the knee-joint1 dividing everything else straight down to the bone1 and sawing the bone slightly above the plane of the muscles1 thus forming a flat-faced stump1 with a bonnet of integument to fall over it4 ,the operator standing on the right side of the limb1 seizes it between his left forefinger and thumb at the spot selected for the base of the flap1 and enters 7,plate ,,ii4 fig4 #h7 the point of the knife close to his finger1 bringing it round through skin and fat below the patella to the spot pressed by his thumb2 then turning the edge downwards at a right angle with the line of the limb1 he passes it through to the spot where it first entered1 cutting outwards through everything behind the bone 7,plate ,,iv4 fig4 #af74 ,the flap is then reflected1 and the remainder of the soft parts divided straight down to the bone2 the muscles are then slightly cleared upwards1 and ,i saw it applied4 ,i have ventured to make a slight change in the method of performing this most excellent operation1 for having found the posterior flap1 as cut in the method above described1 rather scanty in the earlier cases in which ,i have had occasion to perform it1 after dissecting back the anterior flap and cutting into the knee-joint1 ,i shape a slightly convex posterior flap of skin only1 at least one and a half inches in length in adult1 and allow it to retract before dividing the muscles by a circular cut to the bone1 and have had every reason to be satisfied with the change4 ,,amputation ,,of ,,the ,,thigh4--,amputation of the thigh has been the favourite battle-ground where flap and circular1 antero-posterior and lateral1 long and short flaps1 double1 triple1 and conical incisions1 have striven with each other2 so were ,i to attempt to describe one quarter of the various methods employed1 ,i should need to rewrite the history of ,amputation4 ,it will suffice merely to describe the best modes of amputating the thigh through its lower1 middle1 and upper thirds respectively1 and at the hip-joint4 ,in one word1 it may be stated that1 with the exception of those amputations performed through the lower third of the bone1 the flap method is to be preferred1 and the flaps should in almost every case be made by transfixion4 ,in the lower third1 however1 the flap method1 though exceedingly easy1 and capable of very rapid performance1 has certain defects2 the chief of these being the tendency which the muscular flaps 7the necessary result of transfixion7 have to cause undue retraction1 and hence protrusion of the bone4 ,this is seen specially in the hamstrings1 which from the great distance of their origin1 and the purely longitudinal direction of their fibres1 retract to a very great extent1 much more than the anterior muscles can do from the pennate direction of their fibres1 and the manner in which they are mutually bound down to each other and to the bone4 ,even in this one position1 the lower third of the thigh1 the methods that may be needed are various1 and require separate notice2--for operations here are extremely frequent from the frequency of strumous disease of the knee-joint in our variable climate1 and from the fact that compound fractures or dislocations of the knee-joint so very often necessitate amputation4 ,in cases where the skin over the patella is uninjured and available1 the operation by long anterior flap 7either by ,teale's method1 or by ,mr4 ,spence's modification of it1 which curiously is almost exactly similar to the amputation of ,benjamin ,bell by a single flap7 is suitable enough4 ,but1 ,i believe1 preferable to either of these is the operation of ,mr4 ,carden1 already described4 ,in cases where the knee-joint is injured1 and the skin over the patella unavailable1 and yet where it is not necessary to go higher up the limb1 the modified circular amputation of ,mr4 ,syme will be found very suitable4 ,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 found1 it affords the best opportunity for comparing in their detail the three almost similar plans of ,b4 ,bell1 ,teale1 and ,spence--after which ,mr4 ,syme's modified circular may be described4 ,,benjamin ,,bell',s ,,flap ,,operation ,,above ,,the ,,knee 7reported in his own words1 slightly abbreviated74--,when this operation is to be performed above the knee1 it may be done either with one or two flaps1 but it will commonly succeed best with one4 ,the flap answers best on the fore part of the thigh1 for here there is a sufficiency of the parts for covering the bones1 and the matter passes more freely off than when the flap is formed behind4444 ,the extreme point of the flap should reach to the end of the limb1 unless the teguments are in any part diseased1 in which case it must terminate where the disease begins1 and its base should be where the bone is to be sawn4 ,this will determine the length of the flap1 and we should be directed with respect to the breadth of it by the circumference of the limb1 for the diameter of a circle being somewhat less than a third of its circumference1 although a limb may not be exactly circular1 yet by attention to this we may ascertain with sufficient exactness the size of a flap for covering a stump 7,plate ,,iv4 fig4 #ag74 ,thus a flap of four inches and a quarter in length will reach completely across a stump whose circumference is twelve inches2 but as some allowance must be made for the quantity of skin and muscles that may be saved on the opposite side of the limb1 by cutting them in the manner ,i have directed1 and drawing them up before sawing the bone1 and as it is a point of importance to leave the limb as long as possible1 instead of four inches and a quarter1 a limb of this size1 when the first incision is managed in this manner1 will not require a flap longer than three inches and a quarter1 and so in proportion1 according to the size of the limb4 ,the flap at its base should be as broad as the breadth of the limb will permit1 and should be continued nearly1 although not altogether1 of the same breadth till within a little of its termination1 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 limb4 ,this being marked out1 the surgeon1 standing on the outside of the limb1 should push a straight double-edged knife with a sharp point to the depth of the bone1 by entering the point of it at the outside of the base of the intended flap2 and carrying the point close to the bone1 it must here be pushed through the teguments at the mark on the opposite side4 ,the edge of the knife must now be carried downwards in such a direction as to form the flap1 according to the figure marked out2 and as it draws toward the end1 the edge of it should be somewhat raised from the bone1 so as to make the extremity of the flap thinner than the base1 by which it will apply with more neatness to the surface of the sore4 ,the flap being supported by an assistant1 the teguments and muscles of the other parts of the limb should1 by one stroke of the knife1 be cut down to the bone1 about an inch beneath where the bone is to be sawn2 and the muscles being separated to this height from the bone with the point of a knife1 the soft parts must all be supported with the leather retractors till the bone is sawn1 etc41 arteries tied1 and dressings applied4#dg ,,amputation ,,of ,,thigh ,,by ,,rectangular ,,flap--7,teale's74--,i take the opportunity here of describing fully1 and as far as possible in his own words1 ,mr4 ,teale's method of amputating1 this being the situation where his method is most frequently available4 ,the same principle may be applied to amputations at almost any other part of the body4 ,after advising the surgeon to mark out the proposed line of incision with ink before the operation1 he gives the following directions for fixing the exact size of the flap3--,supposing the amputation to take place 7,plate ,,ii4 figs4 #i1 #aj7 at the lower part of the middle third of the thigh1 the circumference of the limb is to be measured at the point where the bone is to be divided4#dh ,assuming this to be sixteen inches1 the long flap is to have its length and breadth each equal to half the circumference1 namely1 eight inches4 ,two longitudinal lines of this extent are then traced on the limb1 and are met at their lower points by a transverse line of the same length4 ,the inner longitudinal line should be first traced in ink as near as practicable to the femoral vessels1 without including them within the range of the long flap4 ,the outer longitudinal line1 which is somewhat posterior1 is next marked eight inches distant from the former and parallel to it4 ,these two lines are then joined by a transverse line of the same extent1 which falls upon the upper border of the patella1 or upon some lower portion of this bone4 ,the short flap is indicated by a transverse line passing behind the thigh1 the length of this flap being one-fourth that of the long one2 or1 assuming the circumference of the limb to be sixteen inches1 and the length of the long flap eight inches1 the length of the short flap is two inches4 ,the operator begins by making the two lateral incisions of the long flap through the integuments only4 ,the transverse incision of this flap1 supposing it to run along the upper edge of the patella1 is made by a free sweep of the knife through the skin and tendinous structures down to the femur4 ,should the lower transverse line of the flap fall across the middle or lower part of the patella1 the transverse incision can extend through the skin only1 which must be dissected up as far as the upper border of the patella1 at which place the tendinous structures are to be cut direct to the thigh-bone4 ,the flap is completed by cutting the fleshy structures from below upwards close to the bone4 ,the posterior short flap1 containing the large vessels and nerves1 is made by one sweep of the knife down to the bone1 the soft parts being afterwards separated from the bone close to the periosteum1 as far upwards as the intended place of sawing4444 ,in adjusting the flaps1 the long one is folded over the end of the bone1 and brought1 by its transverse line1 into union with the short flap1 the two corresponding free angles of each being first united by suture4 ,one or two additional stitches complete the transverse line of union4 ,care is now required in arranging the two lateral lines of union4 ,as the long flap is folded upon itself so as to form a kind of pouch for the end of the bone1 it is requisite that it should be held in its folded state by a point of suture on each side4 ,another stitch on each side secures the lateral line of the short flap to the corresponding part of the long one4 ,a longitudinal line of union thus passes at right angles each end of the transverse line4#di ,mr4 ,teale's account of the resulting stumps is too long to quote entire1 but in a few words1 we find that by retraction of the short posterior flap1 the cicatrix is drawn up quite behind and out of the way of the bone1 that a soft mass without any large nerves or vessels is the result of the partial atrophy of the long flap1 and that the patient is able to bear one-half1 two-thirds1 or even in some cases the entire weight of his body on the face of the stump4 ,such a power of support is to be found in no other flap except in ,mr4 ,syme's amputation at the ankle-joint4 ,,spence',s ,,amputation ,,by ,a ,,long ,,anterior ,,flap4#ej--,the method used by ,mr4 ,spence in amputations just above the knee-joint obtains the advantages of ,teale's method1 and avoids many of its disadvantages4 ,he makes two flaps4 ,the anterior one1 which is to fall loosely over and cover in the posterior segment of the stump1 must have a breadth fully equal to one-half of the circumference of the limb1 and must be gently rounded at its extremity1 so as to adjust itself readily to the curve of the cut margin of the posterior half of the stump4 ,he begins the anterior incision below1 or on a level with1 the lower margin of the patella1 and when the skin is retracted to a little above the patella1 cuts down obliquely to the bone1 so as to divide the soft parts up to the base of the flap4 ,for the posterior incision1 he begins about two fingers'-breadth below the base of the anterior flap1 and the assistant retracting the skin1 the edge of the knife is carried obliquely up to the bone 7in ,alanson's manner7 and the posterior soft parts divided1 the bone is sawn through--or immediately above--the condyloid portion4 ,mr4 ,spence does not advise or practise this method high up4 ,the results are good1 for by these means the end of the bone has a thick covering1 including muscular fibres1 over it1 and the cicatrix is not pressed upon in walking4 ,the stump remains full1 mobile1 and fleshy1 as in ,mr4 ,teale's method1 without the disadvantage which it has1 in requiring the bone to be divided so far above the seat of injury or disease4 ,this is an exceedingly good method of operating in the lower third of the thigh1 in muscular patients the very best1 and in all cases only equalled in value by ,carden's method4 ,the next is now hardly ever used here1 except in cases where the skin over the patella is destroyed4 ,,modified ,,circular ,,at ,,lower ,,third ,,of ,,thigh 7,syme's74--,two equal semilunar flaps of skin should be cut 7,plate ,i4 fig4 #bj1 ,plate ,,iii4 fig4 #f71 one anterior1 the other posterior1 their convexities being towards the knee4 ,the skin and subcutaneous cellular tissue should be raised from the fascia1 and then retracted to a further distance of at least two inches2 the muscles should then be divided right down to the bone1 on a level as high as they are exposed in front1 and as low as they are exposed behind4 ,this allows for the different amount of retraction at the two sides of the limb1 and leaves the muscles cut on a level2 the whole mass of muscles should then be drawn well up1 and the bone exposed1 and sawn through at a level about two inches higher than where it was first exposed by the anterior incision through the muscles4 ,in very weak thin flabby limbs this process may be simplified by just at once including the muscles in the skin flaps1 and carefully exposing the bone higher up4 ,in performing the retraction the assistant should be cautioned not to overdo it1 lest he strip the periosteum from the bone higher than is necessary4 ,this is very easy to do in the weak limbs of strumous patients1 and may cause exfoliation1 and greatly delay cure4 ,,amputation ,,in ,,the ,,middle ,,third ,,of ,,the ,,thigh4--,a very short notice will suffice here4 ,the exact position1 shape1 and size of the flaps must in every case be modified by the nature of the injury for which the operation is performed1 taking the flaps where they can be obtained4 ,as a general rule1 a long anterior flap with a short posterior1 on the principle described above1 should be preferred4 ,in cases where the long anterior cannot be obtained1 two equal flaps should be made by transfixion4 ,the flaps should always be antero-posterior1 the lateral flaps introduced by ,vermale1 and indorsed by ,chelius and ,erichsen1 having the great disadvantage of allowing the bone1 which is drawn up by the psoas and iliacus1 to project at the upper angle4 ,supposing the right thigh is to be amputated1 the surgeon1 standing on the inside of the leg1 should raise the skin and muscles of the front of the limb in his left hand1 and entering the knife just in front of the vessels1 should transfix the limb1 the knife passing in front of the bone1 and including as nearly as possible an exact half of the limb 7,plate ,,iv4 fig4 #ai72 having by a sawing motion brought out the knife and cut a flap of the required length1 the knife is re-entered at the same place1 and passing behind the bone1 the point must be brought out at the angle on the other side4 ,both flaps being then held back by an assistant1 the bone is cleared by a circular turn of the knife1 and the saw applied1 the vessels are found cut high up in the inner angle of the posterior flap4 ,in muscular patients it is often better to make the incision through the skin first and allow it to retract before transfixing2 this is slower and not so brilliant looking1 but avoids redundancy of muscle4 ,,amputation ,,at ,,the ,,hip-,,joint4--,this operation1 exceedingly dangerous from the amount of the body removed1 the great hmorrhage1 and the risk of pymia1 is of comparatively modern invention4 ,though the proportion of recoveries is at present to that of deaths about one to two or two and a half1 it is still a perfectly justifiable operation in many cases of disease and injury4 ,like amputation at the shoulder1 amputation at the hip has given rise to very many various methods of performance4 ,under the heads of single flap1 double flap1 oval1 circular1 and mixed flap and circular1 at least twenty distinct methods have been put on record1 and1 including modifications1 there are thirty-seven or thirty-eight different surgeons who have each their own plan of operation4 ,the reason of this fearful complexity in its literature depends on this fact1 that this amputation has generally been performed for cases of such severe injury of the limb1 that no milder amputation was possible1 and thus the flaps had to be taken just where the surgeon could get them best4 ,and this will have to be the guiding principle in most amputations at this joint2 the surgeon must just cut his coat according to his cloth--get his flaps where and how he can4 ,in cases1 however1 where it is possible to have a choice1 and to select the flaps1 the following is1 ,i believe1 both the best and quickest method3-- ,this is one of the very few operations in which quickness of performance is a desideratum2 the use of ansthetics has1 in most other cases1 given time for elaboration of flaps1 and careful dissection2 here the risk of loss of blood1 specially from the posterior flap1 renders rapid disarticulation imperative4 ,amputation by double flap1 anterior the longer4--,in hip-joint amputations1 besides the ordinary sponge-squeezers1 two assistants are necessary1 whose duties are exceedingly important4 ,the first is to check hmorrhage4 ,pressing with a firm pad on the external iliac just as it passes the bone1 he must be prepared1 the instant the anterior flap is cut1 to follow the knife and seize flap and artery in his hand1 and he is to hold it there till all the vessels in the posterior flap are first tied4 ,the second has to manage the limb1 and on the manner in which he performs his duty much of the success and nearly all the celerity of the operation depend4 ,while the surgeon is transfixing the anterior flap1 this assistant is to support the limb in a slightly flexed position1 so as to relax the muscles2 the instant the flap is cut he is to extend the limb forcibly1 and at the same time be careful not to abduct it in the least1 but to turn the toes inward so as to bring the great trochanter well forwards on a level with the joint2 if this precaution is neglected1 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 trochanter4 ,if it is the left side1 the operator1 standing on the outside of the limb1 enters the point of a long straight knife midway between the anterior superior spinous process of the ilium and the great trochanter1 and passes it as close to the front of the joint as possible1 making the point emerge close to the tuberosity of the ischium 7,plate ,,iv4 fig4 #bj-bj74 ,with a rapid sawing movement he then cuts a long anterior flap1 avoiding any pointing of it1 and endeavouring to make the curve equal4 ,the fingers of the assistant must be inserted so as to follow the knife and seize the vessel even before it is divided4 ,the flap being raised out of the way1 the surgeon1 without changing his knife 7as used to be advised71 opens the joint1 divides the ligaments as they start up on the limb being extended and adducted1 the round ligament1 and the posterior part of the capsule2 and then getting the knife fairly behind both the head of the bone and the trochanter1 cuts the posterior flap as rapidly as possible4 ,instantly on the limb being separated1 assistants should be ready with large dry sponges or pads of dry lint to press against the surface of the posterior flap1 till the large branches1 chiefly of the internal iliac1 which are cut in it1 are tied one by one4 ,the lever invented by ,mr4 ,richard ,davy1 by which the common iliac is compressed from the rectum1 has in many cases proved of great service in preventing hmorrhage1 but has dangers of its own in cases of abnormal position of rectum1 or even in sudden movements of the patient4 ,in every case the abdominal tourniquet will be found of great service in checking hmorrhage1 during the operation of amputation at the hip-joint4 ,it consists of an arch of steel fitted with a pad behind1 which rests against the vertebral column1 and a pad in front playing on a very fine and long screw1 through an opening in the arch4 ,when screwed down tightly on the aorta just before the incisions are commenced1 it checks hmorrhage admirably without injuring the viscera4 ,when this is applied1 a method of amputation once practised by ,mr4 ,syme1 though not so rapid as the double-flap method by transfixion1 will be found very easy1 and to result in most excellent flaps4 ,he cut an anterior flap in the usual manner by transfixion1 then made a straight incision from its outer edge down to about two inches below the great trochanter1 thus exposing it fully1 and from the lower end of this incision transfixed again1 cutting a posterior flap nearly equal in size to the anterior2 a few strokes of the knife round the joint finished the disarticulation4 ,the resulting flaps came together with great accuracy1 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 disarticulation4 ,in some cases of amputation where the femur has been badly shattered1 it is a good plan to amputate through the upper third of thigh1 tie all the vessels1 and then1 aided by an incision at outer side1 dissect out the head of the bone4 ,mr4 ,furneaux ,jordan of ,birmingham carries out this principle by first dividing the soft parts in circular direction low down the thigh1 and then dissecting out the head of the bone from the muscles by a long incision on the outer aspect of the limb4 ,note4--,in severe cases of smash when both lower limbs have required amputation1 the author has derived much assistance from the method of managing the operation detailed below3-- ,double ,primary ,amputation of 7both7 ,thighs from railway smash--,rapid recovery4--,g41 a healthy-looking man1 aged twenty-seven1 but looking much older1 while driving a horse near ,granton1 caught his foot on the edge of a rail at a point1 fell1 and both his legs were run over by several loaded wagons4 ,a special engine was procured1 his thighs tightly tied up1 and he was sent up to hospital at once4 ,i was in hospital at the time1 so with as little delay as possible he was placed on the operating table1 and the necessity for amputation being too evident1 ,i obtained his leave to remove both his legs above the knee2 but his pulse was very feeble1 and he was intensely nervous1 throwing his arms wildly about1 panting for breath1 and looking very ill1 cold1 and exhausted4 ,i determined that by great rapidity he might be got off the table alive1 so operated in the following manner3--,fixing the tourniquet firmly near both groins1 ,i first amputated the right leg by ,carden's method1 and tied the femoral only1 wrapped up the stump in a towel wrung out of carbolic solution #a-bj1 then took off the other limb by ,mr4 ,spence's method1--it had been injured higher than the right1 so that ,i could not save the condyles of the femur1--then tied the femoral there1 and fixed it up with another towel2 then returning to the first1 ,i tied one or two large branches which spouted1 and rolled it up again1 then back to the left one1 doing the same1 and getting the tourniquet off both limbs4 ,on going back to the right the surface was nearly dry and glazed1 so1 asking ,dr4 ,maclaren1 who assisted me1 to stitch it up and insert a drainage-tube1 ,i did the same for the left1 so rapidly that the patient was in his bed with his limbs dressed and bandaged in #bd-a_/b minutes from the time he entered the hospital gate4 ,the strictest antiseptic precautions were observed1 two engines being used to furnish spray4 ,of course this great rapidity was due to the fact that everything was ready1 the assistants all in hospital1 admirably disciplined1 and steam had been up in the spray engines4 ,shock was comparatively trivial2 his temperature once1 and only once1 reached #ajj4 ,his stumps healed by first intention1 and he was in the garden on the seventh day after the operation4 ,i have now in three cases found the benefit of this mode of dealing with double primary amputation in avoiding shock1 lessening the time needed1 and greatly diminishing the number of vessels requiring to be tied4 ,in a previous case of double amputation for railway smash at the knees1 the patient was almost pulseless1 and had he been kept many minutes more on the table would not have left it alive4 ,he also rapidly recovered4 ,the case is interesting also as showing that1 when the assistants know their work1 the strictest adherence to antiseptic precautions need not in itself make either the operation or the dressing tedious1 though it can easily be made an excuse for much fussing and many delays4#ea ,,footnotes3 #bd ,for details see article ,amputation in ,cooper's ,surgical ,dictionary1 and the short sketch of the history in ,mr4 ,lister's paper in the third volume of ,holmes's ,system of ,surgery4 #be ,see a most interesting foot-note to ,professor ,lister's paper on ,amputation1 in ,holmes's ,system of ,surgery1 vol4 iii4 pp4 #eb1 #ec4 #bf ,manuel d',oprations chirurgicales4 #bg ,,fig4 ,,iv4 shows dorsal view of incision4 ,,fig4 ,,iii4 shows face of completed stump2 ,r1 radial2 ,u1 ulnar4 #bh ,as the surgeon will find it most convenient to stand on his own right side of the limb to be removed1 the knife will be entered on the palmar side of the radius of the right arm1 of the ulna of the left4 #bi ,teale1 ,on ,amputation by ,rectangular ,flaps1 pp4 #df-dh4 #cj ,johnson's folio ed41 p4 #cdb4 #ca ,gross's ,surgery1 #fth ed4 vol4 ii4 p4 #aajc4 #cb ,international ,encyclopdia of ,surgery1 vol4 i4 p4 #fda4 #cc ,spence's ,surgery1 pp4 #hjj1 #hja4 #cd ,gross's ,surgery1 #hvo41 #fth ed41 vol4 ii41 p4 #aajf4 #ce ,excision of ,scapula1 p4 #cc4 #cf ,hey's ,observations1 #c;d ed4 pp4 #eeb1 #eef4 #cg ,roux's ,parallel between ,english and ,french ,surgery4 ,translation abridged from ,cooper's ,surgical ,dictionary1 p4 #ajf4 #ch ,syme's ,principles1 #dth edit4 p4 #ade4 #ci ,international ,encyclopdia1 vol4 #a4 p4 #fee4 #dj ,observations in ,clin4 ,surgery1 p4 #dh4 #da ,monthly ,journal of ,medical ,science for #ahdi1 vol4 ix4 p4 #iea4 #db ,med4 ,times and ,gazette1 ,june #c1 #ahfe4 #dc ,operative ,surgery1 p4 #agj4 #dd ,annali ,universali de ,medicina1 ,milano1 #aheg4 #de ,med4 ,chir4 ,transactions of ,london1 vol4 liii41 p4 #age4 #df ,carden's 7of ,worcester7 ,pamphlet1 pp4 #e1 #f2 and ,british ,medical ,journal1 #ahfd4 #dg ,b4 ,bell's ,surgery1 #fth ed4 vol4 vii4 pp4 #ccf-cci4 #dh ,in diagram the amputation is drawn as if for middle third of thigh4 #di ,teale1 op4 cit41 pp4 #cd1 #ci4 #ej ,edin4 ,med4 ,journal1 for ,april #ahfc4 #ea ,edin4 ,medical ,journal1 ,march #ahgi4 ,,chapter ,,iii4 ,,excision ,,of ,,joints4 ,historical4--,beyond a passage ascribed to ,hippocrates1 but of very doubtful authenticity1 and slight allusions in the works of ,celsus and ,paulus gineta1 the ancients give us no information whatever on this subject4 ,hippocrates says1--,complete resections of bones in the neighbourhood of joints both in the foot1 in the hand1 in the tibia up to the malleoli1 and in the ulna at its junction with the hand1 and in many other places1 are safe operations1 if that fatal syncope does not at once occur1 and continued fever does not attack the patient on the fourth day4 ,celsus and gineta both advise the removal of protruding ends of bone in compound dislocations1 but without giving any cases4 ,from the days of these classic fathers of ,surgery1 we have hardly an indication of any attention whatever having been paid to their hints till quite within the last hundred years4 ,the first distinct publication on the subject was by ,henry ,park of ,liverpool1 in a letter to ,percival ,pott in #aghc4 ,he proposed the removal of the articulating extremities of diseased elbow and knee-joints to obtain cures4 ,he says he was led to this by its having been the invariable custom1 for more than thirty years1 at the ,liverpool ,infirmary1 to take off the protruded extremities of bones in cases of compound dislocation4 ,the chief credit1 however1 in practically elevating excisions into the catalogue of recognised surgical operations1 is owing1 ,british surgeons most cordially own1 to two provincial surgeons of ,france1 the ,moreaus 7father and son7 of ,bar-sur-,ornain4 ,they took the lead in the most marked manner1 having excised the shoulder in #aghf1 the wrist and elbow in #agid1 knee and ankle in #agib1 and had followed this up so well that1 in #ahjc1 the younger ,moreau could boast1 the town has become in some sort the refuge of the unfortunate afflicted with carious joints1 after they have tried all the means usually recommended by professional men1 or have had recourse to empirical nostrums1 or when amputation seemed to them the last resource4 ,moreau's papers and cases1 which1 between #aghf and #aghi1 he frequently read to the ,french ,academy1 were1 some violently opposed1 others utterly neglected by his compatriots1 and many of them lost and buried in the unpublished papers of that body4 ,and though diseased joints did not decline in frequency1 and though injured ones were extremely numerous during these long years of ,european war1 excisions were but rarely performed4 ,with the exception of the removal of head of humerus after gunshot injury1 hardly any ,british1 and but very few ,french1 limbs were saved by excision taking the place of amputation4 ,the limbs that were saved by ,percy by excision of the head of the humerus really owe their recovery and safety to the elder ,moreau2 for an operation of his1 at which he was assisted by that distinguished military surgeon1 gave the latter the hint1 which he followed so successfully1 that by #agie he had performed it nineteen times1 and had indoctrinated ,sabatier1 ,larrey1 and others1 and elevated it into a recognised operation of military surgery4 ,so far1 however1 as the application of the great improvement of the ,moreaus to disease went1 the ,french surgeons have little reason to boast1 for it is to ,english surgery1 and especially to one ,edinburgh surgeon1 that this class of operations owes nearly all its improvement in methods and frequency of performance4 ,for though 7as we shall see under the special heads7 here and there one or two cases were performed1 it was not till the publication of ,mr4 ,syme's monograph on the excision of diseased joints1 in #ahca1 that the importance and value of the discovery were fairly brought before the profession2 and the conservative surgery1 of which excision as preferred to amputation is the great type1 must ever be associated with ,british surgeons--,syme1 ,fergusson1 ,mackenzie1 ,jones of ,jersey1 ,butcher of ,dublin4 ,on the ,continent--,langenbeck1 ,stromeyer1 ,heyfelder1 ,ollier1 ,esmarch of ,kiel1 specially in the surgical history of the first ,schleswig-,holstein war1 have followed up the example set them here4 ,before proceeding to describe the operations on the various joints1 one or two questions may be briefly asked and answered by way of introduction4 ,in what cases1 or sorts of cases1 are excisions suitable8 #a4 ,in cases of compound injury or dislocation of a large joint1 as used by ,filkin1 ,park1 ,white1 and other ,english surgeons long ago4 ,in hospital practice1 or in private1 where there is every advantage of rest1 food1 and appliances1 such operations will frequently be found suitable where the joint is alone or chiefly the seat of injury1 and where the general health seems fit to bear a prolonged suppuration4 ,but long and sad experience has shown that1 as a general rule in military practice1 with the difficulties of transport1 the generally bad sanitary state of the hospitals1 and the want often of adequate dressings and attention1 excisions are much more fatal than amputations1 and1 except in elbow and shoulder 7q4v471 should be as a general rule avoided4 #b4 ,excision for deformity 7generally speaking for bony anchylosis7 will require for decision the consideration of many points1 i4e4 the joint affected1 the nature of the disease or injury which has caused the anchylosis3 and in each case--7#a47 the state of health of the patient2 and 7#b47 his occupation1 and the consequent position of limb which would suit him best4 ,as a general rule1 ,i believe1 experience will prove that such operations on the lower extremity are almost absolutely inadmissible1 except under very special urgency on the part of the patient1 and a very high condition of health--while in the upper1 the elbow-joint is the only one which you will ever be likely to be asked to remedy1 or should comply with the request if asked2 as the shoulder1 even if anchylosed1 will 7#a47 from its own weight generally become so in the most favourable position2 and 7#b47 from the extreme mobility which the scapula can acquire1 its anchylosis will not be so much felt4 ,the elbow1 however1 from the frequency of fractures of the condyles of the humerus obliquely into the joint1 and from the manner in which these are so often neither recognised nor properly treated1 very often becomes anchylosed in the most awkward possible position1 i4e4 nearly straight2 and operations undertaken for such deformities are in general both quite safe and very satisfactory4 ,mr4 ,syme had one case 7resulting from a fall1 causing a double fracture71 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 assistance4 ,excision of both joints cured him4 ,the author excised with success for disease the elbow-joint of a patient whose other arm had required the same operation4 ,the occupation of the patient must always be taken into consideration when settling the position of an anchylosis1 or the necessity or advantage of a resection4 ,thus1 ,bryant#eb tells of a painter who wished his arm to be fixed in a straight position1 and of a turner whose knee at his own request was permitted to stiffen at a right angle1 as that position allowed him to turn his wheel4 #c4 ,excision for ,disease of the ,joint4--,in our cold climate1 so cursed by scrofula1 and specially among the children of the labouring poor1 such joint diseases are very prevalent1 and whether the disease commences in the synovial membrane1 the articular cartilages1 or the heads of the bones1 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 patient4 ,the difficulty of diagnosing the cases in which excisions are suitable or necessary is often very great2 and we must balance its performance--7#a47 against the possibly good results of an expectant treatment2 7#b47 against amputation of the limb4 7#a47 ,against expectant ,treatment4--,the patient has youth on his side1 could we give him fresh sea air1 good diet1 cod oil1 etc41 we might very likely obtain anchylosis2 true1 but he may die while trying for this anchylosis1 and also this anchylosis1 when got1 may so lame or deform him that resection may still be required4 ,these points must all be considered1 but as a general rule1 ,i would say that such attempts at preservation of the limb are much more justifiable1 and longer justifiable in the hip and knee-joints than in the elbow or shoulder2 for the results in the lower limb will probably be as good1 if the patient survive1 if not better1 than those obtained by excision1 while the danger of the operation is greater2 while in the upper limb1 the danger to life in operating is less than that of leaving the limb on1 and the results obtained by a successful operation1 with well-managed after treatment1 are far more satisfactory than the best possible anchylosis4 ,another point bearing on this1 of very great importance3 ,in children1 the most frequent subjects of such disease1 excision of the lower limb may1 by removing the epiphyses1 cause to a very considerable degree disparity in their length1 thus rendering them nearly useless1 while in the upper such disparity is neither so extensive nor so injurious to the usefulness of the limb1 which is not required for purposes of progression4 ,in the hip-joint especially1 all the resources of the art should be tried in the expectant treatment1 for amputation at the hip-joint is hardly ever admissible for disease of the joint1 while excision has anything but satisfactory statistics4 7#b47 ,against ,amputation4--,many questions must be considered1 chiefly under the heads of the separate joints3-- #a4 ,as to the difficulties and dangers of the operations contrasted4 ,such as the following3-- ,excisions give the surgeon more trouble1 require more manual dexterity2 take longer to perform2 are very painful operations4 ,not valid objections in these days of chloroform and operative surgery on the dead body4 ,excisions have the special peculiarity and danger of dealing chiefly with cancellated bone1 broadened out1 open1 with numerous patulous canals for large veins1 tending on any irritation or inflammation to set up a diffuse suppuration1 and to culminate in phlebitis1 myelitis1 and other pymic conditions4 ,excisions are performed through degenerate or disorganised1 amputations through healthy1 tissue4 ,excisions require extreme care and absolute rest 7i4e4 in lower limb7 for many weeks and months after the operation4 ,but1 on the other hand1-- ,amputations remove a portion of the body2 excisions a much less one4 ,amputations are always necessarily nearer the centre than the corresponding excisions1 and statistics show that the fatality of operations increases in exact proportion as they approach the centre4 ,a successful excision1 especially in arm1 saves a limb nearly perfect2 an amputation at best is only the stump for a wooden one4 ,on the whole1 there is actually very little difference in the mortality of excisions and amputations4 #b4 ,as to the results of the operation on the usefulness of the limb1 depending on joint involved1 age of patient1 and amount of bone removed3-- ,a4 ,joint involved4--,these must be noticed separately1 but one thing is absolutely certain1 that a much higher standard of usefulness1 both in equality of length1 amount of anchylosis1 and position1 is needed in the lower than in the upper limb4 ,for a leg hanging like a flail1 or shortened by some inches1 is not so good for purposes of locomotion as a wooden leg is1 while an arm1 even though powerless at the elbow1 and perhaps much shortened1 can be so strengthened and supported by slings and bandages as to give a most useful hand1 the complex movements and uses of the fingers of which no mechanism can at all imitate4 ,b4 ,age of ,patient4--,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 managed1 and the stunted limb1 especially in the leg1 will eventually be of little advantage1 though after the operation it looked excellently well1 if a few years later it be found to be seven or eight inches shorter than its neighbour4 ,c4 ,amount of ,bone removed4--,from an erroneous view of the pathological changes in the bone affected1 far too much was removed by many of the earlier operators1 especially ,moreau and ,crampton4 ,the reason that this is often still the case1 is well seen in many preparations4 ,the bones are thickened to a considerable distance1 and covered with irregular warty excrescences4 ,these1 which used to be considered evidences of disease1 are only compact new healthy bone1 thrown out like the callus of a fracture in consequence of the irritation4 ,in a word1 what we require to remove is the following3-- #a4 ,all the cartilage1 dead or alive1 healthy or diseased4 #b4 ,only the bone involving the articular extremities1 in thin slices1 or with the occasional use of the gouge1 till a healthy bleeding surface is obtained4 #c4 ,the synovial membrane1 however gelatinous or thickened looking1 really requires very little care or notice2 it will disappear of itself1 partly by sloughing1 partly by absorption during the profuse suppuration4#ec ,,excision ,,of ,,the ,,shoulder-,,joint4--,before considering the method of operating1 a word or two is required on the subject of how much is to be removed1 and in what cases the operation should be performed4 ,the shoulder and hip joints are the only ones in which partial excision is ever admissible1 indeed1 in the shoulder excision of the head of the humerus only is in many cases found to be all that is necessary1 while in all it is much less dangerous to life than when the glenoid cavity also requires to be interfered with4 ,it is rarely necessary to remove more of the bone than merely its articular extremity 7when performed for disease of the joint71 and if possible this should be done inside the capsule1 i4e4 through an incision in the capsule1 but without involving its attachment to the neck of the bone4 ,when the glenoid is also diseased1 mere gouging or scraping the cartilaginous surface will not suffice1 but the neck must be thoroughly exposed1 so that the whole cup of the glenoid may be removed by powerful forceps4 ,cases suitable for ,excision4--,cases of chronic disease of the head of the humerus 7generally tubercular71 or of chronic ulceration of the cartilages which has resisted counter-irritation4 ,cases of gunshot injury of the joint1 or of compound dislocation1 or fracture involving the joint4 ,cases of limited tumours affecting merely the head and upper third of the bone1 and non-malignant in character4 ,anchylosis very rarely requires and would not be much benefited by such an operation4 ,operation4--,though perhaps not the easiest1 the following method is the one followed by the best results4 ,it is suited especially for cases of caries or other disease of the joint1 where the head of the humerus is either alone or chiefly affected3-- ,a single straight incision 7,plate ,i4 fig4 ,a47 is made from a point just external to the coracoid process downwards along the humerus for at least three inches4 ,it corresponds almost exactly to the bicipital groove1 and has the advantage of avoiding the great vessels and nerves4 ,the long head of the biceps may then be raised from its groove1 and drawn to a side so as to be preserved4 ,this is deemed of importance by ,langenbeck and others4 ,mr4 ,syme1 however1 did not attach much value to its preservation1 as it is often diseased4 ,the capsule1 which is often much altered1 perhaps in part destroyed1 is then opened1 and the tendons of the muscles which rotate the head of the humerus divided in succession1 while the elbow is rotated first inwards and then outwards by an assistant so as to put them on the stretch4 ,the arm being then forced backwards1 the head of the bone can be protruded through the wound1 and sawn off at the necessary distance down the shaft4 ,the glenoid must then be carefully examined1 and any diseased bone removed by the cutting pliers4 ,one or two small branches supplying the anterior fold of the axilla are the only vessels divided1 and may not even require ligature1 unless1 indeed1 from necrosis1 or to remove a tumour1 a larger portion of the humerus than usual has been removed4 ,if the limit of capsule has been infringed on below1 the circumflex vessels may probably be cut1 in which case the bleeding may be considerable4 ,n4,b4--,in cases of fracture of neck of humerus1 or of compound gunshot injury1 or where the head has been separated by necrosis from the shaft1 or where1 as has happened to ,stanley and others1 the bone broke in the endeavour to tilt the head out1 the surgeon will require to seize the detached head with strong forceps1 and dissect it out with care4 ,other methods of ,resection4--,when from great thickening and induration of the soft parts1 enlargement of the head of the bone1 or other reason1 the straight incision may be deemed insufficient for the purpose 7and we may remark that there are comparatively few cases in which it is insufficient71 access may be obtained to the joint by raising a flap from the deltoid 7,plate ,,iii4 fig4 ,a74 ,its shape--,v-shaped1 semilunar1 or ovoid--is not of much consequence1 for there are no great nerves or vessels to wound on the outside of the joint1 and the surgeon should be guided1 as in all other operations on the joint1 very much by the position of any pre-existing sinuses4 ,this flap being raised upwards towards its base1 very free access is gained to the joint4 ,in these cases1 fortunately comparatively rare1 in which there is reason to believe that the glenoid is chiefly involved in disease1 and yet that the disease can be removed without amputation1 access will be gained most easily by an incision 7,plate ,,iii4 fig4 ,b47 on the posterior surface of the joint1 corresponding in size and direction to the linear incision in front4 ,this gives a much easier mode of access to the glenoid4 ,i have seen this practised in one very remarkable case by ,mr4 ,syme1 in which the glenoid cavity and neck of the scapula were extensively diseased1 while the head of the bone was quite sound4 ,after-treatment is exceedingly simple2 for the first day or two the shoulder is to be supported on a pillow with a simple pad in the axilla1 if there is any tendency for the arm to drag inwards2 after this the patient should be encouraged to sit up and move about with his arm in a sling1 the elbow hanging freely down4 ,results4--,hodge records ninety-six cases in which this excision was performed for gunshot injury1 of which twenty-five proved fatal1 and fifty for disease1 of which only eight died1--results which are more encouraging than those of amputation at the shoulder-joint for disease2 though for injury the mortality is much greater than ,larrey's famous ,statistics of ,amputation1 q4v4 p4 #fe4 ,spence had thirty-three cases1 with three deaths4 ,he generally made a counter-opening behind to get rid of discharges1 and inserted a drainage-tube4 ,gurlt's statistics of excision for gunshot injury give of #affa cases #ajfg recoveries1 #bg doubtful results1 and #efg deaths1 the mortality being #cd4gj per cent4 ,,excision ,,of ,,the ,,elbow-,,joint--,in what cases should it be performed8--#a4 ,for disease of the elbow-joint which has resisted ordinary remedies1 and is wearing down the patient's strength1 including caries1 ulceration of cartilages1 and gelatinous synovial degeneration4 #b4 ,for wounds of the elbow penetrating the joint1 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 excision4 ,this is especially the case when the wound of the joint is small and punctured1 but if the case is seen early and treated by free drainage1 with antiseptic precautions1 excision may not be required4 #c4 ,for anchylosis1 in cases where after disease or injury the limb has stiffened in a bad position1 especially when1 with a straight elbow1 the hand is rendered almost perfectly useless4 ,how much should be removed8--,in the elbow-joint1 more than any other joint in the body1 complete excision is absolutely necessary2 any portion of the articular surface being left proves a source of unfavourable result4 ,the surgeon is apt to err rather in removing too little than too much4 ,for the removal of too little bone is1 on the one hand1 apt to result in long-standing sinuses1 on the other1 to induce anchylosis4 ,in making the section of the bones1 the saw ought to be applied to the humerus transversely just at the commencement of its condyloid projections1 and to the radius and ulna1 at least at a level with the base of the coronoid process of the ulna4 ,but while removing enough1 we must not be led into the error of removing too much4 ,if this is done1 as was done by ,sir ,philip ,crampton in his first case1 and as happens occasionally of necessity in cases of excision for gunshot wounds or other accidents1 much of the power of the arm is lost as a consequence of the shortening and excessive mobility4 ,a mistaken pathology sometimes deceives in the examination of the state of the bones1 and causes an unnecessary amount to be removed4 ,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 repair1 and while the cartilaginous surfaces are denuded of cartilage1 soft1 and porous1 the bones close by are roughened with a stalactitic-looking growth1 projecting in knobs and angles4 ,now1 if this be mistaken for disease and removed1 too much will almost certainly be taken away1 and the result will be unsatisfactory4 ,much less care need be taken exactly to discriminate and remove the diseased soft parts2 indeed they may be left alone2 the synovial membrane in a state of gelatinous degeneration sometimes presents a very formidable appearance of disease1 but if the bones be properly removed1 all this swelling will soon go down1 and a healthy condition of parts succeed1 without any clipping or paring on the surgeon's part4 ,operation4--,the back of the joint is of course chosen for the seat of the incisions1 both because the bones are there just under the skin1 and because the great vessels and nerves lie in front of the joint4 ,the form and number of the incisions vary considerably1 and ought to vary according to the nature of the case and the amount of disease or injury4 ,though it is now little used1 for historical interest ,i retain the description of the ,h-shaped incision 7,plate ,,iii4 fig4 ,c471 used first by ,moreau1 and re-introduced by ,mr4 ,syme1 and used by him for most of his very numerous cases4 ,the posterior surface of the joint being exposed1 the surgeon1 with a strong straight bistoury1 makes a transverse incision into the joint just above the olecranon4 ,it should begin just far enough outside of the internal condyle to avoid the ulnar nerve1 which the surgeon should protect by the forefinger of his left hand1 and should extend transversely across to the outer condyle4 ,from each end of this incision the surgeon should next make at a right angle two incisions1 each about one inch and a half or two inches long1 right down to the bone1 thus marking out two quadrilateral flaps4 ,these should next be raised from the bones1 up and down1 as much of the soft parts being retained in them as possible1 so as to add to their thickness4 ,the olecranon is thus exposed1 and should be removed by saw or pliers by cutting into the greater sigmoid notch2 the lateral ligaments must then be cut1 if they are not already destroyed by the disease1 and the humerus protruded1 a proper amount of which is then to be sawn off in a transverse direction4 ,the head of the radius is then easily removed by the bone-pliers1 and the ulna also protruded1 the attachment of the brachialis anticus to the coronoid process divided1 and the bone sawn across just at the base of that process4 ,few vessels1 if any1 will require ligature1 and the arm being bent to nearly a right angle1 the transverse incision must be very carefully sewed up with silver sutures closely set and deeply placed1 as much of the future success of the joint depends on the completeness of the primary union of this incision4 ,the external incision may also be accurately adjusted1 the internal one not so completely1 to allow free vent for the discharge1 which is aided by the ligatures1 if any are required1 being brought out at its lower angle4 ,a figure-of-#h bandage should be applied over pads of dry lint1 and the limb laid on a pillow4 ,no splint is necessary2 in a few days the patient will be able to rise and walk about4 ,passive motion should be begun so soon as the first inflammatory symptoms have passed off4 ,if properly performed1 in a tolerably healthy subject1 the surgeon should not be satisfied with any results short of almost perfect restoration of motion in the joint4 ,flexion and extension to their full extent1 with a very considerable amount of pronation and supination1 are to be expected1 with proper care1 in a patient of average intelligence4 ,numerous cases are now on record where almost perfect performance of all the duties of life was retained after excision of the elbow-joint4#ed ,in most cases it is possible1 and in nearly all advisable1 to excise the joint by means of a less complicated incision4 ,thus one long vertical incision at the posterior surface1 with its centre about midway between the ulna and the external condyle1 with a transverse incision at right angles to it1 and reaching almost to the internal condyle1 has been often practised with a very good result4 ,by nearly universal consent this single straight incision is now used1 and when it is properly dressed and drained gives admirable results4 ,a single vertical incision 7,plate ,,iii4 fig4 ,d47 without any transverse one1 as long ago recommended by ,chassaignac1 is1 in most cases1 quite sufficient to give access4 ,it is most suitable in cases of anchylosis1 where there is little deposit of new bone1 or in cases of disease of the joint1 accompanied with little swelling or thickening of surrounding tissues4 ,it has the advantage of avoiding the cicatrix of a transverse incision1 which doubtless may1 if at all a broad one1 somewhat interfere with the future flexion of the limb1 but1 on the other hand1 unless care is taken1 it does not give such free egress for the discharge1 and when there is much delay in healing1 the vertical incision may leave a cicatrix nearly as troublesome as the other4 ,the following modification1 suggested and practised by the late ,mr4 ,maunder1 seems to be a step in the right direction when it is practicable4 ,after a longitudinal incision crossing the point of the olecranon ,i next let the knife sink into the triceps muscle1 and divide it longitudinally into two portions1 the inner one of which is the more firmly attached to the ulna1 while the outer portion is continuous with the anconeus muscle1 and sends some tendinous fibres to blend with the fascia of the fore-arm4 ,it is these latter fibres that are to be scrupulously preserved4 ,two points have to be remembered3 first1 the ulnar nerve1 often unseen1 must be lifted from its bed1 and carried over the internal condyle to a safe place1 and then the outer portion of the triceps muscle with its tendinous prolongation1 the fascia of the fore-arm and the anconeus muscle must be dissected up1 as it were1 in one piece1 sufficiently to allow of its being temporarily carried out over the external condyle of the humerus4#ee ,this method aids in retaining the power of active extension of the elbow-joint4 ,excision for osseous anchylosis in the extended position of the joint may be sometimes rendered very difficult by the density1 firmness1 and extensive hypertrophy of the bones1 which become fused into one solid mass4 ,any attempt to isolate the bones1 and remove the anchylosed joint entire1 by incising the bones as if for disease1 will both prove very laborious1 and also probably end in doing some damage to the vessels and nerves in front4 ,but by sawing through the anchylosis about its centre1 as was pointed out many years ago by ,mr4 ,syme1 the fore-arm may be flexed1 and the bones as easily displayed1 cleaned1 and removed1 as in the operation for disease4 ,in this operation1 as there is less thickening of the skin and subjacent textures1 and in consequence more risk of deficiency and even sloughing of the flaps made by the ,h-shaped incision1 a single straight incision will serve the purpose admirably4 ,partial incisions of the elbow-joint are1 as a rule1 less successful and more dangerous to life than complete ones1 except in cases of excision for anchylosis4 ,even in gunshot wounds1 where the bones were previously healthy1 and where uninjured portions might have been left with some hopes of success1 this is the case4 ,dr4 ,heron ,watson has devised the following operation for cases of anchylosis the result of injury3--7#a47 ,a linear incision over ulnar nerve at inner side of olecranon4 7#b47 ,the ulnar nerve to be carefully turned over the inner condyle4 7#c47 ,a probe-pointed bistoury to be introduced into the elbow-joint in front of the humerus1 and then behind and carried upwards1 so as to divide the upper capsular attachments in front and behind4 7#d47 ,a pair of bone-forceps to be next employed to cut off the entire inner condyle and trochlea of the humerus1 and then introduced in the opposite diagonal direction so as to detach the external condyle and capitulum of the humerus from the shaft4 7#e47 ,the truncated and angular end of the humerus to be divided1 turned out through the incision1 and smoothed across at right angles to the line of the shaft by means of the saw1 whereby 7#f47 room might be afforded1 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 arm4#ef ,six cases have had satisfactory results4 ,the mortality from this operation is considerably less than that from amputation of the arm4 ,of a series of excisions for disease1 injury1 and anchylosis1 #bb4ae per cent4 died1 while out of a similar series of amputations of the arm the mortality was #cc4d per cent4#eg ,our mortality of excision of the elbow here is certainly much less than the above4 ,all of the cases1 between thirty and forty1 in which ,i have done it have recovered with but one exception1 and ,mr4 ,syme lost only one during the time ,i was his assistant4 ,professor ,spence lost only #af in #ahi cases1 or #h4c per cent4 ,gurlt's statistics for gunshot injury give a mortality of over #bd per cent4 ,out of #hb cases where the joint was excised for injury in the ,schleswig-,holstein and ,crimean campaigns1 only #af died2 and out of #aae cases in which the joint was excised for disease1 only #ae died4 ,the period after the injury at which the excision is performed seems to be important4 ,deaths4 ,thus of #aa cases within first twenty-four hours1 #a #a-aa #bj between second and fourth days1 #d #a-e #i eighth and thirty-seventh1 #a #a-i -- -- #dj #f ,,excision ,,of ,,the ,,wrist4--,very various methods have been proposed and executed for the purpose of excising this joint4 ,these vary much in difficulty and complexity1 in proportion to the endeavours made to save the tendons from being cut4 ,the principles which must guide all attempts at operative interference with this joint are-- #a4 ,to remove all the diseased bone1 including the cartilage-covered portions of the radius1 ulna1 and of the metacarpal bones1 as little of these bones being removed as possible1 beyond the cartilage-covered portions4 #b4 ,to disturb the tendons as little as possible1 especially to avoid isolating them from the cellular sheath4 #c4 ,to commence passive motion of the fingers very soon after the operation4 ,it is rarely possible to remove the carpal bones as a whole1 from the diseased condition which renders the operation necessary1 and the digging out of the various bones piecemeal renders the operation very tedious1 especially if the proximal ends of the metacarpal bones are involved and require to be removed1 hence this operation was practically impossible till after the discovery of ansthesia4 ,in describing the operation elaborated and described by ,professor ,lister1 the type of the various plans in which the tendons are saved is given1 while a very few words descriptive of the incisions used by others who cut the tendons will suffice4 ,,lister',s ,,operation ,,of ,,excision ,,of ,,the ,,wrist-,,joint4--,even an abridgment of ,mr4 ,lister's account of his operation must necessarily be long1 because the operation itself is so complicated and prolonged1 and guided by such precise principles1 as to render much abridgment almost impossible4 ,a tourniquet is put on1 to prevent oozing1 which would conceal the state of the bones2 any adhesions of the tendons must be then broken down by free movement of all the joints4 ,the radial incision 7,plate ,,iv4 fig4 ,a47 is then made4 ,it commences at the middle of the dorsal aspect of the radius1 on a level with the styloid process1 passes as if going towards the inner side of the metacarpo-phalangeal joint of the thumb1 in a line parallel to the extensor secundi internodii1 but turns off at an angle as it passes the radial border of the second metacarpal1 and then longitudinally downwards for half the length of that bone4 ,the extensor carpi radialis brevior tendon is divided in the incision4 ,the soft parts at the radial side are to be carefully dissected up1 and the tendon of the extensor carpi radialis longior divided at its insertion4 ,the cut tendons1 and the extensor secundi internodii tendon and the radial artery can thus be pushed outwards1 enabling the trapezium to be separated from the carpus by cutting-pliers4 ,the extensor tendons being relaxed by bending back the hand1 the soft parts must be cleared from the carpus as far as possible towards the ulnar side4 ,illustration3 ,,fig4 ,,vi4#eh ,the ulnar incision 7,plate ,,iv4 fig4 ,b47 extends from two inches above the end of the ulna1 in a line between the bone and the flexor carpi ulnaris1 straight down as far as the middle of the palmar aspect of the fifth metacarpal4 ,the dorsal lip of this incision is then raised1 and the tendon of the extensor carpi ulnaris cut at its insertion1 and reflected up out of its groove in the ulna along with the skin4 ,the extensor tendons are then raised from the carpus1 and the dorsal and lateral ligaments of the wrist divided1 the tendons still being left as far as possible undisturbed in their relation to the radius4 ,in front the flexor tendons are cleared from the carpus1 the pisiform bone separated from the others though not removed1 and the hook of the unciform divided by pliers4 ,the knife must not go further down than the base of the metacarpal bones1 in case of dividing the deep palmar arch4 ,the anterior ligament of the wrist being now divided1 the carpus and metacarpus are to be separated by cutting-pliers1 and the carpus extracted by strong sequestrum forceps4 ,by forcible eversion of the hand1 the ends of radius and ulna can be protruded at the ulnar incision2 as little as possible should be removed1 consistent with removing all the disease4 ,the ulna should be cut obliquely1 leaving the base of the styloid process1 and removing all the cartilage-covered portion4 ,a thin slice of the radius is then to be cut also with the saw1 so thin as to remove only the bevelled ungrooved portion1 and leaving the tendons as far as possible undisturbed in their grooves4 ,the ulnar articular facet is to be snipped off with bone-pliers4 ,if the bones are more deeply carious1 the diseased parts must at all hazards be removed with pliers or gouge4 ,the metacarpal bones must then be treated in precisely the same way1 their ends sawn off and their articular facets snipped off with the bone-pliers longitudinally4 ,the trapezium is then to be seized by forceps and carefully dissected out1 the metacarpal bone of the thumb pared like the others1 the articular surface of the pisiform removed1 the rest of the bone being left if it is sound4 ,the radial incision is stitched closely throughout1 and also the ends of the ulnar incision1 any ligature being brought out through the centre of the ulnar incision1 which is kept open with a piece of lint1 which also gives support to the extensor tendons4 ,the after-treatment is important1 the principal specialities being--7#a47 early and free movement of the fingers2 7#b47 secure fixing of the wrist to procure consolidation4 7#a47 ,by passive motion of the joints of the knuckles and fingers1 commenced on the second day1 and continued daily after the operation2 7#b47 ,by a splint supporting the fore-arm and hand1 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 palm2 this prevents the splint from slipping up the arm1 and by a turn of a bandage insures fixation of the wrist-joint4 ,the anterior part of this splint below the fingers may be gradually shortened1 allowing more and more passive motion of the fingers1 but the patient must wear it for months1 indeed1 till he finds his wrist as strong without it as with it4 ,among the various operations that have been devised1 the following require notice3--,mr4 ,spence1 ,dr4 ,gillespie1 ,dr4 ,watson1 and the author1 use a single dorsal incision with excellent results1 and find it quite easy to remove all the bones from it4 ,mr4 ,spence had sixteen cases without a death4 ,,posterior ,,semilunar ,,flap1 from carpal attachment of metacarpal of index finger round to styloid process of ulna2 dividing integuments only1 then separating the tendons of the common extensor longitudinally1 and drawing them aside by blunt hooks1 the diseased bones are removed piecemeal by curved parrot-bill forceps4#ei ,,posterior ,,curved ,,flap4--,an incision down to the carpal bones1 extended from a point two lines to the ulnar side of the extensor secundi internodii pollicis1 and from a quarter to half an inch below the radio-carpal articulation1 swept in a curvilinear direction downwards1 close to the carpal extremities of the metacarpal bones1 to a point just below the end of the ulna4 ,the flap thus marked out was dissected up1 and consisted of the integuments1 areolar tissue1 and extensor tendons of the four fingers1 together with large deposits of fibrine1 the products of repeated and prolonged inflammatory action4 ,the tendon of the second extensor and its soft parts around were separated from the bones4 ,the remains of the ligaments were cut1 flexion of the hand protruded the carious ends of radius and ulna4 ,the bones were then dissected out1 leaving the trapezium1 which was not diseased1 and hand placed on a splint4#fj ,,excision ,,of ,,the ,,hip-,,joint4--,the question as to the propriety of performing this operation in any case is still debated by some surgeons1 and the selection of suitable cases for the operation is greatly modified by the varying opinions of the different schools of surgery4 ,enough here to describe the method of operating1 and the amount of the bone which is to be removed4 ,as in the shoulder-joint1 the head of the femur is much more liable to disease1 and1 as a rule1 much earlier attacked than is the acetabulum1 but unfortunately the acetabulum does eventually become affected also in probably a much larger proportionate number of cases than the glenoid4 ,caries of the head1 neck1 and trochanters of the femur is a very common disease in this variable climate1 and frequently connected with the strumous taint4 ,after much suffering1 abscesses form and discharge1 giving considerable pain1 and often end by carrying off the patient4 ,as a result of the abscess and destruction of the ligaments1 the head of the bone is apt to be displaced1 and under some sudden muscular exertion or involuntary spasm1 consecutive dislocation of the femur 7generally on to the dorsum ilii7 very often occurs4 ,in such a case the operation of excision of the head of the femur is by no means difficult1 and not excessively dangerous1 especially in young children4 ,operation4--,it is hardly necessary1 or indeed possible1 to lay down exact rules for the performance of this operation1 in so far as the external incisions are concerned1 for the sinuses which exist ought in general to be made use of4 ,when the surgeon has his choice1 a straight incision 7,plate ,,ii4 fig4 ,a471 parallel with the bone1 extending from the top of the great trochanter downwards for about two inches1 and also from the same point in a curved direction with the concavity forwards1 upwards towards the position of the head of the bone 7see diagram71 will be found most convenient4 ,the incisions should be carried boldly down to the bone1 which will often be felt exposed and bathed in pus1 any remains of the ligamentous structures must be cautiously divided with a probe-pointed bistoury1 and then by bringing the knee of the affected side forcibly across the opposite thigh1 with the toes everted1 the head of the bone is forced out of the wound4 ,the head1 neck1 and great trochanter should be fully exposed1 and the saw applied transversely below the level of the trochanter1 so as to remove it entire4 ,if this is not done1 it prevents discharge1 protrudes at the wound1 and besides this it is almost invariably diseased along with the head4 ,chain saws are quite unnecessary1 it being in most cases easy to apply an ordinary one to the bone1 if it is properly everted4 ,great care in the after-treatment is required to prevent undue shortening of the limb1 or in the event of a cure to secure the most favourable position for the anchylosis4 ,the femur occasionally tends to protrude at the wound1 and hence may require to be counter-extended by splints4 ,if required at all1 the splint should be made with an iron elbow opposite the wound to admit of its being easily dressed4 ,in most cases counter-extension may be best managed by a weight and pulley4 ,various forms of hammock swings to support the whole body1 and slings of leather or canvas to support the limb only1 have been found to aid recovery1 and render the patient much more comfortable4 ,when the acetabulum is also diseased the prognosis is much more unfavourable than when it is sound4 ,the experiments of ,heine and ,jger on the dead body1 and operations by ,hancock1 ,erichsen1 and ,holmes1 on patients1 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 viscera4 ,the details of incisions for such an operation need scarcely be given1 as they must vary in each case with the amount of bone diseased1 and the position of the already existing sinuses4 ,the amount of bone that may be removed varies much4 ,erichsen in one case excised the upper end of the femur1 the acetabulum1 the rami of the pubis1 and of the ischium1 a portion of the tuber ischii1 and part of the dorsum ilii4#fa ,a less formidable proceeding may be useful in cases where the acetabulum is diseased1 but not deeply4 ,the moderate use of an ordinary gouge may succeed in removing the diseased bone4 ,experience and the cold evidence of statistics prove1 however1 that the prognosis in any case is modified very much for the worse by the presence of any disease of the acetabulum1 more than one-half of the cases proving fatal in which it is diseased1 whether attempts to remove the disease of the acetabulum be made or not1 and that those cases do best in which the head of the femur has been displaced1 and lies outside the joint almost like a loose sequestrum among the soft parts4 ,the results of excision of the hip have as yet been very discouraging1 the mortality of the whole series of published cases being1 according to ,dr4 ,hodge's careful table1 very little under #a in every #b cases1 viz41 #a in #b-e_/ec4 ,later statistics are however more favourable4 ,like all other excisions1 the mortality increases very much with the patient's age4 ,thus of #ajc completed cases in which the age is given1 #ec recovered and #ej died1 but dividing the cases at the end of the sixteenth year1 we find that of the children below this age #dc recovered and #bi died1 a mortality of #dj4b per cent42 of the adults1 #aj recovered1 and #ba died1 or a mortality of #fg4f per cent4 ,if we remember the marvellous power of recovery from joint diseases we find in childhood1 under the influence of good diet1 cod-liver oil1 and fresh air1 we cannot shut our eyes to the fact that such results and such a mortality are by no means encouraging4 ,from an extensive experience in a special hospital for hip-disease1 where fresh air1 abundant nourishment1 and very excellent nursing are provided1 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 children1 and he believes that operation is rarely necessary1 or even warrantable1 except for the removal of sequestra4 ,mr4 ,holmes's#fb statistics are interesting4 ,he has operated on no fewer than nineteen cases4 ,of these seven died1 one after secondary amputation at the hip4 ,another required amputation and recovered4 ,two others died of other diseases without having used their limb4 ,of the remaining nine1 three were perfectly successful1 four were promising cases1 and two unpromising4 ,professor ,spence in #ai cases had #f deaths1 or a mortality of #ca4f per cent4 ,culbertson's collection gives out of #dbf cases1 #aib deaths1 or #de per cent4 ,mr4 ,croft1 whose skill and success as an operator are well known1 has recorded #de cases of excision of hip in his own practice2 of these #af died1 #aa were under treatment1 #ah had recovered1 of which #af had moveable joints and useful limb2 the other two are potentially cured4#fc ,various other incisions have been devised for gaining access to the joint4 ,the most noticeable are those in which a flap is made instead of a linear incision4 ,sedillot makes a semilunar or ovoid flap1 the base of which is just below the great trochanter1 and which includes it1 the convexity being upwards and the flap being turned down4 ,gross's modification of this is preferable1 being turned the opposite way1 the convexity being downwards 7,plate ,,iii4 fig4 ,e471 and the flap thus being turned up4 ,results in successful cases4--,of fifty-two in ,hodge's table1 thirty-one had useful limbs1 six indifferent1 three decidedly useless1 four died within three years1 and of the remaining eight no details are given4 ,the shortening is always considerable1 a high-heeled shoe being required in most cases2 a stick is indispensable2 in many1 crutches are necessary4 ,various operations have been devised for the treatment of osseous anchylosis of the hip-joint when in a bad position4 ,all are more or less dangerous4 ,perhaps one of the least dangerous is the plan of subcutaneous division of the neck of the femur by a narrow saw1 proposed by ,mr4 ,adams of ,london4 ,it is sometimes a very laborious operation4 ,,excision ,,of ,,knee-,,joint4--,removal of ,bone4--,in every case the excision of the joint ought to be complete4 ,some attempts have been made to save one or other of the articular surfaces1 but they have proved failures4 ,the patella has frequently been left when it was not diseased1 as is often the case1 but the results have not been such as to recommend such a practice4 ,direction of ,section of the ,bones4--,the bones should be cut transversely1 and1 as far as possible1 be in accurate and complete apposition4 ,a slight bevelling at the expense of the posterior margin will produce an anchylosis of the limb in a very slightly flexed position1 which is found to aid the patient in walking4 ,it has been proposed by some#fd to cut both bones obliquely1 so as to obviate the difficulty of making the transverse surfaces parallel4 ,this involves a still greater practical difficulty in keeping these oblique surfaces in position during the after-treatment4 ,this plan might possibly be valuable in cases where the disease was limited to one or other edge of the bone4 ,among the various incisions recommended1 the best seems to be the ,semilunar ,incision4 ,operation4--,the limb being held in an extended position1 a single semilunar incision 7,plate ,i4 fig4 ,b47 is made1 entering the joint at once1 and dividing the ligamentum patell4 ,it should extend from the inner side of the inner condyle of the femur to a corresponding point over the outer one1 passing in front of the joint midway between the lower edge of the patella and tuberosity of the tibia4 ,the flap is then dissected back1 the ligaments divided1 when by extreme flexion of the limb the articular surface of the tibia and femur are thoroughly exposed4 ,the crucial ligaments must then be divided cautiously1 and the articular portion of the femur cleaned anteriorly by the knife1 posteriorly by the operator's finger1 so far as possible to avoid injury of the artery4 ,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 bone4 ,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 more4 ,it must involve all the bone normally covered by cartilage2 and this being removed1 if the section shows evidence of disease1 slice after slice may require removal till a healthy surface is obtained4 ,occasionally1 if the diseased portion appears limited1 though deep1 the application of a gouge may succeed in removing disease without involving too great shortening of the limb4 ,specially in children1 it is of great importance to avoid removing the whole epiphysis4 ,the tibia must then be exposed in a similar manner1 and a thin slice removed2 if the bone be tolerably healthy1 even less than half an inch will prove quite sufficient4 ,this method has an immense advantage in that it provides an excellent anterior flap for the amputation1 which may be required in cases where the disease of bone is found too extensive to admit of the excision being practised4 ,this method1 with slight deviations1 is substantially that of ,richard ,mackenzie of ,edinburgh1 ,wood of ,new ,york1 ,jones of ,jersey4 ,hmorrhage must then be stopped1 and that as thoroughly as possible1 by torsion1 cold1 and pressure1 and the flap brought accurately together with sutures4 ,in some rare cases1 it may be found necessary to divide the hamstring tendons to rectify spastic contraction of the muscles2 but this can generally be done quite well from the original wound4 ,holt makes a dependent opening in the popliteal space for drainage4 ,this is unnecessary if the incisions are made sufficiently far back1 and if the wound is properly drained4 ,it is unsafe1 as approaching so close to the artery and veins4 ,if much bagging takes place1 the use of a drainage-tube will prove quite sufficient4 ,after-treatment4--,wire splints lined with leather and provided with a foot-piece2 special box-splints with moveable sides1 as ,butcher's2#fe plaster-of-,paris moulds are used by ,dr4 ,p4,h4 ,watson#ff of ,edinburgh and others2 this last form of dressing is the best1 and allows the limb to be suspended from a ,salter's swing4 ,h-shaped incision4--,the internal incision should commence at a point about two inches below the articular surface of the tibia1 and in a line with its inner edge2 it should then be carried up along the femur in a direction parallel to the axis of the extended limb1 so as to pass in front of the saphena vein1 and thus avoid it1 for a distance of five inches4 ,the external incision1 commencing just below the head of the fibula1 must be carried upwards parallel to the preceding for the same distance4 ,both incisions must be made by a heavy scalpel with a firm hand1 so as to divide all the tissues down to the bone4 ,the vertical incisions are then united by a transverse one passing across just below the lower angle of the patella4 ,the flaps thus formed must then be dissected up and down1 and the internal and external lateral ligaments divided1 thus thoroughly opening the joint and exposing the crucial ligaments4 ,these must be divided carefully1 remembering the position of the artery4 ,the bones are then to be cleared and divided1 as in the operation already described4 ,this is the method of ,moreau and ,butcher4#fg ,patella and ,ligamentum ,patell retained4--,a longitudinal incision1 full four inches in extent1 was made on each side of the knee-joint1 midway between the vasti and flexors of the leg2 these two cuts were down to the bones1 they were connected by a transverse one just over the prominence of the tubercle of the tibia1 care being taken to avoid cutting by this incision the ligamentum patell2 the flap thus defined was reflected upwards1 the patella and the ligament were then freed and drawn over the internal condyle1 and kept there by means of a broad1 flat1 and turned-up spatula2 the joint was thus exposed1 and after the synovial capsule had been cut through as far as could be seen1 the leg was forcibly flexed1 the crucial ligaments1 almost breaking in the act1 only required a slight touch of the knife to divide them completely4 ,the articular surfaces of the bones were now completely brought to view1 and the diseased portions removed by means of suitable saws1 the soft parts being hold aside by assistants4#fh ,results of ,excision of ,knee-joint3--,holmes's ,table of recent cases from #ahgc-ahgh-- #bde cases2 #be deaths1 and #dg failures4 ,spence's--#cc cases2 #bb recovered1 #aa died4 ,,buck',s ,,operation ,,for ,,anchylosed ,,knee-,,joint4--,the principle of this operation is to remove a triangular portion of bone1 which is to include the surfaces of the femur and tibia1 which have anchylosed in an awkward position1 and by this means to set the bones free1 and enable the limb to be straightened4 ,access to the joint may be obtained by either of the two methods already described4 ,sections of the bones are then to be made with the saw1 so as to meet posteriorly a little in front of the posterior surface of the anchylosed joint1 and thus remove a triangular portion of bone2 the portion still remaining1 and which still keeps up the deformity1 is then to be broken through as best you can1 either by a chisel1 or a saw1 or forced flexion4 ,the ends are to be pared off by bone-pliers1 and the surfaces brought into as close apposition as possible4 ,the operation is a difficult one1 a gap being generally left between the anterior edges of the bones1 from the unyielding nature of the integuments behind1 and the difficulty of removing the posterior projecting edges from their close proximity to the artery4 ,of twenty cases on record1 eight died1 and two required amputation4 ,relation of ,age to result in ,excision of ,knee-,joint from ,hodge's ,tables4 ,of #ahb complete cases3-- #fh below #af years3 #ej recovered--#ah died2 or #bf per cent4 died4 #aad above #af years3 #ee recovered--#ei died2 or #ea4g per cent4 died4 ,,excision ,,of ,,the ,,ankle-,,joint4--,in what cases is it to be done1 and how much bone is to be removed8 ,in cases of compound dislocation of the ankle-joint1 the tibia and fibula are apt to be protruded either in front or behind4 ,when this happens it is a dislocation generally very difficult to reduce1 and when reduced to retain in position4 ,in such cases1 if there seems to be any chance of retaining the foot1 excision of the articular ends of tibia and fibula greatly add to the probabilities in its favour4 ,it may be done without any new wound1 and1 in general1 by an ordinary surgeon's saw4 ,when the astragalus does not protrude1 it seems to matter little for the future result whether its articular surface be removed or not4 ,when1 on the other hand1 it protrudes1 as a result either of the displacement of the entire foot1 or of a dislocation complete or partial of the astragalus itself1 there is no doubt that excision either of its articular surface or of the entire bone will give very excellent results4 ,jger reports twenty-seven such cases1 with only one fatal1 and one doubtful result4 ,in cases of disease of the ,ankle-joint4--,excision has been performed a good many times1 and should in most cases be complete4 ,a work like this is not the place to discuss the propriety of operations so much as the method of performing them1 but one remark may be permitted4 ,few points of surgical diagnosis are more difficult than it is to tell whether in any given case disease is confined to the ankle-joint1 and whether or not the bones of the tarsus participate4 ,if they do even to a slight extent1 no operation which attacks the ankle-joint only has any reasonable chance of success4 ,it may look well for a time1 but sinuses remain1 the irritation of the operation only hastens the progress of the disease of the bone1 and the result will almost certainly be disappointing1 amputation being almost the inevitable dernier ressort4 ,methods of ,operating3-- ,mr4 ,hancock has been very successful by the following method3-- ,commence the incision 7,plate ,,ii4 figs4 ,b4,b47 about two inches above and behind the external malleolus1 and carry it across the instep to about two inches above and behind the internal malleolus4 ,take care that this incision merely divides the skin1 and does not penetrate beyond the fascia4 ,reflect the flap so made1 and next cut down upon the external malleolus1 carrying your knife close to the edge of the bone1 both behind and below the process1 dislodge the peronei tendons1 and divide the external lateral ligaments of the joint4 ,having done this1 with the bone-nippers cut through the fibula1 about an inch above the malleolus1 remove this piece of bone1 dividing the inferior tibio-fibular ligament1 and then turn the leg and foot on the outside4 ,now carefully dissect the tendons of the tibialis posticus and flexor communis digitorum from behind the internal malleolus4 ,carry your knife close round the edge of this process1 and detach the internal lateral ligament1 then grasping the heel with one hand1 and the front of the foot with the other1 forcibly turn the sole of the foot downwards1 by which the lower end of the tibia is dislocated and protruded through the wound4 ,this done1 remove the diseased end of the tibia with the common amputating saw1 and afterwards with a small metacarpal saw placed upon the back of the upper articulating process of the astragalus1 between that process and the tendo ,achillis1 remove the former by cutting from behind forwards4 ,replace the parts in situ2 close the wound carefully on the inner side and front of the ankle2 but leave the outside open1 that there may be a free exit for discharge1 apply water-dressing1 place the limb on its outer side on a splint1 and the operation is completed4 ,skin1 external1 and internal ligaments1 and the bones are the only parts divided1 no tendons and no arteries of any size4#fi ,barwell's method by lateral incisions is briefly as follows3-- ,on the outer side1 an incision over the lower three inches of the fibula turns forward at the malleolus at an angle1 and ends about half an inch above the base of the outer metatarsal4 ,the flap is to be reflected1 fibula divided about two inches from its lower end by the forceps1 and dissected out1 leaving peronei tendons uncut4 ,a similar incision on the inner side terminates over the projection of the internal cuneiform bone2 the sheaths of the tendons under inner angle are then to be divided1 and the artery and nerve avoided2 the internal lateral ligament is then to be divided1 the foot twisted outwards1 so as to protrude the astragalus and tibia at the inner wound4 ,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 other4#gj ,dr4 ,m4 ,buchanan of ,glasgow has described an operation by which the joint can be excised through a single incision over the external malleolus4 ,results4--,so far as can be gathered from cases already published1 the results are very often 7at least in one out of every two cases7 unsatisfactory4 ,sinuses remain1 which do not heal1 the limbs are useless1 and amputation is in the end necessary4 ,langenbeck has performed it sixteen times during the last ,schleswig-,holstein war 7in #ahfd71 and the ,bohemian war in #ahff1 with only three deaths4 ,in these cases the operation was subperiosteal4 ,,excision ,,of ,,the ,,scapula4--,more or less of the scapula has in many cases been removed along with the arm1 and even with the addition of portion of the clavicle4 ,excision of the entire bone1 leaving the arm1 has been performed in two instances by ,mr4 ,syme4 ,the procedure must vary according to the nature and shape of the tumour on account of which the operation is performed4 ,mr4 ,syme operated as follows3-- ,in the first case1 one of cerebriform tumour of the bone1 he made an incision from the acromion process transversely to the posterior edge of the scapula1 and another from the centre of this one directly downwards to the lower margin of the tumour4 ,the flaps thus formed being reflected without much hmorrhage1 ,i separated the scapular attachment of the deltoid1 and divided the connections of the acromial extremity of the clavicle4 ,then1 wishing to command the subscapular artery1 ,i divided it1 with the effect of giving issue to a fearful gush of blood1 but fortunately caught the vessel and tied it without any delay4 ,i next cut into the joint and round the glenoid cavity1 hooked my finger under the coracoid process1 so as to facilitate the division of its muscular and ligamentous attachments1 and then pulling back the bone with all the force of my left hand1 separated its remaining attachments with rapid sweeps of the knife4 7,plate ,,iii4 fig4 ,g47 ,mr4 ,syme's second case was also one of tumour of the scapula2 the head of the humerus had been excised two years before4 ,he removed it by two incisions1 one from the clavicle a little to the sternal side of the coracoid1 directed downwards to the lower boundary of the tumour1 another transversely from the shoulder to the posterior edge of the scapula4 ,the clavicle was divided at the spot where it was exposed1 and the outer portion removed along with the scapula4#ga ,the author has in a case of osseous tumour removed the whole body of the scapula1 leaving glenoid1 spine1 acromion and anterior margin with excellent result and a useful arm4 ,large portions of the shafts of the humerus1 radius1 and ulna have been removed for disease or accident1 and useful arms have resulted2 but as the operative procedures must vary in every case1 according to the amount of bone to be removed1 and the number and position of the sinuses1 no exact directions can be given4 ,for very interesting cases of such resections reference may be made to ,wagner's treatise on the subject1 translated and enlarged by ,mr4 ,holmes1 and to ,williamson's ,military ,surgery1 p4 #bbg4 ,,excision ,,of ,,metacarpals ,,and ,,phalanges4--,to excise the metacarpal implies that the corresponding finger is left4 ,except in cases of necrosis1 where abundance of new bone has formed in the detached periosteum1 the results of such excisions do not encourage repetition1 the digits which remain being generally very useless4 ,it is quite different1 however1 if it is the thumb that is involved2 and every effort should1 in every case1 be made to retain the thumb1 even in the complete absence of its metacarpal bone4 ,for the good results of a case in which ,mr4 ,syme excised the whole metacarpal bone for a tumour1 see his ,observations in ,clinical ,surgery1 p4 #ch4 ,the operation is not difficult1 and requires merely a straight incision over the dorsum1 extending the whole length of the bone4 ,in the same way the proximal phalanx of the thumb may be excised1 and yet1 if proper care be taken1 a very useful limb be left4 ,i quote entire the following case by ,mr4 ,butcher of ,dublin3-- ,,excision ,,of ,,proximal ,,phalanx ,,of ,,the ,,thumb4-- ,the thumb of the right hand was crushed by the crank of a steam-engine4 ,the proximal phalanx was completely shivered2 its fragments were removed1 the cartilage of the proximal end of the distal phalanx1 and also of the head of the metacarpal bone1 were pared off with a strong knife4 ,the digit was put up on a splint fully extended4 ,in about a month cure was nearly complete1 a firm dense tissue took the place of the removed phalanx1 and the power of flexing the unguinal was nearly complete4#gb ,,excision ,,of ,,the ,,joints ,,of ,,the ,,fingers4--,these operations may be performed for compound dislocation1 specially when the thumb is injured2 no directions can be given for the incisions4#gc ,in cases of disease it is rarely necessary or advisable to attempt to save a finger1 but if the metacarpo-phalangeal joint of the thumb be affected1 excision should be performed with the hope of saving the thumb4 ,a single free incision on the radial side of the joint will give sufficient access4 ,,excision ,,of ,,the ,,os ,,calcis4--,in those comparatively rare cases in which the os calcis is alone affected1 the rest of the tarsus and the ankle-joint being healthy1 a considerable difference of opinion exists as to the proper course to be followed4 ,by some surgeons it is considered best merely to gain free access to the diseased bone1 and then remove by a gouge all the softened and altered portions1 leaving a shell of bone all round1 of course saving the periosteum and avoiding interference with the joint4 ,this operation requires no special detailed instruction4 ,we find many surgeons1 among them ,fergusson and ,hodge1 supporters of this comparatively modest operation4 ,the author has many times performed this operation with excellent results4 ,even when nothing but periosteum is left1 the new bone becomes strong and of full size4 ,excision of the whole of the diseased bone at its joints1 with or without an attempt to leave some of the periosteum1 has been deemed necessary by others4 ,holmes1 who has had considerable experience1 removes the bone at once by the following incisions1 without paying any reference to the periosteum3-- ,operation4--,an incision 7,plate ,,iii4 fig4 ,f47 is commenced at the inner edge of the tendo ,achillis1 and drawn horizontally forwards along the outer side of the foot1 somewhat in front of the calcaneo-cuboid joint1 which lies midway between the outer malleolus and the end of the fifth metatarsal bone4 ,this incision should go down at once upon the bone1 so that the tendon should be felt to snap as the incision is commenced4 ,it should be as nearly as possible on a level with the upper border of the os calcis1 a point which the surgeon can determine1 if the dorsum of the foot is in a natural state1 by feeling the pit in which the extensor brevis digitorum arises4 ,another incision is then to be drawn vertically across the sole1 commencing near the anterior end of the former incision1 and terminating at the outer border of the grooved or internal surface of the os calcis1 beyond which point it should not extend1 for fear of wounding the posterior tibial vessels4 ,if more room be required1 this vertical incision may be prolonged a little upwards1 so as to form a crucial incision4 ,the bone being now denuded by throwing back the flaps1 the first point is to find and lay open the calcaneo-cuboid joint1 and then the joints with the astragalus4 ,the close connections between these two bones constitute the principal difficulty in the operation on the dead subject2 but these joints will frequently be found to have been destroyed in cases of disease4 ,the calcaneum having been separated thus from its bony connections by the free use of the knife1 aided1 if necessary1 by the lever1 lion-forceps1 etc41 the soft parts are next to be cleaned off its inner side with care1 in order to avoid the vessels1 and the bone will then come away4#gd ,attempts may occasionally be made in such an operation to save a portion of periosteum in attachment to the soft parts1 but success or failure in this seems to have very little effect on the future result4 ,hancock's ,method4--,a single flap was formed in the sole1 with the convexity looking forwards1 by an incision from one malleolus to the other4 ,greenhow's ,method4--,incisions made from the inner and outer ankles1 meeting at the apex of the heel1 and then others extending along the sides of the foot1 the flaps being dissected back so as to expose the bone and its connections4#ge ,,excision ,,of ,,astragalus4--,a curved incision on the dorsum of the foot extending from one malleolus to the other1 and as far forwards as the front of the scaphoid4 ,the chief caution required is to divide all ligaments which hold the bone in place1 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 lie4#gf ,,excision ,,of ,,astragalus ,,and ,,scaphoid4--,an incision similar to the anterior one in ,syme's amputation at the ankle4 ,the flap was then turned back from the dorsum of the foot4 ,the joint was then opened1 the lateral ligaments of the ankle-joint divided1 the foot dislocated so as to show the astragalo-calcanean ligaments1 and allow them to be divided4 ,the bones were then grasped with the lion-forceps and pulled forwards1 while the posterior surface of the astragalus was very cautiously cleaned1 so as to avoid the posterior tibial artery4#gg ,,excision ,,of ,,metatarso-,,phalangeal ,,joint ,,of ,,great ,,toe4--,butcher performs it by splitting up the sinuses leading to the carious joint1 exposing it and cutting off with bone-pliers the anterior third of the metatarsal bone1 and the proximal end of the first phalanx4 ,he also cuts subcutaneously the extensor tendons to prevent them from cocking up the toe4#gh ,pancoast prefers a semilunar incision4 ,a lateral incision is usually to be preferred4 ,the author has performed this excision frequently for disease2 when the whole cartilages are removed and the wound is freely drained1 an admirable result is obtained4 ,in cases of compound dislocation of the head of the metatarsal bone1 it will occasionally be found necessary to excise it either by the original1 or a slightly enlarged wound4 ,the author lately excised one-half of shaft of metatarsal and the corresponding half of proximal phalanx of great toe for exostosis1 with antiseptic precautions4 ,the result was a useful toe with a mobile joint4 ,,excision ,,of ,,metatarsal ,,bone ,,of ,,great ,,toe4--,for this operation a quadrilateral flap has been recommended1 but this is quite unnecessary4 ,a single straight incision along the inner border of the foot1 extending the whole length of the bone1 renders it very easy to remove the whole bone from joint to joint4 ,this is an operation1 however1 which is rarely needed1 and which would leave a very useless flail of a toe4 ,the operation1 which is at once more commonly required1 and also gives promise of a more satisfactory result1 is the one performed for cario-necrosis of the shaft only1 and in the following manner3-- ,a straight incision through all the tissues1 including the periosteum1 right down to the bone2 then with nail or handle of the knife to separate the periosteum from the bone2 then with a pair of bone-pliers or a fine saw to divide the shaft from both its extremities and remove it entire4#gi ,,footnotes3 #eb ,on ,diseases and ,injuries of ,joints1 p4 #aba4 #ec ,for a very large amount of most interesting and valuable information on the whole subject of excisions of joints1 ,i would refer to ,dr4 ,hodge's most excellent work on this subject--,on ,excisions of ,joints4 ,by ,richard ,m4 ,hodge1 ,m4,d41 ,boston1 ,massachusetts4 #ed ,see ,syme's ,observations on ,clinical ,surgery1 pp4 #ee1 #eg2 ,hodge on ,excision of ,joints1 p4 #fc4 #ee ,maunder's ,operative ,surgery1 #b;d ed4 p4 #abc4 #ef ,edin4 ,med4 ,journal1 ,may #ahgc4 #eg ,quoted by ,mr4 ,porter4 ,dublin ,quarterly ,journal for ,may #ahfg1 p4 #bfd4 #eh ,a-,a4 ,deep palmar arch2 ,b4 ,trapezium2 ,c4 ,articular surface of ulna2 ,dotted lines include the amount removed in ,lister's earlier operations2 ,unshaded portions are those removed by ,lister in cases where the disease is limited to the carpus4 7,reduced from ,lister's diagram in ,lancet1 #ahfe47 #ei ,skey1 ,op4 ,surg41 #b;d ed4 p4 #dch4 #fj ,abridged from ,butcher1 ,op4 and ,con4 ,surgery1 p4 #bjh4 #fa ,science and ,art of ,surgery1 #c;d ed4 p4 #gde4 #fb ,on the ,surgical ,treatment of ,children's ,diseases1 pp4 #ded-f4 #fc ,clinical ,society's ,transactions1 vol4 xiii4 p4 #ga4 #fd ,billroth of ,vienna and ,pelikan of ,st4 ,petersburg1 quoted from ,heyfelder by ,hodge on ,excision of ,joints1 p4 #afa4 #fe ,operative and ,conservative ,surgery1 pp4 #bh1 #ach4 #ff ,on ,excision of ,knee-,joint1 pp4 #ah1 #bj4 #fg ,operative and ,conservative ,surgery1 p4 #afi4 #fh ,mr4 ,jones of ,jersey1 ,med4 ,chir4 ,trans41 vol4 xxxvii4 p4 #fh4 #fi ,lancet1 ,oct4 #a1 #ahei4 #gj ,barwell ,on ,diseased ,joints1 p4 #dfd4 #ga ,syme ,on ,excision of the ,scapula1 pp4 #ac-bf1 #ahfd4 #gb ,butcher's ,operative and ,conservative ,surgery1 p4 #bbe4 #gc ,for an excellent case1 see ,annandale on ,diseases of the ,finger and ,toes1 p4 #bfa4 #gd ,holmes's ,surgery1 #c;d edition1 vol4 iii4 p4 #gga4 #ge ,brit4 and ,foreign ,med4 ,chir4 ,review for ,july #ahec4 #gf ,mr4 ,holmes in ,lancet for ,february #ah1 #ahef4 #gg ,ibid4 for ,may #ahfe4 #gh ,butcher1 ,operative and ,conservative ,surgery1 p4 #ced4 #gi ,see ,butcher1 ,operative and ,conservative ,surgery1 p4 #cef4 ,,chapter ,,iv4 ,,operations ,,on ,,cranium ,,and ,,scalp4 ,,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 pivot4 ,when the motion is given to the saw simply by rotation of the hand of the operator1 as is common in this country1 it is called trephining2 when 7as used to be the case in this country1 and still is on the ,continent7 the motion is given by an instrument like a carpenter's brace1 the operation is called trepanning4 ,the nature of the operation varies according to the nature of the case for which it is performed4 ,thus 7#a47 it may be performed through the uninjured cranium in the hope of evacuating an abscess of the diploe or dura mater1 or of relieving pressure caused by suppuration in the brain itself1 or by extravasation into the brain or membranes2 or 7#b47 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 portions2 or 7#c47 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 cranium4 #a4 ,in cases where the cranium and its coverings are entire4--,there are certain positions where1 if it is possible1 the trephine should not be applied4 ,these are the longitudinal sinus1 the anterior inferior angle of the parietal bone1 where the middle meningeal artery is in the way1 the occipital protuberance1 and the various sutures4 ,these being avoided1 a crucial incision is to be made through the skin1 and its flaps reflected4 ,the pericranium should then be raised from the centre1 for a space large enough to hold the crown of the trephine4 ,the pericranium should never be removed1 but carefully raised and preserved1 as its presence will greatly aid in the restoration of bone4#hj ,the centre pin should then be projected for about the eighth of an inch and bored into the bone4 ,on it as a centre the saw is then worked by semicircular sweeps in both directions alternately1 till it forms a groove for itself4 ,whenever this groove is deep enough the pin should be retracted1 lest from its projection it pierce the dura mater before the tables of the skull are cut through4 ,were the cranium always of the same thickness1 and even of similar consistence1 the operation would always be exceedingly easy2 but in both these particulars different skulls vary much from each other1 and thus by a rash use of the instrument the dura mater may possibly be injured4 ,the tough outer table is more difficult to cut than the softer and more vascular diploe1 and the inner table is denser than either1 but more brittle4 ,in many old skulls1 however1 the diploe is wanting altogether1 and the two tables are amalgamated1 and often very thin4 ,great care must be taken in every case to saw slowly1 to remove the sawdust1 and examine the track of the saw by a probe or quill1 lest one part should be cut through quicker than another4 ,the last turns of the instrument must specially be cautious ones4 ,when the disk of bone does not at once come away in the trephine1 the elevator or the special forceps for the purpose will easily remove it4 ,if the abscess1 extravasation1 or exostosis be then discovered and removed1 all that remains is to remove any sawdust or loose pieces of bone1 and possibly to smooth off any sharp edges of the orifice by an instrument called the lenticular4 ,this is very seldom required1 and now hardly ever used4 #b4 ,in cases of depressed or punctured fracture the trephine is occasionally required 7when symptoms of compression are present7 for the purpose of enabling the depressed portion to be elevated4 ,it is unsafe to apply it to the depressed or fractured bone1 lest the additional pressure of the instrument should cause wound of the dura mater or brain4 ,it is generally applied on some projecting corner of sound bone under which the depressed portion is locked1 and hence it is rarely necessary to remove a complete circular portion4 ,in fact very many cases of such displacement may be remedied more easily by a pair of strong bone-forceps1 or a ,hey's saw1 applied to remove the projecting portion of sound bone4 ,the same precautions must be used as in the operation already described1 and the sawing must be done even more cautiously1 as it is rarely more than a semicircle that requires cutting4 ,in former days trephining was a much more frequent operation than it is now1 and apparently more successful4 ,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 brain1 which probably never would have appeared at all1 and that the operation itself is one by no means dangerous4 ,very numerous applications of the trephine have been made in the same individual--two1 four1 six1 and even in one case twenty-seven disks having been removed from the same skull1 and yet the patients have survived4 ,,tumours ,,of ,,the ,,scalp1 ,removal of4--,by far the most frequent are the encysted tumours1 or wens4 ,these consist of a thick firm cyst-wall1 which contains soft1 curdy1 or pultaceous matter1 sometimes almost fluid1 at others dry and gritty4 ,they are loosely attached in the subcutaneous cellular tissue1 and unless they have become very large1 or have been much pressed on1 are non-adherent to the skin4 ,the treatment is thus very simple4 ,they should merely be transfixed by a sharp knife1 the contents evacuated1 and the cyst seized by strong dissecting forceps and twisted out4 ,if they have once become adherent1 they must be dissected out in the usual manner1 after the adherent portion of skin has been defined by elliptical incisions4 ,in the case of large wens on visible parts of scalp or face1 the author avoids scar1 by the following plan3-- ,make a small incision1 two lines at most1 through skin only1 then with a blunt probe separate the cyst from the skin subcutaneously2 then1 pulling it to the wound with catch-forceps1 empty the cyst and gradually pull it out1 as if taking out an ovarian cyst4 ,no scar but a dimple will remain4 ,,footnotes3 #hj ,see case by the author in the ,edin4 ,med4 ,jour4 for ,june #ahfh4 ,,chapter ,v4 ,,operations ,,on ,,eye4 ,operations on the ,eye and its ,appendages4 ,,operations ,,on ,,the ,,lids4-- ,illustration3 ,,fig4 ,,vii4#ha ,illustration3 ,,fig4 ,,viii4#hb #a4 ,,for ,,entropium ,,or ,,inversion ,,of ,,the ,,lids1 ,,often ,,combined ,,with ,,trichiasis1 ,,irregularity ,,of ,,the ,,cili4--,as in many cases the entropium seems to depend partly on a too great laxity of the skin of the lid1 combined occasionally with spasm of the orbicularis1 the simplest and most natural plan of operation is 7a7 to remove 7,fig4 ,,vii4 a7 an elliptical portion of skin1 extending transversely along the whole length of the affected lid1 including the fibres of the orbicularis lying below it1 and then to unite the edges with several points of fine suture4 7b7 ,an improvement on this in obstinate cases is proposed by ,mr4 ,streatfeild 7,fig4 ,,viii47 ,he continues the same incision1 but in addition removes a long narrow wedge-shaped portion of the tarsal cartilage1 grooving it without entirely cutting it through1 in such a manner that the retraction of the skin bends the cartilage backwards1 thus everting to a very considerable extent the previously inverted cili4#hc #b4 ,,ectropium is the opposite condition from entropium2 in it the eyelids are everted and the palpebral conjunctiva is exposed4 ,if the result of cicatrix1 of a burn1 or of disease of bone1 the treatment must be varied according to circumstances1 and in many cases1 skin must be transplanted to fill the gap4 ,in the more usual cases resulting from chronic inflammation the following simple operations are required3--#a4 ,in mild cases the excision of an elliptical portion of conjunctiva may suffice1 the edges must not be left to contract1 but should be brought carefully together4 #b4 ,in more chronic cases1 where all the tissues of the lid are very lax1 it is necessary to remove 7,fig4 ,,vii4 b7 a ,v-shaped portion of lid and skin1 and then stitch it very carefully up with interrupted sutures4 ,,tumours ,,of ,,eyelids4--#a4 ,encysted tumours2 cysts of the lids2 tarsal tumour4--,under these and similar names are recognised a very frequent form of disease1 chiefly in the upper lid3 small tumours which rarely exceed half a pea in size1 convex towards the skin1 which is freely moveable over them2 they give no pain1 and are annoying only from their bulk and deformity4 ,operation4--,evert the lid1 incise the conjunctiva freely over the tumour1 insert the blunt end of a probe and roughly stir up the contents of the cyst1 thus evacuating it4 ,if the tumour is large and of old standing it may be requisite to cut out an elliptical or circular portion of its conjunctival wall4 ,the probe may require to be reapplied once or twice at intervals of two or three days1 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 silver4 ,in no case is it ever necessary to excise the tumour from the outside of the eyelid2 when this has been done in error there frequently remains an awkward and unsightly scar4 #b4 ,fibrous cysts1 frequently congenital1 are met with in one situation1 just over the external angular process of the frontal bone4 ,these are larger in size than the preceding1 ranging from the size of a barley pickle to that of an almond4 ,their treatment is excision by a prolonged and careful dissection from the periosteum1 to which they almost invariably are adherent4 ,,operations ,,on ,,the ,,lachrymal ,,organs4--,in a system of ophthalmic surgery1 various operative procedures might be detailed under this head1 authorised and sanctioned by old custom4 ,excision of a diseased lachrymal gland1 and removal of stones in the gland or ducts1 need no special directions for their performance1 and the operation immediately to be described1 under the head of ,mr4 ,bowman's operation1 is applicable in almost every one of the diseased conditions of the lachrymal canal1 sac1 and nasal duct1 to the exclusion of all the older methods4 ,mr4 ,bowman's ,operation4--,in cases of obstruction of the punctum1 canaliculus1 and nasal duct1 resulting in watery eye1 accumulation of mucus in the canal1 and dryness of the nose1 great difficulty used to be experienced in the treatment4 ,to pass a probe along the punctum was extremely difficult1 in fact1 possible only with a very small one1 while the common operation of opening the dilated sac1 through the skin1 and then passing probes through this artificial opening1 was found quite useless from the rapid closure of the wound1 unless the treatment was followed up by the insertion and retention of a style in the nasal duct4 ,this was painful1 unsightly1 often unsuccessful2 and even in some cases dangerous1 from the amount of irritation1 suppuration1 and even caries of the nasal bones which is set up4 ,the principle of ,mr4 ,bowman's most excellent operation is1 that the punctum1 canaliculus1 and nasal duct resemble in many respects the urethral passage1 and in cases of stricture require to be treated on the same principle4 ,if1 then1 it were possible to pass instruments gradually increasing in size through the seat of stricture1 it would be gradually dilated4 ,it is1 however1 in the normal state of parts1 impossible to pass any instrument beyond the size of a human hair past the curve which the canaliculus makes on its entrance to the duct1 hence the proper dilatation cannot be performed4 ,again1 it is found that the puncta1 specially the lower one1 are themselves very often to blame1 in cases of watery eye1 sometimes because they are inverted or everted1 more often because1 sympathising with the lid1 they are turgid1 angry1 and inflamed1 pouting and closed like the orifice of the urethra in a gonorrhoea4 ,mr4 ,bowman found that by slitting up the inferior punctum and canaliculus as far as the caruncula1 several advantages were gained3--7#a47 ,the swollen1 angry1 displaced punctum no longer impeded the entrance of the tears2 7#b47 and chiefly when the canaliculus was slit up1 the curve1 or rather angle1 which impeded the passage of probes1 was done away with1 and the nasal duct could be readily and thoroughly dilated4 ,operation4--,the surgeon stands behind the patient1 who is seated1 and leans his head on the surgeon's chest4 ,the affected lid is then drawn gently downwards on the cheek1 so as to evert and thoroughly expose the lower punctum4 ,into this the surgeon introduces a fine probe of steel gilt1 the first inch of which is very thin1 especially at the point1 and deeply grooved on one side1 exactly like a small 7and straight7 ,syme's stricture director4 ,keeping the canal relaxed by relaxing his hold on the lid1 the surgeon now gently wriggles the probe along the canaliculus1 gradually stretching it as the probe advances1 so as to avoid catching of the sides of the canal before the point of the instrument1 till he is satisfied that it has fairly entered the nasal duct4 ,he then stretches the eyelid1 brings the handle of the probe out over the cheek so as to evert the punctum as much as possible1 and then with a fine sharp-pointed knife enters the groove 7,fig4 ,,ix471 and fairly slits up the punctum and the canal to the full extent4 ,the incision should be as straight as possible1 and through the upper wall of the canaliculus4 ,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 duct1 the usual rule being observed of passing it downwards and slightly backwards1 the handle of the probe passing just over the supraorbital notch4 ,illustration3 ,,fig4 ,,ix4#hd ,for several days after the operation the probe will have to be passed1 both to prevent the wound in the canaliculus from healing up1 which it is too apt to do1 and also to gradually dilate the nasal duct if it has been previously strictured4 ,probes and directors of various sizes are required2 in fact very much the same instruments 7in miniature7 as are required for the treatment of stricture of the urethra4 ,mr4 ,greenslade has invented a very ingenious little instrument1 of which1 through his kindness1 ,i am able to show a woodcut 7,fig4 ,x471 for slitting up the canaliculus without having to fit the knife in the groove4 ,illustration3 ,,fig4 ,x4 ,,pterygium1 the reddish fleshy triangular growth1 with its base at the inner canthus1 and its apex spreading to and often over the cornea1 requires invariably a small operation for its removal4 ,in most cases it will be found sufficient merely to raise the lax portion over the sclerotic with forceps1 and divide it freely1 removing a transverse portion4 ,if it has encroached upon the cornea1 the portion interfering with vision must be dissected off with great care and removed4 ,in some cases1 however1 it has been found that after removal of a large pterygium1 a retraction of the caruncle and the semilunar fold is apt to take place1 which renders the eyeball unpleasantly prominent4 ,to avoid this the pterygium may be carefully dissected up from its apex to near its base1 and then displaced laterally either upwards or downwards1 its apex and sides being stitched to a previously prepared site of conjunctiva4 ,,operation ,,for ,,convergent ,,strabismus4--,division of the internal rectus4--,subconjunctival operation4--,the spring-wire speculum 7,c7 separating the lids1 the surgeon divides the conjunctiva by a pair of scissors in a horizontal line 7,fig4 ,,xi4 ,a ,a7 from the inner margin of the cornea1 a little below its transverse diameter to the caruncle1 then snipping through the sub-conjunctival tissue1 he passes a blunt hook bent at an obtuse angle under the tendon of the internal rectus1 and endeavours by depressing the handle to project the point of the hook at the wound4 ,then with successive snips of the scissors he divides the tendon on the hook1 close to its sclerotic margin4 ,lest it should not be freely divided1 various dips with the hook may be made to catch any stray fibres left untouched2 but very great care should be taken not to wound the conjunctiva beyond the first horizontal cut in it4 ,the tendon being divided satisfactorily1 the edges of conjunctiva should be replaced1 and the eye closed for a few hours4 ,illustration3 ,,fig4 ,,xi4#he ,the original operation of ,dieffenbach1 now rarely practised1 consisted in making an incision1 ,b ,b1 across the tendon1 then1 by cutting the areolar tissue exposing the insertion of the tendon1 and dividing it freely2 after which the sclerotic in the neighbourhood was to be cleaned and any band of fibres divided4 ,there are risks on the one hand of a most unseemly exophthalmos with divergent squint1 and on the other of a retraction of the semilunar fold1 so that the sub-conjunctival operation is always preferable4 ,,operations ,,for ,,divergent ,,squint4--,this very serious deformity is often the result of the operation for convergent squint1 and is associated with a fixed1 leering1 and prominent eye1 and frequently with most annoying double vision4 #a4 ,in a simple case of primary divergent strabismus 7very rare7 it is sufficient simply to divide the external rectus in the manner already described for division of the internal4 #b4 ,if secondary to an operation for convergent squint1 the indication is to restore the cut internal rectus to a position on the sclerotic a little behind its previous one1 as the cause of the divergence is found in a complete detachment of the internal rectus4 ,this is attempted in various ways4 7#a47 ,jules ,gurin carefully divided the conjunctiva over it1 and sought for the remains of the internal rectus1 freeing it from its attachments4 ,he then passed a thread through the sclerotic on the outer side of the globe1 and by pulling on it and fixing it across the nose1 rotated the eye inwards1 in the hope that the remains of the internal rectus would secure a new attachment4 7#b47 ,graefe's modification of this is more certain4 ,without any minute dissection he merely separated the internal rectus1 along with the conjunctiva1 and fascia over it1 so that it can be pulled forwards1 then cut the external rectus1 and inverted the eyeball to a sufficient extent by means of a thread passed through the portion of the tendon of the external rectus1 which remains attached to the sclerotic4 ,the risk of all these operations1 in which both muscles are divided1 is protrusion of the eyeball from the removal of muscular tension4 7#c47 ,solomon's operation for the radical cure of extreme divergent strabismus1#hf is at first sight a very curious one4 ,without going into all the details1 the steps are as follows3-- a4 ,a square-shaped flap1 with its attached base at the nasal side1 is raised1 containing the remains of the inner rectus and its adjacent parts4 b4 ,a flap similar in shape and size1 but different in the position of its attached base1 is made on the other side of the cornea4 ,it is made by dividing the external rectus just behind its tendon1 and then reflecting forwards the tendon with its conjunctiva4 c4 ,these two flaps are united over the vertical meridian of the cornea by sutures1 three generally being sufficient4 ,this entirely hides the cornea for a time1 but eventually shrivels and contracts1 and the remnants are to be cut off with scissors three weeks after the operation4 ,,puncture ,,of ,,the ,,cornea4--,paracentesis of the ,anterior ,chamber4--,tapping of the ,aqueous ,humour4--,this very simple operation is in many cases extremely useful4 ,in cases of corneal ulcer1 the result either of injury or disease1 where there is much pain in the bone1 and evidence of tension of the globe1 it gives great relief1 and when repeated at short intervals greatly hastens a cure4 ,sperino of ,turin recommends its frequent use in cases of chronic glaucoma4 ,operation4--,the surgeon stands behind the patient1 who is seated2 the lids being fixed1 the upper by the surgeon's left hand1 and the lower by an assistant1 the cornea is punctured a little in front of the sclerotic margin1 either with a broad needle1 or1 what is as good1 a well-worn ,beer's knife4 ,care must be taken on entering the knife1 on the one hand1 not to wound the iris1 which is sometimes arched forwards in the cases of commencing glaucoma1 and1 on the other1 fairly to enter the anterior chamber1 not merely split up the layers of the cornea4 ,on withdrawing the cataract knife1 the aqueous humour gets out by its side1 aided by a slight turn of the knife1 sometimes with great force1 and in much larger quantity than usual4 ,if the operation has been done by a needle1 a blunt probe requires to be introduced on the removal of the needle4 ,once punctured1 the remarkable fact is that the same wound suffices for many succeeding tappings1 which are effected by pressing the probe into the wound day after day1 sometimes several times a day1 with great relief to the symptoms4 ,if the probe is to be used for succeeding evacuations1 the operator must be careful to remember the exact spot at which the needle or knife was entered4 ,to facilitate remembering it1 it is best1 when nothing prevents it1 to operate always in the same spot4 ,sperino chooses the horizontal meridian of the cornea at the temporal side1 at the junction of the cornea and sclerotic4 ,,cataract ,,operations4--,here we cannot enter into any discussion of the pathology of cataract and the varieties of it4 ,enough for our purpose to know that the lens is in some cases hard1 in others soft1 and that thus in the latter it may be removed piecemeal1 and by a small incision1 while in the former1 removal must be almost entire1 and by a larger opening4 ,in cataract1 the lens1 which should be transparent1 has become opaque1 and the object of treatment is to get it out of the line of sight1 to prevent it from obstructing1 now that it can no longer assist sight4 ,the operations used for this end may be classed under three heads3-- #a4 ,operations for the removal of the lens out of the way without its removal from the eye4--,these used to be extensively practised under the name couching1 and are of two kinds1--,depression1 where the lens is simply pushed down from its place by a needle2 ,reclination1 in which it is shoved backwards 7turning on its transverse axis7 as well as downwards4 ,these are relics of old surgery1 and very rarely practised by any oculists of eminence1 as1 though easy to perform1 and with very flattering immediate results1 the risks of chronic inflammation of the whole globe and injury to the retina are very great4 #b4 ,for solution4--,,the ,,needle ,,operation4--,suitable 7among other cases7 especially in congenital cataracts in infants1 and in cases of diabetic cataract4 ,the principle of this operation is that the lens1 once the capsule is freely opened in front and the aqueous humour admitted1 is found rapidly to become absorbed and disappear1 if the cataract has been a soft one4 ,operation4--,a needle with a lance-shaped head is to be used4 ,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 point1 and yet not so small as to allow the aqueous humour to escape rapidly4 ,the pupil has been dilated1 the patient is lying on his back1 and the globe is fixed by forceps attached to the conjunctiva of the inner side of the eye1 and held by an assistant4 ,the surgeon then enters the needle close to the sclerotic margin of the cornea1 carries it fairly on in the anterior chamber1 till the centre of the pupil is reached4 ,he then1 by bringing forward the handle1 projects the point backwards against the anterior capsule1 which he freely lacerates with the point and edge in several directions4 ,in infants1 where processes of repair go on very rapidly1 the whole lens may be freely broken up4 ,in diabetic cataract1 or indeed in all cases of solution1 where the patient is adolescent or adult1 or the eye at all weak1 only a small portion of the lens should be attacked at one sitting4 ,the needle should then be withdrawn gradually and with great care1 that the broad axis of the blade be in exactly the same position in which it entered1 i4e4 flat and parallel with the iris1 lest the iris be wounded1 entangled1 or prolapsed4 ,the eye is then to be closed for twenty-four hours2 if there is much pain1 atropia must be freely used4 ,varieties in the ,operation4--,some use two needles at once for breaking up the lens4 ,some surgeons prefer to enter the needle through the sclerotic2 this complicates the operation and renders it less certain1 as the point of the needle is of course out of sight in its progress between the iris and the lens4 ,even in children this operation requires in most cases to be repeated at least once1 while in adults it may be required at short intervals for many months4 #c4 ,by ,extraction4--,in these operations the lens is at once removed from the eye-- 7#a47 ,by linear1 or perhaps1 more correctly1 rectilinear incision4 ,this method is specially suited for cases of soft cataract4 ,operation4--,a fine spear-shaped needle is very cautiously introduced through the cornea1 about a line from its outer margin1 and the anterior capsule lacerated1 and the lens broken up1 great care being taken not to injure the posterior capsule4 ,the pupil must then be kept freely dilated1 the wound heals at once1 and the aqueous humour reaccumulates4 ,illustration3 ,,fig4 ,,xii4 ,illustration3 ,,fig4 ,,xiii4 ,from three to six days after this first operation1 a linear incision 7,fig4 ,,xii47 is made in the outer side of the cornea by a straight stab from a double-edged knife1 or rather spear4 ,the size of the incision must vary with the size and consistence of the lens1 and can be regulated by the breadth of the knife and the distance to which it is entered4 ,by careful withdrawal of the knife1 in many cases a large portion of the soft lens can be removed along with it1 and then what remains must be cautiously lifted out by a flat spoon introduced through the wound1 and behind the remains of the lens4 ,care must be taken lest any of the lens substance remain in the wound2 with this precaution the incision generally heals rapidly1 and with much less risk of general inflammation of the ball than in the ordinary flap operation of extraction4 ,,extraction ,,of ,,soft ,,cataract ,,by ,,suction4--,mr4 ,t4 ,p4 ,teale1 of ,leeds1#hg has invented an instrument by which the removal of soft cataract is made more easy1 through a linear incision by suction1 applied through the medium of a hollow curette furnished with an india-rubber tube and mouth-piece4 ,the curette is of the usual size1 but is roofed in 7instead of being merely grooved7 to within one line of its extremity1 thus forming a tube flattened above1 but terminating in a small cup4 ,this is screwed into an ordinary straight handle1 which is hollow for a short distance1 far enough to join with a second tube fixed at right angles to the handle1 and into which the india-rubber pipe and mouth-piece1 through which suction is to be made1 is attached4 ,in many cases it seems to serve its purpose extremely well4 ,certain points require attention3--#a4 ,that the puncture to admit the curette is large enough2 #b4 ,that its end be sufficiently rounded2 #c4 ,its open end must be held in the area of the pupil1 and not allowed to pass behind the iris1 else there is great risk of the iris being drawn in4 ,among other advantages claimed by its inventor1 the chief seems to be a more thorough removal of the lens than by the ordinary means1 and consequently less risk of opaque deposit in the posterior capsule4 7#b47 ,,extraction ,,by ,,flap4--,when properly performed in a suitable subject1 and when free from accident1 this operation is one of the most thoroughly beautiful and satisfactory in the whole domain of surgery2 but it is difficult1 and liable to many risks which neither skill nor caution can completely guard against4 ,it is required in many cases of hard cataract1 which are amenable neither to solution nor linear extraction4 ,operation must be considered in various stages3-- a4 ,to make a flap of cornea large enough to permit of the removal of the entire lens without pressure or bruising4 ,to make it of cornea only1 to prevent the escape of the vitreous1 and to avoid injury of the iris4 ,the great difficulty in making the required section of the cornea is1 that we are debarred from using scissors or any ordinary knife or scalpel in making it1 for this reason1 that the sawing movements required in all ordinary cutting are inadmissible here1 as any withdrawal of the blade1 however slight1 would permit evacuation of the aqueous humour1 and at once be followed by prolapse of the iris before the knife4 ,hence we are compelled to make the requisite flap by one steady push of a knife1 which1 too1 must be of such a shape as in its entrance constantly to fill up the wound it makes4 ,very various shapes and sizes of knives have been proposed1 the one called ,beer's knife being the sort of model or common parent from which all the others are derived4 ,it is triangular in shape1 with a straight back1 about #ab-ajths of an inch in length1 and #d-ajths broad at the base of the blade1 tapering at a straight edge from its base to its point1 and also diminishing in thickness to the point4 ,considerable difference of opinion exists as to the relative merits of an upper or lower section of the cornea4 ,the general view at present seems to be that an upper section is to be preferred2 but in cases where the surgeon is not ambidexterous1 it is better that he should make the section which lies easiest to his hand than attempt an upper section in a less favourable position4 ,the patient should be placed flat on his back1 the lids should be gently opened1 the upper one by the surgeon1 the lower one by his assistant1 who is to press the lid downwards against the malar bone without exercising any pressure on the ball4 ,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-forceps1 still with no downward pressure on the ball4 ,the point of the knife must then be introduced about a line from the outer sclerotic margin of the transverse diameter of the cornea 7,fig4 ,,xiii471 the blade being held parallel with the fibres of the iris1 pushed steadily across the anterior chamber1 and protruded as nearly as possible at the corresponding spot at the inner side of the cornea4 ,the aqueous humour should not escape till the section is completed4 ,if it does1 the iris is almost certainly projected forwards and entangled in the blade of the knife1 a most annoying accident1 and one which is not easily remedied4 ,the books tell us of various manoeuvres by pressure or otherwise1 by which the iris may be pushed back4 ,practically1 however1 if it has once occurred it is not easily saved from being cut4 ,if a small portion only is involved1 it is not of much consequence2 if a large portion be in danger1 it is sometimes necessary to withdraw the knife before the section is completed1 and finish it with a probe-pointed1 curved bistoury4 ,if1 however1 the flap is safely finished1 the lids should be gently allowed to close for a few seconds4 ,on opening them again the surgeon must decide whether the corneal flap is sufficiently large to allow the lens to come out without force2 if not1 he must enlarge it either by the narrow probe-pointed secondary knife or by a pair of sharp scissors4 ,occasionally the lens1 and even a little vitreous humour1 may escape at once on the section being completed1 but this is not to be desired4 b4 ,laceration of the ,capsule of the ,lens4--,this is performed by insinuating a sharp curved needle under the corneal flap1 avoiding the iris1 and then tearing up the anterior capsule through the dilated pupil1 the chief point to be attended to being that the capsule be lacerated in its entire length4 c4 ,removal of the ,lens4--,this must be done with the most extreme caution and gentleness1 lest the vitreous humour be also evacuated4 ,the surgeon's object is to tilt the lens so as to turn it slightly on its transverse axis1 and cause the edge nearest the section to rise out of the capsule and appear at the wound4 ,this is best done by gentle pressure at the required spot by the back of the needle1 or by a common probe4 ,when the lens begins to protrude the pressure must be very1 gentle1 lest it be forced out suddenly and the vitreous follow it4 ,soft portions of the lens are apt to remain adherent to the wound in the cornea4 ,these must be removed by scoop or probe4 ,varieties in the method of ,flap ,extraction4--,jacobsen of ,knigsberg in every case gives chloroform4 ,he always makes his flap in the boundary line of the cornea and the sclerotic1 through a vascular structure1 and he believes that union is on this account more rapid1 and after extraction removes that portion of the iris which appears to have been most exposed to bruising during the exit of the lens4 ,the operation of extraction may in many cases be either preceded or followed by iridectomy1 as proposed by ,mooren1 ,von ,graefe1 and others4 ,the following operation seems to diminish the risks to a very great extent3-- ,professor ,von ,graefe's ,operation4--,the lids are separated by a speculum1 and the eyeball is drawn down by forceps placed immediately below the cornea4 ,the point of a small knife1 of which the edge is directed upwards1 is inserted at a point fully half a line from the margin of the cornea near its upper part1 so as to enter the anterior chamber as peripherally as possible4 ,the point should not be directed at first towards the spot for counterpuncture2 nor till the knife has advanced fully three and a half lines within the visible portion of the anterior chamber1 should the handle be lowered and the point directed so as to make a symmetrical counterpuncture1 which will give the external wound a length of four and a half or five lines4 ,as soon as the resistance to the point is felt to be overcome1 showing that the counterpuncture is effected1 the knife must at once be turned forward1 so that its back is directed almost to the centre of the ideal sphere of the cornea1 whether the conjunctiva is transfixed or not1 and the scleral border is divided by boldly pushing the knife onwards and again drawing it backwards4 ,this portion of the operation is concluded by the formation of a conjunctival flap a line and a half or two lines in length4 ,a section thus made is almost perpendicular to the cornea1 a circumstance much facilitating the passage of the lens1 and the line of incision is nearly straight1 so that the wound does not gape4 ,the iris should be excised to the very end of the wound1 and the capsule most freely opened by a ,v-shaped laceration4 ,any lens1 even the hardest1 may then be removed without the introduction of an instrument into the eye1 but ,von ,graefe's experience shows it to be advisable to assist the evacuation by the hook in about one case in eight4 ,in a certain number of cases the lens will escape without difficulty when the operator presses on the posterior lip of the wound1 especially when the back of the spoon is made to glide along the sclera2 should this not occur1 ,von ,graefe uses a peculiar blunt hook1 or occasionally1 though rarely1 a spoon4 ,a compressing bandage is applied1 and replaced at intervals4#hh ,we are recommended to perform it in two sets of cases3-- #a4 ,those in which the eye is known to be unhealthy and liable to inflammations1 specially of iris1 retina1 or choroid4 ,in cases where the patient has already lost an eye1 ,von ,graefe thinks iridectomy should always precede extraction4 ,in the above1 then1 it is a precautionary measure1 and1 if convenient1 should be performed three1 four1 or even six weeks before the extraction4 #b4 ,it is recommended to be performed at the same time as extraction in all cases in which the operation has presented any special difficulties1 or has not gone smoothly1 e4g4 in cases where the lens has required much force to expel it1 either from the flap of cornea being too small1 or from adhesions between the lens and capsule2 or1 again1 in cases in which there is a tendency to prolapse of the iris1 in which any of the cortical substance has been necessarily left behind1 or in which old adhesions had existed between the iris and capsule1 or between the cornea and iris4 ,,operations ,,for ,,artificial ,,pupil4--,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 retina4 ,in cases of excessive prolapse of the iris after extraction of the lens1 where the iris has formed adhesions to the wound1 and still more frequently in cases where central opacities of the cornea have fairly occluded the natural pupil1 the only chance for vision is to enlarge the old one1 or make a new pupil by removal of the iris4 ,very various operations have been proposed1 and exceedingly numerous and complicated instruments invented for this purpose4 ,we can notice here only one or two of the most approved procedures3-- #a4 ,incision is the simplest4 ,this is practicable and effectual only in cases where the iris is so far healthy as still to retain its contractile power1 and so far free from adhesions as to be able to make use of it4 ,the best example of such a case is that of a cataract1 in which after extraction a prolapse of the iris has occurred to such an extent as to obliterate the pupil1 and where1 at the same time1 the only adhesions are to the wound1 none to the cornea4 ,operation4--,a double-edged needle is introduced through the cornea near its margin2 on arriving at the place where the pupil ought to be1 one edge is drawn against the iris1 and divides it transversely1 if possible1 without injuring the lens2 the fibres of the iris start back1 contract1 so that a sufficiently large central pupil may be obtained4 #b4 ,excision4--,in the far more frequent cases in which there exist adhesions between iris and cornea1 or iris and anterior capsule1 incision is not sufficient1 and it is necessary to excise a portion of the iris4 ,the simplest and safest operation is the following3-- ,the patient recumbent1 and the lids held apart by a speculum1 the eyeball should be steadied by the forceps of an assistant4 ,a broad cutting needle should then be introduced at the lower or outer edge of the corneal margin4 ,this must be very gently withdrawn so as to retain as much aqueous humour as possible4 ,into the wound thus made the surgeon must introduce the blunt hook 7known as ,tyrrell's7 at first with its point forwards1 then1 on arriving opposite the edge of the pupil1 which it is intended to enlarge or replace1 with its point turned backwards1 so as to hook over the edge of the iris and thus drag on it4 ,once the hook has fairly got hold1 it must again be rotated forwards1 and withdrawn in the same direction as it was put in4 ,the iris thus pulled out of the wound is to be cut off with a pair of fine scissors1 so as to remove a sufficient amount to make a new pupil of the required size4 ,but in those cases in which the whole or greater part of the pupillary margin is adherent1 the blunt hook will not do1 because there exists no edge round which to hook it4 ,one of two plans is generally chosen to remedy this3-- 7#a47 ,a free incision made with a double-edged needle2 through this a pair of canula forceps is introduced1 with which a portion of iris is seized and dragged to the external wound2 it can then either be cut off or tied 7see ,iridesis72 or1 7#b47 ,a previous attempt may be made to free a portion to form an edge to catch hold of1 either by incision or by ,corelysis 7q4v47 ,,iridesis4--,critchett's ,operation of ,ligature4#hi--,patient being put under chloroform1 the ball is fixed by the wire speculum1 and also by a fold of conjunctiva being seized by forceps4 ,an opening is then made with a broad needle through the margin of the cornea1 close to the sclerotic1 just large enough to admit the canula forceps1 with which a small portion of iris close to its ciliary attachment is seized and drawn out2 a piece of fine floss silk1 previously tied in a small loop round the canula forceps1 is slipped down and carefully tightened round the prolapsed portion4 ,this speedily shrinks1 and the loop may generally be removed about the second day4 ,the chief advantage claimed for this method is the ease with which the size of the new pupil can be regulated4 ,it is also suitable in cases of conical cornea1 where it is wished to change the form of the pupil into a narrow slit4 ,n4,b4--,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 cornea1 or even into the ball1 by retraction of the fibres of the iris4 ,,corelysis4--,freeing of the ,pupil4--,an operative procedure for separating posterior adhesions of the iris to the lens4 ,in it the surgeon hopes to act1 not on the iris1 as in the operations for artificial pupil1 but only on the bands of false membrane which distort the pupil4 ,the operation is briefly as follows3--,the eye being firmly held by a wire speculum1 and forceps pinching up the conjunctiva1 a broad needle is passed rapidly through the cornea at a point which may give easy access to the adhesion to be torn through4 ,this point is generally at the opposite margin of the irregular pupil1 so that the needle may pass through the cornea in front of the one side of the iris1 then through the orifice of the pupil1 so as to reach the back of the other side4 ,the needle is withdrawn gradually1 so as to lose as little of the aqueous humour as possible1 and then the spatula hook1 called after the inventor of the operation1 ,mr4 ,streatfeild1 is introduced4 ,it is used first as a spatula1 that is1 with its blunt1 though polished edge1 to separate the adhesions1 and if this is unsuccessful1 as a hook 7,,fig4 ,,xiv471 so as to catch and tear them4 ,in cases which resist the instrument used in both of these ways1 ,mr4 ,streatfeild has used very fine canula-scissors to cut the adhesions4#ij ,such a further complication of the operation practically alters its character into an operation for artificial pupil1 q4v4 ,illustration3 ,,fig4 ,,xiv4#ia ,,iridectomy4--,in cases of acute glaucoma1 irido-choroiditis1 and all deep inflammations of the eye in which the ocular tension is increased1 also in certain cases of flap extraction already alluded to1 the operation of iridectomy as originally proposed by ,von ,graefe will be found of use4 ,operation4--,the patient recumbent1 and the eye absolutely fixed by speculum and forceps1 a linear incision1 varying in length from one-sixth to one-fourth of an inch1 is made just at the margin of the cornea4 ,the point of election is the upper pole of the cornea4 ,the lens must not be wounded4 ,the best instrument for making the section is an ordinary linear extraction knife1 bent at an angle to admit of its being introduced from above4 ,the iris will protrude through the wound1 or1 if adherent1 must be drawn out by forceps1 and then is to be cut off with scissors4 ,the operation is rarely successful1 unless a third1 or at least a fourth1 of the iris be removed4 ,,excision ,,of ,a ,,staphylomatous ,,cornea4--,there are certain cases in which the whole or greater part of the cornea bulges forward in a great blue projecting tumour4 ,it is very ugly as it protrudes between the lids and prevents their closure2 besides this1 from its exposure it frequently inflames1 even ulcerates1 and has a most injurious effect on the other eye4 ,in the cases suitable for operation vision is completely gone1 without hope of its restoration by any operative procedure4 ,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 eye4 ,various means have been suggested for doing this1 varying in extent and severity from a mere shaving off the apex of the staphyloma to excision of the whole eyeball4 ,by far the best method of operating is the one proposed and practised by ,mr4 ,critchett4 ,illustration3 ,,fig4 ,,xv4#ib ,illustration3 ,,fig4 ,,xvi4#ic ,the object of it is to remove an elliptical portion of the front of the staphyloma1 or the whole staphyloma1 when it is possible1 and at the same time to prevent as far as possible the escape of the vitreous4 ,operation4--,three1 four1 or five small curved needles armed with thread are passed through the staphyloma from above downwards1 being each entered a little above the line of the intended upper incision1 and brought out a little below the line of the intended lower one 7,fig4 ,,xv47 ,to remove the included elliptical portion1 ,mr4 ,critchett pierces the sclerotic with a ,beer's knife1 just in front of the tendinous insertion of the external rectus4 ,through this incision a pair of probe-pointed scissors is introduced1 and the piece cut just within the points of the needles4 ,on the removal1 the needles1 which have retained the vitreous by their pressure1 are drawn through and the threads cautiously tied4 ,union by first intention very often occurs1 and an excellent stump is left with a narrow depressed transverse cicatrix#id 7,fig4 ,,xvi47 ,,extirpation ,,of ,,the ,,eyeball4--#a4 ,of the ,eyeball only4--,a circular incision should be made with curved scissors through the conjunctiva1 a little beyond the corneal margin1 then1 beginning with the external rectus1 muscle after muscle should be raised with the forceps1 and divided1 after which the optic nerve is cut through with the scissors4 ,a slight preliminary extension outwards of the optic commissure will facilitate the dissection1 and must be secured with metallic sutures2 any vessels should be tied1 and the orbit filled up with a light compress of charpie secured with a bandage4 #b4 ,of the contents of the ,orbit4--,this may be required for malignant disease1 but with a very poor prognosis4 ,the optic commissure should be freely divided1 and then1 by bold strokes of curved scissors1 or curved probe-pointed bistoury1 the orbit may be fairly emptied by scooping out its contents4 ,even the periosteum may require to be scraped off1 and the optic nerve divided as far back as possible4 ,the hmorrhage may be pretty smart1 but can generally be easily checked by compresses2 if necessary1 these can be soaked in the solution of the perchloride of iron4 ,the author has done this operation many times1 in cases extensive and of old standing1 for malignant disease1 melanotic and encephaloid4 ,all have recovered1 and in no instance has there been any trouble in stopping the bleeding4 ,,footnotes3 #ha a4 ,elliptical incision for entropium2 b4 wedge-shaped incision for ectropium4 #hb ,fig4 ,,viii4 illustrates ,streatfeild's operation for entropium4--a4 section of skin2 b4 section of levator palpebrae2 c4 section of cartilage of lid2 d4 section of conjunctiva2 e4 wedge-shaped portion excised4 #hc ,ophthalmic ,hospital ,reports1 vol4 i4 p4 #aba4 #hd ,rough diagram of ,bowman's operation1 showing the grooved director in the punctum1 and the knife in the groove just before it slits up the canaliculus4 #he ,diagram of operations for convergent squint--,a ,a1 line of sub-conjunctival incision2 ,b ,b1 line of ,dieffenbach's operation2 ,c1 wire speculum4 #hf ,the ,radical ,cure of ,extreme ,divergent ,strabismus4 ,j4 ,vose ,solomon1 ,f4,r4,c4,s41 #ahfd4 #hg ,ophthalmic ,hospital ,reports1 vol4 iv4 part ii4 p4 #aig4 #hh ,biennial ,retrospect for #ahfe-ff4 ,syd4 ,soc4 pp4 #cfc-d4 ,for a thorough discussion of the merits of this operation1 see papers by ,von ,graefe in ,brit4 ,med4 ,jour4 for #ahfg1 vol4 i4 pp4 #cgi1 #ddf1 #dii1 #feg1 #gfe4 #hi ,ophthalmic ,hospital ,reports1 vol4 i4 p4 #bbd4 #ij ,streatfeild on ,corelysis4 ,ophthalmic ,hospital ,reports1 vol4 ii4 p4 #cji4 #ia a iris2 b lens2 c cornea4 ,the hook is seen applied to the adhesion between lens and iris4 #ib ,the staphyloma with the needles inserted1 the lids held asunder by a spring speculum4 ,the elliptical dotted line shows the amount to be removed2 the vertical one1 the position of the preliminary incision with the ,beer's knife4 #ic ,resulting stump after the stitches are inserted4 #id ,ophthalmic ,hospital ,reports1 vol4 iv4 part #a4 ,,chapter ,,vi4 ,,operations ,,on ,,the ,,nose ,,and ,,lips4 ,,rhinoplastic ,,operations4--,the operations for the restoration or repair of lost or mutilated noses are so various1 and the minuteness of detail necessary for full description of them so great1 that a complete account in a manual such as this is impossible2 a brief notice of some of the most important varieties of the operation is all that can be given4 ,principles4--#a4 ,it is necessary in every case that a suitable edge be prepared on which to fix the flap of skin1 however obtained4 ,to be suitable1 this edge1 should be 7a7 made in healthy skin1 not in old or weak cicatrices2 hence no trace of the original disease should be left2 7b7 it should be made thoroughly raw1 by the removal of an appreciable amount of its edge2 it should be pared1 not merely scraped4 #b4 ,it is useless to attempt to restore a nose unless the patient is in good general health1 well nourished1 and perfectly free from all remains of disease in the nose or its neighbourhood4 ,the flaps which are to form the new nose may be obtained either from 7#a47 the cheeks2 7#b47 the forehead2 7#c47 a distant part either of the patient or of another person4 7#a47 ,from the ,cheeks4--,when the cheeks are healthy1 and specially if they are tolerably full and lax1 the flaps from the cheeks produce much the most satisfactory result4 ,as performed by ,mr4 ,syme1 the operation consists in the shaping of two equal flaps 7,a1 ,a7 from the skin of the cheek at each side1 having the attachment above4 ,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 7see ,fig4 ,,xvii47 ,illustration3 ,,fig4 ,,xvii4#ie ,the flaps are then raised from their attachments to the upper jaw-bone1 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 orifice4 ,if any septum remains of the old nose1 it may be made very useful as a fixed point1 a straight needle being thrust through one flap close to its outer lower edge1 then through the septum1 and out at a corresponding point of the other flap4 ,the edges of the wound left in the cheek at each side can generally be1 to a certain extent1 approximated by silver stitches 7,b1 ,b7 and the triangular portion 7,c1 ,c71 which is necessarily left to heal by granulation1 proves an advantage1 as by its depression it enhances the apparent height and prominence of the new organ4 ,the cavity should be very gently distended with lint1 and may be supported by the blades of a small pair of forceps1 applied so as to embrace the nose4 7#b47 ,from the ,forehead4--,the ,indian operation may be used as a last resource1 in cases where1 from disease1 the cheeks also have suffered1 and are not to be trusted to for flaps4 ,operation4--#a4 ,it should be decided as to the shape and size of the portion of skin necessary1 by fitting on pieces of soft leather or moulding wax4 ,to allow for shrinking1 the flap should be made at least one-third larger than is at first apparently necessary4 ,the exact boundaries of the flap to be raised should then be marked out on the forehead by lightly pencilling it with nitrate of silver1 the mark from which is not effaced by blood1 as is sure to be the case with an ink line4 ,various shapes have been proposed for the flap varying in length of neck1 in the shape of the angles1 and especially in the arrangements made for the formation of a columna4 ,some 7as ,liston7 prefer afterwards to provide for the columns separately1 by a flap raised from the upper lip in a subsequent operation4 ,the flap is then to be raised from the forehead1 care being taken not to injure the periosteum4 ,the incision is to be carried lower down on the side 7generally the left71 to which the flap is to be twisted4 ,the flap is then to be brought round 7,fig4 ,,xviii47 and carefully fitted on to the edges previously prepared for its reception4 ,the neck must be left as lax as possible1 lest by tight twisting the supply of blood be cut off1 and the flaps thus deprived of nourishment4 ,both silk and metallic sutures are recommended4 ,hamilton of ,dublin1#if after a large experience of both1 prefers the former4 ,illustration3 ,,fig4 ,,xviii4#ig ,there are various risks2 sloughing of the whole flap at once1 shrinking of it after weeks or even months2 certain inevitable drawbacks1 as the cicatrix on the forehead1 the very various and ludicrous changes of colour to which the new organ is subject1--these cannot be remedied by further operation4 ,two points generally require a second use of the knife a few weeks after3--7#a47 ,the neck of the flap is sure to be redundant and prominent1 but can be pared4 7#b47 ,the columna almost always requires improving1 and1 in ,liston's method1 to be made4 ,he pared the inner surface of the apex of the nose1 and then raised a central flap of the lip in the middle line1 about a quarter of an inch broad1 and extending from the remains of the old septum to the free border1 raising it from the gum1 and stitched the free end of it to the prepared apex1 bringing together the two divided portions of the lip by ordinary harelip sutures4 ,tho columna1 if redundant1 could be shaved down1 and it was found that the mucous surface very quickly became like skin on exposure4 ,for other points with regard to the operation1 reference may be made to the works of ,liston and ,skey1 and ,hamilton's monograph1 referred to above4 ,note4--,the tongue and groove suture proposed by ,professor ,pancoast1 and recommended by ,professor ,gross1 is said to be specially suitable for such plastic operations4 ,it is very complicated1 as it requires one edge to be bevelled to a wedge shape1 the other being grooved to include the wedge1 thus opposing four raw surfaces1 which are retained in contact by being transfixed by fine silk sutures4 7#c47 ,there are certain cases in which neither cheeks nor forehead are available for flaps1 and yet the patients press very much for some operation4 ,if they have patience and determination1 the ,taliacotian or ,italian operation may be attempted4 ,without going into detail1 the principle of it is as follows3--#a4 ,a piece of skin of suitable size was marked out over the left biceps1 and defined by two longitudinal incisions1 and raised from the subcutaneous cellular tissue1 thus being left attached by its two ends only2 a piece of linen was pulled below it4 #b4 ,after a few days the upper end was also divided1 and the flap thus contracted4 ,in a few days more the sides of the old nose were made raw1 and the upper free surface of the flap also made raw and stitched to them1 the arm being fastened up by a most elaborate series of bandages4 #c4 ,after a fortnight in this position1 the last attachment of the flap to the arm was severed1 and the new nose could then be modelled at pleasure4 ,the literature of the subject is exceedingly curious1 especially the cases in which the new material was obtained from an accommodating friend or servant4 ,,operative ,,treatment ,,of ,,lupus4--,we may here notice a mode of treatment which has admirable results4 ,the patient being put deeply under an ansthetic1 the surgeon with a sharp spoon carefully pares away all the diseased tissues1 and then destroys the base either by nitric acid or a strong solution of chloride of zinc4 ,the author has done this in a great number of cases with excellent effect4 ,,nasal ,,polypi1 ,removal of4--,of these there are different kinds4 #a4 ,,ordinary ,,mucous ,,polypi4--,these grow from the spongy bones1 generally the superior one1 are non-malignant in their character1 soft and vascular1 often fill up the whole of both nasal cavities1 and frequently hang down behind into the pharynx4 ,the practical point to remember is that1 however large and numerous they may be1 they invariably have their origin from a comparatively limited spot1 the edge of the spongy bone1 and always hang from a narrow neck4 ,hence the treatment is easy and satisfactory1 if the neck be attacked1 and not the body of the tumour4 ,slightly curved1 narrow-bladed forceps should be passed along by the side of the superior spongy bone1 with their blades open1 till the neck of the polypus is seized4 ,holding it firmly1 the forceps should then be slowly twisted round till the neck is destroyed and the polypus detached4 ,this should be repeated till the patient can blow freely through both nostrils4 ,if attempts are made to seize the body of the polypus1 it will break down under the forceps1 bleed1 and give much trouble4 #b4 ,,the ,,fibrous ,,polypus4--,this form is fortunately much more rare than the other4 ,it is almost invariably single1 is attached to the posterior margin of the nares by a narrow but very strong root1 is extremely firm in consistence1 may grow to a large size so as to obstruct both nostrils1 generally gives rise to severe and frequent hmorrhages4 ,the hmorrhage during any attempt to remove it is generally of the most severe character1 but ceases immediately on its complete detachment4 ,we owe nearly all that we do know about the treatment of this form of polypus to ,mr4 ,syme4 ,his method is--,by the ordinary polypus forceps described already1 he seized the tumour through the nostril1 and then with the fore and middle fingers of the left hand introduced behind the soft palate1 he attacked the point of attachment1 and by his nails1 aided by the forceps1 detached it from its narrow base4#ih #c4 ,,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 also4 ,this is very rarely the case4 7,see ,excision of ,superior ,maxilla47 ,,operations ,,on ,,the ,,lips4--#a4 ,epithelial cancers of the lower lip are very frequent1 and require removal4 ,if the tumour or ulcer is small1 and involves a considerable thickness of the lip1 it is most easily removed by a ,v-shaped incision 7,fig4 ,,xix4 ,a ,b ,a74 ,its shape permits the most accurate apposition of the cut surfaces2 and if the lips are full and the tumour small1 very slight trace of the operation will remain4 ,illustration3 ,,fig4 ,,xix4#ii ,again1 if the tumour be more extensive1 involving a large portion of the prolabium1 and yet not extending deeply into the substance of the lip1 it may be very easily removed by a pair of curved scissors1 applied in the direction shown in the diagram 7,fig4 ,,xx4 ,a ,b74 ,the skin must then be stitched to the mucous membrane by numerous points of interrupted suture4 ,illustration3 ,,fig4 ,,xx4#ajj ,but if the tumour be at once extensive and deep1 mere removal is not sufficient1 but some provision must be made for supplying the blank left by the operation4 ,in cases where a third1 or even a half1 of the lower lip has thus been removed1 it may be found sufficient freely to dissect what is left of the lip from the gums1 and thus approximate the cut surfaces in the middle line4 ,this alone1 however1 would so much diminish the buccal orifice1 and twist its corners1 as to cause great deformity4 ,the addition of an incision horizontally outwards1 at one or both angles of the mouth1 will do away with such risk1 and allow the surfaces to come together without puckering2 while by stitching the skin and mucous membrane together in the course of these horizontal incisions1 we can increase the size of the buccal orifice almost ad libitum4 ,lastly1 when the lower lip has been entirely removed1 it is still possible to supply its place in the following manner1 which was devised by ,mr4 ,syme3 ,the tumour being fairly isolated by a ,v-shaped incision 7,fig4 ,,xxi47 ,c ,a ,c including the whole thickness of the lip1 each of the incisions should be prolonged downwards and outwards1 as shown by the dotted lines ,a ,d1 ,a ,d4 ,the flaps thus marked out must be separated from the bone1 brought upwards1 and approximated in the middle line4 ,possibly it may be necessary still further to enlarge the buccal orifice by short lateral incisions1 ,c ,c4 ,whether these are required or not1 silk stitches are to be introduced to unite the skin and mucous membrane along the lines ,a ,c4 ,the gap left between ,d ,b ,d must be left to granulate1 but in most cases may be very much diminished in size by additional sutures at its outer corners1 near ,d4 ,the granulating surface ,e ,e very rapidly heals up1 leaving a dimple on each side1 which rather improves the appearance1 by adding to the prominence of the chin1 ,b4 ,illustration3 ,,fig4 ,,xxi4#aja ,illustration3 ,,fig4 ,,xxii4#ajb ,,the ,,operations ,,for ,,harelip1 though all conducted on the same general principles1 vary considerably in extent required according to the position and size of the fissure or fissures to be remedied4 #a4 ,for ,single ,harelip4--,where the fissure extends only from the prolabium up to the attachment of the lip to the gums3 this is very easily remedied1 the chief risk being lest the surgeon should not remove enough of the edges of the fissure4 ,operation4--,bleeding being controlled by an assistant1 the surgeon fixes a pair of spring artery forceps into the mucous membrane and skin at the salient angle at each side of the fissure4 ,taking one of these in his left hand1 he puts the edge to be pared on the stretch1 and then with a sharp narrow straight bistoury he transfixes the lip at the point just beyond the upper angle of the fissure1 and cuts outwards1 being careful to remove the whole thinner part of the lip1 and to leave the edge rather concave than convex4 ,if left convex1 or even quite straight1 there is a risk that1 after union has taken place1 an angle remain showing the position of the cleft4 ,the same is then to be done on the other side4 ,the bleeding is then to be controlled by twisting the larger vessels1 and if oozing still continues from the smaller ones1 a pad of lint should be placed in the wound1 and a few minutes' delay given1 as1 to facilitate immediate union1 it is of the greatest importance that all hmorrhage should have ceased before the edges are brought together4 ,when the bleeding has ceased1 the edges should be approximated by two or more points of interrupted metallic suture inserted very deeply through the tissues1 and taking a good hold of the edges of the wound4 ,if the edges do not fit accurately1 one or two horse-hair sutures will help4 ,some surgeons still prefer the old harelip needles secured by a figure-of-eight suture4 ,a silk suture inserted through the prolabium is of great advantage1 as it keeps the inner surface of the wound closed1 which without it is very apt to be kept open by the pressure of the teeth or gums1 and in infants by the movements of the tip of the tongue4 ,various methods have been devised to utilise1 if possible1 the portion of the edge of the lip which is separated during the operation of refreshing the edges1 for the purpose of filling up the sort of cleft or gap which is apt to be noticed at the edge of the prolabium4 ,the most ingenious and simplest of these is that proposed by ,m4 ,nelaton1 for use in cases where the fissure does not extend so far up as the nose4 ,it consists in leaving the two portions which are pared off 7,fig4 ,,xxiii47 the sides of the cleft attached to each other as well as to the free edge of the lip1 then pulling them down1 so as to bring their bleeding surfaces into apposition1 and make a diamond-shaped wound instead of a triangular cleft 7,fig4 ,,xxiv47 ,when brought together by sutures a projection is left at the edge of the lip2 this1 in most cases1 disappears2 if it does not1 it can easily be pared down4 ,illustration3 ,,fig4 ,,xxiii4#ajc ,illustration3 ,,fig4 ,,xxiv4#ajd #b4 ,when the fissure1 though single1 extends upwards into the nose1 the operation is more difficult1 and the result frequently less satisfactory4 ,the first thing to be done is to separate the lips from the gums1 so as to make them more freely mobile4 ,the whole edges of the cleft require refreshing4 #c4 ,double ,harelip1 without bony deformity1 and where the intervening portion of the skin is vertical1 does not project1 and can be made useful for the new lip4 ,such cases are not very common1 but when they do occur the question arises1 ,how are they to be managed--in two separate operations or at once8 ,i believe1 in every case1 at once4 ,the central wedge-shaped portion is not large enough to extend downwards as far as the prolabium1 but still should not be removed altogether1 as it may be of great use1 especially in bearing the columna nasi1 and allowing its full development4 ,the edges should be pared in the same way1 and to the same extent as in single harelip1 with the addition that the intervening portion should have its edges completely removed1 and be left in the form of a wedge1 with its apex downwards4 ,the highest suture should be passed through first one side1 then the base of the wedge1 and then the other side2 the second one through both1 and the apex of the wedge2 and a third should unite the prolabium1 not including the wedge4 ,illustration3 ,,fig4 ,,xxv4#aje #d4 ,double ,harelip combined with fissures of the hard palate1 and projection of a central bone4 ,this is the analogue of the inter-maxillary bone in the lower animals1 and bears the two middle incisor teeth1 and projects very variously in different cases4 ,in some it projects horizontally forwards in the most hideous manner1 in others it lies at an angle more or less oblique2 in very few does it maintain its proper position2 when projecting forwards1 and as the teeth also share in its projection1 it entirely prevents approximation of the edges of the fissures by operation1 so it must first be dealt with in one of two ways1 either-- ,illustration3 ,,fig4 ,,xxvi4#ajf 7#a47 ,it may be at once removed with bone-pliers1 the piece of skin over it being saved4 ,this is the best that can be done in cases of old standing after the first year or two1 though attempts have been made to break the neck of the projecting portion1 and thus permit of its being shoved back4 7#b47 ,by gradual pressure by a spring truss1 strapping1 or a bandage1 it may be forced back4 ,this is possible only in cases where the deformity has been comparatively slight1 and the patient has been seen early4 ,the edges must then be pared and approximated as directed above4 ,one or two points about the operation for harelip require a special notice3-- #a4 ,when to operate4--,great differences in opinion exist4 ,some say not before two or three years1 others within two or three days1 or even hours1 after birth4 ,probably the safest time is not much earlier than the second month in very strong children1 the fifth in weakly ones1 up to the commencement of the first dentition2 and when once dentition has commenced it is not so safe to operate till it is over4 ,prior to dentition the operation is attended with rather more risk1 but again1 if delayed1 there is great risk that the teeth do not come in properly4 #b4 ,with regard to the most delicate part of the operation1 the management of the prolabium4--,some are satisfied1 and ,i believe rightly1 with careful apposition by a silk suture after a sufficient amount of the edges has been removed2 others have proposed various plans to obviate any risk of an angle remaining4 ,malgaigne proposes to retain a small portion of the parings of the edge to make small flap at each side2 ,lloyd a single one from the long half of the lip1 and brings it up under the opposite one1 securing it with a stitch4 ,,footnotes3 #ie ,operation for formation of a new nose from the cheeks2 ,a ,a1 flaps approximated in middle line2 ,b ,b1 outer part of bed of flaps stitched up2 ,c ,c1 triangle at each side left to granulate4 #if ,the ,restoration of a ,lost ,nose by ,operation1 p4 #eg2 an excellent monograph on the subject4 #ig ,operation for formation of a new nose from the forehead3--a1 prominence of flap which is to be used as septum2 b1 left-hand corner of flap1 which is twisted and fastened at c2 d1 one of the tubes or quills over which the nose is moulded4--7,modified from ,bernard and ,huette47 #ih ,syme's ,observations in ,clinical ,surgery1 p4 #acb4 #ii ,diagram of ,v-shaped incision2 ,a ,b ,a1 dots showing points for sutures4 #ajj ,diagram of incision for scooping out a shallow tumour by scissors4 #aja ,diagram of incisions3--,c ,a ,c1 outline of incision for removal2 ,c ,a ,d1 outline of flap on each side2 ,b1 prominence of chin2 ,c ,c1 dotted lines1 showing incisions to enlarge mouth1 if required4 #ajb ,diagram of flaps in position3--,a ,a1 corners of flaps brought up and approximated by silver sutures2 ,c ,c1 new lip got by lateral incisions1 skin and mucous membrane being united by silk threads2 ,e ,e1 gap left to granulate4 #ajc ,fig4 ,,xxiii4 shows the incision bounding the cleft4 #ajd ,fig4 ,,xxiv4 shows the diamond-shaped wound before the sutures are applied4 #aje ,diagram of operation for double harelip3--a1 stitch through both sides and wedge-shaped portion1 which also aids the septum2 b1 other stitches approximating edges4 #ajf ,diagram of double harelip1 with projecting bone3--a1 central piece of lip1 dotted lines showing incision2 b1 projecting bone bearing teeth1 which are generally small and stunted4 ,,chapter ,,vii4 ,,operations ,,on ,,the ,,jaws4 #a4 ,,excision ,,of ,,the ,,upper ,,jaw4--,with regard to the morbid conditions for which this operation is undertaken1 it may be sufficient here to observe1 that in no case can the operation be called justifiable in which the disease extends beyond the upper jaw-bone and the corresponding palate-bone1 for unless the morbid growth be entirely removed1 recurrence is inevitable1 and no advantage is gained by the operation4 ,it is undertaken for the removal of tumours of the antrum and of the alveolar margins1 in all which cases the section for its removal must be made through healthy bone1 and wide of the disease1 so as to insure that the whole is removed4 ,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 behind1 for example1 to naso-pharyngeal polypi with extensive attachments4 ,in describing the operation for the excision of the entire upper jaw1 we have to consider--7#a47 what incisions through the soft parts will expose the tumour best1 and with least deformity2 7#b47 what bony processes require to be divided1 and where4 ,very various incisions have been recommended by various authors2 some describing three1 in various directions1 forming flaps of different sizes1 while others1 again1 are satisfied with a very small division of the upper lip into the nose1 or even attempt removal of the bone without any incision through the skin at all4 ,these discrepancies depend in great measure on different views of what constitutes excision of the upper jaw1 the more complicated ones contemplating removal of the whole bone anatomically so called1 including the floor of the orbit1 while the less complicated ones are suitable for cases in which a much less extensive removal is required4 ,to remove the whole bone1 an incision 7,fig4 ,,xxvii4 ,a7 of the skin must extend from the angle of the mouth upwards and outwards in a slightly curved direction with its convexity downwards1 as far on the malar bone as half an inch outside of the outer angle of the eye4 ,the flaps must then be raised in both directions1 the inner one specially dissected off the bones1 so as to expose thoroughly the nasal cavity4 ,it is of great importance thoroughly to display the floor of the orbit1 so that the attachment of the orbital fascia may be accurately cut through1 the inferior oblique muscle divided at its origin1 and the eye and the fat of the orbit cautiously raised from its floor4 ,illustration3 ,,fig4 ,,xxvii4#ajg ,three processes of bone then require attention and division4 7#a47 ,the articulation with the opposite bone in the hard palate4 ,to divide this1 one incisor tooth at least must be drawn1 the soft palate divided by a knife to prevent laceration1 and the thick alveolar portion sawn through in a longitudinal direction from before backwards4 7#b47 ,the articulation with the malar bone at the upper angle of the incision through the skin4 ,this must be notched with a small saw in a direction corresponding to the articulation1 and then wrenched asunder by a pair of strong bone-pliers4 7#c47 ,the nasal process of the upper jaw must now be divided by the pliers1 one limb of which is cautiously inserted into the orbit1 the other into the nose4 ,if the disease extends high up in this process1 it may be necessary partially to separate the corresponding nasal bone1 and thus reach the suture between the nasal process and the frontal bone4 ,the pliers must now be inserted into the groove already made by the saw on the hard palate1 and the separation continued to the full extent backwards4 ,a comparatively slight force exerted on the tumour either by the hand1 or 7when the tumour is small7 by a pair of strong claw forceps1 will suffice to break down the posterior attachments of the bone and remove it entire4 ,the necessary laceration of the soft parts behind is so far an advantage1 as it lessens the risk of hmorrhage from the posterior palatine vessels4 ,the hmorrhage from this operation was at one time much dreaded1 but is rarely excessive2 very few vessels require ligature1 except those divided in the early stages in making the skin flaps2 the hollow left should be stuffed with lint1 which may be soaked in the perchloride of iron should there be any oozing4 ,the incisions recommended for this operation have been very various1 and a knowledge of some of them may occasionally be useful1 on account of specialities in the shape and size of the tumour4 ,liston entered the bistoury over the external angular process of the frontal bone1 and carried it down through the cheek to the corner of the mouth4 ,then the knife is to be pushed through the integument to the nasal process of the maxilla1 the cartilage of the ala is detached from the bone1 and lip cut through in the mesial line2 the flap thus formed is to be dissected up and the bones divided4#ajh ,dieffenbach made an incision through the upper lip and along the back or prominent part of the nose1 up towards the inner canthus1 from whence he carried the knife along the lower eyelid1 at a right angle to the first incision as far as the malar bone4 ,in cases where the tumour is of moderate size1 ,sir ,w4 ,fergusson found#aji it sufficient to divide the upper lip by a single incision exactly in the middle line1 this incision to be continued into one or both nostrils1 if required4 ,the ala of the nose is so easily raised1 and the tip so moveable as to give great facilities to the operator for clearing the bone even to the floor of the orbit4 ,in cases where the tumour is larger1 or the bones more extensively affected1 ,sir ,w4 ,fergusson preferred an extension of the foregoing incision 7,fig4 ,,xxvii4 ,b7 upwards along the edge of the nose almost to the angle of the eye1 and thence at a right angle along the lower eyelid1 as far as may be necessary1 even to the zygoma4 ,the advantages claimed for such procedures are that the deformity is less and the vessels are divided at their terminal extremities4 #b4 ,,excision ,,of ,,the ,,lower ,,jaw4--,removal of portions1 greater or smaller1 of the lower jaw1 for tumours1 simple or malignant1 are now operations of very frequent occurrence1 while in some few cases the whole bone has been removed at both its articulations4 ,the operative procedures vary much1 according to the amount of bone requiring removal1 and also the position of the portion to be excised4 7#a47 ,of a portion only of one side of the body of the bone4--,this is perhaps the simplest form of operation1 and is frequently required for tumours1 specially for epulis4 ,incision4--,if the parts are tolerably lax and the tumour small1 a single incision just at the lower edge of the bone1 of a length rather greater than the piece of bone to be removed1 will suffice2 this will divide the facial artery1 which must be tied or compressed1#aaj while the surgeon1 dissecting on the tumour1 separates the flaps in front1 cutting upwards into the mouth1 and then detaches the mylohyoid below1 and clears the bone freely from mucous membrane4 ,he then1 with a narrow saw1 notches the bone beyond the tumour at each side1 and1 introducing strong bone-pliers into the notches1 is enabled to separate the required portion4 ,the wound is then stitched up1 and a very rapid cure generally results with very little deformity1 as the cicatrix is in shadow4 ,if from the size of the tumour more room is needed1 it can easily be got by an additional incision from the angle of the mouth joining the former4 ,to prevent deformity1 which is apt to result from the centre of the chin crossing the middle line1 it is often a wise precaution to have a silver plate prepared fitting the molar teeth of both jaws on the sound side1 and thus acting as a splint4 ,such a precaution may be required in any operation in which the lower jaw is sawn through4 ,n4,b4--,there are certain cases in which the epulis is small and confined to the alveolar margin1 in which an attempt may be made to retain the base of the jaw entire1 and remove the tumour without any incision of the skin4 ,the mucous membrane on both sides being carefully dissected from the affected part1 the bone may be sawn as before1 but only through the alveolar portion1 the groves of the saw converging as they penetrate1 then by a pair of strong curved bone-pliers1 the affected alveolar portion is to be scooped out without injuring the base4 ,this proceeding1 which has been practised by ,syme1 ,fergusson1 ,pollock1 the author in many cases1 and others1 leaves no deformity1 but1 it must be owned1 is much more liable to the risk of recurrence of the disease1 and for this reason is strongly condemned by ,gross4 ,note4--,in this1 as in all other operations on the jaws1 the very first thing to be done is to draw the teeth at the spots at which the saw is to be applied4 7#b47 ,excision of a portion involving the ,symphysis4--,free access is of importance4 ,the best incision is probably one which 7,fig4 ,,xxvii4 ,c7 commences at the angle of the mouth opposite the healthy portion of jaw1 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 section4 ,the flap is to be thrown up and the bone cleared4 ,the next point to be noticed is1 that when1 in clearing the bone behind1 the muscles attached to the symphysis are divided1 the tongue loses its support1 and unless watched may tend to fall backwards1 embarrassing respiration and even perhaps choking the patient4 ,the tongue1 being confided to a special assistant1 must be drawn well forwards4 ,various plans have been devised for keeping it in position1 as stitching it to the point of the patient's nose2 putting a ligature into its apex1 and fastening it to the cheek by a piece of strapping1 and transfixing its roots with a harelip needle1 used to stitch up a central incision in the chin4 ,the tendency to retraction very soon ceases1 new attachments are formed by the muscles1 and after the first five or six days there is very little risk of the tongue giving rise to any untoward consequences by its displacement4 7#c47 ,disarticulation of one1 or both ,joints4--,when the portion of bone implicated involves disarticulation for its complete removal1 the difficulty of the operation is much increased4 ,the remarkably strong attachments of the joint1 especially the relation of the temporal muscle to the coronoid process1 and the close proximity of large arteries and nerves1 especially the internal maxillary artery and the lingual nerve1 render this disarticulation very difficult4 ,the chief points to be attended to seem to be 7#a47 that the incision through the skin should extend quite up to the level of the articulation2 7#b47 that the bone should be sawn through at the other side of the tumour1 and freely cleared from all its attachments1 before any attempt be made at disarticulation1 for by means of the tumour great leverage can be attained1 so as to put the muscles on the stretch1 and allow them to be safely divided2 7#c47 that the articulation should always be entered from the front1 not from behind1 and the inner side of the condyle should be very carefully cleaned1 the surgeon cutting on the bone so as to avoid1 if possible1 the internal maxillary artery2 7#d47 free and early division of the attachment of the temporal muscle to the coronoid process4 ,disarticulation of the entire bone has been very rarely performed4#aaa ,if necessary1 it can be performed without any incision into the mouth1 by one semilunar sweep from one articulation to the other1 passing along the lower margin of each side of the body1 and just below the symphysis of the chin4 ,disarticulation of the ,ramus without opening into the cavity of the ,mouth4--,that this operation is possible1 though it may not be often required1 is shown by the following case by ,mr4 ,syme4 ,it was a tumour of the ramus1 extending only as far forwards as the wisdom-tooth3-- ,an incision was made from the zygomatic arch down along the posterior margin of the ramus1 slightly curved with its convexity towards the ear1 to a little way beyond the base of the jaw4 ,the parotid gland and masseter muscle being dissected off the jaw1 it was divided by cutting-pliers immediately behind the wisdom-tooth1 after being notched with a saw4 ,the ramus was then seized by a strong pair of tooth-forceps1 and notwithstanding strong posterior attachments1 was drawn outwards1 its muscular connections divided and turned out entire4 ,there was thus no wound of the mucous membrane of the mouth1 the masseter and pterygoid muscles were not completely divided1 and the facial artery was intact4#aab ,fergusson#aac 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 lips4 ,a large lunated incision below the lower margin of the bone1 with its ends extending upwards to within half an inch of the lips1 will give free access1 and yet avoid both hmorrhage and deformity1 as the labial artery and vein are not cut1 and there is no trouble in readjusting the lips4 ,some tumours of lower jaw can be removed without any wound of skin4 ,,footnotes3 #ajg ,diagram of operations on the jaws3--,a1 incision for removal of the whole upper jaw2 ,b1 incision for removal of alveolar portion and antrum2 ,c1 incision for removing the larger half of lower jaw2 the opposite side is the one supposed to be operated on1 and the incision is crossing the symphysis and turning up at a right angle4 #ajh ,operative ,surgery1 p4 #bfe4 #aji ,lancet1 ,july #a1 #ahfe4 #aaj ,temporary compression of the facial can be easily managed1 in cases where it is of much importance to avoid loss of blood1 by passing a needle from the outside through the skin above the vessel1 then under the vessel1 and out again through the skin below4 ,a figure-of-eight suture can then be thrown round both ends of the needle1 and the artery thus thoroughly compressed4 #aaa ,syme1 ,contributions to the ,path4 and ,practice of ,surgery1 p4 #ba2 ,carnochan of ,new ,york1 ,cases in ,surgery4 #aab ,contributions to the ,path4 and ,prac4 of ,surgery1 pp4 #bc1 #bd4 #aac ,lancet1 ,july #a1 #ahfe4 ,,chapter ,,viii4 ,,operations ,,on ,,mouth ,,and ,,throat4 ,,salivary ,,fistula1 ,operation for4--,after a wound or abscess of the cheek1 in which the parotid duct is implicated1 a salivary fistula is very apt to remain4 ,the saliva thus discharges in the cheek1 giving rise to considerable annoyance1 as well as injury to the digestion4 ,it is by no means easy to cure this4 ,perhaps the best operation is the one of which a rude diagram is given 7,fig4 ,,xxviii474 ,the duct 7,c7 communicates with the fistula 7,d74 ,one end of a thread1 either silken or metallic1 should be passed through the fistula1 and then as far backwards as convenient through the cheek into the mouth2 the needle should then be withdrawn1 the thread being left in4 ,the other end being threaded should then be re-inserted at the fistula1 and carried forwards in a similar manner2 the needle should be again unthreaded in the mouth and withdrawn2 the two ends should then be tied pretty tightly inside1 and allowed to make their way by ulceration into the cavity of the mouth4 ,a passage will thus be obtained for the saliva into the mouth1 and every possible precaution should be taken to enable the external wound to close4 ,illustration3 ,,fig4 ,,xxviii4#aad ,,excision ,,of ,,the ,,tongue1 for malignant disease of the organ1 may be either complete or partial4 ,complete excision affords a hope of permanent and complete relief from the disease1 but it is an operation of extreme difficulty and danger4 ,it may be performed in either of the following methods4 ,the first is the only one in which absolute completeness of removal is insured4 #a4 ,syme's method of excision4--,the patient being seated on a chair1 chloroform was not administered1 so that the blood might escape forwards1 and not pass into the pharynx4 ,the operation is thus described3#aae-- ,having extracted one of the front incisors1 ,i cut through the middle of the lip and continued the incision down to the os hyoides1 then sawed through the jaw in the same line1 and insinuating my finger under the tongue as a guide to the knife1 divided the mucous lining of the mouth1 together with the attachment of the genio-hyoglossi4 ,while the two halves of the bone were held apart1 ,i dissected backwards1 and cut through the hyoglossi1 along with the mucous membrane covering them1 so as to allow the tongue to be pulled forward1 and bring into view the situation of the lingual arteries1 which were cut and tied1 first on one side1 and then on the other4 ,the process might now have been at once completed1 had ,i not feared that the epiglottis might be implicated in the disease1 which extended beyond the reach of my finger1 and thus suffer injury from the knife if used without a guide4 ,i therefore cut away about two-thirds of the tongue1 and then being able to reach the os hyoides with my finger1 retained it there while the remaining attachments were divided by the knife in my other hand close to the bone4 ,some small arterial branches having been tied1 the edges of the wound were brought together and retained by silver sutures1 except at the lowest part1 where the ligatures were allowed to maintain a drain for the discharge of fluids from the cavity4 ,the patient was able to swallow from a drinking-cup with a spout on the day following the operation1 and was able to travel upwards of #bjj miles within four weeks of the operation4 #b4 ,by the craseur4--,nunneley of ,leeds has recorded cases in which he made a small incision through the skin1 and mylohyoid and geniohyoid muscles1 and through this passed a curved needle bearing the chain of the craseur completely round the base of the tongue4 ,in one case the chain was unsatisfactory1 but strong whipcord was introduced as it was withdrawn1 and tied with all possible force4 ,the organ eventually sloughed away1 with a cure which lasted at least for some months4 ,sir ,james ,paget operates as follows3-- ,the patient is placed under the influence of chloroform1 and the mouth held widely open4 ,the tongue is then drawn forwards1 the mucous membrane and soft parts of the floor of the mouth1 including the attachment of the genio-hyoglossi to the symphysis being divided close to the bone4 ,the steel wire of an craseur is then passed round its root as low down as possible1 slowly tightened1 and the tongue thus divided through its whole thickness in a very few minutes4 ,the bleeding is slight1 being almost entirely from the parts cut with the knife4 ,recovery has been rapid in the recorded cases4#aaf ,to ,dr4 ,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 line4 ,in at least one instance the cure after five years is still permanent4 ,partial excisions of the tongue are as unsatisfactory in their results as they are unsound in principle1 yet many cases present themselves1 in which1 while the patient urges some operative measure for his relief1 the tumour is so limited as not to warrant the exceedingly dangerous operation of complete excision4 ,portions may be removed in various ways3-- #a4 ,by the knife4 ,if in the apex1 by a ,v-shaped incision2 if in the lateral regions1 by a bold free incision with a probe-pointed bistoury round the tumour4 #b4 ,by ligature1 drawn as tightly as possible1 and1 if the portion included be large1 in successive portions4 #c4 ,by the craseur4 ,mr4 ,furneaux ,jordan has removed the whole tongue with success by means of two craseurs worked at the same time4#aag #d4 ,by the galvano-caustic wire4 #e4 ,the author has in nine cases removed the affected half of the tongue by means of the thermo-cautery1 first splitting it in the middle line and then cutting through the base with a curved platinum knife at a low red heat4 ,in one only was there any trouble from hmorrhage1 and all made good recoveries4 ,mr4 ,barwell has recorded 7,lancet1 #ahgi1 vol4 i47 an easy1 safe1 and comparatively painless mode of removing the tongue by craseurs4 ,mr4 ,walter ,whitehead1#aah of ,manchester1 has had a very large experience of an operation devised by himself1 in which1 after pulling the tongue well forward by a string previously introduced near its apex1 and the mouth being held open by a gag1 he detaches the organ from jaw and fauces by successive short snips with scissors1 and then in same manner divides the muscles1 tying or twisting the vessels as they bleed4 ,his success has been very great by this method1 though others who have tried it have sometimes found bleeding troublesome4 ,it is comparatively seldom now necessary to split the jaw and perform ,syme's operation1 and in all operations on the tongue the thermocautory 7,paquelin's7 is of great use4 ,regnoli's method#aai may deserve a brief notice4 ,a semilunar incision along the base of the jaw1 from one angle to the other1 detaches the muscles and soft structures1 and is thrown down2 the tongue is then drawn through the opening1 and can be freely dealt with either by knife or ligature4 ,after removal the flap is replaced4 ,,fissures ,,in ,,the ,,palate4--,the operations requisite for the cure of fissures in the soft and hard palates are so complicated in their details1 that a small treatise would be required thoroughly to describe the various procedures4 ,different cases vary so much in the nature and amount of their deformity1 that at least five different sets of cases have been described4 ,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 respectively4 ,in all operations on the palate1 two conditions used to be considered requisite for success3--#a4 ,that the patient should have arrived at years of discretion1 at twelve or fourteen years at least2 that he be possessed of considerable firmness1 and be extremely anxious for a cure1 so as to give full and intelligent co-operation4 #b4 ,that for some days or weeks prior to the operation the mouth and palate should have been trained to open widely and to bear manipulation1 without reflex action being excited4 ,professor ,billroth of ,vienna1#abj and ,mr4 ,thomas ,smith#aba of ,london1 have had cases which prove the possibility of performing this operation in childhood1 under chloroform1 with the assistance1 in the ,english cases1 of a suitable gag1 invented by ,mr4 ,smith4 ,the effect of the operation on the voice of the child has been very encouraging1 as much more improvement takes place than in cases where the operation is performed late in life4 ,fissure in the soft palate only appears as a triangular cleft1 the apex of which is above1 the base being a line between the points of the bifid uvula1 which are widely separated4 ,to cure this it is required-- #a4 ,that the edges of the fissure should be brought together without strain or tightness4 ,in small fissures this can generally be done easily enough2 but where the fissure is extensive1 some means must be used to relieve tension4 ,for this1 ,sir ,william ,fergusson long ago proposed the division of the palatal muscles1 the levator1 tensor1 and palato-pharyngeus muscle of each side4 ,the incisions in the palate for this purpose certainly aid apposition1 but many surgeons entertain doubts whether the division of the muscles has much to do with the good result1 and believe that the simple incisions in the mucous membrane1 in a proper direction1 are all that is required 7see ,fig4 ,,xxix474 ,illustration3 ,,fig4 ,,xxix4#abb #b4 ,that the edges of the fissure be made raw1 so as to afford surfaces which will readily unite4 ,complicated instruments1 such as knives of various strange shapes1 have been devised for this purpose2 an ordinary cataract knife1 very sharp1 and set on a long handle is perhaps the best4 ,it greatly facilitates the section if the parts are tense1 so the point of the uvula should be seized by an ordinary pair of spring forceps1 and drawn across the roof of the mouth1 while the knife should enter in the middle line1 a little above the apex of the fissure1 and make the cut downwards as in harelip4 #c4 ,that sutures should be inserted to keep the edges in apposition1 yet not so tightly as to cause ulceration4 ,they may be either of metal1 silver being preferable1 or of fine silk well waxed4 ,the metallic sutures are now generally preferred4 ,some dexterity is required in their introduction1 and various instruments have been devised2 the best seems to be a needle with a short curve fixed on a long handle1 which should be entered on the 7patient's7 left side of the fissure in front1 and brought out on the right side4 ,if silk sutures be used1 the chief difficulty1 that of passing the thread through the second side from behind forwards1 can be avoided in the following manner4#abc ,a curved needle is passed through one side of the fissure1 and then towards the middle line1 till its point is seen through the cleft4 ,one of the ends of the thread is then seized by a long pair of forceps1 and drawn through the cleft2 the needle is then withdrawn1 leaving the thread through the palate1 and both ends are brought outside at the angle of the mouth4 ,another needle is then passed through a corresponding point at the opposite side of the palate1 till its point again appears at the cleft2 this time a double loop of the thread is also brought out through the cleft by the forceps into the mouth4 ,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 cleft1 it is easy1 by withdrawing the loop through the palate1 to finish the stitch 7see ,fig4 ,,xxix474 ,all the stitches should be passed and their position approved before any one be tied1 and it is most convenient to secure them from above downwards4 ,to prevent confusion1 each pair of threads after being inserted should be left very long1 and brought up to a coronet fixed on the brow1 which is fitted with several pairs of hooks numbered for easy reference4 ,this will prevent twisting of the threads or any mistake in tying4 ,,fissure ,,of ,,the ,,hard ,,palate4--,this may vary in extent from a very slight cleft in the middle line behind1 up to a complete separation of the two halves of the jaw1 including even the alveolar process in front1 and sometimes complicated with harelip4 ,to close such fissures by operation is difficult1 as the breadth of the cleft is so great as to prevent the apposition of the edges when prepared1 without such extreme tension as quite prevents any hope of union4 ,through the researches of ,avery1 ,warren1 ,langenbeck1 and others1 a method has been discovered of closing such fissures by operation1 which1 though certainly not easy1 is1 when properly performed1 generally successful4 ,operation4--,in addition to the usual paring of the edges of the cleft1 an incision is made on each side of the palate1 extending from the canine tooth in front to the last molar behind1#abd along the alveolar ridge 7,fig4 ,,xxx474 ,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 curved4 ,with this the whole mucous membrane and as much of the periosteum as possible should be completely raised from the bone1 attachments for nourishment of the flap being left in front and behind where the vessels enter4 ,illustration3 ,,fig4 ,,xxx4#abe ,the flaps thus raised will be found to come together in the middle line1 sometimes even to overlap1 and1 when united by suture1 form a new palate at a lower level than the fissure1 experience having shown that in cases of fissure the arch of the palate is always much higher than usual4 ,the flaps do not slough1 being well supplied with blood1 unless they have been injured in their separation4 ,the edges must be carefully united by various points of metallic suture1 and the fissure of the soft palate closed at the same sitting1 unless the patient has lost much blood1 or is very much exhausted with the pain4 ,the stitches may be left in for a week1 or even ten days1 unless they are exciting much irritation4 ,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 operation4 ,,excision ,,of ,,tonsils4--,to remove the whole tonsil is of course impossible in the living body1 the operation to which the name of excision is given being only the shaving off of a redundant and projecting portion4 ,when properly performed it is a very safe1 and in adults a very easy operation1 but in children it is sometimes rendered exceedingly difficult by their struggles1 combined with the movements of the tongue and the insufficient access through the small mouth4 ,many instruments have been devised for the purpose of at once transfixing and excising the projecting portion2 some of them are very ingenious and complicated4 ,by far the best and safest method of removing the redundant portion is to seize it with a volsellum1 and then cut it off by a single stroke of a probe-pointed curved bistoury2 cutting from above downwards1 and being careful to cut parallel with the great vessels4 ,the ordinary volsellum is much improved for this purpose by the addition of a third hook in each tonsil placed between the others1 with a shorter curve1 and slightly shorter2 this ensures the safe holding of the fragment removed1 and prevents the risk of its falling down the throat of the patient4 ,if both tonsils are enlarged they should both be operated on at the same sitting1 and the pain is so slight that even children frequently make little objection to the second operation4 ,bleeding is rarely troublesome if the portion be at once fairly removed1 but if in the patient's struggles the hook should slip before the cut is complete1 the partially detached portion will irritate the fauces1 cause coughing and attempts to vomit1 and sometimes a troublesome hmorrhage4 ,the plentiful use of cold water will generally be sufficient to stop the bleeding1 though cases are on record in which the use of styptics1 or even the temporary closure of a bleeding point by pressure1 has been necessary4 ,m4 ,guersant has operated on more than one thousand children1 with only three cases of any trouble from hmorrhage1 while four or five out of fifteen adults required either the actual cautery or the sesqui-chloride of iron4#abf ,,footnotes3 #aad ,rough diagram of operation for salivary fistula3--,a1 section of cheek close to buccal orifice2 ,b1 section of zygoma1 muscles1 etc42 ,c1 the duct of the parotid2 ,d1 the fistulous opening of the cheek2 ,e ,e1 the thread knotted inside the mouth2 ,f1 the palate4 #aae ,lancet1 ,feb4 #d1 #ahfe4 #aaf ,med4 ,times and ,gazette for ,feb4 #aj1 #ahff4 #aag ,lancet1 ,april #bj1 #ahgb4 #aah ,transactions ,international ,medical ,congress1 #ahha1 vol4 ii4 p4 #dfj4 #aai ,gross's ,surgery1 vol4 ii4 p4 #dgb4 #abj ,langenbeck1 ,archiv1 ii4 p4 #feg4 #aba ,med4 ,chir4 ,trans4 for #ahfg-h4 #abb ,diagram of staphyloraphy1 chiefly to illustrate the passing of the threads3--a1 the first thread2 b1 the second4 ,the dotted line at edge of fissure shows amount to be removed2 the other dotted lines showing size and position of the incision through the mucous membrane above4 #abc ,holmes's ,surgery1 vol4 ii4 pp4 #ejd-eac4 #abd ,edinburgh ,medical ,journal for ,jan4 #ahfe1 ,mr4 ,annandale's instructive paper on ,cleft ,palate4 #abe ,diagram of fissure of hard palate3--a1 anterior palatine foramina2 b1 posterior palatine foramina with groove for artery2 c1 incisions requisite to free the soft structures4 #abf ,holmes's ,diseases of ,children1 p4 #eee4 ,,chapter ,,ix4 ,,operations ,,on ,,air ,,passages4 ,,operations ,,on ,,the ,,larynx ,,and ,,trachea4--,the great air passage may be opened at three different situations1 and to the operations at these different places the following names have been given3-- ,laryngotomy1 when the opening is made in the interval between the cricoid and thyroid cartilages1 through the crico-thyroid membrane4 ,laryngo-tracheotomy1 when the cricoid cartilage and the upper ring of the trachea are divided4 ,tracheotomy1 when the trachea itself is opened by the division of two1 three1 or more rings4 ,of these the last1 tracheotomy1 is by far the most frequent1 important1 difficult1 and dangerous1 and requires a very detailed description4 ,chassaignac#abg says the only really rational operation for the opening of the air passages by the surgeon is tracheotomy4 ,,tracheotomy4--,anatomy4--,between the cricoid cartilage and the level of the upper border of the sternum1 the middle line of the neck is occupied by the upper portion of the trachea4 ,its depth from the surface varies1 gradually increasing as the trachea descends1 and varying very much according to the fatness1 muscularity1 and length of the neck4 ,it is1 however1 almost subcutaneous at the commencement below the cricoid1 and on the level of the sternum it is in most cases at least an inch from the surface1 in many much deeper4 ,again1 its length varies1 even in the adult1 from two and a half to three1 or even four inches4 ,this is important1 as affecting the simplicity of the operation1 which1 as a rule1 is easier the longer the neck is4 ,the trachea has most important and complicated anatomical relations--some constant1 others irregular4 #a4 ,the carotid arteries and jugular veins lie at either side1 but1 where these are regular in their distribution1 do not practically interfere in a well-conducted operation4 #b4 ,the thyroid gland lies in close relation to the trachea1 one lobe being at each side 7,fig4 ,,xxxi4 ,b ,b71 and the isthmus of the thyroid crosses the trachea just over the second and third cartilaginous rings4 ,in fat vascular necks1 or where the thyroid is enlarged it may occupy a much larger portion of the trachea4 ,the position of the isthmus practically divides the trachea into two portions in which it is possible to perform tracheotomy4 ,both have their advocates1 but the balance of authority tends to support the operation below the thyroid4 ,a separate notice of each will be required immediately4 ,illustration3 ,,fig4 ,,xxxi4#abh #c4 ,the muscles in relation to the trachea are the sterno-hyoid and sterno-thyroid of each side4 ,the latter are the broadest1 are in close contact across the trachea by the inner edges below1 but gradually diverge as they ascend the neck4 ,in thick-set1 muscular necks1 however1 they are in close contact for a considerable distance1 and require to be separated to give access to the trachea4 ,the arteries are in most cases unimportant2 no named branch of any size ought to be divided in the operation4 ,however1 occasionally very free bleeding may result from the division of an abnormal thyroidea ima running up the trachea to the thyroid body from the innominate1 or even from the aorta itself4 ,the veins are very numerous and irregularly distributed4 ,there is generally a large transverse communicating branch between the superior thyroid veins just above the isthmus4 ,the isthmus itself has a large venous plexus over it4 ,below the isthmus the veins converge into one trunk 7or sometimes two parallel ones7 lying right in front of the trachea4 #d4 ,the last anatomical point which may give trouble in normal necks is the thymus1 which is present in children below the age of two1 and covers the lower end of the trachea just above the level of the sternum4 ,where this is not only not diminished1 but enlarged1 as it sometimes is in unhealthy children1 it may give a very great deal of trouble1 rolling out at the wound and greatly embarrassing proceedings4 ,abnormalities are very various and sometimes very dangerous3 vessels crossing the trachea1 as the innominate did in ,macilwain's case1#abi or where two brachiocephalic trunks are present1 as recorded by ,chassaignac4#acj ,one of the most frequent dangers to be guarded against is a possible dilatation of the aorta or aneurism of the arch4 ,this may very possibly1 as happened in one case to the author1 give rise to suffocative paroxysms from its pressure on the recurrent laryngeal nerves4 ,tracheotomy may be deemed necessary1 and there is a great risk1 unless proper precautions be taken1 of wounding the aorta1 where it passes upwards in the jugular fossa4 ,in the author's case the vessel had actually to be pushed downwards by the pulp of the forefinger while the trachea was opened1 the knife being guided on the back of the nail of the same finger4 ,,the ,,operation4--,in a work of this kind it would be utterly impossible to go at all into the subject of what diseases1 injuries1 etc41 warrant or require the operation4 ,it is enough to describe the various methods of operating1 their dangers and difficulties4 #a4 ,the operation above the isthmus of the thyroid4--,a spot about a quarter or half of an inch in vertical diameter between the cricoid cartilage 7,fig4 ,,xxxi47 and thyroid isthmus4 ,advantages4--,it is near the surface1 the vessels are few and comparatively small4 ,it is most suitable in cases of aneurism4 ,professor ,spence#aca 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 aneurism1 the low operation being still best in cases of croup or diphtheria4 ,disadvantages4--,the space is too small1 requires very considerable disturbance of the thyroid isthmus1 or actual division of it4 ,it is too near the point where the disease is2 so much so1 that in most cases of croup or diphtheria it would be perfectly useless4 ,however1 if required1 or if the operation lower down be contra-indicated1 this may be performed easily enough4 ,a straight incision being made in the middle line about one inch and a half in length1 expose the upper ring by careful dissection1 if possible draw aside the veins1 and depress the thyroid isthmus1 divide the rings thus exposed1 and introduce the tube4 ,the operation below the isthmus4--,this1 though more difficult in its performance1 is a much more scientific and satisfactory operation4 ,considerable coolness and a thorough knowledge of the anatomy of the part are absolutely required4 ,the patient being in the recumbent posture1 the shoulders should be well raised1 and the head held back so as to extend the windpipe1 and thus bring it as near as possible to the surface4 ,a pillow1 or the arm of an assistant1 behind the neck will be of service4 ,n4,b4--,be careful lest too great extension by an anxious assistant1 accompanied by closure of the mouth1 should choke the patient 7whose breathing is of course already much embarrassed7 before the operation be begun4 ,chloroform may occasionally be given1 and1 if well borne1 renders the operation very much easier than it would otherwise be4 ,an incision must then be made exactly in the median line of the neck1 from a little below the cricoid cartilage1 almost to the upper edge of the sternum2 at first it should be through skin only1 then the veins will be seen1 probably turgid with dark blood2 the larger ones should be drawn aside1 if necessary divided1 the bleeding stopped by gentle pressure4 ,the deep fascia must then be cautiously divided1 great care being taken to keep exactly in the middle line1 and the contiguous edges of sterno-thyroid muscles separated from each other by the handle of the knife4 ,a quantity of loose connective tissue1 containing numerous small veins1 must now be pushed aside1 the thyroid isthmus pressed upwards1 still with the handle of the knife4 ,the forefinger must then be used to distinguish the rings of the trachea4 ,if there is much convulsive movement of the larynx and trachea1 they should be fixed by the insertion of a small sharp hook with a short curve1 just below the cricoid cartilage1 and this should be confided to an assistant4 ,the surgeon should then1 with the forefinger of his left hand1 fix the trachea1 and open it by a straight sharp-pointed scalpel1 boldly thrusting it through the rings with a jerk or stab1 the back of the knife being below1 and divide two or three of the rings from below upwards4 ,any attempt to enter the trachea slowly with a blunt knife or trocar will probably be unsuccessful1 as the rings1 especially in children1 give way before the knife1 which merely approximates the sides of the trachea without opening it4 ,question of ,hmorrhage4--,it is often a question of some importance1 and one which sometimes it is not easy to settle1 how far attempts should be made completely to arrest the venous hmorrhage before opening the trachea4 ,on the one hand1 if not arrested1 besides the risk of weakening the patient1 we have to dread the much more serious complication of the admission of blood into the wound4 ,and this is very serious in a patient whose respiration has already been much impeded1 whose lungs are probably engorged1 and who has certainly1 by the mere existence of a wound in his trachea1 lost the power of coughing properly2 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 chest1 may be a fatal obstacle to respiration in one already weakened by disease4 ,thus any well-marked arterial hmorrhage from cut branches1 or from the isthmus of the thyroid1 must certainly be arrested prior to opening the trachea4 ,besides this1 blood once having entered the bronchi is apt to extend into their smaller ramifications and prove a cause of death1 by acting as a local irritation1 and setting up intra-lobular suppurative pneumonia4 ,the author has found this to be the case both after tracheotomy and still more frequently in suicide by cut throat4 ,but1 on the other hand1 it is equally true that there is almost always a considerable amount of oozing from small venous radicles divided during the operation1 which depends simply on the great venous engorgement resulting from the obstruction to the respiration1 so that while to attempt to tie every point would be simply endless1 we may be almost certain that the oozing will cease whenever the trachea is opened1 and respiration fairly improved4 ,slight pressure on the wound is generally sufficient to stop the bleeding till the venous engorgement has disappeared4 ,of late years many tracheotomies have been done bloodlessly by use of the thermo-cautery1 for division of the soft parts1 but the subsequent sloughing of the wound is a great objection to this method4 ,in cases of extreme urgency1 all such minor considerations as suppression of venous oozing must be ignored1 and the trachea simply opened as rapidly as possible4 ,i had once to perform the operation after respiration had entirely ceased1 and no pulse could be felt at the wrist1 with no assistance except that of a female attendant4 ,merely feeling that no large arterial branch was in the way1 ,i cut straight through all the tissues1 opened the trachea1 and commenced artificial respiration4 ,the patient eventually recovered4 ,question of ,tubes1 etc4--,once the trachea is opened1 the next question is1 ,how is the opening to be kept pervious8 ,for the moment the handle of the scalpel is to be inserted in the wound1 so as to stretch it transversely2 this will probably suffice to allow of the escape of any foreign body4 ,but where1 to admit air1 the wound is to be kept open1 how is this to be done8 ,it used to be advised that an elliptical portion of the wall of the trachea be removed2 this1 though succeeding well enough for a time1 was unscientific1 as the wound always tended to cicatrise1 and ended of course in permanent narrowing of the canal of the trachea4 ,it may be necessary thus to excise a portion of the trachea1 in cases where it is very intolerant of the presence of a tube4 ,such a case is recorded by ,sir ,j4 ,fayrer of ,calcutta4#acb ,not much better is the proposal to insert a silk ligature in each side of the wound1 and by pulling these apart thus mechanically to open the wound4 ,this also is evidently a merely temporary expedient4 ,various canul and tubes have been proposed4 ,the ones recommended by the older surgeons had all one great fault2 they were much too small1 and were many of them straight1 and thus liable to displacement4 ,the smallness of their bore was their greatest objection1 and ,mr4 ,liston conferred a great benefit on surgery by his insisting upon the introduction of tubes with a larger bore1 and with a proper curve1 so as thoroughly to enter the trachea4 ,the tube ought to be large enough to admit all the air required by the lungs1 without hurrying the respiration in the least4 ,there is a mistake made in the construction of many of the tubes even of the present day2 the outer opening is large and full1 while for convenience of insertion the tube tapers down to an inner opening1 admitting perhaps not one-half as much air as the outer one does4 ,it must be remembered that for some days there is great risk of the tube becoming occluded1 by frothy blood or mucus1 especially in cases of croup1 and in children4 ,to prevent this a double canula will be found of great service1 providing only that it be remembered that the inner canula1 not the outer merely1 is to be made large enough to breathe through1 and that the inner should project slightly beyond the outer one4 ,the inner one can thus be removed at intervals and cleansed1 by the nurse1 without any risk of exciting spasm or dyspnoea by its absence and reintroduction4 ,after-treatment4--,the after-treatment of a case in which tracheotomy has been performed demands great care and many precautions4 ,for the first day or two the constant presence of an experienced nurse or student is always necessary to insure the patency of the tube4 ,the temperature of the room should be equable and high1 and it seems of importance that the air should be kept moist as well as warm by the use of abundance of steam4 ,a piece of thin gauze1 or other light protective material1 should be placed over the mouth of the tube1 to prevent the entrance of foreign bodies4 ,in cases where the operation has been performed for some temporary inflammatory closure of the air passage1 retention of the tube for a few days may suffice4 ,it may then be removed1 but it must be remembered that the wound will generally close with great rapidity1 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 tube4 ,in cases where from long-standing disease or severe accident the larynx is rendered totally unfit for work1 and the tube has to be worn during the rest of the patient's life1 care must be taken 7#a47 lest the tube do not fit accurately1 in which case it may ulcerate in various directions1 even into the great vessels2#acc 7#b47 lest the tube become worn1 and lest the part within the windpipe fall into the trachea and suffocate the patient4#acd ,,laryngotomy4--,as a temporary expedient in cases of great urgency1 where proper instruments and assistants are not at hand1 laryngotomy is occasionally useful1 though from the want of space without encroaching on the cartilages of the larynx1 and from its close proximity to the disease1 laryngotomy is by no means a suitable or permanently successful operation4 ,in the adult1 especially in males with long spare necks1 the operation itself is exceedingly easy to perform4 ,the crico-thyroid space 7,fig4 ,,xxxi4 ,a7 is so distinctly shown by the prominence of the thyroid cartilage1 and is so superficial that it is quite easy to open it in the middle line with a common penknife1 there being merely the skin and the crico-thyroid membrane to be cut through1 with very rarely any vessel of any size4 ,the opening can then be kept patent by a quill or a small piece of flat wood4 ,this simple operation has in many cases1 where a foreign body has filled up the box of the larynx1 succeeded in saving life1 and even in cases of disease ,i have known it useful in giving time for the subsequent performance of tracheotomy4 ,easy as it appears and really is1 cases are on record in which the thyro-hyoid space has been opened instead of the crico-thyroid1 such operations being of course perfectly useless4 ,the incision is best made transversely4 ,,laryngo-,,tracheotomy4--,this modification consists in opening the air passage by the division of the cricoid cartilage vertically in the middle line1 along with one or two of the upper rings of the trachea4 ,it seems to combine all the dangers with none of the advantages of the other methods of operating4 ,it is close to the disease1 involves cutting a cartilage of the larynx1 and almost certain wounding of the isthmus of the thyroid2 and it is not easy to see what corresponding advantages it has over tracheotomy in the usual position4 ,,thyrotomy is an operation by which the larynx is opened in the middle line by a vertical incision1 and its halves separated1 while any morbid growths are excised from the cords or ventricles4 ,the merits and dangers of this operation have been discussed at length by ,mr4 ,durham#ace and ,dr4 ,morell ,mackenzie4#acf ,,laryngectomy ,,or ,,excision ,,of ,,the ,,larynx1 first performed by ,dr4 ,heron ,watson in #ahff1 has been lately frequently performed for carcinoma and sarcoma4 ,each case presents its own difficulties1 which vary according to the amount and extent of the disease for which it is done4 ,the trachea must be divided and tamponed by a ,trendelenburg canula1 after which the larynx must be carefully dissected out4 ,the immediate mortality1 i4e4 in first ten days1 is fifty per cent41 and ,dr4 ,gross holds that life has not been prolonged by the operation4#acg ,,oesophagotomy4--,this operation is very rarely required1 and has as yet been performed only for the removal of foreign bodies impacted in the oesophagus1 and interfering with respiration and deglutition4 ,to cut upon the flaccid empty oesophagus in the living body would be an extremely difficult and dangerous operation1 from the manner in which it lies concealed behind the larynx1 and in close contact with the great vessels4 ,when it is distended by a foreign body1 and specially if the foreign body has well-marked angles1 the operation is not nearly so difficult4 ,it has now been performed in forty-three cases at least1 of which eight or nine have proved fatal4 ,seven1 along with another in which he himself performed it with success1 were recorded by ,mr4 ,cock of ,guy's ,hospital4#ach ,three others were performed by ,mr4 ,syme1 with a successful result4 ,of the seven cases collected by ,mr4 ,cock only two died1 one of pneumonia1 the other of gangrene of the pharynx4 ,operation4--,unless there is a very decided projection of the foreign body on the right1 the left side of the neck should be chosen1 as the oesophagus normally lies rather on the left of the middle line4 ,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 muscle2 with it as a guide1 the omohyoid may be sought and drawn downwards and inwards1 the sheath of the vessels exposed and drawn outwards1 the larynx slightly pushed across to the right1 the thyroid gland drawn out of the way by a blunt hook1 the superior thyroid either avoided or tied4 ,the oesophagus is then exposed1 and if the foreign body is large1 it is easily recognised2 if the foreign body be small1 a large probang with a globular ivory head should then be passed from the fauces down to the obstruction2 this will distend the walls of the oesophagus1 and make it a much more easy and safe business to divide them to the required extent4 ,the wound in the oesophagus should be longitudinal1 and at first not larger than is required to admit the finger1 on which as a guide the forceps may be introduced to remove the foreign body1 or1 if necessary1 a probe-pointed bistoury still further to dilate the wound4 ,for some days or even weeks the patient must be fed through an elastic catheter introduced through the nose and retained1 or by an ordinary stomach-tube through the mouth4 ,in introducing the latter there is always a risk of opening the wound4 ,no special sutures for the wound in the oesophagus are required1 nor is it advisable too closely to sew up the external wound4 ,,footnotes3 #abg ,leons sur la ,trachotomie1 p4 #aj4 #abh ,rough diagram of larynx and trachea3--,a1 crico-thyroid space1 laryngotomy2 ,b ,b1 dotted outline of thyroid isthmus and lobes1 defines the upper and lower positions for tracheotomy2 ,c1 thyroid--,d1 cricoid cartilages2 ,e1 dotted outline of thymus gland in child of two years2 ,f ,f1 outline of clavicles and jugular fossa4 #abi ,surgical ,observations1 p4 #cce4 ,see also ,harrison ,on the ,arteries1 vol4 i4 p4 #af4 #acj ,leons sur la ,trachotomie1 p4 #i4 #aca ,lectures on ,surgery1 #c;d ed41 vol4 ii4 p4 #ijj4 #acb ,clinical ,surgery in ,india 7#ahff71 p4 #adc4 #acc ,mr4 ,john ,wood1 ,path4 ,soc4 ,trans41 vol4 xi4 p4 #bj4 #acd ,south's ,chelius1 vol4 ii4 p4 #djj2 and case recorded by ,spence1 in ,ed4 ,med4 ,journal1 for ,august #ahfb4 #ace ,med4 ,chir4 ,transactions of ,london1 #ahgb4 #acf ,british ,med4 ,journal 7,nos4 #fdc1 #fdd71 #ahgc4 #acg ,gross's ,surgery1 #fth ed41 vol4 ii4 p4 #cdb4 #ach ,guy's ,hospital ,reports for #aheh4 ,,chapter ,x4 ,,operations ,,on ,,thorax4 ,,excision ,,of ,,mamma4--,when the whole breast is to be removed1 two incisions1 inclosing an elliptical portion of skin along with the nipple1 must be made in the direction of the fibres of the pectoralis muscle4 ,the distance between the incisions at their broadest must depend upon the nature of the disease for which the operation is performed1 and the extent to which the skin is involved2 in every case the whole nipple should be removed4 ,the incisions should1 if possible1 be parallel with the fibres of the pectoralis major1 and extend across the full diameter of the breast4 ,during the operation the arm should be extended so as to stretch both skin and muscle4 ,the lower flap should be first raised and dissected downwards1 with care that the cuts are made in the subcutaneous fat1 and wide of the disease2 the upper flap is then thrown open1 and the edge of the gland raised1 so that the fibres of the pectoralis are exposed below it4 ,these should be cleanly dissected1 so as to insure removal of the whole gland4 ,any bleeding during the operation can easily be checked by the fingers of an assistant1 and if the arteries entering the gland from the axilla be divided last1 they can be at once secured4 ,if there are many bleeding points1 the application of cold for a few hours before the wound is finally closed is a wise precaution4 ,the requisite stitches may be inserted while the patient is under chloroform1 but not tightened4 ,the arm should then be brought down to the side1 and a folded towel laid over the wound after it is finally closed4 ,great benefit results from the free use of drainage-tubes in most cases2 for this purpose a dependent opening in the lower flap is often made4 ,surgeons now operate even when the axillary glands are diseased1 and by a very free dissection and removal1 even in hopeless-looking cases1 life may be prolonged4 ,to insure the removal of the lymphatic vessels as well as the glands1 it is best not to separate the breast at its axillary margin1 but keep it attached by the tail of lymphatics surrounded by fat1 which will lead up to the glands4 ,section of the great pectoral muscle will aid the dissection4 ,when the tumour is very large1 and the skin has been much stretched and undermined1 more complicated incisions may be necessary2 these must be governed a good deal by the presence and positions of adhesions or ulcerations of the skin4 ,the best direction1 when the surgeon has his choice1 that these incisions can take1 is that of radii from the nipple1 bisecting the flaps made by the original elliptical incision4 ,n4,b4--,in operating for malignant disease1 the one paramount consideration is that all the disease be excised1 however curious1 inconvenient1 or awkward1 even insufficient1 the flaps may look4 ,partial excisions are worse than useless4 ,,paracentesis ,,thoracis1 for the relief of pleurisy1 acute and chronic1 and empyema1 is an operation of extreme simplicity4 ,the proper selection of cases1 the settling of the suitable position for the tapping1 and the choosing of the suitable time for it1 are more difficult1 and not within the scope of the present work4 ,on these subjects much information may be obtained from the papers of ,dr4 ,bowditch of ,boston1 of ,dr4 ,hughes and ,mr4 ,cock1#aci and an exceedingly interesting and valuable paper by ,dr4 ,warburton ,begbie4#adj ,where is it to be performed8 ,not above the sixth rib1 else the opening is not sufficiently dependent2 very rarely below the eighth on the right side1 and the ninth on the left4 ,the intercostal space generally bulges outwards if fluid is present1 and this bulging acts as an aid to diagnosis4 ,as the intercostal artery lies under the lower edge of the upper rib in each space1 the trocar should be entered not higher than the middle of the space2 and because the artery is largest near the spine1 and also the space is there deeply covered with muscle1 the tapping should never be behind the angle of the rib4 ,in most of the manuals we are told to select a spot midway between the sternum and spine for the puncture2 but ,bowditch1 ,cock1 and ,begbie1 who have had large experience1 prefer1 and ,i believe rightly1 a position considerably behind this1 an inch or two below the angle of the scapula1 between the seventh and eighth1 or between the eighth and ninth ribs4 ,the operation may be performed with a simple trocar and canula1 round1 about an eighth of an inch in diameter1 and at least two inches in length4 ,the point must be sharp1 and it must be pushed in with considerable quickness1 so as to penetrate1 not merely push forwards1 the pleura1 which may be tough1 and thicker than usual4 ,once the skin is pierced1 the instrument must be directed obliquely upwards1 so as to make the opening and position of the trocar dependent4 ,when the trocar is withdrawn the fluid may be allowed to flow so long as it keeps in a full equable stream2 whenever it becomes jerky and spasmodic1 the canula should be removed before the sucking noise of air entering the chest is heard4 ,in more chronic cases1 where the quantity of fluid is large1 and especially if it is thick and curdy1 the exhausting syringe of ,mr4 ,bowditch is an improvement on the simple trocar and canula4 ,it consists of a powerful syringe1 which fits accurately to the trocar with which the puncture is made4 ,there is a stop-cock between the trocar and syringe1 and another at right angles to the syringe4 ,the trocar being introduced1 it is held firmly in position by an assistant1 by means of a strong cross handle2 the first stop-cock is then opened1 and the syringe worked slowly till it is filled with fluid through the trocar1 the other delivery stop-cock being closed4 ,the first is then closed1 and the second opened2 the syringe is then emptied through the second into a basin4 ,by a repetition of this process1 the fluid can be removed at pleasure1 without any risk of the entrance of air4 ,dieulafoy's aspirateur1 which the author has now used in a very large number of cases1 will be found the best method yet devised of safely removing the fluid in cases of serous effusion4 ,but in severe cases of empyema the pus is sure to be reproduced in the great majority1 and then a free incision1 with strict antiseptic precautions1 will be needed1 and subsequent free drainage4 ,the author has used with great benefit silver tubes1 like long narrow trachea-tubes1 with broad shields1 to insure free drain4 ,,footnotes3 #aci ,both in ,guy's ,hospital ,reports1 second series1 vol4 ii4 #adj ,edinburgh ,medical ,journal for ,june #ahff4 ,,chapter ,,xi4 ,,operations ,,on ,,abdomen4 ,,paracentesis ,,abdominis4--,to withdraw fluid from the abdominal cavity is an exceedingly simple operation in itself1 though certain precautions are necessary to render it safe4 ,trocar4--,the usual instrument used to be a simple round canula with a trocar1 the point of which should be very sharp1 and in the shape of a three-sided pyramid4 ,it should be about three inches in length1 and a quarter of an inch in diameter4 ,it may for convenience have an india-rubber tube fixed to its side or end1 for the purpose of conveying the fluid to the pail or basin1 but any other additions or alterations have not been improvements4 ,lately surgeons have been diminishing the size of the tube so as to withdraw the fluid more slowly1 and taking many precautions to insure the wound being kept aseptic4 ,where to tap4--,in the linea alba1 midway between the umbilicus and pubes1 or rather nearer the umbilicus4 ,here1 there are no muscles nor vessels1 the opening is a dependent one1 and the bladder is quite out of the way of injury4 ,n4,b4--,it is a wise precaution1 in every case where there is a possibility of doubt as to the state of the bladder1 to pass a catheter4 ,i have myself known at least one case in which a surgeon was asked to tap an over-distended bladder1 as a case of ascites4 ,the ,operation4--,as there is great risk of syncope coming on during the operation1 from the sudden relief to the pressure on the organs1 a broad flannel bandage should be applied to the belly1 the ends of which are split into three at each side1 and crossed and interlaced behind4 ,an assistant should stand at each side to make gradual pressure by pulling on the ends of the bandage1 thus assisting the flow1 and maintaining the pressure4 ,a hole should be cut in the bandage at the spot where the puncture is to be made1 and the trocar inserted by one firm push1 without any preliminary incision1 unless the patient is inordinately fat4 ,as the trocar is withdrawn1 the canula should be pushed still further in4 ,the surgeon should be ready at once to close the canula with his thumb1 if the flow begins to cease1 lest air should be admitted4 ,if the flow ceases from any cause before all the fluid seems to be evacuated1 the trocar should not be re-introduced1 lest the intestines be wounded1 but a blunt-headed perforated instrument fitting the canula should be inserted4 ,when all the fluid that can be easily obtained is evacuated1 the canula may be withdrawn1 and a pad of lint secured over the wound by strapping4 ,,gastrotomy4--,cutting into the stomach for the extraction of a foreign body has now been performed at least ten times1 and all but one recovered4 ,a typical example is that by ,dr4 ,bell of ,davenport1 who removed a bar of lead one pound in weight and ten inches in length1 by an incision four inches in length from the umbilicus to the false ribs4 ,the opening into the stomach was as small as possible1 and required no sutures4 ,,gastrostomy has within the last few years been practised very frequently4 ,gross has collected #gi cases1 #eg of which were for carcinoma of oesophagus1 all of which died within a few weeks1 except eight who survived for periods varying from three to seven months4 ,the results in cases of cicatricial and syphilitic strictures are more favourable4--,howse's method seems the best1 consisting of two stages4 #a4 ,a curved incision is made through the parietes parallel with1 and a finger-breadth below1 the lower margin of chest wall on left side1 the peritoneum should be opened at the linea semilunaris1 the stomach sought for1 and then attached to the abdominal wall by an outer ring of sutures and to the edge of the wound by an inner ring4 ,it should then be dressed with carbolised lint and supported by a bandage4 #b4 ,a small opening should be made four or five days after the first stage and the patient should be fed through this opening4 ,for full details1 see ,mr4 ,durham's paper in vol4 i4 of ,holmes's ,surgery1 edition of #ahhc1 pp4 #hja-d4 ,,gastrectomy4--,excision of whole or part of the stomach is one of the latest developments of operative daring1 first done as a regular operation by ,pean in #ahgi1 it has now been repeated sixteen times2 four cases have survived the operation for more than ten days4 ,the chief points to be attended to are prevention of death from shock and hmorrhage1 and very careful stitching up of the wound4 ,considering the difficulty of the diagnosis1 the danger of the operation1 and the almost certain recurrence of the disease1 the propriety of such operation seems very doubtful4 ,,ovariotomy4--,for the pathology of ovarian disease we must refer to ,sir ,spencer ,wells's work on the subject1 and to the smaller ,monograph on ,ovarian ,pathology1 by the late lamented ,dr4 ,charles ,ritchie1 junior4 ,even the modifications in the method of operating which have been devised are so various and numerous1 that if collected from the medical journals of the last ten years they would fill a large volume4 ,besides this1 the operation of ovariotomy is one attended by so many complications1 that individual cases vary from each other as much as do individual cases of hernia and tracheotomy2 and as the specialities of each case require to be met by specialities of treatment1 there is hardly any operation in surgery which requires greater readiness of invention1 or more individual sagacity in the operator4 ,to lay open the abdominal cavity from the sternum to the pubes1 and rapidly dissect out of this cavity an enormous tumour with a narrow neck1 the operator's only embarrassment being the peristaltic movements of the bowels1 and his only care being to tie the neck of the tumour firmly with strong string1 sew up the wound1 and trust to nature1 was an operation very easy to perform1 and requiring free cutting rather than dexterity1 and rashness more than true surgical insight4 ,such were the ovariotomies prior to #aheg4 ,an ovariotomy in #ahhc is a very different business1 varying in certain important particulars4 7#a47 ,instead of the incision extending from sternum to pubes1 it is now made as short as possible4 7#b47 ,instead of being removed entire1 the cyst is now emptied with the greatest possible care 7prior to its removal71 and none of the contents allowed to enter the peritoneal cavity4 7#c47 ,the pedicle is brought to the surface1 and in every case where it is possible is secured outside the wound4 ,besides these three important and cardinal points1 there are other minor matters almost equally essential2 these are--7#a47 ,the proper management of the adhesions and the thorough prevention of all hmorrhage from them2 7#b47 the stitching up of the external wound1 including the peritoneum2 7#c47 the treatment of the patient during the first few days of convalescence4 ,operation in a typical case1 after the method of ,sir ,spencer ,wells and ,dr4 ,thomas ,keith4--,the patient having had her bowels gently opened on the previous day1 and being as far as possible in her usual state of health1 should be warmly clad in flannel1 both in body and limb1 and laid on an operating table of convenient height1 in or near the room she is to occupy4 ,no carrying from ward to operating theatre and back again is admissible4 ,it will be found both cleanly and convenient to have a large india-rubber cloth over the whole abdomen1 cut out in the centre so as to expose so much of the tumour as is necessary1 but gummed on or otherwise secured to the sides of the abdomen1 and thus protecting the clothes1 and hanging down over the edge of the table2 this will prevent all wetting of the clothes and unnecessary exposure of the patient's person1 and can be easily removed after the operation4 ,chloroform being administered1 the bladder is evacuated by means of a catheter1 and the patient's head and shoulders are elevated on pillows4 ,an incision is then made in the linea alba1 between the umbilicus and pubes1 for about four inches in length at first1 so as to be large enough to admit the hand1 through all the tissues down to and through the peritoneum4 ,care is necessary in dividing the peritoneum1 on the one hand1 not to divide too much1 in which case the cyst-wall will be penetrated1 and the contents effused into the peritoneal cavity2 or1 on the other hand1 too little1 in which case the peritoneum may be mistaken for the cyst1 and separated from the transversalis fascia under the idea that adhesions exist4 ,once the peritoneal cavity is opened1 the incision through the peritoneum must be extended to the full length of the external wound by a probe-pointed bistoury4 ,the operator's hand must now be passed into the abdomen1 and the tumour isolated from its connections as far as possible4 ,when no adhesions exist it is extremely easy to pass the hand quite round the tumour1 ascertain its relations to the uterus and ,fallopian tubes1 and the length and thickness of its pedicle4 ,the presence of adhesions adds very seriously to the danger and duration of the operation4 ,we will suppose at present that none exist in this typical case1 and that the pedicle is found of a satisfactory size and shape4 ,the surgeon now protrudes the anterior portion of the cyst-wall through the wound1 and pierces it with a large trocar1#ada to which is attached an india-rubber tube1 by means of which the effused fluid can be easily got rid of in any direction4 ,during the escape of the fluid from the cyst a special assistant keeps up the tension by careful pressure on the abdomen4 ,in cases where the cyst is multilocular1 and thus only a portion of the contents of the tumour is at first evaluated1 the operator should1 by partially withdrawing the trocar1 without removing it entirely from the cyst1 endeavour to pierce and evacuate the other cysts1 still through the original opening in the first one4 ,while doing this1 great care must be taken lest he pierce the external wall of the tumour1 and let any of the contents escape into the abdominal cavity2 to guard against this1 the punctures should be made by the right hand1 while the left1 re-inserted into the abdomen1 supports the cyst-wall4 ,the tumour having been as far as possible emptied of its fluid contents1 must now be dragged out of the wound1 care being still taken lest any of its fluid contents escape into the peritoneal cavity4 ,in favourable cases the pedicle is now brought easily into view4 ,this may vary very much in length and thickness4 ,it is sometimes entirely absent1 the tumour being sessile on the broad ligament of the uterus2 sometimes it is thick and strong1 sometimes long and slender4 ,the manner in which it is to be managed depends on its length and thickness4 ,varieties in treatment will be noticed immediately4 ,we will suppose that it is four inches in length and one or two fingers in breadth4 ,this is quite a suitable case for the use of the clamp1 the principle involved in the use of which is1 that the pedicle should be brought quite out of the abdomen through the wound and secured on the surface4 ,the best form seems to be one made like a carpenter's callipers1 with long but removable handles1 and a very powerful fixing-screw4 ,the blades of this clamp being protected by pads of lint should be made to embrace the pedicle close to the cyst1 in a direction at right angles to the abdominal wound1 and lying across it1 the handles should then be removed1 and pads of lint placed below the clamp to protect the skin4 ,the cyst may now be cut away at some little distance above the clamp1 enough being left to prevent all danger of its slipping4 ,further to avoid this danger1 the pedicle may be transfixed by one or two needles above the clamp4 ,the wound is now to be sewed up by several points of interrupted suture1 some inserted very deeply through all the tissues1 including even the peritoneum1 others in the intervals of the first1 including little more than the skin4 ,they may be either of iron1 silver1 platinum1 telegraph-wire 7,mr4 ,clover's copper1 coated with gutta-percha71 or silk4 ,it seems of very little consequence which is used4 ,sir ,spencer ,wells1 after many trials1 uses silk1 as being removed with least pain to the patient1 and really causing no more suppuration than the metallic ones do1 if only removed early enough1 viz41 about the second or third day1 by which time the union of the wound should be firm4 ,the after-treatment should be very simple4 ,except under special circumstances1 stimulants are rarely necessary1 and indeed1 to avoid vomiting1 as little as possible should be given by the mouth during the first twenty-four hours4 ,the patient should be allowed to suck a little ice to allay thirst1 and opiate and nutritive enemata will be found quite sufficient to keep up the strength in ordinary cases4 ,the urine should be drawn off by the catheter every six hours4 ,the room should be kept quiet1 and the temperature equable1 so long as there is no interference with a plentiful supply of fresh air4 ,some of the specialities and abnormalities involving special risks may now be briefly noticed3-- #a4 ,adhesions4--,these vary much in amount1 in position1 in organisation1 and danger4 a4 ,in amount4--,in certain cases no adhesions exist1 while in others1 omentum1 intestines1 tumour1 uterus1 and abdominal wall may be all matted together in one common mass4 b4 ,in organisation4--,occasionally they are so soft and friable as to break down under the finger with ease1 and so slightly organised as not to bleed at all in the process1 while again they may be so firm and close as to require a careful and prolonged dissection1 and so vascular as to require many points of ligature to be applied to large active vessels4 c4 ,there are special dangers connected with the presence of these adhesions1 and varying much in different cases4 ,thus adhesions to the intestines can generally be separated with comparative ease1 and seem1 as a rule1 to require the application of fewer ligatures than those which unite the tumour to the abdominal wall4 ,adhesions to the wall are sometimes so firm as to be quite inseparable1 and thus to necessitate some of the cyst-wall being left adherent4 ,in ,sir ,spencer ,wells's cases1 adhesions to the liver and gall-bladder occasionally occurred1 requiring careful dissection to separate them1 and yet the patients all survived1 while pelvic adhesions1 especially to the bladder and uterus1 on more than one occasion prevented the completion of the operation4 ,vascular adhesions to the wall which require many ligatures certainly add to the dangers of the case1 while adhesions to the anterior wall of the abdomen render the operation1 especially its first stages1 much more difficult1 preventing the cyst from being recognised4 #b4 ,the condition of the pedicle is of great importance4 ,if it is too short1 it prevents the use of the clamp1 as if applied it is apt either to pull the uterus up1 or1 pulling the clamp down1 to make undue traction on the wound1 and rupture any adhesions4 ,this is especially the case where much flatus is generated1 or where the patient is naturally stout4 ,treatment4--,where the pedicle is just long enough to allow the clamp to be applied1 and yet too short to leave room for any distension of the abdomen without undue tension1 the best plan is to transfix it with a stout double thread just below the clamp1 tie it in two halves1 and bring the threads out past the clamp1 so that1 if tension does occur1 the clamp may be removed1 the part beyond it cut off1 and the rest allowed to slip back into the pelvis1 the ligatures being kept out at the mouth of the wound4 ,or again1 it is sometimes possible1 after applying one clamp firmly as near the tumour as possible1 to apply another above it when the greater part of the tumour has been cut away2 when the second is firmly fixed it may then be safe to remove the first1 and thus an artificially elongated pedicle is obtained4 ,when still shorter1 two plans remain for selection--7#a47 to transfix the pedicle in one or more points1 then1 securing it in two1 three1 or more portions1 cut it off above the ligatures and return it1 leaving the ligatures at the lower end of the wound4 ,this gives a free drain for pus1 but theoretically the sloughing pedicle might be expected to set up peritonitis2 7#b47 to transfix and tie the pedicle with one or more loops of stout string1 cut the ends off short1 and return the whole affair1 closing the external wound at once4 ,theoretically there are grave objections to this plan1 but it has proved very successful1 especially in the hands of ,dr4 ,tyler ,smith4 ,another ingenious modification1 sometimes useful in a short narrow pedicle1 is to tie it as close to the cyst as possible1 bring the ligature out at the wound1 and then with a strong harelip needle transfix the pedicle1 along with both sides of the wound1 just below the ligature4 ,when the pedicle is excessively broad and stout1 it should be transfixed by strong needles and double threads in various places1 and thus tied in several portions4 ,absence of the pedicle greatly adds to the danger in any given case4 ,various plans have been tried1 as cutting the attachment through slowly by the craseur1 ligature of each vessel separately1 so many as twelve being sometimes required1 and cauterising the stump4 ,the latter1 as used by ,mr4 ,baker ,brown1 has met with a large measure of success1 and is much used now4#adb ,dr4 ,keith for a time operated with antiseptic precautions1 but has now 7#ahhc7 entirely given up the use of the spray1 which he believes has especial dangers in abdominal surgery4 ,,operation ,,for ,,strangulated ,,inguinal ,,hernia4--,the great rule to be remembered with regard to this1 as well as all other operations for hernia1 is1 that the earlier it is performed the better chance the patient has4 ,once a fair trial has been given to the taxis1 aided by proper position of the patient1 the warm bath1 and specially chloroform1 the operation should be performed4 ,the patient should be placed on his back with his shoulders elevated1 and the knee of the affected side slightly bent4 ,the groin should then be shaved1 and the shape and size of the tumour1 with the position of the inguinal canal1 carefully studied4 ,the surgeon should then lift up a fold of skin and cellular tissue1 in a direction at right angles to the long axis of the tumour1 and holding one side of this raised fold in his own left hand1 commit the other to an assistant4 ,he then transfixes this fold with a sharp straight bistoury1 with its back towards the sac1 and cuts outwards1 thus at once making an incision along the axis of the hernia without any risk of wounding the sac or bowel4 ,any vessel that bleeds may now be tied4 ,this incision will be found sufficiently large for most cases2 if not1 however1 it can easily be prolonged either upwards or downwards4 ,the surgeon must now devote his attention to exposing the neck of the sac1 and in so doing1 defining the external inguinal ring4 ,the safest method of doing so is carefully to pinch up1 with dissecting forceps1 layer after layer of connective tissue1 dividing each separately by the knife held with its flat side1 not its edge1 on the sac1 and then by means of the finger or forceps raising each layer in succession and dividing it to the full extent of the external incision4 ,it is not always an easy matter to recognise the sac1 especially as the number of layers above it1 which are described in the anatomical text-books1 are often not at all distinct4 ,the thickness of the connective tissue of the part varies immensely2 sometimes six layers or even more can be separately dissected1 while1 again1 one only may be found before the sac is exposed4 ,if small and recent1 the sac may be recognised by its bluish colour1 and by the fact that it is possible to pinch up a portion of it between the finger and thumb1 and thus to rub its opposed surfaces against each other4 ,if large and of old standing1 it is sometimes so thin as not to be recognisable1 or again so enormously thickened1 and so adherent1 as to be defined with great difficulty4 ,if it is small1 i4e4 when the whole tumour is under the size of an egg1 it ought to be thoroughly isolated1 and its boundaries everywhere defined4 ,if large1 and specially if adherent1 the neck alone should be cleared4 ,the sac thus being reached1 the external abdominal ring should be clearly defined1 and the finger passed into it so as if possible to determine the presence or absence of any constriction in it4 ,if it feels tight1 the internal pillar of the ring should then be cautiously divided on the finger by a probe-pointed narrow bistoury1 in a direction parallel to the linea alba4 ,at this stage the question comes to be considered as to whether the sac should or should not be opened4 ,much has been said and written on both sides4 ,not to open the sac avoids the risk of peritonitis1 and of injury to the bowel2 but1 on the other hand1 exposes the patient to the danger of the hernia being returned unreduced2 for in many cases the stricture is to be found in the sac itself1 and adhesions very rapidly form between coils of intestine in the sac and the inner wall4 ,again1 not to open the sac prevents us from discovering the condition in which the bowl is2 it may possibly be gangrenous1 in which case such a return en masse would be almost necessarily fatal4 ,a general rule or two may be given here3-- #a4 ,the sac should be opened in every case where there is any reason for doubt about the condition of the bowel1 where there has been long-continued vomiting1 or much tenderness on pressure4 #b4 ,even in cases in which there is every reason to believe the bowel is perfectly sound1 the sac should be opened1 unless the whole contents can be easily and completely reduced out of the sac into the belly1 as in cases where this cannot be done there probably exist either a stricture in the neck of the sac itself1 or adhesions of the bowel to the sac4 ,we should endeavour to avoid opening the sac in cases of old scrotal hernia of large size1 where the symptoms have not been urgent1 especially in large unhealthy hospitals1 as the risk of peritonitis is so great4 ,antiseptic precautions seem considerably to diminish the risk of opening the sac4 ,if the sac then is not to be opened1 the rest of the operation is very simple4 ,endeavour to reduce the bowel out of the sac1 and then return the sac itself1 unless the hernia is of old standing1 and adhesions prevent its reduction4 ,a few silver stitches to close the wound and a carefully adjusted pad are now all that is requisite4 ,if the sac is to be opened1 how can it be done with least danger to the bowel8 ,if the hernia is small1 and it is possible to define it all1 the sac should be opened at its lower end1 as there a small quantity of serous fluid which intervenes between the sac and the bowel will be found4 ,where this is present1 there is no danger of wounding the bowel1 as the sac can be easily pinched up2 but this is by no means invariably the case1 so great care should always be taken4 ,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 sac4 ,a few drops of serum will then escape1 and the glistening surface of the bowel be exposed2 the finger should then be introduced at the opening1 and the incision enlarged by a probe-pointed bistoury4 ,if the hernia is small the sac should be slit up to its full extent2 if large1 only a sufficient portion of the neck should be opened4 ,as soon as the opening in the sac is large enough to admit the point of the operator's forefinger1 it should be inserted so as to protect the intestines1 and the remainder of the sac slit up on it as a guide4 ,the sac thus opened1 the next step is to divide the constriction1 wherever it be4 ,it is most likely to be found at the neck of the sac1 just where it protrudes through the internal ring in an oblique hernia1 or through the tendons of the transversalis and internal oblique1 where the hernia is direct4 ,now1 this constriction might be divided in any direction were it not for the risk of wounding the epigastric artery1 and also of injuring the spermatic cord1 which is in close relation to the neck of the sac of an oblique hernia4 ,wound of the epigastric artery is the chief danger1 for in all cases it is close to the neck of the sac4 ,were its position in relation to the neck of the sac constant1 it might be easily avoided by an incision in the opposite direction2 but as this relation varies according to the nature of the hernia1 an element of danger is introduced4 ,thus1 in oblique inguinal ruptures1 where the sac passes out through the internal ring 7,fig4 ,,xxxii4 ,,ir71 the artery will always be found to the inside of the neck of the sac2 while in direct herni1 where the bowel has made its escape through the triangle of ,hesselbach 7,fig4 ,,xxxii4 71 and passed through the conjoint tendon straight to the external ring1 the epigastric artery will be found on the outside of the neck of the sac4 ,in recent herni the differential diagnosis is comparatively easy1 but in those of old standing and large size1 in which the obliquity of the canal has been much diminished1 it is almost impossible to tell of what kind the hernia originally was1 and consequently to determine in which direction it is safe to incise the neck of the sac4 ,such being the case1 the best rule is to incise the neck of the sac directly upwards1 i4e4 in a line parallel with the linea alba1 and also to cut it very cautiously bit by bit1 in every case1 if possible1 with the finger inserted as a guide to the position of a vessel and a protection to the gut4 ,the spermatic vessels lie sometimes behind1 sometimes on either side of the sac1 and in very old herni may be separated from each other so as really to surround the sac4 ,the cut directly upwards is also the safest for them4 ,all constrictions being overcome1 it is not sufficient merely to push back the gut into the belly4 ,its condition must be carefully examined1 and it must be decided whether the constriction has caused gangrene or not4 ,to examine this properly1 it is generally best to pull down an inch or two more of the gut1 so as thoroughly to bring into view the constricted portion1 as it is most likely to be fatally nipped4 ,it is not always easy to decide as to the condition of the bowel4 ,certain points must be observed3-- 7#a47 ,colour4--,there may be very great alteration in the colour of the bowel from congestion1 and yet no gangrene4 ,it may be dark red1 claret1 purple1 or even have a brownish tint1 and yet recover2 where it is black1 or a deep brown1 the prognosis is unfavourable4 7#b47 ,glistening4--,so long as the proper glistening appearance of the bowel remains1 there is hope for it1 even when the colour is bad2 if it has lost it1 and especially if1 instead of being tense and shining1 it is dull and flaccid and in wrinkles1 the bowel is almost certainly gangrenous4 7#c47 ,thickness4--,if much thickened1 and especially if rough on the surface1 the bowel has probably been forming adhesions to the sac1 or to contiguous coils1 and the prognosis is less favourable4 7#d47 ,smell4--,the peculiar gangrenous odour on opening the sac is very characteristic4 ,in cases where ulceration and perforation have occurred1 the odour is fcal4 #a4 ,if1 then1 the bowel is tolerably healthy-looking1 though discoloured1 it should be returned gradually1 not en masse1 into the abdomen1 the wound sewed up1 and a pad of lint put on1 with a bandage4 #b4 ,if there are adhesions of bowel to sac or to a neighbouring coil1 or of omentum to sac1 the stricture should be freely divided1 the protruding coils of intestine should be emptied of their contents1 but no rash attempt made to force their return4 ,especially is this rule to be observed with protruded1 swollen1 or adherent omentum1 for considerable risks attend any attempt at excision of the protruded portion--risks of hmorrhage1 peritonitis1 and ulceration of the contiguous bowel4 ,if the bowel be returned1 or even the continuity of the canal restored by the cutting of the stricture1 though the bowel be not returned1 no great risks accrue from the retention of a piece of omentum in the sac1 in a position which it may possibly have already occupied for years4 #c4 ,if the bowel is absolutely gangrenous1 even in a very small portion of its length1 no reduction should be attempted1 but the gangrenous portion should be kept outside1 with the hope that adhesive inflammation may be set up1 so as to glue the bowel to the abdominal wall1 prevent fcal extravasation1 and form a temporary artificial anus4 ,if the gangrenous portion be very full of fces or flatus1 incisions may be made into it4 ,this should be avoided in cases where the patient is already much prostrated1 as ,i have seen cases in which the opening of the bowel seemed to inflict a fatal shock4 ,enterectomy or excision of the gangrenous portion has recently been recommended and performed by some surgeons4 ,the very high authority of the late ,professor ,spence is against such procedure4#adc ,cases of gangrene of even large portions of bowel are by no means necessarily fatal4 ,they may recover with an artificial anus1 the remedy of which by surgical means we must notice in its proper place4 ,,operation ,,for ,,strangulated ,,femoral ,,hernia4--,while the general principles guiding treatment and ruling the conduct of the operation are the same as in inguinal1 there are some differences in points of detail which render a brief separate description necessary4 ,a single word on the anatomy4 ,tracing a femoral rupture from within outwards1 we find that its first stage is to push its way through the weak point of the arch formed by ,poupart's ligament1 that is1 the spot called the crural arch1 bounded on its outer side by the sheath of fascia which surrounds the femoral vein2 above by ,poupart's ligament2 on its inner side by the curved fibres of ,poupart's ligament1 which1 curving backwards1 are inserted into the ilio-pectineal line1 have a sharp falciform edge1 and have been dignified by the special name of ,gimbernat's ligament 7,fig4 ,,xxxii4 ,g72 and below by the os pubis itself4 ,this arch or ring thus bounded is1 in the normal state of parts1 filled by a layer of fibrous texture1 a little fat1 and occasionally a small gland4 ,these parts are pushed forwards in the descent of the hernia1 and in a small recent one may be said to form a sort of inner covering2 in a larger and older one they are split by the hernia1 and1 while forming a constriction round its neck1 leave the fundus of the sac1 so far as they are concerned1 quite uncovered4 ,a femoral hernia may stop there1 satisfied with merely coming through the ring1 and1 if sudden and recent in a healthy1 well-knit subject1 such a rupture is exceedingly dangerous1 the constriction being very severe1 and the consequent gangrene of the bowel very rapid if unrelieved4 ,in most cases1 however1 it makes its way still further out1 and the next covering it gains is from the cribriform fascia4 ,this is the layer of fibres1 pierced 7as its name implies7 with orifices for the passage of veins and lymphatics1 which stretches between the two curved edges of the saphenous opening4 ,it varies much in strength2 when the rupture has been slow and gradual1 it will certainly add a covering of greater or less thickness1 but where the hernia is large and old we must not expect to find many traces of the cribriform fascia1 at least over the fundus of the tumour4 ,the ordinary superficial fascia of the part1 with its fat1 nerves1 veins1 and lymphatics1 and the thin skin of the groin1 are the only remaining coverings4 ,it is very remarkable how exceedingly thin all the so-called coats become in large femoral herni of long standing1 especially in thin old people4 ,operation4--,various incisions are recommended4 ,the one which gives freest access and exposes the sac best1 is shaped like a ,t1 the horizontal limb of which is oblique1 the direction of the obliquity varying on the two sides4 ,the horizontal incision should be made just over ,poupart's ligament1 and parallel to it1 the centre of the incision corresponding to the neck of the sac1 and its length varying according to the size of the tumour and the depth of the parts2 the other should extend downwards from the centre of the former1 as far as is necessary to display the whole sac4 ,the first should be made by pinching up and transfixing the skin1 the second by ordinary incision1 to the same depth as the first4 ,the small flaps thus made must now be thrown back2 any vessels that have been divided are to be tied4 ,now1 with great care and caution the surgeon is to pinch up and divide any layers of condensed cellular tissue which may still cover the sac1 till it is thoroughly exposed to its full extent1 and remove any glands which may intervene4 ,the neck of the sac being exposed1 it may be possible in some very exceptional cases to give the patient the benefit of the minor operation1 which consists in leaving the sac unopened4 ,in such a case 7to be described immediately71 the surgeon passes his finger along the neck of the sac as far as possible into the ring1 and then with a probe-pointed bistoury very cautiously nicks the upper edge of ,gimbernat's ligament1 in one or more places1 being careful to feel for any pulsation before dividing a single fibre4 ,he may then be able to empty the sac of its contents1 and return the bowel and omentum1 still retaining the sac outside4 ,on the other hand1 where it is determined to open the sac1 the pinching up of the sac must be managed with great care1 to avoid injury of the bowel4 ,there is generally a little fluid to be found at the fundus1 which will protect the bowel4 ,in one case in which ,liston operated1 he tells us1 there was no possibility of pinching up the sac1 either with the fingers or forceps2 it contained no fluid1 and was impacted most firmly with bowel2 very luckily the membrane was thin2 and1 observing a pelleton of fat underneath1 ,i scratched very cautiously with the point of the knife in the unsupported hand1 until a trifling puncture was made1 sufficient to admit the blunt point of a narrow bistoury4#add ,if the sac contains bowel and omentum1 it is safer to open it over the omentum than over the bowel4 ,when a small opening is made1 an escape of the contained fluid takes place1 and then the sac should be slit up as far as its neck by a probe-pointed bistoury1 guided by the finger1 introduced to protect the bowel1 whenever the opening is sufficiently large4 ,the forefinger must now be cautiously insinuated into the neck of the sac1 the nail being directed to the bowel1 the pulp to the crescentic margin of ,gimbernat's ligament1 and any constriction very cautiously divided4 ,the bowel should then be drawn down a little1 the constricted point carefully examined1 and then returned or not1 according to its condition4 ,two points require a brief separate notice3-- #a4 ,in what direction is the crural arch to be divided8 ,not outwards certainly1 on account of the vein1 nor downwards1 as the bone prevents that direction4 ,is it to be upwards or inwards8 ,not upwards1 for such an incision would endanger the spermatic cord or round ligament1 besides greatly weakening the abdominal wall by the division1 partial or complete1 of ,poupart's ligament4 ,inwards then it must be2 and little more need be said about it1 were it not for the occasional existence of an abnormal course and distribution of the obturator artery4 ,illustration3 ,,fig4 ,,xxxii4#ade ,the usual origin of this vessel is from the internal iliac1 in which case 7,fig4 ,,xxxii4 ,n ,o7 it never comes near the sac at all4 ,in certain cases 7#a in #c-a_/b7 it rises from the epigastric1 and in a very few 7#a in #gb7 from the external iliac4 ,if rising from either of the two last1 it most commonly passes downwards at the outer side of the hernia1 in which case 7,fig4 ,,xxxii4 ,s ,o7 no harm can possibly result2 but in a few rare cases1 perhaps #a in every #fj of those operated on1 the vessel winds round the hernia 7,fig4 ,,xxxii4 ,o71 crossing at its inner side1 and thus may be 7and has actually been7 divided by a rash incision4 ,with due care1 however1 and by cutting a very little at a time1 even this danger may be avoided4 #b4 ,under what circumstances is it possible or justifiable to reduce a femoral hernia1 without previously opening the sac8 ,only in certain very select cases1 where the hernia is recent1 the constricting parts lax1 the general symptoms very mild1 and where there is reason to believe the bowel has completely escaped injury by compression or the taxis4 ,there are both difficulties and dangers in this so-called minor operation3--#a4 ,difficulties1 ,for it is not easy to divide the constriction without the assistance of the finger in the sac1 and it is not easy to reduce the contents with the sac unopened1 except through a much freer opening than is necessary when the bowel has been fairly exposed4 #b4 ,dangers1 ,of reducing sac and viscera1 together with the strangulation still kept up by tightness in the neck of the sac2 or of supposing the sac is emptied while a knuckle of bowel still remains in it1 and is strangulated2 or1 lastly1 of reducing the intestine which has already become gangrenous4 ,it is very remarkable how very soon gangrene may come on1 in a case of a small recent femoral hernia1 in which the fibrous tissues constricting the neck of the sac are tense and undilatable4 ,a protrusion for eight hours has been sufficient to destroy the life of a knuckle of bowel4 ,a note here on a certain condition very frequent in femoral herni1 which may occasionally give a good deal of trouble4 ,symptoms of strangulation have been well marked1 yet when the sac is opened nothing is to be seen except a mass of omentum1 perhaps tolerably healthy-looking4 ,to reduce this en masse would be very unsafe2 it is necessary carefully to unravel it1 and disengage the knuckle of bowel which is almost certainly included in it1 and which has given rise to the symptoms of strangulation4 ,,operation ,,for ,,strangulated ,,umbilical ,,hernia4--,the operation is practically the same1 whether the hernia is a true umbilical one1 or one which with more strict accuracy might be called ventral4 ,true umbilical hernia is a disease of infancy and childhood1 being almost always congenital1 and the viscera protrude through the umbilical aperture4 ,this rarely requires operation1 as it may generally be returned with ease1 and even cured by a proper bandage and compress4 ,ventral hernia1 commonly called umbilical1 is generally a protrusion of viscera through a new preternatural aperture in the fibrous tissues close to the navel1 may often attain a large size1 is liable to strangulation1 and is not easily palliated or cured4 ,in either case the operation requires a very brief description4 ,if the hernia is small1 under the size of a hen's egg1 a crucial incision through the thin skin which covers it will thoroughly expose the sac when the flaps are dissected back4 ,the forefinger should then be inserted in the round opening1 and the edges cautiously incised in several directions1 each incision however being very small4 ,if the rupture is large1 a single linear1 or a ,t-shaped incision1 exposing the base of the tumour1 will be sufficient to allow the requisite dilatation of the opening to be made4 ,it is not at all necessary in every case to open the sac of the peritoneum4 ,if required1 it must be done with great caution1 as the sac is generally very thin4 ,in cases where the hernia is chiefly omental1 the sac should be opened1 lest a knuckle of bowel be inclosed and strangulated in the omentum4 ,,obturator ,,hernia is an extremely rare lesion1 and a large proportion of the recorded cases were discovered only after death4 ,when diagnosed during life and strangulated1 some have been reduced by taxis1 and only a very few cases have been operated on1 some with success4 ,it is not likely that a diagnosis could be made1 except in very emaciated patients1 in whom pain at the obturator foramen was a prominent symptom1 and in whom it could be ascertained positively that the crural ring was empty4 ,an incision over the tumour1 sufficient to allow the pectineus muscle to be exposed and divided1 is necessary4 ,the hernia may then be reduced without opening the sac1 if recent2 if of long standing1 the sac must be opened4 ,one case is recorded by ,dr4 ,lorinzer1 in which1 after strangulation for eleven days1 he opened the sac and found the bowel gangrenous4 ,the patient had a fcal fistula2 but survived the operation for eleven months4 ,nuttel1 ,obr1 and ,bransby ,cooper have each diagnosed and treated such cases4#adf ,other forms of hernia are so rare1 and the treatment of each case must necessarily vary so much in its circumstances1 as not to require or admit of any detailed account of the operations requisite for their relief4 ,,operations ,,for ,,the ,,radical ,,cure ,,of ,,hernia4--,the inconveniences and discomfort caused by even the best-adjusted trusses or bandages1 the unsatisfactory support they afford1 and the risk of their slipping and allowing the hernia to escape1 have given rise to many attempts to cure hernia by operation4 ,even to enumerate these would be quite beyond the limits of the present volume2 suffice it to classify a few of the most important of them according to the principle involved in each1 and then give a very brief account of the method of operating which seems to be at once the most scientific1 least dangerous1 and most permanently useful4 ,the question at issue is briefly this4 ,we have1 in a hernia1 the following condition3--,the walls of a great cavity are at one or more points specially weak1 the contained viscera have protruded1 either by extension and stretching of a natural opening1 or by the formation of a new breach in the walls1 and1 in protruding1 they have brought with them as a covering a serous membrane1 extremely extensible1 highly sensitive to injury1 and1 when injured1 certain to resent it by severe1 spreading1 and dangerous inflammation4 ,do we desire to remedy this protrusion1 we may act-- #a4 ,on the intestines themselves2 but for all surgical purposes1 they are out of our reach4 ,we cannot do more than1 by diminishing their contents1 diminish their volume1 and by position and rest reduce to the utmost their tendency to protrude4 ,this includes the medical and prophylactic treatment of hernia1 or rather of the tendency to hernia4 #b4 ,we may try what can be done with the sac which the intestines have pushed down before them4 ,can it be obliterated8 ,if it can1 perhaps the intestines may be retained in their cavity4 ,very many plans of dealing with the sac have been tried4 ,to cause obliteration of its cavity many methods have been proposed3--by ligature of it along with the spermatic cord1 involving loss of the testicle1 either by gradual separation1 by sloughing1 or by immediate removal2--by cutting into it1 and then stitching it up2--by constricting it with wire1 as in the punctum aureum2 by pinching sac and coverings up1 by passing needles under them as they emerge from the external ring1 as ,bonnet of ,lyons did2 by constricting sac alone with a double wire1 by subcutaneous puncture1 as ,dr4 ,morton of ,glasgow has done2--by severe pressure from the outside with a strong tight truss and a pad of wood1 as proposed by ,richter2 by setons of threads or candlewicks1 as proposed by ,schuh of ,vienna2--by injection of tincture of iodine or cantharides1 as by ,velpeau and ,pancoast2--by the introduction into the sac of thin bladders of goldbeaters' skin1 which were then filled with air1 and were intended to excite inflammation1 as in the radical cure of hydrocele2 or by the still more severe method of ,langenbeck1 consisting in exposing the sac by a free incision at the superficial ring1 separating it from the cord1 and passing a ligature round the sac alone1 leaving the ligatured portion in the scrotum either to become obliterated or to slough out4 ,schmucker of ,berlin varied this1 by cutting away the constricted portion below the ligature4 ,the objections to these methods are various3 the more gentle are uncertain and inefficient2 of the more severe1 some involve mutilation1 by the loss or removal of the testicle2 others1 as those of ,langenbeck and ,schmucker1 are very dangerous and fatal1 by the inflammation spreading to the peritoneal cavity 7#bj to #cj per cent4 died72 while all of these methods afford at best only temporary relief4 ,and this is only what might have been expected1 for the sac was only a result of the protrusion1 not a cause2 and so long as the weakness and insufficiency of the parietes of the abdomen remain1 so long will the extensible loosely-attached peritoneum continue to furnish new sacs for visceral protrusions4 #c4 ,we have now only the canal left to act upon2 and the operations on the canal may be divided into two great classes3-- 7a47 ,those in which the operator attempts to plug up the dilated canal4 7b47 ,those in which he tries to constrict it1 by reuniting its separated sides4 7a47 ,attempts to plug the canal have1 in most cases1 been made by invagination of the skin of the scrotum and its fascia4 ,these have been very numerous and various in their adaptation of mechanical appliances1 but have all been designed with the same object4 ,dzondi of ,halle1 and ,jameson of ,baltimore1 incised lancet-shaped flaps of skin1 and endeavoured to fix them by displacement over the ring4 ,gerdy invaginated a portion of scrotum and fascia into the enlarged canal1 by the forefinger pushed it up1 and secured it in its place by a thread passed from the point of his finger first through the invaginated skin1 then through the abdominal walls1 endeavouring to include the walls of the inguinal canal1 causing the point of the needle to project some lines above the inguinal ring2 the same process being effected with the other end of the thread on the other side of the finger1 and the two ends which have been brought out near each other on the abdominal wall1 being tied tightly over a cylinder of plaster4 ,the ensheathed sac was then painted with caustic ammonia to excite inflammation1 and a pad put on over all4 ,signoroni modified this by fixing the invaginated skin by a piece of female catheter1 retained in its place by transfixion by three harelip needles1 tied by twisted sutures4 ,wtzer of ,bonn1 again1 modified this1 by substituting a complicated instrument1 consisting of a stout plug in the inguinal canal1 held in position by needles which are passed through the anterior wall of the canal in the groin4 ,compression between plug and compress1 with the intention of causing adhesion between skin1 fascia1 and sac1 is then managed by means of a screw4 ,the plug is retained for about seven days4 ,modifications of this method have been tried by ,wells1 ,rothmund1 and ,redfern ,davies1 all aiming in the direction of simplicity2 but by far the most simple and efficacious method on the ,wtzer principle yet devised is that of ,professor ,syme1 which he described in the pages of the ,edinburgh ,medical ,journal for ,may #ahfa1 in which the invagination of integument is both simply and securely managed by strong threads1 as in ,gerdy's method1 while a piece of bougie or gutta-percha1 to which the threads are fixed1 replaces ,wtzer's expensive and complicated apparatus4 ,sir ,j4 ,fayrer of ,calcutta has had a very large experience of ,wtzer's method1 and also of a plan of his own4 ,out of #ajb cases by the latter method1 #gg were cured1 #i relieved1 #ad failed1 and #b died4#adg ,mr4 ,pritchard of ,bristol has proposed an additional step in operations on the invagination principle1 consisting in the stripping of a thin slip of skin from the orifice of the cutaneous canal1 and then putting a pin through the parts to get them to unite1 and thus close the aperture completely4 ,now1 what results follow these operations8 ,at first they are almost invariably successful1 but the complaint is that1 in most cases1 the rupture recurs4 ,the principle is to plug up the passage by the mechanical presence of the invaginated skin1 the plug being retained in position by adhesive inflammation between it and the edges of the dilated ring4 ,but the ring is left dilated1 or1 indeed1 generally its dilatation is increased2 and as1 on continued pressure from within1 the new adhesions give way1 or1 as often happens1 a new protrusion takes place in the circular cul-de-sac necessarily left all round the apex of the invagination1 the still lax ring and canal offer no resistance to the protrusion4 7b47 ,the principle of constriction of the canal by reuniting its separated sides4 ,this is the principle of the various methods introduced by ,mr4 ,wood of ,king's ,college1 and described by him in his most able and exhaustive work4#adh ,he applies sutures through the sides of the dilated inguinal or crural canals1 or umbilical openings1 in such a manner as to insure their complete closure4 #a4 ,for inguinal hernia4--,to stitch together the two sides of the canal with safety requires attention to several points--7#a47 ,that it be done nearly1 if not entirely1 subcutaneously4 7#b47 ,that the protruding bowel should be kept out of the way1 and not be transfixed by the needle4 7#c47 ,that the spermatic cord should be protected from injurious pressure4 ,these different indications are attained by ,mr4 ,wood by a very ingenious mode of operating1 which ,i can describe here only briefly1 and for a full description of which ,i must refer to ,mr4 ,wood's own monograph already alluded to4 ,for his first twenty cases ,mr4 ,wood used strong hempen thread for the stitches2 of late1 however1 he has proved the greater advantage of strong wire4 ,when a large old hernia in an adult is the subject of operation1 it is thus performed by ,mr4 ,wood3--,the pubes being shaved1 and the patient put thoroughly under the influence of chloroform1 the rupture is reduced1 and the operator's forefinger forced up the canal so as to push every morsel of bowel fairly into the abdomen4 ,an assistant then commands the internal ring by pressure1 to prevent return of the rupture4 ,an incision is made in the scrotum over the fundus of the sac1 large enough to admit a forefinger and the large needle used in the operation2 the edges of the skin are to be separated from the fascia below for about one inch all round4 ,the forefinger is then to be passed in at the aperture and pushed upwards1 invaginating the detached fascia before it1 and it must be made to enter the inguinal canal far enough to define the lower border of the internal oblique muscle stretched over it4 ,a large curved needle 7unarmed7 is then passed on the finger as a guide1 through the internal oblique tendon1 the internal portion of the ring1 and the skin of the abdomen2 it is then threaded and withdrawn4 ,again1 the needle 7now with a thread7 is guided by the finger and pushed through ,poupart's ligament and the external pillar of the ring as before2 while by a little manipulation its point is made to protrude through the same opening in the skin as before1 a loop of thread is now left there1 and the needle1 still threaded1 is again withdrawn4 ,the next stitch1 still guided on the finger1 takes up the tendinous layer of the triangular aponeurosis covering the outer border of the rectus tendon close to the pubic spine2 the point of the needle is then turned obliquely1 so as to protrude through the original puncture in the skin a third time1 the needle is then freed from the thread and withdrawn1 thus leaving two ends and one intermediate loop of thread all at the one opening4 ,these are so arranged that when they are tightened they draw together the sides of the canal2 they are then secured over a compress of lint4 ,the compress is removed and the stitches loosened1 at dates varying from the third to the seventh day4 ,mr4 ,wood now uses wire instead of thread4 ,it has the advantage of greater firmness1 excites less suppuration1 and may be left much longer in situ1 in consequence of which there is less risk of suppuration or pymia1 and more chance of a good consolidation of the parts4 ,in congenital herni1 and small ruptures in children and young boys1 ,mr4 ,wood uses rectangular pins in the following manner3--,the scrotum being invaginated 7without any incision through the skin7 as far as possible up the canal1 a rectangular pin1 with a slightly-curved spear-pointed head1 is passed through the skin of the groin to the operator's forefinger2 guided by it1 it is brought safely down the canal1 and brought out through the skin of the scrotum just over the fundus of the hernial sac4 ,a second pin is passed from the lower opening 7still guided by the finger7 in an upward direction1 transfixing in its course the posterior surface of the outer pillar of the superficial ring1 its point being brought out through1 or at least close to1 the first puncture made by the first pin4 ,the pins are then locked in each other's loops--the punctures and skin protected by lint or adhesive plaster1--and the whole is retained by lint and a spica bandage4 ,the pins should generally be withdrawn about the tenth day4 ,the author has now in many cases stitched with catgut the edges of the ring after the ordinary operation for hernia with the best effect4 #b4 ,for ,femoral ,rupture4--,cases suitable for operation are very infrequent2 but should such a one be met with1 ,mr4 ,wood proposes the following operation on the same plan as the preceding4 ,the hernia being fully reduced and the parts relaxed by position1 an incision about an inch long should be made over the fundus of the tumour1 and its edges raised so as to admit the finger fairly into the crural opening4 ,the vein is then to be pushed inwards1 and the needle passed through the pubic portion of the fascia lata of the thigh1 and then through ,poupart's ligament1 appearing on the skin of the abdomen1 a wire is then passed through the eye of the needle and hooked down1 appearing through the wound1 it is then withdrawn1 and the needle again passed through the pubic portion of the fascia lata1 but about three-quarters of an inch to the inside of the first puncture1 then through ,poupart's ligament again1 and protruded through the same orifice in the skin2 the other end of the wire is then hooked down as before1 leaving a loop above1 at the needle orifice1 and two ends at the wound in the skin below4 ,both loops and ends must be managed as before4 ,the author after operating for the relief of strangulation in a case of very large femoral hernia in a girl aged #bc1 stitched up the neck of the sac1 and also stitched it to ,gimbernat's ligament4 ,the result for some months was admirable1 though the hernia had been a very difficult one to replace from its size1 and had been long in the habit of coming down4 ,eventually protrusion occurred to a very slight extent1 but a truss keeps it completely up4 #c4 ,for ,umbilical ,rupture4--,the principle involved in ,mr4 ,wood's operation for umbilical rupture is precisely the same as for inguinal and crural4 ,it consists in stitching the two edges of the tendinous aperture by wire2 the needle is passed on a sort of small scoop or broad grooved director1 which at once invaginates the skin and protects the bowel4 ,two stitches are thus inserted on each side4 ,for the ingenious method by which they are introduced subcutaneously1 ,i must refer to the detailed description in ,mr4 ,wood's monograph4 ,the wires are thus twisted and tightened over a pad of lint or wood1 drawing together the edges of the opening in the tendon4 ,,operations ,,for ,,artificial ,,anus4--,in children the condition known as imperforate anus may sometimes be remedied by exploratory operations in the perineum1 guided by the protrusion caused by the distended intestine4 ,there are other cases1 however1 in which the rectum1 as well as the anus1 seems to be deficient1 and in which1 from the want of protrusion1 there is no warrant for attempting an operation there2 in these the only chance of life that remains is in an attempt to open the bowel higher up4 ,in adults1 again1 absolute closure of the rectum and anus1 and complete obstruction1 may be the result of malignant disease1 or even1 very rarely1 of simple organic stricture4 ,in such cases1 where the patient is tolerably strong and yet evidently doomed from the complete obstruction1 an attempt at the formation of an artificial anus is warrantable1 and in many cases afford great relief1 and prolongs life for months4 ,without going into all the various positions proposed for such operations1 ,i select the two most warrantable1 which have borne the test of experience4 ,these are--#a4 ,colotomy in the left loin4 ,this is applicable in the case of adults with rectal obstruction4 #b4 ,colotomy in the left groin applicable in cases of imperforate anus and deficiency of rectum in infants4 #a4 ,colotomy in the left loin1 generally known by the name of ,amussat's operation4--,the patient is laid upon his face1 a pillow placed under the abdomen1 rendering the left flank prominent4 ,a transverse incision should then be made at a level about two finger-breadths above the crest of the ilium1 extending from the outer edge of the erector spin muscle forward for four or five inches1 according to the fatness of the patient2 the muscles must then be carefully divided till the transversalis fascia is exposed4 ,it is then to be pinched up and divided1 as in the operation for strangulated hernia4 ,the muscular wall of the colon uncovered by peritoneum is then in most cases very easily recognised from its immense distension4 ,the bowel should then be hooked up by a curved needle1 two or three points at least secured to the margins of the wounds by stitches1 and then the bowel should be opened by a longitudinal incision of at least an inch in length4 ,when the distension has been great1 there is generally a rush of fluid fces1 which must be provided for1 special care being taken lest any get into the cavity of the peritoneum4 ,illustration3 ,,fig4 ,,xxxiii4#adi #b4 ,colotomy in the left groin1 for absence of anus and deficiency of rectum in newly born infants4--,the dissections of ,curling1 ,gosselin1 and others have shown that in infants the operation of lumbar colotomy is very difficult1 and its results uncertain1 while it is comparatively easy to open the colon in the left groin4 ,huguier1 again1 has shown that in certain cases the colon is not to be found in the left groin1 but is accessible in the right groin4 ,this abnormality seems1 as shown by ,curling1 to occur not oftener than once in every ten cases4 ,operation4--,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 ligament1 extending a little above the anterior-superior spinous process of the ilium4 ,the fibres of the abdominal muscles should be divided on a director passed beneath them1 and the peritoneum should next be cautiously opened to a sufficient extent4 ,the colon will most likely protrude1 but if small intestine appear the colon must be sought for higher up4 ,a curved needle armed with a silk ligature should be passed lengthways through the coats of the upper part of the colon1 and another inserted in the same way below1 and the bowel1 being drawn forwards1 should then be opened by a longitudinal incision4 ,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 needles4 ,,operation ,,for ,,the ,,removal ,,of ,,an ,,artificial ,,anus1 in cases where the bowel is patent below4--,after the operation for hernia in a case where the bowel is gangrenous1 the only hope of the patient's recovery consists in the formation of adhesions between the bowel and the external wound1 and the presence1 for a time at least1 of an artificial anus4 ,if adhesions do form1 and the patient recovers1 it becomes a matter of great importance for his future comfort that the canal of the intestine should be re-established1 and the fistulous opening allowed to close4 ,this1 however1 is by no means easy1 as even when the portion of intestine destroyed has been very small1 a septum or valve remains which directs the contents of the bowel outwards1 and so long as it exists is an effectual obstacle to any of the fcal contents passing into the distal portion of the bowel4 ,this septum or peron is formed by the mesenteric side of the two ends of the bowel4 ,to destroy this without causing peritonitis is the aim of the surgeon1 and it is not an easy matter to accomplish4 ,to cut it away would at once open the peritoneal cavity1 so the mode of treatment now adopted in the rare cases where it is necessary is that recommended by ,dupuytren4 ,the principle of it is to destroy the peron by pressure so gradual as to cause adhesive inflammation between the two surfaces1 and thus seal up the cavity of the peritoneum1 before the continuance of the same pressure shall have caused sloughing of the septum4 ,this is managed by the gradual approximation by a screw of the blades of a pair of forceps1 to which ,dupuytren gave the name ,enterotome4 ,the process1 which extends over days and weeks1 must be carefully watched lest the inflammation go too far4 ,plastic operations are occasionally required to close the opening after the passage is restored4 ,for a good example of such an operation see ,edin4 ,med4 ,journal for ,august #ahgc1 in which ,mr4 ,john ,duncan describes a case4 ,,footnotes3 #ada ,description of ,sir ,spencer ,wells's ,trocar4--,it consists of a hollow cylinder six inches long1 and half an inch in diameter1 within which another cylinder fitting it tightly plays4 ,the inner one is cut off at its extremity1 somewhat in the form of a pen1 and is sharp4 ,the sharp end is kept retracted within the outer cylinder by a spiral spring in the handle at the other end1 but can be protruded by pressing on this handle when required for use4 ,when thus protruded it is plunged into the cyst up to its middle2 the pressure on the handle is taken off1 and the cutting edge is retracted within its sheath4 ,the fluid rushes into the tube1 and escapes by an aperture in the side1 to which an india-rubber tube is attached1 the end of which drops into a bucket under the table4 ,the instrument is furnished at its middle with two semicircular bars1 carrying each four or five long curved teeth like a vulsellum4 ,these teeth lie in contact with the outer surface of the cylinder1 but can be raised from it by pressing two handles4 ,when the cyst begins to be flaccid by the escape of the fluid1 these side vulsellums are raised1 and the adjoining part of the cyst is drawn up under the teeth1 where it is firmly caught and compressed against the side of the tube4 #adb ,for further details on the operations described above1 reference may be made to ,sir ,spencer ,wells's work on ovarian disease1 and to the very valuable papers contributed by ,dr4 ,thomas ,keith to the ,edinburgh ,medical ,journal4 ,to the latter especially the author is indebted for much oral instruction1 and for the opportunity of seeing his careful and dexterous mode of operating4 #adc ,lect4 on ,surgery1 #c;d ed41 vol4 ii4 p4 #iih4 #add ,operative ,surgery1 p4 #dfb4 #ade ,rough diagram of abnormal course of obturator and its relation to the neck of a hernia4 ,parts seen from the inside3 ,h1 femoral hernia2 ,a1 femoral artery2 ,v1 femoral vein2 ,e1 epigastric artery2 ,o1 obturator from epigastric 7dangerous72 ,s ,o1 obturator from epigastric 7safe72 ,n ,o1 normal course of obturator2 ,i ,r1 internal inguinal ring2 ,sp ,c1 spermatic chord and its vessels2 ,g1 ,gimbernat's ligament2 1 in triangle of ,hesselbach4 #adf ,holmes's ,surgery1 #c;d ed41 #ahhc1 vol4 ii4 p4 #hcg4 #adg ,clinical and ,pathological ,observations in ,india1 pp4 #dd1 #cbe4 #adh ,wood ,on ,rupture1 #ahfc4 #adi ,diagram of an artificial anus1 showing small sutures which unite the edges of the gut and the skin1 and the large ones stitching up the wound beyond4 ,,chapter ,,xii4 ,,operations ,,on ,,pelvis4 ,,lithotomy4--,however interesting and even instructive it might be1 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 this4 ,it will be sufficient here to describe the operations recommended and practised in the present day4 ,there are three different situations in which the bladder may be entered for the purpose of removing a calculus3-- #a4 ,the perineum1 where access is gained through the urethra1 prostate1 and neck of the bladder4 #b4 ,above the pubes1 where the portion of bladder not covered by peritoneum is opened from above4 #c4 ,from the rectum4 #a4 ,,lithotomy ,,through ,,the ,,perineum1 by far the most frequent position for the operation4--,very various methods for its performance have been devised1 differing in the nature and shape of the instruments employed1 the direction and size of the incisions1 the nature of the wound2 but all resemble each other in certain very cardinal and important particulars4 ,thus all agree that it is absolutely necessary to enter the bladder at one spot--the neck of the bladder2 and that to do this safely the urethra must be opened1 and some instrument previously introduced by the urethra is to be used as a guide for the knife4 ,but an instrument in the urethra and bladder is surrounded for at least an inch of its course by the prostate2 and thus the knife1 gorget1 or finger1 which1 guided by the instrument in the urethra1 is intended to cut or dilate the entrance to the bladder for the purpose of allowing the calculus to be removed1 cannot do this without also cutting or dilating this prostate gland4 ,experience has proved that much of the success of the operation depends upon the position and amount of incision made in this prostate gland4 ,but it might be asked1 ,why can we not enter the bladder by one side1 avoiding altogether its neck and this prostate gland8 ,for this1 among other reasons1 that the bladder normally contains1 and so long as the patient lives must contain1 a certain quantity of a very irritating fluid4 ,it is surrounded by the loose areolar tissue of the pelvis1 into which1 if any of this fluid escapes1 abcesses will form and death probably ensue2 this result will almost certainly follow any opening made into the bladder except at one spot4 ,this spot is the neck of the bladder4 ,why does urinary infiltration not occur there8 ,because the fascia of the pelvis 7which when entire can resist infiltration7 is prolonged forwards at the neck of the bladder1 over the prostate 7,fig4 ,,xxxiv4 ,,pf71 for which it forms a very strong funnel-like sheath4 ,so long as this sheath is not cut where it covers the sides of the prostate1 urinary infiltration of the pelvis is impossible1 the urine being carried forwards and fairly out of the pelvis in this urine-tight funnel4 ,illustration3 ,,fig4 ,,xxxiv4#aej ,but it may now be said1 ,if this be the case1 we are very much limited in the size of the incision we may make into the bladder4 ,we cannot remove a large stone1 for the prostate ought not to be larger than a good-sized chestnut1 and any cut we might make through a chestnut without cutting out of its side must be very small4 ,very true2 but fortunately the sheath of the prostate1 unlike the rind of the chestnut1 is very freely dilatable1 and will allow the passage of a very considerable stone4 ,again1 an inquirer might ask1 ,if it is so dilatable1 why should we run the risk of cutting the prostate at all8 ,why should we not introduce instruments gradually increasing in size into the membranous portion of the urethra1 and thus dilate prostate and neck of bladder8 ,for this reason1 that the urethral canal passing through the prostate is itself lined immediately outside of the mucous membrane by a firm membranous sheath 7,fig4 ,,xxxiv4 ,,rr71 which resists dilatation to the utmost4 ,experience tells us that any attempts to dilate or even forcibly to tear this ring of fibrous texture are both ineffectual and dangerous1 while a clean cut into it and through it into the substance of the prostate is at once effectual and comparatively safe4 ,in a word1 we can describe the relation of the prostate to the operation of lithotomy somewhat in this manner3--,its fibrous sheath surrounding the urethra must be cut freely4 ,the gland substance may be cut and freely dilated by the finger4 ,its fibrous envelope must1 as far as possible1 be preserved intact1 but this interferes the less with the operation1 as it is comparatively freely dilatable4 ,the firm lining of the urethra1 which must be cut1 is specially strong at its base1 forming a tough resisting band just at the aperture of the bladder1 which1 unfortunately1 is often so high up in the pelvis in tall patients1 or in cases in which the prostate is much enlarged1 as to be almost out of reach of the finger1 and so far up the staff as perhaps to escape division4 ,you will be warned of such an occurrence by the urine in the bladder failing to make its appearance2 and if any attempt be made to dilate the opening and introduce the forceps without further incision of the base of the prostate1 the result will very likely be fatal1 generally from pymic symptoms depending on a suppurative inflammation of the prostatic plexus of veins 7,fig4 ,,xxxiv474 ,in fact1 upon a recognition of this fact is founded the aphorism1 that cases in which the forceps have been introduced before the bladder fairly begins to empty its contents are generally fatal4 ,illustration3 ,,fig4 ,,xxxv4#aea ,we have thus traced the necessary guiding principles as to our incisions from the bladder outwards through the prostatic portion of the urethra4 ,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 conditions1 namely1 freedom of escape for the urine1 and room enough to remove the stone4 ,both of these are gained at once by a free incision of the membranous portion1 dividing especially those anterior fibres of the great sphincter muscle of the pelvis1 the levator ani1 which embrace the membranous portion1 under the special names of compressor 7,fig4 ,,xxv47 and levator urethr 7,guthrie's and ,wilson's muscles74 ,the principles which guide the position and size of the preliminary incisions which enable the urethra to be opened are very simple3--7#a47 ,the wound in the perineum should be large enough to give free access to the urethra1 and easy egress to the stone2 7#b47 ,it should be conical1 with its base outwards1 so as to favour escape of urine and prevent infiltration2 7#c47 ,it should not wound any important organ or vessel2 that is1 it must avoid the rectum1 the corpus spongiosum1 especially the bulb1 if possible1 the artery of the bulb1 and in every case should leave the pudic artery intact4 ,so far for broad general principles1 which must guide all methods of successful lithotomy4 ,,the ,,lateral ,,operation4--,operation of ,cheselden4--7#a47 ,instruments required4--,a staff with a broad substantial handle1 and a longer curve than the ordinary catheter requires1 furnished with a very deep and wide groove1 which occupies the space midway between its convexity and its left side4 ,the one used should invariably be large enough to dilate fully the urethra4 ,a knife1 with its blade three or four inches in length1 but sharp only for an inch and a half from its point1 its back straight up to within a sixth of an inch of its point1 and there deflected at an angle to the point1 which again curves to the edge4 ,the angle from the back to the point permits the knife to run more freely along the groove in the staff4 ,a probe-pointed straight knife with a narrow blade may occasionally be useful in enlarging the incision in the prostate1 when this is required by the size of the stone4 ,forceps of various sizes and shapes1 some with the blades curved at an angle to reach stones lying behind an enlarged prostate1 all with broad blades as thin as is consistent with perfect inflexibility1 the blades hollowed and roughened in the inside1 but without the projecting teeth sometimes recommended1 which are dangerous from being apt to break the stone4 ,a scoop to remove fragments or small stones1 sometimes useful with the aid of the forefinger in lifting out a large one4 ,a flexible tube of at least half an inch calibre1 and about six inches long1 rounded off and fenestrated above1 fitted at its outer end with a ring and two eyelet-holes for the tapes1 with which it is tied into the bladder4 ,prior to the operation the patient's health should be attended to1 the stomach and bowels regulated1 and any disorder of the kidneys or bladder as far as possible alleviated4 ,if his health has been good and habits active1 three or four days' confinement to his room on low diet1 with a full purge the evening before the operation1 is all the preparatory treatment that is necessary4 ,it is of the utmost importance for the safety of the operation and the patient's comfort after it1 that the rectum be completely unloaded before the operation1 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 necessary4 ,if there is any doubt as to the effect of the laxative1 a large stimulant enema should be administered on the morning of the operation4 ,position4--,much depends on the proper tying up of the patient4 ,he should be placed with his breech projecting over the edge of a narrow table1 with head slightly raised on a pillow1 but the shoulders low4 ,the hands are then to be secured each to its corresponding foot1 by a strong bandage passing round wrist and instep1 or by suitable leather anklets1 the knees should be wide apart1 and on exactly the same level1 so that the pelvis may be quite straight4 ,an assistant should be placed to take charge of each leg4 ,the staff is next introduced and the stone felt2 if there is little water in the bladder a few ounces may be injected1 but this is rarely necessary1 for the patient should be ordered to retain as much water as possible1 and when he cannot retain it1 injection of water may do harm1 and will probably not be retained1 but at once come away along the groove in the staff4 ,the staff is then committed to a special assistant1 who must be thoroughly up to his duty1 and attend to the staff alone4 ,some surgeons direct the assistant to make the convexity of the staff bulge in the perineum1 to enable the groove to be struck more easily4 ,it will be1 however1 safer both for the rectum and the bulb1 if the staff be hooked firmly up against the symphysis pubis1 as advised by ,liston4 ,the same assistant can also keep the scrotum up out of the way4 ,if the perineum has not been previously shaved1 this is now done4 ,the operator sits down on a low stool in front of the patient's breech1 his instruments being ready to his hand1 and then steadying the skin of the perineum with the fingers of his left hand1 enters the point of the knife in the raphe of the perineum1 midway between the anus and scrotum 7one inch in front of anus--,cheselden1 ,crichton2 one and a quarter--,gross1 ,skey1 and ,brodie2 one and three-quarters--,fergusson2 one inch behind the scrotum--,liston71 and carries the incision obliquely downwards and outwards1 in a line midway between the anus and tuberosity of the ischium4 ,the length of the incision must vary with the size of the perineum1 and the supposed size of the stone1 but there is less risk in its being too large1 so long as the rectum is safe1 than in its being too small4 ,its depth should be greatest at its upper angle1 where it has to divide the parts to the depth of the transverse muscle of the perineum1 and least at its lower angle1 where a deep incision is not required1 and would be almost sure to wound the rectum4 ,the forefinger of the left hand is now to be deeply inserted into the wound1 and any remaining fibres of the levator ani in front are to be divided1 the edge of the knife being directed from above downwards4 ,the left forefinger being still used to push its way through the cellular tissue1 the groove in the staff is now felt in the membranous portion of the urethra covered by the deep fascia of the perineum4 ,now comes the deeper part of the incision4 ,guided by the finger-nail of the left hand1 the surgeon introduces the point of the knife into the groove of the staff4 ,he then takes hold of the staff for a moment to feel that it is held up properly against the pubis1 and in the middle line1 and also that the knife is fairly in the groove4 ,giving the staff back again to the assistant1 and keeping the rectum well out of the way by the left hand1 he now steadily directs the knife along the groove of the staff till the bladder is fairly entered1 and the ring at the base of the prostate completely divided4 ,when this is the case a gush of urine takes place1 following the withdrawal of the knife4 ,when making the deep incision1 and in the groove of the staff1 the blade of the knife should lie neither vertical nor horizontal1 but midway between the two1 so as to make the section of the left lobe of the prostate in its longest diameter1 that is1 in a direction downwards and backwards 7,fig4 ,,xxxiv4 ,l74 ,the knife is now withdrawn1 and the left forefinger inserted4 ,in most cases it will be long enough to reach the bladder and touch the stone1 and may then be freely used by gradual pressure to dilate the wound2 this may be done very freely when necessary for a large stone1 if only the ring of fibrous tissue surrounding the urethra be first cut and the bladder fairly entered4 ,whenever the stone is felt by the finger1 the assistant may withdraw the staff4 ,when the operator has thus felt the stone and sufficiently dilated the wound1 the next step is to introduce the forceps2 this should be done under the guidance of the finger1 and with the blades closed4 ,when the stone is felt the blades should be opened very widely1 slightly withdrawn1 and then pushed in again1 the lower one1 if possible1 being insinuated under the stone4 ,the blades must be made fairly to grasp and contain the stone in their hollow1 for if they only nibble at the end of an oval stone1 extraction is impossible4 ,extraction should then be performed slowly1 with alternate wrigglings of the forceps from side to side1 so as gradually to dilate1 not to tear1 the prostate1 and the operator must remember to pull in the axis of the pelvis1 not against the os pubis or the promontory of the sacrum4 ,if there is much resistance1 it may possibly be caused by the stone having been caught in its longer axis1 and this may be remedied by careful manipulation by means of the finger and forceps4 ,if the stone is still too large to be extracted without greater force than is warrantable1 there are still various expedients 7see infra1 pp4 #bfe1 #bgj74 ,in most cases1 however1 the stone is removed rapidly enough by the single incision4 ,the finger1 or a sound1 must then be introduced to feel if any more stones are present4 ,the closed forceps make a very effectual instrument for this purpose4 ,much information may be gained from the appearance of the first stone1 the presence or absence of facets4 ,its smoothness or roughness enables us to form a pretty certain opinion2 yet the bladder should always be carefully searched2 and if the stone has been friable or broken in extraction1 should be washed out by a current of water4 ,where the calculi are very numerous1 or where many fragments have separated1 the scoop will be found useful1 both for detecting and removing them4 ,all the stones being extracted1 there is in most cases little or no bleeding 7see infra1 ,hmorrhage74 ,the tube already described may now be inserted and tied into the bladder4 ,it may be retained for forty-eight or seventy-two hours1 according to circumstances4 ,care must be taken lest it be closed up by coagula during the first hour or two after the operation4 ,in children the tube is not necessary1 and from their restlessness might possibly do harm1 but in adults 7though neglected by some surgeons7 experience shows it is a valuable adjunct in the after-treatment4 ,having thus traced the course of an ordinary uncomplicated case of lithotomy by the lateral operation1 a brief notice is suitable of some of the obstacles and difficulties1 some of the dangers and bad results which may be met with1 and the best methods of overcoming them4 #a4 ,large size of the stone1 as an obstacle to extraction4 ,when1 either from the enormous size of the stone1 generally to be made out before the operation1 or from some congenital or acquired deformity of the pelvis1 it is obvious beforehand that the calculus cannot pass through the bony pelvis entire1 a choice of two courses remains1 either-- 7#a47 ,the high or supra-pubic operation 7q4v4 infra72 or 7#b47 ,crushing of the calculus in the bladder1 and removal piecemeal4 ,instruments of great strength have been devised for this latter operation4 ,the risk to the bladder is very great1 and fragments are apt to be left behind2 these are sure to form nuclei of new calculi4 #b4 ,peculiarities in the position or relations of the stone in the bladder3-- 7#a47 ,it may lie in a sort of pouch behind the prostate1 and thus be out of the reach of the forceps4 ,this may be remedied by the use of curved forceps1 or1 better still1 by the finger in the rectum to tilt up the stone into the bladder4 7#b47 ,it may lie above the pubis in the anterior wall of the bladder4 ,pressure on the hypogastrium1 or the use of a strong probe as a hook1 will generally suffice to dislodge it4 7#c47 ,the stone may be encysted4 ,this is extremely rare1 and1 as ,fergusson says1 we hear more of these from bunglers who have operated only several times1 than from those who have had large experience4 #c4 ,an enlarged prostate is at once a source of difficulty and of some danger4 ,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 bladder4 ,this renders the introduction of the forceps more difficult and uncertain1 the dilatation more prolonged1 and the extraction more dangerous4 ,if very large1 the groove of the staff may not reach the bladder1 and thus the deep incision may fail of cutting the ring at the base of the gland1 and the urine may thus not escape1 and all the dangers of laceration of the ring may result4 ,such cases may be well managed by the insertion of a straight deeply grooved staff into the insufficient incision1 and fairly into the bladder1 and on this1 pushing a cutting gorget through the uncut portion of the gland4 ,this insures a sufficient yet not dangerous incision1 which we cannot so safely perform with the knife1 as the parts are so far beyond the reach of the guiding forefinger4 ,under the head of risks after lithotomy we may class the following3-- #a4 ,sinking1 or shock4 ,in the very aged or very young1 or after a very prolonged or painful operation1 shock may now and then kill the patient within a few hours4 ,since the days of chloroform this result is extremely rare4 #b4 ,hmorrhage seems to be a very infrequent risk4 ,the transverse perineal artery1 which is always cut in the operation1 is small1 and rarely bleeds much4 ,if the bulb is wounded1 as no doubt frequently occurs1 the flow from it can easily be checked4 ,the pudic is so well protected from any ordinary incision as to be practically safe2 and if wounded by some frightfully extensive incision1 it can be compressed against the tuberosity of the ischium4 ,there is an abnormal distribution of the dorsal artery of the penis1 in which1 rising higher up than it ought1 and coursing along the neck of the bladder1 and the lateral lobe of the prostate1 it may be divided4 ,this may give trouble1 and even result in fatal hmorrhage4 ,fortunately it is rare4 ,the author has met with one case in a boy of eleven1 in whom a very severe hmorrhage was not to be explained4 ,the patient recovered without another bad symptom4 ,again1 a general oozing may often appear a few hours after the operation1 when the patient is warm in bed1 apparently from the substance of the prostate4 ,if raising the breech and the application of cold fail to arrest it1 it may be necessary to plug the wound4 ,this is done by stuffing it with long strips of lint round the tube4 ,great care must be then taken lest the tube become occluded4 #c4 ,infiltration of urine may occur as a result of a too free incision of the vesical fascia 7in adults71 and still more frequently of a too small external wound4 ,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 fascia4 ,in them the prostate is so exceedingly small and undeveloped1 that even the forefinger could not be introduced into the bladder without a complete section of the prostate4 ,probably from the blander nature of their urine1 and the greater vitality of their tissues1 this is of less consequence1 as it is rarely found that any bad effects result from this section4 ,among other risks we find peritonitis1 inflammation of neck of bladder1 inflammation of prostatic plexus of veins1 resulting in pymia1 suppression of urine1 and other kidney complications4 ,for the symptoms and treatment of these there is no place in a mere manual of surgical operations4 ,wound of rectum and recto-vesical fistula4--,such wounds were not uncommon1 and in many cases unavoidable1 before the days of chloroform1 from the struggles of the patient2 now they are comparatively rare1 and should be still rarer4 ,they probably occur in more cases than the surgeon is aware of1 and heal up without his knowledge2 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 of4 ,they occasionally heal without giving any trouble1 but1 at other times1 as the external wound contracts1 a communication forms between rectum and the urethra1 in which the contents are apt to be interchanged in a most disagreeable manner1 flatus passing per urethram1 and urine per rectum4 ,when it is evidently not going to heal spontaneously1 the septum between the external orifice of the wound and the communication with the gut should be laid open1 as in the operation for fistula in ano4 ,there are certain modifications and varieties in the method of operating for stone through the perineum1 which deserve at least a brief notice3-- #a4 ,the bilateral operation4--,though he was not the inventor1 ,dupuytren's name is justly associated with this operation4 ,the principle of it is to divide both sides of the prostate equally1 so as to give more room for extraction of a large stone1 without the necessity of much laceration1 or the risk of cutting through the prostatic sheath of fascia4 ,the operation4--,a semilunar incision is made transversely across the perineum1 extending from a point midway between the right tuber ischii and the anus1 upwards1 crossing the raphe nearly an inch above the anus1 and then curving downwards to a corresponding point on the opposite side4 ,the skin1 superficial fascia1 and a few of the anterior fibres of the external sphincter1 are thus divided1 and the groove of the staff sought by the forefinger4 ,the membranous portion of the urethra is then laid open in the middle line1 and the beak of a double lithotome cach securely lodged in the groove4 ,it is then pushed into the bladder with its concavity upwards1 and when fairly in it is turned round1 its blades protruded to the required extent1 and withdrawn with its concavity downwards1 thus dividing both lobes of the prostate in a direction downwards and outwards 7,fig4 ,,xxiv4 ,d ,d74 ,the operation is finished in the usual manner4 ,though it is a comparatively easy operation1 and theoretically may be proved to have many advantages1 experience has shown that the results are not so favourable as those of the ordinary lateral operation4 #b4 ,buchanan's medio-lateral operation on a rectangular staff4--,the staff is bent at a right angle three inches from the end1 and deeply grooved on its left side4 ,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 rectum4 ,the angle projects in the perineum1 so that the operator with his left forefinger in the rectum is enabled1 by a stab with a long straight bistoury 7held horizontally and with the cutting edge to the left side71 at once to enter the groove1 and1 by following the groove1 the bladder4 ,whenever the escape of urine shows that the bladder is fairly reached1 the knife is withdrawn so as to make a lateral section of the prostate1 and then1 with the finger still in the rectum1 to make an incision in the ischio-rectal fossa1 of sufficient size to allow the stone to be easily withdrawn4 ,the inventor claims for this method that it is easier1 that there is less risk of hmorrhage1 wound of the rectum1 and infiltration of urine4 #c4 ,allarton's operation of median lithotomy suits admirably for stones known to be small1 but is quite unsuitable for large ones4 ,probably in most cases it should be superseded by lithotrity4 ,operation4--,a large curved staff with a central groove is to be held firmly hooked up against the symphysis pubis1 and then steadied by the left forefinger in the rectum4 ,the operator pierces the raphe of the perineum with a long straight bistoury about half an inch above the verge of the anus1 enters the groove of the staff1 and cuts inwards1 almost1 but not quite1 into the bladder4 ,in withdrawing the knife the wound in the urethra is enlarged upwards towards the scrotum4 ,a ball-pointed probe is then passed on the staff into the bladder1 the staff is withdrawn1 and the finger1 guided by the probe1 is used to dilate the neck of the bladder1 to an extent sufficient for the removal of the stone by a small pair of forceps4 ,in this operation the prostate is hardly incised at all4 ,the results are not better than those of the lateral operation4 #b4 ,,lithotomy ,,above ,,the ,,pubes1 or the ,high ,operation4--,in cases where1 from the known size of the stone1 or from the deformity of the bones of the pelvis1 it is impossible that the stone can be extracted entire in the usual manner2 in cases where the prostate is very much enlarged1 or where there is any real or supposed likelihood of inflammation of the neck of the bladder1 the supra-pubic operation may be warrantable4 ,its performance is easy1 it does not involve any wound of the peritoneum if properly performed1 and there is no risk of hmorrhage4 ,there are certainly great risks attending it of peritonitis and urinary infiltration4 ,in more than one case this operation has been attended by wound of peritoneum and subsequent escape of intestines through the wound1 even when dressed antiseptically and performed under spray4 ,operation4--,the patient lies on his back1 with his head and shoulders slightly raised1 so as to relax the abdominal muscles1 and his legs hanging down over the edge of the table4 ,if his bladder can bear it1 it should be fully distended1 either by voluntary retention of the urine1 or by injection with tepid water4 ,a vertical incision is then made in the middle line1 separating the recti muscles from below upwards1 care being taken to push the peritoneum well out of the way1 which is easily done by the finger in the loose cellular tissue of the part4 ,the anterior wall of the bladder is then exposed1 uncovered by peritoneum2 it must be opened with great care1 also in the middle line1 while the wound in the parietes is held aside by retractors4 ,the wall of the bladder should be transfixed by a curved needle1 and thus held in position before it is opened4 ,the stone is then removed by a pair of straight forceps1 generally with great ease4 ,attempts used to be made to leave a catheter or canula in the bladder wound to prevent infiltration4 ,probably the safest method now will be to close the bladder wound at once by metallic stitches1 and stitching the abdominal wound carefully with deeply entered wires1 to leave the patient on his back4 ,when compared with the lateral operations the statistics of the supra-pubic operation are discouraging1 the mortality being one in three and a half to one in four4 ,but in cases where the stone is known to be very large and of firm consistence1 the risks are probably less from this method than from lateral lithotomy1 followed by efforts to crush the stone through the wound prior to its removal4 ,the late ,mr4 ,george ,bell1 a most successful lithotomist1 proposed to perform this operation in two stages4 ,in a case of greatly enlarged prostate1 where the bladder had been punctured above the pubes by a country surgeon for retention of urine1 he dilated the track of the canula by means of sponge-tents gradually increased in size1 and then succeeded in extracting through the dilated opening several large calculi4 ,the case recovered1 and may encourage similar attempts4 #c4 ,,operations ,,through ,,the ,,rectum4--7a47 ,sanson's ,recto-vesical ,operation4--,the principle of this operation consisted in laying the two canals1 the rectum and the urethra1 into one4 ,a large staff1 grooved on its convexity1 being inserted into the urethra1 the operator1 with the forefinger of his left hand in the rectum as a guide to the knife1 pierces the anterior wall of the rectum1 reaches the groove of the staff just in front of the prostate1 and cutting outwards divides the rectum1 the anterior fibres of levator ani1 and the sphincter1 as well as the skin of the perineum in the middle line4 ,entering the knife again into the groove of the staff1 it is to be pushed right onwards into the bladder1 dividing the prostate1 and avoiding if possible the seminal vesicles and ducts2 the stone is then very easily removed4 ,though this operation was supposed to lessen the risk of pelvic infiltration it is not found to do so1 and it adds the additional inconvenience of almost inevitable rectal fistula1 through which the urine escapes4 ,it is certainly a very easy operation1 but the mortality is found to be greater than in the ordinary lateral operation4 7b47 ,lithotomy through the rectum above the prostate4--,the presence of a small portion of bladder beyond the prostate in close relation to the rectum renders it possible1 in cases where the prostate is not enlarged1 to enter the bladder and remove a stone of moderate size1 without interfering with the peritoneum1 prostate1 or neck of the bladder4 ,this ingenious but difficult operation was performed for the first time by ,drs4 ,sims and ,bauer in #ahei4 ,i quote the brief notice of the operation by ,dr4 ,sims from the ,lancet of #ahfd 7vol4 i4 p4 #aaa73-- ,the patient was placed on the left side1 and my speculum was introduced into the rectum1 exposing the anterior wall of the rectum1 just as it would the vagina in the female4 ,a sound was passed into the bladder4 ,the doctor entered the blade of a bistoury in the triangular space bounded by the prostate1 the vesicul seminales1 and the peritoneal reduplication4 ,he passed the finger through this opening1 felt the stone1 and removed it with the forceps without the least trouble4 ,the operation was done as quickly and as easily as it would have been in a female through the vaginal septum4 ,after the removal of the stone1 ,dr4 ,bauer kindly asked me to close the wound with silver sutures1 which ,i did1 introducing some five or six wires1 with the same facility as in the vagina4 ,there was no leakage of urine4 ,the patient recovered without the least trouble of any sort4 ,the wires were removed on the eighth day1 and on the ninth day the patient rode in a carriage with ,dr4 ,bauer a distance of four or five miles1 to call on1 and report himself to1 our distinguished countryman1 ,dr4 ,mott4 ,the chief risks in this operation seem to be the chance of wounding the peritoneal cul-de-sac1 as the amount of free space between it and the prostate seems to vary much in individuals and in races4 ,dr4 ,marion ,sims mentioned to me in conversation that he believed this operation impossible in the negro race1 from the greater projection downwards of the peritoneal reduplication4 ,an enlarged prostate would be an insuperable objection4 ,the use of silver wire1 to close up the wound at once1 diminishes very much any risk of recto-vesical fistula4 ,,lithotrity ,,or ,,lithotripsy4--,there exist cases of stone in the bladder1 which1 under certain conditions1 may be relieved without lithotomy1 by an operation which crushes the stone into fragments small enough to be discharged through the urethra4 ,to enter with any fulness into the history1 literature1 and varieties of this operation1 and the instruments required1 would in itself require a large volume4 ,suffice it here to describe the case suitable for the operation1 the essentials required in the instrument1 and the method of performance4 #a4 ,for a case to be suitable the stone should not be too large1 and especially not too hard1 also there should not be too many of them4 ,the urethra should be capacious enough to let the instrument pass easily and painlessly4 ,the bladder should be large enough to contain four ounces of water at least1 should not be much inflamed1 and1 on the other hand1 should not be paralysed4 ,paralysis or want of tone in the bladder prevents the thorough evacuation of its contents1 and still more the expulsion of the fragments of stone4 #b4 ,a good instrument should1 as far as possible1 combine strength with lightness4 ,the curved portion of the fixed blade should be fenestrated to allow escape of the fragments and thorough closure of the instrument4 ,the movable blade must be so arranged as to combine perfect ease of movement up and down in seeking for the stone1 with a powerful1 slow1 and gradual approximation in crushing it4 ,this can be managed by an ingenious arrangement1 which leaves the movable blade under the control only of the operator's thumb till the stone is found1 and yet1 by touching a spring1 gives him the advantage either of a fine screw or of a rack and pinion movement for crushing the stone4 #c4 ,operation4--,the patient being prepared by a free evacuation of the bowels1 and the urethra having been previously fairly dilated1 he is asked to retain his urine as long as possible1 or1 if he cannot do so1 a few ounces of tepid water may be injected per urethram4 ,he is then laid on a sofa or table1 the breech being well raised by pillows1 the shoulders low1 the thighs and knees bent up and separated4 ,the instrument1 well warmed and oiled1 is then introduced with the blades closed4 ,when fairly into the bladder the search for the stone begins4 ,there are differences of opinion regarding the best method of fishing for the stone2 great patience and gentleness1 with a thorough previous acquaintance with bladder manipulation1 are required1 whichever method be chosen4 ,the two chief methods may be described as the ,english and the ,french1 the latter1 ,civiale's1 being now used by ,sir ,henry ,thompson1 and other ,english operators4 ,briefly1 the two are3-- 7#a47 ,heurteloup's and ,sir ,b4 ,c4 ,brodie's4--,in this1 after the instrument is fairly entered1 its handle is elevated1 thus depressing the curved extremity1 the forceps are then opened1 and1 by being kept as low as possible in the bladder1 it is hoped that the calculus will fall into the opened blades by its own weight4 ,in this method the fundus is the scene of crushing1 and there is a risk of injuring the sensitive neck of the bladder1 especially at the moment of opening the blades4 7#b47 ,civiale's--,thompson's4--,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 stone1 and all contact with the wall of the bladder is 7as far as possible7 avoided4 ,the instrument is introduced closed1 and carried fairly away in to the posterior part of the bladder before it is opened at all4 ,it probably grazes the stone in passing1 and1 if so1 is directed to the side of the bladder in which the stone is not lying4 ,then when nearly touching the posterior wall1 the movable blade is withdrawn1 the instrument inclined towards the stone lying unmoved in the most dependent part1 and there seizes it generally with ease4 ,if not felt1 the blades are again to be opened1 turned a little to the other side of the bladder1 and then closed4 ,sir ,h4 ,thompson lays the greatest stress on the importance of always having the blades fairly opened before shifting their position1 for if moved when closed1 the very opening of the movable blade is certain to drive the stone out of the way and prevent its seizure4 ,certain rules are useful3--,move the axis of the instrument as little as possible2 it should be kept in the centre of the bladder1 so far in1 that the movements of the male blade are quite free from the neck of the bladder and prostate1 and the blades only should be moved in the bladder on the centre of the shaft as an axis4 ,there should be no jerking once the stone is caught1 and the crushing should be done as far as possible in the very centre of the bladder1 the blades not touching any of the walls4 ,after the stone is seized1 do not crush till1 by a turn of the blades from side to side1 you discover that none of the mucous membrane of the bladder is caught in the instrument4 ,the lithotrite is not meant to extract stones1 but to crush them1 hence never attempt to withdraw it unless the blades are in absolute apposition4 ,never attempt too much at one time4 ,sir ,h4 ,thompson holds that five minutes is the longest time that should be given1 perhaps in most cases three minutes being long enough4 ,while many surgeons will still agree with the above advice1 ,dr4 ,bigelow of ,boston has lately been highly commending a method which he has called ,litholapaxy1 in which1 at one sitting under chloroform1 the stone is crushed and aspirated1 or sucked out of the bladder at once4#aeb ,since the above was written the operation of ,litholapaxy has made great strides in the favour of surgeons1 and many stones that would have been removed by lithotomy are now broken down by powerful instruments at a single sitting1 and removed piecemeal by the suction apparatus4 ,s4 ,w4 ,gross has collected #cab cases1 of which #ag died or #e4de per cent41 but of #ahj done by experienced surgeons1 ,thompson1 ,bigelow1 ,van ,buren1 ,weir1 and ,stevenson only five died1 or #c4cc per cent41 while of #adgj cases of lithotrity1 as formerly practised1 #aei1 or #aj4ha1 per cent4 died4#aec ,,operations ,,for ,,stricture ,,of ,,urethra4--,under this head many manipulations and operations might be described2 the very instruments devised being exceedingly numerous and complicated4 ,enough here to detail a few of the more simple and practical procedures under the different heads of--#a4 ,dilatation gradual and forced4 #b4 ,internal ,division4 #c4 ,external ,division4 #a4 ,,dilatation4--,under this head we have-- a4 ,vital dilatation4--,the passing of a succession of bougies1 gradually increasing in diameter1 at intervals of three or four days1 for the purpose of exciting an amount of interstitial absorption in the new material constituting the stricture1 sufficient to remove it4 ,passing a bougie1 though certainly often very difficult1 perhaps should hardly come into the category of surgical operations1 yet to preserve a certain completeness in the account of stricture1 a very brief description may be here inserted4 ,the recumbent posture is in most cases to be preferred4 ,the patient should lie flat on his back1 with the knees slightly bent and separated1 and the head and shoulders slightly raised on a pillow4 ,the operator standing on the patient's left side1 raises the penis in his left hand1 and with the right introduces the instrument1 previously warmed and oiled1 into the meatus4 ,he then pushes it very gently onwards1 at the same time stretching the penis with the left hand1 just so far as to efface any wrinkles in the mucous membrane1 till the point reaches the bulbous portion4 ,the axis of the instrument1 which at first for convenience was over the left groin1 has now gradually been approaching the middle line4 ,when this is reached1 the instrument should be raised from the abdomen1 and the handle cautiously carried in the arc of a circle first upwards and then downwards1 till1 when the instrument is fairly into the bladder1 the handle is depressed between the patient's thighs4 ,while this is being done the operator's left hand should be withdrawn from the penis1 and the points of the fingers applied to the perineum4 ,in cases of difficulty certain points may be remembered3-- 7#a47 ,that the point of the instrument may in the first inch or two be occasionally entangled in a lacuna in the roof1 especially when a small instrument is used2 hence the beak should be at first maintained against the inferior wall of the canal4#aed 7#b47 ,that the handle should not be depressed too soon2 if it is1 there is a risk of a false passage being made through the upper wall4 7#c47 ,the opposite error may force the point out of the urethra between the membranous portion and the rectum1 and onwards into the substance of the prostate gland4 ,and certain cautions may be given3-- 7#a47 ,in every exploration of an unknown urethra the surgeon should commence with an instrument of medium size1 certainly not less than ,no4 #g or #h4 7#b47 ,in cases of difficulty occurring in the urethra behind the scrotum1 invariably use the forefinger of the left hand in the rectum as a guide4 7#c47 ,expression of pain on the part of the patient is no indication that a false passage is being made1 nor its absence that the instrument is in the passage1 for it is a remark of ,mr4 ,syme1 that passing an instrument through a stricture is generally more painful than making a false passage through the walls of the urethra4 ,an instrument may be passed1 while the patient is erect1 with the following precautions3--,the patient should stand with his back against a wall1 his arms supported on the back of a chair on each side1 heels eight or ten inches apart1 and four or five inches from the wall2 his clothes thoroughly down1 not merely opened4 ,the bougie should then be held nearly horizontal1 with its concavity over the left groin of the patient1 the penis being raised in the surgeon's left hand4 ,introduced thus for four or five inches1 the handle is gradually raised into the middle line of the abdomen1 and to the perpendicular2 it is then to be lightly depressed1 and1 as the point enters the bladder1 brought down towards the operator until it sinks beneath the horizontal line4 b4 ,mechanical dilatation is of two kinds1 both very rarely used3--7#a47 ,when an instrument cannot be passed1 it consists of passing down day after day the point of an instrument 7sometimes armed with caustic1 sometimes not71 and pressing it against the stricture till it is overcome4#aee 7#b47 ,when an instrument is introduced through an intractable stricture1 and is left there either for some hours1 or for some days1 to excite what is called suppuration of the stricture4#aef c4 ,forced dilatation4--,under this head we might describe at great length mechanical contrivances to force or rupture a stricture4 ,a word or two on a few of the most important3-- 7#a47 ,conical bougies of steel or silver4 7#b47 ,mr4 ,wakley's method1 on which many others have been founded4 ,he passed a small bougie or wire into the bladder1 over which were slipped straight tubes of varying size1 with perfect certainty that they could not leave the urethra4 7#c47 ,mr4 ,holt's method4#aeg--,the principle of it is to rupture the stricture at once1 so that a ,no4 #ab catheter can immediately be passed into the bladder4 ,he attains this object by means of an instrument composed of two grooved blades1 united about one inch from their apex1 into a conical sound1 which at its apex is about the size of a ,no4 #b bougie4 ,this is passed into the bladder1 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 ,no4 #h1 #aj1 or #ab1 bougie4 ,to guide this properly it is made hollow1 and it is passed down over a central wire which lies between the grooved blades of the instrument and is welded to the apex4 ,a great improvement is effected on ,mr4 ,holt's later instruments by this wire being made hollow1 and fitted with a stilette1 for by this means we can with certainty ascertain whether or not the instrument has been passed into the bladder4 ,this instrument1 which is an improvement upon one invented by ,perrve nearly forty years ago1 has been used on very many occasions by ,mr4 ,holt and others with success4 ,the risk to life1 if the case be properly managed1 is trifling1 but1 like every other means of treating stricture1 it has the objection that the stricture is liable to recur1 unless bougies be passed at intervals for months and years4 ,sir ,henry ,thompson has introduced and described another very ingenious instrument for the same purpose1 constructed on somewhat similar principles4 ,his account of it1 to which ,i must refer1 will be found in ,holmes's ,system of ,surgery1 #ast ed4 vol4 iv4 p4 #cii4 #b4 ,,internal ,,division ,,of ,,stricture is a mode of treatment which by many surgeons is highly disapproved1 yet of late years it has been more used than formerly1 especially in resilient strictures4 ,it may be done in two ways3-- 7#a47 ,from before backwards4--,this method1 to be at all admissible1 requires a guide to be previously passed2 a lancet-shaped blade may then be slipped down a groove in this guide till the stricture is divided4 ,this is least objectionable in cases of stricture close to the meatus4 7#b47 ,from behind forwards4--,to make the incision thus1 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 divided4 ,this will be found to be at least equal in size to a ,no4 #c or ,no4 #d catheter4 ,in many instruments it is much larger4 ,civiale's instrument for internal incision of the urethra from behind forwards has the very high recommendation of ,sir ,h4 ,thompson4#aeh ,it consists of a sound with a bulbous extremity 7as large as a ,no4 #e bougie7 which contains a small blade1 which can be made to project for such a distance as the operator wishes4 ,it is passed through the stricture with the blade concealed1 till the bulb is carried about one-third of an inch or more beyond the stricture2 the blade is then projected1 and the incision made by drawing it slowly but firmly outwards towards the meatus1 with the blade towards the floor of the urethra1 till the stricture is divided in its whole extent4 ,sir ,h4 ,thompson recommends this to be used in cases where it is not that the stricture is of very small calibre1 but that it is undilatable1 that prevents the cure4 ,many modifications of above have been devised by ,lund1 ,teevan1 and other surgeons1 on similar principles4 #c4 ,,mr4 ,,syme',s ,,operation ,,of ,,external ,,division4--,mr4 ,syme held that no stricture through which the water can escape should be called impermeable1 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 certainty4 ,the old operation of perineal section for so-called impermeable stricture is very different1 being difficult1 dangerous1 and uncertain in its results4 ,operation4--,a director is passed into the stricture4 ,mr4 ,syme's directors are of different sizes1 the smallest being in diameter less than an ordinary surgical probe4 ,they are made of steel1 are grooved on the convexity1 and have this peculiarity1 that while the lower half is small1 the upper is of full size 7,no4 #h or #aj71 the difference in calibre occurring quite abruptly4 ,the presence of this shoulder on the staff enables the operator to ascertain exactly the position of the stricture1 and also to tell when it is fully divided without the necessity of withdrawing the instrument4 ,this being fairly in the stricture1 the patient is put in the position for lithotomy1 an assistant holds the staff in his right hand1 drawing up the scrotum with his left4 ,the surgeon then makes an incision in the middle line over the stricture for the necessary distance1 from above downwards1 till he exposes the urethra1 and feels exactly the shoulder of the staff4 ,care must be taken not to go past the urethra at either side4 ,when he distinctly feels the outline of the staff1 he takes it in his left hand1 and a short sharp-pointed bistoury in his right4 ,it should be held firmly in the palm of the hand1 with the back of the blade resting on the forefinger1 the pulp of which guides the point to the groove1 and guards it when making the incision2 the knife is to be placed on the groove beyond 7on the bladder side7 of the stricture1 and brought forwards1 slowly cutting through the whole stricture2 till the shoulder of the staff is reached4 ,it requires strength and precision to divide thoroughly the indurated stricture1 which is apt to elude the knife4 ,the shoulder of the staff can now be passed through the stricture if the operation is complete2 if not1 the incision must be extended1 always in the middle line1 and guided by the groove4 ,when thoroughly divided1 the staff is now to be withdrawn1 and a full-sized catheter with a double curve passed into the bladder4 ,this should not be furnished with a stop-cock or plug1 lest the bladder should by inadvertence be allowed to be too full1 and extravasation into the cellular tissue of the urethra take place along the side of the instrument4 ,the catheter should be tied in1 and left for two1 sometimes for three days1 when it can generally be removed with safety1 and a bougie should be passed at intervals of three or four1 till the wound is healed4 ,to prevent recurrence of the stricture1 it is a wise precaution to pass an instrument at intervals for many months after the cure is apparently complete4 ,in certain cases1 where the stricture is far back and the urinary symptoms severe1 ,mr4 ,syme found advantage from the introduction of a shorter double-curved catheter 7only about nine inches long7 through the wound into the bladder1 where it should be left for three days4 ,this seems to diminish the risk of rigors1 and other symptoms of fever1 which are apt to occur when the urine is allowed for the first time to pass over the wound4 ,perineal ,section is an operation both dangerous and difficult2 as ,sir ,astley ,cooper used to say1 the surgeon who performs it requires to have a long summer's day before him4 ,no director or guide can be passed4 ,a full-sized catheter must be passed as far as possible up to the stricture1 and held firmly in the middle line4 ,the patient must be tied up in lithotomy position on a table in the very best light that can be obtained4 ,the perineum being shaved1 an incision must be made in the middle line from over the point of the catheter to the verge of the anus1 if the stricture extends far back4 ,the urethra should then be opened over the catheter1 the edges of the mucous membrane held to each side by silk threads passed through them2 and the surgeon must endeavour to pass a fine probe into the opening of the stricture2 if this can be done1 it is comparatively easy to slit the stricture up4 ,if not1 the surgeon must simply seek for the remains of the urethra by slow1 cautious dissection in the middle line4 ,if successful1 a catheter must be secured in the bladder in the usual way4 ,a stricture near the orifice1 or1 as it is not uncommon1 involving merely the meatus1 can be treated with great ease in the above manner by division on a grooved probe4 ,when quite close to the orifice1 with a well-defined hardness1 as of a ring round the urethra1 it may be divided subcutaneously by a tenotomy knife or other narrow-bladed instrument4 ,it is not necessary to keep a catheter in the bladder in cases where the stricture has been in front of the scrotum4 ,,puncture ,,of ,,the ,,bladder4--,a patient and dexterous use of the catheter prevents this operation from being often required2 still1 circumstances may arise in which it is found impossible to enter the bladder per vias naturales4 ,in such a case the bladder may be punctured from the outside by a curved trocar and canula1 in either of two situations4 #a4 ,from above the pubis4--,this operation is a very simple one1 and when the bladder is distended need not imply a wound of the peritoneum4 ,operation4--,a preliminary incision1 varying in length according to the amount of fat1 should be made above the pubis exactly in the middle line2 the edges of the recti should be separated1 the peritoneum pushed out of the way and upwards by the finger1 and a curved trocar plunged into the distended bladder obliquely backwards4 ,the canula should be retained for a day or two1 and then a flexible catheter with a shield inserted instead4 ,such instruments have been worn for years4 ,the aspirateur pneumatique of ,dr4 ,dieulafoy will be found an exceedingly useful instrument for puncture of bladder and removal of urine4 ,the author has now used it very frequently with the best results4 ,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 necessary4 ,illustration3 ,,fig4 ,,xxxvi4#aei #b4 ,from the ,rectum4--,except in cases of enlargement of the prostate1 it is at once easier and safer to puncture the bladder from the rectum4 ,the well-known triangular space uncovered by peritoneum1 with its apex in front close to the prostate1 and bounded on either side by the vasa deferentia and vesicul seminales1 can be easily reached by a curved trocar4 ,this should be guided by one1 or1 still better1 by two fingers1 into the rectum1 with its concavity upwards1 and the point should be pushed upwards by depression of the handle1 whenever it is fairly behind the prostate4 ,the trocar may then be withdrawn1 and the canula retained for at least forty-eight hours by a suitable bandage4 ,mr4 ,cock1 of ,guy's ,hospital1 had a special canula for the purpose1 which expands at its extremity after its introduction1 and thus is not apt to slip4#afj ,some surgeons insist that the surgeon should be able to ascertain the existence of fluctuation between the finger in the rectum1 and the other hand above the pubes4 ,this is exceedingly difficult to elicit when the bladder is very much distended1 and from the constrained position of the finger in the bowel4 ,,phymosis4--,elongation of the prepuce1 with contraction of its orifice1 in most cases congenital1 sometimes so extreme as to cause difficulty in micturition1 and frequently preventing the uncovering of the glans4 ,operation4--,in all well-marked cases1 the following is required3--,the elongated prepuce should be pulled forwards by a pair of catch-forceps1 and a circle of skin and mucous membrane removed by a single stroke of a bistoury1 or by sharp scissors4 ,care should be taken lest the glans be included in the incision1 as has happened in at least one instance4 ,the skin will then be found to retract very freely beyond the glans1 but the mucous membrane is found still to cover the glans1 and its orifice is still constricted4 ,it must then be slit up 7,fig4 ,,xxxvii4 b b7 on the dorsum of the glans1 with probe-pointed scissors1 as far as the corona1 and the glans will then be thoroughly exposed4 ,the edges of mucous membrane and skin should then be stitched to each other by at least five or six fine silk sutures1 any bleeding points having been first carefully secured4 ,the angles will in time round off1 and a wonderfully seemly prepuce be obtained4 ,this operation may be done as a method of cure for obstinate enuresis in cases in which the prepuce is very long and redundant1 even when it is not too tight4 ,the author has done this in more than twenty cases with excellent results4 ,illustration3 ,,fig4 ,,xxxvii4#afa ,varieties4--,when the prepuce is narrowed at its orifice without being redundant in length1 a milder operation will prove sufficient4 ,the principle is the same as in the former1 but the amount of incision is less1 and nothing is removed4 ,two methods are possible3-- #a4 ,by scissors4--,the blunt point of a pair of scissors is introduced through the preputial orifice1 the other blade being outside1 and the skin and mucous membrane are divided for about half an inch2 the skin being then retracted1 the mucous membrane is still further divided by one or two additional snips1 and then the edges of skin and mucous membrane are stitched together by one or two points of suture4 #b4 ,by knife4--,a director being introduced within the prepuce1 a narrow-bladed knife is guided along it1 and pushed through the prepuce from within1 and then made to divide skin and mucous membrane from within outwards4 ,stitches as before4 ,n4,b4--,be careful lest the director pass into the meatus urinarius1 and the glans be split up4 ,again1 some surgeons prefer two lateral incisions instead of one dorsal one4 ,in this case skin and mucous membrane should be divided by scissors for about a quarter of an inch1 and then a single stitch inserted in the angle of junction4 ,this has been further modified by ,cullerier1 who proposed the division of the tight mucous membrane only1 in three or four points4 ,he used a pair of scissors with one sharp and one probe-pointed blade1 the sharp one thrust in between skin and mucous membrane1 the blunt one between the mucous membrane and the glans4 ,,amputation ,,of ,,the ,,penis4--,this exceedingly simple operation is performed by a single stroke of an amputating knife1 drawn along from heel to point1 while the penis is stretched in the operator's left hand4 ,as there is more risk of redundancy than of deficiency of the skin1 no attempt is made to save it4 ,numerous vessels in the corpora cavernosa require ligature4 ,amputation of the penis may be done bloodlessly by the thermo-cautery even close to its root4 ,transfix the root of corpora cavernosa by a needle2 above this pass two or three turns of an elastic ligature2 then slowly divide at a low red heat the skin and corpora cavernosa below the needles2 split the urethra after dividing its mucous membrane with a knife4 ,the author has done this several times with ease and rapid healing4 ,illustration3 ,,fig4 ,,xxxviii4#afb ,the chief risk is stricture of the orifice of the urethra4 ,to prevent this1 several modifications of the operation have been introduced4 #a4 ,ricord's method4#afc--;,after the amputation the surgeon seizes with forceps the mucous membrane of the urethra1 and with a pair of scissors makes four slits in it1 so as to form four equal flaps1 and with a silk ligature stitches each of these to the skin4 ,contraction of the cicatrix will thus tend to open rather than close the urethral orifice4 #b4 ,teale's method4#afd--;,he slits up1 by a bistoury on a director1 the urethra and skin over it for about two-thirds of an inch1 and then stitches the one to the other1 thus making it a long oval dependent orifice 7,fig4 ,,xxxviii474 #c4 ,miller's proposed method4#afe--;,a narrow-bladed knife is first used to transfix the penis between the spongy and cavernous bodies close to the root2 the knife having been carried forwards for an inch and a half1 its edge is turned perpendicularly downwards1 and the urethra and skin flap are divided1 the cavernous bodies and dorsal integument being then cut perpendicularly upwards where the knife was originally entered for transfixion4 ,a button-hole is afterwards made in the lower flap1 though which the corpus spongiosum and urethra protrude1 while the flap itself is turned upwards1 and attached dorsally and laterally1 so as to cover in the exposed cavernous structure4 ,,hydrocele4--,the very simple operation necessary for hydrocele is thus performed3--,the surgeon supports the tumour in his left hand so as to project it forwards1 and make the scrotum as tense as possible in front4 ,having carefully ascertained the exact position of the testicle1 which can generally be easily enough done by a finger accustomed to discriminate the difference between a soft solid1 and a bag tensely filled with fluid1 aided by the peculiar sensation of the testicle when squeezed1 the surgeon enters a trocar and canula about an eighth of an inch in diameter into the distended cavity of the tunica vaginalis1 near the fundus of the swelling4 ,when it is evident the instrument is fairly entered1 and not till then1 the trocar is withdrawn1 and the fluid allowed completely to drain off4 ,when it ceases to flow the surgeon places his forefinger over the end of the canula to prevent the entrance of air1 till he fits into its orifice a suitable syringe containing two drachms of the tincture of iodine1 made according to the ,edinburgh ,pharmacopoeia3 the tincture of the ,british ,pharmacopoeia is not sufficiently strong4 ,having injected this cautiously into the cavity1 the canula is withdrawn1 and the surgeon1 seizing the now flaccid scrotum in his right hand1 gives it a thorough shake1 so as to spread the iodine over as much as possible of the inner wall4 ,when properly performed this very simple procedure very rarely fails to produce a radical cure2 though less thorough operations1 such as mere evacuation of the fluid1 less stimulating injections1 unguents introduced on probes1 and the like1 often fail of success1 and thus give encouragement to absurdities1 such as wire-setons1 or to more severe operations1 such as laying open the sac4 ,h,,matocele4--,when the contents of the sac of the tunica vaginalis are found to be grumous instead of simply serous1 or when1 as often happens1 only pure blood escapes when the fluid is nearly evacuated1 it is found that simple evacuation and injection are very rarely sufficient to effect a cure4 ,after they have been fairly tried1 the sac of the hmatocele should be laid open in its full extent2 any large vessels which bleed should be tied1 and the cavity then stuffed with lint4 ,when the lint can be removed1 which will be after two or three days1 the edges of the wound should be brought closely together1 and the cavity will then rapidly heal up from the bottom1 and be obliterated by secondary union of granulations4 ,in cases where the walls of the cavity are enormously thickened1 or even1 as sometimes happens1 almost bony in consistence1 an elliptical portion may be removed with advantage4 ,,excision ,,of ,,testicle4--,this operation is rarely required except for tumours of the testicle4 ,hence the size of the incision necessary must vary much with the size of the tumour2 and the amount of skin to be removed 7if any7 on the amount of adhesions it has formed to the tumour4 ,one or two points must be attended to in every case of extirpation of a testicle3-- #a4 ,the incision should commence over the cord just outside of the external ring1 and be continued fairly over the tumour to its base4 #b4 ,as to removal of skin1 some surgeons advise that none should be taken away1 others that a considerable quantity can be spared4 ,there is certainly less risk of secondary hmorrhage if a portion be removed1 than when a flaccid empty bag is left4 ,the author invariably removes a very large quantity of skin if the tumour is large1 as there is much more rapid healing1 and the resulting scrotum is much more comfortable for the patient4 #c4 ,the cord should be exposed at the beginning of the operation1 raised from its bed and given to an assistant1 who should compress it gently1 not from any fear of its escape into the abdomen1 but to prevent hmorrhage4 ,if the tumour has been very large and heavy1 the cord will have been much stretched1 and if divided too high up1 may really give trouble by its elasticity1 unless the above precaution is taken4 ,the cord then having been divided close to the tumour1 the latter is removed1 care being taken not to include the sound testicle in the removal4 ,all the vessels are then to be tied or twisted1 and the spermatic artery is to be secured alone1 not1 as used to be the case1 included in a common ligature with the other constituents of the cord4 ,secondary hmorrhage is very apt to occur from small scrotal branches which may have escaped notice during the operation4 ,,operations ,,on ,,the ,,anus ,,and ,,its ,,neighbourhood4--,,fistula ,,in ,,ano4--,while much might be written on the pathology of fistula1 and a good deal even on its diagnosis1 a very few words will suffice to describe the simple and effectual operation for its relief4 ,dismissing at once all so-called palliatives1 drugs1 unguents1 pressure1 and injections1 as mere waste of time1 and holding that the only method of cure consists in laying the fistula fairly open1 the question narrows itself into this3 ,what is the best method of laying it open8 ,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 anus1 the operations for fistula were most unnecessarily severe2 the gut used to be divided as far up as the sinuses extended2 and large portions of the anus used to be excised bodily along with the sinuses4 ,it is now a much simpler and more satisfactory operation4 ,operation4--,a common silver probe bent to the required shape is passed into the external opening1 or1 if there are more than one1 into the largest and oldest one4 ,the forefinger of the left hand being introduced into the rectum1 the probe is passed through the internal orifice1 and its point brought out by the anus4 ,the portion of tissue raised by the probe can then be easily divided with the certainty that the fistula is laid fully open4 ,anal fistul have been divided by the elastic ligature1 but it seems slower in action and more painful1 with no counterbalancing advantages4 ,the author has for last few years operated almost exclusively by a long knife which is continued into a steel probe4 ,the probe is passed up the fistula1 then into the bowel1 and is hooked out at the anus1 and in being simply pushed on the knife cuts the fistula--tuto1 cito1 et jucunde1 the patient rarely knowing that more has been done than an exploration4 ,in cases where1 from the hardness and density of the parts it is impossible to pass the probe and bring it out at the anus1 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 opening4 ,supported by the finger it can then be made to cut outwards till the whole septum is divided4 ,,fissure ,,of ,,the ,,anus1 ,,ulcer ,,of ,,the ,,anus1 resemble each other alike in the exceeding annoyance which they give to the sufferer1 and in the simplicity of the treatment needed4 ,operation4--,once the presence of either is determined by the finger in the anus1 a sharp-pointed curved bistoury should be introduced1 transfixing the base of the fissure or ulcer1 and then guided on the finger1 completely dividing it1 so as to change the ragged ulceration into a simple wound which will rapidly heal4 ,,prolapsus ,,ani1 ,operation for4--,complete prolapsus in which the whole gut is involved1 as seen in the very young and the very aged1 is suited for palliative rather than radical treatment4 ,cases of prolapsus of the mucous membrane only1 as is not uncommon in connection with or as a result of hmorrhoids in adults1 give opportunity for operative interference4 ,we may act on either the skin or mucous membrane1 or both at once4 #a4 ,the skin is often found loose1 and arranged in radiating folds round the anus4 ,in such cases1 as recommended first by ,dupuytren1 some of these projecting folds may be removed4 ,again it may be prolapsed in a great loose ring or circular fold round the margin1 forming an exaggerated external pile2 in such a case the loose fold may be fairly excised with curved scissors1 as recommended by ,hey of ,leeds4 ,the first of these methods is apt to be insufficient1 the second again has the risk of removing too much4 #b4 ,if the protrusion is chiefly mucous membrane exposed in folds1 or a ring1 which is generally outside1 one of two methods of treatment may be tried3-- a4 ,by ligature1 as recommended by ,mr4 ,copeland4 ,raising a longitudinal fold of the mucous membrane1 he passed a ligature round it as if it were a pile4 ,there is less chance of the ligature slipping if a double thread be used and its base thus transfixed4 ,three1 four1 or even more folds may be thus treated4 b4 ,when the mucous membrane has been so long exposed as to have lost many of its characters1 and to resemble leather in its toughness1 excision will be found less painful and much more rapid than ligature4 ,a longitudinal fold at each side of the anus should be pinched up and excised by a pair of probe-pointed curved scissors4 ,there is always a certain amount of risk of hmorrhage following such an operation4 ,the risk is lessened and the result improved by stitching up the wound in the mucous membrane before the protruded portion of bowel is returned4 ,,polypi ,,of ,,the ,,rectum4--,pedunculated growths varying in consistence1 shape1 and size1 but resembling each other in having a distinct stalk1 and in frequently being protruded at stool4 ,operation4--,invariably by ligature1 which may be single round the stalk1 if the tumour be globular and with a distinct narrow stalk1 or by transfixion1 if 7as sometimes happens7 the tumour be of uniform thickness throughout1 like a worm4 ,h,,morrhoids ,,or ,,piles4--,in the treatment of piles it is the differential diagnosis that is troublesome and occasionally difficult2 the operative interference required is generally very simple1 if the nature of the case be rightly determined4 ,external piles4--,operation4--,the apex of the soft flabby excrescence should be seized by a pair of catch-forceps1 and it should be cut off close to its base with a knife1 or1 what is better1 a pair of curved scissors4 ,any little vessel which jets may then be secured4 ,if1 instead of numerous individual tumours1 a ring of skin round the anus be involved1 the whole of it should be shaved off1 but not very close to its base1 lest too great contraction of the anal orifice should ensue4 ,if the surgeon1 after excising a pile or piles1 will take the trouble to stitch up the wound with catgut1 he will find the cure much more rapid and less painful than when this is omitted4 ,internal piles4--,incision is extremely dangerous1 from the vascularity of the parts1 and their being so inaccessible from their position within the sphincter ani4 ,hence ligature is safer and equally effectual4 ,the patient should be directed to sit over hot water1 and strain till the whole of his piles are fairly protruded4 ,the surgeon should then transfix the base of each separately with a curved needle bearing a strong double thread4 ,the needle being cut off1 the threads should be very firmly tied1 each isolating its own half of the pile4 ,the tying should be exceedingly tight1 so as to cause instant and complete strangulation and death of the tumours4 ,all the piles should be tied at the same sitting4 ,if the piles are very small they may be secured without transfixion in a single noose after being seized by a hook or forceps4 ,there is greater risk of the noose slipping than when the base has been transfixed4 ,the strangulated masses must then be returned into the bowel1 and the patient kept in bed or on a sofa till the ligatures separate1 which is generally not till the fourth or fifth day4 ,a certain amount of urinary irritation1 showing itself sometimes in strangury1 sometimes in complete retention1 occasionally follows this operation4 ,mr4 ,smith of ,king's ,college1 and many other surgeons1 treat internal piles by means of an ivory clamp to hold them tight1 while they are burned off by the actual cautery or the thermo-cautery at a low red heat4 ,they claim that pymia more rarely follows this mode4 ,there are certain cases in which the lower inch or two of the rectum are found red and congested1 and in which every stool is followed by the loss of a certain quantity of florid arterial blood1 and yet no distinct hmorrhoidal tumour is to be seen4 ,in such cases the ligature is not applicable1 and relief is obtained by the application of pure nitric acid1 or other potential caustics to the bleeding surface1 as recommended by ,houston1 ,lee1 ,smith1 ,ashton1 and others4 ,these cases are comparatively rare1 and whenever they can be applied1 the ligature is much simpler1 safer1 and more certain4 ,venous piles4--,when a sudden effusion of blood has occurred into one of the varicose veins or sinuses of a congested anus1 an oval or rounded tumour is felt1 very tense1 shining1 and painful4 ,to slit it freely up with an abscess lancet1 and evert the clot inside1 at once relieves all the symptoms4 ,,footnotes3 #aej ,diagram of section of prostate seen from the inside3--,,pf1 pelvic fascia or prostatic sheath2 ,,rr1 ring which must be cut2 ,l1 position of incision in the lateral operation2 ,,dd1 position of incisions in the bilateral operation4 #aea ,diagram of muscles of membranous portion of urethra seen from the inside3--,,ss1 section of os pubis2 ,u1 urethra2 ,g1 ,guthrie's muscle1 compressor urethr2 ,w1 ,wilson's muscle1 levator urethr4 #aeb ,boston ,medical and ,surgical ,journal1 ,may #bi1 #ahgi4 #aec ,gross1 ,surgery1 #fth ed4 vol4 ii4 p4 #gcf4 #aed ,holmes's ,surgery1 vol4 iv4 p4 #cib4 #aee ,see ,miller's ,practice of ,surgery1 p4 #bab4 #aef ,solly's ,surgical ,experiences1 pp4 #ecg1 #ech1 etc4 #aeg ,the ,immediate ,treatment of ,stricture4 ,by ,bernard ,holt1 ,f4,r4,c4,s4 ,london4 ,third ,edition1 #ahfh4 #aeh ,holmes's ,system of ,surgery1 #ast ed4 vol4 iv4 p4 #djc4 #aei ,diagram of puncture of the bladder3--,b1 bladder2 ,,sp1 symphysis pubis2 ,,sc1 scrotum2 b1 bulb2 pr1 peritoneum2 ,p1 prostate2 ,r1 rectum2 ,s1 sacrum and coccyx4 #afj ,med4 ,chir4 ,trans41 vol4 ,,xxxv4 #afa ,diagram of operation for phymosis3--a1 glans penis2 b b1 mucous membrane exposed by retraction of the skin1 and slit up2 c d1 sutures introduced and ready to be tied1 uniting the skin and mucous membrane4 #afb ,to illustrate ,teale's operation3--c1 section of penis b1 thread inserted uniting mucous membrane and skin2 a1 thread tied4 #afc ,med4 ,times and ,gazette1 vol4 xix4 p4 #ced4 #afd ,miller's ,system of ,surgery1 p4 #abee4 #afe ,miller's ,system of ,surgery1 p4 #abef4 ,,chapter ,,xiii4 ,,tenotomy4 ,for convenience' sake ,i group under this one head certain operations used for the relief of distortion1 in which muscles or tendons are divided subcutaneously4 ,since the discovery of the principle by ,delpech1 and the application of it by ,stromeyer1 ,dieffenbach1 ,little1 and countless successors1 it has been used for very many cases for which it is totally inapplicable1 e4g4 for the division of the muscles of the back in spinal curvature4 ,still there remain several deformities for the relief of which subcutaneous tenotomy is a most important remedy2 chief among these are ,wry ,neck and ,club-foot4 ,,operation ,,for ,,wry ,,neck4--,subcutaneous section of the sterno-mastoid4--,in what cases of wry neck is this operation suitable8 ,in those only in which the muscles are the starting-point of the mischief4 ,these are sometimes congenital1 more frequently they commence in childhood4 ,in cases where the distortion depends on disease of the cervical vertebr1 or is secondary to curvature of the spine1 division of the muscle is worse than useless4 ,operation4--,a tenotomy knife1 which should be sharp-pointed1 narrow in the blade1 with a blunt back1 should be introduced through the skin a little to one side of the sternal portion of the affected muscle1 passed along with its flat edge between the skin and the tendon1 till it has fairly crossed the tendon2 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 sternum4 ,a distinct snap will then be felt or heard1 and the position of the head will be at once much improved4 ,exercise1 warm bathing1 and rubbing1 will generally suffice to complete the cure1 without it being necessary to call in the aid of the instrument-maker with his expensive apparatus4#aff ,,operations ,,for ,,club-,,foot4--,the following are the tendons which may require division in the cure of club-foot1 and the operations for their division4 #a4 ,the tendo ,achillis4--,there are very few cases of true club-foot which can be successfully treated without division of the tendo ,achillis4 ,while in talipes equinis it is generally the only disturbing agent1 in talipes varus and valgus it invariably increases and maintains the deformity1 which the tibiales or peronei seem to originate4 ,operation4--,the foot being held at about a right angle with the leg1 the operator should pinch up the skin over the tendon1 introduce the knife flatwise1 a little to one side of the tendon1 till its point is nearly projecting at the other1 then turn the edge on the tendon and cut inwards with a sawing motion till the tendon gives way with a distinct snap1 and the foot can be completely flexed with ease4 ,dr4 ,little#afg recommends that the tendon should be divided from before backwards4 ,there is more risk by this method of wounding the skin1 and thus losing the subcutaneous character of the operation4 ,professor ,pancoast#afh divides the inferior portion of the soleus muscle instead of the tendo ,achillis4 #b4 ,tibialis posticus4--,next in frequency and importance to that of the tendo ,achillis1 division of this tendon is much more difficult to perform4 ,it may be performed either above or below the ankle4 7a47 ,above the ankle4--,the blade of a tenotomy knife should be entered perpendicularly at the posterior margin of the tibia1 half an inch or an inch above the internal malleolus1 so as to pass between the bone and the tendon of the tibialis posticus1 the blade directed towards the latter2 the assistant should now evert the foot1 the operator pressing the blade against the tendon4#afi 7b47 ,below the ankle1 close to the attachment to the scaphoid4 ,this is the better position of the two when the position of the tendon can be made out1 which is not always the case1 especially in cases of old standing4 ,raising the skin just over the astragalo-scaphoid joint1 the knife should be entered with its blade downwards1 and across the tendon1 and should be made to cut on the bone1 while an assistant everts the foot till the tendon gives way with a distinct snap4 #c4 ,tibialis anticus may in like manner be divided either just above the ankle1 or at its insertion4 ,when it requires division it can generally be made so prominent as to render its division comparatively easy4 #d4 ,peronei4--,these do not often require division1 cases of talipes valgus being usually paralytic in character4 ,if necessary they can be cut as they cross the fibula4 #e4 ,the plantar fascia1 may require division2 when this is the case1 it is so prominent as to render the operation very easy1 if conducted on the principles mentioned above4 ,,footnotes3 #aff ,syme's ,pathology and ,practice of ,surgery1 p4 #bbj4 #afg ,holmes's ,surgery1 vol4 iii4 p4 #egc4 #afh ,cross's ,surgery1 vol4 ii4 p4 #bgc1 #c;d ed4 #afi ,miller's ,system of ,surgery1 p4 #acci2 ,holmes's ,surgery1 vol4 iii4 p4 #ega4 ,,chapter ,,xiv4 ,,operations ,,on ,,nerves4 ,,nerve-,,stretching4--,surgical literature in last ten years is full of cases in which nerves have been stretched for all manner of diseases with varying success3 an example of the operative procedure may suffice3-- #a4 ,stretching of the great sciatic either for sciatica1 sclerosis1 or locomotor ataxia4 ,operation4--,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 direction4 ,a free incision in this line three or four inches in length--the nerve lies just below the the femoral aponeurosis1 beneath the edge of gluteal fold1 requiring no muscular fibres to be divided4 ,it must be raised from its bed and boldly stretched or elongated into a loop4 ,symington's experiments have shown that in the average adult #acj lb4 are required to break the nerve4 #b4 ,the facial has been stretched for spasm4 ,the trunk is easily reached by an incision extending from near the external auditory meatus to the angle of the jaw1 which enables the parotid to be pushed forward and the edge of the sterno-mastoid pulled backwards4 ,,neurotomy ,,and ,,neurectomy4--,chiefly performed for neuralgia of the fifth nerve4 a4 ,this is a very easy operation if directed at the terminal branches only of the nerve1 where they make their exit from the frontal1 supraorbital1 and mental foramina4 ,the author has done it in very numerous cases1 and with great relief1 if care be taken to destroy the nerve in the foramen to some extent--a sharp-pointed thermo-cautery does this easily and safely4 b4 ,the more severe and radical operation of cutting out a portion of the trunk of the fifth nerve just after it has left the skull1 and destroying ,meckel's ganglion1 has been done pretty frequently1 chiefly by ,american surgeons--in various ways4 #a4 ,carnochan's ,operation4--,exposing the whole front wall of antrum1 its cavity is opened into from the front by a large trephine4 ,the lower wall of the infra-orbital canal is cut away by a chisel1 the posterior wall of the antrum by a smaller trephine1 the nerve thus isolated is traced up to and past ,meckel's ganglion1 which is removed close to the foramen rotundum by cutting the nerve by curved blunt-pointed scissors4 #b4 ,pancoast's ,operation4--,expose the coronoid process by a free incision1 divide it at its root and throw it up1 then expose and tie internal maxillary artery1 after which the upper portion of the external pterygoid is to be detached from the sphenoid1 thus exposing the nerve leaving foramen ovale2 the second portion is deeper and not so easily got at4 #c4 ,the spinal accessory occasionally may be divided before it enters the sterno-mastoid in cases of spasmodic wry neck1 with great advantage4 ,this operation is an easy one2 the sterno-mastoid edge being once fairly exposed1 the nerve is easily seen1 and a piece should be cut out at least half an inch in length4 ,,nerve ,,suture is occasionally practised with great advantage in cases where nerves have been divided either by accident or in operation4 ,catgut seems to be the best medium1 and cases are on record in which1 even after months of separation and subsequent paralysis1 improvement has followed an operation for refreshing and joining the divided ends4 ,,addendum ,,to ,,chapter ,,ix4 ,,dr4 ,,solis ,,cohen has recently 7in a paper read before the ,philadelphia ,college of ,physicians1 ,april #d1 #ahhc7 collected the notes of sixty-five cases of excision of the entire larynx4 ,fifty-six of these were done for cancer1 and the remainder for sarcomata1 papillomata1 etc4 ,of the fifty-six done for cancer1 forty are reported as having died1 either shortly after the operation from shock or pneumonia1 or a few months later from recurrence of the disease4 ,in two instances the disease had recurred1 but death had not been reported when the paper was read4 ,fourteen remain in which neither death nor recurrence had been reported4 ,dr4 ,cohen's conclusion is that laryngectomy does not tend to the prolongation of life1 and thinks that the greatest good to the greater number appears better secured by dependence on the palliative operation of tracheotomy4 ,,index4 ,abdomen1 operations on1 #bbb4 ,abernethy on ligature of external iliac1 #h4 ,adams on anatomy of common iliac1 #d4 on hip deformity1 #acc4 gineta1 ,paulus1 on excision of joints1 #ajh4 ,allarton on median lithotomy1 #bfi4 ,amputation and excision contrasted1 #aac4 ,amputation at ankle-joint 7,syme's71 #gh4 of anterior portion of foot 7,hey's71 #gc4 of arm1 #fb4 at elbow-joint1 #fa4 through femur1 condyles of1 #ib4 of fingers1 #ea-ed4 of fore-arm1 #eh4 at hip-joint1 #ajb4 at knee-joint1 #ib4 of penis1 #bhf4 at shoulder-joint1 #fc4 at tarsus 7,chopart's71 #ge4 at thigh1 #id4 double primary of thigh1 #ajf4 of toes1 #fi4 at wrist-joint1 #ef4 ,amussat's operation1 #beb4 ,anchylosis of elbow1 excision for1 #abb4 ,ankle-joint1 excision of1 #acg4 ,annandale on staphyloraphy1 #bjc4 ,anus1 artificial1 operation for1 #beb4 artificial1 removal of1 #bed4 ,arendt1 ligature of external iliac1 #ab4 ,astragalus1 excision of1 #ade4 ,auchincloss on ligature of subclavian1 #cf4 ,avery1 hard palate1 fissures of1 #bjc4 ,barwell on excision of ankle-joint1 #aci4 on excision of tongue1 #aii4 ,baudens on amputation at elbow-joint1 #fa4 on amputation of anterior portion of foot1 #ge4 on amputation at knee-joint1 #ib4 ,bauer on recto-vesical lithotomy1 #bgb4 ,begbie1 ,dr4 ,warburton1 on paracentesis thoracis1 #bbj4 ,bell1 ,benjamin1 on amputation1 #di4 on amputation of ankle1 #hf4 on amputation of thigh1 #if4 ,bell1 ,sir ,charles1 on ligature of femoral1 #bb4 ,bell1 ,george1 on supra-pubic lithotomy1 #bga4 ,bell1 ,john1 on ligature of gluteal1 #ad4 ,bey1 ,gaetani1 on amputation above the shoulder-joint1 #gj4 ,bigelow1 ,dr41 on litholapaxy1 #bgf4 ,billroth1 ,dr41 on fissure of palate1 #bjj4 ,bladder1 puncture of1 #bhd4 ,bonnet on radical cure of hernia1 #bde4 ,botal on amputation1 #dg4 ,bowditch on paracentesis thoracis1 #bba4 ,bowman's operation1 lachrymal canal1 #aec4 ,brachial1 ligature of1 #bdb4 ,brodie1 ,sir ,b4 ,c41 on lithotomy1 #bfb4 on lithotrity1 #bgd4 ,bromfield1 amputation of leg1 #hf4 ,brown1 ,baker1 ovariotomy1 #bca4 ,bryant1 on excision of joints1 #aab4 ,buchanan1 ,dr4 ,a41 on lithotomy1 #bfi4 ,buchanan1 ,dr4 ,g41 on excision of tongue1 #aih4 ,buchanan1 ,dr4 ,m41 on excision of ankle1 #adj4 ,buck's operation for anchylosis1 #acf4 ,butcher1 ligature of subclavian1 #ce4 excision of joints1 #aaj4 excision of wrist-joint1 #abh4 excision of knee-joint1 #ace4 excision of metacarpals4 #adb4 ,campbell1 ,professor1 on ligature of gluteal1 #ae4 ,carden's amputation at condyles of femur1 #ej1 #id4 ,carmichael on ligature of gluteal1 #ad4 ,carnochan on neurectomy1 #cjj4 ,carotid1 ligature of common1 #bh4 ligature of external1 #cb4 ,cataract operations1 #afj4 ,celsus on amputation1 #dh4 on excision of joints1 #ajh4 ,chamberlaine1 on ligature of axillary1 #dj4 ,chassaignac on tracheotomy1 #bjf4 ,cheiloplastics1 ,syme on1 #agh4 ,cheselden on amputation1 #di4 on lithotomy1 #bfj4 ,chopart's amputation1 #ge4 ,civiale on lithotrity1 #bge4 ,club-foot1 operations for1 #big4 ,cock on oesophagotomy1 #baf4 paracentesis thoracis1 #bbj4 on puncture of bladder1 #bhe4 ,colles on ligature of brachial1 #dd4 ,cooper1 ,sir ,astley1 on ligature of aorta and iliacs1 #c1 #aj4 on perineal section4 #bgf4 ,cornea1 puncture of1 #aei4 staphylomatous1 excision of a1 #afh4 ,corelysis1 #agj4 ,crampton1 ,sir ,philip1 on excision1 #aai4 ,crichton on lithotomy1 #bfb4 ,critchett's operation of iridesis1 #afi4 operation for staphyloma1 #agb4 ,croft1 ,mr41 on hip disease1 #acb4 ,culbertson on excision of hip1 #acb4 ,cullerier on phymosis1 #bhg4 ,curling on operation for artificial anus1 #bec4 ,cusack on treatment of brachial aneurism1 #dc4 ,davies1 ,redfern1 on radical cure of hernia1 #bdd4 ,davy's 7,mr4 ,richard71 lever1 #aje4 ,desault on ligature of axillary1 #dj4 ,dieffenbach on excision of upper jaw1 #aia4 ,dieulafoy's aspirateur1 #bhd4 ,dionis' amputation of leg1 #hg4 ,dubrueil1 amputation at wrist1 #eg4 ,duncan1 ,mr4 ,j41 on artificial anus1 #bed4 ,dupuytren on ligature of iliac1 #aa4 on ligature of subclavian1 #cf4 amputation at elbow-joint1 #fb4 removal of artificial anus1 #bed4 on bilateral lithotomy1 #bfh4 ,durand1 case of hmorrhage from iliac1 #ab4 ,durham on thyrotomy1 #bae4 ,dzondi on radical cure of hernia1 #bdf4 ,elbow-,joint1 amputation at1 #fb4 ,ellis on anatomy of iliac arteries1 #f4 ,ectropium1 #aeb4 ,entropium1 #aea4 ,erichsen on excision of hip1 #acj4 ,esmarch on excision of joints1 #aaj4 ,excision and amputation contrasted1 #aab4 ,excision of ankle-joint1 #ach4 of astragalus1 #ade4 of elbow-joint1 #aah4 of hip-joint1 #abh4 of jaw1 upper1 #ahh4 of jaw1 lower1 #aia4 of knee-joint1 #acc4 of mamma1 #baf4 of scapula1 #aci4 of shoulder-joint1 #aae4 of testicle1 #bij4 of tongue1 #aig4 of tonsils1 #bjc4 of wrist-joint1 #abe4 ,eye1 operations on1 #aea4 ,eyeball1 extirpation of the1 #agc4 ,eyelid1 tumours on the1 #aeb4 ,fayrer1 ,sir ,j41 on tracheotomy1 #bab4 on radical cure of hernia1 #bdh4 ,femoral1 ligature of1 #ah4 superficial1 ligature of1 in ,scarpa's space1 #ai4 in ,hunter's canal1 #ba4 ,femur1 amputation through condyles of1 #ib4 ,fergusson1 ,sir ,w41 on ligature of subclavian1 #ch4 on amputation at shoulder-joint1 #gj4 on excision of joints1 #aaj4 on excision of upper jaw1 #aia4 on excision of lower jaw1 #aie4 on fissures of palate1 #bja4 on lithotomy1 #bfb4 ,filkin on excision of joints1 #aaj4 ,fingers1 amputation of1 #ea4 ,fissures in the palate1 soft1 #bjj4 in the palate1 hard1 #bjb4 of anus1 #bib4 ,fistula1 salivary1 operations for1 #aib4 in ano1 operation for1 #bia4 ,fore-arm1 amputation through the1 #eh4 ligature of vessels in1 #dd4 ,forster1 ,mr4 ,cooper1 on gastrotomy1 #bbd4 ,furner1 ligature of both subclavians1 #ch4 ,gastrectomy1 #bbd4 ,gastrostomy1 #bbc4 ,gastrotomy1 #bbc4 ,gersdorf1 ,hans de1 on amputation1 #dh4 ,gerdy on radical cure of hernia1 #bdf4 ,gilbert1 amputation above the shoulder-joint1 #fh4 ,gillespie on excision of wrist-joint1 #abh4 ,gluteal1 ligature of1 #ab4 ,gosselin on colotomy1 #bec4 ,graefe on strabismus1 #aeh4 on cataract operations1 #aff4 or iridectomy1 #aga4 ,green on ligature of subclavian1 #ch4 ,greenhow on excision of os calcis1 #add4 ,greenslade on ,bowman's operation1 #aef4 ,gritti's amputation1 #ic ,gross on amputation at elbow-joint1 #fa4 on amputation1 #ha-hg4 on excision of hip1 #acb4 on lithotomy1 #bfb4 on rhinoplastic operation1 #agh4 on excision of lower jaw1 #aib4 ,gurin1 ,jules1 on amputation of toes1 #gf4 on operation for strabismus1 #aeh4 ,guersant on excision of tonsils1 #bje4 ,guillemeau on amputation at knee-joint1 #ia4 ,gurlt's statistics1 #aah1 #abd4 ,hmorrhoids1 operations for1 #bid4 ,hmatocele1 operation for1 #bhi4 ,hamilton on rhinoplastic operations1 #agg4 ,hancock on excision of hip1 #acj4 on excision of ankle1 #ach4 on excision of os calcis1 #add4 ,harelip1 operations for1 #ahc4 ,harrison on anatomy of iliac1 #f4 on brachial aneurism1 #dd4 ,hart1 ,mr4 ,ernest1 on flexion of limbs1 #bd4 ,heath's case of aneurism of innominate1 #bh4 ,heine on excision of hip1 #acj4 ,hernia1 strangulated inguinal1 #bcb4 strangulated femoral1 #bcg4 strangulated umbilical1 #bdb4 strangulated obturator1 #bdc4 radical cure of1 #bdd4 ,heurtloup on lithotrity1 #bgd4 ,hey on amputation1 #dh1 #gc4 ,heyfelder on excisions1 #aaj1 #acj4 ,hildanus1 ,fabricius1 on amputation1 #dg1 #ia4 ,hip-joint1 amputation at the1 #ajb4 excision of1 #abh4 ,hippocrates on excision of joints1 #ajh4 ,hodgson1 statistics of aneurism1 #ab4 ligature of axillary1 #dj4 ,hodge on excisions #aab1 #acb4 ,hoin on amputation at knee-joint1 #ib4 ,holmes on excision of hip1 #acj1 #acb1 #add4 ,holt's operation for stricture1 #bgi4 ,howse1 ,mr41 on gastrotomy1 #bbd4 ,hughes1 ,dr4 on paracentesis thoracis1 #bbj4 ,huguier on colotomy1 #bec4 ,hunter on ligature of femoral1 #ba4 ,hutchinson's statistics1 #bj4 ,hydrocele1 operation for1 #bhh4 ,iliac1 ligature of common1 #c4 ligature of external1 #g4 ,iliac1 ligature of internal1 #f4 ,innominate1 ligature of the1 #bf4 ,iridectomy1 #aga4 ,iridesis1 #afi4 ,jacobson on cataract operations1 #aff4 ,jger on excision of hip1 #acj4 ,james1 ,mr41 on ligature of aorta1 #c4 ,jameson on radical cure of hernia1 #bdf4 ,jaw1 excision of upper1 #ahh4 excision of lower1 #aia4 ,johnston1 ,dr41 on amputation at ankle-joint1 #hd4 ,joints1 excision of1 #ajh4 ,jones on excision of joints1 #aaj1 #acd1 #acf4 ,jordan1 ,mr4 ,f41 on amputation1 #ajf2 on excision of tongue1 #aii4 ,keith1 ,dr4 ,thomas1 on ovariotomy1 #bbd-bbg4 ,kirby1 ,mr41 on ligature of iliac1 #ab4 ,knife1 ,beer's description of1 #afd4 ,knee1 amputation below and above1 #ij1 #ia4 amputation at1 #ia4 joint1 excision of1 #acb4 ,lachrymal organs1 operations on the1 #aec4 ,lane1 ,mr41 on amputation at knee-joint1 #ia4 ,langenbeck on excision of joints1 #aaj1 #adj4 on fissure in hard palate1 #bjc4 on radical cure of hernia1 #bde4 ,larrey on amputation at shoulder1 #fd4 on excision of joints1 #aji4 ,larynx1 operations on the1 #bjf4 ,laryngectomy1 #baf4 ,dr4 ,solis ,cohen on1 #cjb4 ,laryngotomy1 #bad4 ,laryngo-tracheotomy1 #bae4 ,layraud1 ,dr41 case of hmorrhage from iliac1 #ab4 ,lee1 ,mr4 ,henry1 amputation of leg1 #hh4 ,ligature of the aorta1 #b4 of the axillary1 #ch1 #ci1 #dj4 of the brachial1 #db4 of the carotid1 common1 #bi1 #cj4 of the carotid1 external1 #cb4 of the femoral1 #ah1 #ba4 of the gluteal1 #ab4 of the iliac1 #c4 of the iliac1 external1 #g4 of the iliac1 internal1 #f4 of the innominate1 #bf4 of the lingual1 #cb4 of the popliteal1 #bb4 of the subclavian1 #cc-cg4 of the vessels in fore-arm1 #de4 ,lips1 operations on the1 #ahj4 ,lisfranc on amputation1 #eb1 #gd4 ,lister1 ,professor1 on ,syme's amputation1 #hg4 on excision of wrist1 #abe4 ,liston1 ,mr41 on ligature of subclavian1 #cf1 #cg4 on rhinoplastic operations1 #agg4 on excision of upper jaw1 #ahf4 tracheotomy1 #bac4 on femoral hernia1 #bdj4 on lithotomy1 #bfb4 ,litholapaxy1 ,dr4 ,bigelow on1 #bgf4 ,lithotomy1 #bee4 ,lithotrity1 #bgh4 ,little on club-foot1 #big4 ,lloyd on harelip1 #ahg4 ,lorinzer on obturator hernia1 #bdd4 ,louis on amputation1 #dh4 ,lower extremity1 amputations of1 #fh4 ,lupus1 operative treatment of1 #agi4 ,macilwain on tracheotomy1 #bjh4 ,mackenzie1 ,dr4 ,morell1 on thyrotomy1 #bae4 ,mackenzie1 ,dr4 ,r41 on modification of ,syme's amputation1 #hc4 on excision of joints1 #aaj1 #acd4 ,malgaigne on ,chopart's amputation1 #gg4 on harelip1 #ahg4 ,mamma1 excision of1 #bah4 ,manec on ligature of axillary1 #dj4 ,maunder on excision of the elbow-joint1 #abb4 ,maclennan1 ,dr4 ,g41 on amputation above the shoulder-joint1 #fi4 ,metacarpals1 amputation of1 #ed4 excision of1 #ada4 ,metatarsals1 amputation of1 #gb4 ,miller on amputation of penis1 #bhh4 ,monteiro1 ,dr41 on ligature of aorta1 #c4 ,mooren on cataract operations1 #aff4 ,moreaus1 the1 on excision of joints1 #aji1 #aad1 #abj1 #acb1 #acd4 ,morel1 tourniquet invented by1 #dg4 ,morton1 ,dr41 on radical cure of hernia1 #bde4 ,murray1 ,dr41 on ligature of aorta1 #c4 ,mussey1 case of amputation1 #gj4 ,mynors on amputation1 #dh4 ,nasal polypi1 removal of1 #agi4 ,needle operation for cataract1 #afj4 ,nelaton on harelip1 #ahd4 ,nerve-stretching1 #bii4 ,nerve suture1 #cjj4 ,neurectomy1 #bii4 ,neurotomy1 #bii4 ,norris's statistics1 #ab1 #bj1 #ca4 ,nunneley on excision of tongue1 #aih4 ,oesophagotomy1 #baf4 ,ollier on excision of joints1 #aaj4 ,os calcis1 excision of1 #adc4 ,ovariotomy1 #bbd4 ,paget on excision of tongue1 #aih4 ,palate1 fissures in soft1 #bjj4 fissures in hard1 #bjb4 ,pancoast1 ,professor1 on rhinoplastic operations1 #agh4 on radical cure of hernia1 #bde4 on neurectomy1 #cjj4 on club-foot1 #big4 ,paracentesis thoracis1 #bai4 abdominis1 #bbb4 ,par1 ,ambrose1 on amputation1 #dg4 on amputation at elbow-joint1 #fj4 ,park on excision of joints1 #aaj4 ,peixotto1 ,dr41 on ligature of innominate1 #bg4 ,penis1 amputation of1 #bhg4 ,perineal section1 operation of1 #bgc4 ,percy on excision of joints1 #aji4 ,phymosis1 operation for1 #bhe4 ,pirogoff's modification of ,syme's amputation1 #hj1 #hd4 ,pollock on excision of lower jaw1 #aic4 ,polypi1 nasal1 removal of1 #agi4 anal1 removal of1 #bic4 ,popliteal1 ligature of1 #bb4 ,porta's statistics1 #bj4 ,porter1 ,professor1 on ligature of innominate1 #bg4 on ligature of common carotid1 #bh4 statistics of amputation1 #abb4 ,post on ligature of iliac1 #aj4 ,pritchard1 ,mr41 radical cure of hernia1 #bdh4 ,prolapsus ani1 #bib4 ,pterygium1 operation for1 #aef4 ,puncture of bladder1 #bhd4 ,pupil1 operations for artificial1 #afh4 ,purmannus on amputation1 #dh4 ,quain on anatomy of iliac1 #d4 on anatomy of brachial1 #dc4 ,regnoli on excision of tongue1 #aii4 ,rhinoplastic operations1 #age4 ,richter on radical cure of hernia1 #bde4 ,ricord on amputation of penis1 #bhg4 ,rigaud on amputation above the shoulder-joint1 #fg4 ,ritchie1 ,dr4 ,charles1 on ovariotomy1 #bbd4 ,rodgers1 ,dr41 on ligature of subclavian1 #cf4 ,rothmund on radical cure of hernia1 #bdg4 ,roux on ligature of subclavian1 #ch4 on ligature of axillary1 #dj1 on ,chopart's amputation1 #gg1 #gh4 ,sabatier on excision of joints1 #aji4 ,salivary fistula1 operation for1 #aif4 ,sanson on recto-vesical lithotomy1 #bga4 ,scalp1 tumours of the1 removal of #adi4 ,scapula1 excision of 7,syme71 #adj4 ,schuh on radical cure of hernia1 #bde4 ,schmucker on radical cure of hernia1 #bdf4 ,scultetus on amputation1 #df4 ,sedillot's operation for ligature of carotid1 #cj4 on excision of hip1 #acb4 ,shoulder-joint1 amputation at the1 #ff4 excision of1 #aae4 ,signoroni on radical cure of hernia1 #bdg4 ,sims1 ,dr4 ,m41 on lithotomy1 #bgb4 ,smith1 ,dr4 ,nathan1 on amputation at knee-joint1 #ia4 ,smith1 ,thomas1 on staphyloraphy1 #bjj4 ,smith1 ,dr4 ,tyler1 on ovariotomy1 #bca4 ,smyth on subclavian aneurism1 #bg4 ,skey on ligature of subclavian1 #ch4 on amputation1 #gd1 #ia4 on excision of wrist1 #abg4 on rhinoplastic operation1 #agh4 on lithotomy1 #bfb4 ,solis ,cohen1 ,dr41 on laryngectomy1 #cjb4 ,solomon on strabismus1 #aeh4 ,south on ligature of aorta1 #c4 ,spence1 ,professor1 on amputation1 #ej1 #ff1 #hi1 #ajj4 on excision of shoulder1 elbow1 and wrist joints1 #aah1 #abd1 #abh1 #acf4 ,sperino on puncture of cornea1 #aei4 ,stanley on excision of shoulder1 #aag4 ,steven1 ,professor1 on ligature of internal iliac1 #ae4 ,strabismus1 convergent1 #aef4 divergent1 #aeg4 ,streatfeild on entropium1 #aea4 on corelysis1 #agj4 ,stricture1 operation for1 #bgf4 ,stokes's amputation1 #id4 ,stromeyer on excision of joints1 #aaj4 ,subclavian1 ligature of right1 #cd4 ligature of left1 #ce4 ,surgeon-,general1 ,united ,states1 statistical report by1 #hb4 ,syme1 ,mr41 on amputation at ankle-joint1 #gh4 on amputation through condyles of femur1 #ib4 on amputation at hip-joint1 #ajf4 on amputation above the shoulder-joint1 #gc4 on modified circular amputation1 #aja4 on axillary aneurism1 operation for1 #da4 on cheiloplastic operation1 #aha4 ,chopart's amputation introduced by1 #gg4 on excision of lower jaw1 #aia4 on excision of joints1 #aaa-abj4 on excision of scapula1 #adj4 on excision of tongue1 #aig4 on ligature of femoral1 #bj4 on ligature of gluteal1 #ad1 #ae4 on radical cure of hernia1 #bdg4 on ,hey's operation1 #gc4 on oesophagotomy1 #baf4 on removal of polypi1 #ahj4 on rhinoplastic operation1 #age4 on stricture1 #bgh-bhb4 ,tait on ligature of iliac1 #aj1 #ab4 ,taliacotian operation1 #agh4 ,tarso-metatarsal joint1 amputation at1 #gb4 ,tarsus1 amputation through the1 #ge4 ,teale on amputation1 #ej4 on amputation of fore-arm1 #ei4 on amputation of arm1 #fc4 on amputation of leg1 #hi4 on amputation of thigh1 #ih4 on amputation of penis1 #bhh4 ,teale1 ,t4 ,p41 on cataract1 #afc4 ,tenotomy1 #bif4 ,testicle1 excision of1 #bij4 ,textor on amputation at elbow-joint1 #fj4 ,thigh1 amputations of1 #if4 ,thompson on lithotrity1 #bge4 on stricture1 #bgg4 ,thorax1 operations on the1 #bah4 ,thyrotomy1 #bae4 ,toes1 amputations of1 #fh4 ,tongue1 excision of1 #aig4 ,tonsils1 excision of1 #bjc4 ,tracheotomy1 #bjf-bad4 ,trephining and trepanning1 #adg4 ,trichiasis1 #aea4 ,tripier's amputation1 #gh4 ,trocar of ,sir ,s4 ,wells described1 #bbg4 ,tumours of scalp1 removal of1 #adi4 of eyelids1 removal of1 #aeb4 ,tyrrell on treatment of brachial aneurism1 #dc4 ,upper extremity1 amputation of1 #ej4 ,urethra1 stricture of1 #bgf4 ,velpeau on ligature of iliac1 #ab4 on ligature of subclavian1 #ch4 on amputation at elbow-joint1 #fj4 on amputation at knee-joint1 #ia4 on radical cure of hernia1 #bde4 ,vermale on amputation of thigh1 #ajb4 ,verneuil on ,chopart's amputation1 #gh4 ,vessels of fore-arm1 ligature of1 #dd4 ,wakley on stricture1 #bgi4 ,warren on fissure of hard palate1 #bjc4 ,watson1 ,dr4 ,p4 ,h41 on excision1 #ace4 on excision of elbow-joint1 #abc4 on laryngectomy1 #baf4 ,wells1 ,sir ,spencer1 on ovariotomy1 #bbd-bbi4 trocar1 #bbg4 hernia1 radical cure of1 #bdg4 ,white on amputation of leg1 #hf4 on excision of joints1 #aaj4 ,whitehead1 ,mr4 ,w41 on excision of tongue1 #aii4 ,willet on oesophagotomy1 #baf4 ,wood's statistics1 #cj4 on joints1 #acd4 on radical cure of hernia1 #bdh-bea4 ,wry neck1 operation for1 #bif4 ,wrist-joint1 amputation at1 #ee4 excision of1 #abd4 ,wtzer on radical cure of hernia1 #bdg4 ,wyeth1 ,dr41 statistics1 #cf1 #ch4 ,young1 ,james1 tourniquet introduced by1 #dg4 ,zehender's statistics1 #cj4