file :i* includes ! orig9al illu/rations4 ,see #bdefd-;h4htm or #bdefd-;h4zip3 7https3_/_/www4gut5b]g4org_/dirs_/#b_/d_ /e_/f_/bdefd_/bdefd-;h_/#bdefd-;h4htm7 or 7https3_/_/www4gut5b]g4org_/dirs_/#b_/d_ /e_/f_/bdefd_/bdefd-;h4zip7 ,transcrib]'s note3 ,spell+ mi/akes h be5 left 9 ! text to mat* ! orig9al1 except = obvi\s typographical errors4 ,a ,,manual ,,( ,,! ,,op]ations ,,( ,,surg]y ,= ! ,use ( ,s5ior ,/ud5ts1 ,h\se ,surgeons1 & ,junior ,practition]s4 ,illu/rat$4 by ,,joseph ,,bell1 ,f4,r4,c4,s4 ,,ed94 ,lectur] on ,cl9ical ,surg]y1 ,surgeon to ! ,royal ,infirm>y & to ! ,eye ,infirm>y1 & ,late ,demon/rator ( ,anatomy 9 ! ,univ]sity ( ,ed9burgh4 ,,fif? ,,edition1 ,,revis$ ,,& ,,enl>g$4 ,ed9burgh3 ,macla*lan ,/ew>t1 ,booksell]s to ! ,univ]sity4 ,london3 ,simpk91 ,m>%all1 ,co4 #ahhc4 ,,to ,,! ,,memory ,,( ,,james ,,syme1 ,,esq41 ,f4,r4,c4,s4 ,,& ,f4,r4,s4,e4 ,,surgeon ,,to ,,! ,,que5 ,,9 ,,scotl& ,,pr(essor ,,( ,,cl9ical ,,surg]y ,,9 ,,! ,,univ]sity ,,( ,,ed9burgh ,,etc4 ,,etc4 ,,?is ,,book ,,is ,,d$icat$ ,,by ,,8 ,,old ,,h\se-,,surgeon ,,& ,,assi/ant ,,! ,,au?or4 ,,preface ,,to ,,fif? ,,edition4 ,to reta9 ! small size ( ! "w & to keep x up to date h be5 ! ,au?or's aim 9 ! ,fif? ,edition4 #bj ,,melville ,,/reet1 ,,ed9burgh1 ,augu/ #ahhc4 ,,preface ,,to ,,! ,,fir/ ,,edition4 ,hav+ be5 ask$1 ye> aft] ye>1 by ! memb]s ( my ,class = ,op]ative ,surg]y1 to recomm5d to !m "s ,manual ( ,surgical ,op]ations :i* might at once guide !m 9 _! *oice ( op]ations1 & give m9ute details z to ! mode ( p]=mance1 ,i h be5 gradually l$ to und]take ! production ( ?is little "w4 ,my aim has be5 to describe z simply z possible ^? op]ations :i* are mo/ likely to prove useful1 & especially ^? :i*1 f _! nature1 admit ( be+ practis$ on ! dead body4 ,9 accordance ) ?is plan1 nei!r hi/orical complet5ess ( detail1 nor mu* v>iety 9 ! me?ods ( p]=m+ any giv5 op]ation1 is to be expect$4 ,h5ce1 also1 _m omissions :i* w\ld be unp>donable 9 ! briefe/ sy/em ( ,surg]y are unavoidable4 ,= example1 excision ( tum\rs & op]ations = necrosis are h>dly m5tion$1 because = ^! no special in/ructions c well be giv52 =1 :ile g5]al pr9ciples may guide u to :at %\ld be done1 ! special circum/ances ( ea* case mu/ dictate h[ x is to be done4 ,9 su* a "w z ?is1 to attempt orig9ality w\ld be undesirable & intrusive2 a judici\s selection1 a fai?ful compilation1 are all t c be expect$4 ,t ! selection ( op]ations may sometimes %[ ,nor!rn ,proclivities is possible2 & ?is is p]haps n unnatural to a s*ol> & tea*] 9 ! ,ed9burgh ,s*ool4 ,an e>ne/ endeav\r has be5 us$ to make ! ref]5ces correct & copi\s3 = any mi/akes or omissions ! au?or w\ld crave indulg5ce4 ,! f\r plates :i* prec$e ! lett]press 7 drawn on wood 7f orig9al photographs7 by ,mr4 ,d4,w4 ,williamson1 ,melb\rne ,place1 & ! l9es ( incision = ! v>i\s op]ations 7 add$ by ! au?or4 ,! r\gh woodcuts scatt]$ ?r\gh ! "w 7 drawn on wood by ! au?or1 & = _! r\ghness he1 n 8 engrav]1 is responsible4 ,he also hopes t ! ref]5ces 9 ! lett]press w be accept$ z suffici5t ackn[l$gm5t ( ! true own]%ip1 9 ^? few in/ances 9 :i* ! idea ( ! diagram has be5 borr[$4 ,x has be5 ?\ght unnecess>y to introduce woodcuts ( surgical in/rum5ts1 z ! illu/rat$ catalogues lately publi%$ by ,weiss1 ,maw1 & o!rs1 are suffici5tly accurate4 ,9 excuse ( ! frequ5t baldness & brevity ( ! /yle1 ! au?or mu/ po9t to ! size & price ( ! "w4 ,its composition w\ld h be5 easi] _h its dim5sions be5 great]4 ,?\gh int5d$ *iefly to guide ! /udies1 on ! dead subject1 ( /ud5ts & junior practition]s1 ! au?or v5tures to hope t ! ,manual may be useful to ^? :o1 9 ! public s]vices1 9 ! colonies1 or 9 lonely c\ntry di/ricts1 f9d !mselves con/ra9$ to attempt ! p]=mance ( op]ations :i*1 9 ! t[ns1 usually fall to ! lot ( a few ,hospital ,surgeons4 ,,joseph ,,bell4 #e ,,ca/le ,,t]race1 ,,ed9burgh1 ,july #ahff4 ,,cont5ts4 ,,*apt] ,i4 ,,ligature ,,( ,,art]ies4 ,,page ,ligature ( ,art]ies--,g5]al ,maxims--,ligature ( ,aorta--,iliacs--,gluteal--,femoral--,po pliteal--,innom9ate--,c>otids-- ,l+ual--,subclavian--,bra*ial1 etc41 #a-de ,,*apt] ,,ii4 ,,amputations4 ,eras ( ,amputation--,flap & ,circul> comp>$--,special ,amputation ( ,arm & ,leg1 #df-ajg ,,*apt] ,,iii4 ,,excision ,,( ,,jo9ts4 ,brief ,hi/orical ,sket*--,comp>ison ( ,excisions ) ,amputations--,special ,excisions ( ! six l>g] ,jo9ts--,excisions ( small] ,jo9ts & ,bones1 #ajh-adf ,,*apt] ,,iv4 ,,op]ations ,,on ,,cranium ,,& ,,scalp4 ,treph9+--,excision ( ,w5s1 #adg-aej ,,*apt] ,v4 ,,op]ations ,,on ,,! ,,eye ,,& ,,its ,,app5dages4 ,entropium & ,ectropium--,tri*iasis--,t>sal ,tum\rs--,on ,la*rymal ,organs--,mr4 ,b[man's ,op]ation--,pt]ygium--,/rabismus1 conv]g5t & div]g5t--,p>ac5tesis ( ! ,ant]ior ,*amb]--,op]ations = ,cat>act by ,displacem5t1 ,solution1 & ,extraction--,v>i\s me?ods ( ,extraction--,op]ations = ,artificial ,pupil--,iridesis--,corelysis--,iridecto my--,excision ( ,/aphyloma--,excision ( ,eyeball1 #aea-agd ,,*apt] ,,vi4 ,,op]ations ,,on ,,! ,,nose ,,& ,,lips4 ,rh9opla/ic ,op]ations f ,*eek1 ,=ehead1 & else:]e--,removal ( ,nasal ,polypi--,excision ( ,canc]s ( ,lips--,*eilopla/ic ,op]ations--,op]ations = ,h>elip1 #age-ahg ,,*apt] ,,vii4 ,,op]ations ,,on ,,! ,,jaws4 ,excision ( ,upp] ,jaw--,( ,l[] ,jaw1 #ahh-aie ,,*apt] ,,viii4 ,,op]ations ,,on ,,m\? ,,& ,,?roat4 ,= ,saliv>y ,fi/ula--,excision ( ,tongue1 complete & p>tial--,fissures ( ! ,palate1 s(t & h>d--,excision ( ,tonsils1 #aif-bje ,,*apt] ,,ix4 ,,op]ations ,,on ,,air ,,passages4 ,l>ynx & ,tra*ea--,tra*eotomy--,tubes--,l>yngotom y--,o,esophagotomy--see ,add5dum1 p4 #cjb1 #bjf-bag ,,*apt] ,x4 ,,op]ations ,,on ,,?orax4 ,,page ,excision ( ,mamma--,p>ac5tesis ,?oracis1 #bah-bba ,,*apt] ,,xi4 ,,op]ations ,,on ,,abdom54 ,p>ac5tesis ,abdom9is--,ga/rotomy--,ov>iotomy--,op]a tion = ,/rangulat$ ,h]nia--,+u9al--,femoral--,umbilical--,o p]ations = ! ,radical ,cure ( ,h]nia1 #bbb-bee ,,*apt] ,,xii4 ,,op]ations ,,on ,,pelvis4 ,li?otomy--,v>ieties--,li?otrity--,op]at ions = ,/ricture--,puncture ( ! ,bladd]--,phymosis--,amputation ( ,p5is--,hydrocele--,hmatocele--,ca/ratio n--,op]ation = ,fi/ula--,fissure--,polypi ( ,rectum--,piles1 #bef-bie ,,*apt] ,,xiii4 ,,t5otomy4 ,on ,t5otomy = ,wry ,neck & ,club ,foot1 #bif-bih ,,*apt] ,,xiv4 ,,op]ations ,,on ,,n]ves4 ,n]ve-/ret*+--,n]ve-cutt+--,n]ve suture1 #bii-cja ,,add5dum to ,*apt] ,,ix41 #cjb ,,index1 #cjc-caa ,,li/ ,,( ,,illu/rations4 ,,fig4 ,,page ,i4 ,amputations ( ,f+]s1 #ej ,,ii4 ,diagram ( ,f+] %[+ ,articulations1 #ej ,,iii4 ,dubrueil's ,amputation at ,wri/ 7front view71 #eg ,,iv4 7dorsal view71 #eg ,v4 ,amputations ( ,toes1 #fi ,,vi4 ,excision ( ,wri/-jo9t--,li/]'s1 #abf ,,vii4 ,op]ations = ,ectropium & ,entropium1 #aea ,,viii4 ,op]ation = ,tri*iasis--,/reatfeild's1 #aea ,,ix4 ,op]ation = ,epiphora--,b[man's1 #aee ,x4 ,gre5slade's ,in/rum5t = above1 #aef ,,xi4 ,op]ations = ,squ9t1 #aeg ,,xii4 ,l9e> ,extraction ( ,cat>act1 #afb ,,xiii4 ,flap ,extraction ( ,cat>act1 #afb ,,xiv4 ,op]ation ( ,corelysis--,/reatfeild's1 #aga ,,xv4 ,op]ation = ,/aphyloma--,crit*ett's1 #agb ,,xvi4 ,result ( above1 #agb ,,xvii4 ,rh9opla/ic ,op]ation f ,*eek1 #agf ,,xviii4 ,=ehead1 #agg ,,xix4 ,op]ation on ,lip1 ,v-%ap$ incision1 #aha ,,xx4 ,op]ation on ,lip1 by scissors1 #aha ,,xxi4 ,op]ation = a new ,lip1 incisions1 #ahb ,,xxii4 ,op]ation = ,new ,lip sew$ up1 #ahb ,,xxiii4 ,diagram ( ,p>tial ,fissure 7,h>elip71 #ahd ,,xxiv4 ,nelaton's ,op]ation = ditto1 #ahd ,,xxv4 ,op]ation = ,d\ble ,h>elip1 #ahe ,,xxvi4 ,diagram ( ,d\ble ,h>elip1 #ahf ,,xxvii4 ,excision ( ,upp] & ,l[] ,jaws1 #ahi ,,xxviii4 ,op]ation = ,saliv>y ,fi/ula1 #aif ,,xxix4 ,op]ation = ,fissure 9 ,s(t ,palate1 #bja ,,xxx4 ,op]ation = ,fissure 9 ,h>d ,palate1 #bjc ,,xxxi4 ,diagram illu/rat+ ,op]ations on ,air ,passages1 #bjg ,,xxxii4 ,diagram illu/rat+ ,op]ations = ,h]nia1 #bda ,,xxxiii4 ,diagram ( an ,artificial ,anus1 #bec ,,xxxiv4 ,diagram ( ,section ( ,pro/ate1 #beg ,,xxxv4 ,diagram ( ,membran\s portion ( ,ure?ra1 #bei ,,xxxvi4 ,diagram illu/rat+ ,puncture ( ,bladd]1 #bhd ,,xxxvii4 ,diagram ( ,op]ation = ,phymosis1 #bhf ,,xxxviii4 ,diagram ( ,amputation ( ,p5is1 #bhg ,illu/ration ,,plate ,i4 #a4 ,ligature ( ,aorta--,sir ,a4 ,coop]'s incision4 #b4 ,ligature ( ,aorta--,s\? & ,murray's incision4 #c4 ,ligature ( ,common ,iliac4 #d4 ,ligature ( ,ext]nal ,iliac--,sir ,a4 ,coop]'s4 #e4 ,ligature ( ,femoral 9 ,sc>pa's triangle4 #f4 ,ligature ( ,femoral bel[ ,s>torius4#a #g4 ,ligature ( ,innom9ate4 #h4 ,ligature ( ?ird "p ( ,left ,subclavian4 #i4 ,ligature ( ,axill>y 9 its fir/ "p4 #aj4 ,ligature ( ,axill>y 9 its ?ird "p4 #aa4 ,ligature ( ,bra*ial4 #ab4 ,amputation ( ,arm by d\ble flaps4 #ac4 ,amputation at ,%\ld]-jo9t 7#a/ me?od71 %[+ portion ( sk9 left uncut till ! conclusion ( ! dis>ticulation4 #ad4 ,amputation at ,ankle-jo9t by int]nal flap--,mack5zie's4 #ae-af4 ,amputation ( ,leg j above ! ,ankle-jo9t4 #ag-ah4 ,amputation bel[ ,knee--modifi$ circul>4 #ai4 ,amputation ?r\gh ,condyles ( ,femur--,syme1 & ,pl4 ,,iii4 #e4 #bj4 ,amputation at l[] ?ird ( ,?igh--,syme1 & ,pl4 ,,iii4 #f4 ,a4 ,excision ( ,head ( ,hum]us4 ,b4 ,excision ( ,knee-jo9t2 semilun> incision4 ,,footnotes3 #a ,?is l9e is plac$ too l[ d[n2 x %\ld be 9 ! middle ?ird ( ! ?igh4 ,illu/ration ,,plate ,,ii4 #a4 ,amputation at l[] ?ird ( ,=e-arm--,teale's4 #b-b4 ,amputation at ,%\ld]-jo9t by l>ge po/]o-ext]nal flap--#b;d me?od4 #c-c4 ,amputation at ,%\ld]-jo9t by triangul> flap f deltoid--#c;d me?od4 #d-e4 ,amputation ?r\gh ,t>sus--,*op>t's4 #f-g4 ,amputation at ,knee-jo9t4 #h4 ,amputation by ,s+le ,flap--,c>d5's1 & ,pl4 ,,iv4 #af4 #i-aj4 ,amputation ( ,?igh--,teale's4 ,a4 ,excision ( ,hip-jo9t4 ,b-,b4 ,excision ( ,ankle-jo9t--,hancock's incisions4 ,illu/ration ,,plate ,,iii4 #a4 ,ligature ( ,popliteal4 #b4 ,amputation at ,elb[-jo9t--po/]ior flap4 #c4 ,amputation at ,%\ld]-jo9t--po/]ior incision ( fir/ me?od1 & ,pl4 ,i4 #ac4 #d4 ,amputation at ,ankle-jo9t--,mack5zie's1 & ,pl4 ,i4 #ad4 #e4 ,amputation ?r\gh ,condyles ( ,femur--,syme1 & ,pl4 ,i4 #ai4 #f4 ,amputation at l[] ?ird ( ,?igh--,syme1 & ,pl4 ,i4 #bj4 #g4 ,amputation at ,knee--po/]ior incision4 #h4 ,amputation ( ,?igh--,sp5ce's1 & at ,pl4 ,,iv4 #ah4 #i4 ,amputation at ,hip-jo9t1 & ,pl4 ,,iv4 #bj4 ,a4 ,excision ( ,%\ld]-jo9t--deltoid flap4 ,b4 ,excision ( ,%\ld]-jo9t by po/]ior incision4 ,c4 ,excision ( ,elb[-jo9t--,h-%ap$ incision4 ,d4 ,excision ( ,elb[-jo9t--l9e> incision4 ,e4 ,excision ( ,hip-jo9t--,gross's4 ,f4 ,excision ( ,os ,calcis4 ,g4 ,excision ( ,scapula4 ,illu/ration ,,plate ,,iv4 #a4 ,ligature ( ,c>otid4 #b4 ,ligature ( ,subclavian 7#c;d /age7--,skey's incision4 #c4 ,amputation at ,wri/-jo9t--dorsal incision4 #d4 ,amputation at ,wri/-jo9t--palm> incision4 #e4 ,amputation at ,=e-arm--dorsal incision4 #f4 ,amputation at ,=e-arm--palm> incision4 #g4 ,amputation at ,elb[-jo9t--,ant]ior flap1 & ,pl4 ,,iii4 #c4 #h4 ,amputation at ,arm--,teale's me?od4 #i4 ,amputation at ,%\ld]-jo9t--#a/ me?od1 & ,pl4 ,,iii4 #c4 #aj-aa4 ,amputation ( ,metat>sus--,hey's4 #ab-ac4 ,amputation at ,ankle--,syme's4 #ad-ae4 ,amputation ( ,leg--po/]ior flap--,lee's4 #af4 ,amputation at ,knee-jo9t--,c>d5's1 & ,pl4 ,,ii4 #h4 #ag4 ,amputation ( ,?igh--,b4 ,bell's4 #ah4 ,amputation ( ,?igh--,sp5ce's1 & ,pl4 ,,iii4 #h4 #ai4 ,amputation ( ,?igh 9 middle ?ird4 #bj-bj4 ,amputation at ,hip-jo9t1 & ,pl4 ,,iii4 #i4 ,a4 ,excision ( ,wri/--radial incision4 ,b4 ,excision ( ,wri/--uln> incision4 ,,*apt] ,i4 ,,ligature ,,( ,,art]ies4 ,,ligature ,,( ,,art]ies4--,9 a "w ( ?is nature !re is no room = any discussion ( ! pr9ciples :i* %\ld guide u 9 ! selection ( cases1 or ( ! pa?ology ( aneurism1 or ! local effects ( ! ligature on ! vessels4 ,"o or two fundam5tal axioms may be giv5 9 a few words3-- #a4 ,9 select+ ! spot = ! application ( ! ligature1 avoid z f> z possible bifurcations1 or ! neighb\rhood ( l>ge collat]al bran*es4 #b4 ,a free incision %\ld be made ?r\gh ! sk9 & subjac5t textures1 till ! %ea? ( ! art]y is rea*$ & fairly expos$4 #c4 ,! %ea? mu/ be op5$ & ! art]y clean$ ) a %>p knife till ! :ite ext]nal coat is cle>ly se54 ,! portion clean$ %\ld1 h[ev]1 be z small z possible1 consi/5t ) ?or\gh exposure1 s t ! ligature may be pass$ r\nd ! vessel )\t =ce4 #d4 ,z ! art]y %\ld nev] be rais$ f its b$1 x is g5]ally advisable to pass ! ne$le only s f> z j to p]mit ! eye to be se5 pa/ ! vessel4 ,! ligature %\ld !n be seiz$ by a pair ( =ceps & g5tly pull$ ?r\gh1 ! ne$le be+ cauti\sly )drawn4 ,:5 catgut is us$1 x is bett] to pass ! un>m$ ne$le till ! eye is visible1 !n ?read & )draw x1 ?us pull+ ! catgut ?r\gh4 #e4 ,z a rule1 ! ne$le %\ld be pass$ f ! side ( ! vessel at :i* ! *ief dang]s exi/4 ,?is w g5]ally be 9 ! side at :i* ! ve9 is4 #f4 ,! ligature %\ld be s+le1 & consi/ ( /rong well-wax$ silk1 & %\ld always be drawn z tight z possible1 s z to divide ! int]nal & middle coats ( ! vessel4 ,9 cases :]e ! w\nd is to be treat$ ) antiseptic precautions & an attempt at imm$iate union made1 ! ligature may be ( /rong catgut prop]ly prep>$1 & bo? ends ( x may be cut (f4 #g4 ,be=e ! ligature is tight5$1 x is well to feel t pressure betwe5 ! ligature & ! f+] arre/s ! pulsation ( ! tum\r4 ,,ligature ,,( ,,! ,,aorta4--,x has be5 f\nd necess>y 9 a few r>e cases to place a ligature on ! abdom9al aorta2 no case has z yet surviv$ ! op]ation beyond a v few days1 b !y h 9 _! progress suffici5tly prov$ t ! circulation c be c>ri$ on1 & gangr5e does n necess>ily result ev5 aft] su* a decid$ int]f]5ce ) vascul> supply4 ,op]ation4--,! ligature may be appli$ 9 "o ( two ways1 ! *oice be+ influ5c$ by ! nature ( ! disease = :i* x is done4 #a4 ,a /raight incision 7,plate ,i4 fig4 #a7 9 ! l9ea alba1 j avoid+ ! umbilicus by a curve1 & divid+ ! p]itoneum1 all[s ! inte/9es to be pu%$ aside1 & ! aorta expos$ /ill cov]$ by ! p]itoneum1 z x lies 9 front ( ! lumb> v]tebr4 ,! p]itoneum mu/ aga9 be divid$ v cauti\sly at ! po9t select$1 & ! aortic plexus ( n]ves c>efully dissect$ (f1 9 ord] t !y may n be int]f]$ ) by ! ligature4 ,! ligature %\ld !n be pass$ r\nd1 ti$1 cut %ort1 & ! w\nd accurately sew$ up4 #b4 ,)\t w\nd+ ! p]itoneum4 ,a curv$ incision 7,plate ,i4 fig4 #b71 ) its convexity backw>ds1 f ! project+ end ( ! t5? rib to a po9t a little 9 front ( ! ant]ior sup]ior sp9\s process ( ! ilium4 ,at fir/ ?r\gh ! sk9 & fascia only1 ?is incision mu/ be cont9u$ ?r\gh ! muscles ( ! abdom9al wall1 "o by "o1 till ! transv]salis fascia is expos$1 :i* mu/ !n be scrap$ ?r\gh v cauti\sly1 s z n to injure ! p]itoneum1 :i* is to be deta*$ f ! fascia cov]+ ! psoas & iliacus muscles1 & mu/ be held inw>ds & out ( ! way by b5t copp] spatul4 ,! common iliac w !n be felt pulsat+1 & on x ! f+] may easily be guid$ up until ! aorta is rea*$4 ,! really difficult "p ( ! op]ation n[ beg9s3 to isolate ! vessel f ! sp9e beh9d1 ! inf]ior cava on ! "r side1 & ! plexus ( n]ves 9 ! cellul> tissue all r\nd4 ,! clean+ ( ! vessel mu/ be done 9 great measure by ! f+]-nail1 & mu* dext]ity w be requir$ to pass ! ligature )\t unnecess>ily rais+ ! vessel f its b$1 especially z ! vessel itself may v possibly be diseas$1 & ! aneurism ( ! iliac trunk = :i* ! op]ation is requir$ w displace & confuse ! p>ts1 & may h set up adhesive inflammation4 ,results4--,op]ation has be5 p]=m$ at lea/ t5 times4 ,by ! fir/ me?od by ,sir ,a/ley ,coop] & ,mr4 ,james2 by ! second by ,drs4 ,murray & ,monteiro1 ,m',guire1 ,h]on ,watson1 & ,/okes1 & ,mr4 ,s\?1 & ,cz]ny ( ,heidelb]g4 ,all ! cases prov$ fatal2 ,dr4 ,monteiro's surviv$ = t5 days1 & ev5tually p]i%$ f hmorrhage2 ! re/ all di$ at %ort] int]vals4 ,,ligature ,,( ,,common ,,iliac4--,anatomical ,note4--,?is %ort ?ick trunk v>ies slightly 9 its relations on ! two sides ( ! body4 ,z ! aorta bifurcates on ! left side ( ! body ( ! f\r? lumb> v]tebra1 ! common iliac ( ! "r side w\ld h a long] c\rse to pursue ?an t on ! left1 if bo? end$ at correspond+ po9ts4 ,h[ev]1 ?is is n always ! case1 z has be5 po9t$ out by ,mr4 ,adams ( ,dubl91 z ! "r common iliac (t5 bifurcates soon] ?an ! left does4 ,) ?is slight diff]5ce1 ! position ( ! two vessels is precisely simil>1 ea* ext5d+ along ! brim ( ! pelvis f ! bifurcation ( ! aorta t[>ds ! sacro-iliac syn*ondrosis = ab\t two in*es4 ,sometimes ! division takes place a little high]1 ev5 at ! junction ( ! la/ lumb> v]tebra & ! sacrum4 ,?is v>iation dep5ds *iefly on ! l5g? ( ! art]y1 :i*1 z ,qua9 has %[n1 v>ies f "o in* & a half to m ?an ?ree in*es4 ,! ant]ior surface ( bo? art]ies is cov]$ by ! p]itoneum1 & ea* is cross$ by ! uret] j z x bifurcates into its bran*es4 ,! art]y ( ! "r side is 9 close contact beh9d ) its correspond+ ve91 :i* at its upp] "p projects to ! outside1 & bel[ to ! inn] side4 ,! art]y ( ! left side is less involv$ ) its ve91 :i* lies bel[ x1 & to ! inside4 ,! "r is 9 contact ) a coil ( ileum1 ! left ) ! colon4 ,! inf]ior mes5t]ic art]y crosses ! left "o1 :ile to ! outside ( bo?1 & beh9d !m1 lie ! sympa!tic & obdurator n]ves4 ,!re are no nam$ bran*es f ! common iliac4 ,op]ation4--,! *ief difficulties to be enc\nt]$ are--#a4 ,! close proximity ( ! p]itoneum1 & specially ! risk !re is t x has become adh]5t to ! sac ( ! aneurism2 #b4 ,! dep? ( ! p>ts1 & t5d5cy ( ! inte/9es to roll into ! w\nd2 #c4 ,specially on ! "r side1 ! proximity ( ! great ve9s4 ,) ^! exceptions ! pass+ ( ! ligature is n s difficult z 9 "s situations1 ! lax cellul> tissue 9 :i* ! vessel lies g5]ally yield+ mu* m easily ?an ! t\gh %ea? :i* else:]e1 z 9 ! femoral1 requires accurate dissection4 ,incision4--7,plate ,i4 fig4 #c47--;,f a po9t ab\t half an in* above ! c5tre ( ,p\p>t's ligam5t1 a cresc5tic incision %\ld be made1 at fir/ ext5d+ upw>ds & outw>ds1 s z to pass ab\t "o in* inside ( ! ant]ior sup]ior sp9e ( ! ilium1 & !n prolong$ upw>ds & inw>ds1 z f> z may be r5d]$ necess>y by ! size ( ! aneurism or ! dep? ( p>ts4 ,x mu/ ext5d ?r\gh sk9 & sup]ficial fascia1 expos+ ! t5don ( ! ext]nal oblique1 :i* mu/ !n be slit up to ! full ext5t visible4 ,! sp]matic cord may !n be easily expos$ "u ! edge ( ! int]nal oblique1 & ! =ef+] ( ! left h& ins]t$ on ! cord1 & ?us b5ea? ! int]nal oblique & transv]salis muscles1 ! p]itoneum be+ q safe bel[4 ,on ! f+] ^! muscles may be safely divid$ to ! full ext5t ( ! ext]nal incision4 ,! deep circumflex iliac art]y if possible %\ld n be divid$1 b may ble$ sm>tly & require a ligature4 ,! p]itoneum mu/ !n be v cauti\sly rais$ f ! tum\r1 & support$1 along ) ! inte/9es1 by copp] spatul4 ,! surgeon w r>ely succe$ 9 obta9+ any?+ l a satisfactory view ( ! vessel1 b c expose x = ! ligature by ! aid ( 8 f+]-nail4 ,an ord9>y aneurism-ne$le w g5]ally suffice = ! conveyance ( ! ligature4 ,! difficulties may occasionally be mu* increas$ by special circum/ances1 su* z great /\tness ( ! pati5t1 & consequ5t ?ickness ( ! abdom9al wall2 or l>ge size ( ! aneurism1 :i* may cause alt]ations 9 ! relation ( p>ts & adhesion ( ! p]itoneum4 ,! uret] g5]ally gives no tr\ble1 z 9 press+ back ! p]itoneum x is adh]5t to x1 & is remov$ along ) x t[>ds ! middle l9e4 ,results4--,are n by any means satisfactory4 ,out ( tw5ty-two cases 9 :i* ! common iliac has be5 ti$ = aneurism1 eight recov]$ & f\rte5 di$2 :ile out ( ?irte5 cases :]e x requir$ ligature = hmorrhage aft] amputation1 rupture ( aneurism1 etc41 only "o recov]$4 ,,ligature ,,( ,,int]nal ,,iliac4--,little ne$ be add$ to ! acc\nt j giv5 ( ! op]ation = ligature ( ! common iliac1 z precisely ! same incisions are requir$4 ,! op]ator hav+ rea*$ ! bifurcation ( ! vessel1 mu/1 in/ead ( trac+ x upw>ds1 endeav\r to trace x d[nw>ds1 & ! same "t inw>ds1 into ! bas9 ( ! pelvis4 ,to d ?is 8 f+] mu/ cross ! ext]nal iliac art]y1 :i* w pulsate "u ! jo9t ( ! ungual phalanx1 :ile ! pulp ( ! f+] is t\*+ ! int]nal iliac1--! ext]nal iliac ve91 :i* occupies ! angle =m$ by ! bifurcation ( ! art]y1 ly+ betwe5 ^! two po9ts4 ,! ligature %\ld be appli$ )9 ?ree-qu>t]s ( an in* f ! bifurcation4 ,anatomical ,note4--,?is %ort ?ick trunk ext5ds backw>ds & inw>ds 7,ellis72 d[nw>ds & backw>ds 7,h>rison71 9 front ( ! sacro-iliac syn*ondrosis1 z f> z ! upp] extremity ( ! great sacro-sciatic not*1 a di/ance v>y+ 9 ! adult f "o & a half to two in*es 9 l5g?4 ,x =ms a curve ) its concavity =w>ds1 & at its t]m9ation divides into1 r ?an gives (f1 its two or ?ree pr9cipal bran*es4 ,its correspond+ ve9 is 9 close contact beh9d1 z also ! lumbo-sacral n]ve1 ! obdurator n]ve to its out] side4 ,! p]itoneum cov]s x ant]iorly1 & x is cross$ j at its comm5cem5t by ! uret]4 ,on ! left side x is cov]$ ant]iorly by ! rectum4 ,( its anatomical relations1 t ( ! ext]nal iliac ve9 is p]haps ! mo/ important1 z x is apt to int]f]e ) ! pass+ ( ! ne$le4 ,results4--,?is vessel has be5 ti$ = aneurism ( "o or o!r ( its bran*es1 or = w\nd1 ab\t sev5te5 times4#b ,( ^! sev5 recov]$2 9 t5 ! op]ation prov$ fatal1 9 mo/ ( !m f second>y hmorrhage4 ,9 "o case ! hmorrhage occurr$ )9 twelve h\rs aft] ! op]ation4 ,! circulation ( ! p>ts suppli$ aft] ! ligature is c>ri$ on ma9ly by ! lumb> & lat]al sacral bran*es1 :i* become mu* develop$ ev5 be=e ! op]ation1 9 cases ( aneurism4 ,,ligature ,,( ,,ext]nal ,,iliac4--,anatomical ,note4--,?is art]y ext5ds f ! bifurcation ( ! common iliac to ! c5tre ( ,p\p>t's ligam5t1 :]e x leaves ! abdom51 pass+ "u ! ligam5t1 & becomes ! common femoral4 ,its upp] extremity is ?us n always con/ant1 v>y+ 9 position f ! sacro-lumb> fibro-c>tilage to ! upp] end ( ! sacro-iliac syn*ondrosis1 or ev5 a little l[] d[n4 ,?us1 ?\gh ! position ( ! l[] end is at a fix$ po9t1 ! art]y v>ies 9 l5g?4 ,9 an adult male ( mod]ate /ature x is f ?ree & a half to f\r in*es 9 l5g?4 ,on ! surface ( ! abdom5 ! position ( ?is vessel w\ld be indicat$ by a l9e drawn f ab\t an in* on ei!r side ( ! umbilicus to ! middle ( ! space betwe5 ! symphysis pubis & ! cre/ ( ! ilium4 ,its relations to neighb\r+ p>ts are z foll[s3--,! p]itoneum lies 9 front ( x1 sep>at$ f x only by a subp]itoneal lay] ( loose fascia1 9 :i* ! art]y & ve9 lie1 :i* v>ies mu* 9 consi/5ce & am\nt1 & :i* occasionally gives a good deal ( tr\ble 9 ! op]ation ( ligature4 ,ne> its orig9 x is sometimes cross$ by ! uret]1 & ne> its t]m9ation ! g5ito-crural n]ve lies on x4 ,! sp]matic vessels cross x1 & occasionally a quantity ( subp]itoneal fat m>ks its c\rse4 ,ext]nally4--,! fascia-iliaca & "s fibres ( ! psoas muscle sep>ate x f ! ant]ior crural n]ve1 :i* lies outside ( ! vessel1 & at a some:at deep] level1 hidd5 amid ! fibres ( psoas & iliacus4 ,int]nally4--,! ext]nal iliac ve9 lies on ! same plane1 & to ! inn] side ( ! art]y1 at ,p\p>t's ligam5t1 on bo? sides ( ! body4 ,z we trace x upw>ds we f9d t on ! left side x lies int]nal to ! art]y 9 its :ole c\rse1 :ile on ! "r side x becomes po/]ior to ! art]y z x approa*es ! bifurcation ( ! common iliac4 ,la/ly1 j be=e ! vessel rea*es ,p\p>t1 ! circumflex iliac ve9 crosses x f )9 outw>ds4 ,bran*es4--,! two l>ge bran*es to ! wall ( ! abdom51 ! epiga/ric & ! circumflex iliac1 rise a few l9es above ,p\p>t's ligam5t4 ,_! position is un=tunately apt to v>y upw>ds1 to ! ext5t ( an in* & a half or ev5 two in*es1 & !y are important1 z1 besides be+ liable to be cut dur+ ! op]ation1 _! position v mat]ially modifies ! prognosis1 z1 if too high up1 !y int]f]e ) ! prop] =mation ( ! coagulum4 ,op]ation4--,v>i\s plans ( incision ?r\gh ! sk9 h be5 recomm5d$ by v>i\s op]ators1 ! *ief diff]5ce be+ ) reg>d to ! "p ( ! art]y aim$ at2 ! plan kn[n z t ( ,mr4 ,ab]ne?y1 ) v>i\s modifications1 be+ int5d$ to expose ! art]y pretty high up1 & enable ! surgeon to rea* x f above2 :ile ! me?od go+ by ! "n ( ,sir ,a/ley ,coop]'s exposes ! l[] "p ( ! art]y1 & enables ! surgeon to rea* x f bel[4 ,?\gh ! latt] is 9 "s respects easi]1 ! =m] me?od is g5]ally to be pref]r$1 be+ fur!r f ! seat ( disease1 & especially m out ( ! way ( ! epiga/ric & circumflex art]ies4 ,! high] op]ation 7,,ab]ne?y',s modifi$74--,an incision mu/ be made ?r\gh ! sk9 ab\t f\r in*es 9 l5g?1 b long] 9 proportion to ! am\nt ( subcutane\s fat1 & ! dep? ( ! pelvis1 ext5d+ f a po9t "o in* to ! inside ( ! ant]ior sup]ior sp9e ( ! ilium1 to a po9t half an in* above ! middle l9e ( ,p\p>t's ligam5t4 ,x mu/ be slightly curv$1 ) its convexity look+ outw>ds & d[nw>ds4#c ,! subcutane\s cellul> tissue & ! t5don ( ! ext]nal oblique may !n be divid$ freely 9 ! same l9e4 ,!n at "s "o po9t or o!r 7g5]ally easie/ bel[71 ! int]nal oblique & transv]salis muscles mu/ be cauti\sly scrap$ ?r\gh ) ! aid ( ! =ceps1 till ! transv]salis fascia is rea*$2 !y may !n be freely divid$ by a probe-po9t$ bi/\ry 7gu>d$ by ! f+] pu%$ up bel[ ! muscles7 to ! requir$ ext5t4 ,! muscles be+ held aside by flat copp] spatul1 ! fascia transv]salis mu/ be c>efully scrat*$ ?r\gh ne> ! cre/ ( ! ilium1 & ?us ! op]ator w be enabl$ to pu% ! p]itoneum inw>ds1 & by ! =ef+] w easily recognise ! pulsation ( ! art]y ly+ on ! s(t brim ( ! pelvis4 ,a bran* ( ! circumflex iliac art]y w v likely be cut 9 dissect+ ?r\gh ! muscles1 & mu/ be secur$1 z also any bran*es ( ! epiga/ric :i* may be divid$ 9 ! incisions ?r\gh ! abdom9al wall 7ut supra1 p4 #e74 ,! op]ator %\ld !n1 by press+ ! p]itoneum & its cont5ts g5tly inw>ds1 endeav\r to see ! vessel2 if1 f ! dep? ( ! pelvis1 ?is _c be done1 ! s5se ( t\* w be 9 mo/ cases suffici5t to enable him to isolate ! art]y by ! po9t ( 8 f+]-nail1 or by ! blunt aneurism-ne$le1 f ! ve94 ,! ligature %\ld be pass$ f ! inn] side to avoid includ+ ! ve91 & ?us !re w be less *ance ( w\nd+ ! p]itoneum f ! convexity ( ! ne$le be+ appli$ to x4 ,if possible1 ! g5ito-crural n]ve %\ld n be includ$ 9 ! ligature1 b probably su* an accid5t w\ld d no great h>m4 ,x is ( mu* m consequ5ce to avoid injur+ ! p]itoneum4 ,?is is sometimes v difficult1 f ! adhesions :i* are set up betwe5 ! p]itoneum1 ! art]y1 & especially ! aneurism1 z ! result ( pressure & inflammation4 ,! accid5t ( w\nd+ ! p]itoneum has happ5$ to ,keate1 ,tait1 ,po/1 & o!rs1 & 9 "s cases ) p]fect impunity4 ,h[ev]1 ! p]itoneum %\ld be displac$ z little z possible f its cellul> connections1 z su* displacem5t increases ! risk ( diffuse inflammation ( t membrane2 & ! vessel itself %\ld be rais$ & di/urb$ z little z possible1 le/ de/ruction ( ! vasa vasorum cause ulc]ation ( ! weak coats & second>y hmorrhage4 ,! op]ation f bel[ 7,plate ,i4 fig4 #d71 ,,sir ,,a/ley ,,coop]',s1 is ?us describ$ by ,mr4 ,hodgson3#d--;,a semilun> incision is made ?r\gh ! integum5ts 9 ! direction ( ! fibres ( ! aponeurosis ( ! ext]nal oblique muscle4 ,"o extremity ( ! incision w be situat$ ne> ! sp9e ( ! ilium2 ! o!r w t]m9ate a little above ! inn] m>g9 ( ! abdom9al r+4 ,! aponeurosis ( ! ext]nal oblique muscles w be expos$1 & is to be divid$ ?r\gh\t ! ext5t1 & 9 ! direction ( ! ext]nal w\nd4 ,! flap :i* is ?us =m$ be+ rais$1 ! sp]matic cord w be se5 pass+ "u ! m>g9 ( ! int]nal oblique & transv]se muscles4 ,! op5+ 9 ! fascia :i* l9es ! transv]se muscle ?r\gh :i* ! sp]matic cord passes1 is situat$ 9 ! mid space betwe5 ! ant]ior sup]ior sp9e ( ! ilium & ! symphysis pubis4 ,! epiga/ric art]y runs precisely along ! inn] m>g9 ( ?is op5+1 b5ea? :i* ! ext]nal iliac art]y is situat$4 ,if ! f+] !re=e be pass$ "u ! sp]matic cord ?r\gh ?is op5+ 9 ! fascia1 x w come 9 imm$iate contact ) ! art]y :i* lies on ! outside ( ! ext]nal iliac ve94 ,! art]y & ve9 are connect$ by d5se cellul> tissue1 :i* mu/ be sep>at$ to all[ ( ! ligature be+ pass$ r\nd ! =m]4 ,9 comp>+ ! two me?ods ( op]at+1 we f9d t :ile ! latt] is 9 "s respects easi]1 & ! vessel 9 x lies m sup]ficial1 x has c]ta9 disadvantages :i* m ?an c\nt]balance its advantages4 ,?us1 fir/1 ! epiga/ric art]y is v likely to be w\nd$4 ,x may be said1 ,well1 if s1 ! ends c be ti$2 b ?is ty+ is sometimes v difficult2 &1 z %[n 9 ,dupuytr5's case ( ?is accid5t1 involves consid]able int]f]5ce ) ! p]itoneum1 & a possibly fatal p]itonitis4 ,besides ?is1 by cutt+ ! epiga/ric y de/roy an important ag5t :i* w\ld h c>ri$ on ! ana/omos+ circulation1 & ?us greatly increase ! risk ( gangr5e4 ,by ?is me?od1 also1 ! art]y is expos$ too ne> to ! seat ( disease2 & if f\nd to be enl>g$ & involv$ 9 ! aneurism1 consid]able difficulty may be exp]i5c$ 9 rea*+ ! upp] "p ( ! vessel4 ,aga91 ligature ( ! l[] ?ird or half ( ! vessel1 :i* ?is me?od implies1 is dang]\s f ! occasional high orig9 ( ! circumflex or epiga/ric1 or bo?1 r5d]+ ! =mation ( a clot mu* m difficult1 & second>y hmorrhage mu* m likely4 ,! circumflex iliac ve9 mu/ also be rememb]$1 z x crosses ! art]y f )9 outw>ds 9 ! l[] end ( x1 j be=e x goes "u ,p\p>t's ligam5t4 ,h[ev]1 ! me?od may occasionally v>y ) ! individual case4 ,9 e case ( ligature ( ! great vessels ( ! abdom51 ! b[els %\ld be c>efully evacuat$ be=e ! op]ation1 & ! bladd] empti$4 ,a prop]ly manag$ position1 ) ! %\ld]s rais$ & ! knees semiflex$1 w greatly facilitate ! ga9+ access to ! vessel4 ,9 sew+ up ! w\nds 9 ! abdom9al walls1 advantage w be ga9$ by putt+ 9 a c]ta9 numb] ( /it*es s deeply z to include ! :ole ?ickness ( ! muscles1 & 9 ! int]vals betwe5 ^! deep ones to ins]t o!rs less deeply1 s z accurately to approximate ! edges ( ! sk94 ,?is w bo? facilitate union & also r5d] ! occurr5ce ( h]nia less probable4 ,?is latt] accid5t did occur 9 a case1 o!rwise successful1 9 :i* ,mr4 ,kirby ti$ ! ext]nal iliac4 ,bo? ext]nal iliacs h be5 ti$ 9 ! same pati5t ) success1 on at lea/ two occasions1 once by ,ar5dt1 ) an int]val ( only eight days betwe5 ! op]ations2 & a second "t by ,tait1 at an int]val ( r m ?an elev5 mon?s4 ,?is op]ation is 9 ! great majority ( cases p]=m$ = femoral aneurism1 & naturally second>y hmorrhage is a too frequ5t result4 ,w\nds ( ^! great vessels g5]ally result 9 s rapid dea? f hmorrhage z to give no "t = surgical int]f]5ce4 ,"o case1 h[ev]1 is record$1#e 9 :i* ! ext]nal iliac 0 cut 9 a lad ( sev5te5 by an accid5tal /ab1 & 9 :i* ,drs4 ,layraud & ,dur&1 :o 7 almo/ in/antly on ! spot1 succe$$ 9 /opp+ ! ble$+ by compresses1 till ,velpeau arriv$1 :o ti$ ! vessel above ) p]fect success4 ,( ! fir/ tw5ty-two cases collect$ by ,hodgson1 fifte5 recov]$--a mortality ( #ca4ha p] c5t42 & ( #aec 9 ,norris's collection1 includ+ ,cutt]'s cases1 =ty-sev5 di$--a mortality ( only #cb4e p] c5t41--a v satisfactory result1 consid]+ ! size ( ! vessel & ! importance ( its relations4 ,,ligature ,,( ,,gluteal4--,?is vessel1 ?\gh "o ( ! bran*es ( ! int]nal iliac1 approa*es ! surface s ne>ly z to be occasionally w\nd$4 ,x is also1 ?\gh v r>ely1 ! subject ( spontane\s aneurism4 ,! pr9ciple ( treatm5t & ! op]ation to be select$ 9 any giv5 case1 dep5ds ^u its orig91 :e!r traumatic or spontane\s4 ,= if traumatic1 ! w\nd mu/ almo/ necess>ily be accessible f ! outside2 ! neighb\r+ "p ( ! art]y is probably heal?y1 & h5ce ! case c be treat$ by ! old op]ation1 slitt+ up ! tum\r1 & ty+ ! vessel above & bel[ ! w\nd4 ,:5 ! aneurism is spontane\s1 !re is no guide to tell u :]e ! aneurism may h fir/ orig9at$2 x may be t x is high up 9 ! pelvis1 & t ! visible tum\r is only its expansion 9 ! direction ( lea/ resi/ance1 or ! coats ( ! vessel may be ext5sively diseas$4 ,! only *ance is ligature ( ! int]nal iliac4 #a4 ,! old op]ation1 or ligature ( ! gluteal art]y 9 ! hip4 ,anatomical ,note4--,! gluteal is ! l>ge/ bran* ( ! int]nal iliac1 & leaves ! pelvis by ! great sacro-sciatic not* j at ! upp] edge ( ! pyri=mis muscle4 ,aft] a v %ort c\rse1 x divides into sup]ficial & deep bran*es opposite ! po/]ior m>g9 ( ! glut5s m9imus1 betwe5 x & ! pyri=mis muscles4 ,v precise rules h be5 giv5 to enable ! op]ator to hit on ! exact spot :]e ! art]y leaves ! pelvis4 ,^!1 ?\gh p]haps int]e/+ anatomically1 are q useless 9 a surgical po9t ( view1 = ! only reasons :i* c\ld possibly induce a surgeon to cut d[n ^u ! gluteal 9 ! liv+ body1 are ! exi/5ce ei!r ( a w\nd ( ! vessel or an aneurism4 ,9 ! fir/ ! fl[ ( blood1 9 ! second ! tum\r1 w\ld give suffici5t guidance4 ,9 cases ( traumatic aneurism ! op]ation %\ld be some?+ l ! foll[+3--,a free incision %\ld be made into ! tum\r1 divid+ x 9 its long direction2 ! cont5ts %\ld be rapidly scoop$ out1 & a f+] plac$ on ! ble$+ po9t1 j at ! upp] corn] ( ! sciatic not*4 ,?is w at once /op ! hmorrhage till ! vessel c be secur$4 ,?is s\nds easy en\gh1 & has be5 done sev]al times ) success4 ,?us1 ,john ,bell1 by an incision two feet long1 z he tells u 9 8 hyp]bolical language1 0 enabl$ to tie ! vessel 9 ! case ( ! lee*-ga!r] :o _h punctur$ ! art]y by a pair ( long scissors4 ,c>mi*ael ( ,dubl9 us$ a small] incision1 remov$ "o or two p\nds ( clots1 & ti$ ! vessel1 9 a case ( w\nd by a p5knife4#f ,n[1 ?\gh bo? ( ^! cases 7 ev5tually successful1 bo? pati5ts lo/ dur+ ! op]ation a v l>ge quantity ( blood2 ,john ,bell's especially c\ld n be remov$ f ! op]at+-table = a consid]able "t aft] ! op]ation4 ,! p]iod at :i* ! great loss ( blood took place 0 ! int]val aft] ! incision 0 made1 & be=e ! art]y 0 expos$ to view1 i4e4 ! int]val 9 :i* ! surgeon 0 busy dislodg+ ! clots f ! cellul> membrane1 ! sac ( ! false aneurism4 ,! proc$ure devis$ by ,mr4 ,syme to obviate ?is difficulty1 & :i* 0 put 9 practice by him 9 sev]al v try+ cases1 is be/ giv5 9 8 own t]se description ( an op]ation 9 a case ( traumatic gluteal aneurism3-- ,! pati5t hav+ be5 r5d]$ unconsci\s1 & plac$ on 8 "r side1 ,i ?ru/ a bi/\ry into ! tum\r1 ov] ! situation ( ! gluteal art]y1 & introduc$ my f+] s z to prev5t ! blood f fl[+1 except by occasional gu%es1 :i* %[$ :at w\ld h be5 ! effect ( neglect+ ?is precaution1 :ile ,i se>*$ = ! vessel4 ,f9d+ x impossible to accompli% ! object 9 ?is way1 ,i enl>g$ ! w\nd by degrees suffici5tly = ! introduction ( my f+]s 9 succession1 until ! :ole h& 0 admitt$ into ! cavity1 ( :i* ! orifice 0 /ill s small z to embrace ! wri/ ) a tightness t prev5t$ any cont9u\s hmorrhage4 ,be+ n[ able to explore ! /ate ( matt]s satisfactorily1 ,i f\nd t !re 0 a l>ge mass ( d5se fibr9\s coagulum firmly impact$ into ! sciatic not*2 &1 n )\t us+ consid]able =ce1 succe$$ 9 dis5gag+ ! :ole ( ?is ob/acle to rea*+ ! art]y1 :i* w\ld h prov$ v s]i\s if x _h be5 all[$ to exi/ aft] ! sac 0 laid op54 ,! compact mass1 :i* 0 aft]w>ds f\nd to be n less ?an a p\nd 9 weight1 hav+ be5 ?us deta*$1 s t x mov$ freely 9 ! fluid cont5ts ( ! sac1 & ! g5tleman :o assi/$ me be+ prep>$ = ! next /ep ( ! process1 ,i ran my knife rapidly ?r\gh ! :ole ext5t ( ! tum\r1 turn$ out all t 0 )9 x1 & _h ! ble$+ orifice in/antly "u subjection by ! pressure ( a f+]4 ,no?+ !n rema9$ b to pass a d\ble ?read "u ! vessel1 & tie x on bo? sides ( ! ap]ture4 ,! ble$+ 9 ?is case 0 ?us r5d]$ comp>atively trifl+1 & ! pati5t made a spe$y & complete recov]y4 ,he return$ home )9 six weeks aft] ! op]ation4#g #b4 ,9 "o case1 at lea/1 ! gluteal art]y has be5 ti$ ) success 7= traumatic aneurism7 j :]e x leaves ! pelvis1 )\t ! tum\r be+ op5$4 ,?is 0 9 ! practice ( ,pr(essor ,campbell ( ,montreal4 ,! op]ation 0 a v difficult "o1 & :ile possible only 9 cases se5 v e>ly1 & :]e ! tum\r is v small1 does n appe> to h any advantage ov] ! old me?od4 ,cases ( spontane\s aneurism ( ! gluteal art]y %\ld be treat$ by ligature ( ! int]nal iliac4 ,/ev5's & ,syme's cases ( ligature ( ! int]nal iliac 7 ( ?is nature4 ,manuals ( op]ative surg]y occasionally devote pages to ! description ( special op]ations = ! ligature ( su* art]ies z ! sciatic1 epiga/ric1 circumflex ilii1 & pudic4 ,!y d n require ligature1 except 9 cases ( w\nd ei!r ( ! vessels !mselves or _! bran*es2 &1 accord+ to ! mod]n pr9ciples ( surg]y 9 su* cases1 ! ligature %\ld be appli$ to ! ble$+ po9t1 r ?an to ! vessel at a di/ance above x4 ,,ligature ,,( ,,femoral4--,"u ?is head we practically mean cases ( ligature ( ! sup]ficial femoral1 = ! common femoral1 or 7z call$ by "s anatomi/s7 ! femoral1 be=e ! pr(unda is giv5 (f1 v r>ely requires to be ti$4 ,if x is w\nd$1 ( c\rse ! ble$+ po9t mu/ be s\ght1 & ! art]y ti$ above & bel[ x1 b if an aneurism on ! sup]ficial femoral r5d]s ligature ( t trunk impossible1 exp]i5ce tea*es t ligature ( ! ext]nal iliac gives bett] results ?an ligature ( ! common femoral4 ,eri*s5 ass]ts t out ( twelve cases 9 :i* ! common femoral has be5 ti$1 only ?ree h succe$$1 ! o!rs dy+ f second>y hmorrhage4 ,! exp]i5ce ( ! ,dubl9 surgeons1 ,port]1 ,smyly1 & ,macnam>a1 has be5 m satisfactory1 z 9 eight cases ( ?is op]ation six 7 successful4#h ,a n9? case 0 unsuccessful4 ,reasons to expla9 ! dang] are n f> to seek1 = ! num]\s small muscul> bran*es1 along ) ! sup]ficial epiga/ric1 circumflex1 & pudic trunks1 r$uce ! *ances ( a good coagulum 9 ! common femoral to a m9imum1 ev5 )\t tak+ into consid]ation ! %ortness ( ! trunk be=e ! great pr(unda femoris is giv5 (f4 ,= ! common femoral art]y is only f "o to two in*es 9 l5g?1 & if !re are "s r>e cases 9 :i* x is a little lat] 9 its bifurcation1 !re are o!rs 9 :i* x divides ne>] to ,p\p>t's ligam5t4 ,! sup]ficial femoral is ! "n giv5 to ! ma9 trunk betwe5 ! orig9 ( ! pr(unda1 & ! po9t at :i*1 pass+ ?r\gh ! t5don ( ! adductor magnus1 x receives ! "n ( popliteal4 ,dur+ ?is long c\rse x gives (f no bran* l>ge en\gh or regul> en\gh to receive a "n1 except "o1 ! ana/omotica magna1 :i* rises 9 ,hunt]'s canal1 close to ! end ( ! vessel1 s 9 t respect x is peculi>ly suitable = ! application ( a ligature4 ,aga91 9 ! upp] "p ( its c\rse1 x is sup]ficial1 be+ cov]$ only by sk9 & fascia4 ,a %ort notice ( its mo/ important anatomical relations is necess>y4 ,= ! fir/ two in*es or two in*es & a half ( its sep>ate exi/5ce1 ! sup]ficial femoral lies 9 ,sc>pa's triangle1 cov]$1 z we said1 only by sk9 & fascia4 ,?is triangle is =m$ by ! s>torius & adductor longus muscles :i* meet at its apex1 & by ,p\p>t's ligam5t1 :i* def9es its base4 ,! art]y lies almo/ exactly 9 ! c5tre ( ! space1 & at ! apex is cov]$ by ! s>torius muscle4 ,! spot :]e x goes "u ! s>torius is ! "o select$ = ! application ( ! ligature4 ,! femoral ve9 lies to ! inn] side ( ! femoral art]y 9 ?is triangle1 b _! mutual relations v>y ) ! portion ( ! limb2 =1 on ! level ( ,p\p>t's ligam5t1 ! art]y & ve9 lie side by side on ! same plane1 b 9 diff]5t comp>tm5ts ( _! %ea?2 z ! art]y dives bel[ ! s>torius1 ! ve9 is /ill on ! inside1 b on a plane slightly po/]ior2 :ile1 by ! "t !y rea* ,hunt]'s canal1 ! ve9 has got completely beh9d ! art]y4 ,! sep>ate comp>tm5ts ( ! %ea? 9 :i* ! vessels lie are mu* less m>k$ z ! vessels g d[n ! limb1 ! septum betwe5 ! art]y & ! ve9 be+ 9 mo/ cases v ill m>k$1 ev5 at ! level :]e ! ligature is appli$4 ,! ant]ior crural n]ve1 :i* on ! level ( ,p\p>t's ligam5t lay outside ( ! art]y & on a plane some:at po/]ior1 has divid$ into num]\s bran*es be=e x rea*es ! po9t ( ligature4 ,"o ( its bran*es requires to be m5tion$1 & may sometimes be notic$ & avoid$ dur+ ! op]ation1 namely ! int]nal saph5\s n]ve1 :i*1 fir/ ly+ ext]nal to ! art]y1 crosses x 9 front1 rea*+ its inn] side j be=e x ent]s ,hunt]'s canal1 :]e x leaves ! vessel accompany+ ! ana/omotica magna bran*4 ,,op]ation ,,( ,,ligature ,,( ,,! ,,femoral--,,sc>pa',s ,,space4--,! pati5t be+ plac$ on 8 back1 & be+ br\ght v ?or\ghly "u *lor(orm1 ! knee ( ! affect$ limb %\ld be b5t at an angle ( ab\t #abj1 & support$ on a pill[4 ,hav+ previ\sly asc]ta9$ ! angle ( junction ( ! s>torius & adductor1 ! surgeon %\ld make an incision 7,plate ,i4 fig4 #e7 j ov] ! pulsations ( ! vessel1 9 ! middle l9e ( ! space1 hav+ its l[] end q ov] ! s>torius muscle1 & its upp] "o1 at a di/ance f two & a half to ?ree & a half in*es1 v>y+ accord+ to ! am\nt ( fat & muscle4 ,! saph5a ve9 c g5]ally be recognis$1 & is almo/ always safe out ( ! way ( ?is incision at its inn] side4 ,! fir/ incision %\ld divide ! sk91 sup]ficial fascia1 & fat1 q d[n to ! fascia lata4 ,! edges ( ! w\nd be+ held ap>t1 ! fascia %\ld be c>efully divid$1 & ! s>torius expos$2 its fibres c g5]ally be easily en\gh recognis$ by _! oblique direction2 once recognis$1 ! fascia %\ld be dissect$ f x till its inn] edge be ga9$1 ! corn] ( :i* %\ld !n be turn$ s t x may be held outw>ds by an assi/ant ) a blunt hook4 ,! %ea? ( ! vessels is n[ expos$1 & aft] hav+ ?or\ghly satisfi$ himself ( ! position ( ! art]y by ! pulsation1 ! surgeon %\ld c>efully raise a portion ( ! %ea? ) ! dissect+ =ceps1 & op5 x freely en\gh to all[ ! coats ( ! art]y to be di/9ctly se54 ,if ! p>ts are deep1 z 9 a fat or muscul> pati5t1 great advantage w be ga9$ by seiz+ "o edge ( ! %ea? by a pair ( spr+ =ceps1 & committ+ x to ! c>e ( an assi/ant1 :ile ! op]ator holds ! o!r 9 8 dissect+ =ceps2 !re is ?us no fe> ( los+ ! orifice ( ! %ea?1 :i* )\t ?is precaution may easily happ51 f ! p>ts be+ confus$ ) blood1 or ! position alt]$ by movem5ts ( ! pati5t4 ,n[ comes ! /age ( ! op]ation on :i*1 m ?an on any?+ else1 success or failure dep5ds4 ,a small portion ( ! vessel mu/ be clean$ = ! reception ( ! ligature1 & x mu/ be ?or\ghly clean$1 s t ! ne$le may be pass$ r\nd x )\t bruis+ ( ! coats1 or rupture ( an unnecess>y numb] ( ! vasa vasorum by r\gh attempts to =ce a passage = x4 ,h5ce all compromises1 su* z blunt$ in/rum5ts1 silv] knives1 & ! l1 are dang]\s1 = 9 try+ to avoid ! ,scylla ( w\nd+ ! art]y1 !y fall into ! ,*>ybdis1 on ! "o h&1 ( isolat+ too mu* ( ! vessel & caus+ gangr5e f want ( vascul> supply1 or1 on ! o!r1 expose ! ve9 to ! dang] ( injury by ! aneurism-ne$le 9 _! attempts to =ce x r\nd an unclean$ vessel4 ,! ne$le %\ld 9 mo/ cases be pass$ f ! inn] side1 c>e be+ tak5 to avoid includ+ ! ve9 :i* is on ! inn] side & beh9d ! vessel2 ! int]nal saph5\s n]ve1 if se51 %\ld be avoid$4 ,! ne$le mu/ n be pass$ q r\nd ! vessel rais+ x up1 /ill less mu/ ! vessel be held up on ! ne$le1 z us$ to be done1 z if ! surgeon 0 surpris$ at 8 own success1 b ! ne$le %\ld be pass$ j f> en\gh to expose ! end ( ! ligature1 :i* mu/ be seiz$ by =ceps & cauti\sly drawn ?r\gh4 ,x mu/ !n be ti$ v firmly & secur$ ) a reef knot4 ,! edges ( ! w\nd mu/ be br\ght into accurate apposition1 & secur$ by "o or two /it*es4 ,if antiseptics are us$1 dra9age %\ld be provid$ =4 ,f ! v fact t ligature ( ! sup]ficial femoral is a rem>kably successful op]ation 9 caus+ consolidation ( ! aneurism & a rapid cure1 !re is also a correspond+ dang] t ! limb be n suffici5tly suppli$ ) blood at fir/4 ,! limb may v possibly become cold1 & rema9 s = "s h\rs at lea/ aft] ! op]ation4 ,to avoid ?is z f> z possible1 x %\ld be wrapp$ 9 cotton wadd+1 & v great c>e %\ld be tak5 t x be n ov]-/imulat$ by hot applications1 friction1 or ! l1 any ( :i* measures might v likely excite reaction1 :i* w\ld result 9 gangr5e4 ,complete re/ ( ! limb & ( ! :ole body mu/ be enjo9$2 ! food mu/ be n\ri%+ & 9 mod]ate quantity4 ,! *ief dang] is f gangr5e ( ! limb1 :i* is especially apt to result :5 ! ve9 is w\nd$1 or ev5 too mu* h&l$ dur+ ! op]ation4 ,:5 prop]ly p]=m$1 & 9 suitable cases1 ! op]ation is v successful4 ,mr4 ,syme ti$ ?is art]y = aneurism ?irty-sev5 times1 & ( ^! e "o recov]$4 ,! /ati/ics ( ,norris & ,porta1 :o collect$ all ! cases 9 :i* ligature ( ! femoral _h be5 employ$ = any cause1 %[ a mortality ( some:at less ?an "o 9 f\r4 ,rabe's table up to #ahfi ) ! additional cases collect$ by ,mr4 ,b>well to #ahhj gives #big cases ) #ec dea?s4#i ,mr4 ,hut*9son's table1 aga91 ( fifty cases collect$ f ! records ( ,metropolitan ,hospitals1 %[s ! v />tl+ result ( sixte5 dea?s out ( ! fifty cases1 or a mortality1 9 r\nd numb]s1 ( "o-?ird4 ,c]ta9 anomalies h be5 obs]v$ 9 ! di/ribution ( ! femoral vessels1 ( "s importance z affect+ ! possibility ( apply+1 & ! result (1 ligature2 su* z--#a4 ,a high division ( ! bran*es :i* aft]w>ds become po/]ior tibial & p]oneal4 #b4 ,a d\ble sup]ficial femoral1 bo? bran*es ( :i* may unite & =m ! popliteal1 z 9 ,sir ,*>les ,bell's well-kn[n case4 #c4 ,abs5ce ( ! art]y altoge!r1 z 9 ,manec's case1 :]e ! popliteal 0 a cont9uation ( an imm5sely enl>g$ sciatic4 ,9 su* a case ! abs5ce ( pulsation 9 front1 & ! pres5ce ( increas$ pulsation beh9d ! limb1 ought to prev5t any fruitless attempt at se>*4 ,,ligature ,,( ,,! ,,sup]ficial ,,femoral ,,bel[ ,,! ,,s>torius ,,muscle4--,?is op]ation1 ?\gh once common 9 ,france1 & ?\gh ! "o recomm5d$ by ,hunt] himself1 is n[ comp>atively little us$ 9 ?is c\ntry2 & rightly s2 = :ile x has no advantage ov] ! upp] position1 x is at once ne>] ! seat ( disease1 & ! vessel is m deeply buri$ "u muscles1 & has a m di/9ct fibr\s %ea?1 :i* requires division4 ,x is1 h[ev]1 by no means a difficult op]ation1 & is ?us p]=m$3-- ,! limb be+ laid z be=e on ! outside1 & slightly b5t1 ! sk9 %av$ & ! pulsation ( ! art]y detect$1 an incision 7,plate ,i4 fig4 #f7 mu/ be made f ! l[] edge ( ! s>torius muscle j z x crosses ! vessel1 along ! c\rse ( ! vessel1 avoid+ if possible ! int]nal saph5a ve94 ,! s>torius :5 expos$ mu/ be drawn inw>ds4 ,! fibr\s canal fill+ ! int]space betwe5 ! abductor magnus & va/us int]nus is !n recognis$1 & mu/ be fairly op5$2 ! art]y is n[ se5 ly+ 9 x1 & ov] ! ve9 :i* is po/]ior to x1 b projects slightly on its out] side2 ! int]nal saph5\s n]ve is ly+ on ! art]y4 ,! ne$le is be/ pass$ f )\t inw>ds s z to avoid ! ve94 ,! ana/omotica magna is sometimes a l>ge trunk1 & has be5 mi/ak5 = ! femoral 9 ?is situation1 & ti$ in/ead ( x4 ,,ligature ,,( ,,! ,,popliteal4--,?is op]ation is n[ h>dly ev] p]=m$ = aneurism1 ligature ( ! sup]ficial femoral hav+ q sup]s$$ x1 & x is v r>ely requir$ = w\nds1 f ! mann] 9 :i* ! vessel is protect$ by its position4 ,be=e ! inv5tion ( ! ,hunt]ian pr9ciple ( ligature at a di/ance1 ! old op]ation = popliteal aneurism consi/$ 9 cutt+ into ! space1 cle>+ out ! cont5ts ( ! aneurismal sac1 & ty+ bo? ends ( ! vessel2 f ! dep? ( p>ts & ! close connection ( ! popliteal ve91 ?is op]ation 0 v r>ely successful1 & is n[ q giv5 up4 ,if ! vessel is w\nd$ ! ble$+ po9t is ! object to be aim$ at1 & is g5]ally suffici5t guide4 ,9 cases ( hmorrhage = suppuration ( an aneurismal sac1 x might possibly be advisable1 & !re are c]ta9 cases ( rupture ( ! art]y1 )\t ! exi/5ce ( an ext]nal w\nd1 9 :i* attempts h be5 made to save ! limb by ty+ ! vessel4#aj ,f ! complexity ( ! p>ts1 ! num]\s t5dons1 ve9s1 & n]ves cr[d$ toge!r 9 a n>r[ holl[1 & *iefly f ! great dep? at :i* ! art]y lies1 any attempt at ligature is v difficult4 ,x is lea/ s at ! l[] angle ( ! space1 :]e1 betwe5 ! heads ( ! ga/rocnemius1 ! vessel comes m to ! surface1 b is /ill ov]lapp$ by muscle4 ,op]ation4--,! pati5t ly+ on 8 face1 a /raight incision 7,plate ,,iii4 fig4 #a71 at lea/ f\r in*es 9 l5g?1 %\ld be made ov] ! art]y1 & ?us ne>] ! inn] ?an ! out] ham/r+2 a /rong fibr\s aponeurosis w require division aft] ! sk9 & sup]ficial fascia are cut ?r\gh1 ! limb is !n to be flex$1 & ! t5dons drawn aside ) /rong retractors2 fat & lymphatic gl&s mu/ next be dissect$ ?r\gh1 & !n ! ve9 & art]y1 ly+ on a sort ( %ea? ( cond5s$ cellul> tissue1 are se51 ! ve9 ly+ above ! art]y & obscur+ x4 ,! ve9 mu/ be drawn to ! outside1 & ! ?read pass$ r\nd ! art]y1 :i* lies close to ! bone1 on ! ligam5tum po/icum ( ,w9sl[e4 ,x is a v difficult subject to decide :at op]ations %\ld be describ$ 9 a "w ( ?is "*1 on ! vessels ( ! leg & foot4 ,a v l>ge numb] ( di/9ct me?ods ( op]ations on ! v>i\s p>ts ( ! ?ree *ief art]ies ( ! leg h be5 describ$ by surgeons & anatomi/s1 b specially by ! latt]4 ,! fact is1 h[ev]1 t ^! complicat$ proc$ures are r>ely requir$1 = aneurisms ( ! art]ies ( ! leg & foot are almo/ unkn[n1 :ile 9 cases ( w\nd ( ! vessel1 or rupture result+ 9 traumatic aneurism1 ! prop] treatm5t is n to tie ! vessel high] up1 b by dilat+ ! w\nd & cle>+ out ! clots1 if requir$1 to secure ! ble$+ po9t1 & tie ! vessel above & bel[4 ,aga91 a w\nd ( ! sole ( ! foot (t5 gives rise to v sev]e & p]si/5t hmorrhage1 :ile ! fasci & complicat$ t5dons r5d] ligature ( ! vessel at ! spot v difficult2 yet ligature ( ei!r ! ant]ior or po/]ior tibial w\ld probably be insuffici5t2 & to tie bo? ^! vessels1 ) possibly ! p]oneal & int]osse\s z well1 w\ld be a mu* m sev]e & dang]\s proc$ure ?an ligature ( ! sup]ficial femoral2 :ile probably c>eful plugg+ ( ! w\nd1 comb9$ ) flexion ( ! knee1 w be f\nd to /op ! hmorrhage soon] ?an ei!r ( ! m =midable me?ods4 ,a compet5t k ( ! anatomy ( ! "p1 & ( ! ord9>y me?ods ( *eck+ hmorrhage1 su* z ligatures1 graduat$ compresses1 & /yptics1 aid$ by position1 specially flexion ( ! knee aft] ,mr4 ,erne/ ,h>t's me?od1 w suffice to enable ! surgeon to *eck any hmorrhage ( ! foot or leg1 )\t x be+ necess>y to burd5 ! memory ) ! ?ree positions 9 :i* to tie ! p]oneal1 or ! v>i\s me?ods1 m or less bloody & t$i\s1 by :i* ! po/]ior tibial 9 its upp] ?ird may be secur$4 ,,note4--,:ile1 z a matt] ( surgical pr9ciple to guide our practice on ! liv+1 ,i /ill hold v /rongly ! op9ions "h express$ aga9/ special op]ations = ligature ( ! art]ies ( ! leg1 & all[ ! s5t5ces to /& z 9 ! fir/ edition ( ?is "w1 ,i ins]t 9 a note a brief description ( ! m important ones1 9 def]5ce to ! advice ( fri5ds & ! urg5t reque/ ( pupils1 z ^! op]ations are us$ by ,exam9+ ,bo>ds z te/s ( ! op]ative dext]ity ( c&idates3-- #a4 ,,ant]ior ,,tibial ,,art]y ,,9 ,,l[] ,,half ,,( ,,leg4--,anatomical ,note4--,?is vessel is relat$ on its tibial side to ! tibialis anticus1 & on its fibul>1 to ! ext5sor longus digitorum above1 & ! ext5sor pollicis bel[4 ,! ant]ior tibial n]ve lies fir/ on its out] side1 !n crosses ! art]y1 & ev5tually rea*es its inn] side ne> ! foot4 ,op]ation4--,an incision1 at lea/ ?ree in*es long1 p>allel ) ! out] edge ( ! tibia1 & ab\t ?ree-qu>t]s ( an in* f x1 exposes ! deep fascia4 ,?is be+ divid$1 ! out] edge ( ! tibialis anticus mu/ be f\nd1 & w be ! guide to ! art]y1 :i*1 surr\nd$ by its v5 comites1 lies v deeply betwe5 ! muscles4 #b4 ,po/]ior ,tibial4--,a4 ,9 middle ?ird ( leg4 ,"h ! art]y is sep>at$ f ! inn] bord] ( ! tibia1 by ! flexor longus digitorum1 & is cov]$ by ! soleus4 ,op]ation4--,an incision at lea/ f\r in*es long1 along ! inn] m>g9 ( ! tibia1 exposes ! edge ( ! ga/ro5emius2 !n divide ! t5d9\s atta*m5t1 !n expose ! soleus1 & divide its atta*m5t also2 ! deep fascia w !n be se52 slit x up1 & ! vessel w be f\nd ab\t an in* int]nal to ! edge ( ! bone4 ,! n]ve is !re j cross+ x4 ,gu?rie's1 or ! direct op]ation1 has ! v high au?ority ( ! late ,pr(essor ,sp5ce 9 its fav\r4 ,an incision ?r\gh sk9 & fascia 9 ! middle ( ! back ( ! leg all[s ! two heads ( ! ga/rocnemius to be sep>at$ to ! same ext5t4 ,! soleus is !n to be scrap$ ?r\gh 9 same direction1 & its deep aponeurotic surface c>efully slit up4 ,! art]y & ve9 are !n easily se54 ,b4 ,9 l[] ?ird ( leg4--,?is is an easi] & m sci5tific op]ation1 z x does n involve ! division ( great t5dons4 ,an incision midway betwe5 ! int]nal malleolus & ! t5do ,a*illis1 p>allel ) bo?1 w expose ! v deep & /rong fascia 9 :i* ! t5dons lie4 ,! art]y1 ) its v5 comites1 occupies a c5tral position1 hav+ ! t5dons ( ! tibialis po/icus & flexor communis 9 front betwe5 x & ! int]nal malleolus1 & ! po/]ior tibial n]ve beh9d x1 :ile ! flexor longus pollicis lies /ill ne>] ! t5do ,a*illis4 ,,table illu/rat+ ana/omotic circulation aft] ligature ( art]ies ( l[] limb4 #a4 ,,aorta4--,epiga/ric & mamm>y ( bo? sides4 ,hmorrhoidal & sp]matic1 ) bran*es ( pudic bo? deep & sup]ficial4 #b4 ,,common ,,iliac4--,int]nal iliac & bran*es1 ) ^? ( ! o!r side1 along ) ! foll[+3-- #c4 ,,ext]nal ,,iliac4--,int]nal mamm>y & deep epiga/ric4 ,iliolumb> & lumb> bran*es ( aorta1 ) deep circumflex ilii4 ,pudic f int]nal iliac1 ) sup]ficial pudic ( common femoral4 ,gluteal1 sciatic1 & obturator1 ) ! circumflex & p]=at+ bran*es or deep femoral4 #d4 ,,femoral4--,ext]nal circumflex1 ) ext]nal articul> ( popliteal4 ,p]=at+1 ) bran*es ( gluteal & sciatic4 ,pr(unda bran*es ) ana/omotica & articul> bran*es4 ,obturator & int]nal circumflex ) ana/omotica & sup]ior int]nal articul>4 ,,note4--,! importance ( ! articul> bran*es ( ! popliteal expla9 ! dang] ( gangr5e aft] a sudd5 rupture or increase 9 size ( a popliteal aneurism4 ,,ligature ,,( ,,! ,,innom9ate4--,! p]=mance ( ?is extremely dang]\s1 9 fact almo/ hopeless op]ation1 is by no means s difficult z might be expect$4 ,! pati5t ly+ d[n ) ! %\ld]s rais$ & head ?r[n well back1 ! /]nal atta*m5t ( ! "r /]no-ma/oid mu/ be v freely expos$4 ,?is may be done by an incision 7,plate ,i4 fig4 #g7 along its ant]ior edge f ! upp] edge ( ! /]num1 z f> z may be necess>y2 ano!r ab\t ! same l5g? along ! upp] edge ( ! clavicle1 w meet ! =m] at an acute angle1 & w include a triangul> flap ( sk91 :i* mu/ be c>efully dissect$ up4 ,! /]nal1 & probably a portion ( ! clavicul> atta*m5t ( ! "r /]no-ma/oid1 mu/ !n be cauti\sly divid$4 ,?is be+ done1 ! /]no-hyoid & /]no-?yroid muscles require division imm$iately above _! /]nal atta*m5ts4 ,a d5se process ( c]vical fascia 7j becom+ ?oracic7 n[ cov]s ! vessel1 b9d+ x on ! "r side to ! "r innom9ate ve91 & on ! left ma9ta9+ ! relation ( ! innom9ate art]y to ! tra*ea4 ,! inf]ior ?yroid ve9s lie on ?is fascia1 & mu/ be drawn aside1 n cut4 ,! fascia is !n to be scrap$ ?r\gh v cauti\sly1 expos+ ! root ( ! "r c>otid1 :i*1 be+ trac$ d[nw>ds1 w lead to ! innom9ate4 ,! foll[+ p>ts lie 9 close relation to ! vessel at ! po9t ( ligature1 & mu/ be avoid$3--#a4 ,! left innom9ate ve9 crosses ! art]y 9 front f left to "r1 & mu/ be drawn d[n4 #b4 ,! "r innom9ate ve9 & "r pneumoga/ric are 9 close contact ) ! art]y on ! "r side2 to avoid !m ! aneurism-ne$le mu/ be ent]$ on ! outside 7"r ( ! vessel74 #c4 ,! apex ( ! "r pleura & ! tra*ea are 9 close contact beh9d1 requir+ ! po9t ( ! ne$le to be kept close to ! art]y 9 br++ ! ?read r\nd4 ,x might h be5 expect$ t ! sudd5 arre/ ( s l>ge a proportion ( ! vascul> supply ( ! body1 s v ne> ! he>t1 w\ld cause s]i\s1 or ev5 fatal symptoms2 ?is1 h[ev]1 is n ! case1 no s]i\s inconv5i5ce ( ?is sort be+ exp]i5c$2 yet hi!rto e case has prov$ fatal1 ei!r f second>y hmorrhage or inflammation ( lungs & pleura4 ,9 fifte5 well-au!nticat$1 & 9 ?ree m d\btful cases1 ! ligature has be5 appli$2 all ( ^! di$ at p]iods v>y+ f twelve h\rs 7z 9 ,hut9's case71 to =ty-two days z 9 ,?omson's1 & sixty-sev5 days 7,graefe's74#aa ,a successful case ( ligature ( ! innom9ate along ) ! "r c>otid & 7aft] second>y hmorrhage7 ! "r v]tebral1 9 a mulatto ag$ ?irty-two1 = a subclavian aneurism1 has be5 put on record by ,dr4 ,smy? ( ,new ,orleans1 9 ! ,am]ican ,j\rnal ( ,m$ical ,sci5ce = ,july #ahff4 ,& "h we may also note t ,mr4 ,hea? has lately treat$ a case ( innom9ate aneurism by simultane\s ligature ( ! ?ird "p ( ! subclavian & ! c>otid4 ,bo? ligatures sep>at$ on ! eighte5? day1 & ! tum\r 0 mu* small] "s mon?s aft]w>ds4#ab ,mr4 ,r4 ,b>well has report$ sev]al mo/ int]e/+ cases 9 :i* simultane\s ligature ( c>otid & subclavian h prov$ ( m>k$ b5efit 9 aortic z well z 9 innom9ate aneurisms4#ac ,9 f\r cases ! op]ation 0 attempt$1 b ! op]ators _h to desi/ be=e ! application ( ! ligature1 9 consequ5ce ( ! diseas$ /ate ( ! art]ial coats4 ,( ^!1 ?ree di$1 & "o 7,pr(essor ,port]'s ( ,dubl97 case recov]$1 ! pati5t leav+ ! hospital ) ! aneurism ne>ly consolidat$4 ,dr4 ,peixotto ( ,portugal appli$ a precaution>y ligature to ! innom9ate 9 a case :]e second>y hmorrhage occurr$ f ! c>otid4 ,! ligature 0 n tight5$ beyond :at 0 necess>y m]ely to cause flatt5+ ( ! vessel4 ,! pati5t made a good recov]y4 ,pr(essor ,george ,port] ( ,dubl9 records an int]e/+ case ( subclavian aneurism1 9 :i*1 aft] fail+ to close ! axill>y art]y by acupressure1 he appli$ ,l',e/range's compressor to ! innom9ate itself = ?ree days1 ) tempor>y b5efit4 ,! pati5t ev5tually di$ ( hmorrhage4#ad ,= a v full & int]e/+ acc\nt ( ligatures ( vessels 9 root ( neck we may ref] to vol4 iii4 ( ! #ahhc edition ( ,holmes' ,surg]y1 pp4 #aai-abb4 ,,ligature ,,( ,,common ,,c>otid4--,?\gh ! anatomical relations ( ! "r & left c>otid are diff]5t at _! orig91 !y s precisely resemble ea* o!r 9 ! :ole ( t "p ( _! c\rse :i* is at all am5able to surgical treatm5t1 t "o description w suffice = bo?1 & ! necess>y anatomy w be br\ght out q suffici5tly 9 ! description ( ea* op]ation4 ,f its giv+ (f no collat]al bran*es1 ! common c>otid art]y may be ti$ at any "p ( its c\rse4 ,x has be5 ti$ successfully at ! di/ance ( only ?ree-qu>t]s1 or1 9 "o case by ,port]1 h>dly to be imitat$1 "o-eigh? ( an in* f ! innom9ate1 & up to an equal di/ance f its bifurcation4 ,9 *oos+ ! "p ( ! vessel = op]ation1 ! op]ator mu/ be guid$ by ! position ( ! aneurism1 if on ! vessel itself1 b if ! aneurism be di/ant1 z 9 scalp or orbit1 he ne$ h reg>d to position simply z facilitat+ ! op]ation4 ,! easie/ position 9 :i* to apply ! ligature is j above ! omohyoid muscle1 ! vessel be+ !re sup]ficial4 ,,ligature ,,above ,,omohyoid4--,us+ ! ant]ior bord] ( ! /]no-ma/oid z a guide1 b leav+ x gradually above to a little ne>] ! mesial l9e1 an incision 7,plate ,,iv4 fig4 #a71 v>y+ 9 l5g? accord+ to ! dep? ( fat & cellul> tissue 9 ! neck1 b ) its c5tral po9t opposite ! upp] bord] ( ! cricoid c>tilage1 mu/ be made ?r\gh sk91 platysma1 & sup]ficial fascia4 ,:ile mak+ ! incision ! head %\ld be held back1 & ! face slightly turn$ to ! opposite side2 ! p>ts be+ n[ relax$ by position1 ! edges ( ! w\nd mu/ be held ap>t by blunt hooks or copp] spatul1 & ! deep fascia c>efully divid$ ov] ! vessel1 :i* w be recognis$ by ! pulsation4 ,x may be not$ "h t ev5 9 ?9 subjects ! /]no-ma/oid edge inv>iably ov]laps ! vessel1 ?\gh 9 _m anatomical diagrams x w\ld appe> to be 9 "p subcutane\s4 ,! desc5d5s noni may possibly be se51 b ?is is by no means inv>iably ! case1 cross+ ! %ea? ( ! vessel v gradually f )\t inw>ds 9 its progress d[n ! neck4 ,x mu/ be c>efully displac$ outw>ds4 ,! %ea? ( ! vessel is !n to be cauti\sly op5$ to ! ext5t ( ab\t half an in*4 ,! int]nal jugul> ve91 possibly mu* di/5d$1 may ov]lap ! art]y on its out] side1 & w require to be press$1 empti$1 & held out ( ! way4 ,a small portion ( ! art]y be+ ?or\ghly sep>at$ f ! %ea?1 ! aneurism-ne$le mu/ be pass$ f )\t inw>ds to avoid ! ve91 & keep z close to ! art]y z possible to avoid ! vagus4 ,! t5don ( ! omohyoid muscle1 or1 9 muscul> subjects1 a portion ( its ant]ior fle%y belly1 may be se5 cross+ ! vessel f above d[nw>ds & outw>ds at ! l[] angle ( ! w\nd4 ,an enl>g$ lymphatic gl& has occasionally giv5 mu* tr\ble1 by be+ mi/ak5 = ! vessel & clean$1 :ile ! ligature has ev5 be5 plac$ on a c>efully isolat$ fasciculus ( muscul> fibres4 ,,ligature ,,( ,,c>otid ,,bel[ ,,! ,,omohyoid4--,an incision 9 precisely ! same direction z ! =m]1 b at a slightly l[] level1 is requir$1 b ! dissection is r m difficult4 ,! edge ( ! /]no-ma/oid :5 expos$ mu/ be drawn outw>ds2 ! /]no-hyoid & ?yroid inw>ds2 ! omohyoid upw>ds2 ! %ea? op5$1 & ! desc5d5s noni or its bran*es drawn to ! tra*eal side4 ,! jugul> ve9 & vagus are bo? at ! out] side1 & mu/ be avoid$1 :ile ! inf]ior ?yroid art]y & sympa!tic n]ve bo? lie beh9d ! vessel1 & may be includ$ 9 ! ligature if c>e be n tak54 ,,v>ieties4--,s$illot's ,op]ation4--,to secure ! art]y /ill l[] 9 ! neck3 ,an incision two & a half in*es long1 f ! inn] end ( ! clavicle obliquely upw>ds & outw>ds 9 ! int]val betwe5 ! /]nal & clavicul> atta*m5ts ( ! /]no-ma/oid2 ?is divides ! sup]ficial textures2 ! two portions ( muscle mu/ !n be drawn ap>t4 ,! int]nal jugul> ve9 lies 9 ! int]val1 & mu/ be drawn to ! outside be=e ! art]y c be se5 at all1 & x is ?is t makes ?is op]ation v difficult & dang]\s1 especially on ! left side1 :]e ! ve9 is close to ! art]y1 & probably ev5 cross+ x f left to "r4 ,! ?oracic duct is beh9d4 ,malgaigne's modification ( ! above is an improvem5t3 to expose ! ext]nal atta*m5t ( ! muscle1 to cut x ?r\gh & turn x to ! outside1 z 9 ! op]ation = ligature ( ! innom9ate1 !n to divide or pull inw>ds /]no-hyoid & /]no-?yroid1 ?us expos+ ! %ea?4 ,! ne$le mu/ be pass$ f )\t inw>ds4 ,results4--,pilz has collect$ #fjj cases1 ( :i* #dc4af p] c5t4 di$4 ,! unit$ tables ( ,norris & ,wood give #ahh cases1 ) a mortality ( sixty1 or ne>ly "o 9 ?ree4 ,^! tables include cases 9 :i* ! vessel 0 ti$ = w\nds1 & z a prep>atory /ep 9 ! op]ation ( removal ( tum\rs ( ! jaw1 etc4 ,lat] /ati/ics give a v mu* less5$ mortality1 due *iefly to ! use ( animal ligatures4 ,( ?irty-"o cases 9 :i* x 0 ti$ = pulsat+ tum\rs ( ! orbit1 only two di$ f ! op]ation4#ae ,riv+ton's /ati/ics to a lat] date give =ty-six cases on =ty-f\r pati5ts ) six dea?s4 ,bo? c>otids h be5 ti$ 9 ! same pati5t tw5ty-five times1 at int]vals ( less ?an a ye>2 & x is a v rem>kable fact t only five ( ^! fifty ligatures prov$ fatal1--two 9 :i* bo? 7 ti$ on ! same day1 & ?ree 9 :i* ! op]ation 0 p]=m$ to arre/ hmorrhage f malignant disease ( ! face & jaws--f gun%ot w\nd1--& f syphilitic ulc]ation4 ,! ext]nal c>otid1 & also mo/ ( its pr9cipal bran*es1 h be5 ti$ = aneurisms1 w\nds1 goitres1 enl>gem5t ( ! tongue1 vascul> tum\rs on occiput & o!r lesions2 also z a fir/ /age 9 ! op]ation ( extirpation ( ! upp] jaw1 = ! purpose ( prev5t+ hmorrhage4 ,h[ev]1 su* op]ations are r>e1 & w probably become r>] /ill1 & x is h>dly necess>y to describe ! op]ations on ea* s]iatim4 ,aneurism ( ! ext]nal c>otid or bran*es are r>e2 if idiopa?ic1 ligature ( ! common c>otid w be f\nd at once easi]1 n m dang]\s1 & m effectual ?an ligature ( ! bran*2 if traumatic1 ! aneurism itself %\ld be attack$1 & ! ble$+ po9t secur$ by a d\ble ligature4 ,w\nds are common en\gh1 b if accessible at all1 ! injur$ vessel %\ld be ti$ at ! ble$+ po9t2 if inaccessible 7& "u ?is head we may include w\nds ( ! int]nal c>otid71 ! common c>otid mu/ be ti$4 ,no "o w\ld ?9k ( try+ ! sup]ior ?yroids = goitre1 unless !y 7 s manife/ly enl>g$1 tortu\s1 & pulsat+1 z to r5d] ! op]ation s simple 7f _! sup]ficial position7 z to require no special directions2 besides ?is1 ! cases 9 :i* x has be5 already done h giv5 v little enc\ragem5t to repeat x4 ,z cases may occur 9 :i* any dim9ution ( ! c]ebral supply is contra-indicat$1 & ?us ! m difficult ligature ( ! ext]nal c>otid may be pref]r$ to ! m simple op]ation on ! common trunk1 & z ! l+ual may require ligature ne> its root1 9 consequ5ce ( ob/9ate hmorrhage f ! tongue1 %ort directions are giv5 = ! p]=mance ( bo? ^! op]ations4 #a4 ,,ligature ,,( ,,ext]nal ,,c>otid4--,head 9 same position z = ! common c>otid4 ,a /raight incision p>allel ) ! ant]ior edge ( /]no-ma/oid1 b ab\t half an in* 9 front ( x1 mu/ beg9 almo/ at angle ( jaw1 & ext5d d[nw>ds ne>ly to ! level ( ! ?yroid c>tilage4 ,cauti\sly divide sk91 platysma1 & fascia2 ! l[] end ( ! p>otid mu/ be pull$ upw>ds1 & ! ve9s1 :i* are num]\s1 cauti\sly sep>at$4 ,! ant]ior bord] ( ! /]no-ma/oid mu/ be pull$ backw>ds1 & ! diga/ric & /ylo-hyoid =w>ds & inw>ds4 ,! sup]ior l>yngeal n]ve :i* lies beh9d ! vessel mu/ be avoid$4 #b4 ,,ligature ,,( ,,l+ual4--,to secure ?is vessel ei!r be=e x becomes conceal$ by ! hyo-glossus1 or aft] x is "u ! muscle1 a curv$ incision is necess>y1 foll[+ ! l9e ( ! hyoid bone1 & especially ( its great] cornu1 b a l9e or two above its upp] bord]4 ,aft] ! sk9 & platysma are divid$1 ! po/]ior belly ( ! diga/ric mu/ be recognis$1 :i* aga9 w guide to ! po/]ior edge ( ! hyo-glossus4 ,! edge ( ! sub-maxill>y gl& may v probably require to be rais$ out ( ! way4 ,! art]y c !n be secur$1 ei!r be=e x dips "u ! hyo-glossus muscle1 or aft] x has done s1 by ! division ( a few ( its fibres on a director4 ,c>e is ne$$ to avoid injury ( ! hypo-glossal n]ve1 :i* lies above ! muscle4 ,! int]nal c>otid art]y occasionally1 b v r>ely1 is ! subject ( aneurism4 ,x may1 l any o!r art]y1 be w\nd$1 especially f ! fauces4 ,! treatm5t ( ei!r ( ^! lesions is ligature ( ! common c>otid itself1 9 pref]5ce to ligature ( ! int]nal c>otid4 ,gu?rie's op]ation = secur+ ! ble$+ int]nal c>otid at ! injur$ spot1 by divid+ & turn+ up ! ramus ( ! l[] jaw1 has nev] be5 p]=m$ 9 ! liv+ body1 & is s difficult1 dang]\s1 & unnecess>y1 z n to m]it description4 ,,ligature ,,( ,,subclavian4--,note4--,9 consequ5ce ( ! diff]5ce 9 ! orig91 & v>iety 9 ! anatomical relations ( ! "r & left subclavian art]ies1 9 s f> at lea/ z _! fir/ /age is conc]n$1 x is necess>y to give a v brief sep>ate acc\nt ( ea*4 ,"r ,subclavian4--,! innom9ate art]y divides into ! "r subclavian & "r c>otid exactly beh9d ! /]no-clavicul> articulation4 ,! "r subclavian ext5ds f ?is po9t 9 an ar*$ =m across ! neck1 betwe5 ! scal5e muscles1 ov] ! apex ( ! pleura1 till1 pass+ "u cov] ( ! clavicle1 x *anges its "n to axill>y at ! l[] end ( ! fir/ rib4 ,= conv5i5ce ( description1 ! art]y is divid$ into ?ree p>ts1 :i* h v v>i\s anatomical relations1 & diff] f ea* o!r mu* 9 _! am5ability to surgical treatm5t by ligature4 ,! ant]ior scal5us muscle def9es ! ?ree p>ts1 ! fir/ ext5d+ to ! inn] bord] ( ! muscle1 ! second be+ conceal$ by ! muscle1 & ! ?ird rea*+ f its out] bord] to ! l[] bord] ( ! fir/ rib4 ,bran*es ( ! ,subclavian4--,:ile ! deep relations ( pleura1 ve9s1 & n]ves c be notic$ "u ! head ( ea* op]ation 9 detail1 "o anatomical po9t mu/ nev] be =gott5 z influ5c+ v mu* ! success ( all surgical int]f]5ce ) ! subclavian art]ies--i4e4 ! bran*es giv5 (f4 ,to give any *ance ( success 9 ! application ( a ligature to su* a l>ge vessel1 s ne> ! he>t1 a l>ge portion ( art]y free f bran*es is requir$1 t ! clot may be long1 firm1 & undi/urb$4 ,! fir/ "p ( ! subclavian gives (f ! v]tebral1 ?yroid axis1 & int]nal mamm>y2 ! second1 ! sup]ior int]co/al2 :ile ! ?ird "p has 9 mo/ cases no bran* :atev]4 ,9 ^! anatomical diff]5ces we f9d ! reason = ! almo/ inv>iable fatality result+ on any int]f]5ce ) ! fir/ & second p>ts1 & ! comp>ative safety ( ligature ( ! ?ird "p1 )\t requir+ to acc\nt = ! diff]5ce on o!r gr\nds1 su* z dep? ( "p1 importance ( n]v\s relations1 or ne>] proximity to ! he>t4 ,! second & ?ird p>ts ( bo? art]ies are s simil> to ea* o!r1 t a sep>ate acc\nt is n requir$ = ! two sides4 ,,ligature ,,( ,,"r ,,subclavian4--,fir/ ,"p4--,op]ation4--,an incision j at upp] edge ( /]num & "r clavicle1 ext5d+ f inn] edge ( left /]no-ma/oid transv]sely to out] bord] ( "r /]no-ma/oid ?r\gh sk91 platysma1 & expos+ /]no-ma/oid1 to be jo9$ at an angle by a second incision1 :i*1 two1 ?ree1 or ev5 f\r in*es long1 mu/ ext5d along inn] bord] ( "r /]no-ma/oid4 ,flap to be rais$ upw>ds & outw>ds4 ,! /]nal atta*m5t ( ! /]no-ma/oid mu/ !n be cauti\sly divid$1 z also "p or ! :ole ( its clavicul> atta*m5t1 accord+ z room is requir$4 ,! /]no-hyoid & ?yroid muscles w !n require simil> division4 ,! int]nal jugul> w !n be se5 v prom95t1#af & w require to be drawn inw>ds or outw>ds1 accord+ to circum/ances4 ,! c>otid & "r subclavian art]ies w !n be felt ly+ close toge!r cross$ by ! pneumoga/ric & recurr5t n]ves1 ! latt] turn+ beh9d ! subclavian4 ,! n]ves mu/ be drawn inw>ds2 ! c>diac filam5ts ( ! sympa!tic w !n be obs]v$1 & drawn outw>ds4 ,! subclavian ve9 lies bel[1 conceal$ by ! clavicle1 & w probably n be se5 dur+ ! op]ation4 ,! ne$le %\ld be pass$ r\nd ! art]y f bel[ upw>ds1 c>e be+ tak5 n to injure ! pleura1 :i* lies b5ea? & beh9d ! art]y4 ,results4--,twelve cases1 all ( :i* di$2 t5 ( hmorrhage1 "o ( pleurisy & p]ic>ditis1 & "o f pymia4 ,attempt$ 9 "o case by ,mr4 ,but*]1 b ! art]y 0 too mu* diseas$ to be> a ligature4 ,! pati5t di$ on ! f\r? day4 ,,ligature ,,( ,,left ,,subclavian4--,fir/ ,"p4--,?is op]ation1 :i* has be5 describ$ by "s z impossible1 has1 ,i believe1 be5 only once p]=m$ on ! liv+ body4 ,op]ation4--,incisions z = ! prec$+ op]ation1 except be+ on ! opposite side4 ,aft] ! sk91 platysma1 & muscles h be5 divid$1 z already describ$1 ! deep c]vical fascia requires division close to ! inn] edge ( ! scal5us anticus4 ,! art]y lies excessively deep1 & great difficulty is exp]i5c$ 9 avoid+ injury to ! pleura & ! ?oracic duct4 ,results4--,once p]=m$ by ,dr4 ,rodg]s ( ,new ,york2 dea? f hmorrhage on fifte5? day4 ,anatomical ,note4--,! c\rse ( ! left subclavian 9 its fir/ /age is mu* /raight]1 z its orig9 is mu* deep]1 ?an on ! "r side4 ,! pneumoga/ric1 phr5ic1 & c>diac n]ves lie p>allel to its c\rse2 ! oesophagus & ?oracic duct lie beh9d x1 & to its inn] side4 ,,ligature ,,( ,,subclavian4--,second ,"p4--,?is v r>e op]ation h>dly requires a sep>ate description1 z ! incisions necess>y = ligature ( ! art]y 9 its ?ird "p w1 ) v slight modifications1 be suffici5t = ! purpose4 ,x has1 h[ev]1 special elem5ts ( dang] 9 x1 involv$ 9 ! unavoidable division1 ( "p at lea/1 or probably ! :ole1 ( ! scal5us anticus4 ,! phr5ic n]ve1 f its position on t muscle1 requires special c>e to avoid divid+ x1 & 9 mo/ cases ! int]nal jugul> ve9 is also 9 ! way4 ,! bran*es ( ! ?yroid axis1 :i* cross ! neck1 are q 9 ! l9e ( ! incision4 ,! l[e/ cord ( ! bra*ial plexus lies imm$iately beh9d ! art]y1 betwe5 x & ! middle scal5us4 ,! pleura lies j bel[ x4 ,! subclavian ve9 is g5]ally q safe1 runn+ 9 front ( ! scal5us anticus1 & at a l[] level4 ,! pres5ce ( ! sup]ior int]co/al bran* adds greatly to ! dang] ( ligature ( ! vessel 9 ?is position1 f its int]f]+ ) a prop] clot4 ,results4--,dupuytr5#ag p]=m$ x successfully = a traumatic axill>y aneurism4 ,au*9closs#ah did x = a l>ge true aneurism1 b ! pati5t di$ sixty-eight & a half h\rs aft] ! op]ation4 ,li/on cut ?r\gh ! out] portion ( ! scal5us ) success = an idiopa?ic aneurism4 ,?irte5 h be5 collect$ by ,wye? ) f\r recov]ies & n9e dea?s4 ,,ligature ,,( ,,subclavian4--,?ird ,"p4--,= ?is comp>atively common op]ation1 v>i\s me?ods ( proc$ure h be5 sugge/$ & employ$4 ,9 ! dead body1 :]e ! axilla is free f swell+1 & 9 ?9 pati5ts1 ! art]y 9 ?is ?ird /age is tol]ably sup]ficial1 & c be secur$ ) ease4 ,b 9 v muscul> m51 ) %ort necks & well curv$ clavicles1 & specially :5 ! axilla is fill$ up ) an aneurism1 & ! %\ld] _c be depress$1 ! op]ation becomes v difficult4 ,op]ation ( ,ramsd51 ,li/on1 & ,syme4--,position4--,! pati5t ly+ on 8 back ) 8 %\ld]s support$ by pill[s1 & 8 head ly+ back1 & drawn to ! opposite side2 ! %\ld] ( ! affect$ side mu/ be depress$ z mu* z possible4 ,incisions4--7,plate ,i4 fig4 #h47--,"o ?r\gh sk91 sup]ficial fascia1 & platysma1 along ! upp] edge ( ! clavicle1 = at lea/ ?ree in*es f ! ant]ior edge ( ! trapezius to ! po/]ior bord] ( ! /]no-ma/oid1 & 9 muscul> subjects freely ov]lapp+ ! edges ( bo? muscles4 ,ano!r two in*es 9 l5g? along po/]ior bord] ( /]no-ma/oid meets ! fir/ at an angle4 ,on reflect+ ! *ief flap ?us made upw>ds & backw>ds1 ! ext]nal jugul> w be se51 &1 if possible1 mu/ be drawn to a side2 if n1 x mu/ be divid$1 & bo? ends ti$4 ,! l[] edge ( ! po/]ior belly ( ! omohyoid mu/ !n be s\ght2 ?is leads at once to ! po/]ior or out] m>g9 ( ! scal5us anticus4 ,! connection ( ! deep fascia to t muscle mu/ !n be v c>efully scrap$ ?r\gh1 & by trac+ ! muscle to its ins]tion to ! fir/ rib1 ! art]y is at once rea*$1 ly+ beh9d ! ins]tion4 ,! pulsation ( ! vessel betwe5 ! =ef+] & ! fir/ rib w prove a great assi/ance2 yet c>e is requir$1 le/ "o ( ! bran*es ( ! bra*ial plexus be secur$ in/ead ( ! art]y4 ,! l[e/ cord lies v close to ! vessel4 ,! subclavian ve9 is n likely to give mu* tr\ble1 f its be+ on a l[] level1 & 7unless v mu* dilat$7 ne>ly conceal$ by ! clavicle4 ,! suprascapul> art]y is also hidd51 b ! transv]se c]vical crosses ! v l9e ( incision1 & may give tr\ble1 be+ occasionally mu* enl>g$1 s mu* s z ev5 = a "t to h be5 mi/ak5 = ! subclavian itself4 ,if possible1 bo? ^! bran*es %\ld be sav$1 z be+ important means ( c>ry+ on ! ana/omosis = ! future support ( ! limb4 ,an absorb5t gl& is occasionally 9 ! way1 & has ev5 be5 mi/ak5 = ! vessel & c>efully clean$4 ,su* may be remov$ )\t scruple4 ,c>e mu/ be tak5 n to injure ! pleura1 :i* lies imm$iately beh9d & bel[ ! vessel at ! seat ( ligature4 ,v>i\s in/rum5tal devices h be5 inv5t$ = pass+ ! ligature4 ,! simple/ seems /ill to be be/1 a common aneurism-ne$le ) a consid]able curve4 ,o!r me?ods ( op]at+4--,a s+le curv$ incision above ! clavicle1 ) its concavity upw>ds1 ( ab\t ?ree or f\r in*es long1 ) its inn] end r high] ?an ! out] 7,gre51 ,f]gusson74 ,a l9e> transv]se incision 9 ! same situation 7,velpeau74 ,a s+le l9e> incision p]p5dicul> to ! clavicle 7,r\x74 ,an ar*$ incision 7,plate ,,iv4 fig4 #b7 ) its convexity outw>ds1 & its base on ! po/]ior edge ( ! /]no-ma/oid1 f ?ree in*es above ! clavicle to ! clavicul> atta*m5t ( ! muscle 7,skey74 ,results4--,dr4 ,wye?'s ,tables 9 #ahgg give #bea cases ) #acd or #ec p] c5t4 ( dea?s4 ,! late ,mr4 ,furn] ( ,brighton report$ a mo/ int]e/+ case1 9 :i* he ti$ bo? subclavian art]ies at an int]val ( two ye>s 9 ! same pati5t1 = axill>y aneurisms1 ) success4 ,,ligature ,,( ,,axill>y4--,anatomical ,note4--,?is vessel1 ! next /age 9 ! cont9uation ( ! subclavian d[nw>ds1 may be def9$ surgically z ext5d+ f ! clavicle to ! l[] bord] ( ! t]es major4 ,f ! dep? ( ! vessel at its upp] "p1 ! num]\s n]ves1 & ! close proximity ( ! ve91 ! surgeon has c>efully to /udy ! anatomical relations4 ,x1 l ! subclavian1 is commonly divid$ into ?ree /ages1 &1 also l ! subclavian1 ^! /ages are def9$ by ! relations ( ! art]y to a muscle1 ! pectoralis m9or4 ,surgically we may draw a v close p>allel betwe5 ! two vessels1 = we f9d t 9 ! axill>y1 z 9 ! subclavian1 ! fir/ /age is v deep1 & v r>ely am5able to ligature2 ! second1 /ill deep] & m r>ely attempt$1 z 9 bo? ! op]ation involves division ( a deep muscle2 :ile ! ?ird /age 9 ea* is ! "o mo/ frequ5tly *os5 by ! surgeon4 ,fir/ ,/age4--,betwe5 ! l[] edge ( ! fir/ rib & upp] bord] ( ! pectoralis m9or ! vessel is deeply seat$1 conta9$ 9 t process ( deep fascia call$ ! co/o-coracoid membrane1 & cov]$ above by sk91 platysma1 & ! clavicul> portion ( ! pectoralis major4 ,x lies on ! fir/ int]co/al muscle & ! upp] digitation ( ! s]ratus magnus1 :ile ! cords ( ! bra*ial plexus are on its acromial side1 & ! axill>y ve9 9 close contact ) x on its ?oracic side1 & frequ5tly ov]lapp+ ! art]y4 ,op]ation4--,! great desid]atum is free access4 ,an incision 7,plate ,i4 fig4 #i71 semilun> 9 %ape1 ) its convexity d[nw>ds1 mu/ ext5d f half an in* outside ( ! /]no-clavicul> articulation to v ne> ! coracoid process1 /opp+ j be=e x arrives at ! edge ( ! deltoid1 9 ord] to avoid injury ( ! cephalic ve94 ,x mu/ include sk91 fascia1 & platysma1 & ! flap mu/ be ?r[n upw>ds4 ,! clavicul> portion ( ! pectoralis major mu/ !n be divid$ "r across its fibres1 :i* w retract4 ,! arm mu/ !n be br\ght close to ! side to relax ! pectoralis m9or1 :i* mu/ be drawn aside4 ,! art]y w !n be felt pulsat+1 b hidd5 by ! co/o-coracoid membrane1 :i* acts z its %ea?4 ,?is mu/ be c>efully scrat*$ ?r\gh1 ! n]ves pull$ outw>ds1 ! ve9 avoid$ & pull$ d[nw>ds & inw>ds1 & ! ?read pass$ r\nd f )9 outw>ds4 7,manec1 ,hodgson1 &1 ) slight modification 9 ! incision ?r\gh ! sk91 ,*amb]la9e47 ,ligature has be5 p]=m$ 9 ?is position by sep>at+ ! pectoralis & deltoid muscles1 )\t divid+ ! muscul> fibres 7,r\x1 ,desault74 ,to attempt to ga9 access betwe5 ! clavicul> & /]nal portions ( pectoralis major1 z has be5 propos$ by "s1 is almo/ impracticable 9 ! liv+ body1 f ! position ( ! ve91 to :i*1 r ?an to ! art]y1 ?is incision leads4 ,,ligature ,,( ,,axill>y1 9 its second /age1 is n an advisable op]ation1 :5 x is m]ely int5d$ to ?r[ a ligature r\nd ! art]y = an aneurism l[] d[n4 ,x has be5 p]=m$ at lea/ twice by ,delpe*1 b x is a rude proc$ure2 9 8 cases1 aft] ! muscle 0 cut1 a dive ) ! f+] 0 made to collect ! :ole mass ( vessels & n]ves1 & br+ !m to ! surface ne> ! coll>-bone2 9 ?is position x is said ! art]y 0 easily isolat$ & ti$4 ,9 ,mr4 ,syme's op]ation ( cutt+ into l>ge axill>y aneurisms1 & ty+ bo? ends ( ! vessel1 ! pectoralis m9or may1 inde$ g5]ally has1 to be divid$1 & mu/ take its *ance )\t any special notice or precaution1 9 ! sweep+1 free incisions requir$4 ,,ligature ,,( ,,axill>y 9 its ?ird /age4--,?is is an op]ation v mu* m common1 m easy ( accompli%m5t1 & saf] 9 its results ?an ei!r ( ! prec$+2 ! art]y 9 ?is /age be+ m sup]ficial1 9 fact almo/ subcutane\s4 ,op]ation4--,! arm be+ ext5d$ & sup9at$1 an incision 7,plate ,i4 fig4 #aj7 two & a half or ?ree in*es long1 mu/ be made 9 ! base ( ! axilla ov] ! art]y1 involv+ at fir/ sk9 & sup]ficial fascia only2 ! deep fascia is !n expos$ & mu/ be c>efully scrap$ ?r\gh1 avoid+ injury ( ! basilic ve91 if 7z sometimes occurs7 x has n yet dipp$ ?r\gh ! fascia4 ,! vessel c n[ be felt2 ! m$ian n]ve :i* lies ov] ! art]y1 or slightly to its out] side1 mu/ be drawn outw>ds1 & ! axill>y ve91 :i* lies at ! ?oracic side1 b (t5 ov]laps ! vessel1 mu/ be c>efully drawn inw>ds4 ,! ligature mu/ !n be pass$ f )9 outw>ds4 ,:5 ! pati5t is v fat or muscul>1 ! coraco-bra*ialis muscle may be requir$ z a guide to ! vessel2 b 9 g5]al its sup]ficial position r5d]s any guide q unnecess>y1 ev5 9 ! dead body4 ,anatomical ,note4--,:ile 9 ea* /age ! axill>y art]y gives (f bran*es1 ^? aris+ f ! ?ird /age are by f> ! mo/ important1 especially ! subscapul>1 :i* leaves x at ! edge ( ! muscle ( ! same "n4 ,to avoid ^! ! ligature %\ld be appli$ z l[ d[n on ! vessel z possible1 &1 9 po9t ( fact1 ! op]ation call$ ligature ( ! ?ird /age ( ! axill>y is1 anatomically speak+1 really ligature ( ! bra*ial high up1 & :]e !re is room at all1 !re w be ! less *ance ( second>y hmorrhage1 ! great] ! di/ance is betwe5 ! ligature & ! great subscapul> bran*4 ,mr4 ,syme's ,op]ation = ,axill>y ,aneurism4--,description ( ! op]ation 9 8 own words3-- ,*lor(orm be+ adm9i/]$1 ,i made an incision along ! out] edge ( ! /]no-ma/oid muscle1 ?r\gh ! platysma myoides & fascia ( ! neck1 s z to all[ a f+] to be pu%$ d[n to ! situation :]e ! subclavian art]y issues f "u ! scal5us anticus & lies ^u ! fir/ rib4 ,i !n op5$ ! tum\r1 :5 a trem5d\s gu% ( blood %[$ t ! art]y 0 n effectually compress$2 b :ile ,i plugg$ ! ap]ture ) my h&1 ,mr4 ,li/]1 :o assi/$ me1 by a slight movem5t ( 8 f+]1 :i* _h be5 ?ru/ deeply "u ! upp] edge ( ! tum\r1 & ?r\gh ! clots conta9$ 9 x1 at l5g? succe$$ 9 gett+ comm& ( ! vessel4 ,i !n laid ! cavity freely op51 & ) bo? h&s scoop$ out ne>ly sev5 p\nds ( coagulat$ blood1 z 0 asc]ta9$ by measurem5t4 ,! axill>y art]y appe>$ to h be5 torn across1 & z ! l[] orifice /ill bl$ freely1 ,i ti$ x 9 ! fir/ in/ance4 ,i next cut ?r\gh ! lessor pectoral muscle close up to ! clavicle1 & hold+ ! upp] end ( ! vessel betwe5 my f+] & ?umb1 pass$ an aneurism-ne$le1 s z to apply a ligature ab\t half an in* above ! orifice4#ai ,9 a simil> op]ation lately p]=m$ by ! au?or = traumatic aneurism1 ! result ( a /ab1 v little blood 0 lo/1 ?\gh no incision 0 made above ! clavicle4 ,! pati5t made a good recov]y4#bj ,,ligature ,,( ,,bra*ial4--,to arre/ hmorrhage f a w\nd ( ! art]y itself1 no special directions are requir$1 except to enl>ge ! w\nd1 & secure ! vessel above & bel[ ! ble$+ po9t4 ,!re are1 h[ev]1 r>e cases 9 :i* = ble$+ 9 ! palm 7aft] all o!r means h fail$71 or = aneurism l[] d[n ! arm1 a ligature may be necess>y4 ,op]ation4--,! biceps muscle1 at its inn] edge1 is ! be/ guide to ! position ( ! incision1 or if x be obscur$ by fat or o$ema1 a l9e ext5d+ f ! axilla1 j ov] ! head ( ! hum]us to ! middle ( ! b5d ( ! elb[ w def9e its c\rse4 ,an incision 7,plate ,i41 fig4 #aa7 ?ree in*es 9 l5g?1 ab\t ! middle ( ! arm 7:5 y h ! *oice ( position71 ?r\gh sk9 & sup]ficial fascia1 w expose ! deep fascia1 & probably ! basilic ve94 ,draw+ ! latt] aside1 cauti\sly divide ! deep fascia4 ,! art]y is !n expos$1 b 9 close relation to v>i\s n]ves2 ( ^! ! ones mo/ likely to come 9 ! way are--#a4 ,! m$ian1 :i* lies 9 front (1 b a little to ! outside ( ! art]y1 ?\gh 9 "s r>e cases x lies beh9d x2 #b4 ,! int]nal cutane\s2 #c4 ,! uln>1 bo? ( :i* ought to be r to ! inside ( ! art]y4 ,two bra*ial ve9s accompany & w9d r\nd ! vessel1 occasionally int]lac+4 ,pulsation w1 9 ! liv+ body1 usually suffice to di/+ui% ! art]y f ! o!r textures1 & ! ligature may be pass$ f :i*ev] side is mo/ conv5i5t4 ,note4--,! relation ( ! m$ian n]ve to ! vessel v>ies accord+ to ! "p ( ! arm--?us1 z l[ z ! ins]tion ( ! coraco-bra*ialis x is to ! out] side1 z has be5 describ$1 x !n crosses ! vessel obliquely1 & two in*es above ! elb[ x is on ! inn] side ( ! art]y4 ,aga91 ! op]ator mu/ nev] =get ! possibility ( !re be+ a high division ( ! art]y4 ,?is occurs1 ,mr4 ,qua9 has %[n1 p]haps once 9 e t5 or elev5 cases1 & may necessitate ligature ( bo? trunks4 ,9 ^? cases 7once mu* m frequ5t ?an at pres5t7 :]e an aneurism has =m$ aft] a w\nd ( ! bra*ial at ! b5d ( ! arm 9 v5esection1 ! aneurism may be ei!r circumscrib$ or diffuse4 ,if circumscrib$1 x is advis$ by "s surgeons1 specially by ! late ,pr(essor ,colles ( ,dubl91 t ! bra*ial %\ld be ti$ imm$iately above ! tum\r4 ,9 mo/ cases ( circumscrib$1 & 9 all su* cases ( diffuse aneurism1 ! pref]able op]ation is boldly to lay op5 ! tum\r1 turn out all ! clots1 seek = ! w\nd 9 ! art]y1 & tie ! vessel above & bel[4 ,a t\rniquet above1 or1 bett] /ill1 a tru/wor?y assi/ant1 prev5ts all fe> ( hmorrhage1 & su* a radical op]ation exposes ! limb to f> less *ance ( gangr5e ?an d any attempts at remov+ or less5+ ! tum\r by pressure 7z recomm5d$ by ,cusack1 ,tyrrell1 ,h>rison71 & is mu* m c]ta9 ?an a m]e ligature above4#ba ,,ligature ,,( ,,vessels ,,9 ,,=e-,,arm4--,"h1 z also we f\nd is ! case 9 ! leg1 x is almo/ useless to g on giv+ exact directions z to ! me?od ( ?r[+ a ligature r\nd ! vessels 9 all possible situations4 ,= bel[ ! elb[ spontane\s aneurism is almo/ unkn[n1 & ev5 traumatic aneurisms are extremely r>e4 ,x is !re=e = hmorrhage only t ! vessels are likely to require ligature1 & x is a rule 9 surg]y t to enl>ge ! w\nd & to apply a ligature above & bel[ ! ble$+ po9t is bett] practice ?an to apply a ligature at a di/ance4 ,9 ! case ( w\nds ( ! palm> ar*1 x is extremely difficult1 & v apt to injure ! future usefulness ( ! h&1 ?us to seek = ! ble$+ po9t "u ! palm> fascia1 & = ^!1 ligatures ( radial & uln> h occasionally be5 practis$4 ,h[ev]1 z ev5 ?is has prov$ ineffectual1 & ! int]osse\s has prov$ suffici5t to cont9ue ! ble$+1 ligature ( ! bra*ial at once is pref]able to ligature ( s _m bran*es 9 ! =e-arm4 ,! use ( graduat$ compresses1 c>efully appli$1 comb9$ ) flexion ( ! elb[ ov] a b&age1 w g5]ally prove suffici5t to *eck su* hmorrhage f ! palm1 )\t hav+ rec\rse to ei!r ( ! above m sev]e measures4 ,note4--,z 9 ! l[] limb at page #bd1 & = ! same reasons1 ,i "h ins]t a brief acc\nt ( ! me?ods ( ty+ ! uln> & radial art]ies4 #a4 ,,ligature ,,( ,,uln>4--,only admissible 9 ! l[] half ( its c\rse4 ,op]ation4--,use ! t5don ( ! flexor c>pi uln>is z a guide1 & make an incision along its radial edge1 at lea/ two in*es 9 l5g?2 expose ! deep fascia ( ! arm & !n cauti\sly divide x2 !n b5d+ ! h&1 ! flexor c>pi uln>is is relax$1 & ! art]y is f\nd ly+ pretty deeply betwe5 x & ! flexor sublimis digitorum4 ,! uln> n]ve lies at its uln> side1 & ! v5 comites accompany ! art]y4 ,9 a tol]ably muscul> arm1 ! incision w h to be ab\t an in* inside ( ! uln> bord] ( ! limb4 #b4 ,,radial4--,?is art]y lies m sup]ficial ?an ! prec$+1 & may be ti$ at any "p ( its c\rse4 ,a4 ,op]ation 9 upp] "p ( =e-arm4 ,"h ! art]y lies 9 ! int]val betwe5 ! sup9ator longus & ! pronator radii t]es4 ,9 a muscul> arm1 ! edge ( ! =m] muscle is ! be/ guide2 9 a fat "o1 ! incision may be made 9 a l9e ext5d+ f ! c5tre ( ! b5d ( ! arm to ! inn] edge ( ! /yloid process ( ! radius4 ,! deep fascia mu/ be expos$ & op5$1 & ! muscles relax$ & held aside4 ,! radial n]ve lies on ! radial side ( ! vessel4 ,b4 ,op]ation 9 l[] half ( arm4 ,"h ! vessel is m sup]ficial1 ly+ 9 ! groove betwe5 ! flexor c>pi radialis & sup9ator longus4 ,an incision two in*es 9 l5g?1 & p>allel ) ^! t5dons1 easily exposes ! art]y4 ,! n]ve is /ill on its radial side4 ,c4 ,op]ation at fir/ metac>pal4 ,! art]y may be ti$ easily en\gh 9 ! triangul> space b\nd$ by ! ext5sors ( ! ?umb1 on ! dorsum ( ! proximal end ( ! fir/ metac>pal bone4 ,skey#bb recomm5ds a transv]se1--,/eph5 ,smi?#bc & o!rs1 a longitud9al incision4 ,! au?or _h lately to secure ! radial 9 its l[] ?ird1 ! sup]ficialis vol1 & ! radial aga9 9 ! triangul> space1 9 a case :]e division ( ! art]y by a transv]se cut _h caus$ a l>ge aneurism to =m close above ! annul> ligam5t4 ,,table illu/rat+ ana/omotic circulation aft] ligature ( art]ies ( neck & upp] limb4 #a4 ,common c>otid4 7a7 ,across middle l9e3 ?yroids1 l+uals1 facials1 occipitals2 also t]m9al bran*es ( ext]nal c>otids2 also int]nal c>otids by circle ( ,willis4 7b7 ,( same side3 occipital ) v]tebral2 sup]ior ?yroid ) inf]ior ?yroid1 etc4 #b4 ,subclavian1 #c;d "p4 ,suprascapul> ) dorsal bran*es ( subscapul>2 po/]ior scapul> ) co/al & muscul> bran*es ( subscapul>4 ,?oracic ana/omosis betwe5 int]nal mamm>y & int]co/als1 ) bran*es ( axill>y4 #c4 ,axill>y & bra*ial4 ,ana/omosis v>ies ) ! position ( ! ligature1 b is v free betwe5 ! v>i\s muscul> bran*es ( ^! vessels4 ,,footnotes3 #b ,eri*s51 ,surg]y4 ,six? edition1 vol4 ii4 p4 #aba4 #c ,! l9e #c 9 ,plate ,i4 %[s ! direction requir$4 ,x w n be necess>y to c>ry ! incision s f> up = ! ext]nal z = ! common iliac4 #d ,on ! ,art]ies & ,ve9s1 p4 #dba4 #e ,cyclopdia ( ,practical ,surg]y1 vol4 i4 p4 #bgg4 #f ,john ,bell's ,pr94 ( ,surg41 vol4 i4 #dba2 ,dubl9 ,j\r41 vol4 iv4 #cba4 #g ,obs]vations 9 ,cl9ical ,surg]y1 ,syme1 pp4 #aga-c4 #h ,brit4 ,m$4 ,j\r4 #ahfg1 ,oct4 #e4 #i ,int]national ,encyclopdia ( ,surg]y1 vol4 iii4 p4 #dff4 #aj ,pol&1 ,guy's ,hosp4 ,report1 s]4 iii4 vol4 vi4 #aa ,mr4 ,w4 ,?omson's mo/ int]e/+ pap] on ?is subject is full ( in=mation d[n to ! late/ date4 #ab ,lancet1 ,jan4 #e1 #ahfg4 #ac ,lancet1 ,may #ahgi4 #ad ,dubl9 ,qu>t]ly ,j\rnal1 ,nov4 #ahfg4 #ae ,w4 ,zeh5d]--,monatsbl4 fr ,aug5heilkunde4 #ahfh4 #af ,but*]1 ,op4 & ,cons4 ,surg]y1 p4 #hfa4 #ag ,leons ,orales1 iv4 #ecj4 #ah ,ed4 ,m$4 & ,surg4 ,j\rn4 vol4 xlv4 #ai ,obs]vations 9 ,cl9ical ,surg]y1 pp4 #adh1 #adi4 #bj ,ed94 ,m$4 ,j\rnal1 ,m>* #ahgi4 #ba ,see case ( recurr5ce1 ,f]gusson's ,practical ,surg]y #a/ ed4 p4 #bbb4 #bb ,op]ative ,surg]y1 p4 #bgi4 #bc ,surgical ,op]ations1 p4 #ej4 ,,*apt] ,,ii4 ,,amputations4 ,9 ord9>y surgical language ! "n ,amputation is appli$ to all cases ( removal ( limbs1 or portions ( limbs1 by ! knife1 ?\gh 9 /rict accuracy x %\ld be re/rict$ to ^? cases 9 :i* a limb is remov$ 9 ! cont9uity ( a bone1 its removal at a jo9t be+ call$ a ,dis>ticulation4 ,! briefe/ outl9e ( a hi/ory ( amputation w\ld fill a "w mu* l>g] ?an ! pres5t4 ,i may be all[$ 9 a few s5t5ces to attempt to %[ ! pr9ciple on :i* su* a sket* %\ld be writt51 9 describ+ ! ?ree great eras ( progress 9 improvem5t ( ! me?ods ( amputat+4#bd ,i4 ,prior to ! inv5tion1 or at lea/ prior to ! g5]al introduction1 ( ! ligature & ! t\rniquet1 ! great b>ri] to all improvem5t 9 op]at+ 0 ! impossibility ( *eck+ hmorrhage dur+ an op]ation1 & aft] its conclusion4 ,_m surgeons w\ld n amputate at all1 o!rs only ?r\gh gangr5\s p>ts2 o!rs m bold1 only at ! conf9es ( p>ts 9 :i* gangr5e _h be5 artificially induc$ by tight ligatures4 ,) ! exception ( ,celsus1 :o 9 "o place recomm5ds a flap to be dissect$ up1 & ! bone ?us divid$ at a high] level1 all 7 9 too great a hurry to get ! op]ation complet$ to ?9k ( flaps4 ,cut ?r\gh all ! p>ts at ! same level ) a r$-hot knife1 if y w1 l ,fabricius ,hildanus2 by a s+le bl[ ) a *isel & mallet1 l ,scultetus2 or by a cru%+ guillot9e1 l ,purmannus3 or by two but*]s' *opp+-knives fix$ 9 heavy blocks ( wood1 "o fix$1 ! o!r fall+ 9 a grove1 l ,botal2 & !n try to *eck ! ble$+ by ty+ a pig's bladd] ov] ! face ( ! /ump1 l ,hans de ,g]sdorf2 or ty+ x up 9 ! inside ( a h5 newly kill$2 or by plung+ x at once into boil+ pit*4 ,we are ! less surpris$ to read ( ,celsus's description ( a flap op]ation1 :5 we rememb] t x is almo/ c]ta9 t ,celsus 0 acqua9t$ ) ! ligature z a means ( *eck+ hmorrhage4#be ,,ii4 ,a new era 0 u%]$ 9 :51 ab\t #aefj1 ,ambrose ,p> inv5t$1 or re-introduc$1 ! ligature z a means ( arre/+ hmorrhage1 b n = m ?an a c5tury aft] ?is did ! full b5efit ( 8 discov]y beg9 to be felt1 :5 ! t\rniquet 0 introduc$ by ,morel at ,besanon 9 #afgd1 & ,james ,"y ( ,plym\? 9 #afgh1 & improv$ by ,petit 9 #agjh-aj4 ,n[ surgeons _h "t to look ab\t !m dur+ an amputation1 & to try to get a good cov]+ = ! bone1 s t ! /ump might heal m rapidly & be> pressure bett]4 ,great improvem5ts 7 rapidly made1 & any hi/ory ( ^! improvem5ts w\ld ne$ to trace two great p>allel l9es1 "o ! circul> me?od1 ! o!r ! flap op]ation4 #a4 ,! old me?od 9 :i* ! limb 0 lopp$ (f by "o sweep1 all ! tissues be+ divid$ at ! same level1 might be call$ ! true circul>4 ,?is1 h[ev]1 0 soon improv$-- ,a4 ,by ,*eseld5 & ,petit1 :o inv5t$ ! d\ble circul> incision1 9 :i* fir/ ! sk9 & fat 7 cut & retract$1 & !n ! muscle & bone 7 divid$ z high z expos$4 ,b4 ,by ,l\is1 :o improv$ ?is by mak+ ! fir/ incision include ! muscles also1 ! bone alone be+ divid$ at ! high] level4 ,c4 ,by ,mynors ( ,birm+ham1 :o dissect$ ! sk9 back l ! sleeve ( a coat1 & ?us ga9$ m cov]+4 ,d4 ,!n comes ! great improvem5t ( ,alanson1 :o fir/ cut ?r\gh sk9 & fat1 & all[+ !m to retract1 next expos$ ! bone /ill fur!r up by cutt+ ! muscles obliquely s z to leave ! cut end ( ! bone 9 ! apex ( a conical cavity4 ,e4 ,an easi] mode1 fulfill+ ! same indications1 is f\nd 9 ! triple incision ( ,b5jam9 ,bell ( ,ed9burgh1 :o 9 #agib taught t fir/ ! sk9 & fat %\ld be divid$ & retract$1 next ! muscles1 & la/ly ! bone4 ,f4 ,a slight improvem5t on ,e1 made by ,hey ( ,le$s1 :o advis$ t ! po/]ior muscles ( ! limb %\ld be divid$ at a l[] level ?an ! ant]ior1 to comp5sate = _! great] range ( contraction4 #b4 ,9 ! progress ( ! flap op]ation few] /ages c be def9$4 ,made by cutt+ f )9 outw>ds1 aft] transfixion ( ! limb1 ! flaps v>i$ 9 %ape1 size1 position1 & numb]s1 f ! s+le po/]ior "o ( ,v]duyn ( ,am/]dam1 to ! two equal lat]al ones ( ,v]male1 & ! equal ant]ior & po/]ior ones ( ! ,ed9burgh s*ool4 ,!n came ! battle ( ! s*ools3 flap or circul>4 ,flap4--,spe$y1 easy1 & less pa9ful2 apt to retract1 & t unequally4 ,circul>4--,leav+ a small] w\nd1 b m sl[ 9 p]=mance1 & apt to leave a c5tral adh]5t cicatrix4 #c4 ,! la/ era 9 amputation began aft] ! introduction ( an/hetics4 ,n[ spe$ 9 amputation is no object1 & ! surgeon has full "t to %ape & c>ve 8 flaps into ! curves mo/ suit$ = accurate apposition1 & suitable relation ( ! cicatrix to ! bone4 ,x has also be5 br\ght cle>ly out t diff]5t me?ods ( op]at+ are suitable = diff]5t positions1 & also t ev5 9 ! same op]ation x is possible to unite ! advantages ( bo? ! flap & ! circul> me?od4 ,9 ! modifi$ circul>1 :i* is be/ suit$ = amputation bel[ ! knee1 9 ! long ant]ior flaps ( ,teale1 ,sp5ce1 & ,c>d51 we h illu/rations ( ! mann] 9 :i* ! advantages ( bo? ! flap & circul> me?ods h be5 secur$1 )\t ! disadvantages ( ei!r4 ,! long ant]ior flap1 n l ,teale's to fold ^u itself1 b l ,sp5ce's & ,c>d5's to hang ov] & %ield ! end ( ! bones1 & ! face ( a transv]sely-cut %ort po/]ior flap1 seems to be n[ ! typical me?od = successful amputations4 ,!re may be exceptions1 z :5 ! ant]ior sk9 is m injur$ ?an ! po/]ior1 or :]e an ant]ior flap w\ld dem& too great sacrifice ( l5g? ( limb1 b z a rule x w be f\nd ! be/ me?od = ! pati5t4 ,,amputation ,,( ,,! ,,upp] ,,extremity4--,! extreme importance ( ! human h&1 its tactile s5sibility1 its grasp+ p[]1 & ! irrep>able loss su/a9$ by its removal1 r5d] ! greate/ caution necess>y1 le/ we %\ld remove a s+le digit or portion ( "o t might be sav$4 ,9 cases ( sev]e sma%+ injuries involv+ ! f+]s1 x is ! surgeon's b\nd5 duty n recklessly to amputate ! limb ) neat flaps at ! wri/-jo9t1 b c>efully to endeav\r to save ev5 a s+le f+] f ! wreck1 ?\gh at ! risk ( a long] convalesc5ce1 or ev5 ( a pr(use suppuration4 ,:ile a toe or two1 or a small longitud9al segm5t ( ! foot1 may be comp>atively useless1 & a good artificial foot1 ) an ankle-jo9t /ump1 c]ta9ly pref]able1 a s+le f+]1 provid$ its motions are tol]ably intact1 w prove mu* m valuable to its possessor ?an ! mo/ +5i\sly contriv$ artificial h&4 ,illu/ration3 ,,fig4 ,i4 ,h[ev]1 :ile 9 cases ( ext5sive sma% we endeav\r to save any?+ we c1 ! case is v mu* alt]$ :5 x is only "o or two f+]s t are injur$4 ,"h we f9d ano!r pr9ciple br\ght into play1 & our cons]vative surg]y mu/ be limit$ by ! foll[+ consid]ation4 ,9 endeav\r+ to save a portion ( ! injur$ f+] or f+]s1 w ! sav$ portion int]f]e ) ! important movem5ts ( ! un9jur$ ones8 ,^! two pr9ciples--#a4 ,g5]ally to save z mu* z we c2 #b4 ,n to save any?+ :i* may be detrim5tal or 9 ! way1--w guide u 9 describ+ ! amputations ( ! upp] extremity4 ,illu/ration3 ,,fig4 ,,ii4 ,amputation ( a di/al phalanx4--,?is small op]ation is n v (t5 requir$4 ,9 cases ( :itl[ 9 :i* ! di/al phalanx alone has necros$1 removal ( ! necros$ bone by =ceps is g5]ally all t is necess>y4 ,9 cases ( injury1 h[ev]1 9 :i* nail & di/al phalanx are bo? r$uc$ to pulp1 x w ha/5 recov]y mu* to remove ! extremity4 ,!re is no *oice z to flap1 ! nail prev5t+ an ant]ior "o1 s a flap long en\gh to fold ov] mu/ be cut f ! pulp ( ! f+] 9 ei!r ( two ways 7,fig4 ,i4 #a73--a4 ,hold+ ! fragm5t to be remov$ 9 ! left h&1 & b5d+ ! jo9t1 ! surgeon makes a transv]se cut across ! back ( ! f+]1 "r into & ?r\gh ! jo9t1 cutt+ a long palm> flap f )9 outw>ds z he )draws ! knife4 ,note4--,"s difficulty is (t5 felt 9 mak+ ! dorsal incision s z exactly & at once to hit ! jo9t2 ! mo/ common mi/ake be+1 t ! transv]se incision is made too high1 & ! knife1 in/ead ( /rik+ ! jo9t1 only saws fruitlessly at ! neck ( ! bone above4 ,to avoid ?is1 ! surgeon %\ld take z a guide to ! jo9t1 n ! well-m>k$ & tempt+-look+ dorsal fold 9 ! sk91 b ! palm> "o1 :i* exactly corresponds ) ! jo9t betwe5 ! proximal & middle phalanges1 & is only ab\t a l9e above ! di/al articulation4--7,fig4 ,,ii47 #b4 ,mak+ ! long flap by transfixion1 x may be held back by an assi/ant1 & ! jo9t cut into4 ,amputation ?r\gh ! second phalanx4--,if ! di/al phalanx be s mu* cru%$ t a flap _c be obta9$1 two %ort semilun> lat]al flaps may be dissect$ 7,fig4 ,i4 #b7 f ! sides ( ! second phalanx1 :i* may !n be divid$ by ! bone-pli]s at ! spot requir$4 ,9 cases ( injury :i* d n admit ( ei!r ( ! prec$+ op]ations1 x is q possible to amputate ei!r at ! fir/ jo9t1 or ev5 ?r\gh ! proximal phalanx4 ,pati5ts are sometimes anxi\s = su* op]ations 9 pref]5ce to amputation ( ! :ole f+]4 ,! surgeon %\ld1 h[ev]1 nev] amputate ?r\gh a f+] high] up ?an ! di/al end ( ! second phalanx1 unless absolutely compell$ by ! pati5t1 = ! result+ /ump1 be+ no long] comm&$ by ! t5dons1 w prove m]ely an incumbrance1 & may possibly require a second>y op]ation at no di/ant date = its removal4 ,?is rule is applicable 9 cases 9 :i* a s+le f+] is injur$1 & two or ?ree complete ones are left2 9 cases :]e all ! f+]s h be5 mutilat$ e morsel %\ld be left1 & may be ( use4 ,amputation ( a :ole f+]4--7,fig4 ,i4 #c7--,?is is an op]ation ( great importance1 f its frequ5cy4 ,if ! ?ird or f\r? digits require amputation1 x %\ld be p]=m$ z foll[s3--,! vessels ( ! arm be+ comm&$1 an assi/ant holds ! h&1 sep>at+ ! f+]s at ea* side ( ! "o to be remov$4 ,! surgeon hold+ ! f+] to be remov$1 ent]s ! po9t ( a long /raight bi/\ry exactly 7"s au?orities say half an in*7 above ! metac>po-phalangeal jo9t1 & cuts f ! prom95ce ( ! knuckle "r into ! angle ( ! web1 !n1 turn+ inw>ds !re1 cuts obliquely into ! palm to a po9t ne>ly opposite ! "o at :i* he set out4 ,note4--,:ile mo/ au?orities agree ) ! direction 9 ! text reg>d+ ! palm> t]m9ation ( ! incision1 ,i believe1 9 mo/ cases1 x is n necess>y to g s f>1 & t ! incisions may fitly meet 9 ! palm at a po9t midway betwe5 a po9t opposite to ! knuckle1 & ! c5tre ( ! well-m>k$ sulcus ( flexion4 ,he !n repeats ?is incision on ! o!r side1 makes t5se ! ligam5ts1 fir/ at "o side & !n at ! o!r1 by draw+ ! f+] to ! opposite side1 & cuts !m4 ,! t5dons be+ cut1 ! f+] is deta*$4 ,! vessels be+ ti$1 "o po9t ( suture is put 9 on ! dorsal aspect1 & ! f+]s on ea* side ti$ toge!r at _! extremities1 ) a pad ( l9t betwe5 !m4 ,modification4--,lisfranc's me?od is too long 9 its m9ute description to give 9 detail4 ,! pr9ciple is to make a semilun> flap at "o side 7! "o opposite ! op]ator's "r h&71 by cutt+ f )\t inw>ds1 !n to op5 ! jo9t f ?is cut1 &1 /ill keep+ ! edge ( ! knife close to ! head ( ! phalanx1 cutt+ ! o!r flap f )9 outw>ds4 ,?is c be v rapidly done1 b ! la/ flap is apt to be irregul> & defici5t1 especially 9 ^? common cases1 9 :i*1 aft] :itl[ or ! l1 ! tissues are h>d & brawny1 & ! sk9 does n play freely4 ,x is q unnecess>y to remove ! head ( ! metac>pal1 ei!r = ! sake ( appe>ance1 or to r5d] heal+ m rapid1 & its removal weak5s ! ar* ( ! h&2 :]e ! c>tilage is erod$ by disease1 ! c>tilage-cov]$ portion c be scoop$ (f by a g\ge or remov$ entire by pli]s1 )\t int]f]+ ) ! broad end to :i* ! transv]se ligam5t ( ! palm is atta*$4 ,if requir$ ei!r = injury or disease1 ! metac>pal head may be easily remov$ by a s+le /raight incision f ! knuckle upw>ds1 z f> z ! po9t at :i* x may be deem$ necess>y to saw x ?r\gh1 or bett] /ill1 divide x ) ! bone-pli]s4 ,?is incision %\ld be made z a fir/ /ep 9 ! fir/ incision = amputation ( ! f+]1 & ! f+] %\ld n be dis>ticulat$1 b kept on1 to aid by its lev]age 9 sep>at+ ! metac>pal head4 ,amputation ( ! index or little f+]s4--,?is op]ation diff]s f ! prec$+ only 9 ?is1 t c>e mu/ be tak5 to make a good l>ge flap on ! free side ( ea*2 mak+ ! incision1 :i* beg9s at ! knuckle 7,fig4 ,i4 #d71 enclose a well-r\nd$ flap1 & n all[+ x to ent] ! palm till x rea*es ! level ( ! web betwe5 ! f+]s4 ,! metac>pal heads may "h be cut obliquely ) ! bone-pli]s1 to prev5t undue projection4 ,amputation ( "o or m metac>pals4--,^! op]ations may be r5d]$ necess>y by disease or injury4 ,if ! latt] dem&s _! p]=mance1 no rules c be giv5 = incisions or flaps1 !y mu/ j be obta9$ :]e & h[ !y c be/ be got4 ,if = disease1 a s+le dorsal incision 7,fig4 ,i4 #e7 ov] ! bone w all[ x to be dissect$ out ( ! h&4 ,n4,b4--,9 no case1 except t ( ! ?umb1 %\ld any attempt be made to save a f+] :ile its metac>pal is remov$4 7,see ,excisions ( ,bones47 ,amputation ( fir/ & fif? metac>pals4--,v>i\s special op]ations h be5 devis$ = spe$y & elegant removal ( ^! bones4 ,_! disadvantages1 etc41 are fully detail$ "u ,amputations ( ! ,foot4 ,! vascul>ity & consequ5t vitality ( ! tissues ( ! h& & arm sometimes af=d v enc\rag+ & satisfactory results 9 cons]vative op]ations4 ,! foll[+ is an in/ance ( :at may be accompli%$ 9 a "y heal?y subject4 ,a4 ,a41 t4 #ah1 pl\ghman1 0 h>ness+ a vici\s horse1 :5 x caught 8 "r h& betwe5 its tee?1 & gave a sev]e bite4 ,on admission1 ,i f\nd ! middle & r+ f+]s completely sep>at$ at ! metac>pal jo9ts1 b ea* hang+ on by a portion ( sk91 ! middle by ! sk9 on its radial side1 ! r+ by t on its uln>4 ,! back & ! palm 7 bo? /ripp$ ( sk9 up to ! middle ( ! ?ird & f\r? metac>pal bones1 :i* 7 expos$1 b n fractur$4 ,z x 0 important = him to ma9ta9 ! transv]se ar* ( ! h& intact1 ,i det]m9$ to make an attempt to save ! metac>pals1 & f9d+ t ! sk9 on ! radial side ( ! middle1 & uln> side ( ! r+ f+]s1 0 /ill w>m1 & app>5tly alive1 ,i c>efully dissect$ z long a flap z possible f ea*1 & !n fold$ !m d[n1 "o at ! front1 ! o!r at ! back ( ! h&4 ,! flaps surviv$1 & ! result 0 admirable1 ! pati5t be+ able 9 a v few weeks to guide ! pl\gh4 ,! s5sation 9 8 new palm & back ( ! h& is v peculi>1 !y be+ /ill ! f+]s1 s f> z n]v\s supply is conc]n$4 ,9 amputations involv+ ! metac>pals = injury1 x is always important to avoid ent]+ ! c>po-metac>pal jo9t1 h5ce if x c be done x is be/ to saw ?r\gh ! bones at ! requir$ level1 r ?an dis>ticulate4 ,?is rule %\ld be obs]v$ ev5 9 ^? cases 9 :i* ! ?umb alone c be sav$1 = not)/&+ ! isolation ( ! jo9t betwe5 ! fir/ metac>pal & ! trapezium1 x is v important = ! future use ( ?is "o digit t ! motions bo? ( ! wri/ & c>pal jo9ts %\ld be pres]v$ entire4 ,no exact rules c be giv5 = ! p]=mance ( ^! op]ations1 z ! size & positions ( ! flaps mu/ be det]m9$ by ! nature ( ! accid5t & ! am\nt ( sk9 left un9jur$4 ,9 ! r>e condition :]e ! great] "p ( ! metac>pus is de/roy$1 & yet c>pal jo9ts are un9jur$1 a mo/ useful artificial b&1 pres]v+ ! movem5ts ( ! wri/1 may be fitt$ on2 & z mu* z possible %\ld be sav$1 b 9 cases ( injury1 :]e ! c>pus is op5$ & ! h& irrep>ably de/roy$1 ! "q arises1 ,:]e ought amputation to be p]=m$8 ,to ?is we answ] t !re appe>s no conceivable advantage to be ga9$ by leav+ all or any ( ! c>pal bones4 ,if successful1 x w\ld result only 9 ! ret5tion ( a flapp+ jo9t1 unless f !re be+ no t5dons to act ^u x1 except ! t5don ( ! flexor c>pi uln>is atta*$ to ! pisi=m1 & !re are sev]al risks x w\ld run 9 ! inflammation ( all ! c>pal jo9ts1 & ! almo/ c]ta9 spread ( ?is inflammation to ! bursa und]nea? ! flexor t5dons1 beyond ! annul> ligam5t1 & up ! arm among ! muscles4 ,,amputation ,,at ,,! ,,wri/-,,jo9t4--,?is is an op]ation by no means frequ5t1 & x has ! advantages ( pres]v+ a long /ump1 & reta9+ ! full movem5ts ( pronation & sup9ation1 9 cases :]e ! radio-uln> jo9t is s\nd & un9jur$1 b 9 practice x is (t5 f\nd t fibr\s adhesions limit to a great ext5t ! motions ( ! two bones on ea* o!r1 specially 9 ^? cases :]e ! radio-uln> jo9t has be5 diseas$ or injur$4 ,ano!r advantage is ! extreme ease ) :i* dis>ticulation may be p]=m$ on em]g5cy1 no saw be+ requir$1 & ! ord9>y bi/\ry ( ! pocket-case be+ q suffici5t = cutt+ ! flaps4 ,op]ation4--,by d\ble flap4 ,an incision 7,plate ,,iv4 fig4 #c7 on ! dorsal surface1 ext5d+ 9 a semilun> direction f "o /yloid process to ! o!r1 w def9e a flap ( sk9 only1 :i* mu/ be rais$2 ! jo9t mu/ !n be op5$ by a transv]se incision1 & a long semilun> flap ( sk9 & fascia %\ld be %ap$ 7,plate ,,iv4 fig4 #d7 f ! palm4 ,dis>ticulation is facilitat$ by ! surgeon =cibly b5d+ ! wri/ :5 he makes ! transv]se cut1 & x w be f\nd easi] to %ape ! palm> flap f ! outside by dissection1 ?an to d x by transfixion aft] dis>ticulation1 on acc\nt ( ! prom95ce ( ! pisi=m on ! inn] side ( ! palm4 ,9 ! ?9 wa/$ wri/s ( ! ag$1 or 9 any case :]e ! sk9 is v lax1 ?is amputation may be v easily p]=m$ by ! circul> me?od4 ,:ile an assi/ant draws up ! sk9 z mu* z possible1 ! surgeon makes an accurate circul> incision ?r\gh ! sk91 ab\t an in* bel[ ! /yloid processes1 j graz+ ! !n> & hypo!n> em95ces4 ,ano!r circul> sweep j above ! pisi=m & unci=m bones divides all ! s(t textures1 aft] :i* ! jo9t may be op5$1 &1 if necess>y1 ! /yloid processes cut away ) saw or pli]s4 ,amputation by a long s+le flap1 ei!r dorsal or palm>1 may be r5d]$ necess>y by accid5t4 ,! palm> "o ( ! two is pref]able2 inde$1 r ?an tru/ = a cov]+ to ! ?9 sk9 ( ! back ( ! h&1 ) its num]\s t5dons1 x is bett] to amputate an in* or two high] up ?r\gh ! =e arm4 ,! foll[+ amputation by ext]nal flap has be5 describ$ 7s f> z ,i c discov]1 = ! fir/ "t7 by ,dr4 ,dubrueil1 9 8 "w on op]ative ,surg]y3#bf--;,comm5c+ j bel[ ! level ( ! articulation1 :ile ! h& is pronat$1 ! surgeon makes a convex incision1 beg9n+ at ! junction ( ! out] & middle ?irds ( ! arm beh9d1 rea*+ at its summit ! middle ( ! dorsal surface ( ! fir/ metac>pal1 & t]m9at+ 9 front j bel[ ! palm> surface ( ! jo9t1 aga9 at ! junction ( ! out] & middle ?irds ( ! bread? ( ! arm4 ,?is flap be+ rais$1 ! wri/ is dis>ticulat$1 beg9n+ at ! radial side4 ,a circul> incision f9i%es ! cutt+ ( ! sk94 7,figs4 ,,iii4 & ,,iv47 ,illu/ration3 ,,fig4 ,,iii4#bg ,illu/ration3 ,,fig4 ,,iv4#bg ,,amputation ,,?r\gh ,,! ,,=e-,,arm4--,! me?od ( op]at+ mu/1 9 ! =e-arm1 dep5d a good deal ^u ! "p ( ! arm :]e y require to amputate1 ! muscul>ity ( ! limb1 & ! condition ( ! sk9 & subcutane\s cellul> tissue4 ,x mu/ be rememb]$ t a section ( ! =e-arm involves two bones1 n1 l ! tibia & fibula1 on a con/ant p]man5t relation 9 position to ea* o!r1 b :i* rotate "o ^u ano!r to an am\nt :i* v>ies ) ! "p ( ! limb divid$1 & :i* rotation is a v important elem5t 9 ! future usefulness ( ! /ump2 aga91 t two sets ( muscles occupy1 "o ! back1 ! o!r ! front ( ! limb1 t ^! two are unequal 9 size1 & t ! out] sides or r edges ( ea* bone are subcutane\s2 aga91 t ^! sets ( muscles are comp>atively fle%y 9 ! upp] two-?irds ( ! limb1 & almo/ entirely t5d9\s 9 ! l[] ?ird4 ,rememb]+ ^! po9ts1 we f9d t c]ta9 ?+s require our att5tion1 & c]ta9 difficulties are pres5t 9 amputation ( ! =e-arm1 f :i* amputation ( ! arm1 ) its s+le bone & copi\s muscul> cov]+ on all sides1 is completely free4 ,?us our flaps 9 ! =e-arm mu/ be ant]o-po/]ior2 lat]al flaps are an impossibility4 ,great c>e is requisite to cut !m at all equal1 f ! inequality ( ! muscles on ! two sides4 ,9 ! l[] ?ird we _c obta9 available muscul> flaps4 ,la/ly1 c>e mu/ be tak5 le/1 f ! ev]-v>y+ relations ( ! two bones to ea* o!r 9 ! v>y+ positions ( ! limb1 ! surgeon mi/ake _! position & pass 8 knife betwe5 !m4 ,! next "q t arises is1 ,:]e are we to op]ate8 ,9 cases :]e we h a *oice1 is !re "h1 z 9 ! leg1 any po9t ( election8 ,no4 ,z a rule 9 ! =e-arm1 ! surgeon %\ld endeav\r to save z mu* z possible2 especially :5 ne>+ ! middle ( ! =e-arm1 he %\ld try to save ! ins]tion ( ! pronator t]es1 s important 9 its function ( pronat+ ! radius4 ,,amputation ,,9 ,,l[] ,,?ird ,,( ,,! ,,=e-,,arm4--,by two flaps4 ,^! ant]o-po/]ior flaps mu/ consi/ ( sk9 only1 z ! t5dons are only 9 ! way1 & ?us %\ld be made by dissection f )\t4#bh ,mak+ ! dorsal "o fir/1 ! surgeon %\ld ent] 8 knife at ! palm> edge ( ! bone t is fur!r f him1 & cut a semilun> flap ( sk9 only1 f9i%+ ! incision q on ! palm> edge ( ! inn] bone4 ,! two ends ( ?is incision mu/ !n be unit$ by a simil> semilun> flap ( sk9 on ! palm> side4 ,! two flaps hav+ be5 dissect$ back1 he !n cle>s ! bones by a circul> incision ?r\gh t5dons & muscles1 n =gett+ to pass ! knife betwe5 ! bones1 & retract+ all ! s(t p>ts1 saws ?r\gh ! bones1 at lea/ half or probably ?ree-qu>t]s ( an in* high] up4 ,x is g5]ally easie/ to saw ?r\gh bo? bones at once4 ,long ,dorsal ,flap4--,:]e x is possible f laxity ( ! s(t p>ts & ! wri/ n be+ mu* de/roy$1 to get a long flap f ! back ( ! arm aft] ,mr4 ,teale's me?od1 a v good /ump w result4 ,?is rule is1 ,9 trac+ ! long flap a longitud9al l9e is drawn ov] ! radius1 s z to leave ! radial vessels = ! %ort flap 7,plate ,,ii4 fig4 #a74 ,at a di/ance equal to half ! circumf]5ce ( ! limb1 ano!r l9e p>allel to ! =m] is drawn along ! ulna4 ,^! are !n jo9$ at _! l[] ends1 across ! dorsal aspect ( ! wri/ or =e-arm1 by a transv]se l9e equal 9 l5g? to half ! circumf]5ce ( ! =e-arm4 ,! %ort flap is m>k$ by a transv]se l9e on ! palm> aspect1 unit+ ! long ones at _! upp] f\r?4 ,! op]ator1 9 =m+ ! long flap1 makes ! two longitud9al incisions m]ely ?r\gh ! integum5ts1 b ! transv]se "o is c>ri$ directly d[n to ! bones4 ,9 dissect+ ! long flap f bel[ upw>ds1 ! tissues ( :i* x is compos$ mu/ be sep>at$ close to ! p]io/eum & int]osse\s membrane4 ,! %ort flap is made by a transv]se incision ?r\gh all ! /ructures d[n to ! bones1 c>e be+ tak5 to sep>ate ! p>ts upw>ds close to ! p]io/eum & membrane4 ,! /ump mu/ be plac$ 9 ! prone position1 to all[ ! long dorsal flap to be ! sup]ior :5 ! pati5t is recumb5t1 & ?us fall ov] ! ends ( ! bones4#bi ,! pr9cipal objection to ! long dorsal rectangul> flap 7:i* makes an excell5t cov]+7 is1 t unless x c be obta9$ f ov] ! wri/-jo9t x requires ! bones to be sawn s v high up4 ,?is may be avoid$1 to "s ext5t1 by mak+ x %ort] & r\nd$ (f1 z 9 ,c>d5's ,amputation1 q4v4 ,,amputation ,,9 ,,upp] ,,two-,,?irds4--,:]e ! =e-arm is v fat or fle%y1 ?is amputation c be v easily p]=m$ by two equal ant]o-po/]ior flaps made by transfixion4 ,9 mo/ cases1 h[ev]1 f ! comp>ative leanness ( ! dorsal aspect ( ! limb1 ! foll[+ me?od w h ! be/ result4 ,! surgeon mu/1 z 9 ! =m] case1 %ape a r\nd$ dorsal flap by dissection f )\t 7,plate ,,iv4 fig4 #e71 embrac+ ! :ole bread? ( ! limb d[n to ! palm> edge ( bo? bones4 ,!n at once he transfixes ! two po9ts ( ?is dorsal flap1 & cuts out an equal "o f ! ant]ior aspect ( ! limb 7,plate ,,iv4 fig4 #f74 ,dissect+ up ! dorsal flap he cle>s ! bones at lea/ half an in* above z be=e1 & applies ! saw4 ,n4,b4--,?is op]ation %\ld be p]=m$ ev5 9 cases :]e only an in* ( radius c be reta9$1 z ! atta*m5t ( ! biceps makes a v small /ump ( =e-arm wond]fully useful4 ,,amputation ,,at ,,elb[-,,jo9t4--,9 cases :]e x is f\nd impossible to save any portion ( ! =e-arm1 dis>ticulation at ! elb[-jo9t may be easily p]=m$4 ,?is op]ation 0 propos$ & p]=m$ s long ago z ! days ( ,ambrose ,p>1#cj 0 mu* approv$ by ,dupuytr51 ,baud5s1 & ,velpeau1 _h fall5 into disuse = a "t1 b is n[ aga9 recomm5d$ by "s excell5t surgeons1 especially by ,gross#ca & ,a%hur/1#cb bo? ( ,philadelphia4 ,x is tol]ably easy to p]=m1 & does n involve any saw+ ( bones1 b ! flaps are apt to be cut too %ort1 unless c>e be tak51 f ! mann] 9 :i* ! tro*lea projects d[nw>ds beyond ! l9e ( ! condyles1 s t if ! base ( an ord9>y-%ap$ flap be made on a level ) ! condyles1 x w prove insuffici5t to cov] ! bone4 ,x may be p]=m$ ei!r by ! circul> me?od 7,velpeau71 oval 7,baud5s71 or by a long ant]ior & %ort po/]ior flap 7,textor & ,dupuytr574 ,probably ! be/ me?od is by a long ant]ior flap :5 x c be obta9$1 ?us3--,! arm be+ plac$ 9 a slightly flex$ position1 ! surgeon transfixes 9 front ( ! jo9t1 9 a l9e ext5d+ f ! level ( ! ext]nal condyle to a po9t "o in* bel[ ! int]nal condyle 7,plate ,,iv4 fig4 #g72 ! tissue %\ld be held well =w>d at ! mom5t ( transfixion4 ,! flap %\ld be at lea/ two & a half in*es deep at its apex1 :i* mu/ be r\nd$ (f4 ,! two ends ( ?is flap may !n be unit$ beh9d by a semilun> incision 7,plate ,,iii4 fig4 #b71 :i* w sep>ate ! radial atta*m5ts4 ,! ulna mu/ !n be cle>$1 & ! triceps divid$ at its ins]tion4 ,modifications4--,dupuytr5 us$ to saw ?r\gh ! ulna1 leav+ ! olecranon atta*$4 ,velpeau oppos$ ?is1 b x is aga9 recomm5d$ by ,gross1 :o leaves ! olecranon1 & at ! same "t improves ! %ape ( ! /ump by saw+ (f ! inn] tro*lea on a level ) ! g5]al surface4 ,,amputation ,,( ,,! ,,arm4--,?is amputation is be/ p]=m$ by d\ble flap1 & is ! typical in/ance :i* exhibits all ! advantages ( two equal flaps made by transfixion1 )\t any ( ! disadvantages ( t me?od4 ,^! advantages are1 eas9ess ( p]=mance1 rapidity1 excell5t cov]+ = ! bone1 ) z little sacrifice ( tissue z is possible1 :ile ! fact t ! cicatrix is opposite ! end ( ! bone is h>dly a disadvantage 9 ! arm 7z x c]ta9ly is 9 ! leg71 z no weight has to be borne on x4 ,:5 !y c be obta9$1 ant]ior & po/]ior flaps are g5]ally consid]$ mo/ satisfactory1 b ,mr4 ,sp5ce pref]s lat]al ones1 le/ ! l9e ( union %\ld be int]f]$ ) by ! deltoid rais+ ! bone4 ,if ! "r arm has to be amputat$1 ! op]ator /&+ at ! inn] side raises ! ant]ior muscles ) 8 left h&1 & ent]s ! knife j 9 front ( ! bra*ial vessels 7,plate ,i4 fig4 #ab72 keep+ z close z possible to ! bone1 he br+s out ! knife at a po9t exactly opposite1 !n ) a brisk saw+ motion1 cuts a semicircul> flap1 tak+ c>e to br+ out ! knife m sudd5ly j at ! end1 9 ord] to cut ?r\gh ! sk9 z p]p5dicul>ly to ! arm z possible4 ,! knife is aga9 ent]$ at ! same po9t1 c>ri$ beh9d ! bone1 & br\ght out at ! same angle1 & an exactly correspond+ flap cut f ! o!r side ( ! limb1 ! flaps are !n retract$1 ! bone cle>$ by circul> incision & sawn ?r\gh z high up z x is expos$4 ,9 prim>y cases1 :]e ! muscles are firm & develop$1 ! flaps %\ld be cut a little concave4 ,modifications & ,v>ieties4--,teale's me?od may ( c\rse be us$ "h z else:]e4 ,! int]nal l9e ( incision 7,plate ,,iv4 fig4 #h7 %\ld be made j 9 front ( ! bra*ial vessels4 ,?is me?od requires ! amputation to be p]=m$ high] up ?an w\ld o!rwise be necess>y 7f ! l5g? ( ! ant]ior flap71 & ?is disadvantage is n c\nt]balanc$ by any special advantage 9 ! po/]ior retraction ( ! cicatrix4 ,9 feeble flabby arms1 ! true circul> op]ation is v easily p]=m$1 & ) good results4 ,a circul> sweep ( ! knife is made ?r\gh ! sk9 alone1 :i* is drawn up by an assi/ant1 :ile ! surgeon sep>ates x f ! fascia2 ano!r circul> cut ?r\gh fascia & muscles exposes ! bone1 :i* mu/ !n be cle>$ & cut ?r\gh at a /ill high] level4 ,,amputation ,,at ,,! ,,%\ld]-,,jo9t4--,?is op]ation1 l t at ! hip jo9t1 c1 f ! nature ( ! jo9t to be cov]$1 & ! abundant s(t p>ts 9 ! normal /ate ( ! tissues1 be p]=m$ on ! dead 9 v v>i\s ways1 by s+le1 d\ble1 or triple flaps1 by transfixion or dissection1 rapidly or sl[ly4 ,h5ce manuals ( op]ative surg]y might collect at lea/ tw5ty diff]5t me?ods1 mo/ ( :i* h "s recomm5dation1 & all ( :i* are practicable en\gh4 ,:51 h[ev]1 we reflect t 9 ! liv+ body1 9 cases :]e amputation at ! %\ld]-jo9t is requir$ at all1 ! sev]ity ( ! accid5t1 or ! urg5cy ( ! disease1 w1 9 g5]al1 leave no room = selection1 we %all see h[ utt]ly valueless is any k ( m]e me?ods ( op]at+1 & ( h[ mu* great] importance x is t we %\ld be simply ?or\ghly famili> ) ! anatomy ( ! jo9t4 ,= example1 an accid5t :i* necessitates amputation s high up has1 9 all probability1 op5$ into ! jo9t & de/roy$ ! s(t p>ts on at lea/ "o aspect2 9 su* a case ! flaps mu/ be cut f ! un9jur$ s(t p>ts only4 ,if an aneurism has r5d]$ amputation ?r\gh x & ?r\gh ! jo9t a la/ res\rce1 ! flap mu/ be ga9$ *iefly at lea/ f ! outside2 a malignant tum\r ( ! hum]us w almo/ c]ta9ly prev5t any transfixion1 & require flaps to be made by dissection1 :]ev] ! sk9 is lea/ likely to be involv$4 ,aga91 "s ( ! mo/ vaunt$ & mo/ rapid op]ations almo/ require = _! success ! integrity ( ! hum]us1 :i* has to make itself useful z a lev] 9 dis>ticulation1 :ile 9 mo/ cases ( accid5t we are amputat+ = comp\nd injury ( ! hum]us1 almo/ c]ta9ly imply+ fracture ) comm9ution4 ,f its proximity to ! trunk1 hmorrhage is "o ( ! *ief dang]s to be appreh5d$ dur+ ?is op]ation1 especially f ! axill>y art]y4 ,z f> z possible to obviate ?is dang]1 mo/ plans ( op]at+ are bas$ on ! pr9ciple t ! vessels & n]ves %\ld be ! la/ tissues to be cut2 9 "s !y are n divid$ till aft] dis>ticulation4 ,:ile a good assi/ant1 to make pressure on ! subclavian above ! clavicle1 is a mo/ advisable precaution1 too mu* mu/ n be tru/$ to ?is pressure above1 z ! /ruggles ( ! pati5t & ! spasmodic movem5ts ( ! limb1 :i* are s apt to occur "u ! /imulus ( ! knife1 are apt to r5d] futile ! be/ ef=ts at compression4 ,! op]ator %\ld tru/ r to mak+ ! incisions 9 su* a mann] t ! great vessel be n divid$ till ! h& ( an assi/ant1 or 9 default ( a suitable "o1 8 own left h&1 is able to foll[ ! knife & grasp ! flap4 ,! ble$+ f ! circumflex1 subscapul>1 & po/]ior scapul> art]ies c easily be arre/$ by a dossil ( l9t till ! great vessel is ti$1 & !y c be secur$4 ,9 cases :]e prop] assi/ants _c be _h1 tempor>y closure ( ! axill>y vessel c\ld easily be made by c>ry+ a /rong silv] wire or silk ligature completely r\nd ! vessel by a curv$ ne$le be=e ! incisions are comm5c$1 & by ty+ ?is firmly ov] a pad ( l9t4 ,pressure on ! art]y above ! clavicle is be/ made by ! ?umb ( a /rong assi/ant1 :o endeav\rs to compress x aga9/ ! fir/ rib2 :]e ! p>ts are deep & muscul>1 ! padd$ h&le ( ! t\rniquet1 or ( a l>ge door-key1 w d z ! ag5t ( pressure4 ,a brief notice ( ?ree ( ! be/ me?ods ( op]at+ w be q suffici5t to %[ :at %\ld be aim$ at 9 %\ld]-jo9t amputations3-- #a4 ,9 cases :]e ! surgeon c *oose 8 flaps1 ! foll[+ me?od w be f\nd ! mo/ satisfactory1 z result+ 9 ! smalle/ possible w\nd1 9 hav+ less risk ( hmorrhage dur+ ! op]ation ?an any o!r me?od1 & 9 provid+ excell5t flaps4 ,x is ,l>rey's me?od slightly modifi$4 ,op]ation4--,) a mod]ate-siz$ amputat+ knife an incision ( ab\t two in*es 9 l5g?1 ext5d+ ?r\gh all ! tissues d[n to ! bone1 %\ld be made f ! edge ( ! acromion process to a po9t ab\t "o in* bel[ ! top ( ! hum]us2 f ?is latt] po9t a curv$ incision1 enclos+ a semilun> flap1 %\ld be made on ea* side ( ! limb to ! ant]ior & po/]ior folds ( ! axilla respectively 7,plate ,,iv4 fig4 #i1 & ,plate ,,iii4 fig4 #c74 ,^! flaps %\ld !n be dissect$ back1 includ+ ! muscles & expos+ ! jo9t4 ,:5 ?or\ghly expos$1 ! jo9t mu/ !n be op5$ f above1 & ! bone sep>at$4 ,"o small portion ( sk9 ly+ above ! art]y1 ve91 & n]ves /ill rema9s to be divid$ 7,plate ,i4 fig4 #ac74 ,?is may be done by an oblique cut f )9 outw>ds1 9 su* a direction z to =m "p ( ! ant]ior or int]nal incision1 & ) ! precaution ( hav+ an assi/ant to comm& ! vessels be=e !y are divid$4 ,! result+ w\nd is almo/ p]fectly ovoid1 ! flaps come toge!r ) great ease 9 a /raight v]tical l9e1 :i* admits ( easy & ?or\gh dra9age4 ,union is g5]ally rapid4 ,l>rey's success by ?is me?od 0 v rem>kable3 n9ety out ( a hundr$ cases 9 milit>y practice 7 sav$1 not)/&+ ! well-kn[n risks ( su* op]ations4 #b4 ,z good z ! =m]1 & ne>ly z univ]sally applicable1 is ! me?od devis$ by ,pr(essor ,sp5ce1 & practis$ by him 9 ne>ly e case3--,) a broad /rong bi/\ry ,i cut d[n ^u ! inn] aspect ( ! head ( ! hum]us1 imm$iately ext]nal to ! coracoid process1 & c>ry ! incision d[n ?r\gh ! clavicul> fibres ( ! deltoid & pectoralis major muscles till ,i rea* ! hum]al atta*m5t ( ! latt] muscle1 :i* ,i divide4 ,i !n ) a g5tle curve c>ry my incision across & fairly ?r\gh ! l[] fibres ( ! deltoid t[>ds1 b n ?r\gh1 ! po/]ior bord] ( ! axilla4 ,unless ! textures be mu* torn1 ,i next m>k out ! l9e ( ! l[] "p ( ! inn] section by c>ry+ an incision ?r\gh ! sk9 & fat only1 f ! po9t :]e my /raight incision t]m9at$1 across ! inside ( ! arm to meet ! incision at ! out] "p4 ,?is insures accuracy 9 ! l9e ( union1 b is n ess5tial4 ,if ! fibres ( ! deltoid h be5 ?or\ghly divid$ 9 ! l9e ( incision1 ! flap s m>k$ out1 along ) ! po/]ior circumflex trunk1 :i* ent]s its deep surface1 c be easily sep>at$ f ! bone & jo9t1 & drawn upw>ds & backw>ds s z to expose ! head & tub]osities1 by ! po9t ( ! f+] )\t fur!r use ( ! knife4 ,! t5d9\s ins]tions ( ! capsul> muscles1 ! long head ( ! biceps1 & ! capsule1 are next divid$ by cutt+ directly ^u ! tub]osities & head ( ! bone2 & ! broad subscapul> t5don especially1 be+ v fully expos$ by ! incision1 c be mu* m easily & completely divid$ ?an 9 ! d\ble-flap me?od4 ,by keep+ ! l>ge po/]ior flap out ( ! way by a broad copp] spatula or ! f+]s ( an assi/ant1 & tak+ c>e to keep ! edge ( ! knife close to ! bone1 ! trunk ( ! po/]ior circumflex is protect$4 ,9 reg>d to ! axill>y vessels1 !y c ei!r be compress$ by an assi/ant be=e complet+ ! division ( ! s(t p>ts on ! axill>y aspect1 or to avoid all risk1 ! axill>y art]y may be expos$1 ti$1 & divid$ betwe5 two ligatures s z to all[ x to retract be=e divid+ ! o!r textures4#cc ,ano!r1 b n s good me?od ( mak+ an ext]nal flap1 is ! foll[+3--7a47 ,= ! "r arm4--,! pati5t ly+ well ov] on 8 left side1 ! surgeon /&s to ! inside ( ! arm to be remov$4 ,seiz+ ! deltoid 9 ! left1 ) ! "r he passes an amputat+ knife1 sev5 or eight in*es 9 l5g?1 f a po9t a little ne>] ! clavicle ?an ! middle space betwe5 ! acromion & coracoid processes2 !n1 transfix+ ! base ( ! deltoid1 & j graz+ ! po/]ior surface ( ! hum]us1 ?ru/s ! knife d[nw>ds & backw>ds till x protrudes at ! po/]ior m>g9 ( ! axilla4 ,:5 do+ ?is1 x is important t ! arm be held outw>ds & backw>ds1 & ev5 upw>ds1 z f> z possible to relax ! deltoid2 )\t ?is x w be impossible to make ! flap ( ! full size4 ,! flap mu/ !n be cut ( z full l5g? z c be obta9$1 f\r or five in*es at lea/4 ,an assi/ant !n holds x upw>ds1 :ile ! surgeon1 or 7if ! arm is v muscul>7 ano!r assi/ant1 br+s ! arm =w>ds well across ! pati5t's *e/1 ?us expos+ ! po/]ior aspect ( ! jo9t4 ,?is may h v possibly be5 already op5$ dur+ ! transfixion2 ! atta*m5ts ( muscles mu/ n[ be divid$1 ! knife pass$ beh9d ! head ( ! bone1 :i* is dislocat$ =w>ds1 & a suitable flap ( ! tissues 9 front cut f )9 outw>ds4 ,! assi/ant is to foll[ ! knife ) 8 f+] & compress ! vessels4 7b47 ,if ! left %\ld] is to be amputat$1 ! pati5t ly+ on 8 "r side1 ! surgeon /&s beh9d him1 & rais+ ! elb[ ( ! limb to be remov$ f ! side1 & pull+ x slightly backw>ds1 ent]s ! knife at ! po/]ior fold ( ! axilla 7,plate ,,ii4 fig4 #b71 & pass+ ! po/]ior aspect ( ! head ( ! hum]us1 endeav\rs to protrude x z ne> ! acromion z possible2 ! flaps mu/ be cut & ! re/ ( ! op]ation p]=m$ 9 ! mann] we h j describ$ = ! o!r arm4 #c4 ,:]e ! de/ruction ( tissue has be5 *iefly bel[ ! jo9t1 a v good flap may be obta9$ f above1 compos$ *iefly ( ! deltoid muscle1 & ! sk9 ov] x4 ,?is may be made by transfixion at its base1 b is bett] obta9$ by dissection f )\t4 ,! surgeon cuts 7,plate ,,ii4 figs4 #c1 #c7 9 a semilun> direction 7) ! convexity d[nw>ds7 f "o side ( ! deltoid to ! o!r1 viz41 f ! root ( ! acromion to ne> ! coracoid process2 he !n raises ! l>ge flap upw>ds & ?r[s x back1 op5s ! jo9t1 dis>ticulates1 passes ! knife beh9d ! head ( ! bone1 & cuts out )\t attempt+ to save any flaps bel[1 9 a transv]se direction4 ,by ?is means ! art]y is /ill almo/ ! la/ /ructure to be divid$1 & c be secur$ by a ready assi/ant4 ,9 cases :]e mu* injury has be5 done to ! floor ( ! axilla & wall ( *e/1 ! deltoid flap mu/ be made l>ge 9 proportion1 & triangul> r ?an semilun> 9 %ape4 ,n4,b4--,! /ati/ics ( amputation at ! %\ld]-jo9t br+ out "s int]e/+ facts3 #a4 ,t ! prim>y amputations "h are f> m successful ?an second>y ones4 ,gu?rie records n9ete5 cases ( ! =m] out ( :i* only "o di$1 :ile out ( a simil> numb] 9 :i* ! amputation 0 second>y1 fifte5 di$4 ,9 ! ,crimea1 ,briti% surgeons _h ?irty-n9e cases1 ) ?irte5 dea?s2 ( ?irty-?ree prim>y1 n9e di$2 & ( six second>y1 f\r 7 fatal4 ,s4,w4 ,gross's#cd /ati/ics confirm ?is3 ( "o hundr$ & sev5ty-eight prim>y1 =ty-six di$--#be4h p] c5t42 n9ety-five second>y1 sixty-"o di$--#fd4b p] c5t4 ,,amputations ,,above ,,! ,,%\ld]-,,jo9t4--,"u ?is head we may gr\p ! comp>atively r>e cases 9 :i*1 f accid5t or disease1 ! removal ( portions ( ! scapula & clavicle1 or ev5 ! entire bones1 is r5d]$ necess>y4 ,t x is q possible to survive su* injuries has be5 frequ5tly %[n 9 cases ( accid5t :5 ! scapula along ) ! arm has be5 torn (f1 & yet ! pati5t recov]$4 ,enc\rag$ by su* cases1 ,gaetani ,bey ( ,cairo remov$ ! :ole ( scapula & "p ( ! clavicle 9 a case :]e he _h amputat$ at ! %\ld] = sma%4 ,! pati5t recov]$4 ,h]on ,watson has _h a simil> case4 ,dr4 ,george ,m',lellan amputat$ arm & scapula 9 a y\? ( sev5te5 = an enorm\s encephaloid tum\r4 ,fifty-"o su* cases are n[ on record4 ,syme amputat$ ) success ! arm along ) ! scapula & out] half ( clavicle1 9 a case 9 :i* he _h previ\sly excis$ ! head ( ! hum]us = a tum\r4#ce ,gilb]t1 ,mussey1 ,rigaud1 ,f]gusson1 & o!rs h p]=m$ simil> op]ations1 second>y to amputation at ! %\ld]-jo9t1 = cases ( c>ies & malignant tum\r4 ,x is impossible to give any exact directions = ! incisions :i* mu/ be plann$ = individual cases1 ) two *ief aims1 to avoid hmorrhage z f> z possible1 & to leave abundance ( sk94 ,9 op]ations on ! scapula1 x %\ld be freely expos$ by l>ge en\gh incisions4 7,see ,excisions47 ,,amputations ,,( ,,l[] ,,extremity4--,comm5c+ ) ! mo/ di/al1 & gradually work+ our way upw>ds1 we f9d t p>tial amputations ( ! toes are extremely r>e4 ,only 9 ! case ( ! great toe is su* an op]ation ev] admissible1 = ! o!r toes are s %ort1 & ! /umps left by amputation are at once s useless f _! %ortness1 & s detrim5tal f ! mann] 9 :i* !y project upw>ds & rub aga9/ ! %oe1 t any injury requir+ p>tial amputation ( a less] toe is treat$ by its complete removal4 ,illu/ration3 ,,fig4 ,v4 ,,amputation ,,( ,,di/al ,,phalanx ,,( ,,great ,,toe4--,?is is comp>atively r>ely requir$ n[4 ,x us$ to be ?\ght necess>y = ! cure ( ^? n uncommon cases ( exo/osis ( ! di/al phalanx1 b x is n[ f\nd t mo/ ( ^! c be cur$ by simply clipp+ (f ! exo/osis4 ,:5 necess>y1 h[ev]1 & :5 ! *oice ( flaps is possible1 ! be/ plan is by a long flap f ! plant> surface 7,fig4 ,v4 #d71 z 9 ! simil> op]ation on ! ?umb2 lay+ ! edge ( ! knife ov] ! dorsal aspect ( ! jo9t1 cutt+ ?r\gh x1 & turn+ ! edge ( ! knife r\nd close to ! bone1 s z to cut out a l>ge flap f ! ball ( ! toe4 ,,amputation ,,( ,a ,,s+le ,,less] ,,toe--second1 ?ird1 or f\r?4--,?is op]ation is on exactly ! same pr9ciple z t describ$ = ! correspond+ f+]2 b x mu/ be rememb]$ t ! metat>so-phalangeal jo9t is m deeply situat$ 9 ! s(t p>ts ?an is ! metac>po-phalangeal2 & ?us ! comm5cem5t ( ! elliptical incision :i* is to surr\nd ! base ( ! toe mu/ be proportionally high] up 7,fig4 ,v4 #a74 ,on ! o!r h&1 z x is v important to avoid z mu* z possible any cicatrix 9 ! sole ( ! foot1 ! plant> end ( ! incision ne$ n be c>ri$ to a po9t exactly opposite ! "o f :i* x set out1 b x w be suffici5t if x rea*es ! groove betwe5 ! toe & sole4 ,a little m c>e may ?us be requir$ 9 dissect+ out ! head ( ! fir/ phalanx1 b ?is is q repaid by ! cicatrix 9 ! sole be+ avoid$4 ,e>ly division ( flexor t5dons r5d]s dis>ticulation easy4 ,,amputation ,,( ,,! ,,fir/ ,,& ,,fif? ,,toes4--,! incisions are conduct$ on ! same pr9ciple z 9 ! o!r op]ations1 ! op]ator be+ c>eful to pres]ve z mu* z possible 7,fig4 ,v4 #b7 ( ! h>d useful pad ( ! inn] & out] sides respectively4 ,mo/ surgeons are n[ agre$ t 9 ^! toes x is be/ n to remove ! head ( ! metat>sal bone ) ! toe4 ,cutt+ (f ! l>ge c>tilag9\s head obliquely ) a pair ( bone-pli]s may prev5t an awkw>d unseemly projection1 b x does dim9i% ! /r5g? ( ! transv]se ar* ( ! foot4 ,,amputation ,,( ,,"o ,,or ,,m ,,toes ,,) ,,_! ,,metat>sals4--,x is n necess>y to give v p>ticul> details reg>d+ su* op]ations1 z ! surgeon mu/ be guid$ 9 ! individual cases by ! specialties ( accid5t or disease4 ,"o or two guid+ pr9ciples are important3-- #a4 ,hav+ made up y\r m9d at :at po9t y are to cut ! metat>sal1 if ! amputation be a p>tial "o1 or z to ! exact position ( ! jo9t1 if y int5d to dis>ticulate1 comm5ce y\r dorsal incision 7,fig4 ,v4 #c7 at a po9t fully half an in* high] up ?an ! select$ spot1 z free access is ( ! v la/ importance4 #b4 ,:5ev] x is possible1 cut ! bone ?r\gh its cont9uity r ?an dis>ticulate4 ,specially is ?is important 9 ! case ( ! metat>sal bone ( ! great toe1 t ! ins]tion ( ! t5don ( ! p]oneus longus may be sav$4 ,if1 h[ev]1 ! t]m9al bran* ( ! dorsalis p$is art]y be w\nd$1 x may be necess>y to dis>ticulate ! fir/ metat>sal to secure x r ?an tru/ to compression to /op ! ble$+4 #c4 ,9 cutt+ ?r\gh ! fir/ & fif? metat>sals1 rememb] to apply ! bone-pli]s obliquely1 n transv]sely1 s z to avoid unseemly projection4 #d4 ,z f> z possible avoid cutt+ into ! sole at all4 ,! plant> cicatrix is almo/ a fatal objection to a plan ( remov+ ! fir/ & fif? toes & _! metat>sals :i* has mu* o!rwise 9 rapidity & elegance to recomm5d x4 ,9 ! great toe1 = example1 x is p]=m$ z foll[s3--,seiz+ ! s(t p>ts ( ! inn] edge ( ! foot 9 8 left h&1 ! surgeon draws !m inw>ds1 transfixes j at ! t>so-metat>sal jo9t1 &1 keep+ z close z possible to ! inn] edge ( ! metat>sal bone1 cuts ! flap z long z to ! middle ( ! fir/ phalanx2 !n ! s(t p>ts ( ! foot be+ drawn z f> outw>ds z possible by an assi/ant1 ! surgeon ent]s 8 knife betwe5 ! fir/ & second toes1 & succe$s 9 ent]+ 8 =m] incision s z to sep>ate ! metat>sal bone )\t remov+ any sk94 ,all t rema9s is to op5 ! t>so-metat>sal jo9t4 ,x is a v neat-look+ op]ation1 leaves a v good cov]+ = ! p>ts1 & is p]=m$ ) extreme rapidity4 ,?is la/ is n s mu* requir$ 9 ^! days ( an/hetics1 & ! cicatrix 9 ! sole is a v =midable objection to x4 ,! simple/ & %orte/ rule t c be giv5 = ! amputation ( a toe1 ) ! "p or :ole ( its metat>sal1 is to make "o dorsal incision1 comm5c+ ab\t a qu>t] ( an in* above ! spot at :i* y int5d to divide ! bone or to dis>ticulate1 ext5d+ d[nw>ds 9 a /raight l9e to ! metat>so-phalangeal articulation1 & !n bifurcat+ s z to surr\nd ! base ( ! toe at ! normal fold ( ! sk94 ,! s(t p>ts are !n to be cle>$ f ! metat>so-phalangeal jo9t1 & ! toe /ill be+ reta9$ on ! metat>sal bone1 x %\ld be c>efully dissect$ up1 avoid+ any prick+ ( ! s(t p>ts bel[1 till ! jo9t is rea*$1 or ! spot at :i* ! bone-pli]s are to be appli$ is fully cle>$4 ,,amputation ,,( ,,! ,,ant]ior ,,portion ,,( ,,! ,,foot ,,at ,,! ,,t>so-,,metat>sal ,,jo9t--,,hey',s ,,op]ation4--,?is op]ation1 :i* is n[ comp>atively r>ely p]=m$1 has be5 inve/$ ) a halo ( difficulty & complexity :i* is to a great ext5t unnecess>y4 ,!re is no d\bt t ! anatomical con=mation ( ! jo9ts involv$1 especially ! mann] 9 :i* ! head ( ! second metat>sal 7,fig4 ,v4 ,c7 projects upw>ds into ! t>sus1 & is lock$ betwe5 ! cunei=m bones1 r5d]s dis>ticulation 9 ! heal?y foot r difficult2 b x mu/ be rememb]$ t 9 cases :]e = accid5t we h to deal ) previ\sly heal?y tissues1 x is q unnecess>y to dis>ticulate1 a bett] result be+ atta9$ by simply saw+ ! foot across 9 ! l9e ( ! articulation2 & aga91 :]e we h to op]ate = disease1 ! tissues are s matt$1 & ! bones s s(t1 t complete removal ( ! metat>sus is mu* easi] ?an x appe>s :5 practis+ on ! dead subject4 ,v v>i\s plans ( incision h be5 propos$4 ,mr4 ,hey's orig9al proc$ure has n be5 mu* improv$ ^u4 ,8 %ort acc\nt ( x has at once surgical value & hi/orical int]e/3-- ,i made a m>k across ! upp] "p ( ! foot1 to po9t out z exactly z ,i c\ld ! place :]e ! metat>sal bones 7 jo9$ to ^? ( ! t>sus4 ,ab\t half an in* f ?is m>k1 ne>] ! toes1 ,i made a transv]se incision ?r\gh ! integum5ts & muscles cov]+ ! metat>sal bones 7,plate ,,iv4 figs4 #aj1 #aa74 ,f ea* extremity ( ?is w\nd ,i made an incision 7along ! inn] & out] side ( ! foot7 to ! toes4 ,i remov$ all ! toes at _! junction ) ! metat>sal bones1 & !n sep>at$ ! integum5ts & muscles =m+ ! sole ( ! foot f ! inf]ior "p ( ! metat>sal bones1 keep+ ! edge ( my scalpel z ne> ! bones z ,i c\ld1 t ,i might bo? exp$ite ! op]ation & pres]ve z mu* muscul> fle% 9 ! flap z possible4 ,i !n sep>at$ ) ! scalpel ! f\r small] metat>sal bones at _! junction ) ! t>sus1 :i* 0 easily effect$1 z ! jo9ts lie 9 a /raight l9e across ! foot4 ,! project+ "p ( ! fir/ cunei=m bone :i* supports ! great toe ,i 0 oblig$ to divide ) a saw4 ,! art]ies1 :i* requir$ a ligature1 be+ ti$1 ,i appli$ ! flap :i* _h =m$ ! sole ( ! foot to ! integum5ts :i* rema9$ on ! upp] "p1 & reta9$ !m 9 contact by sutures4444 ,! pati5t c\ld walk ) firmness & ease2 %e 0 9 no dang] ( hurt+ ! cicatrix by /rik+ ! place :]e ! toes _h be5 aga9/ any h>d sub/ance1 = ?is "p 0 cov]$ ) ! /rong integum5ts :i* _h be=e con/itut$ ! sole ( ! foot4 ,! cicatrix 0 situat$ ^u ! upp] "p ( ! foot1 & _h v little bread?1 z ! divid$ p>ts _h be5 kept unit$ aft] be+ br\ght into close contact4#cf ,lisfranc's me?od has1 briefly1 ! foll[+ modifications4--,hav+ fix$ ! position ( ! articulations ( ! fir/ & fif? metat>sals ) ! t>sus1 ! op]ator unites !m by a curv$ incision across ! dorsum ( ! foot1 ) its convexity d[nw>ds4 ,he !n divides ! dorsal ligam5ts ov] ! articulations1 op5s ! fir/ f ! inside1 ! fif?1 f\r?1 & ?ird f ! outside1 he !n ) a /rong n>r[-blad$ knife divides ! int]osse\s ligam5ts betwe5 ! sides & end ( ! head ( ! second metat>sal & ! cunei=ms1 ?us complet+ ! dis>ticulation2 b5d+ ! =e "p ( ! foot d[nw>ds1 he !n keeps ! edge ( ! knife close to ! l[] surface ( ! bones1 sep>at+ ! plant> ligam5ts1 & cutt+ out a long plant> flap ( sk9 & muscles4 ,9 e case x mu/ be rememb]$ t ! upp] end ( ! fif? metat>sal projects f> up along ! out] edge ( ! foot4 ,all[ance mu/ be made = ?is projection 9 comm5c+ ! incision4 ,a rule giv5 by ,mr4 ,syme to guide ! dis>ticulation ( ! ?ree out] metat>sals w (t5 be ( s]vice2 x is ?is3 ,hav+ once ent]$ ! jo9t ( ! fif?1 ! knife mu/ be drawn along 9 a direction ( a l9e drawn t[>ds ! di/al end ( ! fir/ metat>sal2 = ! f\r?1 ! direction mu/ be *ang$ to ! middle ( ! same bone2 & to op5 ! ?ird x w be necess>y to come across ! dorsum ( ! foot z if int5d+ to rea* ! proximal end4 ,to avoid ! difficulties ( dis>ticulation1 ,skey recomm5ds cutt+ (f ! head ( ! second metat>sal ) a pair ( pli]s4 ,baud5s1 ,gur91 & o!rs approve ( saw+ all ! bones across 9 ! l9e desir$4 ,mo/ surgeons are n[ agre$ t 9 ?is op]ation x is bett] to make bo? flaps by cutt+ f )\t1 9 pref]5ce to transfixion ( ! plant> "o f )94 ,9 cases :]e1 f injury & disease1 ! plant> flap is defici5t 9 size1 x may be necess>y to make ! dorsal flap long]4 ,h[ev]1 ! long plant> is pref]able bo? f its sup]ior h>dness1 & also because f its l5g? x p]mits ! cicatrix to be well on ! dorsum ( ! foot1 & !re=e less likely to be injur$ by ! pressure ( ! boot 9 front4 ,,amputations ,,?r\gh ,,! ,,t>sus4--,v>i\s plans ( amputat+ ?r\gh ! t>sus h be5 devis$ & describ$ at great l5g?4 ,! mo/ important ( ^! is ! op]ation ( removal ( ! ant]ior portion ( ! foot1 at ! jo9ts betwe5 ! a/ragalus & scaphoid1 & os calcis & cuboid1 well kn[n to ! pr(ession by ! "n ( its fir/ describ]1 ,*op>t4 ,x has be5 s completely sup]s$$ by ! inf9itely pref]able amputation at ! ankle-jo9t ( ,mr4 ,syme1 z r>ely1 if ev]1 to be practis$ 9 ?is c\ntry4 ,inde$1 amputation at ! ankle-jo9t may be said to h tak5 ! place ( all ^! amputations ?r\gh ! t>sus2 = ?\gh cases are occasionally met ) 9 :i* ! limitation ( ! disease or injury may r5d] ,*op>t's possible1 & ?\gh at fir/ sight x appe>s to h an advantage 9 remov+ less ( ! body1 /ill ! foll[+ objections are ne>ly fatal to its *ance ( be+ select$3--#a4 ,9 cases ( injury1 ?r\gh leav+ a long /ump1 &1 at fir/ sight1 a useful "o1 exp]i5ce %[s t ! t5do ,a*illis soon] or lat] 7be+ unoppos$ by ! ext5sors ( ! toes7 draws up ! heel s z to make ! end ( ! /ump po9t1 & ! cicatrix press on ! gr\nd1 r5d]+ x unable to be> any weight4 #b4 ,9 cases ( removal = disease ( ! t>sus1 ! bones left beh9d1 ?\gh app>5tly s\nd at ! "t1 are almo/ sure to become ev5tually diseas$4 ,z x has an hi/orical int]e/1 & z ?is op]ation 7defective z x is7 _h be5 ! means ( sav+ _m legs prior to ! inv5tion ( amputation at ! ankle-jo9t1 a brief description may be app5d$3-- ,*op>t's own mann] ( op]ation 0 briefly some:at z foll[s3-- ,! t\rniquet hav+ be5 appli$1 ! surgeon is to make a transv]se incision ?r\gh ! sk9 :i* cov]s ! in/ep1 two in*es f ! ankle-jo9t4 ,he is to divide ! sk91 & ! ext5sor t5dons1 & ! muscles 9 t situation1 s z to expose ! convexity ( ! t>sus4 ,he is next to make on ea* side a small longitud9al incision1 :i* is to beg9 bel[ & a little 9 front ( ! malleolus1 & is to end at "o ( ! extremities ( ! fir/ incision4 ,aft] hav+ =m$ 9 ?is way a flap ( integum5ts1 he is to let x be drawn upw>ds by ! assi/ant :o holds ! leg4 ,!re is no occasion to dissect & reflect ! flap1 = ! cellul> sub/ance connect+ ! sk9 ) ! subjac5t aponeurosis is s loose1 t x c easily be drawn up above ! place :]e ! jo9t ( ! calcaneum ) ! cuboides & t betwe5 ! a/ragalus & scaphoides ought to be op5$4 ,! surgeon w p5etrate ! la/ ! mo/ easily1 p>ticul>ly by tak+ = 8 guide ! em95ce :i* indicates ! atta*m5t ( ! tibialis anticus muscle to ! inside ( ! os navicul>e4 ,! jo9t ( ! os cuboides & os calcis lies pretty ne>ly 9 ! same transv]se l9e1 b r obliquely =w>ds4 ,! ligam5ts hav+ be5 cut1 ! foot falls back4 ,! bi/\ry is !n to be put d[n1 & ! /raight knife us$1 ) :i* a flap ( ! s(t p>ts is to be =m$ "u ! t>sus & metat>sus1 long en\gh to admit ( be+ appli$ to ! nak$ bones1 s z entirely to cov] !m4 ,x is to be ma9ta9$ 9 position ) ?ree or f\r /raps ( adhesive pla/]1 etc4#cg ,*op>t's amputation1 aft] an int]val ( comp>ative neglect1 0 introduc$ into ?is c\ntry by ,mr4 ,syme 9 #ahbi4 ,8 me?od ( p]=mance is simpl] & easi] ?an ,*op>t's4 ,he ?us describes x3--,! blade ( ! knife employ$ %\ld be ab\t six in*es long1 & half an in* broad1 %>p at ! po9t & blunt on ! back4 ,! t\rniquet ought to be appli$ imm$iately above ! ankle1 hav+ compresses plac$ ov] ! po/]ior & ant]ior tibial art]ies4 ,! surgeon %\ld measure ) 8 eye ! middle di/ance betwe5 ! malleolus ext]nus & ! head ( ! metat>sal bone ( ! little toe1 :i* is ! situation ( ! articulation betwe5 ! os cuboides & os calcis4 ,plac+ 8 =ef+] "h1 he ought to place 8 ?umb on ! o!r side ( ! foot directly opposite1 :i* w %[ him :]e ! os navicul>e & a/ragalus are connect$4 ,an incision 7,plate ,,ii4 figs4 #d & #e7 some:at curv$1 ) its convexity =w>d1 is !n to be made f "o ( ^! po9ts to ! o!r1 :51 in/ead ( proce$+ to dis>ticulate1 ! op]ator %\ld transfix ! sole ( ! foot f side to side at ! extremities ( ! fir/ incision1 & c>ry ! knife =w>ds s z to deta* a suffici5t flap1 :i* mu/ ext5d ! :ole l5g? ( ! metat>sus to ! balls ( ! toes4 ,! dis>ticulation may f9ally be complet$ ) great ease1 z ! %ape ( ! articul> surfaces conc]n$ is v simple1 & ne>ly transv]se4#ch ,reg>d+ ! me?od ( dis>ticulat+ at ! a/ragalo-calcaneal jo9t1 & remov+ all ! foot except ! a/ragalus1 no detail ne$ be giv54 ,malgaigne advises an int]nal flap1 ?us sacrific+ ! valuable pad ( ! heel4 ,r\x1 ,v]neuil1 & o!rs endeav\r to save ! pad4 ,?is op]ation1 h[ev]1 has n[ fall5 almo/ completely into disuse4 ,,suba/ragaloid ,,amputation has be5 highly recomm5d$4 ,9 x ! flap is made z 9 ,syme's1 !n ant]ior bones remov$ z 9 ,*op>t's1 & os calcis grasp$ by lion =ceps & twi/$ (f1 its atta*m5t & ! ins]tion ( t5do ,a*illis be+ cauti\sly avoid$4 ,if flaps are scanty1 head ( a/ragulus may be cut (f ) a small saw4--,hancock & ,a%ur/4 ,,tripi]',s ,,amputation#ci is a modification ( above1 ! sk9 incisions be+ made z 9 ,*op>t's amputation1 & !n ! calcaneum is sawn ?r\gh on a level ) ! su/5taculum tali on a plane at "r angles to ! axis ( ! leg4 ,,amputation ,,at ,,! ,,ankle-,,jo9t1 ,,or ,,syme',s ,,amputation4--,?is op]ation is "o ( mu* int]e/ & great practical importance4 ,9 our cold v>iable climate c>ies ( ! bones ( ! t>sus1 & /rum\s disease ( ! ankle-jo9t1 are v common & v intractable maladies1 & = bo? ( ^!1 :5 f> advanc$1 ,syme's amputation is ! only ju/ifiable proc$ure4 ,:5 prop]ly done1 accord+ to ! exact plan ( its propos]1 x removes ! :ole ( ! diseas$ p>ts & n an in* m1 is an op]ation ( v slight dang] to life1 & results almo/ inv>iably 9 a ?or\ghly useful com=table /ump4 ,mu* ( its success dep5ds on ! mann] 9 :i* x is p]=m$1 & z _m surgical manuals are n suffici5tly full1 "s positively 9 error reg>d+ ?is po9t1 & z v _m modifications h be5 devis$ dim9i%+ 9 value & applicability v mu* 9 proportion z !y div]ge f ! orig9al description1 ,i ?9k x advisable to describe ! op]ation m9utely1 & po9t out 9 detail ! p>ts ( x :i* seem absolutely ess5tial to success4 ,op]ation4--,! foot be+ held at a "r angle to ! leg1 ! po9t ( a /raight bi/\ry1 ) a pretty /rong blade1 %\ld be ent]$ j bel[ ! c5tre ( ! ext]nal malleolus 7,plate ,,iv4 figs4 #ab1 #ac71 7#a47 & !n c>ri$ "r across ! integum5ts ( ! sole1 9 a /raight l9e 7or 9 ! case ( a prom95t heel1 slightly backw>ds71 7#b47 to a po9t at ! same level on ! opposite side4 7#c47 ,?is incision %\ld rea* boldly ?r\gh all ! tissues d[n to ! bone4 ,hold+ ! heel 9 ! f+]s ( 8 left h&1 ! op]ator !n ins]ts 8 left ?umb-nail into ! incision1 & pu%es ! flap d[nw>ds1 z ) ! knife kept close to ! bone1 & cutt+ on x1 he frees ! flap f its atta*m5ts4 ,! ?umb-nail gu>ds ! knife f 9 any way scor+ ! flap4 7#d47 ,?is process is cont9u$ till ! tub]osity ( ! os calcis is fairly turn$1 & ! t5do ,a*illis ne>ly rea*$4 ,%ift+ 8 left h& he !n ext5ds ! foot1 & jo9s ! extremities ( ! fir/ incision by a transv]se "o "r across ! in/ep4 7#e47 ,?us he op5s ! jo9t betwe5 ! a/ragalus & tibia1 7#f47 divides ! lat]al ligam5ts1 dis>ticulates1 & /ill keep+ close to ! bone1 removes ! foot by ! division ( ! t5do ,a*illis4 ,! l[] ends ( ! tibia & fibula are !n to be isolat$ f ! s(t p>ts1 & a ?9 slice1 includ+ bo? malleoli1 to be remov$4 ,if ! disease ( ! jo9t has affect$ ! l[] end ( ! bone1 slice aft] slice may be remov$1 till a heal?y surface ( cancellat$ texture is obta9$4 ,! vessels are !n secur$4 ,dress+ ( ! ,/ump4--,f its peculi> %ape & position1 ! escape ( any blood into ! /ump is mu* to be deprecat$1 = z x _c easily get out1 on ! "o h& x gives pa91 & may cause sl\gh+ f its pressure1 & on ! o!r x is sure ev5tually to cause suppuration1 & delay union4 ,to avoid su* results c>e mu/ be tak5 to secure e vessel t c be se52 if !re is any g5]al ooz+ x is be/ m]ely to pass ! sutures ?r\gh ! edges ( ! flaps1 b n br+ !m toge!r1 ?us leav+ ! /ump op5 = "s h\rs2 !n apply cold1 & :5 ! surfaces are fairly glaz$ ov]1 remove any clots & br+ ! flaps toge!r4#dj ,ano!r plan introduc$ by ,mr4 ,syme 0 to make a longitud9al slit 9 ! flap1 ?r\gh :i* all ! ligatures are to be drawn2 ^! give a dep5d5t dra9 to any pus t may be =m$1 & by _! pres5ce greatly exp$ite ! heal+ ( ! w\nd4 ,aga91 9 cases :]e f ! am\nt ( disease exi/+ be=e ! op]ation1 & ! gelat9\s ?ick5+ ( ! flap & neighb\r+ p>ts1 mu* suppuration may be look$ =1 probably x w be f\nd be/ to keep ! flaps q ap>t = "s days1 by /uff+ ! w\nd ) l9t1 & aim+ only at second>y union by granulations4 ,a dra9age tube pass$ ?r\gh ! bread? ( ! flap1 & br\ght out at ! angles1 & reta9$ = a few days1 w d admirably4 ,notes4--7#a47 ,if comm5c$ fur!r =w>d1 z 9 ,pirog(f's modification1 x w be f\nd difficult to turn ! corn] ( ! heel2 if fur!r back1 ! nutrition ( ! flap is endang]$4 7#b47 ,?is is v important4 ,9 sev]al well-kn[n text-books1 ev5 9 ! la/ edition ( ,gross's ,surg]y1 ! incision is figur$ pass+ obliquely =w>ds4 ,?is is a fatal error1 = besides mak+ a flap f> too long1 x =ces ! op]ator to cut fairly into ! holl[ ( ! sole1 q (f ! prom95ce ( ! os calcis1 & he f9ds t x is utt]ly impossible to free 8 flap )\t us+ great =ce1 & inevitably scor+ x 9 all directions4 ,sl\gh+ is almo/ inevitably ! result4 7#c47 ,! incision is to /op at lea/ half-an-in* bel[ ! int]nal malleolus4 ,mo/ surgical manuals1 ev5 :5 !y pr(ess to describe ,mr4 ,syme's own me?od ( op]at+1 say t ! incision %\ld ext5d f malleolus to malleolus4 ,if ?is is done1 ! flap becomes unsymmetrical1 too long1 & also ! po/]ior tibial art]y1 on :i* mu* ( ! vascul> supply ( ! flap dep5ds1 is cut4 ,:5 ! incision is prop]ly made1 ! vessel is n cut till aft] its division into ! plant> art]ies4 7#d47 ,scor+ ! flap4 ,"s may ask1 ,:y d y object to a little scor+1 ! tissues are ?ick en\gh1 & besides1 don't y advise a slit 9 ! flap y\rself8 ,yes4 ,"o look at an inject$ prep>ation w %[ t ! vessels supply+ ?is ?ick flap come to x f its inn] surface1 & are inevitably cut across 9 any scor+ ( x1 & also1 t scor+ cuts across ! vessels1 & mu/ divide doz5s ( !m2 ! slit we make is p>allel ) _! c\rse1 & may n divide "o4 7#e47 ,across ! in/ep4 ,"s au?ors recomm5d a semilun> ant]ior flap2 ?is is q unnecess>y1 increases bagg+ & delays union4 ,x c be requir$ only 9 cases :]e ! heel flap has be5 de/roy$ or less5$ by disease1 or by op]ators 9 ^: h&s ! heel flaps occasionally sl\gh4 7#f47 ,x is n impossible t a c>eless op]ator may 7by cutt+ a little too l[7 miss ! jo9t & get into ! holl[ ( ! neck ( ! a/ragalus1 :]e he may cut away = a long "t )\t mak+ mu* progress4 ,advantages4--#a4 ,x is wond]fully free ( dang] to life4 ,x is v h>d to obta9 exact /ati/ical in=mation1 b my exp]i5ce is t ! mortality is c]ta9ly n m ?an ab\t #aj p] c5t41 a v rem>kable result :5 comp>$ ) t ( amputations ?r\gh ! leg1 ! op]ation :i* us$ to be requir$ = ^? cases :i* n[ require only amputation at ! ankle-jo9t4 ,9 ! ,/ati/ical ,report by ! ,surgeon-,g5]al ( ! ,unit$ ,/ates1 #igje cases ( amputation result$ 9 dea?1 ! proportions be+ z foll[s3-- ,amputation ( hip1 #he p] c5t4 di$4 ?igh1 #fd knee1 #ee leg1 #bf ,amputation ( ankle-jo9t1 #ac p] c5t4 di$4 %\ld]1 #ci arm1 #ba =e-arm1 #af #b4 ,x is ! mo/ p]fect /ump t c be made1 9 fact ! only "o 9 ! l[] extremity :i* c be> pressure en\gh to support ! weight ( ! body2 all ! o!rs require ! weight to be di/ribut$ ov] ! g5]al surface ( ! limb by means ( app>atus4 ,a good ankle-jo9t /ump c be> ! :ole weight ( ! body1 z :5 ! pati5t hops on x )\t any artificial aid1 or )\t ev5 ! int]position ( a /ock+ betwe5 ! /ump & a /one floor4 ,m ?an ?is1 ,i h se5 a pati5t :o _h bo? 8 feet amputat$ at ! ankle-jo9t run )\t %oes or /ock+s on ! /one passages1 )\t ev5 ! aid ( a /ick1 & ) v great swiftness4 ,! reason ( ?is may be f\nd 9 ! nature ( ! flap itself1 orig9ally int5d$ to be> ! weight ( ! body1 !re be+ no cicatrix at ! "p on :i* pressure is borne4 ,i h notic$ t p]fection 9 walk+ on an ankle-jo9t /ump has a c]ta9 relation to ! fre$om ( movem5t :i* ! pad has ov] ! face ( ! bone4 ,?is ought to be pretty consid]able4 ,x is expla9$ by ! new atta*m5ts =m$ by ! t5dons1 & is "u ! control ( ! pati5t1 be+ elicit$ :5 he is told to move 8 toes4 ,x has be5 object$ to ?is op]ation t ! flap is apt to sl\gh4 ,:5 improp]ly p]=m$1 z :5 ! flap is scor$ transv]sely 9 its sep>ation1 & especially :5 ! flap is cut too long 7z has be5 already notic$71 ?is may occur2 b t !re is no?+ :atev] 9 ! position or condition ( ! flap itself t at all necessitates its sl\gh+1 is ?or\ghly prov$ by ! foll[+ rem>kable case1 giv5 by ,mr4 ,syme 9 8 volume ( ,obs]vations 9 ,cl9ical ,surg]y4 ,i quote x entire3-- ,p4,c41 ag$ ?irty-?ree1 0 admitt$ into ! hospital on ! #be? ,july #ahfj1 9 ! foll[+ /ate3--,he _h be5 treat$ 9 ! ,man*e/] ,infirm>y = popliteal aneurism by pressure1 s decid$ly appli$ t x _h caus$ an ulc]1 ( :i* ! cicatrix rema9$2 b )\t produc+ ! effect desir$4 ,! femoral art]y 0 !n ti$ ) success1 9 s f> z ! aneurism 0 conc]n$1 b ) ! unpleasant sequel1 "s mon?s aft]w>ds1 ( mortification 9 ! foot1 :i* 0 ?r[n (f1 ) ! exception ( ! a/ragalus & os calcis ) _! integum5ts1 a l>ge raw surface be+ pres5t$ 9 front :]e ! bone 0 b>e4 ,al?\gh ! pati5t 0 extremely weak1 & ! p>ts conc]n$ might be suppos$ m ?an usually dispos$ to sl\gh1 ,i did n hesitate to p]=m ! op]ation1 ) ! spe$y result ( a mo/ excell5t /ump & complete re/oration to heal?4--,pp4 #di1 #ej4 ,! modifications ( ,mr4 ,syme's orig9al op]ation h be5 v v>i\s4 ,x w be unnecess>y ev5 to "n !m all4 ,"o or two may require notice4 ,reta9+ ,mr4 ,syme's incisions 9 _! integrity1 "s op]ators pref] n to dis>ticulate ! foot1 b remove x by saw+ ?r\gh ! tibia & fibula at once1 :ile /ill 9 connection ) ! foot4 ,t mo/ excell5t surgeon & fir/-rate op]ator1 ,dr4 ,john/on ( ,montrose1 us$ to pref] ?is me?od4 ,9 cases :]e ! pad ( ! heel has be5 de/roy$ by disease or accid5t1 s z to be p>tially or entirely unavailable = ! flap1 ! late ,dr4 ,ri*>d ,mack5zie#da practis$ ! foll[+ op]ation by int]nal flap3--,) ! foot & ankle project+ f ! table ) _! int]nal aspect upw>ds1 he ent]$ ! po9t ( ! knife 7,plate ,i4 fig4 #ad7 9 ! mesial l9e ( ! po/]ior aspect ( ! ankle1 on a level ) ! articulation1 c>ri$ x d[n obliquely across ! t5do ,a*illis t[>ds ! ext]nal bord] ( ! plant> aspect ( ! heel1 along :i* x is cont9u$ 9 a semilun> direction4 ,! incision is !n curv$ across ! sole ( ! foot1 & t]m9ates on ! inn] side ( ! t5don ( ! tibialis anticus1 ab\t an in* 9 front ( ! inn] malleolus4 ,! second incision 7,plate ,,iii4 fig4 #d7 is c>ri$ across ! out] aspect ( ! ankle 9 a semilun> direction1 betwe5 ! extremities ( ! fir/ incisions1 ! convexity ( ! incision d[nw>ds1 & pass+ half an in* bel[ ! ext]nal malleolus4 ,precisely ! same pr9ciple might supply ! flap f ! out] side 9 cases :]e ! int]nal flap z well z ! heel 0 defici5t1 b probably ! nutrition ( ! ext]nal flap w\ld be m d\btful4 ,nei!r ! "o nor ! o!r is ne>ly s good z ! true heel flap1 & !y are bo? only v poor sub/itutes = x :5 x _c be _h4 ,! modification devis$ by ,dr4 ,h&yside does n seem to h any advantages ov] ! orig9al op]ation1 & has n be5 adopt$4 ,! modification inv5t$ by ,pr(essor ,pirog(f involves a mu* m important pr9ciple ?an any ( ! prec$+4 ,in/ead ( dissect+ ! flap f ! po/]ior project+ portion ( ! os calcis1 & remov+ ! t>sus entire1 he saw$ (f ! po/]ior portion ( ! os calcis obliquely1 leav+ x 9 contact ) ! pad ( sk91 :i* is reta9$4 ,imm$iately aft] mak+ ! cut :i* def9es ! po/]ior flap & divides ! tissues d[n to ! bone1 he op5s ! jo9t 9 front1 dis>ticulates1 & !n putt+ on a n>r[ saw imm$iately beh9d ! a/ragalus & ov] ! su/5taculum tali1 he saws ! os calcis obliquely d[nw>ds & =w>ds till he rea*es ! fir/ incision2 !n removes ! ends ( ! tibia & fibula & br+s up ! slice ( os calcis into contact ) !m4 ,advantages4--,x is easy ( p]=mance1 sav+ ! dissection f ! heel1 :i* "s f9d s h>d4 ,x leaves a long] limb4 ,x is said to be> pressure bett]1 & !re is c]ta9ly n s mu* *ance ( bagg+ ( pus1 & ! mortality is exce$+ly small1 ,hancock's collect$ cases giv+ only #h4f p] c5t42 9 cases ( injury x is q a w>rantable op]ation4 ,disadvantages4--,x is contr>y to s\nd pr9ciple 9 cases ( disease1 = x wilfully leaves a portion ( ! t>sus1 9 :i* disease is almo/ c]ta9 to return4 ,x leaves too long a limb1 = x is f\nd t ! %ort5+ 9 ,mr ,syme's me?od is j suffici5t to admit ( a prop]ly con/ruct$ spr+ be+ plac$ 9 ! boot to make up = ! loss ( ! ela/ic ar* ( ! foot4 ,x br+s ! firm pad ( ! heel too mu* =w>d1 ?us t5d+ to lean ! weight ( ! body on ! s(t] tissues beh9d ! heel4 ,x takes mu* long] to unite & consolidate4 ,! au?or has n[1 9 a l>ge numb] ( cases ( ,syme's amputation = disease1 f\nd advantage 9 leav+ ! p]io/eum 9 ! heel flap1 i4e4 he cuts fairly into ! os calcis :5 divid+ ! sk9 ( heel1 & !n us+ a p]io/eum scrap] in/ead ( ! knife1 x is q easy to remove ! :ole ( ! p]io/eum f ! bone2 ?is results 9 a l>ge & m r\nd$ pad ( great /r5g? & ?ickness4 ,9 cases :]e f disease or injury x is impossible to obta9 ei!r a heel flap or a sub/itute lat]al "o1 ! "q is1 ,:]e %\ld amputation be p]=m$8 ,x 0 = a long "t ! op9ion ( ne>ly all ! be/ surgeons1 & /ill is ! op9ion ( _m1 t amputation ( ! leg %\ld be p]=m$ at :at 0 kn[n z ! seat ( election1 j bel[ ! knee1 ev5 9 cases :]e abundance ( s(t p>ts c\ld be obta9$ = an amputation mu* l[] d[n4 ,! rule 9 surg]y1 to save z mu* ( ! body z possible 9 e amputation1 0 9 ! leg believ$ to be set aside by objections :i* militat$ /rongly aga9/ all ! o!r op]ations 9 ! leg except ! "o p]=m$ j bel[ ! knee4 ,v briefly1 ^! 7 some:at z foll[s3--#a4 ,j above ! ankle y h l>ge bones ) no?+ to cov] !m except sk9 & t5dons4 #b4 ,high] up 9 ! calf y h pl5ty ( muscle1 b x is all on "o side1 & t ! wrong "o2 x is v heavy1 v difficult to dress & keep 9 position1 & !n :5 y h succe$$ ) x1 ! muscle wa/es away & ! /ump is flabby4 #c4 ,& *iefly1 z 9 all ! amputations ( ! leg1 ! cicatrices are s mu* 9 ! way1 & ! bones are s ill cov]$1 t ! pati5t c nev] re/ 8 leg on ! /ump itself1 b has ei!r to re/ 8 weight on 8 patella imp++ on ! top ( a bottle-%ap$ leg1 or j to /ick out 8 /ump beh9d him & kneel on ! top ( 8 wood5 leg2 !re=e x is no use to h a /ump long] ?an a few in*es2 9 fact1 ! long] ! /ump is ! m x is 9 ! way4 ,& m ?an ?is1 _m ( ! /umps made ne> ! ankle1 or ?r\gh ! calf1 are n only useless1 b positively pa9ful4 ,! sk9 becomes atta*$ to ! bones1 ! cicatrix nev] prop]ly firms at all1 ! pati5t c h>dly be> ! pressure ( a /ock+1 f> less c he make use ( ! limb4 ,= ^! reasons1 second>y amputations bel[ ! knee are ( v common occurr5ce4 ,n[1 ?is idea has be5 mu* modifi$1 & a few isolat$ cases 9 ! pa/1 & s]ies ( cases consid]ably m num]\s 9 ! pres5t day1 %[ t "u c]ta9 conditions1 & z a result ( c]ta9 precautions 9 _! p]=mance1 su* op]ations are bo? w>rantable & successful4 ,9 ! pa/1 z we f9d 9 an erudite note 9 ,s\?'s ,*elius1 ,dionis1 ,:ite1 & ,bromfield _h ea* ( !m _m successful cases ( amputation j above ! ankle1 successful 9 s f> t artificial limbs c\ld be us$ :i* pres]v$ ! motion ( ! knee1 & gave ! pati5t mu* m comm& ( ! limb ?an is possible ) ! %ort /ump bel[ ! knee4 ,a /ill m important po9t to be rememb]$ is1 t amputation j above ! ankle is a mu* less fatal amputation ?an t j bel[ ! knee 7,li/] 9 ,holmes's ,surg]y1 #c;d ed4 vol4 iii4 p4 #gaf2 ,gross1 #f? ed4 vol4 ii4 p4 #aaac2 ,b54 ,bell1 #f? edit4 vol4 vii4 p4 #cab74 ,!re is little d\bt1 h[ev]1 t ! pr9ciple s mu* 9 vogue 9 ! pres5t day1 ( "o long ant]ior or po/]ior flap1 in/ead ( two equal flaps1 or ( circul> amputations1 has done v mu* to make amputations at ! ankle or ?r\gh ! calf ju/ifiable & useful 9 be>+ ! weight ( ! body4 ,,amputation ,,j ,,above ,,! ,,ankle4--,cases admitt+ ( ?is op]ation mu/ always be r>e1 = disease ( ! t>sus or ankle-jo9t h>dly ev] goes s f> z to contra-indicate ! p]=mance ( ,mr4 ,syme's greatly pref]able op]ation2 & an accid5t :i* w\ld require ?is op]ation f injury to ! ankle w\ld 9 mo/ cases require an amputation a good deal high] up f ! spl9t]+ ( ! tibia s apt to occur4 ,9 a suitable case ! plan ( ! op]ation %\ld be z foll[s3--,a long ant]ior flap slightly r\nd$ at ! end %\ld be cut 7,plate ,i4 figs4 #ae1 #af7--;f ! outside1 n by transfixion1--& ! ant]ior muscles dissect$ up along ) x4 ,x %\ld be long en\gh to fall d[n ov] ! face ( ! bones at ! po9t ( section1 & easily cov] ! po9t ( ! po/]ior flap1 :i* is to be made by cutt+ ?r\gh all ! tissues ) "o bold transv]se /roke ( ! knife4 ,?is op]ation1 :i* is ! plan ( ,mr4 ,teale ( ,le$s v slightly modifi$1 is equally applicable at any po9t ( ! leg1 ) ?is diff]5ce only1 t ! l5g? ( ! ant]ior flap mu/ always be c>efully proportion$ to ! mass ( ! muscul> flap beh9d x has to cov] 94 ,?is op]ation provides a sk9 cov]+1 )\t any dang] ( ! cicatrix be+ press$ on or becom+ adh]5t4 ,! au?or has )9 ! la/ few ye>s op]at$ n9e times 9 ?is mann]1 9 cases ( accid5t 9 :i* ! heel flaps _h be5 completely de/roy$2 & se5 a t5? case 9 :i* ,mr4 ,syme did s4 ,all t5 cases recov]$ completely & rapidly1 & walk$ on useful limbs1 ) ! free movem5t ( ! knee-jo9t4 ,:]e f injury 9 a muscul> pati5t a long ant]ior flap _c be _h1 rec\rse %\ld be _h at once to ! op]ation at ! seat ( election1 r ?an run ! risk ( pressure on ! cicatrix by us+ a d\ble flap op]ation1 or tru/ t brok5 re$1 ! long po/]ior flap f ! great muscles ( ! calf4 ,9 ,june #ahfe1 ,mr4 ,h5ry ,lee describ$ a me?od ( op]at+ :i* he hop$ w\ld unite ! b5efits ( ,mr4 ,teale's me?od to ! ease ( p]=mance ( ! old flap f ! calf4 ,i app5d a %ort acc\nt ( 8 me?od4 ,f its position1 h[ev]1 x has ! great disadvantage ( reta9+ ! dis*>ges1 & by its weight /ra9+ ! /it*es & weigh+ d[n ! cicatrix3-- ,,lee',s ,,amputation ( ! ,leg by a long rectangul> flap f ! ,calf4--,! op]ation describ$ 0 p]=m$ accord+ to ,mr4 ,teale's me?od1 z f> z ! ext]nal incisions 7 conc]n$1 b ! long flap 0 made f ! back in/ead ( f ! front ( ! limb 7,plate ,,iv4 figs4 #ad1 #ae74 ,two p>allel incisions 7 made along ! sides ( ! leg1 ^! 7 met by a ?ird transv]se incision beh9d1 :i* jo9$ ! l[] extremities ( ! fir/ two4 ,^! incisions1 :i* =m$ ! ?ree sides ( ! squ>e1 ext5d$ ?r\gh ! sk9 & cellul> tissue only4 ,a f\r? incision 0 made transv]sely ?r\gh ! sk9 9 front ( ! leg s z to =m a flap 9 ?is situation1 "o-f\r? only ( ! l5g? ( ! po/]ior flap4 ,:5 ! sk9 _h some:at retract$ by its natural ela/icity1 an incision 0 made ?r\gh ! p>ts situat$ 9 front ( ! bones1 :i* 7 reflect$ upw>ds to a level ) ! upp] extremities ( ! fir/ longitud9al incisions4 ,! deep] /ructures at ! back ( ! leg 7 !n freely divid$ 9 ! situation ( ! l[] transv]se incision4 ,! conjo9$ ga/rocnemius & soleus muscles 7 sep>at$ f ! subjac5t p>ts1 & reflect$ z high z ! ant]ior flap4 ,! deep] lay] ( muscles1 toge!r ) ! l>ge vessels & n]ves1 7 divid$ z high z ! incision w\ld p]mit1 & ! bones sawn ?r\gh 9 ! usual way4 ,! flaps 7 !n adju/$ 9 ! mann] recomm5d$ by ,mr4 ,teale4#db ,! pati5ts 7 able to be> ! weight ( ! body on ! end ( ! /ump4 ,9 cases ( *ronic disease1 :]e ! muscles are atrophi$ & cond5s$1 ! foll[+ po/]ior flap me?od may be us$ ) advantage4 ,x is approv$ ( by ,mr4 ,sp5ce4 ,an incision is made across ! front ( ! leg f ! po/]ior edge ( ! fibula to ! po/]ior edge ( ! tibia1 or vice v]s1 accord+ to ! limb4 ,! limb is !n transfix$ beh9d ! bones f ! same po9ts1 & a long & g5tly r\nd$ po/]ior flap cut4 ,! bones are !n clean$1 & cut ?r\gh at a little high] level4 ,,amputation ,,imm$iately ,,bel[ ,,! ,,knee at ! true seat ( election4--,! pr9ciples on :i* ?is op]ation is f\nd$ are--#a4 ,t a muscul> flap is n necess>y1 sk9 be+ p]fectly suffici5t2 #b4 ,t z ! muscles retract !y mu/ be cut at a l[] level ?an ! bones1 & z !y retract unequally f _! v>y+ l5g?1 ! cuts mu/ be made ) due ref]5ce to t inequality2 #c4 ,t no m ( ! tibia ne$ be reta9$ ?an :at is j suffici5t to reta9 ! atta*m5t ( ! ligam5tum patell1 & to insure its vitality2 #d4 ,t ! head ( ! fibula mu/ be reta9$ 9 e case1 z 9 a c]ta9 proportion ! tibio-fibul> articulation communicates ) ! knee-jo9t4 ,op]ation4--,two equal semilun> flaps ( sk9 mu/ be cut--f ! outside1 n by transfixion1--"o ant]ior & ext]nal1 ! o!r po/]ior & int]nal1 _! extremities meet+ at po9ts ab\t two in*es bel[ ! tub]osity ( ! tibia on ei!r side 7,plate ,i4 figs4 #ag1 #ah74 ,^! mu/ be reflect$ up1 & ) !m a fur!r ext5t ( sk91 embrac+ ! :ole circumf]5ce ( ! limb1 mu/ be dissect$ up 7z if pull+ (f ! f+]s ( a glove71 s z to expose ! bone "o in* bel[ ! tub]osity4 ,! ant]ior muscles be+ v close to _! orig91 & consequ5tly be+ able to retract v slightly1 mu/ be cut z high z expos$1 & ! po/]ior ones ab\t ! middle ( _! expos$ surface4 ,! bones mu/ !n be sawn z high z expos$1 ) ! foll[+ precautions3--#a4 ,9 ord] to prev5t spl9t]+ ( ! fibula1 endeav\r to saw x along ) ! tibia1 s z to f9i% x fir/2 #b4 ,to prev5t projection ( a %>p prom95ce ( ! edge ( ! tibia1 ent] ! saw obliquely a little high] up ?an :]e y int5d to divide ! bone1 !n )draw x1 & ent] ! saw aga9 at "r angles to ! bone1 & a l9e or two l[] d[n4 ,"s surgeons pref] to make ?is section aft]w>ds ) a f9] saw or ! bone-pli]s4 ,?is op]ation is v frequ5tly requir$ to rem$y pa9ful & unheal$ /umps1 ! result ( amputations l[] d[n1 specially ^? 9 :i* ! long po/]ior flap f ! muscles ( ! calf has be5 us$4 ,9 ! above amputation ! pati5t w n be able to re/ ! weight ( 8 body on ! face ( ! /ump1 b by putt+ ! limb into a well-padd$ case ) s(t r\nd$ edges1 ! weight might be borne p>tly on ! sides ( ! /ump1 & p>tly on ! l[] edge ( ! patella2 & ! pati5t w be able to walk ) great com=t1 pres]v+ ! use ( 8 knee-jo9t4 ,,amputation ,,at ,,! ,,knee-,,jo9t4--,?is relic ( anci5t surg]y1 z ,mr4 ,skey calls x1 has be5 reviv$ only ( late ye>s1 & seems 9 c]ta9 cases to be a ju/ifiable & successful op]ation4 ,practis$ by ,fabricius ,hildanus & ,guillemeau 9 ! sixte5? & sev5te5? c5turies1 x _h fall5 into disuse till reviv$ by ,ho91 ,velpeau1 & ,baud5s1 on ! ,cont95t1 ,pr(essor ,na?an ,smi? 9 ,am]ica1 & ,mr4 ,lane 9 ,london4 ,x is n possible t ?is op]ation c be at all frequ5t1 s9ce ! cases 9 :i* x is applicable are comp>atively r>e2 =1 to be successful1 ! foll[+ conditions are ess5tial3--#a4 ,t !re be abundant sk9 9 front ( ! knee-jo9t to make a long ant]ior flap2 #b4 ,t ! patella & articul> surface ( ! femur are heal?y4 ,^! conditions at once exclude ne>ly e case ( disease or accid5t4 ,if ! jo9t is diseas$ "s amputation ?r\gh ! ?igh mu/ be attempt$2 if injur$1 & ! front ( ! knee is safe1 x may v likely be possible to amputate bel[ ! knee4 ,h5ce ?is op]ation may be useful 9 cases :]e1 = malignant disease1 ! :ole tibia requires removal1 & yet ! knee-jo9t is s\nd1 or = gun%ot injuries1 9 :i* ! tibia is spl9t]$ b ! s(t tissues comp>atively un9jur$4 ,op]ation4--,a long ant]ior flap %\ld be cut ) a semilun> end 7,plate ,,ii4 figs4 #f1 #g71 ext5d+ z f> z ! ins]tion ( ! ligam5tum patell4 ,?is flap1 includ+ ! patella1 %\ld be ?r[n up1 ! jo9t cut into1 & a %ort po/]ior flap made by transfixion4 ,x is important to reta9 ! patella1 if possible1 z x fills up ! holl[ betwe5 ! condyles2 x sometimes becomes an*ylos$1 b 9 o!r cases x rema9s freely mobile1 & adds to ! value ( ! /ump4 ,pr(essor ,pancoa/ has practis$ an amputation at ! knee-jo9t by ?ree flaps1 p]=m$ entirely by ! scalpel1 :i*1 he says1 results 9 a good /ump4 ,"o flap1 ! ant]ior "o1 is longe/ & semilun> 9 %ape1 its convexity pass+ ?ree in*es bel[ ! tub]osity ( ! tibia2 ! o!r two are mu* small]1 & po/]o-lat]al4#dc ,advantages4--,! bone is n cut into at all1 !re is a free dra9 = matt]1 no t5d5cy to retraction ( ! flaps1 & ! weight ( ! body is borne on sk9 previ\sly habituat$ to pressure4 ,! /ati/ics seem to be fav\rable3 out ( #ee cases1 ,cont95tal1 ,am]ican1 & ,engli%1 #ba di$1 a mortality ( #ch p] c5t41 :ile 9 a table ( #ajee cases ( amputation ( ! ?igh1 #dfd di$1 be+ a mortality ( #dd p] c5t4 ,9 "s ( ! ,am]ican cases ! articulat+ extremity ( ! femur seems to h be5 remov$1 z 9 ! foll[+ op]ation3-- ,,amputation ,,?r\gh ,,! ,,condyles ,,( ,,! ,,femur4--,9 ! ,london & ,ed9burgh ,j\rnal ( ,m$ical ,sci5ce = #ahde1 ,mr4 ,syme advocat$ a me?od ( amputation ?r\gh ! condyles ( ! femur z specially suitable 9 case ( diseas$ knee-jo9t4 ,amputation at ?is spot has c]ta9 advantages3--#a4 ,! %aft ( ! bone be+ unt\*$1 !re is no injury ( ! m$ull>y cavity1 & h5ce no fe> ( inflammation ( its l9+ membrane4 #b4 ,!re is less risk ( exfoliation1 ! cancellat$ texture ( ! epiphysis n be+ liable to x4 #c4 ,be+ close to ! jo9t1 ! muscles are cut ?r\gh :]e !y are t5d9\s1 ?us v mu* dim9i%+ ! risk ( retraction & consequ5t protrusion ( ! bone4 #d4 ,a l>ge broad surface ( bone is left to be> ! weight ( ! body1 & "o :i*1 l ! ankle-jo9t /ump1 w r\nd (f & af=d a com=table pad ov] :i* ! sk9 ( ! flap w freely play4 ,"o objection us$ to be urg$ aga9/ ?is mode ( op]at+1 ! fe> le/ ! ?ick5$1 brawny1 & (t5 ulc]at$ textures 9 ! neighb\rhood ( a diseas$ knee-jo9t1 w\ld n make a good cov]+4 ,?is1 h[ev]1 is no long] a bugbe>1 z we see 9 cases ( resection1 :]e ! diseas$ jo9t alone is tak5 away1 h[ v soon all swell+ & disease dep>ts1 once its cause is remov$4 ,mr4 ,syme's orig9al op]ation 0 briefly z foll[s3--,) an ord9>y amputat+-knife make a lunat$ incision 7,plate ,i4 fig4 #ai7 f "o condyle to ! o!r1 across ! front ( ! jo9t1 on a level ) ! middle ( ! patella1 divide ! tissues d[n to ! bones1 & !n draw ! flap upw>ds1 !n cut ! quadriceps ext5sor imm$iately above ! patella4 ,! po9t ( ! blade %\ld !n be pu%$ 9 at "o end ( ! w\nd1 ?ru/ beh9d ! femur1 & made to appe> at ! o!r end2 x %\ld !n be c>ri$ d[nw>ds 7,plate ,,iii4 fig4 #e71 s z to make a flap f ! calf ( ! leg1 ab\t six or eight in*es 9 l5g?1 9 proportion to ! ?ickness ( ! limb2 ! flap %\ld !n be slightly retract$1 & ! knife c>ri$ r\nd ! bone a little above ! condyles to cle> a way = ! saw1 :i* %\ld be appli$ s z to leave ! section z horizontal z possible4 ,?is me?od is n[ h>dly ev] us$1 z ! foll[+ seems a mu* bett] "o3-- ,,gritti',s#dd ,,amputation4--,9 ?is two flaps are =m$--an ant]ior long "o rectangul> & a po/]ior %ort "o4 ,! condyles ( ! femur are divid$ ?r\gh _! base1 & ! l[] surface ( patella is remov$ by a small saw1 & !n ! surfaces ( bone approximat$4 ,,/okes',s#de ,,modification ,,( ,,gritti',s ,,amputation4--,9 ?is supracondyloid amputation1 ! femur is sawn j above ! condyles1 )\t go+ into ! m$ull>y canal4 ,! ant]ior flap is oval1 twice z long z po/]ior1 & ! patella is br\ght up aft] d5udation aga9/ end ( femur4 ,,c>d5',s ,,amputation ,,at ,,! ,,condyles ,,( ,,! ,,femur4#df--,! op]ation consi/s 9 reflect+ a r\nd$ or semi-oval flap ( sk9 & fat f ! front ( ! knee-jo9t1 divid+ ev]y?+ else /raight d[n to ! bone1 & saw+ ! bone slightly above ! plane ( ! muscles1 ?us =m+ a flat-fac$ /ump1 ) a bonnet ( integum5t to fall ov] x4 ,! op]ator /&+ on ! "r side ( ! limb1 seizes x betwe5 8 left =ef+] & ?umb at ! spot select$ = ! base ( ! flap1 & ent]s 7,plate ,,ii4 fig4 #h7 ! po9t ( ! knife close to 8 f+]1 br++ x r\nd ?r\gh sk9 & fat bel[ ! patella to ! spot press$ by 8 ?umb2 !n turn+ ! edge d[nw>ds at a "r angle ) ! l9e ( ! limb1 he passes x ?r\gh to ! spot :]e x fir/ ent]$1 cutt+ outw>ds ?r\gh ev]y?+ beh9d ! bone 7,plate ,,iv4 fig4 #af74 ,! flap is !n reflect$1 & ! rema9d] ( ! s(t p>ts divid$ /raight d[n to ! bone2 ! muscles are !n slightly cle>$ upw>ds1 & ,i saw x appli$4 ,i h v5tur$ to make a slight *ange 9 ! me?od ( p]=m+ ?is mo/ excell5t op]ation1 = hav+ f\nd ! po/]ior flap1 z cut 9 ! me?od above describ$1 r scanty 9 ! e>li] cases 9 :i* ,i h _h occasion to p]=m x1 aft] dissect+ back ! ant]ior flap & cutt+ into ! knee-jo9t1 ,i %ape a slightly convex po/]ior flap ( sk9 only1 at lea/ "o & a half in*es 9 l5g? 9 adult1 & all[ x to retract be=e divid+ ! muscles by a circul> cut to ! bone1 & h _h e reason to be satisfi$ ) ! *ange4 ,,amputation ,,( ,,! ,,?igh4--,amputation ( ! ?igh has be5 ! fav\rite battle-gr\nd :]e flap & circul>1 ant]o-po/]ior & lat]al1 long & %ort flaps1 d\ble1 triple1 & conical incisions1 h /riv5 ) ea* o!r2 s 7 ,i to attempt to describe "o qu>t] ( ! v>i\s me?ods employ$1 ,i %\ld ne$ to rewrite ! hi/ory ( ,amputation4 ,x w suffice m]ely to describe ! be/ modes ( amputat+ ! ?igh ?r\gh its l[]1 middle1 & upp] ?irds respectively1 & at ! hip-jo9t4 ,9 "o ^w1 x may be /at$ t1 ) ! exception ( ^? amputations p]=m$ ?r\gh ! l[] ?ird ( ! bone1 ! flap me?od is to be pref]r$1 & ! flaps %\ld 9 almo/ e case be made by transfixion4 ,9 ! l[] ?ird1 h[ev]1 ! flap me?od1 ?\gh exce$+ly easy1 & capable ( v rapid p]=mance1 has c]ta9 defects2 ! *ief ( ^! be+ ! t5d5cy :i* ! muscul> flaps 7! necess>y result ( transfixion7 h to cause undue retraction1 & h5ce protrusion ( ! bone4 ,?is is se5 specially 9 ! ham/r+s1 :i* f ! great di/ance ( _! orig91 & ! purely longitud9al direction ( _! fibres1 retract to a v great ext5t1 mu* m ?an ! ant]ior muscles c d f ! p5nate direction ( _! fibres1 & ! mann] 9 :i* !y are mutually b\nd d[n to ea* o!r & to ! bone4 ,ev5 9 ?is "o position1 ! l[] ?ird ( ! ?igh1 ! me?ods t may be ne$$ are v>i\s1 & require sep>ate notice2--= op]ations "h are extremely frequ5t f ! frequ5cy ( /rum\s disease ( ! knee-jo9t 9 our v>iable climate1 & f ! fact t comp\nd fractures or dislocations ( ! knee-jo9t s v (t5 necessitate amputation4 ,9 cases :]e ! sk9 ov] ! patella is un9jur$ & available1 ! op]ation by long ant]ior flap 7ei!r by ,teale's me?od1 or by ,mr4 ,sp5ce's modification ( x1 :i* curi\sly is almo/ exactly simil> to ! amputation ( ,b5jam9 ,bell by a s+le flap7 is suitable en\gh4 ,b1 ,i believe1 pref]able to ei!r ( ^! is ! op]ation ( ,mr4 ,c>d51 already describ$4 ,9 cases :]e ! knee-jo9t is injur$1 & ! sk9 ov] ! patella unavailable1 & yet :]e x is n necess>y to g high] up ! limb1 ! modifi$ circul> amputation ( ,mr4 ,syme w be f\nd v suitable4 ,z x is 9 ?is l[] ?ird ( ! ?igh t a v l>ge proportion ( ! cases requir+ a long ant]ior flap is to be f\nd1 x af=ds ! be/ opportunity = comp>+ 9 _! detail ! ?ree almo/ simil> plans ( ,b4 ,bell1 ,teale1 & ,sp5ce--aft] :i* ,mr4 ,syme's modifi$ circul> may be describ$4 ,,b5jam9 ,,bell',s ,,flap ,,op]ation ,,above ,,! ,,knee 7report$ 9 8 own words1 slightly abbreviat$74--,:5 ?is op]ation is to be p]=m$ above ! knee1 x may be done ei!r ) "o or two flaps1 b x w commonly succe$ be/ ) "o4 ,! flap answ]s be/ on ! =e "p ( ! ?igh1 = "h !re is a suffici5cy ( ! p>ts = cov]+ ! bones1 & ! matt] passes m freely (f ?an :5 ! flap is =m$ beh9d4444 ,! extreme po9t ( ! flap %\ld rea* to ! end ( ! limb1 unless ! tegum5ts are 9 any "p diseas$1 9 :i* case x mu/ t]m9ate :]e ! disease beg9s1 & its base %\ld be :]e ! bone is to be sawn4 ,?is w det]m9e ! l5g? ( ! flap1 & we %\ld be direct$ ) respect to ! bread? ( x by ! circumf]5ce ( ! limb1 = ! diamet] ( a circle be+ some:at less ?an a ?ird ( its circumf]5ce1 al?\gh a limb may n be exactly circul>1 yet by att5tion to ?is we may asc]ta9 ) suffici5t exactness ! size ( a flap = cov]+ a /ump 7,plate ,,iv4 fig4 #ag74 ,?us a flap ( f\r in*es & a qu>t] 9 l5g? w rea* completely across a /ump ^: circumf]5ce is twelve in*es2 b z "s all[ance mu/ be made = ! quantity ( sk9 & muscles t may be sav$ on ! opposite side ( ! limb1 by cutt+ !m 9 ! mann] ,i h direct$1 & draw+ !m up be=e saw+ ! bone1 & z x is a po9t ( importance to leave ! limb z long z possible1 in/ead ( f\r in*es & a qu>t]1 a limb ( ?is size1 :5 ! fir/ incision is manag$ 9 ?is mann]1 w n require a flap long] ?an ?ree in*es & a qu>t]1 & s 9 proportion1 accord+ to ! size ( ! limb4 ,! flap at its base %\ld be z broad z ! bread? ( ! limb w p]mit1 & %\ld be cont9u$ ne>ly1 al?\gh n altoge!r1 ( ! same bread? till )9 a little ( its t]m9ation1 :]e x %\ld be r\nd$ (f s z to correspond z exactly z may be ) ! figure ( ! sore on ! back "p ( ! limb4 ,?is be+ m>k$ out1 ! surgeon1 /&+ on ! outside ( ! limb1 %\ld pu% a /raight d\ble-edg$ knife ) a %>p po9t to ! dep? ( ! bone1 by ent]+ ! po9t ( x at ! outside ( ! base ( ! int5d$ flap2 & c>ry+ ! po9t close to ! bone1 x mu/ "h be pu%$ ?r\gh ! tegum5ts at ! m>k on ! opposite side4 ,! edge ( ! knife mu/ n[ be c>ri$ d[nw>ds 9 su* a direction z to =m ! flap1 accord+ to ! figure m>k$ out2 & z x draws t[>d ! end1 ! edge ( x %\ld be some:at rais$ f ! bone1 s z to make ! extremity ( ! flap ?9n] ?an ! base1 by :i* x w apply ) m neatness to ! surface ( ! sore4 ,! flap be+ support$ by an assi/ant1 ! tegum5ts & muscles ( ! o!r p>ts ( ! limb %\ld1 by "o /roke ( ! knife1 be cut d[n to ! bone1 ab\t an in* b5ea? :]e ! bone is to be sawn2 & ! muscles be+ sep>at$ to ?is height f ! bone ) ! po9t ( a knife1 ! s(t p>ts mu/ all be support$ ) ! lea!r retractors till ! bone is sawn1 etc41 art]ies ti$1 & dress+s appli$4#dg ,,amputation ,,( ,,?igh ,,by ,,rectangul> ,,flap--7,teale's74--,i take ! opportunity "h ( describ+ fully1 & z f> z possible 9 8 own words1 ,mr4 ,teale's me?od ( amputat+1 ?is be+ ! situation :]e 8 me?od is mo/ frequ5tly available4 ,! same pr9ciple may be appli$ to amputations at almo/ any o!r "p ( ! body4 ,aft] advis+ ! surgeon to m>k out ! propos$ l9e ( incision ) ink be=e ! op]ation1 he gives ! foll[+ directions = fix+ ! exact size ( ! flap3--,suppos+ ! amputation to take place 7,plate ,,ii4 figs4 #i1 #aj7 at ! l[] "p ( ! middle ?ird ( ! ?igh1 ! circumf]5ce ( ! limb is to be measur$ at ! po9t :]e ! bone is to be divid$4#dh ,assum+ ?is to be sixte5 in*es1 ! long flap is to h its l5g? & bread? ea* equal to half ! circumf]5ce1 namely1 eight in*es4 ,two longitud9al l9es ( ?is ext5t are !n trac$ on ! limb1 & are met at _! l[] po9ts by a transv]se l9e ( ! same l5g?4 ,! inn] longitud9al l9e %\ld be fir/ trac$ 9 ink z ne> z practicable to ! femoral vessels1 )\t includ+ !m )9 ! range ( ! long flap4 ,! out] longitud9al l9e1 :i* is some:at po/]ior1 is next m>k$ eight in*es di/ant f ! =m] & p>allel to x4 ,^! two l9es are !n jo9$ by a transv]se l9e ( ! same ext5t1 :i* falls ^u ! upp] bord] ( ! patella1 or ^u "s l[] portion ( ?is bone4 ,! %ort flap is indicat$ by a transv]se l9e pass+ beh9d ! ?igh1 ! l5g? ( ?is flap be+ "o-f\r? t ( ! long "o2 or1 assum+ ! circumf]5ce ( ! limb to be sixte5 in*es1 & ! l5g? ( ! long flap eight in*es1 ! l5g? ( ! %ort flap is two in*es4 ,! op]ator beg9s by mak+ ! two lat]al incisions ( ! long flap ?r\gh ! integum5ts only4 ,! transv]se incision ( ?is flap1 suppos+ x to run along ! upp] edge ( ! patella1 is made by a free sweep ( ! knife ?r\gh ! sk9 & t5d9\s /ructures d[n to ! femur4 ,%\ld ! l[] transv]se l9e ( ! flap fall across ! middle or l[] "p ( ! patella1 ! transv]se incision c ext5d ?r\gh ! sk9 only1 :i* mu/ be dissect$ up z f> z ! upp] bord] ( ! patella1 at :i* place ! t5d9\s /ructures are to be cut direct to ! ?igh-bone4 ,! flap is complet$ by cutt+ ! fle%y /ructures f bel[ upw>ds close to ! bone4 ,! po/]ior %ort flap1 conta9+ ! l>ge vessels & n]ves1 is made by "o sweep ( ! knife d[n to ! bone1 ! s(t p>ts be+ aft]w>ds sep>at$ f ! bone close to ! p]io/eum1 z f> upw>ds z ! int5d$ place ( saw+4444 ,9 adju/+ ! flaps1 ! long "o is fold$ ov] ! end ( ! bone1 & br\ght1 by its transv]se l9e1 into union ) ! %ort flap1 ! two correspond+ free angles ( ea* be+ fir/ unit$ by suture4 ,"o or two additional /it*es complete ! transv]se l9e ( union4 ,c>e is n[ requir$ 9 arrang+ ! two lat]al l9es ( union4 ,z ! long flap is fold$ ^u itself s z to =m a k9d ( p\* = ! end ( ! bone1 x is requisite t x %\ld be held 9 its fold$ /ate by a po9t ( suture on ea* side4 ,ano!r /it* on ea* side secures ! lat]al l9e ( ! %ort flap to ! correspond+ "p ( ! long "o4 ,a longitud9al l9e ( union ?us passes at "r angles ea* end ( ! transv]se l9e4#di ,mr4 ,teale's acc\nt ( ! result+ /umps is too long to quote entire1 b 9 a few words1 we f9d t by retraction ( ! %ort po/]ior flap1 ! cicatrix is drawn up q beh9d & out ( ! way ( ! bone1 t a s(t mass )\t any l>ge n]ves or vessels is ! result ( ! p>tial atrophy ( ! long flap1 & t ! pati5t is able to be> "o-half1 two-?irds1 or ev5 9 "s cases ! entire weight ( 8 body on ! face ( ! /ump4 ,su* a p[] ( support is to be f\nd 9 no o!r flap except 9 ,mr4 ,syme's amputation at ! ankle-jo9t4 ,,sp5ce',s ,,amputation ,,by ,a ,,long ,,ant]ior ,,flap4#ej--,! me?od us$ by ,mr4 ,sp5ce 9 amputations j above ! knee-jo9t obta9s ! advantages ( ,teale's me?od1 & avoids _m ( its disadvantages4 ,he makes two flaps4 ,! ant]ior "o1 :i* is to fall loosely ov] & cov] 9 ! po/]ior segm5t ( ! /ump1 mu/ h a bread? fully equal to "o-half ( ! circumf]5ce ( ! limb1 & mu/ be g5tly r\nd$ at its extremity1 s z to adju/ itself readily to ! curve ( ! cut m>g9 ( ! po/]ior half ( ! /ump4 ,he beg9s ! ant]ior incision bel[1 or on a level )1 ! l[] m>g9 ( ! patella1 & :5 ! sk9 is retract$ to a little above ! patella1 cuts d[n obliquely to ! bone1 s z to divide ! s(t p>ts up to ! base ( ! flap4 ,= ! po/]ior incision1 he beg9s ab\t two f+]s'-bread? bel[ ! base ( ! ant]ior flap1 & ! assi/ant retract+ ! sk91 ! edge ( ! knife is c>ri$ obliquely up to ! bone 79 ,alanson's mann]7 & ! po/]ior s(t p>ts divid$1 ! bone is sawn ?r\gh--or imm$iately above--! condyloid portion4 ,mr4 ,sp5ce does n advise or practise ?is me?od high up4 ,! results are good1 = by ^! means ! end ( ! bone has a ?ick cov]+1 includ+ muscul> fibres1 ov] x1 & ! cicatrix is n press$ ^u 9 walk+4 ,! /ump rema9s full1 mobile1 & fle%y1 z 9 ,mr4 ,teale's me?od1 )\t ! disadvantage :i* x has1 9 requir+ ! bone to be divid$ s f> above ! seat ( injury or disease4 ,?is is an exce$+ly good me?od ( op]at+ 9 ! l[] ?ird ( ! ?igh1 9 muscul> pati5ts ! v be/1 & 9 all cases only equall$ 9 value by ,c>d5's me?od4 ,! next is n[ h>dly ev] us$ "h1 except 9 cases :]e ! sk9 ov] ! patella is de/roy$4 ,,modifi$ ,,circul> ,,at ,,l[] ,,?ird ,,( ,,?igh 7,syme's74--,two equal semilun> flaps ( sk9 %\ld be cut 7,plate ,i4 fig4 #bj1 ,plate ,,iii4 fig4 #f71 "o ant]ior1 ! o!r po/]ior1 _! convexities be+ t[>ds ! knee4 ,! sk9 & subcutane\s cellul> tissue %\ld be rais$ f ! fascia1 & !n retract$ to a fur!r di/ance ( at lea/ two in*es2 ! muscles %\ld !n be divid$ "r d[n to ! bone1 on a level z high z !y are expos$ 9 front1 & z l[ z !y are expos$ beh9d4 ,?is all[s = ! diff]5t am\nt ( retraction at ! two sides ( ! limb1 & leaves ! muscles cut on a level2 ! :ole mass ( muscles %\ld !n be drawn well up1 & ! bone expos$1 & sawn ?r\gh at a level ab\t two in*es high] ?an :]e x 0 fir/ expos$ by ! ant]ior incision ?r\gh ! muscles4 ,9 v weak ?9 flabby limbs ?is process may be simplifi$ by j at once includ+ ! muscles 9 ! sk9 flaps1 & c>efully expos+ ! bone high] up4 ,9 p]=m+ ! retraction ! assi/ant %\ld be caution$ n to ov]do x1 le/ he /rip ! p]io/eum f ! bone high] ?an is necess>y4 ,?is is v easy to d 9 ! weak limbs ( /rum\s pati5ts1 & may cause exfoliation1 & greatly delay cure4 ,,amputation ,,9 ,,! ,,middle ,,?ird ,,( ,,! ,,?igh4--,a v %ort notice w suffice "h4 ,! exact position1 %ape1 & size ( ! flaps mu/ 9 e case be modifi$ by ! nature ( ! injury = :i* ! op]ation is p]=m$1 tak+ ! flaps :]e !y c be obta9$4 ,z a g5]al rule1 a long ant]ior flap ) a %ort po/]ior1 on ! pr9ciple describ$ above1 %\ld be pref]r$4 ,9 cases :]e ! long ant]ior _c be obta9$1 two equal flaps %\ld be made by transfixion4 ,! flaps %\ld always be ant]o-po/]ior1 ! lat]al flaps introduc$ by ,v]male1 & indors$ by ,*elius & ,eri*s51 hav+ ! great disadvantage ( all[+ ! bone1 :i* is drawn up by ! psoas & iliacus1 to project at ! upp] angle4 ,suppos+ ! "r ?igh is to be amputat$1 ! surgeon1 /&+ on ! inside ( ! leg1 %\ld raise ! sk9 & muscles ( ! front ( ! limb 9 8 left h&1 & ent]+ ! knife j 9 front ( ! vessels1 %\ld transfix ! limb1 ! knife pass+ 9 front ( ! bone1 & includ+ z ne>ly z possible an exact half ( ! limb 7,plate ,,iv4 fig4 #ai72 hav+ by a saw+ motion br\ght out ! knife & cut a flap ( ! requir$ l5g?1 ! knife is re-ent]$ at ! same place1 & pass+ beh9d ! bone1 ! po9t mu/ be br\ght out at ! angle on ! o!r side4 ,bo? flaps be+ !n held back by an assi/ant1 ! bone is cle>$ by a circul> turn ( ! knife1 & ! saw appli$1 ! vessels are f\nd cut high up 9 ! inn] angle ( ! po/]ior flap4 ,9 muscul> pati5ts x is (t5 bett] to make ! incision ?r\gh ! sk9 fir/ & all[ x to retract be=e transfix+2 ?is is sl[] & n s brilliant look+1 b avoids r$undancy ( muscle4 ,,amputation ,,at ,,! ,,hip-,,jo9t4--,?is op]ation1 exce$+ly dang]\s f ! am\nt ( ! body remov$1 ! great hmorrhage1 & ! risk ( pymia1 is ( comp>atively mod]n inv5tion4 ,?\gh ! proportion ( recov]ies is at pres5t to t ( dea?s ab\t "o to two or two & a half1 x is /ill a p]fectly ju/ifiable op]ation 9 _m cases ( disease & injury4 ,l amputation at ! %\ld]1 amputation at ! hip has giv5 rise to v _m v>i\s me?ods ( p]=mance4 ,"u ! heads ( s+le flap1 d\ble flap1 oval1 circul>1 & mix$ flap & circul>1 at lea/ tw5ty di/9ct me?ods h be5 put on record1 &1 includ+ modifications1 !re are ?irty-sev5 or ?irty-eight diff]5t surgeons :o h ea* _! own plan ( op]ation4 ,! reason ( ?is fe>ful complexity 9 its lit]ature dep5ds on ?is fact1 t ?is amputation has g5]ally be5 p]=m$ = cases ( su* sev]e injury ( ! limb1 t no mild] amputation 0 possible1 & ?us ! flaps _h to be tak5 j :]e ! surgeon c\ld get !m be/4 ,& ?is w h to be ! guid+ pr9ciple 9 mo/ amputations at ?is jo9t2 ! surgeon mu/ j cut 8 coat accord+ to 8 clo?--get 8 flaps :]e & h[ he c4 ,9 cases1 h[ev]1 :]e x is possible to h a *oice1 & to select ! flaps1 ! foll[+ is1 ,i believe1 bo? ! be/ & quicke/ me?od3-- ,?is is "o ( ! v few op]ations 9 :i* quickness ( p]=mance is a desid]atum2 ! use ( an/hetics has1 9 mo/ o!r cases1 giv5 "t = elaboration ( flaps1 & c>eful dissection2 "h ! risk ( loss ( blood1 specially f ! po/]ior flap1 r5d]s rapid dis>ticulation imp]ative4 ,amputation by d\ble flap1 ant]ior ! long]4--,9 hip-jo9t amputations1 besides ! ord9>y sponge-squeez]s1 two assi/ants are necess>y1 ^: duties are exce$+ly important4 ,! fir/ is to *eck hmorrhage4 ,press+ ) a firm pad on ! ext]nal iliac j z x passes ! bone1 he mu/ be prep>$1 ! in/ant ! ant]ior flap is cut1 to foll[ ! knife & seize flap & art]y 9 8 h&1 & he is to hold x !re till all ! vessels 9 ! po/]ior flap are fir/ ti$4 ,! second has to manage ! limb1 & on ! mann] 9 :i* he p]=ms 8 duty mu* ( ! success & ne>ly all ! cel]ity ( ! op]ation dep5d4 ,:ile ! surgeon is transfix+ ! ant]ior flap1 ?is assi/ant is to support ! limb 9 a slightly flex$ position1 s z to relax ! muscles2 ! in/ant ! flap is cut he is to ext5d ! limb =cibly1 & at ! same "t be c>eful n to abduct x 9 ! lea/1 b to turn ! toes inw>d s z to br+ ! great tro*ant] well =w>ds on a level ) ! jo9t2 if ?is precaution is neglect$1 ! op]ator 9 mak+ ! po/]ior flap is almo/ c]ta9 to lock 8 knife 9 ! holl[ betwe5 ! head ( ! bone & ! great tro*ant]4 ,if x is ! left side1 ! op]ator1 /&+ on ! outside ( ! limb1 ent]s ! po9t ( a long /raight knife midway betwe5 ! ant]ior sup]ior sp9\s process ( ! ilium & ! great tro*ant]1 & passes x z close to ! front ( ! jo9t z possible1 mak+ ! po9t em]ge close to ! tub]osity ( ! is*ium 7,plate ,,iv4 fig4 #bj-bj74 ,) a rapid saw+ movem5t he !n cuts a long ant]ior flap1 avoid+ any po9t+ ( x1 & endeav\r+ to make ! curve equal4 ,! f+]s ( ! assi/ant mu/ be ins]t$ s z to foll[ ! knife & seize ! vessel ev5 be=e x is divid$4 ,! flap be+ rais$ out ( ! way1 ! surgeon1 )\t *ang+ 8 knife 7z us$ to be advis$71 op5s ! jo9t1 divides ! ligam5ts z !y />t up on ! limb be+ ext5d$ & adduct$1 ! r\nd ligam5t1 & ! po/]ior "p ( ! capsule2 & !n gett+ ! knife fairly beh9d bo? ! head ( ! bone & ! tro*ant]1 cuts ! po/]ior flap z rapidly z possible4 ,in/antly on ! limb be+ sep>at$1 assi/ants %\ld be ready ) l>ge dry sponges or pads ( dry l9t to press aga9/ ! surface ( ! po/]ior flap1 till ! l>ge bran*es1 *iefly ( ! int]nal iliac1 :i* are cut 9 x1 are ti$ "o by "o4 ,! lev] inv5t$ by ,mr4 ,ri*>d ,davy1 by :i* ! common iliac is compress$ f ! rectum1 has 9 _m cases prov$ ( great s]vice 9 prev5t+ hmorrhage1 b has dang]s ( its own 9 cases ( abnormal position ( rectum1 or ev5 9 sudd5 movem5ts ( ! pati5t4 ,9 e case ! abdom9al t\rniquet w be f\nd ( great s]vice 9 *eck+ hmorrhage1 dur+ ! op]ation ( amputation at ! hip-jo9t4 ,x consi/s ( an ar* ( /eel fitt$ ) a pad beh9d1 :i* re/s aga9/ ! v]tebral column1 & a pad 9 front play+ on a v f9e & long screw1 ?r\gh an op5+ 9 ! ar*4 ,:5 screw$ d[n tightly on ! aorta j be=e ! incisions are comm5c$1 x *ecks hmorrhage admirably )\t injur+ ! visc]a4 ,:5 ?is is appli$1 a me?od ( amputation once practis$ by ,mr4 ,syme1 ?\gh n s rapid z ! d\ble-flap me?od by transfixion1 w be f\nd v easy1 & to result 9 mo/ excell5t flaps4 ,he cut an ant]ior flap 9 ! usual mann] by transfixion1 !n made a /raight incision f its out] edge d[n to ab\t two in*es bel[ ! great tro*ant]1 ?us expos+ x fully1 & f ! l[] end ( ?is incision transfix$ aga91 cutt+ a po/]ior flap ne>ly equal 9 size to ! ant]ior2 a few /rokes ( ! knife r\nd ! jo9t f9i%$ ! dis>ticulation4 ,! result+ flaps came toge!r ) great accuracy1 & 7 n burd5$ ) ! great unequal masses ( muscles s (t5 notic$ 9 ! po/]ior flaps :i* are made by cutt+ f )9 outw>ds aft] dis>ticulation4 ,9 "s cases ( amputation :]e ! femur has be5 badly %att]$1 x is a good plan to amputate ?r\gh ! upp] ?ird ( ?igh1 tie all ! vessels1 & !n1 aid$ by an incision at out] side1 dissect out ! head ( ! bone4 ,mr4 ,furneaux ,jordan ( ,birm+ham c>ries out ?is pr9ciple by fir/ divid+ ! s(t p>ts 9 circul> direction l[ d[n ! ?igh1 & !n dissect+ out ! head ( ! bone f ! muscles by a long incision on ! out] aspect ( ! limb4 ,note4--,9 sev]e cases ( sma% :5 bo? l[] limbs h requir$ amputation1 ! au?or has d]iv$ mu* assi/ance f ! me?od ( manag+ ! op]ation detail$ bel[3-- ,d\ble ,prim>y ,amputation ( 7bo?7 ,?ighs f railway sma%--,rapid recov]y4--,g41 a heal?y-look+ man1 ag$ tw5ty-sev51 b look+ mu* old]1 :ile driv+ a horse ne> ,granton1 caught 8 foot on ! edge ( a rail at a po9t1 fell1 & bo? 8 legs 7 run ov] by sev]al load$ wagons4 ,a special eng9e 0 procur$1 8 ?ighs tightly ti$ up1 & he 0 s5t up to hospital at once4 ,i 0 9 hospital at ! "t1 s ) z little delay z possible he 0 plac$ on ! op]at+ table1 & ! necessity = amputation be+ too evid5t1 ,i obta9$ 8 leave to remove bo? 8 legs above ! knee2 b 8 pulse 0 v feeble1 & he 0 int5sely n]v\s1 ?r[+ 8 arms wildly ab\t1 pant+ = brea?1 & look+ v ill1 cold1 & exhau/$4 ,i det]m9$ t by great rapidity he might be got (f ! table alive1 s op]at$ 9 ! foll[+ mann]3--,fix+ ! t\rniquet firmly ne> bo? gro9s1 ,i fir/ amputat$ ! "r leg by ,c>d5's me?od1 & ti$ ! femoral only1 wrapp$ up ! /ump 9 a t[el wrung out ( c>bolic solution #a-bj1 !n took (f ! o!r limb by ,mr4 ,sp5ce's me?od1--x _h be5 injur$ high] ?an ! "r1 s t ,i c\ld n save ! condyles ( ! femur1--!n ti$ ! femoral !re1 & fix$ x up ) ano!r t[el2 !n return+ to ! fir/1 ,i ti$ "o or two l>ge bran*es :i* sp\t$1 & roll$ x up aga91 !n back to ! left "o1 do+ ! same1 & gett+ ! t\rniquet (f bo? limbs4 ,on go+ back to ! "r ! surface 0 ne>ly dry & glaz$1 s1 ask+ ,dr4 ,macl>51 :o assi/$ me1 to /it* x up & ins]t a dra9age-tube1 ,i did ! same = ! left1 s rapidly t ! pati5t 0 9 8 b$ ) 8 limbs dress$ & b&ag$ 9 #bd-a_/b m9utes f ! "t he ent]$ ! hospital gate4 ,! /ricte/ antiseptic precautions 7 obs]v$1 two eng9es be+ us$ to furni% spray4 ,( c\rse ?is great rapidity 0 due to ! fact t ev]y?+ 0 ready1 ! assi/ants all 9 hospital1 admirably discipl9$1 & /eam _h be5 up 9 ! spray eng9es4 ,%ock 0 comp>atively trivial2 8 temp]ature once1 & only once1 rea*$ #ajj4 ,8 /umps heal$ by fir/ int5tion1 & he 0 9 ! g>d5 on ! sev5? day aft] ! op]ation4 ,i h n[ 9 ?ree cases f\nd ! b5efit ( ?is mode ( deal+ ) d\ble prim>y amputation 9 avoid+ %ock1 less5+ ! "t ne$$1 & greatly dim9i%+ ! numb] ( vessels requir+ to be ti$4 ,9 a previ\s case ( d\ble amputation = railway sma% at ! knees1 ! pati5t 0 almo/ pulseless1 & _h he be5 kept _m m9utes m on ! table w\ld n h left x alive4 ,he also rapidly recov]$4 ,! case is int]e/+ also z %[+ t1 :5 ! assi/ants "k _! "w1 ! /ricte/ adh]5ce to antiseptic precautions ne$ n 9 itself make ei!r ! op]ation or ! dress+ t$i\s1 ?\gh x c easily be made an excuse = mu* fuss+ & _m delays4#ea ,,footnotes3 #bd ,= details see article ,amputation 9 ,coop]'s ,surgical ,diction>y1 & ! %ort sket* ( ! hi/ory 9 ,mr4 ,li/]'s pap] 9 ! ?ird volume ( ,holmes's ,sy/em ( ,surg]y4 #be ,see a mo/ int]e/+ foot-note to ,pr(essor ,li/]'s pap] on ,amputation1 9 ,holmes's ,sy/em ( ,surg]y1 vol4 iii4 pp4 #eb1 #ec4 #bf ,manuel d',oprations *irurgicales4 #bg ,,fig4 ,,iv4 %[s dorsal view ( incision4 ,,fig4 ,,iii4 %[s face ( complet$ /ump2 ,r1 radial2 ,u1 uln>4 #bh ,z ! surgeon w f9d x mo/ conv5i5t to /& on 8 own "r side ( ! limb to be remov$1 ! knife w be ent]$ on ! palm> side ( ! radius ( ! "r arm1 ( ! ulna ( ! left4 #bi ,teale1 ,on ,amputation by ,rectangul> ,flaps1 pp4 #df-dh4 #cj ,johnson's folio ed41 p4 #cdb4 #ca ,gross's ,surg]y1 #f? ed4 vol4 ii4 p4 #aajc4 #cb ,int]national ,encyclopdia ( ,surg]y1 vol4 i4 p4 #fda4 #cc ,sp5ce's ,surg]y1 pp4 #hjj1 #hja4 #cd ,gross's ,surg]y1 #hvo41 #f? ed41 vol4 ii41 p4 #aajf4 #ce ,excision ( ,scapula1 p4 #cc4 #cf ,hey's ,obs]vations1 #c;d ed4 pp4 #eeb1 #eef4 #cg ,r\x's ,p>allel betwe5 ,engli% & ,fr5* ,surg]y4 ,translation abridg$ f ,coop]'s ,surgical ,diction>y1 p4 #ajf4 #ch ,syme's ,pr9ciples1 #d? edit4 p4 #ade4 #ci ,int]national ,encyclopdia1 vol4 #a4 p4 #fee4 #dj ,obs]vations 9 ,cl94 ,surg]y1 p4 #dh4 #da ,mon?ly ,j\rnal ( ,m$ical ,sci5ce = #ahdi1 vol4 ix4 p4 #iea4 #db ,m$4 ,times & ,gazette1 ,june #c1 #ahfe4 #dc ,op]ative ,surg]y1 p4 #agj4 #dd ,annali ,univ]sali de ,m$ic9a1 ,milano1 #aheg4 #de ,m$4 ,*ir4 ,transactions ( ,london1 vol4 liii41 p4 #age4 #df ,c>d5's 7( ,worce/]7 ,pamphlet1 pp4 #e1 #f2 & ,briti% ,m$ical ,j\rnal1 #ahfd4 #dg ,b4 ,bell's ,surg]y1 #f? ed4 vol4 vii4 pp4 #ccf-cci4 #dh ,9 diagram ! amputation is drawn z if = middle ?ird ( ?igh4 #di ,teale1 op4 cit41 pp4 #cd1 #ci4 #ej ,ed94 ,m$4 ,j\rnal1 = ,april #ahfc4 #ea ,ed94 ,m$ical ,j\rnal1 ,m>* #ahgi4 ,,*apt] ,,iii4 ,,excision ,,( ,,jo9ts4 ,hi/orical4--,beyond a passage ascrib$ to ,hippocrates1 b ( v d\btful au!nticity1 & slight allusions 9 ! works ( ,celsus & ,paulus g9eta1 ! anci5ts give u no in=mation :atev] on ?is subject4 ,hippocrates says1--,complete resections ( bones 9 ! neighb\rhood ( jo9ts bo? 9 ! foot1 9 ! h&1 9 ! tibia up to ! malleoli1 & 9 ! ulna at its junction ) ! h&1 & 9 _m o!r places1 are safe op]ations1 if t fatal syncope does n at once occur1 & cont9u$ fev] does n attack ! pati5t on ! f\r? day4 ,celsus & g9eta bo? advise ! removal ( protrud+ ends ( bone 9 comp\nd dislocations1 b )\t giv+ any cases4 ,f ! days ( ^! classic fa!rs ( ,surg]y1 we h h>dly an indication ( any att5tion :atev] hav+ be5 paid to _! h9ts till q )9 ! la/ hundr$ ye>s4 ,! fir/ di/9ct publication on ! subject 0 by ,h5ry ,p>k ( ,liv]pool1 9 a lett] to ,p]cival ,pott 9 #aghc4 ,he propos$ ! removal ( ! articulat+ extremities ( diseas$ elb[ & knee-jo9ts to obta9 cures4 ,he says he 0 l$ to ?is by its hav+ be5 ! inv>iable cu/om1 = m ?an ?irty ye>s1 at ! ,liv]pool ,infirm>y1 to take (f ! protrud$ extremities ( bones 9 cases ( comp\nd dislocation4 ,! *ief cr$it1 h[ev]1 9 practically elevat+ excisions into ! catalogue ( recognis$ surgical op]ations1 is ow+1 ,briti% surgeons mo/ cordially own1 to two prov9cial surgeons ( ,france1 ! ,moreaus 7fa!r & son7 ( ,b>-sur-,orna94 ,!y took ! lead 9 ! mo/ m>k$ mann]1 hav+ excis$ ! %\ld] 9 #aghf1 ! wri/ & elb[ 9 #agid1 knee & ankle 9 #agib1 & _h foll[$ ?is up s well t1 9 #ahjc1 ! y\ng] ,moreau c\ld boa/1 ! t[n has become 9 "s sort ! refuge ( ! un=tunate afflict$ ) c>i\s jo9ts1 aft] !y h tri$ all ! means usually recomm5d$ by pr(essional m51 or h _h rec\rse to empirical no/rums1 or :5 amputation seem$ to !m ! la/ res\rce4 ,moreau's pap]s & cases1 :i*1 betwe5 #aghf & #aghi1 he frequ5tly read to ! ,fr5* ,academy1 71 "s viol5tly oppos$1 o!rs utt]ly neglect$ by 8 compatriots1 & _m ( !m lo/ & buri$ 9 ! unpubli%$ pap]s ( t body4 ,& ?\gh diseas$ jo9ts did n decl9e 9 frequ5cy1 & ?\gh injur$ ones 7 extremely num]\s dur+ ^! long ye>s ( ,european w>1 excisions 7 b r>ely p]=m$4 ,) ! exception ( ! removal ( head ( hum]us aft] gun%ot injury1 h>dly any ,briti%1 & b v few ,fr5*1 limbs 7 sav$ by excision tak+ ! place ( amputation4 ,! limbs t 7 sav$ by ,p]cy by excision ( ! head ( ! hum]us really owe _! recov]y & safety to ! eld] ,moreau2 = an op]ation ( 81 at :i* he 0 assi/$ by t di/+ui%$ milit>y surgeon1 gave ! latt] ! h9t1 :i* he foll[$ s successfully1 t by #agie he _h p]=m$ x n9ete5 times1 & _h indoctr9at$ ,sabati]1 ,l>rey1 & o!rs1 & elevat$ x into a recognis$ op]ation ( milit>y surg]y4 ,s f>1 h[ev]1 z ! application ( ! great improvem5t ( ! ,moreaus to disease w5t1 ! ,fr5* surgeons h little reason to boa/1 = x is to ,engli% surg]y1 & especially to "o ,ed9burgh surgeon1 t ?is class ( op]ations owes ne>ly all its improvem5t 9 me?ods & frequ5cy ( p]=mance4 ,= ?\gh 7z we %all see "u ! special heads7 "h & !re "o or two cases 7 p]=m$1 x 0 n till ! publication ( ,mr4 ,syme's monograph on ! excision ( diseas$ jo9ts1 9 #ahca1 t ! importance & value ( ! discov]y 7 fairly br\ght be=e ! pr(ession2 & ! cons]vative surg]y1 ( :i* excision z pref]r$ to amputation is ! great type1 mu/ ev] be associat$ ) ,briti% surgeons--,syme1 ,f]gusson1 ,mack5zie1 ,jones ( ,j]sey1 ,but*] ( ,dubl94 ,on ! ,cont95t--,lang5beck1 ,/romey]1 ,heyfeld]1 ,olli]1 ,esm>* ( ,kiel1 specially 9 ! surgical hi/ory ( ! fir/ ,s*leswig-,hol/e9 w>1 h foll[$ up ! example set !m "h4 ,be=e proce$+ to describe ! op]ations on ! v>i\s jo9ts1 "o or two que/ions may be briefly ask$ & answ]$ by way ( introduction4 ,9 :at cases1 or sorts ( cases1 are excisions suitable8 #a4 ,9 cases ( comp\nd injury or dislocation ( a l>ge jo9t1 z us$ by ,filk91 ,p>k1 ,:ite1 & o!r ,engli% surgeons long ago4 ,9 hospital practice1 or 9 private1 :]e !re is e advantage ( re/1 food1 & appliances1 su* op]ations w frequ5tly be f\nd suitable :]e ! jo9t is alone or *iefly ! seat ( injury1 & :]e ! g5]al heal? seems fit to be> a prolong$ suppuration4 ,b long & sad exp]i5ce has %[n t1 z a g5]al rule 9 milit>y practice1 ) ! difficulties ( transport1 ! g5]ally bad sanit>y /ate ( ! hospitals1 & ! want (t5 ( adequate dress+s & att5tion1 excisions are mu* m fatal ?an amputations1 &1 except 9 elb[ & %\ld] 7q4v471 %\ld be z a g5]al rule avoid$4 #b4 ,excision = de=mity 7g5]ally speak+ = bony an*ylosis7 w require = decision ! consid]ation ( _m po9ts1 i4e4 ! jo9t affect$1 ! nature ( ! disease or injury :i* has caus$ ! an*ylosis3 & 9 ea* case--7#a47 ! /ate ( heal? ( ! pati5t2 & 7#b47 8 occupation1 & ! consequ5t position ( limb :i* w\ld suit him be/4 ,z a g5]al rule1 ,i believe1 exp]i5ce w prove t su* op]ations on ! l[] extremity are almo/ absolutely inadmissible1 except "u v special urg5cy on ! "p ( ! pati5t1 & a v high condition ( heal?--:ile 9 ! upp]1 ! elb[-jo9t is ! only "o :i* y w ev] be likely to be ask$ to rem$y1 or %\ld comply ) ! reque/ if ask$2 z ! %\ld]1 ev5 if an*ylos$1 w 7#a47 f its own weight g5]ally become s 9 ! mo/ fav\rable position2 & 7#b47 f ! extreme mobility :i* ! scapula c acquire1 its an*ylosis w n be s mu* felt4 ,! elb[1 h[ev]1 f ! frequ5cy ( fractures ( ! condyles ( ! hum]us obliquely into ! jo9t1 & f ! mann] 9 :i* ^! are s (t5 nei!r recognis$ nor prop]ly treat$1 v (t5 becomes an*ylos$ 9 ! mo/ awkw>d possible position1 i4e4 ne>ly /raight2 & op]ations und]tak5 = su* de=mities are 9 g5]al bo? q safe & v satisfactory4 ,mr4 ,syme _h "o case 7result+ f a fall1 caus+ a d\ble fracture71 9 :i* bo? arms 7 ?us firmly an*ylos$ 9 su* a position t ! suff]] c\ld absolutely p]=m none ( ! commone/ duties ( life )\t assi/ance4 ,excision ( bo? jo9ts cur$ him4 ,! au?or excis$ ) success = disease ! elb[-jo9t ( a pati5t ^: o!r arm _h requir$ ! same op]ation4 ,! occupation ( ! pati5t mu/ always be tak5 into consid]ation :5 settl+ ! position ( an an*ylosis1 or ! necessity or advantage ( a resection4 ,?us1 ,bryant#eb tells ( a pa9t] :o wi%$ 8 arm to be fix$ 9 a /raight position1 & ( a turn] ^: knee at 8 own reque/ 0 p]mitt$ to /iff5 at a "r angle1 z t position all[$ him to turn 8 :eel4 #c4 ,excision = ,disease ( ! ,jo9t4--,9 our cold climate1 s curs$ by scr(ula1 & specially among ! *ildr5 ( ! lab\r+ poor1 su* jo9t diseases are v preval5t1 & :e!r ! disease comm5ces 9 ! synovial membrane1 ! articul> c>tilages1 or ! heads ( ! bones1 x frequ5tly s disorganises ! jo9t z to make x a "q :e!r some?+ mu/ n be done to pres]ve ! v life ( ! pati5t4 ,! difficulty ( diagnos+ ! cases 9 :i* excisions are suitable or necess>y is (t5 v great2 & we mu/ balance its p]=mance--7#a47 aga9/ ! possibly good results ( an expectant treatm5t2 7#b47 aga9/ amputation ( ! limb4 7#a47 ,aga9/ expectant ,treatm5t4--,! pati5t has y\? on 8 side1 c\ld we give him fre% sea air1 good diet1 cod oil1 etc41 we might v likely obta9 an*ylosis2 true1 b he may die :ile try+ = ?is an*ylosis1 & also ?is an*ylosis1 :5 got1 may s lame or de=m him t resection may /ill be requir$4 ,^! po9ts mu/ all be consid]$1 b z a g5]al rule1 ,i w\ld say t su* attempts at pres]vation ( ! limb are mu* m ju/ifiable1 & long] ju/ifiable 9 ! hip & knee-jo9ts ?an 9 ! elb[ or %\ld]2 = ! results 9 ! l[] limb w probably be z good1 if ! pati5t survive1 if n bett]1 ?an ^? obta9$ by excision1 :ile ! dang] ( ! op]ation is great]2 :ile 9 ! upp] limb1 ! dang] to life 9 op]at+ is less ?an t ( leav+ ! limb on1 & ! results obta9$ by a successful op]ation1 ) well-manag$ aft] treatm5t1 are f> m satisfactory ?an ! be/ possible an*ylosis4 ,ano!r po9t be>+ on ?is1 ( v great importance3 ,9 *ildr51 ! mo/ frequ5t subjects ( su* disease1 excision ( ! l[] limb may1 by remov+ ! epiphyses1 cause to a v consid]able degree disp>ity 9 _! l5g?1 ?us r5d]+ !m ne>ly useless1 :ile 9 ! upp] su* disp>ity is nei!r s ext5sive nor s injuri\s to ! usefulness ( ! limb1 :i* is n requir$ = purposes ( progression4 ,9 ! hip-jo9t especially1 all ! res\rces ( ! art %\ld be tri$ 9 ! expectant treatm5t1 = amputation at ! hip-jo9t is h>dly ev] admissible = disease ( ! jo9t1 :ile excision has any?+ b satisfactory /ati/ics4 7#b47 ,aga9/ ,amputation4--,_m que/ions mu/ be consid]$1 *iefly "u ! heads ( ! sep>ate jo9ts3-- #a4 ,z to ! difficulties & dang]s ( ! op]ations contra/$4 ,su* z ! foll[+3-- ,excisions give ! surgeon m tr\ble1 require m manual dext]ity2 take long] to p]=m2 are v pa9ful op]ations4 ,n valid objections 9 ^! days ( *lor(orm & op]ative surg]y on ! dead body4 ,excisions h ! special peculi>ity & dang] ( deal+ *iefly ) cancellat$ bone1 broad5$ out1 op51 ) num]\s patul\s canals = l>ge ve9s1 t5d+ on any irritation or inflammation to set up a diffuse suppuration1 & to culm9ate 9 phlebitis1 myelitis1 & o!r pymic conditions4 ,excisions are p]=m$ ?r\gh deg5]ate or disorganis$1 amputations ?r\gh heal?y1 tissue4 ,excisions require extreme c>e & absolute re/ 7i4e4 9 l[] limb7 = _m weeks & mon?s aft] ! op]ation4 ,b1 on ! o!r h&1-- ,amputations remove a portion ( ! body2 excisions a mu* less "o4 ,amputations are always necess>ily ne>] ! c5tre ?an ! correspond+ excisions1 & /ati/ics %[ t ! fatality ( op]ations increases 9 exact proportion z !y approa* ! c5tre4 ,a successful excision1 especially 9 arm1 saves a limb ne>ly p]fect2 an amputation at be/ is only ! /ump = a wood5 "o4 ,on ! :ole1 !re is actually v little diff]5ce 9 ! mortality ( excisions & amputations4 #b4 ,z to ! results ( ! op]ation on ! usefulness ( ! limb1 dep5d+ on jo9t involv$1 age ( pati5t1 & am\nt ( bone remov$3-- ,a4 ,jo9t involv$4--,^! mu/ be notic$ sep>ately1 b "o ?+ is absolutely c]ta91 t a mu* high] /&>d ( usefulness1 bo? 9 equality ( l5g?1 am\nt ( an*ylosis1 & position1 is ne$$ 9 ! l[] ?an 9 ! upp] limb4 ,= a leg hang+ l a flail1 or %ort5$ by "s in*es1 is n s good = purposes ( locomotion z a wood5 leg is1 :ile an arm1 ev5 ?\gh p[]less at ! elb[1 & p]haps mu* %ort5$1 c be s /r5g!n$ & support$ by sl+s & b&ages z to give a mo/ useful h&1 ! complex movem5ts & uses ( ! f+]s ( :i* no me*anism c at all imitate4 ,b4 ,age ( ,pati5t4--,x mu/ be rememb]$ t excision 9 a *ild removes ! epiphyses by :i* 9 great measure ! gr[? ( ! bone is to be manag$1 & ! /unt$ limb1 especially 9 ! leg1 w ev5tually be ( little advantage1 ?\gh aft] ! op]ation x look$ excell5tly well1 if a few ye>s lat] x be f\nd to be sev5 or eight in*es %ort] ?an its neighb\r4 ,c4 ,am\nt ( ,bone remov$4--,f an errone\s view ( ! pa?ological *anges 9 ! bone affect$1 f> too mu* 0 remov$ by _m ( ! e>li] op]ators1 especially ,moreau & ,crampton4 ,! reason t ?is is (t5 /ill ! case1 is well se5 9 _m prep>ations4 ,! bones are ?ick5$ to a consid]able di/ance1 & cov]$ ) irregul> w>ty excresc5ces4 ,^!1 :i* us$ to be consid]$ evid5ces ( disease1 are only compact new heal?y bone1 ?r[n out l ! callus ( a fracture 9 consequ5ce ( ! irritation4 ,9 a ^w1 :at we require to remove is ! foll[+3-- #a4 ,all ! c>tilage1 dead or alive1 heal?y or diseas$4 #b4 ,only ! bone involv+ ! articul> extremities1 9 ?9 slices1 or ) ! occasional use ( ! g\ge1 till a heal?y ble$+ surface is obta9$4 #c4 ,! synovial membrane1 h[ev] gelat9\s or ?ick5$ look+1 really requires v little c>e or notice2 x w disappe> ( itself1 p>tly by sl\gh+1 p>tly by absorption dur+ ! pr(use suppuration4#ec ,,excision ,,( ,,! ,,%\ld]-,,jo9t4--,be=e consid]+ ! me?od ( op]at+1 a ^w or two is requir$ on ! subject ( h[ mu* is to be remov$1 & 9 :at cases ! op]ation %\ld be p]=m$4 ,! %\ld] & hip jo9ts are ! only ones 9 :i* p>tial excision is ev] admissible1 inde$1 9 ! %\ld] excision ( ! head ( ! hum]us only is 9 _m cases f\nd to be all t is necess>y1 :ile 9 all x is mu* less dang]\s to life ?an :5 ! gl5oid cavity also requires to be int]f]$ )4 ,x is r>ely necess>y to remove m ( ! bone ?an m]ely its articul> extremity 7:5 p]=m$ = disease ( ! jo9t71 & if possible ?is %\ld be done inside ! capsule1 i4e4 ?r\gh an incision 9 ! capsule1 b )\t involv+ its atta*m5t to ! neck ( ! bone4 ,:5 ! gl5oid is also diseas$1 m]e g\g+ or scrap+ ! c>tilag9\s surface w n suffice1 b ! neck mu/ be ?or\ghly expos$1 s t ! :ole cup ( ! gl5oid may be remov$ by p[]ful =ceps4 ,cases suitable = ,excision4--,cases ( *ronic disease ( ! head ( ! hum]us 7g5]ally tub]cul>71 or ( *ronic ulc]ation ( ! c>tilages :i* has resi/$ c\nt]-irritation4 ,cases ( gun%ot injury ( ! jo9t1 or ( comp\nd dislocation1 or fracture involv+ ! jo9t4 ,cases ( limit$ tum\rs affect+ m]ely ! head & upp] ?ird ( ! bone1 & non-malignant 9 "*4 ,an*ylosis v r>ely requires & w\ld n be mu* b5efit$ by su* an op]ation4 ,op]ation4--,?\gh p]haps n ! easie/1 ! foll[+ me?od is ! "o foll[$ by ! be/ results4 ,x is suit$ especially = cases ( c>ies or o!r disease ( ! jo9t1 :]e ! head ( ! hum]us is ei!r alone or *iefly affect$3-- ,a s+le /raight incision 7,plate ,i4 fig4 ,a47 is made f a po9t j ext]nal to ! coracoid process d[nw>ds along ! hum]us = at lea/ ?ree in*es4 ,x corresponds almo/ exactly to ! bicipital groove1 & has ! advantage ( avoid+ ! great vessels & n]ves4 ,! long head ( ! biceps may !n be rais$ f its groove1 & drawn to a side s z to be pres]v$4 ,?is is deem$ ( importance by ,lang5beck & o!rs4 ,mr4 ,syme1 h[ev]1 did n atta* mu* value to its pres]vation1 z x is (t5 diseas$4 ,! capsule1 :i* is (t5 mu* alt]$1 p]haps 9 "p de/roy$1 is !n op5$1 & ! t5dons ( ! muscles :i* rotate ! head ( ! hum]us divid$ 9 succession1 :ile ! elb[ is rotat$ fir/ inw>ds & !n outw>ds by an assi/ant s z to put !m on ! /ret*4 ,! arm be+ !n =c$ backw>ds1 ! head ( ! bone c be protrud$ ?r\gh ! w\nd1 & sawn (f at ! necess>y di/ance d[n ! %aft4 ,! gl5oid mu/ !n be c>efully exam9$1 & any diseas$ bone remov$ by ! cutt+ pli]s4 ,"o or two small bran*es supply+ ! ant]ior fold ( ! axilla are ! only vessels divid$1 & may n ev5 require ligature1 unless1 inde$1 f necrosis1 or to remove a tum\r1 a l>g] portion ( ! hum]us ?an usual has be5 remov$4 ,if ! limit ( capsule has be5 infr+$ on bel[1 ! circumflex vessels may probably be cut1 9 :i* case ! ble$+ may be consid]able4 ,n4,b4--,9 cases ( fracture ( neck ( hum]us1 or ( comp\nd gun%ot injury1 or :]e ! head has be5 sep>at$ by necrosis f ! %aft1 or :]e1 z has happ5$ to ,/anley & o!rs1 ! bone broke 9 ! endeav\r to tilt ! head out1 ! surgeon w require to seize ! deta*$ head ) /rong =ceps1 & dissect x out ) c>e4 ,o!r me?ods ( ,resection4--,:5 f great ?ick5+ & induration ( ! s(t p>ts1 enl>gem5t ( ! head ( ! bone1 or o!r reason1 ! /raight incision may be deem$ insuffici5t = ! purpose 7& we may rem>k t !re are comp>atively few cases 9 :i* x is insuffici5t71 access may be obta9$ to ! jo9t by rais+ a flap f ! deltoid 7,plate ,,iii4 fig4 ,a74 ,its %ape--,v-%ap$1 semilun>1 or ovoid--is n ( mu* consequ5ce1 = !re are no great n]ves or vessels to w\nd on ! outside ( ! jo9t1 & ! surgeon %\ld be guid$1 z 9 all o!r op]ations on ! jo9t1 v mu* by ! position ( any pre-exi/+ s9uses4 ,?is flap be+ rais$ upw>ds t[>ds its base1 v free access is ga9$ to ! jo9t4 ,9 ^! cases1 =tunately comp>atively r>e1 9 :i* !re is reason to believe t ! gl5oid is *iefly involv$ 9 disease1 & yet t ! disease c be remov$ )\t amputation1 access w be ga9$ mo/ easily by an incision 7,plate ,,iii4 fig4 ,b47 on ! po/]ior surface ( ! jo9t1 correspond+ 9 size & direction to ! l9e> incision 9 front4 ,?is gives a mu* easi] mode ( access to ! gl5oid4 ,i h se5 ?is practis$ 9 "o v rem>kable case by ,mr4 ,syme1 9 :i* ! gl5oid cavity & neck ( ! scapula 7 ext5sively diseas$1 :ile ! head ( ! bone 0 q s\nd4 ,aft]-treatm5t is exce$+ly simple2 = ! fir/ day or two ! %\ld] is to be support$ on a pill[ ) a simple pad 9 ! axilla1 if !re is any t5d5cy = ! arm to drag inw>ds2 aft] ?is ! pati5t %\ld be enc\rag$ to sit up & move ab\t ) 8 arm 9 a sl+1 ! elb[ hang+ freely d[n4 ,results4--,hodge records n9ety-six cases 9 :i* ?is excision 0 p]=m$ = gun%ot injury1 ( :i* tw5ty-five prov$ fatal1 & fifty = disease1 ( :i* only eight di$1--results :i* are m enc\rag+ ?an ^? ( amputation at ! %\ld]-jo9t = disease2 ?\gh = injury ! mortality is mu* great] ?an ,l>rey's fam\s ,/ati/ics ( ,amputation1 q4v4 p4 #fe4 ,sp5ce _h ?irty-?ree cases1 ) ?ree dea?s4 ,he g5]ally made a c\nt]-op5+ beh9d to get rid ( dis*>ges1 & ins]t$ a dra9age-tube4 ,gurlt's /ati/ics ( excision = gun%ot injury give ( #affa cases #ajfg recov]ies1 #bg d\btful results1 & #efg dea?s1 ! mortality be+ #cd4gj p] c5t4 ,,excision ,,( ,,! ,,elb[-,,jo9t--,9 :at cases %\ld x be p]=m$8--#a4 ,= disease ( ! elb[-jo9t :i* has resi/$ ord9>y rem$ies1 & is we>+ d[n ! pati5t's /r5g?1 includ+ c>ies1 ulc]ation ( c>tilages1 & gelat9\s synovial deg5]ation4 #b4 ,= w\nds ( ! elb[ p5etrat+ ! jo9t1 ! prognosis bo? z to ! pati5t's life & ! usefulness ( 8 arm is mu* bett] aft] excision ?an aft] endeav\rs to save ! jo9t )\t excision4 ,?is is especially ! case :5 ! w\nd ( ! jo9t is small & punctur$1 b if ! case is se5 e>ly & treat$ by free dra9age1 ) antiseptic precautions1 excision may n be requir$4 #c4 ,= an*ylosis1 9 cases :]e aft] disease or injury ! limb has /iff5$ 9 a bad position1 especially :51 ) a /raight elb[1 ! h& is r5d]$ almo/ p]fectly useless4 ,h[ mu* %\ld be remov$8--,9 ! elb[-jo9t1 m ?an any o!r jo9t 9 ! body1 complete excision is absolutely necess>y2 any portion ( ! articul> surface be+ left proves a s\rce ( unfav\rable result4 ,! surgeon is apt to err r 9 remov+ too little ?an too mu*4 ,= ! removal ( too little bone is1 on ! "o h&1 apt to result 9 long-/&+ s9uses1 on ! o!r1 to induce an*ylosis4 ,9 mak+ ! section ( ! bones1 ! saw ought to be appli$ to ! hum]us transv]sely j at ! comm5cem5t ( its condyloid projections1 & to ! radius & ulna1 at lea/ at a level ) ! base ( ! coronoid process ( ! ulna4 ,b :ile remov+ en\gh1 we mu/ n be l$ into ! error ( remov+ too mu*4 ,if ?is is done1 z 0 done by ,sir ,philip ,crampton 9 8 fir/ case1 & z happ5s occasionally ( necessity 9 cases ( excision = gun%ot w\nds or o!r accid5ts1 mu* ( ! p[] ( ! arm is lo/ z a consequ5ce ( ! %ort5+ & excessive mobility4 ,a mi/ak5 pa?ology sometimes deceives 9 ! exam9ation ( ! /ate ( ! bones1 & causes an unnecess>y am\nt to be remov$4 ,= 9 _m cases ( disease ! bones 9 ! neighb\rhood ( ! jo9t are /imulat$ to an excessive am\nt ( :at is 9 reality ,nature's ef=t at repair1 & :ile ! c>tilag9\s surfaces are d5ud$ ( c>tilage1 s(t1 & por\s1 ! bones close by are r\gh5$ ) a /alactitic-look+ gr[?1 project+ 9 knobs & angles4 ,n[1 if ?is be mi/ak5 = disease & remov$1 too mu* w almo/ c]ta9ly be tak5 away1 & ! result w be unsatisfactory4 ,mu* less c>e ne$ be tak5 exactly to discrim9ate & remove ! diseas$ s(t p>ts2 inde$ !y may be left alone2 ! synovial membrane 9 a /ate ( gelat9\s deg5]ation sometimes pres5ts a v =midable appe>ance ( disease1 b if ! bones be prop]ly remov$1 all ?is swell+ w soon g d[n1 & a heal?y condition ( p>ts succe$1 )\t any clipp+ or p>+ on ! surgeon's "p4 ,op]ation4--,! back ( ! jo9t is ( c\rse *os5 = ! seat ( ! incisions1 bo? because ! bones are !re j "u ! sk91 & because ! great vessels & n]ves lie 9 front ( ! jo9t4 ,! =m & numb] ( ! incisions v>y consid]ably1 & ought to v>y accord+ to ! nature ( ! case & ! am\nt ( disease or injury4 ,?\gh x is n[ little us$1 = hi/orical int]e/ ,i reta9 ! description ( ! ,h-%ap$ incision 7,plate ,,iii4 fig4 ,c471 us$ fir/ by ,moreau1 & re-introduc$ by ,mr4 ,syme1 & us$ by him = mo/ ( 8 v num]\s cases4 ,! po/]ior surface ( ! jo9t be+ expos$1 ! surgeon1 ) a /rong /raight bi/\ry1 makes a transv]se incision into ! jo9t j above ! olecranon4 ,x %\ld beg9 j f> en\gh outside ( ! int]nal condyle to avoid ! uln> n]ve1 :i* ! surgeon %\ld protect by ! =ef+] ( 8 left h&1 & %\ld ext5d transv]sely across to ! out] condyle4 ,f ea* end ( ?is incision ! surgeon %\ld next make at a "r angle two incisions1 ea* ab\t "o in* & a half or two in*es long1 "r d[n to ! bone1 ?us m>k+ out two quadrilat]al flaps4 ,^! %\ld next be rais$ f ! bones1 up & d[n1 z mu* ( ! s(t p>ts be+ reta9$ 9 !m z possible1 s z to add to _! ?ickness4 ,! olecranon is ?us expos$1 & %\ld be remov$ by saw or pli]s by cutt+ into ! great] sigmoid not*2 ! lat]al ligam5ts mu/ !n be cut1 if !y are n already de/roy$ by ! disease1 & ! hum]us protrud$1 a prop] am\nt ( :i* is !n to be sawn (f 9 a transv]se direction4 ,! head ( ! radius is !n easily remov$ by ! bone-pli]s1 & ! ulna also protrud$1 ! atta*m5t ( ! bra*ialis anticus to ! coronoid process divid$1 & ! bone sawn across j at ! base ( t process4 ,few vessels1 if any1 w require ligature1 & ! arm be+ b5t to ne>ly a "r angle1 ! transv]se incision mu/ be v c>efully sew$ up ) silv] sutures closely set & deeply plac$1 z mu* ( ! future success ( ! jo9t dep5ds on ! complet5ess ( ! prim>y union ( ?is incision4 ,! ext]nal incision may also be accurately adju/$1 ! int]nal "o n s completely1 to all[ free v5t = ! dis*>ge1 :i* is aid$ by ! ligatures1 if any are requir$1 be+ br\ght out at its l[] angle4 ,a figure-(-#h b&age %\ld be appli$ ov] pads ( dry l9t1 & ! limb laid on a pill[4 ,no spl9t is necess>y2 9 a few days ! pati5t w be able to rise & walk ab\t4 ,passive motion %\ld be begun s soon z ! fir/ inflammatory symptoms h pass$ (f4 ,if prop]ly p]=m$1 9 a tol]ably heal?y subject1 ! surgeon %\ld n be satisfi$ ) any results %ort ( almo/ p]fect re/oration ( motion 9 ! jo9t4 ,flexion & ext5sion to _! full ext5t1 ) a v consid]able am\nt ( pronation & sup9ation1 are to be expect$1 ) prop] c>e1 9 a pati5t ( av]age intellig5ce4 ,num]\s cases are n[ on record :]e almo/ p]fect p]=mance ( all ! duties ( life 0 reta9$ aft] excision ( ! elb[-jo9t4#ed ,9 mo/ cases x is possible1 & 9 ne>ly all advisable1 to excise ! jo9t by means ( a less complicat$ incision4 ,?us "o long v]tical incision at ! po/]ior surface1 ) its c5tre ab\t midway betwe5 ! ulna & ! ext]nal condyle1 ) a transv]se incision at "r angles to x1 & rea*+ almo/ to ! int]nal condyle1 has be5 (t5 practis$ ) a v good result4 ,by ne>ly univ]sal cons5t ?is s+le /raight incision is n[ us$1 & :5 x is prop]ly dress$ & dra9$ gives admirable results4 ,a s+le v]tical incision 7,plate ,,iii4 fig4 ,d47 )\t any transv]se "o1 z long ago recomm5d$ by ,*assaignac1 is1 9 mo/ cases1 q suffici5t to give access4 ,x is mo/ suitable 9 cases ( an*ylosis1 :]e !re is little deposit ( new bone1 or 9 cases ( disease ( ! jo9t1 accompani$ ) little swell+ or ?ick5+ ( surr\nd+ tissues4 ,x has ! advantage ( avoid+ ! cicatrix ( a transv]se incision1 :i* d\btless may1 if at all a broad "o1 some:at int]f]e ) ! future flexion ( ! limb1 b1 on ! o!r h&1 unless c>e is tak51 x does n give su* free egress = ! dis*>ge1 & :5 !re is mu* delay 9 heal+1 ! v]tical incision may leave a cicatrix ne>ly z tr\blesome z ! o!r4 ,! foll[+ modification1 sugge/$ & practis$ by ! late ,mr4 ,maund]1 seems to be a /ep 9 ! "r direction :5 x is practicable4 ,aft] a longitud9al incision cross+ ! po9t ( ! olecranon ,i next let ! knife s9k into ! triceps muscle1 & divide x longitud9ally into two portions1 ! inn] "o ( :i* is ! m firmly atta*$ to ! ulna1 :ile ! out] portion is cont9u\s ) ! anconeus muscle1 & s5ds "s t5d9\s fibres to bl5d ) ! fascia ( ! =e-arm4 ,x is ^! latt] fibres t are to be scrupul\sly pres]v$4 ,two po9ts h to be rememb]$3 fir/1 ! uln> n]ve1 (t5 unse51 mu/ be lift$ f its b$1 & c>ri$ ov] ! int]nal condyle to a safe place1 & !n ! out] portion ( ! triceps muscle ) its t5d9\s prolongation1 ! fascia ( ! =e-arm & ! anconeus muscle mu/ be dissect$ up1 z x 71 9 "o piece1 suffici5tly to all[ ( its be+ tempor>ily c>ri$ out ov] ! ext]nal condyle ( ! hum]us4#ee ,?is me?od aids 9 reta9+ ! p[] ( active ext5sion ( ! elb[-jo9t4 ,excision = osse\s an*ylosis 9 ! ext5d$ position ( ! jo9t may be sometimes r5d]$ v difficult by ! d5sity1 firmness1 & ext5sive hyp]trophy ( ! bones1 :i* become fus$ into "o solid mass4 ,any attempt to isolate ! bones1 & remove ! an*ylos$ jo9t entire1 by incis+ ! bones z if = disease1 w bo? prove v labori\s1 & also probably end 9 do+ "s damage to ! vessels & n]ves 9 front4 ,b by saw+ ?r\gh ! an*ylosis ab\t its c5tre1 z 0 po9t$ out _m ye>s ago by ,mr4 ,syme1 ! =e-arm may be flex$1 & ! bones z easily display$1 clean$1 & remov$1 z 9 ! op]ation = disease4 ,9 ?is op]ation1 z !re is less ?ick5+ ( ! sk9 & subjac5t textures1 & 9 consequ5ce m risk ( defici5cy & ev5 sl\gh+ ( ! flaps made by ! ,h-%ap$ incision1 a s+le /raight incision w s]ve ! purpose admirably4 ,p>tial incisions ( ! elb[-jo9t are1 z a rule1 less successful & m dang]\s to life ?an complete ones1 except 9 cases ( excision = an*ylosis4 ,ev5 9 gun%ot w\nds1 :]e ! bones 7 previ\sly heal?y1 & :]e un9jur$ portions might h be5 left ) "s hopes ( success1 ?is is ! case4 ,dr4 ,h]on ,watson has devis$ ! foll[+ op]ation = cases ( an*ylosis ! result ( injury3--7#a47 ,a l9e> incision ov] uln> n]ve at inn] side ( olecranon4 7#b47 ,! uln> n]ve to be c>efully turn$ ov] ! inn] condyle4 7#c47 ,a probe-po9t$ bi/\ry to be introduc$ into ! elb[-jo9t 9 front ( ! hum]us1 & !n beh9d & c>ri$ upw>ds1 s z to divide ! upp] capsul> atta*m5ts 9 front & beh9d4 7#d47 ,a pair ( bone-=ceps to be next employ$ to cut (f ! entire inn] condyle & tro*lea ( ! hum]us1 & !n introduc$ 9 ! opposite diagonal direction s z to deta* ! ext]nal condyle & capitulum ( ! hum]us f ! %aft4 7#e47 ,! truncat$ & angul> end ( ! hum]us to be divid$1 turn$ out ?r\gh ! incision1 & smoo!d across at "r angles to ! l9e ( ! %aft by means ( ! saw1 :]eby 7#f47 room might be af=d$1 s t p>tly by twi/+ & p>tly by dissection ! ext]nal condyle & capitulum are remov$ )\t any division ( ! sk9 on ! out] side ( ! arm4#ef ,six cases h _h satisfactory results4 ,! mortality f ?is op]ation is consid]ably less ?an t f amputation ( ! arm4 ,( a s]ies ( excisions = disease1 injury1 & an*ylosis1 #bb4ae p] c5t4 di$1 :ile out ( a simil> s]ies ( amputations ( ! arm ! mortality 0 #cc4d p] c5t4#eg ,our mortality ( excision ( ! elb[ "h is c]ta9ly mu* less ?an ! above4 ,all ( ! cases1 betwe5 ?irty & =ty1 9 :i* ,i h done x h recov]$ ) b "o exception1 & ,mr4 ,syme lo/ only "o dur+ ! "t ,i 0 8 assi/ant4 ,pr(essor ,sp5ce lo/ only #af 9 #ahi cases1 or #h4c p] c5t4 ,gurlt's /ati/ics = gun%ot injury give a mortality ( ov] #bd p] c5t4 ,out ( #hb cases :]e ! jo9t 0 excis$ = injury 9 ! ,s*leswig-,hol/e9 & ,crimean campaigns1 only #af di$2 & out ( #aae cases 9 :i* ! jo9t 0 excis$ = disease1 only #ae di$4 ,! p]iod aft] ! injury at :i* ! excision is p]=m$ seems to be important4 ,dea?s4 ,?us ( #aa cases )9 fir/ tw5ty-f\r h\rs1 #a #a-aa #bj betwe5 second & f\r? days1 #d #a-e #i eigh? & ?irty-sev5?1 #a #a-i -- -- #dj #f ,,excision ,,( ,,! ,,wri/4--,v v>i\s me?ods h be5 propos$ & execut$ = ! purpose ( excis+ ?is jo9t4 ,^! v>y mu* 9 difficulty & complexity1 9 proportion to ! endeav\rs made to save ! t5dons f be+ cut4 ,! pr9ciples :i* mu/ guide all attempts at op]ative int]f]5ce ) ?is jo9t are-- #a4 ,to remove all ! diseas$ bone1 includ+ ! c>tilage-cov]$ portions ( ! radius1 ulna1 & ( ! metac>pal bones1 z little ( ^! bones be+ remov$ z possible1 beyond ! c>tilage-cov]$ portions4 #b4 ,to di/urb ! t5dons z little z possible1 especially to avoid isolat+ !m f ! cellul> %ea?4 #c4 ,to comm5ce passive motion ( ! f+]s v soon aft] ! op]ation4 ,x is r>ely possible to remove ! c>pal bones z a :ole1 f ! diseas$ condition :i* r5d]s ! op]ation necess>y1 & ! digg+ out ( ! v>i\s bones piecemeal r5d]s ! op]ation v t$i\s1 especially if ! proximal ends ( ! metac>pal bones are involv$ & require to be remov$1 h5ce ?is op]ation 0 practically impossible till aft] ! discov]y ( an/hesia4 ,9 describ+ ! op]ation elaborat$ & describ$ by ,pr(essor ,li/]1 ! type ( ! v>i\s plans 9 :i* ! t5dons are sav$ is giv51 :ile a v few words descriptive ( ! incisions us$ by o!rs :o cut ! t5dons w suffice4 ,,li/]',s ,,op]ation ,,( ,,excision ,,( ,,! ,,wri/-,,jo9t4--,ev5 an abridgm5t ( ,mr4 ,li/]'s acc\nt ( 8 op]ation mu/ necess>ily be long1 because ! op]ation itself is s complicat$ & prolong$1 & guid$ by su* precise pr9ciples1 z to r5d] mu* abridgm5t almo/ impossible4 ,a t\rniquet is put on1 to prev5t ooz+1 :i* w\ld conceal ! /ate ( ! bones2 any adhesions ( ! t5dons mu/ be !n brok5 d[n by free movem5t ( all ! jo9ts4 ,! radial incision 7,plate ,,iv4 fig4 ,a47 is !n made4 ,x comm5ces at ! middle ( ! dorsal aspect ( ! radius1 on a level ) ! /yloid process1 passes z if go+ t[>ds ! inn] side ( ! metac>po-phalangeal jo9t ( ! ?umb1 9 a l9e p>allel to ! ext5sor secundi int]nodii1 b turns (f at an angle z x passes ! radial bord] ( ! second metac>pal1 & !n longitud9ally d[nw>ds = half ! l5g? ( t bone4 ,! ext5sor c>pi radialis brevior t5don is divid$ 9 ! incision4 ,! s(t p>ts at ! radial side are to be c>efully dissect$ up1 & ! t5don ( ! ext5sor c>pi radialis longior divid$ at its ins]tion4 ,! cut t5dons1 & ! ext5sor secundi int]nodii t5don & ! radial art]y c ?us be pu%$ outw>ds1 enabl+ ! trapezium to be sep>at$ f ! c>pus by cutt+-pli]s4 ,! ext5sor t5dons be+ relax$ by b5d+ back ! h&1 ! s(t p>ts mu/ be cle>$ f ! c>pus z f> z possible t[>ds ! uln> side4 ,illu/ration3 ,,fig4 ,,vi4#eh ,! uln> incision 7,plate ,,iv4 fig4 ,b47 ext5ds f two in*es above ! end ( ! ulna1 9 a l9e betwe5 ! bone & ! flexor c>pi uln>is1 /raight d[n z f> z ! middle ( ! palm> aspect ( ! fif? metac>pal4 ,! dorsal lip ( ?is incision is !n rais$1 & ! t5don ( ! ext5sor c>pi uln>is cut at its ins]tion1 & reflect$ up out ( its groove 9 ! ulna along ) ! sk94 ,! ext5sor t5dons are !n rais$ f ! c>pus1 & ! dorsal & lat]al ligam5ts ( ! wri/ divid$1 ! t5dons /ill be+ left z f> z possible undi/urb$ 9 _! relation to ! radius4 ,9 front ! flexor t5dons are cle>$ f ! c>pus1 ! pisi=m bone sep>at$ f ! o!rs ?\gh n remov$1 & ! hook ( ! unci=m divid$ by pli]s4 ,! knife mu/ n g fur!r d[n ?an ! base ( ! metac>pal bones1 9 case ( divid+ ! deep palm> ar*4 ,! ant]ior ligam5t ( ! wri/ be+ n[ divid$1 ! c>pus & metac>pus are to be sep>at$ by cutt+-pli]s1 & ! c>pus extract$ by /rong seque/rum =ceps4 ,by =cible ev]sion ( ! h&1 ! ends ( radius & ulna c be protrud$ at ! uln> incision2 z little z possible %\ld be remov$1 consi/5t ) remov+ all ! disease4 ,! ulna %\ld be cut obliquely1 leav+ ! base ( ! /yloid process1 & remov+ all ! c>tilage-cov]$ portion4 ,a ?9 slice ( ! radius is !n to be cut also ) ! saw1 s ?9 z to remove only ! bevell$ ungroov$ portion1 & leav+ ! t5dons z f> z possible undi/urb$ 9 _! grooves4 ,! uln> articul> facet is to be snipp$ (f ) bone-pli]s4 ,if ! bones are m deeply c>i\s1 ! diseas$ p>ts mu/ at all haz>ds be remov$ ) pli]s or g\ge4 ,! metac>pal bones mu/ !n be treat$ 9 precisely ! same way1 _! ends sawn (f & _! articul> facets snipp$ (f ) ! bone-pli]s longitud9ally4 ,! trapezium is !n to be seiz$ by =ceps & c>efully dissect$ out1 ! metac>pal bone ( ! ?umb p>$ l ! o!rs1 ! articul> surface ( ! pisi=m remov$1 ! re/ ( ! bone be+ left if x is s\nd4 ,! radial incision is /it*$ closely ?r\gh\t1 & also ! ends ( ! uln> incision1 any ligature be+ br\ght out ?r\gh ! c5tre ( ! uln> incision1 :i* is kept op5 ) a piece ( l9t1 :i* also gives support to ! ext5sor t5dons4 ,! aft]-treatm5t is important1 ! pr9cipal specialities be+--7#a47 e>ly & free movem5t ( ! f+]s2 7#b47 secure fix+ ( ! wri/ to procure consolidation4 7#a47 ,by passive motion ( ! jo9ts ( ! knuckles & f+]s1 comm5c$ on ! second day1 & cont9u$ daily aft] ! op]ation2 7#b47 ,by a spl9t support+ ! =e-arm & h&1 ! f+]s be+ held 9 a semiflex$ position by a l>ge pad ( cork fa/5$ firmly on to ! spl9t & made to fit ! palm2 ?is prev5ts ! spl9t f slipp+ up ! arm1 & by a turn ( a b&age insures fixation ( ! wri/-jo9t4 ,! ant]ior "p ( ?is spl9t bel[ ! f+]s may be gradually %ort5$1 all[+ m & m passive motion ( ! f+]s1 b ! pati5t mu/ we> x = mon?s1 inde$1 till he f9ds 8 wri/ z /rong )\t x z ) x4 ,among ! v>i\s op]ations t h be5 devis$1 ! foll[+ require notice3--,mr4 ,sp5ce1 ,dr4 ,gillespie1 ,dr4 ,watson1 & ! au?or1 use a s+le dorsal incision ) excell5t results1 & f9d x q easy to remove all ! bones f x4 ,mr4 ,sp5ce _h sixte5 cases )\t a dea?4 ,,po/]ior ,,semilun> ,,flap1 f c>pal atta*m5t ( metac>pal ( index f+] r\nd to /yloid process ( ulna2 divid+ integum5ts only1 !n sep>at+ ! t5dons ( ! common ext5sor longitud9ally1 & draw+ !m aside by blunt hooks1 ! diseas$ bones are remov$ piecemeal by curv$ p>rot-bill =ceps4#ei ,,po/]ior ,,curv$ ,,flap4--,an incision d[n to ! c>pal bones1 ext5d$ f a po9t two l9es to ! uln> side ( ! ext5sor secundi int]nodii pollicis1 & f a qu>t] to half an in* bel[ ! radio-c>pal articulation1 swept 9 a curvil9e> direction d[nw>ds1 close to ! c>pal extremities ( ! metac>pal bones1 to a po9t j bel[ ! end ( ! ulna4 ,! flap ?us m>k$ out 0 dissect$ up1 & consi/$ ( ! integum5ts1 areol> tissue1 & ext5sor t5dons ( ! f\r f+]s1 toge!r ) l>ge deposits ( fibr9e1 ! products ( repeat$ & prolong$ inflammatory action4 ,! t5don ( ! second ext5sor & its s(t p>ts ar\nd 7 sep>at$ f ! bones4 ,! rema9s ( ! ligam5ts 7 cut1 flexion ( ! h& protrud$ ! c>i\s ends ( radius & ulna4 ,! bones 7 !n dissect$ out1 leav+ ! trapezium1 :i* 0 n diseas$1 & h& plac$ on a spl9t4#fj ,,excision ,,( ,,! ,,hip-,,jo9t4--,! "q z to ! propriety ( p]=m+ ?is op]ation 9 any case is /ill debat$ by "s surgeons1 & ! selection ( suitable cases = ! op]ation is greatly modifi$ by ! v>y+ op9ions ( ! diff]5t s*ools ( surg]y4 ,en\gh "h to describe ! me?od ( op]at+1 & ! am\nt ( ! bone :i* is to be remov$4 ,z 9 ! %\ld]-jo9t1 ! head ( ! femur is mu* m liable to disease1 &1 z a rule1 mu* e>li] attack$ ?an is ! acetabulum1 b un=tunately ! acetabulum does ev5tually become affect$ also 9 probably a mu* l>g] proportionate numb] ( cases ?an ! gl5oid4 ,c>ies ( ! head1 neck1 & tro*ant]s ( ! femur is a v common disease 9 ?is v>iable climate1 & frequ5tly connect$ ) ! /rum\s ta9t4 ,aft] mu* suff]+1 abscesses =m & dis*>ge1 giv+ consid]able pa91 & (t5 end by c>ry+ (f ! pati5t4 ,z a result ( ! abscess & de/ruction ( ! ligam5ts1 ! head ( ! bone is apt to be displac$1 & "u "s sudd5 muscul> ex]tion or involunt>y spasm1 consecutive dislocation ( ! femur 7g5]ally on to ! dorsum ilii7 v (t5 occurs4 ,9 su* a case ! op]ation ( excision ( ! head ( ! femur is by no means difficult1 & n excessively dang]\s1 especially 9 "y *ildr54 ,op]ation4--,x is h>dly necess>y1 or inde$ possible1 to lay d[n exact rules = ! p]=mance ( ?is op]ation1 9 s f> z ! ext]nal incisions are conc]n$1 = ! s9uses :i* exi/ ought 9 g5]al to be made use (4 ,:5 ! surgeon has 8 *oice1 a /raight incision 7,plate ,,ii4 fig4 ,a471 p>allel ) ! bone1 ext5d+ f ! top ( ! great tro*ant] d[nw>ds = ab\t two in*es1 & also f ! same po9t 9 a curv$ direction ) ! concavity =w>ds1 upw>ds t[>ds ! position ( ! head ( ! bone 7see diagram71 w be f\nd mo/ conv5i5t4 ,! incisions %\ld be c>ri$ boldly d[n to ! bone1 :i* w (t5 be felt expos$ & ba!d 9 pus1 any rema9s ( ! ligam5t\s /ructures mu/ be cauti\sly divid$ ) a probe-po9t$ bi/\ry1 & !n by br++ ! knee ( ! affect$ side =cibly across ! opposite ?igh1 ) ! toes ev]t$1 ! head ( ! bone is =c$ out ( ! w\nd4 ,! head1 neck1 & great tro*ant] %\ld be fully expos$1 & ! saw appli$ transv]sely bel[ ! level ( ! tro*ant]1 s z to remove x entire4 ,if ?is is n done1 x prev5ts dis*>ge1 protrudes at ! w\nd1 & besides ?is x is almo/ inv>iably diseas$ along ) ! head4 ,*a9 saws are q unnecess>y1 x be+ 9 mo/ cases easy to apply an ord9>y "o to ! bone1 if x is prop]ly ev]t$4 ,great c>e 9 ! aft]-treatm5t is requir$ to prev5t undue %ort5+ ( ! limb1 or 9 ! ev5t ( a cure to secure ! mo/ fav\rable position = ! an*ylosis4 ,! femur occasionally t5ds to protrude at ! w\nd1 & h5ce may require to be c\nt]-ext5d$ by spl9ts4 ,if requir$ at all1 ! spl9t %\ld be made ) an iron elb[ opposite ! w\nd to admit ( its be+ easily dress$4 ,9 mo/ cases c\nt]-ext5sion may be be/ manag$ by a weight & pulley4 ,v>i\s =ms ( hammock sw+s to support ! :ole body1 & sl+s ( lea!r or canvas to support ! limb only1 h be5 f\nd to aid recov]y1 & r5d] ! pati5t mu* m com=table4 ,:5 ! acetabulum is also diseas$ ! prognosis is mu* m unfav\rable ?an :5 x is s\nd4 ,! exp]im5ts ( ,he9e & ,jg] on ! dead body1 & op]ations by ,hancock1 ,eri*s51 & ,holmes1 on pati5ts1 h %[n t 9 cases ( ext5sive disease ( ! acetabulum x is q possible by a prolong$ & c>eful dissection to remove x all )\t injury ( ! pelvic visc]a4 ,! details ( incisions = su* an op]ation ne$ sc>cely be giv51 z !y mu/ v>y 9 ea* case ) ! am\nt ( bone diseas$1 & ! position ( ! already exi/+ s9uses4 ,! am\nt ( bone t may be remov$ v>ies mu*4 ,eri*s5 9 "o case excis$ ! upp] end ( ! femur1 ! acetabulum1 ! rami ( ! pubis1 & ( ! is*ium1 a portion ( ! tub] is*ii1 & "p ( ! dorsum ilii4#fa ,a less =midable proce$+ may be useful 9 cases :]e ! acetabulum is diseas$1 b n deeply4 ,! mod]ate use ( an ord9>y g\ge may succe$ 9 remov+ ! diseas$ bone4 ,exp]i5ce & ! cold evid5ce ( /ati/ics prove1 h[ev]1 t ! prognosis 9 any case is modifi$ v mu* = ! worse by ! pres5ce ( any disease ( ! acetabulum1 m ?an "o-half ( ! cases prov+ fatal 9 :i* x is diseas$1 :e!r attempts to remove ! disease ( ! acetabulum be made or n1 & t ^? cases d be/ 9 :i* ! head ( ! femur has be5 displac$1 & lies outside ! jo9t almo/ l a loose seque/rum among ! s(t p>ts4 ,! results ( excision ( ! hip h z yet be5 v disc\rag+1 ! mortality ( ! :ole s]ies ( publi%$ cases be+1 accord+ to ,dr4 ,hodge's c>eful table1 v little "u #a 9 e #b cases1 viz41 #a 9 #b-e_/ec4 ,lat] /ati/ics are h[ev] m fav\rable4 ,l all o!r excisions1 ! mortality increases v mu* ) ! pati5t's age4 ,?us ( #ajc complet$ cases 9 :i* ! age is giv51 #ec recov]$ & #ej di$1 b divid+ ! cases at ! end ( ! sixte5? ye>1 we f9d t ( ! *ildr5 bel[ ?is age #dc recov]$ & #bi di$1 a mortality ( #dj4b p] c5t42 ( ! adults1 #aj recov]$1 & #ba di$1 or a mortality ( #fg4f p] c5t4 ,if we rememb] ! m>vell\s p[] ( recov]y f jo9t diseases we f9d 9 *ildhood1 "u ! influ5ce ( good diet1 cod-liv] oil1 & fre% air1 we _c %ut our eyes to ! fact t su* results & su* a mortality are by no means enc\rag+4 ,f an ext5sive exp]i5ce 9 a special hospital = hip-disease1 :]e fre% air1 abundant n\ri%m5t1 & v excell5t nurs+ are provid$1 ! au?or is le>n+ m & m to tru/ to ! p[] ( nature 9 ! cure ( ev5 v advanc$ cases ( hip-disease 9 *ildr51 & he believes t op]ation is r>ely necess>y1 or ev5 w>rantable1 except = ! removal ( seque/ra4 ,mr4 ,holmes's#fb /ati/ics are int]e/+4 ,he has op]at$ on no few] ?an n9ete5 cases4 ,( ^! sev5 di$1 "o aft] second>y amputation at ! hip4 ,ano!r requir$ amputation & recov]$4 ,two o!rs di$ ( o!r diseases )\t hav+ us$ _! limb4 ,( ! rema9+ n9e1 ?ree 7 p]fectly successful1 f\r 7 promis+ cases1 & two unpromis+4 ,pr(essor ,sp5ce 9 #ai cases _h #f dea?s1 or a mortality ( #ca4f p] c5t4 ,culb]tson's collection gives out ( #dbf cases1 #aib dea?s1 or #de p] c5t4 ,mr4 ,cr(t1 ^: skill & success z an op]ator are well kn[n1 has record$ #de cases ( excision ( hip 9 8 own practice2 ( ^! #af di$1 #aa 7 "u treatm5t1 #ah _h recov]$1 ( :i* #af _h moveable jo9ts & useful limb2 ! o!r two are pot5tially cur$4#fc ,v>i\s o!r incisions h be5 devis$ = ga9+ access to ! jo9t4 ,! mo/ noticeable are ^? 9 :i* a flap is made in/ead ( a l9e> incision4 ,s$illot makes a semilun> or ovoid flap1 ! base ( :i* is j bel[ ! great tro*ant]1 & :i* includes x1 ! convexity be+ upw>ds & ! flap be+ turn$ d[n4 ,gross's modification ( ?is is pref]able1 be+ turn$ ! opposite way1 ! convexity be+ d[nw>ds 7,plate ,,iii4 fig4 ,e471 & ! flap ?us be+ turn$ up4 ,results 9 successful cases4--,( fifty-two 9 ,hodge's table1 ?irty-"o _h useful limbs1 six indiff]5t1 ?ree decid$ly useless1 f\r di$ )9 ?ree ye>s1 & ( ! rema9+ eight no details are giv54 ,! %ort5+ is always consid]able1 a high-heel$ %oe be+ requir$ 9 mo/ cases2 a /ick is indisp5sable2 9 _m1 crut*es are necess>y4 ,v>i\s op]ations h be5 devis$ = ! treatm5t ( osse\s an*ylosis ( ! hip-jo9t :5 9 a bad position4 ,all are m or less dang]\s4 ,p]haps "o ( ! lea/ dang]\s is ! plan ( subcutane\s division ( ! neck ( ! femur by a n>r[ saw1 propos$ by ,mr4 ,adams ( ,london4 ,x is sometimes a v labori\s op]ation4 ,,excision ,,( ,,knee-,,jo9t4--,removal ( ,bone4--,9 e case ! excision ( ! jo9t ought to be complete4 ,"s attempts h be5 made to save "o or o!r ( ! articul> surfaces1 b !y h prov$ failures4 ,! patella has frequ5tly be5 left :5 x 0 n diseas$1 z is (t5 ! case1 b ! results h n be5 su* z to recomm5d su* a practice4 ,direction ( ,section ( ! ,bones4--,! bones %\ld be cut transv]sely1 &1 z f> z possible1 be 9 accurate & complete apposition4 ,a slight bevell+ at ! exp5se ( ! po/]ior m>g9 w produce an an*ylosis ( ! limb 9 a v slightly flex$ position1 :i* is f\nd to aid ! pati5t 9 walk+4 ,x has be5 propos$ by "s#fd to cut bo? bones obliquely1 s z to obviate ! difficulty ( mak+ ! transv]se surfaces p>allel4 ,?is involves a /ill great] practical difficulty 9 keep+ ^! oblique surfaces 9 position dur+ ! aft]-treatm5t4 ,?is plan might possibly be valuable 9 cases :]e ! disease 0 limit$ to "o or o!r edge ( ! bone4 ,among ! v>i\s incisions recomm5d$1 ! be/ seems to be ! ,semilun> ,incision4 ,op]ation4--,! limb be+ held 9 an ext5d$ position1 a s+le semilun> incision 7,plate ,i4 fig4 ,b47 is made1 ent]+ ! jo9t at once1 & divid+ ! ligam5tum patell4 ,x %\ld ext5d f ! inn] side ( ! inn] condyle ( ! femur to a correspond+ po9t ov] ! out] "o1 pass+ 9 front ( ! jo9t midway betwe5 ! l[] edge ( ! patella & tub]osity ( ! tibia4 ,! flap is !n dissect$ back1 ! ligam5ts divid$1 :5 by extreme flexion ( ! limb ! articul> surface ( ! tibia & femur are ?or\ghly expos$4 ,! crucial ligam5ts mu/ !n be divid$ cauti\sly1 & ! articul> portion ( ! femur clean$ ant]iorly by ! knife1 po/]iorly by ! op]ator's f+]1 s f> z possible to avoid injury ( ! art]y4 ,! :ole articul> surface ( ! femur mu/ !n be remov$ by a transv]se cut ) ! saw z exactly z possible at a "r angle ) ! axis ( ! bone4 ,! am\nt ( ! femur :i* w require removal w 9 ! adult v>y f an in* to an in* & a half or ev5 m4 ,x mu/ involve all ! bone normally cov]$ by c>tilage2 & ?is be+ remov$1 if ! section %[s evid5ce ( disease1 slice aft] slice may require removal till a heal?y surface is obta9$4 ,occasionally1 if ! diseas$ portion appe>s limit$1 ?\gh deep1 ! application ( a g\ge may succe$ 9 remov+ disease )\t involv+ too great %ort5+ ( ! limb4 ,specially 9 *ildr51 x is ( great importance to avoid remov+ ! :ole epiphysis4 ,! tibia mu/ !n be expos$ 9 a simil> mann]1 & a ?9 slice remov$2 if ! bone be tol]ably heal?y1 ev5 less ?an half an in* w prove q suffici5t4 ,?is me?od has an imm5se advantage 9 t x provides an excell5t ant]ior flap = ! amputation1 :i* may be requir$ 9 cases :]e ! disease ( bone is f\nd too ext5sive to admit ( ! excision be+ practis$4 ,?is me?od1 ) slight deviations1 is sub/antially t ( ,ri*>d ,mack5zie ( ,ed9burgh1 ,wood ( ,new ,york1 ,jones ( ,j]sey4 ,hmorrhage mu/ !n be /opp$1 & t z ?or\ghly z possible1 by torsion1 cold1 & pressure1 & ! flap br\ght accurately toge!r ) sutures4 ,9 "s r>e cases1 x may be f\nd necess>y to divide ! ham/r+ t5dons to rectify spa/ic contraction ( ! muscles2 b ?is c g5]ally be done q well f ! orig9al w\nd4 ,holt makes a dep5d5t op5+ 9 ! popliteal space = dra9age4 ,?is is unnecess>y if ! incisions are made suffici5tly f> back1 & if ! w\nd is prop]ly dra9$4 ,x is unsafe1 z approa*+ s close to ! art]y & ve9s4 ,if mu* bagg+ takes place1 ! use ( a dra9age-tube w prove q suffici5t4 ,aft]-treatm5t4--,wire spl9ts l9$ ) lea!r & provid$ ) a foot-piece2 special box-spl9ts ) moveable sides1 z ,but*]'s2#fe pla/]-(-,p>is m\lds are us$ by ,dr4 ,p4,h4 ,watson#ff ( ,ed9burgh & o!rs2 ?is la/ =m ( dress+ is ! be/1 & all[s ! limb to be susp5d$ f a ,salt]'s sw+4 ,h-%ap$ incision4--,! int]nal incision %\ld comm5ce at a po9t ab\t two in*es bel[ ! articul> surface ( ! tibia1 & 9 a l9e ) its inn] edge2 x %\ld !n be c>ri$ up along ! femur 9 a direction p>allel to ! axis ( ! ext5d$ limb1 s z to pass 9 front ( ! saph5a ve91 & ?us avoid x1 = a di/ance ( five in*es4 ,! ext]nal incision1 comm5c+ j bel[ ! head ( ! fibula1 mu/ be c>ri$ upw>ds p>allel to ! prec$+ = ! same di/ance4 ,bo? incisions mu/ be made by a heavy scalpel ) a firm h&1 s z to divide all ! tissues d[n to ! bone4 ,! v]tical incisions are !n unit$ by a transv]se "o pass+ across j bel[ ! l[] angle ( ! patella4 ,! flaps ?us =m$ mu/ !n be dissect$ up & d[n1 & ! int]nal & ext]nal lat]al ligam5ts divid$1 ?us ?or\ghly op5+ ! jo9t & expos+ ! crucial ligam5ts4 ,^! mu/ be divid$ c>efully1 rememb]+ ! position ( ! art]y4 ,! bones are !n to be cle>$ & divid$1 z 9 ! op]ation already describ$4 ,?is is ! me?od ( ,moreau & ,but*]4#fg ,patella & ,ligam5tum ,patell reta9$4--,a longitud9al incision1 full f\r in*es 9 ext5t1 0 made on ea* side ( ! knee-jo9t1 midway betwe5 ! va/i & flexors ( ! leg2 ^! two cuts 7 d[n to ! bones1 !y 7 connect$ by a transv]se "o j ov] ! prom95ce ( ! tub]cle ( ! tibia1 c>e be+ tak5 to avoid cutt+ by ?is incision ! ligam5tum patell2 ! flap ?us def9$ 0 reflect$ upw>ds1 ! patella & ! ligam5t 7 !n fre$ & drawn ov] ! int]nal condyle1 & kept !re by means ( a broad1 flat1 & turn$-up spatula2 ! jo9t 0 ?us expos$1 & aft] ! synovial capsule _h be5 cut ?r\gh z f> z c\ld be se51 ! leg 0 =cibly flex$1 ! crucial ligam5ts1 almo/ break+ 9 ! act1 only requir$ a slight t\* ( ! knife to divide !m completely4 ,! articul> surfaces ( ! bones 7 n[ completely br\ght to view1 & ! diseas$ portions remov$ by means ( suitable saws1 ! s(t p>ts be+ hold aside by assi/ants4#fh ,results ( ,excision ( ,knee-jo9t3--,holmes's ,table ( rec5t cases f #ahgc-ahgh-- #bde cases2 #be dea?s1 & #dg failures4 ,sp5ce's--#cc cases2 #bb recov]$1 #aa di$4 ,,buck',s ,,op]ation ,,= ,,an*ylos$ ,,knee-,,jo9t4--,! pr9ciple ( ?is op]ation is to remove a triangul> portion ( bone1 :i* is to include ! surfaces ( ! femur & tibia1 :i* h an*ylos$ 9 an awkw>d position1 & by ?is means to set ! bones free1 & enable ! limb to be /raight5$4 ,access to ! jo9t may be obta9$ by ei!r ( ! two me?ods already describ$4 ,sections ( ! bones are !n to be made ) ! saw1 s z to meet po/]iorly a little 9 front ( ! po/]ior surface ( ! an*ylos$ jo9t1 & ?us remove a triangul> portion ( bone2 ! portion /ill rema9+1 & :i* /ill keeps up ! de=mity1 is !n to be brok5 ?r\gh z be/ y c1 ei!r by a *isel1 or a saw1 or =c$ flexion4 ,! ends are to be p>$ (f by bone-pli]s1 & ! surfaces br\ght into z close apposition z possible4 ,! op]ation is a difficult "o1 a gap be+ g5]ally left betwe5 ! ant]ior edges ( ! bones1 f ! unyield+ nature ( ! integum5ts beh9d1 & ! difficulty ( remov+ ! po/]ior project+ edges f _! close proximity to ! art]y4 ,( tw5ty cases on record1 eight di$1 & two requir$ amputation4 ,relation ( ,age to result 9 ,excision ( ,knee-,jo9t f ,hodge's ,tables4 ,( #ahb complete cases3-- #fh bel[ #af ye>s3 #ej recov]$--#ah di$2 or #bf p] c5t4 di$4 #aad above #af ye>s3 #ee recov]$--#ei di$2 or #ea4g p] c5t4 di$4 ,,excision ,,( ,,! ,,ankle-,,jo9t4--,9 :at cases is x to be done1 & h[ mu* bone is to be remov$8 ,9 cases ( comp\nd dislocation ( ! ankle-jo9t1 ! tibia & fibula are apt to be protrud$ ei!r 9 front or beh9d4 ,:5 ?is happ5s x is a dislocation g5]ally v difficult to r$uce1 & :5 r$uc$ to reta9 9 position4 ,9 su* cases1 if !re seems to be any *ance ( reta9+ ! foot1 excision ( ! articul> ends ( tibia & fibula greatly add to ! probabilities 9 its fav\r4 ,x may be done )\t any new w\nd1 &1 9 g5]al1 by an ord9>y surgeon's saw4 ,:5 ! a/ragalus does n protrude1 x seems to matt] little = ! future result :e!r its articul> surface be remov$ or n4 ,:51 on ! o!r h&1 x protrudes1 z a result ei!r ( ! displacem5t ( ! entire foot1 or ( a dislocation complete or p>tial ( ! a/ragalus itself1 !re is no d\bt t excision ei!r ( its articul> surface or ( ! entire bone w give v excell5t results4 ,jg] reports tw5ty-sev5 su* cases1 ) only "o fatal1 & "o d\btful result4 ,9 cases ( disease ( ! ,ankle-jo9t4--,excision has be5 p]=m$ a good _m times1 & %\ld 9 mo/ cases be complete4 ,a "w l ?is is n ! place to discuss ! propriety ( op]ations s mu* z ! me?od ( p]=m+ !m1 b "o rem>k may be p]mitt$4 ,few po9ts ( surgical diagnosis are m difficult ?an x is to tell :e!r 9 any giv5 case disease is conf9$ to ! ankle-jo9t1 & :e!r or n ! bones ( ! t>sus p>ticipate4 ,if !y d ev5 to a slight ext5t1 no op]ation :i* attacks ! ankle-jo9t only has any reasonable *ance ( success4 ,x may look well = a "t1 b s9uses rema91 ! irritation ( ! op]ation only ha/5s ! progress ( ! disease ( ! bone1 & ! result w almo/ c]ta9ly be disappo9t+1 amputation be+ almo/ ! inevitable d]ni] ressort4 ,me?ods ( ,op]at+3-- ,mr4 ,hancock has be5 v successful by ! foll[+ me?od3-- ,comm5ce ! incision 7,plate ,,ii4 figs4 ,b4,b47 ab\t two in*es above & beh9d ! ext]nal malleolus1 & c>ry x across ! in/ep to ab\t two in*es above & beh9d ! int]nal malleolus4 ,take c>e t ?is incision m]ely divides ! sk91 & does n p5etrate beyond ! fascia4 ,reflect ! flap s made1 & next cut d[n ^u ! ext]nal malleolus1 c>ry+ y\r knife close to ! edge ( ! bone1 bo? beh9d & bel[ ! process1 dislodge ! p]onei t5dons1 & divide ! ext]nal lat]al ligam5ts ( ! jo9t4 ,hav+ done ?is1 ) ! bone-nipp]s cut ?r\gh ! fibula1 ab\t an in* above ! malleolus1 remove ?is piece ( bone1 divid+ ! inf]ior tibio-fibul> ligam5t1 & !n turn ! leg & foot on ! outside4 ,n[ c>efully dissect ! t5dons ( ! tibialis po/icus & flexor communis digitorum f beh9d ! int]nal malleolus4 ,c>ry y\r knife close r\nd ! edge ( ?is process1 & deta* ! int]nal lat]al ligam5t1 !n grasp+ ! heel ) "o h&1 & ! front ( ! foot ) ! o!r1 =cibly turn ! sole ( ! foot d[nw>ds1 by :i* ! l[] end ( ! tibia is dislocat$ & protrud$ ?r\gh ! w\nd4 ,?is done1 remove ! diseas$ end ( ! tibia ) ! common amputat+ saw1 & aft]w>ds ) a small metac>pal saw plac$ ^u ! back ( ! upp] articulat+ process ( ! a/ragalus1 betwe5 t process & ! t5do ,a*illis1 remove ! =m] by cutt+ f beh9d =w>ds4 ,replace ! p>ts 9 situ2 close ! w\nd c>efully on ! inn] side & front ( ! ankle2 b leave ! outside op51 t !re may be a free exit = dis*>ge1 apply wat]-dress+1 place ! limb on its out] side on a spl9t1 & ! op]ation is complet$4 ,sk91 ext]nal1 & int]nal ligam5ts1 & ! bones are ! only p>ts divid$1 no t5dons & no art]ies ( any size4#fi ,b>well's me?od by lat]al incisions is briefly z foll[s3-- ,on ! out] side1 an incision ov] ! l[] ?ree in*es ( ! fibula turns =w>d at ! malleolus at an angle1 & ends ab\t half an in* above ! base ( ! out] metat>sal4 ,! flap is to be reflect$1 fibula divid$ ab\t two in*es f its l[] end by ! =ceps1 & dissect$ out1 leav+ p]onei t5dons uncut4 ,a simil> incision on ! inn] side t]m9ates ov] ! projection ( ! int]nal cunei=m bone2 ! %ea?s ( ! t5dons "u inn] angle are !n to be divid$1 & ! art]y & n]ve avoid$2 ! int]nal lat]al ligam5t is !n to be divid$1 ! foot twi/$ outw>ds1 s z to protrude ! a/ragalus & tibia at ! inn] w\nd4 ,! l[] end ( ! tibia & top ( ! a/ragalus are to be sawn (f by a n>r[-blad$ saw pass+ f "o w\nd to ! o!r4#gj ,dr4 ,m4 ,bu*anan ( ,glasg[ has describ$ an op]ation by :i* ! jo9t c be excis$ ?r\gh a s+le incision ov] ! ext]nal malleolus4 ,results4--,s f> z c be ga!r$ f cases already publi%$1 ! results are v (t5 7at lea/ 9 "o out ( e two cases7 unsatisfactory4 ,s9uses rema91 :i* d n heal1 ! limbs are useless1 & amputation is 9 ! end necess>y4 ,lang5beck has p]=m$ x sixte5 times dur+ ! la/ ,s*leswig-,hol/e9 w> 79 #ahfd71 & ! ,bohemian w> 9 #ahff1 ) only ?ree dea?s4 ,9 ^! cases ! op]ation 0 subp]io/eal4 ,,excision ,,( ,,! ,,scapula4--,m or less ( ! scapula has 9 _m cases be5 remov$ along ) ! arm1 & ev5 ) ! addition ( portion ( ! clavicle4 ,excision ( ! entire bone1 leav+ ! arm1 has be5 p]=m$ 9 two in/ances by ,mr4 ,syme4 ,! proc$ure mu/ v>y accord+ to ! nature & %ape ( ! tum\r on acc\nt ( :i* ! op]ation is p]=m$4 ,mr4 ,syme op]at$ z foll[s3-- ,9 ! fir/ case1 "o ( c]ebri=m tum\r ( ! bone1 he made an incision f ! acromion process transv]sely to ! po/]ior edge ( ! scapula1 & ano!r f ! c5tre ( ?is "o directly d[nw>ds to ! l[] m>g9 ( ! tum\r4 ,! flaps ?us =m$ be+ reflect$ )\t mu* hmorrhage1 ,i sep>at$ ! scapul> atta*m5t ( ! deltoid1 & divid$ ! connections ( ! acromial extremity ( ! clavicle4 ,!n1 wi%+ to comm& ! subscapul> art]y1 ,i divid$ x1 ) ! effect ( giv+ issue to a fe>ful gu% ( blood1 b =tunately caught ! vessel & ti$ x )\t any delay4 ,i next cut into ! jo9t & r\nd ! gl5oid cavity1 hook$ my f+] "u ! coracoid process1 s z to facilitate ! division ( its muscul> & ligam5t\s atta*m5ts1 & !n pull+ back ! bone ) all ! =ce ( my left h&1 sep>at$ its rema9+ atta*m5ts ) rapid sweeps ( ! knife4 7,plate ,,iii4 fig4 ,g47 ,mr4 ,syme's second case 0 also "o ( tum\r ( ! scapula2 ! head ( ! hum]us _h be5 excis$ two ye>s be=e4 ,he remov$ x by two incisions1 "o f ! clavicle a little to ! /]nal side ( ! coracoid1 direct$ d[nw>ds to ! l[] b\nd>y ( ! tum\r1 ano!r transv]sely f ! %\ld] to ! po/]ior edge ( ! scapula4 ,! clavicle 0 divid$ at ! spot :]e x 0 expos$1 & ! out] portion remov$ along ) ! scapula4#ga ,! au?or has 9 a case ( osse\s tum\r remov$ ! :ole body ( ! scapula1 leav+ gl5oid1 sp9e1 acromion & ant]ior m>g9 ) excell5t result & a useful arm4 ,l>ge portions ( ! %afts ( ! hum]us1 radius1 & ulna h be5 remov$ = disease or accid5t1 & useful arms h result$2 b z ! op]ative proc$ures mu/ v>y 9 e case1 accord+ to ! am\nt ( bone to be remov$1 & ! numb] & position ( ! s9uses1 no exact directions c be giv54 ,= v int]e/+ cases ( su* resections ref]5ce may be made to ,wagn]'s treatise on ! subject1 translat$ & enl>g$ by ,mr4 ,holmes1 & to ,williamson's ,milit>y ,surg]y1 p4 #bbg4 ,,excision ,,( ,,metac>pals ,,& ,,phalanges4--,to excise ! metac>pal implies t ! correspond+ f+] is left4 ,except 9 cases ( necrosis1 :]e abundance ( new bone has =m$ 9 ! deta*$ p]io/eum1 ! results ( su* excisions d n enc\rage repetition1 ! digits :i* rema9 be+ g5]ally v useless4 ,x is q diff]5t1 h[ev]1 if x is ! ?umb t is involv$2 & e ef=t %\ld1 9 e case1 be made to reta9 ! ?umb1 ev5 9 ! complete abs5ce ( its metac>pal bone4 ,= ! good results ( a case 9 :i* ,mr4 ,syme excis$ ! :ole metac>pal bone = a tum\r1 see 8 ,obs]vations 9 ,cl9ical ,surg]y1 p4 #ch4 ,! op]ation is n difficult1 & requires m]ely a /raight incision ov] ! dorsum1 ext5d+ ! :ole l5g? ( ! bone4 ,9 ! same way ! proximal phalanx ( ! ?umb may be excis$1 & yet1 if prop] c>e be tak51 a v useful limb be left4 ,i quote entire ! foll[+ case by ,mr4 ,but*] ( ,dubl93-- ,,excision ,,( ,,proximal ,,phalanx ,,( ,,! ,,?umb4-- ,! ?umb ( ! "r h& 0 cru%$ by ! crank ( a /eam-eng9e4 ,! proximal phalanx 0 completely %iv]$2 its fragm5ts 7 remov$1 ! c>tilage ( ! proximal end ( ! di/al phalanx1 & also ( ! head ( ! metac>pal bone1 7 p>$ (f ) a /rong knife4 ,! digit 0 put up on a spl9t fully ext5d$4 ,9 ab\t a mon? cure 0 ne>ly complete1 a firm d5se tissue took ! place ( ! remov$ phalanx1 & ! p[] ( flex+ ! ungu9al 0 ne>ly complete4#gb ,,excision ,,( ,,! ,,jo9ts ,,( ,,! ,,f+]s4--,^! op]ations may be p]=m$ = comp\nd dislocation1 specially :5 ! ?umb is injur$2 no directions c be giv5 = ! incisions4#gc ,9 cases ( disease x is r>ely necess>y or advisable to attempt to save a f+]1 b if ! metac>po-phalangeal jo9t ( ! ?umb be affect$1 excision %\ld be p]=m$ ) ! hope ( sav+ ! ?umb4 ,a s+le free incision on ! radial side ( ! jo9t w give suffici5t access4 ,,excision ,,( ,,! ,,os ,,calcis4--,9 ^? comp>atively r>e cases 9 :i* ! os calcis is alone affect$1 ! re/ ( ! t>sus & ! ankle-jo9t be+ heal?y1 a consid]able diff]5ce ( op9ion exi/s z to ! prop] c\rse to be foll[$4 ,by "s surgeons x is consid]$ be/ m]ely to ga9 free access to ! diseas$ bone1 & !n remove by a g\ge all ! s(t5$ & alt]$ portions1 leav+ a %ell ( bone all r\nd1 ( c\rse sav+ ! p]io/eum & avoid+ int]f]5ce ) ! jo9t4 ,?is op]ation requires no special detail$ in/ruction4 ,we f9d _m surgeons1 among !m ,f]gusson & ,hodge1 support]s ( ?is comp>atively mode/ op]ation4 ,! au?or has _m times p]=m$ ?is op]ation ) excell5t results4 ,ev5 :5 no?+ b p]io/eum is left1 ! new bone becomes /rong & ( full size4 ,excision ( ! :ole ( ! diseas$ bone at its jo9ts1 ) or )\t an attempt to leave "s ( ! p]io/eum1 has be5 deem$ necess>y by o!rs4 ,holmes1 :o has _h consid]able exp]i5ce1 removes ! bone at once by ! foll[+ incisions1 )\t pay+ any ref]5ce to ! p]io/eum3-- ,op]ation4--,an incision 7,plate ,,iii4 fig4 ,f47 is comm5c$ at ! inn] edge ( ! t5do ,a*illis1 & drawn horizontally =w>ds along ! out] side ( ! foot1 some:at 9 front ( ! calcaneo-cuboid jo9t1 :i* lies midway betwe5 ! out] malleolus & ! end ( ! fif? metat>sal bone4 ,?is incision %\ld g d[n at once ^u ! bone1 s t ! t5don %\ld be felt to snap z ! incision is comm5c$4 ,x %\ld be z ne>ly z possible on a level ) ! upp] bord] ( ! os calcis1 a po9t :i* ! surgeon c det]m9e1 if ! dorsum ( ! foot is 9 a natural /ate1 by feel+ ! pit 9 :i* ! ext5sor brevis digitorum arises4 ,ano!r incision is !n to be drawn v]tically across ! sole1 comm5c+ ne> ! ant]ior end ( ! =m] incision1 & t]m9at+ at ! out] bord] ( ! groov$ or int]nal surface ( ! os calcis1 beyond :i* po9t x %\ld n ext5d1 = fe> ( w\nd+ ! po/]ior tibial vessels4 ,if m room be requir$1 ?is v]tical incision may be prolong$ a little upw>ds1 s z to =m a crucial incision4 ,! bone be+ n[ d5ud$ by ?r[+ back ! flaps1 ! fir/ po9t is to f9d & lay op5 ! calcaneo-cuboid jo9t1 & !n ! jo9ts ) ! a/ragalus4 ,! close connections betwe5 ^! two bones con/itute ! pr9cipal difficulty 9 ! op]ation on ! dead subject2 b ^! jo9ts w frequ5tly be f\nd to h be5 de/roy$ 9 cases ( disease4 ,! calcaneum hav+ be5 sep>at$ ?us f its bony connections by ! free use ( ! knife1 aid$1 if necess>y1 by ! lev]1 lion-=ceps1 etc41 ! s(t p>ts are next to be clean$ (f its inn] side ) c>e1 9 ord] to avoid ! vessels1 & ! bone w !n come away4#gd ,attempts may occasionally be made 9 su* an op]ation to save a portion ( p]io/eum 9 atta*m5t to ! s(t p>ts1 b success or failure 9 ?is seems to h v little effect on ! future result4 ,hancock's ,me?od4--,a s+le flap 0 =m$ 9 ! sole1 ) ! convexity look+ =w>ds1 by an incision f "o malleolus to ! o!r4 ,gre5h['s ,me?od4--,incisions made f ! inn] & out] ankles1 meet+ at ! apex ( ! heel1 & !n o!rs ext5d+ along ! sides ( ! foot1 ! flaps be+ dissect$ back s z to expose ! bone & its connections4#ge ,,excision ,,( ,,a/ragalus4--,a curv$ incision on ! dorsum ( ! foot ext5d+ f "o malleolus to ! o!r1 & z f> =w>ds z ! front ( ! scaphoid4 ,! *ief caution requir$ is to divide all ligam5ts :i* hold ! bone 9 place1 & dissect x clean on all o!r p>ts be=e m$dl+ ) its po/]ior surface :]e ! groove exi/s = ! flexor longus pollicis t5don ne> :i* ! po/]ior tibial vessels & n]ve lie4#gf ,,excision ,,( ,,a/ragalus ,,& ,,scaphoid4--,an incision simil> to ! ant]ior "o 9 ,syme's amputation at ! ankle4 ,! flap 0 !n turn$ back f ! dorsum ( ! foot4 ,! jo9t 0 !n op5$1 ! lat]al ligam5ts ( ! ankle-jo9t divid$1 ! foot dislocat$ s z to %[ ! a/ragalo-calcanean ligam5ts1 & all[ !m to be divid$4 ,! bones 7 !n grasp$ ) ! lion-=ceps & pull$ =w>ds1 :ile ! po/]ior surface ( ! a/ragalus 0 v cauti\sly clean$1 s z to avoid ! po/]ior tibial art]y4#gg ,,excision ,,( ,,metat>so-,,phalangeal ,,jo9t ,,( ,,great ,,toe4--,but*] p]=ms x by splitt+ up ! s9uses lead+ to ! c>i\s jo9t1 expos+ x & cutt+ (f ) bone-pli]s ! ant]ior ?ird ( ! metat>sal bone1 & ! proximal end ( ! fir/ phalanx4 ,he also cuts subcutane\sly ! ext5sor t5dons to prev5t !m f cock+ up ! toe4#gh ,pancoa/ pref]s a semilun> incision4 ,a lat]al incision is usually to be pref]r$4 ,! au?or has p]=m$ ?is excision frequ5tly = disease2 :5 ! :ole c>tilages are remov$ & ! w\nd is freely dra9$1 an admirable result is obta9$4 ,9 cases ( comp\nd dislocation ( ! head ( ! metat>sal bone1 x w occasionally be f\nd necess>y to excise x ei!r by ! orig9al1 or a slightly enl>g$ w\nd4 ,! au?or lately excis$ "o-half ( %aft ( metat>sal & ! correspond+ half ( proximal phalanx ( great toe = exo/osis1 ) antiseptic precautions4 ,! result 0 a useful toe ) a mobile jo9t4 ,,excision ,,( ,,metat>sal ,,bone ,,( ,,great ,,toe4--,= ?is op]ation a quadrilat]al flap has be5 recomm5d$1 b ?is is q unnecess>y4 ,a s+le /raight incision along ! inn] bord] ( ! foot1 ext5d+ ! :ole l5g? ( ! bone1 r5d]s x v easy to remove ! :ole bone f jo9t to jo9t4 ,?is is an op]ation1 h[ev]1 :i* is r>ely ne$$1 & :i* w\ld leave a v useless flail ( a toe4 ,! op]ation1 :i* is at once m commonly requir$1 & also gives promise ( a m satisfactory result1 is ! "o p]=m$ = c>io-necrosis ( ! %aft only1 & 9 ! foll[+ mann]3-- ,a /raight incision ?r\gh all ! tissues1 includ+ ! p]io/eum1 "r d[n to ! bone2 !n ) nail or h&le ( ! knife to sep>ate ! p]io/eum f ! bone2 !n ) a pair ( bone-pli]s or a f9e saw to divide ! %aft f bo? its extremities & remove x entire4#gi ,,footnotes3 #eb ,on ,diseases & ,injuries ( ,jo9ts1 p4 #aba4 #ec ,= a v l>ge am\nt ( mo/ int]e/+ & valuable in=mation on ! :ole subject ( excisions ( jo9ts1 ,i w\ld ref] to ,dr4 ,hodge's mo/ excell5t "w on ?is subject--,on ,excisions ( ,jo9ts4 ,by ,ri*>d ,m4 ,hodge1 ,m4,d41 ,bo/on1 ,massa*usetts4 #ed ,see ,syme's ,obs]vations on ,cl9ical ,surg]y1 pp4 #ee1 #eg2 ,hodge on ,excision ( ,jo9ts1 p4 #fc4 #ee ,maund]'s ,op]ative ,surg]y1 #b;d ed4 p4 #abc4 #ef ,ed94 ,m$4 ,j\rnal1 ,may #ahgc4 #eg ,quot$ by ,mr4 ,port]4 ,dubl9 ,qu>t]ly ,j\rnal = ,may #ahfg1 p4 #bfd4 #eh ,a-,a4 ,deep palm> ar*2 ,b4 ,trapezium2 ,c4 ,articul> surface ( ulna2 ,dott$ l9es include ! am\nt remov$ 9 ,li/]'s e>li] op]ations2 ,un%ad$ portions are ^? remov$ by ,li/] 9 cases :]e ! disease is limit$ to ! c>pus4 7,r$uc$ f ,li/]'s diagram 9 ,lancet1 #ahfe47 #ei ,skey1 ,op4 ,surg41 #b;d ed4 p4 #dch4 #fj ,abridg$ f ,but*]1 ,op4 & ,con4 ,surg]y1 p4 #bjh4 #fa ,sci5ce & ,art ( ,surg]y1 #c;d ed4 p4 #gde4 #fb ,on ! ,surgical ,treatm5t ( ,*ildr5's ,diseases1 pp4 #ded-f4 #fc ,cl9ical ,society's ,transactions1 vol4 xiii4 p4 #ga4 #fd ,billro? ( ,vi5na & ,pelikan ( ,/4 ,pet]sburg1 quot$ f ,heyfeld] by ,hodge on ,excision ( ,jo9ts1 p4 #afa4 #fe ,op]ative & ,cons]vative ,surg]y1 pp4 #bh1 #ach4 #ff ,on ,excision ( ,knee-,jo9t1 pp4 #ah1 #bj4 #fg ,op]ative & ,cons]vative ,surg]y1 p4 #afi4 #fh ,mr4 ,jones ( ,j]sey1 ,m$4 ,*ir4 ,trans41 vol4 xxxvii4 p4 #fh4 #fi ,lancet1 ,oct4 #a1 #ahei4 #gj ,b>well ,on ,diseas$ ,jo9ts1 p4 #dfd4 #ga ,syme ,on ,excision ( ! ,scapula1 pp4 #ac-bf1 #ahfd4 #gb ,but*]'s ,op]ative & ,cons]vative ,surg]y1 p4 #bbe4 #gc ,= an excell5t case1 see ,ann&ale on ,diseases ( ! ,f+] & ,toes1 p4 #bfa4 #gd ,holmes's ,surg]y1 #c;d edition1 vol4 iii4 p4 #gga4 #ge ,brit4 & ,=eign ,m$4 ,*ir4 ,review = ,july #ahec4 #gf ,mr4 ,holmes 9 ,lancet = ,febru>y #ah1 #ahef4 #gg ,ibid4 = ,may #ahfe4 #gh ,but*]1 ,op]ative & ,cons]vative ,surg]y1 p4 #ced4 #gi ,see ,but*]1 ,op]ative & ,cons]vative ,surg]y1 p4 #cef4 ,,*apt] ,,iv4 ,,op]ations ,,on ,,cranium ,,& ,,scalp4 ,,treph9+ ,,& ,,trepann+ are ! names giv5 to op]ations = ! removal ( portions ( ! cranium by circul> saws :i* play on a c5tre pivot4 ,:5 ! motion is giv5 to ! saw simply by rotation ( ! h& ( ! op]ator1 z is common 9 ?is c\ntry1 x is call$ treph9+2 :5 7z us$ to be ! case 9 ?is c\ntry1 & /ill is on ! ,cont95t7 ! motion is giv5 by an in/rum5t l a c>p5t]'s brace1 ! op]ation is call$ trepann+4 ,! nature ( ! op]ation v>ies accord+ to ! nature ( ! case = :i* x is p]=m$4 ,?us 7#a47 x may be p]=m$ ?r\gh ! un9jur$ cranium 9 ! hope ( evacuat+ an abscess ( ! diploe or dura mat]1 or ( reliev+ pressure caus$ by suppuration 9 ! bra9 itself1 or by extravasation into ! bra9 or membranes2 or 7#b47 x may be requir$ 9 cases ( punctur$ & depress$ fracture = ! purpose ( remov+ project+ corn]s ( bone & all[+ elevation ( ! depress$ portions2 or 7#c47 x is sometimes us$ to remove a circul> portion ( bone 9 cases ( epilepsy 9 :i* pa9 or t5d]ness is felt at "s limit$ portion ( ! cranium4 #a4 ,9 cases :]e ! cranium & its cov]+s are entire4--,!re are c]ta9 positions :]e1 if x is possible1 ! treph9e %\ld n be appli$4 ,^! are ! longitud9al s9us1 ! ant]ior inf]ior angle ( ! p>ietal bone1 :]e ! middle m5+eal art]y is 9 ! way1 ! occipital protub]ance1 & ! v>i\s sutures4 ,^! be+ avoid$1 a crucial incision is to be made ?r\gh ! sk91 & its flaps reflect$4 ,! p]icranium %\ld !n be rais$ f ! c5tre1 = a space l>ge en\gh to hold ! cr[n ( ! treph9e4 ,! p]icranium %\ld nev] be remov$1 b c>efully rais$ & pres]v$1 z its pres5ce w greatly aid 9 ! re/oration ( bone4#hj ,! c5tre p9 %\ld !n be project$ = ab\t ! eigh? ( an in* & bor$ into ! bone4 ,on x z a c5tre ! saw is !n work$ by semicircul> sweeps 9 bo? directions alt]nately1 till x =ms a groove = itself4 ,:5ev] ?is groove is deep en\gh ! p9 %\ld be retract$1 le/ f its projection x pi]ce ! dura mat] be=e ! tables ( ! skull are cut ?r\gh4 ,7 ! cranium always ( ! same ?ickness1 & ev5 ( simil> consi/5ce1 ! op]ation w\ld always be exce$+ly easy2 b 9 bo? ^! p>ticul>s diff]5t skulls v>y mu* f ea* o!r1 & ?us by a ra% use ( ! in/rum5t ! dura mat] may possibly be injur$4 ,! t\gh out] table is m difficult to cut ?an ! s(t] & m vascul> diploe1 & ! inn] table is d5s] ?an ei!r1 b m brittle4 ,9 _m old skulls1 h[ev]1 ! diploe is want+ altoge!r1 & ! two tables are amalgamat$1 & (t5 v ?94 ,great c>e mu/ be tak5 9 e case to saw sl[ly1 to remove ! sawdu/1 & exam9e ! track ( ! saw by a probe or quill1 le/ "o "p %\ld be cut ?r\gh quick] ?an ano!r4 ,! la/ turns ( ! in/rum5t mu/ specially be cauti\s ones4 ,:5 ! disk ( bone does n at once come away 9 ! treph9e1 ! elevator or ! special =ceps = ! purpose w easily remove x4 ,if ! abscess1 extravasation1 or exo/osis be !n discov]$ & remov$1 all t rema9s is to remove any sawdu/ or loose pieces ( bone1 & possibly to smoo? (f any %>p edges ( ! orifice by an in/rum5t call$ ! l5ticul>4 ,?is is v seldom requir$1 & n[ h>dly ev] us$4 #b4 ,9 cases ( depress$ or punctur$ fracture ! treph9e is occasionally requir$ 7:5 symptoms ( compression are pres5t7 = ! purpose ( enabl+ ! depress$ portion to be elevat$4 ,x is unsafe to apply x to ! depress$ or fractur$ bone1 le/ ! additional pressure ( ! in/rum5t %\ld cause w\nd ( ! dura mat] or bra94 ,x is g5]ally appli$ on "s project+ corn] ( s\nd bone "u :i* ! depress$ portion is lock$1 & h5ce x is r>ely necess>y to remove a complete circul> portion4 ,9 fact v _m cases ( su* displacem5t may be rem$i$ m easily by a pair ( /rong bone-=ceps1 or a ,hey's saw1 appli$ to remove ! project+ portion ( s\nd bone4 ,! same precautions mu/ be us$ z 9 ! op]ation already describ$1 & ! saw+ mu/ be done ev5 m cauti\sly1 z x is r>ely m ?an a semicircle t requires cutt+4 ,9 =m] days treph9+ 0 a mu* m frequ5t op]ation ?an x is n[1 & app>5tly m successful4 ,! reason ( ! great] app>5t success c easily be f\nd 9 ! fact t x 0 p]=m$ 9 _m cases m]ely z a precaution>y measure aga9/ dread$ inflammation ( ! bra91 :i* probably nev] w\ld h appe>$ at all1 & t ! op]ation itself is "o by no means dang]\s4 ,v num]\s applications ( ! treph9e h be5 made 9 ! same individual--two1 f\r1 six1 & ev5 9 "o case tw5ty-sev5 disks hav+ be5 remov$ f ! same skull1 & yet ! pati5ts h surviv$4 ,,tum\rs ,,( ,,! ,,scalp1 ,removal (4--,by f> ! mo/ frequ5t are ! ency/$ tum\rs1 or w5s4 ,^! consi/ ( a ?ick firm cy/-wall1 :i* conta9s s(t1 curdy1 or pultace\s matt]1 sometimes almo/ fluid1 at o!rs dry & gritty4 ,!y are loosely atta*$ 9 ! subcutane\s cellul> tissue1 & unless !y h become v l>ge1 or h be5 mu* press$ on1 are non-adh]5t to ! sk94 ,! treatm5t is ?us v simple4 ,!y %\ld m]ely be transfix$ by a %>p knife1 ! cont5ts evacuat$1 & ! cy/ seiz$ by /rong dissect+ =ceps & twi/$ out4 ,if !y h once become adh]5t1 !y mu/ be dissect$ out 9 ! usual mann]1 aft] ! adh]5t portion ( sk9 has be5 def9$ by elliptical incisions4 ,9 ! case ( l>ge w5s on visible p>ts ( scalp or face1 ! au?or avoids sc>1 by ! foll[+ plan3-- ,make a small incision1 two l9es at mo/1 ?r\gh sk9 only1 !n ) a blunt probe sep>ate ! cy/ f ! sk9 subcutane\sly2 !n1 pull+ x to ! w\nd ) cat*-=ceps1 empty ! cy/ & gradually pull x out1 z if tak+ out an ov>ian cy/4 ,no sc> b a dimple w rema94 ,,footnotes3 #hj ,see case by ! au?or 9 ! ,ed94 ,m$4 ,j\r4 = ,june #ahfh4 ,,*apt] ,v4 ,,op]ations ,,on ,,eye4 ,op]ations on ! ,eye & its ,app5dages4 ,,op]ations ,,on ,,! ,,lids4-- ,illu/ration3 ,,fig4 ,,vii4#ha ,illu/ration3 ,,fig4 ,,viii4#hb #a4 ,,= ,,entropium ,,or ,,inv]sion ,,( ,,! ,,lids1 ,,(t5 ,,comb9$ ,,) ,,tri*iasis1 ,,irregul>ity ,,( ,,! ,,cili4--,z 9 _m cases ! entropium seems to dep5d p>tly on a too great laxity ( ! sk9 ( ! lid1 comb9$ occasionally ) spasm ( ! orbicul>is1 ! simple/ & mo/ natural plan ( op]ation is 7a7 to remove 7,fig4 ,,vii4 a7 an elliptical portion ( sk91 ext5d+ transv]sely along ! :ole l5g? ( ! affect$ lid1 includ+ ! fibres ( ! orbicul>is ly+ bel[ x1 & !n to unite ! edges ) sev]al po9ts ( f9e suture4 7b7 ,an improvem5t on ?is 9 ob/9ate cases is propos$ by ,mr4 ,/reatfeild 7,fig4 ,,viii47 ,he cont9ues ! same incision1 b 9 addition removes a long n>r[ w$ge-%ap$ portion ( ! t>sal c>tilage1 groov+ x )\t entirely cutt+ x ?r\gh1 9 su* a mann] t ! retraction ( ! sk9 b5ds ! c>tilage backw>ds1 ?us ev]t+ to a v consid]able ext5t ! previ\sly inv]t$ cili4#hc #b4 ,,ectropium is ! opposite condition f entropium2 9 x ! eyelids are ev]t$ & ! palpebral conjunctiva is expos$4 ,if ! result ( cicatrix1 ( a burn1 or ( disease ( bone1 ! treatm5t mu/ be v>i$ accord+ to circum/ances1 & 9 _m cases1 sk9 mu/ be transplant$ to fill ! gap4 ,9 ! m usual cases result+ f *ronic inflammation ! foll[+ simple op]ations are requir$3--#a4 ,9 mild cases ! excision ( an elliptical portion ( conjunctiva may suffice1 ! edges mu/ n be left to contract1 b %\ld be br\ght c>efully toge!r4 #b4 ,9 m *ronic cases1 :]e all ! tissues ( ! lid are v lax1 x is necess>y to remove 7,fig4 ,,vii4 b7 a ,v-%ap$ portion ( lid & sk91 & !n /it* x v c>efully up ) int]rupt$ sutures4 ,,tum\rs ,,( ,,eyelids4--#a4 ,ency/$ tum\rs2 cy/s ( ! lids2 t>sal tum\r4--,"u ^! & simil> names are recognis$ a v frequ5t =m ( disease1 *iefly 9 ! upp] lid3 small tum\rs :i* r>ely exce$ half a pea 9 size1 convex t[>ds ! sk91 :i* is freely moveable ov] !m2 !y give no pa91 & are annoy+ only f _! bulk & de=mity4 ,op]ation4--,ev]t ! lid1 incise ! conjunctiva freely ov] ! tum\r1 ins]t ! blunt end ( a probe & r\ghly /ir up ! cont5ts ( ! cy/1 ?us evacuat+ x4 ,if ! tum\r is l>ge & ( old /&+ x may be requisite to cut out an elliptical or circul> portion ( its conjunctival wall4 ,! probe may require to be reappli$ once or twice at int]vals ( two or ?ree days1 & 9 c]ta9 r>e cases x may be necess>y z a la/ res\rce freely to caut]ise ! inside ( ! cy/ ) ! solid nitrate ( silv]4 ,9 no case is x ev] necess>y to excise ! tum\r f ! outside ( ! eyelid2 :5 ?is has be5 done 9 error !re frequ5tly rema9s an awkw>d & unsightly sc>4 #b4 ,fibr\s cy/s1 frequ5tly cong5ital1 are met ) 9 "o situation1 j ov] ! ext]nal angul> process ( ! frontal bone4 ,^! are l>g] 9 size ?an ! prec$+1 rang+ f ! size ( a b>ley pickle to t ( an almond4 ,_! treatm5t is excision by a prolong$ & c>eful dissection f ! p]io/eum1 to :i* !y almo/ inv>iably are adh]5t4 ,,op]ations ,,on ,,! ,,la*rymal ,,organs4--,9 a sy/em ( oph?almic surg]y1 v>i\s op]ative proc$ures might be detail$ "u ?is head1 au?oris$ & sanction$ by old cu/om4 ,excision ( a diseas$ la*rymal gl&1 & removal ( /ones 9 ! gl& or ducts1 ne$ no special directions = _! p]=mance1 & ! op]ation imm$iately to be describ$1 "u ! head ( ,mr4 ,b[man's op]ation1 is applicable 9 almo/ e "o ( ! diseas$ conditions ( ! la*rymal canal1 sac1 & nasal duct1 to ! exclusion ( all ! old] me?ods4 ,mr4 ,b[man's ,op]ation4--,9 cases ( ob/ruction ( ! punctum1 canaliculus1 & nasal duct1 result+ 9 wat]y eye1 accumulation ( mucus 9 ! canal1 & dryness ( ! nose1 great difficulty us$ to be exp]i5c$ 9 ! treatm5t4 ,to pass a probe along ! punctum 0 extremely difficult1 9 fact1 possible only ) a v small "o1 :ile ! common op]ation ( op5+ ! dilat$ sac1 ?r\gh ! sk91 & !n pass+ probes ?r\gh ?is artificial op5+1 0 f\nd q useless f ! rapid closure ( ! w\nd1 unless ! treatm5t 0 foll[$ up by ! ins]tion & ret5tion ( a /yle 9 ! nasal duct4 ,?is 0 pa9ful1 unsightly1 (t5 unsuccessful2 & ev5 9 "s cases dang]\s1 f ! am\nt ( irritation1 suppuration1 & ev5 c>ies ( ! nasal bones :i* is set up4 ,! pr9ciple ( ,mr4 ,b[man's mo/ excell5t op]ation is1 t ! punctum1 canaliculus1 & nasal duct resemble 9 _m respects ! ure?ral passage1 & 9 cases ( /ricture require to be treat$ on ! same pr9ciple4 ,if1 !n1 x 7 possible to pass in/rum5ts gradually increas+ 9 size ?r\gh ! seat ( /ricture1 x w\ld be gradually dilat$4 ,x is1 h[ev]1 9 ! normal /ate ( p>ts1 impossible to pass any in/rum5t beyond ! size ( a human hair pa/ ! curve :i* ! canaliculus makes on its entrance to ! duct1 h5ce ! prop] dilatation _c be p]=m$4 ,aga91 x is f\nd t ! puncta1 specially ! l[] "o1 are !mselves v (t5 to blame1 9 cases ( wat]y eye1 sometimes because !y are inv]t$ or ev]t$1 m (t5 because1 sympa?is+ ) ! lid1 !y are turgid1 angry1 & inflam$1 p\t+ & clos$ l ! orifice ( ! ure?ra 9 a gonorrhoea4 ,mr4 ,b[man f\nd t by slitt+ up ! inf]ior punctum & canaliculus z f> z ! c>uncula1 sev]al advantages 7 ga9$3--7#a47 ,! swoll51 angry1 displac$ punctum no long] imp$$ ! entrance ( ! te>s2 7#b47 & *iefly :5 ! canaliculus 0 slit up1 ! curve1 or r angle1 :i* imp$$ ! passage ( probes1 0 done away )1 & ! nasal duct c\ld be readily & ?or\ghly dilat$4 ,op]ation4--,! surgeon /&s beh9d ! pati5t1 :o is seat$1 & leans 8 head on ! surgeon's *e/4 ,! affect$ lid is !n drawn g5tly d[nw>ds on ! *eek1 s z to ev]t & ?or\ghly expose ! l[] punctum4 ,into ?is ! surgeon introduces a f9e probe ( /eel gilt1 ! fir/ in* ( :i* is v ?91 especially at ! po9t1 & deeply groov$ on "o side1 exactly l a small 7& /raight7 ,syme's /ricture director4 ,keep+ ! canal relax$ by relax+ 8 hold on ! lid1 ! surgeon n[ g5tly wriggles ! probe along ! canaliculus1 gradually /ret*+ x z ! probe advances1 s z to avoid cat*+ ( ! sides ( ! canal be=e ! po9t ( ! in/rum5t1 till he is satisfi$ t x has fairly ent]$ ! nasal duct4 ,he !n /ret*es ! eyelid1 br+s ! h&le ( ! probe out ov] ! *eek s z to ev]t ! punctum z mu* z possible1 & !n ) a f9e %>p-po9t$ knife ent]s ! groove 7,fig4 ,,ix471 & fairly slits up ! punctum & ! canal to ! full ext5t4 ,! incision %\ld be z /raight z possible1 & ?r\gh ! upp] wall ( ! canaliculus4 ,a dext]\s turn ( ! in/rum5t upw>ds on ! =ehead w g5]ally enable x to be pass$ at once fairly into ! nose ?r\gh ! nasal duct1 ! usual rule be+ obs]v$ ( pass+ x d[nw>ds & slightly backw>ds1 ! h&le ( ! probe pass+ j ov] ! supraorbital not*4 ,illu/ration3 ,,fig4 ,,ix4#hd ,= sev]al days aft] ! op]ation ! probe w h to be pass$1 bo? to prev5t ! w\nd 9 ! canaliculus f heal+ up1 :i* x is too apt to d1 & also to gradually dilate ! nasal duct if x has be5 previ\sly /rictur$4 ,probes & directors ( v>i\s sizes are requir$2 9 fact v mu* ! same in/rum5ts 79 m9iature7 z are requir$ = ! treatm5t ( /ricture ( ! ure?ra4 ,mr4 ,gre5slade has inv5t$ a v +5i\s little in/rum5t1 ( :i*1 ?r\gh 8 k9dness1 ,i am able to %[ a woodcut 7,fig4 ,x471 = slitt+ up ! canaliculus )\t hav+ to fit ! knife 9 ! groove4 ,illu/ration3 ,,fig4 ,x4 ,,pt]ygium1 ! r$di% fle%y triangul> gr[?1 ) its base at ! inn] can?us1 & its apex spread+ to & (t5 ov] ! cornea1 requires inv>iably a small op]ation = its removal4 ,9 mo/ cases x w be f\nd suffici5t m]ely to raise ! lax portion ov] ! scl]otic ) =ceps1 & divide x freely1 remov+ a transv]se portion4 ,if x has encroa*$ ^u ! cornea1 ! portion int]f]+ ) vision mu/ be dissect$ (f ) great c>e & remov$4 ,9 "s cases1 h[ev]1 x has be5 f\nd t aft] removal ( a l>ge pt]ygium1 a retraction ( ! c>uncle & ! semilun> fold is apt to take place1 :i* r5d]s ! eyeball unpleasantly prom95t4 ,to avoid ?is ! pt]ygium may be c>efully dissect$ up f its apex to ne> its base1 & !n displac$ lat]ally ei!r upw>ds or d[nw>ds1 its apex & sides be+ /it*$ to a previ\sly prep>$ site ( conjunctiva4 ,,op]ation ,,= ,,conv]g5t ,,/rabismus4--,division ( ! int]nal rectus4--,subconjunctival op]ation4--,! spr+-wire speculum 7,c7 sep>at+ ! lids1 ! surgeon divides ! conjunctiva by a pair ( scissors 9 a horizontal l9e 7,fig4 ,,xi4 ,a ,a7 f ! inn] m>g9 ( ! cornea1 a little bel[ its transv]se diamet] to ! c>uncle1 !n snipp+ ?r\gh ! sub-conjunctival tissue1 he passes a blunt hook b5t at an obtuse angle "u ! t5don ( ! int]nal rectus1 & endeav\rs by depress+ ! h&le to project ! po9t ( ! hook at ! w\nd4 ,!n ) successive snips ( ! scissors he divides ! t5don on ! hook1 close to its scl]otic m>g94 ,le/ x %\ld n be freely divid$1 v>i\s dips ) ! hook may be made to cat* any /ray fibres left unt\*$2 b v great c>e %\ld be tak5 n to w\nd ! conjunctiva beyond ! fir/ horizontal cut 9 x4 ,! t5don be+ divid$ satisfactorily1 ! edges ( conjunctiva %\ld be replac$1 & ! eye clos$ = a few h\rs4 ,illu/ration3 ,,fig4 ,,xi4#he ,! orig9al op]ation ( ,dieff5ba*1 n[ r>ely practis$1 consi/$ 9 mak+ an incision1 ,b ,b1 across ! t5don1 !n1 by cutt+ ! areol> tissue expos+ ! ins]tion ( ! t5don1 & divid+ x freely2 aft] :i* ! scl]otic 9 ! neighb\rhood 0 to be clean$ & any b& ( fibres divid$4 ,!re are risks on ! "o h& ( a mo/ unseemly exoph?almos ) div]g5t squ9t1 & on ! o!r ( a retraction ( ! semilun> fold1 s t ! sub-conjunctival op]ation is always pref]able4 ,,op]ations ,,= ,,div]g5t ,,squ9t4--,?is v s]i\s de=mity is (t5 ! result ( ! op]ation = conv]g5t squ9t1 & is associat$ ) a fix$1 le]+1 & prom95t eye1 & frequ5tly ) mo/ annoy+ d\ble vision4 #a4 ,9 a simple case ( prim>y div]g5t /rabismus 7v r>e7 x is suffici5t simply to divide ! ext]nal rectus 9 ! mann] already describ$ = division ( ! int]nal4 #b4 ,if second>y to an op]ation = conv]g5t squ9t1 ! indication is to re/ore ! cut int]nal rectus to a position on ! scl]otic a little beh9d its previ\s "o1 z ! cause ( ! div]g5ce is f\nd 9 a complete deta*m5t ( ! int]nal rectus4 ,?is is attempt$ 9 v>i\s ways4 7#a47 ,jules ,gur9 c>efully divid$ ! conjunctiva ov] x1 & s\ght = ! rema9s ( ! int]nal rectus1 free+ x f its atta*m5ts4 ,he !n pass$ a ?read ?r\gh ! scl]otic on ! out] side ( ! globe1 & by pull+ on x & fix+ x across ! nose1 rotat$ ! eye inw>ds1 9 ! hope t ! rema9s ( ! int]nal rectus w\ld secure a new atta*m5t4 7#b47 ,graefe's modification ( ?is is m c]ta94 ,)\t any m9ute dissection he m]ely sep>at$ ! int]nal rectus1 along ) ! conjunctiva1 & fascia ov] x1 s t x c be pull$ =w>ds1 !n cut ! ext]nal rectus1 & inv]t$ ! eyeball to a suffici5t ext5t by means ( a ?read pass$ ?r\gh ! portion ( ! t5don ( ! ext]nal rectus1 :i* rema9s atta*$ to ! scl]otic4 ,! risk ( all ^! op]ations1 9 :i* bo? muscles are divid$1 is protrusion ( ! eyeball f ! removal ( muscul> t5sion4 7#c47 ,solomon's op]ation = ! radical cure ( extreme div]g5t /rabismus1#hf is at fir/ sight a v curi\s "o4 ,)\t go+ into all ! details1 ! /eps are z foll[s3-- a4 ,a squ>e-%ap$ flap1 ) its atta*$ base at ! nasal side1 is rais$1 conta9+ ! rema9s ( ! inn] rectus & its adjac5t p>ts4 b4 ,a flap simil> 9 %ape & size1 b diff]5t 9 ! position ( its atta*$ base1 is made on ! o!r side ( ! cornea4 ,x is made by divid+ ! ext]nal rectus j beh9d its t5don1 & !n reflect+ =w>ds ! t5don ) its conjunctiva4 c4 ,^! two flaps are unit$ ov] ! v]tical m]idian ( ! cornea by sutures1 ?ree g5]ally be+ suffici5t4 ,?is entirely hides ! cornea = a "t1 b ev5tually %rivels & contracts1 & ! remnants are to be cut (f ) scissors ?ree weeks aft] ! op]ation4 ,,puncture ,,( ,,! ,,cornea4--,p>ac5tesis ( ! ,ant]ior ,*amb]4--,tapp+ ( ! ,aque\s ,hum\r4--,?is v simple op]ation is 9 _m cases extremely useful4 ,9 cases ( corneal ulc]1 ! result ei!r ( injury or disease1 :]e !re is mu* pa9 9 ! bone1 & evid5ce ( t5sion ( ! globe1 x gives great relief1 & :5 repeat$ at %ort int]vals greatly ha/5s a cure4 ,sp]9o ( ,tur9 recomm5ds its frequ5t use 9 cases ( *ronic glaucoma4 ,op]ation4--,! surgeon /&s beh9d ! pati5t1 :o is seat$2 ! lids be+ fix$1 ! upp] by ! surgeon's left h&1 & ! l[] by an assi/ant1 ! cornea is punctur$ a little 9 front ( ! scl]otic m>g91 ei!r ) a broad ne$le1 or1 :at is z good1 a well-worn ,be]'s knife4 ,c>e mu/ be tak5 on ent]+ ! knife1 on ! "o h&1 n to w\nd ! iris1 :i* is sometimes ar*$ =w>ds 9 ! cases ( comm5c+ glaucoma1 &1 on ! o!r1 fairly to ent] ! ant]ior *amb]1 n m]ely split up ! lay]s ( ! cornea4 ,on )draw+ ! cat>act knife1 ! aque\s hum\r gets out by its side1 aid$ by a slight turn ( ! knife1 sometimes ) great =ce1 & 9 mu* l>g] quantity ?an usual4 ,if ! op]ation has be5 done by a ne$le1 a blunt probe requires to be introduc$ on ! removal ( ! ne$le4 ,once punctur$1 ! rem>kable fact is t ! same w\nd suffices = _m succe$+ tapp+s1 :i* are effect$ by press+ ! probe into ! w\nd day aft] day1 sometimes sev]al times a day1 ) great relief to ! symptoms4 ,if ! probe is to be us$ = succe$+ evacuations1 ! op]ator mu/ be c>eful to rememb] ! exact spot at :i* ! ne$le or knife 0 ent]$4 ,to facilitate rememb]+ x1 x is be/1 :5 no?+ prev5ts x1 to op]ate always 9 ! same spot4 ,sp]9o *ooses ! horizontal m]idian ( ! cornea at ! temporal side1 at ! junction ( ! cornea & scl]otic4 ,,cat>act ,,op]ations4--,"h we _c ent] into any discussion ( ! pa?ology ( cat>act & ! v>ieties ( x4 ,en\gh = our purpose to "k t ! l5s is 9 "s cases h>d1 9 o!rs s(t1 & t ?us 9 ! latt] x may be remov$ piecemeal1 & by a small incision1 :ile 9 ! =m]1 removal mu/ be almo/ entire1 & by a l>g] op5+4 ,9 cat>act1 ! l5s1 :i* %\ld be transp>5t1 has become opaque1 & ! object ( treatm5t is to get x out ( ! l9e ( sight1 to prev5t x f ob/ruct+1 n[ t x c no long] assi/ sight4 ,! op]ations us$ = ?is end may be class$ "u ?ree heads3-- #a4 ,op]ations = ! removal ( ! l5s out ( ! way )\t its removal f ! eye4--,^! us$ to be ext5sively practis$ "u ! "n c\*+1 & are ( two k9ds1--,depression1 :]e ! l5s is simply pu%$ d[n f its place by a ne$le2 ,recl9ation1 9 :i* x is %ov$ backw>ds 7turn+ on its transv]se axis7 z well z d[nw>ds4 ,^! are relics ( old surg]y1 & v r>ely practis$ by any oculi/s ( em95ce1 z1 ?\gh easy to p]=m1 & ) v flatt]+ imm$iate results1 ! risks ( *ronic inflammation ( ! :ole globe & injury to ! ret9a are v great4 #b4 ,= solution4--,,! ,,ne$le ,,op]ation4--,suitable 7among o!r cases7 especially 9 cong5ital cat>acts 9 infants1 & 9 cases ( diabetic cat>act4 ,! pr9ciple ( ?is op]ation is t ! l5s1 once ! capsule is freely op5$ 9 front & ! aque\s hum\r admitt$1 is f\nd rapidly to become absorb$ & disappe>1 if ! cat>act has be5 a s(t "o4 ,op]ation4--,a ne$le ) a lance-%ap$ head is to be us$4 ,x %\ld be s made t ! r\nd$ %aft ( ! ne$le is j l>ge en\gh to play freely 9 ! w\nd made by ! broad] po9t1 & yet n s small z to all[ ! aque\s hum\r to escape rapidly4 ,! pupil has be5 dilat$1 ! pati5t is ly+ on 8 back1 & ! globe is fix$ by =ceps atta*$ to ! conjunctiva ( ! inn] side ( ! eye1 & held by an assi/ant4 ,! surgeon !n ent]s ! ne$le close to ! scl]otic m>g9 ( ! cornea1 c>ries x fairly on 9 ! ant]ior *amb]1 till ! c5tre ( ! pupil is rea*$4 ,he !n1 by br++ =w>d ! h&le1 projects ! po9t backw>ds aga9/ ! ant]ior capsule1 :i* he freely lac]ates ) ! po9t & edge 9 sev]al directions4 ,9 infants1 :]e processes ( repair g on v rapidly1 ! :ole l5s may be freely brok5 up4 ,9 diabetic cat>act1 or inde$ 9 all cases ( solution1 :]e ! pati5t is adolesc5t or adult1 or ! eye at all weak1 only a small portion ( ! l5s %\ld be attack$ at "o sitt+4 ,! ne$le %\ld !n be )drawn gradually & ) great c>e1 t ! broad axis ( ! blade be 9 exactly ! same position 9 :i* x ent]$1 i4e4 flat & p>allel ) ! iris1 le/ ! iris be w\nd$1 entangl$1 or prolaps$4 ,! eye is !n to be clos$ = tw5ty-f\r h\rs2 if !re is mu* pa91 atropia mu/ be freely us$4 ,v>ieties 9 ! ,op]ation4--,"s use two ne$les at once = break+ up ! l5s4 ,"s surgeons pref] to ent] ! ne$le ?r\gh ! scl]otic2 ?is complicates ! op]ation & r5d]s x less c]ta91 z ! po9t ( ! ne$le is ( c\rse out ( sight 9 its progress betwe5 ! iris & ! l5s4 ,ev5 9 *ildr5 ?is op]ation requires 9 mo/ cases to be repeat$ at lea/ once1 :ile 9 adults x may be requir$ at %ort int]vals = _m mon?s4 #c4 ,by ,extraction4--,9 ^! op]ations ! l5s is at once remov$ f ! eye-- 7#a47 ,by l9e>1 or p]haps1 m correctly1 rectil9e> incision4 ,?is me?od is specially suit$ = cases ( s(t cat>act4 ,op]ation4--,a f9e spe>-%ap$ ne$le is v cauti\sly introduc$ ?r\gh ! cornea1 ab\t a l9e f its out] m>g91 & ! ant]ior capsule lac]at$1 & ! l5s brok5 up1 great c>e be+ tak5 n to injure ! po/]ior capsule4 ,! pupil mu/ !n be kept freely dilat$1 ! w\nd heals at once1 & ! aque\s hum\r reaccumulates4 ,illu/ration3 ,,fig4 ,,xii4 ,illu/ration3 ,,fig4 ,,xiii4 ,f ?ree to six days aft] ?is fir/ op]ation1 a l9e> incision 7,fig4 ,,xii47 is made 9 ! out] side ( ! cornea by a /raight /ab f a d\ble-edg$ knife1 or r spe>4 ,! size ( ! incision mu/ v>y ) ! size & consi/5ce ( ! l5s1 & c be regulat$ by ! bread? ( ! knife & ! di/ance to :i* x is ent]$4 ,by c>eful )drawal ( ! knife1 9 _m cases a l>ge portion ( ! s(t l5s c be remov$ along ) x1 & !n :at rema9s mu/ be cauti\sly lift$ out by a flat spoon introduc$ ?r\gh ! w\nd1 & beh9d ! rema9s ( ! l5s4 ,c>e mu/ be tak5 le/ any ( ! l5s sub/ance rema9 9 ! w\nd2 ) ?is precaution ! incision g5]ally heals rapidly1 & ) mu* less risk ( g5]al inflammation ( ! ball ?an 9 ! ord9>y flap op]ation ( extraction4 ,,extraction ,,( ,,s(t ,,cat>act ,,by ,,suction4--,mr4 ,t4 ,p4 ,teale1 ( ,le$s1#hg has inv5t$ an in/rum5t by :i* ! removal ( s(t cat>act is made m easy1 ?r\gh a l9e> incision by suction1 appli$ ?r\gh ! m$ium ( a holl[ curette furni%$ ) an india-rubb] tube & m\?-piece4 ,! curette is ( ! usual size1 b is ro($ 9 7in/ead ( be+ m]ely groov$7 to )9 "o l9e ( its extremity1 ?us =m+ a tube flatt5$ above1 b t]m9at+ 9 a small cup4 ,?is is screw$ into an ord9>y /raight h&le1 :i* is holl[ = a %ort di/ance1 f> en\gh to jo9 ) a second tube fix$ at "r angles to ! h&le1 & into :i* ! india-rubb] pipe & m\?-piece1 ?r\gh :i* suction is to be made1 is atta*$4 ,9 _m cases x seems to s]ve its purpose extremely well4 ,c]ta9 po9ts require att5tion3--#a4 ,t ! puncture to admit ! curette is l>ge en\gh2 #b4 ,t its end be suffici5tly r\nd$2 #c4 ,its op5 end mu/ be held 9 ! area ( ! pupil1 & n all[$ to pass beh9d ! iris1 else !re is great risk ( ! iris be+ drawn 94 ,among o!r advantages claim$ by its inv5tor1 ! *ief seems to be a m ?or\gh removal ( ! l5s ?an by ! ord9>y means1 & consequ5tly less risk ( opaque deposit 9 ! po/]ior capsule4 7#b47 ,,extraction ,,by ,,flap4--,:5 prop]ly p]=m$ 9 a suitable subject1 & :5 free f accid5t1 ?is op]ation is "o ( ! mo/ ?or\ghly beautiful & satisfactory 9 ! :ole doma9 ( surg]y2 b x is difficult1 & liable to _m risks :i* nei!r skill nor caution c completely gu>d aga9/4 ,x is requir$ 9 _m cases ( h>d cat>act1 :i* are am5able nei!r to solution nor l9e> extraction4 ,op]ation mu/ be consid]$ 9 v>i\s /ages3-- a4 ,to make a flap ( cornea l>ge en\gh to p]mit ( ! removal ( ! entire l5s )\t pressure or bruis+4 ,to make x ( cornea only1 to prev5t ! escape ( ! vitre\s1 & to avoid injury ( ! iris4 ,! great difficulty 9 mak+ ! requir$ section ( ! cornea is1 t we are deb>r$ f us+ scissors or any ord9>y knife or scalpel 9 mak+ x1 = ?is reason1 t ! saw+ movem5ts requir$ 9 all ord9>y cutt+ are inadmissible "h1 z any )drawal ( ! blade1 h[ev] slight1 w\ld p]mit evacuation ( ! aque\s hum\r1 & at once be foll[$ by prolapse ( ! iris be=e ! knife4 ,h5ce we are compell$ to make ! requisite flap by "o /eady pu% ( a knife1 :i*1 too1 mu/ be ( su* a %ape z 9 its entrance con/antly to fill up ! w\nd x makes4 ,v v>i\s %apes & sizes ( knives h be5 propos$1 ! "o call$ ,be]'s knife be+ ! sort ( model or common p>5t f :i* all ! o!rs are d]iv$4 ,x is triangul> 9 %ape1 ) a /raight back1 ab\t #ab-aj?s ( an in* 9 l5g?1 & #d-aj?s broad at ! base ( ! blade1 tap]+ at a /raight edge f its base to its po9t1 & also dim9i%+ 9 ?ickness to ! po9t4 ,consid]able diff]5ce ( op9ion exi/s z to ! relative m]its ( an upp] or l[] section ( ! cornea4 ,! g5]al view at pres5t seems to be t an upp] section is to be pref]r$2 b 9 cases :]e ! surgeon is n ambidext]\s1 x is bett] t he %\ld make ! section :i* lies easie/ to 8 h& ?an attempt an upp] section 9 a less fav\rable position4 ,! pati5t %\ld be plac$ flat on 8 back1 ! lids %\ld be g5tly op5$1 ! upp] "o by ! surgeon1 ! l[] "o by 8 assi/ant1 :o is to press ! lid d[nw>ds aga9/ ! mal> bone )\t ex]cis+ any pressure on ! ball4 ,! eye %\ld be /ill fur!r /eadi$ by ! conjunctiva & subjac5t cellul> tissue on ! inn] side be+ seiz$ by a pair ( cat*-=ceps1 /ill ) no d[nw>d pressure on ! ball4 ,! po9t ( ! knife mu/ !n be introduc$ ab\t a l9e f ! out] scl]otic m>g9 ( ! transv]se diamet] ( ! cornea 7,fig4 ,,xiii471 ! blade be+ held p>allel ) ! fibres ( ! iris1 pu%$ /eadily across ! ant]ior *amb]1 & protrud$ z ne>ly z possible at ! correspond+ spot at ! inn] side ( ! cornea4 ,! aque\s hum\r %\ld n escape till ! section is complet$4 ,if x does1 ! iris is almo/ c]ta9ly project$ =w>ds & entangl$ 9 ! blade ( ! knife1 a mo/ annoy+ accid5t1 & "o :i* is n easily rem$i$4 ,! books tell u ( v>i\s manoeuvres by pressure or o!rwise1 by :i* ! iris may be pu%$ back4 ,practically1 h[ev]1 if x has once occurr$ x is n easily sav$ f be+ cut4 ,if a small portion only is involv$1 x is n ( mu* consequ5ce2 if a l>ge portion be 9 dang]1 x is sometimes necess>y to )draw ! knife be=e ! section is complet$1 & f9i% x ) a probe-po9t$1 curv$ bi/\ry4 ,if1 h[ev]1 ! flap is safely f9i%$1 ! lids %\ld be g5tly all[$ to close = a few seconds4 ,on op5+ !m aga9 ! surgeon mu/ decide :e!r ! corneal flap is suffici5tly l>ge to all[ ! l5s to come out )\t =ce2 if n1 he mu/ enl>ge x ei!r by ! n>r[ probe-po9t$ second>y knife or by a pair ( %>p scissors4 ,occasionally ! l5s1 & ev5 a little vitre\s hum\r1 may escape at once on ! section be+ complet$1 b ?is is n to be desir$4 b4 ,lac]ation ( ! ,capsule ( ! ,l5s4--,?is is p]=m$ by ins9uat+ a %>p curv$ ne$le "u ! corneal flap1 avoid+ ! iris1 & !n te>+ up ! ant]ior capsule ?r\gh ! dilat$ pupil1 ! *ief po9t to be att5d$ to be+ t ! capsule be lac]at$ 9 its entire l5g?4 c4 ,removal ( ! ,l5s4--,?is mu/ be done ) ! mo/ extreme caution & g5tl5ess1 le/ ! vitre\s hum\r be also evacuat$4 ,! surgeon's object is to tilt ! l5s s z to turn x slightly on its transv]se axis1 & cause ! edge ne>e/ ! section to rise out ( ! capsule & appe> at ! w\nd4 ,?is is be/ done by g5tle pressure at ! requir$ spot by ! back ( ! ne$le1 or by a common probe4 ,:5 ! l5s beg9s to protrude ! pressure mu/ be v1 g5tle1 le/ x be =c$ out sudd5ly & ! vitre\s foll[ x4 ,s(t portions ( ! l5s are apt to rema9 adh]5t to ! w\nd 9 ! cornea4 ,^! mu/ be remov$ by scoop or probe4 ,v>ieties 9 ! me?od ( ,flap ,extraction4--,jacobs5 ( ,knigsb]g 9 e case gives *lor(orm4 ,he always makes 8 flap 9 ! b\nd>y l9e ( ! cornea & ! scl]otic1 ?r\gh a vascul> /ructure1 & he believes t union is on ?is acc\nt m rapid1 & aft] extraction removes t portion ( ! iris :i* appe>s to h be5 mo/ expos$ to bruis+ dur+ ! exit ( ! l5s4 ,! op]ation ( extraction may 9 _m cases be ei!r prec$$ or foll[$ by iridectomy1 z propos$ by ,moor51 ,von ,graefe1 & o!rs4 ,! foll[+ op]ation seems to dim9i% ! risks to a v great ext5t3-- ,pr(essor ,von ,graefe's ,op]ation4--,! lids are sep>at$ by a speculum1 & ! eyeball is drawn d[n by =ceps plac$ imm$iately bel[ ! cornea4 ,! po9t ( a small knife1 ( :i* ! edge is direct$ upw>ds1 is ins]t$ at a po9t fully half a l9e f ! m>g9 ( ! cornea ne> its upp] "p1 s z to ent] ! ant]ior *amb] z p]iph]ally z possible4 ,! po9t %\ld n be direct$ at fir/ t[>ds ! spot = c\nt]puncture2 nor till ! knife has advanc$ fully ?ree & a half l9es )9 ! visible portion ( ! ant]ior *amb]1 %\ld ! h&le be l[]$ & ! po9t direct$ s z to make a symmetrical c\nt]puncture1 :i* w give ! ext]nal w\nd a l5g? ( f\r & a half or five l9es4 ,z soon z ! resi/ance to ! po9t is felt to be ov]come1 %[+ t ! c\nt]puncture is effect$1 ! knife mu/ at once be turn$ =w>d1 s t its back is direct$ almo/ to ! c5tre ( ! ideal sph]e ( ! cornea1 :e!r ! conjunctiva is transfix$ or n1 & ! scl]al bord] is divid$ by boldly pu%+ ! knife onw>ds & aga9 draw+ x backw>ds4 ,?is portion ( ! op]ation is conclud$ by ! =mation ( a conjunctival flap a l9e & a half or two l9es 9 l5g?4 ,a section ?us made is almo/ p]p5dicul> to ! cornea1 a circum/ance mu* facilitat+ ! passage ( ! l5s1 & ! l9e ( incision is ne>ly /raight1 s t ! w\nd does n gape4 ,! iris %\ld be excis$ to ! v end ( ! w\nd1 & ! capsule mo/ freely op5$ by a ,v-%ap$ lac]ation4 ,any l5s1 ev5 ! h>de/1 may !n be remov$ )\t ! introduction ( an in/rum5t into ! eye1 b ,von ,graefe's exp]i5ce %[s x to be advisable to assi/ ! evacuation by ! hook 9 ab\t "o case 9 eight4 ,9 a c]ta9 numb] ( cases ! l5s w escape )\t difficulty :5 ! op]ator presses on ! po/]ior lip ( ! w\nd1 especially :5 ! back ( ! spoon is made to glide along ! scl]a2 %\ld ?is n occur1 ,von ,graefe uses a peculi> blunt hook1 or occasionally1 ?\gh r>ely1 a spoon4 ,a compress+ b&age is appli$1 & replac$ at int]vals4#hh ,we are recomm5d$ to p]=m x 9 two sets ( cases3-- #a4 ,^? 9 :i* ! eye is kn[n to be unheal?y & liable to inflammations1 specially ( iris1 ret9a1 or *oroid4 ,9 cases :]e ! pati5t has already lo/ an eye1 ,von ,graefe ?9ks iridectomy %\ld always prec$e extraction4 ,9 ! above1 !n1 x is a precaution>y measure1 &1 if conv5i5t1 %\ld be p]=m$ ?ree1 f\r1 or ev5 six weeks be=e ! extraction4 #b4 ,x is recomm5d$ to be p]=m$ at ! same "t z extraction 9 all cases 9 :i* ! op]ation has pres5t$ any special difficulties1 or has n gone smoo?ly1 e4g4 9 cases :]e ! l5s has requir$ mu* =ce to expel x1 ei!r f ! flap ( cornea be+ too small1 or f adhesions betwe5 ! l5s & capsule2 or1 aga91 9 cases 9 :i* !re is a t5d5cy to prolapse ( ! iris1 9 :i* any ( ! cortical sub/ance has be5 necess>ily left beh9d1 or 9 :i* old adhesions _h exi/$ betwe5 ! iris & capsule1 or betwe5 ! cornea & iris4 ,,op]ations ,,= ,,artificial ,,pupil4--,! cases are by no means unfrequ5t 9 :i* x is necess>y to remove or de/roy a portion ( ! iris to admit light to ! ret9a4 ,9 cases ( excessive prolapse ( ! iris aft] extraction ( ! l5s1 :]e ! iris has =m$ adhesions to ! w\nd1 & /ill m frequ5tly 9 cases :]e c5tral opacities ( ! cornea h fairly occlud$ ! natural pupil1 ! only *ance = vision is to enl>ge ! old "o1 or make a new pupil by removal ( ! iris4 ,v v>i\s op]ations h be5 propos$1 & exce$+ly num]\s & complicat$ in/rum5ts inv5t$ = ?is purpose4 ,we c notice "h only "o or two ( ! mo/ approv$ proc$ures3-- #a4 ,incision is ! simple/4 ,?is is practicable & effectual only 9 cases :]e ! iris is s f> heal?y z /ill to reta9 its contractile p[]1 & s f> free f adhesions z to be able to make use ( x4 ,! be/ example ( su* a case is t ( a cat>act1 9 :i* aft] extraction a prolapse ( ! iris has occurr$ to su* an ext5t z to oblit]ate ! pupil1 & :]e1 at ! same "t1 ! only adhesions are to ! w\nd1 none to ! cornea4 ,op]ation4--,a d\ble-edg$ ne$le is introduc$ ?r\gh ! cornea ne> its m>g92 on arriv+ at ! place :]e ! pupil ought to be1 "o edge is drawn aga9/ ! iris1 & divides x transv]sely1 if possible1 )\t injur+ ! l5s2 ! fibres ( ! iris />t back1 contract1 s t a suffici5tly l>ge c5tral pupil may be obta9$4 #b4 ,excision4--,9 ! f> m frequ5t cases 9 :i* !re exi/ adhesions betwe5 iris & cornea1 or iris & ant]ior capsule1 incision is n suffici5t1 & x is necess>y to excise a portion ( ! iris4 ,! simple/ & safe/ op]ation is ! foll[+3-- ,! pati5t recumb5t1 & ! lids held ap>t by a speculum1 ! eyeball %\ld be /eadi$ by ! =ceps ( an assi/ant4 ,a broad cutt+ ne$le %\ld !n be introduc$ at ! l[] or out] edge ( ! corneal m>g94 ,?is mu/ be v g5tly )drawn s z to reta9 z mu* aque\s hum\r z possible4 ,into ! w\nd ?us made ! surgeon mu/ introduce ! blunt hook 7kn[n z ,tyrrell's7 at fir/ ) its po9t =w>ds1 !n1 on arriv+ opposite ! edge ( ! pupil1 :i* x is int5d$ to enl>ge or replace1 ) its po9t turn$ backw>ds1 s z to hook ov] ! edge ( ! iris & ?us drag on x4 ,once ! hook has fairly got hold1 x mu/ aga9 be rotat$ =w>ds1 & )drawn 9 ! same direction z x 0 put 94 ,! iris ?us pull$ out ( ! w\nd is to be cut (f ) a pair ( f9e scissors1 s z to remove a suffici5t am\nt to make a new pupil ( ! requir$ size4 ,b 9 ^? cases 9 :i* ! :ole or great] "p ( ! pupill>y m>g9 is adh]5t1 ! blunt hook w n d1 because !re exi/s no edge r\nd :i* to hook x4 ,"o ( two plans is g5]ally *os5 to rem$y ?is3-- 7#a47 ,a free incision made ) a d\ble-edg$ ne$le2 ?r\gh ?is a pair ( canula =ceps is introduc$1 ) :i* a portion ( iris is seiz$ & dragg$ to ! ext]nal w\nd2 x c !n ei!r be cut (f or ti$ 7see ,iridesis72 or1 7#b47 ,a previ\s attempt may be made to free a portion to =m an edge to cat* hold (1 ei!r by incision or by ,corelysis 7q4v47 ,,iridesis4--,crit*ett's ,op]ation ( ,ligature4#hi--,pati5t be+ put "u *lor(orm1 ! ball is fix$ by ! wire speculum1 & also by a fold ( conjunctiva be+ seiz$ by =ceps4 ,an op5+ is !n made ) a broad ne$le ?r\gh ! m>g9 ( ! cornea1 close to ! scl]otic1 j l>ge en\gh to admit ! canula =ceps1 ) :i* a small portion ( iris close to its cili>y atta*m5t is seiz$ & drawn out2 a piece ( f9e floss silk1 previ\sly ti$ 9 a small loop r\nd ! canula =ceps1 is slipp$ d[n & c>efully tight5$ r\nd ! prolaps$ portion4 ,?is spe$ily %r9ks1 & ! loop may g5]ally be remov$ ab\t ! second day4 ,! *ief advantage claim$ = ?is me?od is ! ease ) :i* ! size ( ! new pupil c be regulat$4 ,x is also suitable 9 cases ( conical cornea1 :]e x is wi%$ to *ange ! =m ( ! pupil into a n>r[ slit4 ,n4,b4--,! ends ( ! ligature mu/ be left suffici5tly long to avoid any risk ( _! be+ drawn out ( sight into ! sub/ance ( ! cornea1 or ev5 into ! ball1 by retraction ( ! fibres ( ! iris4 ,,corelysis4--,free+ ( ! ,pupil4--,an op]ative proc$ure = sep>at+ po/]ior adhesions ( ! iris to ! l5s4 ,9 x ! surgeon hopes to act1 n on ! iris1 z 9 ! op]ations = artificial pupil1 b only on ! b&s ( false membrane :i* di/ort ! pupil4 ,! op]ation is briefly z foll[s3--,! eye be+ firmly held by a wire speculum1 & =ceps p9*+ up ! conjunctiva1 a broad ne$le is pass$ rapidly ?r\gh ! cornea at a po9t :i* may give easy access to ! adhesion to be torn ?r\gh4 ,?is po9t is g5]ally at ! opposite m>g9 ( ! irregul> pupil1 s t ! ne$le may pass ?r\gh ! cornea 9 front ( ! "o side ( ! iris1 !n ?r\gh ! orifice ( ! pupil1 s z to rea* ! back ( ! o!r side4 ,! ne$le is )drawn gradually1 s z to lose z little ( ! aque\s hum\r z possible1 & !n ! spatula hook1 call$ aft] ! inv5tor ( ! op]ation1 ,mr4 ,/reatfeild1 is introduc$4 ,x is us$ fir/ z a spatula1 t is1 ) its blunt1 ?\gh poli%$ edge1 to sep>ate ! adhesions1 & if ?is is unsuccessful1 z a hook 7,,fig4 ,,xiv471 s z to cat* & te> !m4 ,9 cases :i* resi/ ! in/rum5t us$ 9 bo? ( ^! ways1 ,mr4 ,/reatfeild has us$ v f9e canula-scissors to cut ! adhesions4#ij ,su* a fur!r complication ( ! op]ation practically alt]s its "* into an op]ation = artificial pupil1 q4v4 ,illu/ration3 ,,fig4 ,,xiv4#ia ,,iridectomy4--,9 cases ( acute glaucoma1 irido-*oroiditis1 & all deep inflammations ( ! eye 9 :i* ! ocul> t5sion is increas$1 also 9 c]ta9 cases ( flap extraction already allud$ to1 ! op]ation ( iridectomy z orig9ally propos$ by ,von ,graefe w be f\nd ( use4 ,op]ation4--,! pati5t recumb5t1 & ! eye absolutely fix$ by speculum & =ceps1 a l9e> incision1 v>y+ 9 l5g? f "o-six? to "o-f\r? ( an in*1 is made j at ! m>g9 ( ! cornea4 ,! po9t ( election is ! upp] pole ( ! cornea4 ,! l5s mu/ n be w\nd$4 ,! be/ in/rum5t = mak+ ! section is an ord9>y l9e> extraction knife1 b5t at an angle to admit ( its be+ introduc$ f above4 ,! iris w protrude ?r\gh ! w\nd1 or1 if adh]5t1 mu/ be drawn out by =ceps1 & !n is to be cut (f ) scissors4 ,! op]ation is r>ely successful1 unless a ?ird1 or at lea/ a f\r?1 ( ! iris be remov$4 ,,excision ,,( ,a ,,/aphylomat\s ,,cornea4--,!re are c]ta9 cases 9 :i* ! :ole or great] "p ( ! cornea bulges =w>d 9 a great blue project+ tum\r4 ,x is v ugly z x protrudes betwe5 ! lids & prev5ts _! closure2 besides ?is1 f its exposure x frequ5tly inflames1 ev5 ulc]ates1 & has a mo/ injuri\s effect on ! o!r eye4 ,9 ! cases suitable = op]ation vision is completely gone1 )\t hope ( its re/oration by any op]ative proc$ure4 ,! be/ ?+ = ! pati5t is to h j en\gh ( ! /aphyloma remov$ to enable ! rema9s ( ! eyeball to =m a good /ump = an artificial eye4 ,v>i\s means h be5 sugge/$ = do+ ?is1 v>y+ 9 ext5t & sev]ity f a m]e %av+ (f ! apex ( ! /aphyloma to excision ( ! :ole eyeball4 ,by f> ! be/ me?od ( op]at+ is ! "o propos$ & practis$ by ,mr4 ,crit*ett4 ,illu/ration3 ,,fig4 ,,xv4#ib ,illu/ration3 ,,fig4 ,,xvi4#ic ,! object ( x is to remove an elliptical portion ( ! front ( ! /aphyloma1 or ! :ole /aphyloma1 :5 x is possible1 & at ! same "t to prev5t z f> z possible ! escape ( ! vitre\s4 ,op]ation4--,?ree1 f\r1 or five small curv$ ne$les arm$ ) ?read are pass$ ?r\gh ! /aphyloma f above d[nw>ds1 be+ ea* ent]$ a little above ! l9e ( ! int5d$ upp] incision1 & br\ght out a little bel[ ! l9e ( ! int5d$ l[] "o 7,fig4 ,,xv47 ,to remove ! includ$ elliptical portion1 ,mr4 ,crit*ett pi]ces ! scl]otic ) a ,be]'s knife1 j 9 front ( ! t5d9\s ins]tion ( ! ext]nal rectus4 ,?r\gh ?is incision a pair ( probe-po9t$ scissors is introduc$1 & ! piece cut j )9 ! po9ts ( ! ne$les4 ,on ! removal1 ! ne$les1 :i* h reta9$ ! vitre\s by _! pressure1 are drawn ?r\gh & ! ?reads cauti\sly ti$4 ,union by fir/ int5tion v (t5 occurs1 & an excell5t /ump is left ) a n>r[ depress$ transv]se cicatrix#id 7,fig4 ,,xvi47 ,,extirpation ,,( ,,! ,,eyeball4--#a4 ,( ! ,eyeball only4--,a circul> incision %\ld be made ) curv$ scissors ?r\gh ! conjunctiva1 a little beyond ! corneal m>g91 !n1 beg9n+ ) ! ext]nal rectus1 muscle aft] muscle %\ld be rais$ ) ! =ceps1 & divid$1 aft] :i* ! optic n]ve is cut ?r\gh ) ! scissors4 ,a slight prelim9>y ext5sion outw>ds ( ! optic commissure w facilitate ! dissection1 & mu/ be secur$ ) metallic sutures2 any vessels %\ld be ti$1 & ! orbit fill$ up ) a light compress ( *>pie secur$ ) a b&age4 #b4 ,( ! cont5ts ( ! ,orbit4--,?is may be requir$ = malignant disease1 b ) a v poor prognosis4 ,! optic commissure %\ld be freely divid$1 & !n1 by bold /rokes ( curv$ scissors1 or curv$ probe-po9t$ bi/\ry1 ! orbit may be fairly empti$ by scoop+ out its cont5ts4 ,ev5 ! p]io/eum may require to be scrap$ (f1 & ! optic n]ve divid$ z f> back z possible4 ,! hmorrhage may be pretty sm>t1 b c g5]ally be easily *eck$ by compresses2 if necess>y1 ^! c be soak$ 9 ! solution ( ! p]*loride ( iron4 ,! au?or has done ?is op]ation _m times1 9 cases ext5sive & ( old /&+1 = malignant disease1 melanotic & encephaloid4 ,all h recov]$1 & 9 no in/ance has !re be5 any tr\ble 9 /opp+ ! ble$+4 ,,footnotes3 #ha a4 ,elliptical incision = entropium2 b4 w$ge-%ap$ incision = ectropium4 #hb ,fig4 ,,viii4 illu/rates ,/reatfeild's op]ation = entropium4--a4 section ( sk92 b4 section ( levator palpebrae2 c4 section ( c>tilage ( lid2 d4 section ( conjunctiva2 e4 w$ge-%ap$ portion excis$4 #hc ,oph?almic ,hospital ,reports1 vol4 i4 p4 #aba4 #hd ,r\gh diagram ( ,b[man's op]ation1 %[+ ! groov$ director 9 ! punctum1 & ! knife 9 ! groove j be=e x slits up ! canaliculus4 #he ,diagram ( op]ations = conv]g5t squ9t--,a ,a1 l9e ( sub-conjunctival incision2 ,b ,b1 l9e ( ,dieff5ba*'s op]ation2 ,c1 wire speculum4 #hf ,! ,radical ,cure ( ,extreme ,div]g5t ,/rabismus4 ,j4 ,vose ,solomon1 ,f4,r4,c4,s41 #ahfd4 #hg ,oph?almic ,hospital ,reports1 vol4 iv4 "p ii4 p4 #aig4 #hh ,bi5nial ,retrospect = #ahfe-ff4 ,syd4 ,soc4 pp4 #cfc-d4 ,= a ?or\gh discussion ( ! m]its ( ?is op]ation1 see pap]s by ,von ,graefe 9 ,brit4 ,m$4 ,j\r4 = #ahfg1 vol4 i4 pp4 #cgi1 #ddf1 #dii1 #feg1 #gfe4 #hi ,oph?almic ,hospital ,reports1 vol4 i4 p4 #bbd4 #ij ,/reatfeild on ,corelysis4 ,oph?almic ,hospital ,reports1 vol4 ii4 p4 #cji4 #ia a iris2 b l5s2 c cornea4 ,! hook is se5 appli$ to ! adhesion betwe5 l5s & iris4 #ib ,! /aphyloma ) ! ne$les ins]t$1 ! lids held asund] by a spr+ speculum4 ,! elliptical dott$ l9e %[s ! am\nt to be remov$2 ! v]tical "o1 ! position ( ! prelim9>y incision ) ! ,be]'s knife4 #ic ,result+ /ump aft] ! /it*es are ins]t$4 #id ,oph?almic ,hospital ,reports1 vol4 iv4 "p #a4 ,,*apt] ,,vi4 ,,op]ations ,,on ,,! ,,nose ,,& ,,lips4 ,,rh9opla/ic ,,op]ations4--,! op]ations = ! re/oration or repair ( lo/ or mutilat$ noses are s v>i\s1 & ! m9ut5ess ( detail necess>y = full description ( !m s great1 t a complete acc\nt 9 a manual su* z ?is is impossible2 a brief notice ( "s ( ! mo/ important v>ieties ( ! op]ation is all t c be giv54 ,pr9ciples4--#a4 ,x is necess>y 9 e case t a suitable edge be prep>$ on :i* to fix ! flap ( sk91 h[ev] obta9$4 ,to be suitable1 ?is edge1 %\ld be 7a7 made 9 heal?y sk91 n 9 old or weak cicatrices2 h5ce no trace ( ! orig9al disease %\ld be left2 7b7 x %\ld be made ?or\ghly raw1 by ! removal ( an appreciable am\nt ( its edge2 x %\ld be p>$1 n m]ely scrap$4 #b4 ,x is useless to attempt to re/ore a nose unless ! pati5t is 9 good g5]al heal?1 well n\ri%$1 & p]fectly free f all rema9s ( disease 9 ! nose or its neighb\rhood4 ,! flaps :i* are to =m ! new nose may be obta9$ ei!r f 7#a47 ! *eeks2 7#b47 ! =ehead2 7#c47 a di/ant "p ei!r ( ! pati5t or ( ano!r p]son4 7#a47 ,f ! ,*eeks4--,:5 ! *eeks are heal?y1 & specially if !y are tol]ably full & lax1 ! flaps f ! *eeks produce mu* ! mo/ satisfactory result4 ,z p]=m$ by ,mr4 ,syme1 ! op]ation consi/s 9 ! %ap+ ( two equal flaps 7,a1 ,a7 f ! sk9 ( ! *eek at ea* side1 hav+ ! atta*m5t above4 ,a site = ea* flap is =m$ by ! c>eful p>+ away ( ! :ole ?ickness ( ! edge ( ! cavity ( ! lo/ organ 7see ,fig4 ,,xvii47 ,illu/ration3 ,,fig4 ,,xvii4#ie ,! flaps are !n rais$ f _! atta*m5ts to ! upp] jaw-bone1 & approximat$ 9 ! middle l9e by sev]al po9ts ( metallic suture & ! out] edges /it*$ to ! raw surface on ea* side at a prop] di/ance f ! nasal orifice4 ,if any septum rema9s ( ! old nose1 x may be made v useful z a fix$ po9t1 a /raight ne$le be+ ?ru/ ?r\gh "o flap close to its out] l[] edge1 !n ?r\gh ! septum1 & out at a correspond+ po9t ( ! o!r flap4 ,! edges ( ! w\nd left 9 ! *eek at ea* side c g5]ally be1 to a c]ta9 ext5t1 approximat$ by silv] /it*es 7,b1 ,b7 & ! triangul> portion 7,c1 ,c71 :i* is necess>ily left to heal by granulation1 proves an advantage1 z by its depression x enhances ! app>5t height & prom95ce ( ! new organ4 ,! cavity %\ld be v g5tly di/5d$ ) l9t1 & may be support$ by ! blades ( a small pair ( =ceps1 appli$ s z to embrace ! nose4 7#b47 ,f ! ,=ehead4--,! ,indian op]ation may be us$ z a la/ res\rce1 9 cases :]e1 f disease1 ! *eeks also h suff]$1 & are n to be tru/$ to = flaps4 ,op]ation4--#a4 ,x %\ld be decid$ z to ! %ape & size ( ! portion ( sk9 necess>y1 by fitt+ on pieces ( s(t lea!r or m\ld+ wax4 ,to all[ = %r9k+1 ! flap %\ld be made at lea/ "o-?ird l>g] ?an is at fir/ app>5tly necess>y4 ,! exact b\nd>ies ( ! flap to be rais$ %\ld !n be m>k$ out on ! =ehead by lightly p5cill+ x ) nitrate ( silv]1 ! m>k f :i* is n effac$ by blood1 z is sure to be ! case ) an ink l9e4 ,v>i\s %apes h be5 propos$ = ! flap v>y+ 9 l5g? ( neck1 9 ! %ape ( ! angles1 & especially 9 ! arrangem5ts made = ! =mation ( a columna4 ,"s 7z ,li/on7 pref] aft]w>ds to provide = ! columns sep>ately1 by a flap rais$ f ! upp] lip 9 a subsequ5t op]ation4 ,! flap is !n to be rais$ f ! =ehead1 c>e be+ tak5 n to injure ! p]io/eum4 ,! incision is to be c>ri$ l[] d[n on ! side 7g5]ally ! left71 to :i* ! flap is to be twi/$4 ,! flap is !n to be br\ght r\nd 7,fig4 ,,xviii47 & c>efully fitt$ on to ! edges previ\sly prep>$ = its reception4 ,! neck mu/ be left z lax z possible1 le/ by tight twi/+ ! supply ( blood be cut (f1 & ! flaps ?us depriv$ ( n\ri%m5t4 ,bo? silk & metallic sutures are recomm5d$4 ,hamilton ( ,dubl91#if aft] a l>ge exp]i5ce ( bo?1 pref]s ! =m]4 ,illu/ration3 ,,fig4 ,,xviii4#ig ,!re are v>i\s risks2 sl\gh+ ( ! :ole flap at once1 %r9k+ ( x aft] weeks or ev5 mon?s2 c]ta9 inevitable drawbacks1 z ! cicatrix on ! =ehead1 ! v v>i\s & ludicr\s *anges ( col\r to :i* ! new organ is subject1--^! _c be rem$i$ by fur!r op]ation4 ,two po9ts g5]ally require a second use ( ! knife a few weeks aft]3--7#a47 ,! neck ( ! flap is sure to be r$undant & prom95t1 b c be p>$4 7#b47 ,! columna almo/ always requires improv+1 &1 9 ,li/on's me?od1 to be made4 ,he p>$ ! inn] surface ( ! apex ( ! nose1 & !n rais$ a c5tral flap ( ! lip 9 ! middle l9e1 ab\t a qu>t] ( an in* broad1 & ext5d+ f ! rema9s ( ! old septum to ! free bord]1 rais+ x f ! gum1 & /it*$ ! free end ( x to ! prep>$ apex1 br++ toge!r ! two divid$ portions ( ! lip by ord9>y h>elip sutures4 ,?o columna1 if r$undant1 c\ld be %av$ d[n1 & x 0 f\nd t ! muc\s surface v quickly became l sk9 on exposure4 ,= o!r po9ts ) reg>d to ! op]ation1 ref]5ce may be made to ! works ( ,li/on & ,skey1 & ,hamilton's monograph1 ref]r$ to above4 ,note4--,! tongue & groove suture propos$ by ,pr(essor ,pancoa/1 & recomm5d$ by ,pr(essor ,gross1 is said to be specially suitable = su* pla/ic op]ations4 ,x is v complicat$1 z x requires "o edge to be bevell$ to a w$ge %ape1 ! o!r be+ groov$ to include ! w$ge1 ?us oppos+ f\r raw surfaces1 :i* are reta9$ 9 contact by be+ transfix$ by f9e silk sutures4 7#c47 ,!re are c]ta9 cases 9 :i* nei!r *eeks nor =ehead are available = flaps1 & yet ! pati5ts press v mu* = "s op]ation4 ,if !y h pati5ce & det]m9ation1 ! ,taliacotian or ,italian op]ation may be attempt$4 ,)\t go+ into detail1 ! pr9ciple ( x is z foll[s3--#a4 ,a piece ( sk9 ( suitable size 0 m>k$ out ov] ! left biceps1 & def9$ by two longitud9al incisions1 & rais$ f ! subcutane\s cellul> tissue1 ?us be+ left atta*$ by its two ends only2 a piece ( l95 0 pull$ bel[ x4 #b4 ,aft] a few days ! upp] end 0 also divid$1 & ! flap ?us contract$4 ,9 a few days m ! sides ( ! old nose 7 made raw1 & ! upp] free surface ( ! flap also made raw & /it*$ to !m1 ! arm be+ fa/5$ up by a mo/ elaborate s]ies ( b&ages4 #c4 ,aft] a =tnight 9 ?is position1 ! la/ atta*m5t ( ! flap to ! arm 0 sev]$1 & ! new nose c\ld !n be modell$ at pleasure4 ,! lit]ature ( ! subject is exce$+ly curi\s1 especially ! cases 9 :i* ! new mat]ial 0 obta9$ f an accommodat+ fri5d or s]vant4 ,,op]ative ,,treatm5t ,,( ,,lupus4--,we may "h notice a mode ( treatm5t :i* has admirable results4 ,! pati5t be+ put deeply "u an an/hetic1 ! surgeon ) a %>p spoon c>efully p>es away all ! diseas$ tissues1 & !n de/roys ! base ei!r by nitric acid or a /rong solution ( *loride ( z9c4 ,! au?or has done ?is 9 a great numb] ( cases ) excell5t effect4 ,,nasal ,,polypi1 ,removal (4--,( ^! !re are diff]5t k9ds4 #a4 ,,ord9>y ,,muc\s ,,polypi4--,^! gr[ f ! spongy bones1 g5]ally ! sup]ior "o1 are non-malignant 9 _! "*1 s(t & vascul>1 (t5 fill up ! :ole ( bo? nasal cavities1 & frequ5tly hang d[n beh9d into ! ph>ynx4 ,! practical po9t to rememb] is t1 h[ev] l>ge & num]\s !y may be1 !y inv>iably h _! orig9 f a comp>atively limit$ spot1 ! edge ( ! spongy bone1 & always hang f a n>r[ neck4 ,h5ce ! treatm5t is easy & satisfactory1 if ! neck be attack$1 & n ! body ( ! tum\r4 ,slightly curv$1 n>r[-blad$ =ceps %\ld be pass$ along by ! side ( ! sup]ior spongy bone1 ) _! blades op51 till ! neck ( ! polypus is seiz$4 ,hold+ x firmly1 ! =ceps %\ld !n be sl[ly twi/$ r\nd till ! neck is de/roy$ & ! polypus deta*$4 ,?is %\ld be repeat$ till ! pati5t c bl[ freely ?r\gh bo? no/rils4 ,if attempts are made to seize ! body ( ! polypus1 x w break d[n "u ! =ceps1 ble$1 & give mu* tr\ble4 #b4 ,,! ,,fibr\s ,,polypus4--,?is =m is =tunately mu* m r>e ?an ! o!r4 ,x is almo/ inv>iably s+le1 is atta*$ to ! po/]ior m>g9 ( ! n>es by a n>r[ b v /rong root1 is extremely firm 9 consi/5ce1 may gr[ to a l>ge size s z to ob/ruct bo? no/rils1 g5]ally gives rise to sev]e & frequ5t hmorrhages4 ,! hmorrhage dur+ any attempt to remove x is g5]ally ( ! mo/ sev]e "*1 b ceases imm$iately on its complete deta*m5t4 ,we owe ne>ly all t we d "k ab\t ! treatm5t ( ?is =m ( polypus to ,mr4 ,syme4 ,8 me?od is--,by ! ord9>y polypus =ceps describ$ already1 he seiz$ ! tum\r ?r\gh ! no/ril1 & !n ) ! =e & middle f+]s ( ! left h& introduc$ beh9d ! s(t palate1 he attack$ ! po9t ( atta*m5t1 & by 8 nails1 aid$ by ! =ceps1 deta*$ x f its n>r[ base4#ih #c4 ,,malignant ,,polypi %\ld n be m$dl$ ) unless x is absolutely c]ta9 t ! :ole ( ! bone f :i* !y gr[ c be remov$ also4 ,?is is v r>ely ! case4 7,see ,excision ( ,sup]ior ,maxilla47 ,,op]ations ,,on ,,! ,,lips4--#a4 ,epi!lial canc]s ( ! l[] lip are v frequ5t1 & require removal4 ,if ! tum\r or ulc] is small1 & involves a consid]able ?ickness ( ! lip1 x is mo/ easily remov$ by a ,v-%ap$ incision 7,fig4 ,,xix4 ,a ,b ,a74 ,its %ape p]mits ! mo/ accurate apposition ( ! cut surfaces2 & if ! lips are full & ! tum\r small1 v slight trace ( ! op]ation w rema94 ,illu/ration3 ,,fig4 ,,xix4#ii ,aga91 if ! tum\r be m ext5sive1 involv+ a l>ge portion ( ! prolabium1 & yet n ext5d+ deeply into ! sub/ance ( ! lip1 x may be v easily remov$ by a pair ( curv$ scissors1 appli$ 9 ! direction %[n 9 ! diagram 7,fig4 ,,xx4 ,a ,b74 ,! sk9 mu/ !n be /it*$ to ! muc\s membrane by num]\s po9ts ( int]rupt$ suture4 ,illu/ration3 ,,fig4 ,,xx4#ajj ,b if ! tum\r be at once ext5sive & deep1 m]e removal is n suffici5t1 b "s provision mu/ be made = supply+ ! blank left by ! op]ation4 ,9 cases :]e a ?ird1 or ev5 a half1 ( ! l[] lip has ?us be5 remov$1 x may be f\nd suffici5t freely to dissect :at is left ( ! lip f ! gums1 & ?us approximate ! cut surfaces 9 ! middle l9e4 ,?is alone1 h[ev]1 w\ld s mu* dim9i% ! buccal orifice1 & twi/ its corn]s1 z to cause great de=mity4 ,! addition ( an incision horizontally outw>ds1 at "o or bo? angles ( ! m\?1 w d away ) su* risk1 & all[ ! surfaces to come toge!r )\t puck]+2 :ile by /it*+ ! sk9 & muc\s membrane toge!r 9 ! c\rse ( ^! horizontal incisions1 we c increase ! size ( ! buccal orifice almo/ ad libitum4 ,la/ly1 :5 ! l[] lip has be5 entirely remov$1 x is /ill possible to supply its place 9 ! foll[+ mann]1 :i* 0 devis$ by ,mr4 ,syme3 ,! tum\r be+ fairly isolat$ by a ,v-%ap$ incision 7,fig4 ,,xxi47 ,c ,a ,c includ+ ! :ole ?ickness ( ! lip1 ea* ( ! incisions %\ld be prolong$ d[nw>ds & outw>ds1 z %[n by ! dott$ l9es ,a ,d1 ,a ,d4 ,! flaps ?us m>k$ out mu/ be sep>at$ f ! bone1 br\ght upw>ds1 & approximat$ 9 ! middle l9e4 ,possibly x may be necess>y /ill fur!r to enl>ge ! buccal orifice by %ort lat]al incisions1 ,c ,c4 ,:e!r ^! are requir$ or n1 silk /it*es are to be introduc$ to unite ! sk9 & muc\s membrane along ! l9es ,a ,c4 ,! gap left betwe5 ,d ,b ,d mu/ be left to granulate1 b 9 mo/ cases may be v mu* dim9i%$ 9 size by additional sutures at its out] corn]s1 ne> ,d4 ,! granulat+ surface ,e ,e v rapidly heals up1 leav+ a dimple on ea* side1 :i* r improves ! appe>ance1 by add+ to ! prom95ce ( ! *91 ,b4 ,illu/ration3 ,,fig4 ,,xxi4#aja ,illu/ration3 ,,fig4 ,,xxii4#ajb ,,! ,,op]ations ,,= ,,h>elip1 ?\gh all conduct$ on ! same g5]al pr9ciples1 v>y consid]ably 9 ext5t requir$ accord+ to ! position & size ( ! fissure or fissures to be rem$i$4 #a4 ,= ,s+le ,h>elip4--,:]e ! fissure ext5ds only f ! prolabium up to ! atta*m5t ( ! lip to ! gums3 ?is is v easily rem$i$1 ! *ief risk be+ le/ ! surgeon %\ld n remove en\gh ( ! edges ( ! fissure4 ,op]ation4--,ble$+ be+ controll$ by an assi/ant1 ! surgeon fixes a pair ( spr+ art]y =ceps into ! muc\s membrane & sk9 at ! sali5t angle at ea* side ( ! fissure4 ,tak+ "o ( ^! 9 8 left h&1 he puts ! edge to be p>$ on ! /ret*1 & !n ) a %>p n>r[ /raight bi/\ry he transfixes ! lip at ! po9t j beyond ! upp] angle ( ! fissure1 & cuts outw>ds1 be+ c>eful to remove ! :ole ?9n] "p ( ! lip1 & to leave ! edge r concave ?an convex4 ,if left convex1 or ev5 q /raight1 !re is a risk t1 aft] union has tak5 place1 an angle rema9 %[+ ! position ( ! cleft4 ,! same is !n to be done on ! o!r side4 ,! ble$+ is !n to be controll$ by twi/+ ! l>g] vessels1 & if ooz+ /ill cont9ues f ! small] ones1 a pad ( l9t %\ld be plac$ 9 ! w\nd1 & a few m9utes' delay giv51 z1 to facilitate imm$iate union1 x is ( ! greate/ importance t all hmorrhage %\ld h ceas$ be=e ! edges are br\ght toge!r4 ,:5 ! ble$+ has ceas$1 ! edges %\ld be approximat$ by two or m po9ts ( int]rupt$ metallic suture ins]t$ v deeply ?r\gh ! tissues1 & tak+ a good hold ( ! edges ( ! w\nd4 ,if ! edges d n fit accurately1 "o or two horse-hair sutures w help4 ,"s surgeons /ill pref] ! old h>elip ne$les secur$ by a figure-(-eight suture4 ,a silk suture ins]t$ ?r\gh ! prolabium is ( great advantage1 z x keeps ! inn] surface ( ! w\nd clos$1 :i* )\t x is v apt to be kept op5 by ! pressure ( ! tee? or gums1 & 9 infants by ! movem5ts ( ! tip ( ! tongue4 ,v>i\s me?ods h be5 devis$ to utilise1 if possible1 ! portion ( ! edge ( ! lip :i* is sep>at$ dur+ ! op]ation ( refre%+ ! edges1 = ! purpose ( fill+ up ! sort ( cleft or gap :i* is apt to be notic$ at ! edge ( ! prolabium4 ,! mo/ +5i\s & simple/ ( ^! is t propos$ by ,m4 ,nelaton1 = use 9 cases :]e ! fissure does n ext5d s f> up z ! nose4 ,x consi/s 9 leav+ ! two portions :i* are p>$ (f 7,fig4 ,,xxiii47 ! sides ( ! cleft atta*$ to ea* o!r z well z to ! free edge ( ! lip1 !n pull+ !m d[n1 s z to br+ _! ble$+ surfaces into apposition1 & make a diamond-%ap$ w\nd in/ead ( a triangul> cleft 7,fig4 ,,xxiv47 ,:5 br\ght toge!r by sutures a projection is left at ! edge ( ! lip2 ?is1 9 mo/ cases1 disappe>s2 if x does n1 x c easily be p>$ d[n4 ,illu/ration3 ,,fig4 ,,xxiii4#ajc ,illu/ration3 ,,fig4 ,,xxiv4#ajd #b4 ,:5 ! fissure1 ?\gh s+le1 ext5ds upw>ds into ! nose1 ! op]ation is m difficult1 & ! result frequ5tly less satisfactory4 ,! fir/ ?+ to be done is to sep>ate ! lips f ! gums1 s z to make !m m freely mobile4 ,! :ole edges ( ! cleft require refre%+4 #c4 ,d\ble ,h>elip1 )\t bony de=mity1 & :]e ! int]v5+ portion ( ! sk9 is v]tical1 does n project1 & c be made useful = ! new lip4 ,su* cases are n v common1 b :5 !y d occur ! "q arises1 ,h[ are !y to be manag$--9 two sep>ate op]ations or at once8 ,i believe1 9 e case1 at once4 ,! c5tral w$ge-%ap$ portion is n l>ge en\gh to ext5d d[nw>ds z f> z ! prolabium1 b /ill %\ld n be remov$ altoge!r1 z x may be ( great use1 especially 9 be>+ ! columna nasi1 & all[+ its full developm5t4 ,! edges %\ld be p>$ 9 ! same way1 & to ! same ext5t z 9 s+le h>elip1 ) ! addition t ! int]v5+ portion %\ld h its edges completely remov$1 & be left 9 ! =m ( a w$ge1 ) its apex d[nw>ds4 ,! highe/ suture %\ld be pass$ ?r\gh fir/ "o side1 !n ! base ( ! w$ge1 & !n ! o!r side2 ! second "o ?r\gh bo?1 & ! apex ( ! w$ge2 & a ?ird %\ld unite ! prolabium1 n includ+ ! w$ge4 ,illu/ration3 ,,fig4 ,,xxv4#aje #d4 ,d\ble ,h>elip comb9$ ) fissures ( ! h>d palate1 & projection ( a c5tral bone4 ,?is is ! analogue ( ! int]-maxill>y bone 9 ! l[] animals1 & be>s ! two middle incisor tee?1 & projects v v>i\sly 9 diff]5t cases4 ,9 "s x projects horizontally =w>ds 9 ! mo/ hide\s mann]1 9 o!rs x lies at an angle m or less oblique2 9 v few does x ma9ta9 its prop] position2 :5 project+ =w>ds1 & z ! tee? also %>e 9 its projection1 x entirely prev5ts approximation ( ! edges ( ! fissures by op]ation1 s x mu/ fir/ be dealt ) 9 "o ( two ways1 ei!r-- ,illu/ration3 ,,fig4 ,,xxvi4#ajf 7#a47 ,x may be at once remov$ ) bone-pli]s1 ! piece ( sk9 ov] x be+ sav$4 ,?is is ! be/ t c be done 9 cases ( old /&+ aft] ! fir/ ye> or two1 ?\gh attempts h be5 made to break ! neck ( ! project+ portion1 & ?us p]mit ( its be+ %ov$ back4 7#b47 ,by gradual pressure by a spr+ truss1 /rapp+1 or a b&age1 x may be =c$ back4 ,?is is possible only 9 cases :]e ! de=mity has be5 comp>atively slight1 & ! pati5t has be5 se5 e>ly4 ,! edges mu/ !n be p>$ & approximat$ z direct$ above4 ,"o or two po9ts ab\t ! op]ation = h>elip require a special notice3-- #a4 ,:5 to op]ate4--,great diff]5ces 9 op9ion exi/4 ,"s say n be=e two or ?ree ye>s1 o!rs )9 two or ?ree days1 or ev5 h\rs1 aft] bir?4 ,probably ! safe/ "t is n mu* e>li] ?an ! second mon? 9 v /rong *ildr51 ! fif? 9 weakly ones1 up to ! comm5cem5t ( ! fir/ d5tition2 & :5 once d5tition has comm5c$ x is n s safe to op]ate till x is ov]4 ,prior to d5tition ! op]ation is att5d$ ) r m risk1 b aga91 if delay$1 !re is great risk t ! tee? d n come 9 prop]ly4 #b4 ,) reg>d to ! mo/ delicate "p ( ! op]ation1 ! managem5t ( ! prolabium4--,"s are satisfi$1 & ,i believe rightly1 ) c>eful apposition by a silk suture aft] a suffici5t am\nt ( ! edges has be5 remov$2 o!rs h propos$ v>i\s plans to obviate any risk ( an angle rema9+4 ,malgaigne proposes to reta9 a small portion ( ! p>+s ( ! edge to make small flap at ea* side2 ,lloyd a s+le "o f ! long half ( ! lip1 & br+s x up "u ! opposite "o1 secur+ x ) a /it*4 ,,footnotes3 #ie ,op]ation = =mation ( a new nose f ! *eeks2 ,a ,a1 flaps approximat$ 9 middle l9e2 ,b ,b1 out] "p ( b$ ( flaps /it*$ up2 ,c ,c1 triangle at ea* side left to granulate4 #if ,! ,re/oration ( a ,lo/ ,nose by ,op]ation1 p4 #eg2 an excell5t monograph on ! subject4 #ig ,op]ation = =mation ( a new nose f ! =ehead3--a1 prom95ce ( flap :i* is to be us$ z septum2 b1 left-h& corn] ( flap1 :i* is twi/$ & fa/5$ at c2 d1 "o ( ! tubes or quills ov] :i* ! nose is m\ld$4--7,modifi$ f ,b]n>d & ,huette47 #ih ,syme's ,obs]vations 9 ,cl9ical ,surg]y1 p4 #acb4 #ii ,diagram ( ,v-%ap$ incision2 ,a ,b ,a1 dots %[+ po9ts = sutures4 #ajj ,diagram ( incision = scoop+ out a %all[ tum\r by scissors4 #aja ,diagram ( incisions3--,c ,a ,c1 outl9e ( incision = removal2 ,c ,a ,d1 outl9e ( flap on ea* side2 ,b1 prom95ce ( *92 ,c ,c1 dott$ l9es1 %[+ incisions to enl>ge m\?1 if requir$4 #ajb ,diagram ( flaps 9 position3--,a ,a1 corn]s ( flaps br\ght up & approximat$ by silv] sutures2 ,c ,c1 new lip got by lat]al incisions1 sk9 & muc\s membrane be+ unit$ by silk ?reads2 ,e ,e1 gap left to granulate4 #ajc ,fig4 ,,xxiii4 %[s ! incision b\nd+ ! cleft4 #ajd ,fig4 ,,xxiv4 %[s ! diamond-%ap$ w\nd be=e ! sutures are appli$4 #aje ,diagram ( op]ation = d\ble h>elip3--a1 /it* ?r\gh bo? sides & w$ge-%ap$ portion1 :i* also aids ! septum2 b1 o!r /it*es approximat+ edges4 #ajf ,diagram ( d\ble h>elip1 ) project+ bone3--a1 c5tral piece ( lip1 dott$ l9es %[+ incision2 b1 project+ bone be>+ tee?1 :i* are g5]ally small & /unt$4 ,,*apt] ,,vii4 ,,op]ations ,,on ,,! ,,jaws4 #a4 ,,excision ,,( ,,! ,,upp] ,,jaw4--,) reg>d to ! morbid conditions = :i* ?is op]ation is und]tak51 x may be suffici5t "h to obs]ve1 t 9 no case c ! op]ation be call$ ju/ifiable 9 :i* ! disease ext5ds beyond ! upp] jaw-bone & ! correspond+ palate-bone1 = unless ! morbid gr[? be entirely remov$1 recurr5ce is inevitable1 & no advantage is ga9$ by ! op]ation4 ,x is und]tak5 = ! removal ( tum\rs ( ! antrum & ( ! alveol> m>g9s1 9 all :i* cases ! section = its removal mu/ be made ?r\gh heal?y bone1 & wide ( ! disease1 s z to insure t ! :ole is remov$4 ,!re are o!r cases 9 :i* ! :ole or "p ( ! upp] jaw has be5 remov$ = ! purpose ( giv+ access to disease beh9d1 = example1 to naso-ph>yngeal polypi ) ext5sive atta*m5ts4 ,9 describ+ ! op]ation = ! excision ( ! entire upp] jaw1 we h to consid]--7#a47 :at incisions ?r\gh ! s(t p>ts w expose ! tum\r be/1 & ) lea/ de=mity2 7#b47 :at bony processes require to be divid$1 & :]e4 ,v v>i\s incisions h be5 recomm5d$ by v>i\s au?ors2 "s describ+ ?ree1 9 v>i\s directions1 =m+ flaps ( diff]5t sizes1 :ile o!rs1 aga91 are satisfi$ ) a v small division ( ! upp] lip into ! nose1 or ev5 attempt removal ( ! bone )\t any incision ?r\gh ! sk9 at all4 ,^! discrepancies dep5d 9 great measure on diff]5t views ( :at con/itutes excision ( ! upp] jaw1 ! m complicat$ ones contemplat+ removal ( ! :ole bone anatomically s call$1 includ+ ! floor ( ! orbit1 :ile ! less complicat$ ones are suitable = cases 9 :i* a mu* less ext5sive removal is requir$4 ,to remove ! :ole bone1 an incision 7,fig4 ,,xxvii4 ,a7 ( ! sk9 mu/ ext5d f ! angle ( ! m\? upw>ds & outw>ds 9 a slightly curv$ direction ) its convexity d[nw>ds1 z f> on ! mal> bone z half an in* outside ( ! out] angle ( ! eye4 ,! flaps mu/ !n be rais$ 9 bo? directions1 ! inn] "o specially dissect$ (f ! bones1 s z to expose ?or\ghly ! nasal cavity4 ,x is ( great importance ?or\ghly to display ! floor ( ! orbit1 s t ! atta*m5t ( ! orbital fascia may be accurately cut ?r\gh1 ! inf]ior oblique muscle divid$ at its orig91 & ! eye & ! fat ( ! orbit cauti\sly rais$ f its floor4 ,illu/ration3 ,,fig4 ,,xxvii4#ajg ,?ree processes ( bone !n require att5tion & division4 7#a47 ,! articulation ) ! opposite bone 9 ! h>d palate4 ,to divide ?is1 "o incisor too? at lea/ mu/ be drawn1 ! s(t palate divid$ by a knife to prev5t lac]ation1 & ! ?ick alveol> portion sawn ?r\gh 9 a longitud9al direction f be=e backw>ds4 7#b47 ,! articulation ) ! mal> bone at ! upp] angle ( ! incision ?r\gh ! sk94 ,?is mu/ be not*$ ) a small saw 9 a direction correspond+ to ! articulation1 & !n wr5*$ asund] by a pair ( /rong bone-pli]s4 7#c47 ,! nasal process ( ! upp] jaw mu/ n[ be divid$ by ! pli]s1 "o limb ( :i* is cauti\sly ins]t$ into ! orbit1 ! o!r into ! nose4 ,if ! disease ext5ds high up 9 ?is process1 x may be necess>y p>tially to sep>ate ! correspond+ nasal bone1 & ?us rea* ! suture betwe5 ! nasal process & ! frontal bone4 ,! pli]s mu/ n[ be ins]t$ into ! groove already made by ! saw on ! h>d palate1 & ! sep>ation cont9u$ to ! full ext5t backw>ds4 ,a comp>atively slight =ce ex]t$ on ! tum\r ei!r by ! h&1 or 7:5 ! tum\r is small7 by a pair ( /rong claw =ceps1 w suffice to break d[n ! po/]ior atta*m5ts ( ! bone & remove x entire4 ,! necess>y lac]ation ( ! s(t p>ts beh9d is s f> an advantage1 z x less5s ! risk ( hmorrhage f ! po/]ior palat9e vessels4 ,! hmorrhage f ?is op]ation 0 at "o "t mu* dread$1 b is r>ely excessive2 v few vessels require ligature1 except ^? divid$ 9 ! e>ly /ages 9 mak+ ! sk9 flaps2 ! holl[ left %\ld be /uff$ ) l9t1 :i* may be soak$ 9 ! p]*loride ( iron %\ld !re be any ooz+4 ,! incisions recomm5d$ = ?is op]ation h be5 v v>i\s1 & a k ( "s ( !m may occasionally be useful1 on acc\nt ( specialities 9 ! %ape & size ( ! tum\r4 ,li/on ent]$ ! bi/\ry ov] ! ext]nal angul> process ( ! frontal bone1 & c>ri$ x d[n ?r\gh ! *eek to ! corn] ( ! m\?4 ,!n ! knife is to be pu%$ ?r\gh ! integum5t to ! nasal process ( ! maxilla1 ! c>tilage ( ! ala is deta*$ f ! bone1 & lip cut ?r\gh 9 ! mesial l9e2 ! flap ?us =m$ is to be dissect$ up & ! bones divid$4#ajh ,dieff5ba* made an incision ?r\gh ! upp] lip & along ! back or prom95t "p ( ! nose1 up t[>ds ! inn] can?us1 f :5ce he c>ri$ ! knife along ! l[] eyelid1 at a "r angle to ! fir/ incision z f> z ! mal> bone4 ,9 cases :]e ! tum\r is ( mod]ate size1 ,sir ,w4 ,f]gusson f\nd#aji x suffici5t to divide ! upp] lip by a s+le incision exactly 9 ! middle l9e1 ?is incision to be cont9u$ into "o or bo? no/rils1 if requir$4 ,! ala ( ! nose is s easily rais$1 & ! tip s moveable z to give great facilities to ! op]ator = cle>+ ! bone ev5 to ! floor ( ! orbit4 ,9 cases :]e ! tum\r is l>g]1 or ! bones m ext5sively affect$1 ,sir ,w4 ,f]gusson pref]r$ an ext5sion ( ! =ego+ incision 7,fig4 ,,xxvii4 ,b7 upw>ds along ! edge ( ! nose almo/ to ! angle ( ! eye1 & !nce at a "r angle along ! l[] eyelid1 z f> z may be necess>y1 ev5 to ! zygoma4 ,! advantages claim$ = su* proc$ures are t ! de=mity is less & ! vessels are divid$ at _! t]m9al extremities4 #b4 ,,excision ,,( ,,! ,,l[] ,,jaw4--,removal ( portions1 great] or small]1 ( ! l[] jaw1 = tum\rs1 simple or malignant1 are n[ op]ations ( v frequ5t occurr5ce1 :ile 9 "s few cases ! :ole bone has be5 remov$ at bo? its articulations4 ,! op]ative proc$ures v>y mu*1 accord+ to ! am\nt ( bone requir+ removal1 & also ! position ( ! portion to be excis$4 7#a47 ,( a portion only ( "o side ( ! body ( ! bone4--,?is is p]haps ! simple/ =m ( op]ation1 & is frequ5tly requir$ = tum\rs1 specially = epulis4 ,incision4--,if ! p>ts are tol]ably lax & ! tum\r small1 a s+le incision j at ! l[] edge ( ! bone1 ( a l5g? r great] ?an ! piece ( bone to be remov$1 w suffice2 ?is w divide ! facial art]y1 :i* mu/ be ti$ or compress$1#aaj :ile ! surgeon1 dissect+ on ! tum\r1 sep>ates ! flaps 9 front1 cutt+ upw>ds into ! m\?1 & !n deta*es ! mylohyoid bel[1 & cle>s ! bone freely f muc\s membrane4 ,he !n1 ) a n>r[ saw1 not*es ! bone beyond ! tum\r at ea* side1 &1 introduc+ /rong bone-pli]s into ! not*es1 is enabl$ to sep>ate ! requir$ portion4 ,! w\nd is !n /it*$ up1 & a v rapid cure g5]ally results ) v little de=mity1 z ! cicatrix is 9 %ad[4 ,if f ! size ( ! tum\r m room is ne$$1 x c easily be got by an additional incision f ! angle ( ! m\? jo9+ ! =m]4 ,to prev5t de=mity1 :i* is apt to result f ! c5tre ( ! *9 cross+ ! middle l9e1 x is (t5 a wise precaution to h a silv] plate prep>$ fitt+ ! mol> tee? ( bo? jaws on ! s\nd side1 & ?us act+ z a spl9t4 ,su* a precaution may be requir$ 9 any op]ation 9 :i* ! l[] jaw is sawn ?r\gh4 ,n4,b4--,!re are c]ta9 cases 9 :i* ! epulis is small & conf9$ to ! alveol> m>g91 9 :i* an attempt may be made to reta9 ! base ( ! jaw entire1 & remove ! tum\r )\t any incision ( ! sk94 ,! muc\s membrane on bo? sides be+ c>efully dissect$ f ! affect$ "p1 ! bone may be sawn z be=e1 b only ?r\gh ! alveol> portion1 ! groves ( ! saw conv]g+ z !y p5etrate1 !n by a pair ( /rong curv$ bone-pli]s1 ! affect$ alveol> portion is to be scoop$ out )\t injur+ ! base4 ,?is proce$+1 :i* has be5 practis$ by ,syme1 ,f]gusson1 ,pollock1 ! au?or 9 _m cases1 & o!rs1 leaves no de=mity1 b1 x mu/ be own$1 is mu* m liable to ! risk ( recurr5ce ( ! disease1 & = ?is reason is /rongly condemn$ by ,gross4 ,note4--,9 ?is1 z 9 all o!r op]ations on ! jaws1 ! v fir/ ?+ to be done is to draw ! tee? at ! spots at :i* ! saw is to be appli$4 7#b47 ,excision ( a portion involv+ ! ,symphysis4--,free access is ( importance4 ,! be/ incision is probably "o :i* 7,fig4 ,,xxvii4 ,c7 comm5ces at ! angle ( ! m\? opposite ! heal?y portion ( jaw1 ext5ds d[n to ! place at :i* ! saw is to be appli$ & !n along ! base ( ! jaw pa/ ! middle l9e to ! o!r po9t ( section4 ,! flap is to be ?r[n up & ! bone cle>$4 ,! next po9t to be notic$ is1 t :51 9 cle>+ ! bone beh9d1 ! muscles atta*$ to ! symphysis are divid$1 ! tongue loses its support1 & unless wat*$ may t5d to fall backw>ds1 emb>rass+ respiration & ev5 p]haps *ok+ ! pati5t4 ,! tongue1 be+ confid$ to a special assi/ant1 mu/ be drawn well =w>ds4 ,v>i\s plans h be5 devis$ = keep+ x 9 position1 z /it*+ x to ! po9t ( ! pati5t's nose2 putt+ a ligature into its apex1 & fa/5+ x to ! *eek by a piece ( /rapp+1 & transfix+ its roots ) a h>elip ne$le1 us$ to /it* up a c5tral incision 9 ! *94 ,! t5d5cy to retraction v soon ceases1 new atta*m5ts are =m$ by ! muscles1 & aft] ! fir/ five or six days !re is v little risk ( ! tongue giv+ rise to any unt[>d consequ5ces by its displacem5t4 7#c47 ,dis>ticulation ( "o1 or bo? ,jo9ts4--,:5 ! portion ( bone implicat$ involves dis>ticulation = its complete removal1 ! difficulty ( ! op]ation is mu* increas$4 ,! rem>kably /rong atta*m5ts ( ! jo9t1 especially ! relation ( ! temporal muscle to ! coronoid process1 & ! close proximity ( l>ge art]ies & n]ves1 especially ! int]nal maxill>y art]y & ! l+ual n]ve1 r5d] ?is dis>ticulation v difficult4 ,! *ief po9ts to be att5d$ to seem to be 7#a47 t ! incision ?r\gh ! sk9 %\ld ext5d q up to ! level ( ! articulation2 7#b47 t ! bone %\ld be sawn ?r\gh at ! o!r side ( ! tum\r1 & freely cle>$ f all its atta*m5ts1 be=e any attempt be made at dis>ticulation1 = by means ( ! tum\r great lev]age c be atta9$1 s z to put ! muscles on ! /ret*1 & all[ !m to be safely divid$2 7#c47 t ! articulation %\ld always be ent]$ f ! front1 n f beh9d1 & ! inn] side ( ! condyle %\ld be v c>efully clean$1 ! surgeon cutt+ on ! bone s z to avoid1 if possible1 ! int]nal maxill>y art]y2 7#d47 free & e>ly division ( ! atta*m5t ( ! temporal muscle to ! coronoid process4 ,dis>ticulation ( ! entire bone has be5 v r>ely p]=m$4#aaa ,if necess>y1 x c be p]=m$ )\t any incision into ! m\?1 by "o semilun> sweep f "o articulation to ! o!r1 pass+ along ! l[] m>g9 ( ea* side ( ! body1 & j bel[ ! symphysis ( ! *94 ,dis>ticulation ( ! ,ramus )\t op5+ into ! cavity ( ! ,m\?4--,t ?is op]ation is possible1 ?\gh x may n be (t5 requir$1 is %[n by ! foll[+ case by ,mr4 ,syme4 ,x 0 a tum\r ( ! ramus1 ext5d+ only z f> =w>ds z ! wisdom-too?3-- ,an incision 0 made f ! zygomatic ar* d[n along ! po/]ior m>g9 ( ! ramus1 slightly curv$ ) its convexity t[>ds ! e>1 to a little way beyond ! base ( ! jaw4 ,! p>otid gl& & masset] muscle be+ dissect$ (f ! jaw1 x 0 divid$ by cutt+-pli]s imm$iately beh9d ! wisdom-too?1 aft] be+ not*$ ) a saw4 ,! ramus 0 !n seiz$ by a /rong pair ( too?-=ceps1 & not)/&+ /rong po/]ior atta*m5ts1 0 drawn outw>ds1 its muscul> connections divid$ & turn$ out entire4 ,!re 0 ?us no w\nd ( ! muc\s membrane ( ! m\?1 ! masset] & pt]ygoid muscles 7 n completely divid$1 & ! facial art]y 0 intact4#aab ,f]gusson#aac holds t ev5 ! v l>ge/ tum\rs ( ! l[] jaw may be successfully remov$ )\t op5+ into ! orifice ( ! m\? at all by division ( ! lips4 ,a l>ge lunat$ incision bel[ ! l[] m>g9 ( ! bone1 ) its ends ext5d+ upw>ds to )9 half an in* ( ! lips1 w give free access1 & yet avoid bo? hmorrhage & de=mity1 z ! labial art]y & ve9 are n cut1 & !re is no tr\ble 9 readju/+ ! lips4 ,"s tum\rs ( l[] jaw c be remov$ )\t any w\nd ( sk94 ,,footnotes3 #ajg ,diagram ( op]ations on ! jaws3--,a1 incision = removal ( ! :ole upp] jaw2 ,b1 incision = removal ( alveol> portion & antrum2 ,c1 incision = remov+ ! l>g] half ( l[] jaw2 ! opposite side is ! "o suppos$ to be op]at$ on1 & ! incision is cross+ ! symphysis & turn+ up at a "r angle4 #ajh ,op]ative ,surg]y1 p4 #bfe4 #aji ,lancet1 ,july #a1 #ahfe4 #aaj ,tempor>y compression ( ! facial c be easily manag$1 9 cases :]e x is ( mu* importance to avoid loss ( blood1 by pass+ a ne$le f ! outside ?r\gh ! sk9 above ! vessel1 !n "u ! vessel1 & out aga9 ?r\gh ! sk9 bel[4 ,a figure-(-eight suture c !n be ?r[n r\nd bo? ends ( ! ne$le1 & ! art]y ?us ?or\ghly compress$4 #aaa ,syme1 ,contributions to ! ,pa?4 & ,practice ( ,surg]y1 p4 #ba2 ,c>no*an ( ,new ,york1 ,cases 9 ,surg]y4 #aab ,contributions to ! ,pa?4 & ,prac4 ( ,surg]y1 pp4 #bc1 #bd4 #aac ,lancet1 ,july #a1 #ahfe4 ,,*apt] ,,viii4 ,,op]ations ,,on ,,m\? ,,& ,,?roat4 ,,saliv>y ,,fi/ula1 ,op]ation =4--,aft] a w\nd or abscess ( ! *eek1 9 :i* ! p>otid duct is implicat$1 a saliv>y fi/ula is v apt to rema94 ,! saliva ?us dis*>ges 9 ! *eek1 giv+ rise to consid]able annoyance1 z well z injury to ! dige/ion4 ,x is by no means easy to cure ?is4 ,p]haps ! be/ op]ation is ! "o ( :i* a rude diagram is giv5 7,fig4 ,,xxviii474 ,! duct 7,c7 communicates ) ! fi/ula 7,d74 ,"o end ( a ?read1 ei!r silk5 or metallic1 %\ld be pass$ ?r\gh ! fi/ula1 & !n z f> backw>ds z conv5i5t ?r\gh ! *eek into ! m\?2 ! ne$le %\ld !n be )drawn1 ! ?read be+ left 94 ,! o!r end be+ ?read$ %\ld !n be re-ins]t$ at ! fi/ula1 & c>ri$ =w>ds 9 a simil> mann]2 ! ne$le %\ld be aga9 un?read$ 9 ! m\? & )drawn2 ! two ends %\ld !n be ti$ pretty tightly inside1 & all[$ to make _! way by ulc]ation into ! cavity ( ! m\?4 ,a passage w ?us be obta9$ = ! saliva into ! m\?1 & e possible precaution %\ld be tak5 to enable ! ext]nal w\nd to close4 ,illu/ration3 ,,fig4 ,,xxviii4#aad ,,excision ,,( ,,! ,,tongue1 = malignant disease ( ! organ1 may be ei!r complete or p>tial4 ,complete excision af=ds a hope ( p]man5t & complete relief f ! disease1 b x is an op]ation ( extreme difficulty & dang]4 ,x may be p]=m$ 9 ei!r ( ! foll[+ me?ods4 ,! fir/ is ! only "o 9 :i* absolute complet5ess ( removal is insur$4 #a4 ,syme's me?od ( excision4--,! pati5t be+ seat$ on a *air1 *lor(orm 0 n adm9i/]$1 s t ! blood might escape =w>ds1 & n pass into ! ph>ynx4 ,! op]ation is ?us describ$3#aae-- ,hav+ extract$ "o ( ! front incisors1 ,i cut ?r\gh ! middle ( ! lip & cont9u$ ! incision d[n to ! os hyoides1 !n saw$ ?r\gh ! jaw 9 ! same l9e1 & ins9uat+ my f+] "u ! tongue z a guide to ! knife1 divid$ ! muc\s l9+ ( ! m\?1 toge!r ) ! atta*m5t ( ! g5io-hyoglossi4 ,:ile ! two halves ( ! bone 7 held ap>t1 ,i dissect$ backw>ds1 & cut ?r\gh ! hyoglossi1 along ) ! muc\s membrane cov]+ !m1 s z to all[ ! tongue to be pull$ =w>d1 & br+ into view ! situation ( ! l+ual art]ies1 :i* 7 cut & ti$1 fir/ on "o side1 & !n on ! o!r4 ,! process might n[ h be5 at once complet$1 _h ,i n fe>$ t ! epiglottis might be implicat$ 9 ! disease1 :i* ext5d$ beyond ! rea* ( my f+]1 & ?us suff] injury f ! knife if us$ )\t a guide4 ,i !re=e cut away ab\t two-?irds ( ! tongue1 & !n be+ able to rea* ! os hyoides ) my f+]1 reta9$ x !re :ile ! rema9+ atta*m5ts 7 divid$ by ! knife 9 my o!r h& close to ! bone4 ,"s small art]ial bran*es hav+ be5 ti$1 ! edges ( ! w\nd 7 br\ght toge!r & reta9$ by silv] sutures1 except at ! l[e/ "p1 :]e ! ligatures 7 all[$ to ma9ta9 a dra9 = ! dis*>ge ( fluids f ! cavity4 ,! pati5t 0 able to swall[ f a dr9k+-cup ) a sp\t on ! day foll[+ ! op]ation1 & 0 able to travel upw>ds ( #bjj miles )9 f\r weeks ( ! op]ation4 #b4 ,by ! craseur4--,nunneley ( ,le$s has record$ cases 9 :i* he made a small incision ?r\gh ! sk91 & mylohyoid & g5iohyoid muscles1 & ?r\gh ?is pass$ a curv$ ne$le be>+ ! *a9 ( ! craseur completely r\nd ! base ( ! tongue4 ,9 "o case ! *a9 0 unsatisfactory1 b /rong :ipcord 0 introduc$ z x 0 )drawn1 & ti$ ) all possible =ce4 ,! organ ev5tually sl\gh$ away1 ) a cure :i* la/$ at lea/ = "s mon?s4 ,sir ,james ,paget op]ates z foll[s3-- ,! pati5t is plac$ "u ! influ5ce ( *lor(orm1 & ! m\? held widely op54 ,! tongue is !n drawn =w>ds1 ! muc\s membrane & s(t p>ts ( ! floor ( ! m\?1 includ+ ! atta*m5t ( ! g5io-hyoglossi to ! symphysis be+ divid$ close to ! bone4 ,! /eel wire ( an craseur is !n pass$ r\nd its root z l[ d[n z possible1 sl[ly tight5$1 & ! tongue ?us divid$ ?r\gh its :ole ?ickness 9 a v few m9utes4 ,! ble$+ is slight1 be+ almo/ entirely f ! p>ts cut ) ! knife4 ,recov]y has be5 rapid 9 ! record$ cases4#aaf ,to ,dr4 ,george ,bu*anan ( ,glasg[ ! cr$it is due ( ! inv5tion ( ! op]ation ( removal ( ! half ( ! tongue 9 ! m$ian l9e4 ,9 at lea/ "o in/ance ! cure aft] five ye>s is /ill p]man5t4 ,p>tial excisions ( ! tongue are z unsatisfactory 9 _! results z !y are uns\nd 9 pr9ciple1 yet _m cases pres5t !mselves1 9 :i*1 :ile ! pati5t urges "s op]ative measure = 8 relief1 ! tum\r is s limit$ z n to w>rant ! exce$+ly dang]\s op]ation ( complete excision4 ,portions may be remov$ 9 v>i\s ways3-- #a4 ,by ! knife4 ,if 9 ! apex1 by a ,v-%ap$ incision2 if 9 ! lat]al regions1 by a bold free incision ) a probe-po9t$ bi/\ry r\nd ! tum\r4 #b4 ,by ligature1 drawn z tightly z possible1 &1 if ! portion includ$ be l>ge1 9 successive portions4 #c4 ,by ! craseur4 ,mr4 ,furneaux ,jordan has remov$ ! :ole tongue ) success by means ( two craseurs work$ at ! same "t4#aag #d4 ,by ! galvano-cau/ic wire4 #e4 ,! au?or has 9 n9e cases remov$ ! affect$ half ( ! tongue by means ( ! !rmo-caut]y1 fir/ splitt+ x 9 ! middle l9e & !n cutt+ ?r\gh ! base ) a curv$ plat9um knife at a l[ r$ heat4 ,9 "o only 0 !re any tr\ble f hmorrhage1 & all made good recov]ies4 ,mr4 ,b>well has record$ 7,lancet1 #ahgi1 vol4 i47 an easy1 safe1 & comp>atively pa9less mode ( remov+ ! tongue by craseurs4 ,mr4 ,walt] ,:itehead1#aah ( ,man*e/]1 has _h a v l>ge exp]i5ce ( an op]ation devis$ by himself1 9 :i*1 aft] pull+ ! tongue well =w>d by a /r+ previ\sly introduc$ ne> its apex1 & ! m\? be+ held op5 by a gag1 he deta*es ! organ f jaw & fauces by successive %ort snips ) scissors1 & !n 9 same mann] divides ! muscles1 ty+ or twi/+ ! vessels z !y ble$4 ,8 success has be5 v great by ?is me?od1 ?\gh o!rs :o h tri$ x h sometimes f\nd ble$+ tr\blesome4 ,x is comp>atively seldom n[ necess>y to split ! jaw & p]=m ,syme's op]ation1 & 9 all op]ations on ! tongue ! !rmocautory 7,paquel9's7 is ( great use4 ,regnoli's me?od#aai may des]ve a brief notice4 ,a semilun> incision along ! base ( ! jaw1 f "o angle to ! o!r1 deta*es ! muscles & s(t /ructures1 & is ?r[n d[n2 ! tongue is !n drawn ?r\gh ! op5+1 & c be freely dealt ) ei!r by knife or ligature4 ,aft] removal ! flap is replac$4 ,,fissures ,,9 ,,! ,,palate4--,! op]ations requisite = ! cure ( fissures 9 ! s(t & h>d palates are s complicat$ 9 _! details1 t a small treatise w\ld be requir$ ?or\ghly to describe ! v>i\s proc$ures4 ,diff]5t cases v>y s mu* 9 ! nature & am\nt ( _! de=mity1 t at lea/ five diff]5t sets ( cases h be5 describ$4 ,x is suffici5t "h m]ely to describe ! absolutely ess5tial pr9ciples ( ! op]ations = ! cure ( fissures ( ! h>d & s(t palate respectively4 ,9 all op]ations on ! palate1 two conditions us$ to be consid]$ requisite = success3--#a4 ,t ! pati5t %\ld h arriv$ at ye>s ( discretion1 at twelve or f\rte5 ye>s at lea/2 t he be possess$ ( consid]able firmness1 & be extremely anxi\s = a cure1 s z to give full & intellig5t co-op]ation4 #b4 ,t = "s days or weeks prior to ! op]ation ! m\? & palate %\ld h be5 tra9$ to op5 widely & to be> manipulation1 )\t reflex action be+ excit$4 ,pr(essor ,billro? ( ,vi5na1#abj & ,mr4 ,?omas ,smi?#aba ( ,london1 h _h cases :i* prove ! possibility ( p]=m+ ?is op]ation 9 *ildhood1 "u *lor(orm1 ) ! assi/ance1 9 ! ,engli% cases1 ( a suitable gag1 inv5t$ by ,mr4 ,smi?4 ,! effect ( ! op]ation on ! voice ( ! *ild has be5 v enc\rag+1 z mu* m improvem5t takes place ?an 9 cases :]e ! op]ation is p]=m$ late 9 life4 ,fissure 9 ! s(t palate only appe>s z a triangul> cleft1 ! apex ( :i* is above1 ! base be+ a l9e betwe5 ! po9ts ( ! bifid uvula1 :i* are widely sep>at$4 ,to cure ?is x is requir$-- #a4 ,t ! edges ( ! fissure %\ld be br\ght toge!r )\t /ra9 or tightness4 ,9 small fissures ?is c g5]ally be done easily en\gh2 b :]e ! fissure is ext5sive1 "s means mu/ be us$ to relieve t5sion4 ,= ?is1 ,sir ,william ,f]gusson long ago propos$ ! division ( ! palatal muscles1 ! levator1 t5sor1 & palato-ph>yngeus muscle ( ea* side4 ,! incisions 9 ! palate = ?is purpose c]ta9ly aid apposition1 b _m surgeons ent]ta9 d\bts :e!r ! division ( ! muscles has mu* to d ) ! good result1 & believe t ! simple incisions 9 ! muc\s membrane1 9 a prop] direction1 are all t is requir$ 7see ,fig4 ,,xxix474 ,illu/ration3 ,,fig4 ,,xxix4#abb #b4 ,t ! edges ( ! fissure be made raw1 s z to af=d surfaces :i* w readily unite4 ,complicat$ in/rum5ts1 su* z knives ( v>i\s /range %apes1 h be5 devis$ = ?is purpose2 an ord9>y cat>act knife1 v %>p1 & set on a long h&le is p]haps ! be/4 ,x greatly facilitates ! section if ! p>ts are t5se1 s ! po9t ( ! uvula %\ld be seiz$ by an ord9>y pair ( spr+ =ceps1 & drawn across ! ro( ( ! m\?1 :ile ! knife %\ld ent] 9 ! middle l9e1 a little above ! apex ( ! fissure1 & make ! cut d[nw>ds z 9 h>elip4 #c4 ,t sutures %\ld be ins]t$ to keep ! edges 9 apposition1 yet n s tightly z to cause ulc]ation4 ,!y may be ei!r ( metal1 silv] be+ pref]able1 or ( f9e silk well wax$4 ,! metallic sutures are n[ g5]ally pref]r$4 ,"s dext]ity is requir$ 9 _! introduction1 & v>i\s in/rum5ts h be5 devis$2 ! be/ seems to be a ne$le ) a %ort curve fix$ on a long h&le1 :i* %\ld be ent]$ on ! 7pati5t's7 left side ( ! fissure 9 front1 & br\ght out on ! "r side4 ,if silk sutures be us$1 ! *ief difficulty1 t ( pass+ ! ?read ?r\gh ! second side f beh9d =w>ds1 c be avoid$ 9 ! foll[+ mann]4#abc ,a curv$ ne$le is pass$ ?r\gh "o side ( ! fissure1 & !n t[>ds ! middle l9e1 till its po9t is se5 ?r\gh ! cleft4 ,"o ( ! ends ( ! ?read is !n seiz$ by a long pair ( =ceps1 & drawn ?r\gh ! cleft2 ! ne$le is !n )drawn1 leav+ ! ?read ?r\gh ! palate1 & bo? ends are br\ght outside at ! angle ( ! m\?4 ,ano!r ne$le is !n pass$ ?r\gh a correspond+ po9t at ! opposite side ( ! palate1 till its po9t aga9 appe>s at ! cleft2 ?is "t a d\ble loop ( ! ?read is also br\ght out ?r\gh ! cleft by ! =ceps into ! m\?4 ,if !n ! s+le ?read ( ! fir/ ligature :i* is 9 ! cleft be pass$ ?r\gh ! loop ( ! second "o also 9 ! cleft1 x is easy1 by )draw+ ! loop ?r\gh ! palate1 to f9i% ! /it* 7see ,fig4 ,,xxix474 ,all ! /it*es %\ld be pass$ & _! position approv$ be=e any "o be ti$1 & x is mo/ conv5i5t to secure !m f above d[nw>ds4 ,to prev5t confusion1 ea* pair ( ?reads aft] be+ ins]t$ %\ld be left v long1 & br\ght up to a coronet fix$ on ! br[1 :i* is fitt$ ) sev]al pairs ( hooks numb]$ = easy ref]5ce4 ,?is w prev5t twi/+ ( ! ?reads or any mi/ake 9 ty+4 ,,fissure ,,( ,,! ,,h>d ,,palate4--,?is may v>y 9 ext5t f a v slight cleft 9 ! middle l9e beh9d1 up to a complete sep>ation ( ! two halves ( ! jaw1 includ+ ev5 ! alveol> process 9 front1 & sometimes complicat$ ) h>elip4 ,to close su* fissures by op]ation is difficult1 z ! bread? ( ! cleft is s great z to prev5t ! apposition ( ! edges :5 prep>$1 )\t su* extreme t5sion z q prev5ts any hope ( union4 ,?r\gh ! rese>*es ( ,av]y1 ,w>r51 ,lang5beck1 & o!rs1 a me?od has be5 discov]$ ( clos+ su* fissures by op]ation1 :i*1 ?\gh c]ta9ly n easy1 is1 :5 prop]ly p]=m$1 g5]ally successful4 ,op]ation4--,9 addition to ! usual p>+ ( ! edges ( ! cleft1 an incision is made on ea* side ( ! palate1 ext5d+ f ! can9e too? 9 front to ! la/ mol> beh9d1#abd along ! alveol> ridge 7,fig4 ,,xxx474 ,! :ole flap betwe5 ! cleft & ?is incision on ea* side is !n to be rais$ f ! bone by a blunt r\nd$ in/rum5t slightly curv$4 ,) ?is ! :ole muc\s membrane & z mu* ( ! p]io/eum z possible %\ld be completely rais$ f ! bone1 atta*m5ts = n\ri%m5t ( ! flap be+ left 9 front & beh9d :]e ! vessels ent]4 ,illu/ration3 ,,fig4 ,,xxx4#abe ,! flaps ?us rais$ w be f\nd to come toge!r 9 ! middle l9e1 sometimes ev5 to ov]lap1 &1 :5 unit$ by suture1 =m a new palate at a l[] level ?an ! fissure1 exp]i5ce hav+ %[n t 9 cases ( fissure ! ar* ( ! palate is always mu* high] ?an usual4 ,! flaps d n sl\gh1 be+ well suppli$ ) blood1 unless !y h be5 injur$ 9 _! sep>ation4 ,! edges mu/ be c>efully unit$ by v>i\s po9ts ( metallic suture1 & ! fissure ( ! s(t palate clos$ at ! same sitt+1 unless ! pati5t has lo/ mu* blood1 or is v mu* exhau/$ ) ! pa94 ,! /it*es may be left 9 = a week1 or ev5 t5 days1 unless !y are excit+ mu* irritation4 ,! pati5t mu/ ex]cise great self-control & caution 9 ! "* ( 8 food & 8 mann] ( eat+ = t5 days or a =tnight aft] ! op]ation4 ,,excision ,,( ,,tonsils4--,to remove ! :ole tonsil is ( c\rse impossible 9 ! liv+ body1 ! op]ation to :i* ! "n ( excision is giv5 be+ only ! %av+ (f ( a r$undant & project+ portion4 ,:5 prop]ly p]=m$ x is a v safe1 & 9 adults a v easy op]ation1 b 9 *ildr5 x is sometimes r5d]$ exce$+ly difficult by _! /ruggles1 comb9$ ) ! movem5ts ( ! tongue & ! insuffici5t access ?r\gh ! small m\?4 ,_m in/rum5ts h be5 devis$ = ! purpose ( at once transfix+ & excis+ ! project+ portion2 "s ( !m are v +5i\s & complicat$4 ,by f> ! be/ & safe/ me?od ( remov+ ! r$undant portion is to seize x ) a volsellum1 & !n cut x (f by a s+le /roke ( a probe-po9t$ curv$ bi/\ry2 cutt+ f above d[nw>ds1 & be+ c>eful to cut p>allel ) ! great vessels4 ,! ord9>y volsellum is mu* improv$ = ?is purpose by ! addition ( a ?ird hook 9 ea* tonsil plac$ betwe5 ! o!rs1 ) a %ort] curve1 & slightly %ort]2 ?is ensures ! safe hold+ ( ! fragm5t remov$1 & prev5ts ! risk ( its fall+ d[n ! ?roat ( ! pati5t4 ,if bo? tonsils are enl>g$ !y %\ld bo? be op]at$ on at ! same sitt+1 & ! pa9 is s slight t ev5 *ildr5 frequ5tly make little objection to ! second op]ation4 ,ble$+ is r>ely tr\blesome if ! portion be at once fairly remov$1 b if 9 ! pati5t's /ruggles ! hook %\ld slip be=e ! cut is complete1 ! p>tially deta*$ portion w irritate ! fauces1 cause c\gh+ & attempts to vomit1 & sometimes a tr\blesome hmorrhage4 ,! pl5tiful use ( cold wat] w g5]ally be suffici5t to /op ! ble$+1 ?\gh cases are on record 9 :i* ! use ( /yptics1 or ev5 ! tempor>y closure ( a ble$+ po9t by pressure1 has be5 necess>y4 ,m4 ,gu]sant has op]at$ on m ?an "o ?\s& *ildr51 ) only ?ree cases ( any tr\ble f hmorrhage1 :ile f\r or five out ( fifte5 adults requir$ ei!r ! actual caut]y or ! sesqui-*loride ( iron4#abf ,,footnotes3 #aad ,r\gh diagram ( op]ation = saliv>y fi/ula3--,a1 section ( *eek close to buccal orifice2 ,b1 section ( zygoma1 muscles1 etc42 ,c1 ! duct ( ! p>otid2 ,d1 ! fi/ul\s op5+ ( ! *eek2 ,e ,e1 ! ?read knott$ inside ! m\?2 ,f1 ! palate4 #aae ,lancet1 ,feb4 #d1 #ahfe4 #aaf ,m$4 ,times & ,gazette = ,feb4 #aj1 #ahff4 #aag ,lancet1 ,april #bj1 #ahgb4 #aah ,transactions ,int]national ,m$ical ,congress1 #ahha1 vol4 ii4 p4 #dfj4 #aai ,gross's ,surg]y1 vol4 ii4 p4 #dgb4 #abj ,lang5beck1 ,ar*iv1 ii4 p4 #feg4 #aba ,m$4 ,*ir4 ,trans4 = #ahfg-h4 #abb ,diagram ( /aphyloraphy1 *iefly to illu/rate ! pass+ ( ! ?reads3--a1 ! fir/ ?read2 b1 ! second4 ,! dott$ l9e at edge ( fissure %[s am\nt to be remov$2 ! o!r dott$ l9es %[+ size & position ( ! incision ?r\gh ! muc\s membrane above4 #abc ,holmes's ,surg]y1 vol4 ii4 pp4 #ejd-eac4 #abd ,ed9burgh ,m$ical ,j\rnal = ,jan4 #ahfe1 ,mr4 ,ann&ale's in/ructive pap] on ,cleft ,palate4 #abe ,diagram ( fissure ( h>d palate3--a1 ant]ior palat9e =am9a2 b1 po/]ior palat9e =am9a ) groove = art]y2 c1 incisions requisite to free ! s(t /ructures4 #abf ,holmes's ,diseases ( ,*ildr51 p4 #eee4 ,,*apt] ,,ix4 ,,op]ations ,,on ,,air ,,passages4 ,,op]ations ,,on ,,! ,,l>ynx ,,& ,,tra*ea4--,! great air passage may be op5$ at ?ree diff]5t situations1 & to ! op]ations at ^! diff]5t places ! foll[+ names h be5 giv53-- ,l>yngotomy1 :5 ! op5+ is made 9 ! int]val betwe5 ! cricoid & ?yroid c>tilages1 ?r\gh ! crico-?yroid membrane4 ,l>yngo-tra*eotomy1 :5 ! cricoid c>tilage & ! upp] r+ ( ! tra*ea are divid$4 ,tra*eotomy1 :5 ! tra*ea itself is op5$ by ! division ( two1 ?ree1 or m r+s4 ,( ^! ! la/1 tra*eotomy1 is by f> ! mo/ frequ5t1 important1 difficult1 & dang]\s1 & requires a v detail$ description4 ,*assaignac#abg says ! only really rational op]ation = ! op5+ ( ! air passages by ! surgeon is tra*eotomy4 ,,tra*eotomy4--,anatomy4--,betwe5 ! cricoid c>tilage & ! level ( ! upp] bord] ( ! /]num1 ! middle l9e ( ! neck is occupi$ by ! upp] portion ( ! tra*ea4 ,its dep? f ! surface v>ies1 gradually increas+ z ! tra*ea desc5ds1 & v>y+ v mu* accord+ to ! fatness1 muscul>ity1 & l5g? ( ! neck4 ,x is1 h[ev]1 almo/ subcutane\s at ! comm5cem5t bel[ ! cricoid1 & on ! level ( ! /]num x is 9 mo/ cases at lea/ an in* f ! surface1 9 _m mu* deep]4 ,aga91 its l5g? v>ies1 ev5 9 ! adult1 f two & a half to ?ree1 or ev5 f\r in*es4 ,?is is important1 z affect+ ! simplicity ( ! op]ation1 :i*1 z a rule1 is easi] ! long] ! neck is4 ,! tra*ea has mo/ important & complicat$ anatomical relations--"s con/ant1 o!rs irregul>4 #a4 ,! c>otid art]ies & jugul> ve9s lie at ei!r side1 b1 :]e ^! are regul> 9 _! di/ribution1 d n practically int]f]e 9 a well-conduct$ op]ation4 #b4 ,! ?yroid gl& lies 9 close relation to ! tra*ea1 "o lobe be+ at ea* side 7,fig4 ,,xxxi4 ,b ,b71 & ! i/hmus ( ! ?yroid crosses ! tra*ea j ov] ! second & ?ird c>tilag9\s r+s4 ,9 fat vascul> necks1 or :]e ! ?yroid is enl>g$ x may occupy a mu* l>g] portion ( ! tra*ea4 ,! position ( ! i/hmus practically divides ! tra*ea into two portions 9 :i* x is possible to p]=m tra*eotomy4 ,bo? h _! advocates1 b ! balance ( au?ority t5ds to support ! op]ation bel[ ! ?yroid4 ,a sep>ate notice ( ea* w be requir$ imm$iately4 ,illu/ration3 ,,fig4 ,,xxxi4#abh #c4 ,! muscles 9 relation to ! tra*ea are ! /]no-hyoid & /]no-?yroid ( ea* side4 ,! latt] are ! broade/1 are 9 close contact across ! tra*ea by ! inn] edges bel[1 b gradually div]ge z !y asc5d ! neck4 ,9 ?ick-set1 muscul> necks1 h[ev]1 !y are 9 close contact = a consid]able di/ance1 & require to be sep>at$ to give access to ! tra*ea4 ,! art]ies are 9 mo/ cases unimportant2 no nam$ bran* ( any size ought to be divid$ 9 ! op]ation4 ,h[ev]1 occasionally v free ble$+ may result f ! division ( an abnormal ?yroidea ima runn+ up ! tra*ea to ! ?yroid body f ! innom9ate1 or ev5 f ! aorta itself4 ,! ve9s are v num]\s & irregul>ly di/ribut$4 ,!re is g5]ally a l>ge transv]se communicat+ bran* betwe5 ! sup]ior ?yroid ve9s j above ! i/hmus4 ,! i/hmus itself has a l>ge v5\s plexus ov] x4 ,bel[ ! i/hmus ! ve9s conv]ge into "o trunk 7or sometimes two p>allel ones7 ly+ "r 9 front ( ! tra*ea4 #d4 ,! la/ anatomical po9t :i* may give tr\ble 9 normal necks is ! ?ymus1 :i* is pres5t 9 *ildr5 bel[ ! age ( two1 & cov]s ! l[] end ( ! tra*ea j above ! level ( ! /]num4 ,:]e ?is is n only n dim9i%$1 b enl>g$1 z x sometimes is 9 unheal?y *ildr51 x may give a v great deal ( tr\ble1 roll+ out at ! w\nd & greatly emb>rass+ proce$+s4 ,abnormalities are v v>i\s & sometimes v dang]\s3 vessels cross+ ! tra*ea1 z ! innom9ate did 9 ,macilwa9's case1#abi or :]e two bra*iocephalic trunks are pres5t1 z record$ by ,*assaignac4#acj ,"o ( ! mo/ frequ5t dang]s to be gu>d$ aga9/ is a possible dilatation ( ! aorta or aneurism ( ! ar*4 ,?is may v possibly1 z happ5$ 9 "o case to ! au?or1 give rise to suffocative p>oxysms f its pressure on ! recurr5t l>yngeal n]ves4 ,tra*eotomy may be deem$ necess>y1 & !re is a great risk1 unless prop] precautions be tak51 ( w\nd+ ! aorta1 :]e x passes upw>ds 9 ! jugul> fossa4 ,9 ! au?or's case ! vessel _h actually to be pu%$ d[nw>ds by ! pulp ( ! =ef+] :ile ! tra*ea 0 op5$1 ! knife be+ guid$ on ! back ( ! nail ( ! same f+]4 ,,! ,,op]ation4--,9 a "w ( ?is k9d x w\ld be utt]ly impossible to g at all into ! subject ( :at diseases1 injuries1 etc41 w>rant or require ! op]ation4 ,x is en\gh to describe ! v>i\s me?ods ( op]at+1 _! dang]s & difficulties4 #a4 ,! op]ation above ! i/hmus ( ! ?yroid4--,a spot ab\t a qu>t] or half ( an in* 9 v]tical diamet] betwe5 ! cricoid c>tilage 7,fig4 ,,xxxi47 & ?yroid i/hmus4 ,advantages4--,x is ne> ! surface1 ! vessels are few & comp>atively small4 ,x is mo/ suitable 9 cases ( aneurism4 ,pr(essor ,sp5ce#aca gives 8 sanction to ! high op]ation 9 adults ) ?ick %ort necks :5 ! op]ation is p]=m$ = ulc]ation or papilloma ( l>ynx or = spasm f aneurism1 ! l[ op]ation be+ /ill be/ 9 cases ( cr\p or diph!ria4 ,disadvantages4--,! space is too small1 requires v consid]able di/urbance ( ! ?yroid i/hmus1 or actual division ( x4 ,x is too ne> ! po9t :]e ! disease is2 s mu* s1 t 9 mo/ cases ( cr\p or diph!ria x w\ld be p]fectly useless4 ,h[ev]1 if requir$1 or if ! op]ation l[] d[n be contra-indicat$1 ?is may be p]=m$ easily en\gh4 ,a /raight incision be+ made 9 ! middle l9e ab\t "o in* & a half 9 l5g?1 expose ! upp] r+ by c>eful dissection1 if possible draw aside ! ve9s1 & depress ! ?yroid i/hmus1 divide ! r+s ?us expos$1 & introduce ! tube4 ,! op]ation bel[ ! i/hmus4--,?is1 ?\gh m difficult 9 its p]=mance1 is a mu* m sci5tific & satisfactory op]ation4 ,consid]able coolness & a ?or\gh k ( ! anatomy ( ! "p are absolutely requir$4 ,! pati5t be+ 9 ! recumb5t po/ure1 ! %\ld]s %\ld be well rais$1 & ! head held back s z to ext5d ! w9dpipe1 & ?us br+ x z ne> z possible to ! surface4 ,a pill[1 or ! arm ( an assi/ant1 beh9d ! neck w be ( s]vice4 ,n4,b4--,be c>eful le/ too great ext5sion by an anxi\s assi/ant1 accompani$ by closure ( ! m\?1 %\ld *oke ! pati5t 7^: brea?+ is ( c\rse already mu* emb>rass$7 be=e ! op]ation be begun4 ,*lor(orm may occasionally be giv51 &1 if well borne1 r5d]s ! op]ation v mu* easi] ?an x w\ld o!rwise be4 ,an incision mu/ !n be made exactly 9 ! m$ian l9e ( ! neck1 f a little bel[ ! cricoid c>tilage1 almo/ to ! upp] edge ( ! /]num2 at fir/ x %\ld be ?r\gh sk9 only1 !n ! ve9s w be se51 probably turgid ) d>k blood2 ! l>g] ones %\ld be drawn aside1 if necess>y divid$1 ! ble$+ /opp$ by g5tle pressure4 ,! deep fascia mu/ !n be cauti\sly divid$1 great c>e be+ tak5 to keep exactly 9 ! middle l9e1 & ! contigu\s edges ( /]no-?yroid muscles sep>at$ f ea* o!r by ! h&le ( ! knife4 ,a quantity ( loose connective tissue1 conta9+ num]\s small ve9s1 mu/ n[ be pu%$ aside1 ! ?yroid i/hmus press$ upw>ds1 /ill ) ! h&le ( ! knife4 ,! =ef+] mu/ !n be us$ to di/+ui% ! r+s ( ! tra*ea4 ,if !re is mu* convulsive movem5t ( ! l>ynx & tra*ea1 !y %\ld be fix$ by ! ins]tion ( a small %>p hook ) a %ort curve1 j bel[ ! cricoid c>tilage1 & ?is %\ld be confid$ to an assi/ant4 ,! surgeon %\ld !n1 ) ! =ef+] ( 8 left h&1 fix ! tra*ea1 & op5 x by a /raight %>p-po9t$ scalpel1 boldly ?ru/+ x ?r\gh ! r+s ) a j]k or /ab1 ! back ( ! knife be+ bel[1 & divide two or ?ree ( ! r+s f bel[ upw>ds4 ,any attempt to ent] ! tra*ea sl[ly ) a blunt knife or troc> w probably be unsuccessful1 z ! r+s1 especially 9 *ildr51 give way be=e ! knife1 :i* m]ely approximates ! sides ( ! tra*ea )\t op5+ x4 ,"q ( ,hmorrhage4--,x is (t5 a "q ( "s importance1 & "o :i* sometimes x is n easy to settle1 h[ f> attempts %\ld be made completely to arre/ ! v5\s hmorrhage be=e op5+ ! tra*ea4 ,on ! "o h&1 if n arre/$1 besides ! risk ( weak5+ ! pati5t1 we h to dread ! mu* m s]i\s complication ( ! admission ( blood into ! w\nd4 ,& ?is is v s]i\s 9 a pati5t ^: respiration has already be5 mu* imp$$1 ^: lungs are probably engorg$1 & :o has c]ta9ly1 by ! m]e exi/5ce ( a w\nd 9 8 tra*ea1 lo/ ! p[] ( c\gh+ prop]ly2 x mu/ nev] be =gott5 t a quantity ( blood s trifl+ z to be at once eject$ by a s+le c\gh 9 ! case ( a heal?y *e/1 may be a fatal ob/acle to respiration 9 "o already weak5$ by disease4 ,?us any well-m>k$ art]ial hmorrhage f cut bran*es1 or f ! i/hmus ( ! ?yroid1 mu/ c]ta9ly be arre/$ prior to op5+ ! tra*ea4 ,besides ?is1 blood once hav+ ent]$ ! bron*i is apt to ext5d into _! small] ramifications & prove a cause ( dea?1 by act+ z a local irritation1 & sett+ up intra-lobul> suppurative pneumonia4 ,! au?or has f\nd ?is to be ! case bo? aft] tra*eotomy & /ill m frequ5tly 9 suicide by cut ?roat4 ,b1 on ! o!r h&1 x is equally true t !re is almo/ always a consid]able am\nt ( ooz+ f small v5\s radicles divid$ dur+ ! op]ation1 :i* dep5ds simply on ! great v5\s engorgem5t result+ f ! ob/ruction to ! respiration1 s t :ile to attempt to tie e po9t w\ld be simply endless1 we may be almo/ c]ta9 t ! ooz+ w cease :5ev] ! tra*ea is op5$1 & respiration fairly improv$4 ,slight pressure on ! w\nd is g5]ally suffici5t to /op ! ble$+ till ! v5\s engorgem5t has disappe>$4 ,( late ye>s _m tra*eotomies h be5 done bloodlessly by use ( ! !rmo-caut]y1 = division ( ! s(t p>ts1 b ! subsequ5t sl\gh+ ( ! w\nd is a great objection to ?is me?od4 ,9 cases ( extreme urg5cy1 all su* m9or consid]ations z suppression ( v5\s ooz+ mu/ be ignor$1 & ! tra*ea simply op5$ z rapidly z possible4 ,i _h once to p]=m ! op]ation aft] respiration _h entirely ceas$1 & no pulse c\ld be felt at ! wri/1 ) no assi/ance except t ( a female att5dant4 ,m]ely feel+ t no l>ge art]ial bran* 0 9 ! way1 ,i cut /raight ?r\gh all ! tissues1 op5$ ! tra*ea1 & comm5c$ artificial respiration4 ,! pati5t ev5tually recov]$4 ,"q ( ,tubes1 etc4--,once ! tra*ea is op5$1 ! next "q is1 ,h[ is ! op5+ to be kept p]vi\s8 ,= ! mom5t ! h&le ( ! scalpel is to be ins]t$ 9 ! w\nd1 s z to /ret* x transv]sely2 ?is w probably suffice to all[ ( ! escape ( any =eign body4 ,b :]e1 to admit air1 ! w\nd is to be kept op51 h[ is ?is to be done8 ,x us$ to be advis$ t an elliptical portion ( ! wall ( ! tra*ea be remov$2 ?is1 ?\gh succe$+ well en\gh = a "t1 0 unsci5tific1 z ! w\nd always t5d$ to cicatrise1 & end$ ( c\rse 9 p]man5t n>r[+ ( ! canal ( ! tra*ea4 ,x may be necess>y ?us to excise a portion ( ! tra*ea1 9 cases :]e x is v intol]ant ( ! pres5ce ( a tube4 ,su* a case is record$ by ,sir ,j4 ,fayr] ( ,calcutta4#acb ,n mu* bett] is ! proposal to ins]t a silk ligature 9 ea* side ( ! w\nd1 & by pull+ ^! ap>t ?us me*anically to op5 ! w\nd4 ,?is also is evid5tly a m]ely tempor>y exp$i5t4 ,v>i\s canul & tubes h be5 propos$4 ,! ones recomm5d$ by ! old] surgeons _h all "o great fault2 !y 7 mu* too small1 & 7 _m ( !m /raight1 & ?us liable to displacem5t4 ,! smallness ( _! bore 0 _! greate/ objection1 & ,mr4 ,li/on conf]r$ a great b5efit on surg]y by 8 insi/+ ^u ! introduction ( tubes ) a l>g] bore1 & ) a prop] curve1 s z ?or\ghly to ent] ! tra*ea4 ,! tube ought to be l>ge en\gh to admit all ! air requir$ by ! lungs1 )\t hurry+ ! respiration 9 ! lea/4 ,!re is a mi/ake made 9 ! con/ruction ( _m ( ! tubes ev5 ( ! pres5t day2 ! out] op5+ is l>ge & full1 :ile = conv5i5ce ( ins]tion ! tube tap]s d[n to an inn] op5+1 admitt+ p]haps n "o-half z mu* air z ! out] "o does4 ,x mu/ be rememb]$ t = "s days !re is great risk ( ! tube becom+ occlud$1 by fro?y blood or mucus1 especially 9 cases ( cr\p1 & 9 *ildr54 ,to prev5t ?is a d\ble canula w be f\nd ( great s]vice1 provid+ only t x be rememb]$ t ! inn] canula1 n ! out] m]ely1 is to be made l>ge en\gh to brea! ?r\gh1 & t ! inn] %\ld project slightly beyond ! out] "o4 ,! inn] "o c ?us be remov$ at int]vals & cleans$1 by ! nurse1 )\t any risk ( excit+ spasm or dyspnoea by its abs5ce & re9troduction4 ,aft]-treatm5t4--,! aft]-treatm5t ( a case 9 :i* tra*eotomy has be5 p]=m$ dem&s great c>e & _m precautions4 ,= ! fir/ day or two ! con/ant pres5ce ( an exp]i5c$ nurse or /ud5t is always necess>y to insure ! pat5cy ( ! tube4 ,! temp]ature ( ! room %\ld be equable & high1 & x seems ( importance t ! air %\ld be kept moi/ z well z w>m by ! use ( abundance ( /eam4 ,a piece ( ?9 gauze1 or o!r light protective mat]ial1 %\ld be plac$ ov] ! m\? ( ! tube1 to prev5t ! entrance ( =eign bodies4 ,9 cases :]e ! op]ation has be5 p]=m$ = "s tempor>y inflammatory closure ( ! air passage1 ret5tion ( ! tube = a few days may suffice4 ,x may !n be remov$1 b x mu/ be rememb]$ t ! w\nd w g5]ally close ) great rapidity1 s t x is z well to be q sure ( ! pat5cy ( ! natural passage be=e ! artificial "o is all[$ to close by ! removal ( ! tube4 ,9 cases :]e f long-/&+ disease or sev]e accid5t ! l>ynx is r5d]$ totally unfit = "w1 & ! tube has to be worn dur+ ! re/ ( ! pati5t's life1 c>e mu/ be tak5 7#a47 le/ ! tube d n fit accurately1 9 :i* case x may ulc]ate 9 v>i\s directions1 ev5 into ! great vessels2#acc 7#b47 le/ ! tube become worn1 & le/ ! "p )9 ! w9dpipe fall into ! tra*ea & suffocate ! pati5t4#acd ,,l>yngotomy4--,z a tempor>y exp$i5t 9 cases ( great urg5cy1 :]e prop] in/rum5ts & assi/ants are n at h&1 l>yngotomy is occasionally useful1 ?\gh f ! want ( space )\t encroa*+ on ! c>tilages ( ! l>ynx1 & f its close proximity to ! disease1 l>yngotomy is by no means a suitable or p]man5tly successful op]ation4 ,9 ! adult1 especially 9 males ) long sp>e necks1 ! op]ation itself is exce$+ly easy to p]=m4 ,! crico-?yroid space 7,fig4 ,,xxxi4 ,a7 is s di/9ctly %[n by ! prom95ce ( ! ?yroid c>tilage1 & is s sup]ficial t x is q easy to op5 x 9 ! middle l9e ) a common p5knife1 !re be+ m]ely ! sk9 & ! crico-?yroid membrane to be cut ?r\gh1 ) v r>ely any vessel ( any size4 ,! op5+ c !n be kept pat5t by a quill or a small piece ( flat wood4 ,?is simple op]ation has 9 _m cases1 :]e a =eign body has fill$ up ! box ( ! l>ynx1 succe$$ 9 sav+ life1 & ev5 9 cases ( disease ,i h kn[n x useful 9 giv+ "t = ! subsequ5t p]=mance ( tra*eotomy4 ,easy z x appe>s & really is1 cases are on record 9 :i* ! ?yro-hyoid space has be5 op5$ in/ead ( ! crico-?yroid1 su* op]ations be+ ( c\rse p]fectly useless4 ,! incision is be/ made transv]sely4 ,,l>yngo-,,tra*eotomy4--,?is modification consi/s 9 op5+ ! air passage by ! division ( ! cricoid c>tilage v]tically 9 ! middle l9e1 along ) "o or two ( ! upp] r+s ( ! tra*ea4 ,x seems to comb9e all ! dang]s ) none ( ! advantages ( ! o!r me?ods ( op]at+4 ,x is close to ! disease1 involves cutt+ a c>tilage ( ! l>ynx1 & almo/ c]ta9 w\nd+ ( ! i/hmus ( ! ?yroid2 & x is n easy to see :at correspond+ advantages x has ov] tra*eotomy 9 ! usual position4 ,,?yrotomy is an op]ation by :i* ! l>ynx is op5$ 9 ! middle l9e by a v]tical incision1 & its halves sep>at$1 :ile any morbid gr[?s are excis$ f ! cords or v5tricles4 ,! m]its & dang]s ( ?is op]ation h be5 discuss$ at l5g? by ,mr4 ,durham#ace & ,dr4 ,morell ,mack5zie4#acf ,,l>yngectomy ,,or ,,excision ,,( ,,! ,,l>ynx1 fir/ p]=m$ by ,dr4 ,h]on ,watson 9 #ahff1 has be5 lately frequ5tly p]=m$ = c>c9oma & s>coma4 ,ea* case pres5ts its own difficulties1 :i* v>y accord+ to ! am\nt & ext5t ( ! disease = :i* x is done4 ,! tra*ea mu/ be divid$ & tampon$ by a ,tr5del5burg canula1 aft] :i* ! l>ynx mu/ be c>efully dissect$ out4 ,! imm$iate mortality1 i4e4 9 fir/ t5 days1 is fifty p] c5t41 & ,dr4 ,gross holds t life has n be5 prolong$ by ! op]ation4#acg ,,oesophagotomy4--,?is op]ation is v r>ely requir$1 & has z yet be5 p]=m$ only = ! removal ( =eign bodies impact$ 9 ! oesophagus1 & int]f]+ ) respiration & deglutition4 ,to cut ^u ! flaccid empty oesophagus 9 ! liv+ body w\ld be an extremely difficult & dang]\s op]ation1 f ! mann] 9 :i* x lies conceal$ beh9d ! l>ynx1 & 9 close contact ) ! great vessels4 ,:5 x is di/5d$ by a =eign body1 & specially if ! =eign body has well-m>k$ angles1 ! op]ation is n ne>ly s difficult4 ,x has n[ be5 p]=m$ 9 =ty-?ree cases at lea/1 ( :i* eight or n9e h prov$ fatal4 ,sev51 along ) ano!r 9 :i* he himself p]=m$ x ) success1 7 record$ by ,mr4 ,cock ( ,guy's ,hospital4#ach ,?ree o!rs 7 p]=m$ by ,mr4 ,syme1 ) a successful result4 ,( ! sev5 cases collect$ by ,mr4 ,cock only two di$1 "o ( pneumonia1 ! o!r ( gangr5e ( ! ph>ynx4 ,op]ation4--,unless !re is a v decid$ projection ( ! =eign body on ! "r1 ! left side ( ! neck %\ld be *os51 z ! oesophagus normally lies r on ! left ( ! middle l9e4 ,an incision simil> to t requir$ = ligature ( ! c>otid above ! omohyoid %\ld be made ov] ! inn] edge ( ! /]no-ma/oid muscle2 ) x z a guide1 ! omohyoid may be s\ght & drawn d[nw>ds & inw>ds1 ! %ea? ( ! vessels expos$ & drawn outw>ds1 ! l>ynx slightly pu%$ across to ! "r1 ! ?yroid gl& drawn out ( ! way by a blunt hook1 ! sup]ior ?yroid ei!r avoid$ or ti$4 ,! oesophagus is !n expos$1 & if ! =eign body is l>ge1 x is easily recognis$2 if ! =eign body be small1 a l>ge probang ) a globul> ivory head %\ld !n be pass$ f ! fauces d[n to ! ob/ruction2 ?is w di/5d ! walls ( ! oesophagus1 & make x a mu* m easy & safe bus9ess to divide !m to ! requir$ ext5t4 ,! w\nd 9 ! oesophagus %\ld be longitud9al1 & at fir/ n l>g] ?an is requir$ to admit ! f+]1 on :i* z a guide ! =ceps may be introduc$ to remove ! =eign body1 or1 if necess>y1 a probe-po9t$ bi/\ry /ill fur!r to dilate ! w\nd4 ,= "s days or ev5 weeks ! pati5t mu/ be f$ ?r\gh an ela/ic ca!t] introduc$ ?r\gh ! nose & reta9$1 or by an ord9>y /oma*-tube ?r\gh ! m\?4 ,9 introduc+ ! latt] !re is always a risk ( op5+ ! w\nd4 ,no special sutures = ! w\nd 9 ! oesophagus are requir$1 nor is x advisable too closely to sew up ! ext]nal w\nd4 ,,footnotes3 #abg ,leons sur la ,tra*otomie1 p4 #aj4 #abh ,r\gh diagram ( l>ynx & tra*ea3--,a1 crico-?yroid space1 l>yngotomy2 ,b ,b1 dott$ outl9e ( ?yroid i/hmus & lobes1 def9es ! upp] & l[] positions = tra*eotomy2 ,c1 ?yroid--,d1 cricoid c>tilages2 ,e1 dott$ outl9e ( ?ymus gl& 9 *ild ( two ye>s2 ,f ,f1 outl9e ( clavicles & jugul> fossa4 #abi ,surgical ,obs]vations1 p4 #cce4 ,see also ,h>rison ,on ! ,art]ies1 vol4 i4 p4 #af4 #acj ,leons sur la ,tra*otomie1 p4 #i4 #aca ,lectures on ,surg]y1 #c;d ed41 vol4 ii4 p4 #ijj4 #acb ,cl9ical ,surg]y 9 ,india 7#ahff71 p4 #adc4 #acc ,mr4 ,john ,wood1 ,pa?4 ,soc4 ,trans41 vol4 xi4 p4 #bj4 #acd ,s\?'s ,*elius1 vol4 ii4 p4 #djj2 & case record$ by ,sp5ce1 9 ,ed4 ,m$4 ,j\rnal1 = ,augu/ #ahfb4 #ace ,m$4 ,*ir4 ,transactions ( ,london1 #ahgb4 #acf ,briti% ,m$4 ,j\rnal 7,nos4 #fdc1 #fdd71 #ahgc4 #acg ,gross's ,surg]y1 #f? ed41 vol4 ii4 p4 #cdb4 #ach ,guy's ,hospital ,reports = #aheh4 ,,*apt] ,x4 ,,op]ations ,,on ,,?orax4 ,,excision ,,( ,,mamma4--,:5 ! :ole brea/ is to be remov$1 two incisions1 inclos+ an elliptical portion ( sk9 along ) ! nipple1 mu/ be made 9 ! direction ( ! fibres ( ! pectoralis muscle4 ,! di/ance betwe5 ! incisions at _! broade/ mu/ dep5d ^u ! nature ( ! disease = :i* ! op]ation is p]=m$1 & ! ext5t to :i* ! sk9 is involv$2 9 e case ! :ole nipple %\ld be remov$4 ,! incisions %\ld1 if possible1 be p>allel ) ! fibres ( ! pectoralis major1 & ext5d across ! full diamet] ( ! brea/4 ,dur+ ! op]ation ! arm %\ld be ext5d$ s z to /ret* bo? sk9 & muscle4 ,! l[] flap %\ld be fir/ rais$ & dissect$ d[nw>ds1 ) c>e t ! cuts are made 9 ! subcutane\s fat1 & wide ( ! disease2 ! upp] flap is !n ?r[n op51 & ! edge ( ! gl& rais$1 s t ! fibres ( ! pectoralis are expos$ bel[ x4 ,^! %\ld be cleanly dissect$1 s z to insure removal ( ! :ole gl&4 ,any ble$+ dur+ ! op]ation c easily be *eck$ by ! f+]s ( an assi/ant1 & if ! art]ies ent]+ ! gl& f ! axilla be divid$ la/1 !y c be at once secur$4 ,if !re are _m ble$+ po9ts1 ! application ( cold = a few h\rs be=e ! w\nd is f9ally clos$ is a wise precaution4 ,! requisite /it*es may be ins]t$ :ile ! pati5t is "u *lor(orm1 b n tight5$4 ,! arm %\ld !n be br\ght d[n to ! side1 & a fold$ t[el laid ov] ! w\nd aft] x is f9ally clos$4 ,great b5efit results f ! free use ( dra9age-tubes 9 mo/ cases2 = ?is purpose a dep5d5t op5+ 9 ! l[] flap is (t5 made4 ,surgeons n[ op]ate ev5 :5 ! axill>y gl&s are diseas$1 & by a v free dissection & removal1 ev5 9 hopeless-look+ cases1 life may be prolong$4 ,to insure ! removal ( ! lymphatic vessels z well z ! gl&s1 x is be/ n to sep>ate ! brea/ at its axill>y m>g91 b keep x atta*$ by ! tail ( lymphatics surr\nd$ by fat1 :i* w lead up to ! gl&s4 ,section ( ! great pectoral muscle w aid ! dissection4 ,:5 ! tum\r is v l>ge1 & ! sk9 has be5 mu* /ret*$ & und]m9$1 m complicat$ incisions may be necess>y2 ^! mu/ be gov]n$ a good deal by ! pres5ce & positions ( adhesions or ulc]ations ( ! sk94 ,! be/ direction1 :5 ! surgeon has 8 *oice1 t ^! incisions c take1 is t ( radii f ! nipple1 bisect+ ! flaps made by ! orig9al elliptical incision4 ,n4,b4--,9 op]at+ = malignant disease1 ! "o p>am\nt consid]ation is t all ! disease be excis$1 h[ev] curi\s1 inconv5i5t1 or awkw>d1 ev5 insuffici5t1 ! flaps may look4 ,p>tial excisions are worse ?an useless4 ,,p>ac5tesis ,,?oracis1 = ! relief ( pleurisy1 acute & *ronic1 & empyema1 is an op]ation ( extreme simplicity4 ,! prop] selection ( cases1 ! settl+ ( ! suitable position = ! tapp+1 & ! *oos+ ( ! suitable "t = x1 are m difficult1 & n )9 ! scope ( ! pres5t "w4 ,on ^! subjects mu* in=mation may be obta9$ f ! pap]s ( ,dr4 ,b[dit* ( ,bo/on1 ( ,dr4 ,hughes & ,mr4 ,cock1#aci & an exce$+ly int]e/+ & valuable pap] by ,dr4 ,w>burton ,begbie4#adj ,:]e is x to be p]=m$8 ,n above ! six? rib1 else ! op5+ is n suffici5tly dep5d5t2 v r>ely bel[ ! eigh? on ! "r side1 & ! n9? on ! left4 ,! int]co/al space g5]ally bulges outw>ds if fluid is pres5t1 & ?is bulg+ acts z an aid to diagnosis4 ,z ! int]co/al art]y lies "u ! l[] edge ( ! upp] rib 9 ea* space1 ! troc> %\ld be ent]$ n high] ?an ! middle ( ! space2 & because ! art]y is l>ge/ ne> ! sp9e1 & also ! space is !re deeply cov]$ ) muscle1 ! tapp+ %\ld nev] be beh9d ! angle ( ! rib4 ,9 mo/ ( ! manuals we are told to select a spot midway betwe5 ! /]num & sp9e = ! puncture2 b ,b[dit*1 ,cock1 & ,begbie1 :o h _h l>ge exp]i5ce1 pref]1 & ,i believe rightly1 a position consid]ably beh9d ?is1 an in* or two bel[ ! angle ( ! scapula1 betwe5 ! sev5? & eigh?1 or betwe5 ! eigh? & n9? ribs4 ,! op]ation may be p]=m$ ) a simple troc> & canula1 r\nd1 ab\t an eigh? ( an in* 9 diamet]1 & at lea/ two in*es 9 l5g?4 ,! po9t mu/ be %>p1 & x mu/ be pu%$ 9 ) consid]able quickness1 s z to p5etrate1 n m]ely pu% =w>ds1 ! pleura1 :i* may be t\gh1 & ?ick] ?an usual4 ,once ! sk9 is pi]c$1 ! in/rum5t mu/ be direct$ obliquely upw>ds1 s z to make ! op5+ & position ( ! troc> dep5d5t4 ,:5 ! troc> is )drawn ! fluid may be all[$ to fl[ s long z x keeps 9 a full equable /ream2 :5ev] x becomes j]ky & spasmodic1 ! canula %\ld be remov$ be=e ! suck+ noise ( air ent]+ ! *e/ is he>d4 ,9 m *ronic cases1 :]e ! quantity ( fluid is l>ge1 & especially if x is ?ick & curdy1 ! exhau/+ syr+e ( ,mr4 ,b[dit* is an improvem5t on ! simple troc> & canula4 ,x consi/s ( a p[]ful syr+e1 :i* fits accurately to ! troc> ) :i* ! puncture is made4 ,!re is a /op-cock betwe5 ! troc> & syr+e1 & ano!r at "r angles to ! syr+e4 ,! troc> be+ introduc$1 x is held firmly 9 position by an assi/ant1 by means ( a /rong cross h&le2 ! fir/ /op-cock is !n op5$1 & ! syr+e work$ sl[ly till x is fill$ ) fluid ?r\gh ! troc>1 ! o!r deliv]y /op-cock be+ clos$4 ,! fir/ is !n clos$1 & ! second op5$2 ! syr+e is !n empti$ ?r\gh ! second into a bas94 ,by a repetition ( ?is process1 ! fluid c be remov$ at pleasure1 )\t any risk ( ! entrance ( air4 ,dieulafoy's aspirateur1 :i* ! au?or has n[ us$ 9 a v l>ge numb] ( cases1 w be f\nd ! be/ me?od yet devis$ ( safely remov+ ! fluid 9 cases ( s]\s effusion4 ,b 9 sev]e cases ( empyema ! pus is sure to be reproduc$ 9 ! great majority1 & !n a free incision1 ) /rict antiseptic precautions1 w be ne$$1 & subsequ5t free dra9age4 ,! au?or has us$ ) great b5efit silv] tubes1 l long n>r[ tra*ea-tubes1 ) broad %ields1 to insure free dra94 ,,footnotes3 #aci ,bo? 9 ,guy's ,hospital ,reports1 second s]ies1 vol4 ii4 #adj ,ed9burgh ,m$ical ,j\rnal = ,june #ahff4 ,,*apt] ,,xi4 ,,op]ations ,,on ,,abdom54 ,,p>ac5tesis ,,abdom9is4--,to )draw fluid f ! abdom9al cavity is an exce$+ly simple op]ation 9 itself1 ?\gh c]ta9 precautions are necess>y to r5d] x safe4 ,troc>4--,! usual in/rum5t us$ to be a simple r\nd canula ) a troc>1 ! po9t ( :i* %\ld be v %>p1 & 9 ! %ape ( a ?ree-sid$ pyramid4 ,x %\ld be ab\t ?ree in*es 9 l5g?1 & a qu>t] ( an in* 9 diamet]4 ,x may = conv5i5ce h an india-rubb] tube fix$ to its side or end1 = ! purpose ( convey+ ! fluid to ! pail or bas91 b any o!r additions or alt]ations h n be5 improvem5ts4 ,lately surgeons h be5 dim9i%+ ! size ( ! tube s z to )draw ! fluid m sl[ly1 & tak+ _m precautions to insure ! w\nd be+ kept aseptic4 ,:]e to tap4--,9 ! l9ea alba1 midway betwe5 ! umbilicus & pubes1 or r ne>] ! umbilicus4 ,"h1 !re are no muscles nor vessels1 ! op5+ is a dep5d5t "o1 & ! bladd] is q out ( ! way ( injury4 ,n4,b4--,x is a wise precaution1 9 e case :]e !re is a possibility ( d\bt z to ! /ate ( ! bladd]1 to pass a ca!t]4 ,i h myself kn[n at lea/ "o case 9 :i* a surgeon 0 ask$ to tap an ov]-di/5d$ bladd]1 z a case ( ascites4 ,! ,op]ation4--,z !re is great risk ( syncope com+ on dur+ ! op]ation1 f ! sudd5 relief to ! pressure on ! organs1 a broad flannel b&age %\ld be appli$ to ! belly1 ! ends ( :i* are split into ?ree at ea* side1 & cross$ & int]lac$ beh9d4 ,an assi/ant %\ld /& at ea* side to make gradual pressure by pull+ on ! ends ( ! b&age1 ?us assi/+ ! fl[1 & ma9ta9+ ! pressure4 ,a hole %\ld be cut 9 ! b&age at ! spot :]e ! puncture is to be made1 & ! troc> ins]t$ by "o firm pu%1 )\t any prelim9>y incision1 unless ! pati5t is inord9ately fat4 ,z ! troc> is )drawn1 ! canula %\ld be pu%$ /ill fur!r 94 ,! surgeon %\ld be ready at once to close ! canula ) 8 ?umb1 if ! fl[ beg9s to cease1 le/ air %\ld be admitt$4 ,if ! fl[ ceases f any cause be=e all ! fluid seems to be evacuat$1 ! troc> %\ld n be re-introduc$1 le/ ! inte/9es be w\nd$1 b a blunt-head$ p]=at$ in/rum5t fitt+ ! canula %\ld be ins]t$4 ,:5 all ! fluid t c be easily obta9$ is evacuat$1 ! canula may be )drawn1 & a pad ( l9t secur$ ov] ! w\nd by /rapp+4 ,,ga/rotomy4--,cutt+ into ! /oma* = ! extraction ( a =eign body has n[ be5 p]=m$ at lea/ t5 times1 & all b "o recov]$4 ,a typical example is t by ,dr4 ,bell ( ,dav5port1 :o remov$ a b> ( lead "o p\nd 9 weight & t5 in*es 9 l5g?1 by an incision f\r in*es 9 l5g? f ! umbilicus to ! false ribs4 ,! op5+ into ! /oma* 0 z small z possible1 & requir$ no sutures4 ,,ga/ro/omy has )9 ! la/ few ye>s be5 practis$ v frequ5tly4 ,gross has collect$ #gi cases1 #eg ( :i* 7 = c>c9oma ( oesophagus1 all ( :i* di$ )9 a few weeks1 except eight :o surviv$ = p]iods v>y+ f ?ree to sev5 mon?s4 ,! results 9 cases ( cicatricial & syphilitic /rictures are m fav\rable4--,h[se's me?od seems ! be/1 consi/+ ( two /ages4 #a4 ,a curv$ incision is made ?r\gh ! p>ietes p>allel )1 & a f+]-bread? bel[1 ! l[] m>g9 ( *e/ wall on left side1 ! p]itoneum %\ld be op5$ at ! l9ea semilun>is1 ! /oma* s\ght =1 & !n atta*$ to ! abdom9al wall by an out] r+ ( sutures & to ! edge ( ! w\nd by an inn] r+4 ,x %\ld !n be dress$ ) c>bolis$ l9t & support$ by a b&age4 #b4 ,a small op5+ %\ld be made f\r or five days aft] ! fir/ /age & ! pati5t %\ld be f$ ?r\gh ?is op5+4 ,= full details1 see ,mr4 ,durham's pap] 9 vol4 i4 ( ,holmes's ,surg]y1 edition ( #ahhc1 pp4 #hja-d4 ,,ga/rectomy4--,excision ( :ole or "p ( ! /oma* is "o ( ! late/ developm5ts ( op]ative d>+1 fir/ done z a regul> op]ation by ,pean 9 #ahgi1 x has n[ be5 repeat$ sixte5 times2 f\r cases h surviv$ ! op]ation = m ?an t5 days4 ,! *ief po9ts to be att5d$ to are prev5tion ( dea? f %ock & hmorrhage1 & v c>eful /it*+ up ( ! w\nd4 ,consid]+ ! difficulty ( ! diagnosis1 ! dang] ( ! op]ation1 & ! almo/ c]ta9 recurr5ce ( ! disease1 ! propriety ( su* op]ation seems v d\btful4 ,,ov>iotomy4--,= ! pa?ology ( ov>ian disease we mu/ ref] to ,sir ,sp5c] ,wells's "w on ! subject1 & to ! small] ,monograph on ,ov>ian ,pa?ology1 by ! late lam5t$ ,dr4 ,*>les ,rit*ie1 junior4 ,ev5 ! modifications 9 ! me?od ( op]at+ :i* h be5 devis$ are s v>i\s & num]\s1 t if collect$ f ! m$ical j\rnals ( ! la/ t5 ye>s !y w\ld fill a l>ge volume4 ,besides ?is1 ! op]ation ( ov>iotomy is "o att5d$ by s _m complications1 t individual cases v>y f ea* o!r z mu* z d individual cases ( h]nia & tra*eotomy2 & z ! specialities ( ea* case require to be met by specialities ( treatm5t1 !re is h>dly any op]ation 9 surg]y :i* requires great] read9ess ( inv5tion1 or m individual sagacity 9 ! op]ator4 ,to lay op5 ! abdom9al cavity f ! /]num to ! pubes1 & rapidly dissect out ( ?is cavity an enorm\s tum\r ) a n>r[ neck1 ! op]ator's only emb>rassm5t be+ ! p]i/altic movem5ts ( ! b[els1 & 8 only c>e be+ to tie ! neck ( ! tum\r firmly ) /rong /r+1 sew up ! w\nd1 & tru/ to nature1 0 an op]ation v easy to p]=m1 & requir+ free cutt+ r ?an dext]ity1 & ra%ness m ?an true surgical insight4 ,su* 7 ! ov>iotomies prior to #aheg4 ,an ov>iotomy 9 #ahhc is a v diff]5t bus9ess1 v>y+ 9 c]ta9 important p>ticul>s4 7#a47 ,in/ead ( ! incision ext5d+ f /]num to pubes1 x is n[ made z %ort z possible4 7#b47 ,in/ead ( be+ remov$ entire1 ! cy/ is n[ empti$ ) ! greate/ possible c>e 7prior to its removal71 & none ( ! cont5ts all[$ to ent] ! p]itoneal cavity4 7#c47 ,! p$icle is br\ght to ! surface1 & 9 e case :]e x is possible is secur$ outside ! w\nd4 ,besides ^! ?ree important & c>d9al po9ts1 !re are o!r m9or matt]s almo/ equally ess5tial2 ^! are--7#a47 ,! prop] managem5t ( ! adhesions & ! ?or\gh prev5tion ( all hmorrhage f !m2 7#b47 ! /it*+ up ( ! ext]nal w\nd1 includ+ ! p]itoneum2 7#c47 ! treatm5t ( ! pati5t dur+ ! fir/ few days ( convalesc5ce4 ,op]ation 9 a typical case1 aft] ! me?od ( ,sir ,sp5c] ,wells & ,dr4 ,?omas ,kei?4--,! pati5t hav+ _h h] b[els g5tly op5$ on ! previ\s day1 & be+ z f> z possible 9 h] usual /ate ( heal?1 %\ld be w>mly clad 9 flannel1 bo? 9 body & limb1 & laid on an op]at+ table ( conv5i5t height1 9 or ne> ! room %e is to occupy4 ,no c>ry+ f w>d to op]at+ !atre & back aga9 is admissible4 ,x w be f\nd bo? cleanly & conv5i5t to h a l>ge india-rubb] clo? ov] ! :ole abdom51 cut out 9 ! c5tre s z to expose s mu* ( ! tum\r z is necess>y1 b gumm$ on or o!rwise secur$ to ! sides ( ! abdom51 & ?us protect+ ! clo!s1 & hang+ d[n ov] ! edge ( ! table2 ?is w prev5t all wett+ ( ! clo!s & unnecess>y exposure ( ! pati5t's p]son1 & c be easily remov$ aft] ! op]ation4 ,*lor(orm be+ adm9i/]$1 ! bladd] is evacuat$ by means ( a ca!t]1 & ! pati5t's head & %\ld]s are elevat$ on pill[s4 ,an incision is !n made 9 ! l9ea alba1 betwe5 ! umbilicus & pubes1 = ab\t f\r in*es 9 l5g? at fir/1 s z to be l>ge en\gh to admit ! h&1 ?r\gh all ! tissues d[n to & ?r\gh ! p]itoneum4 ,c>e is necess>y 9 divid+ ! p]itoneum1 on ! "o h&1 n to divide too mu*1 9 :i* case ! cy/-wall w be p5etrat$1 & ! cont5ts effus$ into ! p]itoneal cavity2 or1 on ! o!r h&1 too little1 9 :i* case ! p]itoneum may be mi/ak5 = ! cy/1 & sep>at$ f ! transv]salis fascia "u ! idea t adhesions exi/4 ,once ! p]itoneal cavity is op5$1 ! incision ?r\gh ! p]itoneum mu/ be ext5d$ to ! full l5g? ( ! ext]nal w\nd by a probe-po9t$ bi/\ry4 ,! op]ator's h& mu/ n[ be pass$ into ! abdom51 & ! tum\r isolat$ f its connections z f> z possible4 ,:5 no adhesions exi/ x is extremely easy to pass ! h& q r\nd ! tum\r1 asc]ta9 its relations to ! ut]us & ,fallopian tubes1 & ! l5g? & ?ickness ( its p$icle4 ,! pres5ce ( adhesions adds v s]i\sly to ! dang] & duration ( ! op]ation4 ,we w suppose at pres5t t none exi/ 9 ?is typical case1 & t ! p$icle is f\nd ( a satisfactory size & %ape4 ,! surgeon n[ protrudes ! ant]ior portion ( ! cy/-wall ?r\gh ! w\nd1 & pi]ces x ) a l>ge troc>1#ada to :i* is atta*$ an india-rubb] tube1 by means ( :i* ! effus$ fluid c be easily got rid ( 9 any direction4 ,dur+ ! escape ( ! fluid f ! cy/ a special assi/ant keeps up ! t5sion by c>eful pressure on ! abdom54 ,9 cases :]e ! cy/ is multilocul>1 & ?us only a portion ( ! cont5ts ( ! tum\r is at fir/ evaluat$1 ! op]ator %\ld1 by p>tially )draw+ ! troc>1 )\t remov+ x entirely f ! cy/1 endeav\r to pi]ce & evacuate ! o!r cy/s1 /ill ?r\gh ! orig9al op5+ 9 ! fir/ "o4 ,:ile do+ ?is1 great c>e mu/ be tak5 le/ he pi]ce ! ext]nal wall ( ! tum\r1 & let any ( ! cont5ts escape into ! abdom9al cavity2 to gu>d aga9/ ?is1 ! punctures %\ld be made by ! "r h&1 :ile ! left1 re-ins]t$ into ! abdom51 supports ! cy/-wall4 ,! tum\r hav+ be5 z f> z possible empti$ ( its fluid cont5ts1 mu/ n[ be dragg$ out ( ! w\nd1 c>e be+ /ill tak5 le/ any ( its fluid cont5ts escape into ! p]itoneal cavity4 ,9 fav\rable cases ! p$icle is n[ br\ght easily into view4 ,?is may v>y v mu* 9 l5g? & ?ickness4 ,x is sometimes entirely abs5t1 ! tum\r be+ sessile on ! broad ligam5t ( ! ut]us2 sometimes x is ?ick & /rong1 sometimes long & sl5d]4 ,! mann] 9 :i* x is to be manag$ dep5ds on its l5g? & ?ickness4 ,v>ieties 9 treatm5t w be notic$ imm$iately4 ,we w suppose t x is f\r in*es 9 l5g? & "o or two f+]s 9 bread?4 ,?is is q a suitable case = ! use ( ! clamp1 ! pr9ciple involv$ 9 ! use ( :i* is1 t ! p$icle %\ld be br\ght q out ( ! abdom5 ?r\gh ! w\nd & secur$ on ! surface4 ,! be/ =m seems to be "o made l a c>p5t]'s callip]s1 ) long b removable h&les1 & a v p[]ful fix+-screw4 ,! blades ( ?is clamp be+ protect$ by pads ( l9t %\ld be made to embrace ! p$icle close to ! cy/1 9 a direction at "r angles to ! abdom9al w\nd1 & ly+ across x1 ! h&les %\ld !n be remov$1 & pads ( l9t plac$ bel[ ! clamp to protect ! sk94 ,! cy/ may n[ be cut away at "s little di/ance above ! clamp1 en\gh be+ left to prev5t all dang] ( its slipp+4 ,fur!r to avoid ?is dang]1 ! p$icle may be transfix$ by "o or two ne$les above ! clamp4 ,! w\nd is n[ to be sew$ up by sev]al po9ts ( int]rupt$ suture1 "s ins]t$ v deeply ?r\gh all ! tissues1 includ+ ev5 ! p]itoneum1 o!rs 9 ! int]vals ( ! fir/1 includ+ little m ?an ! sk94 ,!y may be ei!r ( iron1 silv]1 plat9um1 telegraph-wire 7,mr4 ,clov]'s copp]1 coat$ ) gutta-p]*a71 or silk4 ,x seems ( v little consequ5ce :i* is us$4 ,sir ,sp5c] ,wells1 aft] _m trials1 uses silk1 z be+ remov$ ) lea/ pa9 to ! pati5t1 & really caus+ no m suppuration ?an ! metallic ones d1 if only remov$ e>ly en\gh1 viz41 ab\t ! second or ?ird day1 by :i* "t ! union ( ! w\nd %\ld be firm4 ,! aft]-treatm5t %\ld be v simple4 ,except "u special circum/ances1 /imulants are r>ely necess>y1 & inde$1 to avoid vomit+1 z little z possible %\ld be giv5 by ! m\? dur+ ! fir/ tw5ty-f\r h\rs4 ,! pati5t %\ld be all[$ to suck a little ice to allay ?ir/1 & opiate & nutritive enemata w be f\nd q suffici5t to keep up ! /r5g? 9 ord9>y cases4 ,! ur9e %\ld be drawn (f by ! ca!t] e six h\rs4 ,! room %\ld be kept quiet1 & ! temp]ature equable1 s long z !re is no int]f]5ce ) a pl5tiful supply ( fre% air4 ,"s ( ! specialities & abnormalities involv+ special risks may n[ be briefly notic$3-- #a4 ,adhesions4--,^! v>y mu* 9 am\nt1 9 position1 9 organisation1 & dang]4 a4 ,9 am\nt4--,9 c]ta9 cases no adhesions exi/1 :ile 9 o!rs1 om5tum1 inte/9es1 tum\r1 ut]us1 & abdom9al wall may be all matt$ toge!r 9 "o common mass4 b4 ,9 organisation4--,occasionally !y are s s(t & friable z to break d[n "u ! f+] ) ease1 & s slightly organis$ z n to ble$ at all 9 ! process1 :ile aga9 !y may be s firm & close z to require a c>eful & prolong$ dissection1 & s vascul> z to require _m po9ts ( ligature to be appli$ to l>ge active vessels4 c4 ,!re are special dang]s connect$ ) ! pres5ce ( ^! adhesions1 & v>y+ mu* 9 diff]5t cases4 ,?us adhesions to ! inte/9es c g5]ally be sep>at$ ) comp>ative ease1 & seem1 z a rule1 to require ! application ( few] ligatures ?an ^? :i* unite ! tum\r to ! abdom9al wall4 ,adhesions to ! wall are sometimes s firm z to be q insep>able1 & ?us to necessitate "s ( ! cy/-wall be+ left adh]5t4 ,9 ,sir ,sp5c] ,wells's cases1 adhesions to ! liv] & gall-bladd] occasionally occurr$1 requir+ c>eful dissection to sep>ate !m1 & yet ! pati5ts all surviv$1 :ile pelvic adhesions1 especially to ! bladd] & ut]us1 on m ?an "o occasion prev5t$ ! completion ( ! op]ation4 ,vascul> adhesions to ! wall :i* require _m ligatures c]ta9ly add to ! dang]s ( ! case1 :ile adhesions to ! ant]ior wall ( ! abdom5 r5d] ! op]ation1 especially its fir/ /ages1 mu* m difficult1 prev5t+ ! cy/ f be+ recognis$4 #b4 ,! condition ( ! p$icle is ( great importance4 ,if x is too %ort1 x prev5ts ! use ( ! clamp1 z if appli$ x is apt ei!r to pull ! ut]us up1 or1 pull+ ! clamp d[n1 to make undue traction on ! w\nd1 & rupture any adhesions4 ,?is is especially ! case :]e mu* flatus is g5]at$1 or :]e ! pati5t is naturally /\t4 ,treatm5t4--,:]e ! p$icle is j long en\gh to all[ ! clamp to be appli$1 & yet too %ort to leave room = any di/5sion ( ! abdom5 )\t undue t5sion1 ! be/ plan is to transfix x ) a /\t d\ble ?read j bel[ ! clamp1 tie x 9 two halves1 & br+ ! ?reads out pa/ ! clamp1 s t1 if t5sion does occur1 ! clamp may be remov$1 ! "p beyond x cut (f1 & ! re/ all[$ to slip back into ! pelvis1 ! ligatures be+ kept out at ! m\? ( ! w\nd4 ,or aga91 x is sometimes possible1 aft] apply+ "o clamp firmly z ne> ! tum\r z possible1 to apply ano!r above x :5 ! great] "p ( ! tum\r has be5 cut away2 :5 ! second is firmly fix$ x may !n be safe to remove ! fir/1 & ?us an artificially elongat$ p$icle is obta9$4 ,:5 /ill %ort]1 two plans rema9 = selection--7#a47 to transfix ! p$icle 9 "o or m po9ts1 !n1 secur+ x 9 two1 ?ree1 or m portions1 cut x (f above ! ligatures & return x1 leav+ ! ligatures at ! l[] end ( ! w\nd4 ,?is gives a free dra9 = pus1 b !oretically ! sl\gh+ p$icle might be expect$ to set up p]itonitis2 7#b47 to transfix & tie ! p$icle ) "o or m loops ( /\t /r+1 cut ! ends (f %ort1 & return ! :ole affair1 clos+ ! ext]nal w\nd at once4 ,!oretically !re are grave objections to ?is plan1 b x has prov$ v successful1 especially 9 ! h&s ( ,dr4 ,tyl] ,smi?4 ,ano!r +5i\s modification1 sometimes useful 9 a %ort n>r[ p$icle1 is to tie x z close to ! cy/ z possible1 br+ ! ligature out at ! w\nd1 & !n ) a /rong h>elip ne$le transfix ! p$icle1 along ) bo? sides ( ! w\nd1 j bel[ ! ligature4 ,:5 ! p$icle is excessively broad & /\t1 x %\ld be transfix$ by /rong ne$les & d\ble ?reads 9 v>i\s places1 & ?us ti$ 9 sev]al portions4 ,abs5ce ( ! p$icle greatly adds to ! dang] 9 any giv5 case4 ,v>i\s plans h be5 tri$1 z cutt+ ! atta*m5t ?r\gh sl[ly by ! craseur1 ligature ( ea* vessel sep>ately1 s _m z twelve be+ sometimes requir$1 & caut]is+ ! /ump4 ,! latt]1 z us$ by ,mr4 ,bak] ,br[n1 has met ) a l>ge measure ( success1 & is mu* us$ n[4#adb ,dr4 ,kei? = a "t op]at$ ) antiseptic precautions1 b has n[ 7#ahhc7 entirely giv5 up ! use ( ! spray1 :i* he believes has especial dang]s 9 abdom9al surg]y4 ,,op]ation ,,= ,,/rangulat$ ,,+u9al ,,h]nia4--,! great rule to be rememb]$ ) reg>d to ?is1 z well z all o!r op]ations = h]nia1 is1 t ! e>li] x is p]=m$ ! bett] *ance ! pati5t has4 ,once a fair trial has be5 giv5 to ! taxis1 aid$ by prop] position ( ! pati5t1 ! w>m ba?1 & specially *lor(orm1 ! op]ation %\ld be p]=m$4 ,! pati5t %\ld be plac$ on 8 back ) 8 %\ld]s elevat$1 & ! knee ( ! affect$ side slightly b5t4 ,! gro9 %\ld !n be %av$1 & ! %ape & size ( ! tum\r1 ) ! position ( ! +u9al canal1 c>efully /udi$4 ,! surgeon %\ld !n lift up a fold ( sk9 & cellul> tissue1 9 a direction at "r angles to ! long axis ( ! tum\r1 & hold+ "o side ( ?is rais$ fold 9 8 own left h&1 commit ! o!r to an assi/ant4 ,he !n transfixes ?is fold ) a %>p /raight bi/\ry1 ) its back t[>ds ! sac1 & cuts outw>ds1 ?us at once mak+ an incision along ! axis ( ! h]nia )\t any risk ( w\nd+ ! sac or b[el4 ,any vessel t ble$s may n[ be ti$4 ,?is incision w be f\nd suffici5tly l>ge = mo/ cases2 if n1 h[ev]1 x c easily be prolong$ ei!r upw>ds or d[nw>ds4 ,! surgeon mu/ n[ devote 8 att5tion to expos+ ! neck ( ! sac1 & 9 s do+1 def9+ ! ext]nal +u9al r+4 ,! safe/ me?od ( do+ s is c>efully to p9* up1 ) dissect+ =ceps1 lay] aft] lay] ( connective tissue1 divid+ ea* sep>ately by ! knife held ) its flat side1 n its edge1 on ! sac1 & !n by means ( ! f+] or =ceps rais+ ea* lay] 9 succession & divid+ x to ! full ext5t ( ! ext]nal incision4 ,x is n always an easy matt] to recognise ! sac1 especially z ! numb] ( lay]s above x1 :i* are describ$ 9 ! anatomical text-books1 are (t5 n at all di/9ct4 ,! ?ickness ( ! connective tissue ( ! "p v>ies imm5sely2 sometimes six lay]s or ev5 m c be sep>ately dissect$1 :ile1 aga91 "o only may be f\nd be=e ! sac is expos$4 ,if small & rec5t1 ! sac may be recognis$ by its blui% col\r1 & by ! fact t x is possible to p9* up a portion ( x betwe5 ! f+] & ?umb1 & ?us to rub its oppos$ surfaces aga9/ ea* o!r4 ,if l>ge & ( old /&+1 x is sometimes s ?9 z n to be recognisable1 or aga9 s enorm\sly ?ick5$1 & s adh]5t1 z to be def9$ ) great difficulty4 ,if x is small1 i4e4 :5 ! :ole tum\r is "u ! size ( an egg1 x ought to be ?or\ghly isolat$1 & its b\nd>ies ev]y:]e def9$4 ,if l>ge1 & specially if adh]5t1 ! neck alone %\ld be cle>$4 ,! sac ?us be+ rea*$1 ! ext]nal abdom9al r+ %\ld be cle>ly def9$1 & ! f+] pass$ into x s z if possible to det]m9e ! pres5ce or abs5ce ( any con/riction 9 x4 ,if x feels tight1 ! int]nal pill> ( ! r+ %\ld !n be cauti\sly divid$ on ! f+] by a probe-po9t$ n>r[ bi/\ry1 9 a direction p>allel to ! l9ea alba4 ,at ?is /age ! "q comes to be consid]$ z to :e!r ! sac %\ld or %\ld n be op5$4 ,mu* has be5 said & writt5 on bo? sides4 ,n to op5 ! sac avoids ! risk ( p]itonitis1 & ( injury to ! b[el2 b1 on ! o!r h&1 exposes ! pati5t to ! dang] ( ! h]nia be+ return$ unr$uc$2 = 9 _m cases ! /ricture is to be f\nd 9 ! sac itself1 & adhesions v rapidly =m betwe5 coils ( inte/9e 9 ! sac & ! inn] wall4 ,aga91 n to op5 ! sac prev5ts u f discov]+ ! condition 9 :i* ! b[l is2 x may possibly be gangr5\s1 9 :i* case su* a return en masse w\ld be almo/ necess>ily fatal4 ,a g5]al rule or two may be giv5 "h3-- #a4 ,! sac %\ld be op5$ 9 e case :]e !re is any reason = d\bt ab\t ! condition ( ! b[el1 :]e !re has be5 long-cont9u$ vomit+1 or mu* t5d]ness on pressure4 #b4 ,ev5 9 cases 9 :i* !re is e reason to believe ! b[el is p]fectly s\nd1 ! sac %\ld be op5$1 unless ! :ole cont5ts c be easily & completely r$uc$ out ( ! sac into ! belly1 z 9 cases :]e ?is _c be done !re probably exi/ ei!r a /ricture 9 ! neck ( ! sac itself1 or adhesions ( ! b[el to ! sac4 ,we %\ld endeav\r to avoid op5+ ! sac 9 cases ( old scrotal h]nia ( l>ge size1 :]e ! symptoms h n be5 urg5t1 especially 9 l>ge unheal?y hospitals1 z ! risk ( p]itonitis is s great4 ,antiseptic precautions seem consid]ably to dim9i% ! risk ( op5+ ! sac4 ,if ! sac !n is n to be op5$1 ! re/ ( ! op]ation is v simple4 ,endeav\r to r$uce ! b[el out ( ! sac1 & !n return ! sac itself1 unless ! h]nia is ( old /&+1 & adhesions prev5t its r$uction4 ,a few silv] /it*es to close ! w\nd & a c>efully adju/$ pad are n[ all t is requisite4 ,if ! sac is to be op5$1 h[ c x be done ) lea/ dang] to ! b[el8 ,if ! h]nia is small1 & x is possible to def9e x all1 ! sac %\ld be op5$ at its l[] end1 z !re a small quantity ( s]\s fluid :i* int]v5es betwe5 ! sac & ! b[el w be f\nd4 ,:]e ?is is pres5t1 !re is no dang] ( w\nd+ ! b[el1 z ! sac c be easily p9*$ up2 b ?is is by no means inv>iably ! case1 s great c>e %\ld always be tak54 ,a small portion ( ! wall be+ ?us p9*$ up %\ld be divid$ 9 ! same mann] z ! lay]s ( cellul> tissue 7 divid$ 9 expos+ ! sac4 ,a few drops ( s]um w !n escape1 & ! gli/5+ surface ( ! b[el be expos$2 ! f+] %\ld !n be introduc$ at ! op5+1 & ! incision enl>g$ by a probe-po9t$ bi/\ry4 ,if ! h]nia is small ! sac %\ld be slit up to its full ext5t2 if l>ge1 only a suffici5t portion ( ! neck %\ld be op5$4 ,z soon z ! op5+ 9 ! sac is l>ge en\gh to admit ! po9t ( ! op]ator's =ef+]1 x %\ld be ins]t$ s z to protect ! inte/9es1 & ! rema9d] ( ! sac slit up on x z a guide4 ,! sac ?us op5$1 ! next /ep is to divide ! con/riction1 :]ev] x be4 ,x is mo/ likely to be f\nd at ! neck ( ! sac1 j :]e x protrudes ?r\gh ! int]nal r+ 9 an oblique h]nia1 or ?r\gh ! t5dons ( ! transv]salis & int]nal oblique1 :]e ! h]nia is direct4 ,n[1 ?is con/riction might be divid$ 9 any direction 7 x n = ! risk ( w\nd+ ! epiga/ric art]y1 & also ( injur+ ! sp]matic cord1 :i* is 9 close relation to ! neck ( ! sac ( an oblique h]nia4 ,w\nd ( ! epiga/ric art]y is ! *ief dang]1 = 9 all cases x is close to ! neck ( ! sac4 ,7 its position 9 relation to ! neck ( ! sac con/ant1 x might be easily avoid$ by an incision 9 ! opposite direction2 b z ?is relation v>ies accord+ to ! nature ( ! h]nia1 an elem5t ( dang] is introduc$4 ,?us1 9 oblique +u9al ruptures1 :]e ! sac passes out ?r\gh ! int]nal r+ 7,fig4 ,,xxxii4 ,,ir71 ! art]y w always be f\nd to ! inside ( ! neck ( ! sac2 :ile 9 direct h]ni1 :]e ! b[el has made its escape ?r\gh ! triangle ( ,hesselba* 7,fig4 ,,xxxii4 71 & pass$ ?r\gh ! conjo9t t5don /raight to ! ext]nal r+1 ! epiga/ric art]y w be f\nd on ! outside ( ! neck ( ! sac4 ,9 rec5t h]ni ! diff]5tial diagnosis is comp>atively easy1 b 9 ^? ( old /&+ & l>ge size1 9 :i* ! obliquity ( ! canal has be5 mu* dim9i%$1 x is almo/ impossible to tell ( :at k9d ! h]nia orig9ally 01 & consequ5tly to det]m9e 9 :i* direction x is safe to incise ! neck ( ! sac4 ,su* be+ ! case1 ! be/ rule is to incise ! neck ( ! sac directly upw>ds1 i4e4 9 a l9e p>allel ) ! l9ea alba1 & also to cut x v cauti\sly bit by bit1 9 e case1 if possible1 ) ! f+] ins]t$ z a guide to ! position ( a vessel & a protection to ! gut4 ,! sp]matic vessels lie sometimes beh9d1 sometimes on ei!r side ( ! sac1 & 9 v old h]ni may be sep>at$ f ea* o!r s z really to surr\nd ! sac4 ,! cut directly upw>ds is also ! safe/ = !m4 ,all con/rictions be+ ov]come1 x is n suffici5t m]ely to pu% back ! gut into ! belly4 ,its condition mu/ be c>efully exam9$1 & x mu/ be decid$ :e!r ! con/riction has caus$ gangr5e or n4 ,to exam9e ?is prop]ly1 x is g5]ally be/ to pull d[n an in* or two m ( ! gut1 s z ?or\ghly to br+ into view ! con/rict$ portion1 z x is mo/ likely to be fatally nipp$4 ,x is n always easy to decide z to ! condition ( ! b[el4 ,c]ta9 po9ts mu/ be obs]v$3-- 7#a47 ,col\r4--,!re may be v great alt]ation 9 ! col\r ( ! b[el f conge/ion1 & yet no gangr5e4 ,x may be d>k r$1 cl>et1 purple1 or ev5 h a br[ni% t9t1 & yet recov]2 :]e x is black1 or a deep br[n1 ! prognosis is unfav\rable4 7#b47 ,gli/5+4--,s long z ! prop] gli/5+ appe>ance ( ! b[el rema9s1 !re is hope = x1 ev5 :5 ! col\r is bad2 if x has lo/ x1 & especially if1 in/ead ( be+ t5se & %9+1 x is dull & flaccid & 9 wr9kles1 ! b[el is almo/ c]ta9ly gangr5\s4 7#c47 ,?ickness4--,if mu* ?ick5$1 & especially if r\gh on ! surface1 ! b[el has probably be5 =m+ adhesions to ! sac1 or to contigu\s coils1 & ! prognosis is less fav\rable4 7#d47 ,smell4--,! peculi> gangr5\s od\r on op5+ ! sac is v *>act]i/ic4 ,9 cases :]e ulc]ation & p]=ation h occurr$1 ! od\r is fcal4 #a4 ,if1 !n1 ! b[el is tol]ably heal?y-look+1 ?\gh discol\r$1 x %\ld be return$ gradually1 n en masse1 into ! abdom51 ! w\nd sew$ up1 & a pad ( l9t put on1 ) a b&age4 #b4 ,if !re are adhesions ( b[el to sac or to a neighb\r+ coil1 or ( om5tum to sac1 ! /ricture %\ld be freely divid$1 ! protrud+ coils ( inte/9e %\ld be empti$ ( _! cont5ts1 b no ra% attempt made to =ce _! return4 ,especially is ?is rule to be obs]v$ ) protrud$1 swoll51 or adh]5t om5tum1 = consid]able risks att5d any attempt at excision ( ! protrud$ portion--risks ( hmorrhage1 p]itonitis1 & ulc]ation ( ! contigu\s b[el4 ,if ! b[el be return$1 or ev5 ! cont9uity ( ! canal re/or$ by ! cutt+ ( ! /ricture1 ?\gh ! b[el be n return$1 no great risks accrue f ! ret5tion ( a piece ( om5tum 9 ! sac1 9 a position :i* x may possibly h already occupi$ = ye>s4 #c4 ,if ! b[el is absolutely gangr5\s1 ev5 9 a v small portion ( its l5g?1 no r$uction %\ld be attempt$1 b ! gangr5\s portion %\ld be kept outside1 ) ! hope t adhesive inflammation may be set up1 s z to glue ! b[el to ! abdom9al wall1 prev5t fcal extravasation1 & =m a tempor>y artificial anus4 ,if ! gangr5\s portion be v full ( fces or flatus1 incisions may be made into x4 ,?is %\ld be avoid$ 9 cases :]e ! pati5t is already mu* pro/rat$1 z ,i h se5 cases 9 :i* ! op5+ ( ! b[el seem$ to inflict a fatal %ock4 ,ent]ectomy or excision ( ! gangr5\s portion has rec5tly be5 recomm5d$ & p]=m$ by "s surgeons4 ,! v high au?ority ( ! late ,pr(essor ,sp5ce is aga9/ su* proc$ure4#adc ,cases ( gangr5e ( ev5 l>ge portions ( b[el are by no means necess>ily fatal4 ,!y may recov] ) an artificial anus1 ! rem$y ( :i* by surgical means we mu/ notice 9 its prop] place4 ,,op]ation ,,= ,,/rangulat$ ,,femoral ,,h]nia4--,:ile ! g5]al pr9ciples guid+ treatm5t & rul+ ! conduct ( ! op]ation are ! same z 9 +u9al1 !re are "s diff]5ces 9 po9ts ( detail :i* r5d] a brief sep>ate description necess>y4 ,a s+le ^w on ! anatomy4 ,trac+ a femoral rupture f )9 outw>ds1 we f9d t its fir/ /age is to pu% its way ?r\gh ! weak po9t ( ! ar* =m$ by ,p\p>t's ligam5t1 t is1 ! spot call$ ! crural ar*1 b\nd$ on its out] side by ! %ea? ( fascia :i* surr\nds ! femoral ve92 above by ,p\p>t's ligam5t2 on its inn] side by ! curv$ fibres ( ,p\p>t's ligam5t1 :i*1 curv+ backw>ds1 are ins]t$ into ! ilio-pect9eal l9e1 h a %>p falci=m edge1 & h be5 dignifi$ by ! special "n ( ,gimb]nat's ligam5t 7,fig4 ,,xxxii4 ,g72 & bel[ by ! os pubis itself4 ,?is ar* or r+ ?us b\nd$ is1 9 ! normal /ate ( p>ts1 fill$ by a lay] ( fibr\s texture1 a little fat1 & occasionally a small gl&4 ,^! p>ts are pu%$ =w>ds 9 ! desc5t ( ! h]nia1 & 9 a small rec5t "o may be said to =m a sort ( inn] cov]+2 9 a l>g] & old] "o !y are split by ! h]nia1 &1 :ile =m+ a con/riction r\nd its neck1 leave ! fundus ( ! sac1 s f> z !y are conc]n$1 q uncov]$4 ,a femoral h]nia may /op !re1 satisfi$ ) m]ely com+ ?r\gh ! r+1 &1 if sudd5 & rec5t 9 a heal?y1 well-knit subject1 su* a rupture is exce$+ly dang]\s1 ! con/riction be+ v sev]e1 & ! consequ5t gangr5e ( ! b[el v rapid if unreliev$4 ,9 mo/ cases1 h[ev]1 x makes its way /ill fur!r out1 & ! next cov]+ x ga9s is f ! cribri=m fascia4 ,?is is ! lay] ( fibres1 pi]c$ 7z its "n implies7 ) orifices = ! passage ( ve9s & lymphatics1 :i* /ret*es betwe5 ! two curv$ edges ( ! saph5\s op5+4 ,x v>ies mu* 9 /r5g?2 :5 ! rupture has be5 sl[ & gradual1 x w c]ta9ly add a cov]+ ( great] or less ?ickness1 b :]e ! h]nia is l>ge & old we mu/ n expect to f9d _m traces ( ! cribri=m fascia1 at lea/ ov] ! fundus ( ! tum\r4 ,! ord9>y sup]ficial fascia ( ! "p1 ) its fat1 n]ves1 ve9s1 & lymphatics1 & ! ?9 sk9 ( ! gro91 are ! only rema9+ cov]+s4 ,x is v rem>kable h[ exce$+ly ?9 all ! s-call$ coats become 9 l>ge femoral h]ni ( long /&+1 especially 9 ?9 old p4 ,op]ation4--,v>i\s incisions are recomm5d$4 ,! "o :i* gives free/ access & exposes ! sac be/1 is %ap$ l a ,t1 ! horizontal limb ( :i* is oblique1 ! direction ( ! obliquity v>y+ on ! two sides4 ,! horizontal incision %\ld be made j ov] ,p\p>t's ligam5t1 & p>allel to x1 ! c5tre ( ! incision correspond+ to ! neck ( ! sac1 & its l5g? v>y+ accord+ to ! size ( ! tum\r & ! dep? ( ! p>ts2 ! o!r %\ld ext5d d[nw>ds f ! c5tre ( ! =m]1 z f> z is necess>y to display ! :ole sac4 ,! fir/ %\ld be made by p9*+ up & transfix+ ! sk91 ! second by ord9>y incision1 to ! same dep? z ! fir/4 ,! small flaps ?us made mu/ n[ be ?r[n back2 any vessels t h be5 divid$ are to be ti$4 ,n[1 ) great c>e & caution ! surgeon is to p9* up & divide any lay]s ( cond5s$ cellul> tissue :i* may /ill cov] ! sac1 till x is ?or\ghly expos$ to its full ext5t1 & remove any gl&s :i* may int]v5e4 ,! neck ( ! sac be+ expos$1 x may be possible 9 "s v exceptional cases to give ! pati5t ! b5efit ( ! m9or op]ation1 :i* consi/s 9 leav+ ! sac unop5$4 ,9 su* a case 7to be describ$ imm$iately71 ! surgeon passes 8 f+] along ! neck ( ! sac z f> z possible into ! r+1 & !n ) a probe-po9t$ bi/\ry v cauti\sly nicks ! upp] edge ( ,gimb]nat's ligam5t1 9 "o or m places1 be+ c>eful to feel = any pulsation be=e divid+ a s+le fibre4 ,he may !n be able to empty ! sac ( its cont5ts1 & return ! b[el & om5tum1 /ill reta9+ ! sac outside4 ,on ! o!r h&1 :]e x is det]m9$ to op5 ! sac1 ! p9*+ up ( ! sac mu/ be manag$ ) great c>e1 to avoid injury ( ! b[el4 ,!re is g5]ally a little fluid to be f\nd at ! fundus1 :i* w protect ! b[el4 ,9 "o case 9 :i* ,li/on op]at$1 he tells u1 !re 0 no possibility ( p9*+ up ! sac1 ei!r ) ! f+]s or =ceps2 x conta9$ no fluid1 & 0 impact$ mo/ firmly ) b[el2 v luckily ! membrane 0 ?92 &1 obs]v+ a pelleton ( fat und]nea?1 ,i scrat*$ v cauti\sly ) ! po9t ( ! knife 9 ! unsupport$ h&1 until a trifl+ puncture 0 made1 suffici5t to admit ! blunt po9t ( a n>r[ bi/\ry4#add ,if ! sac conta9s b[el & om5tum1 x is saf] to op5 x ov] ! om5tum ?an ov] ! b[el4 ,:5 a small op5+ is made1 an escape ( ! conta9$ fluid takes place1 & !n ! sac %\ld be slit up z f> z its neck by a probe-po9t$ bi/\ry1 guid$ by ! f+]1 introduc$ to protect ! b[el1 :5ev] ! op5+ is suffici5tly l>ge4 ,! =ef+] mu/ n[ be cauti\sly ins9uat$ into ! neck ( ! sac1 ! nail be+ direct$ to ! b[el1 ! pulp to ! cresc5tic m>g9 ( ,gimb]nat's ligam5t1 & any con/riction v cauti\sly divid$4 ,! b[el %\ld !n be drawn d[n a little1 ! con/rict$ po9t c>efully exam9$1 & !n return$ or n1 accord+ to its condition4 ,two po9ts require a brief sep>ate notice3-- #a4 ,9 :at direction is ! crural ar* to be divid$8 ,n outw>ds c]ta9ly1 on acc\nt ( ! ve91 nor d[nw>ds1 z ! bone prev5ts t direction4 ,is x to be upw>ds or inw>ds8 ,n upw>ds1 = su* an incision w\ld endang] ! sp]matic cord or r\nd ligam5t1 besides greatly weak5+ ! abdom9al wall by ! division1 p>tial or complete1 ( ,p\p>t's ligam5t4 ,inw>ds !n x mu/ be2 & little m ne$ be said ab\t x1 7 x n = ! occasional exi/5ce ( an abnormal c\rse & di/ribution ( ! obturator art]y4 ,illu/ration3 ,,fig4 ,,xxxii4#ade ,! usual orig9 ( ?is vessel is f ! int]nal iliac1 9 :i* case 7,fig4 ,,xxxii4 ,n ,o7 x nev] comes ne> ! sac at all4 ,9 c]ta9 cases 7#a 9 #c-a_/b7 x rises f ! epiga/ric1 & 9 a v few 7#a 9 #gb7 f ! ext]nal iliac4 ,if ris+ f ei!r ( ! two la/1 x mo/ commonly passes d[nw>ds at ! out] side ( ! h]nia1 9 :i* case 7,fig4 ,,xxxii4 ,s ,o7 no h>m c possibly result2 b 9 a few r>e cases1 p]haps #a 9 e #fj ( ^? op]at$ on1 ! vessel w9ds r\nd ! h]nia 7,fig4 ,,xxxii4 ,o71 cross+ at its inn] side1 & ?us may be 7& has actually be57 divid$ by a ra% incision4 ,) due c>e1 h[ev]1 & by cutt+ a v little at a "t1 ev5 ?is dang] may be avoid$4 #b4 ,"u :at circum/ances is x possible or ju/ifiable to r$uce a femoral h]nia1 )\t previ\sly op5+ ! sac8 ,only 9 c]ta9 v select cases1 :]e ! h]nia is rec5t1 ! con/rict+ p>ts lax1 ! g5]al symptoms v mild1 & :]e !re is reason to believe ! b[el has completely escap$ injury by compression or ! taxis4 ,!re are bo? difficulties & dang]s 9 ?is s-call$ m9or op]ation3--#a4 ,difficulties1 ,= x is n easy to divide ! con/riction )\t ! assi/ance ( ! f+] 9 ! sac1 & x is n easy to r$uce ! cont5ts ) ! sac unop5$1 except ?r\gh a mu* fre] op5+ ?an is necess>y :5 ! b[el has be5 fairly expos$4 #b4 ,dang]s1 ,( r$uc+ sac & visc]a1 toge!r ) ! /rangulation /ill kept up by tightness 9 ! neck ( ! sac2 or ( suppos+ ! sac is empti$ :ile a knuckle ( b[el /ill rema9s 9 x1 & is /rangulat$2 or1 la/ly1 ( r$uc+ ! inte/9e :i* has already become gangr5\s4 ,x is v rem>kable h[ v soon gangr5e may come on1 9 a case ( a small rec5t femoral h]nia1 9 :i* ! fibr\s tissues con/rict+ ! neck ( ! sac are t5se & undilatable4 ,a protrusion = eight h\rs has be5 suffici5t to de/roy ! life ( a knuckle ( b[el4 ,a note "h on a c]ta9 condition v frequ5t 9 femoral h]ni1 :i* may occasionally give a good deal ( tr\ble4 ,symptoms ( /rangulation h be5 well m>k$1 yet :5 ! sac is op5$ no?+ is to be se5 except a mass ( om5tum1 p]haps tol]ably heal?y-look+4 ,to r$uce ?is en masse w\ld be v unsafe2 x is necess>y c>efully to unravel x1 & dis5gage ! knuckle ( b[el :i* is almo/ c]ta9ly includ$ 9 x1 & :i* has giv5 rise to ! symptoms ( /rangulation4 ,,op]ation ,,= ,,/rangulat$ ,,umbilical ,,h]nia4--,! op]ation is practically ! same1 :e!r ! h]nia is a true umbilical "o1 or "o :i* ) m /rict accuracy might be call$ v5tral4 ,true umbilical h]nia is a disease ( infancy & *ildhood1 be+ almo/ always cong5ital1 & ! visc]a protrude ?r\gh ! umbilical ap]ture4 ,?is r>ely requires op]ation1 z x may g5]ally be return$ ) ease1 & ev5 cur$ by a prop] b&age & compress4 ,v5tral h]nia1 commonly call$ umbilical1 is g5]ally a protrusion ( visc]a ?r\gh a new pret]natural ap]ture 9 ! fibr\s tissues close to ! navel1 may (t5 atta9 a l>ge size1 is liable to /rangulation1 & is n easily palliat$ or cur$4 ,9 ei!r case ! op]ation requires a v brief description4 ,if ! h]nia is small1 "u ! size ( a h5's egg1 a crucial incision ?r\gh ! ?9 sk9 :i* cov]s x w ?or\ghly expose ! sac :5 ! flaps are dissect$ back4 ,! =ef+] %\ld !n be ins]t$ 9 ! r\nd op5+1 & ! edges cauti\sly incis$ 9 sev]al directions1 ea* incision h[ev] be+ v small4 ,if ! rupture is l>ge1 a s+le l9e>1 or a ,t-%ap$ incision1 expos+ ! base ( ! tum\r1 w be suffici5t to all[ ! requisite dilatation ( ! op5+ to be made4 ,x is n at all necess>y 9 e case to op5 ! sac ( ! p]itoneum4 ,if requir$1 x mu/ be done ) great caution1 z ! sac is g5]ally v ?94 ,9 cases :]e ! h]nia is *iefly om5tal1 ! sac %\ld be op5$1 le/ a knuckle ( b[el be inclos$ & /rangulat$ 9 ! om5tum4 ,,obturator ,,h]nia is an extremely r>e lesion1 & a l>ge proportion ( ! record$ cases 7 discov]$ only aft] dea?4 ,:5 diagnos$ dur+ life & /rangulat$1 "s h be5 r$uc$ by taxis1 & only a v few cases h be5 op]at$ on1 "s ) success4 ,x is n likely t a diagnosis c\ld be made1 except 9 v emaciat$ pati5ts1 9 :om pa9 at ! obturator =am5 0 a prom95t symptom1 & 9 :om x c\ld be asc]ta9$ positively t ! crural r+ 0 empty4 ,an incision ov] ! tum\r1 suffici5t to all[ ! pect9eus muscle to be expos$ & divid$1 is necess>y4 ,! h]nia may !n be r$uc$ )\t op5+ ! sac1 if rec5t2 if ( long /&+1 ! sac mu/ be op5$4 ,"o case is record$ by ,dr4 ,lor9z]1 9 :i*1 aft] /rangulation = elev5 days1 he op5$ ! sac & f\nd ! b[el gangr5\s4 ,! pati5t _h a fcal fi/ula2 b surviv$ ! op]ation = elev5 mon?s4 ,nuttel1 ,obr1 & ,bransby ,coop] h ea* diagnos$ & treat$ su* cases4#adf ,o!r =ms ( h]nia are s r>e1 & ! treatm5t ( ea* case mu/ necess>ily v>y s mu* 9 its circum/ances1 z n to require or admit ( any detail$ acc\nt ( ! op]ations requisite = _! relief4 ,,op]ations ,,= ,,! ,,radical ,,cure ,,( ,,h]nia4--,! inconv5i5ces & discom=t caus$ by ev5 ! be/-adju/$ trusses or b&ages1 ! unsatisfactory support !y af=d1 & ! risk ( _! slipp+ & all[+ ! h]nia to escape1 h giv5 rise to _m attempts to cure h]nia by op]ation4 ,ev5 to enum]ate ^! w\ld be q beyond ! limits ( ! pres5t volume2 suffice x to classify a few ( ! mo/ important ( !m accord+ to ! pr9ciple involv$ 9 ea*1 & !n give a v brief acc\nt ( ! me?od ( op]at+ :i* seems to be at once ! mo/ sci5tific1 lea/ dang]\s1 & mo/ p]man5tly useful4 ,! "q at issue is briefly ?is4 ,we h1 9 a h]nia1 ! foll[+ condition3--,! walls ( a great cavity are at "o or m po9ts specially weak1 ! conta9$ visc]a h protrud$1 ei!r by ext5sion & /ret*+ ( a natural op5+1 or by ! =mation ( a new brea* 9 ! walls1 &1 9 protrud+1 !y h br\ght ) !m z a cov]+ a s]\s membrane1 extremely ext5sible1 highly s5sitive to injury1 &1 :5 injur$1 c]ta9 to res5t x by sev]e1 spread+1 & dang]\s inflammation4 ,d we desire to rem$y ?is protrusion1 we may act-- #a4 ,on ! inte/9es !mselves2 b = all surgical purposes1 !y are out ( our rea*4 ,we _c d m ?an1 by dim9i%+ _! cont5ts1 dim9i% _! volume1 & by position & re/ r$uce to ! utmo/ _! t5d5cy to protrude4 ,?is includes ! m$ical & prophylactic treatm5t ( h]nia1 or r ( ! t5d5cy to h]nia4 #b4 ,we may try :at c be done ) ! sac :i* ! inte/9es h pu%$ d[n be=e !m4 ,c x be oblit]at$8 ,if x c1 p]haps ! inte/9es may be reta9$ 9 _! cavity4 ,v _m plans ( deal+ ) ! sac h be5 tri$4 ,to cause oblit]ation ( its cavity _m me?ods h be5 propos$3--by ligature ( x along ) ! sp]matic cord1 involv+ loss ( ! te/icle1 ei!r by gradual sep>ation1 by sl\gh+1 or by imm$iate removal2--by cutt+ into x1 & !n /it*+ x up2--by con/rict+ x ) wire1 z 9 ! punctum aureum2 by p9*+ sac & cov]+s up1 by pass+ ne$les "u !m z !y em]ge f ! ext]nal r+1 z ,bonnet ( ,lyons did2 by con/rict+ sac alone ) a d\ble wire1 by subcutane\s puncture1 z ,dr4 ,morton ( ,glasg[ has done2--by sev]e pressure f ! outside ) a /rong tight truss & a pad ( wood1 z propos$ by ,ri*t]2 by setons ( ?reads or c&lewicks1 z propos$ by ,s*uh ( ,vi5na2--by injection ( t9cture ( iod9e or can?>ides1 z by ,velpeau & ,pancoa/2--by ! introduction into ! sac ( ?9 bladd]s ( goldbeat]s' sk91 :i* 7 !n fill$ ) air1 & 7 int5d$ to excite inflammation1 z 9 ! radical cure ( hydrocele2 or by ! /ill m sev]e me?od ( ,lang5beck1 consi/+ 9 expos+ ! sac by a free incision at ! sup]ficial r+1 sep>at+ x f ! cord1 & pass+ a ligature r\nd ! sac alone1 leav+ ! ligatur$ portion 9 ! scrotum ei!r to become oblit]at$ or to sl\gh out4 ,s*muck] ( ,b]l9 v>i$ ?is1 by cutt+ away ! con/rict$ portion bel[ ! ligature4 ,! objections to ^! me?ods are v>i\s3 ! m g5tle are unc]ta9 & ineffici5t2 ( ! m sev]e1 "s involve mutilation1 by ! loss or removal ( ! te/icle2 o!rs1 z ^? ( ,lang5beck & ,s*muck]1 are v dang]\s & fatal1 by ! inflammation spread+ to ! p]itoneal cavity 7#bj to #cj p] c5t4 di$72 :ile all ( ^! me?ods af=d at be/ only tempor>y relief4 ,& ?is is only :at might h be5 expect$1 = ! sac 0 only a result ( ! protrusion1 n a cause2 & s long z ! weakness & insuffici5cy ( ! p>ietes ( ! abdom5 rema91 s long w ! ext5sible loosely-atta*$ p]itoneum cont9ue to furni% new sacs = visc]al protrusions4 #c4 ,we h n[ only ! canal left to act ^u2 & ! op]ations on ! canal may be divid$ into two great classes3-- 7a47 ,^? 9 :i* ! op]ator attempts to plug up ! dilat$ canal4 7b47 ,^? 9 :i* he tries to con/rict x1 by reunit+ its sep>at$ sides4 7a47 ,attempts to plug ! canal h1 9 mo/ cases1 be5 made by invag9ation ( ! sk9 ( ! scrotum & its fascia4 ,^! h be5 v num]\s & v>i\s 9 _! adaptation ( me*anical appliances1 b h all be5 design$ ) ! same object4 ,dzondi ( ,halle1 & ,jameson ( ,baltimore1 incis$ lancet-%ap$ flaps ( sk91 & endeav\r$ to fix !m by displacem5t ov] ! r+4 ,g]dy invag9at$ a portion ( scrotum & fascia into ! enl>g$ canal1 by ! =ef+] pu%$ x up1 & secur$ x 9 its place by a ?read pass$ f ! po9t ( 8 f+] fir/ ?r\gh ! invag9at$ sk91 !n ?r\gh ! abdom9al walls1 endeav\r+ to include ! walls ( ! +u9al canal1 caus+ ! po9t ( ! ne$le to project "s l9es above ! +u9al r+2 ! same process be+ effect$ ) ! o!r end ( ! ?read on ! o!r side ( ! f+]1 & ! two ends :i* h be5 br\ght out ne> ea* o!r on ! abdom9al wall1 be+ ti$ tightly ov] a cyl9d] ( pla/]4 ,! en%ea!d sac 0 !n pa9t$ ) cau/ic ammonia to excite inflammation1 & a pad put on ov] all4 ,signoroni modifi$ ?is by fix+ ! invag9at$ sk9 by a piece ( female ca!t]1 reta9$ 9 its place by transfixion by ?ree h>elip ne$les1 ti$ by twi/$ sutures4 ,wtz] ( ,bonn1 aga91 modifi$ ?is1 by sub/itut+ a complicat$ in/rum5t1 consi/+ ( a /\t plug 9 ! +u9al canal1 held 9 position by ne$les :i* are pass$ ?r\gh ! ant]ior wall ( ! canal 9 ! gro94 ,compression betwe5 plug & compress1 ) ! int5tion ( caus+ adhesion betwe5 sk91 fascia1 & sac1 is !n manag$ by means ( a screw4 ,! plug is reta9$ = ab\t sev5 days4 ,modifications ( ?is me?od h be5 tri$ by ,wells1 ,ro?mund1 & ,r$f]n ,davies1 all aim+ 9 ! direction ( simplicity2 b by f> ! mo/ simple & efficaci\s me?od on ! ,wtz] pr9ciple yet devis$ is t ( ,pr(essor ,syme1 :i* he describ$ 9 ! pages ( ! ,ed9burgh ,m$ical ,j\rnal = ,may #ahfa1 9 :i* ! invag9ation ( integum5t is bo? simply & securely manag$ by /rong ?reads1 z 9 ,g]dy's me?od1 :ile a piece ( b\gie or gutta-p]*a1 to :i* ! ?reads are fix$1 replaces ,wtz]'s exp5sive & complicat$ app>atus4 ,sir ,j4 ,fayr] ( ,calcutta has _h a v l>ge exp]i5ce ( ,wtz]'s me?od1 & also ( a plan ( 8 own4 ,out ( #ajb cases by ! latt] me?od1 #gg 7 cur$1 #i reliev$1 #ad fail$1 & #b di$4#adg ,mr4 ,prit*>d ( ,bri/ol has propos$ an additional /ep 9 op]ations on ! invag9ation pr9ciple1 consi/+ 9 ! /ripp+ ( a ?9 slip ( sk9 f ! orifice ( ! cutane\s canal1 & !n putt+ a p9 ?r\gh ! p>ts to get !m to unite1 & ?us close ! ap]ture completely4 ,n[1 :at results foll[ ^! op]ations8 ,at fir/ !y are almo/ inv>iably successful1 b ! compla9t is t1 9 mo/ cases1 ! rupture recurs4 ,! pr9ciple is to plug up ! passage by ! me*anical pres5ce ( ! invag9at$ sk91 ! plug be+ reta9$ 9 position by adhesive inflammation betwe5 x & ! edges ( ! dilat$ r+4 ,b ! r+ is left dilat$1 or1 inde$1 g5]ally its dilatation is increas$2 & z1 on cont9u$ pressure f )91 ! new adhesions give way1 or1 z (t5 happ5s1 a new protrusion takes place 9 ! circul> cul-de-sac necess>ily left all r\nd ! apex ( ! invag9ation1 ! /ill lax r+ & canal (f] no resi/ance to ! protrusion4 7b47 ,! pr9ciple ( con/riction ( ! canal by reunit+ its sep>at$ sides4 ,?is is ! pr9ciple ( ! v>i\s me?ods introduc$ by ,mr4 ,wood ( ,k+'s ,college1 & describ$ by him 9 8 mo/ able & exhau/ive "w4#adh ,he applies sutures ?r\gh ! sides ( ! dilat$ +u9al or crural canals1 or umbilical op5+s1 9 su* a mann] z to insure _! complete closure4 #a4 ,= +u9al h]nia4--,to /it* toge!r ! two sides ( ! canal ) safety requires att5tion to sev]al po9ts--7#a47 ,t x be done ne>ly1 if n entirely1 subcutane\sly4 7#b47 ,t ! protrud+ b[el %\ld be kept out ( ! way1 & n be transfix$ by ! ne$le4 7#c47 ,t ! sp]matic cord %\ld be protect$ f injuri\s pressure4 ,^! diff]5t indications are atta9$ by ,mr4 ,wood by a v +5i\s mode ( op]at+1 :i* ,i c describe "h only briefly1 & = a full description ( :i* ,i mu/ ref] to ,mr4 ,wood's own monograph already allud$ to4 ,= 8 fir/ tw5ty cases ,mr4 ,wood us$ /rong hemp5 ?read = ! /it*es2 ( late1 h[ev]1 he has prov$ ! great] advantage ( /rong wire4 ,:5 a l>ge old h]nia 9 an adult is ! subject ( op]ation1 x is ?us p]=m$ by ,mr4 ,wood3--,! pubes be+ %av$1 & ! pati5t put ?or\ghly "u ! influ5ce ( *lor(orm1 ! rupture is r$uc$1 & ! op]ator's =ef+] =c$ up ! canal s z to pu% e morsel ( b[el fairly into ! abdom54 ,an assi/ant !n comm&s ! int]nal r+ by pressure1 to prev5t return ( ! rupture4 ,an incision is made 9 ! scrotum ov] ! fundus ( ! sac1 l>ge en\gh to admit a =ef+] & ! l>ge ne$le us$ 9 ! op]ation2 ! edges ( ! sk9 are to be sep>at$ f ! fascia bel[ = ab\t "o in* all r\nd4 ,! =ef+] is !n to be pass$ 9 at ! ap]ture & pu%$ upw>ds1 invag9at+ ! deta*$ fascia be=e x1 & x mu/ be made to ent] ! +u9al canal f> en\gh to def9e ! l[] bord] ( ! int]nal oblique muscle /ret*$ ov] x4 ,a l>ge curv$ ne$le 7un>m$7 is !n pass$ on ! f+] z a guide1 ?r\gh ! int]nal oblique t5don1 ! int]nal portion ( ! r+1 & ! sk9 ( ! abdom52 x is !n ?read$ & )drawn4 ,aga91 ! ne$le 7n[ ) a ?read7 is guid$ by ! f+] & pu%$ ?r\gh ,p\p>t's ligam5t & ! ext]nal pill> ( ! r+ z be=e2 :ile by a little manipulation its po9t is made to protrude ?r\gh ! same op5+ 9 ! sk9 z be=e1 a loop ( ?read is n[ left !re1 & ! ne$le1 /ill ?read$1 is aga9 )drawn4 ,! next /it*1 /ill guid$ on ! f+]1 takes up ! t5d9\s lay] ( ! triangul> aponeurosis cov]+ ! out] bord] ( ! rectus t5don close to ! pubic sp9e2 ! po9t ( ! ne$le is !n turn$ obliquely1 s z to protrude ?r\gh ! orig9al puncture 9 ! sk9 a ?ird "t1 ! ne$le is !n fre$ f ! ?read & )drawn1 ?us leav+ two ends & "o int]m$iate loop ( ?read all at ! "o op5+4 ,^! are s arrang$ t :5 !y are tight5$ !y draw toge!r ! sides ( ! canal2 !y are !n secur$ ov] a compress ( l9t4 ,! compress is remov$ & ! /it*es loos5$1 at dates v>y+ f ! ?ird to ! sev5? day4 ,mr4 ,wood n[ uses wire in/ead ( ?read4 ,x has ! advantage ( great] firmness1 excites less suppuration1 & may be left mu* long] 9 situ1 9 consequ5ce ( :i* !re is less risk ( suppuration or pymia1 & m *ance ( a good consolidation ( ! p>ts4 ,9 cong5ital h]ni1 & small ruptures 9 *ildr5 & "y boys1 ,mr4 ,wood uses rectangul> p9s 9 ! foll[+ mann]3--,! scrotum be+ invag9at$ 7)\t any incision ?r\gh ! sk97 z f> z possible up ! canal1 a rectangul> p91 ) a slightly-curv$ spe>-po9t$ head1 is pass$ ?r\gh ! sk9 ( ! gro9 to ! op]ator's =ef+]2 guid$ by x1 x is br\ght safely d[n ! canal1 & br\ght out ?r\gh ! sk9 ( ! scrotum j ov] ! fundus ( ! h]nial sac4 ,a second p9 is pass$ f ! l[] op5+ 7/ill guid$ by ! f+]7 9 an upw>d direction1 transfix+ 9 its c\rse ! po/]ior surface ( ! out] pill> ( ! sup]ficial r+1 its po9t be+ br\ght out ?r\gh1 or at lea/ close to1 ! fir/ puncture made by ! fir/ p94 ,! p9s are !n lock$ 9 ea* o!r's loops--! punctures & sk9 protect$ by l9t or adhesive pla/]1--& ! :ole is reta9$ by l9t & a spica b&age4 ,! p9s %\ld g5]ally be )drawn ab\t ! t5? day4 ,! au?or has n[ 9 _m cases /it*$ ) catgut ! edges ( ! r+ aft] ! ord9>y op]ation = h]nia ) ! be/ effect4 #b4 ,= ,femoral ,rupture4--,cases suitable = op]ation are v infrequ5t2 b %\ld su* a "o be met )1 ,mr4 ,wood proposes ! foll[+ op]ation on ! same plan z ! prec$+4 ,! h]nia be+ fully r$uc$ & ! p>ts relax$ by position1 an incision ab\t an in* long %\ld be made ov] ! fundus ( ! tum\r1 & its edges rais$ s z to admit ! f+] fairly into ! crural op5+4 ,! ve9 is !n to be pu%$ inw>ds1 & ! ne$le pass$ ?r\gh ! pubic portion ( ! fascia lata ( ! ?igh1 & !n ?r\gh ,p\p>t's ligam5t1 appe>+ on ! sk9 ( ! abdom51 a wire is !n pass$ ?r\gh ! eye ( ! ne$le & hook$ d[n1 appe>+ ?r\gh ! w\nd1 x is !n )drawn1 & ! ne$le aga9 pass$ ?r\gh ! pubic portion ( ! fascia lata1 b ab\t ?ree-qu>t]s ( an in* to ! inside ( ! fir/ puncture1 !n ?r\gh ,p\p>t's ligam5t aga91 & protrud$ ?r\gh ! same orifice 9 ! sk92 ! o!r end ( ! wire is !n hook$ d[n z be=e1 leav+ a loop above1 at ! ne$le orifice1 & two ends at ! w\nd 9 ! sk9 bel[4 ,bo? loops & ends mu/ be manag$ z be=e4 ,! au?or aft] op]at+ = ! relief ( /rangulation 9 a case ( v l>ge femoral h]nia 9 a girl ag$ #bc1 /it*$ up ! neck ( ! sac1 & also /it*$ x to ,gimb]nat's ligam5t4 ,! result = "s mon?s 0 admirable1 ?\gh ! h]nia _h be5 a v difficult "o to replace f its size1 & _h be5 long 9 ! habit ( com+ d[n4 ,ev5tually protrusion occurr$ to a v slight ext5t1 b a truss keeps x completely up4 #c4 ,= ,umbilical ,rupture4--,! pr9ciple involv$ 9 ,mr4 ,wood's op]ation = umbilical rupture is precisely ! same z = +u9al & crural4 ,x consi/s 9 /it*+ ! two edges ( ! t5d9\s ap]ture by wire2 ! ne$le is pass$ on a sort ( small scoop or broad groov$ director1 :i* at once invag9ates ! sk9 & protects ! b[el4 ,two /it*es are ?us ins]t$ on ea* side4 ,= ! +5i\s me?od by :i* !y are introduc$ subcutane\sly1 ,i mu/ ref] to ! detail$ description 9 ,mr4 ,wood's monograph4 ,! wires are ?us twi/$ & tight5$ ov] a pad ( l9t or wood1 draw+ toge!r ! edges ( ! op5+ 9 ! t5don4 ,,op]ations ,,= ,,artificial ,,anus4--,9 *ildr5 ! condition kn[n z imp]=ate anus may sometimes be rem$i$ by exploratory op]ations 9 ! p]9eum1 guid$ by ! protrusion caus$ by ! di/5d$ inte/9e4 ,!re are o!r cases1 h[ev]1 9 :i* ! rectum1 z well z ! anus1 seems to be defici5t1 & 9 :i*1 f ! want ( protrusion1 !re is no w>rant = attempt+ an op]ation !re2 9 ^! ! only *ance ( life t rema9s is 9 an attempt to op5 ! b[el high] up4 ,9 adults1 aga91 absolute closure ( ! rectum & anus1 & complete ob/ruction1 may be ! result ( malignant disease1 or ev51 v r>ely1 ( simple organic /ricture4 ,9 su* cases1 :]e ! pati5t is tol]ably /rong & yet evid5tly doom$ f ! complete ob/ruction1 an attempt at ! =mation ( an artificial anus is w>rantable1 & 9 _m cases af=d great relief1 & prolongs life = mon?s4 ,)\t go+ into all ! v>i\s positions propos$ = su* op]ations1 ,i select ! two mo/ w>rantable1 :i* h borne ! te/ ( exp]i5ce4 ,^! are--#a4 ,colotomy 9 ! left lo94 ,?is is applicable 9 ! case ( adults ) rectal ob/ruction4 #b4 ,colotomy 9 ! left gro9 applicable 9 cases ( imp]=ate anus & defici5cy ( rectum 9 infants4 #a4 ,colotomy 9 ! left lo91 g5]ally kn[n by ! "n ( ,amussat's op]ation4--,! pati5t is laid ^u 8 face1 a pill[ plac$ "u ! abdom51 r5d]+ ! left flank prom95t4 ,a transv]se incision %\ld !n be made at a level ab\t two f+]-bread?s above ! cre/ ( ! ilium1 ext5d+ f ! out] edge ( ! erector sp9 muscle =w>d = f\r or five in*es1 accord+ to ! fatness ( ! pati5t2 ! muscles mu/ !n be c>efully divid$ till ! transv]salis fascia is expos$4 ,x is !n to be p9*$ up & divid$1 z 9 ! op]ation = /rangulat$ h]nia4 ,! muscul> wall ( ! colon uncov]$ by p]itoneum is !n 9 mo/ cases v easily recognis$ f its imm5se di/5sion4 ,! b[el %\ld !n be hook$ up by a curv$ ne$le1 two or ?ree po9ts at lea/ secur$ to ! m>g9s ( ! w\nds by /it*es1 & !n ! b[el %\ld be op5$ by a longitud9al incision ( at lea/ an in* 9 l5g?4 ,:5 ! di/5sion has be5 great1 !re is g5]ally a ru% ( fluid fces1 :i* mu/ be provid$ =1 special c>e be+ tak5 le/ any get into ! cavity ( ! p]itoneum4 ,illu/ration3 ,,fig4 ,,xxxiii4#adi #b4 ,colotomy 9 ! left gro91 = abs5ce ( anus & defici5cy ( rectum 9 newly born infants4--,! dissections ( ,curl+1 ,gossel91 & o!rs h %[n t 9 infants ! op]ation ( lumb> colotomy is v difficult1 & its results unc]ta91 :ile x is comp>atively easy to op5 ! colon 9 ! left gro94 ,hugui]1 aga91 has %[n t 9 c]ta9 cases ! colon is n to be f\nd 9 ! left gro91 b is accessible 9 ! "r gro94 ,?is abnormality seems1 z %[n by ,curl+1 to occur n (t5] ?an once 9 e t5 cases4 ,op]ation4--,an oblique incision f an in* & a half to two in*es 9 l5g? %\ld be made 9 ! left iliac region above ,p\p>t's ligam5t1 ext5d+ a little above ! ant]ior-sup]ior sp9\s process ( ! ilium4 ,! fibres ( ! abdom9al muscles %\ld be divid$ on a director pass$ b5ea? !m1 & ! p]itoneum %\ld next be cauti\sly op5$ to a suffici5t ext5t4 ,! colon w mo/ likely protrude1 b if small inte/9e appe> ! colon mu/ be s\ght = high] up4 ,a curv$ ne$le arm$ ) a silk ligature %\ld be pass$ l5g?ways ?r\gh ! coats ( ! upp] "p ( ! colon1 & ano!r ins]t$ 9 ! same way bel[1 & ! b[el1 be+ drawn =w>ds1 %\ld !n be op5$ by a longitud9al incision4 ,! colon mu/ aft]w>ds be atta*$ to ! sk9 =m+ ! m>g9 ( ! w\nd by f\r sutures at ! po9ts ( entry & exit ( ! ne$les4 ,,op]ation ,,= ,,! ,,removal ,,( ,,an ,,artificial ,,anus1 9 cases :]e ! b[el is pat5t bel[4--,aft] ! op]ation = h]nia 9 a case :]e ! b[el is gangr5\s1 ! only hope ( ! pati5t's recov]y consi/s 9 ! =mation ( adhesions betwe5 ! b[el & ! ext]nal w\nd1 & ! pres5ce1 = a "t at lea/1 ( an artificial anus4 ,if adhesions d =m1 & ! pati5t recov]s1 x becomes a matt] ( great importance = 8 future com=t t ! canal ( ! inte/9e %\ld be re-e/abli%$1 & ! fi/ul\s op5+ all[$ to close4 ,?is1 h[ev]1 is by no means easy1 z ev5 :5 ! portion ( inte/9e de/roy$ has be5 v small1 a septum or valve rema9s :i* directs ! cont5ts ( ! b[el outw>ds1 & s long z x exi/s is an effectual ob/acle to any ( ! fcal cont5ts pass+ into ! di/al portion ( ! b[el4 ,?is septum or p]on is =m$ by ! mes5t]ic side ( ! two ends ( ! b[el4 ,to de/roy ?is )\t caus+ p]itonitis is ! aim ( ! surgeon1 & x is n an easy matt] to accompli%4 ,to cut x away w\ld at once op5 ! p]itoneal cavity1 s ! mode ( treatm5t n[ adopt$ 9 ! r>e cases :]e x is necess>y is t recomm5d$ by ,dupuytr54 ,! pr9ciple ( x is to de/roy ! p]on by pressure s gradual z to cause adhesive inflammation betwe5 ! two surfaces1 & ?us seal up ! cavity ( ! p]itoneum1 be=e ! cont9uance ( ! same pressure %all h caus$ sl\gh+ ( ! septum4 ,?is is manag$ by ! gradual approximation by a screw ( ! blades ( a pair ( =ceps1 to :i* ,dupuytr5 gave ! "n ,ent]otome4 ,! process1 :i* ext5ds ov] days & weeks1 mu/ be c>efully wat*$ le/ ! inflammation g too f>4 ,pla/ic op]ations are occasionally requir$ to close ! op5+ aft] ! passage is re/or$4 ,= a good example ( su* an op]ation see ,ed94 ,m$4 ,j\rnal = ,augu/ #ahgc1 9 :i* ,mr4 ,john ,duncan describes a case4 ,,footnotes3 #ada ,description ( ,sir ,sp5c] ,wells's ,troc>4--,x consi/s ( a holl[ cyl9d] six in*es long1 & half an in* 9 diamet]1 )9 :i* ano!r cyl9d] fitt+ x tightly plays4 ,! inn] "o is cut (f at its extremity1 some:at 9 ! =m ( a p51 & is %>p4 ,! %>p end is kept retract$ )9 ! out] cyl9d] by a spiral spr+ 9 ! h&le at ! o!r end1 b c be protrud$ by press+ on ?is h&le :5 requir$ = use4 ,:5 ?us protrud$ x is plung$ into ! cy/ up to its middle2 ! pressure on ! h&le is tak5 (f1 & ! cutt+ edge is retract$ )9 its %ea?4 ,! fluid ru%es into ! tube1 & escapes by an ap]ture 9 ! side1 to :i* an india-rubb] tube is atta*$1 ! end ( :i* drops into a bucket "u ! table4 ,! in/rum5t is furni%$ at its middle ) two semicircul> b>s1 c>ry+ ea* f\r or five long curv$ tee? l a vulsellum4 ,^! tee? lie 9 contact ) ! out] surface ( ! cyl9d]1 b c be rais$ f x by press+ two h&les4 ,:5 ! cy/ beg9s to be flaccid by ! escape ( ! fluid1 ^! side vulsellums are rais$1 & ! adjo9+ "p ( ! cy/ is drawn up "u ! tee?1 :]e x is firmly caught & compress$ aga9/ ! side ( ! tube4 #adb ,= fur!r details on ! op]ations describ$ above1 ref]5ce may be made to ,sir ,sp5c] ,wells's "w on ov>ian disease1 & to ! v valuable pap]s contribut$ by ,dr4 ,?omas ,kei? to ! ,ed9burgh ,m$ical ,j\rnal4 ,to ! latt] especially ! au?or is indebt$ = mu* oral in/ruction1 & = ! opportunity ( see+ 8 c>eful & dext]\s mode ( op]at+4 #adc ,lect4 on ,surg]y1 #c;d ed41 vol4 ii4 p4 #iih4 #add ,op]ative ,surg]y1 p4 #dfb4 #ade ,r\gh diagram ( abnormal c\rse ( obturator & its relation to ! neck ( a h]nia4 ,p>ts se5 f ! inside3 ,h1 femoral h]nia2 ,a1 femoral art]y2 ,v1 femoral ve92 ,e1 epiga/ric art]y2 ,o1 obturator f epiga/ric 7dang]\s72 ,s ,o1 obturator f epiga/ric 7safe72 ,n ,o1 normal c\rse ( obturator2 ,i ,r1 int]nal +u9al r+2 ,sp ,c1 sp]matic *ord & its vessels2 ,g1 ,gimb]nat's ligam5t2 1 9 triangle ( ,hesselba*4 #adf ,holmes's ,surg]y1 #c;d ed41 #ahhc1 vol4 ii4 p4 #hcg4 #adg ,cl9ical & ,pa?ological ,obs]vations 9 ,india1 pp4 #dd1 #cbe4 #adh ,wood ,on ,rupture1 #ahfc4 #adi ,diagram ( an artificial anus1 %[+ small sutures :i* unite ! edges ( ! gut & ! sk91 & ! l>ge ones /it*+ up ! w\nd beyond4 ,,*apt] ,,xii4 ,,op]ations ,,on ,,pelvis4 ,,li?otomy4--,h[ev] int]e/+ & ev5 in/ructive x might be1 any hi/ory ( ! v>i\s op]ations = ! removal ( calculi f ! bladd] w\ld be q out ( place 9 a manual su* z ?is4 ,x w be suffici5t "h to describe ! op]ations recomm5d$ & practis$ 9 ! pres5t day4 ,!re are ?ree diff]5t situations 9 :i* ! bladd] may be ent]$ = ! purpose ( remov+ a calculus3-- #a4 ,! p]9eum1 :]e access is ga9$ ?r\gh ! ure?ra1 pro/ate1 & neck ( ! bladd]4 #b4 ,above ! pubes1 :]e ! portion ( bladd] n cov]$ by p]itoneum is op5$ f above4 #c4 ,f ! rectum4 #a4 ,,li?otomy ,,?r\gh ,,! ,,p]9eum1 by f> ! mo/ frequ5t position = ! op]ation4--,v v>i\s me?ods = its p]=mance h be5 devis$1 diff]+ 9 ! nature & %ape ( ! in/rum5ts employ$1 ! direction & size ( ! incisions1 ! nature ( ! w\nd2 b all resemble ea* o!r 9 c]ta9 v c>d9al & important p>ticul>s4 ,?us all agree t x is absolutely necess>y to ent] ! bladd] at "o spot--! neck ( ! bladd]2 & t to d ?is safely ! ure?ra mu/ be op5$1 & "s in/rum5t previ\sly introduc$ by ! ure?ra is to be us$ z a guide = ! knife4 ,b an in/rum5t 9 ! ure?ra & bladd] is surr\nd$ = at lea/ an in* ( its c\rse by ! pro/ate2 & ?us ! knife1 gorget1 or f+]1 :i*1 guid$ by ! in/rum5t 9 ! ure?ra1 is int5d$ to cut or dilate ! entrance to ! bladd] = ! purpose ( all[+ ! calculus to be remov$1 _c d ?is )\t also cutt+ or dilat+ ?is pro/ate gl&4 ,exp]i5ce has prov$ t mu* ( ! success ( ! op]ation dep5ds ^u ! position & am\nt ( incision made 9 ?is pro/ate gl&4 ,b x might be ask$1 ,:y c we n ent] ! bladd] by "o side1 avoid+ altoge!r its neck & ?is pro/ate gl&8 ,= ?is1 among o!r reasons1 t ! bladd] normally conta9s1 & s long z ! pati5t lives mu/ conta91 a c]ta9 quantity ( a v irritat+ fluid4 ,x is surr\nd$ by ! loose areol> tissue ( ! pelvis1 into :i*1 if any ( ?is fluid escapes1 abcesses w =m & dea? probably ensue2 ?is result w almo/ c]ta9ly foll[ any op5+ made into ! bladd] except at "o spot4 ,?is spot is ! neck ( ! bladd]4 ,:y does ur9>y infiltration n occur !re8 ,because ! fascia ( ! pelvis 7:i* :5 entire c resi/ infiltration7 is prolong$ =w>ds at ! neck ( ! bladd]1 ov] ! pro/ate 7,fig4 ,,xxxiv4 ,,pf71 = :i* x =ms a v /rong funnel-l %ea?4 ,s long z ?is %ea? is n cut :]e x cov]s ! sides ( ! pro/ate1 ur9>y infiltration ( ! pelvis is impossible1 ! ur9e be+ c>ri$ =w>ds & fairly out ( ! pelvis 9 ?is ur9e-tight funnel4 ,illu/ration3 ,,fig4 ,,xxxiv4#aej ,b x may n[ be said1 ,if ?is be ! case1 we are v mu* limit$ 9 ! size ( ! incision we may make into ! bladd]4 ,we _c remove a l>ge /one1 = ! pro/ate ought n to be l>g] ?an a good-siz$ *e/nut1 & any cut we might make ?r\gh a *e/nut )\t cutt+ out ( its side mu/ be v small4 ,v true2 b =tunately ! %ea? ( ! pro/ate1 unlike ! r9d ( ! *e/nut1 is v freely dilatable1 & w all[ ! passage ( a v consid]able /one4 ,aga91 an inquir] might ask1 ,if x is s dilatable1 :y %\ld we run ! risk ( cutt+ ! pro/ate at all8 ,:y %\ld we n introduce in/rum5ts gradually increas+ 9 size into ! membran\s portion ( ! ure?ra1 & ?us dilate pro/ate & neck ( bladd]8 ,= ?is reason1 t ! ure?ral canal pass+ ?r\gh ! pro/ate is itself l9$ imm$iately outside ( ! muc\s membrane by a firm membran\s %ea? 7,fig4 ,,xxxiv4 ,,rr71 :i* resi/s dilatation to ! utmo/4 ,exp]i5ce tells u t any attempts to dilate or ev5 =cibly to te> ?is r+ ( fibr\s texture are bo? ineffectual & dang]\s1 :ile a clean cut into x & ?r\gh x into ! sub/ance ( ! pro/ate is at once effectual & comp>atively safe4 ,9 a ^w1 we c describe ! relation ( ! pro/ate to ! op]ation ( li?otomy some:at 9 ?is mann]3--,its fibr\s %ea? surr\nd+ ! ure?ra mu/ be cut freely4 ,! gl& sub/ance may be cut & freely dilat$ by ! f+]4 ,its fibr\s envelope mu/1 z f> z possible1 be pres]v$ intact1 b ?is int]f]es ! less ) ! op]ation1 z x is comp>atively freely dilatable4 ,! firm l9+ ( ! ure?ra1 :i* mu/ be cut1 is specially /rong at its base1 =m+ a t\gh resi/+ b& j at ! ap]ture ( ! bladd]1 :i*1 un=tunately1 is (t5 s high up 9 ! pelvis 9 tall pati5ts1 or 9 cases 9 :i* ! pro/ate is mu* enl>g$1 z to be almo/ out ( rea* ( ! f+]1 & s f> up ! /aff z p]haps to escape division4 ,y w be w>n$ ( su* an occurr5ce by ! ur9e 9 ! bladd] fail+ to make its appe>ance2 & if any attempt be made to dilate ! op5+ & introduce ! =ceps )\t fur!r incision ( ! base ( ! pro/ate1 ! result w v likely be fatal1 g5]ally f pymic symptoms dep5d+ on a suppurative inflammation ( ! pro/atic plexus ( ve9s 7,fig4 ,,xxxiv474 ,9 fact1 ^u a recognition ( ?is fact is f\nd$ ! aphorism1 t cases 9 :i* ! =ceps h be5 introduc$ be=e ! bladd] fairly beg9s to empty its cont5ts are g5]ally fatal4 ,illu/ration3 ,,fig4 ,,xxxv4#aea ,we h ?us trac$ ! necess>y guid+ pr9ciples z to our incisions f ! bladd] outw>ds ?r\gh ! pro/atic portion ( ! ure?ra4 ,we h next to discov] :at sort ( an op5+ is necess>y 9 ! membran\s portion ( ! ure?ra consi/5t ) ! fulfilm5t ( ! same conditions1 namely1 fre$om ( escape = ! ur9e1 & room en\gh to remove ! /one4 ,bo? ( ^! are ga9$ at once by a free incision ( ! membran\s portion1 divid+ especially ^? ant]ior fibres ( ! great sph9ct] muscle ( ! pelvis1 ! levator ani1 :i* embrace ! membran\s portion1 "u ! special names ( compressor 7,fig4 ,,xxv47 & levator ure?r 7,gu?rie's & ,wilson's muscles74 ,! pr9ciples :i* guide ! position & size ( ! prelim9>y incisions :i* enable ! ure?ra to be op5$ are v simple3--7#a47 ,! w\nd 9 ! p]9eum %\ld be l>ge en\gh to give free access to ! ure?ra1 & easy egress to ! /one2 7#b47 ,x %\ld be conical1 ) its base outw>ds1 s z to fav\r escape ( ur9e & prev5t infiltration2 7#c47 ,x %\ld n w\nd any important organ or vessel2 t is1 x mu/ avoid ! rectum1 ! corpus spongiosum1 especially ! bulb1 if possible1 ! art]y ( ! bulb1 & 9 e case %\ld leave ! pudic art]y intact4 ,s f> = broad g5]al pr9ciples1 :i* mu/ guide all me?ods ( successful li?otomy4 ,,! ,,lat]al ,,op]ation4--,op]ation ( ,*eseld54--7#a47 ,in/rum5ts requir$4--,a /aff ) a broad sub/antial h&le1 & a long] curve ?an ! ord9>y ca!t] requires1 furni%$ ) a v deep & wide groove1 :i* occupies ! space midway betwe5 its convexity & its left side4 ,! "o us$ %\ld inv>iably be l>ge en\gh to dilate fully ! ure?ra4 ,a knife1 ) its blade ?ree or f\r in*es 9 l5g?1 b %>p only = an in* & a half f its po9t1 its back /raight up to )9 a six? ( an in* ( its po9t1 & !re deflect$ at an angle to ! po9t1 :i* aga9 curves to ! edge4 ,! angle f ! back to ! po9t p]mits ! knife to run m freely along ! groove 9 ! /aff4 ,a probe-po9t$ /raight knife ) a n>r[ blade may occasionally be useful 9 enl>g+ ! incision 9 ! pro/ate1 :5 ?is is requir$ by ! size ( ! /one4 ,=ceps ( v>i\s sizes & %apes1 "s ) ! blades curv$ at an angle to rea* /ones ly+ beh9d an enl>g$ pro/ate1 all ) broad blades z ?9 z is consi/5t ) p]fect inflexibility1 ! blades holl[$ & r\gh5$ 9 ! inside1 b )\t ! project+ tee? sometimes recomm5d$1 :i* are dang]\s f be+ apt to break ! /one4 ,a scoop to remove fragm5ts or small /ones1 sometimes useful ) ! aid ( ! =ef+] 9 lift+ out a l>ge "o4 ,a flexible tube ( at lea/ half an in* calibre1 & ab\t six in*es long1 r\nd$ (f & f5e/rat$ above1 fitt$ at its out] end ) a r+ & two eyelet-holes = ! tapes1 ) :i* x is ti$ into ! bladd]4 ,prior to ! op]ation ! pati5t's heal? %\ld be att5d$ to1 ! /oma* & b[els regulat$1 & any disord] ( ! kidneys or bladd] z f> z possible alleviat$4 ,if 8 heal? has be5 good & habits active1 ?ree or f\r days' conf9em5t to 8 room on l[ diet1 ) a full purge ! ev5+ be=e ! op]ation1 is all ! prep>atory treatm5t t is necess>y4 ,x is ( ! utmo/ importance = ! safety ( ! op]ation & ! pati5t's com=t aft] x1 t ! rectum be completely unload$ be=e ! op]ation1 & ! b[els s f> empti$ z to p]mit ?ree or f\r days aft] ! op]ation to elapse )\t any movem5t ( ! b[els be+ necess>y4 ,if !re is any d\bt z to ! effect ( ! laxative1 a l>ge /imulant enema %\ld be adm9i/]$ on ! morn+ ( ! op]ation4 ,position4--,mu* dep5ds on ! prop] ty+ up ( ! pati5t4 ,he %\ld be plac$ ) 8 bree* project+ ov] ! edge ( a n>r[ table1 ) head slightly rais$ on a pill[1 b ! %\ld]s l[4 ,! h&s are !n to be secur$ ea* to its correspond+ foot1 by a /rong b&age pass+ r\nd wri/ & in/ep1 or by suitable lea!r anklets1 ! knees %\ld be wide ap>t1 & on exactly ! same level1 s t ! pelvis may be q /raight4 ,an assi/ant %\ld be plac$ to take *>ge ( ea* leg4 ,! /aff is next introduc$ & ! /one felt2 if !re is little wat] 9 ! bladd] a few ounces may be inject$1 b ?is is r>ely necess>y1 = ! pati5t %\ld be ord]$ to reta9 z mu* wat] z possible1 & :5 he _c reta9 x1 injection ( wat] may d h>m1 & w probably n be reta9$1 b at once come away along ! groove 9 ! /aff4 ,! /aff is !n committ$ to a special assi/ant1 :o mu/ be ?or\ghly up to 8 duty1 & att5d to ! /aff alone4 ,"s surgeons direct ! assi/ant to make ! convexity ( ! /aff bulge 9 ! p]9eum1 to enable ! groove to be /ruck m easily4 ,x w be1 h[ev]1 saf] bo? = ! rectum & ! bulb1 if ! /aff be hook$ firmly up aga9/ ! symphysis pubis1 z advis$ by ,li/on4 ,! same assi/ant c also keep ! scrotum up out ( ! way4 ,if ! p]9eum has n be5 previ\sly %av$1 ?is is n[ done4 ,! op]ator sits d[n on a l[ /ool 9 front ( ! pati5t's bree*1 8 in/rum5ts be+ ready to 8 h&1 & !n /eady+ ! sk9 ( ! p]9eum ) ! f+]s ( 8 left h&1 ent]s ! po9t ( ! knife 9 ! raphe ( ! p]9eum1 midway betwe5 ! anus & scrotum 7"o in* 9 front ( anus--,*eseld51 ,cri*ton2 "o & a qu>t]--,gross1 ,skey1 & ,brodie2 "o & ?ree-qu>t]s--,f]gusson2 "o in* beh9d ! scrotum--,li/on71 & c>ries ! incision obliquely d[nw>ds & outw>ds1 9 a l9e midway betwe5 ! anus & tub]osity ( ! is*ium4 ,! l5g? ( ! incision mu/ v>y ) ! size ( ! p]9eum1 & ! suppos$ size ( ! /one1 b !re is less risk 9 its be+ too l>ge1 s long z ! rectum is safe1 ?an 9 its be+ too small4 ,its dep? %\ld be greate/ at its upp] angle1 :]e x has to divide ! p>ts to ! dep? ( ! transv]se muscle ( ! p]9eum1 & lea/ at its l[] angle1 :]e a deep incision is n requir$1 & w\ld be almo/ sure to w\nd ! rectum4 ,! =ef+] ( ! left h& is n[ to be deeply ins]t$ into ! w\nd1 & any rema9+ fibres ( ! levator ani 9 front are to be divid$1 ! edge ( ! knife be+ direct$ f above d[nw>ds4 ,! left =ef+] be+ /ill us$ to pu% its way ?r\gh ! cellul> tissue1 ! groove 9 ! /aff is n[ felt 9 ! membran\s portion ( ! ure?ra cov]$ by ! deep fascia ( ! p]9eum4 ,n[ comes ! deep] "p ( ! incision4 ,guid$ by ! f+]-nail ( ! left h&1 ! surgeon introduces ! po9t ( ! knife into ! groove ( ! /aff4 ,he !n takes hold ( ! /aff = a mom5t to feel t x is held up prop]ly aga9/ ! pubis1 & 9 ! middle l9e1 & also t ! knife is fairly 9 ! groove4 ,giv+ ! /aff back aga9 to ! assi/ant1 & keep+ ! rectum well out ( ! way by ! left h&1 he n[ /eadily directs ! knife along ! groove ( ! /aff till ! bladd] is fairly ent]$1 & ! r+ at ! base ( ! pro/ate completely divid$4 ,:5 ?is is ! case a gu% ( ur9e takes place1 foll[+ ! )drawal ( ! knife4 ,:5 mak+ ! deep incision1 & 9 ! groove ( ! /aff1 ! blade ( ! knife %\ld lie nei!r v]tical nor horizontal1 b midway betwe5 ! two1 s z to make ! section ( ! left lobe ( ! pro/ate 9 its longe/ diamet]1 t is1 9 a direction d[nw>ds & backw>ds 7,fig4 ,,xxxiv4 ,l74 ,! knife is n[ )drawn1 & ! left =ef+] ins]t$4 ,9 mo/ cases x w be long en\gh to rea* ! bladd] & t\* ! /one1 & may !n be freely us$ by gradual pressure to dilate ! w\nd2 ?is may be done v freely :5 necess>y = a l>ge /one1 if only ! r+ ( fibr\s tissue surr\nd+ ! ure?ra be fir/ cut & ! bladd] fairly ent]$4 ,:5ev] ! /one is felt by ! f+]1 ! assi/ant may )draw ! /aff4 ,:5 ! op]ator has ?us felt ! /one & suffici5tly dilat$ ! w\nd1 ! next /ep is to introduce ! =ceps2 ?is %\ld be done "u ! guidance ( ! f+]1 & ) ! blades clos$4 ,:5 ! /one is felt ! blades %\ld be op5$ v widely1 slightly )drawn1 & !n pu%$ 9 aga91 ! l[] "o1 if possible1 be+ ins9uat$ "u ! /one4 ,! blades mu/ be made fairly to grasp & conta9 ! /one 9 _! holl[1 = if !y only nibble at ! end ( an oval /one1 extraction is impossible4 ,extraction %\ld !n be p]=m$ sl[ly1 ) alt]nate wriggl+s ( ! =ceps f side to side1 s z gradually to dilate1 n to te>1 ! pro/ate1 & ! op]ator mu/ rememb] to pull 9 ! axis ( ! pelvis1 n aga9/ ! os pubis or ! promontory ( ! sacrum4 ,if !re is mu* resi/ance1 x may possibly be caus$ by ! /one hav+ be5 caught 9 its long] axis1 & ?is may be rem$i$ by c>eful manipulation by means ( ! f+] & =ceps4 ,if ! /one is /ill too l>ge to be extract$ )\t great] =ce ?an is w>rantable1 !re are /ill v>i\s exp$i5ts 7see infra1 pp4 #bfe1 #bgj74 ,9 mo/ cases1 h[ev]1 ! /one is remov$ rapidly en\gh by ! s+le incision4 ,! f+]1 or a s\nd1 mu/ !n be introduc$ to feel if any m /ones are pres5t4 ,! clos$ =ceps make a v effectual in/rum5t = ?is purpose4 ,mu* in=mation may be ga9$ f ! appe>ance ( ! fir/ /one1 ! pres5ce or abs5ce ( facets4 ,its smoo?ness or r\ghness enables u to =m a pretty c]ta9 op9ion2 yet ! bladd] %\ld always be c>efully se>*$2 & if ! /one has be5 friable or brok5 9 extraction1 %\ld be wa%$ out by a curr5t ( wat]4 ,:]e ! calculi are v num]\s1 or :]e _m fragm5ts h sep>at$1 ! scoop w be f\nd useful1 bo? = detect+ & remov+ !m4 ,all ! /ones be+ extract$1 !re is 9 mo/ cases little or no ble$+ 7see infra1 ,hmorrhage74 ,! tube already describ$ may n[ be ins]t$ & ti$ into ! bladd]4 ,x may be reta9$ = =ty-eight or sev5ty-two h\rs1 accord+ to circum/ances4 ,c>e mu/ be tak5 le/ x be clos$ up by coagula dur+ ! fir/ h\r or two aft] ! op]ation4 ,9 *ildr5 ! tube is n necess>y1 & f _! re/lessness might possibly d h>m1 b 9 adults 7?\gh neglect$ by "s surgeons7 exp]i5ce %[s x is a valuable adjunct 9 ! aft]-treatm5t4 ,hav+ ?us trac$ ! c\rse ( an ord9>y uncomplicat$ case ( li?otomy by ! lat]al op]ation1 a brief notice is suitable ( "s ( ! ob/acles & difficulties1 "s ( ! dang]s & bad results :i* may be met )1 & ! be/ me?ods ( ov]com+ !m4 #a4 ,l>ge size ( ! /one1 z an ob/acle to extraction4 ,:51 ei!r f ! enorm\s size ( ! /one1 g5]ally to be made out be=e ! op]ation1 or f "s cong5ital or acquir$ de=mity ( ! pelvis1 x is obvi\s be=eh& t ! calculus _c pass ?r\gh ! bony pelvis entire1 a *oice ( two c\rses rema9s1 ei!r-- 7#a47 ,! high or supra-pubic op]ation 7q4v4 infra72 or 7#b47 ,cru%+ ( ! calculus 9 ! bladd]1 & removal piecemeal4 ,in/rum5ts ( great /r5g? h be5 devis$ = ?is latt] op]ation4 ,! risk to ! bladd] is v great1 & fragm5ts are apt to be left beh9d2 ^! are sure to =m nuclei ( new calculi4 #b4 ,peculi>ities 9 ! position or relations ( ! /one 9 ! bladd]3-- 7#a47 ,x may lie 9 a sort ( p\* beh9d ! pro/ate1 & ?us be out ( ! rea* ( ! =ceps4 ,?is may be rem$i$ by ! use ( curv$ =ceps1 or1 bett] /ill1 by ! f+] 9 ! rectum to tilt up ! /one into ! bladd]4 7#b47 ,x may lie above ! pubis 9 ! ant]ior wall ( ! bladd]4 ,pressure on ! hypoga/rium1 or ! use ( a /rong probe z a hook1 w g5]ally suffice to dislodge x4 7#c47 ,! /one may be ency/$4 ,?is is extremely r>e1 &1 z ,f]gusson says1 we he> m ( ^! f bungl]s :o h op]at$ only sev]al times1 ?an f ^? :o h _h l>ge exp]i5ce4 #c4 ,an enl>g$ pro/ate is at once a s\rce ( difficulty & ( "s dang]4 ,! di/ance ( ! bladd] f ! surface may be s v mu* increas$ by enl>gem5t ( ! pro/ate z to r5d] ev5 ! longe/ =ef+] too %ort to rea* ! /one or ev5 ! bladd]4 ,?is r5d]s ! introduction ( ! =ceps m difficult & unc]ta91 ! dilatation m prolong$1 & ! extraction m dang]\s4 ,if v l>ge1 ! groove ( ! /aff may n rea* ! bladd]1 & ?us ! deep incision may fail ( cutt+ ! r+ at ! base ( ! gl&1 & ! ur9e may ?us n escape1 & all ! dang]s ( lac]ation ( ! r+ may result4 ,su* cases may be well manag$ by ! ins]tion ( a /raight deeply groov$ /aff into ! insuffici5t incision1 & fairly into ! bladd]1 & on ?is1 pu%+ a cutt+ gorget ?r\gh ! uncut portion ( ! gl&4 ,?is insures a suffici5t yet n dang]\s incision1 :i* we _c s safely p]=m ) ! knife1 z ! p>ts are s f> beyond ! rea* ( ! guid+ =ef+]4 ,"u ! head ( risks aft] li?otomy we may class ! foll[+3-- #a4 ,s9k+1 or %ock4 ,9 ! v ag$ or v "y1 or aft] a v prolong$ or pa9ful op]ation1 %ock may n[ & !n kill ! pati5t )9 a few h\rs4 ,s9ce ! days ( *lor(orm ?is result is extremely r>e4 #b4 ,hmorrhage seems to be a v infrequ5t risk4 ,! transv]se p]9eal art]y1 :i* is always cut 9 ! op]ation1 is small1 & r>ely ble$s mu*4 ,if ! bulb is w\nd$1 z no d\bt frequ5tly occurs1 ! fl[ f x c easily be *eck$4 ,! pudic is s well protect$ f any ord9>y incision z to be practically safe2 & if w\nd$ by "s frightfully ext5sive incision1 x c be compress$ aga9/ ! tub]osity ( ! is*ium4 ,!re is an abnormal di/ribution ( ! dorsal art]y ( ! p5is1 9 :i*1 ris+ high] up ?an x ought1 & c\rs+ along ! neck ( ! bladd]1 & ! lat]al lobe ( ! pro/ate1 x may be divid$4 ,?is may give tr\ble1 & ev5 result 9 fatal hmorrhage4 ,=tunately x is r>e4 ,! au?or has met ) "o case 9 a boy ( elev51 9 :om a v sev]e hmorrhage 0 n to be expla9$4 ,! pati5t recov]$ )\t ano!r bad symptom4 ,aga91 a g5]al ooz+ may (t5 appe> a few h\rs aft] ! op]ation1 :5 ! pati5t is w>m 9 b$1 app>5tly f ! sub/ance ( ! pro/ate4 ,if rais+ ! bree* & ! application ( cold fail to arre/ x1 x may be necess>y to plug ! w\nd4 ,?is is done by /uff+ x ) long /rips ( l9t r\nd ! tube4 ,great c>e mu/ be !n tak5 le/ ! tube become occlud$4 #c4 ,infiltration ( ur9e may occur z a result ( a too free incision ( ! vesical fascia 79 adults71 & /ill m frequ5tly ( a too small ext]nal w\nd4 ,"h x %\ld be notic$ t 9 *ildr5 x is =tunately ( v little consequ5ce to pres]ve ! integrity ( ! pro/atic %ea? ( vesical fascia4 ,9 !m ! pro/ate is s exce$+ly small & undevelop$1 t ev5 ! =ef+] c\ld n be introduc$ into ! bladd] )\t a complete section ( ! pro/ate4 ,probably f ! bl&] nature ( _! ur9e1 & ! great] vitality ( _! tissues1 ?is is ( less consequ5ce1 z x is r>ely f\nd t any bad effects result f ?is section4 ,among o!r risks we f9d p]itonitis1 inflammation ( neck ( bladd]1 inflammation ( pro/atic plexus ( ve9s1 result+ 9 pymia1 suppression ( ur9e1 & o!r kidney complications4 ,= ! symptoms & treatm5t ( ^! !re is no place 9 a m]e manual ( surgical op]ations4 ,w\nd ( rectum & recto-vesical fi/ula4--,su* w\nds 7 n uncommon1 & 9 _m cases unavoidable1 be=e ! days ( *lor(orm1 f ! /ruggles ( ! pati5t2 n[ !y are comp>atively r>e1 & %\ld be /ill r>]4 ,!y probably occur 9 m cases ?an ! surgeon is aw>e (1 & heal up )\t 8 k2 we may arrive at ?is conclusion f ! fact t small w\nds are f\nd 9 po/-mortem exam9ations ( cases 9 :i* no su* complication has be5 ?\ght (4 ,!y occasionally heal )\t giv+ any tr\ble1 b1 at o!r times1 z ! ext]nal w\nd contracts1 a communication =ms betwe5 rectum & ! ure?ra1 9 :i* ! cont5ts are apt to be int]*ang$ 9 a mo/ disagreeable mann]1 flatus pass+ p] ure?ram1 & ur9e p] rectum4 ,:5 x is evid5tly n go+ to heal spontane\sly1 ! septum betwe5 ! ext]nal orifice ( ! w\nd & ! communication ) ! gut %\ld be laid op51 z 9 ! op]ation = fi/ula 9 ano4 ,!re are c]ta9 modifications & v>ieties 9 ! me?od ( op]at+ = /one ?r\gh ! p]9eum1 :i* des]ve at lea/ a brief notice3-- #a4 ,! bilat]al op]ation4--,?\gh he 0 n ! inv5tor1 ,dupuytr5's "n is ju/ly associat$ ) ?is op]ation4 ,! pr9ciple ( x is to divide bo? sides ( ! pro/ate equally1 s z to give m room = extraction ( a l>ge /one1 )\t ! necessity ( mu* lac]ation1 or ! risk ( cutt+ ?r\gh ! pro/atic %ea? ( fascia4 ,! op]ation4--,a semilun> incision is made transv]sely across ! p]9eum1 ext5d+ f a po9t midway betwe5 ! "r tub] is*ii & ! anus1 upw>ds1 cross+ ! raphe ne>ly an in* above ! anus1 & !n curv+ d[nw>ds to a correspond+ po9t on ! opposite side4 ,! sk91 sup]ficial fascia1 & a few ( ! ant]ior fibres ( ! ext]nal sph9ct]1 are ?us divid$1 & ! groove ( ! /aff s\ght by ! =ef+]4 ,! membran\s portion ( ! ure?ra is !n laid op5 9 ! middle l9e1 & ! beak ( a d\ble li?otome ca* securely lodg$ 9 ! groove4 ,x is !n pu%$ into ! bladd] ) its concavity upw>ds1 & :5 fairly 9 x is turn$ r\nd1 its blades protrud$ to ! requir$ ext5t1 & )drawn ) its concavity d[nw>ds1 ?us divid+ bo? lobes ( ! pro/ate 9 a direction d[nw>ds & outw>ds 7,fig4 ,,xxiv4 ,d ,d74 ,! op]ation is f9i%$ 9 ! usual mann]4 ,?\gh x is a comp>atively easy op]ation1 & !oretically may be prov$ to h _m advantages1 exp]i5ce has %[n t ! results are n s fav\rable z ^? ( ! ord9>y lat]al op]ation4 #b4 ,bu*anan's m$io-lat]al op]ation on a rectangul> /aff4--,! /aff is b5t at a "r angle ?ree in*es f ! end1 & deeply groov$ on its left side4 ,?is is introduc$ into ! ure?ra s t ! angle projects ! membran\s portion ( ! ure?ra close to ! apex ( ! pro/ate & ! t]m9al /raight portion ent]s ! bladd] p>allel to ! rectum4 ,! angle projects 9 ! p]9eum1 s t ! op]ator ) 8 left =ef+] 9 ! rectum is enabl$1 by a /ab ) a long /raight bi/\ry 7held horizontally & ) ! cutt+ edge to ! left side71 at once to ent] ! groove1 &1 by foll[+ ! groove1 ! bladd]4 ,:5ev] ! escape ( ur9e %[s t ! bladd] is fairly rea*$1 ! knife is )drawn s z to make a lat]al section ( ! pro/ate1 & !n1 ) ! f+] /ill 9 ! rectum1 to make an incision 9 ! is*io-rectal fossa1 ( suffici5t size to all[ ! /one to be easily )drawn4 ,! inv5tor claims = ?is me?od t x is easi]1 t !re is less risk ( hmorrhage1 w\nd ( ! rectum1 & infiltration ( ur9e4 #c4 ,all>ton's op]ation ( m$ian li?otomy suits admirably = /ones kn[n to be small1 b is q unsuitable = l>ge ones4 ,probably 9 mo/ cases x %\ld be sup]s$$ by li?otrity4 ,op]ation4--,a l>ge curv$ /aff ) a c5tral groove is to be held firmly hook$ up aga9/ ! symphysis pubis1 & !n /eadi$ by ! left =ef+] 9 ! rectum4 ,! op]ator pi]ces ! raphe ( ! p]9eum ) a long /raight bi/\ry ab\t half an in* above ! v]ge ( ! anus1 ent]s ! groove ( ! /aff1 & cuts inw>ds1 almo/1 b n q1 into ! bladd]4 ,9 )draw+ ! knife ! w\nd 9 ! ure?ra is enl>g$ upw>ds t[>ds ! scrotum4 ,a ball-po9t$ probe is !n pass$ on ! /aff into ! bladd]1 ! /aff is )drawn1 & ! f+]1 guid$ by ! probe1 is us$ to dilate ! neck ( ! bladd]1 to an ext5t suffici5t = ! removal ( ! /one by a small pair ( =ceps4 ,9 ?is op]ation ! pro/ate is h>dly incis$ at all4 ,! results are n bett] ?an ^? ( ! lat]al op]ation4 #b4 ,,li?otomy ,,above ,,! ,,pubes1 or ! ,high ,op]ation4--,9 cases :]e1 f ! kn[n size ( ! /one1 or f ! de=mity ( ! bones ( ! pelvis1 x is impossible t ! /one c be extract$ entire 9 ! usual mann]2 9 cases :]e ! pro/ate is v mu* enl>g$1 or :]e !re is any real or suppos$ likelihood ( inflammation ( ! neck ( ! bladd]1 ! supra-pubic op]ation may be w>rantable4 ,its p]=mance is easy1 x does n involve any w\nd ( ! p]itoneum if prop]ly p]=m$1 & !re is no risk ( hmorrhage4 ,!re are c]ta9ly great risks att5d+ x ( p]itonitis & ur9>y infiltration4 ,9 m ?an "o case ?is op]ation has be5 att5d$ by w\nd ( p]itoneum & subsequ5t escape ( inte/9es ?r\gh ! w\nd1 ev5 :5 dress$ antiseptically & p]=m$ "u spray4 ,op]ation4--,! pati5t lies on 8 back1 ) 8 head & %\ld]s slightly rais$1 s z to relax ! abdom9al muscles1 & 8 legs hang+ d[n ov] ! edge ( ! table4 ,if 8 bladd] c be> x1 x %\ld be fully di/5d$1 ei!r by volunt>y ret5tion ( ! ur9e1 or by injection ) tepid wat]4 ,a v]tical incision is !n made 9 ! middle l9e1 sep>at+ ! recti muscles f bel[ upw>ds1 c>e be+ tak5 to pu% ! p]itoneum well out ( ! way1 :i* is easily done by ! f+] 9 ! loose cellul> tissue ( ! "p4 ,! ant]ior wall ( ! bladd] is !n expos$1 uncov]$ by p]itoneum2 x mu/ be op5$ ) great c>e1 also 9 ! middle l9e1 :ile ! w\nd 9 ! p>ietes is held aside by retractors4 ,! wall ( ! bladd] %\ld be transfix$ by a curv$ ne$le1 & ?us held 9 position be=e x is op5$4 ,! /one is !n remov$ by a pair ( /raight =ceps1 g5]ally ) great ease4 ,attempts us$ to be made to leave a ca!t] or canula 9 ! bladd] w\nd to prev5t infiltration4 ,probably ! safe/ me?od n[ w be to close ! bladd] w\nd at once by metallic /it*es1 & /it*+ ! abdom9al w\nd c>efully ) deeply ent]$ wires1 to leave ! pati5t on 8 back4 ,:5 comp>$ ) ! lat]al op]ations ! /ati/ics ( ! supra-pubic op]ation are disc\rag+1 ! mortality be+ "o 9 ?ree & a half to "o 9 f\r4 ,b 9 cases :]e ! /one is kn[n to be v l>ge & ( firm consi/5ce1 ! risks are probably less f ?is me?od ?an f lat]al li?otomy1 foll[$ by ef=ts to cru% ! /one ?r\gh ! w\nd prior to its removal4 ,! late ,mr4 ,george ,bell1 a mo/ successful li?otomi/1 propos$ to p]=m ?is op]ation 9 two /ages4 ,9 a case ( greatly enl>g$ pro/ate1 :]e ! bladd] _h be5 punctur$ above ! pubes by a c\ntry surgeon = ret5tion ( ur9e1 he dilat$ ! track ( ! canula by means ( sponge-t5ts gradually increas$ 9 size1 & !n succe$$ 9 extract+ ?r\gh ! dilat$ op5+ sev]al l>ge calculi4 ,! case recov]$1 & may enc\rage simil> attempts4 #c4 ,,op]ations ,,?r\gh ,,! ,,rectum4--7a47 ,sanson's ,recto-vesical ,op]ation4--,! pr9ciple ( ?is op]ation consi/$ 9 lay+ ! two canals1 ! rectum & ! ure?ra1 into "o4 ,a l>ge /aff1 groov$ on its convexity1 be+ ins]t$ into ! ure?ra1 ! op]ator1 ) ! =ef+] ( 8 left h& 9 ! rectum z a guide to ! knife1 pi]ces ! ant]ior wall ( ! rectum1 rea*es ! groove ( ! /aff j 9 front ( ! pro/ate1 & cutt+ outw>ds divides ! rectum1 ! ant]ior fibres ( levator ani1 & ! sph9ct]1 z well z ! sk9 ( ! p]9eum 9 ! middle l9e4 ,ent]+ ! knife aga9 into ! groove ( ! /aff1 x is to be pu%$ "r onw>ds into ! bladd]1 divid+ ! pro/ate1 & avoid+ if possible ! sem9al vesicles & ducts2 ! /one is !n v easily remov$4 ,?\gh ?is op]ation 0 suppos$ to less5 ! risk ( pelvic infiltration x is n f\nd to d s1 & x adds ! additional inconv5i5ce ( almo/ inevitable rectal fi/ula1 ?r\gh :i* ! ur9e escapes4 ,x is c]ta9ly a v easy op]ation1 b ! mortality is f\nd to be great] ?an 9 ! ord9>y lat]al op]ation4 7b47 ,li?otomy ?r\gh ! rectum above ! pro/ate4--,! pres5ce ( a small portion ( bladd] beyond ! pro/ate 9 close relation to ! rectum r5d]s x possible1 9 cases :]e ! pro/ate is n enl>g$1 to ent] ! bladd] & remove a /one ( mod]ate size1 )\t int]f]+ ) ! p]itoneum1 pro/ate1 or neck ( ! bladd]4 ,?is +5i\s b difficult op]ation 0 p]=m$ = ! fir/ "t by ,drs4 ,sims & ,bau] 9 #ahei4 ,i quote ! brief notice ( ! op]ation by ,dr4 ,sims f ! ,lancet ( #ahfd 7vol4 i4 p4 #aaa73-- ,! pati5t 0 plac$ on ! left side1 & my speculum 0 introduc$ into ! rectum1 expos+ ! ant]ior wall ( ! rectum1 j z x w\ld ! vag9a 9 ! female4 ,a s\nd 0 pass$ into ! bladd]4 ,! doctor ent]$ ! blade ( a bi/\ry 9 ! triangul> space b\nd$ by ! pro/ate1 ! vesicul sem9ales1 & ! p]itoneal r$uplication4 ,he pass$ ! f+] ?r\gh ?is op5+1 felt ! /one1 & remov$ x ) ! =ceps )\t ! lea/ tr\ble4 ,! op]ation 0 done z quickly & z easily z x w\ld h be5 9 a female ?r\gh ! vag9al septum4 ,aft] ! removal ( ! /one1 ,dr4 ,bau] k9dly ask$ me to close ! w\nd ) silv] sutures1 :i* ,i did1 introduc+ "s five or six wires1 ) ! same facility z 9 ! vag9a4 ,!re 0 no leakage ( ur9e4 ,! pati5t recov]$ )\t ! lea/ tr\ble ( any sort4 ,! wires 7 remov$ on ! eigh? day1 & on ! n9? day ! pati5t rode 9 a c>riage ) ,dr4 ,bau] a di/ance ( f\r or five miles1 to call on1 & report himself to1 our di/+ui%$ c\ntryman1 ,dr4 ,mott4 ,! *ief risks 9 ?is op]ation seem to be ! *ance ( w\nd+ ! p]itoneal cul-de-sac1 z ! am\nt ( free space betwe5 x & ! pro/ate seems to v>y mu* 9 individuals & 9 races4 ,dr4 ,m>ion ,sims m5tion$ to me 9 conv]sation t he believ$ ?is op]ation impossible 9 ! negro race1 f ! great] projection d[nw>ds ( ! p]itoneal r$uplication4 ,an enl>g$ pro/ate w\ld be an insup]able objection4 ,! use ( silv] wire1 to close up ! w\nd at once1 dim9i%es v mu* any risk ( recto-vesical fi/ula4 ,,li?otrity ,,or ,,li?otripsy4--,!re exi/ cases ( /one 9 ! bladd]1 :i*1 "u c]ta9 conditions1 may be reliev$ )\t li?otomy1 by an op]ation :i* cru%es ! /one into fragm5ts small en\gh to be dis*>g$ ?r\gh ! ure?ra4 ,to ent] ) any fulness into ! hi/ory1 lit]ature1 & v>ieties ( ?is op]ation1 & ! in/rum5ts requir$1 w\ld 9 itself require a l>ge volume4 ,suffice x "h to describe ! case suitable = ! op]ation1 ! ess5tials requir$ 9 ! in/rum5t1 & ! me?od ( p]=mance4 #a4 ,= a case to be suitable ! /one %\ld n be too l>ge1 & especially n too h>d1 also !re %\ld n be too _m ( !m4 ,! ure?ra %\ld be capaci\s en\gh to let ! in/rum5t pass easily & pa9lessly4 ,! bladd] %\ld be l>ge en\gh to conta9 f\r ounces ( wat] at lea/1 %\ld n be mu* inflam$1 &1 on ! o!r h&1 %\ld n be p>alys$4 ,p>alysis or want ( tone 9 ! bladd] prev5ts ! ?or\gh evacuation ( its cont5ts1 & /ill m ! expulsion ( ! fragm5ts ( /one4 #b4 ,a good in/rum5t %\ld1 z f> z possible1 comb9e /r5g? ) lightness4 ,! curv$ portion ( ! fix$ blade %\ld be f5e/rat$ to all[ escape ( ! fragm5ts & ?or\gh closure ( ! in/rum5t4 ,! movable blade mu/ be s arrang$ z to comb9e p]fect ease ( movem5t up & d[n 9 seek+ = ! /one1 ) a p[]ful1 sl[1 & gradual approximation 9 cru%+ x4 ,?is c be manag$ by an +5i\s arrangem5t1 :i* leaves ! movable blade "u ! control only ( ! op]ator's ?umb till ! /one is f\nd1 & yet1 by t\*+ a spr+1 gives him ! advantage ei!r ( a f9e screw or ( a rack & p9ion movem5t = cru%+ ! /one4 #c4 ,op]ation4--,! pati5t be+ prep>$ by a free evacuation ( ! b[els1 & ! ure?ra hav+ be5 previ\sly fairly dilat$1 he is ask$ to reta9 8 ur9e z long z possible1 or1 if he _c d s1 a few ounces ( tepid wat] may be inject$ p] ure?ram4 ,he is !n laid on a s(a or table1 ! bree* be+ well rais$ by pill[s1 ! %\ld]s l[1 ! ?ighs & knees b5t up & sep>at$4 ,! in/rum5t1 well w>m$ & oil$1 is !n introduc$ ) ! blades clos$4 ,:5 fairly into ! bladd] ! se>* = ! /one beg9s4 ,!re are diff]5ces ( op9ion reg>d+ ! be/ me?od ( fi%+ = ! /one2 great pati5ce & g5tl5ess1 ) a ?or\gh previ\s acqua9tance ) bladd] manipulation1 are requir$1 :i*ev] me?od be *os54 ,! two *ief me?ods may be describ$ z ! ,engli% & ! ,fr5*1 ! latt]1 ,civiale's1 be+ n[ us$ by ,sir ,h5ry ,?ompson1 & o!r ,engli% op]ators4 ,briefly1 ! two are3-- 7#a47 ,heurtel\p's & ,sir ,b4 ,c4 ,brodie's4--,9 ?is1 aft] ! in/rum5t is fairly ent]$1 its h&le is elevat$1 ?us depress+ ! curv$ extremity1 ! =ceps are !n op5$1 &1 by be+ kept z l[ z possible 9 ! bladd]1 x is hop$ t ! calculus w fall into ! op5$ blades by its own weight4 ,9 ?is me?od ! fundus is ! sc5e ( cru%+1 & !re is a risk ( injur+ ! s5sitive neck ( ! bladd]1 especially at ! mom5t ( op5+ ! blades4 7#b47 ,civiale's--,?ompson's4--,9 ?is ! pelvis is to be s elevat$ t ! c5tre ( ! bladd] & space b5ea? x give pl5ty ( room = seiz+ ! /one1 & all contact ) ! wall ( ! bladd] is 7z f> z possible7 avoid$4 ,! in/rum5t is introduc$ clos$1 & c>ri$ fairly away 9 to ! po/]ior "p ( ! bladd] be=e x is op5$ at all4 ,x probably grazes ! /one 9 pass+1 &1 if s1 is direct$ to ! side ( ! bladd] 9 :i* ! /one is n ly+4 ,!n :5 ne>ly t\*+ ! po/]ior wall1 ! movable blade is )drawn1 ! in/rum5t incl9$ t[>ds ! /one ly+ unmov$ 9 ! mo/ dep5d5t "p1 & !re seizes x g5]ally ) ease4 ,if n felt1 ! blades are aga9 to be op5$1 turn$ a little to ! o!r side ( ! bladd]1 & !n clos$4 ,sir ,h4 ,?ompson lays ! greate/ /ress on ! importance ( always hav+ ! blades fairly op5$ be=e %ift+ _! position1 = if mov$ :5 clos$1 ! v op5+ ( ! movable blade is c]ta9 to drive ! /one out ( ! way & prev5t its seizure4 ,c]ta9 rules are useful3--,move ! axis ( ! in/rum5t z little z possible2 x %\ld be kept 9 ! c5tre ( ! bladd]1 s f> 91 t ! movem5ts ( ! male blade are q free f ! neck ( ! bladd] & pro/ate1 & ! blades only %\ld be mov$ 9 ! bladd] on ! c5tre ( ! %aft z an axis4 ,!re %\ld be no j]k+ once ! /one is caught1 & ! cru%+ %\ld be done z f> z possible 9 ! v c5tre ( ! bladd]1 ! blades n t\*+ any ( ! walls4 ,aft] ! /one is seiz$1 d n cru% till1 by a turn ( ! blades f side to side1 y discov] t none ( ! muc\s membrane ( ! bladd] is caught 9 ! in/rum5t4 ,! li?otrite is n meant to extract /ones1 b to cru% !m1 h5ce nev] attempt to )draw x unless ! blades are 9 absolute apposition4 ,nev] attempt too mu* at "o "t4 ,sir ,h4 ,?ompson holds t five m9utes is ! longe/ "t t %\ld be giv51 p]haps 9 mo/ cases ?ree m9utes be+ long en\gh4 ,:ile _m surgeons w /ill agree ) ! above advice1 ,dr4 ,bigel[ ( ,bo/on has lately be5 highly comm5d+ a me?od :i* he has call$ ,li?olapaxy1 9 :i*1 at "o sitt+ "u *lor(orm1 ! /one is cru%$ & aspirat$1 or suck$ out ( ! bladd] at once4#aeb ,s9ce ! above 0 writt5 ! op]ation ( ,li?olapaxy has made great /rides 9 ! fav\r ( surgeons1 & _m /ones t w\ld h be5 remov$ by li?otomy are n[ brok5 d[n by p[]ful in/rum5ts at a s+le sitt+1 & remov$ piecemeal by ! suction app>atus4 ,s4 ,w4 ,gross has collect$ #cab cases1 ( :i* #ag di$ or #e4de p] c5t41 b ( #ahj done by exp]i5c$ surgeons1 ,?ompson1 ,bigel[1 ,van ,bur51 ,weir1 & ,/ev5son only five di$1 or #c4cc p] c5t41 :ile ( #adgj cases ( li?otrity1 z =m]ly practis$1 #aei1 or #aj4ha1 p] c5t4 di$4#aec ,,op]ations ,,= ,,/ricture ,,( ,,ure?ra4--,"u ?is head _m manipulations & op]ations might be describ$2 ! v in/rum5ts devis$ be+ exce$+ly num]\s & complicat$4 ,en\gh "h to detail a few ( ! m simple & practical proc$ures "u ! diff]5t heads (--#a4 ,dilatation gradual & =c$4 #b4 ,int]nal ,division4 #c4 ,ext]nal ,division4 #a4 ,,dilatation4--,"u ?is head we h-- a4 ,vital dilatation4--,! pass+ ( a succession ( b\gies1 gradually increas+ 9 diamet]1 at int]vals ( ?ree or f\r days1 = ! purpose ( excit+ an am\nt ( int]/itial absorption 9 ! new mat]ial con/itut+ ! /ricture1 suffici5t to remove x4 ,pass+ a b\gie1 ?\gh c]ta9ly (t5 v difficult1 p]haps %\ld h>dly come into ! category ( surgical op]ations1 yet to pres]ve a c]ta9 complet5ess 9 ! acc\nt ( /ricture1 a v brief description may be "h ins]t$4 ,! recumb5t po/ure is 9 mo/ cases to be pref]r$4 ,! pati5t %\ld lie flat on 8 back1 ) ! knees slightly b5t & sep>at$1 & ! head & %\ld]s slightly rais$ on a pill[4 ,! op]ator /&+ on ! pati5t's left side1 raises ! p5is 9 8 left h&1 & ) ! "r introduces ! in/rum5t1 previ\sly w>m$ & oil$1 into ! meatus4 ,he !n pu%es x v g5tly onw>ds1 at ! same "t /ret*+ ! p5is ) ! left h&1 j s f> z to efface any wr9kles 9 ! muc\s membrane1 till ! po9t rea*es ! bulb\s portion4 ,! axis ( ! in/rum5t1 :i* at fir/ = conv5i5ce 0 ov] ! left gro91 has n[ gradually be5 approa*+ ! middle l9e4 ,:5 ?is is rea*$1 ! in/rum5t %\ld be rais$ f ! abdom51 & ! h&le cauti\sly c>ri$ 9 ! arc ( a circle fir/ upw>ds & !n d[nw>ds1 till1 :5 ! in/rum5t is fairly into ! bladd]1 ! h&le is depress$ betwe5 ! pati5t's ?ighs4 ,:ile ?is is be+ done ! op]ator's left h& %\ld be )drawn f ! p5is1 & ! po9ts ( ! f+]s appli$ to ! p]9eum4 ,9 cases ( difficulty c]ta9 po9ts may be rememb]$3-- 7#a47 ,t ! po9t ( ! in/rum5t may 9 ! fir/ in* or two be occasionally entangl$ 9 a lacuna 9 ! ro(1 especially :5 a small in/rum5t is us$2 h5ce ! beak %\ld be at fir/ ma9ta9$ aga9/ ! inf]ior wall ( ! canal4#aed 7#b47 ,t ! h&le %\ld n be depress$ too soon2 if x is1 !re is a risk ( a false passage be+ made ?r\gh ! upp] wall4 7#c47 ,! opposite error may =ce ! po9t out ( ! ure?ra betwe5 ! membran\s portion & ! rectum1 & onw>ds into ! sub/ance ( ! pro/ate gl&4 ,& c]ta9 cautions may be giv53-- 7#a47 ,9 e exploration ( an unkn[n ure?ra ! surgeon %\ld comm5ce ) an in/rum5t ( m$ium size1 c]ta9ly n less ?an ,no4 #g or #h4 7#b47 ,9 cases ( difficulty occurr+ 9 ! ure?ra beh9d ! scrotum1 inv>iably use ! =ef+] ( ! left h& 9 ! rectum z a guide4 7#c47 ,expression ( pa9 on ! "p ( ! pati5t is no indication t a false passage is be+ made1 nor its abs5ce t ! in/rum5t is 9 ! passage1 = x is a rem>k ( ,mr4 ,syme1 t pass+ an in/rum5t ?r\gh a /ricture is g5]ally m pa9ful ?an mak+ a false passage ?r\gh ! walls ( ! ure?ra4 ,an in/rum5t may be pass$1 :ile ! pati5t is erect1 ) ! foll[+ precautions3--,! pati5t %\ld /& ) 8 back aga9/ a wall1 8 arms support$ on ! back ( a *air on ea* side1 heels eight or t5 in*es ap>t1 & f\r or five in*es f ! wall2 8 clo!s ?or\ghly d[n1 n m]ely op5$4 ,! b\gie %\ld !n be held ne>ly horizontal1 ) its concavity ov] ! left gro9 ( ! pati5t1 ! p5is be+ rais$ 9 ! surgeon's left h&4 ,introduc$ ?us = f\r or five in*es1 ! h&le is gradually rais$ into ! middle l9e ( ! abdom51 & to ! p]p5dicul>2 x is !n to be lightly depress$1 &1 z ! po9t ent]s ! bladd]1 br\ght d[n t[>ds ! op]ator until x s9ks b5ea? ! horizontal l9e4 b4 ,me*anical dilatation is ( two k9ds1 bo? v r>ely us$3--7#a47 ,:5 an in/rum5t _c be pass$1 x consi/s ( pass+ d[n day aft] day ! po9t ( an in/rum5t 7sometimes arm$ ) cau/ic1 sometimes n71 & press+ x aga9/ ! /ricture till x is ov]come4#aee 7#b47 ,:5 an in/rum5t is introduc$ ?r\gh an intractable /ricture1 & is left !re ei!r = "s h\rs1 or = "s days1 to excite :at is call$ suppuration ( ! /ricture4#aef c4 ,=c$ dilatation4--,"u ?is head we might describe at great l5g? me*anical contrivances to =ce or rupture a /ricture4 ,a ^w or two on a few ( ! mo/ important3-- 7#a47 ,conical b\gies ( /eel or silv]4 7#b47 ,mr4 ,wakley's me?od1 on :i* _m o!rs h be5 f\nd$4 ,he pass$ a small b\gie or wire into ! bladd]1 ov] :i* 7 slipp$ /raight tubes ( v>y+ size1 ) p]fect c]ta9ty t !y c\ld n leave ! ure?ra4 7#c47 ,mr4 ,holt's me?od4#aeg--,! pr9ciple ( x is to rupture ! /ricture at once1 s t a ,no4 #ab ca!t] c imm$iately be pass$ into ! bladd]4 ,he atta9s ?is object by means ( an in/rum5t compos$ ( two groov$ blades1 unit$ ab\t "o in* f _! apex1 into a conical s\nd1 :i* at its apex is ab\t ! size ( a ,no4 #b b\gie4 ,?is is pass$ into ! bladd]1 & ! groov$ blades are sep>at$ to any ext5t t is desir$ by pass+ d[n betwe5 !m a /raight rod equal 9 size ( a ,no4 #h1 #aj1 or #ab1 b\gie4 ,to guide ?is prop]ly x is made holl[1 & x is pass$ d[n ov] a c5tral wire :i* lies betwe5 ! groov$ blades ( ! in/rum5t & is weld$ to ! apex4 ,a great improvem5t is effect$ on ,mr4 ,holt's lat] in/rum5ts by ?is wire be+ made holl[1 & fitt$ ) a /ilette1 = by ?is means we c ) c]ta9ty asc]ta9 :e!r or n ! in/rum5t has be5 pass$ into ! bladd]4 ,?is in/rum5t1 :i* is an improvem5t ^u "o inv5t$ by ,p]rve ne>ly =ty ye>s ago1 has be5 us$ on v _m occasions by ,mr4 ,holt & o!rs ) success4 ,! risk to life1 if ! case be prop]ly manag$1 is trifl+1 b1 l e o!r means ( treat+ /ricture1 x has ! objection t ! /ricture is liable to recur1 unless b\gies be pass$ at int]vals = mon?s & ye>s4 ,sir ,h5ry ,?ompson has introduc$ & describ$ ano!r v +5i\s in/rum5t = ! same purpose1 con/ruct$ on some:at simil> pr9ciples4 ,8 acc\nt ( x1 to :i* ,i mu/ ref]1 w be f\nd 9 ,holmes's ,sy/em ( ,surg]y1 #a/ ed4 vol4 iv4 p4 #cii4 #b4 ,,int]nal ,,division ,,( ,,/ricture is a mode ( treatm5t :i* by _m surgeons is highly disapprov$1 yet ( late ye>s x has be5 m us$ ?an =m]ly1 especially 9 resili5t /rictures4 ,x may be done 9 two ways3-- 7#a47 ,f be=e backw>ds4--,?is me?od1 to be at all admissible1 requires a guide to be previ\sly pass$2 a lancet-%ap$ blade may !n be slipp$ d[n a groove 9 ?is guide till ! /ricture is divid$4 ,?is is lea/ objectionable 9 cases ( /ricture close to ! meatus4 7#b47 ,f beh9d =w>ds4--,to make ! incision ?us1 x is ( c\rse necess>y t ! /ricture %\ld be s f> dilatable z to admit an in/rum5t ! po9t ( :i* is l>ge en\gh to conta9 ! blade by :i* ! /ricture is to be divid$4 ,?is w be f\nd to be at lea/ equal 9 size to a ,no4 #c or ,no4 #d ca!t]4 ,9 _m in/rum5ts x is mu* l>g]4 ,civiale's in/rum5t = int]nal incision ( ! ure?ra f beh9d =w>ds has ! v high recomm5dation ( ,sir ,h4 ,?ompson4#aeh ,x consi/s ( a s\nd ) a bulb\s extremity 7z l>ge z a ,no4 #e b\gie7 :i* conta9s a small blade1 :i* c be made to project = su* a di/ance z ! op]ator wi%es4 ,x is pass$ ?r\gh ! /ricture ) ! blade conceal$1 till ! bulb is c>ri$ ab\t "o-?ird ( an in* or m beyond ! /ricture2 ! blade is !n project$1 & ! incision made by draw+ x sl[ly b firmly outw>ds t[>ds ! meatus1 ) ! blade t[>ds ! floor ( ! ure?ra1 till ! /ricture is divid$ 9 its :ole ext5t4 ,sir ,h4 ,?ompson recomm5ds ?is to be us$ 9 cases :]e x is n t ! /ricture is ( v small calibre1 b t x is undilatable1 t prev5ts ! cure4 ,_m modifications ( above h be5 devis$ by ,lund1 ,teevan1 & o!r surgeons1 on simil> pr9ciples4 #c4 ,,mr4 ,,syme',s ,,op]ation ,,( ,,ext]nal ,,division4--,mr4 ,syme held t no /ricture ?r\gh :i* ! wat] c escape %\ld be call$ imp]meable1 = by pati5ce & c>e ! surgeon %\ld always be able to pass a sl5d] director ?r\gh ! /ricture on :i* x may be divid$ ) ease & c]ta9ty4 ,! old op]ation ( p]9eal section = s-call$ imp]meable /ricture is v diff]5t1 be+ difficult1 dang]\s1 & unc]ta9 9 its results4 ,op]ation4--,a director is pass$ into ! /ricture4 ,mr4 ,syme's directors are ( diff]5t sizes1 ! smalle/ be+ 9 diamet] less ?an an ord9>y surgical probe4 ,!y are made ( /eel1 are groov$ on ! convexity1 & h ?is peculi>ity1 t :ile ! l[] half is small1 ! upp] is ( full size 7,no4 #h or #aj71 ! diff]5ce 9 calibre occurr+ q abruptly4 ,! pres5ce ( ?is %\ld] on ! /aff enables ! op]ator to asc]ta9 exactly ! position ( ! /ricture1 & also to tell :5 x is fully divid$ )\t ! necessity ( )draw+ ! in/rum5t4 ,?is be+ fairly 9 ! /ricture1 ! pati5t is put 9 ! position = li?otomy1 an assi/ant holds ! /aff 9 8 "r h&1 draw+ up ! scrotum ) 8 left4 ,! surgeon !n makes an incision 9 ! middle l9e ov] ! /ricture = ! necess>y di/ance1 f above d[nw>ds1 till he exposes ! ure?ra1 & feels exactly ! %\ld] ( ! /aff4 ,c>e mu/ be tak5 n to g pa/ ! ure?ra at ei!r side4 ,:5 he di/9ctly feels ! outl9e ( ! /aff1 he takes x 9 8 left h&1 & a %ort %>p-po9t$ bi/\ry 9 8 "r4 ,x %\ld be held firmly 9 ! palm ( ! h&1 ) ! back ( ! blade re/+ on ! =ef+]1 ! pulp ( :i* guides ! po9t to ! groove1 & gu>ds x :5 mak+ ! incision2 ! knife is to be plac$ on ! groove beyond 7on ! bladd] side7 ( ! /ricture1 & br\ght =w>ds1 sl[ly cutt+ ?r\gh ! :ole /ricture2 till ! %\ld] ( ! /aff is rea*$4 ,x requires /r5g? & precision to divide ?or\ghly ! indurat$ /ricture1 :i* is apt to elude ! knife4 ,! %\ld] ( ! /aff c n[ be pass$ ?r\gh ! /ricture if ! op]ation is complete2 if n1 ! incision mu/ be ext5d$1 always 9 ! middle l9e1 & guid$ by ! groove4 ,:5 ?or\ghly divid$1 ! /aff is n[ to be )drawn1 & a full-siz$ ca!t] ) a d\ble curve pass$ into ! bladd]4 ,?is %\ld n be furni%$ ) a /op-cock or plug1 le/ ! bladd] %\ld by inadv]t5ce be all[$ to be too full1 & extravasation into ! cellul> tissue ( ! ure?ra take place along ! side ( ! in/rum5t4 ,! ca!t] %\ld be ti$ 91 & left = two1 sometimes = ?ree days1 :5 x c g5]ally be remov$ ) safety1 & a b\gie %\ld be pass$ at int]vals ( ?ree or f\r1 till ! w\nd is heal$4 ,to prev5t recurr5ce ( ! /ricture1 x is a wise precaution to pass an in/rum5t at int]vals = _m mon?s aft] ! cure is app>5tly complete4 ,9 c]ta9 cases1 :]e ! /ricture is f> back & ! ur9>y symptoms sev]e1 ,mr4 ,syme f\nd advantage f ! introduction ( a %ort] d\ble-curv$ ca!t] 7only ab\t n9e in*es long7 ?r\gh ! w\nd into ! bladd]1 :]e x %\ld be left = ?ree days4 ,?is seems to dim9i% ! risk ( rigors1 & o!r symptoms ( fev]1 :i* are apt to occur :5 ! ur9e is all[$ = ! fir/ "t to pass ov] ! w\nd4 ,p]9eal ,section is an op]ation bo? dang]\s & difficult2 z ,sir ,a/ley ,coop] us$ to say1 ! surgeon :o p]=ms x requires to h a long summ]'s day be=e him4 ,no director or guide c be pass$4 ,a full-siz$ ca!t] mu/ be pass$ z f> z possible up to ! /ricture1 & held firmly 9 ! middle l9e4 ,! pati5t mu/ be ti$ up 9 li?otomy position on a table 9 ! v be/ light t c be obta9$4 ,! p]9eum be+ %av$1 an incision mu/ be made 9 ! middle l9e f ov] ! po9t ( ! ca!t] to ! v]ge ( ! anus1 if ! /ricture ext5ds f> back4 ,! ure?ra %\ld !n be op5$ ov] ! ca!t]1 ! edges ( ! muc\s membrane held to ea* side by silk ?reads pass$ ?r\gh !m2 & ! surgeon mu/ endeav\r to pass a f9e probe into ! op5+ ( ! /ricture2 if ?is c be done1 x is comp>atively easy to slit ! /ricture up4 ,if n1 ! surgeon mu/ simply seek = ! rema9s ( ! ure?ra by sl[1 cauti\s dissection 9 ! middle l9e4 ,if successful1 a ca!t] mu/ be secur$ 9 ! bladd] 9 ! usual way4 ,a /ricture ne> ! orifice1 or1 z x is n uncommon1 involv+ m]ely ! meatus1 c be treat$ ) great ease 9 ! above mann] by division on a groov$ probe4 ,:5 q close to ! orifice1 ) a well-def9$ h>dness1 z ( a r+ r\nd ! ure?ra1 x may be divid$ subcutane\sly by a t5otomy knife or o!r n>r[-blad$ in/rum5t4 ,x is n necess>y to keep a ca!t] 9 ! bladd] 9 cases :]e ! /ricture has be5 9 front ( ! scrotum4 ,,puncture ,,( ,,! ,,bladd]4--,a pati5t & dext]\s use ( ! ca!t] prev5ts ?is op]ation f be+ (t5 requir$2 /ill1 circum/ances may arise 9 :i* x is f\nd impossible to ent] ! bladd] p] vias naturales4 ,9 su* a case ! bladd] may be punctur$ f ! outside by a curv$ troc> & canula1 9 ei!r ( two situations4 #a4 ,f above ! pubis4--,?is op]ation is a v simple "o1 & :5 ! bladd] is di/5d$ ne$ n imply a w\nd ( ! p]itoneum4 ,op]ation4--,a prelim9>y incision1 v>y+ 9 l5g? accord+ to ! am\nt ( fat1 %\ld be made above ! pubis exactly 9 ! middle l9e2 ! edges ( ! recti %\ld be sep>at$1 ! p]itoneum pu%$ out ( ! way & upw>ds by ! f+]1 & a curv$ troc> plung$ into ! di/5d$ bladd] obliquely backw>ds4 ,! canula %\ld be reta9$ = a day or two1 & !n a flexible ca!t] ) a %ield ins]t$ in/ead4 ,su* in/rum5ts h be5 worn = ye>s4 ,! aspirateur pneumatique ( ,dr4 ,dieulafoy w be f\nd an exce$+ly useful in/rum5t = puncture ( bladd] & removal ( ur9e4 ,! au?or has n[ us$ x v frequ5tly ) ! be/ results4 ,its advantage is t ! ur9e is remov$ ?r\gh an ap]ture s small z to all[ ( ! )drawal & re9troduction ( ! canula z (t5 z is necess>y4 ,illu/ration3 ,,fig4 ,,xxxvi4#aei #b4 ,f ! ,rectum4--,except 9 cases ( enl>gem5t ( ! pro/ate1 x is at once easi] & saf] to puncture ! bladd] f ! rectum4 ,! well-kn[n triangul> space uncov]$ by p]itoneum1 ) its apex 9 front close to ! pro/ate1 & b\nd$ on ei!r side by ! vasa def]5tia & vesicul sem9ales1 c be easily rea*$ by a curv$ troc>4 ,?is %\ld be guid$ by "o1 or1 /ill bett]1 by two f+]s1 into ! rectum1 ) its concavity upw>ds1 & ! po9t %\ld be pu%$ upw>ds by depression ( ! h&le1 :5ev] x is fairly beh9d ! pro/ate4 ,! troc> may !n be )drawn1 & ! canula reta9$ = at lea/ =ty-eight h\rs by a suitable b&age4 ,mr4 ,cock1 ( ,guy's ,hospital1 _h a special canula = ! purpose1 :i* exp&s at its extremity aft] its introduction1 & ?us is n apt to slip4#afj ,"s surgeons insi/ t ! surgeon %\ld be able to asc]ta9 ! exi/5ce ( fluctuation betwe5 ! f+] 9 ! rectum1 & ! o!r h& above ! pubes4 ,?is is exce$+ly difficult to elicit :5 ! bladd] is v mu* di/5d$1 & f ! con/ra9$ position ( ! f+] 9 ! b[el4 ,,phymosis4--,elongation ( ! prepuce1 ) contraction ( its orifice1 9 mo/ cases cong5ital1 sometimes s extreme z to cause difficulty 9 micturition1 & frequ5tly prev5t+ ! uncov]+ ( ! glans4 ,op]ation4--,9 all well-m>k$ cases1 ! foll[+ is requir$3--,! elongat$ prepuce %\ld be pull$ =w>ds by a pair ( cat*-=ceps1 & a circle ( sk9 & muc\s membrane remov$ by a s+le /roke ( a bi/\ry1 or by %>p scissors4 ,c>e %\ld be tak5 le/ ! glans be includ$ 9 ! incision1 z has happ5$ 9 at lea/ "o in/ance4 ,! sk9 w !n be f\nd to retract v freely beyond ! glans1 b ! muc\s membrane is f\nd /ill to cov] ! glans1 & its orifice is /ill con/rict$4 ,x mu/ !n be slit up 7,fig4 ,,xxxvii4 b b7 on ! dorsum ( ! glans1 ) probe-po9t$ scissors1 z f> z ! corona1 & ! glans w !n be ?or\ghly expos$4 ,! edges ( muc\s membrane & sk9 %\ld !n be /it*$ to ea* o!r by at lea/ five or six f9e silk sutures1 any ble$+ po9ts hav+ be5 fir/ c>efully secur$4 ,! angles w 9 "t r\nd (f1 & a wond]fully seemly prepuce be obta9$4 ,?is op]ation may be done z a me?od ( cure = ob/9ate enuresis 9 cases 9 :i* ! prepuce is v long & r$undant1 ev5 :5 x is n too tight4 ,! au?or has done ?is 9 m ?an tw5ty cases ) excell5t results4 ,illu/ration3 ,,fig4 ,,xxxvii4#afa ,v>ieties4--,:5 ! prepuce is n>r[$ at its orifice )\t be+ r$undant 9 l5g?1 a mild] op]ation w prove suffici5t4 ,! pr9ciple is ! same z 9 ! =m]1 b ! am\nt ( incision is less1 & no?+ is remov$4 ,two me?ods are possible3-- #a4 ,by scissors4--,! blunt po9t ( a pair ( scissors is introduc$ ?r\gh ! preputial orifice1 ! o!r blade be+ outside1 & ! sk9 & muc\s membrane are divid$ = ab\t half an in*2 ! sk9 be+ !n retract$1 ! muc\s membrane is /ill fur!r divid$ by "o or two additional snips1 & !n ! edges ( sk9 & muc\s membrane are /it*$ toge!r by "o or two po9ts ( suture4 #b4 ,by knife4--,a director be+ introduc$ )9 ! prepuce1 a n>r[-blad$ knife is guid$ along x1 & pu%$ ?r\gh ! prepuce f )91 & !n made to divide sk9 & muc\s membrane f )9 outw>ds4 ,/it*es z be=e4 ,n4,b4--,be c>eful le/ ! director pass into ! meatus ur9>ius1 & ! glans be split up4 ,aga91 "s surgeons pref] two lat]al incisions in/ead ( "o dorsal "o4 ,9 ?is case sk9 & muc\s membrane %\ld be divid$ by scissors = ab\t a qu>t] ( an in*1 & !n a s+le /it* ins]t$ 9 ! angle ( junction4 ,?is has be5 fur!r modifi$ by ,cull]i]1 :o propos$ ! division ( ! tight muc\s membrane only1 9 ?ree or f\r po9ts4 ,he us$ a pair ( scissors ) "o %>p & "o probe-po9t$ blade1 ! %>p "o ?ru/ 9 betwe5 sk9 & muc\s membrane1 ! blunt "o betwe5 ! muc\s membrane & ! glans4 ,,amputation ,,( ,,! ,,p5is4--,?is exce$+ly simple op]ation is p]=m$ by a s+le /roke ( an amputat+ knife1 drawn along f heel to po9t1 :ile ! p5is is /ret*$ 9 ! op]ator's left h&4 ,z !re is m risk ( r$undancy ?an ( defici5cy ( ! sk91 no attempt is made to save x4 ,num]\s vessels 9 ! corpora cav]nosa require ligature4 ,amputation ( ! p5is may be done bloodlessly by ! !rmo-caut]y ev5 close to its root4 ,transfix ! root ( corpora cav]nosa by a ne$le2 above ?is pass two or ?ree turns ( an ela/ic ligature2 !n sl[ly divide at a l[ r$ heat ! sk9 & corpora cav]nosa bel[ ! ne$les2 split ! ure?ra aft] divid+ its muc\s membrane ) a knife4 ,! au?or has done ?is sev]al times ) ease & rapid heal+4 ,illu/ration3 ,,fig4 ,,xxxviii4#afb ,! *ief risk is /ricture ( ! orifice ( ! ure?ra4 ,to prev5t ?is1 sev]al modifications ( ! op]ation h be5 introduc$4 #a4 ,ricord's me?od4#afc--;,aft] ! amputation ! surgeon seizes ) =ceps ! muc\s membrane ( ! ure?ra1 & ) a pair ( scissors makes f\r slits 9 x1 s z to =m f\r equal flaps1 & ) a silk ligature /it*es ea* ( ^! to ! sk94 ,contraction ( ! cicatrix w ?us t5d to op5 r ?an close ! ure?ral orifice4 #b4 ,teale's me?od4#afd--;,he slits up1 by a bi/\ry on a director1 ! ure?ra & sk9 ov] x = ab\t two-?irds ( an in*1 & !n /it*es ! "o to ! o!r1 ?us mak+ x a long oval dep5d5t orifice 7,fig4 ,,xxxviii474 #c4 ,mill]'s propos$ me?od4#afe--;,a n>r[-blad$ knife is fir/ us$ to transfix ! p5is betwe5 ! spongy & cav]n\s bodies close to ! root2 ! knife hav+ be5 c>ri$ =w>ds = an in* & a half1 its edge is turn$ p]p5dicul>ly d[nw>ds1 & ! ure?ra & sk9 flap are divid$1 ! cav]n\s bodies & dorsal integum5t be+ !n cut p]p5dicul>ly upw>ds :]e ! knife 0 orig9ally ent]$ = transfixion4 ,a button-hole is aft]w>ds made 9 ! l[] flap1 ?\gh :i* ! corpus spongiosum & ure?ra protrude1 :ile ! flap itself is turn$ upw>ds1 & atta*$ dorsally & lat]ally1 s z to cov] 9 ! expos$ cav]n\s /ructure4 ,,hydrocele4--,! v simple op]ation necess>y = hydrocele is ?us p]=m$3--,! surgeon supports ! tum\r 9 8 left h& s z to project x =w>ds1 & make ! scrotum z t5se z possible 9 front4 ,hav+ c>efully asc]ta9$ ! exact position ( ! te/icle1 :i* c g5]ally be easily en\gh done by a f+] accu/om$ to discrim9ate ! diff]5ce betwe5 a s(t solid1 & a bag t5sely fill$ ) fluid1 aid$ by ! peculi> s5sation ( ! te/icle :5 squeez$1 ! surgeon ent]s a troc> & canula ab\t an eigh? ( an in* 9 diamet] into ! di/5d$ cavity ( ! tunica vag9alis1 ne> ! fundus ( ! swell+4 ,:5 x is evid5t ! in/rum5t is fairly ent]$1 & n till !n1 ! troc> is )drawn1 & ! fluid all[$ completely to dra9 (f4 ,:5 x ceases to fl[ ! surgeon places 8 =ef+] ov] ! end ( ! canula to prev5t ! entrance ( air1 till he fits into its orifice a suitable syr+e conta9+ two dra*ms ( ! t9cture ( iod9e1 made accord+ to ! ,ed9burgh ,ph>macopoeia3 ! t9cture ( ! ,briti% ,ph>macopoeia is n suffici5tly /rong4 ,hav+ inject$ ?is cauti\sly into ! cavity1 ! canula is )drawn1 & ! surgeon1 seiz+ ! n[ flaccid scrotum 9 8 "r h&1 gives x a ?or\gh %ake1 s z to spread ! iod9e ov] z mu* z possible ( ! inn] wall4 ,:5 prop]ly p]=m$ ?is v simple proc$ure v r>ely fails to produce a radical cure2 ?\gh less ?or\gh op]ations1 su* z m]e evacuation ( ! fluid1 less /imulat+ injections1 ungu5ts introduc$ on probes1 & ! l1 (t5 fail ( success1 & ?us give enc\ragem5t to absurdities1 su* z wire-setons1 or to m sev]e op]ations1 su* z lay+ op5 ! sac4 ,h,,matocele4--,:5 ! cont5ts ( ! sac ( ! tunica vag9alis are f\nd to be grum\s in/ead ( simply s]\s1 or :51 z (t5 happ5s1 only pure blood escapes :5 ! fluid is ne>ly evacuat$1 x is f\nd t simple evacuation & injection are v r>ely suffici5t to effect a cure4 ,aft] !y h be5 fairly tri$1 ! sac ( ! hmatocele %\ld be laid op5 9 its full ext5t2 any l>ge vessels :i* ble$ %\ld be ti$1 & ! cavity !n /uff$ ) l9t4 ,:5 ! l9t c be remov$1 :i* w be aft] two or ?ree days1 ! edges ( ! w\nd %\ld be br\ght closely toge!r1 & ! cavity w !n rapidly heal up f ! bottom1 & be oblit]at$ by second>y union ( granulations4 ,9 cases :]e ! walls ( ! cavity are enorm\sly ?ick5$1 or ev51 z sometimes happ5s1 almo/ bony 9 consi/5ce1 an elliptical portion may be remov$ ) advantage4 ,,excision ,,( ,,te/icle4--,?is op]ation is r>ely requir$ except = tum\rs ( ! te/icle4 ,h5ce ! size ( ! incision necess>y mu/ v>y mu* ) ! size ( ! tum\r2 & ! am\nt ( sk9 to be remov$ 7if any7 on ! am\nt ( adhesions x has =m$ to ! tum\r4 ,"o or two po9ts mu/ be att5d$ to 9 e case ( extirpation ( a te/icle3-- #a4 ,! incision %\ld comm5ce ov] ! cord j outside ( ! ext]nal r+1 & be cont9u$ fairly ov] ! tum\r to its base4 #b4 ,z to removal ( sk91 "s surgeons advise t none %\ld be tak5 away1 o!rs t a consid]able quantity c be sp>$4 ,!re is c]ta9ly less risk ( second>y hmorrhage if a portion be remov$1 ?an :5 a flaccid empty bag is left4 ,! au?or inv>iably removes a v l>ge quantity ( sk9 if ! tum\r is l>ge1 z !re is mu* m rapid heal+1 & ! result+ scrotum is mu* m com=table = ! pati5t4 #c4 ,! cord %\ld be expos$ at ! beg9n+ ( ! op]ation1 rais$ f its b$ & giv5 to an assi/ant1 :o %\ld compress x g5tly1 n f any fe> ( its escape into ! abdom51 b to prev5t hmorrhage4 ,if ! tum\r has be5 v l>ge & heavy1 ! cord w h be5 mu* /ret*$1 & if divid$ too high up1 may really give tr\ble by its ela/icity1 unless ! above precaution is tak54 ,! cord !n hav+ be5 divid$ close to ! tum\r1 ! latt] is remov$1 c>e be+ tak5 n to include ! s\nd te/icle 9 ! removal4 ,all ! vessels are !n to be ti$ or twi/$1 & ! sp]matic art]y is to be secur$ alone1 n1 z us$ to be ! case1 includ$ 9 a common ligature ) ! o!r con/itu5ts ( ! cord4 ,second>y hmorrhage is v apt to occur f small scrotal bran*es :i* may h escap$ notice dur+ ! op]ation4 ,,op]ations ,,on ,,! ,,anus ,,& ,,its ,,neighb\rhood4--,,fi/ula ,,9 ,,ano4--,:ile mu* might be writt5 on ! pa?ology ( fi/ula1 & a good deal ev5 on its diagnosis1 a v few words w suffice to describe ! simple & effectual op]ation = its relief4 ,dismiss+ at once all s-call$ palliatives1 drugs1 ungu5ts1 pressure1 & injections1 z m]e wa/e ( "t1 & hold+ t ! only me?od ( cure consi/s 9 lay+ ! fi/ula fairly op51 ! "q n>r[s itself into ?is3 ,:at is ! be/ me?od ( lay+ x op58 ,prior to ! discov]y by ,ribes ( ! great pr9ciple t ! int]nal orifice ( ! s9us is always )9 an in* or an in* & a half ( ! orifice ( ! anus1 ! op]ations = fi/ula 7 mo/ unnecess>ily sev]e2 ! gut us$ to be divid$ z f> up z ! s9uses ext5d$2 & l>ge portions ( ! anus us$ to be excis$ bodily along ) ! s9uses4 ,x is n[ a mu* simpl] & m satisfactory op]ation4 ,op]ation4--,a common silv] probe b5t to ! requir$ %ape is pass$ into ! ext]nal op5+1 or1 if !re are m ?an "o1 into ! l>ge/ & olde/ "o4 ,! =ef+] ( ! left h& be+ introduc$ into ! rectum1 ! probe is pass$ ?r\gh ! int]nal orifice1 & its po9t br\ght out by ! anus4 ,! portion ( tissue rais$ by ! probe c !n be easily divid$ ) ! c]ta9ty t ! fi/ula is laid fully op54 ,anal fi/ul h be5 divid$ by ! ela/ic ligature1 b x seems sl[] 9 action & m pa9ful1 ) no c\nt]balanc+ advantages4 ,! au?or has = la/ few ye>s op]at$ almo/ exclusively by a long knife :i* is cont9u$ into a /eel probe4 ,! probe is pass$ up ! fi/ula1 !n into ! b[el1 & is hook$ out at ! anus1 & 9 be+ simply pu%$ on ! knife cuts ! fi/ula--tuto1 cito1 et jucunde1 ! pati5t r>ely kn[+ t m has be5 done ?an an exploration4 ,9 cases :]e1 f ! h>dness & d5sity ( ! p>ts x is impossible to pass ! probe & br+ x out at ! anus1 a /rong probe-po9t$ bi/\ry may be pass$ 9 by ! ext]nal orifice till its probe-po9t c be felt by ! f+] 9 ! b[el at ! int]nal op5+4 ,support$ by ! f+] x c !n be made to cut outw>ds till ! :ole septum is divid$4 ,,fissure ,,( ,,! ,,anus1 ,,ulc] ,,( ,,! ,,anus1 resemble ea* o!r alike 9 ! exce$+ annoyance :i* !y give to ! suff]]1 & 9 ! simplicity ( ! treatm5t ne$$4 ,op]ation4--,once ! pres5ce ( ei!r is det]m9$ by ! f+] 9 ! anus1 a %>p-po9t$ curv$ bi/\ry %\ld be introduc$1 transfix+ ! base ( ! fissure or ulc]1 & !n guid$ on ! f+]1 completely divid+ x1 s z to *ange ! ragg$ ulc]ation into a simple w\nd :i* w rapidly heal4 ,,prolapsus ,,ani1 ,op]ation =4--,complete prolapsus 9 :i* ! :ole gut is involv$1 z se5 9 ! v "y & ! v ag$1 is suit$ = palliative r ?an radical treatm5t4 ,cases ( prolapsus ( ! muc\s membrane only1 z is n uncommon 9 connection ) or z a result ( hmorrhoids 9 adults1 give opportunity = op]ative int]f]5ce4 ,we may act on ei!r ! sk9 or muc\s membrane1 or bo? at once4 #a4 ,! sk9 is (t5 f\nd loose1 & arrang$ 9 radiat+ folds r\nd ! anus4 ,9 su* cases1 z recomm5d$ fir/ by ,dupuytr51 "s ( ^! project+ folds may be remov$4 ,aga9 x may be prolaps$ 9 a great loose r+ or circul> fold r\nd ! m>g91 =m+ an exagg]at$ ext]nal pile2 9 su* a case ! loose fold may be fairly excis$ ) curv$ scissors1 z recomm5d$ by ,hey ( ,le$s4 ,! fir/ ( ^! me?ods is apt to be insuffici5t1 ! second aga9 has ! risk ( remov+ too mu*4 #b4 ,if ! protrusion is *iefly muc\s membrane expos$ 9 folds1 or a r+1 :i* is g5]ally outside1 "o ( two me?ods ( treatm5t may be tri$3-- a4 ,by ligature1 z recomm5d$ by ,mr4 ,copel&4 ,rais+ a longitud9al fold ( ! muc\s membrane1 he pass$ a ligature r\nd x z if x 7 a pile4 ,!re is less *ance ( ! ligature slipp+ if a d\ble ?read be us$ & its base ?us transfix$4 ,?ree1 f\r1 or ev5 m folds may be ?us treat$4 b4 ,:5 ! muc\s membrane has be5 s long expos$ z to h lo/ _m ( its *>act]s1 & to resemble lea!r 9 its t\ghness1 excision w be f\nd less pa9ful & mu* m rapid ?an ligature4 ,a longitud9al fold at ea* side ( ! anus %\ld be p9*$ up & excis$ by a pair ( probe-po9t$ curv$ scissors4 ,!re is always a c]ta9 am\nt ( risk ( hmorrhage foll[+ su* an op]ation4 ,! risk is less5$ & ! result improv$ by /it*+ up ! w\nd 9 ! muc\s membrane be=e ! protrud$ portion ( b[el is return$4 ,,polypi ,,( ,,! ,,rectum4--,p$unculat$ gr[?s v>y+ 9 consi/5ce1 %ape1 & size1 b resembl+ ea* o!r 9 hav+ a di/9ct /alk1 & 9 frequ5tly be+ protrud$ at /ool4 ,op]ation4--,inv>iably by ligature1 :i* may be s+le r\nd ! /alk1 if ! tum\r be globul> & ) a di/9ct n>r[ /alk1 or by transfixion1 if 7z sometimes happ5s7 ! tum\r be ( uni=m ?ickness ?r\gh\t1 l a worm4 ,h,,morrhoids ,,or ,,piles4--,9 ! treatm5t ( piles x is ! diff]5tial diagnosis t is tr\blesome & occasionally difficult2 ! op]ative int]f]5ce requir$ is g5]ally v simple1 if ! nature ( ! case be rightly det]m9$4 ,ext]nal piles4--,op]ation4--,! apex ( ! s(t flabby excresc5ce %\ld be seiz$ by a pair ( cat*-=ceps1 & x %\ld be cut (f close to its base ) a knife1 or1 :at is bett]1 a pair ( curv$ scissors4 ,any little vessel :i* jets may !n be secur$4 ,if1 in/ead ( num]\s individual tum\rs1 a r+ ( sk9 r\nd ! anus be involv$1 ! :ole ( x %\ld be %av$ (f1 b n v close to its base1 le/ too great contraction ( ! anal orifice %\ld ensue4 ,if ! surgeon1 aft] excis+ a pile or piles1 w take ! tr\ble to /it* up ! w\nd ) catgut1 he w f9d ! cure mu* m rapid & less pa9ful ?an :5 ?is is omitt$4 ,int]nal piles4--,incision is extremely dang]\s1 f ! vascul>ity ( ! p>ts1 & _! be+ s inaccessible f _! position )9 ! sph9ct] ani4 ,h5ce ligature is saf] & equally effectual4 ,! pati5t %\ld be direct$ to sit ov] hot wat]1 & /ra9 till ! :ole ( 8 piles are fairly protrud$4 ,! surgeon %\ld !n transfix ! base ( ea* sep>ately ) a curv$ ne$le be>+ a /rong d\ble ?read4 ,! ne$le be+ cut (f1 ! ?reads %\ld be v firmly ti$1 ea* isolat+ its own half ( ! pile4 ,! ty+ %\ld be exce$+ly tight1 s z to cause in/ant & complete /rangulation & dea? ( ! tum\rs4 ,all ! piles %\ld be ti$ at ! same sitt+4 ,if ! piles are v small !y may be secur$ )\t transfixion 9 a s+le noose aft] be+ seiz$ by a hook or =ceps4 ,!re is great] risk ( ! noose slipp+ ?an :5 ! base has be5 transfix$4 ,! /rangulat$ masses mu/ !n be return$ into ! b[el1 & ! pati5t kept 9 b$ or on a s(a till ! ligatures sep>ate1 :i* is g5]ally n till ! f\r? or fif? day4 ,a c]ta9 am\nt ( ur9>y irritation1 %[+ itself sometimes 9 /rangury1 sometimes 9 complete ret5tion1 occasionally foll[s ?is op]ation4 ,mr4 ,smi? ( ,k+'s ,college1 & _m o!r surgeons1 treat int]nal piles by means ( an ivory clamp to hold !m tight1 :ile !y are burn$ (f by ! actual caut]y or ! !rmo-caut]y at a l[ r$ heat4 ,!y claim t pymia m r>ely foll[s ?is mode4 ,!re are c]ta9 cases 9 :i* ! l[] in* or two ( ! rectum are f\nd r$ & conge/$1 & 9 :i* e /ool is foll[$ by ! loss ( a c]ta9 quantity ( florid art]ial blood1 & yet no di/9ct hmorrhoidal tum\r is to be se54 ,9 su* cases ! ligature is n applicable1 & relief is obta9$ by ! application ( pure nitric acid1 or o!r pot5tial cau/ics to ! ble$+ surface1 z recomm5d$ by ,h\/on1 ,lee1 ,smi?1 ,a%ton1 & o!rs4 ,^! cases are comp>atively r>e1 & :5ev] !y c be appli$1 ! ligature is mu* simpl]1 saf]1 & m c]ta94 ,v5\s piles4--,:5 a sudd5 effusion ( blood has occurr$ into "o ( ! v>icose ve9s or s9uses ( a conge/$ anus1 an oval or r\nd$ tum\r is felt1 v t5se1 %9+1 & pa9ful4 ,to slit x freely up ) an abscess lancet1 & ev]t ! clot inside1 at once relieves all ! symptoms4 ,,footnotes3 #aej ,diagram ( section ( pro/ate se5 f ! inside3--,,pf1 pelvic fascia or pro/atic %ea?2 ,,rr1 r+ :i* mu/ be cut2 ,l1 position ( incision 9 ! lat]al op]ation2 ,,dd1 position ( incisions 9 ! bilat]al op]ation4 #aea ,diagram ( muscles ( membran\s portion ( ure?ra se5 f ! inside3--,,ss1 section ( os pubis2 ,u1 ure?ra2 ,g1 ,gu?rie's muscle1 compressor ure?r2 ,w1 ,wilson's muscle1 levator ure?r4 #aeb ,bo/on ,m$ical & ,surgical ,j\rnal1 ,may #bi1 #ahgi4 #aec ,gross1 ,surg]y1 #f? ed4 vol4 ii4 p4 #gcf4 #aed ,holmes's ,surg]y1 vol4 iv4 p4 #cib4 #aee ,see ,mill]'s ,practice ( ,surg]y1 p4 #bab4 #aef ,solly's ,surgical ,exp]i5ces1 pp4 #ecg1 #ech1 etc4 #aeg ,! ,imm$iate ,treatm5t ( ,/ricture4 ,by ,b]n>d ,holt1 ,f4,r4,c4,s4 ,london4 ,?ird ,edition1 #ahfh4 #aeh ,holmes's ,sy/em ( ,surg]y1 #a/ ed4 vol4 iv4 p4 #djc4 #aei ,diagram ( puncture ( ! bladd]3--,b1 bladd]2 ,,sp1 symphysis pubis2 ,,sc1 scrotum2 b1 bulb2 pr1 p]itoneum2 ,p1 pro/ate2 ,r1 rectum2 ,s1 sacrum & coccyx4 #afj ,m$4 ,*ir4 ,trans41 vol4 ,,xxxv4 #afa ,diagram ( op]ation = phymosis3--a1 glans p5is2 b b1 muc\s membrane expos$ by retraction ( ! sk91 & slit up2 c d1 sutures introduc$ & ready to be ti$1 unit+ ! sk9 & muc\s membrane4 #afb ,to illu/rate ,teale's op]ation3--c1 section ( p5is b1 ?read ins]t$ unit+ muc\s membrane & sk92 a1 ?read ti$4 #afc ,m$4 ,times & ,gazette1 vol4 xix4 p4 #ced4 #afd ,mill]'s ,sy/em ( ,surg]y1 p4 #abee4 #afe ,mill]'s ,sy/em ( ,surg]y1 p4 #abef4 ,,*apt] ,,xiii4 ,,t5otomy4 ,= conv5i5ce' sake ,i gr\p "u ?is "o head c]ta9 op]ations us$ = ! relief ( di/ortion1 9 :i* muscles or t5dons are divid$ subcutane\sly4 ,s9ce ! discov]y ( ! pr9ciple by ,delpe*1 & ! application ( x by ,/romey]1 ,dieff5ba*1 ,little1 & c\ntless successors1 x has be5 us$ = v _m cases = :i* x is totally inapplicable1 e4g4 = ! division ( ! muscles ( ! back 9 sp9al curvature4 ,/ill !re rema9 sev]al de=mities = ! relief ( :i* subcutane\s t5otomy is a mo/ important rem$y2 *ief among ^! are ,wry ,neck & ,club-foot4 ,,op]ation ,,= ,,wry ,,neck4--,subcutane\s section ( ! /]no-ma/oid4--,9 :at cases ( wry neck is ?is op]ation suitable8 ,9 ^? only 9 :i* ! muscles are ! />t+-po9t ( ! mis*ief4 ,^! are sometimes cong5ital1 m frequ5tly !y comm5ce 9 *ildhood4 ,9 cases :]e ! di/ortion dep5ds on disease ( ! c]vical v]tebr1 or is second>y to curvature ( ! sp9e1 division ( ! muscle is worse ?an useless4 ,op]ation4--,a t5otomy knife1 :i* %\ld be %>p-po9t$1 n>r[ 9 ! blade1 ) a blunt back1 %\ld be introduc$ ?r\gh ! sk9 a little to "o side ( ! /]nal portion ( ! affect$ muscle1 pass$ along ) its flat edge betwe5 ! sk9 & ! t5don1 till x has fairly cross$ ! t5don2 ! blade %\ld !n be turn$ s t by a gradual saw+ motion ! edge may be made to divide ! t5don ab\t an in* above ! /]num4 ,a di/9ct snap w !n be felt or he>d1 & ! position ( ! head w be at once mu* improv$4 ,ex]cise1 w>m ba?+1 & rubb+1 w g5]ally suffice to complete ! cure1 )\t x be+ necess>y to call 9 ! aid ( ! in/rum5t-mak] ) 8 exp5sive app>atus4#aff ,,op]ations ,,= ,,club-,,foot4--,! foll[+ are ! t5dons :i* may require division 9 ! cure ( club-foot1 & ! op]ations = _! division4 #a4 ,! t5do ,a*illis4--,!re are v few cases ( true club-foot :i* c be successfully treat$ )\t division ( ! t5do ,a*illis4 ,:ile 9 talipes equ9is x is g5]ally ! only di/urb+ ag5t1 9 talipes v>us & valgus x inv>iably increases & ma9ta9s ! de=mity1 :i* ! tibiales or p]onei seem to orig9ate4 ,op]ation4--,! foot be+ held at ab\t a "r angle ) ! leg1 ! op]ator %\ld p9* up ! sk9 ov] ! t5don1 introduce ! knife flatwise1 a little to "o side ( ! t5don1 till its po9t is ne>ly project+ at ! o!r1 !n turn ! edge on ! t5don & cut inw>ds ) a saw+ motion till ! t5don gives way ) a di/9ct snap1 & ! foot c be completely flex$ ) ease4 ,dr4 ,little#afg recomm5ds t ! t5don %\ld be divid$ f be=e backw>ds4 ,!re is m risk by ?is me?od ( w\nd+ ! sk91 & ?us los+ ! subcutane\s "* ( ! op]ation4 ,pr(essor ,pancoa/#afh divides ! inf]ior portion ( ! soleus muscle in/ead ( ! t5do ,a*illis4 #b4 ,tibialis po/icus4--,next 9 frequ5cy & importance to t ( ! t5do ,a*illis1 division ( ?is t5don is mu* m difficult to p]=m4 ,x may be p]=m$ ei!r above or bel[ ! ankle4 7a47 ,above ! ankle4--,! blade ( a t5otomy knife %\ld be ent]$ p]p5dicul>ly at ! po/]ior m>g9 ( ! tibia1 half an in* or an in* above ! int]nal malleolus1 s z to pass betwe5 ! bone & ! t5don ( ! tibialis po/icus1 ! blade direct$ t[>ds ! latt]2 ! assi/ant %\ld n[ ev]t ! foot1 ! op]ator press+ ! blade aga9/ ! t5don4#afi 7b47 ,bel[ ! ankle1 close to ! atta*m5t to ! scaphoid4 ,?is is ! bett] position ( ! two :5 ! position ( ! t5don c be made out1 :i* is n always ! case1 especially 9 cases ( old /&+4 ,rais+ ! sk9 j ov] ! a/ragalo-scaphoid jo9t1 ! knife %\ld be ent]$ ) its blade d[nw>ds1 & across ! t5don1 & %\ld be made to cut on ! bone1 :ile an assi/ant ev]ts ! foot till ! t5don gives way ) a di/9ct snap4 #c4 ,tibialis anticus may 9 l mann] be divid$ ei!r j above ! ankle1 or at its ins]tion4 ,:5 x requires division x c g5]ally be made s prom95t z to r5d] its division comp>atively easy4 #d4 ,p]onei4--,^! d n (t5 require division1 cases ( talipes valgus be+ usually p>alytic 9 "*4 ,if necess>y !y c be cut z !y cross ! fibula4 #e4 ,! plant> fascia1 may require division2 :5 ?is is ! case1 x is s prom95t z to r5d] ! op]ation v easy1 if conduct$ on ! pr9ciples m5tion$ above4 ,,footnotes3 #aff ,syme's ,pa?ology & ,practice ( ,surg]y1 p4 #bbj4 #afg ,holmes's ,surg]y1 vol4 iii4 p4 #egc4 #afh ,cross's ,surg]y1 vol4 ii4 p4 #bgc1 #c;d ed4 #afi ,mill]'s ,sy/em ( ,surg]y1 p4 #acci2 ,holmes's ,surg]y1 vol4 iii4 p4 #ega4 ,,*apt] ,,xiv4 ,,op]ations ,,on ,,n]ves4 ,,n]ve-,,/ret*+4--,surgical lit]ature 9 la/ t5 ye>s is full ( cases 9 :i* n]ves h be5 /ret*$ = all mann] ( diseases ) v>y+ success3 an example ( ! op]ative proc$ure may suffice3-- #a4 ,/ret*+ ( ! great sciatic ei!r = sciatica1 scl]osis1 or locomotor ataxia4 ,op]ation4--,a l9e drawn f ! c5tre ( ! space betwe5 ! tub]osity ( ! is*ium or ! great tro*ant] to a correspond+ po9t betwe5 ! condyles ( ! femur w give ! direction4 ,a free incision 9 ?is l9e ?ree or f\r in*es 9 l5g?--! n]ve lies j bel[ ! ! femoral aponeurosis1 b5ea? ! edge ( gluteal fold1 requir+ no muscul> fibres to be divid$4 ,x mu/ be rais$ f its b$ & boldly /ret*$ or elongat$ into a loop4 ,sym+ton's exp]im5ts h %[n t 9 ! av]age adult #acj lb4 are requir$ to break ! n]ve4 #b4 ,! facial has be5 /ret*$ = spasm4 ,! trunk is easily rea*$ by an incision ext5d+ f ne> ! ext]nal auditory meatus to ! angle ( ! jaw1 :i* enables ! p>otid to be pu%$ =w>d & ! edge ( ! /]no-ma/oid pull$ backw>ds4 ,,neurotomy ,,& ,,neurectomy4--,*iefly p]=m$ = neuralgia ( ! fif? n]ve4 a4 ,?is is a v easy op]ation if direct$ at ! t]m9al bran*es only ( ! n]ve1 :]e !y make _! exit f ! frontal1 supraorbital1 & m5tal =am9a4 ,! au?or has done x 9 v num]\s cases1 & ) great relief1 if c>e be tak5 to de/roy ! n]ve 9 ! =am5 to "s ext5t--a %>p-po9t$ !rmo-caut]y does ?is easily & safely4 b4 ,! m sev]e & radical op]ation ( cutt+ out a portion ( ! trunk ( ! fif? n]ve j aft] x has left ! skull1 & de/roy+ ,meckel's ganglion1 has be5 done pretty frequ5tly1 *iefly by ,am]ican surgeons--9 v>i\s ways4 #a4 ,c>no*an's ,op]ation4--,expos+ ! :ole front wall ( antrum1 its cavity is op5$ into f ! front by a l>ge treph9e4 ,! l[] wall ( ! infra-orbital canal is cut away by a *isel1 ! po/]ior wall ( ! antrum by a small] treph9e1 ! n]ve ?us isolat$ is trac$ up to & pa/ ,meckel's ganglion1 :i* is remov$ close to ! =am5 rotundum by cutt+ ! n]ve by curv$ blunt-po9t$ scissors4 #b4 ,pancoa/'s ,op]ation4--,expose ! coronoid process by a free incision1 divide x at its root & ?r[ x up1 !n expose & tie int]nal maxill>y art]y1 aft] :i* ! upp] portion ( ! ext]nal pt]ygoid is to be deta*$ f ! sph5oid1 ?us expos+ ! n]ve leav+ =am5 ovale2 ! second portion is deep] & n s easily got at4 #c4 ,! sp9al accessory occasionally may be divid$ be=e x ent]s ! /]no-ma/oid 9 cases ( spasmodic wry neck1 ) great advantage4 ,?is op]ation is an easy "o2 ! /]no-ma/oid edge be+ once fairly expos$1 ! n]ve is easily se51 & a piece %\ld be cut out at lea/ half an in* 9 l5g?4 ,,n]ve ,,suture is occasionally practis$ ) great advantage 9 cases :]e n]ves h be5 divid$ ei!r by accid5t or 9 op]ation4 ,catgut seems to be ! be/ m$ium1 & cases are on record 9 :i*1 ev5 aft] mon?s ( sep>ation & subsequ5t p>alysis1 improvem5t has foll[$ an op]ation = refre%+ & jo9+ ! divid$ ends4 ,,add5dum ,,to ,,*apt] ,,ix4 ,,dr4 ,,solis ,,coh5 has rec5tly 79 a pap] read be=e ! ,philadelphia ,college ( ,physicians1 ,april #d1 #ahhc7 collect$ ! notes ( sixty-five cases ( excision ( ! entire l>ynx4 ,fifty-six ( ^! 7 done = canc]1 & ! rema9d] = s>comata1 papillomata1 etc4 ,( ! fifty-six done = canc]1 =ty are report$ z hav+ di$1 ei!r %ortly aft] ! op]ation f %ock or pneumonia1 or a few mon?s lat] f recurr5ce ( ! disease4 ,9 two in/ances ! disease _h recurr$1 b dea? _h n be5 report$ :5 ! pap] 0 read4 ,f\rte5 rema9 9 :i* nei!r dea? nor recurr5ce _h be5 report$4 ,dr4 ,coh5's conclusion is t l>yngectomy does n t5d to ! prolongation ( life1 & ?9ks t ! greate/ good to ! great] numb] appe>s bett] secur$ by dep5d5ce on ! palliative op]ation ( tra*eotomy4 ,,index4 ,abdom51 op]ations on1 #bbb4 ,ab]ne?y on ligature ( ext]nal iliac1 #h4 ,adams on anatomy ( common iliac1 #d4 on hip de=mity1 #acc4 g9eta1 ,paulus1 on excision ( jo9ts1 #ajh4 ,all>ton on m$ian li?otomy1 #bfi4 ,amputation & excision contra/$1 #aac4 ,amputation at ankle-jo9t 7,syme's71 #gh4 ( ant]ior portion ( foot 7,hey's71 #gc4 ( arm1 #fb4 at elb[-jo9t1 #fa4 ?r\gh femur1 condyles (1 #ib4 ( f+]s1 #ea-ed4 ( =e-arm1 #eh4 at hip-jo9t1 #ajb4 at knee-jo9t1 #ib4 ( p5is1 #bhf4 at %\ld]-jo9t1 #fc4 at t>sus 7,*op>t's71 #ge4 at ?igh1 #id4 d\ble prim>y ( ?igh1 #ajf4 ( toes1 #fi4 at wri/-jo9t1 #ef4 ,amussat's op]ation1 #beb4 ,an*ylosis ( elb[1 excision =1 #abb4 ,ankle-jo9t1 excision (1 #acg4 ,ann&ale on /aphyloraphy1 #bjc4 ,anus1 artificial1 op]ation =1 #beb4 artificial1 removal (1 #bed4 ,ar5dt1 ligature ( ext]nal iliac1 #ab4 ,a/ragalus1 excision (1 #ade4 ,au*9closs on ligature ( subclavian1 #cf4 ,av]y1 h>d palate1 fissures (1 #bjc4 ,b>well on excision ( ankle-jo9t1 #aci4 on excision ( tongue1 #aii4 ,baud5s on amputation at elb[-jo9t1 #fa4 on amputation ( ant]ior portion ( foot1 #ge4 on amputation at knee-jo9t1 #ib4 ,bau] on recto-vesical li?otomy1 #bgb4 ,begbie1 ,dr4 ,w>burton1 on p>ac5tesis ?oracis1 #bbj4 ,bell1 ,b5jam91 on amputation1 #di4 on amputation ( ankle1 #hf4 on amputation ( ?igh1 #if4 ,bell1 ,sir ,*>les1 on ligature ( femoral1 #bb4 ,bell1 ,george1 on supra-pubic li?otomy1 #bga4 ,bell1 ,john1 on ligature ( gluteal1 #ad4 ,bey1 ,gaetani1 on amputation above ! %\ld]-jo9t1 #gj4 ,bigel[1 ,dr41 on li?olapaxy1 #bgf4 ,billro?1 ,dr41 on fissure ( palate1 #bjj4 ,bladd]1 puncture (1 #bhd4 ,bonnet on radical cure ( h]nia1 #bde4 ,botal on amputation1 #dg4 ,b[dit* on p>ac5tesis ?oracis1 #bba4 ,b[man's op]ation1 la*rymal canal1 #aec4 ,bra*ial1 ligature (1 #bdb4 ,brodie1 ,sir ,b4 ,c41 on li?otomy1 #bfb4 on li?otrity1 #bgd4 ,bromfield1 amputation ( leg1 #hf4 ,br[n1 ,bak]1 ov>iotomy1 #bca4 ,bryant1 on excision ( jo9ts1 #aab4 ,bu*anan1 ,dr4 ,a41 on li?otomy1 #bfi4 ,bu*anan1 ,dr4 ,g41 on excision ( tongue1 #aih4 ,bu*anan1 ,dr4 ,m41 on excision ( ankle1 #adj4 ,buck's op]ation = an*ylosis1 #acf4 ,but*]1 ligature ( subclavian1 #ce4 excision ( jo9ts1 #aaj4 excision ( wri/-jo9t1 #abh4 excision ( knee-jo9t1 #ace4 excision ( metac>pals4 #adb4 ,campbell1 ,pr(essor1 on ligature ( gluteal1 #ae4 ,c>d5's amputation at condyles ( femur1 #ej1 #id4 ,c>mi*ael on ligature ( gluteal1 #ad4 ,c>no*an on neurectomy1 #cjj4 ,c>otid1 ligature ( common1 #bh4 ligature ( ext]nal1 #cb4 ,cat>act op]ations1 #afj4 ,celsus on amputation1 #dh4 on excision ( jo9ts1 #ajh4 ,*amb]la9e1 on ligature ( axill>y1 #dj4 ,*assaignac on tra*eotomy1 #bjf4 ,*eilopla/ics1 ,syme on1 #agh4 ,*eseld5 on amputation1 #di4 on li?otomy1 #bfj4 ,*op>t's amputation1 #ge4 ,civiale on li?otrity1 #bge4 ,club-foot1 op]ations =1 #big4 ,cock on oesophagotomy1 #baf4 p>ac5tesis ?oracis1 #bbj4 on puncture ( bladd]1 #bhe4 ,colles on ligature ( bra*ial1 #dd4 ,coop]1 ,sir ,a/ley1 on ligature ( aorta & iliacs1 #c1 #aj4 on p]9eal section4 #bgf4 ,cornea1 puncture (1 #aei4 /aphylomat\s1 excision ( a1 #afh4 ,corelysis1 #agj4 ,crampton1 ,sir ,philip1 on excision1 #aai4 ,cri*ton on li?otomy1 #bfb4 ,crit*ett's op]ation ( iridesis1 #afi4 op]ation = /aphyloma1 #agb4 ,cr(t1 ,mr41 on hip disease1 #acb4 ,culb]tson on excision ( hip1 #acb4 ,cull]i] on phymosis1 #bhg4 ,curl+ on op]ation = artificial anus1 #bec4 ,cusack on treatm5t ( bra*ial aneurism1 #dc4 ,davies1 ,r$f]n1 on radical cure ( h]nia1 #bdd4 ,davy's 7,mr4 ,ri*>d71 lev]1 #aje4 ,desault on ligature ( axill>y1 #dj4 ,dieff5ba* on excision ( upp] jaw1 #aia4 ,dieulafoy's aspirateur1 #bhd4 ,dionis' amputation ( leg1 #hg4 ,dubrueil1 amputation at wri/1 #eg4 ,duncan1 ,mr4 ,j41 on artificial anus1 #bed4 ,dupuytr5 on ligature ( iliac1 #aa4 on ligature ( subclavian1 #cf4 amputation at elb[-jo9t1 #fb4 removal ( artificial anus1 #bed4 on bilat]al li?otomy1 #bfh4 ,dur&1 case ( hmorrhage f iliac1 #ab4 ,durham on ?yrotomy1 #bae4 ,dzondi on radical cure ( h]nia1 #bdf4 ,elb[-,jo9t1 amputation at1 #fb4 ,ellis on anatomy ( iliac art]ies1 #f4 ,ectropium1 #aeb4 ,entropium1 #aea4 ,eri*s5 on excision ( hip1 #acj4 ,esm>* on excision ( jo9ts1 #aaj4 ,excision & amputation contra/$1 #aab4 ,excision ( ankle-jo9t1 #ach4 ( a/ragalus1 #ade4 ( elb[-jo9t1 #aah4 ( hip-jo9t1 #abh4 ( jaw1 upp]1 #ahh4 ( jaw1 l[]1 #aia4 ( knee-jo9t1 #acc4 ( mamma1 #baf4 ( scapula1 #aci4 ( %\ld]-jo9t1 #aae4 ( te/icle1 #bij4 ( tongue1 #aig4 ( tonsils1 #bjc4 ( wri/-jo9t1 #abe4 ,eye1 op]ations on1 #aea4 ,eyeball1 extirpation ( !1 #agc4 ,eyelid1 tum\rs on !1 #aeb4 ,fayr]1 ,sir ,j41 on tra*eotomy1 #bab4 on radical cure ( h]nia1 #bdh4 ,femoral1 ligature (1 #ah4 sup]ficial1 ligature (1 9 ,sc>pa's space1 #ai4 9 ,hunt]'s canal1 #ba4 ,femur1 amputation ?r\gh condyles (1 #ib4 ,f]gusson1 ,sir ,w41 on ligature ( subclavian1 #ch4 on amputation at %\ld]-jo9t1 #gj4 on excision ( jo9ts1 #aaj4 on excision ( upp] jaw1 #aia4 on excision ( l[] jaw1 #aie4 on fissures ( palate1 #bja4 on li?otomy1 #bfb4 ,filk9 on excision ( jo9ts1 #aaj4 ,f+]s1 amputation (1 #ea4 ,fissures 9 ! palate1 s(t1 #bjj4 9 ! palate1 h>d1 #bjb4 ( anus1 #bib4 ,fi/ula1 saliv>y1 op]ations =1 #aib4 9 ano1 op]ation =1 #bia4 ,=e-arm1 amputation ?r\gh !1 #eh4 ligature ( vessels 91 #dd4 ,=/]1 ,mr4 ,coop]1 on ga/rotomy1 #bbd4 ,furn]1 ligature ( bo? subclavians1 #ch4 ,ga/rectomy1 #bbd4 ,ga/ro/omy1 #bbc4 ,ga/rotomy1 #bbc4 ,g]sdorf1 ,hans de1 on amputation1 #dh4 ,g]dy on radical cure ( h]nia1 #bdf4 ,gilb]t1 amputation above ! %\ld]-jo9t1 #fh4 ,gillespie on excision ( wri/-jo9t1 #abh4 ,gluteal1 ligature (1 #ab4 ,gossel9 on colotomy1 #bec4 ,graefe on /rabismus1 #aeh4 on cat>act op]ations1 #aff4 or iridectomy1 #aga4 ,gre5 on ligature ( subclavian1 #ch4 ,gre5h[ on excision ( os calcis1 #add4 ,gre5slade on ,b[man's op]ation1 #aef4 ,gritti's amputation1 #ic ,gross on amputation at elb[-jo9t1 #fa4 on amputation1 #ha-hg4 on excision ( hip1 #acb4 on li?otomy1 #bfb4 on rh9opla/ic op]ation1 #agh4 on excision ( l[] jaw1 #aib4 ,gur91 ,jules1 on amputation ( toes1 #gf4 on op]ation = /rabismus1 #aeh4 ,gu]sant on excision ( tonsils1 #bje4 ,guillemeau on amputation at knee-jo9t1 #ia4 ,gurlt's /ati/ics1 #aah1 #abd4 ,hmorrhoids1 op]ations =1 #bid4 ,hmatocele1 op]ation =1 #bhi4 ,hamilton on rh9opla/ic op]ations1 #agg4 ,hancock on excision ( hip1 #acj4 on excision ( ankle1 #ach4 on excision ( os calcis1 #add4 ,h>elip1 op]ations =1 #ahc4 ,h>rison on anatomy ( iliac1 #f4 on bra*ial aneurism1 #dd4 ,h>t1 ,mr4 ,erne/1 on flexion ( limbs1 #bd4 ,hea?'s case ( aneurism ( innom9ate1 #bh4 ,he9e on excision ( hip1 #acj4 ,h]nia1 /rangulat$ +u9al1 #bcb4 /rangulat$ femoral1 #bcg4 /rangulat$ umbilical1 #bdb4 /rangulat$ obturator1 #bdc4 radical cure (1 #bdd4 ,heurtl\p on li?otrity1 #bgd4 ,hey on amputation1 #dh1 #gc4 ,heyfeld] on excisions1 #aaj1 #acj4 ,hildanus1 ,fabricius1 on amputation1 #dg1 #ia4 ,hip-jo9t1 amputation at !1 #ajb4 excision (1 #abh4 ,hippocrates on excision ( jo9ts1 #ajh4 ,hodgson1 /ati/ics ( aneurism1 #ab4 ligature ( axill>y1 #dj4 ,hodge on excisions #aab1 #acb4 ,ho9 on amputation at knee-jo9t1 #ib4 ,holmes on excision ( hip1 #acj1 #acb1 #add4 ,holt's op]ation = /ricture1 #bgi4 ,h[se1 ,mr41 on ga/rotomy1 #bbd4 ,hughes1 ,dr4 on p>ac5tesis ?oracis1 #bbj4 ,hugui] on colotomy1 #bec4 ,hunt] on ligature ( femoral1 #ba4 ,hut*9son's /ati/ics1 #bj4 ,hydrocele1 op]ation =1 #bhh4 ,iliac1 ligature ( common1 #c4 ligature ( ext]nal1 #g4 ,iliac1 ligature ( int]nal1 #f4 ,innom9ate1 ligature ( !1 #bf4 ,iridectomy1 #aga4 ,iridesis1 #afi4 ,jacobson on cat>act op]ations1 #aff4 ,jg] on excision ( hip1 #acj4 ,james1 ,mr41 on ligature ( aorta1 #c4 ,jameson on radical cure ( h]nia1 #bdf4 ,jaw1 excision ( upp]1 #ahh4 excision ( l[]1 #aia4 ,john/on1 ,dr41 on amputation at ankle-jo9t1 #hd4 ,jo9ts1 excision (1 #ajh4 ,jones on excision ( jo9ts1 #aaj1 #acd1 #acf4 ,jordan1 ,mr4 ,f41 on amputation1 #ajf2 on excision ( tongue1 #aii4 ,kei?1 ,dr4 ,?omas1 on ov>iotomy1 #bbd-bbg4 ,kirby1 ,mr41 on ligature ( iliac1 #ab4 ,knife1 ,be]'s description (1 #afd4 ,knee1 amputation bel[ & above1 #ij1 #ia4 amputation at1 #ia4 jo9t1 excision (1 #acb4 ,la*rymal organs1 op]ations on !1 #aec4 ,lane1 ,mr41 on amputation at knee-jo9t1 #ia4 ,lang5beck on excision ( jo9ts1 #aaj1 #adj4 on fissure 9 h>d palate1 #bjc4 on radical cure ( h]nia1 #bde4 ,l>rey on amputation at %\ld]1 #fd4 on excision ( jo9ts1 #aji4 ,l>ynx1 op]ations on !1 #bjf4 ,l>yngectomy1 #baf4 ,dr4 ,solis ,coh5 on1 #cjb4 ,l>yngotomy1 #bad4 ,l>yngo-tra*eotomy1 #bae4 ,layraud1 ,dr41 case ( hmorrhage f iliac1 #ab4 ,lee1 ,mr4 ,h5ry1 amputation ( leg1 #hh4 ,ligature ( ! aorta1 #b4 ( ! axill>y1 #ch1 #ci1 #dj4 ( ! bra*ial1 #db4 ( ! c>otid1 common1 #bi1 #cj4 ( ! c>otid1 ext]nal1 #cb4 ( ! femoral1 #ah1 #ba4 ( ! gluteal1 #ab4 ( ! iliac1 #c4 ( ! iliac1 ext]nal1 #g4 ( ! iliac1 int]nal1 #f4 ( ! innom9ate1 #bf4 ( ! l+ual1 #cb4 ( ! popliteal1 #bb4 ( ! subclavian1 #cc-cg4 ( ! vessels 9 =e-arm1 #de4 ,lips1 op]ations on !1 #ahj4 ,lisfranc on amputation1 #eb1 #gd4 ,li/]1 ,pr(essor1 on ,syme's amputation1 #hg4 on excision ( wri/1 #abe4 ,li/on1 ,mr41 on ligature ( subclavian1 #cf1 #cg4 on rh9opla/ic op]ations1 #agg4 on excision ( upp] jaw1 #ahf4 tra*eotomy1 #bac4 on femoral h]nia1 #bdj4 on li?otomy1 #bfb4 ,li?olapaxy1 ,dr4 ,bigel[ on1 #bgf4 ,li?otomy1 #bee4 ,li?otrity1 #bgh4 ,little on club-foot1 #big4 ,lloyd on h>elip1 #ahg4 ,lor9z] on obturator h]nia1 #bdd4 ,l\is on amputation1 #dh4 ,l[] extremity1 amputations (1 #fh4 ,lupus1 op]ative treatm5t (1 #agi4 ,macilwa9 on tra*eotomy1 #bjh4 ,mack5zie1 ,dr4 ,morell1 on ?yrotomy1 #bae4 ,mack5zie1 ,dr4 ,r41 on modification ( ,syme's amputation1 #hc4 on excision ( jo9ts1 #aaj1 #acd4 ,malgaigne on ,*op>t's amputation1 #gg4 on h>elip1 #ahg4 ,mamma1 excision (1 #bah4 ,manec on ligature ( axill>y1 #dj4 ,maund] on excision ( ! elb[-jo9t1 #abb4 ,macl5nan1 ,dr4 ,g41 on amputation above ! %\ld]-jo9t1 #fi4 ,metac>pals1 amputation (1 #ed4 excision (1 #ada4 ,metat>sals1 amputation (1 #gb4 ,mill] on amputation ( p5is1 #bhh4 ,monteiro1 ,dr41 on ligature ( aorta1 #c4 ,moor5 on cat>act op]ations1 #aff4 ,moreaus1 !1 on excision ( jo9ts1 #aji1 #aad1 #abj1 #acb1 #acd4 ,morel1 t\rniquet inv5t$ by1 #dg4 ,morton1 ,dr41 on radical cure ( h]nia1 #bde4 ,murray1 ,dr41 on ligature ( aorta1 #c4 ,mussey1 case ( amputation1 #gj4 ,mynors on amputation1 #dh4 ,nasal polypi1 removal (1 #agi4 ,ne$le op]ation = cat>act1 #afj4 ,nelaton on h>elip1 #ahd4 ,n]ve-/ret*+1 #bii4 ,n]ve suture1 #cjj4 ,neurectomy1 #bii4 ,neurotomy1 #bii4 ,norris's /ati/ics1 #ab1 #bj1 #ca4 ,nunneley on excision ( tongue1 #aih4 ,oesophagotomy1 #baf4 ,olli] on excision ( jo9ts1 #aaj4 ,os calcis1 excision (1 #adc4 ,ov>iotomy1 #bbd4 ,paget on excision ( tongue1 #aih4 ,palate1 fissures 9 s(t1 #bjj4 fissures 9 h>d1 #bjb4 ,pancoa/1 ,pr(essor1 on rh9opla/ic op]ations1 #agh4 on radical cure ( h]nia1 #bde4 on neurectomy1 #cjj4 on club-foot1 #big4 ,p>ac5tesis ?oracis1 #bai4 abdom9is1 #bbb4 ,p>1 ,ambrose1 on amputation1 #dg4 on amputation at elb[-jo9t1 #fj4 ,p>k on excision ( jo9ts1 #aaj4 ,peixotto1 ,dr41 on ligature ( innom9ate1 #bg4 ,p5is1 amputation (1 #bhg4 ,p]9eal section1 op]ation (1 #bgc4 ,p]cy on excision ( jo9ts1 #aji4 ,phymosis1 op]ation =1 #bhe4 ,pirog(f's modification ( ,syme's amputation1 #hj1 #hd4 ,pollock on excision ( l[] jaw1 #aic4 ,polypi1 nasal1 removal (1 #agi4 anal1 removal (1 #bic4 ,popliteal1 ligature (1 #bb4 ,porta's /ati/ics1 #bj4 ,port]1 ,pr(essor1 on ligature ( innom9ate1 #bg4 on ligature ( common c>otid1 #bh4 /ati/ics ( amputation1 #abb4 ,po/ on ligature ( iliac1 #aj4 ,prit*>d1 ,mr41 radical cure ( h]nia1 #bdh4 ,prolapsus ani1 #bib4 ,pt]ygium1 op]ation =1 #aef4 ,puncture ( bladd]1 #bhd4 ,pupil1 op]ations = artificial1 #afh4 ,purmannus on amputation1 #dh4 ,qua9 on anatomy ( iliac1 #d4 on anatomy ( bra*ial1 #dc4 ,regnoli on excision ( tongue1 #aii4 ,rh9opla/ic op]ations1 #age4 ,ri*t] on radical cure ( h]nia1 #bde4 ,ricord on amputation ( p5is1 #bhg4 ,rigaud on amputation above ! %\ld]-jo9t1 #fg4 ,rit*ie1 ,dr4 ,*>les1 on ov>iotomy1 #bbd4 ,rodg]s1 ,dr41 on ligature ( subclavian1 #cf4 ,ro?mund on radical cure ( h]nia1 #bdg4 ,r\x on ligature ( subclavian1 #ch4 on ligature ( axill>y1 #dj1 on ,*op>t's amputation1 #gg1 #gh4 ,sabati] on excision ( jo9ts1 #aji4 ,saliv>y fi/ula1 op]ation =1 #aif4 ,sanson on recto-vesical li?otomy1 #bga4 ,scalp1 tum\rs ( !1 removal ( #adi4 ,scapula1 excision ( 7,syme71 #adj4 ,s*uh on radical cure ( h]nia1 #bde4 ,s*muck] on radical cure ( h]nia1 #bdf4 ,scultetus on amputation1 #df4 ,s$illot's op]ation = ligature ( c>otid1 #cj4 on excision ( hip1 #acb4 ,%\ld]-jo9t1 amputation at !1 #ff4 excision (1 #aae4 ,signoroni on radical cure ( h]nia1 #bdg4 ,sims1 ,dr4 ,m41 on li?otomy1 #bgb4 ,smi?1 ,dr4 ,na?an1 on amputation at knee-jo9t1 #ia4 ,smi?1 ,?omas1 on /aphyloraphy1 #bjj4 ,smi?1 ,dr4 ,tyl]1 on ov>iotomy1 #bca4 ,smy? on subclavian aneurism1 #bg4 ,skey on ligature ( subclavian1 #ch4 on amputation1 #gd1 #ia4 on excision ( wri/1 #abg4 on rh9opla/ic op]ation1 #agh4 on li?otomy1 #bfb4 ,solis ,coh51 ,dr41 on l>yngectomy1 #cjb4 ,solomon on /rabismus1 #aeh4 ,s\? on ligature ( aorta1 #c4 ,sp5ce1 ,pr(essor1 on amputation1 #ej1 #ff1 #hi1 #ajj4 on excision ( %\ld]1 elb[1 & wri/ jo9ts1 #aah1 #abd1 #abh1 #acf4 ,sp]9o on puncture ( cornea1 #aei4 ,/anley on excision ( %\ld]1 #aag4 ,/ev51 ,pr(essor1 on ligature ( int]nal iliac1 #ae4 ,/rabismus1 conv]g5t1 #aef4 div]g5t1 #aeg4 ,/reatfeild on entropium1 #aea4 on corelysis1 #agj4 ,/ricture1 op]ation =1 #bgf4 ,/okes's amputation1 #id4 ,/romey] on excision ( jo9ts1 #aaj4 ,subclavian1 ligature ( "r1 #cd4 ligature ( left1 #ce4 ,surgeon-,g5]al1 ,unit$ ,/ates1 /ati/ical report by1 #hb4 ,syme1 ,mr41 on amputation at ankle-jo9t1 #gh4 on amputation ?r\gh condyles ( femur1 #ib4 on amputation at hip-jo9t1 #ajf4 on amputation above ! %\ld]-jo9t1 #gc4 on modifi$ circul> amputation1 #aja4 on axill>y aneurism1 op]ation =1 #da4 on *eilopla/ic op]ation1 #aha4 ,*op>t's amputation introduc$ by1 #gg4 on excision ( l[] jaw1 #aia4 on excision ( jo9ts1 #aaa-abj4 on excision ( scapula1 #adj4 on excision ( tongue1 #aig4 on ligature ( femoral1 #bj4 on ligature ( gluteal1 #ad1 #ae4 on radical cure ( h]nia1 #bdg4 on ,hey's op]ation1 #gc4 on oesophagotomy1 #baf4 on removal ( polypi1 #ahj4 on rh9opla/ic op]ation1 #age4 on /ricture1 #bgh-bhb4 ,tait on ligature ( iliac1 #aj1 #ab4 ,taliacotian op]ation1 #agh4 ,t>so-metat>sal jo9t1 amputation at1 #gb4 ,t>sus1 amputation ?r\gh !1 #ge4 ,teale on amputation1 #ej4 on amputation ( =e-arm1 #ei4 on amputation ( arm1 #fc4 on amputation ( leg1 #hi4 on amputation ( ?igh1 #ih4 on amputation ( p5is1 #bhh4 ,teale1 ,t4 ,p41 on cat>act1 #afc4 ,t5otomy1 #bif4 ,te/icle1 excision (1 #bij4 ,textor on amputation at elb[-jo9t1 #fj4 ,?igh1 amputations (1 #if4 ,?ompson on li?otrity1 #bge4 on /ricture1 #bgg4 ,?orax1 op]ations on !1 #bah4 ,?yrotomy1 #bae4 ,toes1 amputations (1 #fh4 ,tongue1 excision (1 #aig4 ,tonsils1 excision (1 #bjc4 ,tra*eotomy1 #bjf-bad4 ,treph9+ & trepann+1 #adg4 ,tri*iasis1 #aea4 ,tripi]'s amputation1 #gh4 ,troc> ( ,sir ,s4 ,wells describ$1 #bbg4 ,tum\rs ( scalp1 removal (1 #adi4 ( eyelids1 removal (1 #aeb4 ,tyrrell on treatm5t ( bra*ial aneurism1 #dc4 ,upp] extremity1 amputation (1 #ej4 ,ure?ra1 /ricture (1 #bgf4 ,velpeau on ligature ( iliac1 #ab4 on ligature ( subclavian1 #ch4 on amputation at elb[-jo9t1 #fj4 on amputation at knee-jo9t1 #ia4 on radical cure ( h]nia1 #bde4 ,v]male on amputation ( ?igh1 #ajb4 ,v]neuil on ,*op>t's amputation1 #gh4 ,vessels ( =e-arm1 ligature (1 #dd4 ,wakley on /ricture1 #bgi4 ,w>r5 on fissure ( h>d palate1 #bjc4 ,watson1 ,dr4 ,p4 ,h41 on excision1 #ace4 on excision ( elb[-jo9t1 #abc4 on l>yngectomy1 #baf4 ,wells1 ,sir ,sp5c]1 on ov>iotomy1 #bbd-bbi4 troc>1 #bbg4 h]nia1 radical cure (1 #bdg4 ,:ite on amputation ( leg1 #hf4 on excision ( jo9ts1 #aaj4 ,:itehead1 ,mr4 ,w41 on excision ( tongue1 #aii4 ,willet on oesophagotomy1 #baf4 ,wood's /ati/ics1 #cj4 on jo9ts1 #acd4 on radical cure ( h]nia1 #bdh-bea4 ,wry neck1 op]ation =1 #bif4 ,wri/-jo9t1 amputation at1 #ee4 excision (1 #abd4 ,wtz] on radical cure ( h]nia1 #bdg4 ,wye?1 ,dr41 /ati/ics1 #cf1 #ch4 ,"y1 ,james1 t\rniquet introduc$ by1 #dg4 ,zeh5d]'s /ati/ics1 #cj4