IF CALIFORNIA 6E OF MEDICINE RARY 1 1974 'ORNIA 92664 SURGICAL TECHNIC T F P H N T P^ 1 n^^^M 0[rf on OPERATIVE SURGERY 7 BY FR. VON ESMARCH, M.D. PROFESSOR OF SURGERY AT THE UNIVERSITY OF KIEL, AND SURGEON-GENERAL OF THE GERMAN ARMY AND E. KOWALZIG, M.D. LATE FIRST ASSISTANT AT THE SURGICAL CLINIC OF THE UNIVERSITY OF KIEL TRANSLATED BY PROFESSOR LUDWIG H. GRAU, PH.D. FORMERLY OF LELAND STANFORD JUNIOR UNIVERSITY AND WILLIAM N. SULLIVAN, M.D. FORMERLY SURGEON OF U.S.S. "CORWIN" ASSISTANT OF THE SURGICAL CLINIC AT COOPER MEDICAL COLLEGE, SAN FRANCISCO EDITED BY NICHOLAS SENN, M.D. PROFESSOR OF SURGERY AT RUSH MEDICAL COLLEGE, CHICAGO " Kurz und Biindig" FOURTEEN HUNDRED AND NINETY-SEVEN ILLUSTRATIONS AND FIFTEEN COLORED PLATES THE MACMILLAN COMPANY LONDON: MACMILLAN & CO., LTD. 1903 All rights reserved uo lAKMi" COPYRIGHT, 1901, BY THE MACMILLAN COMPANY. Set up, electrotyped, and published May, 1901. Reprinted September, 1903. w A b I NotfaooB J. S. Cuihlng & Co. Berwick & Smith Co. Norwood, Mail., U.S.A. SUMMARY OF THE PREFACES OF THE FIRST FIVE GERMAN EDITIONS FOR promoting the interests of humanity in times of peace under the symbol of the Red Cross, f&er Jftajestg tfje German Empress, on the occasion of the Vienna World's Exhibition, offered two prizes, one of them to be awarded for the best Handbook of Surgical Technic. The regulations of competition were the following : " The book should present in as concise and intelligible a form as possible the various methods of bandaging and dressing, as well as all surgical operations ; but above all it should comprise the present advanced status of Surgical Technic, in order to become the indispensable Guide Book and practical compan- ion of every surgeon." The jury selected to award the prize consisted of Professor B. von Lan- genbeck in Berlin, Professor Billroth in Vienna, and Professor Socin in Basle. Unanimously they awarded the first prize to the author of this Surgical Technic. The author strictly fulfilled the requirements of the competition, but at the same time he purposed to make this handbook a practical aid to memory. In his opinion this could be better accomplished by illustrations than by a cumbersome text. A glance at an illustration representing a dressing, an operation, or an anatomical preparation, enables one to recall to memory most rapidly all former knowledge concerning the same. Hence the book contains many illustrations and as concise a text as vi AUTHOR'S PREFACE possible. The author of course endeavored to incorporate all the extraor- dinary progress which Surgery, and especially Surgical Technic, has made during recent years. At the end of the work three indexes of names, subject-matter, and illustrations will largely facilitate the use of this book. FRIEDRICH VON ESMARCH. SEPTEMBER 3, 1900. PREFACE OF THE AMERICAN EDITOR PROFESSOR VON ESMARCH, the senior author of this book, needs no introduction to the medical profession of this country. His name and fame are familiar to every educated physician. As an author and teacher he has few equals. During the last few years he has been ably assisted in his literary work by his former first assistant, Dr. Kowalzig. It was a happy idea when the publishers decided to present the English reading profession with a translation of the great works of Professor von Esmarch in one volume. The translator had a difficult task. The motto, " Kurz und biindig," characterizes the text. No superfluity of words, the language is concise and precise. If there are any shortcomings in the translation, it is an attempt on part of the translator to reproduce the language of the authors as faithfully and as accurately as possible. The great feature of this book are the numerous excellent illustrations which embellish the text and which enable the reader to follow with his eyes every step of all minor and major operations. The American editor has added notes which appear in brackets in places where he deemed it necessary to add to the text or to indicate his own views or methods of practice. N. SENN. CHICAGO, 1901. TRANSLATOR'S PREFACE THE translator believes he is rendering an important service to Ameri- can and English surgeons in presenting an English translation of von Esmarch's " Surgical Technic." Its excellence is acknowledged by all European surgeons, and now that it has received the careful revision and valuable notes from the hands of its learned editor, it may confidently be regarded as the best handbook on the subject of Surgical Technic in the English language. L. H. GRAU. SAN FRANCISCO, May, 1901. viii TABLE OF CONTENTS THE TREATMENT OF WOUNDS PAGE Asefsis 2 Preparations for Aseptic Operations and Dressings 2 Purifying the Operating Room 2 Asepsis of the Surgeon and his Assistants w 3 Sterilization of Instruments 7 Sterilization of Sutures and Ligatures 10 Sterilization of Sea and Gauze Sponges . .... . . . . . . .11 Disinfection of the Patient ............. 13 Sterilization of the Dressing Materials 16 Aseptic Operations 18 Antisepsis 22 Antiseptic Solutions 23 Antiseptic Powders .............. 32 The Drying and the Draining of the Wound 37 Dressings of the Wound 40 Changing the Dressings 47 The Position of the Patient 49 The Position of the Patient in Bed '. . . -51 Secondary Antisepsis ............... 57 Permanent Antiseptic Irrigation . . . . . . . . . . -59 The Antiphlogistic Treatment . . . 61 Open Treatment of Wounds 66 BANDAGING Bandages 68 Bandages for the Head 74 Bandages for the Arm 76 Bandages for the Trunk 80 Bandages for the Leg 82 Cloth Bandages ................ 84 Bandages for the Head 85 Bandages for the Arm . . . . . . . . . . . . .87 Bandages for the Trunk 89 Bandages for the Leg 89 Splints 95 Wooden Splints 95 Sheet Zinc Splints .............. 101 Wire Splints ............... 102 Glass Splints ............... 105 ix X TABLE OF CONTENTS PAGE Pasteboard Splints 106 Plastic Splints no Plastic Dressings . . no Starch Dressing 1 1 1 Potash Silicate Dressing 112 Plaster of Paris Dressing 113 Application of Plaster of Paris Dressing 117 Removable Plaster of Paris Dressing 119 Strengthening Plaster of Paris Dressing 121 Fenestrated Plaster of Paris Dressing 126 Interrupted Plaster of Paris Dressing 127 Plaster of Paris Suspension Splints 133 Position Dressings . . . . . . . . ... . . . .138 Extension Dressings 146 Extension by Weights ............. 147 Elastic Extension and by Adhesive Plaster . . . . . . . . . 153 Temporary Dressings . . . . . . . . . . . . . .159 Temporary Splints . . . . . . . . . . . . . .160 Antisepsis in War . . . . . . . . . . . . . . .168 The Soldier's Antiseptic Dressing Package 1 70 NARCOSIS General Anaesthesia . . . . . . . . . . . . .-. .172 Chloroform Anesthesia . . . . . . . . . . . . .172 Course of Chloroform Anaesthesia . . . . . . . . . . .176 Awakening from Chloroform Anaesthesia . . . . . . . . .178 Unpleasant Occurrences after Anaesthesia . . . . . . . . .179 Unpleasant Accidents during Anaesthesia . . . . . . . . 1 79 Action of Surgeon during Serious Accidents . . . . . . . . .182 Ether Anesthesia 188 Methods of Ether Anaesthesia 188 Course of Ether Anaesthesia 189 Danger from Ether Anaesthesia 189 Awakening from Ether Anaesthesia 190 Combined Anaesthesias ............. 191 Other Anaesthetics 192 Local Antesthesia (Analgesia) . .. . . . . . .. . . 192 Regionary Analgesia 194 Infiltration Analgesia 195 SIMPLE OPERATIONS Incision 197 Puncture 201 Tissue Destruction 203 Union of Margins of the Wound" 209 Suture ................ 209 Removal of Foreign Bodies 218 Removal of Bullets 219 TABLE OF CONTENTS xi OPERATIONS FOR PREVENTION AND ARREST OF HEMORRHAGES AND THEIR CONSEQUENCES PAGE Saving of Blood ................ 224 Bloodless Method .............. 225 Compression of Main Trunk of the Artery .......... 235 By Pressure of the Finger (Digital Compression) 235 By Artery Compressors or Tourniquets , 236 Improvised Artery Compressors 240 Arresting Hemorrhages in the Wound ........... 242 Compression of Wound ............. 242 Medicinal Hemostatics (Styptics) ........... 243 Ligation of Vessels (Ligature) ............ 243 Hemorrhage from Punctured and Gunshot Wounds 247 Ligation of Arteries at the Place of Selection 251 General Rules 251 Ligation of Principal Trunks of Arteries .......... 254 Ligation of Common Carotid Artery 256 External Carotid Artery 257 Internal Carotid Artery 258 Lingual Artery 259 Subclavian Artery .............. 260 Vertebral Artery 262 Axillary Artery ............... 263 Brachial Artery ............... 264 Radial Artery 266 Ulnar Artery 266 Superficial Palmar Arch 267 Abdominal Aorta 268-269 Common and Internal Iliac Arteries ........... 270 Superior Gluteal Artery ............. 271 Sciatic Artery ............... 271 External Iliac Artery .............. 272 Femoral Artery ............... 272 Popliteal Artery 274 Anterior Tibial Artery 275 Posterior Tibial Artery 276 Transfusion and Infusion ............. 277 Bleeding 282 Venesection 282 Operation for Aneurisms .............. 283 Ligation of Artery ..." 285 Operation for Varices .............. 287 Ligation for Long Saphenous Vein ........... 288 Extirpation of Varices ............. 288 Injuries of Walls of Blood Vessels 289 OPERATIONS ON TENDONS Tenotomy 290 Tenotomy of the Tendo Achillis 291 xii TABLE OF CONTENTS Tendinorrhaphy 292 Tendinoplasty 295 OPERATIONS ON NERVES Neurorrhaphy . 296 Neuroplasty 297 OPERATIONS ON SKIN Skin Grafting (Transplantation) 298 Skin Grafting according to Thiersch 299 Plastic Operations ............... 301 Operations on Nails ............... 302 OPERATIONS ON BONES Osteoclasis 305 Osteotomy 307 Subtrochanteric Osteotomy 308 Supracondylic Osteotomy of the Femur 308 Supramalleolar Osteotomy .............. 309 Direct Fixation of Bone Fragments 309 Necrotomy ................312 Osteoplastic Necrotomy 315 AMPUTATIONS AND DISARTICULATIONS Indications ................ 316 General Rules ................ 317 Preparations . . . . . . . . . . . . . . 3 1 ? Division of Soft Parts 318 Circular Amputation (by One Incision) . . . . . . . . . .318 Circular Amputation (by Two Incisions) .......... 320 Amputation by forming Skin Flaps ........... 324 Muscular Flaps ............... 325 Oval Incision ............... 326 Sawing off Bones .............. 326 Union of Wound 331 General Rules for Disarticulation 332 Reamputation 333 Protheses . . . . . . . .... . . . . . . 334 AMPUTATION AND DISARTICULATION OF UPPER EXTREMITIES Disarticulation of Fingers 336 Disarticulation of Third Phalanx 336 Disarticulation of Second Phalanx 336 Disarticulation at Metacarpophalangeal Joint 337 Disarticulation of All Fingers 339 Disarticulation of Thumb at Carpal Joint 340 TABLE OF CONTENTS xiii PAGE Oval Incision 340 Lateral Flap Incision according to von Walther 341 Disarticulation of Last Four Metacarpal Bones 341 Disarticulation of Wrist 342 Circular Incision .............. 342 Flap Incision ............... 343 Radial Flap Incision .............. 344 Amputation of Forearm .............. 344 Disarticulation of Elbow Joint . . . . . 346 Circular Incision .............. 346 Flap Incision ............... 347 Oblique Incision .............. 347 Amputation of Arm ............... 348 Disarticulation of Arm at Shoulder Joint ........... 350 Flap Incision ............... 350 Circular Incision 352 Oval Incision 353 AMPUTATIONS AND DISARTICULATIONS OF LOWER EXTREMITIES Disarticulation of Toes 354 In the Phalangometatarsal Joint 354 Amputation of all Metatarsal Bones ............ 355 Disarticulation of Great Toe together with its Metatarsal Bone ....... 355 Disarticulation of Fifth Toe with its Metatarsal Bone ........ 356 Lisfranc's Disarticulation in Tarso-Metatarsal Articulations 357 Choparfs Disarticulation at Tarsus 359 Malgaigne's Disarticulation of Foot below Astragalus ........ 362 Byrne's Disarticulation of Foot ............. 364 Pirogojfs Disarticulation of Foot ' 367 Giint/ier's Modification of Pirogoff's Amputation . . . . . . . . . 368 Le Fort and von EsmarcKs Modification of Pirogoff's Amputation . . . . . . 370 Amputation of Leg ............... 372 Bier's Osteoplastic Amputation 374 Disarticulation of Leg at Knee Joint 377 Circular Incision 377 Flap Incision ............... 378 Oblique Incision .............. 379 Grittfs and Others' Osteoplastic Amputation . . . . . . . . . 380 Amputation of Thigh .............. 380 Disarticulation of Thigh .............. 383 By an Anterior Large and a Posterior Small Flap ........ 383 Transfixion, Manec's Puncture Method 383 VetsMs Circular Method .. ............ 386 RESECTION OF JOINTS Indications 389 General Rules for Resections 390 xiv TABLE OF CONTENTS RESECTION OF UPPER EXTREMITIES PAGE Resection of Fingers 394 Resection of Lower Articular Ends of Radius and Ulna 395 Total Resection of Wrist 399 By von Langenbeck 's Dorsal Radial Incision 399 By Keeker's Dorso-Ulnar Incision 401 Resection of Elbow Joint 403 By Listen' s T Incision 403 By von Langenbeck's Simple Longitudinal Incision 405 By Hueter's Bilateral Longitudinal Incision 406 By Oilier' 1 s Bayonet Incision 407 By Nelaton's Angular Incision 408 By Keeker's Hook-shaped Incision 408 Resection of Olecranon .............. 409 Resection of Shoulder Joint . . . . . . . . . . . . .411 By von Langenbeck's Longitudinal Incision . . . . . . . . .411 By von Langenbeck's Anterior Longitudinal Incision (Old Method) ..... 413 By Oilier' 1 s Anterior Oblique Incision . . . . . . . . . . .415 By Keeker's Posterior Curved Incision . . . . . . . . . .415 Resection of Articular Surface and Neck of Scapula (von EsmarcK) . . . . . .417 Resection of Scapula By von Langenbeck's Angular Incision . . . . . . . . . .418 By Oilier 1 s Subperiosteal Resection . . . . . . . . . . .418 Partial Resection of Scapula 419 Resection of Clavicle 419 RESECTION OF LOWER EXTREMITIES Resection of Articulations of the Toes 420 Peterson's Resection of Articulation of the Great Toe ........ 420 Resection of Ankle Joint .............. 421 By von Langenbeck's Bilateral Incision .......... 421 By Konig's Bilateral Incision ............ 425 By Kocher's External Lateral Transverse Incision ........ 426 By Girard's External Oblique Incision .......... 427 By Lauenstein's Curved Incision ............ 428 By Hueter's Anterior Transverse Incision .......... 428 Resection of Astragalus ............... 428 By Vogfs Anterior Longitudinal Incision .......... 428 Resection of Os Calcis 429 By Ollier's External Angular Incision .......... 429 By Gnerin's Spur Incision 430 By Kocher's Angular Incision ............ 430 Tarsectomy ................ 430 Resection of Remaining Tarsal Bones 430 Osteoplastic Resection at the Tarsus, according to Miculicz- Wladimiroff . . . .431 Operations for Clubfoot 433 Operations for Flatfoot 434 TABLE OF CONTENTS xv Resection of Knee Joint .............. 435 By 7'exfor's Anterior Curved Incision 435 By Hahrfs Curved Incision ............ 439 By von Volkmanri's Transverse Incision .......... 440 By von LangenbecK 1 s Curved Lateral Incision ......... 440 By Hueter's Internal Longitudinal Incision ......... 442 By Keeker's External Curved Incision 443 Puncture of Knee Joint .............. 444 Drainage of Knee Joint .............. 444 Resection of Hip Joint ............... 445 By A. White's Posterior Curved Incision .......... 445 By von Langenbeck's External Longitudinal Incision ........ 446 By Keeker's Posterior Longitudinal Incision 449 By Lucke-Schede's Anterior Longitudinal Incision ........ 450 By Htteter's Anterior Oblique Incision . . . . . . . . . . 451 By Oilier 's Resection of the Trochanter .......... 452 Arthrotomy for Congenital Dislocation of Hip Joint 453 Resection of Ilium 454 OPERATIONS ON THE HEAD Resection of the Vault of the Cranium 455 Trephining 457 Craniectomy ' . . 461 Osteoplastic Resection of the Skull ........... 463 Cerebral Topography .............. 465 Opening of the Skull at the Base of the Squamous Portion of the Temporal Bone . . 468 Exploratory Perforation of the Skull ........... 469 Lumbar Puncture .............. 470 Ligation of the Middle Meningeal Artery 470 Opening of the Mastoid Process . . 473 Opening of the Lateral Chambers of Antrum ......... 474 Opening of the Frontal Sinus ............ 475 Resection of the Maxilla .............. 476 Resection of the Alveolar Process ........... 476 Resection of the Whole Upper Jaw ........... 477 Resection of Both Upper Jaws ............ 481 Osteoplastic Resection of the Upper Jaw .......... 482 Osteoplastic Resection of Both Upper Jaws ......... 483 Opening of the Antrum of Highmore 485 Resection of the Lower Jaw 487 Resection of the Alveolar Process 487 Resection of One-half of the Lower Jaw - .... . . . 487 Resection of the Maxillary Arch ............ 489 Resection of the Articulation of the Lower Jaw 491 Resection in Ankylosis ............ ..491 Subperiosteal Resection of the Lower Jaw .......... 492 xvi TABLE OF CONTENTS PAGE Nerve Stretching and Nerve Resection ........... 493 Supraorbital Nerve .............. 494 Supramaxillary Nerve .............. 496 With Temporary Resection of the Malar Bone . 498 Inframaxillary Nerve .............. 499 Retrobuccal Method ............. 502 Temporary Resection of the Lower Jaw .......... 502 Temporary Resection of the Zygomatic Arch ......... 504 Lingual Nerve ............... 506 Mental Nerve ......*......... 506 Intracranial Resection of the Ganglion Gasseri ......... 507 Facial Nerve ............... 509 Nervus Accessorius Willisii (Spinal Accessory Nerve) 510 Brachial Plexus 511 Crural Nerve 511 Sciatic Nerve 512 Popliteal Nerve 513 Plastic Operations on the Face . . . . . . . . . . . . .514 Blepharoplasty (Plastic Surgery of the Eyelids) 514 Cheiloplasty (Plastic Surgery of the Lips) 517 Stomatoplasty (Plastic Surgery of the Mouth) . . . . . . . . 526 Meloplasty (Plastic Surgery of the Cheeks) ......... 527 Rhinoplasty (Plastic Surgery of the Nose) .......... 530 Total Rhinoplasty 530 Partial Rhinoplasty .............. 539 Correction of Saddle or Collapsed Noses 541 PLASTIC OPERATIONS FOR CONGENITAL FISSURE FORMATIONS OF THE ORAL REGION Harelip and Maxillary Fissure ............. 544 Single Cleft of Lip (Harelip) 544 Double Harelip 548 Double Harelip and Maxillary Fissure .......... 548 Single Harelip and Cleft Palate 550 Cleft Palate 551 Staphylorrhaphy (Closing Cleft of Soft Palate) 551 Uranoplasty (Closing Cleft of Hard Palate) 555 Palatal Protheses, Obturators 558 OPERATIONS INVOLVING THE FACIAL CAVITIES In the Orbit 561 Extirpation of the Eyeball 562 Enucleation of the Eyeball 562 Exenteration of the Bulb 563 In the Ear 563 Foreign Bodies in the External Auditory Meatus 563 TABLE OF CONTENTS xvii PAGE In the Nares 565 Inspection of Nares 565 Tamponing the Nares 566 Removal of Nasal and Nasopharyngeal Polypi 568 Removal of Mucoid Polypi . . . - 568 Removal of Nasopharyngeal (Fibrous) Polypi 571 Division of the Nose in the Median Line 572 Resection of Nasal Process of the Upper Jaw 572 Temporary Detachment of the Nose . . . . . . . . . . -573 Turning Nose upward . . - . 574 Adenoid Vegetations in Nasopharyngeal Cavity 577 Contraction of Nostrils . . . . . . . . . . . . -579 Deviation (Scoliosis) of the Septum of the Nose . . . . . . . . 580 Subperichondrial Resection of the Septum (Petersen) ....... 580 In the Oral Cavity 581 For Inspecting the Cavity of the Mouth 581 Extraction of Teeth ". 584 Acquired Defects of the Palate ............ 590 Tonsillotomy ............... 591 Extirpation of Tonsils ............. 594 Amputation of the Uvula 595 Operations on the Tongue 597 Excision of a Wedge-shaped Portion from the Tip of the Tongue 597 Amputation of the Tongue ............. 599 Temporary Lateral Resection of the Lower Jaw ........ 600 Temporary Resection of the Lower Jaw in the Median Line ...... 602 Operation for Ranula 604 Extirpation of the Parotid 605 Extirpation of the Submaxillary Gland 607 Salivary Fistula 607 Subhyoid Pharyngotomy 608 Lateral Pharyngectomy ............. 610 Retropharyngeal Abscesses 610 OPERATIONS ON THE NECK Opening of the Air Passages, Bronchotomy . , . . . . . . . . 612 Laryngotomy 612 Median Thyrotomy .............. 612 Transverse Thyrotomy ............. 614 Infrathyroid Laryngotomy ............ 614 Subhyoid Laryngotomy . . . . . . . . . . . . .615 Tracheotomy ............... 615 High Tracheotomy 616 Intubation ............... 619 Inferior Tracheotomy 620 Tamponade of the Trachea 620 Extirpation of Larynx . . . . . . . . . . . . .621 xviii TABLE OF CONTENTS Operations for Goitre (Struma) 625 Parenchymatous Injection 625 Puncture with Subsequent Injection 625 Incision with Suturing Cyst Wall to Skin 626 Extirpation of Struma ............. 626 Resection of Goitre .............. 630 Enucleation of Goitre .............. 631 Ligation of Arteries 631 Palliative Operations 633 Ligation of the Isthmus of the Thyroid Gland 633 Operations on the (Esophagus 635 Introduction of the CEsophageal Tube .......... 635 Foreign Bodies in the CEsophagus 637 Strictures of the CEsophagus 639 External CEsophagotomy 640 OZsophageal Diverticula 644 Tenotomy of the Sternocleidomastoid 644 Extirpation of Sternocleidomastoid 646 Operations for Cervical Tumors ............ 646 OPERATIONS ON THE BREAST Ligation of the Innominate Artery . . . . . . . . . . . -651 Ligation of the Internal Mammary Artery . . . . . . . . . . .652 Resection of the Manubrium Sterni ............ 653 Resection of the Ribs 655 Opening of the Thoracic Cavity 657 Thoracocentesis 657 Puncture with Aspiration 659 Thoracotomy 661 Pneumotomy 664 Pericardiotomy 666 Operations on the Mammary Gland ............ 666 Incision of the Mammary Gland . . . . . . .. . . . 666 Extirpation of the Mammary Gland ........... 666 Amputation of the Breast with Clearing out of the Axilla 667 OPERATIONS ON THE ABDOMEN Opening Abdominal Cavity by Puncture 672 Laparotomy (Cceliotomy) 673 Laparotomy for Ileus 676 Operations on the Stomach and the Intestines 678 Gastrotomy 678 Gastrorrhaphy 679 Gastrostomy ............... 680 By Establishing an Oblique Fistula 682 TABLE OF CONTENTS xix PAGE Resection of the Pylorus 685 Gastro-enterostomy .............. 690 Pyloroplasty ............... 696 Enterotomy ............... 697 Enterostomy (Colostomy) ............. 697 Formation of an Artificial Anus ............ 699 Enterorrhaphy ............... 702 Resection of the Intestine ............. 706 Enteroanastomosis .............. 708 Local Exclusion of Diseased Intestine 710 Resection of the Vermiform Appendix 711 Anus Praeternaturalis 712 Operations for Hernia ............. . 714 Taxis 717 Herniotomy 718 Radical Operation for Hernia ............ 722 For Inguinal Hernia ............. 722 For Femoral Hernia ............. 730 For Umbilical Hernia ............. 731 Operations on the Liver and the Gall Bladder 732 Operation for Echinococcus of the Liver 732 Cholecystotomy 733 Cholecystostomy 734 Cholecystectomy ............... 735 Choledochotomy ............... 736 Operations on the Spleen .............. 738 Splenectomy ............... 738 Splenopexy 739 Operations on the Kidney .............. 740 Nephrotomy 740 Nephrectomy 740 Nephropexy 745 Ureterotomy 746 OPERATIONS ON THE PELVIS Operations on the Urethra and the Bladder 747 Catheterism ............... 747 Stricture of the Urethra 754 Internal Urethrotomy . . . ." 759 External Urethrotomy 761 Urethroplasty 764 Foreign Bodies in the Urethra and the Bladder 766 Suprapubic Puncture of the Bladder 768 Suprapubic Cystotomy ............. 770 Subpubic Cystotomy .............. 776 Extirpation of Urinary Bladder 776 Perineal Cystotomy . 777 XX TABLE OF CONTENTS PAGE Prostalotomy 778 Lateral Prostatectomy 781 Galvanocaustic Excision of the Prostate Gland . . . . . . . . .781 Lithotripsy 782 Litholapaxy 784 Operations for Congenital Cleft Formation of the Anterior Pelvic Region 784 In Ectopia Vesicae (Cystoplasty) 784 Epispadias ................ 788 Hypospadias .... ........... 79 * Operations on the Penis and the Scrotum ........... 79 2 Operation for Phimosis ............. 79 2 Operation for Paraphimosis ............ 794 Amputation of the Penis ............. 79^ Operations for Hydrocele Testis ............ 797 Operation for Varicocele ............. 800 Castration ................ 801 Resection of the Vas Deferens 802 Operations on the Rectum and the Anus ........... 803 Examination of the Rectum 803 Proctoplasty 806 Strictures of the Rectum 807 Strictures of the Anus 809 Operations for Rectal Fistula 809 Prolapsus Recti 812 Resection of the Prolapse of the Rectum 813 Operation for Haemorrhoids 814 Operation for Cancer of the Rectum 817 Extirpatio Ani 818 Resection of the Rectum 818 Resection of the Sacrum 819 Parasacral Incisions 823 Palliative Operations 825 ILLUSTRATIONS FIG. 1. Atomizer for Carbolated Spray. 2. Cabinet for Instruments and Dressings. 3. Small Dressing Table. 4. Aseptic Operating Table. 5. Surgeon's Gowns. 6. Metal Retractor. 7. Metal Retractor. 8. Metal Retractor. 9. Bistoury with Removable Blades. 10. Forceps with Smooth Arms : (0) Surgical, (3) Anatomical. 11. Aseptic Knife. 12. Forceps with Removable Lock. 13. Instrument Sterilizer. 14. Instrument Tray Stand (of Glass). 15. Schimmelbusch's Tin Box for Sterilized Silk. 1 6. Glass Box for Catgut Ligatures. 17. Tampon. 1 8. Portable Hospital Bath (Am. Model). 19. Arm Bath of Sheet Zinc. 20. Leg Bath of Sheet Zinc. 21. Rubber Blanket. 22. Combination Sterilizer : () closed, (^) open, (f) in operation. 23. Beck's Portable Compact Sterilizer. 24. Kny-Sprague's Perfection Surgical Dressing Sterilizer. 25. Improved Irrigator. 26. Irrigator. 27. " Irrigateur a vide bouteille." 28. Fritsch's Steam Sterilizer. 29. Dressing Basin. 30. Large Dressing Basin. 31. Inversion Suture. 32. Inversion Suture. 33. Rubber Drainage Tube. 34. Decalcified Bone Drainage Tube. 35. Lister's Dressing Forceps. 36. Curved Drainage Trocar. FIG. 37. Drainage Openings in the Skin. Last irri- gation. 38. Large Dressing Pad. 39. Elastic Compressive Bandage. 40. Antiseptic Dressing of Large Lateral Wounds on the Neck. 41. Antiseptic Cushioned Dressing of Stump after Amputation. 42. Dressing Scissors. 43. McBurney's Adjustable Telescopic Hip Rest. 44. Improvised Position Apparatus. 45. Adjustable Back Rest. 46. Protector. 47. The Same in Straight Form for Transporta- tion. 48. Invalid Lift (a and ). 49. Suspension Stretcher. 50. Von Volkmann's Suspension Frame. 51. Siebold's Apparatus for Lifting a Patient. 52. Roser's Dilator : () closed. 53. Von Langenbeck's Small Blunt Retractor. 54. Von Langenbeck's Large Blunt Retractor. 55. Sharp Spoon, Curette. 56. Starke's Apparatus for Permanent Irrigation. 57. Von Volkmann's Drop Canula. 58. Von Volkmann's Suspension Splint. 59. Suspension of the Hand according to von Volkmann. 60. Suspension of a Fenestrated Plaster of Paris Dressing. 61. Ice Bag. 62. Cooling Box for the Vertebral Column of the Neck. 63. Esmarch's Cold Coil. 64. Leiter's Cold Head Coil. 65. Irrigation. 66. Fenestrated Plaster of Paris Dressing; Open Treatment of Wounds. 67. Constriction caused by Bandage. XXII ILLUSTRATIONS FIG. 68. Gaping Bandage. 69. Rolling a Bandage. 70. Bandage Roller. 71. Circular and Serpentine Turns. 72. Spiral Bandage. 73. Testudo Inversa. 74. Testudo Reversa. 75. Funda Bandage. 76. Scultet's Many-tailed Bandage. 77. T Bandages. 78. Double-headed Union Bandage (Fascia uniens). 79. Sagittal Bandage. 80. Cross-knot Bandage (Fascia nodosa). 81. Mitra Hippocratis. 82. Halter Bandage. 83. Halter Bandage. 84. Eye Bandage (Monoculus). 85. Bandage for the Nose. 86. Funda Maxillae. 87. Chirotheka. 88. Chirotheka. 89. Spica Manus. 90. Spica Humeri. 91. Bandaging of the Hand and the Arm. 92. Narrow Spica Bandage. 93. Desault's Bandage for Fracture of the Clavi- cle : (a) First Bandage. 94. Desault's Bandage for Fracture of the Clavi- cle : (b) Second Bandage. 95. Desault's Bandage for Fracture of the Clavi- cle : (c ) Third Bandage. 96. Velpeau's Bandage for Fracture of theClavicle. 97. Stellated Bandage (Stella Dorsi). 98. Bandage of the Thorax (Quadriga). 99. Suspensorium Mammae. 100. Double Suspensory Mammary Bandage. 101. Stapes. 102. Double Anterior Spica for the Hip : a, As- cending ; b, Descending. 103. Bandaging the Whole Leg. 104. Von Esmarch's Triangular Cloth. 105. Sailor's Knot. 106. Granny's Knot. 107. Triangular Head Cloth (Anterior view). 108. Triangular Head Cloth (Posterior view). 109. Funda Bandage for the Temporal Region. 1 10. Funda Bandage for the Occiput. FIG. in. Large Square Head Cloth. 112. Large Square Head Cloth. 113. Eye Bandage. 114. Funda Bandage for the Chin. 115. Cravat or Kerchief. 1 1 6. Cravat with inserted Pasteboard. 117. Cross Bandage for the Hand. 118. Shoulder Cloth, Hand Cloth, Elbow Cloth, and Small Sling. 119. Head Cloth, Breast Cloth, Shoulder Cloth. 120. Breast Cloth, Shoulder Cloth. 121. Mitella Triangularis. 122. Other Form of Mitella. 123. Cloth for carrying the Arm. 124. Mitella Bandage. 125. Square Cloth for carrying the Arm. 126. Szymanowsky's Bandage for Fracture of the Clavicle : (a) Posterior view, (3) Anterior view. 127. Roser's Apron Bandage for the Chest. 128. Cloth Bandage for the Lateral Region of the Chest. 129. Cingulum Pectoris. 130. Large Breast Cloth, anterior view. The same, posterior view, see Fig. 119. 131. Bandage for the Pelvis. 132. Cloth for the Buttocks. 133. Hip Cloth. 134. Unna's Gauze Sash. 135. Roser's Apron Bandage for the Inguinal Region. 136. Knee Cloth. 137. Foot Cloth. 138. Mayor's Cloth Bandage for Fracture of the Patella. 139. Mayor's Cloth Bandage for Fracture of the Patella. 140. Fixation Dressing for the Broken Arm. 141. Wooden Splint with Tin Socket. 142. Gooch's Flexible Wooden Splints. 143. Schnyder's Cloth Splints for the Lower Ex- tremity. 144. Von Esmarch's Splint Material (can be cut). 145. Stromeyer's Hand Splint. 146. Stromeyer's Splint for the Arm at an Obtuse Angle. 147. Roser's Dorsal Splint for Fracture of the Lower End of the Radius. ILLUSTRATIONS xxm FIG. 148. Carr's Radius Splint. 149. Clover's Radius Splints. 150. Bell's Hollow-moulded Splints for the Leg. 151. Bell's Four Splints for the Thigh (a, b, ', d}. 152. Von Volkmann's Supination Splint. 153. Watson's Splint for Resection of the Knee Joint. 154. Watson- Vogt's Splint for Resection of the Knee Joint. 155. Von Volkmann's Tin Splint. 156. Salomon's Tin Splint. 157. Splints of Sheet Zinc. 158. Splints of Sheet Zinc. 159. Roser's Wire Splint for the Leg. 160. W 7 ire Splint for the Leg with Handles for Suspension. 161. Cramer's Flexible Wire Splint. 162. Splints of Wire Cloth. 163. Splints of Wire Cloth Applied. 164. Leg Splint of Telegraph Wire with Foot Support. 165. Arm Splint of Telegraph Wire. 1 66. Neuber's Arm Splint of Glass. 167. Neuber's Leg Splint of Glass. 1 68. Pasteboard Splint for the Arm. 169. Model for Arm Splint. 170. Pasteboard Splint for Injuries on the Volar Side of the Wrist. 171. Pasteboard Splint for Fractures of the Humerus. 172. Dumreicher's Alar Splint. 173. Dumreicher's Alar Splint. 174. Danger from a Circular Bandage in Frac- tures of Both Bones of the Forearm (ac- cording to Albert). 175. Merchie's Models for Plastic Splints for the Arm. 176. Merchie's Models for Plastic Splints for the Arm. 177. Merchie's Models for Plastic Splints for the Leg. 178. Merchie's Models for Plastic Splints for the Leg. 179. Schede's Radius Splint. 180. Divided Starch Dressings. 181. Strips of Plaster of Paris Bandage (accord- ing to Pirogoff). 182. Double Pieces of Linen for Plaster of Paris Compressions for the Leg. 183. Plaster of Paris Compress. 184. Board for making Plaster of Paris Bandages. 185. Beely's Plaster of Paris Bandage Machine. 1 86. Wywodzoff's Plaster of Paris Bandage Ma- chine. 187. Plaster of Paris Tin Box. 1 88. Plaster of Paris Bandage with Cotton Band- ages for Padding. 189. Plaster of Paris Dressing with Turned-up Margins. 190. Plaster of Paris Knife. 191. Plaster of Paris Scissors. 192. Case containing Plaster of Paris Knife and Scissors. 193. Plaster of Paris Tutor for the Knee. 194. Beely's Plastic Plaster of Paris Splint. 195. Braatz's Spiral Splint for Fracture of the Radius. 196-197. Wood-shaving Plaster of Paris Dressing on the Humerus. 198-199. Wood-shaving Plaster of Paris Dressing on the Forearm. 200-201. Wood-shaving Plaster of Paris Dressing for Resection of the Elbow Joint. 202. Von Esmarch's Pelvic Support. 203. Von Esmarch's Heel Support. 204. Von Bardeleben's Pelvic Support. 205-207. Wood-shaving Plaster of Paris Dress- ings for the Leg. 208. Stirrup Plaster of Paris Splint for the Knee. 209. Stirrup Plaster of Paris Splint for the Elbow. 210. Beely's Plaster of Paris Hemp Splint for the Knee. I. 211. Beely's Plaster of Paris Hemp Splint for the Knee. II. 212. Bridge Plaster of Paris Splint with Wooden Laths. 213. Pirogoff 's Bridge Plaster of Paris Splint. 214-216. Von Esmarch's Plaster of Paris Suspen- sion Splint for Resection of the Elbow Joint. 217-219. Von Esmarch's Plaster of Paris Suspen- sion Splint for Resection of the Wrist. 220-222. Watson's and von Esmarch's Plaster of Paris Suspension Splint for Resection of the Knee Joint. XXIV ILLUSTRATIONS 223-225. Von Esmarch's Plaster of Paris Suspen- sion Splint for Resection of the Ankle Joint. 226-228. Von Esmarch's Suspension Splints made of Telegraph Wire. 229-230. Von Volkmann's Dorsal Splint. 231-232. Von Esmarch's Interrupted Splint for Resection of the Wrist. 233-234. Von Esmarch's Interrupted Splint for Resection of the Ankle Joint. 235-236. Von Esmarch's Double Splint for Re- section of the Elbow. 237-238. Von Esmarch's Sectional Iron Suspen- sion Splint for Resection of the Elbow Joint. 239. Pott's Lateral Position. 240. Bonnet's Wire Breeches. 241. Wire Breeches flattened for Packing. 242. Double Inclined Plane. 243-244. Von Esmarch's Double Inclined Plane. 245. Dobson's Adjustable Wooden Frame. 246. Von Renz's Abduction Box. 247. Petit and Heister's Fracture Box. 248. Maclntyre's Splint (improved by Listen) for Compound Fractures of the Leg. 249-250. Fialla's Rod Splint. 251. Scheuer's Fracture Box. 252. Stromeyer's Arm Pillow. 253. Stromeyer's Arm Pillow in Position. 254. Middeldorpf 's Triangular Pillow. 255. Middeldorpf 's Triangle. 256. Lister's Wooden Splint for Resection of the Wrist. 257. Desault-Liston's Wooden Splint for Fracture of the Femur. 258. Dupuytren's Splint for Fracture of the Ankle. 259. Foot Board. 260. Manner of applying Strips of Adhesive Plaster. 261. Fastening Strips of Adhesive Plaster. 262. Extension by Weight for Fractures of the Femur. 263. Von Volkmann's Sleigh Apparatus. 264. Fastening the Extension Splint by Two Wet Bandages. 265. Konig's Gliding Stirrup. 266. Extension of the Wrist by Weight. 267. Von Volkmann's Extension Apparatus for the Cervical Portion of the Spine. 268. Extension for Scoliosis. 269. Glisson's Sling. 270. Sayre's Extension Apparatus for Scoliotic Spine. 271. Barwell's Lateral Extension in Scoliosis. 272. Grooved Wooden Plug. 273. India Rubber Hose with Hooks. 274. Von Esmarch's Stretcher Extension Dressing for Transportation in Gunshot Wounds of the Femur. 275. Iron Hook for Separable Wooden Splint. 276. Von Esmarch's Separable Wooden Splint for Elastic Extension of the Thigh. 277. Elastic Extension of the Wrist. 278. Sayre's Adhesive Plaster Dressing (First Strip). 279-280. Sayre's Adhesive Plaster Dressing (Sec- ond Strip). 281-282. Landerer's Adhesive Plaster Dressing with Elastic Extension. 283. Miculicz's Extension Dressing for Genu Valgum. 284. Club-foot Shoe with Elastic Extension. 285. Sayre's Extension Dressing for the Knee Joint. 286. Sayre's Jury Mast. 287. Taylor's Extension Splint. 288. Fastening the Adhesive Plaster Strips. 289. Cloth Bandage of Skirt of Coat. 290. Bandage of Coat Sleeve cut open. 291. Bandage of Sleeve fastened with Safety Pins. 292. Temporary Splints for Fractured Leg. 293. Splint of Trellis of Flower Pot. 294. Splint of Small Branches tied in Bundles. 295. Flat Splint of Twigs arranged Side by Side. 296. Splint of Transverse Pieces of Wood fas- tened with Twine. 297. Straw Splint. 298. Straw Splint. 299. Straw Mat for Splint. 300. Reed Mat for Splint. 301. Porter's Wire Splint. 302. Protecting Frame for Wounded Limb. 303. Military Cloak used for Splint. 304. Boot cut open lengthwise used as Foot Splint. 305. Joined Bayonets used as Splints. ILLUSTRATIONS XXV FIG. 306. Bayonet Splint. 307. Scabbard used for Splint. 308. Musket used for Splint. 309. Dressing Table (Military Model). 310. Von Volkmann's Suspension Apparatus used for Injured Arm. 311. Von Bardeleben's Wire Suspension Appara- tus for Fractured Leg. 312. Cubasch's Suspension Apparatus of Stocking cut open. 313. Von Esmarch's Chloroform Mask. 314. Chloroform Mask packed in Case. 315. Schimmelbusch's Chloroform Mask. 316. Junker's Chloroform Apparatus. 317. Lifting the Lower Jaw. 318. Gutsch's Lower Maxilla Holder. 319. Protraction of Tongue with Forceps. 320. Von Esmarch's Tongue- holding Forceps. 321. Championniere's Hooked Tongue-holding Forceps. 322. Sponge Holder. 323. Nelaton's Inversion and Sylvester's Artificial Respiration (Inspiration). 324. Nelaton's Inversion and Sylvester's Artificial Respiration (Expiration). 325. Juillard's Ether Mask. 326-327. Wanscher-Grossmann's Ether Mask. (Old Form Modern Form.) 328. Flask containing Ethyl Chloride. 329. Syringe and Canute for Infiltration Anaes- thesia. 330-331. Holding the Knife like a Pen. (a) in anatomical Dissection; () in cutting from within outward. 332. Holding the Knife like a Violin Bow. 333. Holding the Scalpel like a Table Knife. 334. Shape of Knife Blades: i, 2 curved; 3,4 pointed; 5 straight; 6 blunt- pointed. 335. Stretching Margins of Wound for External Incision. 336. Grooved Director. 337. Conducting the Knife along the Grooved Director. 338-339. External Incision by raising a Fold of Tissue. 340. Von Volkmann's Sharp Retractor. 341. Von Langenbeck's Blunt Retractor : (a) small, (b) large. 342. Improvised Retractor. 343. Straight Scissors. 344. Cooper's Scissors. 345. Angular Scissors. 346. Trocar. 347. Von Esmarch's Trocar for Akidopeirastik. 348. Syringes for Subcutaneous Injection : (a) Pravaz's syringe, () Overlach's syringe, (<:) Koch's syringe. 349. Subcutaneous Injection. 350. Sharp Spoon. 351. Cautery Iron. 352. Brandis's Cautery Irons of Telegraph Wire. 353. Paquelin's Thermo-cautery. 354. Immersion Battery. 355. Galvano-caustic Wire Loop. 356. Porte-caustique. 357. Surgical Needles: (a) ordinary eye, () springy eye. 358. Dieffenbach's Needle Holder. 359. Hegar's Needle Holder. 360. Kiister's Needle Holder. 361. Roux's Needle Holder. 362. Hagedorn's Needle Holder. 363. Hagedorn's Needles. 364. Interrupted Suture. 365. Sailor's or " Reef Knot." 366. False or " Granny's Knot." 367. Surgeon's Knot. 368-370. Mode of applying Sutures. 371. Superficial and Interrupted Sutures. 372. Removing Suture. 373. Continued or Glover's Suture. 374. Tying a Continued Suture. 375. Languette Suture. 376. Laced Suture, with Margins of Wound turned inward. 377. Laced Suture, with Margins of Wound turned outward. 378. Folding Suture. 379. Quilt Suture. 380. Quilted Suture. 381. Button Suture. 382. Pearl Suture. 383. Twisted Suture. 384. Dressing Forceps. XXVI ILLUSTRATIONS 385. Anatomical Forceps. 386. Splinter Forceps. 387. Removing a Ring by Means of a Narrow Tape wound in a Downward Direction. 388. Flexible Zinc Probe. 389-390. Von Langenbeck's Bullet Forceps. 391. American Forceps for Soft Lead Bullets. 392-393. Forceps for Jacketed Bullets. 394. Liebreich's Electric Bullet Probe. 395. Longmore's Bullet Probe. 396. Chassaignac's Ecraseur. 397. Von Esmarch's Elastic Constrictor. 398. Clamp Buckle. 399. Elastic Bandage and Constrictor. 400. Limb rendered Bloodless on removing Elas- tic Bandage. 401. Elastic Constrictor. 402-403. Nicaise's Constrictor. 404. Von Esmarch's Apparatus for " Bloodless Method." 405-406. Von Esmarch's Clamp for fastening Elastic Tube. 407-408. Bloodless Method for Disarticulation of the Shoulder Joint. 409. Finger rendered Bloodless. 410. Bloodless Method used in Operation on Penis and Scrotum. 411. Bloodless Method in High Amputation of the Thigh. 412. Von Esmarch's Brass Spiral Constrictor. 413. Tourniquet Suspender (von Esmarch). 414. Applying a Tourniquet Suspender. 415. Desmarre's Clamp. 416. Dieffenbach's Ring Forceps. 417. Compression of the Carotid Artery by Finger Pressure. 418. Compression of the Subclavian Artery by Finger Pressure. 419. Compression of Right Subclavian Artery. 420. Compression of Brachial Artery. 421. Compression of Femoral Artery. 422. Compression of Brachial Artery by Tourni- quet. 423. Compression of Femoral Artery by Tourni- quet. 424. Petit's Screw Tourniquet. 425. Spanish Windlass. 426. Pancoast's Aorta Tourniquet. 427. Von Esmarch's Aorta Tourniquet. 428. Von Esmarch's Aorta Tourniquet. 429. Compression of the Aorta with Pad and Rubber Bandage. 430. Brandis's Method of compressing Aorta. 431. Compression of External Iliac Artery. 432. Improvised Spanish Windlass. 433. Compression of the Brachial Artery. 434. Volcker's Stick Tourniquet. 435-437. Spencer Well's Artery Forceps. 438-439. Ligation between Two Hemostatic For- ceps. 440. Ligation with Many Hemostatic Forceps. 441. Ligation of a Blood Vessel. 442. Ligation of Artery by Indirect Ligature. 443. Closing an Artery by Torsion. 444. Koeberle Pean's Clamp Forceps. 445. Doyen's Angiotribe. 446. Arteries of Head, Neck, and Axilla. 447. Arteries of the Thigh. 448. Arteries of the Arm. 449-450. Arteries of the Leg: (a) posterior side, (6) anterior side. 451. Division of Cellular Tissue between Two Forceps. 452. Opening the Sheath of an Artery. 453. Introducing Curved Probe. 454. Introducing Aneurism Needle. 455. Syme's Aneurism Needle. 456. Tying Ligature. 457. Situation of the Carotid Artery (Cervical Section). 458. Branches of External Carotid Artery. 459. Ligation of the Common Carotid Artery. 460. Ligation of the Common Carotid Artery be- tween the Two Heads of the Sternocleido- mastoid. 461. Ligation of the External Carotid Artery. 462. Ligation of Lingual Artery. 463. Ligation of Subclavian Artery in the Supra- clavicular Fossa. 464. Ligation of the Subclavian Artery in the Infraclavicular Fossa. 465. External Incisions for Ligations of Arteries of the Arm. 466. Topography of the Axilla. 467. Ligation of the Axillary Artery. 468. Topography of the Arteries of the Arm. ILLUSTRATIONS xxvii 469. Ligation of the Brachial Artery. 470. Ligation of the Arteria Anconea. 471-472. Ligation of the Radial Artery. 473-474. Ligation of the Ulnar Artery. 475-476. Superficial Palmar Arch : () topog- raphy, () external incision. 477. Iliac Arteries and Veins. 478. Topography of the Femoral Artery. 479. Ligation of the Common and Internal Iliac Arteries. 480. Ligation of the Superior Gluteal Artery and the Sciatic Artery. 481. Ligation of the External Iliac Artery. 482-483. Ligation of the Femoral Artery: () under Poupart's Ligament, (^) below the Profunda Femoris Artery. 484. Ligation of the Femoral Artery in the Mid- dle of the Thigh. 485. Topography of the Right Popliteal Space. 486. Ligation of the Popliteal Artery. 487. Ligation of the Anterior Tihial Artery above the Middle of the Leg. 488. Ligation of the Anterior Tibial Artery in the Lower Third of the Leg. 489. Ligation of the Posterior Tibial Artery above the Middle of the Leg. 490. Ligation of the Posterior Tibial Artery be- hind the Internal Malleolus. 491. Intravenous Infusion, introducing the Ca- nula. 492. Infusion with a Graduated Glass Cylinder. 493-494. Syringe Bottles for Subcutaneous Infu- sion : (~) after healing. 590. Osteoplastic Necrotomy. 591. Amputation of Limb. 592. Amputating Knives. 593. Circular Amputation by One Incision. 594. Reflection of Periosteum. 595. Stump after Circular Amputation by One Incision. 596. Circular Amputation by Two Incisions; Di- viding the Skin. 597. Circular Amputation by Two Incisions ; Loosening the Skin in the Form of a Cuff. 598. Wrong Mode of Incision. 599. Circular Amputation by Two Incisions; Di- viding Muscles. 600. Stump after the Circular Amputation by Two Incisions. 601. Petit's Circular Incision. 602. Amputation by Three Circular Incisions de- taching Muscular Cone. 603. Von Langenbeck's Flap Knife. 604. Two Lateral Flaps of Skin of Equal Length. 605. Long Anterior and Short Posterior Flap. 606. Anterior Skin Flap with Semicircular Poste- rior Incision. 607. Muscular Flap Incision (von Langenbeck's Method). 608. Reiner's Amputating Saw. 609. Nyrop's Amputating Saw. 610. Helferich's Amputating Saw. 611. Sawing off the Bone. 612-613. Divided Compresses: (a) for limbs with one bone; () for limbs with two bones. 614. Reflection of Soft Parts by Means of Divided Compress. 615-616. Knives for dividing Soft Parts in the Interosseous Space (Catline). 617. Method of carrying Knife in the Interos- seous Space. 618. Sawing off Both Bones; Retraction of Soft Parts by a Divided Compress for Limbs with Two Bones. 619. Listen's Bone-cutting Forceps. 620. Liier's Gouge Forceps: () straight, () curved. 621. Amputating Saw. 622. Suturing Periosteum and Deep Muscular Layers. 623. Buried Muscular Suture. 624. Suture of the Skin Margins. 625. Conical Stump. 626-628. Protheses, Claw Hands. 629-630. Peg Legs for Amputated Thigh. 631. Peg Leg. 632. Artificial Limb for Amputated Leg. 633. Skeleton of Finger. 634. Position of Lines of Articulations of the Finger. 635. Disarticulation of First Phalanx. 636-637. Disarticulation of Third Phalanx. 638-639. Disarticulation of Second Phalanx. 640. Disarticulation at the Metacarpophalangeal Joint (Oval Incision). 641-642. Disarticulation at the Metacarpopha- langeal Joint by an Oval Incision. 643-644. Disarticulation of the Metacarpophalan- geal Articulation a, of the thumb, second and fifth fingers. Forming large flaps of unequal size on the fourth finger. Forming two equal flaps on the third. Oval incision from the volar side, b, Wound from the oval and flap incision. 645. Disarticulation of All Fingers. 646-648. Disarticulation of the Thumb by Oval Incision. 649-650. Von Walther's Radial Flap Incision. 651-653. Disarticulation of the Last Four Meta- carpal Bones : a, volar incision ; b, dorsal incision. ILLUSTRATIONS XXIX 652. Volar Incision by Transfixion. 654. Stump after Disarticulation of the Last Four Metacarpal Bones. 655. Disarticulation of the Hand by Circular In- cision. 656. Stump after Disarticulation of the Wrist by Circular Incision. 657-658. Disarticulation of the Hand by Two Skin Flaps. (Ruysch.) 659. Disarticulation of the Hand by von Walther's Method. 660. Stump resulting from von Walther's Method. 661. Transverse Section of the Right Forearm at its Lower Third. 662. Transverse Section of the Right Forearm at its Middle Part (see also Plate XI). 663. Transverse Section of the Right Forearm at its Upper Third (see also Plate XII). 664. Disarticulation of the Elbow Joint by Circular Incision. 665. Stump after Disarticulation of the Elbow Joint by Circular Incision. 666. Transverse Section of the Right Elbow Joint in the Line of Condyles (see also Plate XII). 667. Disarticulation of the Elbow Joint by Flap Incision. 668. Disarticulation of the Elbow Joint by Ko- cher's Oblique Incision. 669. Transverse Section of the Right Arm at its Lower Third (see also Plate XIII). 670. Transverse Section of the Right Arm at its Middle Third (see also Plate XIII). 671. Transverse Section of the Right Arm in Front of the Axilla (see also Plate XIV). 672. Disarticulation of the Shoulder Joint (Flap Incision). 673. Disarticulation of the Shoulder Joint by forming a Second Flap on the Inner Sur- face. 674. Stump after Disarticulation of the Shoulder Joint by Flap Incision. 675-676. Disarticulation of the Shoulder Joint by Circular Incision and Longitudinal : a, dis- articulation of the stump of the arm ; b, sutured stump. 677. Disarticulation of the Shoulder Joint by Lar- rey's Oval Incision. 678. Disarticulation of the Shoulder Joint (Oval Incision). 679. Disarticulation of the Shoulder Girdle. 680. Disarticulation of All Toes ( Plantar Incision) . 681. Disarticulation of All Toes (Dorsal Incision). 682. Stump after Disarticulation of All Toes. 683. Amputation of Foot through the Metatarsal Bones by Sawing. 684. Wound resulting from Sawing off Metatarsal Bones. 685. Disarticulation of the Great Toe with its Metatarsal Bone. 686. Disarticulation of the Fifth Toe with its Metatarsal Bone. 687. Skeleton of the Foot. 688. Lisfranc's Disarticulation of the Tarsometa- tarsal Articulation. 689-690. Lisfranc's Disarticulation of the Foot : a, dorsal incision ; b, dividing articulation. 691. Lisfranc's Disarticulation. Opening Second Metatarsal Articulation. 692-694. Lisfranc's Disarticulation : a, forming plantar flaps ; b, wound surface ; c, stump. 695. Lisfranc's Disarticulation, preserving Hallux. 696-70x3. Chopart's Disarticulation at the Tarsus. 701. Chopart's Disarticulation at the Tarsus (Fin- ishing Plantar Flap). 702. Stump after Chopart's Disarticulation at the Tarsus. 703-704. Chopart's Disarticulation. Preserving Toes (Witzel). 705-708. Malgaigne's Disarticulation between Astragalus and the Os Calcis (below the Astragalus). 709. Disarticulation of the Foot below the Astraga- lus. 710. Stump after Disarticulation of the Foot below the Astragalus. 711-714. Syme's Amputation of the Foot. 715. Syme's Amputation of the Foot (Disarticulat- ing the Os Calcis). 716. Sawing through the Bone. 717-719. Syme's Amputation of the Foot: a, wound surface ; 6, recent stump, anterior view ; c, healed stump, lateral view. 720. Pirogoff's Disarticulation of the Foot (Saw- ing off the Os Calcis). 721. Sawing off Bones by Pirogoff's Operation. XXX ILLUSTRATIONS 722. Wound Surface of Pirogoff's Operation. 723. Stump resulting from Pirogoff's Operation. 724-726. Giinther's Modification of Pirogoffs Operation. 727. Giinther's Method of Dorsal Incision. 728. Giinther's Method of Dividing Bones by Sawing. 729-731. Le Fort's Modification of Pirogoff's Operation. 732. Le Fort's Dorsal Incision. 733. Sawing through the Bones in Le Fort's Operation. 734. Von Bruns's Method of Dividing Bones by Sawing. 735. Stump resulting from Le Fort's Method. 736. Kuster's Modification of Le Fort's Operation. 737-738. Von Langenbeck's Amputation of the Leg by forming a Lateral Skin Flap. 739-741. Bier's Osteoplastic Amputation of the Leg. 742. Transverse Section of the Right Leg at its Lower Third (see Plate XV). 743. Transverse Section of the Right Leg at its Middle Third (see Plate XV). 744. Transverse Section of the Right Leg at its Upper Third. 745. Transverse Section of the Left Thigh through the Condyles. 746. Disarticulation of the Knee Joint (Circular Incision). 747-748. Stump resulting from Disarticulation of the Leg at the Knee Joint by Circular Incision. 749. Disarticulation at the Knee Joint by forming Two Flaps. 750. Stump resulting from Disarticulation of the Leg at the Knee Joint by Flap Incision. 751. Disarticulation of the Leg at the Knee Joint (Oblique Incision). 752. Garden's Intracondyloid Amputation. 753. Gritti's Supracondyloid Osteoplastic Ampu- tation. 754. Sabanejeff's Intracondyloid Osteoplastic Amputation. 755. Transverse Section of the Right Thigh at its Lower Third. 756. Transverse Section of the Right Thigh at its Middle Third. FIG. 757. Transverse Section of the Right Thigh at its Upper Third. 758. Position of Patient in changing the Dressings after Amputation. 759. Disarticulation of the Thigh by an Anterior Large, and a Posterior Small Flap. 760. Forming an Anterior Flap by Transfixion. 761. Disarticulation of the Thigh. Forming Pos- terior Flap. 762. Stump resulting from Disarticulation of the Thigh at the Hip Joint by Flap Incision. 763. Disarticulation of the Thigh at the Hip Joint (Circular Incision). 764. Disarticulation of the Thigh at the Hip Joint. 765. Stump resulting from Disarticulation of the Thigh at the Hip Joint (by Circular and Vertical Incisions). 766. Resection Knife. 767-768. Von Langenbeck's Elevator : (a) small, (^) broad. 769. Lever-like Elevator. 770. Sayre's Elevator. 771. Von Langenbeck's Claw Forceps. 772. Fergusson's Lion Jaw Forceps. 773. Farabceuf 's Forceps. 774. Metacarpal Saw. 775. Von Langenbeck's Metacarpal Saw. 776. Metacarpal Saw. 777. Chain Saw. 778. Helferich's Amputation Saw. 779. Von Langenbeck's Sharp Hook. 780. Replacing a Resected Metacarpal Bone. 781. Resection of the Lower Ends of the Bones of the Forearm (Bourgery's Bilateral Incision). 782. Muscles and Tendons on the Ulnar Side of the Left Wrist (according to Henke). 783-784. Ligaments of the Right Wrist : (a) dor- sal side ; (3) volar side. 785. Muscles and Tendons on the Radial Side of the Left Wrist in Dorsal Flexion (accord- ing to Henke). 786. Muscles and Tendons on the Radial Side of the Left (extended) Wrist (according to Henke). 787. Sawing off the Articular End of the Radius. 788. Frontal Section of the Right Wrist. 789. Von Langenbeck's Method of Resecting the Wrist. ILLUSTRATIONS XXXI 790. Tendons on the Dorsal Side of the Hand. 791. Carpal Bones. 792-793. Kocher's Resection of the Wrist. 794. Resection of the Right Elbow Joint (Listen's T Incision). 795. Ulnar Nerves on the Posterior Side of the Left Elbow Joint. 796. Resection of the Elbow Joint ; denuding the Internal Condyle. 797-798. Ligaments of the Right Elbow Joint : (a) inner side, () outer side. 799. Resection of the Right Elbow Joint by von Langenbeck's External Incision. 800. Ollier's Resection of the Elbow Joint. 801. Nelaton's Resection of the Elbow Joint. 802-803. Kocher's Resection of the Elbow Joint. 804. Socin's Supporting Apparatus for a Loose, Freely Movable Joint after Resection of the Elbow Joint. 805-808. Von Langenbeck's Resection of the Shoulder Joint. 809. Muscular Insertions of the Greater and the Lesser Tuberosities of the Humerus. 810-811. Sawing off the Head of the Humerus. 812. Ligaments of the Shoulder Joint. 813. Ramification of the Axillary Nerve (Poste- rior View). 814. Ollier's Resection of the Shoulder Joint. 815-816. Kocher's Resection of the Shoulder Joint. 817. Von Esmarch's Resection of the Articular Surface and Neck of the Scapula. 818. Ollier's Resection of the Scapula. 819-820. Petersen's Arthrectomy of the Articula- tion of the Great Toe. 821. Hook-shaped Incision (von Langenbeck). 822. Henke's External Side of the Left Ankle Joint. 823. Disarticulation of the Lower End of the Fibula. 824. Ligaments of the Ankle Joint (Posterior Side). 825. Ligaments of the Ankle Joint (External ' Side). 826. Incision upon the Internal Malleolus (An- chor Incision). 827. Inner Side of the Ankle Joint (according to Henke). 828. Ligaments of the Ankle Joint (Inner Side). 829-830. Kocher's Resection of the Ankle Joint. 831. Gerard's Resection of the Ankle Joint. 832. Lauenstein's Method of Opening Ankle Joint. 833. Hueters Resection of Ankle Joint. 834. Ollier's Resection of the Os Calcis. 835. Guerin's Spur Incision. 836. Kocher's Resection of the Os Calcis. 837-840. Miculicz-Wladimiroff's Osteoplastic Re- section. 841. Cuneiform Tarsectomy. 842. Textor's Resection of the Knee Joint. 843. Crucial Ligaments of the Knee. 844. Position of the Popliteal Artery and Vein behind the Wound Surface. 845. Nailing the Resected Knee. 846. Helferich's Method of Sawing out a Curve- shaped Wedge. 847. Flower-pot Trellis as a Splint after Resection of the Knee Joint. 848. Hahn's Curved Incision for Resection of the Knee Joint. 849. Von Langenbeck's Curved Incision for Re- section of the Knee Joint. 850. Inner Side of the Knee Joint. 851. Ligaments of the Knee Joint (Inner side). 852. Ligaments of the Knee Joint (Outer side). 853. Kocher's Arthrectomy of the Knee Joint. 854. Resection of the Hip Joint (A. White's curved incision). 855. Posterior Side of the Hip Joint (Muscles and Sciatic Nerve). 856. Resection of the Hip Joint. Sawing off Head of Femur with the Chain Saw. Re- flection of Soft Parts with a Strip of Zinc. 857. Resection of the Hip Joint. 858859. Muscular Insertions on the Upper End of the Right Femur : () anterior side, (<$) Posterior Side. 860. Ligaments on the Anterior Side of the Hip Joint. 861-862. Kocher's Resection of the Hip Joint: (i) resection of the ilium, (2) resection of the hip joint. 863-864. Resection of the Hip Joint : a, accord- ing to Liicke and Schede ; b, according to Hueter. 865. Lobker's Spoon Elevator. XXX11 ILLUSTRATIONS FIG. 866. Nipping off the Osseous Margin of a Cranial 1-racture with Liier's Gouge Forceps. 867. Hoffman's Rongeur Forceps. 868. Chiselling out Point of Sword. 869. Hand Trephine. 870. Trephining. 871. Blood Vessels on the Internal Side of the Cranium. 872. Bone Screw with Roser's Hook. 873. Stille's Bone-nipping Forceps. 874. Circular Saw and Electromotor. 875. Craniectomy. 876. W. Wagner's Osteoplastic Resection of the Skull. 877. Wagner's Osteoplastic Resection of the Skull. 878. Osteoplasty in Cranial Defects. 679. Cerebral Topography : 1. Region of the oculomotor nerve : Levator palpebrse, movements of the bulb, dilatation of the pupils, turning the head to the opposite side. 2. Upper Extremity: (#) adductor and abductor muscles, (3) extensors, (c) (} Thiersch's Spindle for applying Ligatures in Deep Wounds. 1370. Male Urethra (Home's Wax Cast). 1371. Triangular Ligament. 1372. Triangular Ligament; M. Levator ani; M. Perinei prof, according to Luschka. 1373-1374. Musculus Compressor; Urethrae with- in the Urogenital Diaphragm (Henle) according to Maclise. 1373. Lateral View. 1374. Internal View. 1375. Metallic Catheters. () common; (pend- ing in two tubes at the handle. 1376. Prostatic Catheters, (a) strongly curved; () with simple inflexion; (c) or double inflexion according to Mercier. 1377-1379. Various Modes of Catheterization. 1380. Catheterization in the Female. ILLUSTRATIONS xxxix 1381. Flexible Catheters: (a) common, cone- shaped or probe-pointed; (<) indexed, according to Mercier. 1382. Clove Hitch. 1383-1384. Dittel's Method of fastening Reten- tion Catheter. 1385. Otis's Scale for Urethral Instruments. 1386. Olive -pointed Bougies according to Otis. 1387. Urethrometer : () open; (<$) closed; (~) sec- tional view. 1418. Lithotomy Forceps. 1419. Spoon-shaped Forceps. 1420. Removing Stone with Extended Forefingers. 1421. Trendelenburg's Drainage Tube. 1422. Lithotomy Forceps. 1423. Luer's Lithotrite. 1424. Simon's Dilator for the Female Urethra. 1425. Thompson's Forceps for Tumors of the Bladder. 1426. Watson's Hard Rubber Drainage Tube for Hypertrophy of Prostate. 1427-1428. Zuckerkandl's Prerectal Incision. 1427. External Incision. 1428. Cavity of the Wound. 1429-1430. Kocher's Prerectal Pointed Arch In- cision. 1429. External Incision. 1430. Cavity of the Wound. 1431. Beak of Prostatic Incisor. 1432. Civiale's Lithotriptor. 1433. Bigelow's Lithotriptor. 1434. Otis's Evacuator for Litholapaxy. 1435. Receptacle for Urine. 1436-1438. Wood's Cystoplasty. 1436. Forming Flaps. 1437. Suturing Lateral Flaps over Inverted Middle Flap. 1438. Healing of Wound. 1439. Portable Urinal applied after Cystoplasty 1440. Forming Glans Portion of Urethra. 1441-1443. Closure of Penile Portion of Gutter. 1442. Closure of Open Slit between Glans and Penis. xl ILLUSTRATIONS FIG. 1444. Closure of Funnel. 1445-1446. Rosenberger's Operation for Epi- spadias. 1447-1448. Operation for Phimosis (Roser's Dor- sal Incision). 1449. Operation for Phimosis by suturing trans- versely Two Lateral Incisions (von Es- march). 1450-1451. Reduction of Prepuce (Taxis) in Paraphimosis. 1452. Incising Strangulating Ring. 1453. Amputation of Penis. 1454. Wound Surface. 1455. Suture. 1456. High Amputation of the Penis. Division of the Scrotum. 1457. Puncture for Hydrocele of the Tunica Vaginalis. 1458. Von Volkmann's Incision for Hydrocele. 1459. Operation for Varicocele. 1460-1461. Castration: () external incision; (t>) ligation of the spermatic cord. Vd. vas deferens. 1462. Anatomy of Pelvic Organs. 1463. Fergusson's Rectal Speculum. 1464. Allingham's Rectal Speculum. 1465. Sims's Speculum. 1466. Simon's Speculum. 1467. Forcible Dilatation of Anus. 1468-1469. Proctoplasty. 1468. Fixing Blind Sac in the Wound. 1469. Opening Blind Sac; tying Sutures. 1470. Bushe's Olive-pointed Rectal Bougie. 1471. Glass Bougie. 1472. Fistula Ani : (a) external incomplete fis- tula; (b) internal incomplete fistula; (<-) complete fistula. 1473. Probe for Rectal Fistula. 1474-1475. Operation for Rectal Fistula. 1476. Tube for Dressing in Rectal Fistula. 1477. Allingham's Probe and Scissors for dividing Rectal Fistula. 1478. Division of an Incomplete Rectal Fistula. 1479. Rectal Supporter. 1480. Tenaculum Forceps for Hemorrhoids : (a) Smith's clamps; (b) Curling's; (0 Hahn's; (rf) Luer's. 1481. Allingham's Hemorrhoidal Scissors. 1482. Extirpation of a Hemorrhoid. 1483. Von Langenbeck's Hemorrhoidal Clamps. 1484. Resection of the Sacrum, (a} Kraske's Method; ( a') Bardenheuer's method; (f) von Volkmann-Rose's method. 1485. Position for Sacral Operations. 1486-1493. Resection of the Sacrum. 1494-1495. Perineal Extirpation of Rectum. 1494. Zuckerkandl's Method. 1495. Von Hueter's Method. 1496-1497. Zuckerkandl's Parasacral Incision. SURGICAL TECHNIC SURGICAL TECHNIC THE TREATMENT OF WOUNDS THE scope of this branch of surgery is to keep off all injurious influences that disturb the healing. These deleterious influences are: 1. Every infection of the wound through micro-organisms, since they decompose the secretions of the wound and produce wound-fever, inflamma- tion, suppuration, and all traumatic diseases incident to wounds. In fresh wounds, infection is prevented by the utmost cleanliness (asepsis), and is overcome in already unclean (infected) wounds by destroying the germs of infection existing in them (antisepsis). 2. The collection and retention of blood or lymph in the wound (reten- tion of tJie secretions of tJie wound), since they force apart the margins of the wound and favor the development of any germs of infection that may be present. These noxious influences are prevented by carefully arresting hemor- rhage, by perfectly draining the secretions of the wound (by desiccating the wound), by avoiding dead spaces in the interior of the wound, and by prac- tically applying good absorbent dressings (compressive bandages). 3. The gaping of the wound, because it prevents the healing by primary intention. This is guarded against by a timely and exact union of the surfaces and the margins of the wound (suturing of the wound). 4. Every disturbance of the wound (movement, unnecessary handling, examination, squeezing), because it disturbs the healing and promotes the setting in of hemorrhage and inflammation. The means of protection against these occurrences are : A copious dressing for the wound, the secure fastening of the dressings (protective dressings), the changing of the same as rarely as possible (per- manent dressings), rest of the injured portion of the body (by suitable 2 SURGICAL TECHNIC position, by bandages, splints, fixed dressings, protectors, etc.), constant rest in bed in cases of serious wounds, etc. " Optimum remcdium quics cst" (Celsus) (The best remedy is rest). 5. Every obstruction of the circulation of blood and lymph (stasis) which produces an increased flow of the wound secretions, even gangrene. This is obviated by elevation of the injured parts and by avoiding all strangulation caused by clothing or dressings. 6. The subsequent infection by change of dressings. This is prevented by changing the dressings as rarely as possible, and by applying aseptic dressings under strictly aseptic precautions. 7. Inflammation of the injured parts, and its consequences. This is combated by antiphlogistic treatment, which tends to check inflammation by rest, elevated position, reducing the temperature, and, in inflammation of the joints, by distraction of the articular ends by extension. ASEPSIS Asepsis purposes to prevent infection of the wound by excluding or by destroying all pathogenic micro-organisms before they come in contact with it. Since they are present everywJiere, infection might take place through the air (air-infection) and through the objects that come in contact with the wound (hands, instruments, water, dressings) (contact-infection). The prevention of wound-infection through the most painstaking cleanli- ness and disinfection constitutes the principal object in the following chapter. PREPARATIONS FOR ASEPTIC OPERATIONS AND DRESSINGS PURIFYING THE OPERATING ROOM Lister believed the bacteria floating in the air could be destroyed by an atomized spray of antiseptic fluids (3^ carbolic solution). During the operation and the dressing, he had a carbolic spray created by means of an atomizer directed upon the wound and upon the hands of the surgeon. He used either a small atomizer, operated by hand (Fig. i), or a larger one, operated by steam. If the carbolic spray had to be discontinued for some reason during the operation, Lister tried to protect the wound from the influence of the air by temporarily covering it with carbolized gauze. THE TREATMENT OF WOUNDS The experience of many surgeons, however, has proved that, even with- out using the spray, wounds often heal very satisfactorily ; hence, the car- bolic spray, so greatly obnoxious to all who participate in the operation, may be dispensed with. It is now hardly ever used during an operation, though occasionally before an operation. The use of the spray is, however, no longer necessary, since we know that in still air micro-organisms are gradu- ally precipitated to the floor, thus leaving tJie air purified. For this reason, for some time before the operation, care must be taken not to stir up the dust by cleaning and arranging the room ; the necessary disinfection should be made on the day before the operation, and, in the meantime, no one should enter the room. The settled dust, however, may be removed slowly with a moist cloth. In modern institutions, operating rooms are all arranged with a view to obtaining safe and easy disinfection. The walls are painted in oil, the floor is covered with waterproof material (terrazo, mar- ble, mosaic, tiles), all unnecessary decorations, corners, and niches are done away with. Disin- fection before and after each operating session can be easily obtained by thoroughly washing the rooms with soap and water (irrigating walls and ceiling). But if the operation has to be performed in an ordinary room (in the house of the patient), all unnecessary fur- niture and all "dust catchers "(curtains, carpets, uphol- stered furniture) FIG. i. ATOMIZER FOR CARBOLATED SPRAY are removed. The floor is thoroughly scrubbed, old wall papers are rubbed down with bread (E. von EsmarcJi), and the room is locked up until the operation, which is to take place about 10 or 12 hours afterward. Strongly infected rooms may be disinfected as follows: The doors and windows are closed as securely as possible, and a few sticks of sulphur are burned. Disinfection by means of sulphurous acid is thus created. (Formalin gas is more reliable.) During the operation, the room should be warm (66 to 77 Fhr.). The utensils used during the operation (tables, chairs, vessels) must be free from unnecessary decorations ; they should be made of such material SURGICAL TECHNIC that they can without injury be cleansed by thorough soaping with potash soap, soda, and water which should be as hot as possible; otherwise, they must be sterilized in a larger disinfection apparatus by means of a jet of steam. The most practical utensils are made of iron and glass (e.g. Figs. 2 and 3), and are constructed as simply as possible. The operating table, likewise, consists preferably of the same material, or of enamelled sheet- iron (Fig. 4). Considerably cheaper for practising physi- cians, however, is a strong, plain wooden table, with an ar- rangement for elevating the head (supporting board, see below); this table suffices for most of the operations ; it can be well scrubbed; if at any time it be- comes strongly infected, it can, on account of its cheapness, be easily replaced by a new one. For padding, the operating table is covered with a thick woollen or felt cover, over which a rubber sJicct is spread. ASEPSIS OF THE SURGEON AND HIS ASSISTANTS Always, before touching a wound (operation, changing of dressings), the hands and the forearms of the surgeon, as well as of all his assistants, must be disinfected (rendered free from germs) most carefully. Since the germs of infection are embedded in the many folds and furrows of the external skin and in the fatty secretions of the same (sebaceous glands), simply dipping the ringers into even strong watery antiseptic solutions or moistening them with it produces almost no effect. By an energetic wash- FIG. 2. CABINET FOR INSTRUMENTS AND DRESSINGS THE TREATMENT OF WOUNDS FIG. 3. SMALL DRESSING TABLE FIG. 4. ASEPTIC OPERATING TABLE 6 SURGICAL TECHNIC ing with soap, however, the fatty deposits and incrustations of dirt may be removed mechanically. By means of alcohol, which is a potent solvent of fat, Fiirbringer succeeded in obtaining a complete sterilization of the hands by the following procedure : 1. After the furrows of the nails have been carefully cleansed with the nail-brush and nail-cleaner, the hands are washed energetically from 3 to 5 minutes with soap and brush in water as hot as it can be tolerated. 2. Next, with clean (sterile) towels, they are dried, and the furrows of the nails are examined once more. 3. Then they are brushed for i minute in 80% alcohol and are finally dipped into an antiseptic solution. The best and cheapest soap is a good green soap (potash soap). The brushes, consisting of simple wooden plates with bristles, can be sterilized easily by boiling, after which they are kept in an antiseptic solution (i/oo f sublimate) in a vessel near the apparatus that serves for washing. Moreover, the fact is noticeable that, in a case of emergency even with- out the use of an antiseptic, the hands are rendered aseptic by a somewhat prolonged vigorous brushing with soap and hot water. Of course, in cleansing the fingers, all jewellery is removed, as well for disinfecting the fingers more easily as for protecting the jewellery from the injurious influences of the chemicals. If, during the operation, the disinfected hands have come in contact with some object not disinfected or with pus, urine, or faeces, they must be carefully disinfected again. Since germs of infection easily cling to woollen cloth, and since, on dark material, infectious matter (blood stains) cannot be seen well, not only the surgeon but also his assistants should always wear, during the operation, freshly washed and ironed wJiite linen coats or gowns (Fig. 5). In case of necessity, linen shirts may be substituted for them. If a sufficiently large disinfection apparatus is available, the coats may bo sterilized therein by boiling in a i% soda solution before being used. Previously to each new aseptic operation, the coats must be changed, if they have become soiled during any preceding operation. Practical for this reason are aprons of rubber, which must be thoroughly washed and disinfected with carbolic solution before each operation. The arms up to THE TREATMENT OF WOUNDS the elbow are always completely bare and are disinfected (or covered with disinfected rubber sleeves). Since, in some operations, a great deal of irrigating fluid is used, rubbers may be put on over the shoes to pre- vent the feet from getting wet. STERILIZATION OF INSTRUMENTS All instruments used in the opera- tion and in applying the dressings must be most thoroughly cleansed and dis- infected. In order to facilitate this, the instruments must be made as plain as possible ; they should have few fur- rows, niches, or clefts, because dirt easily collects in them. Accordingly, all plain instruments (knives, retractors, etc.) ought to be made from one piece of steel ; instruments with locks (scissors, forceps) should be so constructed that they can be taken apart (Figs. 6 to 12). Ivory and wooden handles, used formerly, should not be* employed. Before the operation, the instruments are most rapidly and efficiently sterilized by boil- ing. In a suit- FIG. 5. SURGEON'S GOWN able metallic vessel (sterilizer), common water is brought to the boiling-point; the instruments are placed in it for 5 minutes {DavidsoJui). If common washing soda (i%) is added to the water, the steel is prevented from rusting and the disinfecting strength of the water is increased {ScJiimmelbuscli). FIGS. 6-8. METAL RETRACTORS By means of this very simple procedure, all 8 SURGICAL TECHNIC pathogenic bacteria are absolutely destroyed. Even dipping the instru- ments for only a second into the boiling soda solution suffices to destroy the pus germs (staphylococci). For surgical practice, it is best to use on a separate stand a somewhat shallow basin (a vessel of copper or nickel) filled with a solution of soda, which, by means of several flames, can be brought to the boiling-point (Fig. 13). The instruments are spread on a wire frame, fitting in the apparatus, and placed into the solution. After 5 or 10 minutes, the wire frame is lifted out, and the instruments are spread on a sterilized cloth with sterilized forceps. Now and then, during the operation, they are held with the forceps in the boiling solution. The instruments can also be placed in a flat, clean glass or china basin filled with a 3% carbolic solution. Since the edges of sharp instruments soon be- come affected by this solution, it is better to place knives, scissors, and needles into a smaller basin filled with alcohol (Fig. 14). t FIG. 9. BISTOURY WITH REMOVABLE BLADES FIG. 10. FORCEPS WITH SMOOTH ARMS, () Surgical; (<$) Anatomical In the house of the patient, even under the most unfavorable conditions, the instruments may be sterilized as follows : a cooking utensil (a tea kettle, FIG. ii. ASEPTIC KNIFE etc.), filled with the soda solution, is put on the fire, and the instruments, placed in a gauze bag, are boiled in it from 5 to 10 minutes. THE TREATMENT OF WOUNDS If, for any reason, this boiling cannot be accomplished, the instruments are placed, for some time (half an. hour to an hour) before the operation, FIG. 12. FORCEPS WITH RE- MOVABLE LOCK into an instrument basin, and a 3% to $% carbolic or a i % lysol solution is poured over them. This disinfection, however, is not absolutely reliable. After instruments have been used, they must be washed off with hot water, energetically brushed, and mechani- cally freed from the co- agula of blood, from pus, etc., lodged in the FIG. 13. INSTRUMENT STERILIZER FIG. 14. INSTRUMENT TRAY STAND (OF GLASS) 10 SURGICAL TECHNIC corners; next, they are carefully dried with an aseptic cloth, and those which show any stains are polished with .the finest emery paper and leather. This, however, hardly becomes necessary when the soda solution is used. Unnecessary vigorous brushing injures the instruments. STERILIZATION OF SUTURES AND LIGATURES The materials used most constantly for suturing and ligatures are catgut, silk, silkworm gut, and metal wire. The last three, as well as the instru- ments, are sterilized in boiling water, or by passing steam over them. To place them subsequently into an antiseptic solution is not necessary. The apparatus of Sckimmelbusch (Fig. 15) is very well adapted for the dry preservation of such threads. More difficult is the disinfection of catgut and other absorbent materials. They can be disin- fected in hot air, but this proc- ess requires too much time. Subjected to steam and boiling water, catgut becomes entirely useless. Aseptic (sublimate) cat- gut is best prepared in the fol- lowing manner : Common catgut, which can be purchased anywhere (raw catgut), is wound around a glass cylinder (flasks) in a single layer and vigorously brushed with potash soap and hot water. Next, it is rinsed in clean water, wrapped around smaller glass spools, and placed for at least two entire days into a i% sublimate alcohol (sublimate, 10 parts; alcohol absol., 800 parts ; aq. dest, 200 parts). The fluid, which at first becomes turbid, must now and then be renewed. Shortly before using, the spools are placed into a vessel filled with sublimate alcohol, i : 2000 (e.g. in the glass case according to Hagcdorn Fig. 16), in which a second smaller case stands inverted, from the bottom of which threads are drawn out through small openings ; small ball-bearing valves prevent the threads from slipping back. In a similar manner are prepared the other absorbent materials (ten- dons of whale-, reindeer-, kangaroo-parchment and leather). Moreover, the requirements of the Military and Sanitary Regulations for the preparation of sublimate catgut are easily carried out. Raw catgut FIG. 15. SCHIMMELBUSCH'S TIN Box FOR STERILIZED SILK THE TREATMENT OF WOUNDS II is immersed for from 8 to 12 hours in a S/oo watery sublimate solution, and is afterward preserved in alcohol until used. The treatment of catgut with carbolized oil, first recommended by Lister, does not se- cure perfect steril- ization, and hence is hardly ever used at the present time. The chromic acid catgut, how- ever, introduced afterward by Lis- ter, is very strong and resists absorp- tion better than the sublimate catgut, for which reason FIG. 16. GLASS Box FOR CATGUT LIGATURES it is preferable in some operations. Catgut is placed for 48 hours in a 10% carbolized glyc- erine and then for five hours in a watery 0.5% chromic acid solution. KocJier's juniper catgut is durable and aseptic. Catgut is immersed for 24 hours in oil of juniper (Oleum juniperi), and is afterward preserved in alcohol. For more convenient handling, outside the hospital, catgut and silk are wound around smaller glass spools, which are placed in a row on a glass staff ; these spools are kept in small boxes or test-tubes, which can be closed by means of a screw apparatus, and easily carried in the pocket. STERILIZATION OF SEA AND GAUZE SPONGES Sea Sponges. For wiping off the blood, sponges cannot be dispensed with in many operations, especially when it is desirable by a single stroke quickly to wipe the surface of the wound perfectly clean. But they ought to be used only after all impurities contained in them have been most care- fully removed, and after they have been rendered free from germs. Sponges can not be sterilized in the disinfection apparatus, because they become thereby hard and friable. Keeping them for weeks in strong anti- septic solutions (5% carbolic acid, i/ 00 sublimate) does not, according to experiments that have been made, disinfect them perfectly. 12 SURGICAL TECHNIC For perfect sterilization of sponges, it is necessary to beat them first in a dry state with a wooden mallet, between cloths, until the sand is com- pletely removed. Next, they are repeatedly kneaded in clean boiled luke- warm water (in hot water they shrink). After that, they are placed for 24 hours in a cold i/oo solution of potassium permanganate, which is renewed once after 12 hours. After they have been rinsed in boiled lukewarm water, they are placed into a solution of sodium hyposulphite (i%), to which the fifth part of a mixture of concentrated hydrochloric acid and water (8%) is added. In this they are well stirred with a wooden staff for several minutes, until their brown color disappears. (If they remain too long in the solution, they become too friable and tear easily.) Finally, they are rinsed in clear water until they become perfectly odorless. For 25 large sponges, about 5000 grams of the sodium hyposulphite so- lution and 1000 grams of the hydrochloric acid mixture are required (Keller}. For destroying the dry spores, after their germination, for by this treatment they have by no means been rendered innocuous, the sponges are placed in lukewarm water and kept there from three to five days in a warm place (95 to 100 Fhr.). The water is changed daily. Not until then are they placed in a 5% carbolic or a i/oo sublimate solution, which after 2 days is changed once more. In this they remain until used. Every fortnight the solution is renewed, and the sponges must have been kept in the solution at least 8 days before they can be safely used. Less complicated and more rapid is the procedure of ScJdmmelbusch. After the sponges have been thoroughly cleansed by beating and freed from sand and fragments of shells, they are thoroughly washed with water and kneaded. Next, well wrung out, they are placed into a gauze bag, which is dipped for half an hour into a vessel containing a hot soda solution (i%), nearly reaching the boiling-point. Previously, the flame under the vessel is turned off ; for in a boiling solution the sponges would be rendered useless. Finally, they are vigorously wrung out, and are kept in a sublimate solution (o.5/oo)- This procedure seems to be safe; for, after remaining in the hot solution only 10 minutes, sponges infected by pus or faeces are sterilized perfectly. Sponges which, during the operation, have become bloody, are rinsed in clear water, after which they are dipped again into the carbolic or subli- mate solution, before they are wrung out and handed to the operator. Sponges that have been used in aseptic operations must first be cleansed from coagula and fatty matter by repeated washing in soap, water, and THE TREATMENT OF WOUNDS 13 solution of soda. They must then be kept for 8 days in a 5 % carbolized water solution before they can be again safely used in an operation. Sponges used in infected, sanious, and gangrenous wounds should be burned at once. For cleansing the surrounding portions of wounds and for wiping off the pus in changing dressings, sea sponges should be discarded, and gauze sponges and the wound douche should be used instead. Gauze sponges are loose balls of prepared absorbent cotton, cellulose, jute, etc., wrapped in aseptic gauze (Fig. 17). Prepared absorbent cotton (from which all oily matter has been extracted) absorbs very rapidly. When the fluid is pressed out of it, however, the cotton is compressed into a compact and poorly absorbent mass. For this reason, it is practical to use cellulose for the central portion of the gauze sponge, since the elasticity of the fibre prevents the compression of the cotton. Sponges made of other material do not absorb so well. The gauze sponges, together with the materials for dressing, are sterilized by steam in the same apparatus. On account of their inexpensiveness and sterility, they can be used everywhere ; but espe- cially in operations for septic conditions, since it is not desirable to infect sea sponges. After being used, they are destroyed (by burning). A still simpler material for sponges, and one that possesses still greater absorbent power, is a small compress of loose gauze, fastened together by a few stitches (Gersuny)\ or pieces of gauze as large as the hand, between which a thin layer of cotton or common compressed crinoline gauze is in- serted. The quantity of gauze used thereby is considerable. The plain gauze sponges are cheaper. DISINFECTION OF THE PATIENT Before each operation of any importance, and before dressing a fresh wound, if possible, the whole body of the patient should be washed thoroughly in a full bath with potash soap and brush. For this purpose, the portable Hospital Bath on rollers is especially well adapted (Fig. 18), because, with a comfortable position of the patient, the tub requires com- SURGICAL TECHNIC paratively little water to fill it. For cleansing a single limb, and especially for permanent baths, are used the arm and foot tubs (Figs. 19 and 20) FIG. 18. PORTABLE HOSPITAL BATH (AM. MODEL) made of zinc, the covers of which have openings at one side. At the two length-sides are fastened handles, to which bandages supporting the limbs may be tied; To cleanse the region of the pel vis, sitz baths in sitz tubs are used. Immediately before the opera- tion, the field of operation, the whole neighborhood of the wound, is once more thoroughly cleansed and disinfected on the operating table. FIG. 19. ARM BATH OF SHEET ZINC First, all the hair in the region of the wound is removed by shaving, because pathogenic germs are espe- cially liable to settle upon it and in the hair follicles ; on the head, the hair should be shaved off at least 4 centimeters beyond the margin of the wound. In larger operations (trephining), it is best to shave the whole scalp. Next, the region of the wound is rubbed down with a piece of cotton ADJUSTABLE LAR SHAPE, THE TREATMENT OF WOUNDS 15 that has been dipped in ether or spirits of turpentine, to dissolve and remove the grease of the skin. Thereupon follows a thorough washing with soap and brush, and finally the disinfection with sublimate solution. Last of all, the whole field of operation may be rubbed down with iodoform ether (i :7). Before operations on the hands and the feet, the thick upper epidermis layers, after they have been softened by means of soap baths, must be removed as far as possible with stiff brushes ; especially must the dirt between the toes and under the nails be carefully removed. It is safer to wrap all these parts with sterilized bandages, since they have to be touched often during the operation. (A thin pellicle of collodium and cott<$h furnishes the best protection.) Before operations on the mouth and in the mouth, the teeth must be cleansed very carefully with brush and tooth soap ; tartar, as well as carious teeth, must be removed, and the mouth must be rinsed repeatedly with a solution of acetate of aluminium, boric solution, or potassium permanganate. Before operations in the abdominal cavity, it is advisable to cover the abdominal walls for severalhours (during the night) with a moist antiseptic compress. Several days previous to operations in the region of the amis and the sexual organs, the intestines, if possible, must be thoroughly evacuated by means of purgatives, enemata, and irrigations. At the beginning of the operation, the mucous membrane is wiped off dry, and then boric solution is applied. Mucous membranes cannot be disinfected completely. Very active poisonous remedies (carbolic acid, sublimate), on account of the danger of being absorbed in toxic quantities, must not be used for disinfect- ing mucous membranes. If, on the field of operation, crusts or scabs are present, they are rubbed off with a ball of absorbent cotton saturated with turpentine oil ; ulcerations or granulations must be scraped off with the sharp spoon ; next, the wound surface is disinfected with iodoform ether, solution of chloride of zinc (8%), iodoform powder, or with the thermo-cautery. Since this procedure is pain- ful, it is not performed until the patient is under the influence of the anaesthetic. The patient, preferably perfectly naked, is placed upon the operating table covered with a rubber sheet, with his head and thorax slightly raised. In long-continued operations (laparotomies), the patient is protected from taking cold by a hot-water cushion placed beneath him, or by having his legs wrapped with cotton bandages (perineal operations). He may also be clothed with freshly sterilized woollen jackets or trousers. If, during the 1 6 SURGICAL TECHNIC operation, a great deal of irrigating fluid is used, the wet sheet under the patient should be changed. For this purpose, operating tables provided in the middle with clefts or drainage funnels are very practical (Jiiillard, Hagedorn, von Bergmann\ After disinfecting the field of operation, the patient is completely covered with freshly sterilized linen cloths, so that only the operating field is exposed. FIG. 21. RUBBER BLANKET For this purpose may also be used large rubber blankets, which have been previously washed thoroughly with carbolic solution. For operations on the extremities, the blanket has a hole through which the limb is placed (Fig. 21). In operations on the face and the neck, the hair of the head is covered with a bandage or a rubber bath cap. STERILIZATION OF THE DRESSING MATERIALS As everything that comes in contact with the wound should be sterilized, so likewise the dressings that are applied at the end of the operation must be free from germs. Concerning the various kinds of material used for dressings, see below. Sterilization is most rapidly and safely obtained by a current of saturated steam. Many kinds of apparatus for sterilizing have been devised for this purpose. The sterilizer of Rietschel and Henneberg answers the greatest requirements. For smaller requirements, a more practical and convenient apparatus has been invented, in the construction of which it is chiefly important that the steam have a certain pressure, and that its density be everywhere uniform. In this way, excessive saturation of the materials for dressings is avoided (Fig. 22, a, b, and c}. If, in this apparatus, the mate- rials to be sterilized are penetrated by steam from half an hour to an hour, THE TREATMENT OF WOUNDS all pathogenic germs are destroyed with certainty. For small requirements, moreover, a common steam cooking apparatus, according to Koch, is per- fectly sufficient. This consists of a cylindrical vessel, holding i or 2 liters of water. About a hand's breadth above the surface of the water is a wire net, in which the materials for dressing are placed. The instruments may be boiled at the same time with the dressings. Since the pressure of steam in this apparatus is not very great, after the apparatus is completely filled with steam, the sterilization must be FlG - 22 - COMBINATION STERILIZER. O) Closed continued at least from a quarter to half an hour. C. Beck's Portable Compact Steril- izer (Fig. 23), for boiling instruments and sterilizing dressings by steam, is very practical. The apparatus consists of a series of telescopic, square copper boxes which can be set into each other, and thus occupy but very little space. The lower box measures 6 x \2\ inches, and is 2 inches deep. It is provided with a perforated tray for immersing and lift- ing out the instruments which are to be boiled in it. For the simul- taneous sterilization of dressings, a series of (0 Sterilizer in operation three copper boxes without bottoms is provided, each fitting on the top of the next smaller size, the smallest fitting on the instrument tray. Likewise, The Kny-Sprague Perfection Surgical Dressing Sterilizer i8 SURGICAL TECHNIC (Fig. 24), a combination dry-oven with a steam-pressure sterilizer, is excellent. Until recently, all materials were sterilized in considerable quantities in a large apparatus, and were kept for some time in well-closed glass closets in a special room. It is much safer, for the purpose of securing perfect sterilization, and but little more inconvenient, to sterilize in the operating FIG. 23. BECK'S PORTABLE COMPACT STERILIZER room before each operation, so that all the materials to be used can be brought directly from the steam sterilizer upon the wound. For the most practical results, the apparatus, placed near the operating table, should be large enough to contain not only the gauze compresses, pads, and bandages, but also the tampons and the cloths serving to cover the patient. ASEPTIC OPERATIONS The performance of an aseptic operation is very simple after the above preparations. The patient, who has been previously bathed, is brought upon the operating table and narcotized ; next, the operating field is shaved, thoroughly disinfected, and surrounded on all sides with sterilized cloths. During this time the operator and his assistants have prepared themselves by thorough hand disinfection ; the instruments are taken out of the boiling water and spread on a sterilized cloth. The compresses and sponges intended for the operation are placed at the side of the assistant in a large basin filled with sterilized salt water (0.6%). The surgeon selects the most convenient position for himself, the assistant stands opposite to him, another THE TREATMENT OF WOUNDS assistant hands the required instruments and threads the needles. After the external incision has been made, the operator advances by layers. In doing this, it is of the greatest im- portance to the surgeon that the blood be wiped off skil- fully for the better inspec- tion of the field of operation. If the operation is per- formed under elastic con- striction of the limb (the "bloodless method"), the sponging of the blood is very rarely required. In less vas- cular regions on the trunk, it is sufficient to wipe off the blood now and then ; but in very difficult operations in vascular regions for in- stance, enucleation of glands on the neck the sponging must be done with especial care, if the surgeon is to be assisted in distinguishing easily the important parts involved. After each incis- ion, as well as when it is im- portant to survey the whole surface of the wound, the blood must be wiped off by a rapid stroke with the sponge. On the other hand, by sponging, smaller places are rendered free from blood, as the progress of the opera- tion requires it. It is the principal duty of the assist- ant in using the sponge to FIG. 24. KNY-SPRAGUE PERFECTION SURGICAL DRESSING see to it that he does not STERILIZER obscure the field of operation. "Good sponging distinguishes the good 20 SURGICAL TECHNIC assistant." Hemorrhages from smaller vessels are ar- rested mostly by prolonged pressure with the sponge ; if this does not succeed, they must be grasped with hema- static forceps and ligated on both sides. Muscles, tendons, and nerves are protected as much as possible and pushed aside. If, however, their injury cannot be avoided, the corresponding ends are sewed together after the operation. Irrigation is not per- formed at all, since, in by far the majority of cases, no infected fluids have to be removed from the wounds. Larger quantities of blood are wiped off by a vigorous stroke with the sponge. Should an irrigation be desirable, however, the improved irrigator (Fig. 25) may be used, with improved germ-proof fil- ter cup stopper ground in, and automatic pul- ley, by means of which the apparatus can be raised or lowered to any desired height, or the irrigator of crystal glass (Fig. 26), with glass cover, in iron frame to suspend from wall, with folding bracket to carry the soft rubber tubing. If no douche or irrigator is at hand, an apparatus can be improvised by removing the bottom from a wine bot- tle, inserting a rubber tube through the perforated cork, and filling the inverted bottle from the bottom (Fig. 27). " Irrigateur a vide bouteille." tf? FIG. 26. IRRIGATOR FIG. 25. IMPROVED IRRIGATOR THE TREATMENT OF WOUNDS 21 A more simple apparatus is a common glass pitcher, from the spout of which the fluid is allowed to trickle slowly over the wound. For irrigating fluid, sterilized (boiled) water is used, to which some salt (0.6%) has been added. For the use of larger quantities of sterilized water, the apparatus of Fritsch (Fig. 28) recommends itself. FIG. 27. " IRRIGATEUR A VIDE BOUTEILLE ' FIG. 28. FRITSCH'S WATER STERILIZER To receive the water that flows off there may be used variously shaped dressing basins (pus basins) of tin, hard rubber, or glass, the margins of which apply themselves accurately to the surface of the body (Figs. 29 and 30). When the dressing basins are changed, the empty one is placed under the full one, that the latter may always be seen and that none of its con- tents be spilled. The contents of the full basin must be emptied at once into a pail. A rule to be observed, however, is that the surgeon use irrigating fluids as little as possible. Last of all, the whole wound surface must be examined 22 SURGICAL TECHNIC once more with reference to small overlooked blood vessels, and every hemorrhage must be carefully arrested before the wound is sutured. In most cases, drainage is unnecessary if all the above precautions have been observed. Large cavities of the wound are diminished by the use of buried sutures, and, if necessary, temporary tamponade is resorted to. The wound of the skin is sutured throughout. For dressing, a compress of loose sterile gauze is used, over which a layer of cotton or a pad of gauze is fastened with a bandage. This dressing remains undisturbed until healing of the wound has taken FIG. 29. DRESSING BASIN FIG. 30. LARGE DRESSING BASIN place. On removing it after 10 or 12 days the surgeon finds that the wound has healed with a linear scar and that the catgut sutures have been mostly absorbed, so that their knots remain adhering to the dressings ; silk and metallic sutures are removed, and the small stitch openings are covered with a light protective dressing. This kind of treatment of wounds, ''the ideal asepsis," however, can be performed only under the most favorable circumstances and in well- equipped hospitals ; it requires a very expensive equipment and excellently trained attendants, so that, by a minute observance of the given directions, a complete guarantee can be given that no link is missing from the long chain of aseptic precautions. Hence, in order to produce a good healing of the wound, even under less favorable circumstances, not only aseptic but also antiseptic measures are employed. ANTISEPSIS Antisepsis purposes to destroy all infectious germs that settle in the wound and produce fever, suppuration, and putrefaction or at least to arrest their development. The use of antisepsis, therefore, presupposes the presence or at least the suspicion or the possibility of an infection of the wound. There are many substances that will destroy infectious germs and remove the consequences caused by the same (Antiseptics). THE TREATMENT OF WOUNDS 23 The merit of having first used intelligently and methodically, in opera- tions and dressings, one of these substances known before namely, carbolic acid is due to Joseph Lister, the founder of the antiseptic treat- ment of wounds (1865-1870). It is this treatment that has brought about the great change in modern surgery. Its brilliant and safe success has encouraged surgeons to undertake the bold procedure of treating surgical affections formerly considered beyond the reach of human aid. Whilst aseptic treatment can be carried out successfully only under very specially favorable external conditions, the antiseptic treatment of wounds meets with success everywhere, even under the most unpromising conditions. By it, the practising physician, even in the country, can obtain good results in cases that, without it, would be considered hopeless or which, in order to save life, would necessitate amputation. Lister used carbolic acid almost exclusively ; in the course of time, how- ever, by indefatigable research, there has been found a whole series of similar or of still more effective substances that possess the specific virtue of destroying micro-organisms and also their spores, or at least of arresting their development to such an extent that they cannot injure the wound. Many of these substances possess additional properties poisonous to man ; some are absolutely non-poisonous ; some are adapted for being used in solutions, others in powder form for saturating the materials for dressing, for irrigating or rubbing the surface of the wound, for preparing the material for suturing, for disinfecting the skin, etc. ANTISEPTIC SOLUTIONS Carbolic acid, phenylic acid, C 6 H 6 O (Lister}, a very effective antiseptic, appears in the anhydrous state as colorless crystalline needles, is volatile, and acts as a powerful caustic ; hence, it must be used only in solution. By long-continued action, an aqueous solution of i : 1000 arrests the develop- ment of schizomycetes ; their development is perfectly arrested, however, only after the concentrated solution of 5 : 100 has acted upon them for 24 hours ; but the spores are not destroyed thereby. Solutions in oil or proof spirits, according to Koch, have no antiseptic effect. Carbolic acid is used : (a) As a weak carbolized solution (3 : 100) to disinfect the hands, the instruments, the skin in the neighborhood of the wound, the wound itself, the sponges, and the air (carbolic spray). () As a strong solution (5:100) to disinfect septic wounds; by its 24 SURGICAL TECHNIC cauterizing quality, however, a slight whitish film is formed, and a more profuse secretion is produced. . (c) As a carbolized glycerine ($%-io%) to disinfect instruments. (d) To saturate materials for dressing, especially mull (Lister-gauze, carbol-mull). Since carbolic acid is very volatile, and since, by evaporation, its strength very rapidly decreases in impregnated materials, it is best not to impregnate them until shortly before using the dressings thus prepared. Carbolized gauze, according to von Bruns, is made in the following manner : To 400 grams of finely powdered colophonium, 100 grams each of proof spirits and carbolic acid, and 80 grams of oleum ricini (or 100 grams of melted stearine) are added in succession. The mixture is stirred until it possesses the uniform consistency of an extract (which easily crumbles when handled) ; it is preserved immediately in a closed air-tight vessel. On being used, the mixture is dissolved in 2 liters of proof spirits under continuous stirring. Next, the gauze is saturated by pouring the mixture over one kilogram of mull loosely spread in a flat basin ; the mull readily absorbs the mixture. For the purpose of uniform distribution, the gauze must be wrung out two or three times from one end to the other from 3 to 5 minutes, or it must be passed through a wringing machine. Finally, the material for dressing is hung up to dry ; it should remain, however, only as long as is absolutely necessary, that is, until the larger portion of the spirits has evaporated. Accordingly, in summer and in the open air, it is exposed about 5 minutes; in winter and in a moderately warm room, from 10 to 15 minutes. The material for dressings is kept in closed tin boxes. Carbolic acid, however, is poisonous, not only when used internally, but also when used externally, since it is quickly absorbed even through the intact skin. The symptoms of poisoning in mild cases are headache, dizziness, faint- ing, ringing in the ears, vomiting, irregular respiration, small pulse, olive- green coloring of the urine (carbol-urine from phenol-sulphuric acid). In serious cases, unconsciousness sets in, combined with muscular contraction ; the pupils become contracted and no longer react ; the pulse is scarcely perceptible ; moreover, urinary troubles (dysuria, anuria, and albuminuria), intestinal hemorrhages, etc., are present. When the use of the acid is con- tinued, even in small quantities, marasmus combined with headache, faint- ness, and decreased appetite are produced. The acid, moreover, causes a violent irritation of the skin, producing erythema and eczema, often with THE TREATMENT OF WOUNDS 25 fever ; thus the neighborhood of the wound may still be greatly affected by the carbolic acid, whilst the wound itself has already healed. Especially obnoxious and disagreeable is the irritation of the skin on the fingers and the hands of many surgeons who largely employ this remedy. Strong solutions produce a cauterizing effect on the surfaces of the wound and irritate them, causing an increased wound secretion. Test : Carbol-urine with chloride of iron yields a violet color ; by heat- ing with Milloris reagent, a purple-red ; with a solution of chlorinated soda, a dark blue color ; with bromine water, a precipitate of tribromphenol ; or, the carbolic acid is extracted from the urine with ether ; the ether extract, floating on the surface, is poured off, and a stick of soft wood (for instance, fir wood) is dipped into it. The stick is afterward placed into a solution of hydrochloric acid (acid, mur., 50 parts ; aq. dest, 50 parts ; cal. chlor., 0.20 parts); it is then exposed for some time to sunlight. Even in a i : 6000 carbolic strength, the stick is colored blue (Hoppe-Seyler, Tomasi). The treatment for carbolic poisoning consists above all in the immediate discontinuance of the remedy, if it has been used as a dressing for the wound. Sugar of lime, albumen, milk, sodium, and magnesium sulphate (5%) are given internally. Against the several symptoms, the physician has to prescribe symptomatically analeptic and stimulating remedies. In spite of its many unpleasant properties, however, carbolic acid, up to the most recent time, has maintained itself as the most reliable antiseptic at the head of all. There are two other remedies that are said to produce a similar or even better effect ; namely, creolin and lysol, both prepared from coal tar. Both contain as effective ingredients a series of cresol ; but they are not pure preparations. Creolin forms with water a milky solution, and has about three times the strength of carbolic acid. It is used in i%2% solutions, and visibly promotes granulation and healing. Lysol is a soapy fiquid, con- taining about the same ingredients as creolin ; it yields with water rather clear solutions, which, even at o.$%-2%, produce an antiseptic effect. Both remedies, notwithstanding their high antiseptic qualities, are non- poisonous, and are, therefore, especially suitable for cases where the surgeon is compelled temporarily to intrust the treatment of the wound to laymen. Solveol {Hammer), a cresol compound, even in 0.5% solution, produces a stronger effect on bacteria than a 5% carbolized solution. It is used in solutions of 37 : 500-2000. Sublimate (Hydrargyrum bichloratum corrosivum, HgCl 2 Koch, von Bergmann}'v:> the most powerful but also the most poisonous of all disinfect- 26 SURGICAL TECHNIC ants. According to Koch, the spores of the anthrax bacillus are killed by a solution of i : 20,000, whilst their development is arrested by a solution of even i : 300,000. It is white, crystalline, odorless, and inexpensive. Since sublimate is at once decomposed by coming in contact with metals, it can neither be kept in metal vessels nor be used for disinfecting instru- ments. Hence, the irrigators for sublimate solutions must be made of glass ; and the basins, of glass, enamel, china, or varnished pasteboard. Sublimate is used : (a) As a weak aqueous solution of i : 5000, for disinfecting the hands and the region of the wound, for impregnating sponges, and for irrigating the wound by means of the wound douche before the suture is applied. (b} As a strong watery solution of i : 1000, for the energetic irrigation of septic wounds, in which case it acts much more effectively and is less dangerous than the 5 % carbolic solution. (c) As an alcoholic solution of i : 1000, for preserving catgut, silk, sponges, and drainage tubes. (^/) For preparing the materials for dressings. The materials are saturated with a solution of i part of sublimate, 100 parts of chloride of sodium, in 40 parts of glycerine and 1000 parts of water ; the excess of the fluid is pressed out with the hands or with the wringing machine, and the material is allowed to dry in a moderate heat ; or, gauze is saturated with a solution of 10 parts of sublimate, 500 parts of glycerine, 1000 parts of alcohol, and 1 500 parts of water (sublimate gauze, von Bergmami). ScJiede uses a solution of i part of sublimate, 10 parts of glycerine, and 90 parts of water. According to the Military and Sanitary Regulations of 1886, there should be used for the preparation of sublimate gauze a solution of 5 grams of sublimate, 500 grams of proof spirits, 750 grams of water, 250 grams of glycerine, and 0.05 grams of fuchsine ; this is sufficient for forty meters of gauze. Since watery solutions and materials saturated with them sometimes greatly irritate the skin, and since the sublimate, after some time, evaporates from the material impregnated therewith (Lasarski), Lister suggested mixing the sublimate with the serum of the blood of horses (i : 100) and saturating the gauze with it (sublimate-serum gauze}. It loses thereby its irritating but not its antiseptic properties. Sublimate combines with the albumen of the alkaline secretions of the wound and forms albuminate of mercury. Thereby the strength of the solution is considerably impaired. To prevent this and to preserve the THE TREATMENT OF WOUNDS 2/ sublimate in solution, small quantities of acids have been added (for instance, tartaric acid). The solution (i part of sublimate, 5 parts of tartaric acid, 1000 parts of water) is used for saturating the gauze (sublimate-tartaric gauze, Laplace}. But if the poisonous effect of the sublimate is to be decreased, then chloride of sodium is added to the solution. This promotes the formation of albuminate of mercury, but, at the same time, considerably increases the absorbent strength of the materials used for dressings. Maas prepares the sublimate-sodium gauze by saturating 1000 grams of gauze with 500 grams of sodium, 1 50 grams of glycerine, and I gram of sublimate. Sublimate, moreover, combines very readily with the earthy constituents always present in plain water, but the addition of chloride of sodium prevents this precipitate. Hence, it is necessary always to use distilled w ater f or the solutions. For this reason in practice, for the rapid preparation of sublimate solutions at a patient's house, very convenient and exceedingly practical are the sublimate tablets of Angerer, prepared with the aid of chloride of sodium (they contain one gram of sublimate and one gram of chloride of sodium). To prevent mistakes, they are colored with eosin. It is advisable to make all sublimate solutions recognizable by some definite color; otherwise, through error, poisoning may easily be caused. (In the Rush Medical Col- lege clinic the sublimate solution is stained blue, carbolic solution red, saline solution yellow.) The symptoms of intoxication by this, the most poisonous of all mercurial compounds, manifest themselves locally in itching, burning, and irritation of the skin (eczema, rhagades) ; this is especially the case when the poison- ing is due to dressings that have been applied in a moist condition ; other symptoms are : dizziness, restlessness, languidness, vomiting, inflamma- tion of the mucous membrane of the mouth with salivation and bleeding from the gums, intestinal hemorrhages, bloody diarrhoea, colitis, proctitis, tenesmus, inflammation of the kidneys, and fatty degeneration and calcifica- tion of the uriniferous tubules ; often causing death. The treatment for sublimate poisoning, apart from the immediate discon- tinuance of the remedy, consists in administering milk, albumen, and baths ; further than this, it is symptomatic gargles of a saturated solution of potassium chlorate being used to combat oral symptoms ; stimulants, in cases of depression. Chloride of zinc, ZnC\^R 2 O (Lister\ is a moderately strong antiseptic, does not attack the uninjured epidermis, has a caustic effect upon the other tissues of the body, is odorless, non-poisonous, and inexpensive. 28 SURGICAL TECHNIC It serves : (a) As a strong (S%) watery solution (Lister), for the energetic disin- fection of septic tissues that are in a state of disintegration or in an existing purulent and putrid condition, etc. (b} As a concentrated solution (aa. with water), with which the cotton tampons are saturated, as an excellent caustic in gangrene (Konig). (c) As a weak solution (0.2%) for antiseptic compresses and for impreg- nating material for dressings (jute, gauze). (d) As a dry chloride of zinc jute (5 %-io% Bardeleben\ for antiseptic dressings, which are very cheap. In a hundred parts of chloride of zinc dissolved in 1250 parts (i^ liters) of hot water, 1000 parts of jute are kneaded until all the fluid is absorbed. Next, the jute is spread out and dried in the air or on a stove. Boric acid, BO 3 H 3 (Lister), is a moderately strong antiseptic, which in a dilution of I : 136 arrests the development of schizomycetes, irritates tissues little or not at all, and does not possess any poisonous properties. It is not very soluble in cold water (i : 30), but readily in hot water. It is used : (a) As a watery solution ($.% : 100), in place of carbolic and sublimate solutions, in operations in the abdominal cavity, on the rectum, etc. ; also, according to Thiersch, for the same purpose, with the addition of salicylic acid (2 grams of salicylic acid, 12 grams of boric acid, 1000 grams of water). (b) As boric lint, to cover small wounds ; for this purpose it is espe- cially useful on the face. It is prepared by dipping English lint into a solu- tion of i part of boric acid in 3 parts of boiling water ; in the same way, boric cotton and boric gauze are prepared. (c) As boric salve, to cover sutured wounds on which a large antiseptic dressing cannot be well used ; for instance, after plastic operations on the face ; also to cover small granulating wounds. Lister's boric salve is prepared thus : acid, borici pulv., cerae alb., aa. 5 parts; oleum amygd. dulc., paraffini, aa. 10 parts. Still better, because simpler and more easily preserved, is a mixture of 20 parts of boric acid with 100 parts of vaseline or ung. glycerini, or the boro-glycerine-lanolin (Graf}. Tetraboric sodium (borax) (Jdnicke) is more easily soluble and therefore more effective than boric acid, and can be used in solutions of 15^-70%. It is non-irritant and non-poisonous. Aluminium acetate (Burow) is a very powerful antiseptic. In a 2.5% solution, it not only arrests the development of the schizomycetes, but, after THE TREATMENT OF WOUNDS 29 acting 24 hours, destroys their power of propagation (Pinner). It quickly removes offensive odors of wounds and secretions of the skin, and is non- poisonous and inexpensive ; it can be used, however, only in fluid form, because the acetic acid evaporates in drying, and only the ineffective alu- minium hydrate remains. Since it injures the instruments and makes the hands rough, its application in operations is not practical ; but, as a power- ful astringent, it restrains the capillary hemorrhage, and is therefore suit- able for saturating tampons. A i % solution is prepared by mixing 24 parts of alum and 38 parts of sugar of lead with i liter of water. This is allowed to stand for 24 hours, and is then filtered. It is used as a watery solution of o.$%-i% for saturating gauze com- presses, for poultices, for purifying warm baths, in suppurating and sanious fetid wounds and ulcers, in eczemas, and fetid perspirations (axilla, anus, scrotum); and, of all antiseptics, is most suitable f or permanent irrigation in progressive phlegmonous inflammation and gangrene. A still more powerful effect has aluminium acetico-tartaricum, which is a more fixed chemical compound, and only slightly cauterizes the surfaces of the wound. It is used in i%-3% solutions. Lead acetate, an antiseptic of moderate potency, which in a solution of i : 20 kills the spores, is less frequently used at the present time than for- merly. As aqua Goulardi (subacetate of lead solution), it was once used largely in the treatment of wounds and inflammation. Salicylic acid, C 7 H 6 O 3 (ThierscJi), a strong antiseptic, irritates the wounds little, is non-poisonous, easily evaporates from the materials for dressings, produces coughing and sneezing, and is expensive. It is used in solutions (i : 300) to irrigate wounds, preferably mixed with boric acid, whereby its solubility is increased. It acts as an emulsion (1:5 water), or, as salicylic salve (10% with vaseline or glycerine salve), in an excellent manner in eczema caused by carbolic acid and sublimate. As salicylic cotton and jute (3% and 10%), freshly prepared, it was once largely used. It cannot, however, be recommended for practice, since during transportation the salicylic acid falls out of the meshes of cotton, and materials saturated with it do not absorb well. Chromic acid, Cr^O^ Lister), is a very strong antiseptic and twenty times more effective than carbolic acid ; but it is very poisonous and is a power- ful cauterizer. It is, therefore, not used at all in the treatment of wounds, but only in the preparation of catgut, which Lister placed in a solution of i part of chromic acid, 200 parts of carbolic acid, and 4000 parts of water. 30 SURGICAL TECHNIC Thymol, C 10 H 14 O (Ranke), is a good antiseptic, since an emulsion of even I : 200 kills the schizomycetes, and a solution of I : 2000 arrests their development. It has a pleasant odor, irritates the skin but little, limits the secretion of wounds, and is but little poisonous, though expensive. It is used as a watery solution of I : 1000, with the addition of 10 parts of alcohol and 20 parts of glycerine. As thymol gauze, it is prepared by saturating 1000 parts of gauze with 500 parts of cetaceum, 50 parts of resin, and 16 parts of thymol. Used in burns, i % of thymol should be added to the liniment generally used (oleum lini and aqua calcariae, aa.); it alleviates the pain and is anti- septic. A i /oo solution is also to be recommended as a mouth wash. Potassium permanganate is easily soluble, inexpensive, and non-poison- ous, and is a moderately strong antiseptic, since even in a 5% solution it destroys resting spores, and, after a short irrigation, entirely removes the fetid odor of putrid wounds. But its effect is only of short duration, be- cause it is speedily decomposed by the wound secretion, and is precipitated in the form of a mucous brown deposit, which at once causes again the offensive odor. It is used as a watery solution of a color from claret to dark red (i : 1000-100), according to the degree of putrefaction {Candy's fluid). It is largely used also as a mouth wash for deodorizing and disinfecting the buccal cavity and carious teeth. Benzole acid (Kraske) is a good, apparently non-poisonous, antiseptic. It is used as a solution of i : 250, and does not irritate the wound. As an alcoholic solution, as a tincture ( Tinctura benzoes) its good effect has long been known. In preparing cotton or jute as materials for dressings, $%io% of the acid is used for saturating them. Resorcin, prepared from benzoic acid, is used in i%-2% solutions as a good and effective irrigating remedy (especially in cystitis). Benzosol is said to be a better substitute for it. Trichloride of iodine (Langenbucfi) is a non-poisonous antiseptic, effective in even a i / 00 solution, in destroy ing schizomycetes. In the dilution given above it has the effect of 4% of carbolic acid. Trichlorphenol (Butschik) is effective in i%-io% solutions, but is used only in Russia. Creosote also is now but little used, though formerly as aqua Binelli, a i % solution, it was used in fetid suppurations, in empyema, etc. Chlorine is a very powerful antiseptic, and, long before Lister ; was used as chlorine water (aqua chlori} for cleansing sponges and for irrigating THE TREATMENT OP WOUNDS 31 wounds. The compounds of chlorine also have antiseptic properties ; thirty years ago hydrochloric acid in a I % solution was used by me in permanent dressings. Chloride of lime (Semmelweiss), even in a twenty-fold watery solution, disinfects very energetically. It was used for disinfecting material for dressings and linen wear, for cleansing gangrenous ulcers, and for white- washing infected rooms and objects. Chlorinated soda is used in 5%-6$> solutions in decomposing wounds ( Verncuil). Natrium chloroborQsum and chloroboricum are recommended in solutions and in powders. Chloride of sodium has been known for a long time for its effects in arresting putrefaction (pickling). In strong solutions it irritates the wound and causes pain. In about \%2% solutions it can be used for cleansing, especially wounds that discharge a great deal of pus. For irrigating fresh aseptic wounds, a 0.6% solution of chloride of sodium is now generally used (von EsmarcJi). Its strength corresponds to that contained in the healthy tissues, and therefore, so to speak, represents a physiologic irrigating fluid. Maas utilizes the great absorbing power of chloride of sodium in the prepa- ration of sublimate gauze (see page 27). Chloral hydrate, in a i%-2% solution, in connection with chloride of sodium, is a remedy much esteemed by many for disinfecting septic wounds, since chloral has to a great extent the power to prevent the decomposition of putrefying substances. Ferrum sesquichloratum (ferric chloride), formerly almost exclusively used as a remedy for arresting hemorrhages, has strong antiseptic proper- ties, but cauterizes, and forms a crust on the surface of the wound. In weak solutions it can be used for saturating cotton. In very greatly diluted form it was used by Kb'berle for cleansing the abdominal cavity. Some sulphides are also good antiseptics. Sulphurous acid, even in a dilution of I : 500, is effective and non-poisonous. In 5 % solutions it is used for permanent irrigation, and as a gas for disinfecting infected rooms. Alum, aseptin (i part of alum, 2 parts of boric acid, 18 parts of water), cuprum and zincum sulphuricum (zinc sulphate), are serviceable in i % solu- tions for irrigating and cauterizing ulcerating wounds. Zincum sulphocar- bolicum (zinc sulphocarbolate) has been recommended in recent times by Bottini as a good and non-poisonous antiseptic (5%). Aseptol, even in 2% solutions, is effective. It is non-irritant and non-poisonous, and is used mostly in 10% solutions. Aseptinic acid (acidum asepticuni), a powerful, 32 SURGICAL TECHNIC non-poisonous styptic remedy, is used in S%~ IO % solutions. It promotes granulation and cicatrization. Rotter prepared a very powerful but non-poisonous antiseptic by com- bining several antiseptic remedies into one solution, too small a quantity of each being used to produce any poisonous effects. This Rotterin, which can be had also in pastils, contains in one liter of water : sublimate, 0.05 ; chlo- ride of sodium, 0.25; acid, carbolic., 2; zinc, chlorat. and zinc, sulpho- carbolic. aa. 5 ; acid, boric, 3 ; acid, salicyl., 0.6 ; thymol, o. i ; acid, citric., O.I. These tablets are prepared now also without carbolic acid and sublimate. Volatile oils, balsams, etc., have been also used as antiseptics such as camphor, styrax, balsam of Peru, aloe, turpentine, terebene, tar, and petro- leum. More frequent use is made of eucalyptus oil, in which the effective ingredient, eucalyptol, operates antiseptically in a very energetic manner. Lister used it as a substitute for carbolic acid. Eucalyptus gauze is prepared with i part of the oil of eucalyptus, 2 parts of gum dammar, and 3 parts of paraffin. In an alcoholic solution or in a mixture (0.3%) to be shaken before use for irrigation and for compresses, it produces a rapid reduc- tion of temperature (Schulze). Oil of juniper, a very powerful antiseptic, is used by Kocher in preparing catgut. Having placed it in oil for 24 hours, he keeps it until used in 95% alcohol. Hydrogen peroxide {Tromntsd&rff} is a very powerful antiseptic, non- poisonous, and, even in a 3% watery solution, is very effective for disinfect- ing putrid wounds as well as sick-rooms. It is an excellent styptic remedy. Absolute alcohol is a moderately strong antiseptic, useful for disinfecting instruments, especially knives and scissors, the edges of which are not affected by it. Aniline dyes are likewise strongly antiseptic. Of these, methyl violet was for a time very much recommended in the form of pyoc- tanin, by Stilling ; but it seems not to have met with success. ANTISEPTIC POWDERS lodoform, CHI 3 (von Mosetig-Moor/tof}, a lemon-yellow crystalline powder of peculiar odor, insoluble in water, easily soluble in alcohol, ether, and oils, is, properly speaking, not an antiseptic, since it does not destroy the bacteria directly, but, by means of the decompositions produced by them (ptomaines, toxalbumin) it is broken up, and the liberated iodine neutralizes the products of metabolism in the micro-organisms, rendering them harmless, and arresting their further development THE TREATMENT OF WOUNDS 33 It irritates the surface of the wound and its surroundings, produces good granulations, especially in fungous diseases, and very considerably limits secretion ; but it is poisonous, especially to old people and to those who suffer from heart and kidney diseases. Its unpleasant odor may be miti- gated or entirely avoided by the addition of cumarin, oil of bergamot, oil of sassafras, or by a mixture with powdered coffee. lodoform is used : (a) As a powder to sprinkle fresh wounds, such as contusions and gunshot wounds, where healing by primary intention cannot be expected. It is espe- cially useful also in the neighborhood of the natural orifices of the body (mouth, anus, vagina), where infection cannot be avoided. () As iodoform ether (i : 7) to disinfect the field of operation. (c) As iodoform etlier-alcohol ( i : 2 : 8) (de Ruyter) to be rubbed on poorly granulating, especially tubercular wounds. (d) As iodoform glycerine (10-20: 100) for injecting punctured cold ab- scesses. (e) As iodoform collodion (1:9) for protecting small completely sutured wounds (for instance, as a dressing after herniotomy Kiister). (f) As iodoform pencils (iodoform, 20 parts ; gummi Arab, glycerini, amyli, aa. 2 parts) for the treatment of fistulous canals and cavities difficult to disinfect. (g) As iodoform gauze, applied in a single layer below the other dress- ings, for covering fresh wounds united by suturing, and for insertion into wounds of the mucous cavities that remain open (mouth, nose, pharynx, rectum, vagina, bladder, and urethra), where thorough antisepsis is impos- sible. lodoform gauze is prepared by sprinkling in a clean basin 10 meters of gauze with 100 grams of iodoform, and by rubbing the same with clean hands until it has become uniformly yellow. lodoform gauze, useful for all purposes, can also be made very rapidly by sprinkling iodoform ether upon the gauze, and by rubbing it until the ether has evaporated. lodoform is then distributed uniformly in the gauze in very fine crystals. Saturating with the following mixture is more practi- cal : 50 grams of iodoform, 5 grams of glycerine, 20 grams of colophonium, 1,000 grams of proof spirits, and 500 grams of gauze. lodoform adheres better to this material, and does not fall out from its meshes so easily. These procedures are of course more expensive than the one described above. Billrottis adhesive iodoform gauze is most suitable for the mucous 34 SURGICAL TECHNIC cavities, because it firmly adheres to the surfaces of the wound, preventing putrefaction for weeks. It is prepared by drawing through a solution of 100 grams of colophonium in 50 grams of glycerine and 1200 grams of alcohol (95%), 6 meters of gauze, which, after drying, is rubbed with 230 grams of iodoform. The Military and Sanitary Regulations prescribe the following prepara- tion : Eight meters (250 grams) of gauze are spread on a clean plate and irrigated from a flask with a narrow neck, containing a mixture of 600 grams iodoform, 250 grams of alcohol, and 250 grams of glycerine, until the gauze has turned uniformly yellow. It is then passed several times through a wringing machine, and the fluid that has been wrung out each time is poured over it again. The symptoms of iodoform poisoning which manifest themselves are as follows : In mild cases, redness of the skin, headache, languor, loss of appetite, nausea, and vomiting ; in severe cases, loss of sleep, increased fre- quency of the pulse, fever, restlessness, delirium, attacks of mania, coma, and tvvitchings of the muscles of the face and of the trunk. If these latter symptoms have occurred, death generally follows in a short time, even when the remedy is discontinued. The presence of iodine in the urine is ascertained by the addition of dilute sulphuric acid and fuming nitric acid, with a few grams of chloro- form ; the mixture is vigorously shaken, when the same will turn red violet, if any iodine is present. After discontinuing the remedy, the treatment consists in thoroughly irrigating the surface of the wound, especially in administering alkalies (potassium bicarb., etc.), and in infusing chloride of sodium; further than this, the physician must combat the symptoms as they appear. Bismuth, NO 3 [OH] 2 Bi (Kocher) (Bismuthum subnitricum, Magisterium Bismuthi), a white crystalline powder, only slightly soluble in water, is a good antiseptic. It has a strong drying effect on wounds, but is not entirely non-poisonous. It is used in a I % solution for the wound and the materials for dressings; $% 10% emulsions produce a more caustic, but also a more poisonous, effect (stomatitis, enteritis, nephritis). Naphthalin (E. Fischer} is a very good antiseptic ; it does not irritate wounds, is non-poisonous and very cheap, but has a very unpleasant pene- trating odor. As a powder, sprinkled on open wounds, it disinfects them rapidly and permanently. Gauze, rubbed with naphthalin, furnishes a very useful antiseptic material for dressings. Oxide of zinc (Peterseri), a moderately strong, non-poisonous antiseptic, THE TREATMENT OF WOUNDS 35 is used as a powder in a i%-io% mixture (thin and thick milk of zinc); it is also used for saturating materials for dressings. For covering sutured wounds, Socin used a paste of 50 parts of oxide of zinc, 5 parts of chloride of zinc, and 50 parts of water. lodol (Ciamician\ a yellowish, odorless, non-poisonous powder, is said to possess all the good qualities of iodoform. It is used as a powder, in a 10% glycerine emulsion, and as iodol gauze, which is prepared in the same manner as iodoform gauze. Sozoiodol (Trommsdorff) as well as its compounds, especially with sodium, quicksilver, and zinc through its constituents, iodine and carbolic acid, also produces an antiseptic effect. It is non-poisonous, and, as a pow- der and in solutions and in the form of gauze and salve, is used with very great success in the treatment of wounds, ulcers, and catarrhs. Dermatol, prepared in most recent times, is said to produce a still more favorable effect, and is especially useful in diseases of the skin. Aristol also, used like the latter, is greatly praised for its properties in promoting granulation and in healing ulcerated surfaces. In effectiveness, however, it is said to be surpassed by diiodothioresorcin. Sulfaminol, a non-irritant, odorless drying powder, that produces antiseptic effects, is suitable for the after treatment of wounds, especially in the buccal cavity and in the nares. Salol, consisting of carbolic and salicylic acid, in the form of a powder, is used with great success in the treatment of chronic ulcers. Likewise charcoal, sugar, and coffee have recently come into limited use. Pulverized charcoal and coffee (Opplcr} are used especially in gangrenous ulcers ; in consequence of their action, the fetid secretion of the wounds soon becomes odorless. Sugar (Liicke), in spite of its tendency to ferment, is efficient in preventing decomposition (sour reaction of secretions of the wounds). In a very thick layer, it is used as a powder on sutured wounds (Fischer). Since, moreover, it produces a powerful drying effect, the dress- ings can remain in position from 8 to 14 days. (The editor has used for years with the most satisfactory results, both in military and civil practice, as a drying and antiseptic powder, a combination of boric and salicylic acid in the proportion of 4 : i.) Of this large number of antiseptic remedies, the enumeration of which is by no means exhausted, only comparatively few are universally used. They are principally : carbolic acid, sublimate, boric acid, and iodoform ; the first two, because they are among the most powerful remedies for disinfec- tion ; boric acid, because, notwithstanding its great colyseptic qualities (pre- venting putrefaction), it is non-poisonous and can, therefore, be used where 36 SURGICAL TECHNIC (for instance, in mucous membranes and in large serous cavities) toxic reme- dies, by absorption, might easily cause poisoning ; finally, iodoform, because it is the most excellent remedy for preventing a subsequent decomposition of the secretions of aseptic wounds (or wounds rendered aseptic). As long as only a few of its crystals are present in the wound, it is still safely effec- tive, and is, therefore, apart from its good services in tubercular diseases, especially suitable for permanent dressings. In the antiseptic treatment of fresh wounds, not made by the surgeon himself (primary antisepsis), after a most careful cleansing, antiseptics are used, only in weak solutions, to destroy the germs of infection that have entered the wound, or to remove them by irrigation. For irrigating the field of operation, the following are suitable : sublimate, i : 5000 ; carbolized solution, 2:100; boric solution, 3:100; in these solutions, likewise, the sponges are wrung out. Too large quantities of poisonous antiseptics should be avoided on account of their accompanying effects, and irrigation should be performed only when it seems necessary hence, especially at the end of an operation, before applying the suture. The danger of absorption, more- over, is considerably decreased if the operation is performed under elastic constriction of the limb ; under such conditions the application of even stronger solutions is admissible, because absorption cannot take place, and hence the antiseptics affect merely the surface of the wound. After such irrigations, the whole wound should be carefully dried. After application of the suture and after drainage, the wound is once more irrigated with an antiseptic solution, and is firmly pressed together with a large sponge or tampon, that the fluid still remaining in it may be squeezed out. This press- ure is continued until the sponge is exchanged for the first piece of dress- ing (pad or crinoline gauze), which should likewise be pressed firmly on the wound by the fixation bandage (Fig. 37). Wounds that can be united by means of the suture are covered with sublimate gauze or iodoform gauze. This is firmly pressed on by a cush- ion of moss or a thick layer of cotton, and the whole is fastened with a bandage. If the surgeon does not succeed in suturing the wound completely, or if, in a diseased appearance of the same, he prefers not to apply the suture at all, then on the whole surface of the wound iodoform powder is sprinkled, in the form of a thin film, preferably with a brush ; after this the wound is covered with gauze. The dressings of wounds that heal by granulation must be renewed oftener every 2-6 days, according to the amount of their secretion ; while the dressings on sutured and drained wounds can, in THE TREATMENT OF WOUNDS 37 most cases, remain in position until they are healed. The drainage tubes also need not be removed until after this period. By the agglutination of their walls the canals formed by the tubes close in a few days after their removal. Small wounds that neither bleed nor suppurate can be hermetically sealed in a very simple manner with adhesive plaster, English plaster, zinc paste, pJwtoxylin, traicmaticin, or collodion. It is necessary, however, to cleanse them previously with antiseptic remedies, and also to moisten the English plaster with a disinfecting solution (not with saliva) ; very useful, indeed, is the application of iodoform collodion (with an addition of ricinus oil or of turpentine) ; this produces an antiseptic effect, keeps the wound securely covered, and contracts it moderately. Such plasters, however, adhere only to a dry skin. Even if a slight hemorrhage occurs, they are raised from the skin and fall off ; under these circumstances, in the majority of cases, they have done more harm than good. THE DRYING AND THE DRAINING OF THE WOUND In wounds which have been treated aseptically and which have been irrigated, if at all, only with a solution of sodium chloride, the secretion is usually very moderate, since the surfaces of the wound have not been unnecessarily irritated. In order to limit the secretion even more, it is important : first, to arrest as carefully as possible the hemorrhage from even the smallest vessels ; next, not to sttture the wound too tightly to prevent any secretions from filtering through the interstices of the sutures ; finally, to apply a firm, well-absorbing c&mpressive bandage, which closely approxi- mates the surfaces of the wound and accomplishes healing by agglutination. Cavities should be avoided as much as possible ; or they should be removed by suturing their walls in layers (buried suture, "etagen" suture}, and by deep-reaching sutures of the skin. Rigid walled cavities in the bone, after having been scraped out with the sharp spoon or chiselled out, or ir- FlGS> 3I _ 32 IN - VERSION SUTURES regularly formed cavities of the wound after the removal of tumors, can be allowed to fill with blood after an exact suturing of the margins of the skin. If no infection has taken place, this blood, in the course of time, becomes organized into cellular tissue SURGICAL TECHNIC (healing under the scab, Lister, CJieyne, Sc/icde}. (The blood clot is never converted into connective tissue, but simply serves the purpose of an absorb- able temporary scaffolding which is removed by the granulations which invade it from the walls of the wound cavity.) The formation of cavities, however, may be entirely avoided by drawing over the cavity the margins of the skin in a lateral direction, fastening them in this position, and covering the groove of the bone with them ("Einstul- pungs "-suture, inver- sion sutures Figs. RUBBER DRAINAGE TUBE If it is to be expected that either through the irritating effect of the powerful antiseptics or through infection, considerable quantities of secre- tions will collect in the wound, care must be taken that the same are not retained, but have free exit. Drainage by means of perforated rubber tubes effects this (CJiassaignac) (Figs. 33-34). The tubes are introduced into the wound in such a manner that they occupy the most depend- ent part of the cavity, projecting only a little beyond the sur- face ; the rest of the wound is sutured. In this position, the tubes are fastened by safety pins placed transversely or by an interrupted suture at the margin of the wound. P"or the insertion of drainage tubes into narrow cavities, Lister uses special dressing forceps (Fig. 35). In most cases, however, moderately strong dressing forceps, somewhat bent, ren- der the same service. Sometimes in large cavities of wounds, special openings (counter openings} must be made in the skin at the most dependent part to secure a free escape for the secretions and furnish space for the drainage FIG. 34. DECALCIFIED BONE DRAINAGE TUBE FIG. 35. LISTER'S DRESSING FORCEPS THE TREATMENT OF WOUNDS 39 FIG. 36. CURVED DRAIN- AGE TROCAR tubes. This is done in the simplest manner, from without, upon the skin, projected by means of dressing forceps pushed through the tissues from within, outward. Chassaignac used a drainage trocar (Fig. 36), which he pushed from within through the most dependent portion of the wound. To the barbed hook of the point, he fastened the drainage tube and then withdrew the instrument together with the tube. Instead of rubber tubes, there have been used also glass tubes, metal tubes, decalcified bone tubes; also wicks of gauze, wool, catgut, spun glass, wire, and horsehair, which by means of their capillarity become strongly absorbent. (Nussbaum used for drainage small strips of protective silk.) Boiling these substances for some time disinfects them. Rubber tubes cannot stand prolonged boiling ; but they become completely sterilized by being placed, even for a minute, in a boiling soda solution. They are preserved in a 5% carbolic solution. In order to avoid introducing foreign bodies into the wound, the drain- age, moreover, may be so established that the wound can be sutured loosely and that the lower angle of the wound especially is to be left open. Into this angle, a bunch of gauze from the dressings is loosely inserted, so that the secretions can flow out from the opening by the force of gravity ; or, at the depend- ent portions, the skin is per- forated parallel to and along the suture of the skin. The : perforations thus made, from ; the margins of which the pro- truding fat is cut off, are made gaping by tension on part of the suture, and serve as openings for the escape of the discharge (see Fig. 37). In large wounds, which may eventually cause consid- erable bleeding or which had to be made in pathologically suspicious tissues (tuberculosis, oedema, sepsis), FIG. 37. DRAINAGE OPENINGS IN THE SKIN Last irrigation 40 SURGICAL TECHNIC it is safest, not to apply any suture nor to insert any drainage, but to leave the margins of the wound wide open, and to pack the whole cavity of the wound with gauze (tamponing). By this procedure, the most rapid absorption of the secretions is procured. In spite of the tamponing, healing may still take place by primary intention, if, after the course of two or three days, when the gauze has been removed, the wound appears to be covered with good granulations. It can then be closed in its whole extent by deep and superficial sutures (secondary sutures). If, on the removal of the tampon, a bad condition of the wound, with profuse sup- puration, is found, the surgeon has to dispense with the suture and allow the wound to heal by means of granulation and continued tamponing. For tamponing, especially if the gauze is to remain in position for some time, iodoform gauze is almost universally preferred. In the case of very large cavities, too large quantities of the gauze might occasionally produce symp- toms of poisoning. Under such circumstances it is advisable to use either very weak iodoform gauze or sterilized gauze for the upper layers of the tampon ; or else the walls of the cavity are covered with a single or a double layer of iodoform gauze ; into the remaining part of the cavity steril- ized gauze is packed. This is removed layer by layer, and thus the cavity gradually decreases in size (Miculicz). But if it becomes necessary to remove very infectious secretions of the wound, permanent immersion and irrigation (see below) often render better services than tamponing and drainage. DRESSINGS OF THE WOUND These have to fulfil the following indications : 1. They are intended to protect the wound from external injurious influences, especially from bacteria of putrefaction entering the same. Hence they must cover the whole region of the wound liberally, must fit well everywhere, and must hug the surface closely along the margins of the wound (cover dressings, protective dressings). 2. They must readily absorb the secretions (blood, serum, pus) that exude from the wound, and must allow them to evaporate rapidly (dressings for drying the wound). 3. They must prevent the decomposition (putrefaction) of the secretions (antiseptic dressings, Lister). The materials for dressings that are to cover the wound : i. Must be absolutely pure (aseptic). THE TREATMENT OF WOUNDS 41 2. Must contain the agents that destroy the germs of putrefaction (antiseptics). 3. Must be soft and elastic, so that, under moderate pressure, they can be well fitted to the surface of the body. 4. Must readily absorb fluids of all kinds must possess great ab- sorptive capacity. 5. Must be freely pervious to air, in order that the absorbed fluids may evaporate rapidly and combine with the oxygen of the air. Materials most frequently in use are the following : 1. Gauze (muslin for dressings), a loosely woven cotton cloth that has been rendered hygroscopic (that is, all oily substances have been removed from it) by boiling in a solution of caustic soda. It is used : (a) For the immediate covering of the wound, either in layers, folded repeatedly smoothly upon one another, as a compress (Lister}, or in pieces loosely and carelessly folded, as " kmell" gauze (loose or lost gauze) (von Volkmanri). (b) Made into sacks of different sizes, filled with other materials for dressings (peat, moss, sawdust, cellulose, etc.), and laid as a cushion or a pad over the few layers of gauze directly over the wound. (f) Cut into bandages from 6 to 12 centimeters wide, which, sterilized or dipped into an antiseptic fluid (carbolized, sublimated water), serve for fastening the protective dressings. 2. Cotton, (a) Hygroscopic charpie-cotton (wound cotton, Bruns\ from which the oil has been extracted by means of a caustic soda solution, absorbs water rapidly. Hence, in the form of tampons or gauze balls that are to be used but once, it is very suitable for washing soiled parts of the body and for packing secreting surfaces (axilla, etc.); but it should not be applied directly upon the wound itself, because with the admixture of the secretions a hard, compact, and impermeable layer or crust is formed. Hence, it is used only for the second layer of dressings over the gauze (the layer should be somewhat thick), and is restricted to smaller wounds in which there is but little secretion. In larger wounds, the dressings must be changed oftener, because the cotton, once saturated with pus, etc., becomes hard and is no longer absorbent. It is, therefore, not especially suitable for permanent dressings. For these, ciishioned dressings are preferable. (b) The common non-absorbent cotton is used for upholstering splints, and especially, in the form of cotton bandages from 10 to 15 centimeters wide, for padding and covering the margins of the dressings, since cotton, 42 SURGICAL TECHNIC as we know, is the best filter for the germs of infection suspended in the air. 3. Lint, a cotton tissue with a rough surface, similar to parchend, is mostly employed for covering small wounds, especially after previous satu- ration with a hot boric solution (borated lint). It is frequently used as a means of applying salves. To fill the above-mentioned gauze bags for cushioned dressings, the follow- ing more or less hygroscopic materials are used : 1 . Peat coarsely powdered, as peat mull (Neither), The light brown vari- ety (peat moss) absorbs very well (nine times its weight), if somewhat mois- tened before application ; black peat absorbs less, but possesses antiseptic qualities, owing to the humic acid it contains. 2. Peat moss (sphagnum). This can be found everywhere in forests and bogs ; it can easily be made aseptic by washing and subsequent sterilization. It is very compressible, an excellent absorbent, and cleaner than peat turf. The needles of sphagnum are finer and absorb better. 3. Sawdust, wood wool, and cellulose. These are good materials for dressings, because they are all elastic, absorb fairly well and rapidly, are easily rendered aseptic by the different methods of sterilization, and are not expensive. Sawdust (Porter) can be had everywhere. The dust of poplar absorbs best of all ; that of fir has also antiseptic qualities. Wood wool and cellulose are made in factories, and can be had reasonably cheap. The latter are especially suitable for artificial sponges to be used in operations in the place of sea sponges, and for filling the pads of splints. Cellulose cotton made of fir wood fibre is also manufactured in sheets, is very soft, and a rapid absorbent. Pine wool, oakum, jute (Araucan hemp), flax, blotting paper, sand, and ashes are less generally used, partly because they are not soft enough, partly because they are not sufficiently absorbent. It may be stated here that the power of absorption of all of these sub- stances may be considerably increased by the addition of agents that quickly absorb water, such as chloride of sodium, glycerine, etc. They also absorb more actively if they are previously moistened before applying them. Owing to the manufacture of these cushioned dressings on a large scale, their use has been rendered so convenient that they can be used now almost everywhere. Leisnnk and Hagedorn had sphagnum pasteboard manufac- tured, by strong compression, in sheets of various sizes. These are very THE TREATMENT OF WOUNDS 43 clean for usage, and need only to be wrapped in gauze to furnish an excellent sphagnum pad. They can also be purchased already sewed up in gauze coverings. They occupy very little space, but swell up very con- siderably when moistened. Just as useful are compressed pine wool and wood cotton (wood cotton sheets "HolffWattetafeln"), Formerly many various sizes were mentioned for the pads of very large dressings; for instance, pads large, 50-70 centimeters square (Fig. 38); small, 5-10 centimeters square. It is sim- pler and more practical, however, even in large wounds, to apply several smaller pads. It is necessary, therefore, to keep on hand only about two or three sizes 5, 10, 30 square centimeters. Pads 50 centimeters long and 15 centi- meters wide are suitable for padding the splints. Before applying these pads, their con- tents are so displaced by shaking that they apply themselves well to all the irregular surfaces of the region of the wound, so as to exert a uniform pressure upon the whole wound, and also that the principal mass comes to lie on the most dependent part of the wound for instance, upon the back, in dressings of the breast and the region of the axilla. By turning over the edges for instance, in the case of amputation stumps the surgeon should attempt to exclude the wound completely by the dressing. First of all, the pad is wrapped with a gauze bandage in such a way that it applies itself uniformly and firmly to the portion of the body ; over this, another layer of cotton may be applied, and the whole then fastened with a cambric or gauze bandage. All cavities and lacunae for instance, the axillary region are care- fully packed with cotton or " krull " (loose) gauze before the bandage is applied. Finally, in cases where the operation has been performed on the ex- tremities under elastic constriction, an elastic bandage of thin rubber is placed over the whole dressing, in order to add to the compression during the first two or three hours ; and in operations near the anus, such a bandage FIG. 38. LARGE DRESSING PAD 44 SURGICAL TECHNIC is placed around the marginal portions of the dressings, in order to prevent the entrance of intestinal secretions into the dressings (Fig. 39). Waterproof materials are only rarely used in dressing wounds, since it has been found that they do more harm than good, preventing the secretions of the wound from evaporating. Among these materials is Listens protective silk {protective taffeta}, which he used directly on the wound, to protect it from the irritating effect of carbolic acid, etc. If the materials for dressings possess sufficient power of absorption, this protection is just as little needed as the spun glass wool, recommended for the same purpose by Schede. The same must be said, also, of the expensive mackin- tosh which, in the original Lister dressings, was placed between the seventh and the eighth gauze layer, to pre- vent any of the secretions of the wound from reaching the surface of the dressing. If something of this kind is to be applied, the less expensive glazed paper is preferable. This can be prepared by the physician himself in the fol- lowing manner : Brush silk paper with linseed varnish to which 3 % of siccative or varnish extract has been added. Hang up the saturated sheets on threads in an airy room for 48 hours, until they are completely dry. To render the paper antiseptic, add to the varnish I % of thymol. The var- nished paper is quite suitable, also, for covering the compresses and keeping them moist (Priessnitffs compresses, cataplasms); for this purpose, more- over, parchment paper, oil cloth, and gutta percha may be used. Stronger waterproof materials, such as cotton cloth saturated with oil or caoutchouc varnish (for instance, BillrotJis batiste, oil cloth, etc.), are used to protect the bed linen in changing the dressings, in permanent irrigation, etc. The pure caoutchouc materials of raw brown caoutchouc are very suit- able for covering the operating table, for protecting other portions of the body during operations and dressings (see Fig. 21), and for aprons of the surgeon and his assistants. From the same material the caoutchouc band- ages 5-10 centimeters wide are made. Bandages serve to keep in contact with the surface and hold in position the dressings and splints, to cover, support, and fix in an immovable posi- tion injured portions of the body. They are manufactured : FIG. 39. ELASTIC BANDAGE THE TREATMENT OF WOUNDS 45 (a) Of gauze. These apply themselves well if previously moistened. When they have been saturated with starch (prgantine) they become agglu- tinated in drying, so that the dressings can be no longer displaced (aggluti- native bandages). They are chiefly used for fastening antiseptic dressings and for plaster of paris dressings. (b) Of cambric. These are very soft and pliable, and can be fitted to the surface of the body as well as flannel bandages ; they are less expensive than flannel, are very durable, and can be easily washed. They are espe- cially suitable for applying difficult dressings and for the fixation of splints. (c ) Of cotton. These are very soft and compressible, and are, therefore, quite suitable for the first layer in antiseptic wound dressings and for padding splints and plaster of paris dressings. (d) Of linen, preferably torn or cut in the direction of the threads from old, soft linen that has been often washed. Bandages of new linen cannot be well applied, because they are too stiff. (/) Flannel. These are soft and elastic, and can be well applied ; they are especially suitable for bandaging entire limbs and for surface layers in starch and plaster of paris dressings. (/) Of shirting or stouts. These are cheaper than linen, and are well adapted to starch dressings. (g) Of tricot (" tricot schlanch "). These are highly elastic and pliable, and are especially suitable as a substitute for cambric bandages. (/i) Of caoutchouc, either pure, as brown caoutchouc bandages, or of materials woven with caoutchouc threads. These, aside from their great elasticity, have the advantage of allowing the air to pass through, so that the moisture and the heat of the skin, so annoying in using pure rubber bandages, are avoided. They are used : 1 . For bandaging limbs in procuring local anaemia. 2. As bandages over the whole dressings of the wound after bloodless operations on the extremities, in order to increase the compression during the first two hours until the danger of after-bleeding is passed. 3. For compressing the margins of the dressings (Fig. 40), in order that no air may penetrate the protective layer of the dressings ; for instance, during the movements of the breast in breathing, or of the abdomen ; or in order that no faecal matter may enter it, as after operations on the perineum. In applying aseptic or antiseptic dressings, great care should be taken that the materials for dressing safely cover the region of the wound and its neighborhood, in order that no infection may occur after the dressing has 4 6 SURGICAL TECHNIC been applied by the entrance of microbes between the dressing and the surface of the body. For this reason, dressings of the present day, com- pared with those of former septic times, are very large and extensive. In opera- tion wounds for instance, on the neck the turns of the bandage, for a firm support and for a good adaptation of the dressings, must be carried, not only around the head, but also around the chest (Fig. 40). In wounds of the thigh, the region of the pelvis must at the same time be included by the bandage (Fig. 41). Whether in this case the rules of the former art of bandaging are minutely fol- lowed is of little consequence, with the soft and elastic materials for dressings of the present time (agglutinative dressings), provided the dressings are kept in contact with the surface and are firmly applied. As mentioned above, the very first condition for a good dressing is its sterility namely, that it be absolutely free from all living germs. Although this sterilized dressing can be easily obtained in larger institu- tions having steam sterilizers, it is difficult, and perhaps inconvenient, for FIG. 40. ANTISEPTIC DRESSING OF LARGE LATERAL WOUNDS ON THE NECK FIG. 41. ANTISEPTIC CUSHIONED DRESSING OF STUMP AFTER AMPUTATION the practising physician to procure for himself the necessary smaller quan- tities in a perfectly sterile condition. For when the materials for dressing from larger sterilized packages are not entirely used, the rest no longer remains absolutely aseptic. THE TREATMENT OF WOUNDS 47 Very useful in practice, therefore, are the dressing boxes mentioned by Diilirssen boxes of tin containing everything needed for the dressings of a certain portion of the body, in simple, sterilized antiseptic materials, and in quantities no greater than will be needful in a single operation. The boxes contain, according to the size of the dressings to be made, various quantities of sterilized iodoform gauze, absorbent cotton, cambric and starch bandages. These boxes containing a few grams of iodoform powder, in addition, can be purchased. By using these dressing boxes, which are prepared in factories, the physician, apart from the inconvenience of personally sterilizing the materials, has the best guarantee of the aseptic condition of each dressing. CHANGING THE DRESSINGS The dressings of purely aseptic wounds should, if possible, remain in position until the wound is completely healed ; or, at least, they should be changed as rarely as possible {permanent dressings). But in order not to miss the right period for changing the dressings, the physician must frequently examine and inspect them, especially at their most dependent portion. Moreover, he must take the temperature of the body by means of a thermometer, and observe carefully the general con- dition of the patient. When secretions from the wound penetrate the dressings and reach their outer surface, they begin at once, through the influence of the air, to decom- pose ; and this decomposition spreads rapidly, through the layers of the dressings, to the wound. To prevent this, it is above all necessary that these secretion stains should dry up rapidly. If this occurs, the development of the germs of infection, which thrive especially in a moist nutritive soil, is most effectively prevented. If the drying up does not proceed rapidly enough (for instance, in larger hemorrhages), the uppermost layers of the dressings, at the place where the secretions made their appearance, must be disinfected at once with a sublimate solution or with iodoform powder, and then must be covered with an absorbent pad extending far beyond the stain. (The best method to proceed in such cases is to dust the moist surface freely with boro-salicylic powder and apply a thick cushion of absorbent cotton.) If the stain of secretion is larger than the hand, it is better to remove the uppermost layers of the dressings down to the gauze that lies directly upon the wound, and to substitute for them new, sterile, dry dressings (pad, cotton). 48 SURGICAL TECHNIC A change of the whole dressing becomes necessary : 1. If a violent pain in the wound sets in. 2. If there is fever with such disturbances of the general condition of the patient that sepsis of the wound appears probable (septic fever). But if, notwithstanding an increased temperature (up to about 102 Fhr.), the general condition remains good, the skin and the tongue moist (aseptic fever), then sepsis of the wound need not be apprehended. 3. If an unpleasant odor emanates from the dressing. 4. If drains have been inserted in the wound. Then the dressings must be changed, after a few days, in order that the drainage tubes may be removed. If the same remain in position longer than necessary, they some- times produce a more copious secretion of the wound, and the canals created by them close only very slowly. A change of dressings must be made as rapidly as possible. It is, there- fore, necessary to have in readiness everything that might be required in making the change. Before removing the dressings, the patient is placed so that a new dress- ing can be applied conveniently. The bed is protected from being soiled and saturated by a rubber sheet, placed under the patient. If the uppermost layers of the dressings consisted of agglutinative bandages, they must be previously moistened, if tearing off the agglutinated turns should be painful to the patient; cambric band- ages can be unrolled more easily. But if it is not nec- essary to be economical with the dressings, they may be FIG. 42. DRESSING SCISSORS removed most rapidly by being cut lengthwise with a large pair of strong scissors (dressing scissors Fig. 42). Care must be taken that the scissors do not grasp the layer of cotton that may have been placed under the bandages ; for cotton is hard to cut, and is more easily torn apart with the fingers. If the wound is found to be aseptic and dry, it is entirely unnecessary to irrigate it. The surroundings alone are cleansed by wiping off with tampons or wads of cotton, and then a new dressing is rapidly applied. If rubber drainage tubes have been inserted, they are extracted, cleansed from blood clots or pus, and placed again in position only if, under pressure, secretions are still discharged from the depth of the wound. THE TREATMENT OF WOUNDS 49 If the wound in healing shows superficial granulations, a little borated lint or a piece of gauze covered with boric vaseline is applied to it. Cicatrization proceeds still more rapidly under a very light dusting with iodoform powder. Prolific hypertrophic granulations that project beyond the surrounding margins of the skin, and thereby prevent cicatrization, are dealt with by light cauterization with a lunar caustic pencil or by the appli- cation of a 2%-3% salve of zinc sulphate (zincum sulphuricum). The cauterization is perfectly painless if the physician is careful not to cauter- ize the tender epithelial margin. Flaccid, glassy, hypertrophic granulations are best removed with the sharp spoon; afterward the wound is dusted with iodoform. (It has been found that dusting such surfaces with aristol or dermatol is more conducive to improve the granulating process and epi- dermization than the use of iodoform.) The surgeon may proceed in a similar manner if the formation of granulation is scanty and the wound does not heal. In such a case, the surface of the wound may also be painted with a tincture of iodine or with some irritating salve. (Balsam of Peru is one of the most potent tissue stimulants known.) If eczema is found in the neighborhood of the wound, the irritated place is thickly painted with salicylic glycerine salve, boric vaseline, lanolin, or Lassar's paste (zinc, oxydat, amyl. tritic. aa. 10 parts; acid, salicyl., i part ; vaseline, 20 parts). If the healing has not taken place by first intention, an antiseptic dress- ing is again applied, and is as often changed as the secretion of the wound demands. But if the wound has become septic, if inflammation, suppuration, lym- phangitis, phlegmon, or erysipelas has set in, all sutures must be removed immediately; the wound must be opened sufficiently, and must be thoroughly disinfected and drained as described further below (see secondary antisepsis). In applying the first dressings after the operation, or in changing larger dressings, THE POSITION OF THE PATIENT is of especial importance. The patient must be placed in such a position that the portion of the body to be dressed is freely accessible from all sides, and that the whole body may retain this position unchanged while the dressings are in position. For the support of the body serves partly the operating table or the bed, partly the adjustable telescopic hip rest (Fig. 43). For adults, this support should be 20 centimeters in height, and in many ca'ses two of them are E SURGICAL TECHNIC FIG. 43. McBuRNEY's ADJUST- ABLE TELESCOPIC HIP REST required. The hands of the assistants or of the nurses hold the body firmly in the position indicated. In many cases of dressings on the leg, good use can be made also of a support for the heels (see (' \ below). ,. p Dressings on the head are best applied when the patient is sitting or is held in a sitting posi- tion; likewise, in the case of dressings on the thorax; if the patient is still under anaesthesia, he is placed across the operating table, while his arms are moderately drawn aside. In dressing the region of the pelvis, a pelvic support is placed under the sacral region, or the patient is placed in a lateral position on two supports. In abdominal dressings (after laparotomies), two supports for the back are very convenient. In dressing the leg, the pelvic support is not placed transversely, but parallel to the axis of the body, under the healthy side of the pelvis, so that the diseased leg can be held in a free suspended position. The assistants should always take such a position that they do not obstruct the manipulations of the surgeon ; their hands should render the necessary aid in such a manner that, notwithstanding the resting position of the limb, they cause no obstruction. For this reason, the assistant should observe the rule of rendering assistance with outstretched arms and of holding the limb to be bandaged far from his person, so that the surgeon can conveniently carry the bandage through the loop of the arms thus formed. If the hand is to be dressed, the assistant grasps the four fingers with one hand and the thumb with the other. If the foot is to FIG. 44. IMPROVISED POSITION APPARATUS be dressed, the assistant, with one hand, firmly holds the toes anteriorly, while with the points of three fingers of the other hand he supports the heel. Figure 44 shows how, in war, for want of pelvic supports, the surgeon must THE TREATMENT OF WOUNDS 51 help himself with objects always at hand ; for instance, during the applica- tion of a pelvic dressing, on account of an injury to the femur, knapsacks, cooking utensils, and tin boxes are employed for this purpose. In case of necessity, even the edge of a ditch or of a rampart may be used. In time of peace, the surgeon will be less embarrassed to improvise and quickly procure such supports. THE POSITION OF THE PATIENT IN BED This requires a great deal of attention and practical experience. First, the bed should be so placed that it is, as far as possible, accessible from all sides ; hence, it should not touch the wall anywhere. Since, how- ever, this would limit the space very greatly, generally only three sides are left accessible, the head of the bed being placed against the wall, preferably against that which contains a window, because the patient is not then incon- venienced by the light. If the bed is so placed that the light falls upon it laterally, then that wall must be selected from which the diseased portion of the body receives the full light ; else, in dressing the wound, the surgeon has to work in the shadow. For a comfortable position of very feeble, decrepit patients, air cushions and water cushions often cannot be dispensed with. If the patient, for instance, during his meals, desires to as- sume a sitting or half-sitting position, the placing of many pillows behind his back is rather uncomfortable. More practical is the adjustable back rest (Fig. 45), which can be changed to any desired position and which, after being folded, can remain under the pillow. For it may be substi- tuted a light chair reversed, having its back and the anterior edge of the seat placed in a downward direction behind ,, M1 Tr .. . vrc ,, r .1 FIG. 415. ADJUSTABLE BACK REST the pillow. If it is difficult for the patient to raise himself in bed, he may be easily assisted by a "releveur," a loop carried from the end of the bed and placed within reach of his hand. Bandaged limbs are always elevated upon " chaff '" ^(^d^^br-^ip^on aji apparatus described below. They are protected from the ppe^jtrS v of^ "rire bed coverings, often causing inconvenience, and from other casual , co^tacis ^ c SURGICAL TECHNIC Fio. 46. PROTECTOR by a protecting basket consisting of three loops of strong wire connected by three bars of the same material (Figs. 46-47). Finally, if patients are the subjects of such serious wounds that it is advisable for them to lie as nearly immovable as possible to prevent the pain caused by each movement, or if they are uncon- scious, an apparatus for lifting them is very beneficial. By means of it, the patient can be easily and comfortably raised in his bed, whenever it becomes necessary to renew the dressings or the bed linen, to cleanse and wash the pos- terior portion of his body, and to prevent it from becoming sore by lying in one position, or to facilitate the alvine evacuation. The Invalid Lift, an apparatus for lifting patients (Fig. 48, a and b} is especially to be recommended, and is in general use both on account of its safety and on account of the ease with which it can be managed. It consists of five pairs of arms, the lower ends of which (spatula shaped) are padded and support the patient safely (like the hands of so many nurses). By means of a crank with an endless screw, the patient, lying in the arms of this ap- paratus, as if held by forceps, can be lifted uniformly into any de- sired position. Since this apparatus is somewhat expensive, it will probably be used only in hospitals. Hence it is desirable to improvise such an apparatus rapidly and with less expense for more modest demands. The suspension stretcher (Fig. 49), on account of its simplicity and prac- tical arrangement, is to be recommended. Four bros-d strips of canvas are provided on one side with loops and on the o^ner with straps; two of these are placed under the thorax of the patient, and two under his legs ; one pole of the stretcher is placed on one - /fy f / l/ Pr. t FIG. 47. THE SAME IN STRAIGHT FORM FOR TRANSPORTATION THE TREATMENT OF WOUNDS 53 side through the loops, and on the other side the straps are buckled to a second pole. Both poles are lifted at the same time at the head and at the FIG. 48 (a). INVALID LIFT end of the bed, and are there kept apart by two transverse bars provided with holes. 54 SURGICAL TECHNIC FIG. 48 (). INVALID LIFT THE TREATMENT OF WOUNDS 55 The wounded portion (here, the region of the hips) remains free, so that the dressings can be changed conveniently. A similar apparatus has been mentioned by Laub. The suspension frame (Fig. 50), according to von Volkmann, is also very suitable for these purposes. The canvas stretched on the wooden frame has a hole in the middle for defecation. By means of the two lifters of girth fastened to the ends, the FIG. 49. SUSPENSION STRETCHER frame, with the patient, is lifted, and kept in this position by means of wooden supports that can be turned up. Roller supports for extension treat- ments are fastened to the frame itself. Moreover, the suspensory apparatus for patients (Fig. 51), invented by Siebold, is to be recommended on account of its simplicity. The strong supporting pole is easily raised by means of a pulley fastened to the ceiling of the room. Since the straps, provided with buckles, in which the patient is placed, apply themselves firmly to the body when the pole is raised, in places where this is to be avoided a board must be inserted above the portion of the body, as shown in the illustration to the left. This keeps the straps apart. SURGICAL TECHNIC FIG. 50. SUSPENSION FRAME FIG. 51. SIEBOLD'S APPARATUS FOR LIFTING A TATIENT THE TREATMENT OF WOUNDS 57 SECONDARY ANTISEPSIS All fresh wounds that have evidently become infected and all wounds considered at first aseptic, in which symptoms of sepsis (profuse secretion of the wound, pain and swelling in the region of the wound, inflammation, sup- puration, and wound fever) have set in, must be immediately subjected to thorough disinfection; and this must be the more energetic, the more threatening the septic symptoms are. Here are to be observed the same principles that hold good for primary antiseptic treatment of wounds; and, since the surgical treatment required in most cases is very painful, it is advisable to place the patient on the operating table and to narcotize him, in order that the surgeon may not be hindered by his restlessness and his lamentations from performing the disinfection with the nec- essary degree of thoroughness. The surgeon begins, as in all opera- tions, by carefully cleansing and disin- fecting the whole neigh- borhood of the wound. Next, if it concerns wounds on the limbs, after raising the same vertically, he interrupts the circulation by resort- a, open; ing to elastic constric- tion; he enlarges the wound to the requisite extent by cutting the skin, and by forcing apart the soft parts with the finger, dressing for- ceps, or the dilator (Fig. 52); and by means of blunt retractors (Figs. 53-54), he draws the wound margins so far apart that the entire internal surface becomes acces- r _ ^ JIGS. 53-54 Slble for inspection. VON LANGENBECK'S Then, first, all coagula and granulations are scraped off BLUNT RETRACTORS FIG. 52. ROSER'S DILATOR. b, closed 58 SURGICAL TECHNIC with the finger, with sponges, and the sharp spoon (Fig. 55). All bloody or pus-infiltrated fragments of tissue, membranes, layers of cellular tissue, and portions of the muscles are removed with forceps, scissors, and knife ; all foreign bodies (portions of the clothing, loose fragments of bone, bullets, earth, dirt) are removed ; the operator penetrates with his finger into all FIG. 55. SHARP SPOON, CURETTE the pockets and sinuses of the cavity of the wound, at the end of which he makes incisions through the fascia and skin upon forceps thrust through the remaining tissues from within (counter openings, buttonholes) for the insertion of drainage tubes. Next, a thorough washing and irrigation of the cavity of the wound is made with antiseptic solutions, which in strength must be according to the degree of septic infection. In milder cases, the weak carbolic (3%), or sublimate solutions (i : 5000) are sufficient; in more serious cases, stronger solutions of carbolic acid (5%), sublimate (i /oo), lysol (2%), or the chloride of zinc solution (8%) must be used. Then, everywhere, and especially in the sinuses, so many drainage tubes are inserted that the drainage of the secretions from all parts of the wound is perfect ; after this, the incisions of the skin are partly, though not too tightly, sutured. Next follows an antiseptic compressive bandage, preferably of loose gauze, which remains in position until the drainage tubes are removed ; this should be done as soon as possible (in five or six days). (It is advisable to substitute the best moist antiseptic compress for the dry dressing in the treatment of all infected wounds?) A primary healing is often successfully obtained in this manner. But if sepsis has progressed far, if the secretion has an offensive odor, if the tissue of the wound is coated or decomposed, or if the contused soft parts are in a state of gangrene, then primary healing cannot be expected. The wound should be sufficiently enlarged, left open, and covered with anti- septic dressings or packed (tamponing). lodoform gauze is especially suitable for this purpose. It safely prevents further decomposition without producing local cauterization, as do the strong antiseptics. THE TREATMENT OF WOUNDS 59 In large open septic wounds (crushings by machinery, contusions, etc.) are employed antiseptic compresses (gauze compresses dipped in acetate of aluminium, sublimate, or carbolic solution). These are changed frequently (every hour); and with each change of dressings, either the wound is irri- gated with the same fluid or the antiseptic immersion is employed that is, in an antiseptic solution, the injured portion of the body is immersed day and night, or at least for many hours during the day. Permanent antiseptic irrigation sometimes renders excellent service in the worst cases of acute septic phlegmonous inflammation (which, in severe lacerated wounds and in large diffuse extravasations of blood, sometimes occurs on the first day) in which the rapidly advancing sanious infiltration of the cellular tissue is recognized by the hard, dark red, and painful oedema- tous swelling of the skin, rapidly spreading over the whole limb, and accom- panied with high fever and rapid loss of strength. PERMANENT ANTISEPTIC IRRIGATION This purposes to allow fresh antiseptic fluid to enter the wound continu- ally, and by this means to wash away the putrid secretions. In order to obtain this, apart from the surgical treatment described be- fore, the operator makes numerous small incisions from 2 to 3 centimeters long multiple scarifications through the skin and the f ascias, especially in all places where the layers of epidermis are detached from their basement membrane, in order to create free drainage for the secretions of the wound, and allow the antiseptic fluids everywhere to penetrate into its depths. If the hemorrhage from the inflamed tissues is very great, which is usually the case, it is best arrested by a firm packing (tamponing), and by bandaging with antiseptic gauze bandages, which are allowed to remain in position for several hours. Then, into all the openings, drainage tubes are introduced deep into the wound ; into some of them the nozzles of irrigators are inserted. The latter have been placed on a shelf above the bed, and contain non-poisonous antiseptic fluids for instance, solutions of acetate of aluminium (o. 5 % I %), of potassium permanganate (3%), or better of hydrogen dioxide (3%), of boric acid (4%), creolin (0.5%), thymol (o. i$>). The two first-mentioned solutions produce oily precipitates, which clog the tubes and necessitate more frequent irrigation of the same. Poisonous antiseptics cannot, with- out danger, be used for this purpose. Next, a stream of these fluids, the rapidity of which must be regulated 6o SURGICAL TECHNIC by stop-cocks, is allowed to enter the wound. The fluid issuing from the drainage tubes that remained free flows upon a waterproof sheet placed under the limb and is drained into a pail. The position of Bardeleben and the wire slings of von Volkmann (see below) are very suitable for this pur- pose. Very practical for permanent irrigation is the apparatus of Starkc (Fig. 56). It consists of a glass tube, 50 centimeters long and 5 centimeters wide, on which are made drainage openings for five rubber tubes ; the latter are provided with glass points introduced into the drainage tubes. By means of stop-cocks the force of the stream can be regulated in each tube, and by means of inserted wires, the desired position can be secured for the tubes. A very practical apparatus, used in Czerny's clinic, was described by von Meyer. It is necessary always to watch the effect of the irriga- tion apparatus. The antiseptic fluid must not run through in a continuous stream, but only in a rapid fall of drops. In order to effect this prop- erly, it is sometimes practical to introduce a medicine dropper (Fig. 57) into the irrigator tube, as mentioned by von Volkmann. Generally, after the irrigation, a fall of the temperature and an improvement of the general condition soon set in. At any rate, the application is rather complicated, and requires preparation FlG TT VON and constant superintendence. Its efficiency seems especially VOLKMANN'S to lie in the rapid drainage of the secretions of the wound, less DROP CAN - in the disinfection of the secreting surface of granulations, which in most cases is strongly irritated, cauterized, and excited to profuse secretion. At any rate, the careful packing (tamponing) with iodoform FIG. 56. STARKE'S APPARATUS FOR PERMANENT IRRIGATION THE TREATMENT OF WOUNDS 6l gauze or lysol gauze, which is to be renewed as often as necessary, seems to work just as well, and has the advantage of being simpler and more easily managed. While antisepsis in the widest sense of the word removes the inflamma- tion, or, at any rate, the infection of wounds of all kinds, nevertheless, for combating the inflammation of such tissues as lie deep under the uninjured skin and beyond the reach of the air, we use THE ANTIPHLOGISTIC TREATMENT: REST, ELEVATED POSITION, AND REDUCTION OF TEMPERATURE are the chief antiphlogistic remedies. A large portion of the following chapters treats of securing rest for the injured and inflamed portions of the body (dressings, position). Elevated position promotes the return of venous blood and of lymph and diminishes the arterial pressure thereby antagonizing hyperaemia and promoting the absorption of extravasations and exudates. For elevation of the limbs, longitudinal pillows filled with chaff, chopped straw, sand, etc., are used. Several of these, as the case may require, are placed one upon another, and their easily displaceable contents are forced to each side, so that a longitudinal groove is formed for the reception of the arm or leg. A number of less simple appliances are used to secure a higher degree of elevation. Thus, for a high elevation of the hand, are used : - (a) The adjustable oblique board (von Esmarch Fig. 65), which rests on a table standing near the bed, or on a board fastened to the bed, and which, at the same time, is so constructed that it conducts into a pail the solution i when permanent irri- gation is practised. (b) The suspen- sion splint (von Volk- mann Fig. 58). On . FIG. 58. VON VOLKMANN s SUSPENSION SPLINT this the whole arm is fastened with serpentine turns of a bandage, and, by means of a cord tied to the lower end of the splint, it is raised and suspended (to a post). (Fig. 59> 62 SURGICAL TECHNIC FIG. 59. SUSPENSION OF THE HAND ACCORDING TO' VON VOLKMANN For a high elevation of the leg, either various fixation splints (Petit's fracture double inclined plane, etc.), may be use after fixation of the limb by means of cords and wooden boards, the limbs m; suspended in such a way that the foot i pended higher than the rest of the body (F 60). For the same reason, in injuries of the ventral position, and in injuries of and neck, the half reclining position, recommended. For the reduction of tem- perature in inflamed parts, cold, or the abstraction of heat, is employed in various ways : i. In the form of cold compresses. These, if they are really to abstract heat the box, , or, few r be FIG. 60. SUSPENSION OF FENESTRATED PLASTER OF PARIS DRESSING THE TREATMENT OF WOUNDS constantly, must be changed very frequently ; if they remain in position long enough to become warm, they disturb the injured part, and pro- duce an irritating effect {Priessnitzs com- presses). It is best to use two compresses, one, well wrung out, being used while the other lies in a basin of cold water near the bed. It is well to place a few pieces of ice in the water. If a sufficient quantity of cold water cannot be had, it is advisable to use a refrigerating mixture (i part of am- monia and 3 parts of saltpetre, coarsely powdered with a mixture of 6 parts of vine- gar and 12-24 parts of water) (Schmucker). 2. As dry cold, preferably by means of ice in rubber bags (ice bags). These ice bags must be securely closed by wooden tampons or large corks (cham- pagne corks), around which the closed ori- fice of the bag is securely fastened by means of a narrow band (Fig. 61). Ice bags provided with a screw cap do not keep waterproof very long, and are more expensive. If the cooling becomes excessive, a few layers of linen or gauze are placed between the ice bag and the body; other- wise, either congelation or gangrene might set in. The cold should at all times produce a pleasant sensation, for it is then that it relieves pain most effectually. It is not advisable to use bladders, as they are not perfectly waterproof, and, moreover, they soon decompose. To be made water-tight, before being used, they are either painted outside and inside with varnish or rubbed thoroughly with fat. Decomposition is prevented by washing them in anti- septic solutions before each new filling. Glass bottles and tin boxes, filled with ice or cold water, abstract the heat even more energetically than rubber bags, but they do not adapt themselves so well to the part to which they are applied. In practice among the poor, however, or as a makeshift, the cold bottles can be very well employed for instance, on the perineum, in the axilla, and the inguinal region. In the treatment of inflammatory diseases of the vertebras (spondylitis), FIG. 61. ICE BAG 6 4 SURGICAL TECHNIC tin boxes moulded to the shape of the body and filled with cold water render excellent service (von Esmarcli), both because the patients can lie upon them comfortably and because the abstraction of heat is very con- siderable. Figure 62 shows a cooling box for the vertebral column of the neck. FIG. 62. COOLING Box FOR THE VERTE- BRAL COLUMN OF THE NECK FIG. 63. ESMARCH'S COLD COIL In inflammations of the extremities, a very decided effect can be ex- pected from the cold coil (von Esmarch Fig. 63), a long rubber tube wrapped in coils about the inflamed part. One end of this coil, provided with a stone or a perfo- rated tin block, is placed in a pail filled with ice water, whilst the other end is conducted into an empty pail. Through suction at the lower end, circulation of the ice water is produced, and this circulation can be regulated by tying a string around the lower portion of the tube. If the upper pail has become empty, it is filled again by pouring into it the water that has flowed off. For the same purpose, Letter used thin flexible lead FIG. 64. LEITER'S COLD HEAD COIL tubes, which refrig- THE TREATMENT OF WOUNDS erate still more rapidly and efficiently, because metal, as we know, con- ducts heat better than rubber (Fig. 64). In order to abstract heat from the whole body in febrile diseases, it may be covered with a cooling cover, consisting of a linen cover, one side of which is sewed with closely running coils of a rubber tube (von EsmarcJi). It is simpler to fill a large water bag with water of the desired temperature and to place the patient upon the same. This constant effect of the cold, of course, is then felt to be more unpleasant than a cold pack in wet sheets or the short stay in a full cool bath, wherewith similar results may be produced. 3. By irrigation with cold water (Fig. 65). From an irrigator hung up over the bed, cold water is allowed to trickle in drops upon the injured part, covered with a bandage in which the water is diffused. The rapidity of the falling of the drops is regulated by a straw placed in the point of the irrigator. In- stead of an irrigator, a rubber tube may be used, one end of which is provided with a stop- cock, while the other, provided with a perforated tin plug, is lowered into the pail filled with water. The tube works like a siphon, and must be set to work by suction. Smaller siphons of glass or tin tubes may also be used for this purpose. The heat-abstracting effect of the irrigation is very great, in consequence of the evaporation of the water. Hence, water of very low temperature need not be used. The water that flows off must be caught on an inclined plane or on a waterproof sheet (oil cloth), placed beneath it, and be conducted into a pail placed under it. 4. By cold local permanent baths (immersion). For this purpose, tubs are used for the arms and the legs (Figs. 19, 20). FIG. 65. IRRIGATION 66 SURGICAL TECHNIC The injured limb is placed in the tub on strips of bandages fastened to the tub by buttons on each side. A very low degree of temperature is not required, since the effect of the permanent bath is very powerful. Water from 69 to 72 Fhr. cools very perceptibly in a bath continued for a long time. Generally the regulation of the temperature by the addition of cold water may be left to the patient himself. Note. Through the experiments of Volcker and Zerssen, it has been proved that it is possible to cool a part of the body to a greater depth by the local withdrawal of heat. A thermometer introduced 3-5 centimeters into the interior of the tibia after necrotomy showed that in this place the temperature was decreased : by the application of ice bags 50 Fhr. in 9 hours ; by the permanent bath in water gradually becoming cooler (86- 54) 54 in 14 hours; by irrigation with cold well water (46-5o) 52 in 9 hours. The temperature of the body taken in the rectum sank during this time hardly perceptibly, and did not reach the normal minimum {Esmarch, " Verbandplatz und Feldlazareth," 2d edition, 1871, pp. 140-143). If the irrigation and the immersion in antiseptic solutions just described are employed in the treatment of wounds, they can very well serve as a sub- stitute for permanent irrigation. Especially by means of the permanent bath do cleansing of infected wounds and inclination toward healing set in rapidly. OPEN TREATMENT OF WOUNDS Before the antiseptic treatment of wounds became generally known, by far the most successful of all prior methods was the " Open Treatment" (Bartscher, Burow). This left the wound without any medical assistance, so to say, to itself and provided only for a constant discharge of the secretions from the open wound, devoid of all dressings. Its advantages consist : in drying by a constant escape of the secretions, in the drying up of these secretions, and in the forming of scabs, which do not furnish a favorable nutritive soil for the germs of infection ; in securing rest for the wound, which is mostly disturbed by the frequent changes of dressings often with unclean material, lint, old linen, adhesive plaster, etc. This method has, however, great disadvantages. The surgeon from the beginning does not expect any primary Jicaling of the wound and allows the air free access to its surface. In consequence of this, in badly ventilated, dirty rooms, infection and decomposition of the secretions may easily ensue. For this reason, the method is employed only when for some reason the THE TREATMENT OF WOUNDS antiseptic treatment of the wounds cannot be carried out. For war it is not at all suitable. After the wound has been cleansed from gross impurities and after all hemorrhage has been arrested, the limb is elevated, and under it is placed a FIG. 66. FENESTRATF.D PLASTER OF PARIS DRESSING small basin to receive the secretions. To protect the wound against insects and dust, linen in a single layer or gauze may be placed over it. If fixation dressings are necessary as in complicated fractures, severe contusions, and after resections of joints the place over the wound must be left open in the dressings by cutting a fenestra (Fig. 72), or the object is attained by the application of interrupted suspended splints (see below), which are especially useful for this purpose. BANDAGING A bandage must not only be practical and good, but must also be well applied ; for it is the only part of the operation that the layman sees, and from it he may often form an opinion of the surgeon's skill. In pre- antiseptic times, especial value was attributed to bandages applied according to the rules of technique and according to exact regulations. Now, we must pay especial attention to the condition of the materials for dressing, and 68 SURGICAL TECHNIC since most modern materials are very soft and pliable, only little skill is necessary to apply them well. Nevertheless, without spending too much time in applying the dressings, the surgeon should always aim, not only to make them practical, but also to make them appear well. Even without special natural ability, dexterity and a light hand may to some extent be acquired by practice. For bandaging single portions of the body, for fastening on the wound the dressings, the splints, etc., bandages and clot/is are usually used. Band- ages are used exclusively for the first dressing of the wound and for larger dressings that are to remain in position for some time ; cloths are used for smaller dressings that are to be changed often, and especially as a valuable substitute for dressings where no bandages are at hand or where their appli- cation would require too much time and expense. Moreover, since the cloth dressings can be applied more easily and simply than the bandages, they are, in the hands of laymen, especially suitable for a temporary bandage. BANDAGES The application of the bandages that is, the bandaging itself must be performed with very great care and exactness, since a badly applied bandage ahvays does harm. If the bandage is applied too loosely, it does not fulfil its purpose. The several turns become displaced, come to lie one upon the other, and thus produce pressure. If the bandage is applied too tightly, then from the constriction under violent pains venous stasis immediately occurs in the parts below the con- striction ; and if this is not soon relieved gangrene (Fig. 67), or an incurable degeneration of the fi- bres of the muscle, cut off for some time from the circulation of the blood, will occur (is- chemic paralysis of the FIG. 67. CONSTRICTION CAUSED BY BANDAGE muscles and contrac- ture von Volkmami}. Poorly fitting also is the bandage if it gapes largely that is, if one margin is drawn tight and presses into the skin, while the other stands off from the surface of the body (Fig. 68). This occurs most frequently when the bandage is "tortured" that is, when, neglecting the prescribed rules, THE TREATMENT OF WOUNDS 69 FIG. 68. GAPING BANDAGE the operator forces it to take a course that it does not take of itself. A bandage should be applied with moderate tightness, so that it does not get out of place, nor yet cause pressure; the right measure for this can be learned only by practice. Bandages that have been applied dry, but that have afterward become wet (from com- presses, irrigation), contract greatly and may then cause stasis ; on the other hand, band- ages applied wet (starch bandages) become loose from subsequent drying. The latter, therefore, may be drawn more tightly from the beginning; while the former are best applied wet. Rubber bandages must not be drawn at all, since even slight elastic pressure in time becomes unbearable. Before a bandage is applied, it must be rolled firmly and smoothly : First, make a small stiff roll by simply winding and turning between the fingers one end of the bandage ; next, place this upon the inner surface of one hand so that the part to be rolled passes between the thumb and the fore finger or between the fore finger and the middle finger ; then, with the other hand, by means of supination movements in the hollow of the hand, gradu- ally roll up the free end of the bandage until it can be forced through the fingers only with difficulty (Fig. 69). The more firmly a bandage is rolled, the more easily can it be applied. If a larger number of bandages are to be rolled up quickly, it is better to use a bandage roller (Fig. 70). Bandages rolled up from beginning to end are called "one-headed" those rolled from each end to the middle are called "two- headed." To apply the bandage, hold one end firmly with the left thumb to the portion of the body to be bandaged ; roll the bandage around this from left to right until its beginning is covered, and thereby held in posi- tion ; next, carry it as closely as possible along the body, preferably allowing it always to unroll of its own accord upon the body itself slowly in the tours FIG. 69. ROLLING A BANDAGE 70 SURGICAL TECHNIC described below, but always centripetally and corresponding to the lymph current. or fastening the end of the bandage, a pin, or, better, a safety pin, may be used. If such is not to be had, or if the surgeon wishes to do without it, he divides the end of the bandage by tearing it lengthwise especially the jauze bandage and ties it together in front with the other end. FIG. 70. BANDAGE ROLLER To unwrap the bandage, catch it loosely at one end, like a skein, and pass the rolled-off part carefully from one hand to the other. In this way, the bandage is made to pass in the air around the limb without touching it, or without drawing it to and fro. Inexpensive gauze bandages are divided with scissors. THE TREATMENT OF WOUNDS 71 We distinguish the following turns : i. The circular turn (circular bandage, fascia circularis) surrounds the portion of the body in the form of a ring in tours covering one another completely (Fig. 71 below). 2. The screw or spiral course (screw or spiral bandage, dolabra ascendens) encircles the limb in the form of a screw, gradually ascending; the sev- eral tours cover one another about one-half (Fig. 72). 3. The serpentine turn (dolabra repens) ascends in steeper spiral turns, covering the limb only incompletely. On limbs with an increasing circumference (cone-shaped), these tours form themselves of their own accord if the head of the bandage is allowed to run along the skin and, as it were, to roll off of its own accord (Fig. 71 above). In order to secure an even envelopment on parts of increasing thickness (lower arm, thigh, and leg), as soon as the bandage begins to ascend too steeply, the operator must turn it down again on the other side. This is the 4. Reversion (dolabra reversa, renverse). To make this tour : At the place where the bandage no longer covers the preceding turn, place the tip of the left thumb upon its lower margin. Next, with the right hand guiding, change the bandage from FIG. 71. CIRCULAR AND t h e pronation to the supi- SERPENTINE TURNS , nation same time, so bring it in contact with the limb that, though previously drawn tight, it now becomes per- fectly loose. Turn the head of the bandage once in a downward direction so that the hand is again prone. Having thus formed a smooth fold in the bandage, guide the rolling end in a descending direction around the limb, and turn it over again in line with the former fold. If, in making these turns, many inversions of the bandage follow each other, their angles for the sake of good , . n c , . .... SPIRAL BANDAGE appearance should form a regular zigzag line in the axis of the limb. The several turns cover each other about one-half. To SURGICAL TECHNIC make these reversed turns well and rapidly requires practice and skill. The bandage applies itself almost of its own accord, if it is held loosely and drawn tight again immediately after the reversion has been made. Strong tension in making the reversed turns produces unsightly projections. 5. The cross turn, figure-of-8 (spica tour\ is used where the bandage passes over a joint toward another portion of the body where, owing to a great difference in circumference, simple ascending turns of the bandage cannot be made. In this case, the bandage is carried obliqriely over one side of the joint, transversely to the other side ; and then, ascending obliquely, is carried across the first oblique turn. The point of crossing lies about in tbe median line. The several turns do not cover one another completely, but only about two-thirds (Fig. 89). In accordance as tbey are repeated in ascending or in descending lines, spica ascendens or descendens is obtained. The crossings form a figure faintly resembling the position of the grains in an ear of corn. If the places of crossing, however, cover one another and if the turns of the several tours extend on both sides like a fan, there is produced 6. The fan turn (ray, turtle turn, testudo). This is used only for band- aging the bent knee and the elbow joint. In accordance as the operator commences with the turns from the sides, advances toward the middle, and ends here with a circular tour, or commencing with a circular tour gradually covers both sides (the open- ing or the closing of a fan), we distinguish the testudo inversa and the testudo re- versa (Figs. 73, 74). Of bandages that were formerly much used, though now but seldom employed, the following are to be mentioned for special purposes : The double-headed band- age, rolled up from each end, was especially used on the head and on amputation FIG. 75. FUNDA BANDAGE stumps. It can be employed also for the approximation of the margins of the wound and in ulcers of the leg (see Fig. 78). FIG. 73. TESTUDO INVERSA FIG. 74. TESTUDO REVERSA THE TREATMENT OF WOUNDS 73 The many - tailed bandage (Scrtltefs band- age), which consisted of many short strips cover- ing each other one-half, was sometimes used for bandaging complicated fractures and for plaster of paris dressings (Fig. 76). The funda bandage, about i meter long and divided from each end to the middle with the exception of a small joint - piece, makes a very practical dressing for smaller projections (nose, chin) ; the mid- dle portion is applied to the part to be protected, the two lower ends are carried upward and the two upper ends down- ward (Fig. 75). FIG. 76. SCULTET'S MANY-TAILED BANDAGE FIG. 77. T BANDAGES The T bandage, a strip of muslin to the middle of which another strip has been fastened at a right angle, is used for some dressings on the pelvis and on the head (Fig. 77). 74 SURGICAL TECHNIC BANDAGES FOR THE HEAD The double-headed union bandage (fascia uniens Fig. 78). The middle part of this bandage is applied opposite to the place of injury; the heads are passed by each other and then back to the point of starting ; in this way turns are repeated several times and are allowed to cover each other in turns anteriorly and posteriorly. The sagittal bandage (fascia sagittalis Fig. 79), a T bandage, is especially suitable for uniting transverse wounds of the skull. The cross-knot bandage (fascia nodosa Fig. 80) is a double-headed bandage. At right angles and under strong traction, its turns are allowed to cross the wound covered with a thick compress, as in tying up a package. 7 FIG. 78 FIG. 79 FIG. 80 DOUBLE-HEADED SAGITTAL BANDAGE CROSS-KNOT BANDAGE UNION BANDAGE (Fascia nodosa') It is especially suitable as a temporary bandage for wounds which bleed profusely and upon which a stronger pressure is to be exerted (tourniquet). A cravat firmly drawn around the limb or a rubber bandage answers the same purpose. The mitra Hippocratis (Fig. 81) is a double-headed bandage. One end of this bandage is carried around the forehead and the occiput by circular turns and so fixes the turns of the other end, which, covering one another one-half, are carried in turns over the right and the left parietal bone. The halter bandage (capistrum Figs. 82, 83). The first turn com- mences on the vertex, descends on the right cheek, and passing under the chin ascends on the left cheek to the vertex. The second turn passes in a posterior direction behind the right ear to the neck, on its left side ante- riorly under the chin, and over the right cheek up to the vertex ; thence closely again behind the left ear to the nape of the neck, past the right side of the neck, under the chin and over the left cheek back to the vertex. THE TREATMENT OF WOUNDS 75 After these turns have been repeated two or three times, covering one another like the tiles of a roof, about two-thirds, they are fastened by a cir- cular turn around the forehead and the occiput, which turn can if necessary be repeated several times. In antiseptic surgery, this bandage is well adapted to the treatment of injuries of the jaw, and is preferable to all others after operations on the head ; since, in using broader bandages, the whole head and neck, with the exception of the face, may be enveloped with its turns (Fig. 83). If it is applied with moist starch bandages, the essential course of the turns must be observed in order that the bandage may fit well. FIG. 8 r MlTRA HlPPOCRATIS FIG. 82 HALTER BANDAGE FIG. 83 HALTER BANDAGE The eye bandage (monoculus Fig. 84), to cover the region of the eye, commences with a circular turn around the forehead and the occiput ; to this is added an oblique turn over the parietal bone to the other side below the ear. These two turns of the bandage are repeated several times so that the circular turns always cover one another ; but the oblique turns are spread fanlike on the parietal region and below the ear, and across each other in front of the nose over the glabella. To cover both eyes, the turns are applied on both sides, so that a star of six rays is formed, with the root of the nose as centre (binoculus). Bandage for the nose (Fig. 85) is made in the simplest manner with a roller 60-70 centimeters long, the middle of which is placed upon the nose. The ends on both sides of the nose are turned once around their axis, carried obliquely across the cheek and the occiput, and tied there. This dressing can also be applied with a funda bandage, the ends of which, crossing each other at the side of the alae of the nose, extend above and below the auricle to the occiput. The funda maxillae (Fig. 86), for fixing the broken lower jaw and for smaller wounds of the region of the chin, is applied with a roller about I 7 6 SURGICAL TECHNIC meter long and 6 centimeters wide. By tearing from each end to the middle portion about 5 centimeters wide, it is turned into a funda bandage. The middle portion, provided with a slit, is placed on the middle of the chin ; FIG. 84 EYE BANDAGE (Monoculus) FIG. 85 BANDAGE FOR THE NOSE FIG. 86 FUNDA MAXILLA the upper ends are conducted horizontally backward to the occiput, and crossing here are carried obliquely in an anterior direction to the forehead ; the lower ends ascend across the cheek to the vertex, and descend again on the other side. BANDAGES FOR THE ARM For bandaging the several fingers (chirotheka) , it is best to use a small flannel or cambric bandage (finger bandage). From a circular tour around the wrist, the turns pass obliquely across the back of the hand to the base of the fingers. The finger is bandaged by serpentine tours to its point ; thence the bandage ascends in spiral tours to the base of the finger, and, cross- ing the first turn on the back of the hand, it returns to the wrist. The manner of bandaging all the fingers may be in- ferred from what FlG> FIG. 87. CHIROTHEKA CHIROTHEKA has just been said : Starting from the wrist, the surgeon may begin bandag- ing the forefinger or the little finger ; after bandaging each finger, he THE TREATMENT OF WOUNDS 77 FIG. 89. SPICA MANUS carries the bandage in an upward direction to the wrist so that finally it forms a spica on the back of the hand over each metacarpal bone (Figs. 87, 88). The cross bandage of the hand (spica manus Fig. 89), for covering the back and the palm of the hand, commences with a circular turn over the wrist or around the base of the fingers, and passes thence in several ascending and descending spica turns around the middle of the hand. In a similar manner is ap- plied the spica pollicis, which envelops the base of the thumb. Similarly, with a circular turn commenc- ing around the four points of the fingers, continuing in spica turns, and advancing to the wrist, the whole hand together wit/i the thumb may be bandaged. The testudo cubiti is applied on the flexed elbow, as described above, so that the several turns cross one another on the flexure of the joint. The spica humeri (Fig. 90) commences with a circular turn in the upper third of the humerus, passes from the left, across the eminence of the shoulder and the back, to the axilla of the other side, and crossing, on the diseased shoulder, the first turn, returns to the beginning end of the bandage ; thence it takes its course again parallel to the first turn, and covering it one-half, continues to the axilla of the other side ; here the turns should cover each other completely, and so forth until the whole region of the shoulder is bandaged. Finally, a few turns are carried around the first circular turn on the humerus or around the chest. The bandaging of the whole arm (involntio bracJiii Fig. 91) commences with bandaging the several fingers and the thumb with a long narrow roller. With a broader bandage, the spica manus is next applied across the many small turns of the bandage on the back of the hand, and ends with a circular turn around the wrist. In one or two spiral turns, it ascends along the forearm to which a series of reversed turns is added as far as the elbow, which is bandaged by figure-of-8 turns ; ascending thence to the arm, it runs FIG. 90. SPICA HUMERI SURGICAL TECHNIC in continuous spiral turns to the axilla ; the shoulder is bandaged with a spica turn. General rules for bandaging in injuries of the hand and of the fingers : No strangulation ! untie the buttons of the shirt ! cut open the sleeves of the shirt and of the undershirt to the axilla! do not commence the bandaging of the hand with a tight circular turn around the wrist ! avoid the hanging posi- tion of the hand ! In fresh simple wounds, secure union by means of English court plaster, wet or dry gauze bandages saturated with traumati- cin or collodion, or fine sutures (epidermis suture Donders\ Hemorrhage must be arrested mostly by pressure (bandaging). In contused wounds of the fingers, band- age with small gauze bandages that have been dipped into a weak antiseptic solu- tion and moisten them from time to time. It is better, however, to use reliable anti- septic dressings. In fractures of the fin- gers, use either plaster of paris dressings bandage over small flannel bandages ; or splint dressings small wooden splints padded with cotton and fastened with wet starch bandages or with dry gauze bandages saturated with traumaticin or collodion. In fractures of single metacarpal bones, a large cotton ball is placed in the palm of the hand. On this, the hand is firmly wrapped with flannel bandages (ball band- ages). In case of strong retraction, an extension dressing with strips of adhesive plaster is practical ; these are made tense by means of a rubber ring on a hand board (see Fig. 266). After cxarticulation of a finger, the narrow spica bandage may be used (Fig. 92). In fracture of the clavicle, the displacement of the fragments may be corrected, even if not permanently, by the bandage of Desault. It is true FIG. 91. BANDAGING OF THE HAND AND THE ARM THE TREATMENT OF WOUNDS 79 that this is no longer in fashion, but it is an excellent object lesson- its several turns are used in nearly all the bandages of the shoulder. The first bandage (Fig. 93), by means of turns encn- cling the chest, fastens g wedge-shaped pad in the ax- illa of the abducted arm. After the arm has been brought to the side against the pad, it is fixed against the thorax by the second bandage (Fig. 94) and is, at the same time, forced back- ward, while the shoulder is drawn away from the trunk over the pad. The third bandage supports the arm in the form of a mitella (Fig. 95). It takes its course from the axilla of the healthy side to the shoulder of the diseased side ; and, pass- ing around the elbow of the same, it returns to the axilla. These three FIG. 92. NARROW SPICA BANDAGE FIG. 93. DESAULT'S BANDAGE FOR FRACTURE OF THE CLAVICLE. (a) First bandage FIG. 94. DESAULT'S BANDAGE FOR FRACTURE OF THE CLAVICLE. () Second bandage FIG. 95. DESAULT'S BANDAGE FOR FRACTURE OF THE CLAVICLE. (<:) Third bandage 8o SURGICAL TECHNIC points are always touched in the same order axilla, shoulder, elbow. The last end of the bandage is carried from the healthy shoulder downward around the wrist and to the diseased shoulder, and is fastened there. To prevent the displacement of the turns of the bandage, impregnate the bandage with starch paste, or for the last turn use starch or plaster of paris bandages. The bandage of Velpeau (Fig. 96) which fixes the hand of the diseased side upon the healthy shoulder and fastens the elbow in front of the ensiform process is useful as well in fractures of the clavicle, as also in chronic inflammations of the shoulder joint. It consists of horizontal turns encircling the thorax and the arm, and of vertical turns which take their course from the diseased shoulder, around the elbow, to the healthy axilla. The elbow rests as if in a sling, and is drawn upward. The turns, applied alter- nately, cross each other in front of the dis- eased arm in the form of a spica. Concerning the adhesive plaster bandage according to Sayre, see page 155. BANDAGES OF THE TRUNK In the stellated bandage for the chest and the back (fascia stellata, Stella Fig. 97), the turns are carried on both sides in spica or figure-of-8 turns around the supraclavicular region and under the two axillae, in such a way that they cross one another in the median line in front of the sternum and behind the vertebral column. A few turns placed around the trunk or both shoulders serve for fixation. In this way a similar bandage, formerly much used, can be made namely, the quadriga, which, according to rules, is applied with a double- headed bandage (Fig. 98). The bandaging of the thorax and the abdomen becomes very simple if a broad bandage is applied in spiral turns. In order that the bandage may be applied firmly, and especially that it may not become displaced laterally, it is well to place a few spica turns (figure-of-8 turns) around the shoulder or the hip. Bandages in the region of the pelvis are mostly applied in spica FIG. 96. VELPEAU'S BANDAGE FOR FRACTURE OF THE CLAVICLE THE TREATMENT OF WOUNDS 8l coxae 'turns (anterior for instance, after operations for hernia, on the bladder, penis, scrotum, etc.). For operations on the anus, the T bandage is best. It is, moreover, just as practical to use so-called bathing drawers, which apply themselves well everywhere and which are not expensive. FIG. 97. STELLATED BANDAGE (Stella Dorsi) FIG. 98. BANDAGE OF THE THORAX (Quadriga) The compressive bandage for the female breast can be applied in various ways : either in several single oblique turns, which pass from the healthy shoulder below the diseased mamma, and, covering each other in the form of overlapping turns or in the manner of a testudo, extend to the axilla of the diseased side ; or else in turns which are applied around the healthy axilla and allowed to cross each other over the shoulder (Fig. 99). In arranging the turns of the breast ascending from below upward, the mamma is not only compressed but also supported (compressorium et sus- pensorium mamma). A suspensorium mamma duplex (Fig. 100) is best applied with the turns of the above described stellated bandage (Fig. 97), to which a few circular turns around the lower mammary region are added. The bilateral compressive bandage for the breast (compressorium mamma duplex) is made in spica or figure-of-8 turns, which cross each other in front of the sternum. The bandage is carried from the superior side of one mamma to the inferior side of the other; across the back to the 82 SURGICAL TECHNIC inferior side of the first and to the superior side of the other ; thence across the back again to the superior side of the first. This process is continued in such a way that the turns, like a testudo, always approach more and FIG. 99. SUSPENSORIUM FIG. 100. DOUBLE SUSPENSORY MAMMARY BANDAGE more a central point namely, the nipple. For a firmer fixation of the bandage, either the final tours are carried around the shoulders or a few circular turns are added around the thorax. BANDAGES OF THE LEG The toes are covered together with a circular bandage, and bandaging each toe separately is dispensed with. The stapes (Fig. 101), for bandaging the dorsum of the foot, consists of two or three spiral turns, fastened by a spica turn carried across the ankle joint. The spica pedis is applied in the same manner as the spica manus : to the circular turn over the malleoli are added three or four circular turns across the dorsum of the foot. The whole foot can be bandaged very well by increasing the number of these turns with a broad bandage only the heel is left imperfectly covered. If the heel is also to be well protected, then the foot is FIG. 101. STAPES bandaged in the following manner (involutio pedis) : THE TREATMENT OF WOUNDS The bandage begins immediately above the toes with a circular turn ; then follow two or three reversed turns on the dorsum of the foot, next three spica turns around the dorsum of the foot and the malleoli. Having arrived closely in front of the ankle joint, the bandage now takes its course from the plantar surface to the right (of the patient), around the calcaneus over the Achilles tendon, anteriorly from the left to the right again over the Achilles tendon, on the left around the calcanens toward the plantar surface, anteriorly over the ankle joint, posteriorly around the heel ; it then ascends across the malleolus to the leg. The testudo genu has been de- scribed above on page 72. The spica coxae for the hip (Fig. 102) resembles essentially the spica humeri. After a circular turn around the upper third of the thigh, there fol- low three or four spica turns, encir- cling the pelvis. The crossings may be placed upon the anterior, lateral, or posterior region of the hip. Applied on both sides, this spica coxes duplex is the best bandage for the pelvis. Fig. 102 shows a bilateral spica coxae anterior ascendens, on the right leg descendens on the left leg. Bandaging of the whole leg (involutio Thedenii Fig. 103) commences with the bandaging of the foot described above. Thereupon follows the bandaging of the leg, by a broader ascending spiral bandage with reversed Ascending Descending FIG. 102. DOUBLE ANTERIOR SPICA FOR THE HIPS FIG. 103. BANDAGING THE WHOLE LEG turns ; of the knee, by a testudo ; of the thigh, by an ascending spiral bandage with reversed turns ; of the region of the hip joint, by a spica coxae completed with a few circular turns around the hypogastric region. 8 4 SURGICAL TECHNIC Many of the bandages here described are obsolete, and are used in practice little or not at all. They can all be very well made use of, how- ever, in practice work ; and although the application of a moist gauze bandage is easier than that of a stiff linen one, nevertheless, for exact anti- septic bandaging, a thorough knowledge of the technique of bandaging is indispensable. CLOTH BANDAGES With linen or cotton (shirting, stouts) of triangular (kerchief) or square (handkerchief, napkin) form, most dressings may be applied just as well as with bandages, many even better. For the application of cloths, only little practice is necessary, since the danger of strangulation and stasis even in a poorly applied bandage is less than when gauze bandages are used ; the cloth bandages are especially suitable for temporary dressings, particularly when made by laymen who render the first assistance (Samaritan). But they can also be well employed for bandaging wounds for instance, for amputation stumps, for fixation of small dressings, compresses, splints, etc. FIG. 104. VON ESMAKCH'S TRIANGULAR CLOTH Cloth bandages had already been most favorably mentioned sixty years ago by Gerdy and Mayor ; but they were forgotten, and were brought into common use only by the introduction of my triangular cloth (Fig. 104). This is printed with figures on which the various bandages are illustrated. By these, the expert obtains a quick survey of what he has learned, while THE TREATMENT OF WOUNDS FIG. 105. SAILOR KNOT an inexperienced person obtains a good object lesson for his action, a lesson of great advantage, especially to soldiers on the battle-field. We make a distinction between square cloths and large and small tri- angular cloths. The former must consist of square pieces, the sides of which are from 90 to 130 centimeters long. The latter (large triangles) are obtained by an oblique cut ; by cutting from the point to the middle of the base, they may be divided again into two halves (small triangles). A triangular cloth has a point, two extremities, two small sides, and one long side. For fastening the extremities to- gether, it is best either to use the sailor knot (Fig. 105), which holds more se- curely than the granny's knot (Fig. 106), or by the use of safety pins. As can be seen from the pictures printed upon the cloths, they can be used for various purposes in different forms and sizes ; now, as a cloth bandage folded together from the point to the base into a long and small cravat ; now, as an open triangle with a manifold application of the extremities, by doubling them, inverting them, tying them together, or fastening them with safety pins. On the several parts of the body, the cloths are used in the following manner : For bandages of the head, the following are serviceable : i. The triangular head cloth (capitium triangulare Figs. 107, 108). The middle of this triangular cloth is applied over the vertex so that the long side hangs down transversely in front of the forehead, while the point hangs down over the neck. Next, the two extremities are carried across both ears in a posterior direction and allowed to cross each other over the occiput and over the point which hangs down; thence they are carried again anteriorly FIG. 106. GRANNY'S KNOT FIG. 107. TRIANGU- LAR HEAD CLOTH (Anterior view) FIG. 1 08. TRIANGU- LAR HEAD CLOTH (Posterior view) 86 SURGICAL TECHNIC FIG. 109. FUNDA BANDAGE FOR THE TEMPORAL REGION FIG. no. FUNDA BANDAGE FOR THE OCCIPUT and are knotted together over the forehead. Finally, the point hanging down posteriorly is drawn forcibly downward, turned up over the occiput, and fastened over the vertex with a safety pin. 2. The funda capitis (Figs. 109, no). This is a square -cloth, 60 centi- meters long and 20 centimeters wide, split on the two small sides like a divided funda bandage. If the operator desires to use it in fastening a dressing over the pari- etal region, he knots the two posterior extremities below the chin and ties the two anterior together over the nape of the neck (Fig. 109). But if the dressing is to be fastened over the occiput, the anterior ex- tremities are tied together under the chin and the posterior over the forehead (Fig. no). In a similar manner, a funda capitis is made for the frontal region. 3. The large square head cloth (capitium magnum quadrangulare Figs. 1 11-112). This covers, like a hood, not only the skull but also the whole auricular region, the neck, and the throat. It is, therefore, a very practical protective dressing in bad and in cold weather. A large cloth (napkin) about I meter square is folded together diagonally, so that the long margin of the upper half recedes behind the long margin of the lower part as much as the width of the hand. In this way, a rectangle is formed. This is applied to the head of the patient as follows : The mid- dle line of the cloth cov- ers the sagittal suture; the free margin of the lower surface hangs down to the tip of the nose ; the margin of the upper surface extends to the superciliary region ; the narrow margins fold themselves upon the two shoulders. Of the four extremities hanging down anteriorly upon the breast, first the two exterior are tied together under the chin ; next, the margin of the lower surface hanging down in front of the eyes is turned up toward the forehead, and the two inner extremities of the same are FIG. 112. LARGE SQUARE HEAD CLOTH FIG. in. LARGE SQUARE HEAD CLOTH THE TREATMENT OF WOUNDS drawn backward over the ears and tied together over the nape of the neck. With the triangular cloth folded in the shape of a cravat there can be very easily formed a frontal bandage, a buccal bandage, and an eye bandage (Fig. 113). With two such cloths, also a four-tailed bandage for the chin may be extem- porized (Fig. 114). This is done by placing the middle of one cloth upon FIG. 113 EYE BANDAGE FIG. 114 FUNDA BANDAGE FOR THE CHIN FIG. 115 CRAVAT OR KER- CHIEF FIG. 116 CRAVAT WITH IN- SERTED PASTEBOARD the anterior surface of the chin and by tying together the ends over the nape of the neck, while the other cloth is carried up to the vertex from the lower surface of the chin. For fastening the bandage over the neck, the kerchief is of service (Fig. 115). This is a triangular cloth folded together in the form of a cravat. If a piece of stiff paste- board QT leather, etc., is incorporated, the bandage becomes still more secure, and the head can then be bent toward the injured side (transverse wounds), provided the maxil- lary margin of the healthy side has been raised by a suffi- ciently high insertion (Fig. 116). For bandages of tJie arm, we use : 1. The vinculum carpi, cross bandage for the hand (Fig. 117). This is a folded cloth, which is placed around the metacarpus in spica or figure-of-8 turns. The cross- ing is made over the place of the injury. 2. The hand cloth, gauntlet (Fig. 118). This is used for bandaging the whole hand. Upon the middle of the long side of the unfolded cloth, the flat hand is so applied that the wrist lies upon the margin, while the fingers correspond with the apex. This apex FIG. 117. CROSS BAND- AGE FOR THE HAND 88 SURGICAL TECHNIC is turned over the dorsal portion of the hand, the lateral extremities are tied over the wrist, and the apex is used for covering the knot. Amputation stumps may be bandaged in the same way (Fig. 119). 3. The elbow cloth. This is applied folded, and bandages the region of the elbow joint in circular and spica or figure-of-8 turns. 4. The shoulder cloth. This is ap- plied : either folded together in a spica tour around the shoulder, the ends being tied in the healthy axilla ; or ^lnfolded t the apex upon the shoulder and the extremities tied together in the other axilla. In this way, the brachium (arm) is also covered, and a restful position is thereby secured. It is very well to employ this method after exarticulation of the shoulder joint (Fig. 120). It is more practical, how- ever, to use two clot/is, placing one, folded as a loose sling, around the neck or around the neck and the healthy axilla and under this the other with its apex unfolded is carried and fastened, while the extremities are tied around the brachium (arm) (Figs. 118, 119). Cloths are most frequently used to meet the following indications : i. To support the arm (mi- tclla). The mitella parva is a sling made of the folded cloth (Fig. 118). Generally, how- ever, the cloth is unfolded (mitella triangularis}. It is FIG. 119. HKAD CLOTH, BREAST CLOTH, SHOULDER CLOTH FIG. 118. SHOULDER CLOTH, HAND CLOTH, ELBOW CLOTH, AND SMALL SLING THE TREATMENT OF WOUNDS 89 grasped at the apex and at one extremity. This extremity is carried over the healthy shoulder, while the apex is carried behind the elbow of the diseased arm ; the arm itself is placed horizontally upon the cloth ; the extremity hanging down is turned upward to the diseased shoulder and tied together with the other extremity over the neck; finally, the apex is drawn from behind the elbow and fastened in front of the arm with a safety pin (Fig. 121). When the shoulder of the diseased side cannot tolerate any pressure, the two extremities may also be carried over the healthy shoulder (Fig. 122). If, however, the healthy arm is to remain entirely free, then the two ends are tied together over the diseased shoulder (Fig. 123). For a safer and firmer position of the arm for instance, after reducing a dislocation of the shoulder, or in case of fracture of the clavicle a broad cravat, applied across the mitella, is added ; this presses the arm against the breast (Fig. 124). The large square cloth for carrying the arm (mitella quadrangularis Fig. 125) is applied with a napkin, etc. The ends are fastened with safety pins, since the knots easily cause pressure, especially over the nape of the neck. 2. To bandage a fractured clavicle. According to Szymanowsky this bandage is made with three cloths; it draws the injured shoulder backward and upward (Fig. 126). 3. To bandage the trunk. In various ways, bandages for this purpose can easily be made with several cloths ; e.g. the cingulum pectoris (Fig. 129), Rosers apron bandage (Fig. 127). 4. To bandage the whole chest For this purpose, the cloth is so applied that the apex can be carried over the shoulder ; the extremities on both sides are carried around the thorax to the back, where the three corners are knotted together (Figs. 119, 130). The back bandage is made by applying the cloth inverted. Bandaging the region of the pelvis (Fig. 131). For this purpose, the apex of the cloth is carried from in front across the perineum, the extremi- ties are tied around the hips, and the apex is fastened to them (improvised bathing drawers). The cloth for the buttocks is inverted (Fig. 132). Unnas gauze sash (Fig. 134) consists of two strips, one of which sur- rounds the hips, while the other, fastened to it, supports the penis and the scrotum, as if in a bag (suspensorium). 6. To bandage the leg. For this purpose, the following are service- able : SURGICAL TECHNIC FIG. 120. BREAST CLOTH, SHOULDER CLOTH FIG. 121. MITELLA TRIANGULARIS FIG. 122. OTHER FORM OF MITELLA FIG. 123. CLOTH FOR CARRYING THE ARM THE TREATMENT OF WOUNDS FIG. 124. MITELLA BANDAGE FIG. 125. SQUARE CLOTH FOR CARRYING THE ARM a, Posterior view b, Anterior view FIG. 126. SZYMANOWSKY'S BANDAGE FOR FRACTURE OF THE CLAVICLE SURGICAL TECHNIC FIG. 127. ROSER'S APRON BANDAGE FOR THE CHEST FIG. 128. CLOTH BANDAGE FOR THE LATERAL REGION OF THE CHEST FIG. 129. CINGULUM PECTORIS FIG. 130. LARGE BREAST CLOTH Anterior view The same, posterior view, see Fig. 119 THE TREATMENT OF WOUNDS 93 (a} The hip cloth (Fig. 133). This is applied with an unfolded and a folded cloth, in the same manner as the shoulder cloth and Roser's apron bandage (Fig. 135). FIG. 131. BANDAGE FOR THE PELVIS FIG. 133. HIP CLOTH FIG. 132. CLOTH FOR THE BUTTOCKS FIG. 134. UNNA'S GAUZE SASH (b*) The knee cloth (Fig. 1 36). This, folded together, is carried around the region of the joint in a spica or figure-of-8 turn. 94 SURGICAL TECHNIC FIG. 135. ROSER'S APRON BAND- AGE FOR THE INGUINAL REGION FIG. 137. FOOT CLOTH FIG. 138. MAYOR'S CLOTH BANDAGE FOR FRACTURE OF THE PATELLA FIG. 139. MAYOR'S CLOTH BANDAGE FOR FRACTURE OF THE PATELLA (c) The patella bandage. This is used for fracture of the patella. It is made with three cloths according to Mayor; but it is not especially effective, though very good for instruction on bandaging (Figs. 138-139). THE TREATMENT OF WOUNDS 95 (d) The foot cloth (Fig. 137). This is applied in the same manner as the hand cloth described above, by turning the apex over the dorsum of the foot, while the extremities, crossing each other, are carried over the dorsum and over the ankle joint. SPLINTS Splints are used for the purpose of securing rest for injured limbs, especially when their bones and joints are diseased or injured. The missing internal support of the limb is supplied by the splint until the disease or the injury has been repaired. These supporting bandages, therefore, must embrace not only the diseased bone, but also the two neighboring joints and a portion of the fol- lowing section of the limb, in order to secure com- plete rest and immobility for the injured part. Of the large number of splints formerly used for the most various purposes, now comparatively few are in use. The most common are the fol- lowing : I. WOODEN SPLINTS Simple boards, well padded, are fastened by means of cloths or bandages to the limb, previ- ously wrapped with bandages. Figure 140 shows such a fixation dressing for the broken brachium (arm). If such splints at their ends are provided with tin sockets and joints (von Esmarch\ any desired size can be made by joining these together (for instance, for the whole leg). This wooden splint, which can be taken apart, can be very easily packed up, and occupies but little space. It is especially suitable for an extension splint during transportation (see below). FIG. 140. FIXATION DRESSING FOR THE BROKEN ARM FIG. 141 Gooctis flexible wooden splints consist of thin strips of fir (6 millimeters), cut into parallel strips I centimeter wide by means of light, not perfectly SURGICAL TECHNIC penetrating, parallel cuts, and glued upon leather 'or canvas. They are per- fectly flexible transversely, and perfectly firm longitudinally (Fig. 142). FIG. 142. GOOCH'S FLEXIBLE WOODEN SPLINTS Through the attached strips of leather, straps with buckles are passed ; these serve for fastening. FIG. 143. SCHNYDER'S CLOTH SPLINTS FOR THE LOWER EXTREMITY Schnyders cloth splints consist of thin tablets of flexible walnut (veneer) from 2 to 2.5 centimeters wide and 3 millimeters thick, sewed THE TREATMENT OF WOUNDS 97 closely side by side between two pieces of canvas or cotton cloth (Fig. 143)- Similar is von EsmarcKs splint material, which can be cut (Fig. 144). It consists of two layers of material (stouts, shirting, canvas), between which FIG. 144. VON ESMARCH'S SPLINT MATERIAL. (Can be cut) thick paper strips are placed side by side at intervals of 5 millimeters and firmly agglutinated with silicious varnish, paste, or glue. This splint material is very light, can be made rapidly and inexpensively, can be cut with the scissors, and, rolled up, can be packed away in large quantities, since it requires but little space. As a temporary splint for transportation, it is very serviceable. Stromeyer's padded strips of wood are very much used for injuries and diseases of the arm. They consist of light wood padded with cotton and covered with canvas or some waterproof material. The simple board for FIG. 145. STROMEYER'S HAND SPLINT the hand (Fig. 145), to secure perfect rest for the hand and the fingers, is used everywhere, not only in fractures, but also especially in serious felon, phlegmonous inflammation, etc. N/laton's abduction splint (pistol splint) serves for fractures at the lower end of the radius. 9 8 SURGICAL TECHNIC First, the hand is fastened securely upon the anterior part of the splint ; next, the splint is turned so that it comes in close contact with the forearm, to which it is fastened. The abducted position of the hand draws apart the two ends of the fracture, which lie one upon the other. The splint for FIG. 146. STROMEYER'S SPLINT FOR THE ARM AT AN OBTUSE ANGLE the forearm serves for fractures of the forearm when the elbow joint has to be held at a right angle ; it is supported by a mitella. The splint for the arm at an obtuse angle (Fig. 146) is useful in contusions, sprains, inflamma- tions of the elbow, where ice bags are to be employed, and where the patient is confined to his bed. FIG. 147. ROSER'S DORSAL SPLINT FOR FRACTURE OF THE LOWER END OF THE RADIUS Roser's dorsal splint for fracture of the lower end of the radius is applied on the extensor side of the arm ; by a special padding; the dorsal part of the hand is bent toward the volar ; the fingers remain free (Fig. 147). Carr's radius splint has an exca- vation for the wrist, while the fingers, which remain free, grasp the trans- FIG. 148. CARR'S RADIUS SPLINT verse bar (Fig. 148). Clover's radius splints (Fig. 149) are provided with an excavation for the wrist, and the part for the hand bent off at an angle. THE TREATMENT OF WOUNDS 99 FIG. 149. CLOVER'S RADIUS SPLINTS The English hollow-moulded splints (Bell, Pott, Clini) are very neatly carved and fitted to the contour of the limb ; at their external surface, FIG. 150. BELL'S HOLLOW-MOULDED SPLINTS FOR THE LEG FIG. 151. BELL'S FOUR SPLINTS FOR THE THIGH leather strips are fastened ; through these are drawn straps provided with buckles, which serve for fastening the splints to the limb. The hollow 100 SURGICAL TECHNIC FIG. 152. VON VOLKMANN'S SUPINATION SPLINT FIG. 153. \\'ATSON'S SPLINT FOR RESECTION OF THE KNEE JOINT FIG. 154. WATSON-VOGT'S SPLINT FOR RESECTION OF THE KNEE JOINT FIG. 155. VON VOLKMANN'S TIN SPLINT THE TREATMENT OF WOUNDS IOI internal surface, of course, should be padded. Figure 150 shows two of Bell's splints for tlie leg. Figure 151 shows four splints for the thigh; these are so applied that a, b, c, d, come to lie on the anterior, the interior, the posterior, and the external side of the limb respectively. Von Volkmanris supination splint (Fig. 152), suitable for all injuries 'of the forearm, is a wooden arm splint. The part for the hand is fastened at a right angle to its surface, so that the hand occupies a position halfway between pronation and supination. Von Volkmanris knee splint is a short splint similar to Bell's (Fig. 151, r); it is fastened to the popliteal space in order to prevent the knee joint from moving after extravasations into the same, and in order to prevent the pressure of the applied bandages upon the vessels in the popliteal space. Watson- Vogt's splint for resection of the knee joint (Figs. 153, 154) is suitable only for cases in which a more frequent change of dressings is required. It is applied with starch_ or plaster of paris bandages. In the normal course of wound-healing, von Volkmanris splint may be substituted for it (Fig. 155). 2. TIN SPLINTS Splints made of tinned sheet iron have long been used as hollow splints, especially for the leg. For the arm, the lighter kinds of splints are better, especially when the patient can walk about. Petit 1 s boot, a flat, hollow-moulded splint, with a foot board and an open- ing for the heel, was improved by von Volkmann ; he simplified it and pro- vided it with a T-shaped adjustable iron foot support, to prevent the foot from turning over laterally. This T splint of von Volkmann is now used everywhere in the treatment of large wounds of the leg. It is a substitute for the numerous suspension and resection splints, since in cases which take an aseptic course, the bandages may remain in position for weeks until healing has been completed. In the Danish FIG. 156. SALOMON'S TIN SPLINT arm y> Salomon intro- duced flat splints of thin tin plate, 35 centimeters long and 10 centimeters wide. These have at one end two small projections, each divided in thrfc end are two slits, into which these projections can be ins LOS IO2 SURGICAL TECHNIC by bending ; in this way splints of any desired length can be easily and rapidly made (Fig. 156). For immediate use, splints may be cut from sheet zinc by means of strong scissors. These may be bent with the hand and moulded to the FIG. 157. SPLINTS OF SHEET ZINC contour of the limb (Figs. 157, 158). Models for these splints were men- tioned by von Hoeter, Sc/toen, Port, and others. We must mention here also Lee's flexible, perforated, nickel-plated metal splints. They adapt themselves well to any flexion of the surface of the body, and are, moreover, light, durable, and inexpensive. Still lighter would be splints of aluminium, which, on account of the growing cheapness of the metal, will probably soon be in general use. FIG. 158. SPLINTS OF SHEET ZINC Tin splints, on account of the ease with which they are made and packed, aside from their great cleanliness, are especially suitable for military use ; also, in time of peace, they are in great favor on account of their practical adaptation. They are surpassed, however, by 3. WIRE SPLINTS These have the following merits : they are very light and clean ; they allow every inaction of the dressing to be noticed at once ; they do not THE TREATMENT OF WOUNDS 103 prevent the secretions from evaporating ; and they hold the bandages in place better than smooth tin. Roser has mentioned several splints of iron wire. Figure 159 shows one for the leg. More recently, other models of tinned wire have been used FIG. 159. ROSER'S WIRE SPLINT FOR THE LEG more extensively (e.g. Fig. 160). Cramer's flexible wire splint (Fig. 161) is most excellent and is applicable for all purposes. It consists of strong FIG. 1 60. WIRE SPLINT FOR THE LEG, WITH HANDLES FOR SUSPENSION tinned wires, between which finer wires have been stretched, like the rounds of a ladder. The several pieces can be fastened in front one above another ; they can be bent on the flat and on the edge ; wherever desired, openings can be made by breaking out several of the thin wires ; or thinner portions can be formed by bending the wires in short, there is no form of a splint which could not be rapidly extempo- rized with Cramer's splint. Moreover, it is light, clean, and elegant. Almost as useful are the splints of wire cloth (von EsmarcK) (Figs. 162, 163), which are light, inexpensive, and flexible. Splints of telegraph wire (Porter) probably will not be used SO frequently FIG. 161. CRAMER'S FLEXIBLE WIRE SPLINT 104 SURGICAL TECHNIC FIG. 162. SPLINTS OF WIRE CLOTH FIG. 163. SPLINTS OF WIRE CLOTH APPLIED FIG. 164. LEG SPLINT OF TELEGRAPH WIRE WITH FOOT SUPPORT FIG. 165. ARM SPLINT OF TELEGRAPH WIRE THE TREATMENT OF WOUNDS 10$ in the future, because the telegraphic circuits are now made with cast bronze wires, which cannot be so well bent. With telegraphic wire, the most com- mon wood and tin splints can be very well substituted, but the making of such splints is always laborious and requires time and especially practice. Figures 164 and 165 show some splints which are frequently used, but for which the wire splints described above may be substituted more easily and inexpensively. 4. GLASS SPLINTS The splints for the arm and the leg mentioned by Netiber, made of thick cast glass, are very clean and, to a certain degree, aseptic ; they also allow FIG. 1 66. NEUBER'S ARM SPLINT OF GLASS the smallest infection or penetrating secretion to be recognized at once ; but they have the disadvantage of being heavy, very expensive, and fragile. FIG. 167. XEUBER'S LEG SPLINT OF GLASS In large and rich hospitals they may be of advantage. Figures 166 and 167 show glass splints for the arm and the leg. io6 SURGICAL TECHNIG SPLINTS OF PASTEBOARD From thick gray pasteboard, splints of any desired form can easily be cut with a sharp knife ; the straight edges in which the splint is to be bent to form a groove must be sufficiently incised from the outside with a knife, FIG. 1 68. PASTEBOARD SPLINT FOR THE ARM so that the edge can be turned over evenly. If the pasteboard is strong enough, the splints have sufficient power of resistance ; this, however, may be increased by painting the pasteboard with glue, silicious varnish, or lin- seed varnish, or by nailing thin wooden laths upon the splints. FIG. 169. MODEL FOR ARM SPLINT Pasteboard is used especially for fixation of the arm. Figure 168 shows a pasteboard splint for the arm, which is very practical for all injuries of the elbow joint, forearm, and wrist ; it can be easily and quickly made from the model (Fig. 169), either as a semicircular or as an THE TREATMENT OF WOUNDS TO/ angular tube. In wounds on the palmar surface of the hand with injuries of the tendons and nerves (after the ends have been sewed), the end of the splint projecting beyond the hand is bent upward like a cap and holds the hand in supination bent toward the volar side (Fig. 170). FIG. 170. PASTEBOARD SPLINT FOR INJURIES ON THE VOLAR SIDE OF THE WRIST In fractures of the humerus, especially at its upper end, it is advisable to make at one end of the broad pasteboard splint four longitudinal cuts at equal intervals. The five small projections thereby formed are bent over the shoulder in the form of a cap, and the whole is fastened with a spica humeri (Fig. 171). In fractures of the lower end of the humerus, the pasteboard splint is sufficient (Fig. 168). The alar splint, according to Diimreicher (Figs. 172, 173), is an excellent method of fixation for fractures of both bones of the forearm, since by it the forearm is held in a half-pronated position with the elbow flexed, whereby as satisfactory a healing of the two injured bones as possible is ob- tained. One rectangular pasteboard splint is firmly pressed to the volar and another to the dorsal side of the half-supinated fore- and for fastening them, a narrow splint arm provided with square alar processes is ap- plied to the ulnar side. The whole dressing FIG. 171. PASTEBOARD SPLINT FOR FRACTURES OF THE HUMERUS io8 SURGICAL TECHNIC is fastened with bandages. By means of the pressure of the lateral splints upon the muscles, the bones which run parallel to each other are forced apart at the places of fracture. Without them (for instance, upon a com- mon pasteboard splint, in full pronation) the ends of the bones would be FlG. 172. Dl'MREICHER'S ALAR SPLINT FIG. 173. DUMREICHER'S ALAR SPLINT forced by a circular bandage in the direction of the intra-osseous space, and would either heal together in the shape of an X, or perhaps cross each other completely (Fig. 174). The method described above should be followed in applying all the other splints for the forearm. FIG. 174. DANGER FROM A CIRCULAR BANDAGE IN FRACTURES OF BOTH BONES OF THE FOREARM (according to Albert) Moulded pasteboard splints, which can be well applied to the contour of the body, are made over arm and leg models. The moistened pasteboard is allowed to dry upon the model, and is afterward painted with varnish ; by this means it becomes hard. Me re hie has recommended such bivalve splints (Figs. 175-178). They may serve as models for all splints that can be made by moulding. More practical, however, are materials so prepared that they will soften when heated and harden when rapidly cooled. Packed in flat sheets, they occupy little space ; and, cut to the required size, they make accurately fit- ting splints for the patient. THE TREATMENT OF WOUNDS 109 FIG. 175. MERCHIE'S MODELS FOR PLASTIC SPLINTS FOR THE ARM. FIG. 176 FIG. 177. MERCHIE'S MODELS FOR PLASTIC SPLINTS FOR THE LEG. FIG. 178 HO SURGICAL TECHNIC These are called : 6. PLASTIC SPLINTS Plastic pasteboard, according to P. Bruns, is obtained by saturating common pasteboard with a strong solution of shellac ; it softens when ex- posed to the vapor of boiling water or by the dry heat of the oven or hearth, and after a short time becomes as hard as wood. Plastic cellulose sheets (R. De Fischer] consist of thick, factory-made wood-fibre plates, which on one side are saturated with silicious varnish. If they are moistened on the varnished side with boiling water, they become soft and can be exactly moulded to the limb, and rapidly become firm ; they are fastened with moist gauze bandages, the moistened side being placed exteriorly. Glued cellulose sheets (Hiibscher) are especially suitable for producing plastic corsets. Plastic felt {Bruns), poro-plastic felt, is made of common thick sole felt, painted with an alcoholic shellac solution until it is completely saturated ; it is then dried in a warm place. Before it is completely dry, it is ironed and smoothed with a hot flat-iron. Dry or moist heat renders it soft ; in this condition, it is moulded to the body, and is rapidly hardened by pouring cold water over it or by dipping it into cold water. Gutta percha sheets (2-3 millimeters thick) may likewise be rendered flexible by carefully dipping them into hot water at 190 Fhr., so that they can be easily cut and moulded in the desired form. Dipped into cold water, they harden rapidly. These splints, it is true, are rather expensive ; but they are suitable not only for making fracture splints, but also as substitutes for other splints mentioned for certain FIG. 179. SCHEDE'S RADIUS SPLINT purposes, which, having fulfilled their indication, may again be used. Fig- ure 179 shows, for instance, the radius splint according to Schedc. Upon this the hand rests bent toward the volar and ulnar sides ; and by this means, the lower portion of the fracture of the radius, displaced in an upper direction, is best replaced into its natural position. PLASTIC DRESSINGS These surround the limb completely in the form of a firm capsule, like a coat of mail, and cannot be easily removed ; for they are " inamovible" By a special procedure, however, during their application, viz. by dividing or THE TREATMENT OF WOUNDS III separating them, they can be made " amovible" ; hence, as may be deemed necessary, the limb can either be made freely movable or be fixed in the dressings in an immovable position. The dressings are " amovo-inamovible " {Sentiri), Fixed dressings of materials that become resistant by hardening have been used for a long time ; the procedure, however, in most cases was very complicated (gum arabic, albumen, adhesive plaster, etc.) until starch and plaster of paris were introduced. These essentially simplified the applica- tion of such bandages. THE STARCH DRESSING was invented by Seutin (1840). Preparation of the starch : Stir starch with cold water until an even mass is formed ; while stirring it continuously, add sufficient boiling water to form a clear thick paste. Starch bandages consist of strips of shirting drawn through the fresh paste and rolled. Starch splints are made of strips of pasteboard which are quickly drawn once through hot water ; then starch is applied thickly on both sides. Application of a starch dressing. The limb is first very carefully wrapped with a moist flannel bandage, after the depressions about the joints have been padded with cotton. Over this, a starch bandage is applied, and upon this the soft starch splints are laid and fastened with a starch bandage. Finally, the whole dressing is covered with a dry cotton or gauze bandage. Instead of the bandages, strips of paper may be used. These are drawn through the paste and are applied in the manner of a Scultef s bandage. Burg-grave s cotton pasteboard dressing is very simple and practical. Splints of pasteboard are cut according to the contour of the limb. After starch is applied to them, a layer of cotton is placed on one side. The splint is applied with the cotton side next to the limb, to which it is securely fastened with muslin bandages commencing with serpentine turns. Over the muslin bandage, starch paste is liberally applied either with the hands or with a large brush ; and finally the whole dressing is covered with a dry calico bandage. It takes from two to three days for the starch bandage to become per- fectly dry and hard ; the drying may be accelerated by exposure or by the heat of the sun or the oven. To make the dressings removable, they are divided throughout their whole length with a pair of strong scissors ; the capsule is bent apart, and 112 SURGICAL TECHNIC calico bandage strips, painted on one side with starch, are pasted over the margins of the cleft. Next, the dressing capsule is again applied and fastened with a few straps provided with buckles (Fig. 180). FIG. 1 80. DIVIDED STARCH DRESSINGS Of similar construction is the glue dressing ( Veiel, Bruns) in which, instead of starch, common carpenters glue is used for saturating the band- ages and the splints; glue dries more rapidly than starch. It is still more difficult to make gum arable chalk dressings {Bryant, Wblfler) with a mix- ture of gum arabic paste and chalk, and paraffin dressings (Lawson, Tait). The tripolith dressing was recommended by von Langenbeck ; tripolith is an ash-gray powder, used like plaster of paris powder. It has, however, this advantage : it is not spoiled by the addition of water, it hardens more rapidly, and furnishes light porous dressings. POTASH SILICATE DRESSINGS If bandages are saturated with a freshly prepared concentrated solution (old solutions irritate and cauterize the skin) of neutralized potash silicate (K 2 SiO 3 ), of a specific gravity of 1.35-1.40 (Bohni), they can be used for dressings that become perfectly firm and hard, as soon as the water has evaporated. For accelerating the hardening, it is best to add to the potash silicate finely pulverized chalk or a mixture of slaked lime, Ca(HO) 2 and chalk (1:10 Bohm\ magnesite (Konig\ or cement (MitscJierlicJi). The paste thus becomes as thick as honey. Into it, the bandages are dipped, or with it the applied bandages are painted with a large brush. Finally the whole dressing is sprinkled and rubbed with the dry powder. If a little alcohol is applied over it with a brush, a hard glasslike surface is formed. The THE TREATMENT OF WOUNDS potash silicate dressings are distinguished especially for their great light- ness ; but, since they need several days to harden completely, they are not generally used. PLASTER OF PARIS DRESSING was invented in 1852 by MatJiysen. It has over all others the advantage of becoming hard and firm in the shortest space of time. Plaster of paris cream is best prepared in a porcelain dish by mixing equal quantities of plaster of paris and cold water under constant stirring, until the mixture has the consistency of thick cream. It hardens into a com- pact mass in about 5 to 10 minutes. The better and finer the plaster of paris powder, the more rapidly the mass hardens. Alabaster gypsum is excellent. If the setting of the plaster is to be delayed, more water is used, or a little starch, glue, gum arabic, dex- trine, milk, beer, or borax is mixed with the water. If the setting is to be hastened, less water, or better, hot water, is used, or some salt, alum, lime water, potash silicate, or cement powder is added. If the plaster has been spoiled by absorbing water from the air, it can be made serviceable again by heating in an open pan, until it no longer yields watery vapors. Plaster of paris dressing can be applied in various ways: i. Strips of plaster of paris band- age : strips of bandage material, dipped into the plaster of paris FlG - l8l STRIPS OF PLASTER OF PARIS /vi o 7j * i- j \ BANDAGE (according to Pirogoff) cream, are (like Scultet s bandages) directly applied around the limb, previously lubricated with oil or vaseline, or shaved (Adelmanri). SURGICAL TECHNIC Instead of bandage strips, cut up pieces of old clothing (woollen stockings, drawers, undershirts, etc.), or coarse sackcloth may be used; these absorb a great deal of the plaster of paris cream (Pirogoff Fig. 181). 2. Plaster of paris compresses. The plaster of paris cream is spread between two pieces of linen or cotton cloth, connected in the middle by a longitudinal suture; with this, the limb, wrapped with a roller bandage or FIG. 182. DOUBLE PIECES OF LINEN FOR BLASTER OF PARIS COMPRESSES FOR THE LEG FIG. 183. PLASTER OF PARIS COMPRESS cotton, is enveloped (Figs. 182, 183). As soon as the plaster of paris has hardened, both halves, which are connected posteriorly by the suture, may be turned aside, exposing the injured place. In modern times, this kind of plaster of paris dressing, which was for- merly very rarely employed, has come into more frequent use through Fickert's plaster of paris plate dressings and Breiger's very practical plaster THE TREATMENT OF WOUNDS 115 of paris cotton, which is made in factories and is saturated with plaster of paris powder. The pieces are merely dipped in hot water and fastened to the limb. After eight or ten minutes they become fixed and hard. This is the cleanest manner of applying a plaster of paris dressing, and is, therefore, suitable for making plastic plaster of paris splints (see page 120). 5. Plaster of paris bandage. This bandage is, so to say, the model for all plastic dressings; it is the most frequently used, and, for that reason, will FIG. 184. BOARD FOR MAKING PLASTER OF PARIS BANDAGES FIG. 185. BEELY'S PLASTER OF PARIS BANDAGE MACHINE be' described more minutely. Over a bandage properly applied to the limb and the bony prominences well protected by cotton, plaster of paris band- ages are applied in four to six thicknesses ; for hastening the hardening, the whole dressing is finally covered with a layer of the plaster of paris cream. For the sake of economy, plaster of paris bandages may be made by the surgeon himself. Place the end of the head of the bandage through an upright small board provided with two longitudinal slits (Fig. 184), in front of which a quantity of plaster of paris powder is heaped. In this heap of plaster of paris, roll up the bandage with the fingers. This can be accomplished more rapidly if the bandages are made in one of the numerous plaster of paris bandage machines (Figs. 185, 186). FIG. 186. WYWODZOFF'S PLASTER OF PARIS BANDAGE MACHINE For plaster of paris bandages (starched), gauze bandages (star ch-orga.ntm bandages) are used almost exclusively. Plaster of paris bandages and plas- n6 SURGICAL TECHNIC ter of paris powder are kept together in a tin box in the middle of which the above-mentioned board separates the powder from the bandages (Fig. 187). FIG. 187 The plaster of paris bandages made in factories are essentially cleaner, but are more expensive; they can be purchased singly, neatly packed in pasteboard or tin boxes. Plaster of paris bandages are rarely applied over the bare skin. For padding the limbs, cotton bandages are used as a protection for the limb. If the layers are too thick, the dressings become too cumbersome. It is best to take apart the agglutinative cotton bandages lengthwise and by their FIG. 188. PLASTER OF PARIS BANDAGE WITH COTTON BANDAGES FOR PADDING surface, and to apply the halves with the agglutinated side outward (Fig 1 88). Dry muslin or flannel bandages are just as suitable. THE TREATMENT OF WOUNDS II/ Application of plaster of paris bandages. Immediately before using the plaster of paris bandage, immerse it in a basin of water until it is completely covered. When all air bubbles have escaped from the bandage, take it out, squeeze it lightly, and commence the bandaging. To prevent constriction, a plaster of paris bandage must be drawn not too tightly ; for after drying it contracts somewhat. As few reversed turns as possible are made, since too many would produce unevenness in the thickness of the dressings; technical application is avoided; the bandage is applied in spiral tours ascending slowly from below upward ; care must be taken that the band- age does not gape and does not compress with one margin. For making the dressings everywhere uniformly thick, considerable practice is required ; it is best to use as broad bandages as possible (10-15 centimeters); with small bandages an unevenness cannot well be avoided. If, in spite of all care, a place too thin is discovered, the defect can be remedied by past- ing over it correspondingly long strips of bandage, covering each other completely. A dressing applied with bandages dries rather slowly. In most cases, therefore, it is advisable to apply a layer of plaster of paris cream over the dressings; stir plaster of paris with hot water into a rather thin mass, apply it rapidly and everywhere uniformly. Before it sets completely (which occurs rapidly), it is well to give a good appearance to the surface of the dressing by smoothing the bandages with the hands, which have been dipped in warm water. Any small unevenness is filled with plaster of paris powder, rubbed in with moi^t hands. If the dressing has hardened, it may be polisJicd with a smooth piece of metal (handle of a knife, etc.), while the water is still evaporating ; it thereby becomes more durable and the color does not come off. In applying the dressing, especial at- tention must be paid to the margins, since there the layer of plaster of paris in most cases is thin, and hence easily crumbles off It is most advisable and practical to allow the under layer (cotton, bandages) to project somewhat from under the layer of plaster of paris. After the dress- ing is finished, these projecting margins are turned up like a cuff and P LASTER OF PARIS DRESSING WITH TURNED-UP MARGINS !l8 SURGICAL TECHNIC fastened upon the plaster of paris with a plaster of paris bandage or some plaster of paris powder (R is, Billroth Fig. 1 89). The drying of the dressings, after they have set, requires time of varying length. It is best to leave them ^lncovered, so that the water can evaporate; wherever it is possible, the drying can be accelerated by the heat of the sun or of an oven (or by fanning). If cracks occur in the fresh dressings from awkward movements during transportation or from restlessness of the patient, they should be rapidly cemented by applying a very thin plaster of paris cream, which enters deeply into the cracks. If the dressings are to be made waterproof, they are painted, when com- pletely dry, with linseed oil varnish, damar varnish, copal varnish, etc. For removing a plaster of paris dressing, it is best to make a furrow in the uppermost layer with a strong short knife (Fig. 190), and to deepen it FIG. 190. PLASTER OF PARIS KNIFE with the cone-shaped sharp point on the handle by moving it to and fro until the layer of dressings is reached ; this is carefully divided with a pair of strong scissors with long arms (Fig. 191). The capsule is then bent apart and the limb is lifted out. The furrow may also be irrigated with strong brine, from which plaster of paris quickly softens, and the layer of FIG. 191. PLASTER OF PARIS SCISSORS bandages can be more easily divided. The desired end is obtained most rapidly, however, by striking the dressings with the point of a slender hammer ; the strokes should not be conducted vertically, but as obliquely as possible (tangentially) in order not to cause pain to the patient. If the cap- THE TREATMENT OF WOUNDS 119 sule of plaster of paris is so thick that it can be bent apart to the required width only with great difficulty, a flat groove is chiselled on the opposite side ; in this groove the capsules can move as on a hinge. Moreover, instead of a hammer, a small flat saw {plaster of paris saw) may be used for obtaining smoother mar- gins for the cut. Removable plaster of FlG ' I92- CASE CONTAINING PLASTER OF PARIS KNIFE AND SCISSORS pans dressing. Very fre- quently a plaster of paris dressing is applied with the intention of having it worn for some time as a removable support (tutor), for instance, after resec- tions, especially of the knee joint, or as a plaster of paris corset in the treat- ment of scoliosis. In this case, it is more important that the dressings should fit well and be light and durable. For a cover of the surface, it is best to use tricot t which fits well all the contours of the body. Commercial tricot hose is used for the most part ; it must be twice as long as the dress- ings to be applied ; one-half serves as an under layer for the plaster of paris dressings ; the other is turned over the set dressings as a cover. For such tutors only plaster of paris bandages are used. They are applied according to Sayre as follows : The bandages, about 5 to 8 centimeters wide, are applied as smoothly as possible around the limb in spiral turns; reversed turns are avoided by cutting the bandage at the place involved; during the application, each turn is well rubbed together with the following. This is best done by an assistant, who follows with both hands the descending bandage and strokes it firmly to the limb ; thereby greater firmness and a more complete agglutination of the several layers are effected ; the thickness of the dressings should rarely exceed half a centimeter. When the dressing has nearly set, the bandages are divided with a very sharp knife, in a straight line previously marked, and the tricot is divided with a pair of scissors. In order to prevent injury to the patient, which might easily occur, it is well, before applying the dressings, to place a strip of pasteboard, or of wood, or something similar, under the tricot at the place where the cut is to be made ; a longitudinal roll of cotton or a cord may be used instead {Szymanowski}. After the dressing has been cut, the margins I2O SURGICAL TECHNIC of the splint are carefully turned aside far enough to enable the limb to be removed from it and is then set aside for drying. After 2 to 3 days, it is covered with tricot. Along the margins, the tricot is sewed together with the inner layer so that the whole dressing becomes lined ; laces or strips of leather and buckles should be attached to the edges of the slit made in the dressing preferably by an instrument maker (Fig. 193). Common cotton jackets and trousers, which serve for a lining, or long knee-stockings, of which one is used for an under layer and the other for a cover, are generally cheaper than the tricot material. Especially with stockings, plaster of paris boots, which look very well, can be applied (for corrected flat feet, club feet resections, etc.). Plastic plaster of paris splints {Beefy) are made of rolls of hemp, flax, jute, or straw which has been made soft by beating (Anschutz). Having been dipped in the thin plaster of paris cream, they are applied to the limb FIG. 193. PLASTER OF PARIS TUTOR FOR THE KNEE FIG. 194. BEELY'S PLASTIC PLASTER OF PARIS SPLINT (previously lubricated and wrapped with a moist muslin bandage). The bundles of fibre, only about i centimeter thick, are applied one after another, covering each other, and finally the surface is smoothed with plaster of paris cream. These removable plaster of paris splints are especially well adapted to the treatment of compound fractures. If the limbs are to be suspended in them, it is well to insert in the paste, at sev- eral places, hooks and eyes of wire (Fig. 194). Such splints may be applied with Breiger's plaster of paris cotton in a still more convenient and cleanly FlG ' I95> BRAATZ>S SpIRAL SpLINT FOR RADIUS FRACTL*RE manner; for instance, for radius frac- tures, Braatz's spiral splint, which holds the hand securely in flexion and abduction, without limiting the movement of the fingers (Fig. 195). THE TREATMENT OF WOUNDS 121 STRENGTHENING PLASTER OF PARIS BANDAGES In order to make the plaster of paris bandages more durable, a thicker layer of plaster of paris cream may be applied ; by this means, however, the dressings unfortunately become awkward, clumsy, and heavy. It is more practical to give it greater firmness by inserting strips of wood {Volcker's " tapetenspan " or shoemakers' shavings Neudovfer\ narrow splints of veneered wood, strips of tin or wire, without making it thereby essentially heavier. Of these materials, the strips of wood are most preferred, on account of their lightness and cheapness ; hence, for the WOOD SHAVING PLASTER OF PARIS DRESSINGS the following rules may be observed : (a) On the liumerus (in fractures of the humerus and inflammations of the shoulder joint). The arm, bent at a right angle in the elbow and abducted, is carefully wrapped with flannel bandages as far as and above the elbow joint ; from there the arm and the shoulder are wrapped with cotton bandages. Next, the whole arm from the wrist to the shoulder is wrapped with a plaster of FIG. 196 FIG. 197 WOOD-SHAVING PLASTER OF PARIS DRESSING ON THE HUMERUS paris bandage, brought to the side of the chest, and supported by a mitella, Next, the middle portion of a long " tapetenspan " (strip of wood) is applied under the elbow ; its two halves are carried along the anterior and posterior 122 SURGICAL TECHNIC sides of the arm, and its ends are allowed to cross each other over the shoulder. A second long strip of wood is applied along the outer surface of the arm from the wrist to the side of the neck (Fig. 196). Finally, the strips of wood, the arm, and the mitella are enveloped in plaster of paris bandages, applied according to Desault (Fig. 197). () Fractures of the forearm and inflammation of the elbow joint. After the arm, bent at a right angle at the elbow, has been wrapped with cotton and next with plaster of paris bandages, two long strips of FIG. 199 WOOD-SHAVING PLASTER OF PARIS DRESSING ON THE FOREARM wood like reins are applied around the joint, of which one takes its course along the anterior and posterior sides of the forearm, while the other. ascends around the elbow to the arm. Two strips are added for the superior and inferior surfaces of the arm, and all four are fastened with a plaster of paris bandage (Figs. 198, 199). In more serious injuries and after resection of the elbow joint, the (fenes- trated) plaster of paris dressing may be applied, with the joint at a flexion THE TREATMENT OF WOUNDS of an obtuse angle and the forearm in semi-supination. 20 1 show the arrangement of the strips in such a case. 123 Figures 200 and FIG. 201 WOOD-SHAVING PLASTER OF PARIS DRESSING AFTER RESECTION OF THE ELBOW JOINT (c) Fracture of the leg. The plaster of paris dressing in fractures of the leg has recently become materially limited ; at the present time it is used only in fractures of the shaft, of the tibia or the malleoli, or of the bones of the foot. In fractures of the femur, the treatment by extension yields better results. In severe injuries of the pelvic bones, and especially in order to secure immobilization for the hip joint in inflammation, or to give a firmer support to the leg for after-treatment after resection of the head of the femur, the plaster of paris dressing is still largely used. Likewise, as a light support (tutor) after resection of the knee or ankle joint. If a plaster of paris dressing is to be applied on the leg, to encircle at the same time the pelvis, the patient must be placed in such a position that the posterior side of the pelvis also becomes freely accessible; an ordi- nary Volkmann pelvic support is not sufficient, since it covers too much space. It is better, therefore, to use the pelvic supports mentioned for that purpose. They can be screwed to the table (von Esmarch, von Bardclcben Figs. 202, 204) upon which the patient is placed, with the sacrum resting, while one (or two) assistants hold his legs, and by making traction upon them the perineum of the patient is drawn toward the iron pole, wrapped with cotton (counter extension). For the support of the heel during the 124 SURGICAL TECHNIC application of the dressings, an adjustable heel support (Fig. 203) may be used. The back is supported by a padded pelvic support or a high pillow, so that the patient is suspended in a horizontal position about 8 inches above the table. FIG. 202. VON ESMARCH'S PELVIC SUPPORT FIG. 203. VON ESMARCH'S HEEL SUPPORT FIG. 204. Vox BARDELE- BEN'S PELVIC SUPPORT Next, the leg and then the pelvis are wrapped with cotton bandages over which a plaster of paris bandage is applied. Then a long strip of wood is applied along each of the four sides of the leg ; the ends are held in posi- tion by assistants (Fig. 205). The strips are fastened temporarily with a plaster of paris bandage in serpentine turns (Fig. 206), and over them several broad plaster of paris bandages are applied, surrounding the pelvis in figure-of-8 turns ; a layer of plaster of paris cream is spread upon them. Since, in such dressings of the hip, the weakest point is the groin, in which THE TREATMENT OF WOUNDS 125 by imprudent movements and especially in rising a fracture may easily be produced, it is advisable sufficiently to strengthen the layer of plaster of paris at this place, if necessary, by incorporating a strip of tin or something similar. Wooden strips are here less useful, since they too are flexible on FIG. 207 WOOD-SHAVING PLASTER OF PARIS DRESSINGS FOR THE LEG their surface. Finally, the projecting ends of the chips are cut off, the margins of the dressings are smoothed, and in any existing wounds or fis- tulae, a fenestra is made at the corresponding place (Fig. 207). Dittel places the patient on two iron rods (gas pipe), which are connected near one end by a movable crossbar as long as the hand. The end is put 126 SURGICAL TECHNIC on the edge of a table, and the patient is placed upon the rods in such a manner that only the head and the chest rest on the table, while the abdo- men and the legs are balanced by the diverging rods. After the dressings have been applied, the rods are withdrawn from under the layer of bandages. The preparations recommended by several surgeons for position and extension in this dressing are rather complicated and cannot be carried out everywhere. The plaster of paris dressing for the knee must, if it is to be effective, extend to the thigh and the leg from the trochanter to the ankle. In fracture of the shaft or the malleoli of the leg, the dressings should extend from the toes to the knee joint. Since, especially in this region, ow- ing to the strong muscular contraction, there may result very great displace- ments of the fragments, which cannot always be balanced by the strength of the assistant who makes the extension, it is advisable to attach to the foot a loop by which the broken limb is drawn up vertically by a pulley, whereby the body of the patient makes the counter extension. In this posi- tion, all displacements become adjusted ; the position can be maintained without any trouble until the plaster of paris dressing has completely set. FENESTRATED PLASTER OF PARIS DRESSINGS At a point corresponding with the location of small wounds or fistulous openings, the plaster of paris dressings must be supplied with correspond- ing openings (fenestrae\ to make these places accessible for suitable treat- ment, for inspecting the wound at any time, and for securing free drainage for the secretions (Figs. 201, 207). These places are either left free at the time of applying the plaster of paris bandage, by making reversed turns or by cutting out the dressing at one margin of the fenestra to be formed and continuing the bandaging at the other side, or with a sharp knife fenestrae are made after the splint has been applied by cutting out a piece correspond- ing in size to the cutaneous defect. In order to reach the right place, it is advisable to place upon the region of the wound, covered thickly with dressing materials, some object which forms a projection and upon which the cuts can be made without hesitation ; for instance, a cotton compress, a tampon, cork, small basin, potato, etc. To prevent secretions of the wound from infiltrating between the skin and the plaster of paris dressings, the margins of the fenestrae must be firmly padded with common cotton ; this ring of cotton may be made still more waterproof by brushing it with collodion, varnish, shellac, or putty. THE TREATMENT OF WOUNDS 127 Varnished paper does not occlude the wound so well as adhesive plaster, if it is used from the start for making fenestrae. For this purpose, make of it tubes in length of a finger, turn over one end nicked at several places, and apply upon the wound, so that they rest upon the skin like chimneys ; next apply the plaster of Paris dressing in the usual manner, so that the lumen of the tubes remains free, and line the uppermost layers with the end that projects over the dressing. But if the wounds are so large that through a correspondingly large fenestra the firmness of the dressings would become diminished, for instance, after severe compound fractures, or if the whole contour of the limb has to remain free at one place, in order to renew the dressings as often as neces- sary, as, for instance, after resection of the joints, then the plastic dressings are applied in two halves, which are connected with one another by means of a strong arch (stirrup bridge). This is, then, an INTERRUPTED PLASTER OF PARIS DRESSING In the antiseptic treatment of wounds, this dressing need hardly ever be used, since the dressing is rarely changed, and since, moreover, a sufficient substitute is offered by the simple wire splints and wooden splints. In former times, however, on account of the frequent change of the dressings, they were more in demand and were essentially instrumental in saving time and work for the physician and pain for the patient. If, therefore, in cases of sepsis or suppuration of the joints, the surgeon desires to proceed conser- vatively, they may be recommended even now as very convenient dressings, rendering the frequent change of dressings possible in a short time and without any special assistance. FIG. 208. STIRRUP PLASTER OF PARIS DRESSING FOR THE KNEE Thus the region of the wound may be bridged over at two sides by strong arches of sheet iron, the straight ends of which are incorporated in 128 SURGICAL TECHNIC the plaster of paris dressings (Figs. 208, 209). For lessening the elastic motion of these iron arches, wrap them with hemp or jute dipped in plaster of paris cream. With these plaster of paris hemp splints alone, a stirrup dressing can be constructed (Beely Figs. 210, 211), which can be easily suspended by means of a few eyelets fastened in the plaster of paris. FIG. 209. STIRRUP PLASTER OF PARIS DRESSING FOR THE ELBOW FIG. 210. BEELY'S PLASTER OF PARIS HEMP SPLINT FOR THE KNEE. I. An interrupted splint can also be made with the straight wooden laths bridge, especially if the limb has to be made accessible only on one side. After the regular plaster of paris dressing has been applied, above and be- low the injured place, both parts are connected by pieces of lath (poles), which are incorporated in the dressings with cotton or tow compresses saturated with plaster of paris ; in addition, they are fastened with plaster of paris bandages (Fig. 212). Similar is Pirogoff's bridge plaster of paris dressing, which has proved to be very good, especially as a temporary dressing; a piece of coarse THE TREATMENT OF WOUNDS 129 FIG. 211. BEELY'S PLASTER OF PARIS HEMP SPLINT FOR THE KNEE. II. FIG. 212. BRIDGE PLASTER OF PARIS DRESSING WITH WOODEN LATHS FIG. 213. PIROGOFF'S BRIDGE PLASTER OF PARIS DRESSING SURGICAL TECHNIC FIG. 216. VON ESMAKCH'S PLASTER OF PARIS SUSPENSION SPLINT FOR RESECTION OF THE ELBOW JOINT FIG. 217 THE TREATMENT OF WOUNDS FIG. 218 FIG. 219. VON ESMARCH'S PLASTER OF PARIS SUSPENSION SPLINT FOR RESECTION OF THE WRIST FIG. 220 132 SURGICAL TECHNIC FIG. 222. WATSON'S AND VON ESMARCH'S PLASTER OF PARIS SUSPENSION SPLINT FOR RESECTION OF THE KNEE JOINT FIG. 224 THE TREATMENT OF WOUNDS 133 sackcloth (sleeve, trousers) is dipped in a plaster of paris cream and applied on the lower side of the limb as a strong plaster of paris splint ; on the upper side, above and below the wound, two large tow compresses (straw, hay), saturated with plaster of paris cream, are applied, and over them the wooden lath is fastened like a bridge upon its pillars with broad linen strips of plaster of paris bandages (Fig. 213). Still more convenient and also lighter are the so-called resection splints in connection with suspension wires (plaster of paris suspension splints), which are securely fastened to the limb by plaster of paris bandages. This mode of dressing was first employed for the knee joint by Watson ; after- wards, for the other joints, by von Esmarch. The splints are made narrow at the place destined for the resection and form a small connecting bridge, while the wire belonging to it forms an arch at this place. This dressing is applied in the following manner : After the diseased joint has been dressed antiseptically and the whole limb bandaged with cotton bandages, the well-cleansed splint is covered with two moss pads, which allow the small bridge between them to remain free. FIG. 225. Vox ESMARCH'S PLASTER OF PARIS SUSPENSION SPLINT FOR RESECTION OF ANKLE JOINT The latter is wrapped with india-rubber cloth, made sterile, or is protected in some other manner from the contact of secretions ; next, the splint is fastened on the lower side of the limb with plaster of paris bandages, and thus the region of the joint remains completely free. With the last plaster 134 SURGICAL TECHNIC of paris bandage, the suspension wire is fastened with plaster of paris cream at the anterior surface of the limb, and as soon as the dressing is completely dry, the limb is held by the frame in free suspension. Figures 214-225 show these splints for various joints. Instead of wooden splints, in case of necessity, splints similarly shaped may be cut from strong tin or bent to- gether from telegraph wire (Figs. 226-228). FIG. 227 FIG. 228 VON ESMARCH'S SUSPENSION SPLINTS MADE OF TELEGRAPH WIRE Von Volkmantis wooden dorsal splint (Figs. 229, 230), which is firmly applied with plaster of paris or starch bandages at the superior surface of the limb, affords the diseased joint a firm support and is especially suitable for all cases in which large wound surfaces, fistulae, or decubitus are on the lower side of the limb. THE TREATMENT OF WOUNDS FIG. 229 135 FIG. 230. VON VOLKMANN'S DORSAL SPLINT FIG. 231 FIG. 232 VON ESMARCH'S IRON ARCH SPLINT FOR RESECTION OF THE WRIST 136 SURGICAL TECHNIC But if the whole contour of the limb is to remain free, a dorsal and a volar splint may be connected by strong wire arches (yon EsmarcJt). These iron arch splints are especially suitable for the wrist joint and ankle joint ; they are fastened with plaster of pans bandages and are light and com- fortable (Figs. 231-234). FIG. 233 FIG. 234 VON ESMARCH'S IRON ARCH SPLINT FOR RESECTION OF THE ANKLE JOINT For the elbow joint, my double splint, which can be easily constructed, is very useful (Figs. 235, 236). In changing the dressing, the interrupted padded arch splint upon which the arm rests is lifted from the lower board. My divided iron suspension splint for the elbow joint is very convenient but somewhat large and heavy ; it consists of three folding splints, the arms of which, movable on hinges, are fastened to an iron pole ; in applying the dressing, the middle splint is removed (Figs. 237, 238). THE TREATMENT OF WOUNDS 137 FIG. 235 FIG. 236 VON ESMARCH'S DOUBLE SPLINT FOR RESECTION OF THE ELBOW JOINT 138 SURGICAL TECHNIC FIG. 237 FIG. 238 VON ESMARCH'S DIVIDED IRON SUSPENSION SPLINT FOR RESECTION OF ELBOW JOINT POSITION DRESSINGS These serve for a comfortable and secure position of the injured limbs, either alone or in connection with other dressings. They essentially lessen the sufferings of the patient, especially in exten- sive and serious wounds. But since they are rather heavy and bulky, they are not so well adapted to transportation as to hospital treatment. For military service, the most practical are those which are not too heavy, nor too complicated and expensive, and which can be made by any mechanic from a drawing. THE TREATMENT OF WOUNDS 139 If, in serious injuries of the leg, other conveniences are not available, then as the sim- plest temporary position use the side position according to Pott (Fig. 239); that is, place the patient's leg on pil- lows, with the half-bent knee and hip joint on the exter- nal side ; the muscles thus become relaxed and im- pediments to circulation are avoided. If the injured person is to be transported in this posi- tion, the pillows are fastened around the limb with cords. For the further transpor- tation of such severely injured persons, especially when both lower extremities are injured, Bonnet's wire breeches are use- ful (Fig. 240). This splint consists of a well-padded wire frame, in which the broken limbs are fairly well immo- bilized. Openings can be FlG - 2 39- POTT'S SIDE POSITION made in it, for bandaging the wound without moving the limb from its posi- FIG. 240. BONNET'S WIRE BREECHES tion. At the foot end are appliances for extension. This apparatus is very 140 SURGICAL TECHNIC comfortable for the patient, but too expensive and bulky, and hardly answers the present requirements of surgical cleanliness. FIG. 241. WIRE BREECHES FLATTENED FOR PACKING (according to von Esmarch) Of woven wire cloth (wire gauze), which can be purchased, wire splints can be made, which are lighter than Bonnet's and so flexible that they occupy but little space when flattened (Fig. 241). Moreover, they can be more readily cleaned. FIG. 242. DOUBLE INCLINED PLANE The double inclined plane (planum inclinatum duplex) is especially suit- ; for serious injuries and fractures of the leg ; it is constructed either, as Figure 242 indicates, according to Petit' s fracture box, or more simply, as THE TREATMENT OF WOUNDS 141 Figure 243 indicates, of a few boards provided on their lateral margins with wooden pegs by which the margins of the cushion upon which the leg rests are pressed against it. FIG. 243 FIG. 244 VON ESMARCH'S DOUBLE INCLINED PLANE If the wound is on the posterior side of the limb, a piece is sawed out of the board on that side (Fig. 244). Two longer wooden pegs, between which a bandage is stretched in figure-of-8 tours, serve as a support for the foot. By means of Dobsons wooden frame (Fig. 245), placed under the mattress in the region of the knee, a practical double in- clined plane for both legs can be extemporized. Von Renz's abduction box (Fig. 246) is especially adapted to cases of compound fractures R& DOBSOX , S WOQDEN FRAME of the femur, in which the upper fragment is in a strongly abducted position. Since the splint can 142 SURGICAL TECHNIC FIG. 246. VON RENZ'S ABDUCTION Box FIG. 247. PETIT AND HEISTER'S FRACTURE Box THE TREATMENT OF WOUNDS 143 easily be made by any carpenter, it might prove valuable in practice in small places situated at some distance from large cities, where the physi- cian must help himself. Openings are made over the wounds. During defecation, the round pillow, which occupies the part of the splint corre- sponding with the perineal region, is removed. For compound fractures of the leg, previous to antiseptic times, Petit 's fracture box, introduced into Germany by Heister, was extensively used (Fig. 247). The leg is wedged in between straw cushions by means of the movable side pieces ; for the change of dressings, each side of the lower portion of the leg can be made ac- cessible, one after the other, without changing y|| | the position of the leg. By means of the mova- ble supports, the angu- lar position of the knee joint can be easily regu- lated In England, Macln- tvre 's splint improved by Liston and made of sheet iron, is used in preference for the same purpose (Fig. 248). The same has a movable foot board, which can be changed in various directions ; by means of a screw on the back, the angular position of the knee joint can be changed very gradually. The transverse board at the lower end gives the splint a secure position. The portion for the thigh can be lengthened or shortened. Fialla s rod splint (Figs. 249, 250) con- sists of a row of thin rods which, by means of a screw, can be pressed together into any desired position around a common axis. It may serve as a substitute for the leg splints and the double inclined planes, especially since it can be easily folded, MAC!NTYRE'S SPLINT (IMPROVED BY LISTON) FOR COM- POUND FRACTURES OF THE LEG FIG. 249. FIALLA'S ROD SPLINT occupies little space, and can be placed in various angular positions. The fracture box devised by Scheuer has this advantage : it can be very rapidly constructed with a few wooden laths (Fig. 251). In modern times, the hollow straight splints with foot board (Fig. 155) 144 SURGICAL TECHNIC are probably preferred by most physicians to all kinds of fracture boxes. FIG. 250. FIALLA'S ROD SPLINT FIG. 251. SCHEUER'S FRACTURE Box In compound fractures of the humerus and in injuries of the shoulder joint, Stromeyers arm pillow is very useful. This is a triangular soft upholstered horsehair pillow, covered with some waterproof material (Fig. 252). The apex of the pillow edge is placed in the axilla and fastened in front and behind with safety pins to a strip of bandage, which is carried over the opposite shoulder. The arm, bent at a right angle, and the pil- low upon which it is placed are fast- ened together with a sling (Fig. 253). FIG. 253. STRUMEYEKS ARM Plixow FIG. 252. STROM EYER'S ARM PILLOW THE TREATMENT OF WOUNDS 145 It secures rest for the arm by preventing the movements of breathing from being conducted to the fracture. In fractures of the upper end of the humerus with an obstinate abduc- tion of the upper fragment, the whole humerus can be placed in an abducted position by Middeldorpf's triangle, a triangular wedge-shaped pil- low (Fig. 254), or a double inclined plane made of three boards (Fig. 255), the base of which is fastened to the trunk with belts or bandages, while the FIG. 254. MIDDELDORPF'S TRIANGULAR PILLOW FIG. 255. MIDDELDORPF'S TRIANGLE arm, bent at an obtuse angle, is placed upon the short sides and fastened there. This triangle can also be made from wire splints. On account of the dependent position of the arm, oedema is likely to ensue ; hence, the whole arm must be very carefully bandaged from below upwards. Lister's leather-covered wooden splint (Fig. 256), for resection of the wrist, secures a proper position for the hand and the fingers during the after treatment, when more frequent movements of the fingers become necessary. Many of the hand splints described above are superior, consequently it can almost be dispensed with. Modern surgery, especially in the case of injured 146 SURGICAL TECHNIC limbs, rarely makes it necessary to resort to all of these position appliances, and contents itself with the cleaner modern splints. For special and very tedious cases, they might be used advantageously even to-day. FIG. 256. LISTER'S WOODEN SPLINT FOR RESECTION OF WRIST EXTENSION DRESSINGS (DISTRACTION DRESSINGS) These permanently exert an extending force on some part of the body and are frequently employed with great advantage : 1. For removing great displacements in simple and compound fractures. 2. For correcting diseased contraction of the 'muscles and the consequent increased pressure upon diseased bones and joints and for the after treat- ment of some resections. 3. For removing or rather stretching curvatures. To the incomplete but simple extension appliances, which may eventu- ally be used as a temporary dressing for transportation, belongs Desault- Liston's wooden splint f or femoral fractures (Fig. 257). A cloth fastens the foot to the lower end improved by Hayncs Walton (Fig. 257, a) while a second cloth conducted over the perineum secures counter extension. By means of a third cloth (girdle cloth), the upper end of the splint is fastened to the pelvis. By means of a fourth and a fifth cloth, the thigh and leg are fastened laterally to the splint. Similar is Dnpuytreris splint for fracture of the ankle. This splint, provided with a thick pad, is fastened laterally to the calf of the leg, while by means of cloths or bandages, the foot is fastened THE TREATMENT OF WOUNDS 147 c FIG. 257. DESAULT-LISTON'S WOODEN SPLINT FOR FEMORAL FRACTURES at the lower end in such a manner that the broken ends of the bone are brought in proper position (Fig. 258). For extension, however, the use of weights and elastic extensors is much better. To make these means effective it is necessary, by a careful dis- tribution of the points of attach- ment over a large surface, to make the permanent extension endurable for the patient. This has been accomplished by Cros- by s adhesive plaster loop. Since this method is preferably and most frequently employed in fractures of the femur, the extension dressing for the thigh may serve as an illustration of this method of treatment. Crosby's adhesive plaster loop consists of a strong, broad strip of adhesive plaster (spread upon canvas), which is applied along both sides of the leg as far as the frac- tured part of the femur. In the loop against the plantar FIG. 258. DUPUYTREN'S SPLINT FOR FRACTUEE OF THE ANKLE FIG. 259. FOOT BOARD FIG. 260. APPLYING STRIPS OF ADHESIVE PLASTER surface of the foot is placed a small foot board provided with a ring (Fig. 259), to prevent pressure against the malleoli and furnish a point of attach- ment for the cord, and by means of a second strip of adhesive plaster, which encircles the leg spirally, the two strips of plaster are held in place (Fig. 260). 148 SURGICAL TECHNIC Next, with a cambric bandage the whole leg is firmly bandaged from the toes as far as the upper ends of the first adhesive plaster strip. These ends are turned over the last turn of the bandage (Fig. 261). By means of a cord FIG. 261. FASTENING STRIPS OF ADHESIVE PLASTER running over pulleys, a weight is fastened to the ring of the foot board ; by means of this weight, the leg is drawn toward the lower end of the bed. The increase of the weight must be made very gradually ; preferably only after JQ to 12 hours, in order that the adhesive plaster may become firmly attaChe4 to the skin. If the leg were left without any further support, it would sink into the mattress, and the friction would either entirely or partly neutralize the effect FIG. 262. EXTENSION BY WEIGHT FOR FRACTURES OF THE FEMUR of the extension. The fragments would, moreover, suffer a rotation from the lateral movements of the foot. To prevent both these results, the leg may be placed on von Volkmanris sleigh apparatus (Fig. 263), a short, hollow, iron splint provided with an THE TREATMENT OF WOUNDS 149 opening for the heel, a foot board, and under the same a narrow transverse bar, resting and sliding upon two smooth, triangular wooden bars. If this splint is not at hand, a prismatic transverse piece of wood may be fastened transversely to the dorsal side of the tibia by means of a plaster of paris bandage, which is also carried around the foot ; this transverse piece is allowed to slide on the two wooden prisms connected by parallel iron wires (Fig. 262). In most cases, however, von Volkmanns tin splints are provided with such prismatic transverse pieces of wood. In many patients, com- mon adhesive plaster causes a troublesome itchins: of the FIG. 263. VON VOLKMANN'S SLEIGH APPARATUS skin and eczema ; hence, it is better to use non-irritant adhesive plaster ; for instance, the excellent though expensive adhesive india-rubber plaster, or the zinc plaster muslin. In cases where not even this is well borne, or where no adhesive materials can be used, a substitute must be found. The extension splint can be fast- ened very well by two wet bandages, each double the length of the whole leg, in the middle of which a small slit is cut for the ring of the foot board. Two of the four ends hanging therefrom are carried in an anterior and the other two in a posterior direction in serpentine turns around the limb (Fig. 264). If another dry bandage is carefully wrapped over them as far as the fracture, considerable extension is secured without causing the bandages to slip ; by coating the bandages with paste or flour, they can be made still more FIG. 264. FASTENING THE EXTENSION SPLINT BY Two WET BANDAGES secure. By sewing or fastening the several turns of the bandage with safety pins, a firm hold is secured even with a common bandage. Likewise, the trellis finger catcher, made of fibres of the palm leaf (" Fingerfanger," " Madchenfanger "), which under tension becomes tighter, 150 SURGICAL TECHNIC and which cannot be stripped again from the limb, can be used in case of necessity as a substitute for adhesive plaster. Although a plaster of paris bandage applied on the bare skin adheres, it is less to be recommended. The traction by the attached weight varies from 2 to 1 2 kilograms, accord- ing to circumstances ; for most cases 5 to 8 kilograms are sufficient. Very powerful muscles sometimes cannot be overcome by means of weight extension. Counter extension is made by means of a padded cord carried over the perineum and the groin, or by means of a thick India rubber cord wrapped with cotton, and fastened laterally to the head of the bed ; this prevents the patient from being drawn down in his bed by the weight. Or the weight of the body is used for this purpose by raising the foot of the bed with blocks of wood or bricks placed under it. In the treatment of coxitis by extension, the counter extension is made in the abducted position of the limb on the diseased side, and in the adducted position on the healthy side. After resection of the hip joint, extension must be made with the limb in the abducted position. Von DnmreicJier used the weight of the limb for an extension by placing it upon a single inclined splint with rollers (railway apparatus). Much simpler and more practical is Konig9 gliding stirrup (Fig. 265), a dorsal splint which allows the leg to be suspended upon two iron arches fastened laterally. To pre- vent outward rotation of the frag- ments, the thigh is fixed with short splints ; for instance, those of Goock ( Fig. 140) and Bell (Fig. 151). FIG. 265. Rome's GLIDING STIRRUP If the upper fragment is dis- placed much anteriorly, or if on account of uncleanliness the patient's dressings become greatly soiled from the prolonged supine position (which is the case in fractures of the femur in little children), it is advisable to make vertical extension. The leg is drawn up straight on a gallows, so that the body exerts the extension (Schede). For extension of the arm, the adhesive plaster strips are fastened on the internal and external side of the arm, so that the cross-board is placed under the elbow, with the forearm bent at a right angle. If the forearm is sup- ported by a sling, the weight can be fastened to the cross-board, and the patient can walk about. Or the arm is fastened on a suspension splint, THE TREATMENT OF WOUNDS 151 similar to von Volkmanris, at the elbow part of which the extension cord is carried over a pulley ; the patient must then remain in bed. For extension of the wrist in the treatment of inflammation, as well as resection of the same, loops of equal length of adhesive plaster strips are fastened to all the fingers in the form of a gauntlet (Fig. 88), and through these loops a thin rod is inserted. A weight carried over a pulley is fast- FIG. 266. EXTENSION OF THE WRIST ened to this by means of fine cords. The counter extension can be effected by a large adhesive plaster loop, applied to both sides of the forearm, and fastened by means of a cord with an India rubber ring to the head of the bed. The arm rests on an inclined plane (Fig. 266). Extension of the trunk is resorted to more especially in the treatment of diseases or curvatures of the spine, and can only be accomplished by a complicated apparatus. Among these numerous appliances, the following will be mentioned briefly : Von Volkmanris extension apparatus for the cervical portion of the spine in the treatment of spondylitis (Fig. 267). FIG. 267. VON VOLKMANN'S EXTENSION APPARATUS FOR THE CERVICAL PORTION OF THE SPINE The head is extended in a horizontal direction by means ^/r// sling, which encircles the chin and the occiput; to this sling, pr_pvidf;d , wi Cr luLl_iLH\. 152 SURGICAL TECHNIC FIG. 269. GLISSON'S SLING a curved iron cross-bar, the extending weight is fastened and carried over a pulley at the head of the bed. If it becomes necessary to increase the exten- sion, this can be done by attaching weights to both lower extremities. Instead of the weights, counter extension is made by raising the head of the bed. For Glissoris suspension sling, two loops of adhesive plaster may be substi- tuted; these are placed around the chin and the occiput, united over the head, and kept apart by a transverse piece of wood. With Glissoris suspension sling, according to Sayre, an extension can also be exerted on the scoliotic spine. By means of a pulley the patient lifts himself with both arms until only his toes touch the floor, the weight of the body becoming thus the extending force (Fig. 268). In this position, in which the spine is stretched as much as possible, a fixa- tive dressing (plas- ter of paris felt corset) is applied in cases in which such treatment is indicated. The extension is more endurable and still more effective if axillary extensors are added to Glis- soris sling (Fig. 269). By this com- bined extension the whole upper section of the vertebral column is lifted (Fig. 270), so that the cur- vature is diminished or corrected. These suspension exercises are re- peated daily, and the time is gradu- ally increased. Scoliotic curvatures may also be removed temporarily by a lateral extension. Banvell places the patient . "fcith the prominence of the curva- ture into, a girth sling, which, when FIG. 268. EXTENSION FOR SCOLIOSIS FIG. 270. SAYRE'S EXTENSION APPARATUS FOR SCOLIOTIC SPINE THE TREATMENT OF WOUNDS 153 traction is made by weight and pulley, presses the curvature into its normal position (Fig. 271). This position is also suitable for applying plastic corsets in an " over correction " (Peterson}. Although elastic extension becomes very effective on account of its active force, its effect can be less easily gauged than that of extension by weight and pulley ; on the other hand, it has the advantage of being lighter and more comfortable. For elastic extension, either strong india- rubber rings, such as can be bought every- where, are used ; or, if such are not available, FIG. 271. HARWELL'S LATERAL" EXTEN- a piece of india-rubber hose. SIGN IN SCOLIOSIS Small grooved wooden plugs, provided with hooks, are fastened at both ends (Figs. 272, 273). The simple knot- ting of the ends is less secure, since these knots easily get loose. For a distant transportation, the wounded person is placed at once upon a stretcher and supplied with such an elastic extension by fastening with an FIG. 272. GROOVED WOODEN PLUG FIG. 273. INDIA-RUBBER HOSE WITH HOOKS india-rubber ring the carefully bandaged limb to the lower end of the stretcher ; for counter extension, the belt of the patient, or, in case of neces- sity, the leg of his trousers, cut open at the inner and the outer seam and FIG. 274. VON ESMARCH'S STRETCHER EXTENSION DRESSING FOR TRANSPORTATION IN GUNSHOT WOUNDS OF THE FEMUR rolled up to the perineal region, is fastened with an elastic cord or a sus- pender to the head of the stretcher (Fig. 274). 154 SURGICAL TECHNIC For the same purpose, the separable wooden splint (Fig. 139) can be used ; five sections of the same joined together are sufficient. An iron hook, to which the extension ring is fastened, is applied, when used, at the lowermost part (Fig. 275). At the upper section are two slots, to which are fastened both the pelvic belt and, by means of a second india-rubber ring, the perineal band. If the leg of the trousers is not used for a counter exten- sion, it is carefully folded and used as a padding between the splint and the leg (Fig. 276). The splint, which can be taken apart and which is supplied with a hook and two india-rubber rings, occupies very little space and can be easily packed. FIG. 275. IRON HOOK FOR SEPARABLE WOODEN SPLINT FIG. 276. VON ESMARCH'S SEPARABLE WOODEN SPLINT FOR ELASTIC EXTENSION OF THE THIGH In the same manner the wrist can be provided with a very effective elastic extension. The hand and the forearm, after having been bandaged as described above (Fig. 266), are placed upon a hand splint provided in front and behind with rollers. Next, the extension cords under the splint FIG. 277. ELASTIC EXTENSION OF THE WRIST are stretched tight by means of an india-rubber ring (Fig. 277). The patient can walk about with this dressing. THE TREATMENT OF WOUNDS 155 FIG. 278. SAYRE'S ADHESIVE PLASTER DRESSING (First Strip) Sayres adhesive plaster dressing for fractures of the clavicle is also an extension dressing, as by lifting the shoulder outward, backward, and upward, it corrects the overlapping of the fragments. Cut two strips, 8 to 10 centi- meters wide, of strong adhesive plaster spread upon canvas, one strip long enough to be carried around the arm and also around the thorax, the other long enough to be car- ried from the healthy shoulder over the elbow of the diseased side, and thence back to the healthy shoulder. Apply the first strip below the margin of the axilla around the arm ; next, on the posterior side of the arm, sew it together to form a loop wide enough to leave poste- riorly a portion of the arm free ; this pre- vents strangulation. By means of this loop, draw the arm downward and backward, until the internal sternal fragment of the clavicle has been drawn sufficiently downward by stretching the pectoralis major muscle. Fix the arm in this position by carrying the strip of adhesive plaster around the chest and fasten its end posteriorly to the strip (Fig. 278). Cut in the middle portion of the second strip a small longitudinal slit to receive the olecranon process. Next, place the patient's forearm, bent at an acute angle, upon his breast ; (while an assistant forces the elbow forward and inward, completely reducing the fracture) fix the arm in this position by the second strip, the middle of which receives the tip of the elbow. Carry both ends across the breast and back over the opposite shoulder, where they cross each other, and fasten them with a few safety pins (Figs. 279, 280). In the case of unruly children, apply over this a Desault starched bandage. Similar is Landerer's adhesive plaster dressing f m fractures of the clavicle. Sew a broad strip of adhesive plaster, cut several times lengthwise at one end, together with another strip of equal length by means of a broad piece of strong india-rubber bandage (Fig. 281). Next, apply the first strip upon the diseased shoulder so that its fingerlike attachments come to lie anteri- orly, carry it posteriorly and obliquely across the back, and apply the second strip of adhesive plaster, under strong tension, like a girdle around the healthy side, and fasten it there. The elastic bandage then draws the 5 6 SURGICAL TECHNIC FIG. 279 FIG. 280 SAYRE'S ADHESIVE PLASTER DRESSING (Second Strip) diseased shoulder backward, and hence produces an extension force upon the fragments. In the same manner Landerer applies his extension dressing for genu valgum (knock-knee}. Two broad strips of adhesive plaster encircle the thigh and the leg ; at the inner side of the knee a broad elastic band is stretched tensely between them, or into the ends of the bands of adhesive plas- ter, at the knee, transverse pieces of wood are fastened and are gradually FIG. 281 FIG. 282 LANDERER'S ADHESIVE PLASTER DRESSING WITH ELASTIC EXTENSION contracted more and more by india-rubber rings. The same end may be obtained also by means of a buckle arrangement in the elastic middle piece. THE TREATiMENT OF WOUNDS 157 More effective, however, is Miculics's extension dressing for genu valgum (Fig. 283). The whole leg is bandaged wiih a plaster of paris dressing, into the posterior and the anterior sides of which iron splints with hinges are incorpo- rated, so that the hinges correspond to the region of the knee joint; at the inner side of the plaster of paris dressing, over the thigh and leg, a hook is fastened with a plaster of paris bandage; after the dress- ings have set, a wedge is cut out of the dressings in the region of the knee with its base inward ; thereby two plaster of paris dressings are formed, which can be moved laterally on the hinges of the splints; by means of an elastic extension connecting the two hooks, the leg is gradually straightened. Club-foot shoe with elastic extension (Fig. 284), used in the after treatment of corrected FIG. 283. MICULICZ'S EXTENSION DRESS- club-foot, consists essen- ING FOR GENU VALGUM tially of a solid lace shoe, with lateral steel braces, from the upper end of which an elastic cord extends to the point of the shoe. This exten- sion is to replace artificially the muscles which have become atrophied. According to these principles, it may be changed to meet the require- ments of individual cases. Finally, in connection with more or less complicated appli- ances, extension can be made by means of screw splints ; as exam- ples, may be mentioned here : Say re's extension dressing for the knee joint (Fig. 285). Thigh and leg are covered with adhe- sive plaster strips in the manner of Scultet 's bandage ; these two FIG. 284. CLUB-FOOT SHOE WITH ELASTIC EXTENSION separate dressings are screwed FIG. 285. SAYRE'S EXTENSION DRESS- ING FOR THE KNEE JOINT 158 SURGICAL TECHNIC apart by means of an iron splint, attached on both sides at their extreme ends. Sayres portable extension apparatus for the treatment of cervical spondylitis (Minerva, Jurymast) consists of a curved steel rod incorporated in the posterior median line of a plas- ter of paris jacket, giving support to the head in a Glisson's sling. By means of screw action the rod can be raised and lowered (Fig. 286). Taylor's extension apparatus for the ambulant treatment of coxitis (Fig. 287) consists of a strong steel shaft as long as FIG. 286. SAYRE'S the le & with a pelvic belt at its upper end JURYMAST and a foot support at its lower end. By means of a screw, the splint can be extended, thus stretching the leg fast- ened to it. The apparatus is fastened by means of a five- headed strip of adhesive plas- ter, so that its broad end comes to lie in a downward di- r e c t i o n and somewhat across the in- ner m a 1 1 e o- lus (Fig. 288). Over it, the whole leg is covered with a bandage. After the apparatus has been applied, the patient rides or sits on the perineal strap ; the foot hangs suspended in the air and the diseased joint is FIG. 28^ TAYLOR'S EXTENSION thus relieved from the weight of the body. This original apparatus has undergone numerous FIG. 288. FASTENING THE ADHESIVE PLASTER STRIPS APPARATUS THE TREATMENT OF WOUNDS 159 improvements and has been largely changed (Sayre, Schajfer, Whitehead, and others). TEMPORARY DRESSINGS If the ordinary articles of dressings so far described are not available for dressing wounds, arresting hemorrhage, immobilizing fractures of bones, the physician or the trained layman (Red Cross nurse, Samaritan) has to extem- porize a dressing quickly with whatever material is at hand. Such emer- gencies occur often enough in time of peace (it is said that in Prussia alone considerably more than 100,000 serious injuries occur annually). Especially important, however, is the art of improvising rapidly and well in time of war'. After large battles, with the murderous destructions which the most recent firearms cause and the infinite number of wounds, even the largest supply of materials for dressings becomes exhausted, and the otherwise ample number of trained persons becomes insufficient at least for the moment. In the treatment of wounds, the first principle to be observed is not to touch the wounds unnecessarily^ especially with nnclean (non-aseptic) hands, to forego all indiscreet examinations, probing, removing of foreign bodies, and not to apply any dressings which are not known to be surgically clean ; for to leave the wound open and unprotected from every dressing (the open treatment of wounds) is less hazardous than to cover it with unclean mate- rials. Slight hemorrhages also are more easily arrested by means of the scab which forms in the open air. In the neighborhood of inhabited places in houses, however, with scanty means an aseptic dressing can be made by boiling water for some time ; with this, the wound is cleansed from all im- purities ; next, it is covered with a clean (washed and ironed) cloth (handker- chief) and this dressing is fastened with another cloth. If no aseptic dressing materials are at hand, they may be obtained in a very simple manner by boiling some pieces of gauze, etc. Wound douches for a sufficient irrigation of the wound may be made with vessels open on the top (cooking utensils), into which the end of a rubber hose, weighted with a stone or some similar object, is lowered, while suc- tion is produced at the other end ; or by making a glass douche according to Fig. 28. Funnels and cans can also be used for this purpose. For bandages may be used strips of table cloths, sheets, and shirts. The cloth bandages may be made of a napkin or a handkerchief. An arm sling may be improvised, in want of cloths, from the skirts of a coat, the sleeves of a coat or a shirt cut open, or the uninjured sleeve fastened to the breast i6o SURGICAL TECHNIC with safety pins (Figs. 289-291). In the case of women place the arm into the apron thrown over the shoulder. FIG. 289 CLOTH BANDAGE OF SKIRT OF COAT FIG. 290 BANDAGE OF COAT SLEEVE CUT OPEN FIG. 291 BANDAGE OF SLEEVE FAST- ENED WITH SAFETY PINS When hemorrhages cannot be arrested by means of a firmly applied dressing, then, first of all, elevate the limb ; in case of necessity, compress the bleeding artery above the wound with the finger or with a tourniquet quickly improvised. In serious injuries of the large vessels, constrict the whole limb between wound and heart with an elastic tube, suspender, or a bandage which is subsequently moistened. If bones are fractured, in addition to the greatest gentleness and cir- cumspection possible in touching and moving the injured person, splints should be quickly procured. For temporary splints may be used: (a) Wooden splints, rulers, laths, poles, boards (Fig. 292), strips of wood, trellis of flower pots (Fig. 293), flexible wooden covers (like Gooctis flexible wooden splints Fig. 140). Useful, also, are twigs or small branches, tied together in bundles (Fig. 294), or arranged side by side smoothly, fastened by tying them together with transverse pieces of wood (Fig. 295), or with THE TREATMENT OF WOUNDS 161 FIG. 292. TEMPORARY SPLINTS FOR FRACTURED LEG FIG. 293. SPLINT OF TRELLIS OF FLOWER POT FIG. 294. SPLINT OF SMALL BRANCHES TIED IN BUNDLES Surf FIG. 295. FLAT SPLINT OF TWIGS ARRANGED SIDE BY SIDE 1 62 SURGICAL TECHNIC twine in the form of a chain (Fig. 296). In a similar manner, the smooth bark of straight trees (willows, beeches), or the dried leaves of banana trees, or thin, flexible veneering may be used. Also, the splint cloth (illus- trated in Fig. 142), which can be cut, may easily be prepared ; in lack of some adhesive substance, strips of wood, twigs, etc., are sewed to the material. () Straw splints. Stalks of straw in as good condition as possible are tied together in bundles (Fig. 297). Two of these straw splints are wrapped into both ends of a cloth, placed under the limb in such a manner that they come to lie close to the limb on both sides, and can be fastened to it by means of boards {straw splint Fig. 298). Also, straw, reeds, or rushes can be sewed into mats (yon Beck\ and the limb can be enveloped with them and a bandage applied over them ; when rolled up on each side they can also be used for lateral splints (Figs. 299, 300). Door mats, lino- leum, strips of carpet, etc., can be used in the same manner. (c) Pasteboard splints can be easily prepared everywhere according to the models mentioned on page 128. In lack of pasteboard, old book covers, maps, boxes, or layers of newspapers, pasted together, may be used. (a} With a pair of strong scissors, tin can be cut into any desired form of splints (Figs. 156, 157). Apiece of roof gutter makes a very practical splint. (e) Wire splints are prepared from strong wire taken from fences, enclosures, or from woven wire gauze, which can be purchased. In time of war, the use of telegraph wire, from lines broken during battle, is of espe- cial importance. With a strong pair of pincers and a file, even with little experience, simple splints may be quickly prepared. They are light, clean, and transparent. Figure 301 shows Porter's splint, which can be easily made. Figure 302 shows a protecting frame for wounded limbs. The construction of other splints from wire presents greater technical difficulties (see Figs. 164, 165). (/) Objects which the wounded man has on his person sometimes furnish very useful material for splints. Articles of clothing- (for instance, coats, trousers, cloaks, bootlegs) may be employed. A military cloak, for instance, is rolled up on both sides and fastened to the limb by a belt or a cloth (Fig. 303). The sleeves, filled with straw, moss, or earth, can be used as splints. A boot cut open lengthwise and in front in its middle portion, the leather of the leg of which is wrapped about a piece of wood applied exteriorly, provides a foot splint, which, THE TREATMENT OF WOUNDS 163 FIG. 296. SPLINT OF TRANSVERSE PIECES OF WOOD FASTENED WITH TWINE FIG. 297. STRAW SPLINT FIG. 298. STRAW SPLINT FIG. 299. STRAW MAT FOR SPLINT 1 64 SURGICAL TECHNIC FIG. 300. REED MAT FOR SPLINT FIG. 301. PORTER'S WIRE SPLINT FIG. 302. PROTECTING FRAME FOR WOUNDED LIMB FIG. 303. MILITARY CLOAK USED AS SPLINT THE TREATMENT OF WOUNDS 165 like Volkmanrts T. prevents the lateral movements of the injured foot (Fig. 304). FIG. 304. BOOT CUT OPEN LENGTHWISE USED AS FOOT SPLINT Weapons like swords, cutlasses, bayonets, sabres, scabbards, muskets, rammers, lances, leather, felt of the saddle, spokes of wheels, canes, umbrellas, and parasols may be used for splints without any further prepa- ration (Figs. 305, 306, 307, 308). () In cases of great emergency, when nothing at all is at hand, the healthy leg is used as a splint for the injured one, and the thorax for the diseased arm. Often there are to be had neither tables nor practical position apparatus for applying the bandages. The military model is excellent as an operating and dressing table (Fig. 309). Upon this, by a kind of double music stand, two men can be dressed at the same time. By means of boards and pillows this arrangement can easily be fixed to any large common table. Position appliances and means of suspension for injured limbs may easily be made with wire and strips of cloth (Figs. 310, 311). A double inclined plane is made by two laths nailed together at an obtuse angle, a Heister's fracture box, by placing the leg upon a very low bench, the legs of which have been sawed off in a manner that accomplishes the object. A suspension apparatus for a fractured leg can be made by means of several triangular cloths, which as slings are carried across a transverse pole. It can be prepared in a still simpler manner if the stocking is cut open anteriorly and if two rods are fast- ened to its margins. These are hung up on a stronger rod or pole (Fig. 312). The position appliances in Figs. 243, 245, 246, 251, which can be made rapidly by any carpenter, are especially serviceable. i66 SURGICAL TECHN1C FIG. 305. JOINED BAYONETS USED AS SPLINT FIG. 307. SCABBARD USED AS SPLINT FIG. 308. MUSKET USED AS SPLINT THE TREATMENT OF WOUNDS I6 7 FIG. 309. DRESSING TABLE (Military Model) FIG. 310. VON VOLKMANN'S SUSPENSION APPARATUS FOR INJURED ARM FIG. 311. VON BARDELEBEN'S WIRE SUSPENSION APPARATUS FOR FRACTURED LEG FIG. 312. CUBASCH'S SUSPENSION APPARATUS OF STOCKING CUT OPEN !68 SURGICAL TECHNIC ANTISEPSIS IN WAR It is the urgent demand of humanity to have every wounded soldier, even in war, enjoy the protection and the blessings of the antiseptic treatment of wounds. To be able to fulfil this demand it is necessary that : (a) Not only all military surgeons be perfectly familiar with the anti- septic treatment and the practical application of the same, (b) But also that all persons of the hospital corps (litter bearers, Red Cross nurses) are versed in the principles of antisepsis, and are competent to render efficient first aid. (c} Not only the field hospitals and the hospital corps, but also the wagons for medical supplies of the troops, the knapsacks for the dressings, and the pouches of the hospital assistants must be sufficiently provided with antiseptic material for dressings. ( a minute), until the effect of the movements is recognized by the artificial carotid pulse and the contraction of the pupils. In most serious cases, where even massaging the cardiac region did not effect the desired result, life was saved by intravenous infusion of sodium chloride. Faradization of the heart by means of electro puncture (Steiner), formerly recommended, must be rejected as injurious. Rhythmic faradization of the exposed cardiac muscle has been suggested. i88 SURGICAL TECHNIC ETHER ANESTHESIA Ethylic ether, sulphuric ether, C 4 H 10 O, is the oldest anaesthetic. It was first used for anaesthesia in 1846 by Jackson and Morton. Only pure ether should be used for anaesthesia (aether purissimus pro narkosi, anhydrous ether, Pictef). If ether contains alcohol, it turns red by adding fuchsine ; if it contains water, powdered tannin will be dissolved into a thick mass on addition. Ether to be used for anaesthesias is best kept in dark bottles of 100 to 200 grams each. It should be brought in contact with air and light as little as possible. Any portion of ether remaining over from one anaesthesia should not be used for a subsequent narcosis. Ether evaporates very easily, its vapors are heavier than air and combustible to a high degree. Hence, it renders operations dangerous for the surgeon as well as for the patient, especially when they are performed with artificial light or the use of the thermo-cautery. Ether is much less poisonous than chloroform ; its largest toxic dose is about five to seven times greater than that of chloroform. According to Gurlfs statistics death from anaesthesia occurred at the rate of i to 5000. Still, in some clinics a much higher ratio of anaesthesias has been obtained ; for instance, Oilier at Lyons reports that since the introduction of ether no death occurred in 40,000 anaesthetized persons. On account of its less toxic qualities, much larger quantities are required for a full anaesthesia. Ether does not act so rapidly and effectively as chloroform, but when properly administered most of the dreaded and danger- ous symptoms are absent. Two methods of ether ancest/tesia are used : First, the asphyxiating form. For this purpose a large mask is used, covering the whole face. On its inner side the mask has several layers of gauze, flannel, or cotton, on its outside it is covered with some impermeable air-tight material (Fig. 325). Into the mask about 20 grams of ether are poured at a time ; the mask is then firmly pressed upon the face, so that very little, if any, air is admitted. For the purpose of admitting still as little air as possible a towel may be applied tightly around the margin of the THE TREATMENT OF WOUNDS 189 mask. Anaesthesia comes on almost as rapidly as with chloroform ; the apprehension that too much carbonic acid and too little oxygen is under the mask has no foundation {Dreser). When administering more ether the anaesthetizer should proceed as rapidly as possible, lest too much air is in- spired by raising the mask. This method is very convenient and simple. The amount of ether used is about 100 to 150 grams an hour. Sometimes even larger quantities can be administered without injury to the patient. Second, the intoxicating form. Pour the ether in a WanscJiers mask, a large rubber bag whose opening can be applied almost air-tight to the mouth and nose (Figs. 326 and 327). Pour at first about 50 grams into the mask, hold it before the nose and mouth of the patient, and gradually apply it tight. By shaking the lower part of the mask more ether is caused to evaporate, hence tJie dose of ether can be regulated to some degree. Anaesthesia, of course, comes on much less rapidly, but it has less unpleasant symptoms and after effects. The course of ether anaesthesia is es- sentially similar to that of chloroform. In the beginning of it the patient ap- pears excited, often in a cheerful frame of mind. The face turns red, large maculated exanthem appears on the neck and chest, coughing, singultus (hiccough), salivation, perspiration, and lachrymation occur from its irritating effect. Cyanosis of the face in most cases is very pronounced, the blood pressure is often increased to twice or three times its normal, the beats of the pulse mostly remain normal. The condition of the pupils is with ether less important than with chloroform ; in most cases they at first dilate and afterward contract, but not always. The occurrence of clonic contractions (" Aetherzittern ")is often very annoy- ing. When after more or less pronounced excitation the stage of tolerance occurs, inspiration is regular and stertorous. Dangers from anaesthesia involve less the heart, as in chloroform, than the respiration. The very profuse secretions of saliva are aspirated ; coarse crepitant rales are heard in breathing ; the patient may die at the end of FIG. 326 FIG. 327 Old Form Modern Form WANSCHER-GROSSMANN'S ETHER MASK 190 SURGICAL TECHNIC anaesthesia or several days afterward of broncho-pneumonia. Hence, it is the principal duty of the anaesthetizer to see to it that the mucous secretions from the mouth are cleared. Place the patient in a position with his head very dependent and turned well to one side ; raise the angle of the lower jaw, place the forefinger hooklike behind the angle of the jaw, and draw it downward. Clear with a sponge the mucous secretions which have collected in the cavity of the mouth, this being the deepest point. With these pre- cautions the tracheal rale (for a long time considered characteristic of ether anaesthesia) is avoided. For ether, aside from a slight increase of saliva, produces no excitation whatever upon the mucous membrane of the air passages (Holscher). In the stage of fullest tolerance, when too large a dose has been admin- istered, primary cessation of respiration is to be apprehended. It should be treated according to the rules mentioned in chloroform asphyxia. Hence, it is even more important in ether anaesthesia than in chloroform anaesthesia to observe carefully the respiration of the patient. Any disturbance of the cardiac action which makes the use of chloroform so incalculable, is to be apprehended with ether only as a secondary cause. Hence, ether should not be used : In diseases of the air passages (bron- chitis, bronchiectasis, tuberculosis, and in the case of old patients with rigid thorax which renders expectoration difficult). Moreover, it is not preferably used in operations on the face, since the effects of ether anaesthesia become neutralized by frequently raising the mask. The awakening from an ether anaesthesia takes place more rapidly than from chloroform ; sometimes analgesia continues for some time after con- sciousness has been restored. With some patients subsequently great ex- citation occurs. Vomiting does not occur so regularly as with chloroform. For many patients the odor of ether (often lasting for days) of the expirated air is unpleasant ; still, according to Drescher, the larger quantity of ether has been disassimilated one hour after anaesthesia. As after effects should be mentioned, above all, bronchitis, pneumonia, oedema of the lungs ("we lose our patients anaesthetized with chloroform on the operating table, those anaesthetized with ether in their beds"); more- over, albuminuria and acetonuria {Becker); apoplexy observed in the case of aged patients after ether anaesthesia (but also after chloroform) may be explained from the considerably increased blood pressure. Etherization per rectum (Pirogoff), which was abandoned, has been recommended again recently (Starke). It will hardly be adopted generally. THE TREATMENT OF WOUNDS 191 COMBINED ANAESTHESIAS Chloroform-ether anaesthesia. In prolonged anaesthesias chloroform and ether in succession have been used with the best results. The anaesthesia begins with chloroform, and when the stage of tolerance has occurred, it is kept up with ether, after the mask has been changed.* The advantages of this method are : very little ether is required for keeping up anaesthesia ; the same can be continued for several hours ; no unpleasant consequences as in prolonged chloroform anaesthesia need be apprehended ; according to statis- tics the mortality is very low. Ether-chloroform anaesthesia {Madclung} is used much more rarely, mostly with patients who from ether inhalations become exceptionally excited, who have a pronounced tracheal rale, cyanosis, and hiccough (singultus), or with whom the occurrence of full anaesthesia is retarded in spite of large doses of ether. It has the advantage of avoiding primary syncope caused by the effects of chloroform. If chloroform is administered, after ether anaesthesia has occurred, the subsequent part of anaesthesia takes an especially favorable course {Konig). Very frequently a subcutaneous injection of morphine is previously made (see p. 177) (with the addition of 0.03 grams oxyspartein (to regulate the action of the heart), or o.ooi gram atropin (to regulate respiration)). The stage of excitation is thereby shortened, and with a smaller quantity of the anaesthetic narcosis takes a more tranquil course. After an injection of 0.01-0.03 morphine 15 to 20 minutes previous to anaesthesia, the latter can be kept up with ether (morphine-ether anaesthesia, Riedel), or it can be brought on with a very small quantity of chloroform (morphine-chloroform anaesthesia). This kind of anaesthesia is of especial advantage in the case of very excitable, frightened patients; with drunkards, who become considerably less excited from it ; and in all operations on the face or on the neck during which blood is liable to enter the air passages, because the patient is not completely unconscious and when requested coughs out the blood which has been aspirated, and yet the pain inflicted is slight (for instance, in re- section of the upper jaw, amputation of the tongue, etc.). Thus only anal- gesia with consciousness still partly preserved is produced. Instead of morphine 2 to 3 grams of chloral hydrate may be given. Anaesthesias with chloroform mixtures have the advantage of less danger than those of pure chloroform, but they are not frequently used in Germany. 192 SURGICAL TECHNIC Billrottts mixture is known best of all (chloroform-ether-alcohol, 3:1:1) from which one death occurred in 3370 anaesthesias. The English A. C. E. mixture (i :2:3) brings on anaesthesia rapidly without causing any serious injury to the heart. Tillmanns prefers chloroform and ether mixed in equal parts. For anesthesias of short duration in operations which can be quickly performed, ethylene bromide has been used in modern times : 1 5 to 20 grams at a time, poured into an impermeable mask and inhaled with as complete an exclusion of air as possible produces, after one minute or less, anaesthesia which is complete for about 3 to 5 minutes. After this time analgesia can continue for some time. Sometimes, however, the desired relaxation of the muscles does not occur. During anaesthesia cyanosis, disturbance of respiration, nausea, and vomiting have been observed. On awakening the patient feels perfectly well, still the expirated air has for days an odor of garlic. If anaesthesia is to be prolonged, it is not advisable to administer again ethylene bromide ; it is better to use ether (ethylcne- bromide-ether anesthesia, Kocher). Ethylene chloride (Kelen), which is syringed upon a common tricot mask, can also be recommended according to Sou-tier and Lotheisen for anaesthesias of short duration. Likewise bromoform has been used successfully. Pental, which has a pungent odor of oil of mustard, cannot be recom- mended for anaesthesia on account of its great dangerous qualities. The other numerous anaesthetics, nitrogen monoxide, methylic pichloride, dimethyl acetal, diethylene acetal, and their combinations with one another or with chloroform, ether, oxygen, and others, are of little importance for surgical purposes. LOCAL ANAESTHESIA (ANALGESIA) For rendering only one certain part of the body as anesthetic as possible, and hence for alleviating or removing the pain of an operation, strong pressure was, even in olden times, exerted either upon the principal nerve or upon the whole circumference of the limb ; by this means, aside from the partial interruption of the nerve transmission, the circulation of the blood becomes retarded, and' thereby the hemorrhage diminished. In the same manner, the elastic bandage in the bloodless method, after some time, proves antalgic. The fact that frozen limbs are always without sensation led to the use of refrigeration as an anaesthetic. The part involved was treated with a freezing mixture, covered with a piece of ice or with ice bags. Richardson THE TREATMENT OF WOUNDS 193 used the ether spray, which quickly evaporates, for reducing the tempera- ture in a very short time to the freezing point. The cold, thus produced in a few minutes, renders the skin insensible. After a momentary redness, the place of the surface of the skin subjected to the spray turns white ; next, after prolonged spraying, the skin becomes wrinkled almost like parchment. Minor operations which have to be performed rapidly and which are confined mainly to the skin can then be performed in a painless manner. In conse- quence of the ether spray as well as of the thawing of the refrigerated part, very violent pricking pains generally occur, which often continue for a long time. Immersion of the part in warm water will somewhat mitigate the pain {Kochcr). In a similar manner liquid carbonic acid and methyl chloride, both in small siphons, have been used. Most convenient is ethyl chloride, a color- less liquid which boils at n C. It is sold in glass tubes with a capillary opening and an air-tight cover (Fig. 328). Likewise, mixtures of ethyl chloride and methyl chloride are used. On removing the cover the liquid FIG. 328. FLASK CONTAINING ETHYL CHLORIDE begins to boil from the ordinary temperature of the room, and still more from that of the hand. It squirts forth in a fine spray. If the glass tube is held i o to 20 centimeters distant from the portion of skin to be refriger- ated, the skin turns white almost instantly, and snow is formed on the cutaneous hair. This refrigeration is indeed painful, but it renders the skin antalgic for punctures or incisions. A disadvantage for handling the knife is the solid icy condition of the refrigerated part. After the thawing, which occurs rapidly, often a marked redness of the skin remains. This redness, as well as the pain, may be reduced during refrigeration by previously lubri- cating the portion of skin. By means of elastic constriction of the limb, and by ischaemia thus effected, refrigeration occurs more rapidly and continues for a long time. Cocaine and its salts, especially cocainum muriaticum, however, is mostly used for producing local anaesthesia {Koller, 1 884). It possesses the prop- erty of rendering antalgic mucous membranes and wounds, but not the tin- injured skin. It paralyzes the sensory nerve fibres, while, at the same time, 194 SURGICAL TECHNIC a contraction of the lumen of vessels occurs. The anaesthetic is used in solutions of i ID to 20 < ja. Cocaine solution heated to 50 F. is still more effect- ive (Costa). Since the solutions easily become mouldy, it is better to have them freshly prepared, or to use them when only a few days old. By sterilizing them in a temperature of 212 F. they lose in effectiveness. Mucous membranes, surfaces of wounds, and ulcers are rendered antalgic when brushed with a solution of 5 ^ to io^>. After a few minutes anaes- thesia will occur and minor operations can be made. If any part with uninjured skin is to be rendered antalgic the anaesthetic is administered irora a Pravaz syringe in and under the skin, and also into the deeper layers. For this purpose weaker solutions (l $& to 5 jfc) are sufficient, of which not more than o. i gram of cocaine as the maximum dose should be administered, else toxic symptoms can occur. The place of puncture made by the syringe can be rendered antalgic by ethyl chloride. For direct analgesia by means of cocaine (Reclus) inject about 0.05 to o. i of cocaine, distributed in one or several syringes, into the field of operation and its immediate neighborhood. The operation can begin after a few minutes. Analgesia will not last longer than 15 to 20 minutes. If ischae- mia can be brought on by elastic constriction (on the limbs), the effect of cocaine lasts longer. But the injection into tough, and especially inflamed, tissues is very painful before anaesthesia occurs, hence, a rapid incision, for instance, the division of a simple felon (panaritium), can be borne as easily as an injection. Regionary analgesia (Obersf) is quite especially adapted to such cases in which a portion of limb by means of elastic constriction can be ren- dered anaesthetic by injecting cocaine into the region of the nerve trunks, cen- trally from the field of operation. Originally recommended by Oberst for the fingers and toes, this method has been extended to the hand and foot (Mans). Bcrndt amputated even an arm and a thigh under regionary analgesia. Analgesia for the fingers and toes is made as follows : First, encircle the base of the limb with a rubber tube or a small bandage, subsequently moistened, so firmly that complete ischaemia occurs. Next, under a spray of ether or ethyl chloride inject immediately at tJie place of constriction in the direction of the tip of the forefinger and at the four sides of the limb i to a Pravaz syringe filled with a i salve), etc., are less gener- ally used. Only briefly may it be stated here that the surgeon can, by psychical influence (suggestion), also render an expected pain much less severe to the consciousness of the patient, when he has been perfectly assured that "it will not hurt." The efficiency of the " suggestion," especially in the hyp- notic state, has been made manifest by many excellent examples. But even without a methodically induced hypnotic state, it is sometimes successful to anaesthetize a patient suitable for such treatment, by merely holding a dry mask or one moistened with a few drops of some ethereal fluid over the nose. In these experiments, which can sometimes be tried as an expedient, much, of course, depends on the personality of the physician as well as on that of the patient. SIMPLE OPERATIONS The operation wound, in the great majority of cases, is made by an incision with the surgeon's knife (scalpel). How this is to be held and manipulated depends on the personal practice and manual dexterity of the operator. Generally, however, we distinguish the following metJiods of holding the knife : If fine shallow incisions are to be made, or if the operator wishes to pro- ceed by way of anatomical dissection, so to speak, the knife is held like a pen, the little finger resting on the surface of the body (Figs. 330, 331). If it is desirable to use more strength for making long, flat incisions, hold the 198 SURGICAL TECHNIC knife like a violin bow (Fig. 332); by holding the knife in this manner, the entire blade rather than its point is made effective. In using still greater power, in dividing tougher tissues, hold the scalpel like a table knife, the FIG. 330. (a} In anatomical dissection FIG. 331. (^) In cutting from within outward HOLDING THE KNIFE LIKE A PEN FIG. 332. HOLDING THE KNIFE LIKE A VIOLIN Bow 333- HOLDING THE SCALPEL LIKE A TABLE KNIFE forefinger resting on the back of the knife (Fig. 333). Finally, for dividing all soft parts with one firm stroke down to the bone, hold the knife with the whole hand like a sword. The shape or form of the blade (Fig. 334), whether curved or straight, and also the pre- scribed manner of holding it ac- cording to the rules of art, is a matter of little importance for one who knows how to handle a knife dexterously, gracefully, and easily, provided the wound made with it shows a smooth clean FIG. 334. SHAPE OF KNIFE BLADES. 1-2, curved; incision . whi ch has everywhere 3-4, pointed; 5, straight; 6, blunt-pointed uniform depth and no jagged, THE TREATMENT OF WOUNDS 199 contused, and mangled margins. Especially uncomely are the " tail ends " in skin incision, viz., when the angles of the wound are made only superfi- cially into the skin. In order to make smooth uniform incisions, it is of the F IG - 335. STRETCHING MARGIN OF WOUND FOR EXTERNAL INCISION greatest importance to stretch the skin as tense as possible. In smaller in- cisions it is made tense by stretching the skin between two fingers applied near the margins of the wound (Fig. 335); in larger incisions, by applying both hands. In most cases the smooth incision of the knife is the most appropriate procedure in penetrating downward. If the operator reaches any muscular septa and other layers of connective tissue, he may advance FIG. 336. GROOVED DIRECTOR more rapidly in a blunt manner by tearing them apart with the handle of the knife or with the finger. If distinct layers are present, the grooved director (Fig. 336) may be used. Insert it under such a layer and conduct the knife along the groove (Fig. 337). The incision by raising a fold of tissue (Figs. 33^, 339) is more conservative, and is especially to be recommended for the fine dissection of numerous thin layers. In incising the skin, raise it with two fingers at each side of the intended line of incision. Next, grasp with forceps a portion of the underlying layer of tissue. Let an assistant grasp another portion close by. The raised fold is superficially divided between the two forceps, and this is repeated layer after layer, until the desired depth has been reached. The operator proceeds in such a manner most frequently in exposing an artery or a hernial sac. FIG. 337. CONDUCTING THE KNIFE ALONG THE GROOVED DIRECTOR 2OO SURGICAL TECHNIC FIG. 338 FIG. 339 EXTERNAL INCISION BY RAISING A FOLD OF TISSUE Retractors (Figs. 340-342) should always be applied with great care ; if in smaller wounds they occupy too much space, light ligature loops may be practically substituted for them ; with these, the margins of the wound are retracted. The liga- tures are finally used in suturing the wound. In places where larger veins might be injured only blunt retractors should be used. Likewise, in resections, else from the large traction and the repeated insertion of the sharp prongs, the wound surface is unnecessarily irritated. The wound can also be deepened rapidly and FIG. 340 FIG. 341. VON LANGEN- FIG. 342 VON VOLKMANN'S BECK'S BLUNT RETRAC- IMPROVISED SHARP RETRACTOR TORS, a, small; b, large RETRACTOR easily with the scissors (Figs. 343, 344, 345)- THE TREATMENT OF WOUNDS 2OI Scissors, however, cause contusion, and hence make rough incision mar- gins ; nevertheless, the operator can very conveniently and safely work with them ; for instance, in the enucleation of some tumors. In addi- FIG. 343. STRAIGHT SCISSORS FIG. 344. COOPER'S SCISSORS FIG. 345. ANGULAR SCISSORS tion to the straight scissors, the bent or angular scissors are also used for deepening and enlarging incisions. Cooper's scissors, which are slightly curved, are used especially for shallow or surface incisions. PUNCTURE This serves for evacuating fluids from the cavities of the body, for recog- nizing pathological transformations in the deeper layers, and finally for administering medicines in fluid form. Larger puncture openings may be made with a small pointed knife held perpendicularly and pushed into the skin. If it is desirable, however, to avoid hemorrhage from the larger ves- sels, use round tubes pointed at one end. The trocar (acus triquetra) (Fig. 346) consists of a metal tube, the lumen of which is filled by a stylet that can be withdrawn ; the stylet is three-edged at its point. The instru- ment is inserted by one plunging movement, and the stylet w^thdrawn,^ when the fluid can be evacuated through the canula. If it is desirable^ to" ^ make the puncture very small, so that it closes of its own accord on St8/ (\! drawing the instrument and heals without any further treatment, lorig, ftrre _ , ^ trocars, pointed like a writing pen, are used, with a closely fitting syringe with which the fluid is removed by suction, and with which fluids can be 2O2 SURGICAL TECHNIC injected. For larger cavities use the various kinds of aspiration apparatus mentioned under Figs. 1248-1249. For diagnostic purposes (Akido-peirastik Middeldorpf, 1856), trocar- shaped instruments are used. Behind the point of the stylet, they have a small circular groove, in which, while the stylet is inserted or withdrawn FIG. 346. TROCAR FIG. 347. VON ESMARCH'S TROCAR FOR AKIDO-PEI- FIG. 348. SYRINGES FOR SUBCUTANEOUS INJECTION, a, Pravaz's syringe ; l>, Over- lach's syringe; c, Koch's syringe from the canula, small quantities of tissue sufficient for microscopic exami- nation are caught. There are also instruments with a divided point, which opens of its own accord when the canula is withdrawn (harpoon) (Fig. 347). For injecting medicines, syringes with a long fine hollow needle are used. Pravaz's well-known and largely used syringe (Fig. 348) contains exactly one gram of fluid ; its cylinder is marked by a scale divided into ten equal parts, so that a definite quantity may be injected into the body by pushing forward the piston. The injection is made as follows : Fill the syringe by suction with the desired quantity of solution, and expel the air which may have entered by pushing forward the piston with the point raised. Raise a fold of skin at some portion of the body ; insert the needle quickly through the base of the fold and into the superficial facia ; THE TREATMENT OF WOUNDS 203 convince yourself by a few lateral movements that the point did not enter the corium merely, or perhaps even a vein ; empty its contents by slowly pushing the piston forward (Fig. 349). Next, withdraw the needle and place the forefinger for a few moments upon the puncture, to prevent the injected fluid from flowing out. A slight pressure exerted simultaneously with the middle finger and the ring finger and a gentle rubbing promote the diffusion and resorption of the solution. FIG. 349. SUBCUTANEOUS INJECTION Preliminary even to this trifling operation, it is necessary carefully to cleanse and disinfect, not only the syringe and the fingers of the operator, but also the place on the skin selected for the injection. Otherwise, subcu- taneous abscesses may be caused from it. For some cases it is better to make the injection not merely subcu- taneously, but deep into the muscles (intramuscularly), for instance, in the case of quicksilver solutions, which, injected subcutaneously, can cause gangrene. Insert with a quick movement the fine hollow needle perpendicu- larly to the surface of the skin down to its hilt. The skin is drawn some- what laterally in order that the puncture of the skin does not form a straight line with the punctured canal in the deep layers. The same procedure is observed in injections of arsenic into malignant tumors and in injections of iodine into struma (parenchymatous injections). TISSUE DESTRUCTION This can be made mechanically^ by thermo-cautery or by cauterization with chemical substances. Soft tissues can be scraped away with the sharp spoon (von Volkmann, Fig. 350), especially lupus, fungous granulations, soft tumors, and caries. If the instrument is properly manipulated with firm repeated strokes over the whole diseased portion, it serves at the same time for diagnostic purposes, 2O4 SURGICAL TECHNIC since only diseased tissues can be scraped away, while healthy tissues resist the action of the spoon. This operation is valuable and frequently resorted to in the treatment of lupus. During the operation, some portions of lupus FIG. 350. SHARP SPOON can be recognized as new foci from their characteristic softness. By boring movements with the spoon, fistulas and foci which penetrate downward, especially tubercular softening of the bone, can be followed, exposed, and removed. The cautery iron (cauterium actuale) was formerly used most extensively, not only for destroying tissues but also in arresting hemorrhage, and as a substitute for the knife. The cau- tery iron has a straight handle or one bent at an angle. The ends are variously shaped. It is heated on a coal basin, hearth fire, etc., until it is red hot or white hot. In man y cases, the old cautery iron (Fig- 35 is often the best agent in effecting tissue destruction ; country physicians especially can- easily improvised, for instance, Roll up a piece of FIG. 351. CAUTERY IRON not do without it. Moreover, it can be from a piece of iron shaped suitably for the purpose, thick wire (telegraph wire in time of war) at one end in the shape of a cone or disk ; fasten the other pointed end (by means of a file) into a wooden handle (Brandis, Fig. 352). On the whole, however, the cau- tery iron is not so much used since Paquclin invented the thermo- FIG. 352. CAUTERY IRON OF TELEGRAPH WIRE (according to Brandis) cautery (Fig. 353), which can be handled more conveniently but which unfortunately is rather expensive. Its effect consists in a hollow cauterizing point made of platinum, con- taining a platinum sponge. It is brought to a bright red heat by benzole THE TREATMENT OF WOUNDS 205 or benzine vapors forced into the point from a bottle by a double rubber bulb. Heat the platinum point (a) over a spirit flame for a few minutes (Fig. 353) ; next, work the bulb (b\ first slowly, then gradually more rapidly, until the platinum point becomes a bright red heat. By means of the bulbs the desired heat can be maintained for any length of time. Care must be taken to hold the bottle, containing the benzine, always perpendicularly and lower than the red-hot point, else an explosion may occur from benzine entering into the platinum point. If the thermo-cautery does not work, heat it for some time in a strong flame without forcing any vapors into it. After using FIG. 353. PAQUELIN'S THERMO-CAUTERY it, do not dip it into cold water to cool it more rapidly. Since the introduc- tion of thermo-cautery, which appears comely and can be manipulated so easily, the actual cautery has lost its terror in surgery, and its application has vastly increased. Accordingly, as the operator selects ball-shaped, knife-shaped, or needle-shaped points, he may destroy surfaces with the instrument or make bloodless incisions, and hence, whenever it seems necessary, substitute it for the knife or make the finest punctures (with the so-called micro burner, to the platinum .point of which a fine copper needle has been welded). White heat, to be sure, destroys the tissues more rapidly, but it cannot be relied upon in preventing or arresting hemorrhage. Red heat chars the tissues more slowly and thus becomes a potent hemo- 2O6 SURGICAL TECHNIC static. If the points remain too long in the wound, the charred tissue frag- ments adhering to the red-hot metal often lessen its effect. Outside of the wound, the coating must be removed by increasing the heat. The eschars produced by the thermo-cautery do not necessarily interfere with the primary healing of the wound, especially when they are superficial ; for this reason, even in the abdominal cavity, the dull red-hot thermo-cautery is used for dividing adhesions, arresting hemorrhages of stumps, etc. Galvano-cautery {Middeldorpf) purposes making a piece of platinum wire red hot by an electric battery. If the operator possesses the necessary FIG. 354. IMMERSION BATTERY FIG. 355. GALVANO-CAUSTIC WIRE LOOP apparatus, its application is comparatively simple. Since this battery, how- ever, is rather expensive, it will probably be used more in hospitals and by specialists than by the practising physician. At the present time, immersion batteries are especially used, for instance Voltolini's, and the handle recom- mended by Bruits and Bocker (Fig. 354), in which the various attachments are inserted. While, however, for surgical purposes, thermo-cautery can be substituted almost everywhere, the galvano-caustic wire loop (Fig. 355) has this great advantage over it : the wire can be introduced into the tissues while cold (for instance, in a fistula, or around a pedicle or a cord (" Strang ") in the depth of the wound), and after the operator has convinced himself of its correct position, it is instantly brought to a red heat by closing the current. In this manner tissues can be divided bloodlessly by a fine THE TREATMENT OF WOUNDS 2O/ incision. Galvano-cautery is probably most frequently employed for the delicate operations in the nares, the larynx, and the ear. Galvano-puncture causes a slow destruction of tissues by introducing two platinum needles into the diseased portion ; the needles are connected with the electric battery. The galvanic current passes through the tissue from one needle to the other, causing a circumscribed linear destruction of the tissue. In this manner, small warts, hair follicles, etc., may be destroyed ; but even larger tumors, at least partly, may be caused to disap- pear (electrolysis). For the destruction of tissue, moreover, chemicals that form an eschar, or cauterize, are used (escharotics, caustics, cauterium potcntiale). Kali causticum potassa, caustic potassa in white sticks about as thick as a pencil, very deliquescent when brought in contact with the tissues, cauter- izes deeply, and if the necessary care is not exercised in preventing its diffu- sion also attacks the surrounding tissues. The eschar is white. Solid nitrate of silver, argentum nitricum fusum, lapis infcrnalis, lunar caustic, of like shape and color as the preceding, affects only the place touched with it; it is especially used for touching profuse granulations, which it covers with a white eschar of silver albuminate. The mixture of lunar caustic and saltpetre (i : I or i : 2) is harder and produces a milder effect than pure lunar caustic (lapis mitigatus), Cuprum sulphuricum (copper sulphate) in sticks (blue stick) cauterizes only superficially. Alumen iistum, dried alum, can be used only for very superficial cauterizations. Either the caustic sticks are held with the bare hand (the sticks are previously wrapped at one end with a little gauze or cotton) or instruments like penholders or pincers are used for holding them (porte-caustiques, Fig. 356). Care should be taken that the caustic stick is lodged firmly in the holder so that it cannot fall into the wound during appli- cation. Simple and very convenient are the quills and wooden sockets into which the caustic sticks have been inserted. They can be purchased anywhere. The application of the stick G ' 3 - causes only moderate pains, especially if care is taken not to TIQUE touch the tender white epithelial margin of a healing wound. Large ulcerating surfaces, tumors that cannot be removed with the knife, can be destroyed with the soft caustic pastes. Vienna caustic (pasta Viennensis*). Stir 6 parts of quicklime and 5 parts of caustic potassa with alcohol into a paste ; apply it about 5 milli- 208 SURGICAL TECHNIC meters thick with a chip of wood; after 6*to 10 minutes, the very deliques- cent paste has produced a firm gray eschar, which in its circumference appears as a gray line. Next, remove the paste and neutralize the cauter- ized part with acidulated water. The eschar is cast off in about 8 days after a severe inflammation. Paste of zinc chloride (Canquoin). Powdered chloride of zinc and rye flour are kneaded with a little water into a dough in various proportions (according to the intended strength of the mixture, i :2, i : 3, i : 4). It is applied in layers of |- : i centimeters thick, which are not removed until after 12 to 24 hours. At the place to be cauterized, the epidermis must be previously removed by means of a hot hammer, since chloride of zinc does not cauterize the intact epidermis. The cauterization is well denned and produces a leathery tough eschar ; but it causes violent pain, which may be mitigated by the addition of opium or morphine. After 8 to 10 days, the eschar is cast off and the wound presents good granulations. If necessary, the cauterization must be repeated by the application of freshly prepared paste. Arsenic paste (pasta arsenicalis Frtre C6sme\ Cosme powder (originally arsenici albi, 3.5; sanguinis draconis, 0.7; cinnabaris, 8; cineris solearum antiquarum combustarum, 0.5), is mixed with a little water into a paste, or more simply i part of arsenic is mixed with 15 parts of starch and water. It is applied only as thick as the blade of a knife and not on a large surface (poisoning). Amidst the most violent pains, it produces a leatherlike eschar, which is cast off after 10-20 days, leaving a good granulating sur- face which soon becomes cicatrized. Poisoning by rapid absorption is especially to be apprehended in parts which are not covered with epidermis. Less poisonous and less painful, especially for destroying vascular tumors, is the application of arsenic caustic powder, consisting of : acid, arsenicos. morph. muriat. aa. 0.25; calomel, 2; gummi arab., 12. (von Esmarc/i}. Ointment of tartrate antimony (i part tartarus stibiat., 4 parts adeps) is sometimes still used for superficial cauterization and revulsion. Sulphuric acid cauterizes the tissues so that they show a gray or brown eschar. Fuming nitric acid and chromic acid produce a yellowish green eschar (xanthoproteine). Chromic acid, however, even with careful applica- tion, can cause general poisoning and death. Pure carbolic acid cauterizes without causing pain, leaving a whitish eschar. Sublimate (i : 10 collodion) is applicable only for very small lesions (warts) on account of its poisonous tendencies. Lactic acid cauterizes tumors until they form a blackish mass ; THE TREATMENT OF WOUNDS 209 but it leaves normal tissues uninjured (von Mosetig}. Lactic acid paste, consisting of equal parts of the remedy and of silicic acid, is spread as thick as the blade of the knife on india-rubber paper, and applied to the diseased part; it remains in position 12 hours. In the application of all fluid and soft cauterizing agents, it is necessary to protect the surrounding parts from unintentional injuries by placing strips of adhesive plaster upon them, or by applying a thick layer of fat, collodion, etc. Union of the margins of the wounds is effected in clean, fresh wounds, and in such operation wounds as are not intended to close by granulation, by the SUTURE The suture is applied with straight needles or such as are curved on the surface, smooth at the point, with two cutting edges (Fig. 357). Large needles are managed with the free hand ; smaller ones are held with the needle holder, which affords a more safe and convenient guidance. DieffenbacKs for- ceps-like needle holder is most simple and useful for all purposes (Fig. 358). Hcgars (Fig. 359) and K iister's " s^van" needle holders (Fig. 360) are FIG. 357. SURGICAL NEEDLES, a, ordi- FIG. 358 nary eye; b, springy eye Dieffenbach's FIG. 359 Hegar's NEEDLE HOLDERS FIG. 360 Kiister's Swan FIG. 361 Roux's pecially suitable for suturing deep wounds and in cavities. Roux's needle holder (Fig. 361), the ends of which can be drawn apart and are closed by a sliding tube, is now less generally used ; but it is very practical. 2IO SURGICAL TECHNIC FIG. 363. HAGEDORN'S NEEDLES Hagcdorn recommended, in place of needles curved on the surface, needles bent on the edge and bevelled (like curved sabres Fig. 363); this shape produces punctured canals, which do not gape when the suture is drawn tight, but remain in the form of a slit ; the operator can sew with them very easily and con- veniently, if he uses the needle holder specially adapted for them (Fig. 362) ; the holder can be taken apart and sterilized. The following materials are used for suturing : i . Catgut. Catgut cords of vary- ing thickness (violin strings) are prepared in factories. They swell in the tissues of the body and are gradually absorbed. The catgut is rendered free from living germs and made aseptic according to the rules laid down on page 10. If the cat- gut sutures are not sterilized, this animal material will cause suppuration in the punctured canals. Since suppuration may occur even with the most careful sterilization, attempts have been made to substitute for it less septic materials, such as, sutures made of tendons of the reindeer, kangaroo, and whale., 2. Silk unbleached, raw Chinese silk, can easily be rendered free from living organisms by boiling ; it is also saturated with antiseptics : carbolized silk, by boiling it in a 5% carbolic solution and placing it in a 3% carbolic solution (Czerny)\ sublimated silk, by placing the boiled threads into a. i% sublimate solution ; iodoform silk, by placing it in iodoform ether. Best of all is plaited silk (Turner). Silk is not absorbed, but causes no irritation. Still, sometimes after a long period buried sutures are eliminated like foreign bodies under slight suppuration. 3. Flax thread can be used as well as silk, and is a somewhat cheaper material. More recently it has been saturated with celluloid and thus has become similar to silk gut (Pagenstechcr). 4. Seegras, silk-worm gut, Fil de Florence (obtained from the silk-worm), long, smooth, white, shining threads about \ meter long, furnish a most excellent (and also not too expensive) suture material, since they can be left for a long time in the tissues of the body without causing any irritation and without being absorbed ; they can be easily tied ; moreover, they very rarely tear; hence, are of especial use in closing wounds in which after tying FIG. 362 HAGEDORN'S NEEDLE HOLDER THE TREATMENT OF WOUNDS 211 the sutures much tension remains, and for relaxation sutures. They are sterilized in a 3% carbolic solution and are kept in a dry state, or boiled shortly before being used. Repeated boiling makes them brittle. Horsehair is a cheap substitute for these materials, especially in military and country practice. (The horsehair suture is almost indispensable in coaptating the margins of the skin and more particularly in plastic operations. They are somewhat elastic and can remain in the tissues indefinitely without causing irritation.) 5. Metal wire. Silver wire and iron wire can easily be rendered free from living organisms by boiling them or heating them in a spirit flame ; they serve a useful purpose especially for relaxation sutures and for the union of wounds which are subsequently exposed to tension (laparotomies, neck of hernial sac), and for bone sutures. The suturing is done in various ways : i. The interrupted suture (Fig. 364) is the one most commonly used and the most practical because it effects a very exact union of the edges of the wound. After the thread has been passed through both sides, it is tied and cut off about I centimeter ^ in front of the knot. Always apply the knot lat- ~~^ ^ I ^ erally from the line of the wound, for if applied FIG. 364. INTERRUPTED directly over the wound it causes slight pressure and SUTURE thus impairs exact adhesion. It is also important to tie the suture with a safe double knot, which does not become loose. The "reef knot" (Fig. 365) serves for this purpose; in this, the two ends of the thread are passed through both loops in the same direction, whilst in the false or granny's knot (Fig. 366), which does not hold securely, the ends are passed through the loops in opposite directions. FIG. 365. REEF KNOT FIG. 366. GRANNY'S KNOT The " re ef knot " is made in such a manner that in tying the first and the second knot the same end is placed uppermost, or lowermost. This is done in the simplest way as follows : 212 SURGICAL TECHNIC Draw the right end from below over the left end and over the point of the left forefinger in such a manner that, after the first knot has been tied, the right hand comes to lie upwards to the left, and the left hand down- wards to the right (position "over the hand"). Next, bring the right hand back in the same way into the position first occupied, that is to say, pass the right end over the left, and, below it, draw it out in a right upward direction. In another manner the knot can be tied with the hands by changing the ends of the sutures. Of the ends of the loop hanging down, pass the left with the right hand over the right, held with the left hand, and draw it out to the right ; next, by changing hands, carry it over the right and toward the left, so that each hand now holds the end it first held. When the margins of the wound are very tense, it is necessary, for the first knot, to pass the threads twice around each other (surgeon's knot Fig. 367), and to tie the second knot upon it as in a "reef knot." The first knot already holds the margins of the wound firmly together, whilst in the "reef" and "granny's" knots, the ends must be held tense when the second knot is tied : else, they become 367. SURGEON s KNOT * loosened. If a large wound is to be closed with the interrupted suture, the pro- cedure is as follows : First, approximate the margins of the wound and hold them as closely together as possible in the manner in which they are to be sutured ; next, apply the first suture in the middle ; the two subsequent sutures at the middle of both sides between the first suture and the angles of the wound ; and all subsequent sutures, according to requirements, always at the middle between two sutures, until the margins of the wound everywhere have been brought in close approximation. (The suturing of a large wound is much simplified and facilitated by inserting all of the deep sutures first ; and by tying them in the order mentioned above, referring to their insertion. This is more especially true in cases requiring approximation of the deeper parts of the wound by buried sutures.) If the edges are everywhere equally thick, pass the needle through on both sides at an even depth. If, in tying the knot, you find that one margin of the wound lies deeper than the other, raise it somewhat with forceps or a fine hook ; or else, depress the other suffi- ciently (Fig. 368). If the margins of the wound are of unequal height, carry the needle superficially through the thicker margin, but more deeply through THE TREATMENT OF WOUNDS 213 the thinner and nearer to its edge (Fig. 369) ; if the thin edges of the wound turn up inwardly, introduce the needle close at their margin (Fig. 370), and in tying the knot, raise the edges of the wound with fine hooks ; or, if possible, press together with two fingers both margins of the wound into a FIG. 368 FIG. 369 FIG. 370 small fold, and unite them in this position. If one margin of the wound is a little longer than the other, make the interspaces on the longer one somewhat larger than on the shorter, the number of stitch openings being equal. In tying the sutures, compress somewhat the longer margin, and unite it with the other (" verhalten ndhen "). If it is desirable to obtain a very exact union, carry the needle through near the edge of the wound and only superficially ; for farther away from the margin of the wound and introduced more deeply, the suture relaxes rather the tension of the super- ficial line of suture and unites the deeper parts of the wound. Usually both kinds of sutures, in closing a deep wound, are used in such a manner that a few deep interrupted sutures are first applied ; the approximated edges are next exactly united with superficial sutures ; the necessary relaxation sutures, ac- cording to requirement, are finally added (Fig. 370- After the healing of the wound, it is easy to remove the sutures, if the operator has used good catgut for suturing ; the portion of the loop of the suture which lies in the wound has been absorbed ; the other portion with the knot lying on the skin is adhering to the dry dressing, and is removed with the same. If no absorption has occurred, or if other materials have been used for suturing, grasp one end of the knot with forceps, raise it gently and divide the suture with a pair of scissors between the knot and the skin, and extract it laterally toward the side which has been cut off (Fig. 372). The fresh adherent margins of the wound are not drawn apart in doing this, but pressed one against the FIG. 371. SUPERFICIAL AND DEEP INTERRUPTED SUTURES FIG. 372. REMOVING A SUTURE 214 SURGICAL TECHNIC other. Sometimes silk sutures do not heal in without reaction in spite of careful asepsis, and very unpleasant suppuration may be caused by them in the punctured canal. The suture methods with extractable (buried) sutures try to remedy this disadvantage. The sutures are applied in such a manner that from some places externally of the wound a whole row of sutures can be removed at once. These experiments, however, have not met with such a success that they can be recommended for general use (Tonnasko, Link, Stapler, and others). 2. The continued or glover's suture (Fig. 373) can be applied much more rapidly than the interrupted suture, and it unites the margins of the wound very accurately. Commence at one angle of the wound with an interrupted suture ; do not cut off the thread after it has been tied ; at a little distance, introduce the needle again, and pass it vertically to the line of the wound through both edges. Make tense to some extent the thread taking then an oblique direction to the wound, and continue applying the sutures to the other angle of the wound in the manner already described. Finally, for tying the knot, do not draw the last suture tight, but tie its loop with the end of the thread carried through the other edge of the wound (Fig. 374); or apply the continued suture across the line of sutures just applied, returning thus to the beginning (in this way, the stitches are placed in the form of a cross) ; finally, tie the end of the suture with the other end of the inter- rupted suture first applied and kept long for this purpose. FIG. 373. CONTINUED OR GLOVER'S SUTURE FIG. 374. TYING A CON- TINUED SUTURE FIG. 375. LANGUETTE SUTURE 3. A modification of the continued suture, often very useful, is the languette suture (Fig. 375); the point of the needle before it is drawn out is passed each time under the thread loop of the preceding suture. Deep sutures, which approximate and hold in contact the surfaces of deep wounds, are applied in order to obviate dead spaces at the base of the wound. If these spaces are of a very irregular form, and if the depth of the wound is considerable, buried or subcutaneous sutures (with catgut) are applied; these unite the different layers of tissue separately, and are applied in successive rows (dtage suture). They can be applied as contin- THE TREATMENT OF WOUNDS 21$ ued or as interrupted sutures. At the same time, however, the deeper layers in simple wounds can be united with the overlying skin by deep interrupted sutures, provided the needle is carried properly and at a sufficient distance from the edge of the wound, and provided all layers, one after another, are pierced separately with the needle. They are firmly pressed together by tying the knot. 4. The laced suture was especially used by Dieffenbach for closing smaller openings, fistulae, etc. He applied it as a subcutaneous suture by allowing the thread to take a circular course under the skin of the opening to be closed. He stitched about the circumference of the circle in three or four sections, when, by continuing the suture, the needle was carried back to the first suture (" Ausstichoffnung "). Finally, the ends were tied loosely and thus the opening closed, or at least contracted. Similar is the tobacco pouch suture which is again used by Doyen and DC Qnervain, especially for closing peritoneal wounds (stomach, intestines, vermiform FIG. 376. LACED SUTURE WITH MARGINS FIG. 377. LACED SUTURE WITH MARGINS OF WOUND TURNED INWARD OF WOUND TURNED OUTWARD appendix, gall bladder, peritoneum of the laparotomy incision). The inver- sion suture (Fig. 376) serves for closing a hollow organ covered exteriorly with serous membrane ; the eversion suture (Fig. 377) is especially adapted to close the lower portion of the abdominal cavity covered with displaceable serous membrane. As a rule the wound should not be longer than 8 to 10 centimeters. The part of the sutures lying toward the abdominal cavity should be as short as possible to effect a more extensive approximation of the peritoneal surfaces. When the first suture opening has been reached again, traction is made slowly and steadily on the ends, but not too firmly, to prevent necrosis. The following sutures are especially used as deep subcutaneous sutures : (In uniting deep wounds without buried sutures, dead spaces can often be avoided by including in the deep sutures the floor of the wound. A large curved needle must be used for this purpose.) 5. The folding suture, " Faltennaht " (Fig. 378) serves especially for uniting very thin and flaccid edges of skin (for instance, on the eyelid). 216 SURGICAL TECHNIC The edges are raised to form a fold, and thus the surfaces of contact are made larger. 6. The quilt suture (Fig. 379) is like the preceding, only the needle is carried through much more deeply. It is sometimes used as a relaxation suture. if FIG. 378. FOLDING SUTURE FIG. 379. QUILT SUTURE 7. The quilled suture (Fig. 380) is made with small, round rods (quills, portions of probes, catheters), which are firmly drawn together with silk or metal threads. 8. The button suture (Lister Fig. 381) is made with silver wires. The ends of each wire are attached to lead buttons perforated in the centre. They are fastened across the upturned ends or wings of the buttons by figure-of-8 turns. FIG. 380. QUILLED SUTURE FIG. 381. BUTTON SUTURE 9. In the pearl suture ( Thiersch Fig. 382) the silver wire is carried first through the lead buttons and next through glass pearls. It is fastened by winding around a little rod. 10. The shot suture, " Schrotkugel," is similar but simpler. The ends of the thread (silk, sil- ver wire) are passed through perforated shot, and with a pair of clamping forceps the latter are compressed with the wound margins in proper position upon the thread over the skin. These last sutures, as can be seen already from their appurtenances, can be made only after the necessary preparations ; they served for certain purposes, especially FIG. 382. PEARL SUTURE THE TREATMENT OF WOUNDS 217 as sutures in the perineum, rectum, vagina, and are probably used very rarely now. Likewise : 1 1. The twisted suture (Fig. 383). It is applied with insect needles, the points of which are shaped like the head of a lance. After they have been passed through the skin, at some distance from the edges of the wound, sterilized thick cotton threads are wound around them in alternating circle and figure-of-8 tours in such a manner that the edges of the skin are evenly and uniformly drawn in apposition. Likewise little rubber bands Q, FIG. 383. TWISTED SUTURE may be stretched over the needles. The ends of the needles are then cut off with a pair of nippers. For a more uniform union of the margins of the wound, apply a few fine interrupted sutures in the interspaces between the needles. The stumps of the needles may be extracted on the second day by twisting movements with forceps. The roll of threads, which are mostly agglutinated with the skin by the dried wound secretions, remains in position several days longer. Very small superficial wounds, the edges of which do not gape, may also be united without suture by means of small compresses of absorbent cotton, or small pieces of gauze, which are saturated with iodoform collodion or zinc paste (see also p. 37). Very convenient is also the greatly ad- hesive zinc oxide plaster. English plaster and ordinary adhesive plaster can be used for only very small wounds, provided the hemorrhage has been arrested completely and the wound is not infected ; for by occlusion with adhesive plaster the drainage becomes obstructed for the escape of the secretions, and inflammation, suppuration, etc., may set in. " A physician who closes up a fresh wound with adhesive plaster, with- out any antiseptic precautions, exposes himself to the risk of prosecution for damages " (yon Nussbauni). 218 SURGICAL TECHNIC REMOVAL OF FOREIGN BODIES If a foreign body has entered from without and is lodged only super- ficially in a cavity of the body or in a wound, so that it can be easily reached and grasped, it is not difficult to remove it. To prevent symptoms of inflam- FlG. mation, this should be done as soon as possible ; and to prevent unintentional secondary injuries, it should be done as gently as possible. The foreign body is grasped with dressing forceps (Fig. 384); smaller ones with good anatomical forceps (Fig. 385). Sometimes, in narrow cavities, the operator FIG. 385. ANATOMICAL FORCEPS succeeds better in passing around the body a wire loop (for instance, made of a hairpin) and extracting it by pressure from behind. Concerning for- eign bodies in the cavities and canals of the body, see details, under the various headings. Sharp-pointed objects which have penetrated under the skin often cause difficulty and sometimes render an enlargement of the generally small skin wound necessary ; this is especially the case with fragments of glass, which lacerate the wound with their sharp edges. Splinters of decayed wood, frequently entering beneath the nail, in most cases cannot be well grasped, since their projecting part generally has been broken off by attempts at removing them. Hence, either a small wedge must be excised from the margin of the nail, or else the portion of the nail over the splinter must be removed with the knife. It is simpler to grasp the foreign body with the pointed splinter forceps (Fig. 386). For the extraction of broken-off blades of knives, etc., which cannot be grasped very well on account of their smoothness, wind around the end of the dressing or other forceps a few THE TREATMENT OF WOUNDS 219 FIG. 386. SPLINTER FORCEPS strips of adhesive plaster ; else, use a needle holder with jaws lined with soft lead. Needles, provided they can be felt through the skin, can be pressed between two fingers against the skin in such a way that they pierce it from the inside. (The Rontgen ray has become almost indispensable in ascertaining the presence and exact location of metallic substances in the body, and hence it is a very valuable aid to the surgeon in finding and extracting them.) Crochet needles may be extracted without any difficulty by a vigor- ous pull. Fishhooks, arrow heads, and other similar foreign bodies with strong barbed hooks must be pushed forward in the direction of the point of entrance, or must be exposed by an incision. If small objects, splinters, needles, etc., are to be removed from the tissues by an incision, a resort to the bloodless method is of very great advantage ; otherwise, the foreign body is either very hard to find in the bleeding wound, or is overlooked altogether. The exposure to the Rontgen rays furnishes the safest diagnosis concerning the presence and position of the foreign body. The removal of metal rings (finger rings, keys, etc.), which have been stripped over a finger or the penis, may sometimes cause a great deal of trouble, since the parts on the distal side of the circular compression begin to swell to such a degree that the strangulating ring is often not visible. In very easy cases, the operator will succeed, after the strangulated part has been lubricated with soap or fat, in removing the ring by turning movements ; the oedema, which prevents the removal of the ring, is reduced in the quickest and most efficient manner by bandaging it with a small rubber bandage. In the absence of such an elastic bandage, a thread or narrow tape is applied closely and firmly from the tip to the ring ; the end of the thread is passed below the ring and is now wound in a downward direction, whereby the ring is gradually drawn down (Fig. 387). If it is not possible to remove the ring in this man- ner, it must be divided with a pair of nippers or with a fine saw, and bent apart. In war, the removal of bullets from wounds is of special importance. Of course, with the great penetrating power of modern firearms, bullets will remain lodged in the body more rarely than formerly. FIG. 387. REMOV- ING A RING BY MEANS OF A NARROW TAPE WOUND IN A DOWNWARD DI- RECTION 220 SURGICAL TECHNIC If a bullet has not completely pierced the portion of the body, but has remained lodged in it, the wounded person desires most urgently to be freed from it, considers himself saved when this has been successfully done, and shows the greatest gratitude and due recognition to the surgeon. As simple as this operation is in most cases, as much as the young surgeon rejoices over its success and the gratitude of the wounded, it is, nevertheless, unpar- donable unless the surgeon is able to perform it aseptically, which on the battle-field and in field hospitals is generally difficult and in most cases unnec- essary. For experience teaches us that bullets can remain in the body for a long time without causing injury, and that gunshot wounds, even with an extensive comminuted fracture can heal under a simple antiseptic com- pressive dressing, provided the wound has not previously been examined with unclean or only seemingly disinfected fingers, probes, or forceps. The great difference between wounds which have been touched with the fingers and those which have been left untouched, the sad consequences which such a rash examination can have for their healing or even for the life of the wounded person, should always call to the mind of every surgeon (and most especially in war), the first principle of all medical action, "Do no harm ! " For the experience gained during the wars of the last fifteen years shows that even severe splintered fractures of joints healed smoothly under an aseptic occlusion dressing and immobilization of the limb, although the bullet was still in the body. For, according to Langenbuch, a gunshot wound is to be considered as aseptic. To extract a bullet which can be felt under tJic skin, is by no means a difficult operation. With a sharp knife, a bold cut is made down to the bullet, kept steady with the fingers of the left hand until it becomes visible in the wound, when it is extracted with dressing forceps or bullet forceps. If a soft lead bullet has become very deformed by meeting with resistance, or is very distended and jagged, the cellular tissue and the fascia must often be divided in several directions, in order to extract it without using force. The extraction of deep-seated bullets does not cause any especial difficul- ties under the protection of asepsis, since the operator need not hesitate to divide the soft parts to such an extent as may be required for finding the foreign body. (The Spanish-American, Philippine, and Boer wars have demonstrated the wisdom of abstaining from examining recent gunshot wounds and of pursuing a conservative course of treatment. There are very few cases, indeed, in which it is justifiable to search for and make attempts to remove the bullet. The modern bullet becomes more readily THE TREATMENT OF WOUNDS 221 encapsulated than the old leaden missiles. The best results are obtained by healing the wound with the first aid antiseptic dressing and immobilization of the injured limb or part.) In evacuating the blood clots from fresh wounds, the bullets which may have entered are removed at the same time, and no other instruments are needed for this purpose except the common dressing forceps or the American bullet forceps (Fig. 391) ; with these, the bullets can be readily grasped, since the sharp hooks of the same firmly penetrate the lead. FIG. 388. FLEXIBLE ZINC PROBE But if it becomes necessary to remove bullets that are in the depth of granulating wounds and that prevent the definite cicatrization of the same, that cause fistulas of long duration, or that cause trouble by pressing on the nerve trunks or other important organs, the extraction can, after all, become very difficult, especially when the bullets are very much deformed, are lodged at dangerous places, or firmly impacted in the bone. Sometimes the question must be first decided whether a foreign body is at all in the depth of the wound and of what quality it is. The safest information gives the exposure to the Rontgen rays, radioscopy and radiography, which already, in very many clinics, are used extensively to establish the presence of foreign bodies. Likewise in the last wars the procedure has rendered good service. If a bullet or a fragment of the same is present, it can be recognized at once in the skiagraph. The presence of small bullets healed in without causing any symptoms of inflam- mation etc., has established a new principle, namely, to disturb these foreign bodies as little as possible, but rather to promote their incapsulation. Shot and pistol bullets up to a calibre of 9 millimeters can remain in the body, even in the brain or the lungs, without causing any injury (von Bergmami). Hence, the surgeon should well consider whether probing in the last two organs would not cause greater injury than the bullet itself. The removal of the foreign body, however, is necessary when great injury has been 222 SURGICAL TECHNIC caused ; for instance, when the bullet is lodged in a nerve or upon an articu- lar surface, when serious symptoms have occurred in the organ involved. It is often very difficult to see from the skiagraph at what depth the bullet is lodged, hence, by means of pictures taken from various positions the exact location of the bullet must be established. Else a probe must be introduced, if the canal caused by the gunshot is still open, or if any fistulous opening exists. The shadow of the probe will lead to the exact location of the bullet. But if the exposure to the Rontgen rays cannot be made, and if it is imperative to remove the bullet, probing for the same is justifiable. The operator should not use for this purpose the common thin silver probes, with which nothing can be felt distinctly and whose fine points are especially apt to lead in a wrong direction, but he should use the flexible zinc probes (Fig. 388), about I foot in length and as thick as a goosequill or a lead pencil, with which no injury is caused, if they are manipulated gently. FIG. 389 FIG. 390 VON LANGENBECK'S BULLET FORCEPS FIG. 391 AMERICAN FORCEPS FOR SOFT LEAD BULLETS FIG. 392 FIG. 393 FORCEPS FOR JACKETED BULLETS If the bullet is felt, the operator should try to grasp it with one of the various bullet forceps (Figs. 389-393) and extract it carefully. If the bullet is lodged in a bone, it can be bored into with a bullet screw THE TREATMENT OF WOUNDS 223 and thus be extracted. But if it is found to be very firmly lodged in the bone, not too much force should be used, since dangerous inflamma- tions of the bone may be caused thereby. It is better either to wait until the bullet of its own accord is liberated by inflammatory absorption of the bone tissue, or, after an adequate incision of the soft parts, to remove with chisel and hammer enough of the surrounding bone to enable the bullet to be extracted with forceps without force. (In all future wars the Rontgen ray will be largely relied upon in ascer- taining the presence and exact location of bullets lodged in the body. It proved to be of inestimable value during the Spanish-American war.) If the operator is in doubt whether the hard body felt in the depth is the bullet or not, with the soft lead bullets of former wars, he could obtain assurance of it either by using Nelatoris probe, tipped with an unglazed porcelain bulb, which, when rubbed against the bullet, is stained by the lead ; or by means of Lecomte-Liier 1 s exploring- instrument for bullets with which a small particle of lead may be nipped off from the bullet ; or finally by the use of Liebreictis electric bullet probe (Fig. 394), which sets the mag- netic needle of a galvanometer in motion as soon as the isolated points of the probe or of the forceps touch a metallic body. (AT/fa ton's probe has lost much of its diagnostic value in searching for modern jacketed bullets, as the lead test no longer can be elicited since the lead part of the bullet has been encased by firmer metals. The changes in the construction of the modern bullets have rendered also the use of the old bullet forceps obsolete. The editor has devised a bullet forceps which grasps with certainty jacketed bullets of any size.) If the bullet cannot be felt in the wound, but can be felt at some other place under the skin, and if the operator is in doubt whether he feels a bul- let or a piece of bone, he can assure himself by inserting two steel needles with handles (acupuncture needles), which are placed in connection with Liebreich's electric bullet probe. More recently electric microphonic bullet probes have been mentioned, for instance, by Fowler and Klein, by means FIG. 394. LIEBREICH'S ELECTRIC BULLET PROBE 224 SURGICAL TECHNIC of which a small sound is produced in a little telephone as soon as a needle touches the bullet. Of a similar construction is Wells's telephonic bullet probe and forceps. If an electric bullet probe is not at hand, it can be improvised (according to Longmore) from a copper coin and a bent piece of zinc, which are kept apart by a piece of flannel dipped into diluted acid. One of the two insu- lated copper wires which end in acupuncture needles is wound several times around a pocket compass, the needle of which moves as soon as the current is closed by coming in contact with the bullet (Fig. 395). FIG. 395. LONGMORE'S BULLET PROBE If bullets which have been imbedded in the bone for years or which in necrotic portions of bone lie in so-called "coffins" (involucra) are to be removed (after osteomyelitis, a very frequent occurrence in consequence of contusion of the bone by gunshot), then the broad opening in the bone (necrotomy) must be performed. OPERATIONS FOR THE PREVENTION AND ARREST OF HEMORRHAGES AND THEIR CONSEQUENCES SAVING OF BLOOD From all times, surgeons have endeavored in operations and injuries to limit the loss of blood to a minimum. In olden times, before amputations, the limb was encircled with cords, the cautery iron was next used for arrest- ing the hemorrhage, or the stumps were dipped into boiling pitch. Until THE TREATMENT OF WOUNDS 225 about twenty-five years ago, surgeons confined themselves to reducing the loss of blood in amputations by preventing the arterial flow of blood to the wound. This was effected by compressing the trunk of the artery, either with the finger or with the pad of the tourniquet. With the same agencies they tried to combat arterial hemorrhage in acci- dental injuries. The attempts to remove a large portion of the body in a bloodless way by ligature (von Grafe} and by crush- ing them with a chain (ifcrasement Chassaignac, Fig. 396) have met only with temporary success. Not until the bloodless method was invented were surgeons enabled to avoid the loss of blood in all operations on the extremities, to keep off during the operation the disturbing flow of blood, and thus to operate on the living body with the same ease as on a cadaver. The bloodless method, temporary ischamia (von Esmarch, 1873), purposes two things: (a) To expel the blood present in the vessels from the portion of the body to be operated upon. () To prevent the afferent flow of blood through the arteries. F IG> The procedure is as follows : CHASSAIGNAC'S i. The limb from the points of the fingers or toes upward and beyond the field of operation is firmly bandaged with an elastic band, preferably of pure india-rubber. The several tours of the bandage overlap each other about one-half. Crossed and reversed turns are not made ; it is unnecessary to bandage the several fingers and the heel according to the rules of bandaging. The compression bandage is carried up as far as the place where the elastic constrictor is to be applied, and here it is fastened by placing the head of the bandage under the last tour. For practical reasons, it is advisable to carry the bandaging always as far as the upper part of the arm or the thigh (Figs. 399, 400). Such parts as contain pus, sanious matter, or soft tumor tissue, must not be bandaged, because thereby infectious matter might be pressed into the cellular tissue and the lymph channels. In such cases, the operator must be satisfied to hold the limb up perpen- dicularly for a few minutes until it has become visibly pale. Light superfi- cial stroking with the hand promotes the return of blood from the veins. (Very few surgeons now make an attempt to render the limb bloodless by elastic compression as a preliminary step to elastic constriction, as the limb is rendered practically bloodless by holding it for five minutes in a ver- tical position.) Q 226 SURGICAL TECHNIC 2. At the place where the bandaging ends the constrictor is applied. For this purpose, it is best to use an elastic band 5 centimeters wide and about 140 centimeters long with inwoven rubber threads (rubber bandage), which FIG. 397. ELASTIC CONSTRICTOR (according to von Esmarch) FIG. 398. CLAMP BUCKLE under continued tension is carried around the limb in circular turns so that the several turns cover each other. In this manner, each tttrn strengthens the effect of the preceding turn ; it is, therefore, not always necessary, espe- FIG. 399. ELASTIC BANDAGE AND CONSTRICTOR dally with new elastic bandages, to stretch them to the limit of their elas- ticity, because, especially in the arm, considerable pain is caused, sometimes even paralysis. The right measure of force to be used is learned by practice. FIG. 400. LIMB RENDERED BLOODLESS ON REMOVING ELASTIC BANDAGE In applying the elastic band, its starting end is pressed firmly with the thumb against the limb and held in position by the next turn, which passes over it. The rolled-up head of the band does not descend closely upon the turns of THE TREATMENT OF WOUNDS 227 the limb as in the application of a common bandage ; but, in order to secure the requisite tension, it is carried around the limb at a distance of 6 to 8 inches. The end \s fastened \>y a clamp buckle, which is pushed toward the FIG. 401. RUBBER CONSTRICTOR hook fastened to the upper end of the band (Figs. 401, 402), or else the end of the band is pushed under the last turn, best of all over the main trunk of the artery, and fastened thus (Fig. 398). Nicaise's elastic band is also practical. It consists of a hook and a number of rings sewed in a row at one end of the band (Figs. 401, 402). In case of necessity, the end of the constrictor can be fastened with a safety pin (Fig. 401). 3. When the elastic bandage below the constricting band is removed, the limb pre- sents a perfect post mortem pallor. Any operation can be performed upon it without the loss of blood. The operator is not hin- dered by the flow of blood from seeing or from recognizing the diseased tissues, and is not obliged to do much wiping or spong- ing ; hence, he operates with less assistance, and with the same facilities as on the cadaver, even if the operation should be a prolonged one. Experience has taught that the flow of blood can be interrupted in this manner for several hours without causing any essen- tial injury or fear of gangrene. Cases are even known in which the constrictor re- mained in position from 7 to 10 or 12 hours without resulting in gangrene or paralysis. FlG- 402 FlG> 403 4. At places where the application of a NICAISE'S ELASTIC BAND 228 SURGICAL TECHNIC broad constrictor is difficult, as in the iliac region and the axilla, it is advisa- ble to use the thick elastic tube which was originally used for constricting the limb, and which, under strong tension, is carried in circular turns two or three times around the part of the body, when its ends are tied or fastened with hooks and chain (Fig. 403). For fastening the ends of the elastic tube, a clamp can be used, for instance, a metal ring with an opening lengthwise from the diameter of the tube (Fig. 404); in the cleft of this ring, both stretched ends can easily be pressed. But if the ten- sion is relaxed, they become fixed FIG. 404. VON ESMARCH s APPARATUS J FOR BLOODLESS METHOD by pressing upon each other from opposite directions (Fig. 405). (The simplest manner to fasten the ends of an elastic constrictor band or tube is to apply a strong forceps over the crossing of the two ends after the constriction has been made in a satisfactory manner.) In the application of the elastic constrictor on limbs which are the seat of an oedematous swelling, attention must be paid to the fact that the effect upon the vessels often ceases as soon as the serum has been displaced from the tis- sues at the con- stricted place. In such cases, as soon as the limb assumes a reddish color, the constrictor must be quickly removed and immediately re- applied at the deep groove caused by it. In operations in and on the shoulder FASTENING ELASTIC TUBE (von Esmarch) joint, an elastic tube as thick as a finger, after it has been carried through below the axilla under strong tension, must be kept in position on the FIG. 405 FIG. 406 THE TREATMENT OF WOUNDS 229 shoulder by a strong hand or by a tube clamp (Figs. 407, 408). By draw- ing the ends toward the neck, they are prevented from slipping off. Care FIG. 407 FIG. 408 BLOODLESS METHOD FOR DISARTICULATION OF SHOULDER FIG. 409 FINGER RENDERED BLOODLESS must also be taken not to divide the elastic tube and to guard against its slipping over the wound (after a very high amputation or disarticulation of the humerus). FIG. 410. BLOODLESS METHOD USED IN OPERATION ON PENIS AND SCROTUM FIG. 411. BLOODLESS METHOD IN HIGH AMPUTATION OF THIGH For tying off the circulation from a finger, a rubber tube as thick as a goosequill is sufficient ; this is applied as represented in Fig. 409. 230 SURGICAL TECHNIC With a similar elastic tube, the root of the penis and the scrotum can be tied off, if the operator desires to perform operations on the external male organs of generation without any loss of blood (Fig. 410). In high amputations of the thigh, the elastic tube is carried closely below the crural arch once or twice with considerable force around the thigh; the ends are made to cross over the inguinal re- gion, and are then carried around the posterior sur- face of the pelvis and finally hooked together by a chain in the hypo- gastric region (Fig. 411). In disarticulations at and resections of the hip FIG. 412. BRASS SPIRAL BANDAGE (von Esmarch) . i i joint, provided the intes- tines have been previously evacuated thoroughly, the arterial flow may be most safely controlled by compressing the aorta in the umbilical region (see p. 236). Of course, elastic constriction with a rubber tube may also be applied in any other place, instead of the regular constrictor. Still, the latter is pref- erable, since its elasticity is more limited, and hence its effect never so powerful as that of the tube applied under the greatest tension. Moreover, the pressure of a broad bandage is more agreeable and can be borne without any dangerous consequences, since the circle of compression is a wider one. In fact, constriction produced by an excessively stretched tube may cause pa- ralysis of long duration, which occurs only very rarely when the broad con- strictor is applied, and with ordinary care in applying the same hardly ever occurs. If, in operations under local anaesthesia, the pressure caused by the con- striction is found to be too painful, apply, either above or below, a new constrictor and then release the constricted part. It is a deplorable fact, however, that rubber bandages and textile fabrics, when kept for any length of time, especially in a very hot or cold climate, become brittle and unfit for use. Hence it is more practical (for expeditions, voyages on shipboard, in the tropics, and in the polar regions, for preser- vation in military arsenals, etc.) to have the constrictors made of fine brass spirals, laid side by side, covered with glove leather and provided with a clamp buckle (Fig. 412). This constrictor is not liable to deteriorate, and THE TREATMENT OF WOUNDS 231 its elasticity answers every purpose in substituting it for the ordinary rubber elastic constrictor. It is to be hoped that, just as in the various armies of foreign countries, so also in Germany, the constrictor of this simple and durable form will be introduced and that it will displace the old-fashioned tourniquet, which is not by any means as safe and effective. For the advantages of elastic constric- tion are apparent. They consist chiefly in the fact that it is unnecessary, even injurious, to place a pad upon the main trunk of the artery as is done in the use of the tourniquet. Suck a pad is altogetJicr foreign to the bloodless method. In making use of elastic constriction, the surgeon desires to produce an effect not only ^^pon the artery but uniformly upon all vessels ; it interrupts the entire circulation in the constricted part, and, for this reason, can be used in major operations as well as in arresting seri- ous arterial and venous hemorrhage from accidental wounds; in fact, it serves a useful purpose in the treatment of poisoned wounds by preven- ting absorption of the poison, without presupposing an exact anatomical knowledge. These considerations suggested the idea of supplying laymen with an elastic constrictor in the form of a pair of suspenders as an aid in sudden accidents. The tourniquet suspender (von Esmarch, 1881) consists of an elastic band 1 50 centimeters long, 4 centimeters wide, provided at each end with hooks and eyelets ; by untying three loops it is transformed into a very light and comfortable band (Fig. 413). Its elasticity is sufficient to constrict successfully the thigh of a powerful man. If this inexpensive wearing apparel were worn by every workman and soldier, then, with proper instruc- tion, many accidents could be mitigated by a proper application of the bandage ; and especially death from hemorrhage might be prevented. Indeed, a very large number of such cases have been reported already, both by physicians and by laymen. FIG. 413. TOURNIQUET SUSPENDERS (von Esmarch) 232 SURGICAL TECHNIC FIG. 414. APPLYING A TOURNIQUET SUSPENDER In emergency cases, when an elastic bandage is not at hand, apply a linen bandage in circular turns as firmly as possible around the limb, and then moisten it with water; the swelling of the bandage caused by the moisture increases the constriction. The ascending bandaging of the limb may also be made more effective with a cloth bandage subsequently mois- tened. Likewise, the Spanish windlass, represented in Fig. 425, can be made use of for circular constriction without any pad. When the constriction bandage is removed at the end of the operation, the limb, which until then presented a deadly pallor, turns as red as a boiled lobster, and a very considerable hemorrhage occurs in the wound, because the walls of the blood vessels were in a state of paresis and had become flaccid from the continued pressure upon the vasomotor nerves ; hence, they allow more blood to pass through them than in their normal condition. The consequence is that the blood gushes forth from the operating wound as from THE TREATMENT OF WOUNDS 233 a sponge. The arteries spirt forcibly, and even the finest capillary vessels bleed almost twice as much as without the use of elastic constriction. The hemorrhage is, of course, most violent if the constrictor is removed slowly, because the blood immediately enters the arteries of the part which was constricted ; but since it cannot return immediately through the veins, which are still compressed by the last turns of the bandage, as in the operation of bloodletting, venous congestion is likely to occur in addition to the paralysis of the vasomotor system. Hence, it is necessary to remove the constrictor not slowly, but quickly. The profuse parenchymatous secondary hemorrhage, which is the greatest disadvantage of elastic constriction, can be avoided, before removing the constricture : 1. If all visible vessels that have been divided are most carefully ligated ; next, 2. If the wound in its depth and at its margins is sutured so that no dead spaces remain anywhere ; and finally, 3. If a uniform compressive bandage, every where firmly applied, is placed upon the sutured wound. Cavities of the wound which must heal by granula- tion, or which are intended to be closed by secondary sutures, are firmly tamponed. The constriction band is not removed until the dressing has been completely applied ; hence, it is advisable to apply the constrictor from the beginning as high above the field of operation as possible, in order not to cause any difficulty in removing it rapidly. . 4. If, after the removal of the constrictor, the limb is raised and placed in a vertical position for several hours ; in suitable cases, also, the com- pressive bandage can be strengthened by an elastic bandage under moderate tension. If these rules are observed, a secondary hemorrhage need not be apprehended. If the surgeon, however, from excessive fear of secondary hemorrhage, or because he thinks himself not sufficiently skilled in finding smaller divided vessels, does not venture to suture the wound and to bandage it before the constriction is removed, then, after removal of the bandage, with the limb held in a vertical position, a large compressive bandage or a sponge must be firmly pressed for several minutes upon the surface of the wound, and the vessels which are still bleeding or spirting must next be sought for and tied. If the parenchymatous hemorrhage, however, continues, it is arrested by irrigating the wound with a sterile or antiseptic fluid as cold as ice. For this purpose, an ice douche is used, that is, a glass irrigator in the middle of which a glass tube filled with a cold mixture (pounded ice and salt) is 234 SURGICAL TECHNIC inserted. Digital compression of the principal artery is also useful in arrest- ing parenchymatous hemorrhage. The advantages of elastic constriction over former methods, especially the advantages of the application of the tourniquet, are generally known ; they consist chiefly in the fact : 1. That the blood interruption is safe and can be maintained conveniently for a long time. 2. A displacement during transportation, as is the case with the pad of the tourniquet, need not be apprehended. 3. The constrictor can be applied on any desirable part of the limb. 4. For applying the constrictor band, no anatomical knowledge is neces- sary. In contradistinction to these advantages, it is hardly necessary to refute the assertions again and again made by some persons that the procedure had the following disadvantages : 1. More profuse parenchymatous hemorrhage. 2. Gangrene of the margins of the wound, or even of the whole con- stricted limb. 3. Paralysis of the nerves from the pressure of the constrictor. 4. The danger of infection from pus or tumor cells from compression of the limb. None of tJiese disadvantages exist, if the above simple rules are observed in applying the bandages. Only briefly may it be mentioned here that formerly a successful attempt was made to interrupt the flow of blood by pressure limited to the field of operation. Desmarres invented his clamp for opera- tions on the eyelids; these are clamped upon the plate by means of the ring (Fig. 415). Dieffenbach used forceps ending in two rings, between which he clamped the cheek, the tongue, or the lip, in order to remove bloodlessly angiomata, etc. (Fig. 416). In the operation for harelip or the cutting out of a wedge-like portion in cancer of the lips, the flow of blood from the coronary arteries can be arrested on FlG> 4l6 i ., ., ... _ , DIEFFENBACH'S RING both sides of the field of operation with FORCEPS FIG. 415 DESMARRES'S CLAMP THE TREATMENT OF WOUNDS 235 two long hemostatic forceps. In the same manner operates the constriction of the root of the tongue in amputations of the tongue, and the stitching about of the neighborhood of the wound in tumors of the tongue and cheek, and in tracheotomy. We may mention here also RicorcFs forceps for phimosis operation. The transverse and parallel forceps for compress- ing the pedunculated base of many tumors and as an aid in circular gastror- rhaphy and enterorrhaphy, etc. Finally, may be mentioned the application of the rubber tube in most recent times, in amputation of the rectum, in supra-vaginal amputation of the uterus, and in the Caesarean operation. Compared with the bloodless method, the other blood-saving methods of former times are used only in exceptional cases, since they are performed with difficulty and are uncertain in their results. They all have for their object THE COMPRESSION OF THE MAIN TRUNK OF THE ARTERY above the wound. i . By pressure of the finger (digital compression) , the artery can be com- pressed effectually only in places where a hard base is furnished by the bone and where the vessel lies not too deeply concealed in the soft parts. The most suitable places for digital compression are : For the common carotid artery, the anterior lateral region of the neck between the larynx and the median margin of the sterno- cleidomastoid, where the finger presses the artery against the cervical column (Fig. 417). For the subclavian artery, the supraclavicular fossa on the lateral margin of the sterno- cleidomastoid, where the artery is behind the scalenus anticus muscle and is pressed against the first rib. The access of the finger is facilitated by press- ing forward the shoulder and the clavicle (Fig. 418). The subclavian artery also can be compressed by strong retrac- FIG ^ COMPRESSION OF THE CAROTID ARTERY tion of the shoulder in a pos- BY FINGER PRESSURE 236 SURGICAL TECHNIC tenor direction and with the aid of the other arm, between the clavicle and the first rib (like a compression stopcock). The hand is made to grasp from behind the bend of the elbow of the healthy arm ; the latter is pressed forward and both arms are tied together in this position by cloths or bandages (Fig. 419). For the axillary artery, the anterior margin of the axillary space (the anterior border of the axillary hair) where the artery can be compressed against the head of the humerus when the arm is raised. For the brachial artery, the internal side of the humerus in its whole length, where the artery can be everywhere compressed easily against the humerus along the internal margin of the biceps muscle (Fig. 420). The abdominal aorta with flaccid abdominal walls and empty intestines can be compressed at the level of the umbilicus against the vertical column. In most cases, however, the pressure cannot be tolerated long without anaesthesia. The same is to be said of the external iliac artery in its upper part, where it can be compressed against the lateral margin of the inlet of the pelvis. It can be compressed more easily and for a longer time a little in front of its exit from the pelvis above the middle of Pouparfs ligament against the superior border of the horizontal ramus of the pubis. The femoral artery is most easily compressed directly below Poupart's ligament against the iliopectineal eminence (Fig. 421). The vessel is found in the middle of a line drawn from the anterior superior spinous process of the ilium to the symphysis of the pubis. In its further course as far as the lower third of the femur, it can be compressed against the femur ; digital compression, however, on account of the thickness of the soft parts lying between, is difficult and unsafe, especially in stout and very muscular subjects. Since a successful digital compression can be performed for some time only by a well-trained and strong hand, but during the transportation of seriously injured persons, not at all, attempts have been made to supply the same by various appliances. 2. By artery compressors or tourniquets; they consist essentially of a bandage with which a hard pad (pelotte} or a roller is firmly pressed against the trunk of the artery. The tourniquet can be applied correctly only by a surgeon who is familiar with the anatomic conditions. It must be constantly watched, for if it becomes displaced by imprudent movements or during trans- portation, it does not operate any longer and can even become injurious by causing stasis by pressure on large veins, which always accompany the artery. THE TREATMENT OF WOUNDS 237 FIG. 418. COMPRESSION OF THE SUBCLAVIAN ARTERY BY FINGER PRESSURE FIG. 419. COMPRESSION OF RIGHT SUBCLAVIAN ARTERY FIG. 420. COMPRESSION OF BRACHIAL ARTERY FIG. 421. COMPRESSION OF FEMORAL ARTERY 238 SURGICAL TECHNIC The tourniquet is applied in the places mentioned above for digital com- pression selected on the limbs, and of these again, the arm and the thigh near the trunk, because here the artery can be found rather easily and can be most successfully compressed (Figs. 422, 423). FIG. 422. COMPRESSION OF BRACHIAL ARTERY BY TOURNIQUET FIG. 423. COMPRESSION OF FEMORAL ARTERY BY TOURNIQUET Petifs screw tourniquet was most generally used (Fig. 424) ; in this, the circular band is stretched by a strong screw, and the pressure exerted by the pad upon the artery can be increased at pleasure. The Spanish windlass (Fig. 425) consists of a strap with a buckle, to which a hard pad is fastened, a plate, and a short stick. After the pad has been applied over the trunk of the artery, the strap is buckled loosely around the limb and then firmly drawn tight across the plate by twisting with the stick. Pancoasfs aorta tourniquet (Fig. 426) is operated with a long screw, which moves a broad pad against the posterior cushion. Of similar construction is : Von Esmarc/is aorta tourniquet (Figs. 427, 428). Its pad, provided with a handle, is pressed against the vertebral column by elastic bandages, which are stretched between the adjustable hooks of the posterior cushion. The steel handle of the pad is provided with a slit, through which the turns of THE TREATMENT OF WOUNDS 239 240 SURGICAL TECHNIC rubber bandage can be drawn, and with two pads of different size. The upper pad is kept in position by the hand of an assistant, so that the lower one cannot slip off from the aorta. IMPROVISED ARTERY COMPRESSORS The aorta can also be successfully compressed with a linen bandage 8 meters long and 6 centimeters wide, firmly wound around the middle of a stick as thick as the thumb and a foot in length. This pad, applied over the aorta below the umbilicus, is held in position by an assistant, and is pressed forcibly against the vertebral column by a number of turns of a rubber bandage 6 centimeters broad, carried around the body (Fig. 429). If circular constriction of the ab- domen is to be avoided, the linen band- age is wound, according to Brandts, around the middle portion of a longer stick, and its ends are pressed downward through the turns of the rubber bandage and passed under the plate of the operating table (Fig. 430). In a similar manner, a tourni- quet can be made for compres- sion of the external iliac artery, FIG. 429. COMPRESSION OF THE AORTA BY PAD AND RUBBER BANDAGE FIG. 430. BRANDIS'S METHOD OF COMPRESSING AORTA FIG. 431. COMPRESSION OF EXTERNAL ILIAC ARTERY directly above Pouparts ligament, with a bandage and a pad firmly pressed upon the artery by a strong rubber bandage, applied in cross turns (Fig. 431) for high amputations of the thigh. THE TREATMENT OF WOUNDS 241 A stick tourniquet (Spanish windlass) can also be improvised by wind- ing around the limb a handkerchief or a triangular cloth, which is tied into FIG. 432. IMPROVISED SPANISH WINDLASS FIG. 433. COMPRESSION OF THE BRACHIAL ARTERY a firm knot or in which a flat, smooth stone has been wrapped ; by twist- ing it with a stick or some similar object (sword, ramrod, key) inserted under the cloth, it can be firmly constricted (Fig. 432). For compressing the brachial artery, a com- paratively light pressure exerted with a thick stick against the internal surface of the arm is sufficient (Fig. 433); this pressure forces apart the bellies of the muscles in an anterior and posterior direction, and presses the artery flat against the bone. The arm is pressed firmly against the body by a cloth or a bandage. The arm can also be very effectually compressed between two sticks tied together on both sides ( VblckeSs stick tourniquet Fig. 434). 3. By position : Adelmann recommended as a remedy for arresting arterial hemorrhages hyperflexion of the limbs. By this, the arteries become so strongly bent that they do not per- FIG ^ VoLCKER , s STICK mit the passage of blood. If, for instance, in TOURNIQUET 242 SURGICAL TECHNIC arterial hemorrhages from the forearm or the hand, the forearm in supina- tion is strongly flexed and firmly tied against the arm by a bandage or a cravat, the pulse in the radial artery ceases immediately. In the same manner, by a forcible flexion of the knee, hemorrhage from the vessels of the leg and the foot, and, by a hyperflexion of the thigh, hemorrhage from the femoral artery, can be momentarily arrested. In cases where other means for arresting hemorrhage are not at hand, hyperflexion can be re- sorted to successfully. Still, it must not be forgotten that such a strongly flexed position as is required for safely arresting the hemorrhage cannot, in most cases, be endured for a long time, and if the bones are broken at the same time, it cannot be made use of at all. 4. Lastly, the blood supply is very considerably decreased by raising the limb vertically. At times, -venous hemorrhage yields to this simple expedient, provided all articles of clothing, garters, etc., which tend to promote congestion have been previously removed. ARRESTING HEMORRHAGES IN THE WOUND Violent hemorrhage from injured vessels endangers life directly, and must be arrested as rapidly as possible. In the simplest manner, at least temporarily, the hemorrhage is arrested by compressing the wound : 1. By the finger or the hand, which, of course, must be clean. In some cases of serious injuries, the injured person may compress the wound with his own finger. Since, however, the pressure of the finger, for any length of time, cannot be well continued for instance, during transportation and when the hemostatic resources discussed in the preceding section are not at hand, or cannot be applied it is necessary that 2. A dressing be substituted for them, which shall exert sufficient pressure upon the wound. Before applying such a compressive dressing, the wounded limb must be bandaged carefully and completely from below upward, to prevent the dangerous collection of blood in the meshes of the cellular tissue (diffuse bloody infiltration). Next, a firm dressing is laid upon the wound, and fastened in place under considerable pressure by a bandage prefer- ably an elastic bandage. In deep wounds, the hemorrhage can be arrested still more effectively. 3. By tamponade. The cavity of the wound is packed firmly by forcing with the finger the middle portion of a piece of antiseptic gauze (iodoform gauze) as deep into the wound as possible, and, after the finger has been withdrawn, the cavity is firmly packed with sterilized gauze. In tubular THE TREATMENT OF WOUNDS 243 wounds, first smaller, then larger, tampons can be introduced into the cavity packed with gauze, until the last reach far beyond the surface of the skin. The tampons are firmly pressed upon the wound by a bandage, if possible an elastic bandage ; this, if packed with aseptic material, can remain in position for many days, until the bleeding vessel or vessels have become occluded by thrombosis. This is especially the procedure in hemorrhages from the cavities of the body for instance, from the nose, vagina, uterus, rectum. It is necessary to provide these several tampons, or portions of gauze, with a long thread by which they can be removed again in the gentlest manner. The inflation of a small elastic bag, introduced in a collapsed condition, with air or ice water (Rhineurynter, Colpeurynter, see Fig. 1412) is likewise very effective, but it is not so simple as the common tamponade. MEDICINAL HEMOSTATICS (STYPTICS) These partly promote the coagulation of the blood, and the contraction of the vascular walls, partly produce a firmly adhering crust. They should be used only in case of greatest necessity, when the hemorrhage cannot be arrested by tamponade, for fresh wounds are more or less irritated, and even strongly cauterized, by all these agents, so that healing by primary intention is made impossible. To the oldest agents of this kind belong agaric, the cautery iron (see page 26), and the solution of ferric chloride (liquor fcrri sesquicJilorati} ; even now the latter is used in the form of a dry, yellow, styptic cotton, just like Penghawar Yambi. To this class of agents belong also vinegar, solution of alum, of creosote (i : 100 aqua binelli), oil of turpentine (Baum, Billroth), chloride of zinc in saturated solution, tannin (Graf) in powder form, peroxide of hydrogen (von Nussbaum}. To the more modern styptics belong antipyrine in a 20% solution, or in powder form (BoswortJi), a 20% cocaine solution, fibrin ferment solution (Wright}, cornu- tine, sclerotinic acid, ferripyrine and gelatine. Irrigation with ice cold or hot sterile water and the use of steam (vaporization, Atmokausis, Zestokausis) may be mentioned here. The best and safest procedure for arresting hemorrhage permanently is : LIGATION OF THE VESSELS (LIGATURE) All bleeding vessels, arteries, and veins in a wound (after operations or injuries) are grasped and clamped with hemostatic forceps. These instru- ments are now relied upon exclusively in grasping bleeding orifices, and are 244 SURGICAL TECHNIC variable in their construction, the principal object of all of them being to seize and compress the bleeding vessel (Figs. 435-437). In major operations - for instance, in amputations large vessels are drawn somewhat forward FIG. 435 FIG. 437 SPENCER WELL'S ARTERY FORCEPS from the surface of the wound with forceps, and are then securely closed by torsion with the aid of a second transversely applied forceps. If larger vessels cross the field of operation, they are grasped transversely with two hemostatic forceps, and divided between them (Figs. 438, 439). As many I-'H;. 438 FIG. 439 LlGATION BETWEEN TWO HEMOSTATIC FORCEPS hemostatic forceps as are required are applied, and allowed to remain in position. Ligation with catgut does not commence until all the bleeding vessels have been temporarily secured with forceps (Fig. 440). The pro- cedure is as follows : THE TREATMENT OF WOUNDS 245 Make slight traction on the instrument which grasps the vessel ; pass a simple knot around its point ; push it with the tip of the forefingers over the vessel (Fig. 441), draw it tight, place a second knot (" reef knot ") upon it, next cut off the two threads closely in front of the knot with a pair of curved scissors, and remove the forceps. For ligat- ing large vessels it is advisable not to use too heavy catgut, because its knots loosen more easily, especially if the threads have been cut off very closely. Many surgeons prefer silk for ligatures. (The editor has for the last ten years applied a double ligature | to ^ of an inch apart in ligating arteries the size of the brachial. The bloodless space between the two liga- tures is securely closed in the course of 7 days by definitive obliteration of the lumen of the vessel. The proximal liga- ture includes the accompany- ing vein or veins.) Ligation. If a bleeding vessel cannot be well drawn forward from its surrounding tissue, or if it cannot be grasped for instance, in the scalp or in hardened cicatricial tissue it must be ligated with an ordinary round curved needle armed with the liga- ture. The needle is carried through the connective tissue surrounding the bleeding portion, and with the loose connective tissue included the ligature is tied (Fig. 442). If many vessels are found in tough, broad layers of connective tissue, they can be grasped separately with care and time. The same F L object can be accomplished more rapidly, however, BLOOD VESSEL and with the same degree of certainty by ligating FIG. 440. LIGATION WITH NUMEROUS HEMOSTATIC FORCEPS 246 SURGICAL TECHNIC tissues, including the vessels, in sections by indirect ligatures. Thinner layers are clamped with hemostatic forceps, and secured with a double ligature (Ligature en masse). If only a few or no ligatures are on hand, smaller arteries can also be closed by torsion. Grasp the artery with torsion forceps, draw it forward, FIG. 442. LIGATION OF ARTERY BY INDIRECT LIGATURE FIG. 443. CLOSING ARTERY BY TORSION and, according to its thickness, twist it from six to eight times around its axis, holding the central end of the projecting portion with the fingers or, better, with another pair of forceps (Amussafs clamp forceps Fig. 443). By this procedure, the inner coat of the artery (tunica intima) is torn, and is rolled up in an upward direction, thereby forming a very safe valvular occlusion, strengthened by the twisted tissues. The same effect is produced by a very strong press- ure exerted upon the artery. Koberle" and Ptan have devised for this purpose clamp or pressure forceps (Fig. 441) similar to small dressing forceps, which greatly contuse the grasped tissue by the fixation of its compressed ends. After a quarter of an hour the forceps may be removed without any previous ligature, since the contused inner coat (tunica intima) is rolled up like a cuff in the lumen of the vessel, and the tissues, from the strong pressure, become as desiccated as if they were burned {ford- pressure}. The clamp forceps are used especially in places where a ligature can " be a Pp!ied only with difficulty or not at Fi( , ^ DoYEN>s all, and as a substitute for the ligatures ANGIOTRIBE CEPS THE TREATMENT OF WOUNDS 247 en masse. As the contused tissue does not become necrotic, forcipressure has the advantage over the ligature of not introducing any foreign substance into the wound. When applied to large arteries the forceps must remain in situ from 12 to 24 hours. A still greater effect is produced by angiotripsy (Doyen). By means of it, with very strong forceps (vasotribe, Fig. 445) under an immense pressure (up to 2000 kilometers), not only the vessels, but also all tissues grasped by the forceps (as in ligations of pedicles and " en masse "), are crushed to plates as thin as paper, from which no hemorrhage can occur any more. HEMORRHAGE FROM PUNCTURED AND GUNSHOT WOUNDS If the injury in question is a hemorrhage from a larger vessel which, in the depth of a punctured or a gunshot wound, manifests itself directly or after some time by a continued oozing of blood through the bandages, or which occurs in the subsequent course of the wound from erosion of the vascular wall or from thrombosis of the veins (phlebostatic hemorrhage, Stromeyer), no time should be lost in exposing at once the bleeding vessel at tJie place of injury and in ligating it in the wound itself (direct ligation). Before this often very difficult task is attempted the anatomical posi- tion of the trunks of the vessels should always be called to mind. Figs. 446-450 may serve to recall the anatomical locations and surgical relations of the principal arterial trunks. The paramount condition for executing such operations easily, rapidly, and thoroughly is a large external incision, which is made from the wound in an upward and downward direction and longitudinally to the limb in such a manner that it corresponds to the course of the injured vessel. Where it is a matter of life it is indifferent whether the incision is an inch or a foot in length. If arresting the hemorrhage meets with success and the wound remains aseptic, the large incision heals as well and as rapidly without suppuration as a small one. As to the rest, the procedure is exactly the same as that described in secondary antiseptics (page 57). Having incised the skin to the requi- site extent, the operator penetrates in the depth of the wound with the left forefinger, divides with a probe-pointed knife the deeper layers, the cellular tissue, the fascias and muscles as far as necessary ; the divided parts are then retracted with large sharp or blunt retractors. Next, the blood clots filling the whole cavity of the wound (the so-called aneurysma traumaticum diffusum) are quickly and thoroughly removed with 248 SURGICAL TECHNIC the fingers and sponges, and in most cases in the depth of the wound the injured vessel or at least a bloody infiltrated layer of tissue is found, in / FIG. 446. ARTERIES OF HEAD, NECK, AND AXILLA which the artery, veins, and nerves can eventually be found and identified. The operator should try to separate these several parts by careful dissection. The finding of the injured vessels is essentially facilitated by making use of the bloodless metliod. If, however, the trunks of the veins are entirely empty and have collapsed, it may be difficult to distinguish them from the THE TREATMENT OF WOUNDS 249 layers of cellular tissue. For this purpose it is advisable to form a blood reservoir below the wound by placing, for instance, before the elastic bandag- ing of the injured arm, a constrictor band around the wrist. If this con- strictor is subsequently removed, and if the arm is raised, the blood which had remained confined in the hand fills the veins, and, in case one of the veins is injured, gushes from the vein wound. When the injured place of the artery or the vein has been found, and has been exposed so far that the whole extent of the injury can be sur- veyed or inspected, the vessel must be isolated and firmly and securely ligated in the healthy part above and below the injury with catgut or silk ("reef knot"). Next, if the continuity of the vessel is not already in- terrupted by the injury, it is divided in the mid- dle between the two liga- tures, and the operator convinces himself that no principal branches of the vessel are interposed between the two ligatures. If such branches are found they must also be well isolated, ligated, and separated from the trunk of the vessel. In order to proceed with absolute safety the injured portion of the vessel lying between the two ligatures can be excised. FIG. 447. ARTERIES OF THE THIGH 250 SURGICAL TECHNIC Next, the constrictor band is removed, and all the vessels from which blood is still oozing are carefully ligated, while the limb is raised in order to limit the parenchymatous hemorrhage. FIG. 448 ARTERIES OF ARM FlG - 449 FIG. 450 ARTERIES OF LEG. a, posterior side; b, anterior side THE TREATMENT OF WOUNDS 25 1 LIGATION OF ARTERIES AT THE PLACE OF SELECTION (HUNTER'S INDIRECT LIGATION) The Hgation of an artery above the wound is hardly ever resorted to at the present time for arresting hemorrhages; but it is much to be recom- mended for practising the technique and for testing the knowledge of topo- graphical anatomy. Ligation of arteries, however, is often made to prevent permanently the flow of blood to certain parts of the body in important and bloody operations, or to heal diseased conditions. Thus the carotid artery is ligated in resection of the upper jaw; the lingual, in operations on the tongue; the thyroid arteries, in struma vasculosa (vascular goitre); the sub- clavian, in the disarticulation of the shoulder joint ; the common iliac, in disarticulation of the thigh ; the hypogastric, in tumors of the pelvis and hypertrophy of the prostata. (Preliminary ligation of large arteries in performing the operations mentioned above is seldom performed at the present time, since the surgeon has been placed in possession of local hemostatic resources which, if properly applied, make him master of the situation in arresting the hemorrhage.) The following rules should be observed in finding and ligating the trunks of the principal arteries: 1. The surgeon should recall very exactly and vividly to his memory the anatomical relations of the place of ligation before commencing the oper- ation. The direction and length of the skin incision is made accordingly. It is of advantage to indicate the incisions by a line drawn upon the surface of the skin. (This advice may be of some benefit to the novice in surgery, but no experienced surgeon would think for a moment of adopting it.) 2. The portion of the body is placed in the most advantageous position for the operation, and in the best light. 3. If the operation is to be performed on one of the extremities, it is advantageous to constrict the same previously, and to ait ojf the flow of blood with the modification mentioned above in direct ligation. As soon as it is of importance to feel the pulsation of the artery, the upper con- strictor is removed. C ^U-PKN 4. The external incision is made either free hand, while the x fingers. (o the left hand stretch well the surrounding integument ahd the F:nj1ie v {iene- trates everywhere the whole thickness of the skin (*%. 3$ft)jOr3*rhen, the artery or other important parts are lying directly under the skin, by raising ^ SURGICAL TECHNIC a transverse cutaneous fold, which is divided with one sweep of the knife (Fig. 338). 5. In penetrating deeply, with care, the operator and his assistant grasp with two good forceps the uppermost layer of cellular tissue on both sides of the axis of incision, and at the same time raise the cellular tissue so that the air can enter into its meshes (emphysema). One sweep with the knife divides the raised cellular tissue (Fig. 451). Immediately both forceps release their hold and grasp, now above and now below, the slit thereby made ; again the layer of cellular tissue is lifted up toward the knife, which divides the fibres until the layer is divided from one angle of the wound to the other. This procedure is repeated in dividing the remaining layers until the sJieath of the artery is reached. Any veins, small arteries, nerves, and muscles which are met are drawn aside with blunt retractors. 6. As soon as the sheath of the artery has been exposed, the forceps grasp the middle of the sheath of the artery, lift it upward, and raise it in the form of a cone ; the handle of the knife is lowered laterally and so far in an exterior direction that the lateral surface of the blade is turned against the artery, while the point of the knife enters at a right angle to the point of the forceps, and under it into the grasped cone (Fig. 452). FIG. 451. DIVISION OF CELLULAR Tissn: KE- TWEEN Two FORCEPS FIG. 452. OPENING SHEATH OF THE ARTERY A small incisiion opens the sheath, and while the forceps lift up the tri- atigular segment formed thereby, the point of the knife carefully separates the sheath of the artery from the arterial wall. (In Kgating large vessels, their sheaths should be incised freely, as it facilitates their isolation from adjacent important structures, and does in THE TREATMENT OF WOUNDS 253 no way interfere with the nutrition of the ligated ends. By applying the ligature through a small slit in the sheath, important structures are often included in the ligature.) 7. In the case of large arteries, this procedure is con- tinued as follows : while the surgeon still holds the divided cone, he introduces with his right hand another pair of closed for- ceps into the opening at the base of the cone between the artery and the cellular sheath ; here he grasps the inner wall of the cellular sheath and draws it forward. By this means, the artery is gently rolled around its axis, and the cellular tissue fibres, which fasten the sheath to the lateral and posterior wall of the artery, appear to view ; they are detached in the same careful manner and only as far as the opening first made. If the sheath of the artery is detached too far, the artery can become necrotic, and then sec- ondary hemorrhage occurs at the place of ligation. (In his experiments on the lower animals, the editor isolated arteries the size of the common carotid to the extent of 2 inches or more, and after double ligation never observed necrosis or sec- ondary hemorrhage.) In case of the largest arteries, the procedure must also be repeated on the other side after one-half of the circumference has been liberated. 8. As soon as the artery has been freed on all sides, a curved probe (or a strabismus hook) is carefully intro- duced, and always carried around the vessel from the side on which the principal vein lies, while with a forceps the margin of the incision of the sheath is held taut (Fig. 453). 9. With a probe, the artery is lifted up so far that a small Cooper's or Syme's aneurism needle (Fig. 455) with an eye at its point can be passed around the same in an opposite direction (Fig. 454). FIG. 455 10. Next, the probe is removed, a strong catgut or silk thread is S YME'S ANEURISM passed through the eye of the needle, and the needle is with- NEEDLE FIG. 453. INTRODUCING CURVED PROBE FIG. 454. INTRODUCING ANEU- RISM NEEDLE 254 SURGICAL TECHNIC drawn ; the middle portion of the ligature remains in position under the artery. ii. The ligature is tied around the artery and tied in a "reef knot" see Fig. 365 (not with a " granny knot" -see Fig. 366) and without dis- placing the artery ; the knots must be tied in the depth of the wound with the points of the two index fingers (Fig. 456). FIG. 456. TYING LIGATURE 12. It is advisable to ligate the artery doubly and to divide the vessel between the two ligatures so that the two ends can retract into the sheath of cellular tissue. (Double ligation of an artery in its continuity without division of the ves- sel, if the operation is performed under the necessary aseptic precautions, furnishes absolute protection against secondary hemorrhage.) LIGATION OF THE PRINCIPAL TRUNKS OF THE ARTERIES CAROTID ARTERY The common carotid takes its course from the sternoclavicular articula- tion behind the sternocleidomastoid perpendicularly upward, and is crossed opposite the lower margin of the cricoid cartilage by the omohyoid muscle on a level with the sixth cervical vertebra (tuberculum caroticum CJias- saignac}. Below the omohyoid muscle it lies behind platysma, fascia, sterno- mastoid muscle, sternohyoid, sternothyroid, and the anterior jugular vein ; in front of it lies the inferior thyroid artery and the recurrent laryngeal nerve. Above the omohyoid muscle, the artery lies only behind the pla- tysma, cervical fascia, and the internal margin of the sternocleidomastoid. The strong sheath of the artery contains, toward the median line, the caro- tid, laterally the internal jugular vein, and in a posterior direction between the two the nervus vagus (pneumogastric) ; the descendant branch of the hypoglossal nerve passes over it, and closely behind it the sympathetic nerve (Fig. 457). At the height of the third cervical vertebra opposite the superior mar- gin of the thyroid cartilage, the common carotid divides into the external and the internal carotid. The external carotid is covered at its ori- gin from the common carotid at the height 5. of the superior margin of the thyroid carti- c. lage, only by skin, platysma, cervical fascia, sternocleidomastoid, and the facial vein, as- cends in a gentle curve to the height of the neck of the lower jaw (collum mandibulae), FIG. 457. SITUATION OF THE CAROTID and is Crossed in its Course at the height of ARTERY (Cervical Section). I, carotid; 2, jugular vein; 3, pneumogastnc the hyoid bone by the biventer muscle, the nerve; 4, hypoglossal nerve; 5,brach- hypoglossal nerve, and further Up by the ial plexus; 6, sympathetic nerve; stylohyoid muscle. Upon its external mar- 7 ' v ' gin, the descending ramus of the hypoglossal nerve takes its course. At its A. pharyngea asc. ^J A. lingualis ,1 /Vl A. maxillaris exlerna ; I M. liventer A. femppralis-^^ *- .'''>'' ' ' ' ! M. mytohyoideus* A. maxillaris int. A. aitricularis post. M. .stylohyoideus ,M. bivente: A. occipitalis Caroiis interna Carotis externa Carotis communis M. omohyoideus M. sternothyreoideus FIG. 458. BRANCHES OF THE EXTERNAL CAROTID ARTERY posterior surface it is crossed by the superior laryngeal nerve, a branch of the lingual artery, and the glossopharyngeal nerve above the biventer 256 SURGICAL TECHNIC muscle. It can be ligated most easily between the branches given off as the superior thyroid artery and the lingual artery. The internal carotid ascends from the bifurcation of the common carotid as its continuation to the carotid canal in the petrous portion of the 'tem- poral bone, and lies somewhat posteriorly and externally from the external carotid (Fig. 458). LIGATION OF THE COMMON CAROTID ( LlGATION OF THE SUPERFICIAL PALMAR ARCH Longitudinal incision from the place of union of the thenar eminence and hypothenar eminence to the fourth finger (Kocker^ Plate V. 5). Beneath the crossing of this incision with the middle transverse fold of the skin the artery is felt, which, after division of the adipose tissue and the palmar fascia, appears to view. If it is not found here, the strong ulnar branch on the pisiform bone can be ligated. According to Bockel, the arch is found by means of a transverse incision in the middle of the palm, i.e. in the centre of a line drawn from the web of the greatly hyperextended thumb obliquely across the palm and the middle palmar fold (Fig. 476). 268 SURGICAL TECHNIC Vogt makes a curved incision from the limit of the middle and lower third of the line of the thumb to the middle of the communicating line between the pisiform bone and the base of the ring finger. FIG. 475 FIG. 476 SUPERFICIAL PALMAR ARCH, a, topography; b, external incision In injuries of the deep volar arch, which, on account of its deep posi- tion, can be isolated and ligated only with difficulty, hemorrhage is best arrested by firm tamponing. AORTA, ILIAC, AND FEMORAL ARTERIES The abdominal aorta, descending along the anterior surface of the ver- tebral column a little more to the left, near the vena cava, divides at the level of the lower margin of the fourth lumbar vertebra into the common iliac arteries, descending on both sides of the fifth lumbar vertebra along the inner margin of the psoas muscle covered by the perito- neum, only loosely connected with it to the sacro- iliac synchondrosis, where they divide into the hypogastric artery (internal iliac) and the external iliac artery. The common iliac vein lies on the artery (Fig. 477). The ureter passes obliquely from without inward over the bifurcation of the common iliac artery. PLATE VI External Incisions, i, External Iliac Artery. 2, Common and Internal Iliac Arteries legation of the External Iliac Artery Ligation of the Common Iliac and the External Iliac Artery THE TREATMENT OF WOUNDS 269 V ffc The internal iliac artery, the trunk of which is only 2 to 4 centimeters in length, descends obliquely in an anterior direction in front of the sacro- iliac synchondrosis and into the true pelvis. The external iliac artery takes its course obliquely outward upon the iliac fascia cover- ing the psoas muscle to the groin, covered on its anterior and internal side by the parietal N peritoneum and crossed by the spermatic ves- A sets. The lumbar nerves take a lateral course. The femoral artery begins at the middle of Ponparfs ligament, and passes to the lower end of the middle third of the thigh, along its anterior and internal side in an almost straight V line drawn from the middle of Poupart's liga- ment to the epicondylus internus femoris ; in the upper third of the thigh lies the artery, with the vein of the same name on its inner side traversing Scarpas triangle, bounded on the outside by the sartorious muscle, on the inside by the adductor longus. At the lower end of Scarpa's triangle it gives off a large branch, the deep femoral artery (profunda). In the middle of the thigh the femoral artery lies upon the vein beneath the sartorious mus- cle, between the vastus internus and the adductor magnus muscle, perforates next the insertion of this muscle (Hunter s canal), in which behind the long saphenus nerve it enters on the posterior surface of the thigh the pop- FIG> ^ TopOGRAPHY OF FEMORAL liteal space. ARTERY LIGATION OF THE ABDOMINAL AORTA BELOW THE RENAL ARTERIES (a) Extraperitoneally (Maas, Murray}. 1. External incision along the anterior margin of the left quadratus lumborum, from the last rib to the crest of the ilium. 2. After division of the abdominal muscles and the transversalis fascia, the wound is drawn apart with blunt retractors, so far that the retroperitoneal space can be inspected below the kidney and the aorta can be exposed. 2/0 SURGICAL TECHNIC () Transperitoncally {Cooper, von Nussbauni). 1. External incision, 15 to 20 centimeters in length, in the linea alba, as in laparotomy. 2. After the abdominal cavity has been opened, the intestines are displaced to the right, the posterior layer of the parietal peritoneum is :ncised over the artery, which then can be easily reached ; next, the aorta is ligated. LIGATION OF THE COMMON AND INTERNAL ILIAC ARTERIES (Plate VI. 2) I. External incision, 10 to 12 centimeters in length, beginning 3 centi- meters inward and downward from the anterior superior spine of the ilium and ascending in a slightly concave curve vertically and near to the last rib. FIG. 479. LIGATION OF THE COMMON AND INTERNAL ILIAC ARTERIES 2. Division of the fatty layer of the thin superficial fascia of the muscular layer of the obliquus externus, the obliquus internus, the horizontal fibres of the transversalis and the thin transversalis fascia, until the peritoneum is exposed. 3. The peritoneum (/>) is carefully pushed inward toward the umbilicus, and, with the fingers, drawn toward the internal margin of the wound (Fig. 479). PLATE VII A Below Foumart's Ligament At the middle of the thigh behind the Sartorius Below the Profunda External Incisions Femoris Artery At the orifice at the lower end of Hunter's canal Ligatton of the Femoral Artery THE TREATMENT OF WOUNDS 271 4. The ureter (u) usually remains in contact with the peritoneum, else it is seen coursing together with the external spermatic nerve (sp) obliquely across the bifurcation of the common iliac artery. Care must be taken not to injure it. 5. The whole common iliac artery is now exposed at the internal margin of the iliopsoas muscle (m) from the aorta to its bifurcation. The iliac vein lies to the left on its inner side ; on the right it lies behind the artery. For ligating the internal iliac artery, draw the external iliac artery and the common iliac vein inward ; carry the needle from within around the trunk of the internal iliac artery. On account of the great depth of the operating wound and the extensive detachment of the peritoneum, it is better to expose this artery by means of laparotomy (" transperitoneally " in pelvic high position). The external incision extends, then, either toward the median line in the linea alba, or along the outer border of the rectus. LIGATION OF THE SUPERIOR GLUTEAL (Plate VIII. I) 1. External incision obliquely , /f across the gluteal in a line be- A tween the posterior sttperior spine of tJie ilium and the great trochan- ter(\g. 480). 2. After division of the fascia and the fibres of the glutens maxi- mus, the lower border of the glu- teus mediiis is exposed and drawn jipward. 3. Along the upper margin of the greater sciatic notch above the pyriformis, the artery is found at the side of the superior gluteal nerve. ARTERY FIG. 480. LIGATION OF THE SUPERIOR GLUTEAL AND OF THE SCIATIC ARTERY LIGATION OF THE SCIATIC ARTERY (Plate VIII. 2) 1. External incision, 8 to 10 centimeters in length, from the posterior infe- rior spine of the ilium to the outer margin of the tuberosity of the ischium. 2. After division of the fascia and the fibres of the glutens maximus, the pyriform muscle and the great sacrosciatic ligament are exposed. 2/2 SURGICAL TECHNIC 3. The artery is found on the inner border of the pyriform muscle after its exit from the inferior margin of the sciatic notch. LIGATION OF THE EXTERNAL ILIAC ARTERY (Plate VI. I) 1. External incision, I centimeter above Poupart's ligament and parallel to the same, 8 to 10 centimeters in length, begins in a fiat convex manner, 3 centimeters inward from the anterior superior spine, and ends over the internal inguinal ring (without exposing it and the spermatic cord). 2. Division of the fatty layer of the thin superficial fascia, of the strong tendinous aponeurosis of the obliquus externus, next the muscular fibres of the obliquus interims ; next the hori- zontal muscular fibres of the transvcrsalis abdominis in the external angle of the wound (Fig. 481). 3. Careful division of the thin transversalis fascia, fol- lowed in the corpulent by still another thin layer of fat. 4. The peritoneum (/) must be pushed carefully toward the umbilicus with the fingers bent like a retractor (without stripping FIG. 481. LIGATION OF THE EXTERNAL ILIAC ARTERY the iliac f asda and the lar er vessels from the pelvic wall !). 5- The artery lies on the inner border of the iliopsoas muscle ; on its inner side the vein (v), on its external side the crural nerve (n), covered by the iliac fascia. The external spermatic nerve (sp) passes obliquely across the artery. LIGATION OF THE FEMORAL ARTERY (Plate VII. 1-4) (a) Under Poupart's ligament. 1 . The external incision begins in the middle between the anterior superior spine and the symphysis, 2 millimeters above Poupart's ligament, and is extended 5 centimeters downward. 2. Division of the superficial fascia. 3. Division of the fatty layer; removal of the lymphatic glands, either by drawing them aside or by extirpating them. 4. Division of 'the fascia lata. PLATE VIII Artery External Incision Legation Ligation of the Popliteal Artery legation of the Gluteal Artery External Incisions Ligation of the Sciatic Artery Ligation of the Superior and Inferior Gluteal Arteries THE TREATMENT OF WOUNDS 2/3 5. Division of the sJteatli of the vessel, I centimeter below Poupart's liga- ment (/) (because the deep circumflex iliac artery (ac) and the deep epigas- tric artery (ae) branch off directly under it Fig. 482). . 6. lihefemo ral vein (v) lies inside, the crural nerve () outside, oftJie artery, (b) Below the prof unda f emoris artery (at tlie inferior point of the trigo- nuin ilio femorale, Scarpa's triangle). 1. External incision, 5 centimeters in length along the internal margin of the sartorius muscle, commences six ringers' breadth (8 to 10 centimeters) below Poupart's ligament (Fig. 172, 2). 2. The border of the sartorius muscle (s) is exposed and drawn outward. ac. FlG. 482. LlGATION OF THE FEMORAL ARTERY UNDER POUPART'S LIGAMENT FlG. 483. LlGATION OF THE FEM- ORAL ARTERY BELOW THE PROFUNDA FEMORIS ARTERY FlG. 484. LlGATION OF THE FEMORAL ARTERY IN THE MIDDLE OF THE THIGH 3. Opening of tJie sheath of the vessel. The femoral vein {v) lies to the inner side and somewhat behind the artery ; the femoral nerve (;/) on the outer side (Fig. 483). (f) In the mid&le of the thigh (behind the sartorius). 1. Skin incision 8 to 10 centimeters long down to the sartorius in the middle of a line drawn from the anterior superior spine to the internal condyle of the femur. 2. The sheath of the sartorius is divided. The muscle (s} is freed and drawn outward, until the posterior wall of the sheath of the tmiscle appears to view, which covers the vessels. 3. After the sheath has been opened, the artery is exposed. The saphenus nerve passes over it (); the femoral vein is behind it (vc). The saphenus vein (vs) lies superficially and more inwardly (Fig. 484). 274 SURGICAL TECHNIC At the orifice at the lower end of Hunter's Canal. 1. External incision 10 centimeters long at the beginning of the lower third of the thigh, flexed at the hip and knee, and abducted at the outer border of the sartorius muscle (long saphenus vein !). 2. Division of fascia. The sartorius muscle is drawn inward ; tinder it lies, on the inner surface of the internal vastus muscle, the white shining tendinous band of the abductor magnus muscle (cover of Hunter's canal). 3. Division of the tendons on a grooved director from below. The artery appears to view (rather close to the bone), inwardly and behind it the vein ; above it lies the internal saphenus nerve. -Jf. biceps THE POPLITEAL ARTERY The popliteal artery occupies the middle of the popliteal space surrounded by adipose tissue, usually a little toward the inner side of the middle line. The popliteal vein and the tibial nerve lie on its outer side (Fig. 485). Along the upper border of the soleus muscle, often in the popliteal space, the artery divides into the anterior and posterior tibial arteries. The former, cov- ered by the soleus muscle, crosses the interosseous ligament in a line drawn between the external con- dyle of the tibia and the first intermetatarsal space, on the an- terior side of the leg downward between the tibialis anticus and the flexor communis digitorum. At the ankle joint it lies between the tendons of the tibialis anticus and the extensor hallucis. It passes then as the dorsalis pedis artery along the dorsum of the foot between the tendons of the extensor hallucis longus and brevis obliquely in the space between the first two metatarsal bones. The larger posterior tibial artery passes along the inner side of the leg, covered by the peroneus muscles, between the tibialis posticus and the flexor .Caput txt. Oastrocnemii K. saph. ext. FIG. 485. TOPOGRAPHY OF THE RIGHT POPLITEAL SPACE PLATE IX Ligation above the middle of the leg Ligation at the lower third of the leg Ligation of the Anterior Tibial Artery THE TREATMENT OF WOUNDS 2/5 longus digitorum. It is accompanied by two veins; the tibial nerve takes its course along its external side. Behind the internal malleolus the artery lies superficially under the integument and fascia, between the accompanying veins and beneath the plantar nerve. LIGATION OF THE POPLITEAL ARTERY (Plate VIII) 1. External incision 8 centimeters in length along the external border of the semi-mem- branosus, down through the whole popliteal space. 2. Division of the thick adipose layer, until the tibial nerve appears to view (Fig. 486). 3. The tibial nerve (ii) is drawn in a lateral direction ; behind it and a little toward the median lies the popliteal vein (?>), which is freed and drawn somewhat aside ; behind the vein and a little toward the median lies the artery. FIG. 486. LIGATION OF THE POPLITEAL ARTERY FIG. 487. LIGATION OF THE ANTERIOR TIBIAL ARTERY ABOVE THE MIDDLE OF THE LEG LIGATION OF THE ANTERIOR TIBIAL ARTERY (Plate IX) (a) Above the middle of the leg (Plate IX. 1. External incision 6 to 8 centimeters in length, 3 centimeters outward from the crest of the tibia (in the middle between the tibia and the fibula). 2. Division of the fascia in the direction of the tendinous white line, which indicates the space between the tibialis anticus (to) and the extensor Jiallncis longus muscles (eh). This intermuscular space is sought for and enlarged with the point of the in- dex finger, until the deep fascia is reached 487). 3. After a careful division of the deep 276 SURGICAL TECHNIC fascia, the artery is exposed between the two accompanying veins ; on its outer side lies the anterior tibial nerve (;/). (b). In the lower third of the leg (Plate IX. 2). 1. External incision 5 to 6 centimeters in length, vertical, a finger's breadth outward from the crest of the tibia. 2. Division of the fascia. In the space between the tibialis anticus (/a) and the extensor hallucis longns (eh), the index finger is inserted, and by upward and downward strokes separates the bellies of the muscles as far as the interosse- ous membrane (2 to 3 centimeters deep) (Fig. 488). 3. On this lies the artery between two veins, accompanied in front and on the inside by the deep branch of the anterior tibial nerve (). (, according to Wolfler; c, d, according to Trnka; The sliding is finally made 3. By twisting, after the flaps have been cut in such a manner that they remain in connection with the vascular supply only on one side as a pedicle with the wound surface {pedunculated flaps, Figs. 554, 555). According to Thiersch, pedunculated flaps can be lined over the wound surface with mucous membrane or skin ; large flaps can also be doubled by turning over their margins, and thus be used for covering defects in the walls of the body. The details of plastic operations on the face to cover defects of the eyelids, cheek, lips, nose, etc., are given on pp. 514-558. Of the OPERATIONS ON NAILS the most important and frequent treatment is for ingrown nail of the great toe. Since this very painful affection recurs often, it is all-important not only to remove the diseased portion of the nail, but also to resort to suitable treasures to prevent a recurrence. The following operation yields the best results : i. Under local anaesthesia or under the influence of a general anaesthetic, the pointed blade of a pair of strong, straight scissors is inserted under the THE TREATMENT OF WOUNDS 303 u * u-1 & A. it i i r * * -. ^_ ^ ^- *i r 1 1 j J 1^ v- ^ ! 1 1 1 r J i - * - - ~ - - j J ( i i- 304 SURGICAL TECHNIC middle of the free anterior edge of the nail, pushed forward as far as its posterior margin, and the nail divided with one stroke (Fig. 556). The two halves are grasped one after the other with strong forceps, and, by twisting them around their axis, in an outward direction over the margin of the bed of the % nail, they are extracted. 2. Next, the diseased (internal) edge of the matrix is grasped with for- ceps, and removed by sawing movements with a sharp knife ; the incision is extended along the inner granulating margin of the soft parts as far as the point of the toe, whereby all diseased tissue is removed at the same time (Fig. 556). The wall of the nail fold is thereby made completely even. 3. The little wound and the exposed nail bed are covered with iodoform gauze, and left to heal by granula- tion. Or, after vivifying the nail bed with the knife con- FlG - 55 6 ducted in a flat manner, skin grafting is made immediately according to Thiersch (from the thigh). Healing by primary intention occurs. In subsequent dressings it is advisable to allow the lowermost layer of gauze which covers the nail bed to remain in position as a protective dressing. Subsequently it falls off of its own* accord. The patient can walk without pain after three to four days. Hdgeler obtained an eminence of the toe covered only by skin in this manner : He extracted the nail, and removed by a deep cuneiform incision on both sides the lateral nail folds. Having excised the transverse fold and scraped off the nail bed, he united by sutures the movable lateral flaps upon the middle of the dorsum of the toe. This procedure, to be sure, is very radical ; but it yields the best perma- nent results. All others are likely to fail. The simple removal of the whole nail or its diseased half, without removing the corresponding matrix segment, the insertion of foreign bodies between the granulating nail fold and the sharp edge of the nail pressing upon it, recommended for ages, the scraping out of a shallow longitudinal groove in the middle of the nail to render it more elastic, and the application of an elastic clamp, which raises the edge of the nail from the tissues beneath it, prove unsuccessful in most cases. In milder cases, where the inflammation of the lateral nail fold is not far advanced, success is obtained by cutting the nail either straight or in a concave manner, and by inserting cotton under both corners. THE TREATMENT OF WOUNDS 305 OPERATIONS ON BONES Osteoclasis, that is, the subcutaneous fracturing of bones, is made for vicious union after fractures ; if not too much time has elapsed since the injury, in most cases (especially in children) the still soft callus yields to extension and manual redressment. Under some circumstances, it is neces- sary to infract the bone like a green stick across the knee or the edge of FIG. 557. SCHNEIDER-MENNEL'S EXTENSION APPARATUS a table to effect correction of the deformity. In some cases of badly united and not too old fractures, especially of the femur, Wagner has again recommended the extension apparatus of Schneider-Mennel, which was originally mentioned for setting old irreducible luxations, to correct the shortening and irregularity. In this apparatus the patient is securely fixed, and the fragments are brought in proper position by cog-wheel extension (Fig. 557)- But if the fractured ends are firmly united by bony callus, in most cases this method of treatment is inadequate, and greater force must be employed. Von Bardeleben extended the lever arms formed by the ends of the bones by fastening long laths to the ends of the fracture by a strong plaster of paris dressing ; for instance, in a fracture near the ankle joint, a wooden splint 2 feet long was fastened to the foot and leg, below the fracture, whereby the ankle joint was immobilized, while the seat of fracture remained free. While an assistant held the upper portion of the leg immovable, pressure was exerted upon the free end of the splint, and the callus was easily fractured by manual force. 306 SURGICAL TECHNIC Simple and very effective also is von Ef march's osteoclast (Fig. 558), a one-armed long wooden lever, which is pressed forcibly upon the limb placed between two firm cushions. FIG. 558. VON ESMARCH'S OSTEOCLAST FIG. 559. RIZZOLI'S OSTEOCLAST Formerly, for refracturing a bone, much more complicated appliances were used. For instance, the dysmorphosteopalinclast, Bosch and Oster- leiris screw-press. Rizzotfs osteoclast operates in a much more simple man- ner, according to the same principle (Fig. 559); this instrument infracts the bone with the limb immobilized between two rings (Fig. 560). Robin s excellent osteoclast (Fig. 560) is extensively used in France. Of a similar construction is the apparatus of Lorenz. Even if good success may eventually be obtained with these machines, still at the present time in most cases osteot- omy aseptically performed is the opera- tion of choice, especially since the place of the intentional artificial fracture can FIG. 560. ROBIN'S OSTEOCLAST be determined with accuracy, and the great contusion of the soft parts is avoided, which in the application of all osteoclasts is unavoidable. THE TREATMENT OF WOUNDS 307 OSTEOTOMY Bone section is made for the purpose of straightening deformities caused by vicious union of fractures, in curvatures of bones, the result of disease, and in deformities of the leg caused by the body weight (" Belastungsdefor- mitaten "). The operation is performed as follows : i. The limb is made bloodless by elastic constriction, and a small longi- tudinal incision is made with a strong knife down to the periosteum at a place where as few important soft parts as possible will be injured. FIG. 561. MACEWEN'S OSTEOTOME 2. A strong chisel (osteotome, Fig. 561) is inserted in the little wound down to the bone, then placed at a right angle to the axis of the bone, and driven into it with strong blows of the hammer. In large bones, after half of the thickness of the bone has been chiselled through, a thinner chisel should be used in order to have more room in the bony groove. After the bone has been divided, except a small bridge, it can be fractured by manual force. During the hammering, the limb is placed upon a firm support (moist sandbag), which yields but little. FIG. 562. ADAMS'S METACARPAL SAW 3. Instead of the chisel, the metacarpal saw is also used (von Langenbeck, Adams Fig. 562). The bone dust produced by the sawing does not inter- fere with the healing of the wound as long as asepsis is maintained. Still, on the whole, the chisel is preferable. 4. After the chisel has been removed from the bony groove which often requires some strength the little wound is either sutured or left to heal bv granulation. The constrictor is removed, and the limb immobilized 308 SURGICAL TECHNIC in the corrected position by plastic dressing, which is applied at once. The healing usually takes place under the first dressing ; if necessary, after a few weeks, a new dressing must be applied, more especially if the deformity has not been entirely corrected in applying the first one. Any defects are then corrected. The typical osteotomies are : Subtrochanteric osteotomy (osteotomia subtrochanterica, von Volkmann). In contractions of the thigh : 1. External incision across the posterior outer side of the trochanter. 2. The periosteum is reflected with the raspatory and the elevator as far as one-third of the circumference of the bone. 3. Next, the bone is divided with a broad chisel; in more serious cases, a corresponding wedge from the external half of the bone is chiselled out (Fig. 563). Supracondylic osteotomy of the femur (Osteotomia snpracon- dylica femoris Maceweri). In genu valgum (and varum) : i. On the inner side of the thigh, at the point of crossing of two lines, of which one is drawn a finger's breadth above the superior extremity of the outer condyle trans- versely across the thigh, the other passing down- ward 2 centimeters in front of the tendon of the adductor magnus muscle, a pointed knife is in- serted down to the bone, and the insertion is enlarged 4 to 5 centimeters upward (Fig. 564^). The fibres of the internus vastus muscle are divided thereby ; the capsular ligament remains intact. 2. Before the knife is withdrawn, an osteotome i|- centi- meters broad is inserted along its side down to the bone (Fig. 561); the knife is then withdrawn, and the chisel is placed transversely to the axis of the bone (Fig. 564^). The femur is chiselled through transversely from within backward, for- ward, and outward (for fear of injuring any blood vessels). After the bone has been sufficiently weakened the fracture is made by manual force (Fig. 565). Hahn completes the bone section more rapidly by using the chisel on the same line from the outer and inner sides through two separate incisions. 3. In some cases, the tibia must also be divided by osteotomy at once or subsequently closely below its tuberosity, from a lateral longitudinal inci- FIG. 563 SUBTROCHAN- TERIC OSTE- OTOMY FIG. 564. SU- PRACONDYLIC OSTEOTOMY. A, external in- cision; B, bone inci- sion; C, line of epi- physes; D, condyles THE TREATMENT OF WOUNDS 309 sion. In curvatures of a high degree, it may become necessary to take out a corresponding wedge from the femur or the tibia. 4. The openings of the wound are covered with iodoform gauze, and the leg in a straight position is immobilized in a plaster of paris dressing. The little wounds heal quickly, otherwise a fenestra must be made in the dressing. Supramalleolar osteotomy (osteotomia supramalleo- laris, Trendelenburg}. In flat foot and angular deformity after fractures of the malleoli, whereby the foot has been displaced outward and has assumed a pronation position : 1. A small skin-incision i centimeter long is made oh both sides across the malleoli. 2. The tibia and the fibula are divided transversely with a small chisel closely above the malleoli, so that the foot becomes completely movable (Fig. 566). 3. Having been restored to its normal position, a plaster of paris dressing is applied with the foot in the corrected position; after about 12 days, a new dressing is FIG. 565. SUPRACON- DYLIC OSTEOTOMY FIG. 566 SUPRAMALLEOLAR OSTEOTOMY applied. DIRECT FIXATION OF BONE FRAGMENTS for effecting bony union in pseudoarthroses and after some resections and sometimes in complicated fractures can be made in various ways. If the ends of the bone can be placed in a firm and secure position, it is mostly sufficient to unite the surrounding periosteum all around by catgut sutures (Periosteal suture) ; but if greater security is desired, the bone itself can be FIG. 567. BONE DRILL sutured by drilling it obliquely at both ends with a simple bone drill (Fig. 567), or with a special drill ; the instruments may be conducted with the 3IO SURGICAL TECHNIC hand. The work is done more rapidly if the fly-wheel of a dental bur (Fig. 568) or an electromotor (Fig. 569) is at one's disposal, and by applying through the perforations silk, or silver wire, aluminum bronze wire (bone suture, Fig. 570), or tJie bones are firmly nailed together with long steel nails (Fig. 571). These remain in the bone from 3 to 4 weeks without causing pain, until the bone is firmly united, and they can be easily extracted at the end of that time. In a similar manner is the procedure with GussenbaneS s bone-clamps (Figs. 572, 573). Instead of nails, formerly ivory nails or ivory pins were very frequently used. (Aseptic bone or ivory nails should be used in preference to metallic nails, because in aseptic wounds they are always absorbed after consolidation of the fracture has taken place. Bone rings and interosseous hollow cylinders are also excellent means of direct fixation.) For a more accurate coaptation of the fragments of bones and for increasing the bone surfaces, the bone ends can be vivified in a cuneiform (Fig. 574) or scalariform manner. With the latter procedure, they are best united by driving in transversely nails, pegs, or screws. Wille perforates the bone for applying the wire suture not obliquely, but transversely. With a drill of special construction, he then carries the wire through the perforation, and finally ties it together. Hausmann screws to one or both sides of the bone small aluminum splints (Fig. 576) which heal in. Fractured ends which are very oblique can be simply tied together in the form of a ring with wire applied in a shallow groove, made with a saw or a chisel, on both sides, to prevent the slipping of the wire ligature (Fig. 575). Likewise good results are obtained with : The procedure of Bircher, who fastens the bone ends with an ivory cylinder (Fig. 577) inserted into the medullary canal of both fragments; the procedure of Semi, who uses intra- and extra-osseous absorbable bone splints. The procedure of Davy, who wedges the cone-shaped pointed end of one bone into the medullary cavity of the other, whereby a considerable shorten- ing is produced, seems to be less recommendable. The attempts to obtain union by plastic operations by detaching and suturing periosteal flaps (Rydygier\ and pedunculated skin-periosteal bone flaps (Miiller), have often met with good success ; the implantation of peri- osteum and bone which have been taken from distant portions of the body or from animals is uncertain in its results. If the operator does not succeed in this manner in forming solid osseous callus, sometimes success is obtained by the use of irritants. To these be- THE TREATMENT OF WOUNDS FIG. 568. DENTAL BUR FIG. 569. ELECTROMOTOR FIG. 570. BONE SUTURE FIG. 571 STEEL NAIL FIG. 572. GUSSENBAUER'S BONE CLAMPS. FIG. 573 FIG. 574. CUNEIFORM VIVIFYING FIG. 575. BONE UNION WITH SILVER WIRE FIG. 576. ALUMINUM SPLINTS FOR BONE UNION FIG. 577. IVORY CYLINDERS 312 long : congestion or hypercsmia by merely applying an elastic hand above the place of fracture (von Dumreicher, Helferich), "healing" by active use of the limb immobilized in a well-fitting apparatus (Hessing and others), massage ; furthermore painting the skin with tincture of iodine, injections of a 10% chloride of zinc solution (Lannelongue\ tamponade with oil of turpen- tine (Banks, Miculicz) ; in open fractures, vigorous rubbing of the fragments against each other (Celsus) under anaesthesia ; finally, the introduction of foreign bodies : driving in nails, ivory pegs, needles, acupuncture with many (5 to 20) needles, which remain in position for weeks (Nicolayseri), and electro- puncture (le Fort\ NECROTOMY The opening of a bone cavity, or operation for the removal of necrosed bone, is made for the purpose of removing pus, dead fragments of bone (sequestra), which are incased by new bone (involucrum) formed by the pre- vious inflammation of the medulla of bone (osteomyelitis), or for the extraction of other foreign bodies (bullets) which have entered from without. If only a bullet em- bedded in the bone cavity is to be removed, the fistulous canal, lead- ing through the wall of the bone to the foreign body, can be most rapidly enlarged with Marshall's osteotribe (Fig. 578). In opera- tions for necrosis, however, this procedure is not sufficient ; on the contrary, the involucrum must be opened in its whole extent, so that its contents can be removed thor- oughly and with ease. This can be done most rapidly and con- veniently with a chisel and a ham- mer (Figs. 579-582); the com- mon large carpenter's chisel with a FIG. 578. MARSHALL'S OSTEOTRIBE wooden handle is more useful than the surgical chisels consisting of one piece of steel. At any rate, in lack of the latter, the tools may be bor- rowed from the next best carpenter or joiner shop. In the clinic at Kiel, THE TREATMENT OF WOUNDS 313 chisels are used for these purposes, the cutting surface or bevelled edge of which is 5 centimeters in width (Fig. 584). FIG. 579 FIG. 580 FIG. 581 CHISELS AND HAMMER FOR NECROTOMY FIG. 582 1. Under elastic constriction the affected bone is freely exposed over the seat of the disease by a longitudinal incision; the divided peri- osteum is reflected with the raspatory on both sides (Fig. 586), and the involucrum opened with chisel and hammer to such an extent that the dead bone is freely exposed ; in order to advance more rapidly^ much benefit is derived from the use of very large gouges (Figs. 580, 584). 2. With the sequestrum forceps (Fig. 587) the dead bone is now extracted ; and all granulations sur- rounding it are thoroughly scraped out with the sharp spoon. Since FIG. 583. OPENING AN INVOLUCRUM OF THE the surgeon can never be sure TlBIA WITH CHISEL AND HAMMER whether still smaller or larger portions of sequestra have remained in the angles and sinuses of the opened involucrum, or whether the granulating 314 SURGICAL TECHNIC canals extend deep into the bone, it is necessary to remove enough from the lateral edges of the involucrum to change the cavity of the bone into an open shallow cavity (alveolus), in which no accessory cavities can remain undiscovered (Fig. 585). The surface of this shallow cavity is finally smoothed with a chisel and the sharp spoon. FIG. 584. NATURAL SIZE OF BEVEL OF CHISELS FOR NECROTOMY FIG. 585. SHALLOW CAV- ITY AFTER NECROTOMY FIG. 586 RASPATORY FIG. 587 SEQUESTRUM FORCEPS 3. At the end of the operation, the margins of the wound are sutured together if possible to effect healing by aid of a moist blood clot, or the bony cavity is firmly packed ; a copious dressing is applied over it and fastened with a bandage. If copious bleeding follows the operation, the whole dressing can be more firmly applied with an elastic bandage. Then only the elastic constriction is rapidly removed. (Most of the surgeons prefer to remove the elastic constrictor before the dressing is applied, as in doing so many of the bleeding vessels can be tied, THE TREATMENT OF WOUNDS 315 leaving only the parenchymatous hemorrhage to be arrested by tampon and dressing. The limb should always be immobilized and kept in an elevated position for at least 24 hours.) The wound heals by forming granulation, which, moreover, with large and deep cavities, takes a very long time. FIG. 588 FIG. 589 NEUBER'S INVERSION SUTURE, a, after the operation ; l>, after healing To promote the healing process, the skin can be detached on both sides of the wound from the fascia and drawn over the surface of the bone, where it is fastened with small steel nails or with a suture (inversion suture Ncuber, Fig. 588). The healing then takes place by adhesion ; the flaps of skin, at first pressed deep into the bone, gradually rise to their normal position by the mass of bone forming underneath it (Fig. 589). Attempts have also been made to fill the gap immediately after the operation with bone chips made by the chiselling, and to sew the skin over them. Senn used in a similar manner decalcified chips of the tibia or femur of an ox; these decalcified chips are preserved in alcohol or iodoform ether. Still, aside from some good successes, many failures have occurred from the fact that some chips did not heal in and were eliminated by suppuration. (Failures after pack- ing bone cavities with decalcified bone chips are due entirely to imperfect disinfection of the cavity or the use of fine material which has not been thoroughly sterilized. Extru- sion of bone chips never takes place from perfectly aseptic cavities.) It is much better, after a complete suturing of the margins of skin, to allow the cavity to be filled with blood and to let it heal by the aid of a moist blood clot (Schede}. With Liicke and Bier's osteoplastic necrotomy, aside from great rapidity and ease of inspection, sometimes even a con- siderably more rapid and better healing of the wound is OSTEOPLASTIC obtained and with a minimum amount of scar tissue. NECROTOMY 316 SURGICAL TECHNIC If the tibia is the seat of necrosis, as is most often the case, an incision is made around the thickened part on three sides down to the bone (Fig. 248). In line with the short transverse incisions, the thickened bone wall is divided at its anterior circumference with a metacarpal saw. The longitudi- nal incision is chiselled deep with a broad straight chisel. With the last strokes of the hammer, by forced leverage, the skin-periosteal-bone flap of the diseased bone is turned up like the cover of a box (whereby the bone at the base of the flap is infracted), and then with one glance the large bone cavity can be inspected and examined as to sequestra, granulations, and abscesses (Fig. 590). After removal of the sequestrum the granulations are scraped out with a large sharp spoon ; the cavity of the bone is cleansed, and the portion of bone turned up with the soft parts is replaced in its former position and fastened by a few sutures. Complete healing has set in, in some cases even where the necrosis was extensive, in 3 or 4 weeks. In other cases after a long interval fistulae occurred again, so that the broad opening with an alveolar formation is indeed more tedious, but surer of success. AMPUTATIONS AND DISARTICULATIONS Amputation of a limb in general should be made only when by this muti- lation the prospect of saving the life of the patient appears to be essentially better than without it in attempts to save the limb. A portion of the limb is amputated : 1. In extensive comminution of the bone and laceration of the large blood vessels and nerves. 2. In lacerations of the whole musculature, even when the bone is involved only to a small extent. 3. In very extensive destruction of the skin (ulceration), when the limb has become thereby useless, and a formation of skin grafting is impos- sible. 4. In. gangrene of a part of a limb (frost-bites, burns, senile gangrene). 5. In malignant tumors, to prevent general infection. 6. In serious septic or pycemic infections, if the surgeon by other methods fails in removing the source of infection. 7. In suppurations of long duration, when the strength of the patient has been reduced to such a degree that apparently he can not resist the prolonged drain, and when by an amputation of the limb health can be restored in a. shorter time ; finally, as a favor. THE TREATMENT OF WOUNDS 317 8. In atrophied paralytic limbs, when the patient desires of his own accord the removal of such portions of his body as have become not only entirely useless, but an incumbrance. GENERAL RULES PREPARATIONS i. The patient is placed in such a position that he can be well ansesthe- tized, and that the surgeon and his assistants have sufficient room. The cut surface of the limb to be amputated must be turned toward the full light. FIG. 591 2. Each assistant receives a certain position and a certain work to per- form. The assistant who takes care of the .wound stands opposite to the operator. The assistant handling the instruments stands close to him with- out hindering his movements or interfering with the light. A third assistant holds the part of the limb to be amputated with outstretched arms. The anassthetizer stands at the head of the patient. If a sufficient number of assistants are not present, the operator must be content with fewer or even with only one. In such a case, the surgeon himself takes the instruments 318 SURGICAL TECHNIC from the basin, while the assistant holds the limb and subsequently the stump. 3. It is best for the operator to take such a position that the amputated limb falls to his right side. 4. Previous to the operation, the skin is shaved extensively in the region of the field of operation, cleansed with soap and brush, and thoroughly dis- infected as described on pages 13-16. As soon as anaesthesia has set in, the limb is constricted above the place of amputation, and after removal of the bandage is once more disinfected. In inflammations and tumors it suffices to hold the limb for some time in a vertical position, so that the circulation of the blood becomes decreased. The constrictor is then applied, but always so far in an upward position, that it can be easily removed after application of the dressings. Fistulous openings and suppu- rating or gangrenous surfaces are covered with compresses dipped in anti- septic solutions to prevent any possible infection of the instruments and hands from carelessness. Of course, during the amputation, all rules of antisepsis and asepsis must be strictly observed. DIVISION OF THE SOFT PARTS The soft parts must be so divided that they will cover the sawed-off bone without tension. The muscles are divided vertically to the axis of the limb ; the incision must not be made by pressure, but by see-saw motions of the knife, as in cutting roast beef. By an oblique section of the muscles the blood vessels are also divided obliquely, rendering their ligation more diffi- cult. For this reason, of all methods most to be recommended are the circular incisions of the skin and muscles. CIRCULAR AMPUTATION (BY ONE INCISION Celsus) While an assistant holds the limb encircled with both hands over the place of amputation, and thereby fixes skin and muscles, all soft parts are divided by one circular sweep of the amputating knife (Fig. 592) down to the bone; the length of the knife depends on the thickness of the limb (Fig- 593); the bone is then sawed through at once. The surgeon should hold the long amputating knife with his whole hand, in order to reach around the whole circumference of the limb ; the point of the knife is applied upon the anterior side of the limb turned toward him, vertically and transversely THE TREATMENT OF WOUNDS 319 to its axis ; next it is pushed with a slight pressure toward his own breast, whereby the blade, dividing all soft parts down to the bone, enters as far FIG. 592. AMPUTATING KNIVES as the handle, when it is carried by short sawing movements around the bone and back to where the incision was commenced. Others divide with the knife, applied near the handle, in a long sweep, first the soft parts of the FIG. 593. CIRCULAR AMPUTATION BY ONE INCISION limb on the side opposite to the operator, then apply the knife in an opposite direction at the beginning of the incision, and divide the soft parts on the operator's side. The bone is then sawed through at once. In order that the soft parts may be united withoitt tension over the bone, the end of the bone must be again sawed off to the extent of half of the diameter of the limb. For this purpose, the bone stump is grasped with lion-jawed forceps, and while the 320 SURGICAL TECHNIC soft parts are well retracted, the periosteum is reflected with a gouge-shaped raspatory (Fig. 594), until the bone is sufficiently exposed (von Esmarcti). FIG. 594. REFLECTION OF PERIOSTEUM In limbs with one bone, this is the best of all methods in creating the smallest and most even wound surface ; it is adapted not only to limbs sup- plied with powerful muscles, but especially to emaciated patients, who are exhausted from long-continued suppuration. For a limb with two bones circular ampu- tation by one incision is not well adapted ; in such cases adequate reflection of the soft parts and of the periosteum after division of the interosseum is accomplished by a lateral longitudinal incision on each side after com- pletion of the circular operation. The wound can be united by sutures in each direction. Figure 595 shows the appear- ance of the fresh stump after a transverse suturing ; Fig. 624, after a vertical closure of the wound. A modification of this operation is circular amputation (by two incisions Petit, 1718), by which the skin and the muscles are divided in two planes by separate circular incisions. By a circular incision the skin is divided down to the fascia (Fig. 596); next, the skin is loosened all around, while an assistant retracts the skin upward by repeated incisions made perpendicularly to the axis of the limb FIG. 595. STUMP AFTER CIRCULAR AMPUTATION BY ONE INCISION THE TREATMENT OF WOUNDS 321 down to the fascia (Fig. 597, not as in Fig. 598). The skin is freed to such an extent that its margin can be grasped with the fingers of the left hand and FIG. 596. CIRCULAR AMPUTATION BY Two INCISIONS. (Dividing the skin) be turned upward like a cuff. The length of the manchette or cuff must equal nearly half the diameter of the limb. If the margin of the incision of FIG. 597. CIRCULAR AMPUTATION BY Two INCISIONS. (Loosening the skin) the skin is too narrow, because the limb increases in circumference above the place, the skin can be divided by a short longitudinal incision at one 322 SURGICAL TECHNIC or two opposite places. Close to the place of reflection of the skin cuff, by a second circular incision, all muscles are divided down to the bone (Fig. 599) ; the periosteum is pushed back with the raspatory, and then the bone is sawed through. FIG. 598. WRONG MODE OF INCISION Figure 600 shows the appearance of a fresh stump. Amputation made by two circular incisions has been described in various modifications. Petit and Cheselden first divided only the skin in a circular manner ; next, while all the soft parts were drawn forcibly upward FIG. 599. CIRCULAR AMPUTATION BY Two INCISIONS. (Dividing muscles) (Fig. 601), they divided them close to the margin of the retracted skin down to the bone in one sweep. Louis divided all soft parts in one cut down to the bone, but detached from the bone by a second circular incision the small muscular cone, which after the retraction of the superficial muscles is formed THE TREATMENT OF WOUNDS 323 by the deep muscles more firmly attached to the bone. Desault went farther by dividing in layers first the skin, next the superficial muscular layer, and FIG. 600. STUMP AFTER CIRCULAR AMPUTATION BY Two INCISIONS finally the deeper layer, on a level to which the former had retracted (amputation by three circular incisions) (Fig. 602). The wound then forms FIG. 601. PETIT'S CIRCULAR INCISION a funnel. Much better, however, than the several divisions of the muscles, is the reflection of the periosteum and sawing off the bone at a higher plane FIG. 602. AMPUTATION BY THREE CIRCULAR INCISIONS. (Detaching muscular cone} (yon Esmarch), whereby abundant soft parts are secured for covering the stump. 324 SURGICAL TECHNIC (All methods of circular amputation have become unpopular owing to the scar which always forms in the centre of the stump over the end of the bone to which it becomes attached. An ideal stump is only obtained by suturing the wound, not over, but to one side, of the end of the bone or bones, and this can only be accomplished by the flap methods.) AMPUTATION BY FORMING SKIN FLAPS (Lowdkam, 1679) With a broad scalpel or a flap knife, according to von Langcnbeck (Fig. 603), semilunar flaps of skin are formed and detached from the fascia by incisions directed vertically to their surface as far as their base, when they are reflected. Either two lateral FIG. 603. VON LANGENBECK'S FLAP KNIFE fl a P s f skin f e( l ual length are formed (Fig. 604), after the union of which the cicatrix takes its course across the middle of the stump, or, what is more preferable, a long anterior and a short posterior flap (Fig. 605) are made, so that the subsequent cicatrix comes to lie on one side of the stump, where it is less liable to be subjected to pressure. The operation can also be modified so that, in the wearing of an artificial limb, after a long anterior skin flap has been made, the skin over the posterior aspect of the limb can be divided by a semicircular in- cision (Fig. 606), when it is de- tached and re- flected in the form of a short flap. In this case, the base of the anterior large flap must be a little small- er than half the FIG. 605. LONG ANTERIOR AND SHORT POSTERIOR FLAP circumference FIG. 604. Two LATERAL FLAPS OF SKIN OF EQUAL LENGTH THE TREATMENT OF WOUNDS 325 of the limb ; its length, however, must be equal to the sagittal diameter of the same. Close to the place of reflection of the flaps of skin all muscles are divided by a circular incision down to the bone, and the latter is sawed FIG. 606. ANTERIOR SKIN FLAP WITH SEMICIRCULAR POSTERIOR INCISION off. The anterior flap hangs then like a curtain over the surface of the wound, and permits good drainage for the secretions, as well as a favorable lateral position for the subsequent scar. MUSCULAR FLAPS The methods by which muscles and skin are utilized in making the flaps are not to be recommended, because they result in larger wound surfaces, and above all, on account of the oblique section of the arteries. The flaps can be cut either from without inward (Langenbeck Fig. 607), for which very sharp flap knives are used, or from within outward (Verduiii), by transfixing the soft parts at the base of the flap close to the bone with a long two-edged knife, and carrying the same obliquely downward and out- ward from the bone with long sawing movements toward the surface. .(See disarticulation of the thigh, Fig. 760.) The latter method is seldom resorted to at the present time ; in amputa- tions for gunshot fractures, it is especially to be avoided, because the knife is easily arrested by bullets concealed in the soft parts or by splinters of bone. Moreover, two-edged knives are not safe, because the edge of the 326 SURGICAL TECHNIC back, if the knife is carried unsteadily, may nick the blood vessels in the flap at several places. Moreover, two-edged knives are more difficult to grind than a one-edged knife, with which the formation of flaps can be made just as well from within outward, especially when the point of the knife is always directed in such a manner as to form a straight line with the back of the knife. FIG. 607. MUSCULAR FLAP INCISION (von Langenbeck's method) A modification of amputation by the muscular flap incision is the oval incision (Langenbeck). In the operation by this method two flaps join posteriorly in a transverse incision so that the wound has the form of a heart (Fig. 643). It is espe- cially adapted for disarticulating smaller joints (fingers and toes). In other localities, aside from the rapidity of its execution, which, with the use of chloroform and the " bloodless method," is of little consideration, it has no advantage over other methods. For an exact execution of the operation, much practice and very sharp flap knives are required. SAWING OFF OF THE BONES After division of all soft parts, the operator changes the knife for an amputation saw (Figs. 608-610), applies the nail of his left thumb upon the bone to steady the blade of the saw (Fig. 611), and saws along it with long, very light movements, making first a guiding furrow ; then with long, vigor- ous movements, he saws through the bone with moderate rapidity, without exerting any pressure. During the sawing, the soft parts are retracted by the first assistant using his hands or by means of a sterilized divided compress (Figs. 612, 613), THE TREATMENT OF WOUNDS 327 FIG. 608. REINER'S AMPUTATION SAW FIG. 609. NYROP'S AMPUTATION SAW FIG. 610. HELFERICH'S AMPUTATION SAW FIG. 611. SAWING OFF THE BONE 328 SURGICAL TECHNIC while the second assistant holds the lower portion of the limb firmly and securely, but lowers it toward the end of the sawing, lest the blade of the saw should become wedged between the yielding bone surfaces. When the bone has been nearly sawed through, the saw is used carefully and more slowly, while the section of the limb is no longer lowered by the assistant, or else the bone easily breaks ojfznd becomes splintered. FIG. 612 FIG. 613 DIVIDED COMPRESSES, a, for limbs with one bone; b, for limbs with two bones In limbs with two bones, the soft parts must be completely divided in the interosseous space before the sawing of the bone. A small one-edged or a two-edged knife (Catline)('\gs. 615, 616) is inserted, sliding along one bone, first from one side and then from the other, and the edge is made to cut as indicated in Fig. 617. The knife, lying with its back close to one bone, is inserted from below into the interosseous space, carried transversely through the interosseous space to the other bone, guided with its edge along its inner surface, and then drawn out in a downward direction. Next, the edge is turned against the opposite bone, and the same procedure is repeated. With a doubly split compress, the middle flap of which is drawn through the interosseous space with dressing forceps, the soft parts are drawn up- THE TREATMENT OF WOUNDS 329 FIG. 616 KNIVES FOR DIVIDING SOFT PARTS IN THE INTEROSSEOUS SPACE (Catline) FIG. 614. REFLECTION OF SOFT PARTS BY MEANS OF DIVIDED COMPRESS FIG. 617. METHOD OF CARRYING KNIFE IN THE INTEROSSEUS SPACE (?) ward (Fig. 618), and both bones are divided at the same time. If, as on the leg, one bone is considerably thinner than the other, the saw is so conducted as first to make a guiding groove in the tibia to prevent the splintering of the fibula; next, the fibula is divided, and then with the last move- ments the tibia also. (In amputations of the lower ex- tremity above the ankle joint it is exceedingly important to perform the operation with a view of obtaining, besides satisfactory wound healing, an ideal, painless conical stump well adapted to the wearing of an artifi- cial limb. These conditions must be complied with to obtain such a result : i. Lateral position of scar. 2. Cover end of bones with periosteum. 3. Saw through the fibula at least an inch i u , , .,. N FIG. 618. SAWING OFF BOTH BONES. Retraction than the tibia.) of soft parts by means of divided compress for After the bone has been sawed limbs with two bones 330 SURGICAL TECHNIC off, any projecting portions of bone are nipped off with Listen's bone forceps (Fig. 619), or with Liters gouge forceps (Fig. 620) ; sharp edges are removed with a fine saw (Fig. 62 1 ) or smoothed with a file. Next, all divided blood vessels, arteries and veins which can be recog- nized as such, and the position of which, if necessary, has been called to mind by sectional drawings (Plates XI-XVI), are ligated (Fig. 440). The larger blood vessels can easily be recognized ; the smaller vessels must be looked for in the intermuscular septa. It is also advisable to draw forward with forceps the ends of the trunks of large nerves projecting into the wound FIG. 619 LISTON'S BONE- CUTTING FORCEPS FIG. 620. LUER'S GOUGE FORCEPS a, straight; b, curved FIG. 621 AMPUTATION SAW and to resect them with a pair of sharp scissors ; by doing so, the pains in the wound or in the cicatrix are prevented, or at least alleviated. A surgeon who has the necessary practice in ligating can then proceed to unite the wound, and to leave the constrictor in position until the dressing is applied. If the surgeon does not dare to pursue such a course for fear of subsequent hemorrhage, proceed as indicated on page 233. (We now recognize more than ever the importance of careful hemostasis as an essential element in the satisfactory healing of wounds. Hence it is under all circumstances necessary to remove the constrictor before sutur- THE TREATMENT OF WOUNDS 331 ing the wound, and resort to the most pedantic measures in arresting the bleeding before the wound surfaces are brought in contact by sutures.) UNION OF THE WOUND This must be made in such a manner that blood and serum cannot collect in it, but must at once appear at the surface, where they are quickly absorbed by the antiseptic or aseptic compressive dressing. With careful hemostasis and perfect asepsis, it is sufficient to unite the margins of the skin over the soft parts by suture ; the angles of the wound should be left open, or supplied with drainage tubes, and a firm, compres- sive bandage should be applied, which presses the surfaces of the wound upon each other, and prevents the collection of secretions. If drainage is to be made, the drainage tubes should be supplied with a long thread which is brought out through the dressing, and by means of which the tube can be extracted on the second or third day without chang- ing the dressing. These drainage tubes, provided with threads (Koc/ier), have the advantage of securing the drainage of the secretions as any other drainage tube, while their canals, after the tubes have been withdrawn, at once become closed by the apposition of their walls, so that, in spite of the drainage, complete healing can take place in ten to twelve days. If it is not desirable to insert any drainage tubes, then the lowermost angle of the wound is left open in order that any secretions may drain off, or the several layers are stitched together in layers by deep or buried sutures, whereby all sinuses in the surface of the wound are avoided, and the collec- tion of secretions prevented. The following illustrations show the applica- tion of the sutures after an amputation of the thigh with a single circular incision : First, the retracted periosteum is drawn forward and united with a few catgut sutures over the sawed surface of the bone (Fig. 622). Next, with long, slightly curved needles and heavy catgut sutures, first the deeper (Fig. 622), then the superficial, layers of the muscles (Fig. 623) are sutured, and finally the margins of the skin are carefully stitched together with a double glover's suture (Fig. 624), whereby only the lowermost angle of the wound is left slightly gaping. (In suturing this amputation wound the periosteal flap should be first fastened over the end of the bone by two or three fine catgut sutures. Next a few strong catgut sutures must be used to supply the end of the muscles with a temporary point of anchorage to prevent undue retraction, and finally the 332 SURGICAL TECHNIC flaps are sutured with silk or silkworm gut and horsehair. Drainage should be established where it is most needed, at the most dependent part of the wound, preferably through a separate buttonhole at the base of the posterior flap.) Only after a permanent dressing, as described on page 43, and illus- trated in Fig. 41, has been applied, is the constriction band removed. FIG. 622. SUTURING PERIOSTEUM AND DEEP MUSCULAR LAYERS FIG. 623. BURIED MUS- CULAR SUTURE FIG. 624. SUTURE OF SKIN MARGINS As a rule the dressings can remain in place for several weeks, until complete healing by primary intention has taken place ; and finally all blood that the patient has lost since the amputation is found in the form of a small, dry, odorless crust on the inner surface of the dressing. (The stump, after amputation, should be immobilized upon a hollow, well- fitting and well-padded splint, and kept in an elevated position at an angle of 40 for at least twelve to twenty-four hours.) GENERAL RULES FOR DISARTICULATION 1. In most cases of disarticulation it is best for the operator to take a position with his face turned toward the patient, and to seize with his left hand the limb to be removed. 2. For division of the soft parts the circular incision is not as well adapted as the flap incision. Since in this operation it is generally necessary to cover a large surface of bone, comparatively large flaps must be formed either from the skin alone, or consisting of skin and the underlying muscles. In many cases, an anterior large flap and a posterior small flap (knee, shoulder, hip) are most advantageous ; in some cases (ankle joint, metatarsus) the posterior flap must be the longest to protect the cicatrix from pressure. THE TREATMENT OF WOUNDS 333 For small joints (fingers, toes) the oval incision is especially well adapted. 3. Having divided the covering soft parts, the articulation is opened by forcibly stretching the exposed tendons by suitable movements, and by divid- ing them with a flap knife. 4. By dividing the other tendons and the capsular ligaments all around, the disarticulation is completed, and if necessary a portion is sawed off from the opposite articular end of the bone. On the whole the procedure is the same as in an amputation. REAMPUTATION 1. If in an amputation insufficient soft parts have been saved, or if they have retracted during the healing in consequence of osteitis, or have been lost by gangrene, a so-called conical stump (Fig. 625) is the result; that is, the end of the bone projects so far that a complete cicatrization cannot be effected (ulcus prominens) ; or, finally, the thin cicatrix produced breaks down again and again as soon as the patient wears an artificial limb. Similar difficulties arise in stumps which are the result of frost-bite, burns, or gangrene. The bone of every even well-formed stump becomes atro- phied after some time from inactivity, and conical. 2. In such cases, operators formerly per- . FIG. 625. CONMCAL STUMP formed another amputation higher up, or they sought to cover the cicatrix by the transplantation of skin flaps. The former procedure is in most cases unnecessary, and is just as dangerous as the first amputation ; while the latter procedure only rarely yields a satisfactory result, because the skin on the extremities is not well adapted to plastic operations. 3. It is far better to make the subperiosteal resection of the bone stump that is, the cicatrix or the ulcerated surface implicated is circumscribed with a strong knife, the soft parts of the stump are divided downward, or on two sides (avoiding the region where the large blood vessels and princi- pal trunks of nerves are located) down to the bone, and the periosteum is reflected upward so far with a raspatory that a sufficiently large por- tion of the bone can be removed with a metacarpal saw or a chain saw. The hemorrhage, as a rule, is inconsiderable. The wound is united with 334 SURGICAL TECHNIC deep and superficial sutures after a drainage tube, if necessary, has been in- serted as far as the end of the bone. The wound generally heals by primary intention, and the result is a good stump completely covered with healthy soft parts. 4. When the first amputation was made near a joint, the subperiosteal disarticulation may follow in the same manner under similar circumstances (compare Fig. 737). In a perfect aseptic course the disadvantage just mentioned of the conic diaphysis stump will not occur. Still, the surface of the stump is always more or less sensitive to pressure. Hence, in making the prothesis atten- tion should be paid that no pressure is exerted upon the stump. Bier has remedied this disadvantage by osteoplastic amputation. He closed the ampu- tated bone surfaces by means of a bone cover (see p. 374) and thereby effected non-sensitive stumps, which were well able to bear pressure. More recently Hirsch has shown that the same success can be obtained likewise with a stump amputated in the ordinary manner if, immediately after the wound has healed, massage and pressure movements by walking are made daily. PROTHESES For rendering the limb mutilated by amputation somewhat useful again, or at least for supplementing its former shape, the patient wears an artificial limb, a prothesis. Protheses are made in various forms, from the simplest apparatus to* artistic and most perfect machines. In general, for patients who must work with their protheses, the simplest apparatus is to be recom- mended. The artificial limbs, in form and power of motion often strikingly similar to the missing limb, are rather ornamental, and must be often repaired for injuries which easily occur. An amputated hand, together with the arm, can be replaced by a claw hand (Figs. 626-628), a hook, clamp, plate, or something similar, attached to the end of a well-fitting leather case, with which the patient, after some practice and ingenuity, can perform a great deal of ordinary work most skilfully. A hand made of wood and covered with a glove can likewise be attached to the leather stump ; it serves more for ornamentation 1 than use. The artificial arms provided with movable fingers, in which the mus- cles are imitated by means of spiral springs and threads, are adapted only to lighter work. They are very expensive, and easily get out of order. THE TREATMENT OF WOUNDS 335 An amputated leg is replaced in the simplest and most durable manner by a peg leg; that is, a firm wooden stump fastened to a well-fitting case. When the leg has been ampu- tated very high the patient kneels upon it (Fig. 631). When the thigh has been amputated very high he sits upon the well-padded margin of the support (Figs. 629, 630). The "artificial leg," made of light, firm wood, is movable at the knee and the ankle joint by a hinge joint (Fig. 632). As beautiful as it may appear, still, if the patient wishes to walk rapidly and for a long time, the simple support is mostly preferred, FlG - 626 because it is more durable and can be repaired more easily and inexpensively than an artificial leg FIG. 627 CLAW HANDS FIG. 628 FIG. 629 PEG LEGS FIG. 630 for amputated thigh FIG. 631. PEG LEG FIG. 632. ARTIFICIAL LEO for amputated leg 336 SURGICAL TECHNIC (If, after an amputation of the leg or thigh, the patient can bear the expenses of an artificial limb, the stump must be properly prepared. Arti- ficial atrophy should be induced by systematic bandaging, and the skin properly prepared by washing with diluted alcohol for at least three months.) AMPUTATIONS AND DISARTICULATIONS OF THE UPPER EXTREMITIES DISARTICULATIONS OF THE FINGERS DISARTICULATION OF THE THIRD PHALANX (By forming a volar flap from without inward) i. The hand is held in pronation toward the operator. He takes hold of the point of the finger and flexes the third phalanx. FIG. 633. SKELETON OF FINGER FIG. 634. POSITION OF LINES OF ARTICULATIONS OF THE FINGER FIG. 635. DISARTICULATION OF FIRST PHALANX 2. A flat curved incision 2 millimeters below the eminence of the joint (Fig. 634), made transversely across the head of the second phalanx, opens the capsular ligament (Fig. 635). 3- The point of the knife divides both j atera j ligaments ; the blade is inserted with its edge turned downward behind the volar surface of the third phalanx (Fig. 636), and a well-rounded flap is formed by saw- ing movements from the skin of the volar side (Fig. 637). In suturing the wound FIG. 636 FIG. 637 the cicatrix comes to lie on the dorsal surface, while the new finger tip is covered with normal skin. DISARTICULATION OF THE SECOND PHALANX (By forming a flap from within outward by transfixion) i. The hand is held in supination toward the operator; he takes hold of the extended point of the finger, inserts a small knife below the fold of the THE TREATMENT OF WOUNDS 337 joint from one side to the other between skin and joint, and carries the blade by sawing movements first tow- ard himself, then upward, so that a well-rounded flap is formed (Fig. 638). 2. The flap is turned upward, the joint is forcibly stretched, and from the wound the knife divides in one sweep the capsular ligament, the lat- FlG - 6 3 8 FlG - 6 39 eral ligaments, and the skin on the dorsal side of the joint in a transverse direction (Fig. 639). DISARTICULATION AT THE METACARPOPHALANGEAL JOINT (#) Oval incision. i. The operator, standing on the left side of the limb, with his back toward the face of the patient, seizes, while an assistant draws aside with his left hand the two neighboring fingers, the diseased finger, hyperextends it so far that he can see the volar surface, carries a small knife from the FIG. 640. DISARTICULATION AT THE METACARPOPHALANGEAL JOINT (oval incision) right to the volar surface of the first phalanx, divides here at the level of the tense web the soft parts transversely, carries the knife around the right side of the phalanx to the dorsal side, and here in a curve upward as far as the head of the metacarpal bone (Fig. 640). 338 SURGICAL TECHNIC 2. The knife is carried under the left hand around the left side of the finger as far as the beginning of the first incision ; here it penetrates down to the bone ; it is then carried at the level of the web around the left side of the first phalanx to the dorsal side, and here it is drawn upward in a curve to the end of the first incision (Fig. 641). FlG. 641. DlSARTICULATION AT THE METACARPOPHALANGEAL JOINT BY AN OVAL INCISION 3. Both incisions are made in the same order, but penetrating more deeply toward the joint. They divide, while the finger is always inclined toward the Opposite side, the tendons, the lateral ligaments, and the capsular ligament. The wound is heart-shaped (Fig. 642). (^) Flap incision. 1. This incision is best adapted to the first, second, and fifth fingers, because they are more easily accessible on one side. A large half-oval flap is made, the base of which corresponds with the level of the articulation from the volar, dorsal, or lateral skin of the first phalanx, and is reflected upward. 2. Next, a smaller skin flap is formed on the opposite side, and likewise turned up. 3. Finally, the tendons are divided at the level of the articulation, and the latter is completely disconnected (Fig. 643). THE TREATMENT OF WOUNDS 339 If the metacarpus of the finger involved must be removed at the same time, it is best to extend the dorsal angle of the wound to the carpus. The FIG. 643 FIG. 644 DlSARTICULATION AT THE METACARPOPHALANGEAL JOINT. a, of the thumb, second' and fifth fingers. Formation of flaps of unequal size on the fourth finger; of two equal flaps on the third. Oval incision from the volar side, b, Wound from the oval incision and flap incision metacarpal bone is then disarticulated without great difficulty from the carpometacarpal articulation. The wound is sutured completely. DlSARTICULATION OF ALL FINGERS 1. If the last four fingers must all be amputated, they may be singly dis- articulated in the manner just described ; more useful, however, is a dorsal circular incision and the formation of a volar flap. 2. Under strong volar flexion of the fingers a transverse incision is made through the skin and tendons across the base of the four fingers from one margin of the hand to the other. 3. Next, the knife cuts along the volar side (the fingers being flexed dorsally), in the fold of the joint, along the margin of the web a small flap, the ends of which meet the dorsal incision. 4. Each finger is then disarticulated singly, and next the margins of the wound are sutured (Fig. 645). The cicatrix occupies the dorsal side. FlG. 645. DlSARTICULATION OF ALL FINGERS 340 SURGICAL TECHNIC DISARTICULATION OF THE THUMB AT THE CARPAL JOINT (#) Oval incision. 1. The first incision begins at the ulnar side of the first phalanx at the level of the web, is carried obliquely across the phalangometacarpal joint as far as the radial side of the metacarpal bone, and along this as far as its base. 2. The second incision, carried from the same point around the radial side, meets the first at the middle of the metacarpal bone (Fig. 646). FIG. 646 FIG. 648 DISARTICULATION OF THE THUMB (oval incision) 3. By repeated incisions in the same direction along the bone, the latter is freed from the muscles. It is of importance to preserve as much as possible of the muscles, and especially of the periosteum, in order to obtain a somewhat movable stump. 4. From the ulnar side, the articulation is opened between the trapezium and the metacarpal bone, whereby the edge of the knife must be carried close to the base of the latter for fear of opening the articulation between the metacarpal bone of the index and the trapezium, connected with the other carpal joints. 5. The division of the articular ligaments on the radial side (Fig. 647) completes the operation, which leaves a linear scar after the wound has been sutured (Fig. 648). Since a hand without a thumb is not very useful, a stump should be preserved on the metacarpus wherever it is possible, no matter how small. If it is impossible, according to Lancnstein, the meta- carpus of the second and fifth fingers can be sawed through transversely by THE TREATMENT OF WOUNDS 341 dorsal longitudinal incisions. The two fingers are then turned 180 around their axis and healed in this position. They then stand in opposition to the third and fourth fingers (as in a parrot's foot). ($) Lateral flap incision according to von Walther. i. The thumb is held in abduction, the knife is applied over the middle of the web, and carried upward by sawing movements between the first and FIG. 649 VON WALTHER'S RADIAL FLAP INCISION FIG. 650 second metacarpal bones until it reaches the ulnar margin of the base of the first metacarpal bone (Fig. 649). 2. By avoiding the joint between the metacarpal bone of the index and the trapezium, the point of the knife is carefully carried under* the base of the bone, and thereby the carpometacarpal joint is opened. 3. The thumb can be abducted even more forcibly ; the knife penetrates the joint to the radial side of the metacarpal bone, and is again carried on this downward, forming a radial flap, the rounded point of which ends at the level of the web (Fig. 650). DISARTICULATION OF THE LAST FOUR METACARPAL BONES (WITH PRESERVATION OF THE THUMB) 1 . On the palmar surface a semilunar flap is circumscribed by an oblique curved incision, beginning at the web of the thumb and ending at the ulnar margin of the base of the fifth metacarpal bone (Fig. 651). The flap can also be formed from within outward by transfixion at its base (Fig. 652). 2. An incision is made upon the dorsal side of the hand, beginning at the 'web of the thumb and extending obliquely upward as far as the upper third of the second metacarpal bone ; thence it extends at the same level across 342 SURGICAL TECHNIC the last three metacarpal bones ; at the ulnar margin of the hand, it meets the volar flap (Fig. 653). 3. After both flaps have been dissected back as far as the region of the carpometacarpal articulations, the latter are opened from the ulnar side under forcible abduction of the metacarpus, until also the connection of the second FIG. 651 FIG. 653 FIG. 652. VOLAR INCI- FIG. 654. STUMP DlSARTICULATION OF THE LAST FOUR METACAR- SION BY TRANSFIXION AFTER DlSARTIC- PAL BONES, a, volar incision; b, dorsal incision ULATION OF THE LAST FOUR META- CARPAL BONES carpometacarpal bone with the trapezium is divided. During the last act, the incision must be made very carefully and always be directed toward these two bones in order to avoid injury of the articulation between the trapezium and the metacarpal bone of the thumb. 4. It is exceedingly advantageous to preserve the thumb for working purposes (Fig. 654). DlSARTICULATION OF THE WRIST (a) Circular incision. 1. A circular incision circumscribes the hand upon the middle of the metacarpus 4 centimeters below the styloid processes. 2. The skin is separated all around by vertical incisions until it can be turned back like a cuff or manchette over the styloid processes. 3. The pronated hand is strongly flexed ; a slightly curved incision with the convexity directed upward, across the wrist from one styloid process to the other, divides the extensor tendons and opens the wrist. THE TREATMENT OF WOUNDS 343 4. The lateral ligaments are divided under both styloid processes, and finally the anterior capsular wall and all flexor tendons are divided with one sweep of the knife (Figs. 655, 656). (^) Flap incision. i . The operator takes hold of the lower portion of the hand in pronation, flexes it, and makes from the point of one styloid process to the other a semilunar incision across the middle of the dorsal side of the hand (Fig. FIG. 656. STUMP AFTER DlSAR- TICULATION OF 2. The skin flap is THE WRIST BY detached from the ex- CIRCULAR IN- J J CISION tensor tendons, turned upward, and the joint is opened in the same manner as in the circular incision. FlG. 655. DlSARTICULATION OF THE HAND BY CIRCULAR INCISION FIG. 657 FIG. 658 DlSARTICULATION OF THE HAND BY TWO FLAPS OF SKIN (Ruysch) 3. The fasciculus of the flexor tendons is forced forward with the point of the left forefinger into the wound from the volar surface, and carefully 344 SURGICAL TECHNIC divided by to and fro motions of the knife ; next, a small skin flap is made on the volar side (Fig. 658). It is advisable by an incision to indicate the volar flap at the beginning of the operation. (V) Radial flap (yon Walther, 1810). 1. From the skin covering the metacarpal region of the thumb, a semilunar flap is formed, the base of which comprises the radial third portion of the carpus, the point of which reaches the base of the first phalanx. 2. After the flap has been dis- sected off from the muscles of the thumb and turned upward, a half- circular incision circumscribes the two remaining thirds of the carpus at the ulnar side (Fig. 659). 3. The skin is drawn forcibly upward, and the carpus, as described STUMP RESULT- above, is separated from the bones of G FROM VO , N r W A L T H E R S the forearm. Figure 660 shows the METHOD FIG. 660 FlG. 659. DlSARTICULATION OF THE HAND (von Wal- ther's method) appearance of the sutured stump. AMPUTATION OF THE FOREARM For amputating the forearm, the circular incision in two tempos (Figs. 599-600) and the skin flap incision (Fig. 605) are adapted. During the p.l. Ttf.d- n.m. a.u. a.r. m,u.e. FIG. 661. SECTION OF THE RIGHT FOREARM AT ITS LOWER THIRD. /./. palmar, long.; n.m. nerv. medianus; t.r.i. tendo rad. int.; a.r. art. radialis; b. brachioradialis; n.r.s. nerv. radial, superf.; a.p.l. abductor pollicis longus; r.e.l. radialis ext. longus; r.e.b. radialis ext. brevis; e.d.c. extensor dig. comm.; m.u.e. muse, ulnaris extern.; a.u. art. ulnaris; m.f.d. muse. flex, dig. comm. prof. PLATE XI At its lower third X At the middle of the right fore-arm Sections of the right fore-arm THE TREATMENT OF WOUNDS m.p.l. 345 tun m.e.p FIG. 662. SECTION OF THE RIGHT FOREARM AT ITS MIDDLE PART (see also Plate XI). m.p.l. muse, palmaris longus; n.tn. nerv. medianus; a.r. art. radialis; m.p.t. muse, pronator teres; n.r. nerv. radialis; t.r. tendo radialis ext. long.; m.e.p. muse, extens. poll, long.; a.u. art. ulnaris n.r.s. -n.u. FIG. 663. SECTION OF THE RIGHT FOREARM AT ITS UPPER THIRD (see also Plate XII). a.r. art. radialis; n.r.s. nerv. radialis superf.; n.r.p. nerv. radialis profundus; a.i. art. interossea; a.u. art. ulnaris; n.u. nerv. ulnaris; n.m. nerv. medianus 346 SURGICAL TECHNIC operation, the forearm must always be held in full supination, especially in sawing off the bones ; else the radial stump becomes somewhat shorter. If flaps are formed, it is best to select a volar and a dorsal flap, or only a volar flap, which must correspond to the diameter of the limb. Directly above the wrist, it is often difficult to divide the tendons ; they must be drawn for- ward with tenaculum forceps, and cut off with a pair of scissors. The union of the wound is best made in a vertical direction, while the arm is placed in pronation. As little as possible should be removed from the forearm, and especially when the amputation must be made very high and close to the elbow joint, a small forearm stump should always be preferred to disarticulation of the elbow, which can be made more easily. The stump is subsequently of great importance for the movement of any prothesis which may be applied. DISARTICULATION OF THE ELBOW JOINT (a) Circular incision, i . A circular incision divides the skin 4 centimeters below the condyles of the humerus ; the manchette is dis- sected back and re- flected. 2. A transverse incision across the vo- lar side opens widely the hyper - extended articulation. 3. An incision above the head of the radius divides the external lateral lig- ament ; an incision below the internal con- dyle divides the inter- nal lateral ligament. 4. The articula- tion gapes widely ; the olecranon is forced into the wound ; an incision above its point separates the tendon of the triceps from it (Fig. 664). Figure 665 shows the form of the stump sutured transversely. FIG. 664. DISARTICULATION OF THE ELBOW JOINT (circular incision) FIG. 665. STUMP AFTER DISARTICULATION OF THE ELBOW JOINT BY CIRCULAR INCISION PLATE XII At its upper third \ Through the elbow joint in the line of Condyles Sections of the Right Fore-arm THE TREATMENT OF WOUNDS 347 () Flap incision. i. A curved incision, beginning 2 centimeters below one condyle and ending 2 centimeters below the other circumscribes on the volar side of the n.c.e. v.m. v.c n.c^.m. n.m. n.T. m.r. FIG. 666. SECTION OF THE RIGHT ELBOW JOINT IN THE LINE OF CONDYLES (see also Plate XII). n.c.e. nerv. cutaneus ext. ; v.c , vena cephalica ; n.r. nerv. radialis; v.m. vena mediana; v.b. vena basilica; n.c.i.m. nerv. cutaneus int. major; n.m. nerv. medianus; m.r. muse, radialis int.; n.u. nerv. ulnaris forearm a large semilunar skin flap, which is detached from the fascia and turned upward. 2. The arm is strongly flexed and turned in such a way that the posterior side of the articulation faces anteriorly. 3. A shallow curved incision across the olecra- non exposes its tip (Fig. 667). 4. A transverse incision from one condyle to the other divides the tendon of the triceps and the two lateral ligaments ; a second, all the soft parts on the volar side of the articulation. (*:) Obliqtie incision. i. While the elbow joint is held flexed at an angle of about 135, the incision penetrating imme- ,.,,, .i_v J f 4-UT f FlG. 667. DlSARTICULATION diately down to the bone extends from the line of op T / RE ELBQW JomT articulation of the elbow (beginning over the head (fl ap incision) 348 SURGICAL TECHNIC of the radius) parallel to the axis of the arm and a hand's breadth below the tip of the olecranon along the dorsal side and around the limb back to the elbow. 2. The dorsal flap is detached, together with the muscles (triceps, anconeus tissue), and the periosteum as far as the posterior surface of the humerus. 3. After division of the external ligament follows the opening of the articulation, and finally, after division of the internal ligament, the forearm is disarticulated. 4. The flap is turned into the elbow and sutured in this position ; the cicatrix comes to lie laterally and is protected from the pressure of the stump. On account of the very uneven articular surface of the humerus, it is advisable also to saw off its lower extremity and extirpate the articular capsule (transcon- dylary amputation, Pirogoff\ FIG. 668. DISARTICULA- TION OF THE ELBOW JOINT (Kocher's ob- lique incision) AMPUTATION OF THE ARM In emaciated subjects, a single circular incision with the soft parts forcibly reflected and a sufficient high subperiosteal division of the bone by sawing FIG. 669. SECTION OF THE RIGHT ARM AT ITS LOWER THIRD (see also Plate XIII). v.c. vena cephalica;.r. nerv. radialis; n.c.e.s. nerv. cutan. ext. superfic.; n.c.e. nerv. cutaneus ext.; a.b. art. brachialis; ./. nerv. medianus; v.b. vena basilica; n.c.i.m. nerv. cutan. int. major; n.u. nerv. ulnaris PLATE XIII At its lower third At its middle third In front of the Axilla Sections of the Right Arm THE TREATMENT OF WOUNDS 349 350 SURGICAL TECHNIC (Fig- 594) is the simplest and most rapid procedure. In muscular patients it is better to make a circular flap. The skin flap incision is made either with two flaps (Fig. 605) or with one long anterior flap and a half posterior circular incision (Fig. 606). In reflecting the periosteum and hi sawing, injury to the radial nerve, which lies directly upon the bone, must be care- fully avoided. The same is forcibly drawn forth before the wound is sutured and cut off as high up as possible. DISARTICULATION OF THE ARM AT THE SHOULDER JOINT (a) Flap incision. i. The patient lies at the edge of the table half on his healthy side, with his thorax somewhat raised. The more he is placed in a sitting position, the more convenient it is for the operator, but the more dangerous for anaesthesia. FIG. 672. DISARTICULATION OF THE SHOULDER- JOINT (flap incision) 2. On the external surface of the shoulder, a rounded square flap is out- lined with the knife, the base of which extends from the coracoid process to the root of the acromion, and the inferior border of which corresponds with the inferior limits of the deltoid muscle (Fig. 672). THE TREATMENT OF WOUNDS 351 3. With long sweeps of the knife, penetrating more and more deeply into the deltoid muscle, the flap is detached as far as the acromion, and turned upward so that the outer surface of the shoulder joint is freely exposed. 4. A bold incision across the head of the humerus, forced upward, above the two tuberosities, divides the capsule together with the tendons lying over it. 5. The head of the humerus is forced forward, the knife inserted behind it, and the posterior capsule is divided. 6. The operator with his left hand draws the head of the humerus toward himself, directs the knife with long sawing movements down along the inner side of the bone as far as 6 centimeters below the axillary fold ; FlG. 673. DlSARTICULATION OF THE SHOULDER JOINT BY FORMING SECOND FLAP ON THE INNER SURFACE FIG. 674. STUMP AFTER DISARTICULATION OF THE SHOULDER JOINT BY FLAP INCISION then he turns the edge inward (against the thorax), and divides with one sweep all soft parts in which the large blood vessels and nerves are coursing. 7. In such cases, where he does not succeed in arresting complete. ly the afferent flow of the circulation by compressing the j^&^^^Qr-3Ssistant, before the last incision is completed, must rea&h^ntV) the W-<^K\ ^fem above, and compress with his thumb the axillary artery aga&ist ttie^skjnj'^ug; .673). 8. Figure 674 shows the appearance of the tt r und\s*lier suturing. 352 SURGICAL TECHNIC (b) Circular incision. 1. The arm is held in abduction. A circular incision at the level of the ower limit of the deltoid muscle divides all soft parts down to the bone. 2. The bone is sawed off at the same level ; all visible blood vessels are ligated. 3. A longitudinal incision from the anterior margin of the acromion to the circular incision divides all soft parts down to the bone. 4. The lower end of the bone is grasped with strong bone-holding for- ceps or with the left hand, and while an assistant draws apart with strong retractors the margins of the wound of the longitudinal incision, the operator removes the bone from the articulation by continuous rotations (Fig. 675). FIG. 675 FIG. 676 DISARTICULATION OF THE SHOULDER JOINT (circular incision and longitudinal division) a, disarticulation of the stump of the arm; 6, sutured stump This disarticulation is made by short incisions always directed against the bone, or in suitable cases by detaching tJic periosteum with elevators and tJie raspatory. 5. r ' In .order to remove the acromion and the coracoid process, which pro- ject into the wound, they should be resected as much as may be deemed necessary (Ifffffric/t). 6. Figure 676 shoWs the appearance of the stump. The skin flaps can also be rounded 3ff fy cutting off the lower edge. THE TREATMENT OF WOUNDS 353 (<:) Oval incision. The point of the oval can be placed either on the outside below the acro- mion in which case the deltoid muscle must be removed in part (Fig. 677), or the operator begins with an anterior longitudinal incision in an out- FlG. 677. DlSARTICULATION OF THE SHOUL- DER JOINT (Larrey's oval incision) FlG. 678. DlSARTICULATION OF THE SHOUL- DER JOINT (oval incision) ward direction from the coracoid process below the clavicle, circumscribes with the knife the border of the deltoid muscle, and then returns transversely across the posterior side of the arm to the axillary fold, and from there upward to its beginning (KocJier, Fig. 678). If the edges of the incision in Fig. 675 are largely rounded off, almost the same incision is produced. The latter methods are especially adapted to cases in which the operation is performed for tumors, when it is desirable first to establish the diagnosis. The longitudinal incision is made first, and the circular or oval incision is added to it. For disarticulating the shoulder girdle (shoulder together with clavicle and scapula) for the removal of tumors, it is best to make an oval incision (Fig. 679) with its point above the clavicle, which passes down in a curve in front to the anterior axillary fold, posteriorly passes across the acromion, and unites with the anterior incision in the axilla (Berger). 2A FlG. 679. DlSARTICULATION OF THE SHOULDER GIRDLE 354 SURGICAL TECHNIC AMPUTATIONS AND DISARTICULATIONS ON THE LOWER EXTREMITY DISARTICULATION OF THE SEVERAL TOES This is made in the same manner as the disarticulation of the fingers (see pages 336-340). DISARTICULATION OF ALL TOES IN THE PHALANGOMETATARSAL JOINTS i. While the left hand forcibly flexes all the toes upward, a curved incision beginning (on the left foot) at the median border of the first pha- langometatarsal joint and ending at the lateral border of the joint of the same name of the fifth toe is made in the groove between the plantar surface and the base of the toes (Fig. 680). (On the right foot the incision is reversed.) 2. A similar in- cision, the ends of which meet those of the first, is made under a forcible plantar flexion of the toes along the dorsal side of the base of all the toes (Fig. 68 1). Both incisions penetrate between the toes as far as the middle of the web. 3. Both semilunar flaps are dissected back as far as the heads of the metatarsal bones. 4. Next, each toe is separately disarticulated, leaving the sesamoid bones at the head of the first metatarsal bone in position. 5. Should the skin not be sufficient to cover conveniently the prominent heads of the metatarsal bones, they can be singly removed with the pha- langeal saw or the bone-cutting forceps. 6. Figure 682 shows the appearance of the stump. FIG. 680. DISARTICULATION OF ALL TOES (plantar incision) FIG. 68 1. DISARTICULATION OF ALL TOES (dorsal incision) THE TREATMENT OF WOUNDS 355 AMPUTATION OF ALL METATARSAL BONES JAGER's METATARSAL AMPUTATION 1. A curved incision is made from one border of the foot to the other across the anterior limiting furrow of the plantar surface, and the semilunar flap of the skin is dissected back to the place where the amputation is to be made. 2. Upon the dorsum of the foot, a smaller semilunar flap is made, the ends of which meet those of the plantar flap at the borders of the foot. FIG. 682. STUMP AFTER Dis- ARTICULATION OF ALL TOES FIG. 683. AMPUTATION OF FOOT THROUGH THE METATARSAL BONES BY SAWING FIG. 684. WOUND RESULTING FROM SAWING OFF META- TARSAL BONES Instead of the dorsal flap, a semicircular incision can be made, provided the skin of the plantar surface is sufficient for covering the surface of the wound. 3. At the base of both flaps, the soft parts are carefully divided with a small knife upon and between the several metatarsal bones. 4. By means of small strips of sterilized gauze, which, with forceps, are drawn between the several bones, the soft parts are drawn forcibly upward, and all the bones close to them are sawed through at the same time (Figs. 683, 684). DISARTICULATION OF THE GREAT TOE TOGETHER WITH ITS METATARSAL BONE The oval incision is made in the same manner that has been described on page 340, in disarticulation of tJic thumb. 356 SURGICAL TECHNIC On account of the great breadth of the base of the first metatarsal bone, it is advisable to make upon the upper end of the incision a transverse incision at a right angle across the articulation (Fig. 685). This is about 4 centimeters in front of the eminence of the tubercle of the scaphoid bone, and the upper and lower flaps formed thereby are dissected back until the whole bone and the articulation are exposed. 2. The tendons of the extensor and flexor longus hallucis are divided over the articulation ; the articulation is opened on the dorsal side, and while the bone is constantly rotated around its axis in opposite directions, its con- nections with the internal cuneiform bone are detached. FlG. 685. DlSARTICULATION OF THE GREAT TOE TOGETHER WITH ITS METATARSAL BONE DlSARTICULATION OF THE FIFTH TOE TOGETHER WITH ITS METATARSAL BONE Flap incision. 1. This incision can be made in a similar manner as previously described in the disarticulation of the thumb (page 340). 2. The left hand forcibly abducts the fifth toe from the fourth ; the right hand carries a small knife from the web with sawing movements between the two metatarsal bones upward un- til it meets with resistance (Fig. 686). 3. The end of the skin incision, as well on the dorsal side as on the plantar side, is extended about i cen- timeter upward. 4. Under a forcible abduction of the fifth metatarsal bone, its base is first separated from the fourth meta- tarsal bone, and next from the cuboid Fic " 686 ' DISARTICULATION OF THE FIFTH TOE , WITH ITS METATARSAL BONE bone. 5. The knife is then carried around the tuberosity of the fifth metatarsal bone projecting upward ; thence closely along the outside of the bone in sawing movements downward; a tongue-shaped external flap is thus formed, THE TREATMENT OF WOUNDS 357 the point of which must be rounded off exactly at the level of the first incision in the web (Fig. 686). 6. In the same manner, the second, third, and fourth toes, together with their metatarsal bones, can be extirpated. LISFRANC S DISARTICULATION IN THE TARSO-METATARSAL ARTICULATIONS (EXARTJCULATIO TARSOMETATARSEA) 1. Along the external border of the foot, between the cuboid bone and the metatarsal bone, the joint lying directly in front of the tuberosity of this bone is sought ; at the internal border of the foot, the articulation is sought for between the internal cunei- form bone and the first metatarsal bone, which is 4 centimeters in front of the tuberosity of the scapJioid bone. The line is marked by small incisions with the knife. 2. From one of these points to the other (from left to right), while the foot is raised, a large semilunar flap is circumscribed with the knife on the plantar surface, the convexity of which passes over the heads of the metatarsal bones. 3. The foot is lowered and strongly flexed, the knife is carried from one point of the plantar flap to the other in a shallow curve, across the dorsum of the foot, dividing all soft parts down to the bone (Fig. 689). 4. The small dorsal flap is drawn upward, the point of the knife searches gropingly, to open the articulation farthest to the left (on the right foot, the fifth metatarsal joint), while the left hand flexes the front of the foot strongly toward the plantar surface. 5. As soon as the joint gapes, the knife is carried farther in a curve slightly convex anteriorly ; the knife opens the fourth and LlSFRANC'S DlSARTICri-ATION OF THE r TARSOMETATARSAL ARTICULATION third joints (a), slides across the FIG. 687. SKELETON THE FOOT FIG. 358 SURGICAL TECHNIC base of the second metatarsal bone and opens the first articulation (c) (Fig. 690). 6. The articulation of the second metatarsal bone, located about one centi- meter higJier than that of the first, is opened by a small transverse incision (); the lateral connections of the bone with the internal and external cuneiform bones, be- tween which the base of the bone articulates, are divided by inserting the knife with its edge directed upward (Fig. 691). 7. All articulations are now gaping more extensively ; the knife divides the remaining connections of the joint along the lateral borders and on the plantar side, and divides the muscles on the plantar surface for the greater part; next, its FIG. 689 FIG. 690 i j j r i edge is directed forward in LlSFRANC'S DlSARTICULATION OF THE FOOT. a, dorsal i i i n incision; b, dividing articulation completing the plantar flap (Fig. 692). Figure 693 shows the appearance of the wound before its union ; Fig. 694, that of the stump. If the well-defined extent of the disease permits it, the surgeon should endeavor to preserve the healthy meta- carpal bone or bones (atypi- cal amputation. Kiistcr ob- tained a good success by dis- articulating the second to the fifth metatarsal bones. He preserved the first metatarsal bone as well as the great toe, FlG - 69 1 whereby the important sup- port of the foot, the condyle of the first metatarsus, was preserved (Fig. 695). Else the surgeon can disarticulate the first metatarsus and saw off LlSFRANC'S DlSARTICULATION OPENING SECOND METATARSAL ARTICULATION THE TREATMENT OF WOUNDS 359 only a portion from the other metatarsal bones, whereby likewise the impor- tant support of the tuberosity of the fifth metatarsus is left in position. If the tliree cuneiform bones must be removed, the cuboid bone, together with FIG. 692 FIG. 693 FIG. 694 LISFRANC'S DISARTICULATION. a, forming plantar flap; b, wound surface; c, stump FIG. 695. LISFRANC'S DISARTICULATION. Preserving hallux the tuberosity of the fifth metatarsus, can "be preserved. But it is better to make in that case a transverse amputation by dividing transversely the cuboid bone at an equal height with the anterior line of articulation of the scaphoid bone (intertarsal disarticulation, Jager, Bond]. CHOPART S DISARTICULATION AT THE TARSUS MEDIOTARSAL DISARTICULATION 1. The disarticulation is made in the joint connecting the scaphoid bone with the head of the astragalus, and the cuboid bone with the os calcis (Fig. 696). 2. The line of the joint is found and marked along the internal border of the foot, i centimeter above the tuberosity of the scaphoid bone, and at the external border of the foot, 2 centimeters above the tuberosity of the fifth metatarsal bone. 3. Across the plantar surface of the raised foot, a curved skin incision is made, extending from the point marked on the left anteriorly along the border of the foot, a thumb's breadth behind the heads of the metatarsal bones, transversely across the plantar surface, and along the other border of the foot back to the point on the right side (Figs. 697-699). SURGICAL TECHNIC 4. The foot is lowered and forcibly pressed downward, the knife is in- serted in the left angle of the wound and carried in a small curve across the FIG FIG. 697 FIG. 698 FIG. 699 FIG. 700 CHOPART'S DISARTICULATION AT THE TARSUS dorsum of the foot, only through the skin, as far as the right angle of the wound of the plantar incision (Fig. 700). 5. The little dorsal flap is retracted forcibly, a deep incision transversely across the articulation divides all tendons, and penetrates at once into the 36i articular connection (most safely, first above the tuberosity of the scaphoid bone, which can be distinctly felt), 6. Under the edge of the knife, carried across the union of the joint (slightly ^-shaped curve), the joints are opened with a cracking noise. The point of the knife divides the tense ligaments everywhere, last on the plantar side, until the front of the foot can be completely pressed downward against the heel. 7. After a somewhat deeper incision has been made of the plantar flap on both borders of the foot, the edge of the knife, directed forward, is applied to the lower side of the freed scaphoid and cuboid bones, and drawn forward by sawing movements until the plantar flap is com- pleted (Fig. 701). 8. Figure 702 shows the appearance of the stump. The anterior inferior edge of the os calcis, which projects conspicuously and is apt to produce decubitus of the stump, can be chiselled off to some extent (HelfericJi). During the healing pro- cess the foot must be placed in strong dorsal flexion (if necessary, by making tenotomy of the tendon of Achilles). After the healing, a sole extending obliquely upward is useful for walking, since the stump is apt to assume the talipes-equinus position. To prevent the same, Helferich advises, after a previous tenotomy of Achilles, to open the astragalo-crural articu- lation from CJioparfs wound, and, after removal of its cartilaginous surfaces, to effect a coalescence (arthrodesis), the limb being placed in a right-angular position. If the disease involves only the metatarsus, the dis- articulation can be made in Choparfs joint, thus preserving the toes (Linck, 1887, Witzel). i. From the extremities of the dorsal transverse incision longitudinal FIG. 701. CH OPART'S DISARTICULATION AT THE TARSUS. Finishing plantar flap FIG. 702. STUMP AF- TER CHOPART'S DISARTICULATION AT THE TARSUS 362 SURGICAL TECHNIC incisions are made along the exterior and interior border of the foot toward the toes and beyond the diseased portion. The extremities of these incisions are connected by a dorsal transverse incision, so that a square soft-part flap is produced thereby (Fig. 703). 2. Disarticulation in Choparfs joint and amputation of the diseased bones from the plantar soft parts, after the metatarsal bones have been sawed through either transversely, or after they have been disarticulated in the joints of the toes. FIG. 703 FIG. 704 CHOPART'S DISARTICULATION; PRESERVING TOES (Witzel) 3. Ligation of the dorsal artery of the foot and of the communicating branch of the plantar arch in the metatarsal interstice. 4. The portion of toe hanging loosely at the plantar bridge is united by wire suture with the skin of the upper dorsal flap, whereby a strong trans- verse roll of soft parts is formed on the plantar side (Fig. 704), which con- tracts after a few weeks. It is drained on both sides, and an immobilization dressing is applied for 4 weeks. 5. The result is a well-formed, but considerably shortened, small foot without any arch ; it does not assume any talipes-equinus position, and is well movable in the astragalo-crural articulation. The dorsal extension of the toes, of course, does not take place, since the sutures of the tendons have been omitted. MALGAIGNE'S DISARTICULATION OF THE FOOT BELOW THE ASTRAGALUS i. Two lateral flaps are formed by an incision, beginning behind directly above the tuberosity of the os calcis and detaching the tendon of Achilles from it ; encircling the external malleolus in a large curve, it extends across the lower half of the os calcis (Fig. 705) and thence ascends across the middle of the cuboid bone to the dorsum of the foot, over the anterior margin of the scaphoid bone (Fig. 706) ; it then descends perpendicularly downward along the internal side of the metatarsus (Fig. 707), until it reaches the middle of the plantar surface (Fig. 708) ; from here it turns at THE TREATMENT OF WOUNDS 363 a right angle backward, meeting the beginning of the incision at the inner border of the tendon of Achilles. FIG. 705 FIG. 706 FIG. 707 FIG. 708 MAI.GAIGNE'S DISARTICULATION BETWEEN THE ASTRAGALUS AND THE Os CALCIS (below the astragalus) 2. The two flaps are detached from the bone until both lateral surfaces of the calcaneum and of Choparfs articulation are exposed. Care must be taken not to come too near the tips of the malleoli, for fear of injuring the tibiotarsal articulation. 364 SURGICAL TECHNIC 3. By the disarticulation of Clioparfs joint, the amputation is completed. 4. With bone forceps, the anterior border of the os calcis is grasped, and while the bone is pressed downward and held in supination, the calcaneo- fibular ligament is divided with a small knife i centi- meter below the tip of the external malleolus ; it next enters the joint, divides the firm intertarsal liga- ment, while the bone ro- tates around its long axis ; finally the external astrag- alocalcaneal ligament is freed about 3 centimeters below the internal malleolus (see illustrations of ligaments in resection of the ankle joint). 5. In spite of the very irregular form of the inferior surface of the astragalus (Fig. 709), this operation yields a very useful stump for walking (Fig. 710). 6. To improve this form of the stump, especially in cases in which the soft parts are scanty, the head of the astragalus can be sawed off. Hancock applied osteoplastically the sawed-off tubercle of the os calcis to the vivified inferior surface of the astragalus. After disarticulation below the astragalus Ssabanejeff healed that part of the foot in front of Chopart's joint (having been sawed off in Lisfranc's line) to the vivified surface of the astragalus (similarly as in Fig. 704). FIG. 709. DISARTICULATION OK THE FOOT BELOW THE ASTRAGALUS FIG. 710. STUMP AFTER DISARTICU- LATION OF THE FOOT BELOW THE ASTRAGALUS SYME S DISARTICULATION OF THE FOOT MALLEOLAR AMPUTATION 1. The foot flexed at a right angle is well elevated, and an incision pene- trating everywhere down to the bone is made from the tip of one (the left) malleolus to that of the other (the right) transversely across the plantar sur- face (Figs. 711-713). 2. The foot is lowered and forcibly pressed downward with the left hand, and a second incision is made from one tip of the malleolus to the other, transversely across the anterior side of the tibiotarsal articulation (Fig. 714). 3. A transverse incision across the articular surface of the astragalus opens the articulation in front ; two incisions below the two malleoli divide THE TREATMENT OF WOUNDS 365 the lateral ligaments, and the superior articular surface of the astragalus is freely exposed. 4. The left hand forces the foot more and more toward the posterior side of the leg; next, while it is rotated around its axis in turns, first to one FIG. 711 FIG. 713 FIG. 712 FIG. 714 SYMK'S AMPUTATION OF THE FOOT side and then to the other, the o s calcis is enucleated from the skin covering the heel, " Fersenkappe " (sustentaculum tali), and detached from the tendon of Achilles by incisions closely following each other, and alternating, now from above, now from the sides, and finally from behind and below, but always directed toward the bone. (Care should be taken not to injure the posterior tibial artery behind the internal malleolus.) (Fig. 715.) 366 SURGICAL TECHNIC In inflammatory diseases, it is well to enucleate the os calcis from the periosteum, not with the knife, but subperiosteally with the elevator and the raspatory {Oilier). 5. The heel flap and the skin are drawn up- ward all around over the malleoli ; a circular incision closely above the articular surface of the tibia divides the other soft parts (tendons and periosteum). 6. The saw divides the bones in such a man- that only the two ner malleoli and a thin layer of cartilage are removed from the articular surface of the tibia (Figs. 716, 717). FIG. 715. SYME'S AMPUTATION OF THE FOOT (Disarticulating the os calcis) FIG. 716. SAW- The malleoli can be nipped off with bone-cutting forceps, THE BoNE as was done repeatedly by Syme. FIG. 717 FIG. 718 FIG. 719 SYME'S AMPUTATION OF THE FOOT, a, wound surface; b, recent stump, anterior view; c, healed stump, lateral view THE TREATMENT OF WOUNDS 367 7. After ligation of all bleeding vessels, the skin over the outer side of the tendon of Achilles is divided with a small knife, a drainage tube is inserted through the opening, and the wound (Fig. 717) is united by suture (Figs. 718, 719). PIROGOFF'S DISARTICULATION OF THE FOOT (AMPUTATIO TIBIOCALCANEA OSTEOPLASTICA) 1. The soft parts are divided in the same manner as in Symes method (page 209). 2. After disarticulation of the joint, the foot is forcibly flexed until the posterior border of the astragalus appears to view. FIG. 720. PIROGOFF'S DISARTICULATION OF' THE FOOT (Sawing off the os calcis) FIG. 721. SAWING OFF BONES BY PIROGOFF'S OPERATION 3. Immediately behind it, the saw is applied upon the upper surface of the os calcis, and the same is sawed through vertically and exactly in the plane of the plantar incision (Figs. 720, 721). 4. The two malleoli and a thin layer of the articular surface of the tibia are sawed off, as in Syme's method. 5. The tendon of Achilles is divided transversely, closely above its inser- tion, and the skin is fenestrated at the same place to make space for a drainage tube. 6. Figures 722 and 723 show the appearance of the surface of the wound and of the stump. 368 SURGICAL TECHNIC Rydygier's procedure is worthy of notice for suitable cases, namely, to make Pirogoff's operation with a very large plantar flap, which serves for covering a large loss of substance (incurable ulcer) on the anterior surface of the leg. FIG. 722. WOUND SURFACE OF PIROGOFF'S OPERATION FIG. 723. STUMP RESULTING FROM PIRO- GOFF'S OPERATION GUNTHER'S MODIFICATION OF PIROGOFF'S AMPUTATION 1. The plantar incision begins and ends closely in front of the malleoli, passing transversely across the plantar surface in the region of the posterior margin of scaphoid bone (Figs. 724-726). 2. The dorsal incision forms a small semilunar flap, extending as far as the scaphoid bone (Fig. 727). 3. After the articulation has been opened, the soft parts are dissected off on both sides of the os calcis obliquely upward in a posterior direction as far as the insertion of the tendon of Achilles ; injury to the posterior tibial artery must be carefully avoided. 4. Immediately in front of the insertion of the tendon of Achilles, a metacarpal saw is applied upon the os calcis; and the same is sawed through obliquely from behind, above, forward, and downward. 5. In the same manner, the tibia and the fibula are divided obliquely from behind, above, forward, and downward (Fig. 728). THE TREATMENT OF WOUNDS 369 6. The sawed surfaces of the bone can easily be brought in apposition by this procedure without dividing the tendon of Achilles. (Division of the tendon of Achilles is superfluous if the necessary mechanical precautions are practised to prevent retraction of the heel. FIG. 726 GUNTHER'S MODIFICATION OF PIROGOFF'S OPERATION FIG. 728 GUNTHER'S METHOD OF DIVIDING BONES BY SAWING FIG. 725 FIG. 727 The two bone surfaces can be kept in accurate uninterrupted contact by : (i) Suturing of extensor to flexor tendons ; (2) direct fixation of os calcis to tibia with an ivory nail ; (3) silver wire suture.) 370 SURGICAL TECHNIC LE FORT AND VON ESMARCH's MODIFICATION OF PIROGOFF'S AMPUTATION i. The plantar incision begins 2 centimeters below the tip of the external malleolus (on the right foot), extends in a shallow convex manner across the FIG. 731 LE FORT'S MODIFICATION OF PIROGOFF'S OPERATION FIG. 730 FIG. 733 LE FORT'S METHOD OF DIVIDING BONES BY SAWING FIG. 732 plantar, surface of the cuboid and scaphoid bones, and ends at the inner side, 3 centimeters in front and below the internal malleolus (Figs. 729-731). THE TREATMENT OF WOUNDS 371 2. The dorsal incision from the same points forms a slightly curved flap, the anterior border of which passes across Choparfs line of articulation (Fig. 732). 3. The dorsal flap is dissected upward as far as the tibiotarsal articula- tion, and the joint is opened as in Pirogoff's method. 4. The foot is turned backward, and the upper surface of the os calcis is dissected free far enough to enable a metacarpal saw to be inserted behind the upper border of the tuberosity of the os calcis and the upper third of the bone to be removed by a horizontal incision from behind, for- ward and backward (Fig. 733). 5. As soon as the saw has penetrated into Choparfs articulation, the bones of this articulation are separated in the same manner as by Choparfs method. 6. The two malleoli and the articular surface of the tibia are sawed off as in Pirogoff's operation. 7. According to von Brims, the os calcis can also be sawed off in a concave manner with the metacarpal saw, and the bones of the tibia and fibula convexly (Fig. 734). By this method the stump receives a very broad surface for walking (Fig. 735). 8. In all these op- erations it is advisable, after union of the soft parts, to fasten the bones together with a long steel nail (Fig. 571), driven in from the plantar surface through the os calcis deep into the tibia. If the wound is and remains aseptic it heals rapidly by primary intention ; the nail does not interfere with an ideal healing of the wound. It can be extracted easily after three weeks. If only the external or the internal side of the foot FlG - 735- STUMP KESULT- , _. . . _ .. , i- j ING FROM LE FORT'S is diseased, Pirogoff s operation may finally be modified METHOD in this manner : the os calcis is sawed through in a sagittal line, its healthy surface is laterally turned upon the sawed surface of the leg ( Tauber). Or else, with Malgaignes mode of incision, the inte- rior half, well rounded off at its borders with the bone-cutting forceps, can FIG. 734. VON BRUNS'S METHOD OF DIVIDING BONES BY SAWING 372 SURGICAL TECHNIC be inserted into the bifurcation of the malleoli which has been left unin- jured (Quimby). Kiister recommends as a good substitute for Le Fort's op- eration to open the ankle joint from the incisions indicated in Figure 736, to remove the astragalus, to disarticulate the foot between os calcis, cuboid, and sca- phoid, and to heal firmly the os calcis left FIG. 736. KUSTER'S MODIFICATION OF uninjured into the malleolar bifurcation LE FORT'S OPERATION without removing any portion of bone. AMPUTATION OF THE LEG Circular amputation by two incisions and the skin flap incision are best adapted to the amputation of the leg. In the lower third (above the malleoli), two lateral skin flaps of equal length are especially suitable (Fig. 604); an anterior skin flap can easily be perforated by the sharp spine of the sawed-off tibia ; a posterior skin flap draws the margins of the wound apart by its weight. (The spine of the tibia should always be removed with the saw. If this is done, and the posterior flap is well supported by dress- ing and bandage, and the limb immobilized upon a posterior splint, there is little or no risk of pressure decubitus occur- ring.) In the middle, likewise, two skin flaps are formed, or, ac- cording to von Langenbeck, one long oval lateral flap (on the inner side) with half a circu- lar incision on the opposite side, whereby the cicatrix is placed laterally (Fig. 738). This method is also well adapted to the upper third, where the amputation is usually made below the tnberosity of the tibia (place of selection). FIG. 737 FIG. 738 VON LANGENBECK'S AMPUTATION OF THE LEG BY FORMING A LATERAL SKIN FLAP THE TREATMENT OF WOUNDS 373 (The best stump for the wearing of an artificial limb is obtained by per- forming the amputation at the junction of the lower with the middle third. The skin flaps should include the strong muscular fascia, and must be taken from the side of the limb where the tissues are best adapted to a suitable covering for the wound, in preference to a long oval anterior and a short oval posterior flap.) Von Bardeleben formed at this place a large anterior skin flap, in which he included at the same time the periosteum {cut around in the shape of aflaf) of the anterior smooth surface of the tibia ; the sawed surface of the tibia is covered with this periosteal flap, and by the new formation of bone the sharp edge of the tibia is somewhat rounded off. The same object is obtained by sawing off the sharp border of the tibia obliquely. HclfericJi forms on the inner side of the leg an oval flap in which the fascia and the whole periosteum of the circumsected tibial surface is pre- served ; the periosteum is carefully elevated from the bone. Next, a circular incision is made through the skin at the base of the flap, the soft parts and the interosseum are divided vertically ; the bones are sawed off. When the suture is applied a cuneate lobule is formed over the eminence of the tibial surface by the abundant skin. This lobule protects the bone. The band of periosteum covers the sawed surfaces. Hiiter proceeded as follows : Longitudinal incision upon the crest of the tibia, corresponding in length to the manchette (cuff) to be formed ; the incision penetrates through the periosteum down to the bone. At its lower end, across the free surface of the tibia, a short transverse incision is made as far as the inner margin, and from this angular incision the skin, together with the periosteum, is reflected from the tibia ; the broad strip of periosteum thus formed is sub- sequently applied upon the sawed surface of the tibia. The transverse incision is next completed into a circular incision through the skin down to the fascia, and the rest of the operation is made in the same manner as in circular amputation. The amputation at the place of selection (von Esmarch) produces stumps which can support most, and with which the patient, kneeling on a simple wooden leg (broom-handle fixed in a plaster of paris dressing) can walk about very well (Fig. 631). Hence, if the patient has not the means to buy an expensive artificial limb, which must be often repaired, it is advis- able to make the amputation at the place of selection, even if a healthy part of the leg must be sacrificed. To make longer stumps of the leg useful in directly supporting the 374 SURGICAL TECHNIC weight of the body upon a peg leg, the primary closure of the opened medullary cavity is advisable by means of a bone cover taken from the tibia. BIER'S OSTEOPLASTIC AMPUTATION i. Skin flap incision. Beginning a thumb's breadth in an outward direction from the anterior border of the tibia and ending at the opposite side, a large skin flap is circumsected, the base of which corresponds to half the circumference of the limb. Without injuring the periosteum it is dis- sected back in an upward direction as far as its base (Fig. 739). Fir,. 739 FIG. 741 FIG. 740 BIER'S OSTEOPLASTIC AMPUTATION OF THE LEG 2. Formation of bone cover. From the periosteum of the tibia a square! flap is excised, large enough to cover the sawed surfaces of the tibia and fibula. The longitudinal incisions lie a little beyond the tibial borders. From the transverse incision the flap is reflected in an upward direction for about \ centimeter. Next, a fine amputation saw with its blade placed obliquely is inserted in the transverse incision and a fine furrow is sawed. From this furrow a lamella is sawed out from the tibial surface in an upward direction, while an elevator keeps the saw incision gaping. Arrived at the base of the skin flap, the saw is carried more toward the periosteum for the purpose of completing the bone flap ; the periosteal bone portion is then deflected, and the periosteum only is somewhat reflected at its upper end. The pedunculated bone flap is inverted in an upward direction (Fig. 739). 3. The amputation is then made from the extremities of the skin flap with a deep circular incision through the calf ; division of the interosseus space, sawing off the tibia close at the border of the inverted bone flap, next of the fibula at an equal height (without reflecting the periosteum). PLATE XIV At its lower third At its middle third At its upper third Through the knee-joint (Ivine of Condyles) Sections of the Right Leg THE TREATMENT OF WOUNDS 375 n.p.s, a.jj, v.s.e. ^ n.ss. m. FIG. 742. SECTION OF THE RIGHT LEG AT ITS LOWER THIRD (see Plate XIV). n.p.s. nerv. peron. superf. ; a.p. art. peronasa; /./. peron. long.; v.s.e. vena saphena ext.; n.ss.m. nerv. suralis major; t.a. tendo achillis; t.p. tendo plantaris; n.t.pl. nerv. tib. post.; a.t.p. art. tib. post.; v.s.i. ven. saph. int.; n.sph.m. nerv. saph. major; a.t. a. art. tib. antica. a.t.a. m.e.h.l t.p. FIG. 743. SECTION OF THE RIGHT LEG AT ITS MIDDLE THIRD (see Plate XV). a.f.a. art. tibial. antica; m.e.h.l. muse. ext. hall, long.; m.fh. muse. flex, hall.; a.p. art. peronsea; n.c.p. nerv. cutan. post, ext.; n.ss.m. nerv. suralis major; v.s.e. vena saph. ext.; t.p. tendo plantaris; n.sph.m. nerv. saph. major; v.s.i. vena saph. int.; a.t.p. art. tibialis post.; m.f.d.c.l. muse. flex, dig. comm. long. 376 SURGICAL TECHNIC THE TREATMENT OF WOUNDS 377 4. After ligation of the vessels the periosteum bone band is turned over the sawed surfaces and fastened in this position by a few sutures (Fig. 740). 5. The skin flap is turned down and sutured with the circular incision. Figure 741 shows the complete stump, which, after healing, is painless and capable of bearing. DISARTICULATION OF THE LEG AT THE KNEE JOINT (/z) Circular incision. 1. While the leg is extended, a circular incision divides the skin of the leg 8 centimeters below the patella. The skin is dissected off all around as far as the inferior border of the patella and turned up like a cuff ; to facili- tate the latter, the manchette can be divided by a small longitudinal incision on one or both sides. 2. While the knee is flexed, first the ligamentum patellae is divided just below the patella ; next, the anterior capsular ligament and the two lateral ligaments are divided close to the border of the femur, in order that the menisci and the larger part of the articular capsule may re- main in connection with the tibia. 3. After increased flexion of the knee, the crucial ligaments are detached from the inner surfaces of the two condyles of the femur. The knee is then again extended, and with one sweep of the knife from before back- ward, the remaining soft parts are divided on the posterior side of the articulation (Fig. 746). 4. The wound can be united transversely (Fig. 747); also in an antero-posterior direc- tion, so that the cicatrix comes to lie between the two condyles (Fig. 748). 5. If, according to BillrotJfs method, the patella and the superior protrusion of the articular capsule are to be removed, then, after the circular incision has been finished, a longitudinal incision is made across the middle of the patella beginning 4 centimeters above its upper border. The patella is then removed from FIG. 746. DISARTICULATION OF THE LEG AT THE KNEE JOINT, BY CIRCULAR INCISION 378 SURGICAL TECHNIC the extensor tendon ; the latter is turned upward, and the portion of the capsule lying under it is dissected out. FIG. 747 FIG. 748 STUMP RESULTING FROM DlSARTICULATION OF THE LEG AT THE KNEE JOINT BY CIRCULAR INCISION ($) Flap incision. i. On the posterior side of the leg well elevated, by a curved incision beginning I centimeter below the middle of the lateral margin of one con- dyle of the femur and ending I centimeter below the middle of the other condyle, a semilunar flap 8 centimeters long is formed from the skin of the upper part of the calf, and detached from the fascia as far as the base. 2. Next, the leg is low- ered, flexed at the knee, and from the same FlG. 749. DlSARTICULATION OF THE LEG . , . , FlG. 750. STUMP RESULTING FROM DlS- AT THE KNEE JOINT BY FORMING Two P ARTICULATION OF THE LEG AT THE FLAPS anterior side a KNEE JOINT BY FLAP INCISION THE TREATMENT OF WOUNDS 379 larger skin flap 10 to 12 centimeters long is circumscribed with the knife, detached as far as the lower margin of the patella, and reflected (Fig. 749). 3. The separation of the articular ends is made in the same manner as in the circular incision. Figure 750 shows the appearance of the stump. (c) Oblique incision (anterior flap). With the leg half flexed an incision is made in an anterior direction from the posterior line of articulation in the popliteal space about three inches below the tuberosity of the tibia (Fig. 751). For the remainder, see the preceding page. If there is a lack of skin for making the flap suffi- ciently large, or if the lower surface of the condyles is diseased or injured, then by forming smaller flaps, of which the anterior extends about as far as the tuber- osity of the tibia, a portion of the condyles of the femur can be sawed off in its greatest width {Syme and Car- den s intracondyloid amputation, Fig. 752). The sharp edges of the sawed surface must be rounded off sub- sequently with the saw or the bone-cutting forceps. With a small saw the bone can be sawed off in a curve parallel to the surface of the condyles (Butcher\ In children, it is simpler to divide the condyles in the line of the epiphysis (Buckanan\ which can be generally done with an elevator. When the patella is healthy, it can be made to unite with the sawed surface of the condyles ; the stump is thereby made longer and stronger for FIG. 751. DISARTICU- LATION OF THE LEG AT THE KNEE JOINT (Oblique incision) FIG. 752. GARDEN'S IN- TRACONDYLOID AMPU- TATION FIG. 753. GRITTI'S OSTEO- PLASTIC SUPRACON- DYLOID AMPUTATION FIG. 754. SABANEJEFF'S OSTEOPLASTIC INTRA- CONDYLOID AMPUTATION SURGICAL TECHNIC support (Gritti's osteoplastic supracondyloid amputation, Fig. 753). For this purpose, the cartilaginous surface of the patella must be removed with the saw in the form of a thin disk, and after the union of the skin wound, it must be nailed upon the sawed surface of the condyles. After dissecting off the anterior flap this can be done most easily if immediately the pos- terior surface of the patella, on which the lower ligament of the patella has been preserved for the purpose of support, is removed vertically with a broad amputation saw from before backward. To make the two sawed surfaces correspond in size, it is necessary to saw off the condyles entirely, but without opening the medullary cavity. Sabanejcff excised from the anterior surface of the tibia a portion which he left in connection with the patella, and which he nailed upon the sawed surface of the condyles of the femur (osteoplastic intracondyloid amputation, Fig. 754). The patient walks on the anterior tibial surface as in the amputation on the place of selection. The tibia and femur can be sawed off obliquely (Djelitzyn). AMPUTATION OF THE THIGH In the lower and the middle third the circular amputation is the simplest procedure. It is made by one incision, especially in the lower part, and in FIG. 755. SECTION OF THE RIGHT THIGH AT ITS LOWER THIRD (see Plate XV). n.p. nerv. peroneus; n.t. nerv. tibialis; v^.i. vena saph. int.; n.s.m. nerv. saph. major; a.c. art. cruralis. PLATE XV At its lower third At its middle third Sections of the Right Thigh THE TREATMENT OF WOUNDS 381 subjects with defective muscular development and freely movable skin; just as good, however, is the circular operation by two incisions with or with- out reflection of the skin cuff. In the middle of the thigh, where the sur- face of the wound is larger, the skin flap incisions with a large anterior and a small posterior flap are to be recommended. In the upper third it is best to form a large anterior rounded square skin flap, the base of which is wider than half the circumference of the limb and FIG. 756. SECTION OF THE RIGHT THIGH AT ITS MIDDLE THIRD (see Plate XV). n.s.m. nerv. saph. major; a.c. art. cruralis; n.i. nerv. ischiadicus; a.p. art. profunda; v.s.i. vena saph. int. the length of which must be equal to the diameter of the limb (third part of the circumference). This is dissected back in an upward direction, and the skin is divided at the posterior side, either by a circular incision, or still better, by a slightly curved incision, and forcibly retracted ; next, the soft parts are divided down to the bone by a circular incision, as smooth as pos- sible. After the bone has been sawed off, the large flap falls like a curtain over the large surface of the wound, and can be united with the posterior skin incision without tension. The drainage of the secretions takes place according to gravitation ; the cicatrix comes to lie laterally. 382 SURGICAL TECHNIC For applying and changing the dressings after the amputation of the thigh, von Volkmanns procedure* is to be recommended. The patient is raised, and a square piece of wood or a hard cube-shaped pillow covered with rubber (pelvic support) is placed under the buttock of a. T. a. g- FIG. 757. SECTION OF THE RIGHT THIGH AT ITS UPPER THIRD (see Plate XVI). a.c. art. cruralis; n.s. nerv. saph. major; a.p. art. profunda fern.; r.a.g. rami art. glutasae inf.; n.i. nerv. ischiadicus; s. semimembranosus; v. vena saphena int. the healthy side so that the amputation stump can be balanced freely during the dressing and need not be held by an assistant. The lumbar region above the sacrum becomes thereby so accessible that the tours of the spiral bandage of the hip which fasten the dressings can be carried around the body (Fig. 758). PLATE XVI At its upper third Section of the Right Thigh THE TREATMENT OF WOUNDS 383 FIG. 758. POSITION OF PATIENT FOR CHANGING THE DRESSINGS AFTER AMPUTATION DISARTICULATION OF THE THIGH I. BY AN ANTERIOR LARGE AND A POSTERIOR SMALL FLAP (Transfixion, Manec's Puncture Method) 1. The patient is placed in such a po- sition that the pelvis of the diseased side projects half over the lower edge of the table. The thorax must be well fixed, the scrotum must be drawn upward toward the healthy side (Fig. 759> 2. After the leg has been rendered bloodless according to the method de- scribed on page 229, FIG. 759. DISARTICULATION OF THE THIGH BY AN ANTERIOR LARGE AND A POSTERIOR SMALL FLAP SURGICAL TECHNIC FIG. 760. FORMING ANTERIOR FLAP BY TRANSFIXION a large anterior flap is made by cutting from within outward in the follow- ing manner: The operator inserts a long pointed amputation knife (Fig. 760) in the middle between the anterior superior spine of the ilium and the tip of the trochanter, and allows the point of the knife to glide along first parallel with Poupart's ligament across the head of the femur (whereby the capsule is opened) ; next, he turns the point down- ward and inward, and brings it out on the inner side of the thigh near the perineum (Fig. 760). By carrying the knife downward with rapid sawing movements, he cuts a well-rounded flap 1 8 to 20 centimeters long, which is im- mediately turned upward and held there in position by an assistant. 3. The knife is then applied be- neath the thigh along its inner side, and a smaller posterior flap is cut from without inward, the convexity of which extends as far and below the gluteal fold, the base of which meets on both sides the base of the anterior flap (Fig. 761). 4. A quick incision, made with a small flap knife perpendicularly upon the exposed head of the femur (as if the operator intended to divide the head and leave the upper portion in the acetabulum), opens the articular cap- sule, while the leg is forcibly hyperextended and rotated outwardly. With a smacking noise the air enters the joint, the head of the femur projects half from the acetabulum ; on dividing the ligamentum teres it escapes from the acetabulum. 5. The operator takes hold of the head of the femur with his left hand, draws it toward him, and divides the posterior portion of the capsular liga- ment, the muscles inserted in the great trochanter, and all soft parts which have remained undivided until then. 6. After ligation of all visible blood vessels, a large drainage tube is inserted into the acetabulum and brought out at the middle of the wound. It is also practical to remove with the bone-cutting forceps the projecting cotyloid margins (Hclfericti). The anterior flap is turned down and united with the margin of the posterior flap as indicated in Fig. 762. (It is much better to make a buttonhole in the posterior flap at the most depend- THE TREATMENT OF WOUNDS 385 FlG. 761. DlSARTICULATION OF THE THIGH. FORMING POSTERIOR FLAP ent point of the wound for the drain, as by doing so the whole amputation can be sutured with the expectation of obtaining primary healing through- FlG. 762. STUMP RESULTING FROM DlSARTICULATION OF THE THIGH AT THE HlP JOINT BY FLAP INCISION out, which is no small advantage in the treatment of such a large wound.) 2 C 386 SURGICAL TECHNIC For preventing the hemorrhage which in this operation (now rarely per- formed) especially is very profuse, Rose, after having formed two skin flaps, divided the soft parts in successive layers, grasped each vessel immediately with hemostatic forceps, and ligated it; hence, he extirpated the femur, so to say, like a tumor. Since very many ligatures must be applied, this operation in most cases lasts several hours. Trendclenburg controlled the hemorrhage to a certain degree during the operation by inserting a long straight steel pin obliquely through the base of the thigh from the anterior side beneath the femoral artery, and con- stricted the soft parts over it with a rubber tube applied around the ends of the pin (acupressure). Wyeth transfixed two long needles through the thigh for preventing the tube slipping off which had been applied in a cir- cular manner. Senn applied a double rubber tube on the anterior side of the femur transversely through the limb and tied it in front and behind. In some cases (in thin, flaccid abdominal walls) the hemorrhage can be prevented by compression of the aorta (see Fig. 420), or by compression of the external iliac (see Fig. 431). In all difficult cases, however, the preliminary ligation of the common iliac artery and vein is advisable. The rubber tube for the bloodless method on the thigh (Fig. 412), however, can be employed with safety only in the II. DISARTICULATION BY THE CIRCULAR METHOD ( Vetsdl) 1. Under the bloodless method, all soft parts are divided down to the bone by a rapid, vigorous circular incision 1 2 centimeters below the tip of the great trochanter ; the latter is immediately sawed off in the same plane (or better, a little below). 2. All blood vessels which can be recognized as such, arteries and veins, are grasped with hemostatic forceps and ligated with catgut (see transverse section, on Plate XVIII). 3. Only in cases where for some reason the bloodless method cannot be employed with safety is it advisable (according to Larrcy} to expose, prior to the circular incision, the femoral artery and vein in the iliofemoral tri- angle by a longitudinal incision, to secure them with two hemostatic forceps, and after dividing them between the forceps to ligate the lower ends ; the upper ends are held upward until the amputation is finished (Fig. 763). 4. If all hemorrhage has been arrested after the removal of the constrictor, a flap knife is inserted 5 centimeters above the tip of the great trochanter down to the head of the femur, and from here a longitudinal incision is THE TREATMENT OF WOUNDS 387 : FIG. 763. DISARTICULATION OF THE THIGH AT THE HIP JOINT (Circular incision) FIG. 764. DISARTICULATION OF THE THIGH AT THE HIP JOINT 388 SURGICAL TECHNIC made over the middle of the great trochanter downward as far as the cir- cular incision, dividing all the structures down to the bone (Dieffenbach). 5. The operator grasps the lower end of the bone stump with strong bone forceps, and while the margins of the wound of the longitudinal incision are drawn apart by an assistant, he reflects . with the raspatory the perios- teum all around from the bone until he reaches the firmer insertions of the muscles, which must be detached from the bone by short cuts with a strong knife. 6. After the bone has been dissected free in this manner as far as the cap- sule of the articulation, the latter is opened as described above ; and the head of the femur is disarticulated (Fig. 764). Dur- ing this part of the operation the hemorrhage is usually very slight. Figure 765 shows the appearance of the stump. 7. In very muscular subjects circular ampu- tation by two incisions instead of one can be employed, or a large anterior skin flap can be formed and the soft parts divided posteriorly below the gluteal fold by a circular incision. 8. If sufficient soft parts are not present on the anterior side, a large flap can be formed from the posterior side (von Langcnbeck), and a transverse incision can be made in front below Poupart's ligament. But then a large drainage FIG. 765. STUMP RESULTING FROM .. , . , r , ,. DISARTICULATION OF THE THIGH tube must be inserted as far as the stumps of AT THE HIP JOINT BY CIRCULAR the psoas and iliac muscles, which retract into lN ~ the pelvic cavity, in order that no secretions may be retained there. (Most surgeons have abandoned the preliminary high amputation of the thigh to disarticulation at the hip joint. By constriction above transfixion pins, or by making a dislocation of the head of the femur through a short vertical incision and tunnelling the soft tissues with strong hemostatic for- ceps (Semi), and constricting the base of the thigh in two sections by two strong rubber tubes or cords, the hemorrhage can be safely controlled. The removal of the remaining portions of the femur after a preliminary amputation is a very difficult task.) INCISION AND VERTICAL CISION THE TREATMENT OF WOUNDS 389 RESECTION OF JOINTS Resection of joints is made to remove detached or diseased portions of the articular ends, by wounding the healthy soft parts as little as possible, and thus preserve not only life but also the utility of the limb. Not only the blood vessels, but also muscles, tendons, ligaments, and especially the nerves, must be preserved to prevent muscular atrophy; furthermore, the capsule and the periosteum must be preserved to secure as far as possible reproduction of the bones destroyed by the disease and removed by the operation. Resections are made : 1. In serious injuries (extensive complicated splinter fractures) where the conservative treatment remained without success. 2. In serious suppurative or sanious inflammations or chronic diseases of the articular ends of the bones or of the capsule, after antiseptic drainage has been given a fair trial and has failed. 3. In serious complicated and old irreducible dislocations. 4. In angular anchylosis, which renders the limb useless. 5. In some neoplasms of the articular extremities. 6. In loose, freely movable joints caused by paralysis, for effecting anchy- losis (arthrodesis). A special indication is presented by tubercular disease of the joints {fungus). First the attempt should be made by rest, ice, and extension, or by injecting emulsion of iodoform, or formatin glycerine, or by artificial con- gestion and hyperaemia {Bier), to effect a healing, or at least an improve- ment ; and only when these therapeutic agencies have failed the joint should be opened. While in former times typical resections were made for this pur- pose, that is, from both bodies of the joints such portions were sawed off smoothly in such a way that the line of section was made through healthy tissue (whereby often a considerable portion of the healthy bone was sacri- ficed), now the operator is content, wherever it is possible, to remove in an atypical manner only diseased tissue so as not to interfere with the growth and development of the diseased bones (arthrectomy, Willemer, von Volkmami). Accordingly, as the disease has implicated the capsule of the joint or the bone, we distinguish : synovial arthrectomy, that is, the com- plete extirpation of the diseased capsule without removing the epiphyses and the articular cartilage ; and the osseal arthrectomy (arthrectomia ossalis), that is, the removal of all diseased portions of bone with the sharp spoon, chisel, or saw ; in most cases, howevef, the capsule must be extirpated 390 SURGICAL TECHNIC (synovial and osseal arthrectomy). If the operation is made very thoroughly and all diseased portions, especially of the capsule, are removed as carefully as in operations for malignant disease (Konig), arthrectomy yields good results, for the joints remain normal in their contour, the limb is not short- ened, and joint motion is often restored. Moreover, the growth of the bones is not arrested when the epiphyses have been preserved. If the healing of a diseased joint has been effected by conservative means, it is often necessary to improve a subsequent malposition by a later resection. GENERAL RULES FOR RESECTIONS 1. The incisions in skin and muscle must preferably be made in the axis of the limb, and every injury of large blood vessels, nerves, and tendons must be carefully avoided. 2. The preservation of the periosteum in connection with all the tendons and muscles inserted into the region of the joint (subperiosteal resection, von Langenbeck, Oilier} is of great importance, as well for the healing of the wound as also for the subsequent restoration of the function of the limb ; hence it should always be attempted. The operation is thereby made more difficult in recent cases, but is rendered easier in chronic cases. For this reason, in resections of the several joints, the older (non-subperiosteal) methods will be described. 3. To preserve the periosteum, it must be divided in the direction of the external incision, and reflected in connection with the overlying soft parts by means of blunt instruments (raspatory, Fig. 586) and the periosteal ele- vator (Figs. 766-770 " Skelettierung " of the bone). 4. The fibrous capsular ligaments, the accessory ligaments, and the in- sertions of the muscles cannot be detached with blunt instruments, but must be detached from the bone with strong short-bladed knives (Fig. 766), by incisions made vertically upon the bone ; they must, however, always remain in connection with the neighboring periosteum. Hence, during this opera- tion the surgeon must constantly change from the knife to the blunt eleva- tor, and must operate as carefully as possible in order not to contuse or lacerate the periosteum. 5. In many cases, this work can be facilitated by detaching with the ham- mer and chisel (according to Vogf) the cortical lamellae of the processes of the bones (tubercles, malleoli, condyles, trochanters) in which the muscles and ligaments are inserted. 6. After the articular ends have been bared of all soft tissues, they are forced out of the wound, grasped with strong forceps (Figs. 771-773), THE TREATMENT OF WOUNDS 391 FIG. 766 RESECTION KNIFE FIG. 767 FIG. 768 VON LANGENBECK'S ELEVATORS a, small; b, broad FIG. 769 LEVER-LIKE ELEVATOR FIG. 770 SAYRE'S ELEVATOR FIG. 771 VON LANGENBECK'S FORCEPS FIG. 772 FERGUSSON'S LION JAW FORCEPS FIG. 773 FARABCEUF'S FORCEPS 392 SURGICAL TECHNIC and removed with a saw (Figs. 774-778) ; the soft parts must be retracted and protected by blunt retractors or a strip of zinc (Fig. 787). FIG. 775. VON LANGENBECK'S METACARPAL SAW FIG. 774 METACAR- PAL SAW FIG. 777. CHAIN SAW FIG. 776 METACAR- PAL SAW FIG. 778. HELFERICH'S AMPUTATION SAW 7. If an articular extremity has become separated by disease or injury (gunshot), it can be grasped and extracted with von Langcnbeck 's sharp hook (Fig. 779). If the bone has been comminuted, the several fragments are grasped with forceps and re- moved, if no attempt is to be made to let them heal in at the place of FIG. 779. VON LAXGENBECK'S SHARP HOOK . , , M . , i injury under immobilization in a plas- ter of paris dressing. This has met with very good success in the last wars. 8. Since regeneration of the joint is usually most complete when only one articular end has been removed, it is advisable, when the injury of one THE TREATMENT OF WOUNDS 393 articular end is very extensive, to resect this alone, and to leave the other intact {partial resection), at least in the joints of the upper extremity. 9. Most resections can be made with great advantage under the blood- less method. But at the end of the operation, all divided blood vessels must be carefully ligated before the wound is closed, else secondary hemorrhage is liable to occur, which may necessitate an early removal of the dressings and unnecessary disturbance of the wound. 10. When healing of the resection wounds does not take place rapidly, entirely, or for the greater part, by primary intention, but slowly after long suppuration, then, in consequence of the prolonged rest, the ligaments and tendons may contract and become adherent to the surrounding tissues, caus- ing stiffness, deformity, atrophy (paralysis from inactivity). To the lay- man, in such a case, the whole limb appears to have become useless ; indeed, it remains subsequently in this useless condition, unless something is done for it. 11. For preventing this condition or for correcting it, immediately after cicatrization of the wound, methodical passive movements must be made of all the joints of the extremity, first under anaesthesia if the manipulations cause too much pain (apolysis, according to Neudorfer). 12. The joints of the upper extremity, especially of the fingers, which it is desirable to render useful as soon as possible, can be kept movable from the beginning by careful passive motions and position; by giving, for in- stance, at each change of dressings other positions to the joints and by excluding the fingers from dressings. 13. The function of mtisclcs and nerves can be soon restored by warm baths and by applying electricity. Methodical massage of the limbs after previous cold douclics and subsequent movement cures are usually still more effective for this purpose. 14. If an excessive mobility and flaccidity of the resected joint (loose, freely movable joint) has remained after the resection, the limb can be made useful by the wearing of an artificial support. 394 SURGICAL TECHNIC RESECTIONS OF THE UPPER EXTREMITIES RESECTION OF FINGERS 1 . For resecting the articulation of a finger an incision is made 2 to 3 centimeters long laterally along the border of the extensor tendon (digital artery and nerve !) through all soft parts down to the articulation. 2. While the soft parts are elevated and reflected toward both sides, the articular capsule is split by a longitudinal incision. While the finger is flexed in a lateral direction, the condyle of the diseased articulation is turned out and nipped off with the bone-cutting forceps. 3. Now the peripJieral free body of the joint can also be removed in the same manner, but if it is healthy it is left in position uninjured. The resection of an entire phalanx can be made from a unilateral or bilateral dorsal incision which passes over the neighboring articulations laterally from the extensor tendon. The incision is made immediately down to the bone. After elevation of all soft parts around the bone, and a transverse division of the articulations, the phalanx is disarticulated from its condyle to the base, the cavity of the wound is sutured, and drainage provided. The resection of a metacarpal bone is made from a dorsal incision extend- ing over both articulations. On the thumb and little finger the longitudinal incisions are made, respectively, on the radial and ulnar exterior sides. After division of the skin, the extensor tendons are carefully drawn aside, the periosteum is divided and elevated with the elevator toward both sides for the whole length of the bone, and the metacarpophalangeal articulation is opened by a transverse incision. At this place the bone is grasped with forceps or a bone hook and disarticulated subperiosteally toward the carpus from the volar soft parts. Finally, it is also disarticulated at its base, or, if possible, divided in its basal line of epiphyses, whereby the opening of the articula- tion is avoided. The cavity of the wound, according to the man- ner of disease, can be sutured or tamponed in its entire extent. For the purpose of replacing a miss- ing mctacarpal bone, Bardenheuer divided a neigh- boring metacarpal bone longitudinally and inserted one-half of it into the defect (Fig. 780). FIG. 780. REPLACING A RE- SECTED METACARPAL BONE THE TREATMENT OF WOUNDS 395 RESECTION OF THE LOWER ARTICULAR ENDS OF THE RADIUS AND THE ULNA BY BOURGERY'S BILATERAL INCISION i. A longitudinal incision, beginning below the styloid process of the ulna, divides the skin 4 to 5 centimeters on the ulnar side of the ulna upward (Fig. 781). FIG. 781. RESECTION OF THE LOWER ENDS OF THE BONES OF THE FOREARM (Bourgery's bilateral incision) 2. In the same direction, the periosteum is then divided exactly between the extensor and flexor carpi ulnaris muscles, and reflected from the bone with the raspatory and elevator, first on the dorsal side, next on the volar side (pronator quadratus) as far as the interosseous ligaments (Fig. 782). 3. The denuded portion of the os triquetrum ext. carp. uln. extens. digit. ulna ulna is sawed through below the upper angle of the incision with a metacarpal saw, or nipped off with strong bone - cutting for- ceps. 4. Next the sawed-off portion is grasped with bone forceps, ro- tated outward, and disarticulated by cutting it off from the inter- osseous ligament, the lateral ulnar ligament, and the straight acces- sory ligament (Figs. 783, 784). 5. A second longitudinal in- cision, beginning below the styloid flex, digit, subl. art. ulnaris -- flex. carp, ulnar. os pisiforme aid. dig. V. FIG. 782. MUSCLES AND TENDONS ON THE ULNAR SIDE OF THE LEFT WRIST (Henke) 396 SURGICAL TECHNIC FIG. 783. Dorsal side LIGAMENTS OF THE RIGHT WRIST FIG. 784. Volar side process of the radius, divides the skin for 5 to 6 centimeters on the radial side of the radius, upward. flex. carp. rod. - supin. long. - mm abd. poll. long, ext. poll. brev. art. rod,. ar- J mi(I / /.J. ext. carp. rod. brev. ext. carp, rad, long. _. ext. poll. long. FIG. 785. MUSCLES AND TENDONS ON THE RADIAL SIDE OF THE LEFT WRIST IN DORSAL FLEXION 6. The tendons of the extensor brevis pollicis and the abductor longus pollicis, coursing obliquely across the radius, are drawn toward the dorsum vhile the hand is forcibly extended (Fig. 785). THE TREATMENT OF WOUNDS 397 flex. carp. rad. . supin. long., art. rad _._ dbd. poll. long. ext. poll. brev. ext. carp. rad. brev. ext. carp. rad. long. ext. poll. long. FIG. 786. MUSCLES AND TENDONS ON THE RADIAL SIDE OF THE LEFT (EXTENDED) WRIST (Henke) FIG. 787. SAWING OFF DENUDED RADIUS 398 SURGICAL TECHNIC 7. The tendon of the supinator longus muscle (Fig. 786) is divided from the styloid process of the radius. The periosteum of the radius is divided longitudinally, and detached with the raspatory, elevator, and knife first on the dorsal side, next on the volar side (pronator quadratus) in connection with all synovial sheaths, until, about 3 to 4 centimeters on the articular surface, the soft parts can be elevated all around from the denuded bone. In early resections the periosteum still adheres so firmly to the bone that it is very difficult to detach it in connection with the synovial sheaths of the tendons, and without injury to them. In this case it is recommended (according to Vogf) to remove with a fine chisel a shallow lamella of the compact layer of the bone, together with the periosteum first on the dorsal surface of the radius, and next on the styloid process, beneath the abductor pollicis. 8. A broad strip of zinc is inserted between the bone and the perios- teum on the volar side to protect the soft parts ; and while on the dorsal side the periosteum, together with the soft parts, is drawn upward by a similar strip or a blunt retractor, the lower end of the radius is sawed off with a metacarpal saw or a fine resection saw (Fig. 787). 9. The sawed-off portion is grasped with the bone forceps, and is drawn forward into the wound ; and, after division of the capsular ligaments, the articular ligaments (lateral radial ligament, rhomboid ligament, and accessory oblique ligament Figs. 783, 784), it is extracted. 10. If only the lower articular ends of the bones of the forearm are injured or diseased, the wrist is left uninjured, and only the diseased portions are removed. Especially in injuries, it is a rule to resect as little as possible, and to effect heal- ing wherever it seems possible by a conservative treatment. But if the intercarpal joints are also dis- eased, all carpal bones (perhaps with the exception of the trapezium and FIG. 788. FRONTAL SECTION OF THE RIGHT WRIST .*_ j the pisiform bone) must be removed, because all joints of the several carpal bones are connected with one another, and with the metacarpal bones (Fig. 788). In such cases it becomes necessary to make the THE TREATMENT OF WOUNDS 399 TOTAL RESECTION OF THE WRIST BY VON LANGENBECK'S DORSAL RADIAL INCISION i. The operator sits at a small table upon which the hand is placed in light ulnar flexion, and with the dorsal side upward. An assistant sits opposite to him. ext. carpi radialis longus extensor pott, longus ext. carpi radialis brevis ligam. carpi comm. dorsalc - FIG. 789. VON LANGENBECK'S FIG. 790. TENDONS ON THE DORSAL SIDE OF THE HAND METHOD OF RESECTING THE WRIST 2. An incision, beginning at the middle of the ulnar margin of the meta- carpal bone of the index finger divides the skin 9 centimeters upward as far as and over the median line of the dorsal surface of the epiphysis of the radius (Fig. 789). 3. On the radial side of the extensor tendon of the forefinger, and with- out injuring its sheath, the incision penetrates more deeply, continues farther 4OO SURGICAL TECHNIC above on the ulnar margin of the tendon of the extensor carpi radialis brevis (where it is inserted at the base of the third metacarpal bone), and divides the ligamentum carpi dorsale exactly between the tendon of the extensor longus pollicis and the extensor digiti indicis as far as the limit of the epiphysis of the radius (Fig. 790). 4. While an assistant draws apart the soft parts with fine retractors the capsular ligament is divided lengthwise, and next detached from the bone in connection with the remaining ligaments in the following manner : 5. First, the fibrous sheaths containing the tendons of the extensor longus pollicis and the extensor carpi radialis longus et brevis lying in the grooves of the radius, and the ten- don of the brachioradialis (supinator longus), must be detached from the bone toward the radial side partly with the knife, partly with the elevator. 6. Next, in the same manner, toward the ulnar side, the tendons of the extensor communis digitorum, together with the ensheathing cellu- lar layers of the ligamentum carpi dorsale, in connection with the peri- osteum and the articular capsule, must be detached and drawn toward the ulna. 7. The radiocarpal articulation is now exposed. The hand is flexed so that the articular surfaces of the up- per carpal bones become prominent. pisif. FIG. 791. CARPAL BONES 8. The scaphoid bone is detached from the trapezium and the trapezoid, the semilunar and cuneiform bones from the os magnum and the unciform bone by dividing the intercarpal ligaments, and raising them gently with a small elevator ; the trapezium and the pisiform bone can be left in position (Fig. 791). 9. Next, the bones of the anterior carpal row are disarticulated. The globular articular surface of the os magnum is grasped with the fingers of the left hand or with the dressing forceps, and, while an assistant abducts the thumb, the articular connection of the trapezoid with the trapezium is THE TREATMENT OF WOUNDS 401 divided, and from here the operator tries to penetrate toward the ulnar side into the carpometacarpal articulation by dividing the ligaments on the extensor side of the upper heads of the metacarpal bones, while an assistant flexes the latter forcibly. Thus the three carpal bones of the anterior row (trapezoid, os magnum, and unciform bone) can be lifted out and removed together. In fungus disease of the carpus, the ligaments connecting the several bones are mostly destroyed, so that it is comparatively easy to remove the carpal bones singly with the sharp spoon alone. 10. If the bones of the forearm are also diseased, then, finally, the hand being in volar flexion, the epiphyses of the radius and ulna are made to project from the wound, and all soft parts detached from them (as described above), when they are sawed off. Care must be taken not to injure the large dorsal branch of the radial artery passing over the trapezium to the first metacarpal interspace (Fig. 786). 11. After completion of the operation, and after the application of the dressing, the limb must be placed upon one of the splints illustrated in Figs. 219, 232, and 256, and must be immobilized in proper position with the hand extended and fingers flexed. As soon as possible the extension treatment should commence (see Figs. 266, 277) with passive motion of the fingers. For the purpose of protecting the insertion of the extensor carpi radialis, and also for inverting the articulation, thereby obtaining a better inspection, it is advisable to open BY KOCHER'S DORSO-ULNAR INCISION 1. With the hand in slight radial flexion, an incision 7-8 centimeters long is made from the middle of the interspace between the fourth and the fifth metacarpal bones across the middle of the wrist on the dorsal surface of the forearm ; the dorsal branch of the ulnar nerve must be pre- served (Fig. 792). 2. After division of the fascia and the posterior annular ligament of the wrist, the operator penetrates between the tendons of the extensor digiti minimi and the extensor communis, opens the capsule at the base of the fourth metacarpal bone upon the unciform bone and the ulna, and detaches them toward both sides, after the tendons of the extensor digiti minimi and the extensor uinaris have previously been drawn forward from the grqp<$?&- of the ulna (//') and the tendon of the extensor ulnaris has beftn^detacheycL ^ - ti\~\~M.^~^ from the fifth metacarpal bone. 2D 402 SURGICAL TECHNIC 3. Next, the operator penetrates into the cleft between the pisiform and the semilunar bones (/), and leaves the tendon of the flexor carpi ulnaris in connection with the latter bone. 4. The unciform process is freed ; next the bundle of the flexor tendons is raised from its groove ; the capsule along the third to the fifth metacarpal bones on the palm and the tight capsular insertion on the volar border of the radius are detached ; the tendinous insertion of the flexor carpi radialis on the second metacarpal bone, however, is preserved. 5. Upon the dorsal border of the radius, the capsule is detached as far as and beneath the tendons of the extensor carpi and the extensor longus pollicis and lifted out of their grooves. The insertion of the supinator longus is detached from the styloid process of the radius. 6. The hand is then forcibly dislocated in the radiovolar direction until the thumb touches the ra- dial side of the forearm (Fig. 793); the radio- carpal articulation can then be completely in- spected. The removal of the diseased bones of the wrist, the re- moval of as thin a layer as possible from the bones of the forearm, cause no difficulty. Gritti opened the wrist by a long trans- verse incision across the dorsal side of the car- pus, dividing all tendons at the same time. By forcible volar flexion, the articular surfaces can be sepa- rated from each other ; after removal of all diseased portions, the hand is placed in its normal position, and the divided tendons are carefully sutured. Cattcrina reached the (anterior) parts of the carpus by dividing the metacarpus anteriorly. He divided the web between the third and fourth metacarpus and split their interstices. The volar incision is only 5 centi- meters long (volar arch ! ) ; the dorsal incision, 1 5 centimeters long, extends ~/ / ^- er tne car } >us - The halves of the hand are then turned apart and the *y i disease^ portions removed. FIG. 792 FIG. 793 KOCHER'S RESECTION OF THE WRIST THE TREATMENT OF WOUNDS 403 During the after treatment, it is necessary in all resections of the wrist to place the hand upon a splint, fixing the wrist in dorsal flexion but permit- ting the movements of the fingers. RESECTION OF THE ELBOW JOINT LISTON'S T-INCISION 1. The posterior side of the elbow bent at an obtuse angle is presented to the operator by an assistant, holding the forearm with one hand and the arm with the other (Fig. 796). 2. A longitudinal incision 8 centimeters in length, the middle of which corresponds with the inner margin of the olecranon, opens the articular capsule between this and the internal condyle (Fig. 794). triceps extensor carpi rad. lonpus ancoaeus.__. quartus extensor carpi _ ulnaris i II FIG. 794. RESECTION OF THE RIGHT EL- BOW JOINT (Lis- ton's T-incision) n. ulnaris flexor carpi ulnaria FIG. 795. ULNAR NERVE ON THE DORSAL SIDE OF THE LEFT ELBOW JOINT 3. While the nail of the left thumb forcibly draws the soft parts from the internal condyle inwardly, a short knife divides them completely by incisions made vertically tipon the bone, until the epicondyle projects free from the wound (Fig. 796). During this procedure, the forearm must be flexed more and more by the assistant. The ulnar nerve lies in the middle of the parts dissected off and does not appear to view (Fig. 795). 404 SURGICAL TECHNIC 4. By a semicircular incision made below the internal condyle, the internal lateral ligament (Fig. 797) and the origins of the flexor muscles are divided. 5. The arm is then extended, and the external incision is made trans, versely across the olecranon from the lower border of the external condyle to the middle of the first incision (see Fig. 794). 6. Upon the posterior side of the ulna, the periosteum is detached with the elevator from the internal margin, but remains in connection with the FIG. 796. RESECTION OF THE ELBOW JOINT DENUDING INTERNAL CONDYLE tendon of the triceps, which must be separated from the tip of the olecranon with the knife. 7. Both are pushed outward over the external condyle ; the articulation then gapes ; a few incisions in the articular connection between the head of the radius and the articular surface of the external condyle above divide the annular ligament of the radius and the external lateral ligament (Fig. 798). 8. The articulation is now more freely exposed ; the free articular end of the humerus is grasped with bone forceps, and sawed off at the limit of the cartilaginous covering. 9. By an incision toward the point of the coronoid process of the ulna, the superior fibres of the internal brachial muscle are detached ; the ole- THE TREATMENT OF WOUNDS 405 cranon is grasped with the forceps, and the denuded part of the ulna, as far as it is covered with cartilage, is sawed off. 10. Next, the head of the radius is excised. FIG. 797. Inner side FIG. 798. Outer side LIGAMENTS OF THE RIGHT ELBOW JOINT ii. After the hemorrhage has been arrested, the tendon of the triceps is first stitched with catgut sutures to the periosteum of the ulna ; next, the transverse incision is united by sutures, the longitudinal incision, however, only at its two ends. A drainage tube can be inserted into the middle of the wound down to the resected ends. VON LANGENBECK S SIMPLE LONGITUDINAL INCISION SUBPERIOSTEAL RESECTION 1. An incision 8 to 10 centimeters in length, extending over the extensor side of the articulation a little inwardly from the middle of the olecranon, begins 3 to 4 centimeters above the tip of the olecranon and ends 5 to 6 cen- timeters below the same upon the posterior border of the ulna; it penetrates the muscle, tendon, and periosteum everywhere down to the bone (Fig. 799). 2. With the raspatory and elevator, the periosteum of the ulna is first pushed toward the inner side ; the internal half of the tendon of the triceps, 406 SURGICAL TECHNIC in connection with the periosteum, is divided (by short parallel longitudinal incisions always directed toward the bone). 3. With the nail of the left thumb, the soft parts covering the internal condyle and including the ulnar nerve are drawn toward the tip of the epi- condyle and detached by curved incisions close to each other, always directed toward the bone, until the epicondyle projects and is freely exposed. The last incisions encircle the inner condyle, and divide the origins of the flexor muscles, as well as the internal lateral ligament from the same, without destroying the connection of these parts with the periosteum. 4. After the detached soft parts have been replaced into their former positions, the external part of the ten- don of the triceps is drawn outward, detached by short incisions from the olecranon, but left in connection with the periosteum of the external side of the ulna, which, together with the anconeus muscle, is elevated from the bone. 5. By incisions made close to each other and di- rected toward the bone, the fibrous articular capsule is detached from the margin of the articular surface of the humerus, first at the trochlea, next at the head of the bone, until the external condyle appears to view. 6. Next, the external lateral ligament, as well as the origins of the extensor muscles, are so detached from it that all these parts remain in connection with each other and the periosteum of the humerus. 7. After the external condyle has thus been divested from all attach- ments of soft parts, the joint can be strongly flexed ; the articular ends are forced out of the wound and sawed off in the manner described above. 8. If it appears desirable to saw off the ulna below the coronoid process, the superior fibres of the tendon of the brachialis internus must be detached from it without destroying the connection of the tendon with the periosteum of the ulna. BY HUETER'S BILATERAL LONGITUDINAL INCISION I. A longitudinal incision 2 centimeters in length exposes the internal condyle ; a curved incision, encircling its base, divides the internal lateral ligament. FIG. 799. RESECTION OF RIGHT ELBOW JOINT BY VON LAN- GENBECK'S EXTERNAL INCISION THE TREATMENT OF WOUNDS 407 2. A longitudinal incision over the outer surface of the joint 8 to 10 centimeters in length extends over the external condyle and the head of the radius. 3. The soft parts are drawn apart, and the external lateral ligament, together with the annular ligament of the radius, is divided. 4. The head of the radius is cleared of all attachments and removed with the metacarpal saw. 5. The insertion of the capsule of the joint is detached from before back- ward, first from the border of the rotula, then from the trochlea. 6. By abducting the forearm toward the ulnar side, the humerus is forced out of the wound when the ulnar nerve slips off from its posterior surface, and its articular end is excised with the saw. 7. The olecranon is then cleared and removed with the saw. BY OLLIER S BAYONET INCISION 1. With the forearm flexed (130), the external incision on the pos- terior side of the elbow between the externus anconeus and the supinator longus, beginning 6 centimeters above the articulation, is made down to the lateral epicondyle ; from here, it turns downward at an obtuse angle to the olecranon, and then descends 4 to 5 centimeters along the posterior border of the ulna (Fig. 800). The middle oblique portion of the incision corresponds about to the inter- space between the triceps and the anconeus quartus muscles. 2. In the upper portion of the incision, after division of the fascia, the operator advances between the triceps and the supinator longus and the extensor carpi radialis longus down to the bone, and divides the articular capsule in the direction of the skin incision. 3. With the arm slightly extended, the tendon of the tri- ceps, together with the periosteum, which must be carefully preserved, is detached from the bone with the raspatory. The articulation is then opened behind after the olecranon has been exposed. 4. On the humerus, the periosteum, together with the lateral accessory ligament, is reflected with the raspatory, and the humerus is luxated laterally by dividing the median and anterior articular ligaments. 5. Finally, the articular surfaces of the humerus, radius, and ulna are excised with the saw. ER'S RESEC- TION OF THE ELBOW JOINT 408 SURGICAL TECHNIC Nttaton made an angular incision extending along the outer side of the humerus as far as the head of the radius, and turning from here at a right angle backward as far as the ulna (Fig. 801). It is true that the articulation and especially the head of the radius are well exposed thereby, but the anconeus muscle is trans- versely divided ; this disadvantage can be avoided by making the resection BY KOCHER'S HOOK-SHAPED INCISION 1. An incision beginning at the radial posterior side 4 centimeters above the line of articulation extends on the outer side of the inferior border of the humerus as far as the head of the radius, and 4 to 6 centimeters below the tip of the olecranon, and turns here about I to 2 centimeters upward as far as the median side of the ulna (Fig. 802). 2. The knife penetrates between the brachioradial mus- cle (supinator longus), extensor carpi radialis longus and brevis, and the extensor carpi ulnaris in front, and the anco- neus muscle behind as far as the lateral border of the humerus and the cap- sule of the head of the radius, and deviates upon the lower third of the anconeus as far as the lateral side of the ulna. FIG. 801. NELA- TON'S RESECTION OF THE ELBOW JOINT FIG. 802 FIG. 803 KOCHER'S RESECTION OF THE ELBOW. JOINT, a, m. anconeus quartus; , extensor carpi ulnaris; t, m. triceps; s, supinator longus 3. After division of the capsule the olecranon is divided at its base with a chisel transversely in the line of incision (more deeply on its posterior THE TREATMENT OF WOUNDS 409 side), next turned up with the triceps and the anconeus toward the ulna, and subsequently enucleated if it is diseased. 4. If the olecranon is to be preserved, the external head of the triceps, with the periosteum and the capsular insertion, is detached from the humerus, also the anconeus from the external surface of the ulna, the insertion of the triceps from the tip of the olecranon, and a portion of the internal ulnar muscle from the internal surface of the ulna; this triceps anconeus flap is turned inward like a cap over the olecranon with the arm extended (Fig. 803). 5. After the detachment of the external lateral ligament and of the cap- sule on the external condyle of the humerus and on the neck of the radius, the articulation is opened freely. 6. Before the bones are sawed off, the internal lateral ligament must be carefully detached from the internal border of the ulna and the median surface of the trochlea, and the muscles, together with the periosteum, must be freed from the internal and the external condyle. The articular ends are sawed off in a light curve to guard against any subluxation which might occur during the healing process. RESECTION OF THE OLECRANON This can be made, according to von Langenbeck, by a posterior longi- tudinal incision (Fig. 799). The soft parts and the periosteum are then detached with the raspatory on both sides, and the olecranon is removed with the metacarpal saw or chisel and hammer. TEMPORARY RESECTION OF THE OLECRANON (Trendelenburg) can be made, aside from the incisions mentioned heretofore, also from behind, by chiselling off the olecranon, and by subsequently reuniting it with the bone suture. For this purpose a curved incision is made with the convexity directed upward across the extensor side of the articulation from one epicon- dyle to the other. The skin flap is detached from the tendon of the triceps and the olecranon, and the soft parts are elevated bluntly from the internal side of the olecranon, preserving carefully the periosteum and the ulnar nerve. The portion of the capsule of the joint lying under it is divided transversely ; the olecranon is chiselled off transversely, and finally, in the same plane, the anconeus muscle and the portion of the articular capsule lying under it are divided transversely. The olecranon can then be turned in an upward direction ; with a flexed position of the arm a free inspection of the inside of the joint is obtained. 4io SURGICAL TECHNIC The olecranon is finally united with the ulna by a bone suture, the external incision is sutured, and the arm is bandaged in an extended position. It seems just as well to form the skin flap with an upper base, and to turn it up in connection with the olecranon to be sawed off. In the after treatment, the advice of Roser to bandage the resected elbow joint first in the extended position to prevent the dislocation of the ends of the bone (subluxation), and to guard against the formation of a loose 'freely mov- able joint, must be strictly observed. The splints illus- trated in Figs. 146, 152, 216, 236, and 238 can be used for this purpose. But also with a right-angular position a loose, freely mov- able joint can be avoided if the surgeon, in as exten- sive a manner as possible, places in apposition only the extremities of the bone. Thereby the resected bones of the forearm are prevented from coming to lie in front of the humerus. For this purpose ulna and humerus can be sawed off obliquely and placed in apposition, or the humerus end can be in- FIG. 804. SOCIN'S SUPPORTING APPARATUS FOR A LOOSE, FREELY MOVABLE JOINT AFIER RESECTION OF THE ELBOW JOINT cised in the form of a A (or be divided longitudinally), the ulna cut out in the form of a wedge be inserted into the fissure. The radius can be sawed off to such an extent that it comes to lie upon the humerus (Bardenhener). To prevent anchylosis with the limb in this position the forearm, as soon as the wound has healed or nearly healed, must be gradually flexed at the elbow with each change of dressings, and must be kept in the new position from one dressing to another until the desired degree of flexion is reached. If a loose, freely movable joint has formed after resection of the THE TREATMENT OF WOUNDS 411 elbow, firmness and usefulness can be restored by Sociris supporting appa- ratus (Fig. 804), to which are attached rubber rings which accomplish flexion. (In all resections of the elbow joint temporary resection of the olecranon should be practised unless it is the seat of disease. After the resection has been completed the olecranon is united with the shaft of the ulna by a bone or ivory nail. In young subjects fixation by durable catgut sutures embracing the periosteum and the tissues outside of it will answer the purpose.) RESECTION OF THE SHOULDER JOINT BY VON LANGENBECK'S ANTERIOR LONGITUDINAL INCISION (OLDER METHOD) 1. The patient is placed on his back, the shoulder pressed forward by a pillow, and the arm held in such a manner that the external condyle of the humerus is directed forward. 2. An incision, beginning at the anterior border of the acromion, very near its articu- lar connection with the clavi- cle and extending 6 to 10 centimeters vertically down- ward, penetrates through the deltoid muscle down to the capsule of the joint and the periosteum (Fig. 805). 3. The margins of the muscular incision are drawn apart with blunt retractors; the tendon of the long head of the biceps is seen lying in its sheath (Fig. 806). 4. An incision along the external side of the tendon JrlG. 007 opens its sheath ; the knife, VQN LANGENBECK . S R ESEC TION OF THE SHOULDER JOINT with its back in the bicipital groove, divides the whole sheath of the tendon and the capsule as far as the acromion. FIG. 805 FIG. 806 412 SURGICAL TECHNIC 5. The tendon of the biceps is lifted from its groove and drawn outward with a blunt retractor. 6. While an assistant slowly rotates the arm outward a curved incision across the lesser tuberosity of the humerus is made with a strong knife applied vertically to the bone. This incision divides the capsule and the insertion of the subscapular muscle (Fig. 807). 7. The arm is then rotated inward ; the tendon of the biceps is drawn inward and buried there. Bitpraspinatus infrcapinatvs teres minor sulscapularis tendo licipitit teres major FIG. 809. INSERTIONS OF THE MUSCLES OF THE GREATER AND LESSER TUBEROSITY OF THE HUMERUS 8. The knife is again carried in a larger circle from the capsular division above the greater tuberosity of the humerus, and divides the capsule with the insertions of the supraspinatus, the infraspinatus, and the teres minor muscles (Figs. 808, 809). 9. The head of the humerus is forced out of the wound by pressure from below, grasped with strong forceps (best of all, Farabceuf's forceps Fig. 810), and after the posterior portion of the capsule is divided, it is excised with a metacarpal saw (Fig. 811). THE TREATMENT OF WOUNDS 413 10. When the head of the humerus has been separated from the diaphy- sis by a bullet, it must be seized with a sharp bone hook and ex- tracted (see Fig. 779). If the head is crushed into several pieces, the fractured portions can be grasped singly with forceps and enucleated with a blunt-pointed knife or a probe-pointed knife. 11. After this method of oper- ating, in most cases a flail joint with displacement of the humerus toward the thorax is formed, or a poor and defective articular con- nection with the coracoid process is established. Free active motion is more likely to be restored if the connections of all muscles sur- rounding the articulation with the FIG. 810 FIG. 8n capsule and the periosteum of the SAWING OFF HEAD OF SHOULDER diaphysis are carefully preserved during the operation. This is effected by THE SUBPERIOSTEAL OR SUBSCAPULAR RESECTION BY VON LANGENBECK'S ANTERIOR LONGITUDINAL INCISION 1-4. As in the foregoing operation. 5. Along the internal border of the bicipital groove, the periosteum is divided with the scalpel and carefully reflected with a small elevator from the spine of the lesser tuberosity of the humerus as far as the lesser tuberosity (Fig. 812). 6. With the knife and tenaculum forceps, the tendon of the subscapular muscle (Fig. 809) is freed from the bone without dividing the connections of the capsule with the detached periosteum. During this procedure the arm must be slowly rotated outward, and during the further progress of detach- ment the knife must be frequently exchanged for the elevator. 7. The arm is then rotated inward, the tendon of the biceps is raised from its groove and buried inward. 8. The periosteum of the external surface of the neck of the humerus is detached in connection with the insertions of the supraspinatus, infraspi- 414 SURGICAL TECHNIC natus, and teres minor at the larger tuberosity in the same manner as described under 6. This detachment is somewhat difficult in primary resections, because the periosteum is usually very thin. 9. The head of the humerus is forced out of the wound, and sawed off as in the preceding operation. If it is deemed neces- sary to resect only the head of the humerus at the upper extremity of the tubercle (which always yields the best functional result), re- flection of the periosteum is superfluous. In this case, the insertions of the muscles are detached from the bone as much as neces- sary, commencing from the articular cavity. Attention must be paid that the muscles are not cut off transversely, but retain their con- nection with the bone below. Since the head, however, under these circumstances cannot be forced from the wound, it must be sawed off with a fine metacarpal saw or with the chain saw. 10. After the hemorrhage has been ar- rested, an opening is cut in the posterior side of the wound in the skin, at the posterior border of the deltoid muscle ; through this " o ' 'opening a drainage tube is inserted into the ' wound. The anterior wound can then be completely united by buried and superficial sutures. An antiseptic dressing is applied and re- tained by a bandage, the tours of which fasten the arm, flexed at the elbow, to the side of FIG. 813. RAMIFICATION OF AXIL- the chest in the manner of a mitella, which LARY NERVE. Posterior view, i, cir- rr- e ;, - cumflex nerve; 2, cutaneous nerve; suffices for the fixation of the limb. 3> nerve of teres minor muscle . 4> ra _ In order better to protect the deltoid mus- dial nerve; 5, ramifications coursing cle and the branches of the circumflex nerve towards the trice P s and anconeus (axillary, Fig. 813), and consequently avoid paralysis of this muscle, the joint should be opened. FIG. 812. LIGAMENTS OF THE SHOUL- DER JOINT THE TREATMENT OF WOUNDS 415 BY OLLIER'S ANTERIOR OBLIQUE INCISION 1. With the knife directed toward the head of the humerus, the incision is made to correspond with the course of the fibres of the deltoid, from the external border of the coracoid process obliquely down- ward and outward across the lesser tuberosity and as far as the shaft of the humerus, dividing all of the soft tissues down to the bone (Fig. 814). 2. The lesser tuberosity and the bicipital groove are immediately exposed, and can be easily cleared of the attached soft tissues. Next, the arm is rotated inward, and the greater tuberosity is detached. On the whole, the procedure is the same as described in the preceding operation. Since from an anterior incision only the head of the humerus can be removed conveniently (decapita- tion), while the other portions of the articulation, especially the glenoid cavity, can be inspected or resected in a somewhat unsatisfactory manner, it is FlG - 8l 4- O LLIER ' S RESECTION , n .... ,. OF THE SHOULDER JOINT better in all cases in which a more extensive disease of the whole articulation necessitates free access to all its parts, to expose the articulation of the shoulder by KOCHER S POSTERIOR CURVED INCISION 1. External incision from the acromioclavicular articulation over the eminence of the shoulder to the middle of the spine of the scapula and in the form of a curve downward toward the posterior axillary fold. Division of the acromioclavicular articulation (Fig. 815, c). Longitudinal incision through the fascia at the posterior border of the deltoid muscle. The inferior portion of it is exposed and forcibly drawn forward; the fibres inserted farther on at the crest are divided. 2. The insertion of the cucullaris (trapezius) is detached from the spine of the scapula upward, and the supraspinatus is raised with the elevator ; the infraspinatus is detached downward until the external border of the spine can be encircled. 3. After an elevator has been placed under the neck of the acromion for protection, the crest (sc) is divided with a chisel (from above downward) (Fig. 815); an injury of the subscapular nerve coursing beneath the supra- spinatus and infraspinatus muscles should be guarded against. 416 SURGICAL TECHNIC 4. After division of the bone, the acromial portion is rolled forcibly forward with a sharp bone hook, and dislocated in the acromioclavicular articulation (Fig. 816), whereby the deltoid muscle ( a> sinus longitudinalis . which are not yet Completely divided. b, sinus transversus; c, art. mening. med. FIG. 870. TREPHINING OPERATIONS ON THE HEAD 459 Previously, however, a little bone screw, Heine s tire fond (Fig. 872), is inserted into the central hole. 3. As soon as the bone disk has been freed on all sides, it is carefully lifted out by inserting in the upper hole of the bone screw a hook bent at right angles. With this hook, also, it can be ascertained whether depressed fragments of bone are movable (Roser)\ and with it, or with a stronger elevator, or with forceps, the operator attempts to raise or remove them. If, during this operation, violent hemorrhage occurs from the abnormally dilated veins of the diploe, it is arrested by forcing into the bleeding openings a ball of carbolic wax softened in hot water, or by inserting a thick catgut thread. Hemorrhage from the branches of the middle meningcal artery can be arrested by a ball of wax, if it is impossible to grasp the divided artery and ligate it. (Spiking the arterial or venous channels in bone with an aseptic ivory or bone nail or a toothpick is a procedure which in troublesome cases can be relied upon.) Hemorrhage from a lacerated sinus is usually F g B arrested by antiseptic tamponade, or by applying a com- W1TH ROSER'S HOOK pressive bandage. Most surgeons, in recent times, employ this method of trephining only in rare cases, preferring the operation with chisel and hammer, whereby an opening of any size and shape can be obtained more rapidly and securely. FIG. 873. STILLE'S BONE-NIPPING FORCEPS Likewise, with Stille's "Knochenbeisszange," bone-nipping forceps (Fig. 873), a portion of the skull can be rapidly cut all around. (In this country the bone-cutting forceps of De Vilbiss is most popular.) 460 SURGICAL TECHNIC In hospital work a small rotating circular saw, operated by foot or electro- motor, which sets it in very rapid rotation (Fig. 874), is an instrument which lately has come into more general use. FIG. 874. ROTATING CIRCULAR SAW AND ELECTROMOTOR TREPHINING FOR INTRACRANIAL DISEASE should be performed as follows : 1 . After a curved incision has been made in the soft parts, the vault of the skull, having been exposed, is opened with chisel and hammer. As it is impossible for the operator to know beforehand whether the cranial bones are thick and dense or thin and soft, he must use the chisel cautiously by short strokes ; and, after each stroke, he must ascertain the condition of the bone and the depth reached. It is best to use a sharp gouge of medium size, applied more or less obliquely. The strokes must not be made with too much force, because fissures and other unintentional injuries to the underlying parts the dura mater, the brain or especially the so-called " Verhammerung," injury to the brain by hammering {Koch, File/me), and its consequences might ensue. These dangers are not to be feared when the circular saw is used. 2. When the dura mater has been exposed, it is best opened in the shape of a broad pedunculated flap by making an incision into the dura along the margin of the bony opening and about two millimeters in front of it ; the flap is then turned up. If the incision is made thus, any lacerated blood OPERATIONS ON THE HEAD 461 vessels can be grasped and ligated easily, since the peripheral end cannot recede under the bone (Horsley). 3. The surface of the brain is now exposed. After it has been carefully examined as to any changes such as discoloration, fluctuation, hardness, scars, absence of pulsation the operation on the brain itself begins with an incision made exactly vertical to the surface, since in this manner the blood vessels are least likely to be injured. If hemorrhage occurs, a compress of iodoform gauze is pressed upon it until it is arrested. 4. If a tumor is found, a circular incision is made around it in the healthy parts. The tumor is lifted out carefully with a knife, curved on the flat, or a spatula Horsley uses flexible knives of soft iron ; and the cavity thus produced is tamponed. In case of cortical epilepsy, the surgeon should try first by a direct fara- dization of the surface of the brain to locate more definitely the field of the cerebral cortex involved. After this the diseased portion of the cortex is excised superficially. If an abscess is found, it is drained toward the open- ing without much irrigation. The shock arising from operating on the cortex can be obviated by irri- gation with hot water. If, in the neighborhood of a large venous sinus, its injury, together with the entrance of air, is to be feared, the danger can be avoided by double ligation, or by profuse irrigation of the field of operation. 5. The wound of the scalp is sutured, and a drainage tube is inserted. During the first days the dressings must be renewed daily. It is advan- tageous to remove the drainage tube even after 24 hours; if, after its removal, during the next few days, there appears any tension of the sutured margins in consequence of retained secretions, a small drainage opening is made with a probe between two of the sutures. In profuse hemorrhage from the brain, wliicJi cannot be arrested, it is advisable to tampon the whole wound with iodoform gauze from 2 to 3 days ; and, at the end of that time, to apply secondary sutures under anaesthesia (von Bergmann). Craniectomy (craniotomy) (Lannelongue, Lane), the resection of portions of the vault for the purpose of creating more space for the brain, confined by a too premature ossification of the sutures and fontanelles in idiocy and microcephalus, has been made in recent times with some degree of justifica- tion, but with varying success, when it becomes necessary to remove severe general or more or less localized cerebral affections. A long skin incision is made along the sagittal suture, from the ante- rior to the posterior limits of the hairy scalp. The periosteum is divided 462 SURGICAL TECHNIC and pushed back on both sides to such an extent that with the chisel and the rongeur forceps (Fig. 867) a strip of bone as broad as the finger can be removed craniectomie lineaire. The dura is not opened (Fig. 875). Finally, the skin is sutured over the groove of the bone. If necessary, the same operation may be afterward performed on the other side. If some centres are especially involved, correspondingly large portions of the vault over them (disks) are removed in the same manner, as in resection of the skull, described on page 460. Sometimes it is advisable at the same time to remove the periosteum to the extent of the portion of bone to be removed for the purpose of preventing a premature closure of the opening by ossifi- cation. FIG. 875. CRANIECTOMY FIG. 876. W. WAGNER'S OSTEO- PLASTIC RESECTION OF THE SKULL Gersuny made the bone incision around the skull in the same manner as in a post-mortem, so that the whole vault could be raised in such a way as to make the vault of the skull lie movable upon the brain. After the healing of trephine wounds, although the periosteum has been preserved, the reproduction of bone to fill the opening very rarely takes place. Hence there is left in the skull a soft place covered only by skin and easily exposed to injury. A protector of some hard material should be worn to protect the opening in the skull against injury. To remedy this defect, various attempts have been made to close the opening with bone. OPERATIONS ON THE HEAD 463 OSTEOPLASTIC RESECTION OF THE SKULL The subsequent reposition of the round disks of bone as they fall out of the trephine, and the healing in of the same, have met with success only in rare cases. The procedure, moreover, is accompanied by danger, since retention of secretion in the underlying tissues may easily ensue. Macewen, therefore, fragmented the sawed-out bone disk into many smaller pieces, with which he filled the wound. Thus, in most cases, he secured healing and reproduction of bone. It is more practical, according to Senris procedure, to use decalcified bone chips, kept ready for use in sublimate alcohol. Likewise the fresh chips of bone obtained by gouging may be used for paving the exposed dura (autoplasty). Gerstein replaced a large fragment of bone, the result of an injury, and obtained healing with ossification. The attempt to implant celluloid plates into the opening of the skull has also met with good success in some cases (Jieteroplasty). W. Wagner forms a bone flap from the portion of the skull to be opened, and turns it temporarily away from the brain like a door on its hinges. The soft parts are divided down to the periosteum in the form of the Greek letter O. At the margin of the somewhat con- tracting flap of the skin, he incises the periosteum and in the same line chisels through the bone. With a small, fine chisel, he first forms a gutter. This he deepens with a small tolerably thick chisel, with an oblique edge on one side, ap- plying it obliquely with bev- elled edge directed toward the margin of the defect. In the two angles only a gutter is gouged, growing deeper from without inwardly ; from this the bridge of bone still remaining is divided subperiosteally with a small chisel. The whole piece of bone can then be raised with the ele- vator and turned downward (Fig. 877). The healing-in into the opening of the temporarily detached piece of bone is fairly well secured by the^ bridge, and by the uninjured condition of the soft parts covering it. WAGNER'S OSTEOPLASTIC RESECTION OF THE SKULL When the 464 SURGICAL TECHNIC operation is completed the wound is sutured and drained at only one or at both angles. Miiller proceeds in a similar manner by chiselling off only the external table of the skull (Konig\ in the form of a flat disk, which he leaves in vascular connection with the soft parts that cover it and which is made to cover the cranial defect. Larger defects of the skull are best covered by the ostcoplastic operation of Miiller and Kb'nig as follows : After incising the skin over the defect in the form of a broad pedunculated flap (a), chisel out from the diploe a second reserve flap (), lying near the first and somewhat larger, in connection with the underlying periosteum and a thin layer of bone. Preserve between the two flaps a spindle-shaped portion of intact skin, and over this slide the two flaps on their pedicles so that the periosteum-bone flap can be sutured over the defect. Plant the first simple skin flap over the surface of the diploe of the reserve flap. The reserve flap, placed over the opening, forms a bony covering, and in the course of time the continuity of the skull is restored. Before the surgeon decides to open the skull for intracranial disease, he must be perfectly sure as to the site of the diseased portion of the brain. Important symptoms which enable the surgeon to determine the seat of sucJi diseases are furnished by the manifestations of irritation or paralysis thereby produced (focal symptoms), concerning the origin of which, espe- cially in the cortical centres, experimental physiology and the experience of surgeons and pathologists shed more and more light. Figure 879 represents the position of the most important motor and sensory cortical areas in rela- tion to the principal convolutions and fissures of the cerebrum. By a knowledge of the cortical areas (localizations), their distribution on the brain surface, and their position relative to the outer surface of the skull, we are enabled to ascertain the exact place for the opening of the latter. Since these cortical areas are situated principally in the neighborhood of the central sulcus (sulcns centralis) and the Sylvian fissure (fossa Sylvii ), the exact location of that portion of the skull under which they are situated FIG. 878. OSTEOPLASTY IN CRANIAL DEFECTS OPERATIONS ON THE HEAD 465 is imperative. The position of the other fissures and convolutions can then be judged more or less correctly. The location of the central fissure (fissure of Rolando), according to Thane, is determined in the following manner : _S.interparietalis FIG. 879. CEREBRAL TOPOGRAPHY 1, region of the oculomotor nerve. Levator palpebrse; motions of the eyeball; dilatation of the pupils; turning the head to the opposite side 2, upper extremity, a, adductors and abductors; b, extensors; c, d, flexors, supinators, and prona- tors; e, muscles of the hand 3, lower extremity, a, flexors; b, extensors 4, facial nerve, region of the face, a, muscles of the mouth 5, speech centre and lingual motions (anteriorly, aphasia; posteriorly, region of hypoglossus) 6, visual centre. See also Tillmanns, II. I. 70, 122; Keetley, "Index of Surgery," 207, 209; Senn, " Principles," 276 From the root of the nose (glabella) to the inion (occipital protuberance), draw a line over the sagittal suture and divide it into two equal parts. From the middle of this line and 13 millimeters posteriorly from it, the Rolandic fissure begins, running forward and downward at an angle of 67^. It is about 10 centimeters long (Fig. 880). Or, according to Bennet, draw two parallel lines 5 centimeters apart downward from the sagittal suture and at right angles to it. The anterior line (Fig. 880, ccT) crosses the anterior margin of the external auditory meatus ; the posterior line (<& Jselted' w# the skin of the arm, ac- cording to the method of Tagliacosza (professor at Bologna, 1 597, " De curtorum chirurgia per insitionem ") and Grafe(i8i6)( Italian method). For this purpose, a flap with a double pedi- cle is formed from the middle of the arm by FIG. 1019. NELATON'S RHINOPLASTY two incisions ; a little gauze placed beneath the flap prevents it from uniting with the under- lying parts. When the cicatricial contraction commences in the flap, one bridge is divided, and the wound surface is sewed to the vivified nasal defect. If the healing proves successful, the other bridge on the arm is also divided (Fig. 1020). When the Italian method is employed, the arm must remain securely fastened to the head in a fixed position (by bandages or plaster of paris dressing) ; the patient inhales constantly the se- cretions of the granulating sur- faces of the wound, and the new nose, on account of the inferior value of the skin of the arm as compared with that of the face, is more heterotopic and possessed of less vitality, and progressive contraction is the rule. These disadvantages have prevented the FIG. 1020. TAGLIACOZZA AND GRAPE'S RHINO- met h o d from being adopted to any PLASTY BY A FLAP FROM THE ARM . , considerable extent. At best, it may, in case of necessity, serve as a substitute for the Hindoo method. 538 SURGICAL TECHNIC In recent times, however, it has been occasionally used with success. For example, Israel restored the nose in order to avoid the disfiguring frontal cicatrization by transplanting a skin-bone flap taken from the ulnar side of the forearm, the bony part of which consists of the border of the ulna lying directly under the skin (Fig. 1021). In the case of a saddle nose, he corrected the deformity by transplanting a fragment of bone sawed off from the tibia. With all these methods, nevertheless, the new-formed nose often leaves much to be de- sired. Moreover, it has still a tendency to slough, and, in many cases, to contract more and more in the course of time. Hence, a surgeon who desires to obtain permanent suc- cess is wise in making the nose from the start large enough to make due allowance for con- traction. A much better cosmetic result may be ob- tained by the nasal protheses now manufactured in excellent form from vulcanized rubber (Saner) or celluloid (Kleinmann), especially since, in fitting, the most suitable form may be found for the physiognomy of the patient by using noses cut out of masks (Kleinmann) or from the FIG. 1021. ISRAEL'S RHINOPLASTY FIG. 1022 TIEMANN'S NASAL PROTHESES FIG. 1023 models of sculptors (Gronwald). These protheses are held in place by a spectacle frame (as in masks) or by two wires extending in the form of pincers with a support on the margins of the pyriform aperture, or the PLASTIC OPERATIONS ON THE FACE 539 remains of the turbinated bones. The line of application is made invisible as much as possible by colored collodium or zinc paste (" zinkleim "), etc. Simple pasting on without a supporting apparatus does not furnish the necessary support. PARTIAL RHINOPLASTY serves to supply separate portions of the nose ; for instance, one-half a nose, one ala, the tip, or the septum. If one side of the nose is lost by injury or disease, it can be supplied by the Hindoo method of turning down from the skin of the forehead a flap in the form of a divided nose model, and by sewing it into the defect. In the same manner, larger or smaller defects of the bridge of the nose can be cov- ered by narrow flaps from the forehead formed in accordance with the defect. If the loss involves the ala of the nose and the skin overlying the same, the flap is taken from the other half of the nose (von LangenbecK}. FIG. 1024 FIG. 1025 VON LANGENBECK'S METHOD OF RESTORING AN ALA OF THE NOSE FROM THE OTHER HALF OF THE NOSE A small rectangular flap is cut out from the healthy side, whose base is at the inner angle of the eye of the diseased side, whose sides extend obliquely over the bridge of the nose, and whose lower transverse incision terminates closely over the margin of the healthy ala of the nose ; the flap, detached from its base, and a few millimeters longer than the defect, is turned over the remaining " spur " toward the diseased side and sewed in position. By (cicatricial) contraction of its lower free margin, the new nostril assumes the same form as the healthy one, whilst the secondary defect heals by granulation or is grafted at once with skin ( Thierscti). The success of this operation is excellent (Figs. 1024, 1025). 540 SURGICAL TECHNIC Smaller defects of the alae of the nose are covered either by drawing over pedunculated flaps from the neighboring skin of the cheek (Figs. 1026, 1027, 1028), or by sliding down a V-shaped flap, and by applying a Y-shaped suture P'IG. 1026 FIG. 1027 FIG. 1028 RESTORING AN ALA OF THE NOSE BY PEDUNCULATED FLAPS FROM THE CHEEKS according to Dieffenbach (Figs. 1029, 1030). From the upper lip also a restorative flap can be obtained as represented in Fig. 1027 (O. Weber}. Smaller defects of the tip of the nose may be restored in many different ways by the tissues of the nose itself ; for example, by forming small flaps with a vascular bridge in a suitable position, and by sliding. Secondary defects become more and more obliterated, until they are scarcely noticeable. W. Busch covered a defect which occupied the tip and one ala of the nose FIG. 1029 FIG. 1030 FORMING NOSTRIL BY SLIDING A SMALL FLAP FIG. 1031 W. BUSCH'S METHOD OF RESTORING THE TIP OF THE NOSE AND ONE ALA by a lateral pedunculated flap from the skin of the bridge of the nose and the glabella (Fig. 1031). The procedure of Hueteris original ; he transplanted as a substitute for the tip of the nose the plantar eminence of the little toe, excised by a cuneiform incision. PLASTIC OPERATIONS ON THE FACE 541 FOR RESTORING THE SEPTUM may be used : i. The skin of the philtrum of the upper lip (Dieffenbach}. By means of two perpendicular incisions throughout the -whole thickness of the lip, its middle portion is excised and turned up so that the mucous membrane lies FIG. 1032 FIG. 1033 DIEFFENBACH'S METHOD OF RESTORING THE SEPTUM FIG. 1034 FIG. 1035 VON LANGENBECK'S METHOD OF RESTORING THE SEPTUM externally. The flap is then sewed to the portion of the nostril, previously vivified, and the wound of the lip is closed completely by suture (Figs. 1032, 1033). 2. The skin of the upper lip, from which an oblique flap is formed with an upper base. By lateral sliding, it is sewed into the nares ; the pedicle must be cut off subsequently and placed in the middle (yon Langenbeck, Figs. 1034, 1035). 3. The skin of the bridge of the nose, from which a small flap is formed and turned down laterally (Hueter, Figs. 1036, 1037). FIG. 1036 FIG. 1037 HUETER'S METHOD OF RESTORING THE SEPTUM The correction of saddle noses or of collapsed noses, the bones and carti- lages of which have been destroyed by ulcers or injuries (saddle noses), in most cases is not permanently successful, if only flaps of skin are employed without any solid support, because, owing to the contraction of the new skin structure, the deformity soon recurs. 542 SURGICAL TECHNIC In cases in which the cartilaginous framework is still partly preserved, but the tip of the nose is deeply depressed and retracted (retrousse"), von Langcnbeck proceeded as follows : By a convex transverse incision in an upper direction, he divided the tip of the nose one wing from the other, and with a sharp hook drawn down- ward and forward, he brought it out of its recess. In the defect thus produced, of a semilunar form, he implanted a pedunculated flap correspond- ing in shape, taken from the skin of the forehead, turned down and fastened by sutures to the lateral margins and the nasal eminence (Figs. 1038-1041). FIG. 1038 FIG. 1039 FIG. 1040 FIG. 1041 VON LANC;ENBECK'S METHOD OF CORRECTING COLLAPSED NOSES Konig formed a bony bridge of the nose by a flap from the bone and the soft parts of the forehead. After a transverse division of the soft parts of the nose at its deepest point, a flap of skin about I centimeter wide is cut out from the middle of the forehead with its base at the glabella (Fig. 1042). This strip of skin, together with the periosteum and a thin lamella of bone, is detached with a small chisel from the frontal bone, turned straight downward in such a way that the bone surface lies outward, and sewed together with the eminence of the nose, which has previously been made movable (Fig. 1043); over this bony support, the new nose is then formed according to the Hindoo method. But in order to obtain the normal depression between forehead and nose and a narrower dorsum, he divided the connecting bridge of the frontal flap and implanted it more deeply. Israel allowed the skin-bone flap first to become covered with epidermis, then he divided the underlying skin of the nose lengthwise in the form of two door-shaped flaps, which he fastened laterally to the vivified bony sup- port, thus forming the lateral surfaces of the nose. The frontal flap consists of a lamella of bone only 4 millimeters wide, around which the portion of PLASTIC OPERATIONS ON THE FACE 543 skin at least 2 centimeters wide is united. Upon this newly formed nose, covered with epidermis, the skin of the saddle nose is implanted subsequently. Oilier made two incisions around the nose, which, beginning at the alae, converged at the glabella at an acute angle, included at this place the peri- osteum in the flap, and transplanted its point about 4 centimeters downward, fastening it in this position. Analogous to the blepharoplasty of Dieffenbach, the skin of the bridge of the nose thereby becomes more abundant anteriorly, and the tip is forced downward. FIG. 1042 KONIG'S RHINOPLASTY FIG. 1043 FIG. 1044 Miculicz formed a septum from the existing depressed soft parts. He detached them on the margin of the pyriform aperture by two lateral incisions, turned them toward the median line, and sewed their vivified surfaces together. Over this newly formed septum, which is in connection only with the mem- branous septum, a new nose was constructed. The procedures of Schimmel- busch (page 535) and of Israel (page 538), described above, have also been used for the correction of saddle noses. If all these attempts result unsatisfactorily, the surgeon must content him- self with artificial protheses, which are made of gold, caoutchouc, amber, etc. ^Eyrdpdd raised many saddle noses with permanent good success by wire, hard rubber, and soft caoutchouc protheses, which form a kind of artificial septum, and which are inserted from the inside through an opening in the hard palate. In a simultaneous destruction of the nose and the upper lip, which not seldom occurs in consequence of syphilis and lupus, the restoration of these parts can be made in one sitting (Fig. 1044). For this purpose as much as possible of the existing useful portions of skin is saved, some of which are used for covering, others for lining, the nasal passage. PLASTIC OPERATIONS FOR CONGENITAL FISSURE FORMATIONS OF THE ORAL REGION I. HARELIP AND MAXILLARY FISSURES Most of these operations can be made immediately after birth. In serious cases, however, it is advisable to wait until the children have grown some- what older (one to two years), in order to have better-developed portions of skin at the disposal of the operator. Moreover, in maxillary fissures, by a preliminary operation and by properly applied pressure, the margins of the fissure can be approximated considerably. Older children may be operated upon under anaesthesia, and, if prefer- able, with the head in a dependent position (Rose} ; infants ought not to be chloroformed ; they should be either fastened in an upright position to the operating table or else held securely in a sitting position by an assistant. At each side, an assistant, by pressure with his fingers and with sponges, can control the hemorrhage from the lip ; and any blood flowing into the mouth is removed with sponges provided with a holder. A. SINGLE CLEFT OF THE LIP (HARELIP) The simple vivifying of the margins of the cleft with subsequent sutur- ing in most cases leaves a disfiguring depression from the ensuing contraction of the cicatrix. The following procedures, therefore, endeavor to avoid this depression and to procure an adequate length for the lip. FIG. 1045. Vivifying FIG. 1046. Wound FIG. 1047. Suture NELATON'S OPERATION FOR HARELIP In incomplete clefts of less degree not extending to the nostril, the surgeon may proceed in various ways according to their depth. 544 PLASTIC OPERATIONS OF THE ORAL REGION 545 1. Nelaton divides the lip above the angle of the cleft parallel to its margins. Next, he draws down the angle of the cleft and unites the rhom- boidal wound lengthwise, in such a manner that a prominence is produced, which subsequently, by cicatricial contraction, disappears. 2. J. Wolff, according to von Langenbcctt s method, cuts off the entire border of the lip as far as and close to the angles of the mouth, draws it down, and unites the margins of the wound lengthwise. By a horizontal FIG. 1048. Vivifying FIG. 1049. Wound FIG. 1050. Suture VON LANGENBECK'S AND WOLFF'S METHOD OF DISTORTION OF THE MARGINS OF THE LIPS suture he attaches the margin of the lip to the newly formed upper lip, after he has cut off as much from the vermilion border of the lips as to leave only a moderate projection. This is again united by a longitudinal line of sutures (distortion of the margins of the lips). 3. Malgaigne makes a semicircular incision around the angle of the cleft. At both ends of this incision, he makes two smaller incisions on the FIG. 1051. Vivifying FIG. 1052. Wound MALGAINE'S METHOD FIG. 1053. Suture lip obliquely outward and downward, turns the segments thus formed down- ward, and sews together in the median line the margins of the cleft thereby extended. 4. Mirault excises only one little flap from one margin of the cleft (best, the lateral). He vivifies the other margin correspondingly in the form of an 546 SURGICAL TECHNIC angle, and forms the margin of the lip by sewing the flap to the oblique margin of the wound of the other side. FIG. 1054. Vivifying FIG. 1055. Wound FIG. 1056. SUTURE MIRAULT'S (VON LANGENBECK'S) METHOD 5. Giraldcs forms at the lateral margin a small flap with a lower base ; from the apex of this, he makes an incision outwardly and beneath the ala of the nose. From the inner margin of the cleft, a small flap is cut with an upper base, which, on being drawn upward, forms the lower margin of the nostril, whilst the little flap of the other side is drawn down and used as a border for the lip. FIG. 1057. Vivifying FIG. 1058. Wound GIRALDES' METHOD FIG. 1059. Suture These older methods have been modified in many ways in recent times, and have been improved by Konig, Maas, and Hagedorn. The mode of making the incisions purposes to elongate the margins of the wound as much as possible ; the details of the method may be seen in Figs. 1060- 1068. FIG. 1060. Vivifying FIG. 1061. Wound KONIG'S METHOD FIG. 1062. Suture I, myself, since 1854, in all these formations of clefts (especially in somewhat older children, where sufficient soft parts are at the disposal of PLASTIC OPERATIONS OF THE ORAL REGION 547 the surgeon) have proceeded according to " the principle of economy" estab- lished by myself. That is, along all the margins of the cleft, I cut around FIG. 1063. Vivifying FIG. 1064. Wound MAAS'S METHOD FIG. 1065. Suture the flaps exactly at the limit of the vermilion border of the lips, retrovert the mucous membrane, and sew together with the finest sutures the flaps of the mucous membrane, so that they form a basement membrane with the FIG. 1066. Vivifying FIG. 1067. Wound HAGEDORX'S METHOD FIG. 1068. Suture surface of the wound turned in an anterior direction ; upon this, I slide the margins of the skin together and unite them by sutures (Figs. 1069, 1070). This procedure is more laborious and requires more time than any of the others, and on that account it is applicable only in the case of older FIG. 1069. Vivifying FIG. 1070. Suture Vox ESMARCH'S METHOD children; but it produces by far the most satisfactory cosmetic results, especially when the lip is sufficiently detached from the jaw by deep incisions 548 SURGICAL TECHNIC beginning at the duplicature of the mucous membrane, thereby rendering the lip more movable. The liberation of the lip is of the greatest importance in all these operations. B. DOUBLE HARELIP In double harelip, the median peninsula is vivified according to the methods just described and then united with the lateral portions. For this purpose, it is especially important to be as economical as possible with the existing soft parts; that is, not to cut away anything that might be used. FIG. 1071. Vivifying FIG. 1072. Wound MAAS'S METHOD FIG. 1073. Suture The median portion must be cut around along the margins of the mucous membrane, so that either a square margin (von Langenbcck] or a round margin (von Esmarcli) of the wound is secured ; to this the fresh lateral FIG. 1074. Vivifying FIG. 1075. Wound HAGEDORN'S METHOD FIG. 1076. Suture margins are sewed in various ways. If the margins are not sufficiently wide, they may be extended by lateral incisions and by sliding together without any tension (Maas, Hagedorn, Figs. 10711076). C. DOUBLE HARELIP AND MAXILLARY FISSURE The protuberance (Biirzel), or premaxillary bone, which is present in these cases, as a rule projects considerably ; it is, therefore, necessary to force it back before the union of the clefts of the lip is made. PLASTIC OPERATIONS OF THE ORAL REGION 549 The procedure of Bardelcben is most suitable for this purpose. He divides the vomer subperiosteally immediately behind the intermaxillary bone, For this purpose, he makes on the lower margin of the vomer and exactly in the median line an incision about I centimeter in length do~wn to the bone, in order not to injure the nasopalatine arteries, which lie on each side (Fig. 1077). Next, with a fine spatula, he detaches on both sides the muco- periosteal covering, pushes the points of bone-cutting forceps perpendicularly upward under the periosteum on both sides of the vomer, and divides it throughout its whole extent. By pressure upon the protuberance (Biirzel) anteriorly, the two bone plates are now made to overlap each other, pressing the projecting premaxillary bone back into the maxillary fissure (Fig. 1078). FIG. 1077 FIG. 1078 BARDELEBEN'S METHOD OF FORCING BACK THE PRE- MAXILLARY BONE FIG. 1079. FORCING BACK PREMAXILLARY BONE BY ELASTIC PRESSURE In order to retain the intermaxillary bone in its new position, the child is supplied with a little cap, to which a rubber band is fastened in such a manner that it comes to lie directly across the upper lip under the nose, keeping back the protuberance without preventing the child from taking nourishment (Fig. 1079). This arrangement is better than the " Thiersck butterfly," in which the rubber band is kept in position by strips of adhesive .plaster, fastened to the cheek, since the adhesive plaster is very apt to produce eczema. When the protuberance is broader than the intermaxillary space, enough of the lateral margins of the premaxillary bone must be cut off with bone- cutting forceps to fit into the cleft ; it is then fastened in position in the cleft with silver wire. If tooth germs are found when incisions are made, they may be scooped out with a small curette. The union of the clefts of the lips may be made at once ; it is better, however, to do this later, when the soft parts are more developed. 550 SURGICAL TECHNIC The simple excision of a cuneiform portion from the vomer together with its coverings, according to Blandin, is less practical because the premaxillary portion remains movable and hemorrhage from the severed nasopalatine arteries may prove very troublesome. The artery, however, may escape injury in the de- tached periosteum if the cuneiform excision is made subperiostcally according to Cscrny. The procedure of Simon does not produce good results. He liberated the lateral flaps by curved incisions around the alae of the nose and by lateral incisions so far that the flaps were sufficiently movable and could be sewed to the vivified lateral margins of the projecting premaxillary bone ; in this case, he did not pay attention at first to the defective appearance of the lip thus formed ; only afterward, when by the stretching of the lateral flaps the premaxillary bone had been replaced backward sufficiently, was the lip restored. FIG. 1080. BLANDIN'S METHOD OF RESECTING CUNEIFORM PORTION FROM THE VOMER FIG. 1081. Vivifying FIG. 1082. Temporary stitch- ing of lateral flaps SIMON'S METHOD FIG. 1083. Suture The simple excision of the whole premaxillary bone is under no circum- stances justifiable, because permanent deformity of the oral region remains as an inevitable consequence. D. SINGLE HARELIP AND CLEFT PALATE In this case, the premaxillary bone projects very obliquely toward the other side and thus forms a great obstacle to the union of the soft parts. In order to make it movable and to displace it backward, a spoon-shaped gouge chisel, with some force, is pushed upward from below, at the place where the intermaxillary bone unites with the alveolar process, through the margin of the jaw, until the intermaxillary portion can be turned around its axis and pressed into the cleft of the jaw, where it is then held in position PLASTIC OPERATIONS OF THE ORAL REGION 551 by the elastic band attached to the cap ; the union of the soft parts can be made immediately or at a subsequent time. For the removal of the projecting premaxillary bone and the lateral deviation of the tip of the nose toward the healthy side, Samter advises section of the cartilaginous septum of the nose with scissors by an incision ascending almost perpendicularly between the upper lip and the premaxillary bone, whereby the tip of the nose is made movable. On the other hand, J. Wolff does not employ any of the methods of reposition, because in his opinion the upper lip subsequently recedes too much. II. CLEFT PALATE This congenital defect very often presents itself in connection with harelip. Formerly surgeons postponed operative procedures until the children were sufficiently advanced in age so that they were intelligent enough to be subjected to the operation. In most cases, however, they desired the opera- tion of their own accord. In modern times very early closure has produced even better results ( Wolff \ because children learn to speak with greater facility. At any rate, it seems to be safer not to operate on children during the first year, but somewhat later, at the age of five to seven years. (Dr. Brophy, of Chicago, operates during early infancy, and his method of operating has yielded admirable results.) In order that the operation may be successful, it is of the greatest importance to make the child practise articulation methodically for some time. The operation is best performed with the head in a dependent position under partial anaesthesia. Adults may be operated upon in a sitting position, without chloroform, in which case they can spit out the blood from time to time, and cleanse the mouth with ice-water. Severe hemorrhages are arrested by temporary tamponade. STAPHYLORRHAPHY (CLOSURE OF CLEFTS OF THE SOFT PALATE BY SUTURE) The operation is performed in the following manner (von Grafe, 1816): The patient sits on a chair opposite the light, wh^st jin. Distant; fixers ^^ the head of the patient steadily ; the operator sits in front of, the patient. The mouth is kept patent either by the oral speculum of Whtteh^atf or by a wedge of india rubber forced between the molar-te&h, whilst the oral 552 SURGICAL TECHNIC opening, as far as possible, is kept widely distended on both sides by von Langenbeck's oral retractors (Fig. 1084, //). a b c d e f f it i FIG. 1084. VON LANGENBECK'S INSTRUMENTS FOR STAPHYLORRHAPHY. a, two-edged pointed knife for vivifying margins in staphylorrhaphy; b, c, pointed and probe-pointed knife for detaching the soft palate from the mucous membrane of the nose and the palate bone; d, curved knife for making lateral incisions; e, f, sickle-shaped knives for dividing palatal muscles; g, sharp hook; A, oral retractor; i, " diadem " The mucous membrane of the whole palate and of the base of the tongue is rendered insensible by brushing it with a ten per cent solution of cocaine. i. Vivifying margins of the cleft. With Frb'hlictis (Fig. 1085, a} long hooked forceps, or a little sharp hook (Fig. 1084, g\ the left apex of the bifid uvula is grasped first, drawn downward, and made tense ; next, near the place where the uvula has been grasped, and a few millimeters distant from its margin, a small pointed knife (Fig. 1084, a}, with the edge turned upward, is pushed through the whole thickness of the uvula, and, with saw- ing movements, carried upward as far as and a little above the angle of the cleft (Fig. 1085). That portion of the margin of the cleft of the uvula first grasped is cut off in a downward direc- FIG. 1085. STAJ.HYI.ORPIUPHY (Closure of tion dosel y alon g the J aw f the for - defts of the soft palate by suture) ceps, and the upper end of the margin PLASTIC OPERATIONS OF THE ORAL REGION 553 thus detached is severed from the angle of the cleft of the hard palate. In the same manner the right margin of the cleft of the soft palate is vivified. 2. In order to relieve the tension of the margins of the wound, there may be made according to Diejfenbacli some incisions throughout the whole thickness of the soft palate. These incisions are made on both sides of the margins, and at some distance from them. It is better, according to Fergusson and von Langenbeck, to divide tJie palatal muscles which ele- vate the soft palate and move the palatopharyngeal pillars of the fau- ces (namely, levator veil palatini et mnsculns pharyngo-palatinus} (Fig. 1086). A pointed knife, curved like a sickle (Fig. 1084, /), is pushed, with its edge directed upward, closely below and a little to the outer side of the hamular process of the sphenoid (Jiamulus pterygoi- dens\ from without inward and from before backward through the soft palate and as far as the posterior pharyngeal wall. Next, with saw- ing movements, the soft palate is divided throughout its whole thick- ness as far as the posterior margin M. Pharyngo-palatinus M. Azygos uvulae M. Levator veli palatini M. Thyreo-palatinus FIG. 1086. MUSCLES OF THE SOFT PALATE a, incision for dividing muscles, taking their origin from the hamular process of the sphenoid; b, in- cision for separating muco-periosteal flaps in uranoplasty of the palate bone (Fig. 1086, a). The trunks of the pterygopalatine artery, which take their course more anteriorly through the pterygopalatine canals, are not injured thereby. Moreover, if the tension of the margins of the wound is not too great, these incisions are superfluous. 3. The suture is best applied with von LangenbecV s needle holder, a curved needle bent at an obtuse angle and provided with a handle (Fig. 1088). Closely behind the point of this needle, a very fine watchspring, bent at its end in the form of a hook, can be projected by making pressure upon a little disk on the handle. The needle is inserted from before backward, close to the vivified margin of the cleft, and when its point becomes visible in the cleft, the disk is pushed forward. By this means, the hook projects from the 554 SURGICAL TECHNIC needle and enters the oral cavity from behind fonvard, through the cleft of the palate. By means of a thread carrier, an instrument which carries the suture (a guiding staff terminating in two angles Fig. 1087), an assistant carries the loop of the suture to the little hook, and as soon as the suture is behind it, the operator allows the watchspring to recede. The hook thus FIG. 1089 APPLYING THE SUTURE LU FIG. 1087 FIG. 1088 VON LANGEN BECK'S NEEDLE HOLDER AND SUTURE CARRIER FIG. 1090 SUTURE COMPLETED FIG. 1091 HAGEDORN'S NEEDLE HOLDER FIG. 1092 BRUNS'S NEEDLE, PROVIDED WITH A HANDLE grasps the suture and draws it forward. The instrument, by a combined posterior and anterior movement, is now drawn, together with the suture, from the margin of the cleft ; and, after the watchspring is pushed forward, the suture is liberated from the hook. The corresponding site on the other margin of the cleft is then perforated with the needle ; and the opposite end of the ligature stretched over the suture carrier is grasped with the little PLASTIC OPERATIONS OF THE ORAL REGION 555 hook, and, on withdrawing the needle, the suture is drawn out of the mouth (Fig. 1089). The suturing is done with silk, commencing from the angle of the cleft and proceeding toward the apex of the uvula. As soon as all the suttires have been inserted in the manner described above, they are tied with a surgeon's knot and a simple knot over it, in the same order in which they were introduced, and are then cut off close to the knot. In order that the numerous threads hanging out of the mouth may not become entangled, it is advisable to fasten them to a piece of pasteboard in notches arranged corre- spondingly. (Clamping the corresponding ends of the sutures with hemo- static forceps is an excellent way of disposing of them until they are tied. The traction made by the weight of the forceps adds materially to the facility in adjusting the wound margins.) Still more convenient is von Langenbeck 's suture holder, a semicircular ring of tin with clamps riveted to them ; this ring, by means of an elastic band, is fastened like a diadem in front of the patient's forehead (Figs. 1084, i, and 1085). For staphylorrhaphy, rarely more than three to six sutures are required. Moreover, the sutures may be applied just as well with other instruments than von Langenbeck' s instrumentarium ; the simpler these instruments are, the better. Instead of the suturing apparatus, Roser and Stromeyer used plain needle holders and straight needles. The needle holder devised by Roux is also very practical. If the operation is performed under anaesthesia with the head in a dependent position, the sutures may be inserted very conven- iently with Hagedorris needles and needle holder for deep sutures the so-called " schiefmaul" (Fig. 1091). A number of complicated suturing devices have been invented ; the best known of all is, perhaps, Passavanfs, which works like the needle of a sewing-machine. Brunss needle, provided with a handle, is essentially similar to von Langenbeck' s (Fig. 1092). URANOPLASTY (CLOSING CLEFTS OF THE HARD PALATE BY BLOODY SUTURE) (Von Langenbeck, 1860) This operation is made almost in the same manner as in closing clefts of the soft palate. i. After similar preparations, the margins of the cleft of the hard palate are vivified with a convex scalpel (Fig. 1084, d\ 556 SURGICAL TECHNIC 2. To relieve tension of the margins of the wound, two lateral incisions ( Warreti) are made through the coverings of the palate (mucous membrane and periosteum) down to the bone, running closely along tJie alveolar arch, beginning posteriorly at the hamular process of the sphenoid and ending anteriorly between the external and the middle incisors, so that anteriorly they form a bridge i centimeter wide adhering to the alveolar process, while posteriorly an uninterrupted connection with the soft palate remains (care should be taken of the palatine artery) (Fig. 1086, b). 3. Starting from these incisions, the operator detaches from the bone the whole covering of the palate and thus forms two mucoperiosteal double pedunculated flaps. For this purpose, he inserts a curved raspatory in the lateral incision, presses it firmly against the bone, and then forces or pushes the periosteum with the mucous membrane from the bone toward the median line. If the detachment has been successful for about i centimeter along the alveolar margin, where the attachments are firmest, the median portions may be more easily separated from the bone by means of curved elevators. The flaps thus formed are approximated in the median line. Next follows : 4. The insertion of the sutures exactly in the same manner as described on page 1 19. In single clefts of the palate that is, when the other half of the palate has united with the vomer often only one lateral incision is required on the corresponding side ; or the mucoperiosteal flap is formed from the side of the vomer facing the margin of the cleft and is united with the vivified margin of the fissure of the hard palate (Lannelongue). If, in a very wide cleft and deep palate, the material for the flaps is com- paratively scanty, the proposition of Brandt is noteworthy; namely, to extract all the molar teeth of the upper jaw a few months before the opera- tion, thereby obtaining a flat palate and more material. But if abundant material is present, so that the flaps can be easily united, von Langenbcck advises to make the lateral incisions in such a manner that a small vascular bridge remains standing in their middle portion (at about c of Fig. 1086) ; thus the flaps are retained in closer apposition with the palate and gravitate less toward the tongue. If, as in most congenital defects, the hard palate, as well as the soft palate, is defective, then, in the above described manner, staphylorrhaphy is com- bined with uranoplasty. The lateral incisions, which begin at the hamular process of the sphenoid, meet with the tension-relieving incision through the velum. In detach- ing the mucoperiosteal flaps, after the posterior margin of the palate bone PLASTIC OPERATIONS OF THE ORAL REGION 55; has been reached and after the velum of the palate has been lifted from it, the posterior mucous covering of the soft palate, facing the nasopharyngeal cavity, is divided throughout its whole breadth and detached from the palate bone. Von Langenbeck has recommended for this purpose a special curved probe-pointed knife (Fig. 1084, b, c). The tension-relieving incisions in the soft palate, however, are usually superfluous, provided the mucous membrane of the nose is sufficiently divided along the posterior margin of the hard FIG. 1093 FIG. 1094 STAPHYLORRHAPHY AND URANOPLASTY IN CONGENITAL CLEFT OF THE PALATE BY SLIDING TWO PEDUNCULATED MUCOPERIOSTEAL FLAPS palate (Kiister}. The detached large flaps, which are freely movable, hang down loosely into the cavity of the mouth (like "hammocks") and almost touch each other in the median line, so that no tension is produced in apply- ing the suture. No dressing is required. The gaping lateral incisions are usually tamponed with iodoform gauze ; but the apposition of the flaps and the healing take place more rapidly without tamponade (Kiister). In the after treatment, during the first few days, the patient has to observe absolute silence and can take only fluid nourishment. Cleansing and irriga- tion of the cavity of the mouth with weak antiseptic solutions should be made especially after each meal. The sutures may be removed gradually from the fifth day on. Any small remaining fistulas heal by applying tincture of cantharides ; larger ones are sutured with silver wire. In spite of a successful operation and subsequent methodical articulation exercises, the voice remains more or less nasal, a defect brought about espe- cially by the fact that the velum of the palate, having become too short, can- not apply itself completely against the posterior pharyngeal wall in order to close the nares. 558 SURGICAL TECHNIC To remedy this evil, Passavant, as a substitute for staphylorraphy, devised the palatopharyngeal suture, by which he sewed the two severed halves of the soft palate to the posterior pharyngeal wall. Schonborn per- formed staphyloplasty devised by Trendelenburg ; he filled the angular cleft of the soft palate with a similarly shaped pedunculated flap from the pharyn- geal wall. By this procedure, of course, a closure of the nares is produced ; but, at the same time, its function is completely abolished ; the patient can breathe only through the mouth, cannot blow his nose, and the olfactory function is destroyed. Von Mosetig-MoorJiof tried to re- move these troubles caused by the complete closure of the nares, by mak- ing an opening in the Jiard palate in front closely behind the incisors, in or- der to remove the nasal twang (fistulous formation on the foramen incisivum). 1095 FIG. 1096 KUSTER'S STAPHVLORRHAPHY B ^ chiselling out a piece as large as a lentil, and by inserting a short metal tube, he succeeded in restoring nasal breathing and partly also the function of the olfactory organ. Kuster proceeds more simply and more success- fully by elongating the uvula which is too short by lateral incisions as in Malgaigne's operation for harelip (Figs. 1095, 1096). The operative closure of palatal fissures, however carefully it may be made, cannot, in many cases, dispense with PALATAL PROTHESES, OBTURATORS, through the practical construction of which an almost normal articulation is effected ; they can even take the place of the operation entirely, provided methodical practice in articulation is continued for a sufficient length of time. The prothetical closure of clefts of the hard palate can be effected with comparative ease by a plate supported by the teeth and covering the hard palate. The older idea of closing such defects by packing with wax, cotton, leather, etc., or by pieces of wood in the form of collar buttons, is not at all practical, since the margins of the opening are more and more forced apart by the foreign body. The principal difficulty arises when it becomes a matter of closing clefts of the soft palate and, at the same time, of obtaining a closure of the nasopharyngeal cavity to improve speech. PLASTIC OPERATIONS OF THE ORAL REGION 559 Especially good results have been obtained in modern times by the systems based upon physiological principles. The construction of the obturator of Siiersen, 1867, is based on the principle of using the superior constrictor muscle of the pharynx as the motive power for closing and opening the passage between the mouth and the nasal cavities. It consists of a ball of vulcanized rubber, the form of which is FIG. 1097 FIG. 1098 SUERSEN'S OBTURATOR, a, side view; b, applied from below determined by a soft model upon which the patient has impressed his con- tracted pharyngeal muscles by speaking aloud. If these muscles are not active, they are retracted ; and sufficient space is made for the passage of air through the nose. But if they are active, they apply themselves against the depression on the ball and close the nares. By means of a small bridge, filling the fissure of the palate itself, the ball is connected with a dental plate, by which it is held in position (Figs. 1097, 1098). The obturator of Kingsley acts by using the levator palati muscle of the soft palate. It consists of an obturator with a movable soft palate, made of rubber resting upon the margins of the fissure. It is lifted toward the pharynx by their action (Fig. 1099). The obturator of Wolff-Schiltsky closes the nasopharyngeal cavity by means of an elastic rubber ball, which in speaking easily adapts itself to the various changes of form of the pharynx. It is kept in position by a rubber plate, is very convenient, and not heavy. At night it is removed, also in the daytime, if the patient does not have to speak. This apparatus 560 SURGICAL TECHNIC can be used as well before as after the operation, since through it the nasal tone is obliterated (Fig. noo). FIG. 1099 KINGSLEY'S OBTURATOR FlG. 1 100. WOLFF-SCHILTSKY'S OBTURATOR FIG. noi. BRANDT'S OBTURATOR Of similar construction is the obturator of Brandt, consisting of an elastic ball of isinglass or of soft rubber. After the air is exhausted from the obturator, it is introduced into the mouth of the patient, and he himself fills it with air by means of a rubber ball. The thin walls of the rubber ball easily adapt themselves to the changes of form of the pharynx caused by muscular action, and allow the air to be pressed to the place where it is needed to effect closure. The prothesis is durable, can easily be replaced, and is adapted to all palate defects (Fig. noi). Concerning the plastic closure of acquired palate defects, see page 589. OPERATIONS INVOLVING THE FACIAL CAVITIES A. IN THE ORBIT . The clearing out of the orbit must be made (evacuatio orbitae) : (a) In very extensive malignant neoplasms of tJ^e skin and the conjunctiva of the eyelids and the lachrymal organs, if the tumor cannot be completely removed without sacrificing the bulb, which is sometimes still healthy. (b) In intra-ocular tumors of the bulb, when they have already perforated Tenon's capsule. 1. After the palpebral fissure has been somewhat enlarged by an incision in an outward direction and after the eyelids have been widely retracted, a long, straight knife is inserted at the conjunctival fold, and, in sawing move- ments, carried closely along the margin of the bone, as much as possible along the fold around the btilb. 2. With a pair of curved scissors, the operator proceeds along the side of the bulb as far as the optic nerve, and divides it with one stroke as near its exit from the skull as possible. 3. The mass of tissue thereby loosened is drawn forward and completely detached with the scissors. 4. For minimizing the hemorrhage, a compression of the cavity for a short time is sufficient. Next, the ophthalmic artery is ligated in the depth ; finally, the remaining fragments of tissue are thoroughly cleared out. If the surgeon intends from the beginning to remove the periosteum, he can facilitate the operation considerably by penetrating at once with the elevator from the orbital margin between the bone and the periosteum, and enucleating almost bloodlessly the entire orbital contents in the form of a cone of tissue surrounded by the periosteum. The large cavity thus produced is tamponed ; the large wound heals with a very disfiguring, deeply contracted cicatrix unless the cavity is covered by a plastic operation. If the eyelids can be saved, they are used for covering the cavity. The vivified margins of the wound are sutured after a careful removal of the conjunctiva and the ciliary margins. 562 SURGICAL TECHNIC But if one lid or even both lids have to be removed, the exposed orbital margin is covered by turning or sliding a flap from the temporal or frontal region (Kiister). In the EXTIRPATION OF THE EYEBALL, that is, the removal of the' eye from its orbit, the eyeball, together with its surrounding tissue and muscles, are excised from the orbit. This operation, however, has been superseded by the more conservative ENUCLEATION OF THE EYEBALL, that is, the removal of the eyeball from Tenon's capsule. This operation is to be made : (a} In cases of intra-ocnlar tumors that have not yet perforated. (fr) In progressive disease of the bulb contents (sympathetic ophthalmia). 1. The conjunctiva is removed after raising a fold of the palpebral liga- ment about 3 millimeters from the right or the left corneal margin. An incision is then made into it with a pair of curved scissors, and it is detached toward the equator. 2. Now, with a strabismus hook, the tendinous insertion of the corre- sponding rectus muscle is searched for and severed from the sclera. By extending the incisions into the conjunctiva upward or downward and always concentrically to the corneal margin, and by grasping and dividing the insertions of the corresponding muscles, a circular conjunc tival wound parallel to the corneal margin is pro- duced, in which the insertions of the four recti muscles are divided. 3. With strong tenaculum for- ceps, the tendinous stump of one of the lateral recti muscles is grasped ; the eyeball is forcibly drawn out and rotated round its axis. Next, with a pair of Cooper s scissors, the operator penetrates downward beside the sclera FIG. 1 102. ENUCLEATION OF THE EYEBALL . . , , ., (Dividing optic nerve) he has gasped, and severs the optic nerve (Fig. 1 102). 4. While the bulb is drawn out still more forcibly, the tendons of the oblique muscles are also divided, and then the enucleated eyeball is removed. OPERATIONS INVOLVING THE FACIAL CAVITIES 563 5. The hemorrhage is not very considerable, and is easily arrested by tamponing the cavity ; the margins of the conjunctiva can be united by a few sutures. Healing takes place in a few days. For removing the disfiguration, the patient is sup- plied with an artificial eye of glass or celluloid, ; which, by means of the preserved stumps of the muscles, can be moved in a satisfactory J PIG. 1103. ARTIFICIAL EYES manner. A still better supporting base for the artificial eye is obtained by the simpler and less dangerous EXENTERATION OF THE BULB (von Grafc\ that is, the evisceration of the eyeball, which at times may be substituted for enucleation, and which, moreover, becomes necessary in serious injuries, in inflammation and degeneration of tJie bulb. For this purpose the corncoscleral junction is punctured with a pointed knife down to the suprachoroidal space. Into the opening a blade of Cooper's scissors is introduced, and the cornea is removed by a circular incision. Then a sharp spoon is introduced close to the inner side of the sclera, and all tlie contents of the bulb are scooped out. After the slight hemorrhage has been arrested, the opening in the sclera is sutured horizontally. A button consisting of sclera thus remains in position, serving as a support for the artificial eye. B. IN THE EAR FOREIGN BODIES IN THE EXTERNAL AUDITORY MEATUS which by their presence cause deafness, pain, and inflammation, must be removed in the gentlest manner possible. By an awkward manipulation, they very easily penetrate still deeper into the meatus, endangering the tympanic membrane. Restless children, who move the head to and fro, and twitch with pain at being touched, should be chloroformed; in the adult, a few drops of cocaine can be instilled. u, 1104. EAR SPEC^ The examination and the removal of the for- eign body must be made very cautiously by means of an ear speculum (Fig. 1 104) and with the best light. 564 SURGICAL TECHNIC In most cases it is sufficient to irrigate the meatus with a small syringe, producing a small but forcible stream. The point of the syringe need not be introduced into the ear for that purpose. The auricle, however, is drawn backward and upward for the purpose of straightening the canal. The jet of water enters at the side of the foreign body, and behind it in front of the tympanic membrane, when it dislodges and ejects the foreign body. The fluid which escapes must be examined for substances removed by the stream. If this procedure does not yield the desired result, either fine instruments are used, which grasp the body anteriorly (forceps bent at an angle, fine dressing forceps), or, still better, such instruments are used as remove it from behind (hooks, ear scoops, wire loops). The latter can quickly be extemporized from a hairpin. Leroy d ' Etiollcs" adjustable curette (Fig. 1105) consists of a small staff, the spoonlike end of which can be placed perpendicularly to its axis by pressure upon a lever on its handle. With this instrument the operator attempts to reach behind the foreign body by keeping close to the lower wall of the meatus, or wherever a small space may be detected with the speculum. If hard bodies fill the whole space, an attempt can be made to bore into them and break them into small pieces. Pearls and other bodies as hard as stone can be extracted by cementing them (brush with molten alum powder, a match with sealing-wax, etc.). Swollen bodies (beans, peas, etc.) are freed from their husks by small scarifications or shrivelled by instilling a few drops of glycerine, which extracts the moisture from them. The operator may try to grasp and extract softer fruits with a very LEROY ^ ne hook. Insects in the meatus are destroyed by introducing a D'ETIOLLES' small compress of cotton dipped in chloroform, after which they ADJUSTABLE are S y rm g ec } ou t; oil poured into the meatus causes them to come quickly to the surface for air. If all these attempts prove fruitless, it is best temporarily to abstain from forcible measures, instil some oil, and advise the patient to lie down on the side of the affected ear. Sometimes the foreign body then falls out. If the object to be removed (as in the majority of cases) consists of hardened cerumen, it is removed, after a sufficient softening with oil or glycerine, in the gentlest manner with a jet of water. If the brownish masses of the same are not lodged too firmly, they can be detached also, as a whole, from the wall of the meatus with small ear scoops. In case of necessity, if nothing else proves effective, the cartilaginous meatus, together with the auricle, must be detached by a curved incision, OPERATIONS INVOLVING THE FACIAL CAVITIES 565 made at its posterior insertion and temporarily turned forward so that the tympanic membrane is exposed (Paul von Aegina). Only in the most serious cases should the mastoid process and the tympanic cavity be opened. C. IN THE NARES INSPECTION OF THE NARES The tip of the nose is turned upward with the finger ; and at the same time, the ala of the nose by backward pressure is distended somewhat. Sometimes it is possible to inspect the lateral walls as far as the turbinated bones and the septum. In most cases, however, special dilating instruments are required for this purpose. The simplest is that of Juracz (Fig. 1106), with which the margin of the nostril can be distended outward, upward, or in any desired direction. In case of necessity, it can be rapidly improvised with a hairpin, bent in the required manner. In FrdnckeTs nasal speculum, the fen- estrated arms can be distended by screw pressure for any distance. They re- main fixed of their own accord to the margins of the nostril. According as its arms are applied to the ala of the nose and the septum, or to both alae, one-half of the nose only or both halves can be rendered accessible for inspection at the same time (Figs. 1107, 1108). Likewise tubular specula (Zattfal's nose fun- nel} have been used for inspection, especially for the lower meatus ; they are similar to the urethroscope illustrated below. For inspecting the nares posteriorly, especially the nasopharyngeal cavity (posterior rhinoscopy), small laryngoscopes are used. The patient sits before the surgeon with his head slightly bent forward ; the base of the tongue is depressed with a tongue depressor (e.g. Turk's, Fig. 1144), which the patient can hold himself; next, the small laryngoscope, with its reflecting surface turned upward, is carefully introduced behind the velum without touching the pharyngeal surface. If this is not successful, or if the uvula is in the way of a free inspection, it can be drawn forward with a blunt hook FIG. 1106 JURACZ'S NASAL SPECULUM FIG. 1107 FIG. 1108 FRANCKEL'S NASAL SPECULUM 566 SURGICAL TECHNIC or a pair of uvula forceps (Franckel, Voltolini}. Under some circumstances the application of cocaine is necessary. Only a skilful practitioner can succeed in informing himself with respect to the changes existing in the nasopharyngeal cavity by making an inspec- tion with the speculum alone. It is, therefore, always advisable to have the inspection followed immediately by palpation with the finger, which is made with the slightly curved forefinger intro- duced behind the soft palate as far as the pos- FIG. 1109. METAL SHEATH FOR ter ior nares (choan3e). The finger is protected PROTECTING FlNGER by a metal s/icaih, either straight or provided with joints (Figs. 1109 and 1113), to prevent the patient from biting it. If it is desirable, however, to gain still more space for palpation and inspection, it is advisable, according to Kocher, to divide the septum longitu- dinally, a little operation in which the operator introduces an open pair of strong scissors as far into the nostrils as possible, and thus divides the cartilaginous septum. Thereby the small arteries of the septum are injured. Two sutures finally unite the wound so exactly that the cicatrix is scarcely noticeable. Still greater access to the nares is created by the operations mentioned on pages 572 and 573. TAMPONING THE NARES This becomes necessary : (a) In violent continuous hemorrJiages from the nose itself, if they cannot be arrested in a simpler manner. (b) Preliminary to some operations on the face and the nose, to prevent the flow of blood through the nose into the air passages while the patient is under anaesthesia. In some cases it is sufficient to pack the nostril from which the blood escapes anteriorly with gauze or cotton, and to compress the alas of the nose externally. If the pieces of gauze or cotton are dipped into a 20% cocaine solution, the hemorrhage is usually arrested. (Antipyrine and tincture of chloride of iron are also excellent styptics.) If the hemorrhage is not arrested thereby, the posterior nares must be tamponed. This is done by means of Bellocqs canula (Figs, mo, 1 1 1 1). The small canula, somewhat curved anteriorly, is introduced through the nostril, along the floor of the nares and toward the pharynx. The watch- spring concealed in the canula is then pushed forward until it slips around OPERATIONS INVOLVING THE FACIAL CAVITIES 567 the soft palate and becomes visible in the mouth ; in the eye, which is at its probe-pointed end, a thread loop has been previously fastened ; into this loop one end of a long silk thread is introduced ; to the middle of this thread the tampon for closing the posterior naris (choana) is fastened ; next, the canula, together with the silk thread, is withdrawn from the nostril. The tampon slips behind the soft palate, and, guided by the left forefinger, which has been introduced, is brought into the choana from behind ; by pulling the thread hanging from the nostril, it is still more firmly drawn into the same. The other end of the silk thread hanging from the mouth serves for withdrawing the tampon, and during its position is fastened to the ear or the cheek with adhesive plaster. FIG. 1 1 10 FIG. mi BELLOCQ'S CANULA IN POSITION If, in addition, the nostril is tamponed anteriorly, the entrance and the exit of the bleeding side of the nose are occluded, and the hemorrhage is arrested. The tampon may be removed after about two days ; previously it is loosened by injecting lukewarm disinfecting solutions. In the absence of a Bellocq's canula^ an elastic catheter can be used, or a catgut string or a thread thoroughly waxed. If the site of the hemorrhage 568 SURGICAL TECHNIC is known, it can be arrested still more rapidly by pressing a compress of absorbent cotton with the dressing forceps upon the bleeding point for several minutes, and by leaving it in position for 24 hours (Hartmami). Macnamara packed the whole nose anteriorly with strips of linen (handker- chief) ; but iodoform gauze is better. A strip a finger's breadth wide and half a meter long is wrapped around a probe to produce a thick plug. This is pushed through the nostril as far as the posterior naris. The probe is then withdrawn, and the remainder of the strip, which hangs out of the nostril, is packed into the nares. Of the many remedies for violent nasal hemorrhage may be mentioned : Deep breathing, ice water, vinegar, alum, cocaine, tannin, ferric chloride cot- ton, ferripyrine, Penghawar-Yambee, etc. ; revulsion by hot foot baths and general baths, sinapisms, venesection, cauterization, enemas, elevating the arms, compression of the carotid artery and jugular vein, compression of the bleeding site with the finger, compression of the alae by a rubber ball, by a rhineurynter {Kuchenmeister, Engliscti). REMOVAL OF NASAL AND NASOPHARYNGEAL POLYPI For the removal of mucoid polypi of the nose, a pair of rather strong well- grasping straight forceps, with jaws somewhat excavated, is used (polypus forceps, Fig. 1112). FIG. 1 1 12. POLYPUS FORCEPS The patient sits on a chair with his head bent slightly forward and held by an assistant from behind ; on the left side of the patient a basin with carbolic solution is placed. After the nares have been made anaesthetic, if necessary, by brushing them with a 5%-io% solution of cocaine, the left fore- finger is introduced through the mouth behind the soft palate, and the point of the finger is curved toward the posterior nares ; next, the pair of forceps is quickly introduced anteriorly thro'ugh the nostril and on the floor of the OPERATIONS INVOLVING THE FACIAL CAVITIES 569 FIG. 1113. REMOVING POLYPUS nares along the septum pushed forward toward the point of the finger ; as soon as the pair of forceps is opened, the polypus falls between its blades ; the forceps are then closed, rotated a little around their axis, and withdrawn with a jerk. The grasped portions of the poly- pus are quickly dropped into the water by shaking movements from the open for- ceps ; the pair of forceps is immediately introduced again in the same manner, and the operator attempts to grasp any remain- ing portions and to remove them, while the point of the finger, placed in the poste- rior naris, presses forward toward the for- ceps any polypi which may have escaped the first seizure. Polypi still remaining can be projected forward by a forcible blowing of the nose, on the part of the patient. The surgeon continues this procedure with the greatest rapidity possible, palpating the whole nares in a systematic manner from below upward, and removing portions of the polypus until the forceps fail to grasp any more. The more radically the surgeon proceeds, the quicker and the more thorough is the success. If portions of the margins of the turbinated bones are broken off, not much harm is done ; Pirogoff, in cases of nasal polypi, went so far as to break out "a priori" all the turbinated bones, in order to remove the soil for any subsequent recurrence. If the nose is filled with very many small polypi, little is accomplished with the forceps, and it is better to scrape the whole mucous membrane of the nares with the sJiarp spoon. The hemorrhage, at first rather violent, is arrested almost without excep- tion, after some time, by irrigation with ice water. In more obstinate and more violent hemorrhages, solutions of tannic acid or ergotine-glycerine alcohol and other styptics should be used. In more urgent cases, the nose must be tamponed (see page 566). This procedure produces just as quick and as safe results as ligating the several pedicles of the polypus by means of the galvanc-cautery loop or the so-called cold ^vire snare (Figs. 1114, 1 115), which can be performed only by experts. The latter is especially adapted to smaller polypi lodged in the upper half of the nasal cavity ; although the operation is more gentle, it is 570 SURGICAL TECHNIC more tedious. To prevent recurrence the whole mucous membrane can be cauterized superficially with the galvano-cautery. In solitary, large nasopharyngeal polypi, with a thin pedicle, the sur- geon can also remove tlicm by ligation. The presence of putrefying FIG. 1114. WiLDE-Du- PLAY'S COLD WIRE SNARE FIG. 1115. LEVRET'S WIRE SNARE FIG. 1116. REMOVING POLYPUS WITH DOUBLE CANULA substances and the remaining of the stump of the pedicle, from which recurrence can result, constitute the disadvantages of this method, which von Langenbeck, with two silk ligatures (Ricord), performed in the following manner: 1. An elastic catheter, transversely perforated, is introduced into the pharynx through the nostril, and with the left forefinger carried into the mouth so far that the first folded thread forming an even loop can be inserted with its open end into the fenestra of the catheter. 2. The catheter is withdrawn, and with it the loop, guided by the left forefinger, slips over the body of the polypus so as to be still visible in the mouth while the free ends hang out of the nostril. OPERATIONS INVOLVING THE FACIAL CAVITIES 571 3. Into the catheter, which is again introduced, the second loop with the closed end (in the form of a loop) is inserted and carried back through the nose so that the free ends come to lie in the mouth, while the loop lies in front of the nostril. 4. Next, the free ends, both in the mouth and in front of the nostril, are placed through the loop; and while the loop in the mouth is carried with the finger as high as possible and around the polypus, both ends are drawn tight (Fig. 1117). 5. After the pedicle has been li- gated in this manner, the polypus is cut off close to the ligature. The ligature can be removed safely after two or * VIG. 1117. VON LANGENBECK'S METHOD OF three days. REMOVING POLYPUS BY LIGATION REMOVAL OF FIBROUS POLYPI (NASOPHARYNGEAL POLYPI) is a much more difficult procedure. Mostly with very broad pedicles, they take their origin from the periosteum or the bone of the base of the skull itself, and their favorite site is in the posterior parts of the nose and in the pharynx. They can project anteriorly into tJie nares, laterally behind the upper jaw into the pterygopalatine fossa, tJie temporal fossa, and superiorly through the sphenoid bone into the cavity of the cranium. These neoplasms must be extirpated as thoroughly as possible ; to render them accessible, preliminary operations varying according to their site and size are required. These preliminary operations are intended to secure as free an access as possible to the nares, so that the posterior portions can also be inspected and palpated with facility and rendered accessible for the required treatment. Hence, they are employed not only for extirpating tumors, but also in necro- sis, caries, ulcers (lupus), and firmly impacted foreign bodies. DIVISION OF THE NOSE IN THE MEDIAN LINE (Dieffenback, Konig} suffices under certain circumstances, and is quickly performed, if necessary, without ansesthesia. A curved pointed knife is introduced through the nostril of the side involved as high as possible and as far as the nasal bone 572 SURGICAL TECHNIC along the septum ; the bridge of the nose close to the median line is then divided longitudinally from within outward (Fig. 1 1 18). If this incision does not afford sufficient space, the nasal process may, in addition, be resected ostcoplastically from the wound ; and, if necessary, the up- per lip may also be divided ; by dissecting it back, the access to the pyriform aperture can be en- larged (Jordan, Baracz}. Kb'nig removes the polypi by vigorous FIG. 1118. KONIG AND BARACZ'S METHOD OF , 1M .. .., , DIVIDING THE NOSE IN THE MEDIAN LINE leverlike traction with large, some- what dull, spoons. The line of incision, afterward carefully sutured, heals with a scar scarcely visible. RESECTION OF THE NASAL PROCESS OF THE UPPER JAW (von Langenbeck, 1854) i. Curved external incision from the internal lower margin of the eye- brow to the bridge of the nose and thence to the process of the ala of the nose in the nasolabial fold (Fig. 1119). FIG. 1119 FIG. 1 1 20 RESECTION OF THE NASAL PROCESS OF THE UPPER JAW (von Langenbeck) a, external incision; b, saw incisions 2. The flap is dissected off toward the eye. 3. The nasal cartilage is detached from its union with the bone; and into this opening, closely below the insertion of the lower turbinated bone, a thin, short, but strong metacarpal saw is introduced. With this, the nasal process is sawed through outward and upward as far as the lachrymal sac ; then straight upward as far as the nose, and, finally, downward, the nasal bone itself or its connection with the nasal process is divided longitudinally. OPERATIONS INVOLVING THE FACIAL CAVITIES 573 The removal of this detached bone plate, consisting of the nasal process of the upper jaw, a piece of the lachrymal bone, the nasal bone, and the inferior turbinated bone, produces sufficient space for inspecting the whole interior of the nares, the posterior nares, and the inferior surface of the body of the sphenoid. Finally, the external wound in its whole extent is united by suture. Although, as a rule, no change in form of the face results from the removal of the portion of bone, von Langenbeck himself subsequently (1859) made a temporary (osteoplastic) resection, in order not to remove the nasal process entirely. This operation he made in the following manner: He sawed through the bone covered by the periosteum, only from below, as far as the lachrymal bone and above in its connection with the nasal bone (Fig. 1 120); then, by means of an elevator introduced into the lower incision made by the saw, he lifted up the bone plate whereby the thin bone lamella of the region of the lachrymal bone was fractured. The portion thus turned up like a cover, at the end of the operation, he turned back into its .former position, in which position it again united. In many cases the TEMPORARY DETACHMENT OF THE NOSE (Rouge} may be advantageous, in which case the soft parts of the nose and the upper lip are displaced upward. Owing to the somewhat severe hemor- rhage which attends this operation, the patient is placed either in a lateral position with the head turned toward the right or in a depend- ent position, in which case, though the hemorrhage is even more violent, the blood is less liable to enter the air passages and cannot be aspired. i. The upper lip, forcibly stretched, is raised upward at both angles of the mouth by the operator and an assistant. After the mucous membrane at the duplicature has been divided doivn to tJie bone by an incision commencing above the first left molar and ending above the right molar, the soft parts are detached from the latter in an upper FlG . II2I . TEMPORARY DETACHMENT direction as far as the anterior nasal spine. OF THE NOSE (Rouge's Method) 574 SURGICAL TECHNIC 2. From this, the cartilaginous septum is detached ; then, from the upper jaw, the alar cartilages are divided with scissors by an incision on each side. The lip and the nose, then completely detached, are turned up toward the fore- head ; if the bony septum is in the way, it is also divided with bone-cutting forceps. It is then easy to remove all diseased parts from the nose ; likewise, deeply seated ulcers and granulations become visible and can be subjected to direct treatment. At the end of the operation, the detached nose is replaced into its normal position like a curtain. Union by sutures is not necessary. No disfiguration follows this operation. The field of operation becomes very accessible by turning up the whole nose together with the en- tire nasal skeleton. For this purpose the latter must be divided from its surroundings with a pointed saw. FIG. 1 122. OLLIER'S TEM- With a knife, Lawrence circumscribed the nose later- PORARY RESECTION OF aU and be] and turned it u p war d. A better pro- THE NOSE cedure is that of Oilier, who, by a skin incision in the form of a horseshoe, detached the lateral margins and the root of the nose ; next he sawed through the bony skeleton of the nose on the same level, and turned the nose downward. The vascular bridges then con- sist of the septum and the alae of the nose (Fig. 1 122). A still better prospect with respect to nutrition is offered by the lateral displacement of the external nose (CJiassaignac- Bruns}. i. The external incision en- circles the nose on three sides, and penetrates everywhere down to the bone. It begins beneath one alar margin, and extends horizontally through the upper lip as far as the region of the first molar of the other side ; next, the skin of the root of the nose, above the nasofrontal suture, is detached by a transverse incision which, on each side, remains FIG. 1123 FIG. 1124 VON BRUNS'S TEMPORARY RESECTION OF THE NOSE a, external incision; b, nose turned up OPERATIONS INVOLVING THE FACIAL CAVITIES 575 about i centimeter distant from the inner angle of the eye. The terminal points of these two incisions are connected on one side by an oblique incision extending exteriorly and inferiorly along the side of the nose (Fig. 1123). 2. With the metacarpal saw the anterior nasal spine is detached hori- zontally; and with the bone-cutting forceps the bony septum is divided in the same direction for some distance. 3. The metacarpal saw is applied with its point in the nares at the lower margin of the pyriform aperture, and the nasal process of the superior maxil- lary bone, together with the anterior end of the inferior turbinated bone, is sawed through, corresponding to the skin incision, as far as the nasal bone. 4. Both nasal bones are sawed off transversely in the nasofrontal suture ; and the septum, if necessary, is divided, with bone-cutting forceps, partly from the inferior and partly from the superior transverse incisions with two incisions meeting posteriorly in the form of an obtuse angle. 5. By introducing an elevator into the upper end of the lateral incision, the union of the nasal bone with the upper jaw of the other side is infracted, and the whole nose is then turned over toward the opposite cheek. A very satisfactory view of the interior of the nose as far as the posterior pharyngeal wall is then obtained. If it is desirable to maintain those parts for some time accessible for the eye and the finger, the nose may remain in this dislocated positioner several weeks (without injury to its nutrition). At the end of this period, of course, a superficial vivification of the margins of the wound will be required on account of their being then in a state of cicatrization. If it is desirable to turn over only one-half of the nares, the transverse skin incisions do not extend beyond the median line. The sawing of the upper jaw is done as described above. The nasofrontal suture is sawed through as far as the median line, and the union of the two nasal bones is infracted in the median line by the use of the elevator. TEMPORARY RESECTION OF THE NOSE according- to Gussenbauer (Fig. 1125), for exposing the frontal sinuses, the ethmoid sinuses, the sphenoidal sinuses, and the orbits : 1. Tamponing the nares. 2. External incision down to the bone from the inner half of the eyebrow along the nasal process of the frontal bone and the superior maxilla down- ward ; next, transversely across the bridge of the nose corresponding to the borders of the nasal bones, and upward to the inner half of the other eyebrow. 576 SURGICAL TECHNIC 3. The nasal process of the upper jaw as far as the inferior edge of the orbit ; the two nasal processes of the frontal bone, in connection with the lachrymal bone ; the orbital plate of the ethmoid bone ; and finally, the connection of the perpen- dicular plate of the ethmoid bone and of the palate bone (the vomer), are all divided with the chisel. 4. The flap of bone and soft parts is turned in an upward direction, the tumor is removed, the cavity of the wound is packed with iodof orm gauze, and the latter brought out of the nostrils ; the flap FIG. 1125. GUSSENBAUER'S j s turned down again, and sutured in its whole TEMPORARY RESECTION OF THE NOSE extent. When the tumors are attacJied to the wall of tlic pharynx or the cervical vertebra, it may be easier, under certain circum- stances, to reach the root of the polypus from the pharynx instead of from the nose. Manne, and afterward Dieffenbach, divided longitudinally the whole soft palate, together with the uvula, in the median line ; the two halves were then drawn apart and subsequently closed again by staphylorrhaphy. Maison- neuve used the same incision, but left the uvula intact (bontonniere palatine}, whereby the subsequent reunion of the soft parts was more easily obtained. Bb'ckel divided the soft palate from the hard palate by a transverse incision. Ne"laton removed, from a T-incision, the posterior part of the hard palate ; and Gussenbauer divided the mucoperiosteal membrane (" Uberzug") of the palate in the median line, detached it toward both sides, and chiselled open the bony roof of the palate. By this procedure the sphenoidal sinuses can also be successfully exposed. C/ialot and Habs chiselled from the hard palate a kind of artificial fissure palate, by dividing, with the wire saw, the vomer from an incision similar to that of Fig. 1 121. From the cavities of the rapidly extracted canine teeth they chiselled off the hard palate along the alveolar margin as far as the insertion of the soft palate ; next they divided the alveolar process between the alveoli of the canine teeth and the nares, and then turned down the middle portion, adhering only to the soft palate like a trap-door. PartscJis procedure is easier, and without the considerable hemorrhage occurring during this operation. From a similar incision of the soft parts extending from the second molar tooth of one side to the second molar tooth of the other, the soft parts are drawn forcibly upward, the bone is rapidly exposed with the elevator, and with a broad chisel the upper jaw above the roots of OPERATIONS INVOLVING THE FACIAL CAVITIES 577 the teeth, the mucous membrane of the base of the nose, and the mucous membrane of the antrum of Highmore are divided horizontally as far as the tuberosity of the superior maxilla until the whole palate under moderate pressure can be turned downward like a visor. After the extirpation of the tumor, the temporarily detached palate is replaced in its former position, and fastened by superficial sutures. The reunion takes place very rapidly, beyond expectation, and without any disturbance of function. For exposing the base of the skull, according to Kocher, by turning up the lower half of the two upper jaws, see page 484. Finally, those tumors which spring from the pterygoid processes of tJie sphenoid bone have their seat in the pterygopalatine fossa behind the upper jaw, and which grow into the temporal fossa (retromaxillary tumors, von Langenbeck), cannot be extirpated either from the mouth or from the nose, and must be exposed by the osteoplastic resection of the upper jaw (see p. 474). EXTIRPATION OF NASOPHARYNGEAL POLYPI, to which access must be obtained in some way or other, is made according to the nature of the tumor present and its degree of vascularity. Hard tumors are removed with knife and scissors ; the base is thoroughly cleared away with the sharp spoon and the raspatory. Sometimes it is possible with these instruments to free the tumor " in toto " from its attachment. If violent hemorrhage occurs, and if the tumor is soft in structure, the thermo- cautcry must be employed, with which even the last vestiges of the stump of the tumor can be destroyed. These tumors have also been destroyed by electrolytic treatment, and in some cases with a permanent result. Whether the painting of the stump with Lngofs solution protects from recurrence is questionable ; on the other hand, with advancing age, these tumors often decrease or disappear of their own accord (Gosselin, Hueter). ADENOID VEGETATIONS IN THE NASOPHARYNGEAL CAVITY (Meyer) Their presence is at once recognized from the expression of the face and the manner of speech of the patients (children). But concerning their extent and nature reliable information is obtained only by the finger, introduced behind the soft palate for palpating the pharyngeal space. The granulations can be easily removed by scraping. The procedure is as follows : After the operator \\v& pointed, to about a right angle, the nails of both his forefingers (the nails, of course, must be somewhat long), the child is placed on a chair, to which his arms and his legs are strapped. The 2P 578 SURGICAL TECHNIC FIG. 1126. POINTED IN- STRUMENT FOR SUP- PLYING FINGERNAIL surgeon, having under some pretext persuaded the unsuspecting child to open his mouth, quickly introduces his finger protected by a metal sheath. He now has free play. Standing at the side and behind the patient's head, he first scrapes with the forefinger, which has been introduced behind the soft palate, the corresponding side of the pharyngeal space ; next, he removes the finger from the sheath, inserts the other forefinger, and performs the same operation on the other side until smooth walls can be felt everywhere. Above all, it is necessary to proceed as radically as possible during the first operation ; for, a second time, it might not be easy to persuade the child to consent to the operation. During the operation the hemorrhage, though violent, is never alarming, and is arrested by cold nasal douches. The patient is confined to his room and his bed during the next few days, and receives cold fluid nourishment, such as milk and eggs. If the operator's nail is not long or hard enough, instruments can be substituted (e.g. Fig. 1126), in which case, of course, the control by the sense of touch is not by any means as perfect. This operation loses much of its barbarous character if the patient is partially anaesthetized, so that, when requested, he coughs out the blood flowing into the larynx ; the use of instruments is preferred by some surgeons. For the removal of these vegetations, Meyer invented his circular knife (Fig. 1127, a). Lange and many others modified it, and now there are knives shaped even like a plane. Meyer 's instrument is introduced into the pharyn- geal space from the lower meatus of the nose ; the instruments bent at an an- gle are introduced from the mouth. In all cases, the fin- ger introduced by the side of the instrument should serve ^ a guide. At the present FORCEPS time, the favorite circular FIG. 1127. CIRCULAR KNIVES According to a, Meyer; b, Schoelz; f, Lange; d, Gottstein FIG. 1128 OPERATIONS INVOLVING THE FACIAL CAVITIES 579 knife is probably Gottsteiris (Fig. 1127, d\ a curette bent on the flat. It is introduced from the mouth high into the pharyngeal space, and then by vigorous downward pressure the masses are scraped away, downward if possible, in a connected piece, and the scraping is continued until the pal- pating finger cannot detect any more diseased tissue. FIG. 1129. BROWN'S PHARYNGEAL SYRINQE Granulations have also been crushed with forceps (Fig. 1 128), or destroyed by the galvano-cautery. Douching the nose with either the irrigator or the pharyngeal syringe {Brown, Fig. 1129) may be used during the after treatment. CONTRACTION OF THE NOSTRILS, originating from plastic operations or from ulcerations, can be removed permanently only by lining the enlarging incisions with skin. The bloodless dilatation with dilating bougies is tedious ; tubes must be worn for years. If the nostril has contracted to a small fistulous opening, the skin dupli- cation may be reached, to some extent, by an oblique T incision (DieffenbacJi). The upper line of the T incision extends along the margin of the ala, while its base comes to lie in the corner between the septum and the upper lip. The flaps thus formed are pushed into the nostril by a tube. FIG. 1130 FIG. 1131 DILATING CONTRACTED NOSTRILS Or the stricture is divided longitudinally in an upward and downward direction, corresponding to the shape of a normal nostril. At the middle of the septum, a tension-relieving incision is made, and the median flap, made more movable thereby, is stitched on each side to the mucous membrane (Figs. 1130, 1131). A small flap (Roser) (see page 527) may also be formed at the extremity of the dilating incision. In serious cases, partial rhinoplasty must be made. 58o SURGICAL TECHNIC IN DEVIATIONS (SCOLIOSIS) OF THE SEPTUM OF THE NOSE, originating from injuries and from abnormal longitudinal growth of the same (combined with catarrh of the nose, or producing it), various methods have been tried to render the meatus (contracted by the convex side of the septum) again free for the entrance of air. Blandin, Rupprecht, and Roser made an opening in the septum for the admission of air into the other healthy meatus. Blandin perforated the curved cartilage with an awl, while Rupprecht and Roser punched a hole in the septum as large as a lentil with special punch or perforating forceps similar to a conductor's punch. Others resected the projecting cartilaginous portion, but avoided per- foration. Dieffenbach excised a correspondingly large oval piece. CJiassaignac and Roser proceeded in a similar manner. The most conservative procedure is the SUBPERICHONDRIAL RESECTION OF THE SEPTUM (Petersen) Under anaesthesia, with the nostril held widely open, with a narrow- bladed knife, a I l-shaped flap with its base upward is circumscribed in the mucoperichondtial covering on the con- vex side. This is dissected back carefully in an upward direction with a fine ele- vator, and the cartilage now exposed, corre- sponding to the lower incision, is divided transversely with the knife. From this in- cision, always from the same nostril, the operator penetrates with the elevator be- tween the cartilage and the perichondrium on the other side, and detaches the same sufficiently. The portion of cartilage, now freed on both sides, is cut out with the scis- sors in the form of a Gothic window, ). The mucoperichondrial flap is turned doivn and fastened by two sutures to the angles of the wound. This method is especially adapted to deviations of the anterior portion of the septum, since the small size of the field of operation, as well as the rather considerable hemorrhage, makes operating at a greater depth impossible, since the surgeon cannot see what FIG. 1132 ADAMS' RHINO- PLASTOS JURACZ'S FORCEPS OPERATIONS INVOLVING THE FACIAL CAVITIES 5 8l he is doing. The bloodless straightening of the curved septum has also been attempted with a special kind of forceps. Adams, with his " rhinoplastos " (Fig. 1132), straightened the septum by pressure, and subsequently inserted for three to five days a compressor consisting of two parallel plates. Jnracz improved the forceps in this man- ner : the anterior part holding the plates can be removed after reposition has been produced by closure of the blades, and remains in position as a compressor (Fig. 1133). D. IN THE ORAL CAVITY FOR INSPECTING THE CAVITY OF THE MOUTH a number of instruments are used, the so-called oral specula. Separate the lips with the fingers, or use the common lip-holder of metal or wood {Liter), or blunt retractors {von Langetibeck), or similar instruments. The rows of teeth, especially when they are tightly compressed, either intentionally or in anaesthesia, are forced apart by wedge- shaped instruments (dilators). The simplest of these is a wedge of soft wood, which is forced laterally between the molar teeth. It has a coarse screw-thread, which is very prac- tical (Fig. 1 1 34). The introduction of this screw wedge succeeds more gently and easily by boring movements. Heisters month gag consists of two steel arms tapering anteriorly, which are forced apart by screw power (Fig. 1136). Of similar construction is Konig-Roser's month gag. Its arms (bent at an angle and lined at their ends with plates of lead) are forced apart by compressing the handle. When in posi- tion and opened, the dilated mouth can be kept o^nforany length of time. When, after the patient opens his mouth of his own accord, it is necessary to keep it open for some time, the operator simply inserts between the rows of molar teeth a cork or Pitha "s month zvedge, a piece of caoutchouc doubly grooved and fastened to a thread. Weinlechner* s gag is of similar construction, but it is provided with a handle. FIG. 1134 SCREW WEDGE GAG 582 SURGICAL TECHNIC FIG. 1137. PITHA'S MOUTH WEDGE Excellent for inspecting the mouth and for keeping it open during some operations (e.g. on the tongue, palate) is White/lead's oral speculum, the two arms of which are kept apart by adjustable ser- rated stops or bars ; the part intended for the lower jaw has also an adjustable tongue plate. (Figs. 1138, 1139 show the instrument closed, opened, and applied.) The English speculum is built on a similar plan (Fig. 1140), the arms of which can be screwed apart by a spiral coil ( TiUmans). B runs' s automatic mouth gag consists of two adjustable furrowed plates, which come to lie upon the rows of teeth, and which, by means of curved arms provided with a spring, constantly provide an elas- tic (springy) movement. Its closing is prevented by a stop, which can be re- moved by the pressure of the finger. FIG. 1136. HEISTER'S . , MOUTH GAG * n some patients the tongue curves considerably, and, on account of this great curvature, as well as on account of its movements, prevents a satis- factory inspection of the pharynx. The tongue is depressed with the finger, or better with a spatula or the handle of a spoon. The angular spatula (Fig. 1 142), the arms of which can be opened only at a right angle, is more convenient. The hand holding it does not shade the entrance to the oral cavity. Turck's tongue spatula must be mentioned here. Its broad plate is affixed laterally at an angle to the handle. It was mentioned in the discussion of posterior rhinoscopy for depressing the base of the tongue. In employing tongue depressors it is of especial importance not to introduce them deeply enough to touch the pillars of the pharynx and the base of the tongue, because choking sensations are produced thereby. Patients, especially children, who offer resistance, are forced to open the mouth by introducing the finger between the rows of teeth, and by folding at the same time the margin of the lower lip between them (Hueter), or by introducing a gag in the aperture behind the molar teeth. Small children open the mouth at once if the surgeon closes the nose with his fingers. Moreover, in most cases, success is obtained more rapidly by kindness than by force. OPERATIONS INVOLVING THE FACIAL CAVITIES 583 FIG. 1138. Front view when applied FIG. 1142. TONGUE SPATULA FIG. 1139. WHITEHEAD'S ORAL SPECULUM Closed and viewed from above FlG. 1140. TlLLMANNS'S ENGLISH SPECULUM FIG. 1141. BRUNS'S AUTOMATIC MOUTH GAG FIG. 1143. TURCK'S TONGUE SPATULA FIG. 1144. TONGUE SPATULA OF GLASS 58 4 SURGICAL TECHNIC For the prevention of the entrance of blood into the trachea and the oesophagus during operations in and on the cavity of the mouth, Rose recom- mends that the head of the patient (lying flat on his back) should hang downward over the end of the oper- ating table (hanging head, Fig. 1145). The blood flows then through the pos- terior nares and out from the nos- trils. The hemorrhage, however, on account of the venous stasis in the blood vessels of the neck, is consider- ably greater. It is better, according to Ried, to raise the whole operating table at its lower end so that the whole body is in the inclined position, the head being FIG. 1145. ROSE'S OPERATION (Head of patient hanging downward) most dependent. EXTRACTION OF TEETH Diseased teeth are extracted : {a) When the/^zVz and disease (caries) has progressed so far (pzilpitis) that by cauterization and by suitable filling of the cavity {plombage) no permanent cure can be expected. (&) When they are the cause of alveolar abscesses (periostitis of the roots) andfistu/as of tJie gums. Sound teeth are extracted only : (a) When they are the probable cause of violent neuralgia. (b) For faulty position when they interfere with the eruption of other teeth and with speech. (c) Preliminary to some operations. A tooth can be extracted from its socket (alveolus), in which its roots are firmly impacted, only after it has been somewhat separated from its alveolar attachments or walls. "Eat forcing apart tJie alveolar walls, formerly the tooth was inclined laterally, whereby mostly that side of the alveolus toward which the tooth was turned broke off. The instruments used for this purpose operated largely by leverage : the tooth key, or key of Garcngeot, the " Uberwurf," the pelican, and the elevator, etc. (Figs. 1146, 1147). OPERATIONS INVOLVING THE FACIAL CAVITIES 585 Tooth forceps, acting more conservatively, are the instruments now generally used. They grasp the neck of the tooth; and, since this is variously shaped in the different teeth, owing to the shape and arrangement of the roots, different forceps are used. FIG. 1147. LECLUSE'S ELEVATOR FIG. 1148 ALVEOLI OF THE UPPER JAW I, 2, incisors FIG. 1149 SKELETON OF THE JAW WITH EXPOSED TOOTH ROOTS 3, canine tooth; 4, 5, bicuspids 6, 7, molars FIG. 1150 ALVEOLI OF THE LOWER JAW 8, wisdom tooth The roots of the several teeth are arranged as follows : In the upper jaw : The incisor teeth and the canine teeth have necks nearly round ; they are grasped with straight forceps with smooth margins (Fig. 1151,4 586 SURGICAL TECHNIC The bicuspids have two roots (often grown together) outside and inside respectively (labial and lingual). For their somewhat rectangular necks, forceps have been made with smooth blades but bent a little on the flat (Fig. 1151, b). The molars have three roots, two externally (labial) and one internally (lingual). The forceps which fit the neck of these teeth (trefoiled) have on their external side two facets, separated by a projection ; on the inner side, they are excavated ; they are bent on the flat. Forceps specially adapted for the right and the left side are used (Fig. 1151, a and b). a b c d FIG. 1151. FORCEPS FOR TEETH IN THE UPPER JAW a, right molars; b, bicuspids; c, incisors and canine teeth; d, left molars FIG. 1152. FORCEPS FOR TF.KTH IN THE LOWER JAW a, right molars ; b, molars of both sides; c, left molars FIG. 1153 UNIVERSAL FORCEPS For the wisdom teeth, the roots of which are almost grown together ( cone-shaped), forceps with smooth blades but well curved are adapted. In the lower jaw : Incisor tcctli and canine teetJi have round necks, as in the upper jaw; hence, the same forceps are used, only they are bent more conveniently on the edge. The same holds good for the bicuspids. All molars, however, have two roots which lie in the axis of the jaw from before backward (proximal and distal); the forceps fitted for the neck of OPERATIONS INVOLVING THE FACIAL CAVITIES 587 these teeth have on both blades two grooves separated by a spine, and are well curved on the edge and on the flat. With them, the operator can extract wisdom teeth also (Fig. 1152). In order not to necessitate too large a number of forceps, the so-called universal forceps (en-tout-cas} have been invented, the smooth margins and slight curve of which are approximately adapted to every neck of the different teeth (Fig. 1153). EXTRACTION The patient is placed on a chair, firmly holding the seat with his hands ; if the operator proceeds rapidly and energetically, it is hardly necessary to have the head held by an assistant (in the upper jaw, slightly bent backward, in the lower jaw, slightly bent forward). Nevertheless, if it appears necessary, the operator takes his position at the right side of the patient, places his left arm around his head, while the fingers of his left hand are free for opening the mouth, lips, etc. With his right hand he manipulates the forceps. In this position, most teeth can be extracted. But if it is more convenient, and if the forceps can be applied more advantageously, the operator takes his position in front, and at the patient's left side, in which case, however, the holding of the head must be omitted (this, moreover, can be prevented "a priori" from being drawn back by pressing the head against the wall, the back of the chair, etc.). The forceps are grasped with the whole hand. The thumb is applied on both blades near the lock ; the fourth and fifth fingers enter between the arms of the forceps and force them apart, guarding thus against a too forcible pressure of the forceps. The open forceps are introduced over the crown of the tooth, and are applied close to the tooth under the gums (which are pushed aside by the sharp margins of the forceps). They are inserted as far as the neck of the tooth and closed. By a few lateral movements outward and inward, the alveolar walls are somewhat freed from the tooth, and the tooth is finally extracted vertically ; the operation occupies from two to three seconds. With some precaution, after the forceps have been correctly applied, the danger of the tooth's breaking off is almost obviated ; for the tooth some- times slips of its own accord into the opening of the forceps, when its blades are closed, owing to their tapering shape. But if the forceps are closed above the neck of the tooth, they operate like a pair of nippers, and easily break off the crown. Hence, it is above all important to insert the forceps as deeply as possible under the gums. The forceps must not be closed with 588 SURGICAL TECHNIC too great force, else the tooth likewise breaks off; the amount of strength to be used to make the tooth follow the long arm of the forceps must be acquired by practice. In teeth with one root, in addition to lateral movements, also a slight rotation around the axis may be made ; for teeth with several roots, this pro- cedure, of course, is not adapted. Anaesthesia can generally be dispensed with in a rapid skilful extraction, else a small cotton compress dipped in a 5% to 10% solution of cocaine may be applied like a cap over the tooth and the margins of the gums ; or an injection into the gums may be made with the same solution. A 5% eucaine solution produces the same effect. Moreover, SchleicJis infiltration and ethyl-chloride are to be recommended. If, in very difficult extractions, especially of several teeth, the operator finds it advisable to ad- minister chloroform or ethyl-bromide, the danger of aspiration of blood in the state of tolerance must be considered. The following procedure is very practical : The patient is told to hold up one arm and to inspire chloroform ; after a few inhalations the arm begins to stagger, and falls limp. The operator quickly removes the tooth ; for at this moment the patient feels no pain, although the state of excitation has not yet set in. In a short time the chloroform intoxication passes off completely. The hemorrhage from the alveolus is usually arrested by irrigations with cold, weak antiseptic solutions ; if it continues, the alveolar margins are somewhat pressed together with the fingers, or the alveolus is closed with a small piece of cork shaped like the root of the tooth, or with a small cotton compress (like a bottle with a cork). Or the alveolus is packed with iodoform gauze, or peroxide of hydrogen is injected. This is nearly always sufficient, else the operator has to resort to ferric chloride and the thermo-cautery. In persons subject to haemophilia or leucaemia, no extraction should be made. As accidents in extracting teeth are to be considered : Breaking off the crown, caused either by awkward manipulation on the part of the surgeon or by abnormal brittleness of the tooth ; breaking off one root, the extensive comminution of an alveolus with subsequent necrosis ; finally, the extraction of the wrong tooth. This accident can happen from too great haste on the part of the operator or from false information on the part of the patient; hence, the operator should never neglect, before apply- ing the forceps, to examine the tooth carefully, to percuss it with the forceps, and to probe various portions with a strabismus hook. After the accident has happened, the attempt can be made, after careful cleansing and disin- OPERATIONS INVOLVING THE FACIAL CAVITIES 589 fection, to reimplant the healthy root into the alveolus (reimplantation), a procedure which sometimes proves successful. The removal of roots which do not project at all over the alveolar margin is more difficult only from the fact that they cannot be easily grasped. Roots which have recently been broken off are the most difficult to extract, because they are firmly attached to the alveolus ; older roots are looser from frequent attacks of inflammation (periostitis), and can be more easily extracted after the gums have receded. Root forceps, or stump for- ceps, made less solid and having smooth sharp lips, are employed in the same manner as the tooth forceps (Fig. 1154, a and b\ But if the operator does not succeed in extracting the root with them, he may use elevators (Fig. 1 1 54, and d). They are inserted perpendicularly. By inclining the handle the root is elevated from the alveolus ; or he may use the root screw (Fig. 1155, a), which is screwed into the axis of the root, thereby obtaining a hold FIG. 1154. INSTRUMENTS FOR EXTRACTING ROOTS OF TEETH a, straight; b, curved root forceps ; c, d, elevators (American) ; e, claw foot FIG. 1155. a, root screw; b, Roser's bone-cutting forceps on the same ; or he may use the claw foot, a leverlike instrument formerly used extensively (Fig. 1154, e). If the root still offers resistance to all these instruments, no other alter- native is left than to divide the alveolus longitudinally and remove the root. Roser has invented for this purpose bone-cutting forceps (similar to List on' s) with which the alveolar margin and the gums are divided perpendicularly (Fig. 1155, *> 590 SURGICAL TECHNIC ACQUIRED DEFECTS OF THE PALATE Openings in the palate caused by injuries, neoplasms, chronic inflammations (tubercular and syphilitic ostitis and necrosis) are closed essentially in the same manner as in the operation of staphylorrhaphy previously described (see page 552). If the surgeon expects to have any success with the operation, he must be very careful, especially in'syphilitic defects, to eradicate the disease completely and to postpone the operation until the defect has cicatrized ; otherwise, the margins of the wound very frequently become necrotic. Clefts of the soft palate are vivified and sutured. Smaller clefts may be closed by a repeated careful application of the cautery iron or the thermo-cau- tery, securing by this treatment cicatricial closure of the defect. Many of these de- fects in the course of time close of their own accord. For clefts of the hard palate occupying the median line (as is generally the case in syphilis), according to von Langenbeck, the sliding of two bridge-shaped flaps yields good results (see page 555). The lateral incisions can be made somewhat nearer to the margin of the defect (Fig. 1156). Instead of the suture above de- scribed, Roser advises carrying the sutures under both flaps and uniting them by tying. Smaller perforations (of the size of a pin) occurring some- times during the healing of uranoplasty at the needle punctures or between two sutures, especially in the anterior part of the cleft behind the incisor teeth, may be closed by touching them with the thermo-cautery or with a needle heated to a dull red heat. If the defects are some distance from the median line, an attempt must be made to close them by transplanting a pednncnlated flap from the surround- ing tissues ; von Langenbeck effected closure by lining. He inserted first a small inverted flap into the defect, and over it he placed a second flap. If sufficient healthy tissue cannot be obtained from the palate, the soft parts must be taken from the neighboring tissues. Thus Rose used the mucous membrane of the lips ; Blasius, the skin of the forehead ; and Thiersch, the cheek in its whole thickness. If, by a great cicatricial contraction, the pillars of the fauces and the soft palate have been distorted to such a degree that disturbances similar to those FIG. 1156. URANOPLASTY IN PERFORA- TIONS OF THE PALATE OPERATIONS INVOLVING THE FACIAL CAVITIES of clefts of the palate are caused thereby, staphylopJiaryngorrJiapJiy and stapJiyhplasty would be indicated (see page 557). Of course, there is always great risk that the flap may become gangrenous either partly or entirely. TONSILLOTOMY Excision of the tonsils for hyperplasia of the same is performed in the fol- lowing manner : The patient sits on a chair, facing the light ; if it seems necessary, on account of very great irritability, the tonsillar region may be made anaesthetic by brushing it with a solution of cocaine. All oral specula and gags for opening the mouth are superfluous ; for in performing this operation, it is especially important to utilize the right moment and to act rapidly just "as if one were in the act of shooting a swallow on the wing" (DieffenbacK). Holding a double hook or tenaculwn forceps (Museux, Frb'hlicli) (Fig. 1157) with the left hand and a long, slightly curved probe-pointed knife (tonsillo- FIG. 1157. DOUBLE HOOK, HOOK FORCEPS, AND PROBE-POINTED KNIFE TONSILLOTOME FIG. 1158. TONSILLOTOMY PERFORMED WITH SCALPEL AND HOOK FORCEPS tome) with the right hand, the surgeon takes his place at the right side be- hind the patient. Into the mouth of the patient, widely open, he introduces the hook (forceps); he grasps the right tonsil, and draws it out from its 592 SURGICAL TECHNIC depression ; next, he quickly raises the soft palate somewhat with the back of the knife, applies its edge at the superior border of the tonsil, and cuts it off with rapid sawing movements from above downward along the pillars of the pharynx. The operator then takes his position in front of the patient and repeats the operation on the left tonsil ; should he desire to cut off also the right tonsil from tlie front, he would be obliged either to cross tlic rigJit hand over the left and thus operate over his own hand, or to hold the scalpel in his left hand. The selection of position depends on practice. If the operation is made rapidly and safely, it is hardly necessary to press down the tongue with a spatula, for an assistant would be required for this purpose. The operation with Fahnestock-Mathieu' s (Fig. 1159) guillotine-like tonsillotome (cut- ting circular knife) in children and very timid adults is very convenient. The forefinger and the middle finger of the right hand are introduced into the two lateral rings, the thumb is intro- duced into the ring at the end of the handle ; by moving the fingers toward each other, the cutting circular knife is pro- jected from the ring, while at the same time the harpoon-like fork is pushed forward and transfixes the tonsil. The in- strument is introduced with the fork turned inward toward the median line. The ring is rapidly applied over the tonsil ; the fin- gers are closed with a vigorous jerk, whereby the tonsil, harpooned and drawn forward by the fork, is cut off by the circular knife from behind forward (Fig. 1 160). Although by this procedure the little operation can be made very conveniently and rapidly, still by employing the circular knife tmpleas- ant accidents may occur, which prevent the completion of the opera- tion (viz., bending of the fork, breaking of the circular knife, tonsillar lithiasis). Since the instrument cannot be freed from a harpooned tonsil, C FIG. 1159. TONSILLO- TOME BEFORE AND AFTER THE OPERA- TION FlG. 1 1 60. TONSILLOTOMY PER- FORMED WITH THE TONSIL- LOTOME OPERATIONS INVOLVING THE FACIAL CAVITIES 593 the operator should always have in readiness a probe-pointed knife, to meet such emergencies. Very soft tonsils, which cannot be grasped either with the hook or with the circular knife, are scraped away with the sharp spoon or are cmsJied either with blunt instruments or with the fingers (tonsillothlipsis). (Ignipuncture with the needle point of the Paquelin cautery often suffices in reducing the swelling in such cases. In the use of the different kinds of tonsillotomes the sense of touch is usually more reliable and useful than sight in guiding the instrument.) An old procedure, otherwise little practised, for these easily tearable forms is the enucleation of the tonsil : The surgeon applies the point of his forefinger between the superior posterior part of the tonsil and the posterior pillar of the pharynx, tears at this place the mucous membrane, and enu- cleates the tonsil out of its recess from the pharyngeal wall until it hangs down with its inferior anterior part loosely attached, as if from a pedicle, into the pharynx. The pedicle is twisted or cut off ; the little operation is almost bloodless {Pollard}. Simple also is Hoffmann and M. Schmidt's longitudinal division of the tonsils, which is heartily recommended, namely, tearing open all follicles and pouches on their surface, to effect the removal of all the germinating foci of bacteria. With a sharp strabismus hook, all lacunae are torn open in an up- ward and downward direction until the hook glides along smoothly every- where ; any folds of mucous membrane produced thereby and a portion of the anterior pillars of the pharynx, covering the tonsil like a valve, are removed with the scissors. The opened recesses are finally disinfected with some antiseptic. The parenchymatous hemorrhage caused by tonsillotomy is, as a rule, arrested spontaneously or by irrigation with cold water or ice water ; more violent hemorrhage, such as would occur in blood disease or any injury of the ascending palatine artery, is arrested by compression. Apply the fore- finger and the middle finger in the mouth on the bleeding surface, and make at the same time counter pressure from the outside (von Langcnbeck), or apply a tampon provided with a handle ; finally, in very obstinate and violent hemorrhage, suture together the two pillars of the pharynx and thus com- press the bleeding surface. (An excellent local styptic is spirits of turpentine, with which a small compress is moistened and held firmly against the bleed- ing surface until hemorrhage ceases.) Injury of the internal carotid artery, so much feared, should hardly ever occur, since this artery generally courses more than i centimeter distant from the tonsil. The various compressing 2-Q 594 SURGICAL TECHNIC instruments which are said to be useful substitutes for digital compression (Fig. 1161), are, as a rule, not available when they are needed. FIG. 1161. MICULICZ'S COMPRESSING INSTRUMENT FOR ARRESTING HEMORRHAGE AFTER TONSILLOTOMY Tonsillar abscesses are opened by inserting a pointed knife, in which case the operator has to guard against any injury to the palatine artery, if he pushes the knife too far in an outward direction through the pillar of the pharynx. Amputation of the tonsil may become necessary in such a case for opening widely the abscess cavity (Rotter}. EXTIRPATION OF THE TONSILS, for malignant neoplasms, can be made successfully from the mouth only in rare cases. Hence, from the outside, access must be obtained to the tonsil by temporary resection of the ascending ramus of the jaw (von LangenbecK) : 1. External incision, tongue-shaped, with an upper base, extends along the anterior and the pos- terior margin of the ascending ramus of the jaw, around the maxillary angle, including the masseter muscle (Fig. 1 162, a). 2. After ligation of the external maxillary artery (facial artery) and division of the periosteum, cor- responding to the anterior incision, the jaw is saivcd through with a metacarpal saw closely in front of the insertion of the masseter. The ascending ramus of the lower jaw, freed thereby, is drawn upward, after a previous careful detachment of the SIGNS FOR EXTIRPATION OF connective tissue on its inner side and Preservation THE TONSILS, a, von Langen- of the muscles of mastication; the mucous mem- beck's method; b, Mikulicz's brane of the oral cavity still remains uninjured. 3. The tumor is then exposed ; externally and behind it lies the external carotid. After the tumor has been thoroughly removed with knife and scissors, in which case the opening of the cavity of the mouth is to be made, if FIG. 1162. EXTERNAL INCI- OPERATIONS INVOLVING THE FACIAL CAVITIES 595 possible, last of all, the luxated part of the lower jaw is replaced into its normal position and united with the maxillary arch by a bone suture. Very similar is the procedure of Miculicz ; the external incision takes its course along the anterior margin of the sternocleidomastoid from the level of the angle of the mouth as far as the great cornu of the hyoid bone (Fig. 1162, b\ After a division in layers of the soft parts and of the periosteum along the posterior mandibular border, the posterior part of the ascending ramus of the inferior maxillary bone is laid bare from the periosteum as far as the sigmoid notch, and divided with the chain saw at the posterior border of the masseter. The sawed-off portion of the lower jaw is completely dis- articulated from its joint without injuring the mucous membrane of the mouth. All diseased tissues can then be extirpated down to the mucous membrane ; finally, the latter is also divided, and thereby the pharynx is opened. The cavity thus produced is packed with iodoform gauze. The defect remaining from this operation is inconsiderable ; the function of the muscles of mastication is partly preserved ; later on even a new formation of the enucleated portion may take place from the preserved periosteum. In some cases it is safer to perform tracheotomy previously to the operation, and to tampon the trachea to avoid broncho-pneumonia, caused by aspiration of particles of food, etc., into the air passages. AMPUTATION OF THE UVULA (KIONOTOMY) Amputation of an excessively long nvula (hypertrophic} is made in a few seconds by a single clip with the scissors. The uvula is grasped at its extremity with a pair of tenaculum forceps and drawn forward. It is then removed with a strong pair of Cooper s scissors (the blades of which are wide open), either only one-half or close to its insertion of the soft palate (completely). Since the easily movable and slippery uvula readily slips back- ward from the pressure of the scissor blades, it is frequently only incised. Hence, it is FIG. 1163. AMPUTATION OF THE UVULA 596 SURGICAL TECHNIC important in this little operation to draw the part grasped with the forceps for a moment forcibly in an anterior direction, and to press the same as deeply as possible into the widely opened blades of the scissors before the cut is made. The hemorrhage, in most cases inconsiderable, ceases spontaneously ; the wound heals in a few days. (The editor prefers to excise the hypertrophied uvula in such a way that the base of the excised portion presents the form of a wedge ; he unites the two little flaps with a fine catgut suture. In this operation the knife is used in place of the scissors.) OPERATIONS ON THE TONGUE The excision of a wedge-shaped portion from the tip of the tongue may be made rapidly in the removal of tumors of the tongue, without great loss of blood, in the following manner (Dieffenbacli) : After a Wliitehead-Mason gag (Fig. 1 138) has been applied, the tip of the tongue is grasped with toothed forceps and stretched by drawing it for- ward. FlG. 1164. Applying silk ligature FIG. 1165. Excision of the tumor FIG. 1 1 66. Tying the two ends of the thread FIG. 1167. Suture EXCISION OF A WEDGE-SHAPED PORTION FROM THE TIP OF THE TONGUE i. On both sides of the intended incisions (which should be made at least I \ centimeters distant from the limit of the neoplasm) a long, strong silk ligature is passed through with a large well-curved needle, so that the lower surface of the middle portion hangs down in the form of a loop (Fig. 1 164). 597 598 SURGICAL TECHNIC 2. While an assistant draws each end of the ligature with one-half of the loop in a lateral direction, and thereby stretches the tongue transversely, the operator, by two converging incisions with a pair of strong scissors or a small knife, rapidly excises from the tip of the tongue the wedge containing the tumor. Immediately he closes the cleft by drawing and tying together the two ends of the thread, which serves the purpose of a deep suture (Figs. 1165, 1166). 3. The rest of the wound is united by several fine interrupted sutures (Fig. 1167). If larger portions must be removed from tJie anterior half of the tongue, the hemorrhage may be arrested by temporary constriction of the whole tongue at its root : The tongue is forcibly drawn forward. An incision about half a cen- timeter long is made under the chin, closely in front of the middle of the hyoid bone. At this incision, a long, straight needle with an eye and a handle is passed through the tongue until the point with the eye appears at the base of the tongue just above the epiglottis. A long, thick double silk FIG. 1168 FIG. 1169 TEMPORARY CONSTRICTION OF THE WHOLE TONGUE AT ITS ROOT thread is inserted into the eye, and drawn out with the needle through the needle puncture. Next, the needle is again passed through the same open- ing, 3&&,past the side of the tongue, drawn in an opposite direction, until the point appears in the oral cavity in front of the pillars of the pharynx. The OPERATIONS ON THE TONGUE 599 thread passed through the root of the tongue is then inserted into the eye of the needle and drawn out with it in a downward direction toward the chin (Fig. 1168). The same procedure is repeated on the opposite side. The four threads, hanging down under the chin from the puncture open- ing, are passed through the rosary of Grafes loop tightener ; and, after the two ends have been fastened, the two loops are so tightened by means of the screw that the blood supply to the tongue is completely interrupted (Fig. 1169). If the disease involves only one side of the tongue, the constriction of that side alone is sufficient (Fig. 1170). FIG. 1170. TEMPORARY CONSTRICTION OF ONE SIDE OF THE TONGUE FIG. 1171. LANGENBUCH'S TEMPORARY CONSTRICTION OF THE TONGUE From the oral cavity, smaller portions of the tongue can be constricted in the same manner by passing, according to Langenbuch, a strong curved needle with a double silk ligature through the middle of the tongue from above downward, and by constricting each half of the tongue with one of the ligatures. To prevent the threads from slipping, Langenbuch passes the threads once more through the tongue at its lateral margins from below upward (Fig. 1171). It is still safer to carry each thread singly, with a curved needle, through the median portion of the tongue and out of the floor of the mouth, so that both threads somewhat overlap in the middle. AMPUTATION OF THE TONGUE If, on account of malignant disease, one-half of the tongue, or even the whole tongue., must be amputated (amputatio lingua), the operation may be performed from the oral cavity without any loss of blood, provided prelimi- 600 SURGICAL TECHNIC nary ligation of one or both lingual arteries is made (see page 258). Like- wise, the facial artery, supplying the floor of the mouth, may be ligated at the same time in the wound. The tongue is then cut off with knife or scissors ; next, the cut surfaces of the stump are sutured in a suitable direction with strongly curved needles and strong catgut. Thus, for example, after the removal of one- half of the tongue, the remaining tip may be stitched laterally by turning it backward to the wound surface of the base of the tongue, and thus a new but smaller tongue may be formed ; in a transverse amputation of the whole tongue, it is best to suture transversely the upper and the lower margins of the wound. Von Langenbeck recommended cutting off the tongue slowly and blood- lessly with the hook-shaped, red-hot blade of the thermo-cautcry. He pro- tected the lips and the palate by applying a WJiitchead oral speculum, which he provided with protective plates. Bottini has amputated from the wide-open mouth more than a hundred tongues, some of them very extensive operations, with the galvano-cautcry. Whiteliead does not resort to preliminary ligation of the lingual artery, but makes the amputation of the tongue (forcibly drawn forward) slowly with small careful incisions with scissors. When he meets the lingual artery, he grasps it with torsion forceps before its division. He next divides it and twists both ends. Very often, especially when the disease of the tongue has also invaded the neighboring parts, the surgeon is compelled to obtain a freer access to the field of operation by preliminary operations. The transverse division of the cheek from the angle of the mouth to the ascending ramus of the jaw causes disfiguration after successful healing, and does not give sufficient space, especially when (as is frequently the case) the disease has passed from the tongue to the palate, the tonsils, and the floor of the mouth as far as the epiglottis. In these cases, the TEMPORARY LATERAL .RESECTION OF THE LOWER JAW (von Langenbeck} offers the best access to this region. 1. External incision from the angle of the mouth of the diseased side perpendicularly downward to a point on a level with the thyroid cartilage ; ligation of the external maxillary artery (facial). 2. From the lower angle of the wound the submaxillary foss.a is opened, and any diseased lymphatic glands are enucleated ; next, the digastric OPERATIONS ON THE TONGUE 60 1 muscle is divided, likewise the hypoglossal nerve ; the hypoglossus muscle is divided longitudinally, and the lingual artery is ligated. 3. After the first molar has been extracted and the floor of the mouth has been perforated at this place with a pointed knife, closely along the lower jaw, the submaxillary bone is sawed through with the metacarpal saw obliquely from behind and above downward and forward, or it is sawed through in a < -shaped or | '-shaped manner (Fig. 928). The hemorrhage from the dental canal is arrested by pressing a little ball of carbolized wax into it. FIG. 1172. Division of the skin and the lower jaw FlG. 1173. Dividing floor of the mouth ; the tongue is drawn forward VON LANGENBECK'S TEMPORARY RESECTION OF THE LOWER JAW 4. The sawed surfaces are drawn apart with two sharp bone hooks (Fig. 1172); with hooked forceps or with a strong thread loop, passed through the tongue, the latter is drawn upward toward the healthy side ; the mucous membrane of the floor of the mouth is divided as far as the anterior pillar of the pharynx and detached from the lower jaw. The lingual nerve is divided. 5. It is now comparatively easy to remove the diseased parts. The pillars of the fauces, if invaded by the disease, are cut off from the soft palate and amputated in a downward direction ; likewise the tonsil and the pharyngeal wall (carotid artery ! ) may be removed with care. The tongue is drawn downward toward the diseased side, and divided in its healthy part according to the seat of the tumor. In a transverse amputatioji clp front of the epiglottis, it is cut off from above downward ahtt rjack\vard^ the glosso-epiglottic ligament or fold is divided last of all. Should trie tigation- - 602 SURGICAL TECHNIC of the other lingual artery be necessary, it can be easily made from below, whilst the tongue is drawn in an upward direction toward the diseased side (Fig. 1173). 6. At the end of the operation, the ends of the jaw, divided by sawing, are reunited by a bone suture of silver wire ; the external wound is closed by interrupted sutures and drained at its most dependent point. The wound of the tongue is best covered with adhesive iodoform gauze, or brushed with a benzoate mixture recommended by Whitehead. During the first days, nourishment is administered through a pharyngeal tube. Frequent irrigation of the mouth (with hydrogen dioxide or boric solution) is imperative. TEMPORARY RESECTION OF THE LOWER JAW IN THE MEDIAN LINE ( is applicable only for rarer diseases of the lower surface of the tongue and of the floor of the mouth. After a vertical division of the lip, as far as and under the chin, the lower jaw is sawed through as described on page 488. By turning aside the two halves of the jaw, access is easily gained to the anterior parts of the mouth. After the necessary operation, the jaw is reunited by a bone suture. Since, however, very little tendency exists in the median line for a dislocation of the parts of the jaw, the bone suture may be omitted, and the periosteum and the soft parts alone may be carefully united. Since sawing through the jaw as a preliminary operation always results in an additional injury, and since the healing of the sawed surfaces is not always accomplished by primary intention on account of the constant irriga- tion with the fluids of the mouth, the attempt has been made by others to make the operating field more accessible by dividing the soft farts only. Billroth exposes, according to Regnotis procedure, the anterior region of the tongue and the floor of the mouth from the chin ; a curved external inci- sion along the lower margin of the chin penetrates to the internal surface of the jaw. Next follows the separation of the periosteum ; then, division of the genioglossus muscle, of the geniohyoid, and of the digastric ; and like- wise division of the mucous membrane of the mouth behind the alveolar margin. From each extremity of this incision, a lateral incision is carried straight downward and outward to the hyoid bone, and extended to the oral cavity. From this opening, the tongue may be drawn down (of course, with difficulty) almost as far as the epiglottis (Fig. 1174). Kffcher makes the extirpation of the tongue from the base by a lateral angular incisian extending from the chin, in the median line, to the middle 7 OPERATIONS ON THE TONGUE 603 between the hyoid bone and the margin of the chin, then transversely and posteriorly in the cervical fold of the floor of the mouth (" Hals-Mundboden falte") as far as the anterior margin of the sternocleidomastoid muscle, thence along the sternocleidomastoid muscle upward to the lobule of the external ear. After the flap has been turned up toward the face and stitched to the cheek, in the exposed submaxillary fossa, the lingual, the maxillary, and the external carotid arteries can be ligated, and any diseased glands can be removed. The whole side of the tongue, as far as the epiglottis, is made easily accessible (Fig. 1175). FIG. 1174. REGNOLI-BILLROTH'S EXTIRPATION OF THE TONGUE FROM THE CHIN FIG. 1175. KOCHER'S EXTIRPATION OF THE TONGUE FROM THE BASE Similar to this operation but simpler, and furnishing less space, is Vernetiil- Maunourys "lower oral route," from which tumors of the tongue and the cheek, of the alveolar margin, and of the palate can be rendered accessible. The external incision extends from the angle of the mouth to the lower border of the submaxillary bone and along the same as far as its angle. The soft parts are divided in layers, and the facial artery is ligated ; the mucous membrane of the oral cavity, however, so far is not invaded. The submax- illary fossa can then be cleared out, and the external carotid can be ligated at the external angle of the wound. Only then the opening of the oral cavity along the jaw, if necessary, after the removal of a portion of the jaw, is made and kept wide open by a pair of spring-catch forceps. The tumor in the cavity of the mouth can now be removed easily and without much hemor- rhage. Since, in cancer of the tongue, the glands and lymphatic vessels of the side involved are always, and those of the other side generally, diseased 604 SURGICAL TECHNIC (Kuttner), it is advisable, for a thorough extirpation of the malignant dis- ease, first to perform the complete clearing out of the floor of the mouth, and, from a curved incision somewhat below the inframaxillary bone, to remove all the glands and the diseased connective tissue ; the lingual arteries are ligated during this procedure. The tongue can then be amputated through the cavity of the mouth as described above. It is advisable, moreover, to facilitate anaesthesia, previously to inject morphine and to make tracheotomy ; directly after the opening of the oral cavity, the upper entrance to the larynx is tamponed. If larger parts, or even the whole tongue, have to be removed, speech, of course, becomes con- siderably impaired ; but it is still intelligible in many cases, if ever so small a portion of the tongue has remained in position (Schnlte'ri). DieffcnbacJi observed a patient with amputated tongue, who could speak better as soon as he took a wooden ladle in his mouth. At the present time, we have even artificial tongues, protheses, which are supported by the inframaxillary bone and consist of a piece of soft caoutchouc. In cystic tumors, located under the tongue, ranula (most frequently origi- nating from Blandin-Nuhri s mucous glands of the tip of the tongue, but also from an obstruction of the duct of Bartholin of the sublingual gland, Fig. 1 1 76), the simple longitudinal division of the sac with drainage or the partial removal of its anterior wall only rarely produces a permanent cure, since, after some time, a recurrence frequently takes place, even from small remaining fragments of the wall. Attempts to destroy the walls of the cyst by applying chloride of zinc, solid nitrate of silver, tincture of iodine, alcohol, etc., have not vielded very satisfactory re- FIG. 1176. RANULA ,. / . r r ,, . , . c suits. (A free exposure of the interior of the cyst, followed by a vigorous application of the actual cautery and tam- ponade, have given better results.) Much better and more practical is the extirpation of tJie cyst (Sc/in/i). The operation is made without anaesthesia, or with local anaesthesia. After a longitudinal division of the thin covering of the mucous membrane on the anterior wall of the cyst, which may be made in the simplest manner by raising a small fold between two forceps and dividing it on a grooved director, the operator penetrates bluntly between the mucous membrane and the wall of the cyst. The extirpation, as a rule, offers no great difficulties, since the EXTIRPATION OF THE PAROTID 605 wall of the cyst in some places adheres so loosely to the surrounding tissues that it may be detached or enucleated by mere traction. If the extirpation offers any difficulties, as a result of former futile operations in consequence of which the adhesions have become firmer, it is sufficient to remove the anterior wall with curved scissors ("Hohlscheere") and to suture the margins of the remainder of the cyst to the mucous membrane of the mouth. EXTIRPATION OF THE PAROTID is to be made in the removal of malignant tumors ; if the tumors are of a benign character (fibroma, chondroma), their extirpation is sufficient ; but in malignant neoplasms (sarcoma, carcinoma), the whole gland must be removed. A total extirpation of the parotid, on account of its anatomical position, involves great difficulties; and, since the facial nerve which passes through the gland is thereby always injured to a greater or less extent, permanent paralysis of this nerve is the inevitable consequence of this operation. (In undertaking an operation on the parotid gland for malignant disease, a distinct understanding should be had between the operator and patient concerning this inevitable and permanent complication.) (Professor Daniel Brainard, the founder of Rush Medical College, was the first surgeon who performed this operation and argued its feasibility in appropriate cases.) The procedure is as follows : 1. After the auditory meatus of the external ear has been protected by a tampon of common cotton, the external incision is carried over the most prominent part of the tumor, according to requirements, either straight and parallel to the ascending ramus of the jaw, or in the form of a flap, or ellipti- cally, encircling diseased portions of the skin. 2. If, by a cautious procedure, the operator has penetrated to the capsule, it should be exposed on its entire anterior surface. Next, from below, along the external carotid, the operator tries to reach its posterior surface. This is best done bluntly with the fingers, or with a Kochers director. If it is necessary to divide any adhesions with the knife, the edge of the knife must always be directed toward the gland. The glandular capsule is held only with blunt hooks or the fingers ; if sharp hooks are applied, it is easily torn. In this procedure, along the posterior surface from below upward, there must be divided, one after another, the anterior and posterior facial veins, the temporal artery under the zygomatic arch, the auricular artery in front 6o6 SURGICAL TECHNIC of the auditory meatus, the transverse facial artery under the condyle, the posterior auricular artery, and the occipital artery at the margin of the sternocleidomastoid muscle. Under some circumstances, it is necessary to ligate even the external carotid (Figs. 1177, 1178). --^Auric.post Occipit.'- 1 . ---Biventerr-4 .---Accessorius "'Max.ext -Stylohyoid rUypoglossui ----Car.ext. i --i-Car.int. - \3 -i-Thur.sup. - : Car. com. - \ FIG. 1177 FIG. 1178 ANATOMY OF THE REGION OF THE PAROTID GLAND ACCORDING TO VON BRUNS 3. After the parotid gland has thus been exposed on all sides, it is enucleated as bluntly as possible from its recess behind the lower jaw, in which procedure, after its detachment from the styloid process, the internal maxillary artery and the ascending pharyngeal artery must be ligated. The ramifications of the facial nerve must be divided in most cases ; if possible, however, the main trunk is preserved. Sckiiller finds the access to the parotid fossa easier and better for in- spection by attacking with the knife the tumor from above, below the lobule of the ear, and from its anterior limit in the face ; by this means, each ves- sel, as it appears to view, is divided after double ligature. The tumor mass gravitating backward leaves the field of operation free and easy of inspection. EXTIRPATION OF THE PAROTID 607 4. The wound cavity is sutured and drained according to its size. In the after treatment, attention should be paid to the timely closure of the eye, to prevent complications caused by the paralysis of the eyelids. If the operation is thus performed in an extracapsular manner, bluntly, and guided by the eye, the gland may be enucleated in a tolerably clean manner and without great loss of blood. These advantages are lost if the incisions are made intracapsular into the frangible loose tissue of the gland itself, or if incisions must be made when the capsule is perforated ; in such a case, a clean extirpation is almost impossible. If the operation however consists only in the enucleation of well-circum- scribed tumors (enchondromata) from the glandular tissue, it may be accom- plished in a comparatively easy manner after splitting the common capstile. Likewise, the facial nerve may be more or less preserved, according to the seat of the tumor. (In the removal of benign tumors of the parotid gland it is advisable to always split the capsule in the direction of the branches of the facial nerve, and largely to make use of blunt instruments in performing the enucleation.) EXTIRPATION OF THE SUBMAXILLARY GLAND can be made more easily, since the gland lies rather superficially between the margin of the lower jaw and the digastric muscle, covered only by the platysma and the cervical fascia. At its external margin lies the facial artery ; at its superior, the lingual nerve ; at its inferior margin, the hypo- glossal nerve. The surgeon may facilitate the enucleation, if he pushes the gland forward with the finger from the floor of the mouth, or if, proceeding from the skin of the chin, he turns it around the border of the lower jaw. SALIVARY FISTULA Fistula of the cheek of Stews duct, resulting from injuries of the same, or ulcerations, often heal of their own accord after some time. The healing may be aided by cauterization with Paquelin's needle-point cautery or with the solid stick of nitrate of silver. If the peripheral end has become obliterated, and if a lip-shaped fistu- lous opening exists, care must be taken to maintain an artificial drainage toward the mouth. For example, perforate the cheek from the fistula with a trocar or a thick needle ; next, vivify the margins of the fistula and suture them. 6o8 SURGICAL TECHNIC De Guise 's procedure promises good results. From the fistulous opening he passes two needles (fastened to the ends of a silk thread) through the cheek (Fig. 1179) in such a manner that their points of exit in the mucous membrane of the cheek are about half a centimeter distant from each other. The thread is drawn after them and knotted in the mouth (Fig. 1 180); next, the margins of the fistulous opening are vivified elliptically and sutured. The saliva can flow into the cavity of the mouth through the perforations that have been made and through the defect produced between them by tlie linear pressure of the thread. The external salivary fistula is thereby changed into an internal one. In fistulous formations of the masseteric tract, an attempt should be made to obliterate and render atrophic the parotid gland, which effect Dcsault accomplished by a permanent compression of the gland, and Viborg by ligation of the salivary duct. FIG. 1179 FIG. 1 1 80 DE GUISE'S OPERATION FOR SALIVARY FISTULA SUBHYOID PHARYNGOTOMY {Malgaigne, von Langenbeck} is made for removing tumors or firmly impacted foreign bodies which are in the posterior or the lateral wall of the pharynx or at the upper entrance to the larynx. Three days previously to this operation, especially in removing tumors, tracheotomy is always made, and the trachea is tamponed (see page 619). 1. External incision 5-6 centimeters long, with the head strongly bent backward or hanging down, parallel to the lower margin of the hyoid bone transversely across the neck (Fig. 1 181). 2. Division of the superficial cervical fascia and of the stcrnohyoid and thyrohyoid muscles until the strong middle thyrohyoid ligament is exposed. 3. The ligament is divided with the thyrohyoid membrane between two forceps by incisions always directed vertically downward ; or a pointed knife having been inserted at the lower extremity of the hyoid bone obliquely upward, the ligament is divided in its whole thickness with a probe-pointed knife toward the forefinger introduced from the mouth, and detached from the posterior surface of the hyoid bone. The mucous membrane of the pharynx thereby exposed is divided transversely and parallel to the lower OPERATIONS ON THE PHARYNX 609 margin of the hyoid bone in the whole extent of the skin incision, whereby the glosso-epiglottic fossa is opened. The upper entrance to the pharynx and the larynx can be made still more accessible after division of the two great cornua of the hyoid bone 1-2 centimeters from their free extremity. (Avoid the lingual artery and the superior laryngeal nerve.) FIG. 1181 FIG. 1182 SUBHYOID PHARYNGOTOMY. a, front view; b, sectional view 4. After division of the tense ligamentous connections, the lower margin of the incision sinks downward, and the wound gapes ; the epiglottis becomes visible in it, is grasped with forceps (" Klauenzange "), and drawn out of the wound ; thereby the aryepiglottic ligaments, as well as the posterior surface of the epiglottis and the whole upper entrance to the larynx, with the arytenoid cartilages, appear to view, and are easily accessible for the removal of any tumors present. For better inspection, and for avoiding the superior laryngeal nerve, Sallas divides even the hyoid bone by a sagittal incision. The wound of the bone, even without being sutured, leaves no functional disturbance. 5. In the same manner the lateral and the posterior wall of the pharynx may be easily surveyed and reached if the larynx is detached to some extent from the pharynx. If any diseased portions must be excised from the same, it is advisable, after a rapid ligation of the ascending pharyngeal artery, if divided, first to tampon the upper entrance to the larynx, and, if necessary, to extend the external incision as far as the lateral thyrohyoid ligaments. If the margins of the wound of the pharynx cannot be united by suture after 6lO SURGICAL TECHNIC the hemorrhage has been arrested, the defect produced is left to heal by granulation. It is covered with antiseptic gauze, and an cesopJiagcal tube is inserted from the nose, past the defect, into the stomach. 6. After the removal of the tampon from the upper entrance to the larynx, the thyrohyoid ligament is reunited by a few interrupted sutures, and the external wound is sutured in its whole extent. If the extirpation of larger portions of the wall of tlie pJiarynx is necessary, another lateral longitudinal incision can be made upon this transverse incision for obtaining better access, or the operator may attempt to reach the pharynx laterally or from the front. LATERAL PHARYNGECTOMY (von LangenbccK) 1. After tracheotomy has been made and the trachea has been tamponed, the external incision is made from the middle of one half of the jaw across the greater cornu of the hyoid bone downward to a level with the cricoid cartilage, and extended close to the tracheotomy wound. 2. After cutting through the superficial cervical fascia, the platysma, and omohyoid muscle, the operator carefully penetrates deeply and ligates the lingual artery, the superior thyroid, and several branches of the facial vein ; the two branches of the superior laryngeal nerve must also be divided. 3. The posterior belly of the digastric muscle and of the styloJiyoid muscle is detached from the hyoid bone so that the lateral pharyngeal wall is exposed. It is divided lengthwise in the whole extent of the wound, and while the larynx is drawn toward the healthy side and rotated a little around its axis, sufficient space has been gained for detaching with blunt instruments the wall of the pharynx from the larynx and from the vertebral column. The surgeon must avoid making a circular resection of the pharynx on account of the subsequent liability to stenosis (Kiister). In this manner even the larynx and the pharynx have been removed. Until recently, in most cases after the operation death from mediastinitis and subcutaneous phlegmon ensued. RETROPHARYNGEAL ABSCESSES Collections of pus between the pharynx (and oesophagus) and the cervical vertebrae are opened as early as possible for the evacuation of pus and to prevent laryngeal stenosis. The patient, who has not been anaesthetized, is seated with his head slightly bent forward (under anaesthesia aspiration must be prevented by OPERATIONS ON THE PHARYNX 6ll the head hanging down). While the introduced forefinger of the left hand palpates the fluctuating site, it is used as a guide to a pointed knife wrapped almost to its point with adhesive plaster, etc., which is pushed into the pharyngeal wall, if possible, at t/te most depend- ent place of the abscess. The opening may be somewhat enlarged so that the pus has free drainage. (A much safer way to open such abscesses is by tunnelling the soft inflamed abscess wall with a small pair of locked hemostatic forceps, using the finger as a guide. The perforation can be enlarged to the requisite extent by dilat- ing the blades of the forceps in withdrawing the instrument.) FIG. 1183. OPENING A RETRO- If the opening heals too soon, it must be PHARYNGEAL ABSCESS reopened by puncturing with a probe or by a new incision. Gargling and irrigating the pharynx with nontoxic antiseptics and insufflations of iodoform, etc., promote the healing of the wound. For the purpose of securing better drainage, and with a view of facili- tating a more thorough examination of the cavity with the finger, BurkJiardt opens retropharyngeal abscesses from the neck as long as they are still retro- visceral. The external incision along the inner margin of the sternocleidomastoid at a level with the larynx penetrates through the platysma. Between the blood vessels coursing on a level with the cricoid cartilage, which vessels are drawn outward and the larynx, the operator penetrates bluntly the loose cellular tissue as far as the inner circumference of the common carotid, which gives off small branches at this place. Close to the larynx, a small opening is made with the knife in the retropharyngeal (thick) tissue. This opening is enlarged bluntly, until the cavity of the abscess is sufficiently exposed. It is drained externally. In the same manner, also, the retro-oesophageal abscesses (vertebral tuberculosis) can be opened and drained. (In the treatment of retropharyngeal tubercular abscesses, puncture, evacuation, and injection of iodoform glycerine emulsion should invariably be given a fair trial before incision and drainage are resorted to, as this treat- ment combined with immobilization of the spine often proves successful, while incision and drainage, in spite of all precautions, are not infrequently followed by pyogenic infection with all its disastrous consequences.) OPERATIONS ON THE NECK OPENING OF THE AIR PASSAGES, BRONCHOTOMY is necessary for removing or preventing suffocation (asphyxia) from a con- striction or obstruction of the larynx. (a) In diseases of the air passages (croup, diphtheria, oedema of the glottis). () In injuries of the cartilages of the larynx (fractures, hemorrhage). (c) In case Qi foreign bodies. (d} In tumors and cicatricial contractions. (i) For artificial respiration. (f) Preliminary to some operations in the mouth and the pharynx. The air passages can be opened in various places ; surgeons dif- ferentiate : I. LARYNGOTOMY Median thyrotomy, the longitudinal division of the thyroid cartilages, is made in injuries (fractures) of the cartilages of the larynx and for removing foreign bodies and tumors (papillomata and tuberculomata) in the larynx. The operation is ahvays preceded by tracheotomy (inferior) and tamponade of the trachea for the entrance of sufficient air during the operation and to guard against aspiration of blood. The patient is placed on a neck cushion with his head well extended. 1. The external incision extends exactly in the median line from the upper limit of the thyroid cartilage as far as the upper margin of the cricoid carti- lage ; the skin is stretched with the left thumb and forefinger of the operator. 2. The cervical fascia is divided in the whitish line between the two sternohyoid muscles ; above the cricotliyroid ligament is found the cricothyroid artery, which should be either ligated double or drawn downward with a small blunt hook (together with any prominent portion of the median lobe of the thyroid gland present). 3. On the lower margin of the thyroid cartilage (after it has been trans- fixed with a sharp tenaculum hook) a pointed knife with its edge turned 612 OPERATIONS ON THE NECK 613 upward is pushed into the cricothyroid ligament, and the thyroid cartilage is divided in an upward direction with sawing movements ; if possible, the upper margin is preserved (insertion of the vocal cords) ; it is still better and more convenient to make the longitudinal division with a pair of strong, straight scissors, or with a probe-pointed knife upon a grooved director. Under some circumstances, in ossification of the commissure, the division of the same with Listons bone-cutting forceps or a fine saw becomes necessary. os hyoideum m. sternohyoideus Kg. crico-thyreoid (conicum) cart, cricoid gl. thyreoid - lig. hyothyreoid cart, thyreoid m. crico-thyreoid trachea FIG. 1184. ANTERIOR VIEW OF LARYNX AND TRACHEA 4. Immediately, two small sharp hooks are inserted into the margins of the fissure. When they are drawn apart, the interior of the larynx appears to view. After the purposed operation in the interior of the larynx during which operation brushing with cocaine is sometimes advantageous for abolishing reflexes has been completed, the thyroid cartilage is again united by a few sutures including the perichondrial tissue, and the wound of the skin is sutured separately. In the reunion, it is especially important to place the vocal cords in correct upposition ; to accomplish this better, the upper portion of the thyroid cartilage may be left undivided, whereby the divided cartilaginous parts are more easily replaced into their former position (partial thyrotomy). This object is attained with a greater degree of certainty by 6 14 SURGICAL TECHNIC TRANSVERSE THYROTOMY (Gersuny) That is, the transverse division of the thyroid cartilage closely above the anterior commissure of the vocal cords, which remain uninjured. The superior half of the thyroid cartilage is turned upward, and thereby the superior laryngeal cavity is rendered accessible to inspection, palpation, and direct operative interference. 1. A median incision from the hyoid bone to the cricoid cartilage exposes the thyroid cartilages, from the sides of which the soft parts are detached bluntly and retracted. 2. One to 2 millimeters above the anterior insertion of the vocal cords(lying in the middle between the deepest point of the notch and the lower margin of the thyroid cartilage), the thyroid cartilage is divided longitudinally and parallel to its superior margin by a transverse incision with the knife (or a fine saw) on each side about i centimeter deep, whereby also the mucous membrane is divided and the laryngeal cavity is opened. 3. Next, the thyroid cartilage is completely divided longitudinally with the bone-cutting forceps as far as its posterior margin, whereby the sinuses of Valsalva (Morgagni) are divided. 4. The superior laryngeal half is forcibly drawn upward with a little hook applied at the middle of the thyrohyoid ligament, whereby the vocal cords and the false vocal cords become accessible. By an incision with the scissors in the median line upward, the operator easily succeeds in exposing the space above the false vocal cords and the aryepiglottic folds ; by extending this incision one-half of the cartilage can finally be turned in an outward direction, and the epiglottis and the root of the tongue can be reached through this large opening. If the parts drawn apart are again approximated, they assume their normal relations ; and only a few sutures are required in holding them in proper position. INFRATHYROID LARYNGOTOMY (Longitudinal incision of the crico-thyroid ligament only) In sudden asphyxia in adults this operation can be made very easily and very rapidly, but furnishes sufficient space for introducing a canula only when the larynx is very large. If the ligament is divided vertically the artery coursing transversely over it must be secured between two ligatures or acupressure applied); more space is gained by a T or + incision. OPERATIONS ON THE NECK 615 In most cases, however, it is necessary to extend the wound in a down- ward direction, and to divide the cricoid cartilage also (cricotomy). If the cricoid cartilage is very hard, or even ossified, after the perichondrium has been retracted, a piece of the cartilage must be resected (cricectomy) to make a space sufficiently large for the introduction of the canula. % SUBHYOID LARYNGOTOMY is the name given by Langenbuch to an operation intended for the removal of small tumors on the anterior commissure of the vocal cords. He made a transverse skin incision closely above the thyroid cartilage, detached the muscles from the hyoid bone, and divided toward the median line (at a right angle to the skin incision) the ligamentous triangle in the upper thyroid notch. From there the root of the epiglottis was divided transversely, the larynx was drawn out by two hooks downward and forward, and the tumor was removed with the scissors. If it becomes necessary to make a tJiorough extirpation of non-malignant tumors or the removal of foreign bodies, then, on account of the freer accessibility, the larynx should be divided longitudinally from the superior -margin of the thyroid cartilage to the infcj tor margin of the cricoid cartilage (laryngo-fissure). If necessary, the first tracheal rings are also divided ; and, on the upper margin of the wound, the thyrohyoid ligament is detached transversely from the thyroid cartilage. In this field of operation, which can be easily surveyed, foreign bodies that cannot be grasped from above (endolaryngeal) can easily be removed ; papillomatous (tubercular) pro- liferations are removed with the sharp spoon, and the site of their attach- ment is destroyed with the cautery iron. After the margins of the cleft have been carefully sutured, the tampon in the trachea, which, as mentioned above, must always be inserted before the operation, is removed ; the voice is then soon restored. II. TRACHEOTOMY The opening of the trachea can be made above or below the isthmus of the thyroid gland. The former, the easier operation, is most frequently made in establishing a new passage for respiration in case of obstruction and constriction of the larynx ; the latter, considerably more difficult, is indicated when the superior tracheal rings are covered by the thyroid gland (as is mostly the case in children), or when tumors in the interior of the larynx have extended to the trachea. It is also very much preferred as a preliminary step to many operations on the upper air passages. 6i6 SURGICAL TECHNIC HIGH TRACHEOTOMY The patient lies with his head well extended over a neck pillow (or over the edge of the operating table). The head is held firmly by an assistant, who, if possible, superintends at the same time the anaesthesia, by which the violent respiratory, movements and the restless ascent and descent of the larynx are somewhat subdued. Infiltration anaesthesia is very much to be recommended for this short operation. The hands of the patient are fastened at both sides of the chest by a bandage, which surrounds the trunk. FIG. 1185. TRACHEOTOMY After the location of the thyroid and the cricoid cartilages, which can be easily felt, has been ascertained : 1. The external incision is made exactly in the median line, about 3 or 4 centimeters long, from the cricoid cartilage downward. 2. The cellular tissue in the intermuscular space is raised between two dissecting forceps and divided ; (as in the ligation of arteries) the sterno- hyoid muscles are equally drawn apart toward both sides with blunt hooks ; if Base's retractor (Fig. 1 186, a) is used, an assistant can be dispensed with ; and, at the same time, the hemorrhage is lessened by the traction. Reismann temporarily stitches the margins of the wound with eight sutures applied as closely to the trachea as possible ; these sutures are tightened, not by knots, but simple loops. 3. Next, the exposed median cervical fascia is opened by a small trans- verse incision at a level with the cricoid cartilage. The inferior margin of. OPERATIONS ON THE NECK 617' this incision is detached from the trachea by a blunt instrument placed under it (grooved director, tenaculum, handle of a knife), and thus, behind the median layer of the fascia, the operator penetrates on the trachea behind the isthmus of the thyroid gland. The same is retracted downward with a blunt hook without causing any hemorrhage ; the anterior tracheal wall is then freely exposed (Bases retrofascial separation of the thyroid gland). 4. Before the tracJiea is opened, every bleeding vessel must be grasped with hemostatic forceps ; not all the vessels need be ligated, since the venous hemorrhage, after the normal respiration has been restored, is nearly always considerably lessened ; besides, the two hemostatic forceps hanging down on each side serve to keep the surfaces of the wound apart. FIG. 1186. a, Bose's retractor; b, c, d, sharp hooks; e, Von Langenbeck's double hook; f, sharp-toothed sliding forceps 5. Opening of the trachea : The same must be held with sufficient firm- ness by inserting a simple sharp hook. It is still better to insert in the median line two small sharp hooks bent laterally (Fig. 1 186, c, d} in the wall of the trachea on both sides of the intended incision ; one of the hooks viz. that on the right side is held by the operator, the other by his assistant. The application of Langenbeck's double hook (Fig. 1186, e), the sharp points 6i8 SURGICAL TECHNIC of which can be opened by pressure upon the lever on the handle, renders an assistant unnecessary. If the operator has two sharp-toothed sliding forceps (Fig. 1186, /), he can apply them in the same manner as the small sharp hooks ; the trachea is drawn apart by their weight alone. At the place thus doubly fixed, the pointed knife is pushed in perpendicularly through the first tracheal ring and carried downward with sawing movements ; from the incision,, which gapes at once from the traction of the hooks, the air escapes with a hissing sound, a sure sign that the tracheal wall has been completely divided. For creating sufficient space in small larynges (children), the necessity of enlarging the incision in an upward direction by dividing the cricoid cartilage (cricotracheotomy) cannot, in the majority of cases, be avoided. 6. Introduction of the canula : Luer-Hagedorri s double canula (Fig. 1 187) consists of two bent tubes fitting exactly into each other attached to a movable shield in front. It is fastened by an elastic band around the neck. 7. For a dressing under the plate of the canula, a small split piece of iodoform gauze is applied. The inner canula must be removed from time tc time and the mucous accumulation removed with a soft feather. If no canula is available, a thick drainage tube, the lower end of which is cut off obliquely, an elastic catheter, or a thick quill is inserted ; or the surgeon makes two hooks (hairpin, Fig. 1188), which are introduced into the tracheal wound on both sides, and which are kept apart by means of an elastic band carried around the neck. If nothing of this kind is at hand, the surgeon can insert a ligature or wire on each side below one of the cartilaginous rings ; by this means, the tracheal wound is kept gaping. There are cases in which it is advisable to postpone inserting the canula until the first paroxysms of coughing have subsided ; generally membranes, aspirated blood, and mucus are ejected with great force. The trachea may also be probed with a wire, which is slightly bent in the form of a hook, and with which any floating membranes can be caught and removed. Although, in the majority of cases, the operation must be performed as rapidly as possible, the surgeon should never lose self-control and presence of mind, since sad consequences and serious technical errors may ensue from FIG. 1187. LUER'S DOUBLE CANULA FIG. 1 1 88. WIRE HOOK OPERATIONS ON THE NECK 619 imprudent haste. For instance : violent hemorrhage with aspiration of blood, if no precautions for thoroughly arresting the hemorrhage have been taken before opening the trachea ; furthermore, incomplete division of the anterior tracheal wall so that the canula enters between the mucous membrane and the cartilage, aggravating the asphyxia ; lateral opening of the trachea ; injury of the posterior tracheal wall, or even of the cesophagus. To reestablish suspended respiration immediately in cases in which life is in imminent danger from asphyxia, the operator should not hesitate either to divide the trachea transversely to admit air or to make an inferior tracheotomy. The canula remains in position until the cause for its introduction is removed, generally two or three days ; in the majority of other cases, it may be removed after the first week ; the wound then heals rapidly. Most fre- quently, the granulations forming at the places where the canula touches the tracheotomy wound cause difficulties in removing the canula. Sometimes they are lodged in the tracheal tube itself, especially when the mucous mem- brane grows into a fenestrated canula (speech canula). In extracting the canula, these polypus-like formations turn into the wound or into the tracheal tube, and cause an attack of suffocation until the canula is inserted again. The wound is enlarged slightly in an upward and downward direction ; the granulations are removed with scissors or destroyed with the actual cautery. Intubation of the larynx ( O 1 Dwyer) the endolaryn- geal introduction of flat can- ulas for removing laryngeal stenoses without tracheot- omy requires a large num- ber of instruments (instru- mentarium), much practice, and constant supervision ; in spite of many good suc- cesses, it is very little em- ployed in Germany. FIG. ii INSTRUMENTS FOR INTUBATION OF THE LARYNX 620 SURGICAL TECHNIC INFERIOR TRACHEOTOMY, the opening of the trachea below the isthmus of the thyroid gland, is made in the following manner : 1. The external incision extends from the cricoid cartilage to the supra- sternal fossa (jugulum, superior margin of the sternum). 2. After cutting through the loose cellular tissue and the superficial fascia, the underlying tissues, very rich in veins, are divided as bluntly as possible ; before their division, blood vessels that cannot be saved are divided between two ligatures or acupressure is applied. (The temporary clamping of blood vessels with hemostatic forceps renders the operation almost bloodless, requires little time, and reduces the use of the ligatures to a minimum.) 3. Next, the deep layer of fascia is divided ; and its margins, together with the sternohyoid muscles, are drawn apart with Base's elastic retractor. 4. The cellular tissue lying in front of the trachea and containing very many large veins, must now be divided ; the abnormal course of the numerous blood vessels in the cellular tissue renders this operation more dangerous (innominate artery, carotid, superior thyroid, vena jugularis media, and the inferior thyroid). This tissue is very carefully dissected off on both sides, and each vessel is at once doubly ligated ; none should be torn. 5. When the trachea is exposed, it is necessary, in most cases, to detach the isthmus bluntly for some distance in an upward direction and draw it in an upward direction with a blunt hook ; the deep margins of the wound are retracted with blunt retractors. The trachea is then grasped with a small hook and opened for i to 2 centimeters with a pointed knife. In introducing the canula, the head must be raised ; otherwise the trachea is too flat. TAMPONADE OF THE TRACHEA In larger operations on the head (with opening of the cavity of the mouth or the larynx), the trachea is tamponed to prevent the blood from gravitating into the bronchial tubes during aiuesthcsia. The opening of the air passages, according to the requirements of this operation, is made at one of the sites described above. After insertion of the canula, it is especially important to pack tightly the free space around the canula. The simplest procedure is to introduce gauze compresses or small com- pressed iodoformizcd sponges, of the size of a bean, attached to a thread. With these the space above the canula is tamponed. When they swell in conse- OPERATIONS ON THE NECK 621 quence of the absorption of secretions, they occlude the trachea completely. It is, however, safer to pack also the space around the respiratory canula. Michael covered the canula with a thick rubber tube. At the present time, Michael- Hahns com- pressed sponge canula, wrapped with iodoform- ized compressed sponge, is most frequently used. This, introduced dry, swells considerably from the absorption of secretions of the wound and trachea (Fig. 1191). Very practical and unique is Trendele nbu rgs tampon canula. He was the first to conceive the idea of tamponing the trachea. The canula is surrounded by a rubber bag insufflated with air through a small tube so that it applies itself everywhere to the tracheal wall. Since the air soon escapes to some extent, it is still better to fill the bag with water, etc. After the introduction of the canula, the inhalation of chloroform is made through a tin funnel over which some flannel has been stretched. The funnel is connected with the tracheal canula by a rubber tube (Figs. 1190, 1192). FIG. 1190. TRENDELENBURG'S TAMPON CANULA FIG. 1191. MICHAEL-HAHN'S COM- PRESSED SPONGE CANULA FIG. 1192. TRENDELENBURG'S TAMPON CANULA (in situ) EXTIRPATION OF THE LARYNX (Czerny, 1870; Billroth, 1873) The total extirpation of the larynx should be made only in such malignant diseases as render a partial extirpation insufficient. The partial extirpation of the larynx is made : 1. In malignant but circumscribed tumors. 2. In circular unyielding stenoses of a high degree. 622 SURGICAL TECHNIC But it is not made : 1. If the patient is too advanced in years and if the respiratory organs are diseased. 2. If the disease has become too extensive. 3. In elastic stenoses. 4. In tuberculomata and syphilomata. Previously to the operation, it is imperative to establish the diagnosis beyond all doubt with the laryngoscope, as well as by a microscopical exami- nation of endolaryngeal portions of the tumor which have been extracted. In cases in which the surgeon is in doubt concerning the extent of the disease in the interior of the larynx, the diagnostic laryngo-fis- sure is made directly before the operation. If only one side is found to be diseased after the ver- tical division of the larynx, and if the progress of the tumor has not extended beyond the median line, extirpation of one-Jialf of the larynx is sufficient. If, however, the proliferations of the tumor have already invaded the tissues beyond the median line, or if only a suspicious infiltration appears on the other side, it is better to remove the whole larynx. After the preliminary tracJic- otomy, which has preceded the operation for some time, and after the tamponade of the trachea (with HaJiris canula), the operation is performed as follows : I. External incision perpen- dicular from the middle of the hyoid bone as far as the second and third tracheal rings. (If nec- essary, horizontal incisions are made at the upper extremity or i ma FIG. 1193. ANATOMY OF THE REGION OF THE LARYNX (to the left in situ; to the right rami- fication of arteries). I, os hyoides; 2, cartilago thyreoidea; 3, cartilago cricoidea; 4, trachea; 5, ligam. thyreohyoid. med.; 6, ligam. thyreohyoid laterale; 7, ligam. cricothyreoid; 8, muse, sterno- hyoideus; 9, muse, omohyoideus; 10, muse, thy reo- hyoideus; II, muse, sternothyreoideus; 12, muse, thyreopharyngeus; 13, muse, cricothyreoideus; art. carotis; art. thyreoidea sup.; art. laryngea sup.; art. lingualis et Ramus hyoideus; art. crico- thyreoidea; art. thyreoidea inf.; art. laryngea inf.; vena jugularis int.; vena thyreoidea ima.; N, laryngeus sup. OPERATIONS ON THE NECK 623 at both extremities; T incision; x incisions like a double door, Bar- denheuer.) 2. After cutting through the superficial fascia, the operator penetrates between the sternohyoid muscles down to the thyroid cartilage (double ligation of the cricothyroid artery}. Having divided the thyroid cartilage, it is advisable once more to make a careful inspection, to make sure of the necessity of total extirpation. 3. With the elevator the soft parts are bluntly detached from the sides of the larynx. The tendinous connection of the stcrnothyroid and thyrohyoid muscles is dissected off laterally, and, together with the lateral horns of the thyroid gland, is drawn outward with blunt hooks and kept open. The inferior laryngeal and the cricothyroid arteries are ligated on both sides. 4. Separation of the larynx from tlie pJiarynx by small, careful incisions with the scissors, keeping always close to the cartilage in order not to injure the external carotid and the superior thyroid arteries, which are in close proximity. 5. The larynx now exposed is drawn to one side, the soft parts are drawn to the other. After ligation of the superior laryngeal artery, the lateral Jiyo thy raid ligament is divided. The same procedure is followed on the other side. 6. Division of the middle Jiyothyroid ligament and the mucous membrane of the pharynx behind the arytenoid cartilages ; ligation of the two inferior laryngeal arteries ; the larynx, made completely movable on all sides below the cricoid cartilage, is cut off transversely from the trachea, which is held by a ligature loop. Preservation of the epiglottis in most cases offers no advantage. On the other hand, Maas advises leaving an annular portion of the cricoid cartilage in position if possible, because it facilitates very much the introduction of the canula, and secures a wide communicating opening between mouth and trachea, even without any apparatus. In case the larynx is to be extirpated from below upward (Billroth\ it is detached from the trachea, first below the cricoid cartilage, after the lateral soft parts have been separated ; next it is drawn forward and upward with a sharp hook applied in the cricoid cartilage ; then its union with the pharynx and finally that with the hyoid bone are severed by incisions with scissors always closely directed against the larynx. If, in an advanced state of the disease, the tissues surrounding the larynx must also be removed, the operation becomes much more bloody and dan- gerous. The blood vessels to be divided in this operation are, in their order, counted from above downward : the hyoid branch of the lingual artery, the 624 SURGICAL TECHNIC superior laryngeal artery, the cricothyroid artery (a branch of the superior thyroid artery), the inferior laryngeal artery (a branch of the inferior thyroid artery), and the corresponding veins. Next the muscles are cut off from the larynx. The same is extirpated, and the surrounding parts are cleared of diseased glands lying along the inner margin of the sternocleidomastoid muscle on the sheath of the large vessels and below the submaxillary bone. The unilateral extirpation of the larynx is confined to the diseased side. In all other respects, however, it is made essentially according to the rules given for total extirpation. It is less dangerous, and the patient can speak distinctly even without a canula. The lateral incisions are sutured; the median incision is only tamponed. The wound of the pharynx is not sutured ; from it an oesophageal tube is introduced into the stomach, and the wound cavity is tamponed with iodo- form gauze. The patient remains in bed on his back; the dressings are changed daily. Even on the next day, an ordinary canula (Hahit) may be substituted for the tampon canula ; the wound above the canula is tamponed with antiseptic gauze. The cavity of the wound rapidly decreases in size if the case runs a favorable course ; patients are able to speak audibly in a whispering tone of voice. If it is desirable to wear a phonetic canula, an " artificial larynx " (Brnns- Bcyerles, Gussenbauer's, or Julius Wolff's} is to be recommended (Figs. 1194, 1195). The patient can speak through these apparatuses with a loud voice. On account of the irritation produced by the canula, FIG. 1194 FIG. 1195 PHONETIC CANULA (Artificial Larynx). , according to Gussenbauer; b, according to von Bruns however, many content themselves with whispering speech. Aside from recurrence, most patients that have been subjected to this operation have died from aspiration of secretions; the greatest care, therefore, must be bestowed upon the after treatment. OPERATIONS ON THE NECK 625 Bardenheuer obtained very good success by forming a septum between the oral cavity and the cavity of the zvound after removal of the larynx. The anterior wall of the oesophagus is sutured to the margin of the mucous membrane (which is preserved as much as possible) below the epiglottis, or with the vivified free margin of the epiglottis. The cavity of the wound is tamponed. The patient is placed with his head lowered backward in such a position that the tracheal stump forms the highest point of the wound and no secretions can flow into the tracheal wound. Since the patient can swallow, he does not insert any oesophageal tube for the introduction of food, and thus the first tampon can remain in position as long as eight days with- out irritating the wound. J. Wolff employs the oesophageal tube, but removes the tampon canula directly after the operation, and sutures the tracheotomy wound. The superior margin of the tracheal stump is sutured all around to the skin, and a common canula is introduced into the trachea from above. Rotter closed the pharyngeal defect by a double row of sutures including the mucous membrane, sewed over it the muscles detached from the larynx in a second layer, and the skin as far as the angles in a third layer. The patient could swallow very well immediately after the operation. OPERATIONS FOR GOITRE (STRUMA) I. Parenchymatous injections. Injections of tincture of iodine or of Lugol's solution (or alcohol, osmic acid, iodoform oil) may sometimes effect a decrease in simple, not too large, goitres (parenchymatous) (after a preceding inflammatory reaction); sometimes, however, they meet with no success. They are administered in intervals of from two to three days, in doses beginning with half a Pravaz's syringeful, but gradually increasing to a full syringe. Whether the syringe has been properly inserted into the tumor is recognized from the movements of the canula in an upward and downward direction during deglutition. It is dangerous to inject the solution into a vein, because sudden death (embolism) may ensue. Hence, it is necessary first to draw the needle a little before making the injection. The injection must be made very slowly. II. Puncture with subsequent injection of tincture of iodine or LugoVs solution is of some value in struma cystica, only when the walls of the cyst 626 SURGICAL TECHNIC are rather thin and have not too many pouch-like distensions of the cyst wall. The puncture is made with a trocar under most careful aseptic precau- tions with the skin drawn tense. The trocar must not be too small, because the contents of the cyst are often composed of a thick (colloid) fluid. The evacuation must be made slowly, because by relieving the pressure too rapidly, hemorrhages are easily caused in the interior of the cyst. For dressing, iodoform-collodion and a light compressive bandage are used. (Parenchymatous injections are useless in adenomata of the thyroid gland and seldom of signal value in cystic goitre. In miasmatic goitre paren- chymatous injections of a 5% solution of carbolic acid repeated at intervals of a week and combined with the internal and external use of iodine seldom fails in reducing the swelling.) III. Incision with suturing of cyst wall to skin (Chelius). In strnma cystica and abscesses. 1. External incision over the most prominent part of the swelling with avoidance or double ligation of the larger veins. 2. Cutting through the superficial cervical fascia. 3. Stitching the exposed wall of the cyst and fascia to the margins of the skin by a continuous quilt suture. 4. Incision of the cyst in the line of the external incision, cleansing, tamponing. In larger cysts, if necessary, the exposed portion of the anterior wall is resected ; under some circumstances, thorough drainage without free incision proves successful in very large cysts. Profuse parenchymatous hemorrhage (in struma cystica parenchymatosa Stromeyer) is arrested by firm packing with iodoform gauze, peroxide of hydrogen gauze, or zinc chloride gauze. If the extirpation of isolated cysts can be made easily, it is to be pre- ferred to incision {Muller). IV. Extirpation of Struma (Strumectomy) (Billroth, Rose, 1878). The total extirpation of the thyroid gland, according to present experience, is no longer permissible, since, in consequence of the operation, epileptic fits, paralysis of the muscles of the larynx, cachexia, myxoedema, fatal tetany, and idiocy are caused or threatened (cachexia thyreopriva KocJier}. It should be considered only in the surgical treatment of malignant disease (sarcoma, carcinoma) ; and then the implantation of fresh glandular substance into the abdominal walls may prevent cachexia after complete extirpation, as well as the administration of the fresh gland or its extracts (thyroidin, iodothyrin Baumanri). OPERATIONS ON THE NECK 627 Hence, in all other cases, only the Unilateral extirpation is considered, and this only when still sufficient healthy glandular substance is present on the other side. Kocher proceeds as follows : i. External incision according to the seat and the size of the tumor in the median line of the neck along the inner margin of the sternocleidomastoid ; FIG. 1196 FIG. 1197 KOCHER'S EXTIRPATION OF STRUMA (Strumectomy). a, transverse incision; b, angular incision in very large strumas, angular incision or trap-door incision. A simple trans- verse incision, " Kragenschnitt," ascending more on the diseased side than on the healthy side, is followed by the slightest cicatrix (Figs. 1196, 1197). (A curved transverse incision with the convexity directed down- ward and following the lower border of the swelling is the one which is now generally resorted to in performing partial and com- plete strumectomy.) 2. After division of the platysma and the superficial fascia, and after a careful double ligation and division of all visible blood vessels, the sternohyoid, the sternothyroid, and the omohyoid mus- cles, if necessary, are separated in the median line close to their insertion into the larynx. If possible, they are divided only partly and in a transverse manner. The sternocleidomastoid, freed suffi- ciently at its anterior margin, is drawn aside with blunt retractors. The external capsule of the goitre now exposed as a thin layer of connective tissue is incised. It is separated with the goitre probe (Fig. 1198) from the struma (ligation of the veins), so PROBE "98 628 SURGICAL TECHNIC that its posterior surface can be reached by passing one finger along the external margin of the goitre. 3. The goitre is turned out toward the median line (luxated) very care- fully and cautiously, in order not to lacerate the blood vessels, which are exposed to great tension. 4. TJie inferior thyroid artery, lying behind the turned-out goitre in the form of a curve from the outer side to its place of insertion on the trachea, is carefully freed (recurrent nerve) and ligated, but not divided ; likewise the accompanying vein. At the inferior margin, the very large thyroid vein is divided after a double ligation. FIG. 1199. RIGHT-SIDED STRUMA, SHOWING THE RAMIFICATION OF SUPERFICIAL VEINS (Kocher) FIG. 1200. DIAGRAM SHOWING LIGATION OF LARGE VEINS NECESSARY IN EXTIR- PATION OF STRUMA (Kocher) I, A. and V. thyreoidea sup.; 2, V. thyroid, sup. access; 3, V. thyroid, inf. access; 4, thyroid, inf.; 5, V. thyr. ima princeps and access. r, 5. Entering with Kocher's director above the isthmus at the medial border of the upper horn, the surgeon, after a double ligation, divides an ascending ramus of the superior thyroid vein in the median line, and draws the upper horn forcibly upward with the fingers until the superior thyroid vessels become very tense. He then isolates them with the director, and ligates them ; he divides the superior thyroid artery and vein. 6. On the superior and inferior borders of the isthmus, the superior and inferior communicating veins are ligated and divided ; the director is slowly OPERATIONS ON THE NECK 629 inserted between the isthmus and the trachea ; the isthmus is secured with two strong ligatures, and divided between them. 7. The goitre is then raised with the left hand from the trachea and its posterior margin, still adhering to the trachea, and is detached from it, care being exercised not to injure the recurrent nerve ascending at this place. Since this nerve can be injured in spite of all precaution, it is more practical, by a vertical incision made parallel to the trachea, but a little distant from it, to leave in position a portion of the posterior portion of the cap- \" sule for its protection. FIG. 1 201. POSTERIOR VIEW OF LARYNX AND TRACHEA WITH NEIGHBORING TRUNKS OF VESSELS (Course of re- current nerve) FIG. 1 202. RECURRENT NERVE AND INFERIOR THY- ROID ARTERY (Wolfier). The recurrent nerve of the pneumogastric nerve, or inferior laryngeal nerve, arises from the vagus, on the right beneath the subclavian artery, on the left beneath the arch of the aorta, ascends behind these vessels, in the groove between the trachea and the oesophagus behind and toward the median line from the common carotid, upward to the lower margin of the cricopliaryngeus muscle. Below this it enters the interior of the larynx from behind, across the upper margin of the lateral cricothyroid ligament, accompanied by the inferior thyroid artery (Figs. 1201, 1202). 630 SURGICAL TECHNIC 8. The external wound is sutured, leaving a space at the most dependent part for free drainage. Under a compressive bandage, the healing can take place in one to two weeks. V. Resection of Goitre (Miculics) is made in diffuse colloid degeneration on both sides, for the purpose of avoiding the serious complications produced by total extirpation (recurrent paralysis), by allowing to remain a portion of healthy glandular substance in connection with the point of entrance of the inferior thyroid artery, whereby the recurrent nerve is most securely pro- tected, and remains uninjured. This procedure, however, can be modified variously, leaving at times the inferior, at times the superior pole, at others the isthmus of the glands. After division of the skin, muscles, and fascia, one-half of the goitre is isolated bluntly ; next, at the superior cornu, the superior thyroid artery and vein are ligated ; at the inferior cornu only the superficial vessels are ligated. The isthmus, bluntly detached from the trachea, is divided after double ligation " en masse," while an assistant laterally compresses with his fingers the blood vessels entering into it. The lateral flap to be resected is detached with the scissors from the anterior and lateral surface of the trachea. The portion situated at the angle between the trachea and the (esophagus is allowed to remain. With the aid of strong clamp forceps, which squeeze otit the parenchyma, it is ligated with strong catgut ligatures, and in several sec- tions tied off like a pedicle by ligatures "en masse." The latter contracts to a nodule of the size of a chestnut in the angle between trachea and oesophagus. To avoid the separation of the tumor from the lateral surface of the trachea, and also the contusion of the recurrent nerve, by the ligature " en masse," risks which are always to be apprehended, Kocher, with the knife, circumscribed the capsule of the gland near the isthmus (hilus) by a circular incision perpen- dicular to it (sagittal). The upper section of the circle, however, must lie completely above the cricoid cartilage. By this means, injury to the recurrent nerve is excluded almost with certainty. Finally, a small flap of the thyroid gland, similar to the normal one, is formed from the remaining stump. Next the pedicle of the detached half of the goitre is divided longitudinally in several sections with probe-pointed scissors ; each part is grasped with strong clamp forceps and ligated, and then the whole tied-off mass is divided with the scissors. VI. Enucleation or intraglandular extirpation (Porta, Socin) in cysts and in well-circumscribed adenomatous nodules and in bilateral goitres. After cutting through the skin, fascia, capsule (capsula extema sive fasciosa, deep OPERATIONS ON THE NECK 631 cervical fascia), and the overlying (healthy) attenuated glandular tissue (glandular capsule}, the several glandular nodules are enucleated bluntly. Sometimes the operator can proceed still more rapidly if, by a deep incision, the adenoma is at once divided into two equal parts, and each half is enucleated with the fingers and the sharp spoon (evacuation, Kocher}', often, however, a very violent hemorrhage ensues. Hence it seems to be more advisable, according to Rose, by means of an elastic tube as thick as the little finger, to constrict the tumor behind its greatest diameter, whereby the hemorrhage is prevented ; at the same time, after the division of the capsule, the glandular tissue is squeezed out of the wound. Of course, in suitable cases, the methods of resection and enucleation just described can be practically combined. ENUCLEATION RESECTION (Kocher) which is to be employed for the removal of all isolated nodules. After the goitre has been luxated from a transverse or angular incision, as described on page 627, without ligating the large blood vessels, the isthmus is first divided after a double ligation. From this incision the internal cir- cumference of the goitrous nodule is separated. The veil of glandular tissue is undermined in an upward and downward direction with Kocher's director, and a double ligature applied in a horizontal line. Next, from this place, the nodule is enucleated with the finger first above and below, then also at its posterior surface from the glandular substance. The latter is then vertically divided with the scissors at its posterior surface as far as the ligatures on the anterior surface between the inferior and superior cornua. The nodule is then removed, together with the tissue covering it. VII. Ligation of the Afferent Arteries (-von Walther, Wolfler). In vascular goitre and Bascdow's disease. (a) Ligation of the superior thyroid artery. 1. External incision 4 centimeters long along the internal margin of the sternocleidomastoid across the great cornu of the hyoid bone as far as the thyroid cartilage. 2. Division of the platysma. The artery is found in front of the great cornu of the hyoid bone in the triangle between the omohyoid, digastric, and sternocleidomastoid muscles. Kocher and Rydygier searched for the artery from a transverse incision extending from the margin of the sternocleidomastoid to the body of the hyoid bone. The anterior branch of the artery is always to be felt on the 632 SURGICAL TECHNIC lar sup. -thyr.sup. cricothyr. median upper side of the superior cornu of the (enlarged) thyroid gland, passing downward at the side of the larynx. (b) Ligation of the inferior thyroid artery. Von Langenbcck made the external incision 6 centimeters long in the groove between the two heads of the sternocleidomastoid -muscle. 1. Division of the platysma, ligation of the transverse cervical vein, the transverse vein of the scapula, the external jugular vein. Division of the deep cervical fascia, splitting the sternocleidomastoid muscle in an upward direc- tion. 2. The tendinous part of the omoJiyoid muscle appears in the middle of the wound, and is drawn outward or divided. The internal jugular vein, which is now exposed, is drawn toward the median line. The carotid, the pneitmogastric nerve, and the anterior scalenus muscle covered by cellular tissue and fascia can be inspected. 3. After blunt division of the lat- ter, the phrenic nerve becomes visible and is pushed outward. Along the internal margin of the anterior scale- nus muscle, which is drawn a little toward the outer side, the arch of the inferior thyroid artery (sympathetic nerve /) is seen. (See also Fig. 1202.) To avoid the danger of injuring the sympathetic nerve, Wb'lfler draws the large blood vessels and the pneumogastric nerve inward. Rydygier in ligating this artery proceeds as follows : 1. The external incision 6-7 centimeters long extends 2 centimeters above and parallel to the clavicle, transversely across the clavicular portion of the sternocleidomastoid muscle and the supraclavicular fossa. 2. After incising the platysma and the superficial cervical fascia, both forefingers penetrate in a perforating manner through the loose cellular and adipose tissue behind the sternocleidomastoid as far as the margin of the anterior scalenns muscle. The lymphatic glands are removed. 3. The sternocleidomastoid with the large blood vessels of the neck and the pneumogastric nerve are lifted with long blunt \\ook& forward and inward, so that the wound gapes widely. Then there appears on the internal margin of the anterior scalenus muscle the thyrocervical trunk, from which the -lar. inf. -thyr. inf. FIG. 1203. DIAGRAM OF ARTERIES SUPPLYING LARYNX AND THYROID GLAND OPERATIONS ON THE NECK 633 inferior thyroid artery branches off in an inward direction. This vessel is secured by a double ligature. Kocher ligates the artery at a place where, behind the carotid, it curves toward the thyroid gland inwardly. 1. External incision transversely across the clavicle (jugulum) in a curve obliquely upward and outward across the sternocleidomastoid. 2. Platysma and sternocleidomastoid are forcibly retracted outwardly, the omohyoid and the sternohyoid muscles are drawn downward and in- ward ; the jugular vein, the common carotid, and the pneumogastric nerve are isolated on the internal margin, and drawn outward. Then between the latter and the margin of the thyroid gland (or the sternothyroid muscle), the operator advances toward the vertebral column. 3. The thyroid gland is raised inwardly, and the convex arch of the artery is then seen lying upon the longus colli muscle beneath the recurrent nerve, which crosses it. If the extirpation of the diseased thyroid gland appears impossible or impractical, the following palliative operations may be attempted : Jaboulay raised the goitre from its natural position and lifted it, so to say, by his exothyreopexia. From a median incision, the goitre is carefully separated bluntly with the fingers from its connections, and the loosened lobes are luxated outward and surrounded with sterilized gauze. After the gauze is removed on the fourth day, the skin contracts over the goitre of its own accord, while the latter gradually contracts, because the distortion of the large vessels has impaired its nutrition. Since this procedure, however, may cause thrombosis, Wb'lfler makes a dislocation of the goitre in a similar man- ner by drawing it out from its bed, where it causes functional disturbances (for instance, between trachea and sternum), and by fixating it under the skin and the sternocleidomastoid, mostly at a higher level. As a substitute for extirpation, which can no longer be performed, owing to the extent or location of the disease, he also recommends puncturing with the needle point of the thermo-cautery. LIGATION OF THE ISTHMUS OF THE THYROID GLAND was recommended by Gipp and Jones for the relief of dyspncca and other pressure symptoms. The external incision extends in the median line from the thyroid cartilage dowmvard. The isthmus is detached bluntly from the trachea, constricted by ligatures " en masse " on both sides of the trachea, and divided between them (or the whole portion pressing upon the trachea is resected). 634 SURGICAL TECHNIC Asphyxia is especially to be feared as a serious accident in operations for goitre. It may be caused : 1. By anesthesia. 2. By paralysis of the recurrent laryngeal nerves. 3. By a complete compression of the scabbard-shaped compressed trachea (when the head is turned laterally and the goitre is turned out) (Figs. 1204, 1205, 1206). /fi V^i \5Krf? ;*!, m FIG. 1204 FIG. 1205 FIG. 1206 SCABBARD-SHAPED COMPRESSED TRACHEAE (Demme) To prevent this compression-stenosis, either the lateral tracheal walls may, during the operation, be drawn apart with sharp hooks, or the lumen of the trachea may be kept patent by simple pressure of the finger upon the anterior wall. For the more permanent removal of the stenosis, a strong catgut liga- ture with a curved needle is passed at two places through the lateral walls of the trachea and drawn together over the angular anterior margin in such a manner that the lateral walls are separated (Kocher). In dyspnoea of a high degree, chloroform anaesthesia must be avoided (not ether, on account of the aspiration of profuse tracheal secretions), and a moderate morphine anaesthesia or local anaesthesia must be attempted. The latter is to be recommended also for all operations for goitre of short duration. (At the present time, Kocher performs all his operations on goitres under Schleich's infiltration method.) OPERATIONS ON THE NECK 635 Tracheotomy should be avoided as much as possible in all these opera- tions, since it renders asepsis almost impossible (phlegmonous mediastinitis ; aspiration). FIG. 1207. KONIG'S FLEXIBLE CANULA FOR TRACHEOTOMY IN STRUMA If, in substernal and firmly adherent goitres, the surgeon is compelled previously to the operation to perform tracheotomy above the seat of com- pression, on account of threatening asphyxia, a long fiexible canula must be introduced extending beyond the stenosis (Konig, Fig. 1207). OPERATIONS ON THE (ESOPHAGUS The introduction of the cesophageal tube is made for relieving the stomach of any injurious contents, or for conveying food into it. For this purpose, the ossophageal tube is connected by a rubber tube with a reservoir (douche, funnel, stomach pump) (Fig. 1208). The reservoir is filled with fluid ; the fluid flows into the stomach when the reservoir is lifted sufficiently ; the fluid and the contents of the stomach are siphoned out, when the reservoir is lowered sufficiently. If the oesophageal tube is to remain in position for some time, or if, on account of the resistance of the patient, it cannot be introduced through the mouth, it must be introduced through the lower meatus of the nose and the pharynx into the oesophagus. It can remain in position for a long time without causing any especial inconvenience. The patient sits on a chair in front of the surgeon with his head extended, his mouth wide open, and his tongue projected. The surgeon depresses with his left forefinger the base of the tongue, and introduces the instrument held near its end with his right hand, like a penholder. Having previously lubricated the instrument well with oil, or, better, with glycerine, he introduces it carefully along the posterior pharyngeal wall into the FlG I2og STOMACH stomach. (The cardiac orifice lies in the adult about 40 PUMP 636 SURGICAL TECHNIC centimeters beyond the incisors.) In introducing the instrument, the sur- geon, as a rule, meets with some resistance in the region of the cricoid cartilage. This resistance can be removed by drawing with the point of the left forefinger the base of the tongue, together with the larynx, forward toward the lower jaw (Fig. 1209). It is also advisable to direct the instrument more toward the left side. If a stronger resistance is felt in the lower sections of the oesophagus (foreign bodies, tumors, strictures, aneurisms), great care must be taken not to use too much force. A perforation is easily caused in the surrounding tissue, which has nearly always undergone a change, lessening its resistance. FIG. 1209. INTRODUCING CESOPHAGEAL TUBE . Should the instrument happen to enter the larynx instead of the oesopha- gus, a violent paroxysm of coughing and asphyxia at once ensues, whereas in most cases only choking sensations are caused by a proper introduction ; these may be mitigated by deep breathing and movements of deglutition. If the instrument has passed the larynx, it can be pushed forward without producing irritation. (In the adult the introduction of the oesophageal tube is very much facili- tated by cooperation of the patient. The unpleasant gagging is often entirely prevented if the patient will manage the tube himself and advance it during efforts at swallowing.) Foreign bodies in the oesophagus must be removed from it as soon as possible, since they provoke inflammation (and perforation) of the oesophag- eal wall, as well as dysphagia. If they are firmly impacted behind the larynx, they may be extracted either with the forefinger, bent like a hook, or with curved dressing forceps ; OPERATIONS ON THE NECK 637 if these prove of no avail, they must be exposed, if necessary, by subhyoid pharyngotomy (see page 608). If they are lodged in the upper portion of the (esophagus itself, the surgeon may, in many cases, succeed in grasping and extracting them with FIG. 1 210. MATTHIEU'S LARYNGEAL FORCEPS FIG. 121 1. TIEMANN'S FLEXIBLE LARYNGEAL FORCEPS FIG. 1212 FIG. 1213 FIG. 1214 LARYNGEAL FORCEPS FIG. 1215 curved long-billed forceps, which open and close in different directions ; great caution, however, must be observed in order not to cause any lacera- tions of the mucous membrane (Figs. 1210-1215). 638 SURGICAL TECHNIC o Flat, hard, coinlike bodies are best grasped with Graft's coin-catcliet (Fig. 1217). The disklike movable blades at the end of this instrument are pushed past the body, and when the instrument is withdrawn, they catch and remove the foreign body. (Grdfes coin-catcher is a very dangerous instrument in removing foreign bodies that are or are liable to become impacted.) Colliris adjustable oesophagus hook (Fig. 1218) also renders excellent service. It consists of a flexible rod, at the end of which there is a small curette-like hook, which, by a screw arrangement on the han- dle, can be adjusted to any desir- able position so that the foreign body can be grasped or released at pleasure. Sharp-pointed bodies (needles and fish bones) are removed by sweeping out the oesophagus with suitable instruments. Weiss s fish- bone catcher (Fig. 1216) has at its lower end a sponge, and over it a network of bristles which, by traction on the handle, open into an umbrella-shaped disk ; the in- strument is introduced closed, and withdrawn open ; by this means, the foreign bodies, if not pushed into the stomach by the sponge, are caught in the bristle work. If the operator does not suc- ceed in extracting the foreign body in spite of all these attempts, he must try to push it down into the stomach, best with a flexible whalebone rod, to the end of which a sponge or an ivory knob FIG. 1216 WEISS'S FISH-BONE CATCHER FIG. 1218 COLLIN'S ADJUSTABLE CESOPHAGUS HOOK FIG. 1217 GRAPE'S COIN-CATCHER AND PROBANG has been fastened (probang or cesophageal bougie, Fig. 1217). For the pur- pose of facilitating the passage of the foreign body through the intestinal canal as harmlessly as possible, the patient should eat potatoes, rice, and bread OPERATIONS ON THE NECK 639 exclusively ; these produce ample faeces to envelop the foreign body ; the stools, of course, must be carefully examined. In this manner, even large bodies with sharp edges (set of teeth) may pass through the intestines with- out causing injury or disease. It is not advisable, however, to increase by purgatives the peristaltic action of the intestines for hastening the passage of the foreign body. If the foreign body is so firmly impacted in the lower section of the oesophagus that it can neither be extracted nor pushed down into the stomach, the attempt must be made to extract it by external cesophagotomy (see page 223). STRICTURES OF THE CESOPHAGUS To determine more accurately the seat of a stricture, a bougie of large caliber is introduced until arrested. Next, the distance of the obstruction from the incisors is measured. By selecting bou- gies of decreasing diameter, the operator endeav- ors successively to pass the stricture with them. Whether this has been successful is ascertained from the fact that the point of the bougie is grasped on being withdrawn. In most cases, it is then possible to pass a bougie of the next smaller diameter through the stricture, and thereby to ascertain its diameter. In attempting gradual dilation the bougie, after it has passed the stricture, is allowed to remain in position 10 to 20 minutes, producing in most cases a slight (inflammatory) softening of the surrounding tissue ; on the next day, after a previous introduction of the same bougie, the next larger one can be immediately introduced ; this, in turn, remains in position for the same length of time. This process is continued until the desired caliber of the lumen has been effected. The treatment with bougies is best conducted by using the piriform point and a thin neck ; whalebone probes, provided with ivory olive-shaped tips of varying sizes (Fig. 1219) are in some cases also useful (more particularly in ascertaining the location and degree of the stenosis). Trousseau's probe (Fig. 1220) has at each end three olives of increasing size. ... . ... FIG. 1219. ELASTIC elastic bougies with a BOUGIES WITH OL- IVE-SHAPED TIPS FIG. 1 220 TROUSSEAU'S PROBE 640 SURGICAL TECHNIC Leyden obtained good results by the use of permanent tubes short, hard rubber tubes which remain in position in the constricted place and facilitate the introduction of food. They are introduced into the stricture by means of a probang with soft conical point ( Wolff \ and can remain in position for months. They can be easily withdrawn by means of a silk thread fastened to them previously, which hangs out of the mouth while the canula remains in position (Fig. 1221). If the surgeon is not successful in dilating the stricture in the desired manner by treatment with bougies, he may attempt to remove the stricture at once by nicking it with instruments made for that purpose. They operate after the manner of urethrotomes and are similarly constructed (cesopJia- gotome) (Figs. 1222, 1223) (internal cesopliagotomy Maisonnenve). It is better and less dangerous, however, in such cases to perform gas- trostomy. Sometimes it is possible subsequently to dilate (cicatricial) stric- tures from this opening in tJie stomacli {retrograde dilatation). Kraske introduced a ligature knot from the mouth through the stricture into the stomach ; he then washed the thread out from the gastric fistula by irriga- tion ; next, by tying to the ligature ivory olives of- gradually increasing size, and by passing them through the stricture, he dilated the stricture gradually and completely (Fig. 1224). Lange tied to such a ligature small three- edged knives (Fig. 1225), as in Maisonneuve 's urethrotome. Drawn up by the thread, they nicked the stricture from below upward. Socin had the patient swallow a bird shot fastened to a ligature for dilating such constric- tions. When this has succeeded and the ligature has been brought out of the opening of the stomach, the surgeon can also make von Hacker s endless probings with stretched caoutchouc threads or drainage tubes stretched tense over a probe and hence made thinner. They are introduced by means of the ligature. When the traction is discontinued, they contract and become thicker. Next, in succession, larger tubes are tied to the thinner one in position in the stricture. These, drawn through the stricture, accomplish the desired dilatation in a very short time. EXTERNAL CESOPHAGOTOMY (Goursaud, 1/38), tJie external opening of the cervical portion of the cesop/iagus, is made : 1. For removing firmly impacted foreign bodies. 2. For bloody or forcible blunt dilatation of strictures, especially when they are situated very low down. The operation is performed on the left side of the neck, because the oesophagus lies more to the left behind the trachea. The patient is placed OPERATIONS ON THE NECK FIG. 1221 LEYDEN'S PROBE WITH PERMA- NE'NT TUBE FIG. 1222. Trelat's FIG. 1223. Collin's CESOPHAGOTOM E FIG. 1224 IVORY OLIVE ACCORD- ING TO KRASKE FIG. 1225. LANGE'S THREE-EDGED KNIVES FOR RETROGRADE DILATATION .1 FIG. 1226. VON HACK- ER'S DRAINAGE TUBES STRETCHED OVER A PROBE AND CUT OFF LATERALLY in a half-sitting position, with his head turned toward the right. If possi- ble, an oesophageal tube, as thick as possible, or a large probe (or the " ectropcesophag"} is introduced into the oesophagus. 642 SURGICAL TECHNIC 1. The external incision, about 5 to 7 centimeters long, extends along the anterior margin of the sternocleidomastoid from a level with the cricoid cartilage downward (as in the ligation of the carotid) (Fig. 1228). 2. After cutting through the platysma and the superficial cervical fascia, care being taken not to injure the external jugular vein, the sternocleido- mastoid is drawn outward. 3. Division of tJie middle cervical fascia, with or without preserving the omohyoid muscle ; the left lateral lobe of the thyroid gland is drawn with blunt retractors toward the median line. FIG. 1227 FIG. 1228 EXTERNAL CESOPHAGOTOMY. a, opening the oesophagus, sheath of vessel drawn outward; b, external incision 4. The operator penetrates as bluntly as possible with two strabismus hooks in the depth of the wound, where he meets first the common sheath, enclosing the carotid, the jugular vein, and the pneumogastric nerve; over the latter passes the descending ramus of the hypoglossal nerve. If the whole sheath is drawn outward with a broad blunt retractor, the wall of the flat roundish oesophagus, with its longitudinal fibres lying behind it, is brought into view (Fig. 1227). 5. After the introduction of an ossophageal tube, the opening of the oesophagus is made easily upon it. If the opening must be performed free hand, it is made best between two dissecting forceps, in which case the OPERATIONS ON THE NECK 643 strong muscular coat and the mucous membrane only, loosely connected with it, are lifted up and divided. The height and length of the opening depend on the seat and the nature of the trouble for which the operation is performed. 6. From this wound, the foreign body can now be exposed and removed. In difficult cases, traction loops are applied through the margins of the wound to keep the visceral wound open (BillrotJi). In case of cicatricial stricture, the incision is best made closely above or below the same, and from this incision the dilatation is made ; in this case, the eye can survey the operation to be performed. The blunt dilatation should be made with dilating forceps (Roser), which are introduced, closed, and then opened (glove stretcher). Finally, with the probe-pointed knife, the cicatricial contraction may be nicked m several places, but very superficially, or the dilatation can be made with a hernia knife guided upon a grooved director (combined cesophagotomy Gussenbauer). 7. After removal of the obstruction, an oesophageal tube is introduced from the nose into the stomach, and the several layers of ossophageal wall are closed over it by sutures. Duplay sutures only the mucous membrane. Fisher allows fluids to be swallowed without an oesophageal tube, a few hours after the operation. The external wound can be loosely sutiired and drained, or, still better, packed, in order to prevent most effectually reten- tions and gravitation (mediastinitis). If the opening of the oesophagus has been made below a tumor, obstruct- ing the lumen of the oesophagus, and if it is not possible to extirpate the tumor from the wound, or, at least, to make the oesophagus permeable, the margins of the oesophageal wound are sutured to the external skin (cesopha- gostomy) ; a lip-shaped oesophageal fistula, through which the patient can be nourished, is thus established. This procedure can be recommended also for very narrow strictures, deeply located, which must probably be treated for some time (von Hacker). In tumors of the oesophagus which are not too large and are well circum- scribed, the oesophagus may be resected (Czerny), i.e. transversely divided above and below the tumor ; if the removed portion is not too large, the two ends can be united by suture, else the operator attempts to bring the lower end by strong traction into approximation with the upper end ; but if this does not succeed, he must suture the lower end into the wound of the skin and thus form an artificial mouth (lip-shaped fistula). In tumors which are entirely inoperable, gastrostomy (see page 680) is indicated as a palliative operation. 644 CESOPHAGEAL DIVERTICULA can be extirpated. From an external incision extending as far as the clavicle (jugulum), the pouch is exposed, separated in part, bluntly; in part, with the knife from the surrounding tissues, and cut off where it is attached to the cesophageal tube. While this is being done, sutures, placed very closely together, are inserted through the mucous membrane of the oesophagus and tied after the removal of the pouch. Likewise, the connective tissue over- lying this row of stitches is sutured separately. A firm tampon is applied upon the cesophageal wound. Likewise, the remaining skin wound, which is only in part sutured, is tamponed for about six days (von Bergmami). Kocher obtained primary healing of the cesophageal wound by applying a double ligature at the neck of the diverticulum before amputation ; he divided the pedicle with the thermo-cautery, and then cauterized the mucous membrane thoroughly. The stump of the mucous membrane was covered first by suturing the muscularis and adventitia, and finally sutured to the cesophageal wall in a longitudinal direction. CEsophagoplasty (von Hacker, Hoclicncgg), after extensive resection, is intended to supply by skin flaps the defects which have been caused. By inverting two lateral flaps, first the posterior wall is formed ; after it has healed firmly, the anterior wall is formed by a flap with the skin side turned inward ; the raw surface of this flap is covered by sliding a lateral cervical flap. TENOTOMY OF THE STERNOCLEIDO- MASTOID in congenital wryneck (torticollis, ca- put obstipum) under the protection of asepsis is no longer made subcutane- ously (Stromeyer), but openly by ex- posing the parts which must be divided (von Volkmanri}. The head is drawn toward the healthy side, so that the fibres of the clavicular and sternal insertions of the sternocleidomastoid are stretched forcibly. FIG. 1229. TENOTOMY OF THE STERNOCLEIDO- MASTOID OPERATIONS ON THE NECK 645 1. External incision, i to 2 centimeters long, extending over the promi- nent band, about a finger's breadth above the clavicle, first, along the inser- tion of the sternomastoid, until the muscle, often degenerated to a white shining tendon, appears to view. After it has been grasped with a tenacu- lum (Fig. 1229), it is lifted out and divided upon the instrument (external jugular vein /). 2. If the cleidomastoid causes tension, it is divided in the same manner, if possible, through the same skin wound. FIG. 1230. STROMEYER'S OBLIQUE BED 3. The little wound is sutured completely. After the operation, the patient is placed upon an extension bed ; his head is drawn upward by a weight, fastened by means of a support to the chin and the neck (Glisson's sling), while the weight of the body itself makes the necessary counter extension, the bed being placed in an inclined position. Afterward, the patient is placed upon this oblique bed for the greater part of the day (Stromeyer, Fig. 1230); his head is kept in position by Glissoris sling, and is turned toward the diseased side by an oblique position of the curved crop piece. The extension of the muscle may be still further increased by having the arm of the diseased side extended by means of a weight and pulley. Since the cicatrix lying between the muscular ends and the connective tissue surrounding the muscle always tend to retract, Miculicz in serious cases made the 646 SURGICAL TECHNIC EXTIRPATION OF THE STERNOCLEIDOMASTOID (MidiUcZ, 1 891) 1. External incision, 3 to 4 centimeters long, between the two heads of the muscle ; division of the platysma. 2. By retraction of the margins of the wound, both tendons are sepa- rated, one after the other, undermined, and cut off upon an elevator (internal jugular vein) immediately above their origin, from the clavicle and the sternum. 3. Each end is grasped with forceps, forcibly drawn upward, and enu- cleated as far as its point of conjunction, in part, bluntly; in part, by pushing with the knife. 4. By inclining the head toward the diseased side, the operator succeeds, from the small skin wound, in freeing the diseased muscle as far as the mastoid process, and in cutting it off with the scissors as closely to the same as possible. But the posterior superior portion of the muscle, perforated by the spinal accessory nerve, must be preserved, else paralysis of the trapezius muscle ensues. 5. The head is then turned as much as possible toward the healthy side, and the tense fibres of the shortened muscular sheath are carefully dissected out. 6. The little wound is sutured throughout ; the mal-position of the head is temporarily but little improved. This operation is followed by a marked disfiguration in the external form of the neck, because the prominence given on that side by the sternocleido- mastoid has been removed ; but the time of treatment is shorter and the correction of the deviation permanent. OPERATION FOR CERVICAL TUMORS Encysted tumors of the neck (deep aiheromatous cysts'} lying upon the vascular sheath, as a rule, require no extirpation, since they can nearly always be obliterated by puncturing with subsequent injections of iodine ; it is necessary, however, to irrigate the sac of the cyst with boracic solutions through the canula of the trocar, until the irrigating fluid flows out clear; not until then should the injection of Lugol's solution be made (see hydro- cele testis). (The removal of diseased cysts by enucleation is a comparatively easy and safe operation, and can always be relied upon in effecting a permanent cure.) OPERATIONS ON THE NECK 647 FIG. 1231. TOPOGRAPHY OF THE REGION OF THE HEAD AND NECK (Superficial Layer), temp. A. and V. temporalis with N. auriculotempor; zygom. A. zygomatica; trans. A. transversa faciei; coron. A. coronaria from A. maxillaris ext.; angul. A. angularis; occip. A. and V. occipitalis major; access. N. accessorius Willisii; at its side supraclavicular nerves; N. auricularis magnus; N. subcutaneus colli med. 648 SURGICAL TECHNIC FIG. 1232. TOPOGRAPHY OF THE NECK (Deeper Layer). (Heitzmann.) I, carotis communis; 2, art. subclavia; 3, carotis externa; 4, carotis interna; 5, A. maxillaris ext.; 6, art. occipitalis; 7, A. temporalis; 8, A. maxillaris interna; 9, A. lingualis; 10, A. thyreoidea sup. ; II, truncus thyreo-cervic; 12, A. vertebralis; 13, A. thyreoidea inf.; 14, A. transversa scapulae; 15, A. cer- vicalis superfic. ; 16, A. transversa colli; 17, A. cervicalis ascend.; ad, Ram. descend, nervi hypoglossi; a, M. sternocleiodomasteus; b, M. cucullaris; c, M. splenius capitis; J, M. scalenus ant.; e, M. omohyoideus; f, M. stylohyoideus; g, M. hyoglossus; h, M. mylohyoideus; t, M. biventer; k, M. sternothyreoideus; /, M. sternohyoideus; m, M. stylopharyngeus OPERATIONS ON THE NECK 649 Extirpation of solid tumors is an operation not attended by any special difficulties, if they are well encysted and not firmly attached to the surround- ing tissues. After the capsule has been exposed, they can be enucleated with the fingers or blunt instruments (Kocher's director, or Cooper's scissors closed} with ease, and without any considerable hemorrhage. But the operation may become extremely difficult when the tumors are intimately connected with the surrounding tissues, more especially with the large blood vessels (jugular vein and carotid artery). Injury to the veins is then always the principal danger, partly on account of the violent hemorrhage, partly on account of the possibility of air entering the -veins, an accident that may cause instant death by air embolism and cardiac insufficiency. Often an accidental nicking of the veins cannot be avoided, for, unless a vein is filled with blood, it cannot with certainty be distinguished from a band of cellular tissue ; hence, the incisions should always be directed toward the tumor, and when the edge of the knife is in the neighborhood of the larger blood vessels (the relative position of which in large tumors may have been materially changed), it is advisable frequently to discontinue the pressure and traction upon the tumor and to allow the veins to become filled with blood, which makes them discernible. In spite of all precautionary measures, sometimes a large vein is injured; the operator, believing that he is divid- ing a band of cellular tissue, may in reality cut off a portion of the jugular vein itself, or a lateral branch inosculating with the same, and make a round opening in the wall of the vessel. In such a case, the wound suddenly be- comes inundated with a flood of dark blood ; if air enters the vessel (in case the patient is in the act of inspiring), a hissing noise is heard, and with the next expiration, the blood, rushing from the central part of the vein, is frothy. Only the immediate application of the finger upon the vein wound or upon the vein on the proximal side of the wound can avert the threatened danger. The attempt must be made to grasp the injured wall of the vein with hemostatic forceps, and to close the open- ing, if it is not too large, by a lateral ligature with a fine, strong, silk ligature (lateral ligature, Fig. 1233); otherwise, if the opening is too large, the vein is separated entirely from its surrounding tissue and ligated above and FIG. 1233. LATERAL below the place of injury. (Such wounds of a vein have occasionally been closed successfully with the continuous suture.) 6$0 SURGICAL TECHNIC The accidental nicking of the artery can be avoided more easily on account of its thicker walls. If, however, the carotid passes through the tumor, or is firmly adherent to it, the portion of the artery involved must be included in a double ligature and resected with the tumor. Injury and ligature of the pneumogastric nerve, which lies behind and between the artery and the vein, must be carefully avoided as far as possible. (Figures 1231 and 1232 may serve to illustrate the topography of the region of the neck.) Suppurating lymphomata softened by caseous degeneration can be cleanly enucleated from the surrounding tissues only in rare cases, because any injury to their capsule (which is often very thin) causes the contents to flow out and the tumor to collapse and lose its tension. In such a case the surgeon should incise them and scoop them out thoroughly with the sharp spoon. The pockets thus produced are dilated with dilating forceps, and smoothed. In the technique of making the incisions, the following rules may be observed : In dissecting out, the edge of the knife should always be directed toward the tumor, and the incisions should be made almost perpen- dicularly upon the capsule. Each vessel, as it becomes visible, is ligated doubly before its division. By traction on the portion to be removed, wher- ever it is possible, the operator should try to create an emphysema of the cellular tissue, which makes the limit of the healthy and the diseased tissue most easily discernible. In this case the surgeon can advance more rapidly with the handle than with the edge of the knife. Finally, never dissect "in the dark." If the tissues are flooded with blood, the blood must be removed by quick sponging before the surgeon proceeds with the operation. If the enucleation does not succeed well in one place and causes difficulties, the surgeon should try some other place. Hence, never persist too long in one certain place, but proceeding first in one place, then in another, as occasion demands, detach the tumor from its base. If muscles that cannot be drawn aside are in the way, they may be divided and subsequently reunited by sutures ; diseased portions of the same must be excised unhesitatingly. The wound, which is sometimes very extensive, can, as a rule, be completely closed by suturing after all the tumors have been thoroughly extirpated. In the most dependent part of the wound cavity a drainage tube is inserted. If suppuration existed, the cavity of the wound is tamponed and subsequently closed by secondary sutures. (In cases in which the glands of the neck are extensively involved, the S-shaped external incision recommended by the editor a number of years OPERATIONS ON THE BREAST 6 5 I ago exposes the field of operation most satisfactorily, and leaves the slightest disfiguration from the resulting scar.) Since the cicatrices resulting from extensive extirpations of the glands swell more and more in the course of time, and cause a very great disfigura- tion, Dollinger, for cosmetic reasons, makes subcutaneous extirpation by a skin incision extending from a level with the external auditory meatus along the limit of the hairy scalp, and I centimeter distant from it to the occiput. From here he succeeds in lifting out bluntly, not only the gland situated behind the superior portion of the sternocleidomastoid and behind the max- illary angle, after the skin has been undermined and elevated with the fingers, but also in enucleating in the same manner the glands lying on the vascular sheath and on the clavicle. After the wound of the skin has been sutured, nothing of the extensive radical operation is noticeable on the neck. OPERATIONS ON THE BREAST LIGATION OF THE INNOMINATE ARTERY (Mott, l8l8) The trunk of the innominate artery, 2 centimeters long, lies behind the manubrium sterni in front of the trachea between the right innominate vein and the left common carotid artery, close upon the right pleural dome. It is covered by the left innominate vein lying transversely over it. Behind the right sternoclavicular articulation it divides into the snbclavian and the rigJit common carotid arteries (Fig. 1234). V.A. FIG. 1234. RAMIFICATION OF THE LARGE BLOOD VESSELS BEHIND THE STERNUM FIG. 1235. EXTERNAL INCISIONS FOR LIGATING INNOMINATE ARTERY Von Langenbeck Bardenheuer The head is well extended and turned a little to the left over the edge of the operating table or a pillow for the neck. i. Curved external incision beginning above the left stern qday^ij^cr articulation and ascending transversely across the upper marjnn jrf the ^ " -\ i'Ltc L.-V < LV 652 SURGICAL TECHNIC manubrium sterni, along the inner margin of the right sternocleidomastoid ( von L angenbeck) (Fig. 1235). 2. After division of the platysma and the superficial cervical fascia, if necessary, the right sternoJiyoid and the sternotJiyroid muscles are divided, and the sternal portion of the right sternocleidomastoid muscle is detached from the sternum. 3. Division of the deep cervical fascia ; the bulbus of the internal jugular vein, with the pneumogastric nerve and the common carotid, are then exposed to light. 4. Whilst the vein and the nerve are carefully drawn outwardly with blunt retractors, the carotid is followed centrally as far as the subclavian, and the latter is likewise followed, carefully avoiding the pneumogastric nerve, the recurrent nerve, and the phrenic nerve, as far as the trunk of the innominate artery. 5. With the artery hook a strong ligature is passed from below upward (injury to the pleura is thus avoided) around the artery as high as possible (toward the aorta). The ligature is tightened very gradually. Since access to the innominate artery is very difficult from above, and since, on account of the depth of the wound, the surgeon cannot obtain a sufficient survey, the sternal end of the clavicle can be resected (von Berg- mann} if it seems necessary, or, according to Bardenheuer, the artery may be exposed by the resection of the manubrium sterni (see page 653). LIGATION OF THE INTERNAL MAMMARY ARTERY in injuries of the same from gunshot or punctured wounds can be made only with difficulty, on account of the limited field of operation after the wound in the intercostal space has been enlarged. Resection of a costal cartilage over the vessel wound affords, however, more space. 1. External incision 5 to 7 centimeters long parallel with and near the sternal margin (Fig. 1236). 2. After division of the superficial fascia, the fibres of the pectoralis major muscle, and the pcrichondrium of the exposed rib, a piece about 2 centimeters long is excised from the latter with the knife (or costal scis- sors) (see also page 655). 3. Perpendicular division of the external intercostal muscle (ligamentum cjafs (Fig. 1272), Liicke's, and others can be employed. These instruments are applied in such a manner that the portion of the pylorus can be excised at least 2 centimeters distant from the margins of the disease. The duodenum is compressed by one clamp ; the stomach by two clamps from above and from below. If the clamp cannot be well applied on the duodenum, on account of firm adhesions, two ligature loops OPERATIONS ON THE ABDOMEN 687 are drawn through the intestinal wall and the mesenteric insertion; by means of these, the intestine is somewhat drawn forward and flexed. On FIG. 1267. Billroth's FIG. 1268. Hahn's FIG. 1269. Rydygier's INTESTINAL CLAMPS FIG. 1270. Wehr and von Heineke's the other side of these clamps, the healthy part of the stomach is closed by the fingers of the assistant ; on the duodenum, however, a second clamp is applied. 5. The tumor is grasped with broad Muzeuxs forceps, and the stomach is cut through with a pair of straight scissors mostly in an oblique direction (Fig. 1273). The incision begins at the lesser curvature above on the left, and extends downward to the right ; each visible blood vessel is ligated after each sweep with the scissors ; when the lumen of the stomach has been opened, its con- tents are at once absorbed by a sponge, introduced into the stomach, and it is wiped antiseptically with a second sponge. At the greater curvature, the stomach is still left in connection with the pylorus corresponding about to the size of the circumference of the duodenum. 6. The wound of the stomach, commencing at the lesser curvature, is at once sutured by a double row of suttires according to Czerny-Lembert (occlu- sion suture, Fig. 1274, a). After that, the incision of the stomach at the greater curvature is completed. 688 SURGICAL TECHNIC 7. Parallel to the incision of the stomach, the operator then divides the duodenum obliquely between tJie two clamps, advancing step by step and carefully arresting the hemorrhage. (Obliquity of visceral incision at the expense of the convex border of the stomach.) FIG. 1271. Gussenbauer's FIG. 1272. Kiister's PARALLEL FORCEPS FIG. 1274. a, occlusion suture; b, cir- cular suture BlLLROTH-WoLFLER'S RESECTION OF THE PYLORUS 8. He then stitches the duodenum to the decreased wound of the stomach (circular suture) according to the rules of circular enterorrJiaphy (see page 704). Commencing at the lesser curvature, he first applies the inner mucous membrane sutures as far as practical, and next over these a second row of sutures according to Lembert (seromuscular). Whether he employs the interrupted suture or the continuous suture makes no differ- ence ; a continuous suture with silk is applied more rapidly, and closes the wound very well. 9. After the rows of sutures have been once more carefully examined and after such parts as appear weak have been strengthened by interrupted sutures placed between them, the surface is sponged with antiseptic solu- tion ; the compress placed beneath it is removed, and the stomach is OPERATIONS ON THE ABDOiMEN 689 returned into the abdominal cavity. The sutures of the external incision are applied as described on page 675. The patient is nourished during the first three or four days exclusively by nutrient enemata ; after that time, liquid nourishment is administered (see page 676). FIG. 1275 FIG. 1276 RYDYGIER'S RESECTION OF THE PYLORUS, a, incisions; b, suture The stitching of the duodenum to the greater curvature (Rydygier, Bill- roth, Wolfler) creates a more useful channel for the passage of the food than its insertion at the lesser curvature, as was done first. The stomach, distended in most cases, becomes by the occlusion suture more like a cul de sac (Fig. 1276). For avoiding such saclike formation in case the lumina to be united differ too much in size, the operator must try to equalize these irregularities by making the incision through the stomach near the great curvature oblique (Fig. 1275, a). Implantation of the duodenum into the middle of the wound of the stomach offers no advantage. In some cases in which the neoplasm has become so extensive that the reunion of the resected parts would be impossible without very great tension, Billroth first made gastro-enterostomy, extirpated the tumor, and closed the opening in the stom- ach and the duodenum by suture (Fig. 1276). Kocher obtains very good success with pylorus resection and gastroduodenostomy. He divides first the duodenum between the two clamps ; next, the stomach along the clamps ; and closes the latter completely by continuous silk sutures extending through all layers (Fig. 1278). A row of Lemberfs sutures FIG. 1277. BILLROTH'S RESECTION OF PYLORUS AND GASTRO-ENTEROSTOMY 690 SURGICAL TECHNIC is applied over this row of sutures. The assistant then turns the poste- rior wall of the stomach anteriorly, pressing it at the same time toward the right margin of the external wound to the duodenum, which has been drawn forward, and which thereby becomes occluded. The posterior mar- gin of the duodenum is then sutured by serous sutures to the posterior wall of the stomach, and the clamp is removed from the duodenum. The posterior side of the stomach is incised longitudinally, about | centimeter FIG. 1278 FIG. 1279 KOCHER'S RESECTION OF PYLORUS AND GASTRODUODENOSTOMY from this sutured place corresponding to the breadth of the duodenum, and after ligation of all bleeding vessels, first the posterior (Fig. 1279), and, in con- nection with it, the circular, sutures are applied, extending through the whole thickness of the intestinal wall, the serous coat, the muscular coat, and the mucous membrane. Over this, the serous suturing of the anterior part is made in addition to the posterior serous sutures previously applied. The success of this procedure has been very good up to the present time. GASTRO-ENTEROSTOMY (Wolfler, 1 88 1), the formation of a fistulous opening between the stomach and the small intestine by suturing a portion of the small intestine to the wall of the stomach, is made as a palliative measure in inoperable cancer of the pylorus or in recurrence of the same after previous resection, and in strictures of tJie duodenum, for the escape of the contents of the stomach into the intestine. i. Longitudinal incision in the linea alba from the ensiform process to the umbilicus ; the peritoneum is divided and stitched with a few sutures to the external skin. OPERATIONS ON THE ABDOMEN 691 \ 2. The transverse colon and the amentum are brought out with the fingers and placed in an upward direction to the right. The duodenojejunal fold of the peritoneum, from which the small intestine emerges, is now seen ; its mesentery always be- comes longer to the left ; and at a distance of 40 to 50 centimeters it is so long that the intestine can be applied to the stomach across the colon (Fig. 1280). 3. This portion of the small intestine is drawn from the ab- dominal wound ; a portion about 10 centimeters long is stripped empty with the fingers, and clamped on both sides with rub- ber bands, with thick silk liga- tures, or with Rydygier's clamps, which are passed through small slits made in the mesentery with forceps (" Schiebern"). Except the two parts which are to be incised, viz. the portion of the small intestine and the wall of the stomach, everything is re- turned into the abdominal cavity, and the whole abdominal wound is covered with sterilized warm compresses. 4. The clamped-off loop of the small intestine is opened by an incision 3 centimeters long at the side opposite to the mesenteric insertion ; the hemorrhage is arrested, and the inner surface is sponged antiseptically. It is advantageous to make the incision as small as possible, since large incisions promote subsequent " spur " formation. 5. The anteiior wall of the stomach is grasped by the assistant, lifted up near the fundus, or even in the middle between the f undus and the pylorus ; it is securely clamped off with his fingers, with GjissenbaueS s clamps, or with Brims' s clamp-forceps ; and then opened between the same by an incision 3 to 5 centimeters long at a place about 4 centimeters above the large curva- ture (where the coronary artery branches off into smaller ramifications). The hemorrhage is arrested, the inner surface of the stomach is irrigated with a weak antiseptic solution. The incisions in the wall of the stomach FIG. 1280. DUODENOJEJUNAL FOLD, TRANSVERSE COLON AND OMENTUM PLACED IN AN UPWARD DIRECTION 692 SURGICAL TECHNIC and the portion of the small intestine may be made either longitudinally (Wolfler, Fig. 1281) or transversely (Socin, Fig. 1282). FIG. 1281. Wolfler's FIG. 1282. Socin's GASTRO-ENTEROSTOMY. a, making incisions; b, coronary artery 6. Applying the stiture. First, the posterior margins of the wound are united by the internal mucous membrane suture (Wolfler, Fig. 1312)35 far as possible ; the remainder is closed by an external mucous membrane suture, and finally the serous coat is closed all around by Lembcrf s suture or by Gushing 1 s continuous rectangular quilt suture (see page 704). The following modifications of this procedure must be mentioned : Von Hacker (and Courvoisier) recommends stitching the loop of the small intestine to the posterior wall of the stomach in order to prevent strangulation of the transverse colon by the loop of the small intestine laid over it. For this purpose, after the colon and the omentum have been turned up, he makes posteriorly in a blunt man- ner a slit in a non-vascular portion of the mcsocolon, stitches its gaping mar- gins to the posterior wall of the stom- ach ; next, he sutures the loop of the small intestine in this opening to the posterior wall of the stomach (Fig. 1283). This can become very difficult ; the transverse colon with the great omen- tum remains in its normal position in front of the loop of the small intestine. Even now, many surgeons recom- mend this as the best operation. FIG. 1283. VON HACKER'S GASTRO- ENTEROSTOMY OPERATIONS ON THE ABDOMEN 693 Wolfler, to prevent vomiting caused by the bile flowing into the stomach and thence with the gastric contents into the proximal part of the intestine, formed a valve over the proximal crus of the small intestine by suturing the right half of the intestinal opening to the intact wall of the stomach, and only the left portion to the margin of the opening of the stomach (Fig. 1287). FIG. 1284 FIG. 1286 DIAGRAM OF GASTRO-ENTEROSTOMY Fig. 1284: M, stomach; C, colon and small intestine in normal position; I, mesentery; 2, meso- colon; 3, gastrocolic ligament; 4, great omentum; ^~>, WQlfler's procedure; s~\l>, von Hack- er's procedure. Fig. 1285: Wolfler's antecolic gastro-enterostomy. Fig. 1286: Von Hacker's retrocolic gastro-enterostomy According to his suggestion, the same end can be attained by completely dividing- the loop of the small intestine and by implanting the inferior distal end into the wound of the stomach, while the superior proximal end, some- what contracted by the suture, is implanted into the distal end (\g. 1288). Von Hacker narrowed the proximal intestinal portion by a serous tobacco- pouch suture. FIG. 1287 FIG. 1288 WOLFLER'S GASTRO-ENTEROSTOMY Lticke takes any loop of the small intestine lying nearest to the wound and having a sufficiently long mesentery, and sutures it to the stomach in such a manner that the distal end comes to lie to the right, but the proxi- mal to the left, so that the peristaltic motion of the stomach and the intes- tine takes place in the same direction from left to right. He tries to ascer- 694 SURGICAL TECHNIC tain the direction of the peristaltic movement by touching it with a crystal of sodium chloride, which, according to NothnagcT s experiments, produces an antiperistaltic motion on the intestine of rabbits. But, unfortunately, the success of this experiment is not perfectly sure in man. KocJicr proceeded in a similar manner by mak- ing the incisions in the stomach and the small intestine and the application of the suture as seen in Figs. 1290 and 1291. Subsequently he operated so as to stitch the intestinal loop, after a transverse opening, to the anterior wall of the stomach, so that the proximal segment came to lie under the distal segment (Fig. 1292). In this case, the distal segment can close the proximal segment ; but not vice -versa. Doyen formed a longitudinal valve on the proximal intestinal segment. He perforated the gastrocolic omentum ; through the opening he placed the entire great omentum into the lesser sac of the peritoneum (to guard against the subsequent compression of the loop by the transverse colon), and stitched the colon to the greater curvature of the stomach. Only then did he suture the intestinal loop to the greater curvature to an extent of 10 to 12 centimeters; in the middle of this suture, he made a fistulous opening FIG. "i 289. LUCRE'S GASTRO-ENTER- OSTOMY FIG. 1290 FIG. 1291 KOCHER'S GASTROENTEROSTOMY. a, incisions; b, suture FIG. 1292 3 to 4 centimeters long. The proximal intestinal segment received thereby a higher position (Fig. 1294), and also a valve extending in longitudinal axis by means of a few Lembert sutures. If the operation must be made as rapidly as possible, on account of the weak condition of the patient, it is advisable to open the abdomen under OPERATIONS ON THE ABDOMEN 695 local anaesthesia, and to form the fistula according to the simplest method ( Wolfler or von Hacker) by employing the Murphy button (see page 705). FIG. 1293 FIG. 1294 DOYEN'S GASTRO-ENTEROSTOMY FIG. 1295 Finally, in cases in which even gastro-enterostomy is impossible, and in which the necessary absolute rest of the intestinal canal for several days might endanger the life of the very much exhausted (starved) patient, it is preferable to make duodenostomy instead of this operation (Maydl\ or, still better, jejunostomy {Albert}, which is easier and less dangerous : 1. The abdominal wall is incised transversely at the pit of the stomach. 2. Fifteen to 20 centimeters from the duodenojejunal fold, the small intestine is drawn forward sufficiently, and completely divided transversely; the peritoneal cavity is closed temporarily by a few sutures. 3. The distal intestinal end is incised 10 centimeters below its margin at the convex side for a distance of 3 centimeters, and the proximal end is implanted laterally by suturing. 4. The peripheral intestinal end is fastened in the left angle of the abdominal wound with four interrupted sutures, so that it projects 2 centi- meters over the skin. The introduction of food through this fistula is easy. The digestive juices from the liver and the pancreas are preserved for the patient as in Fig. 1288. Albert modified jejunostomy by forming an anastomosis at the base of a prolapsed loop (see page 708). He drew forward the apex of the intestine through a second skin-incision above the first, as in Frank's gastros- tomy (see Fig. 1265), and incised it a few days subsequently with the thermo-cautery. The anastomosis lies directly behind the wound of the abdominal wall in the abdominal cavity. 696 SURGICAL TECHNIC If the stricture of the pylorus has been produced by scar contraction, and if, at least at the anterior wall, no considerable adhesions with the surround- ing parts are present, the attempt has been made to dilate the stricture with the finger, by indenting the anterior wall of the stomach with the tip of the finger and pushing it into the pylorus, without incising the stomach, and thus dilating the pylorus. Or the stricture is divulsed through an opening in the stomach by digital or instrumental dilatations (Loreta). Much better and of more permanent effect is the plastic dilatation of tJie pylorus. PYLOROPLASTY, according to Heineke and Miculicz. A longitudinal incision, not too long (58 centimeters), is made through the entire cicatricial portion, and is united again in a transverse direction, so FIG. 1296 FIG. 1297 VON HEINEKE'S PYLOROPLASTY. DIAGRAM OF SUTURE FIG. 1298. Gastroplasty FIG. 1299. Gastroanastomosis IN HOUR-GLASS CONTRACTION OF THE STOMACH that the duodenal angle of the incision is in apposition to the angle of the stomach (Figs. 1296, 1297). OPERATIONS ON THE ABDOMEN 697 In the hour-glass contraction of the stomach, for dilating the constriction, this operation is made in a similar manner (Fig. 1298), or a gastro-anas- tomosis, according to Wb'lfler, is made at the most dependent part of the two sacs. ENTEROTOMY The opening of the intestine by an incision becomes necessary when it is desirable to remove foreign bodies or pedunculated tumors (lipomata, adeno- mata, sarcomata, etc.). For the extraction of an impacted foreign body, the incision is made as long as required, parallel to the longitudinal axis of the intestine on the side opposite to the mesenteric insertion. (A transverse incision on the con- vex side of the bowel furnishes ample room for the extraction of the foreign body, and, after suturing, is not as liable to constrict the lumen of the bowel as when made in an opposite direction.) Pedunculated tumors are cut off after a needle has been passed through the pedicle and the same has been ligated on both sides. Next, the wound in the intestine is closed by enterorrhaphy (see page 702). ENTEROSTOMY, the formation of afistulous opening in the intestine and the abdominal wall, is made either for a temporary or permanent evacuation of the intestinal contents above a place through which their passage is obstructed (acute and chronic intestinal stenosis from invagination, volvulus, adhesions, strangula- tion by bands, reposition of hernias, with the strangulated neck of the hernial sac, reposition " en bloc," from cicatrization following ulceration, and neoplasms that cannot be removed by extirpation). According to the part of the intestine to be opened, we distinguish ileostomy and colostomy. A temporary enterostomy is made in cases of intestinal obstruction, in which the manner and seat of the obstruction cannot be determined with certainty, and in which the distention of the intestine from gaseous or faecal matter (septic intestinal paralysis) has gone so far that there is danger of the patient's not surviving an operation of the magnitude involved in the removal of the obstruction. The intestine is opened at a point lying as nearly above the supposed seat of the stenosis as possible, in order to prevent intestinal exclusion to such an extent as would impair nutrition. With a perfectly certain diagnosis of the seat of the obstruction, the abdomen is opened at the place where this 698 SURGICAL TECHNIC portion of the intestine is located ; if the diagnosis cannot be made with certainty, the operator selects for the incision places where certain sections of the intestine (colon) can be found with some degree of certainty ; the right inguinal region, in which the ccecum is found, and the left inguinal region, where the lower extremity of the descending colon, the sigmoid flexure, lies (inguinal colostomy), or the anterior abdominal region between the umbilicus and the sternum, where the transverse colon takes its course (colostomia media). If, in existing meteorism or tympanites of high degree, instead of the colon, a greatly distended loop of the small intestine presents itself in the wound, the latter is opened, if it is desirable only to create at some place a temporary outlet for the intestinal contents. Colostomy in the inguinal region is made in the following manner : i. External incision, 5 to 6 centimeters long, a finger's breadth above, and parallel to, the external half of Pouparfs ligament, obliquely upward to the anterior superior spine of the ilium (Fig. 1300). 2. Division of the aponeurosis of the external oblique muscle, blunt divi- sion of the fibres of the internal oblique muscle and of the transversalis muscle, until the peritoneum is exposed. 3. Incision of the peritoneum. Stitch- ing of the visce- ral peritoneum to the margins of the external wound. 4. Bringing the large intes- tine into the wound. The large intestine is often surrounded with loops of the small intestine, but it can be distinguished from the latter by its paler color, its sacculated appearance (haustra), and its longitudinal bands (taeniae). In order to deter- mine which is the proximal and which is the distal part, the operator pal- pates along the intestine until he reaches the obstruction ; or, if possible, he injects water from the anus, and follows the course of the distention. (Insufflation with air is better as a diagnostic aid.) 5. The serous coat of the intestine is ^OKOfSulured to the parietal peri- FlG. 1300. Suturing intestine FIG. 1301. Applying suture INGUINAL COLOSTOMY (Sectional View) OPERATIONS ON THE ABDOMEN 699 toneum in the wound with silk sutures, extending only through the serous and the muscular coats of the intestine on one side, and the peritoneum on the other (Fig. 1301); the sutures are applied as closely as possible; the sutures remain long, and are spread in a radiating manner around the wound. The closure becomes still denser if a continuous suture is applied after the application of four interrupted sutures at the angles of the wound and at the middle portion of the wound edges. If it is necessary to relieve the patient as rapidly as possible, the operation is made at one sitting ; then follows : 6. The opening of the intestine longitudinally with the knife or the cutting thermo-cautery ; for the purpose of guarding against the entrance of faecal matter into the peritoneal cavity between the sutures, it is advis- able to cover the whole line of sutures with a thick layer of salicylic vaseline, to powder it with iodoform, or to cover it closely with strips of gauze. If, however, the condition of the patient permits, the operation sJiould be made in two stages, and the intestine should be opened only after 2 to 4 days, when the adhesions between the peritoneal surfaces have taken place in the meantime, furnishing adequate protection against peri- toneal infection from the faecal discharges. The intestine is then irrigated, and into the proximal segment a drainage tube as long as possible is introduced ; this projects beyond the skin, and protects it as much as possible from contamination (eczema). If the origi- nal obstruction has been removed, this temporary intestinal fistula can be easily closed by vivifying its margins and suturing, or by resection and cir- cular enterorrhaphy. FORMATION OF AN ARTIFICIAL ANUS, from which the total intestinal contents can be evacuated permanently, is in- dicated in obstruction of the rectum by tumors that cannot be reached and removed from the anus, and by old obstinate ulcers (syphilis) of the same. The descending colon is opened as low down as possible. According to the older methods, the colon was opened either from behind and extraperi- toneally, or from the front through the abdominal cavity. It is advisable, however, to search for and open the sigmoid flexure in the left inguinal region. Only in exceptional cases does the surgeon still perform : i. Extraperitoneal lumbar colostomy according to Callisen-Amussat : by a vertical incision from the twelfth rib downward to the crest of the ilium ; next, the posterior side of the descending colon, which is not covered by the peritoneum, is sought for, stitched to the wound, and opened. 7oo SURGICAL TECHNIC 2. 77/(? intraperitoneal lumbar colostomy according to Fine : by a vertical incision 15 to 20 centimeters long from the tip of the eleventh rib down- ward the peritoneum is opened ; stitching of the anterior wall of the descend- ing colon to the margins o f the wound. Most generally employed and most practical is the inguinal colostomy of the sigmoid flexure (anus inguinalis, sigmoidostomy), first recommended by Littre (inguinal anus). The operation is made on the left side in the same manner as temporary colostomy described above (see page 698, I to 4). 3. The S. Romanum (sigmoid flexure) can be recognized by its appendices epiploicae, and is sought and drawn forward from the wound as far as its mesenteric insertion ; under this, through a slit made bluntly in the mesen- tery, a gauze compress or a small rod (hard rubber, glass probe, sound, etc.), wrapped with iodoform gauze, is introduced transversely, so that the same rests like a bridge upon the margins of the skin, while the intestine rides upon it (Maydl, Fig. 1302). 6 a FIG. 1302 FIG. 1303 INGUINAL COLOSTOMY. I, intestinal loop drawn forward; 2, intestinal loop divided completely; a, proximal end; b, distal end 4. If the intestine is to be opened at once, the two limbs of the loop are sutured together by serous sutures, below the bridge (Fig. 1303, i), as well as to the margins of the wound, so that the proximal portion has ample space and the distal part is compressed by the latter (Kocher). But if the OPERATIONS ON THE ABDOMEN 701 operation can be made in two stages, then only the limbs are stitched together by a few sutures, and the whole is wrapped with iodoform gauze. The opening is not made until after two to three days, when adhesions have formed. (It is always necessary to suture the base of the loop to the parietal peritoneum. In one case in which this was not done by the editor, during a violent fit of vomiting extensive prolapse of the small intestines occurred.) 5. The intestine is then divided in a transverse direction, preferably with the red-hot knife point of the thermo-cautery. After the lumen has been opened, the aperture is enlarged very gradually (in a rapid evacuation of faeces, collapse and sudden death may occur, ScJionborri). First, only about one-third of the circumference of the intestine is opened ; next, thick rubber tubes are introduced into the two bowel ends, and the contents of the intestine are thoroughly washed out by irrigation. The complete division down to the bridge (Fig. 1303, 2) is not performed until after the expiration of fourteen days. If the operation is made as a palliative measure in incurable disease of the rectum (cancer), it is advantageous, for irrigating the distal excluded inferior extremity more conveniently, to divide the intestine at once com- pletely, and to suture each extremity separately into the wound, so that, if possible, a skin bridge about i centimeter wide is formed between the two intestinal openings (Ha/in, Konig). Witzel makes the abdominal wound more than 12 centimeters long, so that a broad bridge can be sutured be- tween the two openings stitched to the angles of the wound. This is preferable to complete division and closing the lower extremity after inversion of its margin by serous sutures and returning the bowel end into the pelvis (Madehtng). The often observed descent of rectal tumors and the prolapses of the colon through the anus, which are often very extensive, suggest the idea that it may be possible to make high-seated but non-adherent tumors still accessible from the anus by tying the portion to be returned securely to a long rubber tube, which is introduced from the anus by applying over it the occlusion suture. Next, after a forcible dilatation of the anus by daily slow traction on the tube, the operator seeks to make a prolapse of the lower end together with the tumor. If the tumor then lies near the anus or in front of it, it is cut off as described in removing a prolapse of the rectum (von Esmarch\ 702 SURGICAL TECHNIC ENTERORRHAPHY Intestinal suture serves for uniting intestinal wounds. I. In partial division of the intestinal wall. For intestinal sutures are used very fine silk and fine round needles, either entirely straight (English pearl needles, No. 12), or curved only at their points, or semicircular. Von Hagedorris needles are also very useful. (Ordinary sew- ing needles of different sizes are very useful in all kinds of intestinal work.) To avoid losing time during the opera- tion, by tedious threading of the needle, it is well to have a sufficient number of threaded sterilized needles on hand (for instance, in the intestinal needle-case, Fig. 1305, or some similar arrangement). The type of all intestinal sutures now in use is FIG. 1304 FIG. 1305 FIG. 1306 VON ESMARCH'S NEEDLE CASE FOR INTESTINAL SUTURE LEMBERT S SEROUS SUTURE I. In making this suture, the needle is inserted about 4 millimeters from the margin of the wound, is carried for some distance between the mucous membrane and the mus- cular coat, and brought out again closely in front of the margin of the wound. On the other side, the procedure is made in a reversed direction. In tying the knot, the margins of the wound are inverted ; and the serous surfaces are brought in accurate contact with one another (Figs. 1307, 1310). Instead of the interrupted suture, the operator may also use the contin- uous suture, which can be made more rapidly (Fig. 1308). (The student should be made familiar with the importance of includ- ing in the suture a few fibres of the submucous fibrous coat so well studied and described by Halsted. These fibres are the main support of the sero- muscular suture.) 2. Czerny's double-rowed suture is an improvement upon the former {&o In modern times, however, under the pro- tection of asepsis, the operator is justified in opening the abdominal cavity and in resecting the adherent portion of the intestine, whereby success is obtained more rapidly. i. First, for securing more effective asepsis, the opening in the abdomi- nal wall with the two intestinal lumina is circumscribed with the knife in the shape of a myrtle leaf ; the skin lying between the margins of the incision and the intestinal openings is dis- sected off from the fascia, and folded together over the intestinal opening. The margins are then placed perpen- dicularly to each other, and united by a continuous suture so closely that no intestinal contents can escape. (The editor has for a number of years resorted to transverse preliminary suturing of the intestinal opening as a safe precaution against infection during the operation. After the field FIG. 1332. ANUS PR^ETERNATU- RALIS. a, clamp applied; b, section of spur; c, after opera- tion FIG. 1333 FIG. 1334 VON BERGMANN'S DOUBLE RUBBER BALL 714 SURGICAL TECHNIC of operation is once more disinfected and the intestine detached, this row of sutures is covered by Lembert stitches.) 2. The abdominal cavity is now opened ; the intestinal loop is detached and drawn forward from the wound. The latter is decreased in length tem- porarily by a few sutures. 3. After clamping off the two ends in the manner described in resection of the intestine, they are separated transversely at a suitable place, and a corresponding portion of the mesentery is detached. Then follows the union of the two intestinal ends by circular entcrorrhaphy (see page 704). This operation can be performed with greater facility by resorting to Trendelenburg' s position, in which all movable intestines gravitate toward the diaphragm, and only the adherent intestinal loop remains in the wound. OPERATIONS FOR HERNIA All enteroceles must be retained, if possible, by suitable trusses ; else the swelling constantly enlarges, and the danger of strangulation is always increased. The wearing of a truss in infants and young children may often effect a radical cure. Trusses in reality are composed of a pad (pelotte, cushion), which is pressed against the seat of the hernial protrusion, or the mouth of the hernial sac, by means of an FIG. 1335. GERMAN TRUSS elastic steel s P rin applied around the pel- vis, so as to prevent effectually and per- manently the descent of the abdominal contents. In the German truss (Fig. 1335), the pad is immovable, and is connected at an obtuse angle with the spring encircling the pelvis on the diseased side. By a strap or belt, the pad is held in position more securely (Figs. 1336, 1337). In the English truss (Salmon}, the pad, movable on a ball-and-socket joint, is connected with the spring, which, by means of a posterior pad, is supported on the sacrum, and encircles the healthy side of the pelvis. In this truss, the strap can often be dispensed with (Figs. 1339, 1340). Of the many modifications of the pads we may mention here only the glycerine pad, which can be filled from without and the pressure regulated at pleas- ure (Fig. 1338), and the circular air pad, which is said to apply itself every- where, more accurately over the hernial canal, than the common leather pads. OPERATIONS ON THE ABDOMEN 715 In the truss for umbilical hernia, the pad is pressed upon the hernial opening by means of a circular elastic strap surrounding the abdomen. In small children, umbilical hernias can be most successfully treated in most cases by small pads (balls of cotton), which are kept in position by strips of FIG. 1336. For Inguinal Hernia FIG. 1337. For Femoral Hernia GERMAN TRUSS APPLIED FIG. 1338 TRUSS WITH GLYCERINE PAD FIG. 1339 FIG. 1340 ENGLISH TRUSS FIG. 1341 FIG. 1342 TRUSSES FOR UMBILICAL HERNIA FIG. 1343 adhesive plaster upon the skin, raised in two folds on each side of the hernial opening, or by means of a rubber bandage, with a small hemispherical rub- ber ball, which must be applied over the hernial canal (Figs. 1341-1343). 716 SURGICAL TECHNIC Each truss should be manufactured by the trussmaker, under the super- vision of the surgeon, since it is often very difficult, and sometimes almost FIG. 1344. ANATOMY OF INGUINAL REGIONS Femoral vessels and epigastric artery Fascia lata and saphenous opening (/b) External orifice of inguinal canal and through which the saphenous vein spermatic cord passes to join femoral impossible, to make a perfectly fitting truss ; a badly fitting truss, or one that fails to operate effectively, does more harm than good. In order to ascer- FIG. 1345. ANATOMY OF INGUINAL REGION (Internal Abdominal Side). B. bladder; P. Poupart's ligament; G, Gimbernat's ligament; Oi. internal orifice of inguinal canal; A. V. femoral artery and vein; Ae. epigastric artery; Ao. obdurator artery (taking its origin at the left abnormally from the epigastric artery); Vs. spermatic vessels; Vd. vas deferens. I, middle hypogastric or urachal fold; 2, hypogastric fold; 3, epigastric fold. Between I and 2 lies internal inguinal fossa; between 2 and 3 lies middle inguinal fossa; exterior to 3 lies external inguinal fossa tain whether a truss safely prevents the hernial protrusion, the patient is requested to bring into play the muscular apparatus by which the abdomen OPERATIONS ON THE ABDOMEN 717 is compressed (a crouching position, coughing), to spread his legs, to ascend stairs, etc. If a hernia is strangulated, an attempt should always be made to reduce it into the abdominal cavity in a bloodless manner (taxis) (provided the surgeon can exclude gangrene). The procedure is as follows : The patient lies upon his back, with his pelvis elevated and his legs and thighs flexed for relaxing the abdominal walls and, hence, removing all tension from the hernial opening. Next, by a gentle, gradually increasing pressure with the finger tips and the whole hand, the operator attempts to reduce the hernial contents into the abdominal cavity. If, by this manipu- lation, the hernia does not soon recede, the surgeon may try to obtain the desired end by drawing forward the hernia and by lateral manipulations to and fro, by massage, and by directing the pressure upon the neck of the hernial sac, and by reducing always only a little of the contents at a time. P. FIG. 1346. FRONTAL SECTION THROUGH CRURAL ARCH. N. crural nerve; A. V. femoral arterv and vein; Ac. crural ring (exit of femoral hernias) (crural septum); G. Gimbernat's ligament; P. Poupart's ligament; 7'. pubic spine The use of anesthesia may essentially aid these attempts, by securing complete relaxation of the abdominal muscles and insensibility of the patient to pain. The application of cold (ice bag, spraying with ether or ethyl chloride) is often of signal service. In large old inguinal hernias, sometimes reduction is effected by apply- ing an elastic bandage over the whole hernia, and by applying an ice bag. All these attempts must be made quietly and persistently, without exerting too much force ; they must not be continued too long (about a quarter to half an hour) ; for Jierniotomy is safer and less dangerous than taxis continued too long and made too forcibly (laceration of the hernial sac, of the intestine, " reposition en bloc "). NOTE. The old procedure of Fabricins ab Aqnapendente, of suspend- ing the patient by his legs and shaking him, has sometimes, in desperate 7 i8 SURGICAL TECHNIC cases, brought about the desired result, since in this position the intestines gravitate toward the diaphragm, and hence produce traction from within upon the incarcerated intestinal loop. Trendclenbnrg s high pelvic position operates in the same manner ; with this, anaesthesia can also be employed. If, however, all these endeavors have proved unsuccessful, herniotomy must be made at once. HERNIOTOMY 1. External incision across the most prominent part of the swelling at the place of strangulation, after a transverse fold of the skin has been raised ; it is advisable to make the incision not too small (Fig. 1347). 2. Exposure and incision of the hernial sac. Between two forceps at the eminence of the swelling, near the neck of the hernial sac, gradually all movable layers of cellular tissue covering the hernial sac are carefully raised and di- vided in the manner described in the chap- ter on ligation of arteries (page 251). The incisions must divide only the raised fold. As soon as the cellular tissue folds can be raised, with difficulty, or not at all, the operator may assume that he has reached the hernial sac ; into the short incision that has been made, a grooved director is intro- duced in the direction of the two angles of the wound, and upon it all of the layers of the hernial sac are divided until the entire anterior wall of the hernial sac is freely exposed. The hernial sac as a rule may be recognized by its smooth surface, by the small adipose lobules (subserous fat) lying scattered upon it, and by the serous effusion shining through the same. Hence, if the operator is in doubt whether the hernial sac or an intestinal loop lies before him, he should attempt to raise a small fold with his ringers, and rub the inner surfaces of the fold upon each other. If the membrane, on palpation, appears to be thin-walled, it is the exposed hernial sac, for the oedematous swollen intestinal walls are much thicker on palpation, and cannot be raised at all in folds. If the hernial contents are adherent to the hernial sac under the incision, so that no thin fold can be raised with the finger tips, the operator seeks and generally finds another place, the condition of which no longer leaves any FIG. 1347. HERNIOTOMY (External incision) OPERATIONS ON THE ABDOMEN 719 doubt. Here the hernial sac is now raised between two forceps, so that a small fold is formed, and with the knife or scissors a small incision is made, from which the serous effusion immediately escapes with some force ; into this opening, the operator introduces a grooved director, upon which he divides the hernial sac in its entire length, so that he is able to survey the entire hernial contents. 3. With the finger, introduced toward the neck of the hernial sac, he examines the seat of the strangulation, and ascertains whether any adhesions exist, by palpating the hernial contents on all sides with the finger. If adhesions are found, they must be separated carefully and bluntly; but if they are too firm, they are detached with the knife in such a manner that thin portions of the wall of the hernial sac remain adherent to the intestinal wall. :i i Jt FIG. 1348. HERNIA KNIVES (Herniotomes) FIG. 1349. HERNIOTOMY (Relieving strangulation) 4. Relieving the strangulation. A hernia knife (kerniotome) (Fig. 1348) is pressed lengthwise with the blade upon the volar surface of the left fore- finger, and the finger is advanced as. far as possible toward the hernial opening, until its point feels the incarcerating ring. In this position, with a slowly increasing pressure, the oedema of the intestinal loop can often be displaced so far that the tip of the finger can penetrate into the constricted portion of the hernial canal. Next, the blunt end of the herniotome is pushed over the tip of the finger into the abdominal cavity ; the edge of the knife is directed against the strangulating margin ; and the margin is nicked by pressing the back of the knife with the finger. Pulling and cutting move- 720 SURGICAL TECHNIC ments must be avoided. These nicks may be repeated at several places of the hernial ring ( Vidal) (and then only superficially), until the finger tip can be pushed with ease into the abdominal cavity alongside the strangulated intestine. The location of the strangulating ring at which these nicks are made depends entirely on the kind of hernia. In external inguinal hernia, the hernial ring is incised in an outward direction ; in internal inguinal hernia, inward (to avoid tJie epigastric artery}. If any doubt exists as to which of the two kinds of hernia is present, the incision is made in an upward direction (Scarpa). In internal femoral hernia, the incision is made inward toward Gimbcr- nafs ligament ; and, since the obturator artery, springing from the epigastric artery, may take its course at this place (corona mortis) (Fig. 1345), the cut must be made only by pressure, not by drawing movements of the knife, so that the movable artery can recede from the knife and that only the rigid and tendinous parts are divided. By an incision made outward the great femoral blood vessels would be endangered if directed upward through Poupart's ligament, the epigastric artery, the spermatic cord, and the ligamen- tum rotundum or teres ; inferiorly, the saphenous vein might be injured. /;/ strangulations in the fossa ovalis, the operator incises the falciform process in an inward and upward direction. In the very rare variety of external femoral hernia, the incision is made outward. 5. Returning the hernial contents. If in this manner the strangulation has been removed, the operator has next to examine the condition of the strangulated intestinal loop and, above all, that part of the intestinal wall which had been subjected to direct pressure. For this purpose, the intestine must be somewhat drawn forward. If at the place of strangulation a dis- colored gray streak is found, it is to be feared that perforation will occur at this place ; the same fear must be entertained if the intestinal loop itself presents a dark bluish, black, or brownish color, with a dull surface, having lost its glistening, shiny appearance ; such a loop must not be returned. 6. If the intestine is still in good condition that is, if it displays a smooth, glistening surface, if it is colored pale red to dark bluish red (venous stasis), if it turns somewhat paler from pressure of the finger, and if peri- stalsis is excited on touching it with a crystal of sodium chloride it is gently sponged with an antiseptic solution, and returned into the abdominal cavity by pressure of the fingers as in taxis. If any difficulties arise during this manipulation, the hernial sac is drawn tense at its margin with dissecting forceps, whereby the obstructing formation of folds is removed. OPERATIONS ON THE ABDOMEN 721 7.. The hernial sac and its neck can now be treated as described in the radical operation (see page 722). If, however, the intestine presents a suspicious appearance, it may per- haps be returned, but a drainage tube must be introduced into the neck of the hernial sac, and the wound must be tamponed 'to prevent retention of pus, and peritonitis. If a perforation is to be apprehended from gangrene of the intestinal loop, the intestine is not returned ; the operator allows it to remain outside of the abdominal cavity in order to see whether it recovers and gradually recedes into the abdominal cavity, or whether a perforation takes place (anus prceternaturalis}. But, if gangrene is already clearly manifest, the intestinal loop must be prevented from slipping back, and must be fastened in front of the neck of the hernial sac, preferably by a thin bar or drainage tube wrapped with iodoform gauze. This bar is pushed through a buttonhole made in the mesentery (Fig. 1302); besides, the intestinal wall may be stitched to the surrounding parts by interrupted sutures, so that it cannot recede. If tJie gangrenous hernia Jias perforated into the hernial sac, a free incision of the hernial sac is sufficient. The immediate resection of the gangrenous intestinal portion with subse- quent enterorrliaphy has often been made successfully. Since, however, it cannot be ascertained, with any degree of accuracy, how far the inflamma- tion extends into the intestinal wall, and since the sutures do not hold securely in the inflamed tissue, a failure of the operation is always to be apprehended. The long duration of such an operation under anaesthesia, with patients whose general condition has suffered from the strangulation, must also be well considered. The latter disadvantage, however, might be avoided by postponing enterorrhaphy (which takes a very long time) until the following day ; it is then made without anesthesia, since the operation causes but little pain. Helferich makes above the gangrenous place an intestinal anastomosis, which can be rapidly effected. If other contents than the intestinal loop are found in the hernia, the operator must attempt to return the same into the abdominal cavity, if in a normal condition (ovary, bladder}. If he finds adherent, knotty, indurated, and hypertropJiic (lipomatous) omentum, it is cut off near the neck of the hernial sac after previous multiple manifold ligations, and the pedicle is returned into the abdominal cavity. (The stump of the omentum, especially if it is large, should never be reduced into the free abdominal cavity, because it retracts and in the small 722 SURGICAL TECHNIC intestinal area visceral adhesions are very liable to occur which may be- come the direct cause of intestinal obstruction. The stump should be anchored above the inguinal canal to the abdominal wall with a strong cat- gut suture.) RADICAL OPERATION FOR HERNIA is made (a) after herniotomy, if the intestine and the surrounding tissues are in a favorable condition. (&) In reducible hernias, when they cause trouble and can be kept in position by means of trusses only with difficulty, or not at all. (c) In irreducible hernias, if they become troublesome. (a) IN INGUINAL HERNIA The procedure is as follows : 1. External incision by raising a fold of integument over the eminence and largest diameter of the hernia. 2. Careful exposure of the hernial sac between two dissecting forceps in the manner described on page 718 ; likewise, the several layers of the loose cellular tissue surrounding the hernial sac, as far as they are not too firmly adherent, may be divided upon a grooved director, or upon a Kochers direc- tor, until the hernial sac itself is reached. From the same, the layers of cellular tissue are freed bluntly on all sides with the handle of a knife, or a Kochers director, until the whole hernial sac is entirely exposed as far as its neck. 3. The neck of the hernial sac is detached bluntly on all sides of the inguinal canal, and as high up as possible. After the hernial contents have been returned into the abdominal cavity by gentle stroking and compressing manipulations, strong traction is made upon the empty hernial sac, and its neck is firmly ligated as high up as possible with strong catgut ligatures ; to guard against slipping of the ligature, its ends can be carried with a needle through the hernial sac closely below the ligature, and tied around it on both sides. 4. A little below the place of ligation, the hernial sac is cut off trans- versely with knife or scissors, and the stump is returned into the abdominal cavity through the hernial opening. If, in case of adhesions of the hernial contents, the hernial sac must be freely opened to enable the surgeon to find and separate the adhesion, Czerny recommends uniting, by a continuous suture from within, the serous sur- faces of the neck of the hernial sac, forcibly drawn forward. OPERATIONS ON THE ABDOMEN 723 5. Closure of the inguinal canal. Its pillars are united by interrupted sutures. For suturing, either strong silk thread or silkworm gut or, best of all, silver wire is used, the ends of which are not knotted, but twisted (Sckede}. If the operator sutures with silk, the continuous bodice suture or Csernys lace suture may be used. Vivifying the pillars of the canal is unnecessary, as well as a complete closure of the same, which, in inguinal hernia, must be omitted even, in order not to compress the spermatic cord emerging from the lower angle of the canal. Provided the canal remains permanently contracted, the success of the operation is well assured. /;/ congenital inguinal hernia, the spermatic cord is found attached to the entire length of the hernial sac, so that it is difficult to sepa- rate it. In this case, it is advisable to leave the hernial sac together with the testicles in the scrotum, and to detach it from the spermatic cord only above in front of the neck of the hernial sac, and to ligate the latter. The lower portion of the sac containing the testicle is incised, and obliterated by tamponing (ScJiede, Kraske, Kbnig). In adherent hernias, the adhesions must be separated after opening the hernial sac, and the hernial contents must be returned. If the operator finds degenerated omentum, it should be cut off after previous ligation. If the iso- lation of the hernial sac causes any difficulties especially as is the case in large hernias in old people or if the hernial sac is inflamed, which occurs in some herniotomies, it is advisable not to separate the hernial sac, but to tampon it after incision, and to close the wound later by secondary sutures. 6. The wound of the skin is closed in its whole extent by sutures ; for dressing, iodoform collodion, plaster of oxide of zinc gauze, etc., are very convenient ; or the usual antiseptic compress held in by a spica bandage is applied. During the first three or four days after the operation, the patient receives small doses of opium and fluid nourishment. The bowels should not move before the fourth or fifth day. The wound of the skin heals completely after eight or ten days. To secure the success of the operation, the patient is obliged in most cases to wear a truss to prevent a yielding of the cicatrix, and thereby a recurrence of the hernia. In spite of all these precautions, after the just- described simple ligation of the neck of the hernial sac and the suturing of the canal, relapse is comparatively frequent. Macewen, Bassini, and many others recently tried by another procedure to obtain permanent success without the wearing of trusses after the operation. 724 SURGICAL TECHNIC Starting with the idea that by simply ligating or suturing the hernial sac a funnel-like pouch always remains on the peritoneal disk above the canal, into which, during coughing, etc., the contents of the abdominal cavity are impelled like a wave, and which tends to enlarge the canal like a wedge, Macewen tried to prevent this unfortunate condition and the consequent relapse. He forms a plug of the folded hernial sac, which, having been returned into the abdominal cavity, resists the pressure of the abdominal contents like a pad. The walls of the canal, from which the neck of the hernial sac has been detached bluntly, are contracted by a double suture, drawing the internal pillar of the canal toward the external one and toward the strong ligament of Poupart. The operation in inguinal hernia is made in the following manner : 1. After reduction of the hernia, the skin incision is made across the hernial neck, and the external inguinal ring is exposed (Fig. 1350); the finger penetrates into the inguinal canal, and locates the position of the epigastric artery. 2. The hernial sac is detached, together with the adipose tissue adhering to it, and is drawn downward and made tense ; the finger, introduced into the inguinal canal, detaches the sac from the spermatic cord and all around from the abdominal walls as far as and above the internal inguinal ring (Fig. 1351). 3. Suturing of the hernial sac. A needle with a strong catgut thread knotted at the end is passed through the lower end of the hernial sac, and then carried through the sac in an up- ward direction several times in turns (Fig. 1352, a). By drawing the ligature tight, the sac is folded together into a puckered mass like a furled sail (Fig. 1352, b); the free end of the thread is inserted into a hernia needle provided with a handle, carried upward through the hernial canal, and brought out again I centimeter above the internal opening, through the anterior abdomi- nal wall, while the skin is drawn laterally (Fig. 1352, c, d\ The ligature is taken out of the needle and drawn tight until the folded hernial sac disappears in the inguinal canal and places itself like a ball valve in front of the internal inguinal opening. The ligature is held firmly by an assistant until the inguinal canal is closed ; afterward it is fastened by several stitches through the superficial layer of the external oblique muscle. 4. Suturing of the inguinal canal. For this purpose Macewen uses two eye-needles provided with handles, one of which is bent off laterally to the right, the other to the left (Fig. 1353, a, c). The left forefinger is introduced into the canal, and searches for the OPERATIONS ON THE ABDOMEN 725 FIG. 1350. External incision FIG. 1352. Suturing Hernial Sac a bed FIG. 1353. Suturing Inguinal Canal MACEWEN'S RADICAL OPERATION FOR INGUINAL HERNIA 726 SURGICAL TECHNIC epigastric artery, which must be avoided. Guided by the ringer, with the hernia needle (the one bent to the left) a strong ligature (silver wire) is carried through the internal pillar at two places, first near the lower mar- gin from without inward, then above from within outward (Fig. 1353, a); the suture is held above, and the needle is withdrawn (Fig. 1353, b). The lower end of the ligature is inserted into the other hernia needle, and, guided by the finger, is carried from within outward through Poupart's ligament and the united aponeurosis of the three abdominal muscles opposite the lower suture opening of the other side. After the ligature has been removed, the needle is withdrawn (Fig. 1353, c\ In the same manner the upper end of the ligature is carried from within outward through a place lying opposite the internal side of the upper point of insertion. The two ends of the ligature are then tied together upon the external oblique muscle (Fig. 1353, d\ after they have been drawn moderately tight upon the inserted finger so that the spermatic cord does not become strangulated. If the inguinal canal is large, the same suture can be applied once more farther down, whereby the pillars of the canal are pressed still more firmly against each other. 5. The wound of the skin is sutured completely. The patient remains in bed from four to six weeks. He does not resume his work until after the eighth week, and has to take good care of himself as far as the third month. He wears a light truss, which, after that time, becomes unnecessary. In congenital inguinal hernia, the sac is first detached from its connection with the canal, then opened, and divided transversely into two parts, care- fully avoiding the spermatic cord. From the lower portion, a tunica vaginalis is formed for the testicle ; the upper portion is drawn down as far as pos- sible, and incised behind, so that the spermatic cord can be isolated ; it is then closed by a few sutures. Next, it is folded together like a pouch in the same manner as in acquired hernia, drawn up over the internal inguinal ring, and the canal is closed, while the spermatic cord is pro- tected (Fig. 1354). FIG. 1354 Bassini effects the radical cure of hernia by restoring MACEWEN'S RADI- t k e i n g u j na i canal just as it is in its physiological condition CAL OPERATION . / . . FOR CONGENITAL that is, a canal with an anterior and a posterior zvall cours- INGUINAL HER- ing obliquely through the abdominal wall, which permits the spermatic cord to pass through, but which closes like a valve (like the mouth of the ureter in the wall of the bladder) when the muscles are in action, by which the abdomen is compressed (like the vesical OPERATIONS ON THE ABDOMEN 727 He proceeds in the fol- aperture of the ureter in the wall of the bladder), lowing manner : 1. Skin incision across the hernial region, exposing the aponeurosis of the external oblique muscle corresponding to the inguinal canal. 2. Division of the aponeurosis of the external oblique muscle from the external ring as far as, and beyond, the internal inguinal ring ; the same is detached in two flaps from the muscle in an upward and downward direction (Fig. 1355, a). FIG. 1355 FIG. 1356 BASSINI'S RADICAL OPERATION FOR INGUINAL HERNIA FIG. 1357 The hernial sac is then detached at this place from the spermatic cord as far as, and beyond, its orifice in the iliac fossa. Next, the floor of the sac is opened, and the hernial contents are returned after the detachment of any adhesions. The neck of the sac is twisted, and a straight needle with a double ligature is passed through it on a level with the internal inguinal ring. It is then ligated on both sides, and cut off \ centimeter in front of the ligature. The peritoneum ligated in this manner recedes into the iliac fossa. 3. After the spermatic cord has been raised and the two flaps of the aponeurosis of the external oblique muscle have been stretched, the groove, formed by Poupart's ligament, can be surveyed beyond the place of entrance of the spermatic cord. Then the external margin of the rectus abdominis muscle and the conjoined tendon (internal oblique muscle, transversalis, and Cooper's vertical fascia, or Scarpa's) are detached from the aponeurosis of the external oblique muscle (Fig. 1355, b\ and sutured for about 5 to 7 cen- timeters to the posterior free margin of Pouparts ligament beginning at the pubis. The spermatic cord is transferred into the upper angle of the wound, and thus placed about i centimeter outward and upward; thereby the internal ring and the posterior wall of the inguinal canal are reproduced (Fig. 1356, b\ 728 SURGICAL TECHNIC 4. The spermatic cord is returned into its normal position ; the aponeu- rosis is sutured over it as far as the lower angle of the wound, which remains open (external inguinal ring, Fig. 1357). The wound of the skin is closed completely by sutures. Healing takes place in about fourteen days ; the patient need not wear a truss. Relapse after this operation, now made most frequently, has occurred only in exceptional cases. Bottini incises the inguinal canal in the same manner as Bassini ; but, on the lower and upper side of the internal abdominal ring, he passes two or three strong catgut loops with a Hagedorn needle from within outward in such a manner that they grasp on the superior side the transverse muscle, the internal oblique, and the aponeurosis of the external oblique muscle, while on the inferior side they pierce the whole thickness of Pouparfs liga- ment. Next, the loops are firmly tied together, and the closure, if necessary, is still further strengthened by another catgut suture. To avoid as much as possible the weak place, which is not overcome even by Bassini 's method, Frank proceeds as follows : After division of the skin and the hernial sac, the latter is removed at its neck after double ligation. Next, the periosteum is reflected from the middle part of the horizontal ramus of the pubis ; the lateral margin of the rectus muscle is separated, and with a curved chisel, a groove is made in the ramus of the pubis in the direction of the spermatic cord, large enough to receive the little finger. Into this groove, the spermatic cord is placed. Next, the periosteum, the ex- ternal margin of the rectus, and finally the layer consisting of transverse fascia, the transversalis muscle, and the internal oblique muscle are, in their respective order, sutured to Pouparfs ligament; the aponeurosis of the external oblique muscle is finally sutured continuously separately. If the hernial sac is firmly adherent it is not extirpated, but is tamponed like a hydrocele treated by incision. It heals by granulation. Wolfler's method is very much the same as Bassini' s. After exposure of the external abdominal ring and division of the fascia- like layers above the neck of the hernial sac, the hernial sac, without being freed further, is divided on a grooved director, and the margins retracted with dissecting forceps ; the intestines are pushed back and retained above at the internal inguinal ring by a gauze tampon. With the pelvis elevated, after removal of the tampon, the neck of the hernial sac is sutured from within with the interrupted or purse-string suture (external iliac artery !) ; the internal surface of the sac is cauterized with the thermo-cautery. Next, the OPERATIONS ON THE ABDOMEN 729 hernial sac is sutured. The same remains in its position ; only when it can be detached very easily is it forced into the upper part of the inguinal canal. Then the spermatic cord is transposed ; the testicle is drawn from the scrotum after division of Hunter's ligament. It is placed behind the rectus muscle (which is dissected free) into the space between the two recti muscles, and returned finally into the scrotum, where it is sutured to Hunter's ligament. The spermatic cord then occupies a transverse position behind the rectus muscle and obliquely in front of it. Since the inguinal canal is no longer required, it can be sutured completely by stitching to Poupart's ligament the transversalis muscle and, if necessary, also the internal oblique muscle, and finally the external margin of the rectus. Over this follows the careful suturing of the aponeurosis of the external oblique muscle and the pillars of the external abdominal ring formed by it. Kocher also obtained the best results without dividing the abdominal muscles by transposing the hernial sac ; this can be easily done : 1. The skin incision, made as usual, exposes the outer surface of the fascia of the external oblique and the neck of the hernial sac ; the hernial sac is isolated completely. 2. Into the fascia, a small opening is cut in a lateral direction from the middle of Poupart's ligament (region of the internal inguinal ring) ; through FIG. 1358 FIG. 1359 FIG. 1360 KOCHER'S RADICAL OPERATION FOR INGUINAL HERNIA this opening and the anterior wall of the inguinal canal, a pair of slightly curved dressing forceps is inserted and carried along the inguinal canal in front of the spermatic cord as far as the external inguinal ring. The exposed hernial sac is grasped with the forceps (Fig. 1358), and drawn back through the inguinal canal and out of the little opening. 730 SURGICAL TECHNIC 3. While the hernial sac is drawn outward and upward, the portion of the hernial sac lying in the abdominal wall is firmly tied after passing the ligature with a needle around it and through the abdominal wall. Closely above it, a second suture, applied through the whole thickness of the abdomi- nal wall, increases the resistance (Fig. 1359). 4. The hernial sac, folded together, is placed upon the external surface of the oblique abdominal fascia (anterior wall of the inguinal canal) toward the median line (Fig. 1360), and fastened here with two or three sutures reaching down as deep as possible (canal suture). The spermatic cord re- mains uninjured, if protected by the finger, and drawn tense in a downward direction. 5. To prevent with certainty the protrusion of the hernial sac in the direction of the spermatic cord, the sac can be sutured toward the anterior superior spine of the ilium, to the fascia; or an invagination displacement is made that is, the little incision in the region of the internal abdominal ring is deepened down to the peritoneum. The latter is grasped with little hooks, and incised. The forceps are then inserted into the abdominal cavity as far as the apex of the hernial sac, which is inverted toward it, so that it can be readily grasped. When the forceps are withdrawn, the hernial sac becomes inverted like the finger of a glove, and the peritoneal surface is outside. The hernial sac, having been drawn forward, is transfixed and ligated on both sides; a few sutures close the little wound in the abdominal wall. Next, by inverting the fascia of the external oblique, the inguinal canal can be contracted by a few superficial sutures. In women, large inguinal canals can be closed 'very readily by a peri- osteum bone flap turned upward (Borckardt, Kb'rte}. The soft parts of the pubis are detached by carefully preserving the periosteum ; and from the symphysis to the obturator foramen the superior layer of the pubis is chis- elled off; next, turned upward on the upper margin of the horizontal ramus of the pubis, and turned into the inguinal opening. The pillars of the inguinal canal are united over the bone plate, the divided adductor muscles are fastened to the pubis, and the deep wound of the soft parts is sutured in layers. (b} FEMORAL HERNIA Since the normal crural canal, a funnel tapering downward, is closed by the lamina cribrosa connected directly with the fascia lata, Poupart's liga- ment, and the pectineal fascia, Bassini established the normal position and OPERATIONS ON THE ABDOMEN 731 tension of these parts forced apart by the hernia, as follows. After the neck of the hernial sac has been exposed, ligated, doubly divided, and re- turned into the abdominal cavity, he closes the canal with six to seven sutures in the following manner : The first suture, close to the spine of the pubis, passes through Poupart's ligament and, at the side of the crest of the pubis, through the pectineal fascia. Likewise the two following sutures are applied toward the crural vein; the three following sutures grasp the falciform process of the fascia lata and the pectineal fascia. The last suture is placed on the proximal side of the point of exit of the saphenous vein. If the sutures are tied by commencing from above, a C-shaped suture line is formed, which lies close to the pubis. The patient can leave his bed after eight or ten days, with- out wearing a truss. Fabricius effects the closure of the femoral funnel and as firm a stitching as possible of Poupart's ligament to the horizontal ramus of the pubis in the following manner: From a skin incision 10 to 12 centimeters long over Poupart's ligament as far as the spine of the pubis, he opens the hernial sac, returns its contents, and, finally, the ligated and cut-off neck of the hernial sac. He then pushes the vessels forcibly outward, and sutures the somewhat detached ligament of Poupart with a strongly curved needle to the horizontal ramus of the pubic bone through the pectineal fascia, the pectineus muscle, and the periosteum (epigastric artery and vein !). It is advisable, for strengthening the closure, to fasten again, with two or three sutures at the side of the large vessels, the superficial layer of the fascia lata to the pectineal fascia in the median side of the crural vein, and also to contract the external inguinal ring by a few sutures. In large femoral hernias Salzer closes the hernial canal over the ampu- tated neck of the hernial sac by a flap from the pectineal fascia. He forms this flap by a convex curved incision beginning at the pectineal crest and ending in a downward direction at Gimbernat's ligament; this flap is turned upward, and sutured without any tension to the internal third of Poupart's ligament. (c) UMBILICAL HERNIA Gersuny strengthened the yielding fibrous linea alba in the following manner : Having transversely sutured the hernial opening (umbilical mar- gins), which, of itself, has no permanent success, he united over it the recti muscles, after having divided longitudinally their sheath at the free margin. 732 SURGICAL TECHNIC More certain in its results, however, is the excision of the umbilical ring, omphalectomy (Keen, Condamin, von Bruns], by including the whole thick- ness of the abdominal wall. The umbilical region is circumscribed by two semilunar incisions, extend- ing to the internal margin of the recti muscles, and advancing outside of the hernial sac to its neck ; these incisions open the abdominal cavity out- side of the hernial sac. From the wound, the hernial canal and neck of the hernial sac can be incised ; the hernial contents can be well inspected, and returned or removed (masses of omentum). The wound is closed in the same manner as after an ordinary lapa- rotomy. The peritoneum and the posterior sheath of the rectus, the recti and their anterior sheath, and, finally, the skin, are all united in order. OPERATIONS ON THE LIVER AND GALL BLADDER Operation for echinococcus of the liver can be made in various ways. Formerly (before antisepsis was introduced) these cysts were evacuated \>y puncture with the trocar and by aspiration; the trocar canula remained in position; and around it, by adhesions, a fistula was formed, out of which the purulent cystic contents slowly escaped. Simon opened the sac at two points with two trocars, so that between the two openings a bridge of skin 3 to 4 centimeters wide remained, which was divided, after adhesions had formed. Escharotics were also used to exclude the free peritoneal cavity by adhesions. Aseptically performed, the broad opening of the cyst in two stages (von Volkmami) is the best and safest procedure. 1. Over the most prominent part of the swelling, the abdominal wall is incised as far as seems necessary, parallel to the costal arch, at the external margin of the rectus muscle, or in the median line. After the hemorrhage has been arrested, the peritoneum is opened, and stitched to the margins of the skin. The cyst or the layer of hepatic tissue covering it is exposed. Next, the gaping wound is packed with gauze, and a protective dressing is applied. 2. After seven to nine days, within which time sufficiently firm adJicsions between the layers of the peritoneum caused by the irritation have formed, the cyst is opened, either with the knife, if the sac itself is exposed, or with the thermo-cautery, if the incision has to be made through the hepatic tissue lying over the same ; by puncturing it with a Pravaz syringe, information is obtained as to the thickness of the glandular tissue overlying the cyst OPERATIONS ON THE ABDOMEN 733 wall. The opening is made as large as the skin-incision ; while the fluid from the secondary cysts oozes out, the finger is introduced deeply and examines the wall of the primary cyst for any other firmly adhering second- ary cysts, which are removed with dressing forceps. Next, sufficient irri- gation (with sublimate solution) and tamponade or drainage of the cavity of the wound are made; the wound closes gradually by granulation from below, after the wall of the primary cyst has been eliminated. Instead of the simple incision of the abdominal walls, Leisrink recom- mended previous stitching of the cystic sac to the parietal peritoneum by a few quilt sutures, whereby the adhesions would take place sooner and with greater certainty (fourth to fifth day). Since an infection of the peritoneal cavity, if the same is not completely and perfectly shut out from the seat of operation, is to be apprehended from the dissemination of echinococcus germs, it seems less safe to make the operation in one sitting {Lindemann, Landau}; after the peritoneum has been opened, the cystic contents are evacuated by aspiration to such an extent that the cyst wall becomes flaccid ; it is then incised, and the margins of the incision are sutured to the peritoneum lining the incision. Traumatic abscesses of the liver are treated according to similar principles. The resection of portions of the liver for constricted lobe (" Schniirleber ") caused by constriction of the waist or tight lacing (Langenbiicli) and in echinococci (Lorcta) has been made recently with good success ; the hem- orrhage from the surfaces of the incision must be arrested by acupressure with round needles or by the thermo-cautery ; also the superior and the infe- rior margins of the hepatic wound can be sutured together. (Suturing of the liver as a hemostatic resource is a very unreliable agent, owing to the great fragility and vascularity of the organ. The iodoform gauze tampon is more effective and serves at the same time as a useful capillary drain when brought out of the abdominal incision.) Single pedunculated flaps are ligated by elastic constriction. Even after removal of more than half the liver, the lost portion is regenerated in a short time (Ponfick). CHOLECYSTOTOMY The opening of the gall bladder by incision may be made for biliary calculi, provided the gall bladder itself is healthy and not very firmly adherent to its surrounding parts. i. The incision of the abdominal wall extends along the external margin of the right rectus abdominis muscle from the costal arch downward (longi- 734 SURGICAL TECHNIC tudinal incisioti), or it extends as an oblique incision from the tip of the tenth costal cartilage inward and downward toward the umbilicus ( Tait), or it is made transversely a little above or upon the lower border of the liver (Jiepatic border incision} (Courvoisier). 2. After incision of the abdominal wall, the liver, if possible, is turned over, and the gall bladder is drawn forward into the abdominal wound as far as possible, and is held firmly by means of a ligature loop passed through it ; it is punctured with a fine trocar. After its contents have been evacuated, the cavity is irrigated with a disinfecting solution (boric, salicylic). 3. Next, from the place of puncturing, the gall bladder is incised, prefer- ably transversely, and parallel to the lower hepatic border, until the finger can be inserted into the cavity. 4. Any biliary calculi present are removed with the finger or the forceps, retractors, etc. ; concretions firmly lodged in the cystic duct or concealed in the pocket-like diverticula of the walls can be pushed upward from the out- side with the fingers ; or, if necessary, the operator may try to crush them by pressure. 5. After all the stones have been thus removed, the wound of the gall bladder is sutured with "the most painstaking care possible " by a double row of serous sutures according to Czerny (see Fig. 1311); the gall bladder is then returned into the abdominal cavity (cholecystendysis, Courvoisier) \ or its sutured part is fastened to the parietal layer of the periosteum ( cholecystopexia). 6. The abdominal walls are likewise completely united by suture. This so-called ideal cJiolecystotomy (Bernays} reproduces in the best pos- sible manner the original normal conditions, but can be resorted to with safety only when the walls of the gall bladder are healthy ; in inflamed tissue, the sutures would easily tear out, or leakage might take place from a subsequent occurrence of inflammatory hydrops. Hence, if in cholelithiasis the cystic wall is at the same time considerably diseased, and if such firm adhesions exist that the extirpation of the gall bladder seems not advisable, and if the operator is not perfectly sure whether calculi remain in the bile ducts, it is better to perform CHOLECYSTOSTOMY, that is, to establish a biliary fistula. After incision of the abdominal wall, drawing forward the bladder, puncturing and disinfecting its cavity, and removal of calculi as described above, the opened gall bladder is sutured to the margins of the abdominal wound. First, its serous coat is united with OPERATIONS ON THE ABDOMEN 735 the parietal peritoneum all around by sutures applied very closely, in order to close the abdominal cavity. Next, the mucous membrane of the gall bladder is sutured to the external skin, and thus a lip-shaped fistula is pro- duced. Into the same, a short drainage tube or an iodoform wick is introduced. In place of this natural cholecystostomy (at one sitting) (Lawson, Taif), the operation may be made also in two stages (Riedel, Bardenheuer) ; first, the fundus of the gall bladder is stitched unopened to the abdominal wound with sutures, grasping only the walls without injuring its lumen ; and, after a few days, when the adhesions have become firm and the closure of the abdominal cavity seems to be assured, the opening is made, and the calculi are removed. It is true this procedure offers the greatest safety, but it has the disad- vantage of often creating a permanent suppurating and biliary fistula. Its very long continuance often exerts an unfavorable influence upon the condi- tion of the patient, especially since further disadvantages are also caused by stitching the gall bladder to the abdominal wall. If, however, the fistula closes up (or if it is cured by an operation), conditions for the recurrence of the original disease have been thereby created (lithiasis). Hence, Langenbuch (1883) recommended removing all these complica- tions and disadvantages with one stroke by CHOLECYSTECTOMY The excision of the entire gall bladder is indicated : (a) In vesicular cholelithiasis of long standing and frequent recurrence. (b) In dropsy of the gall bladder from obstruction of the cystic duct. (c) In serious disease of the wall of the gall bladder (empyema, ulcers, tumors). (d) In ruptures or wounds of the gall bladder, which cannot be sutured, and in biliary fistulas. On the other hand, the operation should not be made : (a) In the case of firm adhesions with the surrounding parts, especially with the liver. (b) In obstructions of the common duct, which cannot be removed. (c) In cases in which many small calculi are present in the bile ducts. I. A \-like incision of the abdominal walls. Longitudinal incision 10 to 1 5 centimeters long along the euter margin of the right rectus muscle, upon which a transverse incision of equal length is made along the lower margin of the liver. 736 SURGICAL TECHNIC 2. The colon and the small intestines are pushed downward with a flat sponge, the right hepatic lobe is drawn ripward so that the hepatoduodenal ligament, in which the large bile ducts lie and which can be palpated, be- comes tense. The ligament is incised; if a calculus is discovered in the common duct, the operation must not be performed. 3. After the gall bladder has been exposed as far as the cystic duct, the latter is encircled with an aneurism needle armed with a silk ligature, i to 2 centimeters distant from the hilum of the bladder, and doubly ligated. If the operator detects calculi in the same, they must first be pushed back- ward in the gall bladder. 4. Next, the gall bladder is de- tached from, its recess in the fissure of the liver. After its peritoneal cov- ering has been carefully incised, the operator easily succeeds in separating it from the liver, bluntly, by trac- tion, or by cautious incisions with the scissors. Any hemorrhage from the liver substance is arrested either by pressure or with the thermo-cautery. 5 . Cutting off the bladder between the two ligatures in the cystic duct. The remaining stump is folded to- SURFACE OF gether, and securely sutured. 6. Thereupon the abdominal wound is closed completely. If the common duct is obstructed by impaction of calculi, by cicatricial bands and adhesions to the surrounding parts, by the pressure of the largely distended gall bladder (on account of its contents), or by tumors of the neighboring parts (acute and chronic common duct obstruction), the sur- geon must endeavor to reestablish the escape of bile into the intestine, in order to remove the danger of cholcemia. If it is a question of an im- pacted gall stone, the operator may try to render it movable by pressure with the fingers, or to crush it gently with f creeps the blades of which are covered with rubber tubing (choledocho-lithotripsy) from the outside through the walls of the choledoch duct. This should be done very care- FIG. 1361. ANATOMY OF LOWER . THE LIVER (according.to Henle). L.hd. hepato- gastric ligament (divided longitudinally) ; D.h. hepatic duct; D.c. cystic duct; D.ch. common bile duct; A.h. hepatic artery; V.f. portal vein OPERATIONS ON THE ABDOMEN 737 fully, without injuring the internal wall of the canal, already in a state of inflammation. If this does not prove successful, it is better to open the wall of the gall duct over the stone by a longitudinal incision. The escaping bile is care- fully absorbed with sponges or gauze ; and after the removal of the obstruc- tion, the wound is closed again by 3-5 silk sutures (choledocho-lithectomy). The operator should never omit probing the gall duct upward and down- ward. A thick drainage tube is finally introduced as far as the place of suture. If the obstacle cannot be removed (extensive tumors and adhe- sions), an escape for the bile outward may be best established by cholecys- tostomy, and again administered to the patient with the food ; else, after ligation of the common duct, a fistula between the gall bladder and the small intestine may be made by broadly suturing the gall bladder to the duodenum or the small intestine below, in a similar manner as described in gastro- enterostomy and in enteroanastomosis (cholecysto-enterostomy). This opera- tion was first made by von Winiivarter "a triumph of surgical technique and perseverance" and, after him, by Kappeler and others. Murphy's button has also been employed successfully in this operation. (It has proved to be of special signal success in this operation.) OPERATIONS ON THE SPLEEN SPLENECTOMY Excision of the spleen is justifiable in a complete prolapse, cysts and tumors of the same, in abscesses, in floating spleen only when the incon- veniences caused by the same are very great and cannot be overcome by the wearing of well-fitting bandages. On the other hand, the extirpation of the spleen should not be made in tumors caused by serious changes in the blood (lencczmia, malaria, amyloid degeneration, etc.). The difficulty of extirpation consists especially in the separation of the most extensive adhesions to the surrounding parts and the safe ligation of the pedicle. 1. The abdominal incision of the greatest service is in the linea alba and varies in length according to the size of the spleen to be removed. Some- times a transverse incision must be added to it. 2. After the peritoneal cavity has been opened, the hand is introduced into the abdominal cavity ; and the surgeon ascertains by direct palpation the existence of adhesions of the spleen, especially with the diaphragm. If he becomes convinced from this examination that very extensive adhesions may frustrate the success of the operation, it is advisable to abandon the extirpation and to close the abdominal wound. 3. If the operation is decided upon, the adhesions, especially of the spleno-pJirenic ligament, are then detached. This is done with the knife after double ligation of isolated portions of the bands ; mostly, however, on account of broad surface adhesions, this method cannot be employed, and the separation must then be made with the thermo-cautery. Care should be taken under all circumstances that the capsule of the spleen is protected, as otherwise profuse parenchymatous hemorrhage may ensue. If any por- tion of its surface is adherent to any part of the neighboring organs (pancreas), it is preferable to remove a piece from the latter. Adhesions to the omentum may be divided subsequently, when the spleen, after a previous double ligation, has been detached on all sides, and can be rolled out of the abdominal wound. 738 OPERATIONS ON THE SPLEEN 739 4. Next follows the ligation of the pedicle of the gastrosplenic ligament, in which the splenic artery and vein take their course. If this pedicle is short, the greatest difficulties may arise in ligating it, and a portion of the spleen adhering to the pedicle must be left attached to the stump. For ligation, a strong silk thread or rubber band (Olshauseri) can be especially recommended, in which case, two additional simple knots are placed upon a surgeon's knot ; the ends, if necessary, are brought around the pedicle once more, and tied on the other side. After division of the pedicle a finger's breadth in front of the ligature, the lumina of the several blood vessels are sought for in the surface of the incision, and are tied separately. 5. The stump of the pedicle is returned into the abdominal cavity or fastened in the wound, for the purpose of facilitating the arrest of bleeding in the event of secondary hemorrhage (Pfan); the remaining portion of the wound is sutured. If the spleen removed is very large, after the removal of which a dead space remains in the abdominal cavity, tamponade (according to Micidicz see page 675) of the cavity produced is especially to be recommended on account of the danger of secondary hemorrhage from the separated adhesions ( L edderhose\ Under some circumstances for instance, in cysts or a partial crushing only a portion of the spleen should be removed (resection); the hemor- rhage from the surface of the incision is arrested by tamponade, by indirect ligature, or with the thermo-cautery ; also, by elastic constriction with a rubber tube, portions of the spleen can be ligated (Lucke). Splenoplexy that is, the stitching of a floating spleen in most cases proves unsatisfactory. The spleen, however, has been elevated and immo- bilized by inserting it into a pouch cut into the parietal peritoneum and open in an upward direction (Rydygier}, and by stitching it extraperitoneally under the costal arch (Bardenheuer}. OPERATIONS ON THE KIDNEY NEPHROTOMY Incision of the kidney or its pelvis ( pyelotomy) may become necessary : (a) In foreign bodies and calculi, and in anuria and colic caused thereby. (b) In abscesses, echinococci, and single cysts. (c) In hydronephrosis and pyonephrosis. NEPHRECTOMY (Simon, 1869) Extirpation of one kidney is made, if the other kidney is perfectly sound, and if no "horseshoe kidney" exists: (a) In injuries (with violent continuous hemorrhages) of the kidney or the ureter. (b) In suppurative affections (pyelitis and pyelonephrosis calculosa and tuberculosa). (c) In incurable ureteric fistulas. (d) In malignant neoplasms. (e) In migrating or movable kidney, but only if, after an unsuccessful nephrorrhaphy, the kidney causes serious symptoms, and is degenerated. Of the presence of the other kidney the surgeon assures himself by bimanual palpation, either in the dorsal position with the thighs and legs flexed, or better, in the lateral position, with the side to be examined upward, whereby the hip and the knees are slightly flexed. Simon palpated the kidney by rectal palpation. It is safer, however, to palpate the kidney by direct expos- ure from the abdomen or extraperitoneally (Fenger) in the lumbar region. Kocher introduces the hand into the abdominal cavity from the transverse incision made for extirpating the kidney, and palpates the other kidney (Thornton). Of the normal condition of the opposite kidney, the surgeon can convince himself by obtaining the urine from each kidney separately, for examination, by catheterizing the ureter. This is accomplished most easily by the use of the cystoscope ; the older procedures compressing one ureter or ligating it temporarily have in most cases been rendered obsolete. 740 OPERATIONS ON THE KIDNEY 741 To expose the kidney extraperitoneally, various methods of incision have been devised, of which the following are the most important : I. . Simons posterior vertical lumbar incision (Fig. 1364) along the exter- nal margin of the erector spinae muscle begins across the nth rib, extends over the I2th rib, and end's in the median line between the I2th rib and the crest of the ilium (exposes the hilum of the kidney most advantageously). FIG. Transverse Lumbar Incision NEPHROTOMY FIG. 1363. Lateral Lumbar Incisions i, von Bergmann's; 2, Konig's 2. The transverse lumbar incision according to Czerny, Braun, Kocher, Kiister, extends i centimeter below the last rib and parallel to the same from the margin of the erector spinae about 8 to 10 centimeters forward as far as the axillary line (colon ! peritoneum !) (Fig. 1362). 3. Von Bcrgmanns lateral lumbar or oblique lumbar incision extends from the anterior end of the 1 2th rib, descending obliquely forward and downward as far as FlG I364 SlMON . s POSITIO N FOR EXPOSING KIDNEY the junction of the external and middle third of Poupart's ligament (this incision affords the largest space) (Fig. 1363, i). 742 SURGICAL TECHNIC 4. Bardenheuers renal incision extends from the end of the nth rib downward to the middle of the crest of the ilium. At its extremities, along the ribs and the crest of the ilium, transverse incisions are added (trap-door incision). Konig's retroperitoneal laparotomy incision extends from the I2th rib vertically along the margin of the s'acrolumbar muscle toward the crest of the ilium, then in the form of a curve toward the umbilicus to the external border of the rectus muscle. The patient lies during the operation with his healthy side over a large circular cushion, so that the lumbar region on the side to be operated upon becomes prominent and is made tense (Fig. 1364). With his fist, an assistant may push the kidney in a backward and upward direc- tion by making well-directed pres- sure from the abdomen. Lange places the patient in the ventral position, inclined toward the dis- eased side, which is made to project by a pillow placed under FIG. 1365. LAXGE'S POSITION FOR EXPOSING t h e body opposite the kidneys KIDNEY ,_. (Fig. 1365). For most cases, as a normal procedure, Simon s method is to be recommended : 1. External incision, see page 741. Having divided the superficial fascia and the lower margin of the latissimus dorsi muscle, the tough superficial fascia sheath of the sacrolumbalis (^lumbodorsal fascia, lamina superficialis) is incised ; the rounded margin of this muscle is exposed and the incision deepened until the I2th rib appears to view in the upper angle of the wound; the lamina profunda of the lumbodorsal fascia is then reached ; the same is incised; after ligation of the XII intercostal artery and the I lumbar artery crossing the wound, the operator reaches the quadratns lumborum inserted into the lower margin of the I2th rib. (Since, according to Pansch, there are cases in which the pleura extends as far as the level of the transverse process of the first lumbar vertebra, the incision through the deep layer of the fascia must be made only as far as 2-3 centimeters from the lower margin of the 1 2th rib.) 2. Division of the quadratns lumbornm in a longitudinal direction ; the divided margins are drawn apart with blunt retractors ; the entire muscle OPERATIONS ON THE KIDNEY 743 Mid can also be drawn laterally ; under this lies the tough fibrous layer of the peritoneum, which divides the anterior surface of the muscle from the kidney. Having incised this fascia, the lower pole of the kidney appears embedded in loose fatty connective tissue (adi- pose capsule of kidney). 3. Exposure of the kidney. First, the superior half, situated under the ribs, is bluntly sepa- rated from its surrounding tissues with the forefinger; next, the kidney is grasped with three fin- gers, somewhat drawn forward, and slowly and carefully enucle- Fic - J 3 66 - TOPOGRAPHY OF RENAL REGION. Me, m. , . , , c ., . cucullaris; Mid, latissimus dorsi; Sp, m. sacrospina- ated with the forefinger; only ]is (sacro i umbaHs) . Qlt m . quadra t us lumborum; the firmer adhesions at both poles Oe, m. obliquus ext. abd.; Oi, m. obliquus int. abd.; are divided with knife or scissors. T J\ m - transversus abd - ^ fascia lumbodorsalis; ft, kidney; C, colon desc. If the operation is performed for injury, the wound can be sutured and the hemorrhage arrested. If it is done for the removal of cal- culi, after a previous exploration with needles (akidopeirastic), the kidney is divided longitudinally on its convex side by a sufficient incision (as in post mortems), and the calculi are ex- tracted with forceps, spoons, or wire loops (Lange) from the renal pelvis or the calyces (nephrolithotomy). If the kidney is healthy and the ureter permeable, the visceral wound is then closed by several sutures piercing the FIG. 1367. HORIZONTAL SECTION THROUGH LEFT kidney tissue. If the incision has RENAL REGION, i, m. obliquus ext.; 2, m. been ma( J e through the renal pelvis, obliquus int.; 7, m. transversus; 4, fascia trans- . . . versa; 5, fascia lumbodorsalis; 6, its posterior the WOUnd IS reunited by SUtureS layer; 7, its anterior layer; 8, m. sacrospina- which invert the margins of the Us; 9, m. quadratus lumborum; IO, m psoas; WQlmd But j f SU pp Ura tion is pres- n, colon descend.; 1 2, pancreas; 13, kidney; , ., . . , 14, spleen ent, or if the kidney is not entirely 133 744 SURGICAL TECHNIC healthy, it is better to drain and tampon the wound of the soft parts sutured only at its ends. Smaller, well-defined tumors of the cortex can be excised in the form of a wedge ; the margins of the wound are sutured (renal resec- tion). If nephrectomy must be made, the kidney is enucleated still farther, and the adipose capsule is carefully stripped off from its pedicle, until the blood vessels and the ureter can be distinguished. (The ureter lies nearest to the back ; behind it lies the artery ; and deepest of all, the vein.) 4. Ligation of the pedicle. First, all the parts entering the hilum are ligated {ligature "en masse"); next, the kidney is cut off a little in front of the ligature, and all visible lumina are singly ligated. The exposed ureter is ligated after previous invagination. 5. The wound of the soft parts can be closed completely by buried sutures, or drained and only partly sutured. It is safer, however, first to tampon everything ; and, perhaps, subsequently to apply the secondary suture or to allow the wound to heal by granulation. If, on account of greater accessibility (in large tumors), the operator desires to employ one of the lateral lumbar incisions, then the operation is made in a somewhat different manner. 1. External incision according to von Bergmann (Fig. 1363, i). 2. Careful division of the external oblique muscle in the entire length of the wound, then of the internal obliqiie in the upper portion of the wound, and of the transversalis lying beneath it, until the yellowish transversalis fascia appears to view ; under it lies a layer of loose largely adipose con- nective tissue, the praeperitoneal fat. Between this and the transversalis fascia, the finger or a broad grooved director is in- troduced ; and upon it the transverse fascia is divided to the extent of the external wound. 3. After the exposed parietal peritoneum has been displaced by the finger toward the median line, the lower extremity of the kidney appears embedded in loose, largely adipose connective tis- sue (adipose capsule). 4. The kidney is now enucleated from its sur- rounding tissues, and its pedicle is firmly ligated. FIG. 1368. TECH'S IVORY Jf the pedide Hes deep ^ ^ bage of tfae wound) Thiersch's ivory spindle (Fig. 1368) and the forceps devised by Lange to place the ligature render excellent service (Fig. 1369). 5. The wound is tamponed in its whole extent. In very large and firm renal tumors, and with a diagnosis not perfectly OPERATIONS ON THE KIDNEY 745 satisfactory, the transperitoneal nephrectomy (Sanger) has also been made. The incision is made through the linea alba or along the external border of the rectus muscle on the diseased side. In order to reach the kidney, the peritoneum must be opened twice. The enucleation and care of the pedicle is performed similarly as described above ; the cavity of the wound is drained by a counter opening made in the lumbar region; the posterior peritoneal layer is sutured ; the abdomi- nal wound is united as in laparotomy. The success of this operation is not so good as in the extraperito- neal operation. If the case is one of hydronephrosis, caused by an abnormally high and valve-forming insertion of the ureter in the renal pelvis, the cyst is emptied first with a trocar, a hand's breadth distant from the ure- ter posteriorly ; next, the anterior wall is divided lon- gitudinally from the same place downward, and the orifice of the ureter is searched for from the interior of the opened cyst ; then, from the point of insertion, the ureter and the cyst wall are incised with the scis- sors, the whole length of the swelling, in a downward direction, and the margins of the wound of the incised ureter are sutured closely to the margins of the wound of the cyst wall, so that the opening is displaced to the most dependent part of the swelling ( Trendelenburg). Larger sacs of the renal pelvis, which cannot be removed, are sutured into the wound of the soft parts, incised longitudinally, and drained. NEPHROPEXY, fixation of the kidney by sutures {Ha/in, 1881), is indicated in wandering kidney, when the symptoms caused by the same cannot be removed by suitable external mechanical support. 1. External incision about 10 centimeters long, according to Braun or to Simon. 2. After division of the latissimus dorsi and the lumbodorsal fascia, a mass of fat protrudes ; this is cut off. 3. Next there appears to view a brownish red flaccid membrane, which becomes more prominent during inspiration and when the kidney is pressed FIG. 1369 a, Lange's forceps b, Thiersch's ivory spindle for applying ligatures in deep wounds 746 SURGICAL TECHNIC forward by the hand of the assistant (adipose capsule}. After incision of the same, masses of fat again appear ; these are carefully cut away with the scissors until the renal surface can be distinctly recognized. 4. The capsule of the kidney is divided longitudinally by an incision 4 to 6 centimeters long, and . bluntly separated on both sides for about I to 2 centimeters from the underlying renal parenchyma. 5. With a strongly curved (round) needle, 4 to 6 strong silk sutures are placed through the divided capsule of the kidney, the renal parenchyma, and through the margin of the wound of the skin incision, whereby the kidney is safely fastened in the wound. 6. The wound is tamponed, and heals by granulation. The patient has to keep in bed perfectly quiet for at least six weeks. Riedcl fastens the movable kidney to the anterior surface of the quad- ratus lumborum and to the diaphragm. Miculicz established a firm adhesion of the kidney, the colon, and the duodenum from an abdominal incision by brushing the peritoneum covering the kidney with celloidine or collodion. Exposing the ureter (ureterotomy, Israel ) for removing calculi, for extir- pating diseased portions, suturing injuries and fistulas, is possible for the upper portion from the lumbar incisions ; for the lower section, the skin is divided as in the ligation of the common iliac artery ; its course in the pelvis is exposed by the peritoneal flap incision (see Fig. 1494) and the para- sacral longitudinal incision (Fig. 1496). (The editor has for the last five years resorted to nephropexy without suturing with the most gratifying results. The kidney is exposed by Simon's incision. The fatty capsule is freely excised ; the lower lobe of the kidney, drawn well into the incision, is surrounded with iodoform gauze, which re- mains for at least one week. After its removal the granulating surfaces are brought in and out by the bloodless suture. A compress is placed below the costal arch over the kidney, and held in place by a firm abdominal bandage. The patient must remain in bed, lying on the back or side operated upon for four weeks. Of the many cases operated upon by this method, none has relapsed.) OPERATIONS ON THE PELVIS OPERATIONS ON THE URETHRA AND THE BLADDER CATHETERISM The urethra in the male is a membranous canal, the walls of which, in the ordinary relaxed state, lie flat against each other. In its various sections it has an unequal elasticity, as the accompanying joined cast of wax of the urethra (according to Sir Everard Home) indicates. The inequality depends essentially on the yielding power of the tissues surrounding the mucous membrane; for since the injection mass operated with equal pressure upon the walls of the whole urethra, those places will appear the most distended where the surrounding tissues (the vascular cavernous tissue) lying between the mucous membrane and the firm tunica albuginea can be compressed. FIG. 1370. MALE URETHRA (Home's Cast of Wax) Hence its narrowest places are the external tirinary meatus surrounded by the albuginea of the glans and the extremity of the cavernous part emerging from the opening in the rigid lamina media of the perineal fascia (triangul&r ligament, Fig. 1371) (isthmus' urethrae), while the navicular fossa lying behind the meatus and the bulbous portion appear widest, because they are surrounded by a larger mass of the soft vascular corpus spongiosum urethrae. The part of the urethra lying between these distended portions, pars cavernosa, shows a uniform elasticity corresponding to its surrounding parts. 747 748 SURGICAL TECHNIC Of fa& pelvic portion of the urethra lying behind the triangular ligament, the anterior half {pars muscularis sive membranacea) is surrounded by a strong set of voluntary muscles (compressor urethrce, Fig. 1373). Under some circumstances this muscle in the living may cause great obstacles to the dilatation of the urethra (spasmus urethrae), and also in the cadaver it can be forced apart only very little ; the posterior half, surrounded by the smooth musculature of the prostate (pars prostatica), is very elastic in the living, Prostata/ mwsc.per.pr* FIG. 1371. TRIANGULAR LIGAMENT FlG. 1372. LlG. TRIANGULARE, M. LEVATOR ANI, AND M. PERINEI PROF, according to Luschka. p.r. pars rectalis; p.u. pars urethralis; p.p. pars prostatica; muse. per. pr. M. perinei prof, undus. ; Lig. tri. ur. Ligamentum triangulare urethrse while in the cadaver the tough substance of the prostate yields less readily to the pressure of the injection mass ; hence this part appears comparatively too narrow in the cast. The pars cavernosa with the penis is freely movable toward all sides (pars pendnla, penilis\ only its posterior third (root of the penis) is connected more firmly with the symphysis by the suspensory ligament of the penis. The isthmus, on the other hand, is fixed by the firm triangular ligament; from here the pelvic portion of the urethra (pars pelvina) is curved about a quarter of a circle in a posterior direction as far as the proximal end of the urethra. OPERATIONS ON THE PELVIS 749 In catheterization all these anatomical relations must be well considered. The introduction of a catheter is especially required : _ (a) For examining the urethra and the bladder. (b) For evacuating or for filling the bladder. Rigid (silver) instruments are used, the point of which is curved at an arch of about a quarter of a circle, or soft rubber catheters, to which any desired flexion can be given. The same should be used only with aseptic precautionary measures. The metallic catheters are sterilized by boiling for about ten minutes in soda solution in a suitable vessel, and are kept in alcohol until used ; the soft instruments must be placed in a solution of lev./pn FIG. 1373. Lateral view. lev. pr. M. levator prostatae FIG. 1374. From within. 1. a. M. levator ani; //. fascia pelvis MUSCULUS COMPRESSOR URETHRA WITHIN THE UROGENITAL DIAPHRAGM (Henle) according to Maclise 5 % carbolic acid for several hours before being used ; they cannot withstand boiling to any great extent. Instruments of shellacked silk fabric lose their excellent smoothness even by the application of antiseptics ; they are well wiped off before and after employment. Without being especially injured, all these instruments, however, can be kept permanently aseptic in special vessels by means of formaline gas. Before introduction, the instruments are lubricated with boric vaseline, lanolin, or iodoform oil. Also iodoform oil may be previously injected into the urethra with a small syringe ; the urethra, if necessary, is cocainized. The patient is placed in a dorsal recumbent position, his body lying horizontally, with the legs and thighs moderately flexed. A small cushion is placed under the pelvis. 750 SURGICAL TECHNIC In introducing a metal catheter with an ordinary curve (Fig. 1375, a), the operator takes his position at the left side of the patient, seizes the disin- fected, moderately warm, and well-lubricated instru- ment with his right hand (like holding a pen), sup- ports this hand by apply- ing the little finger upon the middle of the abdo- men, and introduces the point of the catheter into the external urethral ori- fice drawn apart with the tips of the fingers of the left hand ; under mod- erate traction, he gently draws the penis over the instrument (Fig. 1377), while the point of the in- strument at the same time is lowered downward as far as and behind the PROSTATE CATHE- strongly curved; b, with simple inflexion ; c, or double inflexion (according to Mercier) FIG. 1376. FIG. 1375. METAL CATHETERS. sym physis, until the bul- TERS. , a, common; b. with double , , , canula bous portion of the ure- thra below the pubic arch in the region of the triangular ligament has been reached. Under constant general traction of the penis, the distal end of the catheter is slowly raised ; exactly in the median line and without em- ploying any force, the operator makes with the beak of the instrument a circular arch around the symphysis. Under proper guidance of the instru- ment, the beak usually passes easily through the isthmus into the mem- branous portion of the urethra (Fig. 1378). If any resistance is felt, care must be taken not to overcome the same by violence ; if the point of the instrument has passed too far behind and below into the elastic bulbous portion, especially in old persons, it impinges against the posterior part of the triangular ligament. If too small a circular arch has been made with the point, it impinges above the isthmus upon the symphysis ; if the instru- ment has not been guided exactly in the median line, the point may press against the portion laterally from the isthmus ; in all these cases the catheter OPERATIONS ON THE PELVIS 751 must be slightly withdrawn, and the motion must be repeated correctly. If violence is employed, danger of making a false passage arises, that is, FIG. 1377 the point will penetrate through the wall of the urethra and into the surrounding loose fascia. If the point has entered into the muscular part, not rarely a resistance is caused by the spastic contraction of the compressor urethra (spasmus urethrae, Figs. 1373, 1374). The same is generally best overcome by waiting 1 FIG. 1378 patiently a few minutes and by exerting a gentle pressure with the point, th position remaining unchanged. A skilful hand readily feels . 752 SURGICAL TECHNIC relaxation of the tense muscular fibres ; thereupon the handle of the catheter is slowly depressed between the legs, whereby the beak, following the curve of the prostatic portion, slips into the bladder (Fig. 1379). Introduction of flexible catheters is much easier. The catheters, consist- ing of silk fabric covered with shellac, to which any desirable curvature may be given by means of a wire inserted into their lumen, are introduced essen- tially in the same manner as the rigid metal instruments ; the very soft catheters of vulcanized rubber (Nelaton) find their way easily and of their own accord through the urethra, provided only small sections at a time are forced into the orifice of the urethra, the penis being held and stretched with the left hand. FIG. 1379 FIG. 1380. CATHETERIZATION IN THE FEMALE The introduction of a catheter into the female urethra can be easily made, if the urethral orifice is exposed (Fig. 1380). With the labia kept well apart, first the orifice of the urethra is disinfected with a compress of cotton, and then immediately the little catheter (mostly of glass and disinfected by boil- ing) is introduced. Never should this little operation be performed in the dark, under the bed covers, since an infection of the bladder is often the consequence. It is advisable not to use too small instruments in normal urethras ; by the point of instruments of too small size, spasm of the urethra is easily provoked, or an existing spasm is aggravated, while a large catheter, whose point irritates less, can, with gentleness and patience, be advanced through the membranous portion of the urethra after a short time. In hypertrophy of the prostate, when the prostatic portion of the urethra, in most cases, is elongated and often more curved, longer and more strongly Curved catheters (prostate catheters, Fig. 1376, a) are used. In cases where middle lobe of the prostate is much enlarged, the bladder is sometimes ~.r OPERATIONS ON THE PELVIS 753 more easily reached with a Merciers prostatic catheter, a straight catheter, whose beak is bent off at the lower end at an obtuse angle in a simple or double inflection (Fig. 1376, d, c). If, from an enlargement of the lateral lobes, the urethra is laterally compressed, Hueter 1 s laterally flattened cath- eters may render good service. For washing out the bladder, employ a common (Ne'laton) catheter and the wound douche. After the contents of the bladder have been evacuated by means of the catheter, the glass point of the douche (the tube of which must not contain any air) is introduced into the opening of the catheter. By raising the douche, a certain quantity of fluid is allowed to enter ; thereby the bladder becomes distended, and its wall is brought everywhere in contact with the fluid. (A great deal of harm has been done by overdistending the bladder by this method of irrigation. Never should more than one fluid be injected at one tima. Thompson's elastic bulb is a better instrument for grading the amount injected than the ordinary irri- gator.) On removing the point of a douche, the con- tents of the bladder are evacuated in the form of a jet ; this procedure of allowing the fluid to flow in and to flow out is repeated until the desired object has been attained. It is more convenient to employ catheters with double cannla (Fig. 1375, b\ the shaft of which is divided into an inlet canula and a discharge canula. If a (Ne'laton) catheter is intended to remain in posi- tion in the urethra for some time, for draining the urine permanently from the bladder (retention catheter), it is fastened to the anterior portion of the penis with a thick cotton thread by making a clove-hitch (Fig. 1382). The catheter is placed through the same ; the thread is drawn tight, and knotted again. The ends are fastened behind the glans by strips of adhesive plaster applied loosely around the penis. The catheter can also be fastened with a safety pin to the prepuce (or it can be stitched to it), as long as the patient is under anaesthesia. But the safest method of fastening it is DitteVs: FIG. 1381 FLEXIBLE CATHETERS, a, common, cone-shaped, or probe-pointed; ^in- flexed according to Mer-' cier FIG. 1382. CLOVE- HITCH 754 SURGICAL TECHNIC A strip of adhesive plaster of a finger's breadth, perforated in the middle for the catheter, is fastened to the anterior and the posterior sides of the _ ^ penis ; the wall of the catheter, closely in front of the perforation, is pierced with a safety pin ; and a second strip, with a similar opening, is fastened at the sides. For greater safety, the whole is strengthened with circular strips (Figs. 1383, 1384). ::OO 3 FIG. 1383 FIG. 1384 DITTEL'S METHOD OF FASTENING RETENTION CATHETER STRICTURE OF THE URETHRA A stricture that is, a lessening of the caliber of a portion of the urethra, caused mostly by contraction of its wall (corpus spongiosum urethrae) can be removed either by a bloodless dilatation or by incision. For ascertaining tJie degree of the stricture, the operator has to start from the normal dilatability of the urethra. By means of his nrethrometer (Fig. 1387), Otis has proved that the dilatability of the urethra is in a certain proportion to the circumference of the ordinary relaxed state of the penis. He found that the lumen of the urethra in the male is, on the average, about 32 millimeters in circumference ; but this circumference in- creases with the circumference of the penis in the following gradation: OPERATIONS ON THE PELVIS 755 CIRCUMFERENCE OF THE PENIS OF THE URETHRA 75 mm 30 mm. 81 " 32 " 87 " 34 " 93 " 36 " 100 " 38 " 112 " 40 " Even if, as a rule, only the more exten- sive strictures (narrow strictures} cause great trouble, still strictures of a less de- gree (strictures of large caliber} not rarely cause considerable disorder (gleet, nervous irritability, pollutions, etc.). For a more exact diagnosis of the seat, the length, and the degree of the stricture, either olive-pointed bougies that is, thin, metal rods (bougies), at the end of which is an olive-shaped point of varying diame- ter (Fig. 1386) or, still better, Otis' s ure- thrometer should be used. This instrument is a thin, metal rod, at the end of which a basketlike arrangement, formed by metal strips, may be distended by means of a screw to a circumference of 45 millimeters (Fig. 1387, A and). To protect the instrument from mois- ture, a thin rubber cover (C) is applied before it is introduced. The instrument is passed closed through the stricture ; next, the basket is distended so far by means of the screw (Z>) that it cannot be withdrawn through the stricture. It is then slowly unscrewed, until it can be with- drawn through the stricture. Thereupon the operator reads from the scale (E) the caliber of the stricture, while its distance from the orifice of the urethra can be read from the scale on the shaft of the instrument. In the gradual dilatation by bougies the operator proceeds as follows : He stands at the right side of the patient. After the urethra has been FIG. 1386. OLIVE- POINTED BOUGIES according to Otis FIG. 1387. URE- THROMETER A, open; , closed ; C, rubber cover 756 SURGICAL TECHNIC lubricated with an antiseptic preparation, by an injection of iodoform oil, a solid bougie is introduced, of a number ^corresponding to the measurement made, by gently drawing the penis up on the instrument (Fig. 1389, 3). If the instrument is arrested by any resistance, it should be withdrawn, and a bougie of smaller size should be employed to pass through the stricture. If this succeeds, on withdrawing the instrument the sensation is imparted ^ u to the operator, indicating that the point is firmly grasped (engaged) by the rigid surround- ing tissue. For entering very narrow strictures, the finest bougies of catgut or whalebone ( filiform bougie, Fig. 1388), or the fine olive-pointed and thin- necked bougies (Fig. 1389, i), are selected. With these, under great tension of the penis, avoiding all violence, the operator tries to enter the lumen of the stricture by slow and careful manipulation. This should be done very 'pa- tiently and gently without causing any great pain to the patient. If too much force is em- ployed, the point, which has become soft, is curved in front of the obstruction, and the bou- gie is rolled up during introduction (Fig. 1391, a) ; or, worst of all, the point pierces the softer tissue at the side of the stricture (false passage, Fig. 1391, b\ If the operator meets with great difficulty in entering narrow strictures, owing to the eccen- tric location of the entrance to the canal, then a spiral curve should be given to the point of FIG 138 BOUGIES cat S ut strin b Y winding it like a screw around a i, probe-pointed; thicker bougie (Fig. 1390). If the bougie is then introduced in a spiral manner, the point is insinuated more easily into the stricture (Fig. 1391, c). Also in very difficult cases an endo- scopic tube (such as is used for inspecting the urethra, Fig. 1392) may be filled with catgut ligatures (Fig. 1393). The endoscope is then introduced into the urethra as far as the stricture, and the operator, by careful probing, tries, with several catgut threads introduced at the same time by manipu- lating one after another, to enter the stricture (Fig. 1391, d}. FIG. 1388 FILIFORM BOUGIES 2, cone-shaped; 3, with common point OPERATIONS ON THE PELVIS 757 (The insertion of a bundle of filiform whalebone bougies, large enough to fill the lumen of the urethra down to the stricture, and then manipulating the bougies in turn is simpler, more practical, and more successful.) If the operator succeeds in introducing a fine catgut thread into the stricture, he should not try too long to push' it at once through the stricture and into the bladder ; for even if a com- plete retention of urine existed, the urine generally first trickles out slowly, then with increasing velocity. Hence it is allowed to remain in posi- tion until it is ejected by the urine. In most cases, it is then comparatively easy FIG. 1390. CATGUT STRINGS WITH CURVED ENDS according to Leroy d'Etiolles FIG. 1392 OTIS'S ENDO- SCOPE FIG. 1391. INTRODUCING BOUGIE INTO STRICTURE OF ECCENTRIC LOCATION FIG. 1393 ENDOSCOPE FILLED WITH CATGUT STRINGS (See also Fig. 1391, , peri- to the catheter a rubber tube, as a siphon, to neum immerse the distal end of the tube in a vessel partly filled with an antiseptic solution, so that all urine is at once siphoned from the bladder. 9. The healing of the wound by granulation has a tendency to dilate that part of the urethra, because, by the contraction of the cicatrix, the floor of the mucous membrane of the urethra is drawn in a downward as well as a longitudinal direction (Roser, Fig. 1403). URETHROPLASTY is intended for the closure of lip-shaped urethral fistula caused by the injuries or ulcerations of the urethra. In most cases a final healing is effected with great difficulty. OPERATIONS ON THE PELVIS 765 BACH'S URETHRO- PLASTY Very small fistulae, of the size of a millet seed, with soft, easily movable margins, can sometimes be closed by simple vivifying and suturing, in which case the interrupted suture or Dieffenbacli s purse-string suture is used. If, however, a somewhat larger defect must be closed, the attempt to approximate by sliding the vivified margins of the fistula over the defect must be made by making lateral incisions and detaching the bridge flaps, formed thereby from the underlying^ tissues. Dief- fcnbach made longitudinal incisions (Fig. 1404), and Nelaton undermined the .sur- roundings of the fistula from two transverse incisions (Fig. 1405). The best effect is obtained by the double plastic closure of the defect. For this purpose, the fistula is circumscribed with a sharp knife in its entire extent along its margin; and with superficial incisions (always directed in- FIG. 1404. DIEFFEN- wa rd toward the median line) the mucous membrane is detached all around from its base, so that its margins can be turned over and made to touch each other ; with fine, closely applied, interrupted catgut sutures the internal margins of the incision are then united, and thereby a new urethral lumen lined with mucous membrane is made (Fig. 1406, c). Over this underlining the wound of the ex- ternal skin is then closed. Either the external lateral mar- gins of the fistulous opening, circu in- scribed with the knife, are detached and ren- dered movable to such an extent that the two lateral halves p-ic. J40 6 VON ESMARCH'S URETHROPLASTY WITH UNDERLINING. formed can be <* circumscribing with the knife margins of fistula; b, turning <;frpfrhprl anrl nniWI margins inward; c, suture; d, suturing approximated margins of skin with interrupted and quilt sutures. The four lower figures with each Other over show their sectional view FIG. 1405. NELA- TON'S URETHRO PLASTY X Y 766 SURGICAL TECHNIC the lining, or a pedunculated flap is excised from the very movable skin of the scrotum free from adipose tissue, and by twisting the pedicle sutured into the defect with interrupted sutures. This flap, of course, must be considerably larger than the surface of the wound to be covered. Finally, in very large and broad fistulae, the definitive closure may be effected by double flaps. One flap is turned backward, and the other, by stretching, is placed over it in the manner described in the operation for epispadias (see page 789) ; but especial care must be taken that the inner flap has no hair-producing surface, else urinary concretions will form around the hair projecting into the -urethra. If sufficient mucous membrane is not present, the urethral lining should be grafted with skin by Thiersch's method. In a very large defect of the urethra in the perineum, Meusel succeeded in grafting the internal layer of the prepuce which can be entirely dis- pensed with into the wound, and in forming with it the missing urethral portion. To prevent the nitration of urine through the fresh line of suturing, an elastic catheter is introduced into the urethra ; to this a siphon is attached, unless the operator desires to make in preference external urethrotomy for evacuation of the urine (Thiersc/i, Dieffenbach}. For the prevention of erections, which after the operation very fre- quently occur and burst the whole line of suturing, large doses of bromide of potassium are to be recommended. FOREIGN BODIES IN THE URETHRA AND THE BLADDER, which have been pushed into it from the front or which have entered from behind and become lodged (renal and urinary calculi, or fragments of the same), must be removed as soon as possible. For this purpose, long, fine forceps are used, for instance, Thompsons urethral forceps (Fig. 1407) or Matthieu's so-called alligator-jaw forceps (Fig. 1408). Smooth bodies, which cannot be grasped well from the urethral orifice, the operatpr should try to force forward from behind, with wire loops or special instruments devised for that purpose ; very useful is Leroy d' Etio lies' adjustable curette (Fig. 1105), or Collins adjustable hook (similar to Fig. 1218). Moreover, a whole series of ingenious instruments have been invented for certain purposes. Figure 1410 shows Nttatoris adjustable litliotrite for the removal of small stones in the urethra ; Fig. 1409, Colliiis catheter-catcher for removing broken-off portions of the catheter from the bladder. In OPERATIONS ON THE PELVIS 767 suitable cases, the position of the foreign body is ascertained by the use of the X-ray (Rontgen) ; the procedure of grasping the foreign body is then considerably facilitated. Its position may also be ascertained by cystoscopy. Fine bodies (needles, bristles) may be made visible by means of the endo- \ FIG. 1407. THOMPSON'S FIG. 1408. MATTHIEU'S (Alligator) URETHRAL FORCEPS FIG. 1409. COL- LIN'S CATHETER- FIG. 1410. NELATON'S LITHOTRITE FOR URETHRA scopic tube. If a needle offers very great resistance to extraction, its point should be made to pierce through the wall of the penis and grasped with dressing forceps. If the foreign body cannot be removed by these procedures, it must be exposed by an incision from the outside, by means of supra-pubic lithotomy or by external perineal tirethrotomy ; or, if it is lodged more anteriorly, by an incision over the foreign body. After the removal of the foreign body, the ;68 SURGICAL TECHNIC wound can be closed at once by sutures, though it must be protected from urine infiltration by introducing a retention catheter. If a foreign body is lodged in the distal part of the urethra in the wide navicular fossa behind the narrow urethral orifice, mcatotomy should be made (see page 791). SUPRAPUBIC PUNCTURE OF THE BLADDER (PUNCTIO VESICJE) Puncture of the bladder is made in retention of urine, if, in spite of all endeavors, the operator does not succeed in introducing a catheter through the urethra into the bladder (especially in prostatic hypertrophy). The largely distended bladder can be felt and is visible as a globular swelling over the symphysis pubis ; its superior limit is ascertained by per- cussion. An injury to the peritoneal cav- ity, if the puncture is made closely above the symphysis, is almost excluded when the bladder is largely distended. 1. The puncture of the bladder is made with the long curved trocar devised by Fleurant (Fig. 1411). Standing at the right side of the patient, the opera- tor inserts the sterilized instrument through the (shaved) abdominal walls with a vigorous push closely above the symphysis. The handle is somewhat raised, whereby the point is introduced into the bladder behind the symphy- sis, and thereupon, while the stylet is withdrawn, the canula (b) is slowly pushed into the bladder as far as the shield. 2. The urine escaping in a stream is momentarily retained by applying the finger over the opening until the blunt-edged canula (c) has been intro- duced into the external canula (^). The rubber tube fastened to its end is placed into a vessel standing somewhat lower for the reception of the urine. FIG. 1411. FLEURANT'S TROCAR FOR PUNC- TURE OF BLADDER, a, stylet; b, exter- nal canula; c, internal canula; d, plug OPERATIONS ON THE PELVIS 769 3. The canula is fastened by bandages conducted around the trunk or by small strips of adhesive plaster. The external canula must remain in position for six to eight days, to allow the punctured tissues to surround it; the internal canula, however, is often removed and cleansed from mucus, etc. 4. At the end of about a week the external canula must also be removed and cleansed from incrustations adhering to it. To prevent missing the punctured canal after the removal of the external canula, it is withdrawn over the plug (" Docke ") (d) previously introduced. The latter remains in position in the canal until the external canula (b) has been introduced again. With this plug (or a catheter, bougie, etc.) the attempt may be made to enter from the punctured opening through the obstacle in the urethra, and thus to make the urethra passable from behind (posterior catheterism, Brainard\ Subsequently a permanent canula of hard rubber or an elastic catheter is introduced ; sometimes a sphincter-like closure is formed by means of the muscular fibres of the recti muscles ; this renders the wearing of the canula unnecessary. In very thick abdominal walls, before the trocar is inserted, it is advisable to divide the skin and the adipose tissue down to the fascia by a small inci-. sion ; the trocar can then be guided more easily and more safely. The simple puncture with a fine exploring trocar and the puncture with a fine aspirator needle and aspiration (see page 660) can be easily made, and are successful ; but neither is especially to be recommended, since infiltration of urine may take place, and since the operation must, in most cases, be repeated several times. On the other hand, as a substitute for the puncture of the bladder described above, in long-continued retention of urine Poncefs cys- totomy can be made. This is easy of execution. With the pelvis elevated, a transverse incision 6 centimeters long is made closely above the symphysis through the abdominal walls, the exposed wall of the bladder is divided trans- versely for a distance of 3 centimeters, and the mucous membrane of its mar- gins are sutured to the margins of the skin. During the first days the patient wears a short curved canula, for which a tin nail is subsequently substituted, until by cicatrization and the fibres of the rectus the closure is effected. A WitzeVs oblique fistula (see Fig. 1254) can also be formed on the exposed vesical wall over an introduced little canula ; this effects a safe closure in the same manner as in gastrostomy. 770 SURGICAL TECHNIC SUPRAPUBIC CYSTOTOMY EPICYSTOTOMY (sECTio ALTA), Peter Franco, 1561 Suprapubic cystotomy is made : (a) For the removal of vesical calculi, especially large and hard calculi (above all, in boys), calculi in diverticula, and other foreign bodies that can- not be well removed through the urethra. (b) In tumors of the bladder and the prostate. (c) In painful, tubercular ulcers and in irritable bladder. (d} In impassable strictures of the posterior urethral portion as a prelimi- nary step to posterior catheterism. PREPARATIONS After the bladder has, for several days, been irrigated with warm antiseptic solutions (boric, salicylic), on account of the catarrh generally existing, and after the rectum has been evacuated thoroughly, a metal catheter with a stop- cock is introduced into the bladder at the beginning of anaesthesia, and remains in position during the whole operation. In order to force the bladder and the duplicature of the peritoneum upward and out of the true pelvis (" kleines Becken "), first a well-lubricated cone-shaped rubber balloon, folded together ( Colpenrynter, Fig. 1412), is introduced into the rectum as far as and above the sphincter, and filled with about 30x3 to 400 cubic centimeters of warm water. Next, by a gentle pressure, about 200 cubic centimeters of warm boric solution are allowed to enter the bladder from an irrigator ; the duplicature of the peritoneum over the anterior abdominal wall is now raised at least 3 to 4 centimeters above the symphysis (G arson, Petersen, Fehleisen, Strong, Figs. 1413, 1414). A globular swelling is now seen over the symphysis, which elicits a dull sound on percussion ; cystotomy can then be made without any danger of injuring the peritoneum. (Instead of water, air can be used for inflating the bladder and the rectal balloon.) For this operation, Trendelenbnrg s position is now generally employed. By raising the trunk and the legs of the patient, his body is placed in an FlG. 1412. COLPEURYNTER. c, folded together; b, inflated by means of apparatus a OPERATIONS ON THE PELVIS 771 oblique, inclined position (45). For this purpose, suitable arrangements are attached to operating tables (Fig. 1415). Tables have also been made for this special purpose. FIG. 1413. Bladder filled FIG. 1414. Bladder and rectum tilled SECTION OF PELVIS, a, position of peritoneal fold (Fehleisen) If such a table is not at hand, the patient may, during the operation, be held in the high pelvic position by a strong nurse (Fig. 1416). With this position, the distention of the rectum and of the bladder is superfluous ; the intestines gravitate toward the dome of the diaphragm, and the bladder is drawn up from the true pelvis by the simple force of gravitation. The entire opera- tion can be made much more easily and safely in this position, and especially a free inspection of the interior of the bladder is obtained. This is of great value if cystotomy has been made for vesical tumors or hypertrophied lobes of the prostate. The tumors can then be extirpated clean with knife or scissors, or can be cau- terized with the thermocautery or FJG ^ OPERATING TABLE WITH ARRANGEMENT the galvanocaustic wire loop. FOR HIGH PELVIC POSITION 7/2 SURGICAL TECHNIC 1. External incision, either a longitudinal incision the length of a finger, exactly in the median line of the symphysis upward, or, better, a transverse incision (Bardenheuer) closely above and parallel to the superior margin of the symphysis, straight or slightly curved, with its convexity toward the symphysis (Fig. 1417). 2. The superficial fascia^ the pyrami dales, the sheath of the rectus, and the lower extension of the linea alba are detached closely at the superior pelvic border, while the left forefinger depresses and steadies the tissues ; thus the FIG. 1416. TRENDELENBURG'S POSITION operator reaches the dark yellow prevesical adipose tissue (rich in veins) of the preperitoneal cavity (cavum Retzii} ; in this he advances bluntly, always keeping close to and behind the syfnphysis, without any considerable hem- orrhage, as far as the anterior wall of the bladder, which can be recognized from the course of the longitudinal fibres of its yellowish muscles. The upper margin of the wound with the duplicature of the peritoneum lying on the bladder, together with the subserous adipose tissue surrounding it, are drawn upward with blunt retractors or by the fingers of an assistant. OPERATIONS ON THE PELVIS 773 If cystotomy is to be made in two stages ( Vidal) as an additional security against opening of the peritoneum, the bladder, which is held by a pair of forceps, is sutured all around to the margins of the skin (Fig. 1417 a), with silk sutures penetrating only as far as the submucous coat without entering the interior of the bladder ; the ends of these sutures remain about as long as a finger. The wound is then tamponed, and the bladder is not opened until ten to fourteen days later, after firm adhesions have taken place all around. Bardenheuer's External Incision FIG. 1417 Suturing Bladder to the mar- gins of the skin SUPRAPUBIC LITHOTOMY (Sectio Alta). a, seen from above; <, sectional view (The editor has made, for a number of years, suprapubic cystotomy in two stages without making use of sutures, and believes that these do more harm than good. During the first stage the bladder is well exposed after free excision of the prevesical fat, and the wound is firmly tamponed with iodoform gauze. On the removal of the gauze prior to the completion of the operation (one week later), the anterior wall of the bladder presents itself as a granulating surface and can be incised without the use of an anaesthetic. This operation is of the greatest service in establishing a suprapubic fistula in the treatment of prostatic enlargement.) If it is desirable to operate at one time, then follows : 3. Opening of the bladder. After the wall of the bladder has been secured by toothed forceps, or, still better, by passing two ligature loops through at the extremities of the intended incision for preventing the bladder 774 SURGICAL TECHNIC from sinking backward, the colpeurynter is evacuated ; next, the bladder near the forceps or between the ligature loops, as closely behind the sym- physis as possible, is opened with the knife, lengthwise or transversely, to the extent of 4 to 5 centimeters. 4. At once, while its contents flow out, the right forefinger is introduced into the opening to ascertain the size of existing calculi, or the seat and nature of the tumor ; on the size of the tumor depends the extension of the incision. The incision can be made with the knife or the scissors, or even bluntly by inserting the left and the right forefinger, side by side, into the opening that has been made, and then gently distending both fingers. 5. If the opening seems large enough, the opened blad- der is held gaping by the assist- ants, with blunt retractors, or the middle of the margin of each incision is stitched to the corresponding margin of the skin without piercing the mu- cous membrane of the blad- der; for drawing apart the wound, the sutures remain long. 6. After a thorough irriga- tion of the bladder with warm boric water, the removal of the stone takes place w,ith the li- thotomy forceps (Fig. 1418) or the spoon-shafed scoop (Fig. 1419). Likewise, the two ex- tended forefingers of the folded hands may be used like a pair of forceps (Fig. 1420); another irrigation is then made. If a sanious catarrh of the mucous membrane of the bladder is found, the wound of the bladder must not be immediately united ; in such a case, the bladder is drained (see below) and tamponed with iodoform gauze. If the mucous membrane of the bladder is in a healthy condition, FIG. 1418 LITHOTOMY FORCEPS FIG. 1419. SPOON- SHAPED FORCEPS OPERATIONS ON THE PELVIS 775 7. The suturing of the wound of the bladder (cystorrhaphy) follows. The sutures, of fine catgut previously drawn through iodoform ether, are applied very closely, interrupted or continuous, in such a manner that they grasp the external two-thirds of the wall of the bladder ; but they must not penetrate the mucous membrane ; in tying the threads, the surfaces of the vesical wound are placed in exact apposition. It is expedient to apply all sutures first, and to tie them all at the same time. The ligatures can also be inserted before the bladder is opened (Neuber). For a broad union of the cystotomy wound, Antal bevels the margins of the wound at the expense of the outer layers ; for a safe closure, Thompson recommends a quilted suture. FIG. 1420 FIG. 1421. TRENDELENBURG'S T-SHAPED RUBBER TUBE In most cases, however, a close superficial suture with silk or chronic catgut suffices ; the latter is only slowly absorbed. 8. After the cystotomy wound has been thus sutured, the bladder is filled through a catheter under a strong pressure (up to i millimeter) with a warm boric solution, to ascertain whether the suturing has been done in a satisfactory and efficient manner ; if the fluid oozes out at any weak places, more sutures must be applied to make the line of suturing water-tight. For greater safety, the sutured bladder may be stitched to the abdominal wound (Cystopexy). 9. Tamponade of the external wound or partial suturing and drainage ; fastening of the dressings with a T-bandage. An elastic catheter is sub- stituted for the metal catheter, and allowed to project only I to 2 centimeters 776 SURGICAL TECHNIC into the interior of the bladder. A tube is fastened to it and placed into a vessel with antiseptic solution, standing below the level of the pelvis. If the operation is performed with a view of removing tumors in the interior of the bladder or the prostate gland, the opening of the bladder must be made as large as possible, and must be easy of access. Best adapted to this purpose is the transverse incision. To gain more space, Helferich chiselled away subperiosteally a portion from the superior border of the symphysis. It is advisable to detach, in addition to the pyramidal muscles, also the insertion of the recti from the symphysis. After such operations, it is always necessary to tampon the bladder loosely, first with iodoform gauze or with iodoform wick, or to drain it with Trendelenburg s T-shaped rubber tube (Fig. 1421), and to suture the bladder, if at all, second- arily after about eight days. Trendelenburg drains the bladder in all cases, and decreases the wound, if at all, by a few sutures from the sides ; the patient must then be placed in a lateral or abdominal position. According to LangenbucKs suggestion, a flap-shaped external incision may be made through the abdominal wall if, in rare cases of very large stones or adhesions of the peritoneum, it is impossible, without injury, to push the peritoneum far enough upward to expose sufficiently the anterior wall of the bladder. The peritoneum is divided transversely and pushed upward together with the skin flap. Under antiseptic tamponade and per- fect rest of the intestines (and the muscular apparatus by which the abdo- men is compressed), by the use of opium, an adhesion of the peritoneum pushed upward takes place after a few days, whereby the exposed surface for cystotomy is greatly increased. For a drainage opening after suprapubic lithotomy and for palpating the bladder, especially in the region of the trigone, Langenbuch has devised the subpubic incision (sectio alta subpubica), for which a ^-shaped incision is made between the inferior border of the symphysis and the root of the penis. Surgeons, however, have employed this operation just as little as Koch's subperiosteal resection of the symphysis, in which only a small inferior portion of bone (lamen) remains in position. Extirpation of the whole urinary bladder (Kiister), which may become necessary for malignant tumors, is accomplished through a suprapubic inci- sion ; after as much space as possible has been created by a broad longitudi- nal division of the soft parts, and chiselling off the superior pelvic border, the bladder is detached bluntly all around; any peritoneal injuries are sutured at once. From a medial, perineal incision, the urethra is then detached transversely, the prostate gland is enucleated bluntly or with the OPERATIONS ON THE PELVIS 777 scissors, the ureters are cut off obliquely, and after a complete enucleation of the bladder and the prostate gland are transplanted into the rectum. PERINEAL CYSTOTOMY, MEDIAN PERINEAL SECTION, that is, opening the membranous portion of the urethra from the perineum, is made : (a) For removing medium-sized urinary calculi and foreign bodies that cannot be removed through the urethra. () For removing tumors of the bladder and the prostate. (c) For digital palpation of the bladder for diagnostic purposes (digital exploration, TJiompsoii). The first part of this operation has been described in the section on external uretJirotomy (see pages 761-763, sections 1-3). 4. After incision of the membranous portion, a ~-shaped grooved director is introduced into the bladder along the grooved staff, which is then removed. 5. The urethrotomy wound is enlarged toward the prostate, until the operator can enter it with the point of the right forefinger. 6. By slow boring movements witJi the fin- ger or by the dilators of Simon and Hegar, or with the dilating forceps or a blunt gorget (Thompson}, the prostate is so far dilated that the finger can enter the bladder and palpate the calculus or the tumor. 7. If the operation is performed for the removal of a calculus, a pair of lithotomy for- ceps (Fig. 1422) is introduced, using the left index finger as a guide, and the stone is grasped. After the operator has convinced himself, by turning movements of the for- ceps, that the mucous membrane has not been included, and if the distance of the blades of the forceps indicates that the stone has been grasped in its smallest diameter, then follows 8. The removal of the calculus by making slightly lever-like movements during traction. If the stone is too large, the prostate can either be nicked FIG. 1422 LITHOTOMY FORCEPS FIG. 1423. LUER'S LlTHOTRITE 778 SURGICAL TECHNIC with a probe-pointed bistoury (see page 779) or with a litliotrite ( Fig. 1423); the calculus may first be crushed into smaller fragments ; the larger pieces are then evacuated with the forceps ; the debris is scooped out with a dull spoon. 9. Finally, after the bladder has been thoroughly irrigated with a warm boric solution, a Nelaton catheter (as large as possible) is introduced through the penis into the bladder, and the wound is tamponed in its whole extent. The catheter (it slips out very easily) is best fastened, according to Lauenstein, by tying a silk thread around the catheter in the wound and by tying the ends of the thread over the tampon. A better access, especially to the prostatic part of the urethra (by which procedure, also, an injury to the bulb is better avoided), is gained by a curved transverse incision between the anus and the bulb of the urethra (see Fig. 1427). The bulb is exposed and next drawn upward with retractors ; the membranous portion of the urethra is carefully dissected free (Nelaton, Konig). In women, the extraction of calculi is considerably easier, on account of the shortness and dilatability of tJie urethra. Only in very large calculi, offering resistance even to lithotripsy, should suprapubic lithotomy be made; in general, however, the dilatation of the female urethra (Simon} is sufficient. The same is made with the dilators mentioned by Simon (Fig. 1424); these are introduced SIMON'S* i n gradually increasing sizes, until the forefinger can be inserted DILATOR with ease into the bladder. In case of necessity, the external uri- FOR nary meatus must be nicked by small incisions ; this is a more URETHRA gentle procedure than a dilatation ntade too violently. Thereby conditions are produced as in external urethrotomy in man (see above). The incontinence occurring during the next few days disappears after a short time. PROSTATOTOMY, that is, incision of the prostate, is indicated : (a) In a considerable enlargement of the same (hypertrophy, inflamma- tion, abscesses). () In tumors and lithiasis. It is made in the same manner as median perineal section (see page 777). Through the incision of the membranous part of the urethra, the left fore- finger is introduced into the bladder, and upon, it the posterior side of the prostatic portion of the urethra is divided with a probe-pointed knife in the OPERATIONS ON THE PELVIS 779 median line. Proceeding from this incision, it is sometimes possible to enucleate bluntly with the finger encapsulated circumscribed tumors (ade- nomata, fibromyomata), also to detach pedunculated tumors and swellings of the middle lobe with Landerers cutting forceps or Thompson s forceps (Fig. 1425). After the hemorrhage has been arrested, a thick rubber tube, wrapped with iodoform gauze, or a Watson hard rubber drainage tube (Fig. 1426) is introduced into the bladder, and left in position for six to eight weeks, until the swelling of the prostate has been reduced by pressure (atrophy from com- pression). It is better to expose the entire posterior surface of the prostate by ZuckerkandVs perineal prerectal incision (Figs. 1427, 1428). The left forefinger is FIG. 1425. THOMPSON'S FORCEPS 1426. WATSON'S HARD RUBBER DRAINAGE TUBE FOR HYPERTROPHY OF PROSTATE introduced into the anus to prevent injury to the anterior wall of the rectum. Next, 3 centimeters above the anus, a slightly curved transverse incision, 7 centimeters long, is made across the perineum, if necessary, as far as the tuberosities of the ischium. After division of the superficial fascia and sepa- ration of the connection between tJie bulbo-cavernosus and the sphincter ani externus, the insertions of the levator ani are separated on both sides from the rectum. The stumps recede toward the pelvis. Next, the operator penetrates bluntly into the connective tissue between rectum, prostate, and bladder, as far as the reflection of the peritoneum. The exposed mem- branous portion of the urethra is then opened upon a lithotomy staff. The SURGICAL TECHNIC finger penetrates through the urethra into the bladder. A probe-pointed knife, introduced upon the finger, splits the posterior wall of the prostate exactly in the median line, close to the peritoneal duplicature. With sharp retractors, the two halves of the prostate are then drawn apart, and the median lobe, if enlarged, as well as portions of the lateral lobe, may be excised from the bisected prostate with knife, scissors, or the thermocau- tery ; any existing calculi can be removed with ease. After the hemorrhage has been arrested, the incision is diminished by partial suturing, ample space being left for a drainage tube (as above). The external wound is likewise sutured in part, and the remaining space packed with gauze. FIG. 1427. External Incision FIG. 1428. Cavity of the Wound ZUCKERKANDL'S PRERECTAL INCISION From the perineal incision, even without incising the urethra and pros- tate gland, the posterior wall of the gland can be made accessible for the incision and drainage of abscesses, and for the removal of tumors. By de- taching the rectum still farther, and with a temporary displacement toward the coccyx and by deepening the wound, even the seminal vesicles and the fundus of the bladder can be reached. Kochers prerectal pointed arch incision (Figs. 1429, 1430) creates similar conditions of the wound, and a still better access to the organs mentioned. Recently, moreover, all these operations on the prostate have been made through a suprapubic incision, the patient being placed in Trendelenburg's position (suprapubic prostatectomy). For this purpose the bladder is opened in a more upward direction (at the apex). The cystotomy wound is drawn apart with strong retractors, so that the interior of the bladder can be well inspected. If- a catheter is then introduced, the operator can see and deter- mine with the wound the location of the obstruction to the escape of the urine (nodules, lobes, wall-like elevations, etc.). All projections are removed (MacGill}. A marked sacculation at the fundus behind the prostate can OPERATIONS ON THE PELVIS 7 8l be removed by deep, tvedge-sJiaped excisions of the wall of the bladder with subsequent suture. Lateral prostatectomy (Dittel) exposes the prostate gland and its sur- roundings from behind. FIG. 1429. External Incision FIG. 1430. Cavity of the Wound KOCHER'S PRERECTAL POINTED ARCH INCISION The patient, into whose urethra an elastic catheter has been introduced, is placed in the right lateral position. The external incision extends in the anal notch from the point of the sacrum to the right, around the margin of the anus as far as the raphe in front of the anus. In penetrating into the ischiorectal fossa, the rectum is detached bluntly from the prostate gland and drawn laterally until first the right lobe of the prostate and, finally, its entire posterior surface are exposed. More space, if necessary, can be gained by removing the coccyx. A procedure that deserves more consideration than it seems to have found until now (Czcrny, Kiimmell, Freudenbcrg} is the galvanocaustic excision of the prostate gland (Bottini) in hypertrophy. It is made with a lithotrite-like instrument, the movable arm of which consists of a little platinum knife about i^ centi- meters high ; this knife is made to project from the slit in the beak of the instrument by screw action (Fig. 1431), the beak serving at the same time as a cooling tube. After the intro- duction of this instrument through the urethra previously anaes- thetized (5 cubic centimeters of a i% cocaine solution), the knife, rendered red-hot by closing an electric current, is slowly drawn from behind forward through the prostate gland. In most cases it is necessary to make several linear cauterizations in various directions, for instance, upward, downward, and at the side of FIG. 1431 BEAK OF PROSTATIC INCISOR 782 SURGICAL TECHNIC the greatest hypertrophy. The operation is completed in a few minutes ; in most cases, the patient can urinate spontaneously after a few hours. Up to this time but few if any failures have occurred. Likewise, the ligation of the different arteries and of the hypogastric arteries, according to Bier, is often followed by shrinking of the hypertro- phied prostate gland. The operation is made with the patient in Trendelen- burg's position and transperitoneally, but offers considerable difficulties. FIG. 1432 FIG. 1433 CIVIALE'S BIGELOW'S LlTHOTRIPTOR LlTHOTRIPTOR LITHOTRIPSY, that is, the operation of reducing to fragments a cal- culus in the bladder without injuring the bladder and the urethra, can be made if the calculi are not too large and not too hard, and if the urethra is of sufficient caliber (strictures, especially at the exter- nal urinary meatus, must be removed previously by dilatation or incision). To obtain good results with the operation, great practice and dexterity in manip- ulating the necessary instruments are required. The crushing is made with the lithotrite, a catheter-like metal instrument with a short, broad beak, consisting of two arms. One of them (the male) can be slid in a groove of the other (the female) like a sledge. The former has a strongly denticulated anterior end fitting into the fenes- trated end of the female blade. By screw power or strokes with a hammer the stone grasped by the arms is crushed (Figs. 1432-1433). For the operation., the patient is placed upon a low table, with his pelvis raised and his legs flexed. He is then anaesthetized. The bladder is several times washed out with boric acid solution, and finally about 50 to 100 cubic centimeters of the solution are left in the bladder. Thompson pre- fers to operate with the bladder empty. If it is desirable to operate without anaesthesia, the bladder can be rendered anaesthetic by injecting 40 to 50 cubic centimeters of a 2% to $% cocaine solution. OPERATIONS ON THE PELVIS 783 1 . Introduction of the lithotrite exactly in the same manner as described in catheterization ; the weight of the instrument facilitates its insertion, pro- vided the urethra possesses the required width. 2. The operator stands at the right side of the patient, holding the cylinder-like shaft of the instrument with his left hand, the handle at the end (wheel, ball) with his right hand. When the handle is raised, the beak of the instrument is gently pressed against the fundus of the bladder, and in this position the operator waits quietly for a few seconds ; when the slid- ing (male) arm of the instrument is withdrawn, its beak is opened so far that the operator feels it touch the neck of the bladder ; the handle is then pushed back again. From the firm resistance distinctly felt, the operator knows that the stone has fallen between the blades of the instrument. If this is not the case, the blades are opened again ; and the operator probes toward the right or the left, repeatedly opening and closing the instrument until the stone has been grasped. 3. Next, by bringing together the halves of the screw concealed in the handle, the " interrupted screw " becomes locked ; and by slowly rotating the handle around its axis, the beak is made to operate, and is very forcibly screwed together until the crushing of the stone is felt and heard ; since the fragments fall toward both sides, the instrument can be completely closed again. During this procedure, the cylinder-like shaft is held firmly and steadily in its position with the left hand. 4. The instrument is at once opened again, and an attempt is made to grasp one of the fragments and to crush it in the same manner ; this pro- cedure is repeated until all of the larger fragments have been crushed ; it can then be taken for granted that the stone has been entirely crushed into small pieces. For grasping even the last portions, the beak is turned down- ward toward the neck of the bladder, so that it can grasp any fragments concealed behind the prostate. 5. If the stone is too hard to be broken by screw power, it may be broken by striking the handle with a hammer. If, in this manner, the stone has been broken into small fragments, another lithotrite is introduced, the female arm of which is not perforated at the end, but scooped out like a spoon (e.g. Fig. 1432). With this the fragments are grasped again, one after another, and ground to a fine gravel. After this has been accomplished, a large evacuation catheter with a large opening at its beak-like end is introduced (Fig. 1434, 3). Through it, the fluid present in the bladder generally flows out with a portion of the fragments of stone. 784 SURGICAL TECHNIC 6. The evacuation of the fragments of stone is then made at once (litho- lapaxy, Bigelow). For this purpose is used the evacnator (Bigeloiv, Otis, Fig. 1434), a suction pump, the end of which is screwed into the opening of the catheter. The whole apparatus is filled with boric solution ; and by compressing the elastic bulb a portion of the solution is forced into the bladder, from the bottom of which it whirls up the debris. If the pressure is discontinued, the bulb aspirates the fluid, bringing with it some of the fragments of stone ; these fall at once into the glass receiver (2) filled with glycerine and screwed FlG. 1434. OriS'S EVACUATOR FOR LlTHOLAPAXY to the apparatus. The compression and suction by the elastic bulb are now slowly but rhythmically continued until no more fragments can be removed from the bladder. The interruption of the current of fluid in the glass receiver by means of a tube opening above and another opening below, prevents the fragments of stone withdrawn from returning into the bladder. If fragments of stone are no longer evacuated, the evacuator is removed, and the lithotrite is introduced once more, to search for any fragments 'that may have remained. If any are found, they are removed in the manner described before. OPERATIONS FOR CONGENITAL CLEFT FORMATION OF THE ANTERIOR PELVIC REGION (a) In ectopia vesicae, that is, exstrophy of the bladder. The congenital defect of the abdominal wall and tJie bladder exists nearly always in connection with a cleft of the pubis, with epispadias and inguinal hernias. For relieving to some extent the pitiable condition of the patient suffer- ing from these defects, the continuous trickling of urine from the vesical OPERATIONS ON THE PELVIS 785 FIG. 1435. RECEPTACLE FOR URINE apertures of the ureters freely exposed in the protruding posterior wall of the bladder, the urine is collected in a suitable receptacle made of soft rubber (Fig. 1435). The operative closure, however, offers exceedingly great difficulties, and the operator can feel satisfied when he has covered the vesical defect so far that some urine may collect in the bladder, which has been forced back. The urine is retained by a trusslike appliance, and is evac- uated at pleasure by removal of the truss. Covering the protruding posterior wall of the bladder (cystoplasty) has been attempted by the formation of flaps ( Wood, TJiierscJi). The flaps of skin must be taken from the immediate neighborhood, that is, from the abdominal wall. They can be stitched di- rectly with their fresh wound surface to the vivified margins of the vesical defect. For this purpose, either one large flap {Hirsckberg) can be employed, or several, simultaneously, or one after another ( ThierscJi). Underlining by turning over a sufficiently large flap (attempted by Nelaton} is not practical, because the epidermis side turned into the interior of the bladder furnishes the cause for obstinate stone formations by deposition of phosphates on the hair. It is sufficient to fasten over the cleft a large flap, with the wound surface toward the bladder. If its healing succeeds, it is true, the flap sub- sequently contracts considerably ; but during cicatrization it partly draws the mucous membrane of the bladder toward its inner surface. Wood and ThierscJi closed the cleft by lining it witJi tJiree flaps (Figs. 1436-1438). First, from the skin of the abdomen over the bladder, a large flap (A) was excised, turned downward, its epidermis side toward the bladder, and sutured to the vivified margins of the bladder ; this flap was then covered by sliding and turning two pednnculated flaps (B and C), obtained from the lateral inguinal regions. The annoying condition mentioned above the forma- tion of concretions might perhaps be removed by grafting (according to Wb'lfler*} the large flap with mucous membrane, as a preliminary step to its transplantation (A), after a superficial removal of the epidermis, or by destroying the several hair follicles by electrolysis or galvanocautery. Tliiersch afterward proceeded as follows : He detached two lateral flaps, having an upper and a lower bridge, near the margin of the bladder, 3E 786 SURGICAL TECHNIC and allowed them to granulate upon a plate of tinfoil, ivory, or glass, placed under them. When the flaps began to contract and fold, he divided the upper bridge, and sutured first one lap over the inferior portion of the bladder; after it had healed, he closed the superior portion by means of the flap of the other side, treated in the same manner ; by a final operation, he closed the transverse cleft remaining between the two flaps. The skin of the scrotum, often considerably enlarged by inguinal hernias, may also be very well used for such flaps ; the healing hardly ever succeeds completely. In most cases, small fistulas remain between the several sutures ; these must be closed subsequently. FIG. 1436 FIG. 1437 FIG. 1438 WOOD'S CYSTOPLASTY. Fig. 1436, forming flaps; Fig. 1437, suturing lateral flaps over inverted middle flap; Fig. 1438, healing of wound Czerny succeeded in directly suturing the margins of the defect by dissect- ing off, all around, the prolapsed mucous membrane of the bladder with the exception of a portion in the middle about as large as a ten-cent piece, and by turning it over and suturing the margins of the wound in the median line. Battle proceeded in a similar manner. Suturing of the margins of skin, however, must be effected by a plastic operation. Schlange and Rydygier sutured the margins of the vesical cleft by including the recti muscles and portions of the pubes ; Pozzi proceeds in a similar manner. Miculicz sutures two bridge flaps, containing the recti and their chiselled- off pubic insertions, with silver wire over the bladder, previously detached and sutured to form a hollow sphere ; he subsequently forms the urethra and the penis by uniting the margins of the cleft vivified longitudinally, and OPERATIONS ON THE PELVIS 787 finally occludes the neck of the bladder by circumscribing it with the knife and inversion suture of the fistula. Poppert, after the bladder had been sutured, effected a rather good continence by allowing the posterior portion of the urethra (which contains the sphincter) to extend for a short distance into the lower wall of the bladder. Stretching of the ring of the sphincter muscle by intravesical pressure cannot then take place. Passavant advantageously employed Dentine's suggestion, that is, to remove first the cleft of tJie pubcs ; having the patient wear a rubber belt or a steel belt provided with screws, or having him lie upon a wooden log with a cuneiform excision P v l he tried very gradually to force together the gaping margins of the pubes, so that they almost touched each other. Meanwhile, by suitable apparatus, he forced back into the abdominal cavity the wall of the bladder (elastic bulb with gutta-percha plate and rubber bandage). When the margins of the cleft had been approximated by this treatment (after several months), he sutured the cleft of the bladder after vivifying broadly ; next, he approximated the pubes by sutures, and then attempted the formation of a sphincter ring, which in its original position forms only a straight muscular band. Finally the groove of the urethra, open in an upward direction, was closed by suturing the corpora cavernosa of the penis, which had been turned upward. Trendelenburg effected reduction in the size of the cleft of the pubis in a much sJiorter time by dividing the sacroiliac articulations. For this pur- pose, the left forefinger is introduced into the rectum of the child lying on the abdomen, and the sciatic notch is sought for. Then the skin over the articulations is divided from without, and the operator - penetrates in the same line through the posterior masses of ligaments, until the connection has been sufficiently loosened to enable a vigorous lateral pressure upon the two pelvic halves to rupture it, so that the stumps of the symphyses touch each other. The wounds are closed by skin sutures. The child is then placed for four to six weeks into an apparatus which keeps the pelvis laterally compressed. Then, after a broad vivifying, the approximated margins of the cleft are sutured with silver wire in a vertical line. If too great a tension is caused thereby, the skin can be made more movable by lateral incisions parallel to the margins of the cleft (as in Fig. 1404). Koch obtained good success with a similar procedure. He decreased the cleft of the symphysis \sy forcibly rupturing the articulations. Konig approximates the divided symphysis after chiselling through the horizontal and the ascending ramus of the pubis on both sides. 788 SURGICAL TECHNIC In exstrophy, with very marked protrusion, Sonnenburg removed the whole bladder, after having detached it carefully from above from the peritoneum (extirpation of the urinary bladder), and sutured the dissected- off ureters into the groove of the penis at the lower sutured extremity of the cavity of the wound covered by sliding lateral flaps. LangcnbucJi pro- ceeded in a similar manner. After extirpation of the bladder, Maydl and others implanted the ureters, together with a portion of the vesical mucous membrane, into the sigmoid flexure. Even in healthy kidneys, Harrison extirpated the left one, implanted the ureter of the right kidney into a small skin-incision of the right lumbar region, and closed the bladder by a plastic operation. The success of all these operations consists in reducing the defect and thus in obtaining a smaller opening at the lower extremity of the covered defect, after the mucous membrane of the bladder, which, owing to its inflammation, is exceedingly painful, has been covered or removed. The small opening resulting from the operation can be closed by the stump of the penis turned upward, and by a suit- able pad ; or, at least, it is better adapted for apply- ing a portable urinal, which is fastened laterally to FIG. 1439. PORTABLE URI- the P adent ' s le g ( Fi g- H39)- Finally, by removing NAL AFTER CvsTopLASTY the cpispadias, which nearly always exists, the urine may also be evacuated through the thick stump of the penis, whereby approximately normal conditions are produced ; or, at least, the continuous irrigation of the scrotum and the perineum with decom- posing urine is lessened. (/;) EPISPADIAS The operation for cpispadias consists in transforming the gutter on the upper surface of the penis into a closed urethral canal. This is done prefer- ably by THE METHOD OF THIERSCH, who proceeded at various sittings as follows : i. Formation of the glans portion of the urethra: By two incisions, extending along the margins of the canal of the glans, obliquely inclined toward each other and penetrating deep into the substance of the glans, the latter is divided into three flaps (Fig. 1440, a, b). After the hemorrhage has OPERATIONS ON THE PELVIS 789 been arrested, the median flap, containing the mucous membrane of the canal, is depressed with a grooved director ; and the two elastic lateral flaps FIG. 1440. FORMING GLANS PORTION OF URETHRA are folded over it and united with deep interrupted or continuous sutures (Fig. 1440, c). After the wound has healed successfully, the attempt is made 2. To close the penile portion of the gutter. On both sides of the gutter two oblong rectangular flaps (Fig. 1441) are excised from the skin of the dorsum of the penis. One of these flaps, the broader, is turned with its free FIG. 1441 FIG. 1442. CLOSURE OF OPEN SLIT BETWEEN GLANS AND PENIS CLOSURE OF PENILE PORTION OF GUTTER FIG. 1443 margin ($) toward the gutter. The smaller of these two flaps with its base (a) (like the leaves of a door) is turned over the gutter in such a manner that its outer (epidermis) surface is directed toward the canal ; the other, the broader flap, is turned over the smaller flap, so that its wound surface comes to lie upon the wound surface of the smaller flap, which has been turned over. After the position of the two flaps has been secured by a few 790 SURGICAL TECHNIC quilt sutures, the margin of the larger flap, serving for a cover, is united by superficial sutures with the opposite margin of the wound of the wall of the penis (Fig. 1443). When, in this manner, after the healing of the flaps, the groove of the penis has been changed into a closed canal, then follows : 3. The closure of the open slit between glans and penis, for which the prepuce, hanging down below the glans like an 'apron, may be used. The same is slit below the corona glandis by a transverse incision (Fig. 1443, c\ and the glans is passed through it as through a buttonhole, so that the pre- puce comes to lie on the slit in the form of a ridge. After the margins of the prepuce have been vivified, they are stitched to the corresponding vivi- fied margins of the glans and the penile tube (Fig. 1442). There remains now : 4. The closure of the funnel existing at the root of the penis. This must be done by pedunculated flaps taken from the neighboring skin of the abdomen (Fig. 1444). Thiersch formed two lateral flaps, a triangular and a rhomboidal flap, which he placed over each other in a similar manner as in forming penile portion of the urethra (Fig. 1442). It is better to form only one flap, and before suturing it to graft its wound surface with mucous membrane by transplantation according to Thiersch, in case the existing mucous membrane of the funnel should not be sufficient for grafting (see page 765). Kiister effected transformation of the groove of the penis into a canal by dividing the inferior surface of the penis by a deep, longitudinal incision extending between the corpora cavernosa. He then turned the two halves upward. Hclfcrich divided even down to the mucous membrane. The deep incision wound is left to granulation. If the penis is very small and in very young subjects, Rosenbcrger proceeded in such a manner as to turn the penis (having been sutured to the scrotum) upward toward the abdo- men, after having vivified the groove broadly ; here it healed into two vivi- fied margins (Fig. 1445). The penis directed upward was subsequently turned downward by excising a flap from the abdomen (Fig. 1446). The wound on the dorsal surface was covered with this flap, and the thin defect of the abdominal wall closed by suturing. * FIG. 1444. CLOSURE OF THE FUNNEL OPERATIONS ON THE PELVIS 791 (Y) HYPOSPADIAS The operator proceeds according to the methods just described ; or he covers the defect according to the methods given in the operations for urethral fistulas (see page 765). By a simpler method and in considerably less time, Landerer's (Rosen- berger's) Procedure seems to bring about the desired end. FIG. 1445 FIG. 1446 ROSENBERGER'S OPERATION FOR EPISPADIAS He restores the missing lower urethral wall from the skin of the scrotum. First two strips about 3 to 4 millimeters wide are vivified on both sides of the groove of the penis as far as and into the scrotum ; the penis is turned down upon the scrotum, its glans portion is sutured to the deepest point of the scrotal wound, and the remaining portion of the penis is fastened on both sides to the scrotum by three superficial sutures (similarly as in Fig. 1445). After the penis has become completely embedded in this position (after six to eight weeks), it is liberated from the scrotum and covered with skin on its lower surface. For this purpose, from the external urinary meatus of the penis drawn upward at the glans, two lateral incisions are made into the scrotum, a little longer than the penis is intended to be, and the rhom- boidal defect caused thereby is closed by suturing it longitudinally. OPERATIONS ON THE PENIS AND THE SCROTUM OPERATION FOR PHIMOSIS The abnormal stenosis of the preputial orifice can be removed : 1. Bluntly, by repeatedly stretching the contracted opening of the prepuce crosswise with dressing forceps, or by pushing it back forcibly several times, whereby any existing adhesions are separated at the same time. This procedure suffices nearly always in little boys, and gives better results than incision. 2. By incision, Roser's dorsal incision. Upon a grooved director, intro- duced between the prepuce and the dorsum of the glans, with a pair of scissors, the prepuce is divided longitudinally beyond the anterior half of the glans (Fig. 1447). (The division can also be made with a curved tenotome from within outward.) By draw- ing back the external layer of the prepuce, the internal layer remains still lying on the glans, its wound angle lies in front of the angle of the external layer. By two lateral incisions with the scis- sors from this angle of the wound, a triangular flap is formed (Fig. 1448, a\ whose point turned over in an up- ward direction is united by suture with the angle of the wound of the external layer (b\ Finally, the two surfaces of the lateral margins can also be united by suture. The two flaps formed by the incision then hang down like a small apron. A better form of prepuce is obtained if similar but smaller incisions are made at both sides of the prepuce, and if the margins of the wound are 792 FIG. 1447 FIG. 1448 OPERATION FOR PHIMOSIS (Roser's dorsal incision) OPERATIONS ON THE PENIS AND THE SCROTUM 793 united transversely by fine sutures (Fig. 1449); or, in less serious cases, the prepuce is divided by a simple incision only to such an extent that it can be retracted as far as the corona glandis. There it remains until the wound has healed, which then extends in a transverse direction. In order not to soil the dressings, the patient may urinate through a wide tube (broken-off test-tube). Likewise, by several very shallow nickings, the opening of the prepuce may be enlarged until it can be retracted as far as the corona glandis. 3. By circumcision, especially if the length of the prepuce is excessive. The prepuce is steadied by two forceps grasping its margin, and held tense. Next, it is cut off with a pair of scissors parallel to its margin in front of the glans without injuring the latter. Still simpler is the procedure if the por- tion to be removed is grasped transversely with forceps, and cut off on the outer side of the same as along a ruler ; the internal and external layers are then united by a few sutures. FIG. 1449. OPERATION FOR PHIMOSIS BY SUTURING TRANSVERSELY Two LATERAL INCISIONS (von Esmarch) The removal of the whole prepuce is rarely required. It is made for malignant disease or for elephantiasis. The dorsal incision is made as far as the corona glandis, and from the angle of the wound the prepuce is removed with the scissors by cutting on both sides close to the sulcus coro- narius as far as the fraenulum ; the internal layer is united by suture with the external layer. In children, sometimes, the whole internal surface of the glans is adhe- rent by epithelium to the prepuce. This can be removed easily soon after birth by retracting the prepuce or by using blunt instruments. But if this is not done, the internal lamella adheres so firmly to the glans that it can- not be detached from the same in this simple manner. If the adhesion were removed with the knife, the former condition would still recur from cicatri- zation. In such cases DieffenbacJi formed a new prepuce by a plastic opera- tion (Posthioplasty). 794 SURGICAL TECHNIC He removed the proboscis-like anterior margin of the prepuce and sepa- rated the external layer, which had been forcibly retracted from the internal layer by superficial incisions, as far as i centimeter behind the corona glan- dis ; next, he carefully dissected off the whole internal lamella from the glans, and cut it off all around along the corona glandis. Then he inverted the free margin of the external layer as far as the sul- cus coronarius, and fastened the thus doubled external layer in this position by a few sutures. A reunion by adhesion could not occur after that, and the surface of the glans became cicatrized after a short time. Probably it is better not to remove the firmly adherent internal layer, but to graft the wound surface of the internal lamella at once with epidermis. The oedema of the prepuce and skin of the penis frequently occurring after all these operations should be prevented by immediately dressing the whole penis with fine gauze or rubber bandages. (Dressing the wound with carbolated vaseline, elastic compression from the tip of the glans to the root of the penis, rest in bed, and elevation of the penis are the most efficient means in preventing oedema and in expediting the healing of the wound.) OPERATION FOR PARAPHIMOSIS If the glans is strangulated by a retracted tight prepuce, oedema and gan- grene of the prepuce and glans soon occur, unless the strangulation is removed. Since the chief obstacle to reduction consists in oedema, which quickly develops, its removal must always be first attempted. This is accom- plished in most cases by wrapping a small elastic rubber bandage around the whole penis. Commencing at the tip of the glans, slowly envelop the whole penis as far as its root under moderate traction of the bandage. The com- pression should be strongest over the glans and diminish gradually in the direction of the root of the penis. After a few minutes the bandage is removed ; then the reduction of the prepuce (taxis) can generally be made without difficulty. 1. The penis is held with the left hand so as to be encircled by the fore- finger and the thumb behind the incarcerated swelling, while with the first three fingers of the right hand pressure is made against the glans in the direction of the constricting ring (Desruelles, Fig. 1450), or 2. While the forefinger and the middle finger of each hand encircle the penis behind the swelling, and push the prepuce over the glans anteriorly, OPERATIONS ON THE PENIS AND THE SCROTUM 795 the two thumbs lying together upon the glans, press the same through the incarcerating ring (Coster, Fig. 1451). FIG. 1450 FIG. 1451 REDUCTION OF PREPUCE (TAXIS) IN PARAPHIMOSIS If these attempts do not succeed, or if gangrene of the prepuce has already set in, it is preferable to incise the strangulating ring (Fig. 1452). Into the middle of the dorsum of the penis a pointed grooved director is pressed from behind beneath the strangulating ring (groove due to compression between the two swellings corresponding to the anterior margin of the pre- puce), and the same is divided with the knife. If the strangulating ring can be exposed by drawing apart the two ridge-like swellings (oedematous internal and external layer of the prepuce), it is completely divided in layers from without inward. FIG. 1452. INCISING STRANGULATING RING After a subsequent reposition of the prepuce, it is sometimes desirable to remove the existing phimosis a few days later. 796 SURGICAL TECHNIC AMPUTATION OF THE PENIS The penis must be amputated for malignant disease involving the glans, prepuce, and the penis. The operation is made by the " bloodless method " by elastic constriction, either in front of the scrotum or behind it, according to the seat of the tumor. i. While an assistant securely holds the root of the penis, the portion to be detached, which is covered with gauze, is grasped with the left hand; the penis is drawn away from the body under moderate traction of the skin, and amputated in the healthy part with one sweep of a medium-sized amputation knife (Fig. 1453). FIG. 1454. WOUND SURFACE FIG. 1453. AMPUTATION OF PENIS FIG. 1455. SUTURE 2. Next, on the surface of the wound (Fig. 1454), the dorsal arteries of the penis, the artery of the corpus cavernosum, and the artery of the bulb are sought for, ligated, or twisted. The hemorrhage from the corpora caver- nosa is arrested by ligatures " en masse" or by closing the surface of inci- sion by drawing over it the albuginea, which is sutured over it. 3. After the constrictor has been removed, and any secondary hemor- rhage has been arrested, the mucous membrane of the urethra is drawn forward (if necessary it is nicked somewhat at its lower margin), and its OPERATIONS ON THE PENIS AND THE SCROTUM 797 margin is united with the external skin by four interrupted sutures (Fig. 1455) to guard against stenosis of the new opening. Between the deep sutures a few superficial sutures may be added, according to necessity. In a very Jtigli amputation the stump, before its complete division, must be grasped with a hook or with tenac- ulum forceps, so that the corpora cav- ernosa cannot retract underneath the skin in case the elastic constriction should not prevent this. If the amputation must be made as far as and into the scrotum, the latter is divided in the median line into two halves, and the carefully dissected-out urethral stump is sutured downward into the slit of the skin (Fig. 1456), or the urethral stump is drawn out through a wound made on the peri- neum (perineal urethra stomy ; see also page 763). By this operation the constant wetting of the scrotum with urine is prevented. For dressing, a small piece of iodoform gauze is used. This is applied on the surface of the wound, removed in urinating, and at once renewed. It is not necessary to introduce a catheter permanently, but sometimes during the first days the evacuation of urine by means of a catheter may be necessary. FIG. 1456. HIGH AMPUTATION OF PENIS DIVISION OF SCROTUM OPERATIONS FOR HYDROCELE TESTIS The simplest procedure for removing an ordinary hydrocele is: i. Puncture and injection of solution of iodine. After the position of the testicle, which in most cases lies at the posterior side of the swelling, has been ascertained, the operator with his left hand grasps the scrotum from behind, and stretches it. With his right hand he inserts a moderately strong trocar through the anterior wall in an upward direction at a point where there are no visible veins ; the depth to which the instrument is to be inserted is fixed by applying the point of the forefinger upon the canula(Fig. 1457). Puncturing the testicle should be avoided. In extracting the stylet, the canula is inserted at the same time as far as its shield, and the contents are then allowed to flow out ; during this pro- 798 SURGICAL TECHNIC cedure the internal opening of the canula must be prevented by skilful manipulations from coming in contact with the opposite wall. After all of the fluid has been drained off, the point of the syringe, fitting exactly into the opening of the canula and filled with 5 to 10 grams tincture of iodine or Lugols solution (iodine, I ; kali jodat. 2 ; aq. 24), are injected into the canula, and its con- tents are slowly emptied into the cavity. While the syringe remains inserted in the canula, the assistant, by kneading massage movements, tries to bring the iodine solution in contact with the whole wall of the sac. Then, by drawing the piston of the syringe, the larger portion of the fluid is removed by aspiration. After removal of the canula, the puncture is sealed with iodoform col- lodion, adhesive plaster, etc. The patient remains in bed for eight days with his scrotum slightly elevated ; he then receives a suspensory, and is dismissed with a request to report about the success of the operation after six months ; for it frequently takes this length of time for the interior of the sac to become obliterated by the irritation of the iodine after a renewed (inflammatory) extravasation. Recurrence occurs after this operation only in rare cases. Hence, in its simplicity, it can be considered the normal procedure, especially in children that do not keep themselves clean. (In this country iodine is seldom used in the radical treatment of hydro- cele, owing to the uncertainty of the results and the violent inflammation which occasionally follows this procedure. The favorite treatment consists in injecting carbolic acid (pure) after puncture and evacuation of the sac (Levis). The amount of carbolic acid injected varies, according to circum- stances, from a few drops to half a drachm.) Incision with suturing of the tunica vaginalis to skin (von Volkmanri). This operation is indicated in k&matocele, pyocele, and hydrocele, when the puncturing, with iodine injection, has proved unsuccessful. FIG. 1457. PUNCTURE FOR HYDROCELE TESTIS OPERATIONS ON THE PENIS AND THE SCROTUM 799 After a careful disinfection, the scrotum is held tense with the left hand from behind, as for puncture, and is incised at its anterior external side by an incision 5 to 10 centimeters long down to the tunica vaginalis. After the hemorrhage has been arrested, the exposed tunica vaginalis propria is punctured with the knife, and the opening is enlarged to corre- spond with the external incision, while the contents escape. Next, the margins of the tunica vaginalis are grasped with forceps, some- what drawn forward, and stitched to t/ie margins of the skin by a few inter- rupted sutures (Fig. 1458). (The tunica vagi- nalis should be united with the skin by a continuous fine catgut suture.) If the testicle has prolapsed, it is replaced into the sac ; and beside it, a short drainage tube is introduced, and the sutured margin of the wound is in- verted and held in place by a few deep sutures. The rest of the wound is tamponed with iodoform gauze, and finally a typical pelvic dressing or a pair of bathing drawers are applied. Konig incises the tunica vaginalis to the extent of the external incision, inspects the cavity, irrigates it thoroughly, and sutures the wound by a continuous suture, with the exception of a small opening into which a strip of iodoform gauze is introduced. (The editor has always placed great stress on the importance of bringing in contact with every part of the parietal and visceral tunica vaginalis iodo- form gauze (one strip), which is allowed to remain for at least six to seven days in order to transform the endothelial into a granulating surface.) Sometimes, especially in thickened walls of hsematoceles of long stand- ing (yaginalitis proliferans\ it is necessary to resect corresponding portions of the parietal tunica vaginalis, and to line the remainder with skin. But, since the healing always occupies some time, the total extirpation of the in- ternal tunica vaginalis (von Bergmamt) is a method that effects a thorough healing in a shorter time. From a skin incision sufficiently large, the whole tunica vaginalis propria is enucleated bluntly as far as and close to the testicle and the spermatic cord, and detached near the testicle with the scis- sors, leaving in position only a small portion ; the wound of the skin is sutured in its whole extent ; an introduced drainage tube is removed after FIG. 1458. VON VOLKMANK'S INCISION FOR HYDROCELE 8oo SURGICAL TECHNIC two days. In a similar manner, the sac is excised in hydrocele of the spermatic cord, The folding together of the divided tunica vaginalis, which Storp places around the testicle (as a soldier folds his cloak around his knapsack), can be employed only for milder cases, and can probably be dispensed with. OPERATIONS FOR VARICOCELE The largely distended veins of the pampiniform plexus are extirpated if they cause symptoms which cannot be removed by wearing a suspensory. After the scrotum of the patient, while standing, has been constricted by a rubber tube in such a manner that the veins greatly swell from stasis by the first (gentle) constriction, while the next tour effects a complete arrest of the circu- lation, after anaesthesia has taken effect, a correspondingly long incision exposing the bundles of the veins is made through the skin of the scrotum. Any incised lumina or veins are closed at once by hemostatic forceps. The dilated veins are then dis- sected off from the surrounding loose con- nective tissue for a distance of a few centi- meters; and after double ligation they are divided near the testicle, dissected off in an upward direction, and also cut off centrally after another double ligation (Fig. 1459). The extremities of the resected veins can be tied together by means of the ligature FIG. 1459. OPERATION FOR VARICOCELE threads, also a piece can be cut off from the skin of the scrotum, if the same is much elongated ; or, still better (according to Kohler, Parker, Scnn\ the longi- tudinal wound of the scrotum can be sutured transversely, whereby the scrotal half becomes considerably shortened. (Elastic constriction at the base of the scrotum is of no special value in the enucleation of varicose spermatic veins. The operation is performed almost bloodlessly by careful dissection. The vein stump should be sutured together with a fine catgut suture enforced by tying the ligature ends together. Excision of the scrotum is superfluous if the scrotal wound is sutured transversely.) OPERATIONS ON THE PENIS AND THE SCROTUM 8oi One or two veins, however, must remain uninjured; likewise an injury to the arteries must be avoided, else atrophy or necrosis of the testicle easily ensues. The wound of the skin is closed by suture as far as the lower angle, and finally an antiseptic dressing is applied. After the healing of the wound, the patient must wear a suspensory. Ricord's subcutaneous ligation is less safe, and has probably been dis- placed completely by the aseptic extirpation. But the double ligation and subsequent division of the exposed veins may be attempted. CASTRATION TJte removal of tJie testicle is indicated in the treatment of malignant tumors and tuberculosis of an advanced degree. i. After the application of the elastic constriction tube around penis and scrotum, the scrotum is seized with the left hand and drawn tense ; external incision over the most prominent part of the tumor or swelling by dividing FIG. 1460 FIG. 1461 CASTRATION, a, external incision; b, ligating spermatic cord; Vd, vas deferens the different layers separately down to the tunica vaginalis. In existing fistulous openings, and in very large tumors, it is desirable to cut away a corresponding (elliptical) portion of the diseased or superfluous skin (Fig. 1460). 2. Incision of the tunica vaginalis, rendering the diagnosis certain by a careful inspection of the testicle. Next, the testicle is enucleated; as SF 'LOS ANGELIES 7 802 SURGICAL TECHNIC as possible from its envelopes, until it is connected only with the spermatic cord. If, in firmer adhesions, the knife must be used, the operator should always cut toward the tumor of the testicle, and guard against opening the scrotal cavity on the other side by an injury to the septum scroti. 3. The vas deferens, which can easily be felt, is sought for, isolated from the loose connective tissue, and divided. 4. The spermatic cord is pierced through in its middle portion with a pair of forceps or a similar instrument ; a double strong catgut thread is passed through the opening, and each half is very firmly ligated and cut off about i centimeter below the ligature (Fig. 1461). To prevent the stump from slipping back into the abdominal cavity, the threads of these ligatures " en masse" are allowed to remain about the length of a finger in the upper angle of the wound, where they serve at the same time for drainage. 5. The large wound is kept patent by retractors, and each bleeding vessel is grasped and ligated; next, after any superfluous skin has been removed with scissors or knife, the surfaces of the wound are sutured by buried sutures, and its margins by interrupted sutures. Drainage in most cases is superfluous. To avoid suturing of the rugous scrotal skin, which is difficult to disinfect, the spermatic cord can also be exposed first beneath the inguinal canal by a longer oblique incision, and then the testicle can be luxated out from this opening (as in post mortem s). In a double castration, a curved ' external incision is made across the raphe', and the greater part of the scrotum is extirpated. Recently, in old men, the double castration has been made (Ramm, White), to relieve the obstructive symptoms incident to hypertrophy of the prostate gland; it is claimed that this operation results in progressive diminution in the size of the prostate gland, and thus relieves the symptoms caused by it. Since, however, serious psychical disturbances are not rarely resulting from this operation, it is advisable to make instead resection of the vas deferens, vasectomy (Mears, HelfericJi), a simple and harmless operation, which, in case of necessity, can be made without narcosis under Schleic/is anaesthesia. From an external incision 3 to 4 centimeters in length across the round cord of the vas deferens, which can be distinctly felt between two fingers in the region of the inguinal opening, or deeper, the vas deferens is liberated from the other spermatic strictures, drawn forward somewhat, cut off cen- trally, and torn from the epididymis. The removed portion often measures from 8 to 10 centimeters. Von Biingner recommended evulsion* whereby, through a gradually increased traction on the exposed vas deferens, a large portioii of It -iln the abdominal cavity is also torn out. OPERATIONS ON THE RECTUM AND THE ANUS 803 OPERATIONS ON THE RECTUM AND THE ANUS EXAMINATION OF THE RECTUM For an external examination, the patient is requested to stoop over a table or a bed, while the coccygeal region is turned toward the light ; still better is the knee-elbow position. Next, the buttocks are drawn apart, and the patient is told to strain so that the anus is made more prominent. FIG. 1462. ANATOMY OF PELVIC ORGANS. S, symphysis; R, rectum; .5, bladder; U, ureter; P, peritoneum; Vd, vas deferens; /., levator ani; Sp, sphincter For internal examination, the forefinger, well lubricated with antiseptic salve (boric vaseline), is introduced into the rectum, previously cleansed by an enema. By slow and gentle turnings, the finger is advanced far enough to palpate the internal surfaces of the rectum. In order to palpate also the higher sections of the rectum with the tip of the finger, the patient is requested to force or to press, or the surgeon himself presses with his other hand upon the abdomen of the patient in a backward and downward direction. 804 SURGICAL TECHNIC But, if it is necessary to inspect the internal surface of the rectum, the resistance of the sphincters must be overcome; for this purpose a rectal speculum (speculum ani) is used. Fcrgussoris speculum (Fig. 1463) consists of a tube closed anteriorly, whose internal surface is coated with mirror glass. The portion of the rec- tum to be inspected is placed in the longitudinal opening of the tube. Of similar construction is Gowlland's speculum. Allinghams speculum (Fig. 1464) consists of four blades; its arms can be separated by compressing the handles, and can be held in position for any width by means of the screw in the middle. With this instrument, the entire lower section of the rectum can be satisfactorily inspected. FIG. 1463. Fergusson's FIG. 1464. Allingham's RECTAL SPECULA In great irritability of the sphincter, and in all serious cases, however, it is advisable to make the examination under anesthesia. After the sphincter has become relaxed from the effects of the anaesthetic, Sims' s (Fig. 1465) or Simon 1 s('\g. 1466) groove-shaped vaginal specula can be introduced without any trouble ; with this, the whole internal surface of the rectum can be in- spected. In the knee-elbow position, after the introduction of these specula, the rectum becomes inflated with air, and can be well inspected. The for- cible dilatation of the anus according to Recamier, made by stretching the sphincter during deep anaesthesia, likewise greatly facilitates the inspection of the lower section of the rectum ; it is made, also, as a preliminary proced- ure for removing diseases of the rectum. First, both thumbs are introduced into the anus, while the four fingers rest on the buttocks (Fig. 1467). Next, OPERATIONS ON THE RECTUM AND THE ANUS 805 the thumbs are slowly removed from each other until the stretching of the anal ring becomes very extensive. The same procedure is then repeated in various directions until the whole anal ring is sufficiently stretched. The sphincter becomes lacerated subcutaneously during this procedure, and finally feels like a well-beaten steak. After the operation very little blood flows from the anus. In difficult cases (in high carcinoma, foreign bodies, ileus) it may become necessary to introduce the whole hand (and the forearm) into the rectum under anaesthesia (Simon). Into the anus, previously dilated, the operator introduces first one fin- ger, then several fingers, then half the hand, and finally the whole hand into the rectal cav- FIG. 1465 SIMS'S SPECULUM FIG. 1466 SIMON'S SPECULUM FIG. 1467 FORCIBLE DILATATION OF ANUS ity, with careful turning movements and a pressure gradually becoming more effective. If the folded hand is not more than 25 centimeters in circumference, it can generally be forced through the anus of an adult with- out lacerating the mucous membrane. (Manual explorations should be undertaken only by surgeons with small, delicate hands.) Posterior sphincterotomy, the posterior rapke incision, is rarely necessary for the purpose of an examination, but it facilitates many operations on the posterior wall of the rectum. With a probe-pointed knife introduced upon the finger as a guide, the whole sphincter is divided in the raphe in a posterior direction as far as the tip of the coccyx. The latter may be displaced down- ward and outward, or be extirpated completely (Vcrneuil). Fecal incontinence, caused by this operation, disappears, as a rule, after eight to fourteen days. 806 SURGICAL TECHNIC PROCTOPLASTY The formation of an opening of the anus is required in the various forms of congenital imperforate anus {atresia ani\ to create a sufficient exit for the collected intestinal contents, and to establish thereby the natural condi' tions as far as possible. The child is placed in a dorsal sacral position, and is but slightly anaes- thetized, since the pressing forward of the perineal region, caused by its crying, essentially facilitates performing the operation. The bladder must be previously evacuated. 1. External incision exactly in the median line from the scrotum (posterior commissure of the labia) as far as the tip of the coccyx. 2. With careful sweeps of the knife, the operator gradually advances deeper as far as the prominence of the blind sac, through the wall of which the shining meconium can be distinctly seen. The connective tissue around the same is detached bluntly so far that the blind sac sinks down somewhat, and fills the gaping wound in the form of a dark blue bladder. 3. By two fine silk threads applied at the two angles of the wound (the ends of which have been introduced into fine needles), the blind sac is fixed in the wound (Fig. 1468) and then incised between these traction ligatures. While the contents of the rectum escape by means of a douche, the warm boric solution is allowed to enter until it flows out clear. 4. Now, with a little hook, the loops of the two threads previously inserted are drawn from the cleft, divided in the middle (Fig. 1469, E}, and employed for four interrupted sutures, by which, anteriorly and posteriorly, the divided blind sac is stitched to the external skin (Fig. 1469). 5. Next, the remaining portion of the margins of the incision of the rectum is sutured to the external skin all around with interrupted sutures {DieffenbacKs labial suture, similar as in Fig. 999), whereby an anal stenosis, which otherwise might occur, is permanently prevented. Even if the atresia extends very high, the attempt should always be made to reach the blind sac by a courageous deepening of the perineal incision if necessary, by opening the perineal sac and by extirpating the coccyx, to gain better access to the deeper layers. In case of necessity, a loop of the large intestine hanging down low may also be drawn forward and sutured to the margins of the wound and opened. Macleod recommends, in difficult cases, even opening the abdominal cavity anteriorly in the median line, searching for the blind sac, detaching it from its connections, and forcing it from above toward the perineal incision. To prevent the escape of meconium, the same OPERATIONS ON THE RECTUM AND THE ANUS 807 is stroked from the lower extremity toward the colon while the child is in Trendelenburg's position. If the rectum terminates in the bladder, urethra, or vagina, the rectum is likewise exposed by a perineal incision ; next, the cellular tissue around the place of inosculation is detached bluntly, and the intestine is cut off FIG. 1468. Fixing blind sac in the wound PROCTOPLASTY FIG. 1469. Opening blind sac Tying sutures transversely with the scissors. The opening thereby produced in the wall of the vagina or the bladder is sutured immediately ; the portion of the rectum, however, is drawn downward into the perineal wound, and fastened there (Riseoli). If the anus cannot, in any manner, be formed in its natural place, an inguinal anus must be established (see page 700) in order to preserve the life of the child. STRICTURES OF THE RECTUM Strictures of the rectum are recognized most readily by digital examina- tion ; if they are located very high, bougies (similar to those described on page 756) must be introduced. If any pass through the stricture, the operator, on withdrawing them, feels their points arrested. Still better are the ivory-olive points fastened to a whalebone rod (Fig. 1470, see also Fig. 1219), in the employment of which the operator has distinctly the sensation of a resistance suddenly overcome, when they have passed through the stricture. Moreover, they do not relax the sphincter so much, when left in position for some time. 8o8 SURGICAL TECHNIC FIG. 1470. BUSHE'S OLIVE-POINTED BOUGIE During these examinations, the patient is best placed in the knee-elbow position or Trendelenburg's position, in order to displace the intestines as much as possible from the true pelvis ; else the operator is very easily deceived by the for- mation of folds, etc. The slow dilatation with bou- gies is best made with olive- tipped bougies or glass-tipped bougies (Figs. 1470, 1471), ac- cording to the principles laid down for urethral strictures. The bougies are passed not too often (every two to four days), and all violence must be avoided, since a slight momentary press- tire influences the firmer tissue of the stricture most effectively. The forcible dilatation must be made only with the tip of the forefinger, which has been introduced slowly and carefully ; if the tissue prove to be very firm, its margin can be nicked very superficially and in several places with a herniotome (as hernial ring in herniotomy, rectotomia interna). After deeper incisions, which might divide the entire wall of the rectum thereby opening the cavity, progressive phlegmon with fatal termination easily ensues. In strictures seated very high, the external rectotomy (Sonnen- burg) is to be recommended. After the posterior surface of the rectum has been exposed by resection of the coccyx and sacrum FIG. 1471 (see page 819), the stricture is divided from without inward; the sphincter remains intact. The wound is tamponed, and heals very slowly (after the manner of external urethrotomy) ; the cicatricial contrac- tion gradually draws all healthy intestinal portions downward. In very serious cases, colostomy, or if there is no hope whatever of im- proving the stricture, an artificial anus must be made. I! GLASS BOUGIE OPERATIONS ON THE RECTUM AND THE ANUS 809 STRICTURES OF THE ANUS can be removed permanently only in rare cases, by a tedious bougie treatment. It is better, in milder cases, to divide the anus longitudinally, and suture the wound transversely. In very narrow strictures, it is better to divide the anus longitudinally in front and behind in the median line, to detach the mucous membrane of the rectum all around so far that it can be drawn down to the external wound when it is sutured to the skin, especially at the angles of the wound (as described on page 526 in the discussion of stomato- plasty). If the cicatricial tissue extends far into the rectum, while the external skin is in a normal condition, two tongue-shaped flaps, after a median divi- sion, are formed from the latter; their point is turned toward the anus. These flaps are detached, drawn across the gaping clefts into the rectum, and fastened here with fine sutures (Dieffenbach). OPERATION FOR RECTAL FISTULA consists in division of the wall of the entire fistulous canal from one end to the other ; this is the simplest, most rapid, and safest method of curing a fistula radically. FIG. 1472. FISTULA AMI. a, externa incompleta; b, interna incompleta; c, completa After the patient has been subjected to a thorough evacuation for several days, he is anaesthetized and placed in a lateral or lithotomy position, i. The internal orifice of the fistula must be searched for. 8io The latter is often located near the sphincter, as a small, hard swelling, toward which a probe can be pushed through the external opening (Fig. 1473)- FIG. 1473. PROBE FOR RECTAL FISTULA / Very small internal openings, located very high, are found in the most satisfactory manner by injecting milky solutions (milk, creoline); while a rectal speculum (e.g. Fig. 1463) is introduced, the solution is injected under moderate pressure with a small syringe, through the external fistulous open- ing ; generally the fluid escapes in a fine spray from the wall of the rectum ; in this manner also the existence of several internal openings is ascertained. (The most reliable diagnosis of the resources in determining the existence of a complete fistula is to inject through the external opening peroxide of hydrogen. If the fistula is incomplete, tension and pain will follow. If it is complete, foam will escape from the anus.) 2. Next, a flexible metal probe-pointed sound, with grooved shaft, is carefully introduced, without great violence, toward the rectal cavity through the external opening; the narrow internal opening, if necessary, is FIG. 1474 FlG. 1475. OPERATION FOR RECTAL FISTULA enlarged by pressing the probe-pointed sound forward, so that it becomes visible in the rectum. While the point of the probe is bent downward (Fig. 1474), and forced out of the anus with the introduced forefinger, the probe is pushed through farther. All soft parts lying between the two open- ings are now lying as a thick fold upon the probe in front of the anus, and OPERATIONS ON THE RECTUM AND THE ANUS may easily be divided with a pointed knife pushed along the groove of the probe (Fig. 1475); or they are incised with the thermo-cautery, or with the galvano-caustic loop. 3. The walls of the divided fistulous canal are thoroughly scraped with the sharp spoon ; for a dressing, a thick tube wrapped with iodoform gauze (Fig. 1476) is introduced ; this, by means of its pressure, arrests the hemor- rhage, in most cases inconsiderable ; likewise it forces apart the margins of the wound and prevents their premature union ; for it is desirable that the wound should heal from its bottom by granulation. FIG. 1476. TUBE FOR DRESSING IN RECTAL FISTULA If the internal opening is located very high, and surrounded by indu- rated tissue in such a manner that the probe point cannot be brought out of the anus, either a wooden gorget (Fig. 1478) may be introduced into the rec- tum for protecting the wall lying opposite to the same, when the operator is cutting with a long-pointed knife along a grooved director ; else Allingham's scissors may be used, one blade of which, provided with a probe-point, glides along a deeply grooved director (Fig. 1477). If there are several external or several internal openings, they must all be divided, and again united with one another ; undermined livid skin-bridges are cut away. FIG. 1477. ALLINGHAM'S PROBE AND SCISSORS FOR DIVIDING RECTAL FISTULA Incomplete fi stulce (Fig. 1472, a, b) must be transformed into complete fistulae. If no internal opening can be found, the wall of the rectum is pierced with the point of the probe at its thinnest place, and the probe is caught 812 SURGICAL TECHNIC FIG. 1478. DIVIDING INCOMPLETE RECTAL FISTULA with the introduced finger or in the groove of a gorget (Fig. 1478); all the portions lying between are divided. If the external opening is absent, and if only a hard place, sensitive to pressure and slightly prominent, indicates that the abscess will break through at this place, it is often possible to push the point of a hook-shaped probe through the internal opening as far as the skin, and to make an incision upon the same ; else a sharp-pointed knife is pushed into the hard place until pus is reached ; then, from the cavity of the abscess, the internal opening is searched for, and all the tissue intervening is divided. The division of the fistula by silk or elastic ligatures is tedious and not without danger. But after laying open the fistula, the indu- rated tissue of the fistulous canal can be extir- pated completely, and the surfaces of the wound can be at once united completely by suture (Stephan, Smith, Lange). PROLAPSUS RECTI is often permanently reduced in children, if they are prevented from violent straining and if the prolapsed rectum is carefully pushed back into position with the lubricated fingers after each evacuation. The inflammatory condition of the mucous membrane and the relaxation of the tissues are removed by brushing the prolapsed mucous membrane with the solid stick of nitrate of sil- ver or the thenno-cautery in radiating lines. If this procedure does not pro- duce the desired object, an energetic cauterization of the whole mucous mem- brane with fuming nitric acid is made under anaesthesia. With this (with- out touching the skin of the anus) the carefully dried mucous membrane is touched, until a dry green eschar has been formed ; next, the prolapse is reduced with a tampon, and the buttocks are drawn together over the same by a broad strip of adhesive plaster. FIG. 1479. RECTAL SUPPORTER OPERATIONS ON THE RECTUM AND THE ANUS 813 Adults may use a rectal supporter (Fig. 1479), that is, an elastic rubber ball which is pressed against the opening of the anus by belts. By a thorough cauterization or the excision of a large myrtle-leaf-shaped portion with sub- sequent suture (DteffenbacJi), sometimes a not too large prolapse can be removed permanently. The anal orifice can also be diminished by a. purse- string suture or by a ring of thick silver wire applied subcutaneously, which has often yielded good results (Thierscii}. Gersuny detached the lower part of the rectum, turned it around its longitudinal axis until the lumen was just passable for a finger, and sutured it in this position. In obstinate cases, however, resection of the entire prolapse is the best and safest procedure, especially when reduction is impossible or dangerous on account of incipient or existing gangrene. Into the intestine, pressed forward as much as possible, a wooden cylinder provided at its superior extremity with a shallow transverse groove, a rectal bougie, or something else, is introduced so far that the prolapse can be constricted with a thin rubber tube around the groove closely in front of the anus (von Esmarch}. Any intestinal loops present in the prolapse must first be reduced. Next, under the bloodless method, the whole intestinal wall is carefully divided, cutting through the several layers separately, 2 centimeters in front of the elastic constrictor ; and, after ligation of all visible blood vessels, first the serous coats and, then (after removal of the tube), the muscular and the mucous coats are sutured together. Instead of the bougie, a tampon tube is introduced, and thereby the sutured intestine is returned. In obstinate cases, however, the resection of the whole prolapse is the best and safest procedure. Miculicz proceeded in a similar manner as follows : 1. After two deep ligature loops have been inserted through the summit of the prolapse, to hold the intestine in position, first the anterior circum- ference of the external visceral canal is divided transversely in layers about i to 2 centimeters in front of the anal fold until the serous surface of the internal intestinal is exposed. If any intestines are found in the opened peritoneal pouch, they must be returned, if necessary, after dilatation of the anus. 2. By interrupted sutures, two intestinal sutures with their peritoneal surfaces facing each other are united on the peritoneal side as carefully as possible, until the peritoneal cavity at this place has been closed completely. 3. Next, the anterior circumference of the internal intestinal tube is divided in layers, and the two visceral canals are united in the entire line 814 SURGICAL TECHNIC of incision by deep interrupted sutures, including all layers ; the ends of the ligature remain long. Finally, the posterior circumference of both intestinal tubes is divided in layers, the vessels of the mesocolon lying between them are ligated, and following the line of division the margins of the incision are united step by step by deep interrupted sutures (see also page 702, enterorrhaphy). 5. After all threads have been cut off short to the knot, the stump, lightly dusted with iodoform, is pushed back carefully into the anus. Tubu- lar tampon and dressing are not required. If the external intestinal tube has a much longer circumference than the inner, a wedge-shaped cleft is left open in the most posterior portion, into which a strip of iodoform gauze is inserted. Helferich makes this resection more rapidly and more easily by longitu- dinally dividing the .entire anterior and the posterior wall of the prolapse ; at the ends of these incisions a suture is applied through all layers ; the base of the formed flaps is pierced with quilt sutures, and cut off transversely before them. In prolapse which cannot be returned, Bogdanik and others obviate resec- tion by drawing back the invaginated intestinal portion after having opened the abdominal cavity, and by fastening it in its normal position to the parie- tal peritoneum with a few sutures, which do not pierce the mucous membrane (colopexy, Bogdanik). The inferior portion of the rectum can be sutured to the coccyx with a few silk sutures after a longitudinal division of the skin from the anus to the coccyx (rectopexy, Verneuil). In the knee-and-elbow position Lange exposed the posterior surface of the rectum by a longitudinal incision of the anal depression and resection of the coccyx, and by buried quilt sutures he formed a deep longitudinal fold of the rectum projecting inwardly (rectoplicatio). After the divided fibres of the levator and sphincter ani have been sutured, the wound of the skin is likewise closed, and the cavity formed by excision of the coccyx is tamponed. For narrowing the dilated amis cauterization with a cautery iron and the radiate excision of several folds (Dupitytreii) are successful only in rare cases. More effective is the excision of a large wedge from the prolapsed mucous membrane, the anus, and the external skin, with subsequent suture (DieffenbacJt). OPERATION FOR HEMORRHOIDS When the phlebectases (varicosities) of the hemorrJwidal plexus, as well by their size and number as by their tendency to hemorrhages, have become OPERATIONS ON THE RECTUM AND THE ANUS 8I 5 troublesome, it is advisable to remove them ; this is best and most thoroughly effected by extirpating the hemorrhoidal swellings in the following manner : After the bowels have been evacuated thoroughly for several days, directly before the operation an enema of very warm water is given, which, by straining, is evacuated into a chamber filled with hot water, whereby all varicosities (intermediary and internal) usually appear to view. The patient is then deeply anaesthetized and placed in the lithotomy position. Milder cases may also be operated upon under ScJilcicKs anaes- thesia. a b c d FIG. 1480. CLAMP FORCEPS, a, Smith's; b, Curling's; e, Hahn's; d, Luer's 1. The anal ring is forcibly dilated (see Fig. 1467), and a large sponge, fastened with a strong silk thread, is introduced high into the rectum ; the latter is thoroughly irrigated with a warm antiseptic solution (boric or salicylic). 2. Next, all the large external swellings, as well as the internal, are grasped with clamp forceps (Fig. 1480) and drawn forward; by the weight of the hanging forceps they are prevented from slipping back. 3. One after the other the base of each hemorrhoid is detached on its internal side, first from the sphincter muscle by a deep incision with a pair of good cutting scissors (AllinghanCs hemorrhoidal scissors, Fig. 1481), or with the knife. It is then drawn forcibly forward, and the mucous membrane 816 SURGICAL TECHNIC above the base is drawn to the external skin with a quilt suture (Fig. 1482). Next, the mass is cut off in front of the suture, all spurting vessels are ligated, and the wound is closed by tying the quilt suture. The margins FIG. 1481. ALLINGHAM'S HEMORRHOIDAL SCISSORS of the wound still gaping are carefully united by superficial catgut sutures, after they have been sponged with a sublimate solution. In the same man- ner all internal and external hemorrhoids are removed. Under some circumstances the entire degenerated mucous membrane of the anus can thus be extirpated in several sections, and the mucous mem- brane of the rectum can be sutured closely all around to the external skin. The threads of the suture remain long for better manipulation, and are FIG. 1482. EXTIRPATING HEMORRHOIDAL SWELLINGS spread in a radiate manner around the anus. For preventing, however, cicatricial contractions occurring subsequently, it is advisable to leave a few small mucous membrane bridges uninjured between the extirpated nodules. After the operation, the sponge introduced into the rectum is removed, and a thick rubber ttibe wrapped with iodoform gauze (Fig. 611) is intro- duced. This remains in position until the next evacuation, which is post- poned to the sixth or eighth day by opiates. OPERATIONS ON THE RECTUM AND THE ANUS 8I 7 The spasmodic retention of urine occurring mostly during the first days after the operation (spasmus urethra) is removed by opium and warm com- presses over the pubic region, or more quickly by a careful introduction of a catheter, which must not be too small. The removal of hemorrhoids by ligation, a favorite method in England, and their destruction by the actual cautery after grasping them with von Langenbeck's clamp forceps (Fig. 1483), have indeed met with just as good success, but they bring about the de- sired end considerably more slowly, since the ligated or cauterized nodules must slough off before healing can take place by granulation, while by extirpation the wound generally heals by primary intention. Also cauterizations with nitric acid {Houston) and pure carbolic acid are used. Recently Pooley, Lange, and others have favorably men- tioned the parenchymatous injection of carbolic acid glyce- rine (aa) with a Pravaz syringe a convenient procedure by which one to two drops can be injected with a fine syringe into the nodules protected by some lubricating substance. No carbolic acid should come in contact with the mucous membrane, else it becomes necrotic. (The old-fashioned hemorrhoidal clamps are all too heavy and cumbersome. The delicate curved clamp devised by Dr. Charles Adams of Chicago is very useful and can be manipulated with the greatest ease.) Hemorrhoidal nodules that are not too large not rarely disappear after a forcible dilatation of the anus ( Verneuil). FIG. 1483 VON LANGENBECK'S CLAMP FORCEPS OPERATION FOR CANCER OF THE RECTUM is made variously, according to the seat and the extent of the disease. Smaller or well-defined pedunculated tumors of the rectal wall are removed by simple excision. If they occupy the anal portion, they are drawn forward with tenaculum forceps ; after a forcible dilatation of the anus, the operator circumscribes them with the knife in the healthy parts, and sutures the surface of the wound completely ; after the hemorrhage has been arrested, if possible, the wound is closed in a transverse direction, in order that no harmful constriction may follow the operation. If, however, the tumor is located so high above tJie anal portion that it cannot be drawn outside of the anus, the latter is incised through the pos- 8l8 SURGICAL TECHNIC terior rapht as far as the tip of the coccyx (DieffenbacK). The margins of the deep wound are now drawn apart with sharp hooks, and the tumor drawn downward is circumscribed with the knife by two semilunar incisions. If the tumor occupies the anterior rectal wall, the anus is divided in the median line toward the perineum (anterior sphincterotomy\ and the anterior wall of the rectum is carefully dissected off from the prostate and the bladder. After the removal of the tumor, the wound is reduced in size by a few sutures, and the remainder is drained. If the anus is the starting point of the trouble, and if the entire anal ring is included in the carcinoma, the anus is circumscribed by two semilunar incisions through healthy tissue ; next, with rapid sweeps of the knife, the operator penetrates into the cellular tissue surrounding the rectum as far as and beyond the limit of the disease, which is determined with the left fore- finger introduced into the rectum. The detached portion of the rectum is now forcibly drawn forward with tenaculum forceps, and the intestine is transversely divided above the limit of the disease. After the hemorrhage has been arrested, the rectum, which has been drawn down, is sutured to the margins of the skin (extirpatio ani, according to Lisfranc). In the course of time the wound heals by granulation and cicatrization ; the contraction following the operation is sufficient to prevent total rectal incontinence. With a view of preventing rectal prolapse, which frequently follows, it is advisable to make use of pressure by a ball of common cotton applied over the new anal opening, and to hold it in place by a suitable bandage. If the tumor occupies the larger portion of the circumference or even tJie whole circumference of the rectal wall (annular), the whole rectum must be removed as far as and beyond the upper limit of the disease (resectio recti). If the tumor, springing from the anal portion, has not yet invaded the sphincters, the anus, according to Dieffenbach, is divided first anteriorly in the raphe" as far as the bulb of the urethra, and then posteriorly as far as the tip of the coccyx ; but the mucous membrane is divided transversely on both sides at the junction with the anal integument ; it is then detached from the internal sphincter. After the two halves of the anus have been drawn apart with large sharp retractors (Simon) by an assistant, the rectum is divided below the tumor transversely on both sides, and detached from its surrounding tissues as far as, and at least 4 centimeters above, the upper limit of the tumor. First, the anterior wall is dissected off carefully from the prostate and the bladder ; next, all around and close to the external wall, the operator OPERATIONS ON THE RECTUM AND THE ANUS 819 penetrates carefully upward, pressing more with the fingers and blunt instru- ments than cutting with the knife, and thus dividing the tense bands of con- nective tissue, and securely ligating every vessel, if possible, before its division. Farther upward, and within reach of the tumor, the operator avoids the rectal wall as much as possible. If the upper limit of the tumor, palpable through the intestinal wall, is situated so high that the lower duplicature of the peritoneum must necessarily be opened, the peritoneum is incised transversely ; it is then easy to draw the rectum downward. Sometimes the surgeon also succeeds by blunt dis- section in pushing the peritoneum carefully upward ; at each inspiration, it bulges like a fish bladder in the large wound cavity ; after a thorough dis- infection, smaller rents are closed immediately by the suture. As soon as the surgeon has reached a part of the bowel at a safe distance above the tumor, he penetrates with his forefinger through the loose cellular tissue to the other side, and now tries, by curving the finger like a hook, and by grasping the tumor with the whole hand, to draw the intestine forcibly downward, and to detach it on all sides until it has been made freely mov- able, when it hangs down in front of the gaping wound. Next, the intestine is divided transversely at least 4 centimeters above the demonstrable proximal limits of the tumor ; all bleeding vessels are ligated. Then the margin of the resected intestine is united with the anal integu- ment by sutures, at least at its anterior surface, for it is better to tampon the posterior surface for effective drainage for the secretions and the faeces. The wounds in the perineum and in the gluteal furrow are somewhat reduced by suturing, and drained. In very high carcinoma, if the coccyx is in the way, it is detached from the sacrum (Kocher). The largest space for the removal of tumors seated very high in the rectum is obtained by RESECTION OF THE SACRUM (Kraske) in the following manner : i. While the anaesthetized patient lies on his right side, a skin incision from the posterior margin of the anus is made in the median line as far as the middle of the sacrum. (The patient should always be placed in the ventral position, the pelvis well elevated for the purpose of facilitating the technical part of an operation, 820 SURGICAL TECHNIC and to minimize the hemorrhage. A cot is preferable to an operating table) (Fig. 1485). 2. Penetrating layer by layer, the operator detaches the insertion of the glutens maximus from the left side of the sacrum and disarticulates tlie coccyx. 3. Next, the lowest portion of the great sacro-sciatic and of the lesser sacro-sciatic ligament is detached from the sacrum ; by this means the superior portion of the posterior wall of the rectum becomes much more accessible. 4. With strong bone-cutting forceps, the lower portion of tJie left border of the sacrum is excised in a line beginning from the left margin at a level with FIG. 1484. RESECTION OF SACRUM. a, according to Kraske; a a', ac- cording to Bardenheuer ; b, according to von Volkmann and Rose FIG. 1485. POSITION OF PATIENT FOR OPERATIONS OF THE SACRUM the third posterior foramen of the sacrum, and extending in a curve inward and downward around the fourth sacral foramen as far as the left inferior sacral cornu (Fig. 1484, a). The spinal canal is not injured ; the sacral nerves, however, are divided as far as the third. 5. The patient is then placed in the lithotomy position with his pelvis elevated ; first, the whole rectum is detached from its adjacent tissues in the manner described before, beyond the limits of the tumor, to such an extent that the diseased portion can be drawn down as far as the anal margin, without great tension. If the operator finds any diseased lymphatic glands OPERATIONS ON THE RECTUM AND THE ANUS 821 in the pelvic connective tissue of the sacral cavity, he enucleates them as bluntly as possible. 6. At the posterior wall of the rectum, always advancing as closely to the same as possible, it is comparatively easy to detach the rectum all around, in part, bluntly; in part, with scissors (see page 819). 7. If the anal portion is not invaded by the disease, it can be preserved uninjured by excising the diseased intestinal portion by two transverse in- cisions in the healthy parts, and by suturing the upper end, after it has been drawn down to the posterior vertical incision of the anal portion. For this purpose, it is best to suture only the anterior half of the intestinal circum- ference, and to leave the posterior half open. 8. The whole wound and the posterior raphe incision are tamponed ; subsequently the latter can be closed by suturing the two lateral flaps of skin ; a tampon tube is introduced high up into the rectum. It is just as good to draw the rectal portion, temporarily closed by a rubber ligature or completely closed by a silk ligature, through the anal portion stripped of its mucous membrane, and to fasten it in this invaginated position (Kocker, Hochenegg). Nicoladoni sutured the proximal end drawn downward to a ring 3 to 4 centimeters wide, wrapped with iodoform gauze to prevent it from slipping back. Rehn proceeds according to Kraske's method in two sittings, by amputat- ing first the diseased rectum ; after about ten days he sutures the stumps. (The editor has had a somewhat extensive experience with Kraske's method of rectal extirpations, and he has come to the conclusion that the additional space secured is but an inadequate compensation for the increased risks incurred to life by the operations. For a number of years he has limited pelvic resection to excision of the coccyx as a preliminary step to excision of the rectum for malignant disease.) If the anal portion has also to be removed, a narrowing to the requisite extent of the rectum, which has been drawn down, is effected by rotating it around its longitudinal axis (Gersuny). A still more convenient access to the true pelvis from behind than by Kraskes method is obtained by the transverse resection of the sacrum according to Bardenhetier. He removes the whole lower portion of the bone as far as the third sacral foramen (Fig. 1484, a-a), advances then toward the rectal wall, and detaches the same as bluntly as possible from the surround- ing tissue. Without any evil consequences, the bone may be chiselled off transversely even as far as the second sacral foramen (von Volkmann, Rose, posterior coeliectomy). ' 822 SURGICAL TECHNIC Von Heineke makes the resection of the sacrum osteoplastically. The posterior sphincter incision is extended in the median line as far as the fourth sacral foramen, the coccyx and the sacrum are divided longitudi- nally in the median line with the broad amputating saw, and the sacrum is then chiselled off transversely and a little obliquely downward along the lower border of the fourth sacral foramen (protection of the fourth sacral nerve). The flaps of bone and soft parts are turned over laterally, Fig. 1489). By a somewhat similar procedure, W. Levy protects the levator ani and its sympathetic nerve originating from the fourth sacral nerve, by dividing the sacrum transversely below the fourth sacral foramen, a finger's breadth above the cornua of the coccyx. From the extremities of this incision, two longitudinal incisions are made 8 centimeters downward, and the skin-bone flap is forcibly drawn downward ( Fig. 1490). ScJilange proceeded in a similar manner only the extremities of the lateral incisions divide below the skin alone (protection of the inferior hemorrhoidal nerves), but above they detach the gluteus maximus and the ligaments from the border of the sacrum. Hegar turned the sacrum over in an upward direction, after he had circumscribed it by two incisions extending from the inferior posterior spine of the ilium to the tip of the coccyx ; below the second sacral foramen, he divided it transversely (Fig. 1491). Rydygier makes the incision through the soft parts obliquely, a little distant from the border of the sacrum, from the superior posterior spine of the ilium as far as the tip of the coccyx, and then in the median line toward the anus. Having detached the soft parts from the sacrum, he chisels through the latter transversely below the third sacral foramen and turns it over to the right, so that the sacral nerves of the right side remain uninjured (Fig. 1493)- O. Zuckerkandl created a passage to the pelvic organs according to Hueters method, on tJie anteiior side of the rectum, by a large horseshoe- shaped incision (Fig. 1494), from which he penetrated between the prostate and the bladder on one side and the rectum on the other as far as the peritoneal reflection. The retraction of the divided levator ani facilitates the operation considerably. After the diseased intestine had been resected, he united the sigmoid flexure with the anal portion by circular enterorrhaphy. It is still better to incise the anus in front and to tampon the wound temporarily. Similar is Hueters operation by a horseshoe incision (Fig. 1495), in which a musculo-cutaneous flap is turned downward, exposing the anterior rectal wall. OPERATIONS ON THE RECTUM AND THE ANUS 823 E. Zuckerkandl suggested, from an anatomical point of view, the parasa- cral incision, for the exposure of the pelvic organs. o i. The patient is placed in a right lateral position ; the incision extends from the left tuberosity of the ischium in a slight curve close to the sacral border as far as the ischiorectal fossa in the middle between the tuberosity of the coccyx and the rectum. 824 SURGICAL TECHNIC 2. The gluteus maximus, the great sacrosciatic and the lesser sacrosciatic ligament, the coccygeal muscle, and, if necessary, also a portion of the levator ani, are cut off close to the sacrum and the coccyx, whereby the extraperitoneal rectal portion is exposed in its whole length (Fig. 1496). / \ FIG. 1494 FIG. 1495 PERINEAL EXTIRPATION OF RECTUM, a, Zuckerkandl's; b, Hueter's 3. If the operator now advances toward Douglas's fossa, he can reach also, after opening the peritoneum, the superior part of the rectum and the sigmoid flexure. Wolfler proceeded in a similar manner, but operated on the right side. If the tumor, on account of extensive adhesions with the surrounding parts, can not be excised, or if the patient is so feeble that he would not FIG. 1496 FIG. 1497 ZUCKERKANDL'S PARASACRAL INCISION survive a major surgical operation, at least a passage must be created for the faeces accumulating above the stricture. This is effected either by removing as much as possible from the tumor mass with the sharp spoon and the thermo-cautery, or by incising the entire posterior wall of the OPERATIONS ON THE RECTUM AND THE ANUS 825 rectum as far as and beyond the superior limit of the tumor, with the thermo-cautery (linear rectotomy, according to Verneuil}. in most cases, however, it is advisable to form an artificial anus, for the escape of the faeces, and by doing so any irritation of the ulcerated surfaces by faeces is prevented (see also page 700). To provide this anus with something like a sphincter, the central extremity maybe sutured into the sacral incision (sacral anus, Hochenegg)\ and the peripheral rectal end, containing the carcinoma, can be sutured ; or the intestinal end, cut off in healthy tissue, is pushed through a transverse opening, made four to five fingers' breadth at the side of the sacral incision between the fibres of the glutei (gluteal rectotomy, Witzel). But if the disease extends so far in an upward direction that the sigmoid flexure or the colon must be used for the new anus, an inguinal anus is estab- lished, as described on page 700. Witsel obtains with this a better closure, by drawing the upper end of the intestine through an incision along the left crest of the ilium under the skin as far as the superior lateral gluteal region (colostomia glutealis). Here, by the fibres of the gluteus maximus, a sphincter is formed ; the portion of the intestine in the extrapelvic tissues can easily be made to serve as a sphincter by making pressure against the ilium. INDEX OF NAMES Adams, Charles, Curved Clamp Forceps, 817. Adams, Metacarpal Saw, 307. Rhinoplastos, 580. Adelmann, Hyperflexion of Limbs, 241. Strips of Plaster of Paris Bandage, 113. JEyrapaii, Protheses for Collapsed Noses, 543. Albert, Duodenostomy, 695. Meloplasty, 527. Allessaitdri, Intestinal Suture, 704. Allingham, Hemorrhoidal Scissors, 815. Rectal Speculum, 804. Scissors for Dividing Rectal Fistula, 811. Von Amman, Blepharoplasty, 515. Rhinoplasty, 531. Amussat, Clamp Forceps, 246. Colostomy, 699. Intestinal Suture, 704. Andrews, E., Intraparietal Oblique Fistula, 683. Andrews, W., Gastrotomy, 679. Anel, Ligation of Arteries, 285. Angerer, Sublimate Tablets, 27. Anschiitz, Plastic Plaster of Paris Splints, 120. Antal, Cystorrhaphy, 775. Antyllus, Ligation of Arteries, 285, 286. Assaky, Neuroplasty, 298. B Baracz, Dividing Nose in the Median Line, 572. Intestinal Suture, 705. Von Dardeleben, Amputation of Leg, 373. Chloride of Zinc Jute, 28. Osteoclasis, 305. Pelvic Support, 123. Premaxillary Bone, 549. Wire Suspension Apparatus for Fractured 167. Bardenheuer, Cholecystotomy, 735. Cystotomy, 772. Extirpation of Larynx, 623, 625. Extraperitoneal Explorative Incision, 676. Ligation of Innominate Artery, 651, 652, 654. Renal Incision, 742. Replacing Metacarpal Bone, 394. Resection of Elbow Joint, 410. Resection of the Lower Jaw, 490. Resection of the Sacrum, 821. Splenopexy, 739. Tarsectomy, 430. Tendinoplasty, 296. Bartsck, Metal Strips for the Resected Maxillary Arch, 490. Bartscher, Open Treatment of Wounds, 66. Barwell, Lateral Extension for Scoliotic Spine, 152. Bassini, Operation for Hernia, 723, 726. Operation for Femoral Hernia, 730. Battle, Cystoplasty, 786. Baujn, Ankylosis, 492. Oil of Turpentine, 243. Baumann, Thyroidin, 626. Bayer, Extension of Tendon of Achilles, 292. Meloplasty, 528. Becker, Acetonuria from Ether, 190. Beck's Portable Compact Sterilizer, 17. Von Beck, Straw Splints, 162. Bellocq, Canula for Tamponing Nostrils, 477, 536. Bell, Splints, 99, 150. Beefy, Plaster of Paris Bandage Machine, 115. Plaster of Paris Hemp Splint, 128. Plaster of Paris Splints, 120. Bengue, Ethyl Chloride, 193. Bennet, Ascertaining Location of Central Fissure, 465. Berger, Disarticulation of Shoulder Girdle, 353. Von Bergmann, Bullets in Human Body, 221. Cerebral Hemorrhage, 461. Closure in Anus praeternaturalis, 713. Enterorrhaphy, 708. Innominate Artery, 652. Nephrectomy, 741, 744. Leg, CEsophageal Diverticula, 644. Operating Table, 16. Operation for Hydrocele Testis, 799. Spindle for Ligations, 744. Sublimate, 25, 26. Trephining the Skull at the Base of the Squamous Portion of the Temporal Bone, 468. Bernays, Cholecystotomy, 734. Berndt, Regionary Analgesia, 194. 827 828 INDEX OF NAMES Beyerle, Phonetic Canula, 624. Bier, Cocainizing Spinal Cord, 195. Ligation of Hypogastric Arteries, 782. Local Exclusion of Diseased Intestines, 711. Osteoplastic Amputation to produce Stumps that bear well, 334. Osteoplastic Necrotomy, 315. Resection of Ilium, 454. Biermer, Thoracocentesis, 658. Bigelow, Litholapaxy, 784. Lithotriptor, 783. Billroth, Adhesive lodoform Gauze, 33. Batiste, Oil Cloth, 44. Enteroanastomosis, 708. Extirpation of Goitre, 626. Extirpation of Larynx, 623. Extirpation of Patella in Disarticulation of Knee Joint, 377. Extirpation of the Tongue, 602. Intestinal Clamps, 686. Margins of Plaster of Paris Bandage, 117, 118. Mixture of Chloroform, 181, 192. CEsophagotomy, 643. Oil of Turpentine as a Styptic, 243. Resection of the Pylorus, 685, 686, 689. Thoracocentesis, 657. Bircher, Direct Fixation of Bones, 310. Gastroplication, 679. Blandin, Deviation of Septum, 580. Excision of Cuneiform Portion from the Vomer, 550. Uranoplasty, 590. Bockel, Division of the Palate, 576. Ligation of Superficial Palmar Arch, 267. Backer, Galvanocaustic Handle, 206. Bogdanik, Colopexy, 814. Bohm, Potash Silicate Dressing, 112. Bona, Intertarsal Disarticulation, 359. Bonnecken, Aluminum Bronze Wire, 490. Bonnet, Wire Breeches, 139, 140. Borchardt, Operation for Hernia, 730. Base, Elastic Retractor, 616, 620. Retrofascial Separation of the Thyroid Gland in Tracheotomy, 617. Bos-worth, Antipyrine, 243. Bottini, Amputation of the Tongue, 600. Ankylosis, 492. Galvanocaustic Excision of the Prostate Gland, 781. Operation for Hernia, 728. Zinc Sulphocarbolate, 31. Bouisson, Rhinoplasty, 534. Bourgery, Resection of Wrist, 395. Braatz, Spiral Splint for Radius Fracture, 120. Brainard, Extirpation of the Parotid Gland, 605. Posterior Catheterism, 769. Brandis, Aorta Tourniquet, 240. Cautery Iron, 204. Brandt, Gastroplication, 679. Obturator, 560. Uranoplasty, 556. Brasdor, Ligation of Arteries, 286. Braun, Resection of Malar Bone, 498, 504. Nephrectomy, 741. Breiger, Plaster of Paris Cotton, 114, 115, 120. Broka, Instruments for Measuring the Skull, 466. Brokaw, Intestinal Suture, 705, 709. Brophy, Cleft Palate, 551. Brown, Pharyngeal Syringe, 579. Von Bruns, Anatomy of the Parotid Gland, 606. Carbolized Gauze, 24. Cheiloplasty, 520, 522, 525. Galvanocaustic Handle, 206. Glue Dressing, 112. Modification of Pirogoff, 371. Needle provided with Handle, 555. Neurectomy of Inframaxillary Nerve, 501. Omphalectomy, 732. Oral Speculum, 582. Phonetic Canula, 624. Plastic Felt, no. Plastic Pasteboard, no. Turning Nose upward, 574. Wound Cotton, 41. Bryant, Gum Arabic Chalk Dressing, 112. Buchanan, Amputation in Line of Epiphyses, 379. Biilau, Aspiration Drainage, 660. yon Bilngner, Evulsion of the Vas Deferens, 802. Burggrave, Cotton, Pasteboard Dressing, in. Burkhardt, Retropharyngeal Abscesses, 6n. Burow, Aluminum Acetate, 28. Cheiloplasty, 522, 523. Open Treatment of Wounds, 66. Skingrafting, 302. , Busch, Restoring Tip of the Nos%, 540. Bushe, Rectal Bougie, 808. Butcher, Disarticulation of Knee Joint, 379. Butschik, Trichlorphenol, 30. Callisen, Colostomy, 699. Canquoin, Paste of Chloride of Zinc, 208. Cantani, Hypodermoclysma, 280. Garden, Intracondylic Amputation, 379. Carr, Radius Splint, 98. Cathart, Location of Sulcus Centralis, 466. Catterina, Resection of Wrist, 402. Celsus, Circular Amputation by One Incision, 318. INDEX OF NAMES 829 Rubbing in Pseudoarthroses, 312. Skingrafting, 302, 303. Chalet, Resection of Hard Palate, 576. Champion niere. Hooked Tongue Holding Forceps, 184. Chassaignac, Drainage, 38. Drainage Trocar, 39, 476. Ecrasement, 225. Ligation of Vertebral Artery, 262. Resection of Coronoidal Process, 489. Resection of Septum, 580. Turning Nose upward, 574. Chelius, Operation for Struma, 626. Cheselden, Circular Amputation by Two Incisions, 322. Cheyne, Healing under the Scab, 38. Chopart, Disarticulation at the Tarsus, 359. Ciamician, lodol, 35. Civiale, Lithotriptor, 782. Urethrotome, 759. Cline, Splints, 99. Clover, Radius Splints, 98, 99. Collin, Adjustable CEsophagus Hook, 638. Catheter Catcher, 766. Intestinal Clamps, 712. CEsophagotome, 641. Condamin, Omphaiectomy, 732. Cooper. Aneurism Needle, 253. Ligation of the Aorta, 270. Scissors, 201, 298. Cosme, Frere, Arsenic Paste, 208. Costa, Cocaine Anaesthesia, 194. Coster, Paraphimosis, 795. Courvoisier, Cholecystendysis, 734. Gastro-enterostomy, 692. \ Hepatic Border Incision, 734. Cramer, Wire Splint, 103. Crosby, Adhesive Plaster Loop, 147. Cubasch, Suspension Apparatus, 167. Curling, Hemorrhoidal Forceps, 815. Cashing, Intestinal Suture, 703. Czerny, Carbolized Silk, 210. Cystoplasty, 786. Extirpation of Larynx, 621. Galvanocaustic Excision of the Prostate Gland, 781. Intestinal Suture, 702. Nephrectomy, 741. Operation for Hernia, 722. Resection of the CEsophagus, 643. Subperiosteal Cuneiform Excision of the Vomer, 550- D Davidsohn, Sterilization of Instruments, 7. Davy, Direct Fixation of Bones, 310. Delpech, Resection of the Lower Jaw, 491. Demme, Cystoplasty, 787. Scabbard-shaped Compressed Trachea, 634. De Quervain, Tobacco Pouch Suture, 215. Desault, Amputation by Three Circular Incisions, 323- Bandage for the Clavicle, 78, 122, 155. Extension Splint, 146. Operation for Salivary Fistula, 608. Desmarres, Clamp for Eyelids, 234. Dieffenbach, Anal Stenosis, 806, 809. Blepharoplasty, 514, 516, 517. Cheiloplastv, 520, 525. Cuneiform Excision of the Anus, 814. Cuneiform Excision of the Tongue, 579. Disarticulation of the Thigh, 388. Division of Nose, 571. Labial Suture, 806. Lace Suture, 215. Needle Holder, 209. Pharyngeal Tumors, 576. Plastic Operation for Contraction of Nostrils, 579. Posthioplasty, 793. Prolapsus Recti, 813. Prothesis for the Tongue, 604. Raphe Incision, 818. Resection of Septum, 580. Resection of Upper Jaw, 478. Resectio Recti, 818. Restoring Ala of the Nose, 540. Restoring Septum of Nose, 541. Rhinoplasty, 531,540. Ring Forceps, 234. Sinuous Incision of Upper Lip, 478, 481. Staphylorrhaphy, 553. Stomatoplasty, 526. Tenotome, 290. Tonsillotomy, 591. Urethroplasty, 765. Dieulafoy, Aspirator, 659. Von Dittel, Lateral Prostatectomy, 781. Position for Pelvic Dressing, 125. Retention Catheter, 753. Djelitzyn, Osteoplastic Amputation, 380. Dobson, Wooden Frame, 141. Danders, Epidermic Suture, 78. Doyen, Angiotripsy, 246, 247. Gastro-enterostomy, 694. Resection of Ganglion Gasseri, 509. Tobacco Pouch Suture, 215. Drencke, Anaesthesia, 179. Drescher, Ether Anaesthesia, 190. Dreser, Ether Anaesthesia, 189. Duchenne, Phrenic Faradization, 186. 830 INDEX OF NAMES Diihrssen, Dressing Box, 47. Von Dumreicher, Alar Splint, 107. Hyperaemia for Forming Solid Callous, 312. Operation lor Necrosis of Lower Jaw, 492. Operation for Necrosis of Upper Jaw, 481. Railway Apparatus, 150. Duplay, CEsophagotomy, 643. Wire Snare, 570. Dupuytren, Contraction of Fingers, 292. Intestinal Clamps, 712. Narrowing Dilated Anus, 814. Splint for Fracture of the Ankle, 146. O'Dwyer, Intubation, 619. Von Eiselsberg, Local Exclusion of Diseased Intes- tine, 711. Englisch, Rhineurynter, 566. Rrb's Paralysis, 179. Von Esmarch, Adjustable Oblique Board, 61. Akidopeirastik, 202. Ankylosis, 492. Antiseptic Dressing Package, 171. Aorta Tourniquet, 238. Arsenic Caustic Powder, 208. Bloodless Method, 225. Brass Spiral Bandage, 230. Chloride of Sodium, 31. Chloroform Apparatus, 174. Clamp Buckle, 226, 228. Cold Coil, 64. Cooling Box, 64. Cooling Cover, 65. Double Inclined Plane, 140. Double Splint, 136. Von Esmarch, ., Cleaning Walls of Room, 3. Elastic Constriction, 226. Glass Bougie, 808. Heel Support, 124. Hydrochloric Acid, 31. Inguinal Colostomy in Tumors of the Rectum, 701. Iron Arch Splint, 136. Iron Suspension Splint, 136. Meloplasty, 527, 530. Modification of Pirogoff 's Operation, 370. Needle Case for Intestinal Sutures, 702. Operation for Harelip, 547, 549. Operation for Phimosis, 792. Osteoclast, 306. Plaster of Paris Suspension Splint, 133. Pole Pressure for Aneurism, 284. Principle of Economy, 547. Prolapsus Recti, 813. Reflection of Periosteum in Amputations, 323. Resection of Articular Surface and Neck of Scapula, 417. Separable Wooden Splint, 95, 154. Splint Material, 97. Stretcher Extension Dressing, 153. Tongue-holding Forceps, 184. Tourniquet Suspender, 231. Triangular Cloth, 84. Urethroplasty, 765. Wire Breeches, 140. Wire Cloth, 103. Estlander, Cheiloplasty, 520. Thoracoplasty, 662. Ewald, Meloplasty, 527. Fabricius, Operation for Femoral Hernia, 731. Fabricius ab Aquapendente, Taxis, 717. Fahnestock, Tonsillotome, 592. Farabceuf, Forceps, 391, 412. Fearn, Ligation of Arteries, 286. Fehleisen, Tamponing Rectum in Sectio Alta, 770. Fenger, Gastrostomy, 680. Nephrectomy, 740. Fergusson, Lion Forceps, 391. Rectal Speculum, 804. Resection of Upper Jaw, 478. Staphylorrhaphy, 553. Fialla, Rod Splint, 143. Fickert, .Plaster of Paris Plate Dressing, 114. Filehne, Injury to the Brain by Hammering, 460. Fine, Colostomy, 700. Fischer, ., Naphthalin, 34. Sugar as Antiseptic, 35. Fischer, R. de. Plastic Cellulose Sheets, no. Gastrostomy, 680. CEsophagotomy, 643. Flashar, Artificial Respiration, 186. Fleurant, Trocar for Bladder, 768. Fowler, Bullet Probe, 223. Franckel, Nasal Speculum, 565. Uvula Forceps, 566. Frank, Intestinal Button, 706. Local Exclusion of Diseased Hernia, 711. Oblique Fistula, 682, 684. Operation for Hernia, 728. Frantzel, Trocar, 659. Freudenberg, Galvanocaustic Excision of the Prostate Gland, 781. Fricke, Blepharoplasty, 515, 516. Fritsch, Water Sterilizer, 21. Frohlich, Hooked Forceps, 552, 591. Furbringer, Sterilization of Hands, 4. INDEX OF NAMES Apparatus for Infusion, 281. Aspirator, 660. G Garson, Cystotomy, 770. Gensoul, Resection of Upper Jaw, 478. Gerdy, Cloth Bandages, 84. Gerstein, Osteoplastic Resection of the Skull, 463. Gerster, Epityphlitis, 711. Gersuny, Compress of Loose Gauze, 13. Craniectomy, 462. Operation for Umbilical Hernia, 731. Pedunculated Flaps, 528. Prolapsus of Rectum, 813. Rotation of Rectum, 821. Transverse Thyrotomy, 614. Gigli, Wire Saw, 480. Gipp, Ligation of the Isthmus in Goitre, 633. Giraldes, Operation for Harelip, 546. Girard, Gastrostomy, 682. Resection of Ankle Joint, 427. Glissoris Sling, 151, 152. Cluck, Costal Scissors, 655. Neuroplasty, 298. Tendinop'.asty, 295. Gooch, Flexible Wooden Splint, 95, 96, 160. Gosselin, Nasopharyngeal Polypi, 577. Gottstein, Circular Knife, 579. Goursattd, External CEsophagotomy, 640. Goyrand, Ligation of Internal Mammary Artery, 653. Graf, Boroglycerine Lanolin, 28. Tannin, 243. Von Grafe, Coin Catcher, 638. Exenteration of the Bulb, 563. Ligature, 225. Loop Tightener, 599. Rhinoplasty, 537. Staphylorrhaphy, 551. Gritti, Resection of Wrist, 402. Supracondylic Osteoplastic Amputation, 380. Grossmann, Ether Mask, 189. Gross, S. W., Prothesis for the Nose, 538. Guerin, Anaesthesia, 180. Resection of Os Calcis, 430. De Guise, Salivary Fistula, 608. Gurlt, Statistics of Chloroform Anaesthesia, 181. Statistics of Ether Anaesthesia, 188. Gussenbauer, Ankylosis, 492. Bone Clamps, 310. Chiselling open the Hard Palate, 576. Combined (Esophagotomy, 643. Parallel Forceps, 686, 690. Phonetic Canula, 624. Resection of Nose, 575. Gutsch, Lower Maxilla Holder, 183. H Hobs, Chiselling Hard Palate, 576. Von Hacker, Endless Probing, 640. Gastro-enterostomy, 692. Gastrolysis, 679. Gastrostomy, 680, 682. CEsophageal Fistula, 643. CEsophagoplasty, 644. Retrograde Dilation, 682. Rhinoplasty, 534. Hagedorn, Gastrostomy, 681. Glass Box for Catgut Ligatures, 10, Needle Holder, 210, 554, 555. Needles, 210, 294, 296. Operating Table, 16. Operation for Harelip, 546, 548. Sphagnum Pasteboard, 42. Tracheal Canula, 6i&, 701. Hageler, Skingraftmg, 304. Hahn, Coloslomy, 701. Compressed Sponge Canula, 477, 621, 622. Curved Incision in Disarticulation of Knee Joim, 439- Gastrostomy, 682. Hemorrhoidal Forceps, 815. Intestinal Clamps, 686. Meloplasty, 528. Nailing Resected Knee, 437. Nephropexy, 745. Haidenhein, Amputation of Breast, 668, Halstead, Amputation of the Breast, 668. Serous Suture, 702. Hammer, Solveal, 25. Hancock, Osteoplastic Disarticulation of Foot, 364- Hannsmann, Victoria Metal Strips, 490. Harrison, Cystoplasty, 788. Hartmann, Tamponing Nares, 569. Hasner von Artha, Blepharoplasty, 516. Hausmann, Aluminum Bone Splints, 310. Hegar, Needle Holder, 209. Resection of Sacrum, 822. Von Heineke, Intestinal Clamps, 686, 707. Pyloroplasty, 696. Resection of Sacrum, 822. Heine, Tirefond, 459. Heister, Fracture Box, 143. Gag, 183, 581. Helferich, Amputation of Leg, 373. Amputation Saw, 392. Ankylosis, 492. Disarticulation of Thigh, 384. Epispadias, 790. Hyperaemia in Forming Osseous Callus, 312. 832 INDEX OF NAMES Intestinal Anastomosis in Gangrenous Hernia, 721. Resection of Acromion in Disarticulation of Shoulder Joint, 352. Resection of Os Calcis in Disarticulation at the Tarsus, 361. Resection of Prolapsus Recti, 814. Sawing Out Curve-shaped Wedge in Resection of Knee Joint, 437. Sectio Alta, 776. Vasectomy, 802. Henle, Anatomy of the Antrum of Highmore, 485. Henneberg, Sterilizer, 16. Hepp, Odor Test, 173. Hermant, Tin Splints, 102. Messing, Healing in Pseudoarthrosis, 312. Heyfelder, Needle for Resection of Upper Jaw, 479. Resection of Both Upper Jaws, 481. Hippocrates, Thoracotomy, 662. Hirsch, Stump to bear pressure, 334. Hirschberg, Cystoplasty, 785. Hochenegg, Local Exclusion of Diseased Intestine, 7x1. (Esophagoplasty, 644. Resection of Sacrum, 821. Sacral Anus, 825. Von Hoeter, Splints of Sheet Zinc, 102. Hoffa, Amputation of the Breast, 670. Arthrotomy for Congenital Dislocation of Hip Joint, 453. Hoffman, Longitudinal Division of Tonsils, 593. Rongeur Forceps, 455. Holscher, Ether Anaesthesia, 190. Holt, Divulsor, 758. Home, Wax Cast of the Urethra, 747. Homen, Thoracoplasty, 662. Hoppe-Seyler, Carbol Test, 25. Horsley, Cyrtometer, 466. Flexible Knife, 461. Instrument for Measuring Skull, 466. Houston, Cauterization of Hemorrhoids, 817. Stretching Facial Nei ve, 509. Howard, Artificial Respiration, 186. Hiibscher, Glued Cellulose Sheets, no. Skingrafting, 300. Hueter, Amputation of Leg, 373. Artificial Mouth, 527. Ligation of Lingual Artery, 259. Naso-pharyngeal Polypi, 577. Neuroplasty, 297. Paratendinous Suture, 293. Plastic Surgery for Restoring Tip of the Nose, 540. Prostatic Catheter, 753. Resection of Ankle Joint, 428. Resection of Elbow Joint, 406. Resection of Hip, 451. Resection of Knee Joint, 442. Resection of Rectum, 822. Restoring Septum of Nose, 541. Rhinoplasty, 534. Tendinoplasty, 295. Hulke, Operation for Ileus, 676. Hunter, Indirect Ligation of Arteries, 251. Ligation in Aneurism, 285. I Israel, Correcting Collapsed Noses, 548. Meloplasty, 528. Purulent Peritonitis, 675. Rhinoplasty, 538, 543. Ureterotomy, 746. J Jaboulay, Exothyreopexia, 633. Jackson, Ether, 188. Jager, Metatarsal Disarticulation, 359. Jaenicke, Tetraboric Sodium, 28. Jaesche, Cheilopiasty, 521, 535. Jassimowsky , Suture of Arteries, 290. jfobert, Invagination, 705. Joes, Finger Pressure during Vomiting in Ana thesia, 180. Jones, Ligation of the Isthmus in Goitre, 633. Jordan, Division of the Nose, 572. Juillard, Ether Mask, 188. Operating Table, 16. Junker, Chloroform Apparatus, 176. Juracz, Nasal Speculum, 565. Septum Forceps, 580. K Kader, Gastrostomy, 684. Kappeler, Asphyxia in Anaesthesia, 183, 184. Chloroform Apparatus, 176. Cholecysto-enterostomy, 737. Kaufmann, Stretching Facial Nerve, 510. Keen, Omphalectomy, 732. Kelen, Ethylene Chloride, 192. Keller, Sterilization of Sponges, 12. Kingsley, Obturator, 559. Klein, Bullet Probe, 223. Kleinmann, Prothesis for the Nose, 538. Knapper, Intrabuccal Incision for Resection of the Upper Jaw, 477. Kny-Sprague, Perfection Sterilizei, 17. Koch, Cystoplasty, 787. Injury to the Brain by Hammering, 460. Resection of Symphysis, 776. INDEX OF NAMES 833 Steam Cooking Apparatus, 17. Sublimate, 25, 26. Syringe, 202. Kocher, Arthrectomy of Knee Joint, 389, 443. Bismuth, 34. Cachexia thyropriva, 626. Colostomy, 700. Division of Septum, 566. Drainage Tubes with Threads, 331. Enucleation Resection of Goitre, 631. Ethelyne-Bromide-Ether Anaesthesia, 192. Ether Spray, 193. Evacuation of Goitre, 630. Extirpation of Coccyx, 819. Extirpation of Palmar Fascia, 292. Extirpation of Tongue, 602. Exposing Antrum of Highmore, 486. Gastroduodenostomy, 689. Gastro-enterostomy, 694. Goitre Probe, 627. Instruments for Measuring Skull, 466. Invagination Displacement, 730. Juniper Catgut, n. Ligation of Carotids, 258. Ligation of Inferior Thyroid Artery, 633. Ligation of Superficial Palmar Arch, 267. Ligation of Superior Thyroid Artery, 631. Ligation of Vertebral Artery, 262. Middle Meningeal Artery, 471. Nephrectomy, 740, 741. CEsophageal Diverticula, 644. Osteoplastic Resection of Both Upper Jaws, 483, 486. Oval Incision in Disarticulation of Shoulder Joint, 353. Prerectal Pointed Arch Incision, 780. Quilt Suture in Tendinorrhaphy, 293. Resection of Ankle Joint, 426. Resection of Elbow Joint, 408. Resection of Hip Joint, 449. Resection of Knee Joint, 435, 443. Resection of Lower Jaw, 488. Resection of Malar Bone, 498, 504. Resection of Pelvis, 454. Resection of Sacrum, 821. Resection of Shoulder Joint, 415. Resection of the Intestine, 707. Resection of Upper Jaw, 477, 478. Scabbard-shaped Trachea, 634. Strumectomy, 627. Temporal Incision, 475, 504. Transposing Hernial Sac, 729. Koeberle, Clamp Forceps, 246. Ferrum sesquichloratum (Ferric Chloride), 31. 3 H Kohler, Anus Praeternaturalis, 713. Ferment Intoxication, 278. Operation for Varicocele, 800. Stirrup of Iron for Locating Central Sulcus, 466, 468. Transfusion of Blood, 218. Konig, Ankylosis, 492. Arthrectomy, 453. Chloride of Zinc Solution, 28. Colostomy, 701. Cystoplasty, 787. Ether-Chloroform Anaesthesia, 191. Flexible Canula for Tracheotomy in Struma, 635. Gliding Stirrup for Extension, 150. Longitudinal Division of Nose, 571. Magnesite Dressing, 112. Massage in Syncope, 187. Mouth Gag, 581. Operation for Harelip, 546. Operation for Hernia, 723. Plastic Splint for Club Foot, 433. Plastic Operation for Collapsed Noses, 542. Resection of Ankle Joint, 425. Resection of Hip Joint, 448. Resection of Skull, 464. Retroperitoneal Laparotomy, 742. Rhinoplasty, 535. Urethrostomy, 763. Korte, Operation for Hernia, 730. Kraske, Benzoic Acid, 30. Meloplasty, 528. Operation for Hernia, 723. Resection of Sacrum, 819. Retrograde Dilatation, 640. Krause, Resection of Ganglion Gasseri, 507. Skingrafting, 299. Kronecker, Infusion of Sodium Chloride, 278. Kronlein, Haematoma posticum, 470. Middle Meningeal Artery, 472. Resection of II and III Ramus of the Trigemi- nus, 505. Retrobuccal Method, 562, 505. Kiichenmeister , Rhineurynter, 566. Kuhn, Neurectomy of the Inframaxillary Nerve, 501. Kiimmel, Galvanocaustic Excision of the Prostate Gland, 781. Operation for Ileus, 677. Kussmaul, Trocar, 657. Kuster, Amputation of the Breast, 670, 671. Ankylosis, 492. Atypical Amputation, 358. Cleft Palate, 558. Covering Orbit, 562. Epispadias, 790. 834 INDEX OF NAMES Extirpation of Bladder, 776. lodoform Collodion Dressing, 33. Modification of Pirogoff, 372. Nephrectomy, 741. Parallel Forceps, 686. Resection of Pharynx, 610. Staphyloplasty, 557. Swan (Needle Holder), 209. Kiittner, Extirpation of Tongue, 604. Laborde, Artificial Respiration, 186. Gelatine Solution, 287. Lancereaux, Gelatine Solution for Aneurism, 287. Landau, Echinococcus of the Liver, 733. Landerer, Adhesive Plaster Dressing, 155. Extension Dressing for the Genu Valgum, 156. Hypospadias, 791. Infusion of Sodium Chloride Sugar, 278. Intestinal Suture, 705. Prostatic Forceps, 779. Resection of Os Calcis, 430. Varix Bandage, 287. Lane, Craniectomy, 461. Lange, Carbolic Acid Injection for Hemorrhoids, 817. Circular Knife, 578. Exposing Kidney, 742. Extirpation of Fistula, 812. Forceps for Ligations, 744. Injection of Claret into the Rectum, 685. . Knife Blade for Retrograde Dilatation, 640. Nephrolithotomy, 743. Rectoplication, 814. Von Langenbeck, A., Ligation of Inferior Thyroid Artery, 632. Von Langenbeck, Amputation of the Tongue, 600. Blepharoplasty, 515. Blunt Retractors, 57, 200. Bullet Forceps, 222. Cheiloplasty, 520, 523. Clamp Forceps, 817. Correcting Collapsed Noses, 542. Disarticulation of Thigh, 388. Distortion of Margins of Lips, 545. Double Hook, 617. Elevator, 391. Extirpation of Tonsils with Extirpation of the Jaw, 594. Extirpation of Varices, 288. Flap Knife, 324. Forceps, 391. Hemorrhage in Tonsillotomy, 593. Instruments for Staphylorrhaphy, 551. Lateral Pharyngectomy, 610. Ligation of Inferior Thyroid Artery, 632. Ligation of Innominate Artery, 651. Metacarpal Saw, 307, 392. Method of Restoring Alae of Nose, 539. Needle Holder, 554. Osteoplastic Resection of the Upper Jaw, 482. Oval Incision, 326. Operation for Harelip, 545, 548. Removing Nasal Polypi by Ligation, 570. Resection of Ankle Joint, 424. Resection of Elbow Joint, 403, 405. Resection of Knee Joint, 437, 440. Resection of Leg with Lateral Skin Flap, 372. Resection of Nasal Process, 572. Resection of Olecranon, 409. Resection of Scapula, 418. Resection of Shoulder, 411. Resection of Upper Jaw, 478, 481. Resection of Wrist, 399. Retromaxillary Tumors, 577. Rhinoplasty, 531, 534, 539. Semilunar Flaps of Skin in Amputations, 324. Sharp Hook, 392. Staphyloplasty, 590. Staphylorrhaphy, 552, 553. Subhyoid Pharyngotomy, 608. Subperiosteal Resection, 390, 440. Suture Bearer, 551, 555. Temporary Resection of Lower Jaw, 600. Tripolith Dressing, 112. Uranoplasty, 555, 557, 590. Langenbuch, Constriction of Tongue, 599. Langenbuch, Trichloride of Iodine, 30. Applying Indirect Ligature, 518. Cholecystectomy, 735. Cystotomy, 776. Resection of the Liver, 733. Subhyoid Laryngotomy, 615. Supramaxillary Nerve, 497. Lannelongue, Craniectomy^ 461. Solution of Chloride of Zinc in Pseudoarthroses, 312. Uranoplasty, 556. Laplace, Sublimate Gauze, 27. Lassar, Paste for Eczema, '49. Laub, Hip Rest, 55. Lauenstein, Closure in Anus Prasternaturalis, 713. Resection of Foot, 428. Resection of Pylorus, 686. Sectio Mediana, 778. Thumbless Hand, 340. Larrey, Disarticulation of Shoulder Joint, 353. Disarticulation of Thigh, 386. INDEX OF NAMES 835 Lawrence, Turning Nose upward, 574. Lawson Tait, Paraffin Dressing, 112. Cholecystectomy, 735. Cholecystostomy, 734. Lazarsky, Sublimate Gauze, 26. Lecluse, Elevator, 585. Lecomte-Luer , Exploring Instrument for Bullets, 223. Ledderhose, Splenectomy, 739. Le Dentu, Ankylosis, 491. Lee, Metal Splints, 102. Le Ford, Electropuncture in Pseudoarthroses, 312. Modification of Pirogoff, 372. Leisrink, Echinococcus of the Liver, 733. Sphagnum Pasteboard, 42. Lembert, Serous Suture, 679, 702. Leroy d' Etiolles, Adjustable Curette, 564, 766. Catgut Strings, 797. Letievant, Neuroplasty, 297. Levis, Operation for Hydrocele Testis, 798. Levy, Resection of Sacrum, 822. Lewin, Cloth Saturated with Vinegar, 178. Von Leyden, Permanent Tube for CEsophagus, 640, 641. Liebreich, Electric Bullet Probe, 223. Lindemann, Echinococcus of the Liver, 733. Linhart, Neurectomy of Inframaxillary Nerve, 501. Link, Preserving Toes, Chopart Disarticulation, 361. Suture, 214. Lisfranc, Disarticulation of Foot, 357. Extirpatio Ani, 818. Tarso-Metatarsal Disarticulation, 364. Lister, Antiseptic Treatment, 23. Boric Acid, 28. Boric Salve, 28. Button Suture, 216. Carbolic Acid, 23. Carbolized Oil, n. Chloride of Zinc, 27, 28. Chromic Acid, 29. Compress, 41. Drainage Forceps, 28. Eucalyptol, 32. Healing under the Scab, 38. Protective Silk, 44. Splint for Resection of Wrist, 145. Spray, 2. Sublimate Gauze, 26. Liston, Bone Cutting Forceps, 330, 480, 613. Listen, Maclntyre's Splint, 143. Extension Splint, 146. Resection of Elbow Joint, 403. Little, Plastic Splint for Clubfoot, 433. Littre, Colostomy, 700. Lobker, Exposing Facial Nerve, 509. Resection in Tendinorrhaphy, 295. Spoon Elevator, 451. Longmore, Bullet Probe, 224. Lorenz, Congenital Dislocation of Hip Joint, 453. Osteoclast, 306. Loret, Wire Snare, 570. Loreta, Pyloroplasty, 696. Resection of the Liver, 733. Lorinser, Phlebotome, 283. Lessen, Resection of Malar Bone, 498, 504. Lotheisen, Ethylene Chloride Anaesthesia, 192. Louis, Circular Amputation by Two Incisions, 322. Lowdham, Amputation by Skin Flap Incision, 324. Liicke, Gastro-enterostomy, 693. Lingual Nerve, 506. Neurectomy of Inframaxillary Nerve, 500. Osteoplastic Necrotomy, 315. Parallel Forceps, 686, 707. Resection of Malar Bone, 498, 504. Resection of Spleen, 739. Sugar, 35. Ludwig, Infusion of Sodium Chloride, 278. Liter, Gouge Forceps, 330, 455. Hemorrhoidal Forceps, 815. Lip Holder, 581. Lithoclast, 778. Tracheal Canula, 618. M Afaas, Amputation of the Breast, 670. Extirpation of Larynx, 623. Ligation of Aorta, 269. Operation for Harelip, 546, 548. Sublimate Gauze, 27, 31. McBurney, Epityphlitis, 711. Mac Ewen, Acupuncture in Aneurism, 287. Operation for Hernia, 723. Osteotome, 307. Resection of Skull, 463. Supracondylic Osteotomy, 308. Mac Gill, Prostatectomy, 780. Maclntyre, Splint, 143. Macleod, Atresia Ani, 806. Macnamara, Tamponing Nose, 568. McBurney, Adjustable Telescopic Hip Rest, 50. Madelung, Cartilaginous Plate Suture, 705. Colostomy, 701. Ether-Chloroform Anaesthesia, 191. Extirpation of Varices, 288. Inguinal Anus, 701. Resection of Intestine, 707. Tendinorrhaphy, 293. 836 INDEX OF NAMES Maisonneuve, Enteroanastomosis, 708. Pharyngeal Tumors, 576. Urethrotome, 759. Major, Triangular Cloth, 170. Alalgaigne, Uisarticulation of Foot, 371. Operation for Harelip, 545. Resection of Upper Jaw, 478. Subhyoid Pharyngotomy, 608. Manec, Disarticulation of the Thigh, Puncture Method, 383. Manne, Pharyngeal Tumors, 576. Manz, Regionary Analgesia, 194. Marshall, Osteotribe, 312. Marshall Hall, Artificial Respiration, 186. Marwedel, Oblique Fistula, 683. Matthieu, Laryngeal Forceps, 637. Tonsillotome, 592. Urethral Forceps, 766. Mathysen, Plaster of Paris Dressing, 113. Maunoury, Lower Oral Route, 603. Maydl, Colostomy, 700. Doudenostomy, 695. Extirpation of the Bladder in Ectopia, 788. Mayor, Cloth Bandages, 84. Cloth Bandage for Fracture of the Patella, 94. Mears, Ankylosis, 492. Vasectomy, 802. Merchie, Moulded Pasteboard Splints, 108. Mercier, Prostatic Catheter, 753. Menne I- Schneider's Extension Apparatus, 305. Meusel, Urethroplasty, 766. Meyer, Amputation of the Breast, 668. Adenoid Vegetation, 577. Circular Knife, 578. Michael, Compressed Sponge Canula, 621. Naso-Pharyngeal Forceps, 579. Miculicz, Compressory Instrument for the Tonsils, 594- Correcting Collapsed Noses, 543. Cystoplasty, 786. Extension Dressing for the Genu Valgum, 157. Extirpation of the Sternocleidomastoid, 646. Extirpation of Tonsils, 595. Nephropexy, 746. Oil of Turpentine in Pseudoarthroses, 312. Operation for Aneurism, 286. Operation for Ileus, 677. Pyloroplasty, 696. Resection of Goitre, 630. Resection of Prolapsus of the Rectum, 813. Stylet for Antrum of Highmore, 486. Tamponing Dead Spaces, 40, 675, 739. Tarsectomy, 431. Temporary Resection of Lower Jaw, 502 Middeldorpf, Akidopeirastik, 202. Galvanocautery, 206. Triangle, 145. Millon, Reagent, 25. Mirault, Operation for Harelip, 545. Mitscherlich, Cement Dressing, 112. Morgan, Cheiloplasty, 523, 524. Morton, Ether, 188. Von Mosetig, Fistulous Formation in Cleft Palate, 558. lodoform, 32. Lactic Acid, 208. Motais, Pointed Instrument for Supplying Finger Nail, 578. Mott, Ligation of Innominate Artery, 654. Miiller, Plastic Operations on Bones, 310. Resection of Skull, 464. Struma Cystica, 626. Murphy, Intestinal Button, 695, 705. Intestinal Button in Gastro-enterostomy, 695. Murray, Ligation of Aorta, 269. Muzeux, Tenaculum Forceps, 591, 687. N Nebinger, Tendinorrhaphy, 294. Nelaton, Abduction Splint, 97. Catheter, 752. Cystoplasty, 785. Inversion in Syncope, 187. Lithotrite, 766. Operation for Harelip, 544. Probe, 223. Resection of Elbow Joint, 408. Resection of Hard Palate, 576. Resection of Upper Jaw, 478. Rhinoplasty, 536. Transverse Perineal Incision, 778. Urethroplasty, 765. Neuber, Cystorrhaphy, 775. Intestinal Suture, 704. Inversion Suture, 315. Glass Splint, 105. Peat Mull, 42. Neudorfer, Apolysis, 393. Shoemaker Shavings, 121. Nicaise, Elastic Band, 227. Nicoladoni, Resection of Rectum, 821. Nikolaysen, Acupuncture in Pseudoarthroses, 312. Nothnagel, Sodium Chloride to produce Antiperi- staltic Motion, 694. Von Nussbaum, Adhesive Plaster, 217. Ligation of Aorta, 270. Protective Silk, 39. INDEX OF NAMES 837 Peroxyde of Hydrogen, 243. Suturing Sigmoid Flexure, 677. O Obalinski, Tarsectomy, 431. Oberldnder, Dilatator, 758. Oberst, Meloplasty, 527. Regionary Analgesia, 194. Oesterlein, Dysmorphosteopalinclast, 306. Ogston, Arthrodeses of Astragalo-Navicular Articu- lation, 434. Oilier, Correcting Collapsed Noses, 543. Ether, 188. Resection of Elbow Joint, 407. Resection of Hip, 452. Resection of Os Calcis, 429. Resection of Scapula, 418. Resection of Shoulder Joint, 415. Subperiosteal Enucleation of Os Calcis, 366. Subperiosteal Resection, 390. Turning Nose upward, 574. Olshausen, Splenectomy, 739. Oppler, Pulverized Coffee, 35. Otis, Arresting Hemorrhage in Urethrotomy, 761. Endoscope, 757. Litholapaxy, 784. Urethrometer, 754. Urethrotome, 759. Overlach, Injection Syringe, 202. Pagenstecher, Celluloid Flax Thread, 210. Paget, Thoracotomy, 661. Pancoast, Aorta Tourniquet, 238. Piiquelin, Therm ocautery, 204. Paravicinl, Exposing Lingual Nerve, 506. Parker, Operation for Varicocele, 800. Partsch, Resection of Lower Jaw, 490. Resection of Palate, 576. Passavant, Cystoplasty, 787. Palato-pharyngeal Suture, 558. Suturing Device for Staphylorrhaphy, 555. Paul von Aegina, Detaching Cartilaginous Meatus, 564- Pean, Clamp Forceps, 246. Splenectomy, 739. Peter Franco, Cystotomy, 770. Petcrsen, Circular Incision for Varices, 228. Cystotomy, 772. Hallux Valgus, 420. Oxide of Zinc, 34. Resection of Septum, 580. Overcorrection, 153. Petit, Boot, 101. Circular Amputation by Two Incisions, 320, 322. Fracture Box, 62, 140, 143. Screw Tourniquet, 238. Phelps, Operation for Clubfoot, 292, 433. Pictet, Ether, 188. Pinner, Arrest for Propagation of Schizomycetes, 29. Pirogoff, Bridge Plaster of Paris Dressing, 128. Disarticulation of Foot, 36. Etherization per Rectum, 190. Nasal Bridge, 569. Strips of Plaster of Paris Bandage, 114. Transcondylary Amputation, 348. Pitha, Oral Wedge, 581. Plessing, Blepharoplasty, 515. Pollard, Enucleation of Tonsils, 593. Poncet, Cystostomy, 769. Gastropexy, 679. Urethrostomy, 763. Ponfick, Regeneration of the Liver, 733. Pooley, Carbolic Acid Injection for Hemorrhoids, 817. Poppert, Cystoplasty, 786. Port, Splints of Sheet Zinc, 102. Porta, Enucleation of Goitre,- 630. Porter, Sawdust, 42. Telegraph Wire Splints, 103, 162, 164. Potain, Aspiration, 659. Pott, Side Position, 139. Splints, 99. Pozzi, Cystoplasty, 786. Pravaz, Syringe, 202. Priessnitz, Compresses, Cataplasms, 44, 63. Prince, Cuneiform Tarsectomy, 433. Q Quimby, Modification of Pirogoff s Amputation, 372. Quincke, Aspiration Drainage, 660. Lumbar Puncture, 195, 470. Pneumotomy, 664, 665. R Ramm, Hypertrophy of the Prostate Gland, 802. Ranke, Thymol, 30. Rawa, Paraneurotic Suture, 297. Recamier, Cheiloplasty, 524. Reclus, Cocaine Analgesia, 194. Regnier, Cheiloplasty, 524. Regnoli, Extirpation of Tongue, 602. Rehn, Irrigating Stomach in Ileus Operation, 677. Resection of Rectum, 821. Suturing Wound of the Heart, 666. Reid, Arresting Circulation in Aneurism, 285. Reiner, Amputation Saw, 327. 838 INDEX OF NAMES Reismann, Stretching Margins of Tracheal Wound, 658. l^on Renz, Abduction Box, 141, 142. Reverdin, Skingrafting, 298, 299. Reybard, Thoracocentesis, 658. Richardson, Ether Spray, 192, 193. Ricord, Forceps for Phimosis, 235. Operation for Varicocele, 801. Removing Polypi by Ligation, 570. Ried, Hanging Head, 584. Riedel, Cholecystostomy, 735. Morphine Ether Anaesthesia, 191. Nephropexy, 745. Ries, Margins of Plaster of Paris Dressing, 117, 118. Rietschel and Henneberg, Sterilizer, 16. Rizzoli, Ankylosis, 492. Osteoclast, 306. Proctoplasty in Atresia Ani, 807. Roberts, Pericardia! Puncture, 665. Trephining, 457. Robin, Osteoclast, 306. Rolando, Location of Central Fissure, 465. Rontgen, Ray, 219, 223, 767. Rose, Enucleation of Goitre, 631. Extirpation of Thigh, 386. Hanging Head, 477, 500, 584. Posterior Cceliectomy, 821. Strumectomy, 626. Uranoplasty, 590. Rose, W., Resection of Ganglion Gasseri, 507. Rosenberg, Anaesthesia, 180. Roser, Apron Bandage, 89, 92. Apron Bandage for the Hip, 93, 94. Bone Cutting Forceps, 459, 589. Bone Screw with Hook, 459. Deviation of Septum, 579. Dilating Forceps in CEsophagotomy, 643. Dilator, 57. Dorsal Splint, 98. Empyema, 663. External Urethrotomy, 764. Gag, 183. Incision for Phimosis, 792. Iron Wire Splints, 103. Mouth Gag, 581. Needle Holder for Staphylorrhaphy, 555. Resection of Elbow Joint after Treatment, 410. Stomatoplasty, 527. Three Handed Chiselling, 487. Transverse Division of Cheek, 506. Uranoplasty, 590. Rotgans, Intrabuccal Incision in Resection of the Upper Jaw, 477. Rotter, Abscesses of Tonsils, 594. Extirpation of Larynx, 625. Pastils, 32. Rouge, Temporal Detachment of Nose, 573. Roux, Needle Holder, 209, 555. Rupprecht, Deviation of Septum, 580. Rush Medical College, Sublimate Tablets, 27. Ruysch, Disarticulation of Wrist, 343. De Ruyter, lodoform Ether Alcohol, 33. Rydygier, Amputation of the Breast, 671. Cystoplasty, 786. Excision of Gastric Ulcers, 678. Inferior Thyroid Artery, 632. Intestinal Clamps, 686, 707. Pirogoff s Disarticulation, 368. Plastic Operation on Bones, 310. Resection of Sacrum, 822. Resection of the Pylorus, 685, 689. Splenopexy, 739. Superior Thyroid Artery, 631. Sabanejeff, Intracondylic Osteoplastic Amputation, 3 6 4. 3 8 - Saenger, Transperitoneal Nephrectomy, 745. Sahlt, Infusion, 280. Salmon, English Truss, 714. Salomon, Tin Splints, 101. Salzer, Local Exclusion of Diseased Intestinal Part, 710. Operation for Femoral Hernia, 731. Resection of Malar Bone, 504. Samter, Removing Projecting Premaxillary Bone, 551. Sauer, Nasal Prothesis, 538. Sayre, Adhesive Plaster Bandage for Fracture of Clavicle, 155. Elevator, 391. Extension Dressing for Knee Joint, 157. Extension for Scoliotic Spine, 152. Jury Mast, 158. Plaster of Paris Corset, 119. Taylor's Extension Apparatus, 158. Scarpa, Herniotomy, 720. Schaffer, Taylor's Extension Apparatus, 158. Schede, Congenital Dislocation of Hip, 453. Healing under the Scab, 38. Ligature of Veins, 289, 290. Moist Blood Clot after Necrotomy, 315. Operation for Hernia, 723. Radius Splint, no. Resection of Hip Joint, 450. Resection of the Pylorus, 686. Silver Wire, 674. Spun Glass Wool, 44. INDEX OF NAMES 839 Sublimate Gauze, 26. Thoracoplasty, 662. Varices, 288. Vertical Extension, 150. Scheuer, Fracture Box, 143, 144. Schiltsky, Obturator for Palate, 559. Schimmelbusch, Mask, 175. Rhinoplasty, 535, 536, 543. Sterilization of Instruments, 7. Sterilization of Sponges, 12. Tin Box for Sterilized Silk, 10. Schlange, Cystoplasty, 786. Resection of Sacrum, 822. Schleich, Infiltration Anaesthesia, 195, 588, 685. Solutions, 196. Schmidt, Exploratory Perforation of the Skull, 469. Longitudinal Division of the Tonsils, 593. Schmucker, Refrigerating Mixture, 63. Schneider- Mennel, Extension Apparatus, 305. Schnyder, Clotii Splints, 96. Schoelz, Circular Knife, 579. Scfioen, Splints of Sheet Zinc, 102. Schonborn, Colostomy, 701. Staphyloplasty, 558. Schuh, Extirpation of Ranula, 604. Schulten, Amputation of the Tongue, 604. Schiiller, Artificial Respiration, 185. Extirpation of the Parotid Gland, 606. Neurorrhaphy, 297. Schulze, Eucalyptus Gauze, 32. Schwab, Gastrotomy, 678. Scultet, Bandage, 73, in, 113, 157. Sedillot, Cheiloplasty, 525, 526. Gastrostomy, 680. Resection of Lower Jaw, 602. Tendinorrhaphy, 293. Semmelweiss , Chloride of Lime, 31. Senn, Boric and Salicylic Acid, 35. Decalcified Chips 'of Bone, 315. Direct Fixation of Bones, 310. Disarticulation of Thigh, 386, 388. Entero-anastomosis, 709. Hydrogen Gas for Intestinal Wounds, 706. Intestinal Suture, 705. Operation for Varicocele, 800. Osteoplastic Resection of Skull, 463. Shortening Mesentery by Folding, 677. Senn, E. jf., Gastrostomy, 684. Incision for Amputation of the Breast, 668. Seutin, Starch Dressing, in. Von Siebold, Suspension Apparatus, 55. Silvester, Artificial Aspiration, 185. Simon, Dilatation of Anus, 805. Dilatation of Female Urethra, 778. Nephrectomy, 740. Operation for Cleft Palate, 550. Operation for Echinococcus of the Liver, 732. Rectal Speculum, 804. Operation for Empyema, 662. Simpson, Chloroform, 172. Sims, Vaginal Speculum, 804. Skinner, Chloroform Apparatus, 175. Smith, Extirpation ot Rectal Fistula, 812. Hemorrhoidal Forceps, 815. Pasteboard Splints in Urethrotomy, 761. Socin, Enucleation of Goitre, 630. Gastro-enterostomy, 692. Oxide of Zinc Paste, 35. Retrograde Dilatation, 640. Skingrafting, 301. Supporting Apparatus for Loose Freely Movable Joint, 410. Sonnenburg, External Rectotomy, 808. Extirpation of the Bladder in Ectopia, 788. Lingual Nerve, 506. Neurectomy of the Inframaxillary Nerve, 500. Treatment of Cavities, 665. Soulier, Ethylene Chloride Anaesthesia, 192. Spencer- Wells, Artery Forceps, 244. Spitzka, Exploratory Puncture of the Brain, 470. Sporon, Tendinoplasty, 296. Stacke, Exposing Lateral Chambers of Antrum, 474- Stapler, Suture, 214. Starke, Etherization per Rectum, 190. Permanent Irrigation, 60. Steiner, Middle Meningeal Artery, 472. Stephan, Extirpation of Rectal Fistula, 812. Stille, Bone Nipping Forceps, 459. Operating Table, 771. Stilling, Pyoctanin, 32. Storp, Operation for Hydrocele, 800. Strong, Cystotomy, 770. Stromeyer, Arm Pillow, 144. Arresting Hemorrhage in Struma, 626. Needle Holder in Staphylorrhaphy, 555. Oblique Bed for Caput Obstipum, 645. Padded Strips of Wood for Splints, 97, 98. Phlebostatic Hemorrhage, 247. Tenotomy, 290. Tenotomy of the Sterno Cleido Mastoid, 644. Suersen, Obturator for Palate, 559. Syme, Aneurism Needle, 253. Disarticulation of Foot, 364. Grooved Sound, 763. Intracondylic Amputation, 379. Resection of Upper Jaw, 478. 840 INDEX OF NAMES Szymanowsky, Cloth Bandage for Fracture of Clavicle, 89,91, 119. Tagliacozza, Rhinoplasty, 537. Tait, Cholecystotomy, 734. Paraffin Dressing, 112. Tauter, Modification of Pirogoff, 371. Tavel, Solution, 673. Taylor, Extension Apparatus, 158. Textor, Resection of Knee Joint, 435. Thane, Ascertaining Location of Central Fissure, 465. Thiersch, Blepharoplasty, 515. Butterfly, 549. Cystoplasty, 785. Epispadias, 788. Extraction of Nerves, 493. Forceps, 494, 500. Improvised Wound Douche, 20. Meloplasty, 527, 528. Pearl Suture, 216. Rhinoplasty, 532, 534, 536, 539. Salicylic Acid, 28, 29. Silver Ring in Prolapse, 813. Skingrafting, 299, 300, 302, 304. Sodium Chloride Solution, 301. Spindle for Ligations, 744. Uranoplasty, 590. Thompson, Digital Palpation of the Bladder, 777. Dilator, 758. Prostatic Forceps, 777. Suture of Bladder, 775. Urethral Forceps, 766. Thornton, Nephrectomy, 740. Tichow, Suture of Veins, 289. Tiemann, Flexible Laryngeal Forceps, 637. Tillaux, Tendinoplasty, 295. Tillmanns, Chloroform, Ether, 192. Ignipuncture, 288. Oral Speculum, 582. Tiling, Resection of Hip, 452. Nasal Protheses, 538. Tontasi, Carbol Test, 25. Tonnasko, Suture, 214. Trager, Exploratory Puncture of the Brain, 470. Trelat, CEsophagotome, 641. Trendelenburg, Cheiloplasty, 521, 522, 524. Cystoplasty, 787. Disarticulation of Thigh, 386. Drainage of the Bladder, 776. Gastrostomy, 68 1. Ligation of the Long Saphenous Vein, 288. Operation for Hydronephrosis, 745. Pelvic High Position, 771. Position in Resection of the Intestine, 714. Resection of Olecranon, 409. Staphyloplasty, 558. Supramalleolar Osteotomy, 309, 434. Tampon Canula, 477, 621. Tricomi, Gastrostenoplasty, 679. Tripier, Blepharoplasty, 516, 517. Trommsdorff, Hydrogen Peroxide, 32. Sozoiodol, 35. Trousseau, Probe, 639. Trnka, Tendinorrhaphy, 294. Tuffier, Extrapleural Palpation, 664. Turk, Tongue Depressor, 565, 582. Turner, Instrument for Measuring the Skull, 466. Plaited Silk, 210. U Unna, Gauze Sash, 89, 93. Vanlair, Neuroplasty, 298. Veiel, Glue Dressing, 112. Velpeau, Bandage for Fracture of the Clavicle, 80. Neurectomy of Inframaxillary Nerve, 501. Resection of Both Upper Jaws, 481. Verduin, Forming Flaps by Transfixion, 325. Verneuil, Chlorinated Soda, 31. Dilatation of the Anus, 817. Extirpation of Coccyx, 805. Linear Rectotomy, 825. Lower Oral Route, 603. Rectopexy, 814. Rhinoplasty, 534. Vetsch, Disarticulation of Thigh, 386. Viborg, Ligation of Salivary Duct, 608. Vidal, Cystotomy in Two Stages, 773. Herniotomy, 720. Vogt, Ligation of Superficial Palmar Arch, 268. Middle Meningeal Artery, 471. Resection of Astragalus, 428. Resection of Wrist, 398. Resection Splint (Watson's), 100, 101. Volcker's Cooling Experiments, 66. Stick Tourniquet, 241. "Tapetenspan " for Plaster of Paris Dressing, 121. Von Volkmann, Arthrectomy, 389. Dorsal Splint, 134. Dressing after Amputation of the Thigh, 382. Drop Canula, 60. Echinococcus of the Liver, 732. Extension Apparatus for the Cervical Portion of the Spine, 151. Ischemic Paralysis of Muscles, 68. Knee Splint, 101. INDEX OF NAMES 841 " Kriill " Gauze, 41. Operation for Hydrocele Testis, 798. Resection of Knee Joint, 440. Resection of Sacrum, 821. Sharp Retractor, 200. Sharp Spoon, 203. Sleigh Apparatus, 148. Subtrochanteric Osteotomy, 308. Supination Splint, 100, 101. Suspension Apparatus for Injured Arm, 167. Suspension Frame, 55. Suspension Splint, 61, 151. T Splint, 100, 101, 165. Tenotomy of the Sternocleidomastoid, 644. Tin Splints, 149. Wire Sling, 60. Voltolini, Immersion Battery, 206. Uvula Forceps, 566. W Wagner, Hollow Elevator, 479. Resection of Skull, 463, 507. Von Walther, Lateral Flap Incision, 341. Ligation of Arteries in Enucleation of Goitre, 631. Radial Flap Incision (Wrist), 344. Walton, Haynes, Extension Dressing, 146. Wardrop, Ligation of Arteries, 286. Warren, Uranoplasty, 556. Watson, Drainage Tube for the Prostate Gland, 779. Resection Splint, 100, 101. Suspension Splint, 133. Weber, Osteoplastic Resection of the Upper Jaw, 483. Resection of Upper Jaw, 478. Rhinoplasty, 540. Wehr, Intestinal Clamp, 686. Weinleckner, Mouth Gag, 581. Weir, Gastroplication, 679. Weiss, Fishbone Catcher, 638. White, Hypertrophy of the Prostate Gland, 802. Resection of Hip Joint, 445. Whitehead, Amputation of the Tongue, 600. Oral Speculum, 551, 582, 600. Taylor's Extension Apparatus, 158. Wilde, Wire Snare, 570. Wille, Bone Suture, 310. Willemer, Arthrectomy, 389. Wilson, Instrument for Measuring the Skull, 466. Von Winiwarter, Cholecysto-enterostomy, 737. Witzel, Colostomy, 701. Gluteal Colostomy, 825. Gluteal Rectostomy, 825. Oblique Fistula, 682, 769. Preserving Toes in Chopart's Disarticulation,36i, 362. Tendinorrhaphy, 294. Wladimiroff, Tarsectomy, 431. Wolberg, Needles, 294. Wolfe, Blepharoplasty, 515. Skin Grafting, 299, 531. Wolff, Distortion of the Margins of the Lips, 545. Cleft Palate, 551. Extirpation of Larynx, 625. Obturator for Palate, 559. Operation for Harelip, 545. Phonetic Canula, 624. Strictures of the (Esophagus, 640. W'olfler, Anatomy of the Neck, 629. Blepharoplasty, 517. Cheiloplasty, 524. Dislocation of Goitre, 633. Gastro-anastomosis, 697. Gastro-enterostomy, 689, 690. Gastroplasty, 696. Gum Arabic Chalk Dressing, 112. Inferior Thyroid Artery, 632. Internal Intestinal Suture, 704. Ligation of Arteries in Enucleation of Goitre, 631. Operation for Hernia, 728. Parasacral Incision, 824. Resection of the Pylorus, 685, 689. Tendinorrhaphy, 294. Wright, Fibrin Ferment as Styptic, 243. Wyeth, Disarticulation of Thigh, 386. Wywodzoff, Plaster of Paris Bandage Machine, 115. Zaufal, Nose Funnel, 565. Zeis, Rhinoplasty, 531. Zerssen, Cooling Experiments, 66. Von Ziemssen, Phrenic Faradization, 186. Zuckerhandl, Parasacral Incision, 823. Perineal Prerectal Incision, 779. Resection of the Rectum, 822. INDEX OF SUBJECT-MATTER Abdomen, Opening the, 673. Operation on the, 672. Puncture of the, 672. Abdominal Cavity, Opening of the, 673. Abduction Box, 141. Splint, 97. Ablatio Mammae, 667. Uvulae, 595. Accidents, Unpleasant, during Anaesthesia, 179. Acid, aseptinic, 31. Acupuncture in Aneurism, 287. for forming Osseous Callus, 312. Adenoid Vegetations in the Naso-pharyngeal Cavity, 577. Adhesive lodoform Gauze, 33. Adhesive Plaster for Wounds, 217. Adhesive Plaster Loop, 147. Dressing for Fracture of the Clavicle, 155. Aditus ad Antrum, Opening of the, 474. Agaric, 243. Agglutinative Bandages, 45. Air Cushion, 51. Air Embolism in Operations on the Neck, 649. Air Infection, 2. Air Passages, Opening of the, 612. Akidopeirastik, 2O2. Alabaster Gypsum, 113. Alar Splint, 107. Alcohol, 32. Alligator Forceps for the Urethra, 766. Alum, 31. as an Escharotic, 207. Aluminum Acetate, 28, 59. Acetico-tartaricum, 29. Splints, 102. Alveolar Process of the Upper Jaw, Resection of the, 476. of the Lower Jaw, Resection of the, 487. Amputation, 316. of the Arm, 348. of the Forearm, 344. of the Leg, 372. of Limbs, 316. of the Scapula, 419. of the Thigh, 383. of the Tongue, 599. of the Tonsils, 590. of the Penis, 796. of the Uvula, 595. Indication for, 316. Intracondylic, 379. Knives, 319. Malleolar, 364. Metatarsal, 355. Osteoplastic, 374, 380. Saw, 327. Supracondylic Osteoplastic, 379. Tibiocalcanea Osteoplastica, 367. Transcondylar of the Arm, 348. Ancesthesia, Action of the Surgeon during Serious Accidents, 182. Awakening from an, 178, 189. Bromoform, 192. By Means of Cocaine, 194. Chloroform, 172. Chloroform-ether, 191. Chloroform Mixture, 191. Combined, 191. Course of Chloroform, 176. Dangers in Ether, 189. Ether, 188. Ethylene Bromide, 192. Ethylene Chloride, 192. General, 172. Infiltration, 195. Pental, 192. Preparations for, 173. Unpleasant Accidents in, 179. Analgesia, Local, 192. Regionary, 194. Anal Perineal Incision, 764. Anastomosis of Nerves, 298. of Tendons, 296. Anatomy of the Axilla, 669. of Centres of the Brain, 465. 843 844 INDEX OF SUBJECT-MATTER of the Head and Neck, 647, 648. of the Inguinal Region, 716. of the Parotid Gland, 606. of Lower Surface of the Liver, 736. of the Pelvic Organs, 803. of the Perineal Region, 763. of the Recurrent Nerve, 629. of the Rectal Fistula, 810. of the Region of the Larynx, 622. of the Renal Region, 743. of the Soft Palate, 553. of the Thorax, 656. of the Trigeminus, 495. of the Urethra, 748, 749. of the Veins of the Head, 628. Crural Arch, 717. Mastoid Process, 474. Temporo-maxillary Articulation, 491. Topographical, of the Innominate Artery, 6 5 i. Aneurism, Extirpation of, 286. Ligation of, 285. Needle, 253. Operation for, 283. Angiotripsy, 247. Angular Incision for Resection of Elbow Joint, 407. Angular Scissors, 201. Spatula, 582. Ankle, Splint for Fracture of the (Dupuytren's), 146. Ankle-joint, Resection of, 421. Iron Arch Splint for Resection of (von Es- march's), 136. Plaster of Paris Suspension Splint for Resec- tion of, 133. Ankylosis, Operation for, 491. Antiphlogistic Treatment, 6l. Antipyrine as an Analgetic, 195. Antiseptics, 22. Antisepsis, 2, 22. in War, 168. Primary, 36. Secondary, 57. Antrum, Opening Lateral Chambers of the, 474. Antrum of Highmore, Opening of the, 485. Tympanicum Opening of the, 474. Anus Artificial, Formation of an, 699. Dilatation of, 804, 805. Extirpation of, 817, 818. Formation of an Opening of the, 806. Inguinal (Littre), 700. Operations on the, 803. Narrowing Dilated, 814. Prseternaturalis, 712. Strictures of the, 809. Aorta, Abdominal, Ligation of, 269. Tourniquet, 238. Apolysis after Resection, 393. Appendicitis, Operation for, 711. Applying of Bandage, 69. Apron Bandage, 89, 94. Aqua, Binelli, 30. Chlori, 30. Goulardi, 29. Arch Splint, Iron, 136. Divided Iron, 136. Arches of Sheet Iron, 127. Argentum Nitricum as a Caustic, 207. Aristol, 35. Arm, Amputation of, 348. Bandaging of the Whole, 77. Bath, 14. Pillow, 144. Splint, 105. Splint for the (at an oblique angle), 98. Tub, 14. Arsenic, Caustic Powder, 208. Paste, 208. Arteries, Aneurism, 285. Anterior Tibial, 275. Axillary, 264. at the Bend of the Elbow {Arteria anconea), 265. at the Place of Selection, 251. Brachial, 265. Common Carotid, 256. Common Iliac, 270. Compression of, 235. External Carotid, 257. External Iliac, 272. External Maxillary, 258. Femoral, 272. Internal Carotid, 258. Internal Iliac, 271. Ligation of, 251. Ligation of Abdominal Aorta, 269. Ligation of Popliteal, 275. Ligation of Ulnar, 266. Lingual, 258. Occipital, 259. Opening Sheath of, 252. Posterior Tibial, 276. Radial, 266. Subclavian, 259. Superior Gluteal, 271. INDEX OF SUBJECT-iMATTER 845 Sciatic, 271. Superficial Palmar Arch, 267. Suture of, 289. Temporal, 258. Topography of, 248-250. Torsion of, 246. Vertebral, 262. Artery Compressor (Tourniquet), 236. Improved, 240. Artery, Dorsal, of the Foot, 276. Forceps, 244. Hypogastric, Ligation of, 782. Inferior Thyroid, Ligation of, 632. Innominate, Ligation of the, 651. Mammary Internal, Ligation of, 652. Middle Meningeal, Ligation of, 470, 507. Superior Thyroid, Ligation of, 631. Arthrectomy, 389. of the Knee Joint, 443. Arthrodesis, 389. in Flat Foot, 434. Articulations, Resection of, 389. Dividing of, 358. Artificial Anus, 806. Larynx, 624. Limb (Prothesis), 334. Mouth, 527. Nose, 538. Oedematization, 195. Respiration, 185. Tongue, 604. Asepsis, 2. Ideal, 22. of Surgeon, 3, 4. Aseptic Operation, 1 8. Aseptin, 31. Aseptinic Acid, 31. Aseplol, 31. Ashes, 42. Asphyxia, Paralytic, 180. Spastic, 1 80. Aspiration of the Lungs, 665. with Aspirator, 658. Aspirator, 659. Astragalonamcular Articulation, Arthrodesis of the, 434. Astragalus, Disarticulation below the, 362. Resection of the, 428. Atheromatous Cysts, 646. Atmokausis, 243. Atresia Ani, 806. Auditory Meatus, Foreign Bodies in the Exter- nal, 563. Auricle, Detaching of the, 564. Autoplasty on the Skull, 463. Autotransfusion, 281. Awakening from an Anaesthesia, 178. Axilla, Clearing out of the, 667. B Back Bandage, 89. Back Rest, Adjustable, 51. Band, Elastic, 225. Bandage, Applying of, 69, 70. Bilateral Compressive, for the Breast, 8l. Binoculus, 75. Compressive, for the Breast, 8l. Cross Turn, 72. Elastic, for Bloodless Method, 225. Elastic, for Dressing, 44. Fastening of, 70. Figure-of-8 Turn of, 72. for the Breast, 81. for the Whole Breast, 89, 90. Gaping, 69. Halter, 74. for the Leg, 82. Linen for Bloodless Method, 232. Material, 45. Roller, 70. Scultet's Many-tailed, 73. Turns of, 71. Unwrapping of, 70. Bandages, 44, 68. for the Arm, 76. Cambric, 45. Caoutchouc, 45. Cotton, 45. Flannel, 45. Gauze, 45. for the Head, 74. for the Leg, 82. Linen, 45. Shirting or Stouts, 45. Thorax, for the, 80, 89. Tricot, 45. Bandaging, 67. the Arm, 77. the Leg, 82, 83. Bath for the Arm, 14. Portable Hospital, 14. Permanent Antiseptic, 59, 65. Batiste (Billroth), 44. Bayonet Incision for Resection of the Elbow Joint, 407. Bayonets used for Splint, 166. 846 INDEX OF SUBJECT-MATTER Benzoic Acid, 30. Benzosol, 30. Biliary fistula, Establishing, 734. Binoculus Bandage, 75. Bismuth, 34. Bismuthum Subnitricum, 34. Bistoury, 8. Bladder, Puncture of the, 768. Washing out the, 753. Foreign Bodies in the, 766. Bleeding, 282. Blepharoplasty, 514. Blood, Saving of, 224. Bloodless Method, 225. Apparatus for, 228. in Aneurism, 225, 285. Secondary Hemorrhage, 233. in Operation on the Lips, 518. in Operation on the Tongue, 598. Blood Vessels, Ligation of, in the Wound, 245. Ligation of, by Indirect Ligature, 245. Injury to Walls of the, 289. Blotting Paper, 42. Bone Cavity, Opening of, 312. Bone Chips, Decalcified, 463. Decalcified for filling Gap after Necrotomy, 3I5- Bone Clamps, 310. Cover for Amputation Stump, 374. Cutting Forceps for Roots of Teeth, 589. Drill, 309, 475. Forceps, 330. Implantation of, 310. Nipping Forceps, 459. Plates, Decalcified for Enterorrhaphy, 704. Section, 307. Screw, 459. Sawing of the, 326. " Skelettierung " of, 390. Suture, 310. Tube, Decalcified, 704. Union, 311. Union, Aluminum Splints for, 311. Bones, Operation on, 305. Boot used as Foot Splint, 165. Petit's, 101. Boric Acid, 28, 35, 59. . Lint, 28. Salve, 28. Boring Chisel, 485. Bougie for the OEsophagus, 640. for the Rectum, 807. for the Urethra, 756. " Boutonniere" 761. Palatine, 576. Brain, Injury to the, by Hammering, 460. Protruding Portions of the, 457. Brass Spiral Bandage, 230. Breast, Compressive Bandage for the, 81. Operations on the, 651. Suspensory Bandage for the, 8l. Bridge Plaster of Paris Dressing, 128. Bromoform Anesthesia, 192. Bronchotomy, 612. Buccal Bandage, 87. Bulbus, Enucleation of the, 561. Exenteration of the, 563. Extirpation of the, 562. Bullet Screw, 222. Forceps, 222. Probe, 223. Probe, Electric, 223. Bullets, Extraction of, 219. Buried Suture, 214. Sutures, 37. Butterfly in Maxillary Fissure, 549. Buttocks, Cloth for the, 89. Button Suture, 216. Cachexia thyreopriva, 626. Canine Fossa, Opening of the, 486. Canula, Bellocq's, 567. for Hypertrophy of the Prostate Gland, 779- for Puncture of the Bladder, 769. for Tracheotomy, 618. for Tracheotomy in Goitre, 635. Phonetic, 624. Caoutchouc Bandage, 45. Pure Materials of, 44, 45. Capistrum Bandage, 74. Caput obstipum, Operation for, 644. Carbolic Acid, Injection of, into Hemorrhoidal Swellings, 817. as an Escharotic, 208. Symptoms of Poisoning of, 24. Test, 25. Carbolized Gauze, 24. Glycerine, 24. Silk, 210. Solution, Strong, 23. Solution, Weak, 23. Carbonic Acid, Liquid, as an Analgetic, 193. Cardiac Region, Massage of, in Chloroform Anaes- thesia, 187. INDEX OF SUBJECT-MATTER 847 Carpenter's Chisel for Necrotomy, 312. Cartilage Plate Suture for Enterorrhaphy, 705. Castration, 801. Catgut, 210. Aseptic, IO. Glass Box for Catgut Ligatures, n. Ring for Enterorrhaphy, 704. Strings as Bougie, 757. Catheter Catcher, 767. Introduction of, 749. with Double Canula, 753. Catheterism, 747. in the Female, 752. in Hypertrophy of the Prostate, 752. Posterior, 764, 769. Catline, 329. Caustic Pastes, 207. Cauterium Actuale, 204. Cauterium Potentiale, 207. Cautery Iron, 204, 243. Cavities, Tubercular Treatment of, 664. Cavity, Shallow, after Necrotomy, 314. Celluloid Thread, 210. Plates in Resection of the Skull, 463. Cellulose Cotton, 42. Sheets, no. Central Fissure, Locating, 464. Centres of the Surface of the Brain, 465. Cerebral Abscess in the Temporal Lobe, 468. Topography, 465. Cerumen, Hardened, 564. Cervical Portion of the Spine, Extension Appa- ratus for, 151. Tumors, Operation for, 646, 647. Chaff Pillows, 51. Chain Saw, 392. Changing the Dressings, 47. Charcoal, 35. Char pie Cotton, 41. Cheek, Transverse Division of the, 506, 600. Cheiloplasty, 517. Chin, Bandage for the, 87. Chirotheka, 76. Chisel for Necrotomy, 314. Chloral Hydrate, 31. Chloride of Lime, 31. Chloride of Sodium, 31. Infusion of, 242. Infusion of, in Chloroform Anaesthesia, 187. Chloride of Zinc, 27, 243. Jute, 28. Paste of, 208. Chlorinated Soda, 31. Chlorine, 30. Water, 30. Chloroform Anaesthesia, 172^ Apparatus, 174, 175, 176. -ether Anaesthesia, 191. English Mixture, 192. Mixtures, 191. Mortality from, 181. Odor Test in, 173. Syncope from, 187. Cholecystectomy, 735. Cholecystendysis, 734. Cholecysto-enterostomy, 737. Cholecystopexia, 734. Cholecystotomy, 733, 734. Ideal, 734. Choledocho-lithectomy, 737. Choledocho-lithotripsy, 736. Chromic Acid, 29. as an Escharotic, 208. Catgut, II. Cingulum Pectoris, 89. Circular Amputation, 323. by one Incision, 318. by two Incisions, 320. by three Incisions, 318. for Varices, 288. Stump after, 320, 323. Circular Bandage, Danger from, in Fracture of Forearm, 108. Circular Enterorrhaphy, 704. Circular Knife for Adenoid Vegetations, 578. for Tonsillotomy, 592. Circular Suture, 688. Circular Turn, 71. Circumcision, 793. Clamp for Fastening Elastic Tube, 228. Forceps (Amussat's), 246. Forceps for Hemorrhoids, 816, 817. Forceps for Operations on the Eyelids, using the " Bloodless Method," 234. Clamp Buckle, 226. Clavicle, Cloth Bandage for Fractured, 89. Resection of the, 419. Temporary Division by sawing off the, 670. Claw Foot, 589. Claw Hand, 334. Clearing out of the Axilla, 667. of the Floor of the Mouth, 604. of the Orbit, 561. Cleft Palate, 551. Clefts of the Hard Palate, 555. INDEX OF SUBJECT-MATTER Cloth Bandages, 84. Bandage for Fracture of the Clavicle, 89. Dressing for Fracture of the Patella, 94. for Pelvic Region, 89. Large Square for the Head, 86. Splints, 96. Triangular, for the Head, 85. Clothing, Articles of, used for Splints, 162. Clove-hitch, 753. Clubfoot, Operation for, 433. Clubfoot Shoe with Elastic Extension, 157. Coagulation of the Blood in Aneurism, 283. Cocaine Anaesthesia, 193. Spray of, in Anaesthesia, 180. Toxic Symptoms of, 195. Cocainizing Spinal Cord, 195. Coccyx, Extirpation of, 806, 819. Ccecal Incision, 711. Cceliectomy, Posterior, 821. Cceliotomy, 673. Coffee as an Antiseptic, 35. Coin-catcher, 638. Cold Coil, 64. Collodion, 37. Colopexy in Prolapse, 814. Colostomy, 697. Gluteal, 825. Colpeurynter, 243, 770. Combined Anesthesias, 191. Compressed Sponge Canula, 621. Compresses, Antiseptic, 59. Cold, 62. Divided, 328. Compression for the Tonsils, 594. Instrument for Resection of the Pylorus, 686. of Main Trunk of the Artery, 235. of the Aorta, 240. of the Subclavian Artery in Disarticulation of the Shoulder Joint, 351. of the Wound, 242. Compressive Bandage for Female Breast, 8l. Compressorium Mamma, 8l. Conical Stump, 333. Constriction caused by Bandage, 68. Temporary, of the Tongue, 598. Tube, 226. Constrictor, Elastic, 226. Contact-infection, 2. Continued Suture, 214. Tying of a, 214. Cooling Box (used instead of Ice-bag), 64. Cover, 65. Coffer Sulphate as an Escharotic, 207. Cornea, Reflex, in Anaesthesia, 177. Cortical Epilepsy, 461. Costal Scissors, 656. Costotome, 655. Cotton, 41. Bandage, 41. Common, 41. Pasteboard Dressing, in. Counter Extension, 150. Cover Dressings, 40. Coxitis Extension, Apparatus for, 158. Cracks in Plaster of Paris Dressing, 118. Craniectomy, 461. Cranio-cephalometer for locating Central Sulcus (Kohler), 466. Creolin, 25, 59. Creosote, 30. Cricectomy, 615. Cricotomy, 615. Cricotracheotomy, 6 1 8. Cross Bandage, 74. for the Hand, 87. Cross Turn of Bandage, 72. Crown Saw (Trephine), 457. Crural Arch, Anatomy of the, 717. Cuneiform Excision from the Alveolar Process, 476. from the Angle of the Jaw, 492. from the Anus, 814. from the Lower Lip, 519. from the Mesentery, 708. from the Tongue, 597. from the Vomer, 550. Cuneiform Tarsectomy, 433. Cuprum Sulphur icum, 31. Curette, 485. Adjustable, 564. Cushioned Dressing, 41. Cystopexy, 775. Cystoplasty, 785. Cystorrhaphy, 775. Cystostomy, 769. Perineal, 777. Subpubic, 776. Suprapubic, 770. Cystotomy, 770. D Death from Chloroform Anaesthesia, 181. Decalcified Bone Drainage Tube, 38. Decapitation of the Head of the Humerus, 4I5- Deep Sutures, 214. INDEX OF SUBJECT-MATTER 849 Defect, Congenital, of the Abdominal Wall and Bladder, 784. Dental Bur for Bone Suture, 310. Dependant Head, 551, 584. Dermatol, 35. Detachment, Temporary, of Mammary Gland, 668. Transverse of the Mesentery, 707. Deviation (Scoliosis) of the Septum, 580. Diadem, 551. Digital Compression, 235. for arresting Hemorrhage, 235. in Aneurism, 284. Digital Palpation of the Bladder, 777. Dilatation of the Anus, 805, 817. of the Female Urethra, 778. of the Mouth, 526. of the Oesophagus, 639. Dilatation, Retrograde, of Strictures of the Oesophagus, 640. Dilator, 57. for the Urethra, 758. for the Female Urethra, 778. Diodothioresorcin, 35. Disarticnlation below the Astragalus, 362. of the Elbow Joint, 346. of the Fingers, 336. of all Fingers, 339. of the Foot, 364. of the Foot ( Pirogoff's Method), 367. General Rules for, 332. Intertarsal, 359. of the Knee Joint, 377. of Limbs, 316. Mediotarsal, 359. of the last four Metacarpal Bones, 341. at the Metacarpo-phalangeal Joint, 337. of the Shoulder Girdle, 353. at the Shoulder Joint, 350. Subperiosteal, 334. Tarso-metatarsal, 357. at the Tarsus (Chopart), 359. of the Thigh, 383. of the Thumb, 340. of the Toes, 355. of the Wrist, 342. Disinfection of the Patient, 13. Diverticula, Oisophageal, 644. Divulsion of Strictures, 758. Divulsor, 758. Dolabra Reversa, 71. Dorsal Splint for Leg, 1 34. for Radius, 98. Double Canula for Tracheotomy, 616. 31 Double-headed Bandage, 72. Union Bandage, 74. Double Hook for Tonsillotomy, 591. for Tracheotomy, 616. Double Inclined Plane, 62, 140. Double-rowed Intestinal Suture, 702. Drainage Forceps, 38. of the Frontal Sinus, 476. of the Knee Joint, 444. of the Maxillary Sinus, 486. of Wound, 38. Openings in the Skin, 39. Trocar, 39, 476. Tube provided with Threads, 331. Tube of Rubber, 38. Dressing with Adhesive Plaster, 155. Basin, 22. Boxes, 47. Forceps, 218. for Drying the Wound, 40. for Fracture of the Clavicle, 78. Glue for, 112. Material for, 40, 41. Package, Soldier's, Antiseptic, 170. Pad, 43. Scissors, 48. Dressings, Antiseptic Cushion for Stump after Amputation, 46. Antiseptic for Large Wounds on the Neck, 46. Changing the, 47. Cover, 40. Extension, 146. for Cervical Spondylitis, 158. for Hip (Taylor's), 158. for the Wrist, 151, 154. Permanent, 47. Plastic, no. Drill, 475. Drop Anesthesia, 176. Drying of the Wound, 37. Duodenostomy, 695. Dysmorphosteopalinclast, 306. Ear Speculum, 563. Echinococcus of the Liver, Operation for, 732. E*crasement, 225. craseur, 22$. Ectopia Vesical, 784. Ectropium, Operation for, 514. " Ectropcesophag," 641. Elastic Bandage for Dressing, 44. Elastic Constriction for Bloodless Method, 226. 850 INDEX OF SUBJECT-MATTER for rendering Limbs Bloodless, 225. in Disarticulation of the Thigh, 383. in Regionary Analgesia, 194. Elastic Extension, 153. Elastic Retractor, 616, 620. Elastic Stocking for Varices, 287. Elastic Support Flap for Rhinoplasty, 534. Elbow Cloth, 88. Elbow Joint, Disarticulation of, 346. Double Splint for Resection of the (von Esmarch's), 137. Plaster of Paris Suspension Splint for Resec- tion of the, 130. Resection of, 403. Stirrup Plaster of Paris Dressing for the, 128. Electrolysis, 207. Electromotor, 311. with Rotating Circular Saw, 460. Electropuncture in Aneurism, 287. in Chloroform Anaesthesia, 187. for forming Osseous Callus, 312. Elevation of Limbs, 61. Elevator, 391. for Extracting Roots of the Teeth, 585, 589. Empyema, After treatment of, 663. Drainage of, by Aspiration, 660. Resection of Rib, 661. Endoscope for the Urethra, 757. Enteroanastomosis, 708. Enterocele, Treatment of, 714. Enterorrhaphy, 702, 703. Circular, 704. Internal, 704. Enterostomy, 676, 679. Temporary, 697. Enterolomy, 697. Enucleation of the Eyeball, 562. of a Goitre, 630, 631. of the Bulb, 561. of the Tonsils, 593. Resection of Goitre, 631. Epicystotomy, 770. Epidural Hamaloma, 470. Epispadias, 788. Epityphlitis, Operation for, 711. . Epulis, 476. Esckarotics, 207. tage Suture, 214. for the Intestine, 702. in Amputations, 331. Ether Anttsthesia, 188. Dangers from, 189. Ether-chloroform Anasthesia, 191. Ether, Clonic Contractions from, 189. Mask, 1 88. Spray for Local Anaesthesia, 193. Etherization per Rectum, 190. Ethylene Bromide Anaesthesia, 192. Bromide Ether Anaesthesia, 192. Chloride Anaesthesia, 192. Chloride, Flask containing, 193. Eucaine, 195. Eucalyptol, 31. Eucalyptus Gauze, 32. Evacuation of the Orbit, 561. of Struma, 631. Evulsion of the Vas Deferens, 802. Excision of Cancer, of the Rectum, 817. of the Lower Lip, 519. of the Tongue, 597. Excitation Stage in Chloroform Anaesthesia, 177. Exenteration of the Bulb, 563. Exothyropexia, 633. Explorative Incision, Extraperitoneal, 676. Exploratory Perforation of the Skull, 469. Exposing Accessory Nerve, 510. Brachial Plexus, 511. Crural Nerve, 511. Facial Nerve, 509. Foramen Ovale, 502. Foramen Rotundum, 499. Inframaxillary Nerve, 499. Lingual Nerve, 506. Mental Nerve, 506. Popliteal Nerve, 513. Supramaxillary Nerve, 496. Supraorbital Nerve, 494. Extension Apparatus for Osteoclasis, 305. Extension Dressings, 146, 147. of the Arm, 150. with Adhesive Plaster, 155. for Femoral Fracture, 146. for the Hip (Taylor's), 158. for the Knee Joint (Sayre's), 157. Separable for the Thigh, 154. of the Trunk, 151. by Weight, 147. Extirpation of Aneurism, 286. of the Anus, 818. of the Cervical Glands, 646. of the Coccyx, 806, 819. of the Eyeball, 562. of the Gall Bladder, 735. of Hemorrhoids, 814. INDEX OF SUBJECT-MATTER 8 5 I of Intraglandular Struma, 630. of the Kidney, 740. of the Larynx, 621. of the Lungs, 665. of the Mammary Gland, 666. of Xaso-pharyngeal Polypi, 577. of the Parotid Gland, 605. of the Pharynx, 610. of Ranula, 604. of Rectal Fistula, 812. of the Sternocleidomastoid, 621. of Struma, 626. Subcutaneous, of Cervical Glands, 651. of Submaxillary Gland, 607. of Testicle, 800. of the Tonsils, 594. of the Urinary Bladder, 776. of Varicocele, 800. Extraction of Teeth, 584, 586. of Roots of Teeth, 589. Extraperiloneal Explorative Incision, 676. Eye, Artificial, 562. Bandage, 75, 87. Enucleation of the, 562. Operations on the, 561. Eyelid, Plastic Surgery of the, 514. False Passage in Catheterism, 756. fan Turn, 72. Faradization of Phrenic Nerve, 1 86. Fascia circularis, 71. nodosa, 74. sagittahs, 74. stellata, 80. uniens, 74. Fasciotomy, 292. Felt, Plastic, no. Femoral Ffernia, Truss for, 715. Radical Operation for, 730. Fene strated Plaste r of Paris Dressing, 126. Ferric Chloride, 243. Ferripyrine, 243. Ferrum Sesquichlor.atum,T t \, Figure-of-8 7'iern of Bandage, 72. Fit de Florence, 210. Filiform Bougies, 756. Finger, Metal Sheath for Protecting, 566. Finger Nail, Pointed Instrument for Supplying, 57 8. Fingers, Bandaging the, 76. Contraction of, 292. Disarticulation of, 336. Disarticulation of all, 340. Resection of Fingers, 394. Fish-bone Catcher, 638. Fissure, Congenital, of Anterior Pelvic Region, Plastic Operation for, 784. of Sylvius, Location of, 464. Fistula Ani, Operation for, 809. Fistu/ous formation on the Foramen Incisivum, 558. Flannel Bandage, 45. Flap Knife, 324. Flask containing Ethylene Chloride, 193. Flat foot, Arthrodesis in, 434. Operation for, 434. Flax, 42. Thread for Suturing Material, 210. Floating Spleen, Stitching of, 739. Flower Trellis as a Splint after Resection of Knee Joint, 847. Folding Suture, 215. Foot, Bandaging of, 82. Board (Crosby), 147. Cloth, 95. Disarticulation of, 364. Osteoplastic Amputation, of the, 367. Resection of the Tarsal Bones of, 430. Skeleton of, 357. Tub, 14. Foramen Ovale, Exposing, 502. Rotundum, Exposing, 499. Forceps, Anatomical, for Ligatures, 244. for Calculi, 744, 777. for Extraction of Nerves, 493. for extracting teeth, 586. for the Urethra, 767. for Nasal Polypi, 568. for Prostatotomy, 779. with Removable Lock, 9. for the Septum, 580. for Hemorrhoids, 816. Hemostatic, 244. Splinter, 218. Surgical, 8. Forcipressure, 246. Forearm, Amputation of, 344. Resection of its Lower Extremity, 394. Splint, 97. Wood-shaving Plaster of Paris Dressing for, 122. Foreign Bodies in the Bladder, 766. in the External Auditory Meatus, 563. in the (Esophagus, 636. in the Urethra^ jfctu Removal of, 218. IELES - U.S.A. 852 INDEX OF SUBJECT-MATTER " Four Masters" Suture of the, 704. Fracture Box, Heister's, 143. Petit's, 62, 140, 143. Scheuer's, 143, 144. French. Rhinoplasty, 537. Frontal Bandage, 87. Frontal Sinus, Opening of, 475. Full Bath, 13. Funda Bandage, 73. Capitis, 86. Maxillae, 75, 87, 91. Gall Bladder, Anatomy of, 736. Extirpation of the, 735. Incision of the, 734. Operations on the, 732. Galvanocautery, 206. Galvanopuncture, 207. Ganglion Gasseri, Resection of, 507. Gaping Bandage, 69. Gastric Ulcers, Gastrotomy, 678. Gastroanastomosis, 697. Gastroduodenostomy, 689. Gastroenterostomy, 690. Gastrolysis, 679. Gastropexy, 679. Gasiroplasty, 679. Gastroplication, 679. Gastroptosis, 679. Gastrorrhagia, Gastrotomy for, 678. Gastrorrhaphy, 679. Gastrostenoplasly, 679. Gastrostomy, 680. Gastrotomy, 678. Gauntlet, 87. Gauze Bandage, 45. Sash, 89. Gauze Sponges, Sterilization of, 13. for Sterilization of, 16. for Tampon, 13. Gelatine, 243. Solution of, in Aneurism, 287. Genu Valgum, Extension Dressing for, 157- Glass Bottle for Dry Cold, 63. Box for Catgut Ligatures, II. Instrument Tray Stand, 9. Irrigator, 20. Splints, 105. Woo/. 44- Glass Bougie for Rectum, So8. -SCJ IS 6 . Gliding Stirrup (Konig's), 150. Glover's Suture, 214. Glue Dressing, 112. Glycerine Pad for Trusses, 715. Goitre, Dislocation of, 633. Ligation of the Isthmus of the Thyroid Gland in, 633. Operations for, 625. Probe, 627. Resection of, 630. Tracheotomy for, 635. Gorget, 812. Gouge Chisel, Spoon-shaped, 550. Gouge Forceps, 330. Gown, Surgeon's, 5, 7. Grafting of Portions of Skin, 298. Granny's Knot, 85, 211. Granulation after Tracheotomy, 619. Grooved Director, 199. Guajacol as an Analgetic, 197. Guide-staff, 761. Guillotine (Tonsillotome), 592. Gum Arabic Chalk Dressing, 112. Gunshot Wounds, Hemorrhage from, 247. Gutta Percha Sheets, 1 1 0. H Hamatoma, Epidural, 470. Hallux, Arthrectomy of the, 420. Halter Bandage, 74. Hammer for Removing Plaster of Paris Dress- ing, 1 1 8. Hammering, Injury to the Brain by, 460. Hand Cloth, 87. Cross Bandage for the, 77, 87. Trephine, 457. Hands, Boards for the, 97. Sterilization of the, 4. Harelip, Double, 548. Operations for, 544. and Maxillary Fissure, 544. Head, Anatomy of the, 647. Bandages for the, 74. Cloth, Square, 86. Cloth, Triangular, 85. Hanging Downward, Operations on the, 584. Healing under the Scab, 38. Heart, Paralysis of, in Anaesthesia, 181. Paralysis of, in Chloroform Anaesthesia, 187. Heel, Support for the, 50, 124. Hemorrhage, Arrest of, 224. Arresting by Compression, 242. Arresting during Operation, 19. INDEX OF SUBJECT-MATTER 853 Arresting by Raising Limb vertically, 242. Arresting by Tamponade, 242. Death from Excessive, 277. Phlebostatic, 247. from Puncture and Gunshot Wounds, 247. after Removing Constriction Bandage, 232. Hemorrhoidal Clamp Forceps, 8 1 6. Scissors, 8 1 6. Hemorrhoids, Operation for, 814. Hemostatic Forceps, 244. Hepatic Border Incision, 733. Hernia, Operation for, 714. Radical Operation for, 722. Hernial Sac, Transposing of the, 729. Herniotome, 719. Herniotomy, 716, 718. Heteroplasty on the Skull, 463. Highmore, Anatomy of the Antrum of, 485. Opening of the, 485. Hindoo Method, Rhinoplasty, 530. Hip Cloth, 93. Dislocation of, Operation for, 453. Joint, Resection of, 445. Joint, Subperiosteal Resection of, 446. Spica Coxae for the, 83. Rest, Telescopic, 49, 123. Hollow-moulded Splint, 99. Hollow Reflector, 497. Hook for Separable Wooden Splint, 154. Hook-shaped Incision for Resection of Elbow Joint, 408. Incision for Resection of Knee Joint, 443. Horse-hair for Suturing Material, 211. Hospital Bath, Portable, 13. Hourglass Contractions of the Stomach, 696. Humerus, Wood-shaving Plaster of Paris Dressing for the, 121. Hydrocele, Operation for, 797. Radical Operation for, 798. Hydrochloric Acid, 31. Hydrogen Dioxide, 59. Hydrogen Gas for Intestinal Wounds, 706. Hydrogen Superoxide, 32. Hydronephrosis, Operation for, 745. Hydropneumothorax, 657. Hyperczmia for Osseous Callus Formation, 312. Hyperflexion for Arresting Hemorrhage, 241. Hypnotism for bringing on Anaesthesia, 197. Hypodermoclysma, 280. Hypospadias, 791. I Ice Bag, 63. Idiocy (Craniectomy), 461. Ileostomy, 697. Ileus, Laparatomy for, 676. Ilium, Resection of the, 454. Immersion, Permanent Antiseptic, 59, 65. Improvising Artery Compressors, 240. Bullet Probe, 224. Stick Tourniquet, 241. Inactivity, Paralysis from, after Resection, 393. Incision, 197. of the Mammary Gland, 666. Incisor Prostatic, 781. India Rubber Hose, with Hooks for Extension Dressing, 153. Indirect Ligature for Cheiloplasty, 518. Infiltration Anesthesia, 195. Infusion, 277. Apparatus for, 281. Canula for, 279. Graduated Glass Cylinder for, 279. Ingrown Nail, 302. Inguinal Anus, Forming of, 700. Hernia, Radical Operation for, 722. Hernia, Radical Operation for, in the Female, 73. Hernia, Truss for, 715. Region, Anatomy of the, 716. Injection in Hemorrhoidal Swellings, 815. Intramuscular, 203. Intravenous, 279. Parenchymatous, 204. Parenchymatous in Goitre, 625. Subcutaneous, 202, 203. Syringe for, 202. Insects in the Auditory Meatus, 564. Inspection of the Nares, 565. of the Oral Cavity, 581. of the Rectum, 804. Interosseous Space, Knives for dividing Soft Parts in the, 329. Interrupted Plaster of Paris Dressing, 1 27. Interrupted Suture, 21 1. Intestinal for Anus Praeternaturalis, 712. Button (Murphy's), 705, 706. Clamps, 687. Scissors, 712. Suture, Needles for, 702. Intestine, Forming a Fistulous Opening in the In- testine and the Abdominal Wall, 697. Local Exclusion of a Diseased Part of the, 710. Opening the, 697. Resection of the, 706. Resection of the, in Anus praeternaturalis, 713. Resection of the, in Grangrenous Hernia, 706. 854 INDEX OF SUBJECT-MATTER Instrument Sterilizer, 9. Instruments, Sterilization of, 7. Intrabuccal Incision for Resection of the Maxilla, 477- Intracranial Resection of the Ganglion Gasseri, 508. Introducing Catheter, 750. CEsophageal Tube, 635. Intubation of the Larynx, 619. Imagination Displacement (Hernial Sac), 730. for Enterorrhaphy, 705. Invalid Lift, 52, 53, 54. Siebold's, 55, 56. Inversion in Chloroform Anaesthesia, 187. Suture, 38. Suture after Necrotomy, 315. Involutio Brachii, 77. Pedis, 82. Thedenii, 83. Iodine, Trichloride of, 30. lodoform, 32, 35. Adhesive (Billroth), 33. Collodion, 33, 37. Ether, 33. Ether-alcohol, 33. Gauze, 33, 40, 58. Glycerine, 33. Pencils, 33. Poisoning, Symptoms of, 34. Powder, 33. Silk, 210. Test of, 34. lodol, 35. Iron Wire Splints, 103. for Suture, 211. Irrigateur, " a vide Bouteille," 21. Irrigation, 65. Permanent Antiseptic, 59. Permanent Apparatus for, 60. Irrigator, Improved, 20. Improvised, 21, 159. Tube, 60. Irritants for forming Osseous Callus, 310. Ischemia, Temporary, 225. Italian Rhinoplasty, 537. Ivory Pegs for Bone Cavity, 310. Pins for Bone Union, 310. Jejunostomy, 695. Juniper Catgut, II. Oil of, 32. Jury Mast, 158. Jute, 48. J K Kali Causticum, 207. Kangaroo Tendons, 2IO. Kelen Anasthesia, 192. Kerchief for Bandage, 87. Kidney, Fixation of the, by Sutures, 745. Operations on the, 740. Kionotomy, 595. Knee Cloth, 93. Splint, 101. Stirrup, Plaster of Paris Dressing for the, 127. Joint, Drainage of, 444. Disarticulation of the Leg at the, 377. Extension Dressing for the, 157. Plaster of Paris Suspension Splint for the, 132. Puncture of the, 444. Resection of the, 435. Knife, Aseptic, 8. Holding it like a Violin Bow in making In- cisions, 198. Methods of holding the, 197. Blades, Shape of, 198. Knives, Three-edged, for Retrograde Dilatation, 641. " Kruell" Gauze, 41, 43. Labial Suture in Atresia Ani, 806. Margins, Sliding of, in Cheiloplasty, 520. Method of Distortion in Harelip, 545. Lace Suture, 215. Lactic Acid as an Escharotic, 208. Lancet for Venesection, 283. Languette Suture, 214. Laparotomy, 673. After treatment, 675. Abdominal Supporter after, 676. for Ileus, 676. Laryngeal Forceps, 637. Laryngofissure, 615. Diagnostic, 622. Laryngotomy, 612. Infrathyroid, 614. Subhyoid, 615. Larynx, Artificial, 624. Extirpation of the, 621. Intubation of the, 619. Region of the, Anatomy of the, 622. Lateral Extension in Scoliosis, 153. Flap Incision for the Thumb, 341. Flap Incision for the Wrist, 344. Position, 139. INDEX OF SUBJECT-MATTER 855 Lead Acetate, 29. Leg, Bandages of the, 82. Bandaging the Whole, 83. splints for the, 101, 105. Wood-shaving Plaster of Paris Dressing for the, 123. Lifting Lower Jaw, 182. Ligation of Afferent Arteries in Vascular Goitre, 631. of Blood Vessels by Indirect Ligature, 245, 246. Direct, 247. of the Hemorrhoids, 816. of the Hypogastric Artery in Hypertrophy of the Prostate, 782. of the Inferior Thyroid, 632. of the Innominate Artery, 651. of the Internal Mammary Artery, 652. of Lateral of Veins, 287, 289. en masse, 246. of the Middle Meningeal Artery, 507. of Nasal Polypi, 570. for Operating in a Bloodless Manner, 225. at the Place of Selection, 251. Removing Xasal Polypus by, 571. of Saphenous Vein, 288. of Subcutaneous vein, for Varicocele, 801. of the Superior Thyroid, 631. of Varices, 288. of Veins, Lateral, 649. of Vessels in Aneurism, 285. in the Wound, 243. Ligature Loop as Retractor, 200. Ligature A'eedle, 253. Ligatures, Sterilization of, IO. Limb, Raising vertically after Bloodless Method, 232. Linen Bandages, 45. Lining for Rhinoplasty, 534. for Urethroplasty, 765. Lint, 41. Lion Forceps, 391. Lips, Plastic Surgery of the, 517. Lithoclast, 778. Manipulation of, 782. Litholapaxy, 784. Lithotomy, 770. , Forceps, 774, 777. Position, 761. Lithotripsy, 782. Lithotriptor, Adjustable, 767. for the Urethra, 767. Manipulation of the, 782. Lithotrite, 777. Liver, Abscesses of the, 733. Anatomy of the, 736. Operations on the, 732. Resection of the, 733. Local Anesthesia, 192. Longitudinal Division of Anal Fistula, 810. Loop Tightener, 599. Loose Gauze (" Kruell "), 41, 43. Freely Movable Joint after Resection, 393. Lower Jaw, Resection of the, 487. Subperiosteal Resection of the, 493. Temporary Resection in the Median Line, 602. Temporary Resection of the, 502, 600. Lower Lip, Restoration of the, 517. Restoration of the Whole Lip, 520. Lower Maxilla Holder, 183. Lifting of, 182. Lumbar, Incision for the Kidney, 741. Incision for Laparotomy, 676. Puncture, 470. Lunar Caustic, 207. Lung, Extirpation of the, 665. Incision of the, 664. Resection of the, 665. Lysol, 25. Gauze, 61. M Macaroni, Pieces of, for Enterorrhaphy, 704. Mackintosh, 44. Malar Bone, Temporary Resection of, 498. Mammary Gland, Ablation of the, with Clearing out of the Axilla, 667. Extirpation of the, 666. Incision of the, 666. Operations on the, 666. Temporary Detachment of the, 667. Manubrium Sterni, Resection of, 653, 654. Many-headed Bandage, 73. Marginal Sutures for Tendons, 294. Margins in Plaster of Paris Dressing, 117. Mask for Chloroform Anaesthesia, 174. for Ether Anaesthesia, 188. Masse, Ligatures en, 246. " Masters, four" Suture of the, 704. Mastoid Process, Anatomy of, 474. Opening of the, 473. Maxilla, Osteoplastic Resection of, 482. Osteoplastic Resection of Both, 483. Resection of the, 476. Resection of Both, 481. Resection of the (Intrabuccal Incision), 477. Resectionof the Xasal Processof the Upper, 572. 856 INDEX OF SUBJECT-MATTER Maxillary Arch, Resection of the, 489. Maxillary Fissure, Double, 548. Operation for, 544. Meatotomy, 760. Meatus, Foreign Bodies in the External Auditory, 563. Meloplasty, 527. Meningeal Artery, Ligation of the, 470. Metacarpal Bone, Resection of a, 394. Bones, Disarticulation of, 341. Saw, 392, 655. Saw for Osteotomy, 307. Saw for Resection of Ribs, 655. Metacarpophalangeal Joint, Disarticulation of, 337- Metal Catheter, 750. Rings, Removing of, 219. Ring for Enterorrhaphy, 704. Splints, 102. Strips as Protheses after Resection of Maxil- lary Arch, 490. Wire, 211. Metatarsal Bones, Amputation of, 355. Resection of the, 421. Methyl Chloride, 193. Microcephalus (Craniectomy), 461. Military Model Operating Table, 165. Minerva, 158. Mitella, Improvised, 159. Large Square, 89. (Sling), 88. Mitra Hippocratis, 74. Model tot Rhinoplasty, 531. Monoculus, 75. M or phium- ether Anazsthesia, 191. Morphium-chloroform Anesthesia, 191. Motor y Centres of the Brain, 465. Mouth, Artificial, 527. Clearing floor of the, 604. Gag, 581, 582, 583. Inspection of the Cavity of the, 581. Plastic Surgery of the, 526. Mucoid Polypi, Removal of, 568. Muscular Cone in Circular Amputation, 323. Flaps, 325. Suture, 332. Musket used as Splint, 166. N Nails, Operations on, 302. Naphthalin, 34. Nares, Inspection of the, 565. Tamponade of the, 566. Nasal Polypi, Removing, 568, 569 Nasal Process, Resection of, 572. Nasal Protheses, 538, 543. Speculum, 565. Naso-pharyngeal Polypi, Removing, 571. Cavity, Adenoid Vegetations in the, 577. Extirpation of, 577. Forceps, 578. Osteoplastic Resection of Both Upper Jaws, 483- Natrium Chloroboricum, 31. Chloroborosum, 31. Tetraboricum, 28. Neck, Antiseptic Dressing for the, 46. Topography of the, 647. Necrotomy, 312. Hammer for, 313. in Gunshwt Wounds, 224. Osteoplastic, 315. Needle for applying Suture, 209. Holder, 209. Holder for Staphylorrhaphy, 554. Needles provided with Handle, 554. Nephrectomy, 740. Transperitoneal, 745. Nephrolithotomy, 743. Nephropexy, 745. Nephrotomy, 740. Nerve, Accessory, Exposing of, 510. Crural, Exposing of, 511. Extraction of Nerve, 493. Facial, Exposing of, 509. Inframaxillary, Exposing of, 499. Lingual, Exposing of, 506. Mental, Exposing of, 506. Popliteal, Exposing of, 513. Recurrent, Course of the, 629. Resection of, 493. Sciatic, Exposing of, 512. Stretching, 493. Supramaxillary, Exposing of, 496. Supraorbital, Exposing of, 494. Trigeminus, Topography of, 495. Phrenic, Faradization of, 1 86. Nerves, Anastomosis of, 298. Operations on, 296. Neurectomy, 493. Neurexairesis, 493. Neuroplasty, 297. Neurorrhaphy, 296. Neurotomy, 493. Nitric Acid as an Escharotic, 208. Nose, Bandage for the, 75. INDEX OF SUBJECT-MATTER 857 Deviation of the Septum of the, 580. Division of the, in the Median Line, 571. Framework of the, 535. Funnel, 565. Plastic Surgery for Restoring Tip of the, 540. Plastic Surgery of the, 530. Plastic Surgery for Restoring Ala of, 539. Restoring Septum of the, 541. Temporary Detachment of, 573. Turning up the Whole, 574. Nostrils, Contraction of, 579. O Oakum, 42. Oblique Bed for Torticollis, 645. Board, Adjustable, 6l. Fistula, Formation of, on the Exposed Vesical Wall, 769. Fistula in Gastrostomy, 683. Obliteration of Varices, 288. Obturators for Palatal Clefts, 559, 560. Occlusion Suture, 687. (Edematization, Artificial, 195. (Esophageal Diverticula, 644. Fistula, Lip-shaped, 643. Forceps, 637. Probang, 638. Tube, Introducing, 635. OLsophagoplasty, 644. QLsophagotome, 640. CEsophagostomy, 643. CEsophagotomy, Combined, 643. External, 641. Internal, 640. (Esophagus, Diverticula of the, 644. Hook, Adjustable, 638. Operations on the, 635. Resection of the, 643. Strictures of the, 639. Oil Cloth, 44. Olecranon, Resection of, 409. Olive for Retrograde Dilatation, 640. Pointed Bougie, for the CEsophagus, 640. for the Rectum, 808. for the Urethra, 755. Opening of the Air Passages, 612. of the Antrum of Highmore, 485. of the Canine Fossa, 486. Echinococcus of the Liver, 732. Frontal Sinus, 475. of the Gall Bladder, 732. of the Mastoid Process, 473. of the Skull, 457. of the Stomach, 678. of the Thoracic Cavity, 657. the Trachea, 617. Operating Table, 3. Military Model, 165. Operation, Aseptic, 1 8. Preparation for an, 2. Oral Retr actor, 552. Oral Route, Lower, for Extirpating Tumors of the Tongue, 603. Oral Specula, 581. Orbit, Evacuation of the, 561. Operations on the, 561. Organtine Bandage, 45. Orthoform, 197. Os Calcis, Resection of, 429. Osleoclasis, 305. Osleoclast, 306. Osteoplastic, Amputation, 374. Amputation of the Foot, 367. Amputation of the Knee Joint, 380. Detachment of the Trochanter, 452. Necrotomy, 315. Operation on the Skull, 464. Resection, see Temporary Resection. Resection of Both Jaws, 483. Resection of the Lower Jaw, 490. Resection of the Manubrium Sterni, 655. Resection of the Maxilla, 482. Resection of the Skull, 463. Osteotome, 307. Osteotomy, 306. for Clubfoot, 433. Subtrochanteric, 308. Supracondylic, 308. Supramalleolar, 309. Osteotribe, 312. P Padded Strips of Wood, 97. Padding for Plaster of Paris Dressing, 116. Palatal Protheses, 558. Palate, Cleft, 551. Defects of the, Acquired, 590. Defects of the, Congenital, 556. Muscles of the, 553. Resection of the, in Pharyngeal Tumors, 577. Falato-Pharyngeal Suture, 558. Palmar Arch, Superficial Ligation of, 267. Paper, Strips of, for Starch Dressing, ill. Paraffine Dressing, 112. Parallel Clamp Forceps for Intestinal Resection, 688. for the Lower Lip, 518. 858 INDEX OF SUBJECT-MATTER Paraneurotic Suture, 296. Paraphimosis, 794. Parasacral Incision, 823, 824. Par ate ndi nous Suture, 293. Parenchyniatous Injection, 204. Parotid Gland, Anatomy of, 606. Extirpation of the, 605. Pasteboard Model for Arm Splint, 106, 108. Splint for the Arm, 106. Splints for Temporary Dressing, 162. Patella, Cloth Bandage for Fracture of the, 94. Patient, Disinfection of the, 13. Pearl Needles for Enterorrhaphy, 702. for Suture, 216. Peat, 42. Moss (Sphagnum), 42. Peg Leg, 335- for Amputated Leg, 335. Pelvic, High Position, 771. in Resections of the Intestine, 714. in Taxis, 717. Organs, Topography of the, 804. Pelvis, Operations on the, 747. Pen, Holding Knife like a, in making Incisions, 198. Pengha-war Yambi, 243. Penis, Amputation of the, 796. Circumference of the, 754. Operations on the, 792. Pental Anirsthesia, 192. Perforation, Exploratory, of the Skull, 469. Pericardiotomy, 665. Pericardium, Puncture of the, 665. Perineal Cystotomy, 777. Resection of the Rectum, 824. Section, Median, 777. Transverse, 778. Perineurotic Suture, 296. Periosteal Suture, 309. in Amputations, 332. Periosteum, Reflection of, in Amputations, 320. Perityphlitis, Operation for, 711. Phalanx, Disarticulation of, 336. Resection of the entire, 394. Pharyngeal Granulations, 577. Syringe, 579. Pharyngectomy, Lateral, 610. Pharyngotomy, Subhyoid, 608. Pharynx, Extirpation of, 610. Phenylic Acid, 23. Phimosis, Operation for, 792. Phlebotome, 283. Phlebotomy, 282. Phlegmonous Inflammation, Acute Septic, 59. Phosphorous Necrosis, 481, 492. Photoxyline, 37. Pine Wool, 42. Plane, Double Inclined, 140. Plaster of Paris Bandage, 115. Bandage Machine, 115. Bandage, Strips of, 113. Boots, 1 20. Box, 1 1 6. Corset, 119. Cotton, 115, 1 20. Cream, Preparing of, 113. Compresses, 114. Dressing, 113. Application of, 113, 117. Cracks in, 118. Drying of, 118. for Forearm, 122. Fenestrated, 126. Spiral Splint, 120. Interrupted, 127. Making of, 115. Removable, 119. Removing of, n8. Strengthening of, 121. Hemp Splint, 128. Knife, 118. Plate Dressing, 1 14. Plastic Hemp Splints, 120, 128. Saw, 119. Scissors, 1 1 8. Suspension Splints, 138. for Ankle Joint, 133. for Elbow, 130. for Knee Joint, 132. Made of Telegraph Wires, 134. for Wrist, 131. Tutor, 1 20. Plastic Felt, 1 10. Plaster of Paris Splints, 120. Splints, no. Pleura, Puncture of the, 657. Plexus Brachialis, Exposing of, 511. Plug, Grooved Wooden, 153. Plumbum Aceticum, 29. Pneumotomy, 664. Pole Pressure in Aneurism, 284. Polypi, Nasal, Removing of, 568. Polypus Forceps, 568. Porte- Caustiques, 207. Position of Apparatus, 50. of Dressings, 138. INDEX OF SUBJECT-MATTER 859 Elevated, 61. of the Patient, 49. of the Patient in Bed, 51. of the Patient for Cystostomy, 769. of the Patient for Operations on the Sacrum, 819. Posthioplasty, 793. Potash Silicate, 112. Dressing, 113. Potassium Permanganate, 30, 59. Potato Plates for Enterorrhaphy, 705. Precautionary Measures for Anaesthesia, 173. Premaxillary Bone in Maxillary Fissure, 548. Forcing back of, 549. Preparations for Anaesthesia, 173. Prepuce, Longitudinal Division of, 791. Removing, 793. Taxis of, 794. Prerectal Incision, 780. Pointed Arch Incision, 781. Principle of Economy, 547. Probe, Curved, for Ligations, 253. Olive-pointed, for the Urethra, 755. for Rectal Fistula, 810. Probes, Olive-pointed, for the Urethra, 755. Pr obi tigs, Endless (OZsophagus), 640. Process, Mastoid, Opening of the, 473. Proctoplasty, 806. Prolapsus Kecti, 812. Prostate Catheters, 750. Galvanocaustic Excision of the, 781. Catheterism in Hypertrophy of the, 802. Ligation of the Hypogastric Arteries, 782. Vasectomy of the, 802. Prostatectomy, Lateral, 781. Suprapubic, 780. Proslatotomy, 778. Protecting Basket, 52. Protective Dressing, 40. Silk, 44. Taffeta, 44. Protheses, ^TA. after Amputation of the Tongue, 604. for Cleft Palate, 558. for the Hand (Claw Hand), 334. for the Nose, 538. Protruding Portions of the Brain, 457. Pruning Shears, American, 656. Pseudoarthroses, Treatment of, 309. Puncture, 201. of the Abdomen, 672. of the Bladder, 768. Exploratory, of the Brain, 469. for Goitre, 625. of Hydrocele, 798. of Knee Joint, /|/]/| of the Pericardium, 665. with Permanent Aspirations, 659, 660. of the Thoracic Cavity, 657. Pupil, the, during Anaesthesia, 177. Purifying Operating Room, 2, 3. Sea and Gauze Sponges, II. Pus Basin, 20, 21. Pyloroplasty, 696. Pylorus, Dilatation of the, 696. Intussusception of the, 696. Resection of the, 685. Pyoctanine, 32. Quadriga, 80. Quilled Suture, 216. Quilt Suture, 216. for Tendons, 294. R Radial Flap, Incision for Disarticulation of Thumb, 340. for the Wrist, 344. Radical Operation of Antrum of Highmore, 486. for Femoral Hernia, 730. for Hernia, 722. for Hydrocele, 798. for Umbilical Hernia, 731. for Varices, 288. Radioscopy for Bullets, 221. Radius Splint, 98, 99, I IO. Railway Apparatus, 150. Ranula, Operation for, 604. Raphe Incision, Posterior, 805, 817. Raspatory, 314, 390. Ray Turn, 72. Reamputation, 333. Rectal Fistula, Operation for, 809. Probe for, 810. Scissors for, 811. Tube for Dressing in, 8l I. Rectal Specula, 804. Rectal Supporter, 8 1 2. Rectangular Intestinal Suture, 703. Rectopexia in Prolapse, 814. Rectoplication, 814. Rectostomy, Gluteal, 825. Rectotomy, External, 808. Internal, 808. Linear, 825. 86o INDEX OF SUBJECT-MATTER Rectum, Cancer of the, Operation for, 817. Operations on the, 803. Perineal Extirpation of the, 824. Prolapse of the, 812. Resection of the, 818. Strictures of the, 807. Reducing to Fragments a Calculus in the Blad- der, 782. Reef Knot, 211. Refrigerating Mixture, 63. Refrigeration as an Anaesthetic, 192. Regionary Analgesia, 194. Reimplantation of the Teeth, 589. Reindeer Tendons, 210. Relaxation Suture, 213. Releveur, 51. Renal Resection, 744. Region, Anatomy of the, 743. Renverse, 71. Replacing Resected Metacarpal Bone, 394. Resection of the Alveolar Process, 476. of Aneurism, 286. of the Ankle Joint, 421. for Anus Praeternaturalis, 713. of the Artificial Surface and Neck of the Scapula, 417. of the Astragalus, 428. of the Bones of the Forearm, 395. of the Bone Stump, Subperiosteal, 333. of Both Jaws, 481. of the Clavicle, 419. of the Coccyx, 806. of the Elbow Joint, 403. of the Fingers, 394. of Ganglion Gasseri, 507. of Gangrenous Hernia, 721. of Goitre, 630. of Hip Joint, 445. of the Ilium, 454. Indications for, 389. of the Intestine, 706. of Joints, 389. of the Kidney, 744. of the Knee Joint, 435. *of the Knee Joint Subperiosteal, 440. Knife, 391. of the Liver, 733. of the Lower Jaw, 487. of the Lung, 665. of the Manubrium Sterni, 653. for Prolapsus Recti, 813. for Urethra Strictures, 763. for Varicocele, 800. of Nasal Process, 572. of Ribs, in Empyema, 662. of Shoulder Joint, 411. of the Maxilla, 476. of the Maxillary Arch, 489. of the (Esophagus, 643. of the Olecranon, 409. of the Os Calcis, 429. of the Pharynx, 611. of the Pylorus, 685. of the Rectum, 818. of the Ribs, 655. of the Sacrum, 454, 819. of the Scapula, 418. of the Septum of the Nose, 580. of the Spleen, 739. of the Stricture of the Urethra, 763. of the Symphysis, 776. of the Toes, 420. of the Tunica Vaginalis, 800. of the Vas deferens, 802. of the Vault of the Cranium, 455. of the Vermiform Appendix, 711. of the Wrist, 399. Osteoplastic, of the Skull, 463. Osteoplastic, of the Sacrum, 823. Splints, 101, 133. Subperiosteal, 390. of the Elbow Joint, 405. of the Shoulder Joint, 413. of the Hip Joint, 446. of the Lower Jaw, 492. Temporary, of the Lower Jaw, 502. Lateral, of the Lower Jaw, 600. of the Malar Bone, 498. of the Nose, 575. of the Zygomatic Arch, 504. Resordn, 30. Respiration, Artificial, 184, 185. Unobstructed, 182. Rest, 61. Restoration of the Lost Eyelid, 514. of the Lips, 517. of the Nose, 530. of the Upper Lip, 525. of the Whole Lower Lip, 520. Retention, Bougie, 758. Catheter, 753. Retractor, 200. Improvised, 200. von Langenbeck's, 57. Retrobuccal Neurectomy of the Infra-maxillary Nerve, 502. INDEX OF SUBJECT-MATTER 86l Retrograde Dilatation (Oesophagus), 640. Retromaxillary Tumors, 482, 577. Retropharyngeal Abscesses, 610. Retropharyngeal Tumors, Osteoplastic Resection of Both Upper Jaws, 483. Reversion, Antiseptic, 59, 62. Tour, 71. (Turn of Bandage), 71. Rhineurynler, 243. Rhinoplastos, 580. Rhinoplasty for Saddle Noses, 541. French Method, 530, 537. Italian, 537. Models for, 531. Partial, 539. Rhinoscopy, Posterior, 565. Rib, Resection of a, 655. Ribs, Resection of, in Empyema, 662. Ring Forceps for the Bloodless Method, 234. Rod Splint, 143. Rolling up Bandage, 69. Rongeur forceps, 455. Root Forceps, 589. Screw, 589. Roots of Teeth, Extraction of, 588. Rotating Circular Saw, 460. Rotterine, 32. Rubber Ball, Double for Anus Prseternaturalis, 7I3- Bandages, 69. Blanket, 16. Constrictor for Bloodless Method, 227, 228. Constrictor for Disarticulaton of the Thigh, 383. Drainage Tube, 38. Ring for Resection of the Intestine, 704. Sacral Anus, 821, 825. Methods, 823. Sacrum, Resection of the, 454, 819. Saddle Noses, Correction of, 541. Protheses, 543. Sagittal Bandage, 74. Sailor Knot, 85. Salicylic Acid, 29. Salivary Fistula, Operation for, 607. Salol, 35. Sand, 42. Saphenous Vein, Long, Ligation of, 288. Saw for Amputation, 327. Sawdust, 42. Sawing off the Bones, 326. Scabbard used as a Splint, 166. Scabbard-shaped Trachea, 634. Scale for Urethral Instruments, 754. Scalpel, 198. Scapula, Partial Resection of the, 419. Resection of the, 417. Scissors, Angular, 201. Straight, 201. Scoliotic Curvature, Extension for, 152. Screw Bandage, 71. or Spiral Course, 83. Splints, 157. Tourniquet, 238. Wedge, 581. Scrotum, Division of the, after Amputation of the Penis, 797. Sea Sponges, Sterilization of, II, 12, 13. Sectio Alta, 770. Media, 777. Subpubica, 776. Section, Anatomical. of the Arm in front of Axilla, 349. at its Lower Third, 348. at its Middle Third, 348. of the Elbow Joint in the Line of the Con- dyles, 347. of the Forearm at its Lower Third, 344. at its Middle Part, 345. at its Upper Third, 345. of the Leg at its Lower Third, 375. at its Middle Third, 375. at its Upper Third, 376. Median, for the Bladder, 769. of the Thigh, in the Line of the Condyles, 376. at its Lower Third, 380. at its Middle Third, 381. at its Upper Third, 382. Secondary Antisepsis, 57. Suture, 40. Seegrass, 210. Septum, Longitudinal Division of the, 566. Resection of the, 580. Sequestrum Forceps, 313. Serous Suture for the Intestine, 702. Serpentine Tour, 71. Sharp Spoon, 203. Sheet Zinc, Sheets of, 102. Shirting Bandages, 45. Shock in Anaesthesia, 181. from Trephining, 461. Shot Suture, 216. 862 INDEX OF SUBJECT-MATTER Shoulder-blade, Resection of the, 418. Shoulder Cloth, 88. Shoulder Girdle, Disarticulation of, 353. Shoulder Joint, Disarticulation of the, 350. Resection of the, 411. Silk as Suturing Material, 210. Silkworm Gut, 210. Silver Wire for Laparotomy, 674. for Suture, 211. Sinus frontales, Opening of, 475. transversus, Opening of, 469. Sinuous Incision (Dieffenbach), 478. Skeletlierung of the Bone in Resection, 390. Skin, Drainage, Openings in the, 39. Grafting of, 298. Operations by forming Flaps of, 324. Operations on the, 298. Plastic Operations of, 301. Skull, Covering Defects of the, 464. Exposing Base of the, 577. Exploratory Perforation of the, 469. Instruments for measuring, 466. Opening of the, at the Place of the Squamous Portion of the Temporal Bone, 469. Sleeve, Sling made of, 159. Sleigh Apparatus, 149. Sliding forceps, Sharp-toothed, 617. Sling, Glisson's, 151, 158. Sodium, Chloride of, 31, 42. Soft Parts, Division of, in Amputations, 318. Soldier's Antiseptic Dressing Package, 170. Solutions, Antiseptic, 23. Solveol, 25. Sozoiodol, 35. Spanish Windlass, 238, 241. Spasmus Urethrez, 748. Sphagnum Pasteboard, 42. Sphenoidal Sinuses, Exposing of, 576. Sphincter otomy, Anterior, 817. Posterior, 805. Spica Coxa for the Hip, 83. (Cross Turn), 72. for the Hand, 77, 87. Humeri, 77. Manus, 77. Pedis, 82. Tour, 72. Spinal Cord, Cocainizing the, 195. ^ Spindle Ivory for Ligatures, 744. Spiral Bandage, 83. Spleen, Operations on the, 738. Splenectomy, 738. Splenoplexy, 739. Splint for the Arm at an Oblique Angle, 98. Bayonets used for, 166. Divided Iron Suspension, 136. Dorsal, for Leg, 134. for Radius, 98. Double, for Elbow, 136. Flat, made of Twigs arranged Side by Side, 161. Gooch's Flexible Wooden, 96. Material which can be cut, 97. Reed Mat for, 164. Tin for Temporary Dressing, 162. Trellis of Flower Pot, 161. of Small Branches Tied in Bundles, 161. Splints, 95. Plastic, no. of Tinned Wire, 103. of Tinned Sheet Iron, 101. Wire for Temporary Dressing, 162. of Wire Cloth, 103, 104. Splinter Forceps, 2 1 8. Sponge-holder, 184. Spoon-shaped Forceps for Lithotomy, 774. Spoon, Sharp, 58, 203. Spray, 2, 193. Spur in Anus Pneternaturalis, 712. Incision for Os Calcis, 430. Squamous Portion of the Temporal Bone, Open- ing Skull at, 468. Stapes, 82. Slaphylopharyngorrhaphy, 557, 591. Staphyloplasty, 557, 591. Staphylorrhaphy, 551, 552. Starch Bandages, 45, 103. Dressing, Application of, III. Divided, 112. Splints, in. Steel Nails for Fixation of Bones, 310. for Fixation after Resection of the Knee Joint, 437- for Fixation of Stump (Pirogoff's Method), 37i- Steel Pin for Disarticulation of the Thigh, 386. for Pirogoffs Operation, 371. Stella Dorsi, 80. Stellated Bandage for Chest and Back, 80. Sterilization of Dressings, 16. of Hands, 4. of Instruments, 7. of Sutures and Ligatures, 10. Sterilizer, Compact Portable (Beck's), 17. (Kny-Sprague) Perfection Surgical Dressing, 17, 18. INDEX OF SUBJECT-MATTER 863 Sterilizing Instruments by Boiling, 7, 8, 9. Sternocleidomastoid, Extirpation of the, 646. Tenotomy of the, 644. Sternum, Resection of the Manubrium of the, 652, 653. Stick Tourniquet, 241, 242. Stilet for opening Antrum of Highmore, 486. Stimulants in Chloroform Anaesthesia, 187. Stirrup Plaster of Paris Dressing, 127. Plaster of Paris Dressing for the Elbow, 128. Stomach, Establishing Fistulous Opening in the, through the Abdominal Walls, 680. Establishing Fistulous Opening between the, and the Small Intestine, 690. Opening of the, 680. Operations on the, 678. Pump, 635. Stomaioplasty, 526. Strangulation of Hernia, 717. Straw Mat for Splint, 163. Straw Splints, 163. Strengthening Plaster of Paris Dressing, 117. Stretcher Extension Dressing, 153. Stricture of Anus, 809. of CEsophagus, 639. of Urethra, 753. Extirpation of, 764. Divulsion of, 758. of Rectum, 807. Struma, Extirpation of, 626. Operation for, 625. Stump, Conical, 333. Subperiosteal Resection of the, 333. that can bear Pressure, 334. Styptics, 234. Subcutaneous Fracturing of Bones, 305. Infusion of Sodium Chloride, 280. Injection, 203. Osteoclasis, 305. Suture, 214. Sublimate, 2;, 35. Catgut, 10. as an Escharotic, 208. Gauze, 26. Silk, 210. Tablets, 27. Submaxillary Gland, Extirpation of the, 607. Subperiosteal Disarticulation, 334. of the Ankle Joint, 421. of the Elbow Joint, 405. of the Hip Joint, 446. of the Knee Joint, 435. of the Scapula, 418. Subperiosteal Resection, 390. of the Bone Stump, 333. of the Clavicle, 419. of the Shoulder Joint, 413. Sugar, 35. Suggestion as an Anaesthesia, 197. Sulcus Centra/is, Location of, 464. Sulfaminol, 35. Sulphurous Acid, 31. as an Escharotic, 208. Supination Splint, 101. Supporting Apparatus after Resection of the Elbow Joint, 410. Suprasymphysis Incision, 676. Surgeon's Gown, 5, 7. Knot, 212. Suspension Apparatus (von Bardeleben's) for Fractured Leg, 167. Apparatus (von Volkmann's) for Injured Arm, 167. Apparatus made of Stocking, 167. of Fenestrated Plaster of Paris Dressing, 62. Splint, 61. Splint Iron, 136. Stretcher, 52, 55. Suspensorium Mamma, 8l. Suture, 209. Bearer for Staphylorrhaphy, 552. Buried, 37, 214. Deep, 214. in Amputations, 331. of Arteries, 290. of Bone Surfaces, 310. of the Amputation Stump, 331. of Veins, Lateral, 289. Paratendinous, 293. Periosteal, 309. Removing a, 213. Twisted, 217. Sutures, Sterilization of, 10. Tying of, 211. Various kinds of, 209. SutttringCyst Wall to Skin in Divided Goitre, 626. Tunica Vaginalis to Skin in Hydrocele, 798. Sword, Holding the Knife like a, in making In- cisions, 198. Removing Broken-off Point of, by Chiselling, 45 6 - Sylvian Fissure, Locating, 464. Syncope, 181. in Chloroform Anaesthesia, 187. Syringe for Infiltration Anaesthesia, 196. for Injection, 202. 864 INDEX OF SUBJECT-MATTER T Bandage^ 73. T Splint, 101. Table Knife, Holding the Scalpel like a, in mak- ing Incisions, 198. Tamponade for arresting Hemorrhage, 242. of Dead Spaces, 674. of the Nares, 566. of the Trachea, 620. Tampon Canula, 621. Tamponing, 58, 60. Tannin, 243. Tarsectomy, 430. Cuneiform, 434. Tarsus, Osteoplastic Resection at the, 431. Resection at the, 430. Tartrate Antimony, Ointment of, 208. Taxis for Paraphimosis, 794. for Strangulated Hernia, 717. Teeth, Extraction of, 584. Accidents in, 588. Hemorrhage from, 588. Reimplantation, 589. Telegraph Wire, Splints made of, 103, 164. Temperature, Reduction of, 61. Temporal Incision, 471, 503. Temporary Constriction of the Tongue, 598. Detachment, Lateral, of the Lower Jaw, 600. of the Mammary Gland, 667. Division of the Clavicle by Sawing, 670. Dressings, 159. Enterostomy, 697. Ischsemia, 225. Resection, of the Lower Jaw, 502. of the Malar Bone, 498. of the Manubrium Sterni, 653. Nasal Process, 572. of Upper Jaw, 482. of the Zygomatic Arch, 504. Splints, 1 60. Temporo-maxillary Articulation, Resection of the, 491. Topography of, 491. Tendinoplasty, 295. Tendinorrhaphy, 292. Tendinous Anastomosis, 296. Tendons, Extension of Shortened, 296. Operations on the, 290. Tenotomy, 290. of Tendon of Achilles, 291. of Clubfoot, 292. Open, 291. Sternocleidomastoid, 292. Test of Carbolic Acid Poisoning, 25. of Iodine, 34. of lodoform, 34. Testicle, Extirpation of the, 801. Testudo, 72. Cubiti, 77. Genus, 72, 83. Tetraboric Sodium, 28. Thermocautery, 205. Thigh, Amputation of the, 372, 380. Disarliculation of the, 383. Peg Leg for Amputated, 335. Thoracic Cavity, Opening of the, 657. Thoracocentesis, 65 7. Thoracoplasty, 663. Thoracotomy, 66 1. Thorax, Anatomy of the, 656. Thumb, Disarticulation of, 340. Lateral Flap Incision, 341. Thymol, 30, 59. Thyroid Arteries, Diagram of, 632. Cartilage, Division of the, 612. Transverse Division of, 613. Gland, Separation of the, in Tracheotomy, 617. Operations on the, 625. Thyrotomy, Median, 6 1 2. Partial, 613. Transverse, 614. Tin Box, 64. for Sterilized Silk (Schimmelbusch's), 10. Splints, 101, 162. Tin Plate Splints, 101. Tirefond, 459. Tissue, Destruction of, 203. Raising Fold for External Incision, 200. Tobacco Pouch Suture, 215. Toe, Disarticulation of the Great, 355. Resection of the, 420. Toes, Disarticulation of, 354. Tolerance, Period of, in Chloroform Anaesthesia, 177. Tongue, Artificial, 604. Excision of a Wedge-shaped Portion from the, 597. Extirpation of the, 602. Spatula, 583. Temporary Constriction of the, 598. Tongue-holding Forceps, 183. Tonsillar Abscesses, 594. Tonsillothlipsis, 593. Tonsillotome, 592. Tonsillotomy, 591. Compressing Instruments for, 594. INDEX OF SUBJECT-MATTER 865 Tonsils, Excision of the, 590, Extirpation of the, 594. Tooth Forceps, 586. Key, 585. Topography of Arteries, 248, 250. of Carotid Artery, 254. of Femoral Artery, 269. of the Iliac Arteries, 269. of the Popliteal Space, 274. Torsion, Closing Arteries by, 246. of the Rectum, 813. Tourniquet Suspender, 207, 231. Trachea, Opening of the, 615. Scabbard-shaped Compressed, 634. Tamponade of the, 620. Tracheotomy, 615. Inferior, 620. in Struma, 635. Superior, 616. Transcondylary Amputation of the Arm, 348. Transfixion of the Thigh, 383. Transfusion, 277. Transperitoneal Nephreclomy, 745. Transplantation of Bone, 311. of Skin, 298. Transposing Hernial Sac, 729. Spermatic Cord in Operation for Hernia, 729, 731. Transverse Incision for Resection of the Ankle Joint, 428. Incision for Resection of the Wrist, 402. Traumaticin, 37. Trephine, 457. Trephining, 457. by means of Chisel and Hammer, 459. Triangle, Middledorpf's, 145. Triangular Cloth, 84, 85. Trichlor phenol, 30. Tricot for covering Surface, 119. Trigeminus, Topography of the, 495. Tripolith Dressing, 112. Trocar for Puncture, 201. for Puncture of the Bladder, 495. with Stop-cock, 658. for Thoracocentesis, 658. Trochanter, Osteoplastic Detachment of the, 452. Tropacocaine, 195. Trunk, Bandages of the, 80. Extension of the, 151. Trusses, 715. Tube for Dressing in Rectal Fistula, 811. Turn, Figure-of-8, 72. Turnip Plates for Enterorrhaphy, 705. 3K Turpentine, Oil of, 243. Tutor of Plaster of Paris, 119. Twisted Suture, 217. U Umbilical Hernia, Radical Operation for, 731. Truss for, 715. Umbilical Ring, Excision of the, 732. Union Bandage, 72. of Bone Fragments by Direct Fixation, 309. of Margins of the Wound, 209. of the Wound after Amputation, 331. Universal Forceps, 586. Upper Lip, Restoring of, 525. Uranoplasty, 555. in Perforations of the Palate, 590. Ureter, Exposing the, 746. Ureterotomy, 746. Urethra, Anatomy of the, 748, 749. Dilatation of the Female, 778. Foreign Bodies in the, 766. Operations on the, 747. Strictures of the, 754. Spasms of the, 748. Urethral Canal, Operations on the, 788. Fever, 758. Forceps, 767. Urethrometer, 755. Urethroplasty, 764. Urethrorrhaphy, 763. Urethrostomy, 763. Urethrotome, 759, 760. Dilating, 759, 760. Perineal, 797. Urethrotomy, External, 761. Internal, 759. Urinary Bladder, Extirpation of the, 776. Incision above the Symphysis, 769. Puncture of the, 768. Urine, Receptacle for, 785. Uvtda, Amputation of the, 595. Uvula Forceps, 566. Varices, Operation for, 287. Varicocele, Operation for, 800. Varix Bandage, 287. Vas Deferens, Resection of, 802. Vasectomy, 802. Vasotribe, 247. Vault of the Cranium, Resection of the, 455. Osteoplastic Resection, 463. Vegetations, Adenoid, 577. 866 INDEX OF SUBJECT-MATTER Veins, Lateral Ligature of, 649. Lateral Ligation of, 289. Venesection, 282. Vermiform Appendix, Resection of the, 711. Vienna Caustic, 207. Vinculum Carpi, 87. Vomer, Cuneiform, Excision of, 550. Vomiting during Anaesthesia, 179. Von Volkmanri's Suspension Apparatus for Injured Arm, 167. W Wandering Kidney, Fixation by Sutures, 745. War, Antisepsis in, 168. Washing out the Bladder, 753. Water Cushion, 51. Sterilizer, 21. Waterproof Materials, 44. Weapons used for Temporary Splints, 165, 166. Wedge-shaped Excision for Ingrown Nail, 302. Whalebone Tendons, 210. Wiping of the Blood, 19. Wire Breeches, 139. Cloth, 103, 162. Hook, for Tracheotomy, 618. Hook, Sharp, for Tracheotomy, 617. Loop, Galvano- caustic, 206. Saw (Gigli), 480. Sling, 167. Snare, Cold, 570. for Nasal Polypi, 570. for the Ear, 564. Splints, 162. Flexible, 103. Wood Cotton Sheets, 43. Wool, 43. Shaving Plaster of Paris Dressing, 121. Shaving Plaster of Paris Dressing for the Arm, 121. Shaving Plaster of Paris Dressing for the Forearm, 122. Shaving Plaster of Paris Dressing for the Leg, 124. Wooden Frame (Dobson's), 141. Laths Plaster of Paris Dressing, 128. Splints, 95. Flexible, 95. for Femoral Fractures, 146. for Temporary Dressings, 161. for the Wrist, 145. Wounds, Drainage of, 37. Dressings of, 40. Open Treatment of, 66. Retractors, 7. Treatment of, I, 159. Wrist, Disarticulation, 342. Elastic Extension for the, 154. Iron Arch Splint for the, 135. Plaster of Paris Suspension Splints for the, 133, 135- Resection of, 394. Total Resection of, 399. Zestokausis, 243. Zinc Chloride, Paste of, in Pneumotomy, 664. Oxide of, 34. Paste, 37. Probe, Flexible, 221. Zincum Sulphocarbolate, 31. Sulphate, 31. Zygomatic Arch, Temporary Resection of, 504. RENAL GROWTHS Their Pathology, Diagnosis, and Treatment. ByT. N. KELYNACK, M.D. (Viet.), M.R.C.P. (London), Pathologist, Manchester Royal Infirmary; Demonstrator and Assistant Lec- turer in Pathology, The Owens College, Manchester. 8vo. Cloth. With 96 illustra- tions. $4.00. " Dr. Kelynack has presented us with an interesting monograph upon a subject which, from the standpoint of the pathologist, is one of the highest interest, but of extreme difficulty. This is tiie first systematic treatise upon tumors of the kidney which has yet appeared in English, and the author's main pretension is ' to indicate the work already accomplished, and to suggest lines for further research.' This he has done exceedingly well. His interesting and suggestive book is a welcome addition to our meagre knowledge. It is beautifully published, and profusely illustrated with photographic reproductions which show gross appearances unusually well. There is an exhaustive bibliography." N. Y. Medical Journal. DISEASES OF WOMEN A text-book for students and practitioners, by J. C. WEBSTER, B.A., M.D. (Edin.), F.R.C.P., Ed. ; Professor of Gynaecology, Rush Medical College, Chicago ; late Demonstrator of Gynaecology, McGill University, Montreal, etc. Illustrated with 241 figures. Crown 8vo. $3.50. DISEASES OF THE HEART AND AORTA By GEORGE ALEXANDER GIBSON, M.D., D.Sc., F.R.C.P. (Edin.), Senior Assistant Physi- cian to and Lecturer on Clinical Medicine at the Royal Infirmary, Edinburgh, etc. With 2 10 illustrations. 8vo. 952pp. Cloth, $6.00; sheep, $7.00. " We have only words of praise for the admirable monograph which is destined to have a perma- nent place in medical literature. It is refreshing, in these days of ceaseless activity in the making of books, to come across one characterized by the completeness and comprehensiveness, the force- fulness of presentation, and the authoritative accuracy of this. Dr. Gibson has, besides having done a fine piece of literary and scientific work, rendered a distinct service to the profession, for which he is deserving of its gratitude and commendation." Philadelphia Medical Journal. MANUAL OF BACTERIOLOGY By ROBERT MUIR, M.D., F.R.C.P., Ed., University of Edinburgh ; Pathologist, Edinburgh Royal Infirmary; and JAMES RITCHIE, M.D., B.Sc., Lecturer in Pathology, University of Oxford, with 108 illustrations. Crown 8vo. New edition. $3.25. "A well-digested, well-arranged, and wisely and clearly expressed epitome of the medical phases of bacteriology and of the bacteriological phases of disease. The book is altogether excel- lent, and is really a modern epitome of a difficult and complex theme, a safe and stimulating guide to the student, and a boon to the busy practitioner." Science. THE MACMILLAN COMPANY 66 FIFTH AVENUE, NEW YORK CITY THE PRACTITIONER'S HANDBOOK OF TREATMENT; OR, THE PRINCIPLES OF THERAPEUTICS By the late J. MILNER FOTHERGILL, M.D., M.R.C.P., Foreign Associate Fellow of the Col- lege of Physicians of Philadelphia. Fourth edition. 8vo. Cloth. $5.00. Edited, and in great part rewritten, by WILLIAM MURRELL, M.D., F.R.C.P. The enormous progress in all departments of medicine during the last ten years has necessi- tated a thorough revision of the work. Considerable additions have been made, but Dr. Fothergill's original design, and, above all, his characteristic style, have as far as possible been preserved. In the Preface to the First Edition of this work, Dr. Milner Fothergill points out that it is not " an imperfect practice of physic, but an attempt of original character to explain the rationale of our therapeutic measures . . . and " is a work on medical tactics for the bedside rather than the examination table." The Lancet, in its obituary notice of Dr. Fothergill, states that " in his profession he exhibited great natural skill in interpreting the indications for treatment of disease, and in many cases of diffi- culty he would clear up the lines of treatment with a hand that was felt to be masterly. ... 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ATLAS OF EXTERNAL DISEASES OF THE EYE By A. MAITLAND RAMSAY, Ophthalmic Surgeon, Glasgow Royal Infirmary ; Professor of Ophthalmology, St. Mungo's College, Glasgow ; and Lecturer on Eye Diseases, Queen Margaret College, University of Glasgow. With 30 full-page colored plates, and 18 full- page photogravures. Sold only by subscription. 4to. Half morocco, gilt top. $20.00. " A work of great beauty. The illustrations are unrivalled, many of them masterpieces in their kind. The text gives connected descriptions of the diseases, supplementing the stages and phases not presented in the illustrations. It is prepared with the utmost care as to precision and compre- hensiveness of language. The book is written for the observing student, describing the etiology, symptomatology, and pathology of the diseases, but omitting the treatment. 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The book is a folio of 220 pages of letterpress, illustrated by 46 figures in black and white, of exquisite work- manship, representing macroscopically and microscopically those parts of the eye which we see with the ophthalmoscope. Bound up in the same volume are 47 large colored plates, containing 107 figures, beautifully drawn and colored, representing the fundus of the eye as seen with the ophthal- moscope. The discussion of the different conditions observed in the fundus bears evidence of very careful observation and research. The direct, concise, and lucid manner in which the descriptions of the various conditions are given is truly admirable." N. Y. Medical Record. " We venture the assertion that of all Ophthalmoscopic Atlases which have been produced in the last forty years, Mr. Frost's book is facile princeps. We wish that it might be found in the library of every physician and surgeon." PROFESSOR JAMES MOORE BALL, Editor The State Medical Journal and Practitioner. THE MACMILLAN COMPANY 66 FIFTH AVENUE, NEW YORK CITT IMPERATIVE SURGERY For the general practitioner, the specialist, and the recent graduate. By HOWARD LILIENTHAL, Attending Surgeon, Mt. Sinai Hospital, New York City, with numerous original illustrations from photographs and drawings. Cloth, Square 8vo, $4.00, net Half morocco, Square 8vo, $5.00, net. "Dr. Lilienthal has limited his work to what are ordinarily known as emergency operations ; that is, to the description of the technics of surgical procedure in conditions which demand active and immediate surgical intervention. It is in this respect that his book is unique in surgical literature. . . . "The chapters on abdominal surgery are especially complete, and, as we shall subsequently point out, are superbly illustrated. Under the description of each operation there is a full statement in detail of the after-treatment. This includes not only the care of the patient immediately following the operation, but his subsequent treatment, covering the time for removal of sutures and for change of dressings. The importance of this feature of the book is self-evident. " The text throughout is marked by earnestness and thoroughness. There is no ambiguity of pro- cedure ; the reader is not left to choose any one of several methods. The choice is made for him, and this is done in a literary style which is exceptionally lucid and concise. The impression that is made by reading the book is one of complete subordination of the unessential to the necessary, of a mass of detail which is clearly set forth and as clearly elucidated, and, finally, of an epitome of an individual surgeon's experience in a branch of the art which, perhaps, is the widest in the saving of life. " It is necessary to speak of the illustrations, which are not only numerous, but of a character rarely encountered in medical books. Many are made from photographs, others from drawings ; but the distinguishing feature which characterizes them is their remarkable clearness. . . . " It is scarcely too much to say that since Dr. Lilienthal's book fills an unoccupied place in sur- gical literature, , and because it is altogether scientific and modern, it must prove one of the suc- cessful books of the year." Extracts from an extended review in the New York Medical Journal, March 17, 1900. A MANUAL OF SURGERY By CHARLES STONHAM, F.R.C.S., Eng., Senior Surgeon to the Westminster Hospital; also Lecturer on Surgery and Clinical Surgery, and Teacher of Operative Surgery ; Surgeon to the Poplar Hospital for Accidents ; Examiner in Surgery, Society of Apothecaries, London, etc., etc. Fully illustrated. Three volumes. Cloth, I2mo, $6.00, net. Vol. I, General Surgery. Vol. II, Injuries. Vol. Ill, Regional Surgery. The work is notably modern, and as such much that is of historical interest merely has been purposely omitted, since it is undesirable to clog a work intended for immediate daily use with material which is out of date so far as actual practice is concerned and is readily accessible in printed works for those who would follow up the historic side of the subject. No better aid can be found for the student or for the general practitioner who wishes to review the very latest of the new discoveries in both the theory and method of treating surgically pathologi- cal conditions. THE MACMILLAN COMPANY 66 FIFTH AVENUE, NEW YORK CITY DATE DUE GAYLORD PRINTED IN U 8 A WO 500 ET6s 1901 Esmarch, Johann F A Surgical technic: a text-book on operative surgery MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664