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Full text of "A text-book of operative surgery, covering the surgical anatomy and operative technic involved in the operations of general surgery, written for students and practitioners"

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^t^^^d^^f^^l^j^i^/ . ^ ^ 








A TEXT-BOOK 



OF 



OPERATIVE SURGERY 

COVERING THE SURGICAL ANATOMY AND 

OPERATIVE TECHNIC INVOLVED IN THE 

OPERATIONS OF GENERAL SURGERY 

WRITTEN FOR STUDENTS AND PRACTITIONERS 



BY 

WARREN STONE BICKHAM, MJ>. and PharJM. (TttUne), MJ>. (Columbia). 

Sure^on to Manhattan StJte Hospital. New York : Assistant Instructor in Operative Surgery. College 

of Physicians and Surijtfons <Ci)lumhia University, New York; Instructor in Surtrerv, New 

York F'list-draJuate MeJical School and Hospital: Late Visitinjj Surpeon to Charity 

Hospital. New Orleans; l.afe Demonstrator of Operative Surgery. MeJiial 

Department. Tulane l!niversilv of L«»uisiana. New Orleans ; Fellow 

<}f the New York AiaJemx ot Medicine, etc. 



^^rconD CDttton. 
Witii 559 JiUudtratione. 



PHILADELPHIA. NEW YORK. LONDON 

W. B. SAUNDERS & COMPANY 

1905 



Set up, Electrotyped, Printed, and Copyri8:hted August, 190}. Revised. Reprinted, and 
Recopyrighted April, 1904 

Copyright, igcu, by W. B. Saunders & Company 
Registered at Stationers' Hall, London, England 



Reprinted. January, 1905 



P«E»S OF 
W B. •AUNOERa A COMPANY 



IN REVERED MEMORY OF MY FATHER 

Cbarled ^aeper Bicftbam 

WHOSE DAILY LIFE EMBODIED THE HIGHEST IDEALS OF CHRISTIAN 
PHYSICIAN, I LOVINGLY DEDICATE THIS WORK 



PREFACE TO SECOND EDITION. 



The exhaustion of the first edition of the present work within a space 
of six months, and the many complimentary notices which have appeared 
in reviews, have been deeply gratifying to the Author — who desires to ex- 
press his appreciation of these evidences that his efforts to present, in an 
acceptable form, a Text-l)ook of the Operative Technic involved in the 
Ol)erdtions of General Surgery have been kindly received. 

Too brief a time has elapsed since the apj^earance of the original edition 
to make any radical revision necessary — but advantage is taken of the neces- 
sity for a second edition to correct some typographical errors, and to introduce 
a few minor changes in the text. 

W. S. B. 

lo East 58TH Strket, 
Nkw York City. 



2 PREFACE. 

In the preparation of these pages, obligations are hereby gratefully and 
fully acknowledged to the writings of many well-known Surgeons in the 
standard works of the day upon Operative Surgery, and in the current surgical 
literature, whose pages have been freely consulted — and to the work of many 
Surgeons, here and abroad, whose operative technic it has been the privilege 
of the author to witness — and to writings upon Anatomy. 

The name of the deviser of an operation is given, in brackets, after the 
title of the operation, wherever known to the author. Where slight de- 
partures from the manner of doing the operation as performed by its originator 
occur, such omission is accidental — or, where the original description is 
ambiguous, the operation is given as it seems to be interpreted by the majority 
of Surgeons. 

Appreciation of encouragement shown during the preparation of the 
manuscript is gratefully acknowledged to Professors Bull, Dennis, Hal- 
sted. Hartley, Matas, Richardson, Senn, Weir, and Wyeth — and to my 
co-workers, Doctors Peck, Schmitt, and Taylor, in the Department of Op- 
erative Surgery at the College of Physicians and Surgeons — and to Doctor 
Gessner, my former co-worker in the Laborator}' of Operative Surgery 
of Tulane University — and to Doctot^ Armstrong and LeBeuf — and to 
other friends whose kindly words have aided and lightened the work of 
preparation. 

The author feels deeply indebted to Miss Eleanora Fr\', who has draNN-n, 
under his close directions, all the illustrations for the book, during mq.ny 
weeks of conscientious work and unflagging interest — the large majority of 
the five-hundred and fifty-nine illustrations being original, and the remainder 
so largely modified as to be, in many instances, practically new pictures. 

I wish to thank the Publishers for the courteous consideration they have 
shown my every expression of wish throughout — for their interest in the 
manuscript — and for the quality of their finished work. 

I desire to express my high valuation of my Wife's ever-ready and untiring 
aid in all the proof-readings of the manuscript during the many months 
of its preparation. 

The imperfections of the present work are ver>' fully realized — and the 
author will be glad to receive all criticisms which may tend to the bettering 
of the text and illustrations. 



WARREN STONE BICKHAM. 



lo East 58TH Street, 
New York City. 



CONTENTS. 



PART I. 
THE OPERATIONS OF GENERAL SURGERY. 



CHAPTER 1. 
OPERATIONS UPON ARTERIES. 

I Ligation of arteries — General consideratiufis, 17. 

II. Surgical Anatomy and Ligation of following Arteries of Head and Neck: — 
Innominate, by angular innsion. Molt's operation, j6 — By oblique incision, aS — By 
partial bony resection, 29 — By partial bony resection, Bardenheucr's ofseration, 30-^ By 
splitting of manubrium sterni, 30 — Common carotid, above omohyoid, 33 — Below omo- 
hyoid, 34 — Elxternal carxjtid, below digastric. 35 — Above digastric, behind ramus of jaw, 
36 — Superior thyroid, 37— Lingual, near origin, 38 — Beneath hyoglossus, 38 — Facial, 
near origin, 40 — Over inferior maxilla, 40 — Occipital, near origin, 41 — Behind mastoid 
process. 41 — Posterior auricular, near origin, 42 — Behind ear, 43 — Temporal, just above 
jiygoma^ 4^— Internal maxillary (surgical anatomy), 44 — Trunk of middle meningeal, 
in cMfuum, through trcphine-ofx^ning exposed by cur\'cd oblique incision. 47— Anterior 
branch of middle meningeal, through ircphine-opcning exposed by horseshoe incision, 
48^ro&lerior branch of middle meningeal, through trephine-opening exposed by horse- 
shoe iJtrkion, 40 — Internal carotid, near origin, 50 — First part of right subclavian, by 
angular indsioo, 5a — First part of left i^ubclavian, by angular incision, 53 — Second part 
of subclavian, 53 — Third part of subclavian, 54 — Vertebral, near origin. 56 — Inferior 
thyroid, 57 — Transvrrsalis colli, at outer margin of slernomastoid, 58— Supras<'apular, 
at outer margin of sternomastoid, 59. 

in. Surgical Anatomy and Ligation of followTng Arteries of Upper Extremity and 
Thorax: — Internal mammar)', in second intercostal space, 60 — First part of axillary, by 
rtirvrd transverse incision below clax-icle. 62— Third part of axillary, 63— Subscapular 
along fiosterior axillary fold, 64 — Brachial, in mid-arm. 65 — At bend of elbow, 66 — 
Radial, in upper third, 6<>— In middle third, 70 — In lower third, 70— On kick of hand, 
71 Deep palmar arch, 72 — Ulnar, in middle third. 74— In lower third. 76 — Superficial 
palmar arch, 76 — Intercostal, by intercostal incision. j(f — Intercostal, by partial sub- 
pcrio«tcal excision of rib, by Hartley's method, 78. 

IV, Surgical Anatomy and Ligation of following Arteriess of Trunk;— Abdominal 
aorta, by transperitoneal method. 80— By retroperitoneal method, 81 — Common iliac, 
by retroperitoneal method. Jij— By transpK?ritoneal method, 84— Internal iliac, by retro- 
perilonra) method, 84 — By transpi-ritoneal method, 84 — Obturator, at th\Toid foramen, 
85— Sciatic, upon buttfxk, 86 — Internal pudic, upon buttock, 8S— In perineum, 88— 
Gluteal, on buttock, 80 — External iliac, by retroperitoneal method, Qo — By trnnspcri- 
lonrat melhiMi, qj — Deep epigastric, near origin. Q3. 

V. Surgical Anatomy and Ligation of following Arteries of Lower Fxiremity-^ 
Common fe,T»oral. at base of Scarpa's triangle. 05— Profunda femoris. near origin. 07 — 
Suj*rfnri*l femoral, at apex of Scarpa's triangle, 07— In Hunter's canal, q8— PopUteal, 
in upper fwrt of popliteal sfmce, from Ijehind, 100 — In upper part of popliiral space, from 
iODer tide of thigh, Jobert's operation, 100 — In lower part of popliteal space, 101 — 

3 



4 CONTENTS. 

Antrrior tibial, in upper third, 104 — In middle third, 105 — In lower third, 105 — Dorsalis 
pedis, just below ankle-joint, 107 — Posterior tibial, in upper third, above peroneal branch, 
loq — In middle third, 109 — In lower third, no — Behind internal malleolus, in — Pero- 
neal, in middle of leg, 112 — External plantar, at origin, 1 14 — In sole of foot, 1 15 — Internal 
plantar, at origin, 115 — In sole of foot, 115. 

VI. Temporary ligation, 116 — Intermediate ligation, 117 — Arteriorrhaphy, 117 — 
Arterial forciprcssurc, 119 — Arteriostrepsis, 120 — Ligation for radical cure of aneurism, 
1 ao— ( )i>('ration for radical cure of aneurism based ujwn Arteriorrhaphy, Matas*s method, 
lai — Other o}>erations for radical cure of aneurism, i2:j — Wyeth's treatment of vascular 
angeiomata, 135. 

CHAPTER II. 

OPERATIONS UPON VEINS. 

Phlelx)tomy, 126— Phleborrhaphy, 126 — Lateral ligation of veins, 127 — Transverse 
ligation of veins, 128 — Temporary ligation of veins, 128 — Venous ligation en masse, 
I ag— Venous forcipressure, 129 — Phlcbostrepsis, 129 — Acupressure of veins, 129 — 
PhlelKTtomy, 129 — Intravenous infusion of normal salt solution, 130. 

CHAPTER III. 

OPERATIONS UPON LYMPHATIC GLANDS AND VESSELS. 

Surgical anatomy of thoracic duct, 132 — Suture of thoracic duct, 132 — Ligation of 
thoracic duct, 133- -Surgi<al anatomy of antero-latcral aspect of neck, 133 — Removal 
of lymphatic glands of neck, 135 — Surgical anatomy of axillary region, 138 — Removal of 
axillary lym|>hatir glands, 130 -Surgical anatomy of Scarpa's triangle, 139 — Removal 
of inguinal lymphatic glands, 140. 

CHAPTER IV. 
OPERATIONS UPON NERVES, PLEXUSES. AND GANGLIA. 

I. Neurotomy! 141 Neurectomy, 142 — Neurectasy, 142 — Nerve-avulsion, 143 — 
Neurorrhaphy, 144 — Neuroplasty, 147 -Nerve-grafting, 149 — Operation for relief of 
nerve ((tmpre.ssed l»y Iwny or fihnms cicatricial tissue, 151 — Intraneural infiltration for 
regional anesthesia, 151 - I'ara-neural infiltration for regional anesthesia, 153. 

n. Surgical Anatomy and K.\[K»surr of following Ner\'es and Ganglia of Head and 
Nf< k: (Jasserian ganglion and thrcr divisions of fifth, by intracranial exposure, Hartley- 
Kraiise method, 155 Same, by extra* ranial exiH)sure, Rose's method, 158 — Supraorbital, 
nt su|>raor)>ital foramen, if>o Meckel's ganglion and superior maxillary, by antral route. 
CarncK-han's <iiMTation, 161 Same, by orbital route, 162 — Same, by pterj'go-maxillary 
route, Hraun-LiH'sscn oprrati«>n, i<>2 -Infraorbital, at infraorbital foramen, 163 — Infe- 
rior maxillar>' nrrvr and «)ti« and submaxillary ganglia (surgical anatomy), 164 — Inferior 
maxillary, at foramen ovale-, 1^4: or superior maxillary, at foramen rolundum, Mixter's 
o|)eration, 164 Inferior denial, in mouth, Paravicini's intrabuccal method, 1A6 — Through 
ascending ramus of inferior maxilla, if)7 At mental foramen, from within mouth, 168 — 
Lingual (gustatory) of inferior maxillary, in mouth. 168 — Facial, in front of mastoid 
prrxess, Kaum's fiperation, i<h) -.Spinal accessory, at anterior border of sternomastoid, 
170 Occipitalis major, beneath (omplexus. 1 7 1 — Posterior divisions of first, second, and 
third (ervical nerves. Keen's operation, 171 Hrachial plexus, in neck, 172. 

III. Surgi<al Anatomy and Exinisure of following Ner\es of Upper Extremity and 
Thorax: Cinumllex, on bark of arm, 173 -Musculocutani^ms, in upper part of arm, 
173— Median, in middle of arm. 174 At Iw'nd of elUw. 174— Ulnar, above middle of 
arm, 175 Just alH)ve internal condyle i»f humerus. 175 — Musculospiral, below middle 
of arm. lytt- K;i<lial, at oriKin. 177 Posterior interosseous, at origin, 177 — Intercostal 
iM'tween angle and middle of rib, 178. 

1\'. Surgical Anati»mv and ExiK»sure of following Nerves of Lower Extremity: — 
Anterior crural, below Poupart's ligament. 178 -Obturator, at thyroid foramen, 179 — 
Superijir gluteal. u|M)n buttotk, i7«j Pudii . u|M»n buttcnk. 170— Great .sciatic, at lower 
bonier of gluteus niaxiinus, 170 Internal Popliteal, at lower part of |K)pliteal space, 180 
— I*osteri<jr tibial, Iwtween origin and ankle, i8o — Behind internal malleolus, 181 — 



CONTENTS. $ 

External popliteal (peroneal)^ behind tendon of bicepSi i8i — Anterior tibial, near origin, 
tS*. 

V. Surgical Anatomy of Cervical Sympathetic Ganglia and Cord, i8a — Total ex- 
cision of cervical sympathetic gangUa and cord, Jonnesco's operation, 183. 

CHAPTER V. 
OPERATIONS UPON BONES. 
Osteotomy in general, 184— Linear trsttiJtomy. by subcutaneous method, 185 — 
linear osteotomy, by open method, 187— Cuneiform osteotomy. 1 8 7— Operations for 
recent or ununited fractures, in general, 188 — ()|)era(ion5 for recent or ununited fracture*, 
by resection of ends of bones, with retention of roaptatrdl ends by immobilizing splints, 
i8q — Same, by wiring of ends of bones, with or wilhuut resection, iqi — Same, by suturing, 
with or without resection, ig^ — Same, by nailing, pegging, or screwing ends of bones, 
with or without resection. 103 — Same, by Parkhiirs clamp, 194 — Other n|>erations for 
recent or ununited fractures, 195 — Operation for recent nr ununited fracture of patella, 
bfV Stimson's method of mediate suture, 107 — Same, by wiring or suturing, ig8 — ^Ii[>cra- 
tion for recent or ununited fracture of olecranon, by wiring or suturing, aoo — Sequcs- 
trotomj. 20 r — Osteoplasty aoa — Excision, 203. 

CHAPTER \ f 
OPERATIONS UPON JOINTS. 
Arthrolomy. 204 — Puncture of joints, ^04 — Erasion, or arthrectomy, 204 — Excision 
«o6. 

CHAPTER Vn 
OPERATIONS UPON MUSCLES. 
Myolomy 207— MyorrhaphVf 307— Muse k-k'nglhening, loS. 

CHAPTER Viri 
OPERATIONS UPON TENDONS AND TENDON-SHEATHS. 
Tenotomy. 211 — Tenorrhaphy, 313 — Tendon-lengthening, a 16 — Tendon-shortening, 
a*a— Tendon-grafting. 221— Repair of ruptured or divided tendon-sheaths, 223 — Exci- 
uon of trndon-sheaths, 224 

CHAPTER IX 

OPERATIONS UPON LIGAMENTS. 

Syndeimotomy, 226— Suturing of ligaments, 226— Lengthening of ligaments, 226 
— SlMftening of ligaments. 226. 

CHAPTER X 
OPERATIONS UPON FASCLE. 
Fuciolomy, 737. 

CHAPTER XT. 
OPERATIONS UPON BURSiE. 
Puncture of burse 228 — Incision of bursic, 228 — Excision of burs*-, 228. 



CHAPTER XII. 
AMPUTATIONS AND DISARTICULATIONS. 
I. General considrrntionfi. 22Q^Ttie general tcchnic in amputating, 332 — Loca- 
tion of line of bf)ne->etti«(n, or disartirulatirm. J32 — Location of limits of skin incisions. 
2J3 — Incision of skin and fascia, 234— Freeing of skin and fascia, 237 — Retraction of 
tkin and fascia, 238 — Division of muscles in circular metho<ts of amputation 23(^— Divi- 



6 CONTENTS. 

sion of muscles in flap methods of amputation, 242 — Freeing and retracting of muscles, 
246 — Making musculo-periosteal, or periosteo-capsular, covering for end of bone, 247 — 
Retraction of soft parts preparatory to sawing bone, 250 — Sawing bone or bones, 251 — 
Removing splintered bone, 252 — Ligating arteries and veins, 253 — Treatment of nerves, 
tendons, and tags of muscle, fascia, and skin, 255 — ^Trimming of flaps, 255 — Re-ampu- 
tation for improperly made flaps, 255 — Adjustment and suturing of musculo-periosteal, 
or periosteo-capsular, covering, 255 — Quilting of muscles, 256 — Drainage, 258 — Suturing 
of stump, 258 — Dressing of wound, 259 — Removal of dressings, 259. 

II. The methods of amputation, 259 — The evolution of amputation methods, 259 — 
Summary of amputation methods, 261 — Circular methods of amputation, 261 — Ordinary 
circular amputation (Amputation circulaire infundibuliforme), 261 — CuflF method of 
circular amputation (Circular amputation k la manchette), 263 — Modified circular ampu- 
tation (Mixed method), 264 — Oval method, 265 — Racket method, 266^Flap methods of 
amputation, 267 — Amputating by single flap of skin and muscle, 267 — By single flap of 
skin, 269 — By equal flaps of skin and muscle, 269 — By equal flaps of skin, 270 — By 
unequal flaps of skin and muscle, 271 — By unequal flaps of skin, 272 — By unequal rec- 
tangular flaps of skin and muscle (Teale's method), 272 — Elliptical method, 273 — Irregular 
methods of amputation, 275 — Selection of amputation method, 275. 

III. The amputation stump, 276 — Qualities of a good stump, 276 — Characteristics 
of a bad stump, 277 — Conditions influencing vitality of stump, 277 — Contractility of 
tissues of stump, 277 — Position of stump cicatrices, 278 — Function of amputation-stumps, 
278. 

IV. Surgical Anatomy, Surface Form and Landmarks, General Surgical Consid- 
erations and Methods in Amputations and Disarticulations about the Fingers: — Ampu- 
tation through last phalanx, by palmar flap, 283 — At second phalangeal joint, by palmar 
flap, 284 — Same, by short dorsal and long palmar flaps, 284 — Through second phalanx, 
by palmar flap, 285 — Same, by short dorsal and long palmar flaps, 285 — At first phalangeal 
joint, by palmar flap, 286 — Same, by short dorsal and long palmar flaps, 286— Through 
first phalanx, by palmar flap, 286 — Same, by short dorsal and long palmar flaps, 287 — 
At metacarpo-phalangeal joints of fingers in general, by oval method, 287 — Same of 
thumb, by oval method, 289 — Same of thumb, by oblique palmar 'flap (Farabeuf), 290 — 
Same of index, by externo-palmar flap (Farabeuf), 290 — Same of little finger, by interno- 
palmar flap (Farabeuf), 291. 

V. Same, in Amputations and Disarticulations about the Hand: — Amputation of 
finger, in general, with part of its metacarpals, by racket method, 295 — Of thumb with 
part of its metacarpal, by racket, 296 — Of little finger with part of its metacarpal, by racket, 
296 — Of two contiguous inside fingers, with part of their metacarpals, by racket, 296 — 
Of three innermost fingers, with parts of their metacarpals, by racket, 296^Same, by 
equal dorsal and palmar flaps, 297 — Of all fingers (except thumb) with parts of their 
metacarpals, by anterior ellipse, 297 — Of an inner finger, with its metacarpal, by racket, 
297 — Of index, with its metacarpal, by racket, 298 — Of little finger, with its metacarpal, 
by racket, 298 — Of thumb, with its metacarpal, by racket, 298 — Of two contiguous inside 
fingers, with their metacarpals, by racket, 299 — Of three inside fingers, with their meta- 
carpals, by racket, 299 — Of three inner fingers, with their metacarpals, by equal dorsal 
and palmar flaps, 300 — Of all fingers (except thumb) with their metacarpals, by anterior 
ellipse, 301 — Of fingers and thumb, at carpo-metacarpal articulation, by palmar flap, 302. 

VI. Same, in Disarticulations about the Wrist-joint: — Disarticulation at wrist-joint 
by anterior ellipse 304 — By palmar flap, 305 — By external lateral, or radial, flap (Du- 
bnieil's method), 306. 

VII. Same, in Amputations about the Forearm: — Through lower third, by modified 
circular, 309 — By circular (cuff variety), 310 — Through upper two-thirds, by equal ante- 
rior and posterior flaps, 311. 

VIII. Same, in Disarticulations about Elbow-joint: — Disarticulation of elbow-joint, 
by anterior ellipse (Farabeuf), 314 — By posterior ellipse, 315 — By long antero-internal 
and short postero-external flaps, 316. 

IX. Same, in .-imputations about the Arm: — Amputation through lower third, by 
modified circular, 320 — Through upper two-thirds, by long anterior and short posterior 
flap>s, 321 — Through surgical neck, by single external flap, 322. 

X. Same, in Disarticulations about the Shoulder-joint: — Disarticulation at 



CONTENTS. 7 

shoulder- joint by anterior racket (Spence's operation), 327 — By external racket (Larrey's 
operation), 329 — By external or deltoid flap, 330, 

XI. Amputation of I'pper Limb, together with Scapula and part of Clavicle, by 
ontero-inferior (or pertoro-axUlarv) and postero-superior lor cervico-scapular) flaps 
(Berger's operation), 331. 

XII. Surgfical Anatomy, Surface F"orm and Landmarks, General Surgical Consid- 
fAmtions, and Methods in Amputations and Disarticulations about the Toes: — Amputa- 
tion through last phalanx, by plantar flap, 336 — At second phalangeal joint, by plantar 
flap, 337 — Through second phalanx, by plantar flap, 338 — At Erst phalangeal joint, by 
oval, 338 — Through first phalanx, by oval, 33Q — Same, by circular, 340 — At mctalarso- 
phalangeat joints of toes in general, by oval method, 340 — At same of great toe, by internu- 
plantar flap (Farabeuf), 341 — At same of little toe, by externn-dorsal flap (Farubcuf), 
341 — Disarticulation of two adjoining tcjes at mctatarso-phalangcal joints, by oval method, 
342 — Of toes en masse, at melatarso-phalangeal joint, by equal short dorsal and plantar 
flaps. 34i. 

XIII. Same, in Amputations and Disarticulations abcmt Frxit. — Amputation of all 
toes through the metatarsus, by short dorsal and long plantar fla))s (Metatarsal amputa- 
tion), 348 — Disarticulation of toe, with its entire meliilarsai, by racket method, 350 — Of 
grrai toe and its metatarsal, by racket, 350 — Of little toe and its metatarsal, by racket, 
35a — Of two or three contiguous toes with their entire metaur*als, by oval or racket, 353 
— Of all toes, at larso-metatarsal joints, by shc^rt dorsal and long plantar flaps (Lisfranc's 
operation), 353 — Of all toes, at tarsometatarsal joints, with sawing off of end of internal 
cuneiform, by short dorsal and long plantar flaps (Hey's operation), 354 — Of anterior 
part of foot at medio-tarsal joint, by short dorsal and long plantar flaps (Chopart's o{>era- 
tioo), 355 — Of foot at astragalo-st aphoid and .-Lstragalo-calcaneal joints, subastragaloid 
culation. by large interno-plantar flap (Farabeuf), 356 — Of foot at astragalo- 
phoid and astragalo-takancal joints, subastnigaloid disarticulation, by heel*flap, 358. 
XIV. Same, in Disarticulations about Ankle-joint:— Disarticulation of fwjt at 
finlde'joint, with removal of malle<ili and articular surface of tibia, by heel-flap (Symc's 
operation), 360 — Di>articulation of fot)t at ankle-joint, with removal of malleoli, articular 
surface of tibia, and anterior part of os calcis, by heel-flap (Pirogoff's osteoplastic ampu- 
tation), 361. 

XV, SSame, in .\mputation about the Leg: — Through supramalleolar region, by 
oblique elliptical incision (Guyon's supramalleolar operation), 365 — Through lower third, 
by large posterior and small anterior flaps (Farabeuf). 365 — Through middle third, by 
long posterior and short anterior flaps (Hey's operation), 367 — Through upper third, by 
large external flap (FarabeuH, 368— Same, by bilateral hooded flaps (Stephen Smith's 
method), 370, 

XVI. Sanne, in Disarticulations about the Knee-joint: — Disarticulation at knee- 
joint by bilateral hocxled flaps (Stephen Smith), 374- 

XVIL Same^ in Amputati<:>ns abcjut the Thigh: — Through condyle* of femur, 
tranwondyloid amputation, by shorter anftrior and longer jxjsterior flaps (Lister's modi- 
bcation of Canien's transcondyloid of^eration), 370 — Just alx>ve rondyle^ of femur, with 
(putting of patella ( supracondyloid osteoplastic amputation of Gritti-Stokes) by longer 
Anterior and shorter posterior flaps, 380 — Through lower third of thigh, by oblique cir- 
tr method, 38j^Through thigh in general, by long anterior and short posterior flaps, 
-Same, by equal anterior and fxjsterior flaps, 3S4 — Through thigh just below trw- 
Qteni, by external oval methr^d, 386. 
,XVIII S»me, in Fxrisions about the Hip-joint:— Disarticulation at hip-joint by 
b'« method, 390 — By external racket, 392 — By anterior racket, 303 
XIX. Osteoplastic- Amputations, 394. 



CHAPTER XIII 

EXaSIONS, 
I. General Considerations, 397 — Excision by «iub|>ericiatral method, 398 — Exri- 
I by op^n meth«id, 401 

IL SuxfiiaU Anatoiny, Surface Form and Landmarks. General Surgical Considem- 



8 CONTENTS. 

tions, and Methods in Excisions about the Fingers: — Excision of terminal phalanges, by 
U-shaped incision, 403 — Of second phalangeal joints, by two lateral incisions, 403— Of 
second phalangeal joint of index, by dorso-extemai incision, 404 — Of second phalangeal 
joint of little finger, by dorso-internal incision, 405 — Of second phalanges of fingers in 
general, by dorso-lateral incision, 405 — Of second phalanx, by dorso-cxtemal incision, 
for index-finger, 405 — Of second phalanx of little finger, by dorso-internal incision, 406^— 
Of first phalangeal joints, by same methods as for second phalangeal joints, 406 — Of first 
phalanges of fingers in general, 406. 

III. Same, in Excisions about Hand: — Excision of metacarpo-phalangeal joints 
o! fingers, in general, by dorso-lateral incision, 406 — Of metacarpals, in general, by dorsal 
incision, 407 — Of metacarpal of thumb, by dorso-extemal incision, 408 — Of metacarpal 
of little finger, by dorso-internal incision, 408. 

IV. Same, in Excisions about Wrist-joint: — Excision of wrist by radial and ulnar 
dorsal incisions (Oilier), 409 — Same, by single dorso-radial incision (Boeckel-Langen- 
beck), 410 

V. Same, in Excisions about Bones of Forearm : — Total excision of ulna, by long 
posterior incision, 41 1 — Same, of radius, by long externo-dorsal incision, 412. 

VI. Same, in Excisions about Elbow-joint: — Excision of elbow-joint, by posterior 
median incision (Langenbeck), 413 — Same by posterior bayonet-shaped incision, with 
or without an additional short vertical ulnar incision (Oilier), 415 — Excision of sui>erior 
radio-ulnar articulation, by posterior vertical incision, 416. 

VII. Same, in Excisions about Humerus: — Excision of humerus, by long external 
incision, 417. 

VIII. Same, in Excisions about Shoulder- joint and vicinity: Excision of shoulder- 
joint, by anterior oblique incision, 418 — Total excision of clavicle, by long axial incision. 
420— Total excision of scapula, by straight incisions along spine and vertebral border, 
forming superior and inferior flaps, 42? . 

IX. Same, in Excisions about the Toes: — Excision of terminal phalanges, 423 — 
Of second phalangeal joints, 423 — Of second phalanges, 423 — Of first phalangeal joint. 
423 — Of first phalanges, 424. 

X. Same, in Excisions about Foot: — Excision of metatarso-phalangeal joints, 424 
— Of metatarsals, 424 — Of astragalus, by external curved incision, 424 — Same, by ex- 
ternal angular and internal curved incisions, 425 — Of os calcis, by horizontal cur^•ed and 
vertical incisions, 427. 

XI. Same, in Excisions about Ankle-joint: — Excision of ankle-joint, by trans- 
versely curved external incision (Lauenstein), 428 — Same, by external curved and internal 
angular incisions, 429. 

XII. Same, in Excisions about Bones of Leg: — Total excision of tibia, by internal 
vertical incision, 430 — Total excision of fibula, by posterior vertical incision, 431 — Total 
excision of patella, by vertical incision, 432. 

XIII. Same, in Excisions about the Knee-joint: — Excision of knee-joint, by curved 
transverse anterior incision, 433. 

XIV. Same, in Excisions about Femur: — Excision of parts of diaphysis, by external 
vertical incision, 435. 

XV. Same, in Excisions about Hip- joint: — Excision of hip-joint, by external 
straight incision (Langenbeck), 436 — Same, by anterior straight incision (Barker), 438 — 
Same, by posterior angular incision (Kocher), 439. 

XVI. Same, in Excisions about Head: — Excision of superior maxilla, by median 
incision (Fergusson), 441 — Of temporomaxillary articulation, by angular incision, 444 — 
Of inferior maxilla, by single incision along inferior and posterior borders, 445. 

XVII. Same, in Excisions about Trunk: — Excision of entire rib and costal cartilage 
by parallel incision over center of rib, 447 — Of coccyx, by posterior median incision, 448. 
XVIII. Osteoplastic Resection of Bones and Joints: — Of anterior tarsus and tarso- 
metatarsus, by internal and external dorso-lateral incisions, 449 — Of mid-tarsus, by ex- 
ternal transverse curved incision, 450 — Of posterior tarsus, by external curved incision, 
451 — Osteoplastic resection of foot, by transverse upper and lower, and oblique 
lateral incisions (Wladimiroff-Mikulicz operation), 452 — Total excision of tarsus, or 
osteoplastic resection of foot, by extemo-lateral curved incision (modification of 
Wladimiroff-Mikulicz operation), 453 — Osteoplastic resection of superior maxilla, by 



CONTENTS. 9 

vertical and horizontal incbion*, 454 — Chondro-plastk rejection of nasd cArtiUges, to 
rzpofie nose and anterior nasopharynx by nasal route, by transverse incision (Rouge), 455 
— Osteoplastic resection of superior maxilla, to expose nasopharynx by palatine route, by 
transverse and median incisions (Annandairt, 455 — Same, to expose nasopharynx by 
majdllary route, by two senulunar incisions (Langenberk), 456 — Osteoplastic resection 
of inferior maxilla, to expose structures in front of fauces through dixided symphysis, by 
median incision, 457. 



PART If. 
THE OPERATIONS OF SPECIAL SURGERY. 



CHAPTER I. 

OPERATIONS UPON THE HEAD. 
I. Cranio-ccrebral Region: — Surgical anatomy of scalp, skull, and brain, 459 — 
Chief cranial landmarks, 463 — Cranio-ccrebral topography, 464 — Localization of brain 
areas, 469 — Chipault's method of cranio-t crebral locatizaUon, 472 — ^Reid'a method of 
same, 476— Chiene's method of determining Rolandic fissure, 478 — General surgical 
coQsidcrations in cranio-cerebral operations, 478 — Instruments, 480 — Craniotomy, in 
general, 480 — Trephining, or circular craniotomy, 4&1 — OsieoplasUc resection of skull, 
48j^Linear craniotomy, 487 — Partial craniectomy, 487 — Explorator)' puncture of brain, 
48*— Operation for intracranial hemorrhage, 48g — Ligation of middle meningeal artery 
mJKl its anterior and posterior branches, 4Q0 — Ligation of longitudinal or lateral sinuses, 
490— Operation for thrombosis of lateral sinus, 41)2 — Trephining for fracture of skull 
4iQ2 — Operation for bullet-wound of brain, 493- — Operation for exposure of a motor center, 
494 — Puncture and drainage of lateral ventricles, 495 — Incision of cerebellar subarachnoid 
space for drainage (Parkin), 496 — Operation for cerebral abscess, 496 — For cerebellar 
ah»ces&, 497 — For cerebral tumor, 498 — For cerebellar tumor, 499 — Operations u|ion 
mastoid antrum and cells, 499 — Operations upon gasserian ganglion, 499. 

IL Bony (Air) Sinuses of Head and Face: — Operations upon mastoid antrum and 
oeIls« 500 — Surgical anatomy, 500 — Surface form and landmarks. 502 — General surgical 
considerations, 503 — Operation for exposure of mastoid antrum and cells (Antrum opera- 
tion of Schwartzc), 504 — Operation for exposing mastoid antrum and cclk, together with 
interior of tympanum and meatus, and the exenteration of middle-ear cavities (the tym- 
pano-Ria*>toid exenteration, or radical operation, of Schwartze-Siacke, or Schwartae- 
Zaufal), 506 — Oj)erations upwn frontal sinuses, 508 — Surgical arutomy, surface form and 
landmarks, and general surgical considerations, 508, 509— Instruments, 510 — Exposure 
and drainage of frontal sinust*, 510 — Operations upon maxiUar>' sinuses, 511 — Surgical 
anatomy, surface form and landmarks* and general surgical considerations, 511, 512 — 
Imtruments, 513 — Opening of maxillary sinus through its facial aspect, above alveolar 
margin, 513 — Opening through socket of second molar tooth. 514. 

III. Eyeball and Orbit: — Operations upon the eyeball, 514 — Surgical anatomy of 
' Mbit, 514— Enucleation of eyeball, 5i5^Evisreration of eyeball, 516. 

IV. Ear and Eustachian Tulje: — Surgical anatomy of membrana tympani, 516— 
[ latrodttction of ear «peculum for examination of membrana tympani, jt; — Paracentesis 
' ^mpani, 517— Introduction of eustachian catheter, 5x7. 

V. Nose and Na.sal Cavities, 518. 

VI. Tongue: — Surgical anatomy, 518 — General surgical considerations, 518— 
In^trumrnt^, 510 — Excision of limited portions of tongue, 520 — ^Excision through nwrnth, 
without preliminary ligation of lingual arteries (Whitehead), 520 — Excision through 
maalk, after preliminary ligation of Unguals in neck, 522— Excision of tongue, together 



lO CONTENTS. 

with cervical and submaxillary glands, by an incision in neck, after preliminary trache- 
otomy and ligation of lingual and facial arteries (Kocher), 522. 

CHAPTER II. 
OPERATIONS UPON THE SPINE AND SPINAL CORD. 

Surgical anatomy, 526— Surface form and landmarks, 527 — General surgical con- 
siderations, 528 — Instruments, 530 — Laminectomy, 530 — Osteoplastic resection of spinc- 
534 — Subarachnoid puncture for spinal anesthesia, 538 — Spinal puncture for drainage of 
subarachnoid space, 539 — Operation for removal of tumors of spinal cord, 539— Intra- 
spinal partial neurectomy of posterior nerve-roots, 539. 

CHAPTER III. 
OPERATIONS UPON THE NECK. 

I. Larynx: — Surgical anatomy of neck, 541 — Surgical anatomy of larynx, 541 — 
Surface form and landmarks, 541 — Instruments, 542 — Laryngotomy, 543 — ^Thyrotomy, 
544 — Complete laryngectomy, 545 — Partial laryngectomy, 546 — Intubation of laiynz 
(O'Dwyer), 547 — Other operations, 548. 

II. Trachea: — Surgical anatomy, 548 — Surface form and landmarks, 549 — Gen- 
eral surgical considerations, 549 — ^Instruments, 550 — High tracheotomy, 550 — ^Low 
tracheotomy, 552 — Other operations, 552. 

III. Pharynx: — Surgical anatomy, 553 — Instruments, 553 — Median pharyngotomy, 
by median vertical incision through mouth, 554-^Lateral pharyngotomy, by curved lateral 
incision through neck (Kocher), 554 — Subhyoid pharyngotomy, by transverse curved 
incision through neck, 555 — exposure of retro-pharyngeal space, by lateral cervical inci- 
sion along posterior border of sternomastoid (Chiene), 556. 

IV Esophagus: — Surgical anatomy, 557 — General surgical considerations, 558 — 
Instruments, 558 — Internal cervical esophagotomy, 558 — Cervical esophagostomy, 560 — 
Partial cervical esophagectomy, 560 — Introduction of esophageal bougie, 561— Other 
operations, 561. 

V. Tonsils: — Surgical anatomy, 563 — General surgical considerations, 563 — 
Instruments, 563 — Tonsillotomy, 563 — Partial tonsillectomy through mouth 564 — Com- 
plete tonsillectomy through mouth, 564 — Complete tonsillectomy through neck (Cheever), 

565. 

VI. Parotid Gland and Stenson's Duct: — Surgical anatomy, 567 — Instruments, 
568 — Excision, 568. 

VII. Submaxillary Gland and Wharton's Duct: — Surgical anatomy, 570 — Instru- 
ments, 570 — Excision, 571. 

VIII. Sublingual Gland and Duct of Bartholin: — Surgical anatomy, 572 — Instru- 
ments, 572 — Excision, through floor of mouth, 572. 

IX. Thyroid Gland: — Surgical anatomy, 573 — Instruments, 573 — Partial thy- 
roidectomy, by angular incision (Kocher), 573 — Complete thyroidectomy, by transverse 
curved incision (Kocher), 575. 

CHAPTER IV. 
OPERATIONS UPON THE THORAX. 

I. Thoracic Wall and Contents: — Surgical anatomy, 576— Surface form and 
landmarks, 578 — Instruments, 579. 

II. Female Mammary Gland: — Surgical anatomy, 579 — Surface form and land- 
marks, 580 — (ieneral surgical considerations, 580 — Incision of breast, 580 — Partial ex- 
cision of breast by elliptical incision, 581 — Radical excision, by Halsted's method, 582 — 
Radical excision, by Warren's method, 584 — Ordinary excision, by elliptical incision, 585 
— ^Subcutaneous excision, by inferior curved incision, 586. 

III. Superior Mediastinum: — Surgical anatomy, 587 — Surface form and land- 
marks, 587 — General surgical considerations, 587. 

IV. Anterior Mediastinum: — Surgical anatomy, 588 — .interior mediastinal thor- 
acotomy, by long median incision (Milton's anterior mediastinotomy), 588 — Anterior 



CONTENTS. 



II 



roediastinal thoracotomy, by osteoplastic rcsecUon of part of sternum corresponding with 
third, fourth, and fifth costal cariilagMi, 590— Other of)eratioiis, 592. 

V. Middle Mediastinum; — Surgical anatomy, 592 — Operations upon middle 
mediastinum, 593. 

VI. Posterior Mediastinum: — Surgical anatomy, 592 — Posterior mediastinal 
thoracotomy, by thoracoplastic flap (Bn-ant), 503- 

Vn. Diaphragm: — Surgical anatomy 595 — Transthoracic exposure of diaphragm, 
by partial excision of two or three ribs, 596. 

VIII. Pleunr-'Surgical anatomy, 599 — ^Surface form and landmarkLs, 600 — Para- 
centesis thoracis, 601— Intercostal thoracotomy. 601 — Thoracotomy, by partial excision 
of one or more ribs, 602 — Thoracoplasty <Flsllaendcr's operation), 604 — Thoracoplasty 
<Schede'8 operation), 607 — Other operations, 6oq. 

IX. Lungs .—Surgical anatomy, 609— Pneumotomy. through a thoracoplastic flap, 
^11 — Partial pneumeclomy, thniugh an ostco-lhoracoplastic flap, 612. 

X. Pericardium: — Surgical anatomy, 614 — Surface form and landmarks 615 — 
Pancentcsis pericardii, 615 — Pericardiotomy, through intercostal incision, 616 — Expo- 
sure of pericardium and heart, by excision of left fifth costal cartilage, 617 — Exy)osure of 
pericardium and heart, by ostco-thoracoplastic resection of anterior chest-wall, 619 — > 
Perirardiorrhaphy, 619. 

XI. Heart: — Surgical anatomy, 619 — Paracentesis of right auricle, 620 — Paracen- 
lesi«of right ventricle, 62 1 — Cardiorrhaphy, 621. 

I XII. Thoracic Trachea; — Surgical anatomy, 622 — Thoracic trat het>tomy, 622. 

XIII. Bronchi: — Surgical anatomy, 622 — Bronchotomy, 623. 
XIV. Thoracic Esophagus, 623 — Surgical anatomy, 623 — Thoracic esophagotomy, 
by posterior mediastinal osteoplastic flap operation, 623. 



CHAPTER V. 
OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 

I. .Abdomino-|)elvic Wall— Surgical anatomy, 624 — Surface form and landmarks, 



I 



637 — General surgical corwidcrations, 629— In.strumcnts, 631 — Median abdominal sec- 
tion, 631 — Anterolateral abdominal section, by McBurney's intramuscular '*gridiron'* 
incision. 637— Anterohitcral abdominal section, by Weir'.s prolongation of the anteroblcral 
intra-muscular incision through rectal sheath, with temporar>- displacement of rectus, 
639 — Anterior abdominal section through ret lal sheath, with temporary displacement of 
rcctu*. by the Battle Jalaguirr-Kammercr method 641 — Median inferior alxlominal 
4e«-tion by Pfannrnatiel's .superficial transverse curve<l, and deep vertical incisions, 6^% — 
Inferior snterolateral abdominal section, by Meyer's "hockey stick*' incision, 644 — Inferior 
anterolateral abdominal section, by Fowler's angular incision, 645 — Superior anterolaterat 
abdominal section, by oblique subctHtal incision, 646 — Lateral abdominal section by 
Viichcr's lumbo-iliac incision, 646 

11. Peritoneum: — Surgical anatomy, 647 — General surgical considerations, 649 — 
Opentions for separation, division, or hgation of peritoneal adhesions, 649 — Paracentesis 
abdominis, 651. 

m. Omentum;— Surgical anatomy, 652 — General surgical considerations, 653 — 
UgatJon of amentum, 653 — Omental grafting, 654. 

IV. Mesentery;— Surgical anatomy, 654— General surgical considrrations 655 — 
Partial etrWon. 655 — Suturing, 65s. 

V. Intestines:— Surgical anatomy of <imall intestines, 655 — Surface form and land- 
mark* nf fmill intestines 6.«;S — Surgical anatomy of large intestines, 658 — Surfjice form 
■r is of large interlines, 661 — General surgical considerations in of)eratione upon 

tb« ' 6ft2 — Instruments, 662 — Entefotomy, 663^Enterorrhaphy. in general, 

^3— By l^mbert'* interrupted suture, 66s — By Cxcrny-I.,embert interrupted suture, 666 
— Br HalAte<rs intcmjpted quilt or mattrcvs suture, 667 — Bv Lemberi's conlinuoas 
ntturr, OftJ^^By Cushing's right-angled continu(»us suture, 668 — By cnmliitie^l overhand 
ooRttnunui Auiure of alt coals, followed by interrupted Lemt>ert suturing of outer coats, 

Enterorrhaphy for wounds of intestine, 670— Partial entrret tomy, 672 — Entero- 
entero«>to«ny (intestinal anastomosis, approximation, and implantation) in general, 67s—* 
(A) Klitero-eniero»tom> by methods of simple suturing, in general, 676 — By simple cod> 



12 CONTENTS. 

tinuous overhand suture of all coats, followed by interrupted or continuous Lembeit 
sutures of outer coats, by author's method, 677 — By Czerny-Lembert interrupted suture. 
685 — By Halsted's method of interrupted mattress or quilt sutures, 686 — By Maunsell's 
invagination method. 688 — (B) Entero-enterostomy by means of absorbable mechanical 
devices left within the intestines, in general, 696 — By means of absorbable bobbins, 697 — 
By absorbable buttons, 698 — By UUmann's modification of Maunsell's method, 699 — 
By CoflFey's method, 701 — (C) Entero-enterostomy by means of non-absorbable mechan- 
ical devices left within the intestinal canal, in general, 702 — By means of the Murphy 
button, 703 — (D) Entero-enterostomy by mechanical means temporarily used for approxi- 
mating the intestinal edges during suturing, in general, 710 — By means of Halsted's in- 
flatable rubber cylinder, 710 — By Lee's intestinal holder, 714 — By Laplace's intestinal 
anastomosis forceps, 718 — Excision of ilio-csecum, 720 — Appendicectomy, by McBumey's 
intramuscular operation, 722 — Appendicectomy, by the ordinary method, 727 — Enteros- 
tomy, in general, 727 — Right inguinal enterostomy (or ileostomy) for establishment of 
temporary fecal fistula, 728 — Right inguinal enterostomy (or ileostomy) for establishment of 
permanent artificial anus, 730 — Colostomy, in general, 731 — Left inguinal colostomy, 732 
— Left lumbar colostomy, 736 — Operation for closure of fecal fistula and artificial anus, 739 
— Enteroplasty, 742 — Colopexy, by Bryant's method, 742 — Rectopexy, by Verneuirs 
method, 743 — Internal rectotomy, 744 — External rectotomy, 744 — Excision of rectum, in 
general, 745— Excision by sacral route by partial excision of sacrum (Kraske's operation), 
745 — Excision by sacral route, by the Rehn- Rydygier osteoplastic flap method, 750 — Ex- 
cision of lower part of rectum by perineal route, 752— Operation for cure of hemorrhoids by 
ligation and excision (AUingham's method), 754 — Operation for cure of hemorrhoids by 
excision (Whitehead's method), 755 — Operation for cure of hemorrhoids by clamp and 
cautery, 756 — Operation for cure of fistula-in-ano by incision, 757. 

VI Stomach : — Surgical anatomy, 760 — Surface form and landmarks, 761 — General 
surgical considerations, 761 — Instruments, 762 — Introduction of stomach-tube, 762 — Gas- 
trotomy, by median incision, 762 — Gastrotomy by oblique subcostal incision, 764 — Gas- 
trorrhaphy, 765 — Gastrostomy, in general, 766 — Gastrostomy, by Ssabanajew-Franck's 
method, 767 — Same, by Witzel's method, 769 — Same, by Marwedel's method, 772 — ^Same, 
by Kader's method, 774 — Gastro-enterostomy, in general, 776 — Anterior gastro-enteros- 
tomy, by simple suturing (Wolfler's method), 777 — Same by the Murphy button, followed 
by single or multiple intestinal anastomosis by the Jaboulay-Braun method, 781 — Posterior 
gastro-enterostomy, by Von Hacker's method, 783 — Same, by the Murphy button, 785 — 
Gastrogastrostomy by Wolfler's method, 785 — Gastroplication, by Weir's modification of 
Bircher's method, 787 — Gastropexy, 788 — Gastrolysis, 789 — Gastroplasty, 789 — Pylo- 
roplasty, by Heineke-Mikulicz method, 789 — Divulsion of pyloric orifice of stomach, by 
Loreta's method, 791 — Dilatation of cardiac orifice of stomach, 791 — Pylorectomy, in 
general, 791 — Pylorectomy, followed by posterior gastroduodenostomy, by Kocher's 
method, 792 — Pylorectomy followed by end-to-end gastro-enterostomy, by Billroth's 
method, 795 — Partial gastrectomy, followed by gastrojejunostomy, together with closure of 
duodenum, and jejunojejunostomy, 798 — Total gastrectomy, 799 — Operation for gastric 
ulcer, 800. 

VII. Liver: — Surgical anatomy, 800 — Surface form and landmarks, 802 — General 
surgical considerations, 802 — Instruments, 804 — Exploratory puncture of liver, 804 — 
Hepatotomy, in general, 805 — Anterior subcostal transperitoneal hepatotomy, by anterior 
oblique incision parallel with costal arch, 806 — Exposure of liver by anterior subcostal trans- 
peritoneal route, by anterior vertical incision through right linea semilunaris, 808 — Ex- 
posure of liver by lateral subcostal transperitoneal route, by lateral horizontally curved in- 
cision below right twelfth rib, 809 — Exposure of liver by intercostal subpleural route, by 
intercostal incision below level of pleura, 809 — Exposure of liver by subpleural route, by 
partial excision of one or more ribs below level of the pleura, 810 — Exposure of liver by 
subpleural route, by partial excision of one or more ribs opposite the pleura, 810 — Exposure 
of liver by transpleural route, by partial excision of one or more ribs opposite the pleura 
812 — Exposure of liver by chondroplastir resection of right costal arch, by anterior oblique 
subcostal incision, 813 — Hepatorrhaphy, 813 — Hepatopexy, 814 — Partial hepatectomvs 
814. 

VIII. Gall-bladder: — Surgical anatomy, 815 — Surface form and landmarks, 816 — 
General surgical considerations, 816 — Instruments, 816 — Cholecystotomy, by oblique sub- 



CONTENTS. 



13 



cDst«I inrision, 816 — ^Cholpcystotomy, by obliqur f^r vertical subcostal incision, 817 — 
Choice vstrndy sis, by oblique or vertical subctisial incision, 819 — Cholecystenieroslomy, by 
Murphv button. Si<) — Cholccystcntcro^vtomy. by 5im|»ic' suturing, H20 — Choleryslolilho- 
trily, Sji — Cholecystfciomy, B21. 

IX. GalUJucts: — Surgical anatomy, S23 — Surface form and landmarks, 823^ 
General sur|;ical considerations, 825 — Itistruments, Ss^ — Cholcdochoiomy, 834 — Chok- 
Ktbotnty. 8ift. 

X. Spleen: — Surgical anatomy, 827 — Surface form and landmarks, 828 — General 
surcJCiil considerations. 828 — Instruments, S2S — Exploratory jmn* ture, S28 — Splenotomy, 
bx oMinur suln-ostal incision, 8jq — F.xpi^ure of spleen by ^ubpleural route, by partial ex- 
ri^on of one or two ribs, Sag — Splenorrhaphy, 830 — Splenopex}', 830 — Partial splenectomy, 
by subtxistal iniision parallel with ribs, 831 — Total splenectomy, by vertical incision in left 
liora^milun;iris, 83 1> 

XI. Pancreas: -Surgical anatomy, Ftj^ji — Surface form and landmarks, 834 — 
Gcnrral surgical considerations, S34 — Inslrume^l^, 835 — Pancreatotomy, by gastrocolic 
Tuutr, 835— Partial pancreatectomy, by ga.str<x:olic route, S^t. 

XII. Kidncj's: — Surgical anatomy, 837 — Surface form and landmarks, 839 — Genera! 
saqpcal considerations, 841 — Instruments, 841 — Retro|)critoneal eXf>osurc of kidney by 
oblique lumbar incision. 841— Retro peritoacal exposure of kidney, by Kocnig's angular 
lumbiH.ilKlomJnal imision, 844 — Retroperitoneal exposure of kidney, by lumbar intm- 
tnusiulox method. 84s— Transperitoneal cxp«.>sure of kidney, by vertical in<ision in Ijnea 
semilunaris. luingcnbu' h's operation. 845 — Transperitoneal cvi>i»sure of kidney by median 
atxiomtnol <«c« tion, 847 -F..x|>osure of kidney by combined abdon.inolumbar operation, liy 
anterior lratvs.jHTUoneaJ and posterior retrojx'ritoneal incisions, 847 — Explorator].' pun< - 
lunr of kidney. 848— Nephrotomy, S4(> Myelotomy, 850 — XephroHihotomy, 850— Nephn*f- 
rluiphy. 851 — Xephropexy. by suturing split and everted pmper cajisule of kidney lo 
kiml>ar wall, EdebohLs's operation, 852 — Xephropexy, by suturing split proper cajisule and 
chvma of kidney to lumbar wall, by oblique lumbar incision, TufTier's operation, 

-Nephropexy, by simple suturing, 857 -Total nephrectomy, by obhV^ue lumbar in- 
cision. 85S- -Partial nephrectomy, by oblique lumbar incision, 850 — Subcapsular ncphrcc- 
ttsmy. 860— Total ncphre*. tomy by anterior lrarvs[>critoneal meth<xi, Hdo, 

XI 11- I'reters — Surgical anatomy, 861 — Surface form and landmarks, 862— General 
4tinp<aJ considrrafions, 862 — Instruments, 863~ExfKisure of ureters, .S63 — rretcrxflomy, 
S64 I. reterorrhaphy, 86<> — Urctero-ureterii! anastomosis (uretcro-uretcrfwtomy), 865— 
IniptaitUtion of unlcrs, in general, 868 — Implantation of ureters into bladder (uretero- 
cy»U»sloroy>. 8fii> -Implantaiicm of urriers into large inlestine {ureterorectostomy) by 
Fo^'lrr's method. 870— Impliinlution of ureters u|jon skin. 873— rreterc**tomy. in general, 
873 —Partial uretem tomy, by oblique himb.ir imision. 874 — Total urclcreclomy, together 
witK removal of kidney, by anterior median ah<lominnl section 874. 

XIV. Bladder:— Surgical anatomy, S75 — Surface form and landmarks, 87fii — General 
MTjKJXJkl consideration*. S77— Instruments, 878 — Introdu* lion of s(jund or catheter, 878 — 
Pamcentesis vesicae, 879 — Cystotomy, in general, 880— Suprapubic cystotomy. S80 — 
lateral perineal cystotomy, for removal of vesical calculus, 883 — Median perineal tysl- 
ntomy, for rpmi»val of vesical calculus, 886— Cystorrhaphy, 887 — I.ithotrity. 888— Lithola* 
jttxy. 888— V'esital drainage. 892— Partial cystectomy, 893 — Total cystectomy, by supra- 
polik median vertical and transverse incisions, 894. 



CHAPTER VI. 

OPERATIONS UPON THE MALE GENITAL ORGANS. 

I, Penis;— Surgical nnalomy, Sf^j; — Instruments, Sg5— Cirrnmci&ion, 84^6 — Partial 
•mputattoo of penis, by flap mcth.ifj, 8<;8— Total amputation, <;oo. 

tl. I'nrthni:— Surgical anatomy 4)f male urethra, 002— Surgical anatomy of female 
urrtlira, 00.5 — Surface form unti lumlmarks, f)03 — Genend surgical « onsideraiions. 003 — 
taatrtunenLs, 904— Introduction of ^ound or catheter. 904— Mcatoiomy, 1)04— Urethrol- 
owyt in general. c)04— Internal urrthnittimy. by dilating urvihrotome, 905— External 
ptfianU unrthrotomy. ujK>n grooved stjifT fSyme's operation), (}07— Fxternal |x*rineal 
■radnolnmy, u|>on filiform guide (Gouley's operation), 908 — External perineal urvlhrot 



14 CONTENTS. 

omy upon grooved staff passed down to stricture (^\^leeIhouse's operation), 909 — Perineal 
section, or external perineal urethrotomy without a guide (Cock's operation), 910 — Ure- 
throrrhaphy, 911 — Urethrostomy, 911. 

III. Scrotum and Testes: — Surgical anatomy, 912 — Paracentesis tunicae vaginalis, 
913 — Partial excision of scrotum, 913 — Operation for hydrocele, by incision of tunica 
vaginalis, Volkmann's operation, 914 — Operation for hydrocele, by incision, with partial 
excision of tunica vaginalis. Von Bergmann's operation, 915 — Orchidectomy, 916. 

IV. Spermatic Cord: — Surgical anatomy, 917 — Instruments, 918 — Partial vasectomy, 
918 — Operation for radical cure of varicocele, Bennett's modification of Howse's opera- 
tion, 919. 

V. Vesiculas Seminales and Ejaculatory Ducts: — Surgical anatomy, 920 — Instru- 
ments, 921 — Total excision of vesiculae seminales and part of ejaculatory ducts, by supra- 
pubic retrocystic extraperitoneal route. Young's operation, 921. 

VI, Prostate Gland: — Surgical anatomy, 922 — Instruments, 923 — Prostatotomy — 
Prostatectomy, in general, 923 — Suj)rapubic prostatectomy, by median vertical incision, 
924 — Perineal prostatectomy, by transverse curved incision, 925 — Prostatectomy by the 
combined median suprapubic and median perineal incisions, Alexander's operation, 
926 — Note, 928. 

CHAPTER VII. 

OPERATIONS UPON THE FEMALE GENITAL ORGANS. 

I. Uterus: — Surgical anatomy of uterus, broad ligaments, round ligaments, and 
vagina, 929 — Surface form and landmarks. 032 — Instruments, 932 — Partial abdominal 
hysterectomy, together with removal of ovaries and lubes (partial abdominal hysterosal- 
pingo-oophorectomy), 933 — Total abdominal hysterectomy, together with removal of 
ovaries and tubes (total abdominal hysterosalpingo-oophorectomy), 935 — Total vaginal 
hysterectomy, 935. 

II. Ovaries: — Surgical anatomy of ovaries, fallopian tubes, 941 — Ovariectomy, or 
oophorectomy, with removal of fallopian tube (salpingo-ovariectomy. or salpingo-oopho- 
rectomy), 942 — Note, 944. 

CH.APTER VIII. 

OPERATIONS FOR HERNIJE. 

I. Inguinal Hernia, 045 — Surgical anatomy. 945 — Cicneral surgical considerations, 
Q46 — Instruments, 948 — 0{)eration for radical cure of oblique inguinal hernia, Bassini's 
method, 948 — Oi)eration for radical cure of same, Halsted's method. 053. 

II. Femoral Hernia, 055 — Surgi( al anatomy, 055 — C'.eneral surgical considerations, 



A TEXT-BOOK 



OF 



OPERATIVE SURGERY 



BICKHAM 



PART I. 

THE OPERATIONS OF GENERAL SURGERY. 



CHAPTER I. 

OPERATIONS UPON THE ARTERIES. 
LIGATION OF ARTERIES. 

GENERAL CONSIDERATIONS. 

Description.— The ligation uf an artery signifies the constrirtimi of the 
artery by means of a ligature, for the purjiose of controlling the circulation in 
thai ve>sel. 

Varieties of Ligation. — A ligation may l^e ** terminal," where the cut 
end of an artery is tied; — " in continuity," where tied in its unbroken course; 
— *• single,'' where but one ligation is used;— "doiible." where two are applied 
(as in dividing a vessel between ligatures); — "immediate," where applied 
Jirectly to the arter\' proper; — "intermediate," where the ligature passes 
round more or less connective or other tissue surrounding the artery (as 
'In ligation for parenchymatous hemnrrhage);—'* permanent." where applied 
lo remain; — or *'temporar}'," where applied for arrest of circulation for a brief 
peritxl. 

Indications for Ligation of Arteries. — Wounds; aneurisms; hemor- 
bugc. from main trunk near site of ligatinn, or from either main trunk or 
ne of its branches at a distance from site of Ugaiion; rupture of vessels; 
anj^iomata; to control hemorrhage in operations distal to site of ligation; 
to lessen nutrition of inoperable tumors; to cause atrophy of an organ by 
diminishing its blood-supply. 

Preparation. — (i) General; — none is necessary for ihe smaller ligations. 
In the case of the ligation of the larger arteries, the constitutional state of the 
patient shouM be looked after as in other major operations. (2) Local; — 
the usual antiseptic preparation of the part — the patienl coming to the table 
with the site of operation in an aseptic dressing. 

Position.— Patient upon table of proper height, and so placed as lo 
bring the involved artery most conveniently and advantageously before the 
surgeon. Surgeim stands where he can best manipulate, which is generally 
on the side of the o|>eration, and usually cuts downward on the right, and 
vard on the left. Assisianl generally stands opposite the surgeon, and 
the field of ojieration by retraction, or assists in the steps of the 
lif^tion. The jMisitioni of patient, surgeon, and assistant will var\' according 
to the arter}' operated upon, and will be given in the individual operations. 
Instruments. — Esmarch bandage and tourniquet; scalpels, heavy and 

2 17 



l8 OPERATIONS UPON THE ARTERIES. 

light; scissors, straight and curved, sharp-pointed and blunt; forceps, dis- 
secting and toothed; hemostatic forceps; grooved director; tenacula; re- 
tractors, various sizes and shapes; aneurism-needles, large and small, straight 
and laterally curved; ligature-carrier; ligaturing and suturing material (v. i.); 
needles, straight and curved, surgeon's and Hagedorn; needle-holder; wound- 
hooks; drainage materials (for special emergencies); means of illuminating 
deep wounds. 

Ligature Materials. — Plain catgut; chromicized catgut; kangaroo 
tendon; ox aorta; silk, plain and floss. For the closure of skin-wounds, 
silkworm-gut or silk sutures. 

(I) For the ligation of smaller arteries — plain catgut. (2) For medium 
arteries — chromicized catgut. (3) For largest arteries — kangaroo tendon 
(flat); ox aorta (flat); chromicized catgut; soft floss-silk. 

Steps of the Operation of Ligation.— For the satisfactory carrying 
out of a ligation, a systematic course should he followed in all cases, the 



LIGATION OF ARTERIES. 



J9 



I 



the 
H of ii 

V tUTt 



accurate guide to the vessel. esiJt'daliy in the early stage of the o|>eriiti()n (for 
instance, in the above case, the brachial artery is often considerably (nerlapped 
by the biceps in a \velI-devcloi:»ed subject), lhnu«ih the latter are the natural 
boundaries, which generally have to be encountered and manlijulated ijefore 
finally reaching the artery, (3) In other cases the line bears no relation what- 
ever to external muscular or tendinous elevations or furrows, and, in such 
GBses, the line alone has to be blindly followed, in the early [jarl of the opera- 
tion, as a guide to the course of the aricry (as in the case of the uj)[>cr [>oriion 
of the ulnar artery, Fi«;. 2^). 

IC) Incision.— (I) Position and Direction of Incision: — In the great major- 
ity of cases the line of incision coincides with the line of the artery, from be.^n- 
ning to end of ojjeralion, superficially and in the rlceper layers (as in ligation 
of ihe popliteal artery in the middle of the ^mpliteai space), and should be so 
placed as lo have its center o\er the site of ligation. In other cases the line 
of incision will follow a muscular marking, even if at a shght variance with 
ihc ret-ognized "line of artery'' (c. g., in ligating the common carotid above 
the om«»hyo(d, the incision is made parallel wilh ihe inner margin of the 
Memomastoid, which, in muscular and well-develo|)ed necks, is known to 
overlap and lie slightly to the inner side of the artery, Fig. 7. F"). In other 
cases the incision follows neither line of artery nor muscular marking, but 
lies in a course parallel with both line of artery and muscular fibers, and is 
so placed as to reach the vessel most advantageously and with least damage 
10 neighboring structures (c. g., ligation of posterior tibial artery in mifldle 
of leg, Fig. 39, I). In other cases the incision may coincide with the line 
of artcn* but cross an overlying muscle at a right angle (c. g., ligation of 
lingual arter\' beneath the hyuglossus muscle (Fig. 7, L). In still other 
cases the incision may cross the course of the artery at a right angle (e. j^., 
ligation of external iliac extra peri ton ealiy. by an incision parallel with Pou- 
|K»rt*s ligament. Fig. 35). (3) Superficial Inci>ion; — Flaving ch risen the line 
of incision as free from superficial vessels ami nerves as circumstances permit, 
steady the area of incision by means of the left thumb and forefinger, which, by 
their separation, put the pans under slight tension and give room for the knife- 
cut between them. Grasp the scalpel in the "pen position " for finer, more lim- 
itcil cuts, and in the "dinner knife position*' for heavier, longer ruts. Enter 
the p<»inl of the scalpel at a right angle to the skin surface — traverse the line 
of incision with the knife-handle at about 45 degrees — and withdraAv the knife 
wilh the |K)int of blade again at a right angle to the surface, thereby cutting to 
al tiepth throughout. This incision should pass through skin and supcrfi- 
.1 fascia, and, while not unneces.sarily long, should he amply long enough 
lo enable subsequent manipulations to be carried on without injury to the struc- 
tures. The length of the incision should rather be determined by the depth 
of ihc arter>' and the nature of the parts to be encountered, than by any 
attempt lo rememljer an arbitrar}' length of incision for each artery. The 
deep fascia is similarly divided in the original line — avoiding, where possible, 
supertJcial vessels, and, esj^cially, nenes. (J) Deep Incision: — Having 
passed through all overlying fascia in the superficial incision, the muscle 
and tendinous lan^lmarks now come to both sight and touch. Generally 
no further cutting is necessary — the rest of the ajtproach and exposure of 
tbc wlery being accomplished by blunt dissection. In by far the majority 
of cases arteries are henceforth reached by following down between muscular 
planes, it lieing ven' rare that muscle-fibers are separated, and rarer still 
t muscles arc cut transversely. At this stage of the operation the muscular 
tendinous boundaries are recognized and followed 10 the known position 
the artery, the intermuscular planes being separated by the handle of the 




20 OPERATIONS UPON THE ARTERIES. 

scalpel rather than by the blade, and this separation being carried out to 
correspond with the length of the superficial wound. The three best means 
of recognizing intermuscular planes, in the order of their reliability, are: — 
sense of touch of tip of left index-finger (which flexion of the limb may aid) ; — 
following down of intermuscular branches of the artery; — the white fascial, 
or yellow fatty, so-called "line" in the intermuscular spaces. It is of great 
importance to recognize the proper intermuscular space at the start, as, 
once in a wrong intermuscular interval, one may wander on indefinitely, 
completely off the track, missing the artery and doing much damage to the 
parts (and injury to one's own feelings). Good retraction should be freely 
used at this stage, and muscles and tendons should be drawn to their prof)er 
sides (flexing the limb often aiding considerably in this retraction). Im- 
portant vessels, nerves, and other structures should be guarded during this 
separation of the parts, and, when in the way, should be displaced to the 
more convenient side of the operation-field — always remembering that nen'es 
are the most important structures to be siifeguarded, in the great majority 
of cases. If an Esmarch have not been used, the wound is kept compara- 
tively dry by frequent sponging of the field with dry gauze-pads. 

(d) Exposure of Artery. — Having gotten down into the region of muscles 
and tendons, these should be clearly identified, and the artery sought by its 
known relation to these structures. The muscles and tendons are the rallying- 
points in the depth of the wound. Three structures, outwardly more or less 
similar in appearance, and often in sensation, are to be distinguished: — (i) 
Arteries are recognized by their known course; their pulsation, when no 
proximal constriction is used (and by the hard, unyielding plaster or starch 
injection in the cadaver) ; their swelling proximally when compressed distally 
(where no constrictor is used); their firm, round, resisting, elastic, cord-like 
feeling; their peculiar sensation when compressed between the fingers, present- 
ing a central depression and two lateral, elevated ridges; their thicker walls; 
their rubber-tube-like feeling when touched and tendency to glide from 
beneath the fingers; the force required to compress them; their regular outline; 
their pinkish or pinkish yellow color. Of these means of recognition, pulsa- 
tion is the conclusive test, provided there can be eliminated all possibility 
of error caused by pulsation transmitted through contact (as a vein or a ner>'e 
made to rise and fall by an artery beating lacneath or to one side of it). 

(2) Veins are recognized by not pulsating (where no Esmarch is used); by 
having thinner coats; by swelling toward the periphery when compressed cen- 
trally (no constrictor being used); by being softer and less resisting to touch; 
by the flat, ribbon-like feeling throughout their whole width when compressed 
between the fingers; by their purplish color; by their wavy, irregular contour; 
by their accompanying the arteries, in many regions, in pairs or companion 
veins; by their larger size than the corresponding arteries; by the ease with 
which they are compressed. It may be mentioned here, in connection with 
the companion veins, that two vena; comites are to be found accompanying 
all arteries below the axilla; all arteries below the knee; most of the smaU 
and medium-sized arteries of the trunk; and that the arteries of the head 
and neck are accompanied by single veins. These veins generally run on 
either side of the artery, communicating across the artery at frequent intervals, 
— generally lying in front of and behind the artery when the intermuscular 
plane enclosing the artery lies anteroposteriorly, — and usually lying to the 
right and left of the artery when the intermuscular plane runs transversely. 

(3) Nerves are distinguished by their known position; their white color; 
their round contour, unyielding consistency, and non- compressibility; their 



LIGATION OF ARTERIES. 



21 



r 



appearance of being made up of parallel bundles; their swelling neither 
proximaliy, like arteries, nor peripherally, like veins, when compressed (no 
constrictor being used). 

(e) Opening the Sheath.— Having identified this structure and brought 
it well within the lield, its wall is to be opened and the contained artery ex- 
posed — for the purjjose of clearing a path for the aneurism -needle (Fig. i). 
Only the main vessels have a distinct sheath of connective tissue, and the 
larger the artery, the more rlistinci the sheath. In some cases the accom- 
panying vein and nerve are included in a common sheath, together with 
the artery — the sheath beinjj compt)sed of more or less condensed connerlive 
tissue. The smaller arteries are surrounded by a less distinct layer of areolar 
tissue, generally not demonstrable as a sheath. The sheath shuuld be opcnetl 
at least 1.3 cm. (J inch) from any branch. With a pair of tmely poinle^l 
forceps, pick up the shealh where it is desired to pass the ligature, and in 
such a way as to raise the sheath in a fold parallel with the long axis of the 




Pf^ 1— l.lcATtov OP *N Artkrv. OpctiiiiK ihc sheath. A. Rrtraclion of adjacent muscW; 
. TootlK-d (ufL(ii» naiitiiii; %hi:ath of atlerv in a loiiKUudiiial fold ; C, incising shealh in long axis of 
MtiCO • ^^> Aner> visible through inci&vd ihcath. 



Yessel (Fig. i, IJ). Let the furceps pick up the sheath upon its anterior 
at«pcct, but slightly to i>ne side of the median longitudinal line, thereby leav 
ing space (o incise the sheath exactly in the middle line. After grasping the 
»hcath, shift the f(jrceps gently up and down tu see that the sheath, held in 
the bight of the force|»s, glides over the coniained vessel, proving, thereby, 
that no part of the artery itself is |»icked up. This longitudinal fold of the 
nhcalh, while held by the f<»rceps ami lifted up from the artery, is incised in 
the long axis of the artery, for a di.^tance of about 6 to 8 mm. {\ to ^ 
h) (the shorter the distance of separation of the shealh the better, to pre- 
• e the vasa vasorum), the flat surface of the knife toeing turned to the 
(Fig. I. C). As Mx»n as the incision is made in the sheath, a gap 
appear.<« between the wall uf ihc artery and the wall of the sheath (Fig. r, D). 
The hcild of the forceps upon the wall of the sheath should be retained, not 
bdng relaxed after once grasping the fold of sheath. In ligating smaller 





22 



OPERATIONS UPON THE ARTERIES. 



arteries, which have no well-defined sheath, the vessel is simply freed of all 
visible connective tissue. (This axial division of the sheath of the artery is 
preferable to the transverse division so often advised.) 

(f) Clearing the Artery. — A path for the passing of the ligature between 
the outer wall of the artery and the inner wall of the sheath is now to be 
made, and the best instrument with which to make it is the dull, flat end of 
a curved aneurism-needle (Fig. 2). Having retained the original hold of 
the forceps upon the sheath or grasping the more convenient lip of the 
incised sheath, insinuate the end of the needle between this wall of the 
sheath and the artery, and while drawing this lip of the sheath gently away 
from the artery, carefully work the point of the needle around one-half of 
the circumference of the artery, in the connective-tissue plane between artery 
and sheath, by a combination of forward movement, on the part of the tip of 
the needle, with a side to side movement, on the part of the lateral margins 
of the curved tip, over a distance of from 6 to 8 mm. (^ to ^ inch) (Fig. 2, 




V\K 2— l.K.ATioN OK AN Akikkv. Clc.iri iiy t Ik" ailfi v . A. A, Rctratt ion of adjacent muscles; 
B, F<inf]is jjraspiii;^ inaun lip m slu-atli ; C, Aneui i>m-tn-fille licaiiiiK artery in its passji^e between 
sheath aiul ve^-sel ; I). I orce])^ j^raspiiii; tin ther lip <jf sheath ; E, .\iieiiiism-iieedle emerging between 
artery and further lip of sheath. 



C). Having thus cleared a path around half the vessel, and still holding the 
tip of the needle in the {)ath already cleared, the forceps for the first time 
relinquishes its hold on the lip of the sheath originally grasped, and grasps 
the opposite lip of the sheath and similarly draws this part of the sheath 
away from the artery (Fig. 2. I)), at the same time also similarly working 
the point of the needle onward and from side to side, until it clears a way 
completely around the artery and aj^pears between the vessel and the further 
lip of the sheath (Fig. 2, ly). Throughout this entire manoeuvre the handle 
of the needle is held approximately at a right angle to the vessel, and the tip 
of the needle hugs the wall of the artery, csj)ecially while working under its 
deepest part, particularly where a common sheath contains other structures, 
and thereby is i)revented from penetrating the sheath and injuring the vessels, 
nerves, or viscera beyond. 

(g) Passing the Ligature.— Once a y)assage has been cleared between 



LIGATION OK ARTERIliS. 



as 



artcn* and sheath, Ihe aneurism-needie readily traverses it— so that as soon 
as the needle has ap|>eared on the further side of the artery, it is withdrawn. 
The needle is now threaded and carefully passed between ves>e! and sheath, 
through the pre\i«>usly cleare<l way, folhnving precisely ihe same course 
and carrying out the s^me steps — fii^t opening the entrance to the passage 
by drawing the sheath away with forceps — then hugging Ihe vessel in making 
the circuit — and fmaliy emerging on the opposite side Ivetween the vessel and 
the further lip of the sheath, which the forceps have now grasf>cci and drawn 
away (Fig. ti). An aneurism needle may be passed with a fine silk Hgature- 
lo<»p as a carrier, and through this '* carrier" the proper ligature may be 
threaded and drawn back. There is no fixed rule for the direction in which 



F 
A 




riK .\ -l.u.ATioM or AN AiiTEHV. I'asniiifi; Uk" lijpnure «iii(1t>liig i)»«- kimi. A. A. Rciraciiou 
cj4 tic-iuMwiilim (Hia»; H, AiM-iifism-MC^'dl*: oarrviMi; liKalurc twiivHlli itilciy; C, TeiiaculiitTi Oniwirijc 
•ffi« cihJ it( UKfiiurc Utidri uilrry, while* aiivurism-riccillc ia Ix'tiig wilhilrawii; D, Tvit»K ^H« kiiut; 

t' V - .: Itpof thratli. 

k N<iT t'sitn INI l,ir,ATiNG MKnii'M AND Largk AnrKKiKS E, Two turns of a fric- 
|)< ^v«a b) n reel'knoi, coiistiiutiiig a aiurt;<.'<»ir& kiioc 



the ntfite should lie passed in each ca>e; the rule should be that tlie 
ncetJlc is U> be passed from the more important structures toward the least im- 
portant, or from the structures more difficult to avoid toward those more easily 
avoided. Therefore the needle may enter the sheath in the reverse order 
lo that in which it has l)een freed from the artery, or vice versii, as seems 
safest and easiest. Having passed the needle completely around the vessel, 
until its threaded eye protrudes on the opposite side, grasp one of the 
threads of the loo|x"d ligjiture with forceps or tenaculum, and, while thus 
held, carefulh' withdraw the needle, following the cur\e of the artery 
(Fig. 3. b, C). Thus a single thread is left beneath the vessel — an end 
coming out bctwccti the artery and sheath on either side. Some surgeons pass 



24 



OPERATIONS UPON THE ARTERIES. 



the needle unthreaded, and thread the eye on the opposite side, then, holding 
one arm of the ligature with forceps, withdraw the needle — with the same 
result. There is no objection to this method in simple cases where the artery 
is accessible and the threading easily done with the needle in situ (as in the 
lower third of the radial), but it should not be attempted in a region where 
the exposure is difficult (as in the retroperitoneal ligation of the common 
iliac). Such an instrument as the Cleaveland needle (ligature-carrier) is 
preferred to the common aneurism-needle by some — the instrument, being 
passed under the arter>' empty, grasps the ligature on the opposite side, and 
draws back one end under the vessel. In arteries too small to have sheaths 
the ligature is simply carried under and around the artery, which has been 
freed of all connective tissue, the general method being the same as just 
descril>ed. 

(h) Tying the Knot. — The largest arteries are most safely and satis- 
factorily tied with the "stay-knot" of 
Ballance and Edmunds. The stay- 
knot of these surgeons is made by con- 
ducting two bundles of soft floss-silk 
around the arter}', parallel with each 
other and side by side; — the first stage 
of a surgeon's knot is then tied in eadi 
bundle, so that two knots lie side by 
side, the force to tie them having been 
sufficient to closely appro.ximate the in- 
ner and middle coats of the arter>' and 
completely stop the flow, but without 
rupturing these coats (Fig. 5, A). After 
_ tying these at first lightly, they are 

l\ \\% "^ (/ M. % both taken up together and gently tight- 

'^^?^UlL% ^\ %, % ened simultaneously. The two ends 

of the two bundles are then taken up 
on the one side, and the two ends of 
the other two bundles on the opposite 
side. — the two bundles on each side 
now being regarded as one, — and these 
two bundles are tied in a single knot, 
after the manner of the second step 
of a reef-knot (Fig. 6, B). Thus a 
knot is formed the first part of which 
will not slip while the second is being tied (which is apt to be the case in 
large arteries, especially if they he pulsating at the time, thus allowing the 
establishment of a small stream of blood). By this method a broad com- 
pression and appro.ximation of the arterial coats will be accomplished, which 
will add strength to the site of ligation against secondary hemorrhage. 
This simple ap|)roximation is sufficient to excite endothelial proliferation 
and union of the opposed surfaces. It is hard to draw such a ligature 
tight enough to rupture the inner coats, \n artery with its two inner coats 
ruptured by ligation has only the strength of its outer coat to withstand 
the strain of the circulation until the secondary phenomena take place, 
which permanently strengthen the site — prior to which secondary hemor- 
rhage may occur. Several i)arallel strands of smaller-sized chromic catgut, 
led under the artery by a carrier, are sometimes used, thus securing 
width for the ligature and the consequent distribution of pressure. All 



^ 




'"•K"- 5 'I'"! 6.— Fi.f>ss-sii-K Stay-knot OF 
Bai.i.an< k ami ICdmi mjs. A, Kirbt staKc; B, 
SccoihI Mayc. 



LIGATION OF ARTIIRIES. 



25 



I 

I 

I 



medium-sized arteries should be lied with a surgeon's knot (a friction-kiiDt 
followed by the second step of a recf-knoi) (Fip;, 4. K). All small arteries 
are safely liefl with the reef knot alone. In making tension ujuin iht ends 
of the ligature, special care should be taken not to lift the artery out 'if 
lis sheath. To avoid this, the lips of the rip;ht and lefl t'orcfrngers should 
come together, end to end, directly upon the knot in the act of being tied, 
and the tightening should be done by putting the terminal and middle 
knuckles of the index-tmgers in apposition, back to back, and using them 
as fulcra (Fig. ,^, D). The thumbs may be similarly used, instead of the 
forefingers. It is a disputed point as to how much tension should be 
used in lightening a ligature. It may be said that it is best lu tighten the 
ligature upon all large vessels sufficiently to thoroughly approximate their 
inner wall in pleats, thereby completely closing the lumen, without ruptur 
ing their two inner coats. The same holds inie of all diseased vessels, in- 
dependently of their size. All medium vessels may be similarly ligated. 
The smaller arteries generally have their ligatures tightened sufficiently to 
rupture iheir inner and middle coats. A tightening almost sutficient to 
sever all coats, especially when using silk, is distinctly to be avoided. 
Secondary' hemorrhage seems less frequent, and the strength of the vessel 
grvaler, where the vessels are only constriclcd enough to closely approximate 
the two inner coats, without causing their rupture. .\ll knots should be cut 
comparatively short. A round ligature tightly drawn will rupture the inner 
coats; a broad ligature will do so far less readily. 

(i) Closure of Wound.— Where a large, well-marked sheath has been 
openetl in exposing the artery, although not absolutely necessary, it is well 
to unite the edges of the sheath by one or two fine catgut sutures. Where 
any muscle tissue has been incised in order to reach the artery, it is usually 
best to repair the dinded muscle tissue by catgul sutures passed through 
the lips of the muscle wound — which suture ljec<jmes buried in the final 
steps of the ofK-ration. Where deep intermuscular planes have been opened 
up, and dead spaces are apt lo be left, it is advi.«wTble to put in a few buried 
catgut sutures through the muscle tissue, drawing together the muscles into 
their normal intermuscular cleavage line. W here no muscle has been wounded. 
— antl in Ihe final step of ihose cases where muscle has been incised and 
sutured, — complete closure of the wound is accomplished by a line of inler- 
rupte<l silkworm -gut or silk sutures, or by a continuous silk suture — the 
suturing, in either case, being materially aided by putting the wound on 
fhc stretch by a wound-hook in either end. No form of drainage is used 
in clean cases. ,\ simple gauze and cotton dressing, held in place by a bandage, 
completes the <iressing, 

(j) After-treatment.— Very little after treatment is indicated in the 
ligation of the smaller arteries. Where a large artery is ligated, a splint 
should be incoqM)rated in the dressing where feasible, in order to control 
all movement of the part. In the case of the main artery of a limb, the 
limb should be encased in cotton, and artificial warmth applied in addition, 
until the new circulation is established. The limb is elevated in bed to 
Ipvor venous return. The skin sutures are removed on the seventh or eighth 
LoiV. A rest in Ixni of from two to four weeks is required in the lig.ition 
of the larger arteries. 

Local Results of Ligation.— (Iblileration of arter>' at site of ligation. 
EslnblishmenI of a new (rollaleral) circulation. 

Chief Dangers in Ligation of Arteries.^Secondary hemorrhage. 
Gangrene. 




26 OPERATIONS UPON THE ARTERIES. 

Comment. — (i) Where it is difficult or impossible to separate one or 
more veins from the artery, the artery and vein, or veins, may be included 
in the one ligature. (2) Especial care should be taken to avoid the inclusion 
of the smallest nerve in the ligature. (3) When a large vein is wounded, 
the wound should be at once closed by lateral ligature (Fig. 70), or by sutur- 
ing (Fig. 69), preferably the former. If this be not feasible, the vein should 
be ligated. All medium and small veins should be ligated if wounded. If 
the ligation of the artery can be accomplished without the likelihood of 
again wounding the vein, it should be completed at the onginal site. If 
there be danger of further complication, a new site should be chosen just 
above or below the one originally selected. (4) It is held by some that 
secondary hemorrhage is less likely if an artery be ligated in two places, 
from 2.5 to 5 cm. (i to 2 inches) apart, and then divided between these two 
ligatures, allowing each end to retract — upon the principle that the arteries 
of the body are constantly under longitudinal tension, and, when ligated in 
continuity (especially where the inner coats are severed), there are present 
the conditions calculated to predispose to secondary hemorrhage. Practical 
experience seems to have borne out the claim of the double ligature with 
division, but the operation is not always feasible, especially in the deeper, 
larger vessels. (5) All ligature material should be thoroughly pliable before 
being used. 



SURGICAL ANATOMY OF INNOMINATE ARTERY. 

Description. — Largest branch of arch of aorta. From 3.8 to 5 cm. 
(1^ to 2 inches) in length. Arises from beginning of arch of aorta, opposite 
fourth dorsal vertebra; runs upward, forward, and to right, to upper border 
of right sternoclavicular articulation, where it divides into right common 
carotid and right subclavian. 

Relations. — Anteriorly: manubrium; origin sternohyoid; origin sterno- 
thyroid; right sternoclavicular joint; remains of thymus gland; left innominate 
vein; right inferior thyroid vein; inferior cervical cardiac brai}ches of right 
pneumogastric. Posteriorly: trachea; right pleura. To right: right in- 
nominate vein ; right pneumogastric nerve ; right pleura. To left : left common 
carotid; remains of thymus gland; left inferior thyroid vein; trachea. 

Branches. — Thyroidea ima (sometimes); thymic branch (sometimes); 
bronchial branch (sometimes). 

Line of Artery. — From center of manubrium, to center of right sterno- 
clavicular joint. 

Indications for Ligation. — .Aneurism of right carotid, subclavian, and 
of innominate itself. 

Sites of Ligation. — From 1.3 to 2 cm. (^ to J inch) below bifurcation 
(Fig. 7)- 



LIGATION OF INNOMINATE ARTERY 

BY ANGULAR IXCISIO.X (MUTTS OPERATION). 

Position. — Patient supine, chest raised, head backward and to opposite 
side. Surgeon to outer side of shoulder. .Assistant opposite surgeon. 
Landmarks. — Clavicle; stemomastoid muscle; sternoclavicular joint. 
Incision. — J^ -shaped (on right — reversed on left). Horizontal portion 



UGATION OF INNOMIXATK ARTERY. 



of incision is made along upper margin of inner third of clavicle, for a distance 
of almul 7.5 rm. (3 inches). Oblique jxirtion (meeting horizonial at an 
acute angle) is made along anterior margin of slernomasloid, for about 7.5 
cm, (3 inches). (Fig. 7, A.) 




P'lC- 7 —l!*cision9 poK LtGATiON OP CiMEp AJtTeRiBS OP Hrad AND Nbck :— A, A. Innom- 
Ite, b)r anfiiljir |ncl<t|i>ii ; B. B. Sime. by uhliqtic iiiciAi«iii ; C, C. Same, by (Niriijtl bony icsrctlon. 
ibn'UicU »fi t>hl(.iuc IikI*|iiii, I). l>. Same, by punlul li-iuy icscctlofj ( BarOc»»b«;Hcf*» i^perntlonf; E. 
nnie. by ^(ihltiit); mtinubtium^ F, Cutniiiou cuiotitj. abuvc ottiohyoul; li. Shui«, b«low omohyoid; 
H. F-»tcrnat cxrotjtl, JHlr>w (lnjnsiTic ; I, b.imc. above dii;:istrK- ; J, TJiyrciuJ, u( oiikiii ; K. Lingual, at 
•wiciit ; L, l.itiKUiil, befit'.ith Iimi^Iiivhus ; M. Factal, n\<i'r itifer|i>r nutxilUt ; N, OLLipituI, bvhinci niAs- 
leti) procfs* , O. Tvn<irt*Ml. ju«,t «1»jvi' <>kuiiui. P. Trunk oi ini>Mlc mrninR'sil, in irriibinp-op^nJng 
czpOKtl b)-curvf:tl obliqiir ith iMoti I lowrr <i( i«v« t rcpbine-DficntnKf) t; Q. .\nu*ri(>r bmnch of inkJrtle 
Mwniitcc*). W tfcpbnic- <iiH.iimi; «.x(m>scH bv brin>.r^hn« inrinioo (bibber i>( two ir€Tibitic-o|i*-niMj|{s>; R, 
l^aatfnor brancb ■*( mldiib- inciiiML;iMt. b» trrpblni'-iipniltiK c\piKstr<l by bors«ihi*p inirivion; S, lnlcrnal 
<iirn(i<i, nrar orticin: T. Third pAM uf »ii)i«.biviAn; l*. Tntii^vct»ali» citlli bikI suprnsLAiMilor. at outrr 
OMrciH «l Mrmumastoid ; V, ltil<.-rn:il m:imiii»ry. In s«ond inlcrcuslu! spttcc i \V, First pari ol axil' 
Ufy, b> rurvnl Iransverw; tncbiinn biflnw cUivicic 




28 OPERATIONS UPON THE ARTERIES. 

Operation. — Having incised skin and superficial fascia, this triangular 
flap is dissected upward. Cut the sternal and clavicular attachments of 
the sternomastoid, as far as exposed. The sternohyoid and sternothyroid 
muscles are also cut, or are nicked and drawn well inward. Expose, ligate 
doubly, and cut the anterior jugular vein betw^een its two ligatures, lying 
beneath the sternomastoid; and also the right inferior thyroid vein. Divide 
the deep cervical fascia along the original lines of incision, thus exposing 
the common carotid. Open its sheath and follow to its origin, avoiding 
the recurrent laryngeal nerve. Thus guided to the innominate, clear its 
trunk — with especial care on the outer side, of the pneumogastric nerve, 
right innominate vein, and pleura — and pass the needle from these structures. 

Comment. — (i) As the chief source of failure is secondary hemorrhage, 
the common carotid and vertebral arteries are also tied — being the chief 
sources through which the recurrent flow occurs. (2) This free section of 
muscles leaves, by their retraction, a deep gap at the root of the neck for 
infection and slow filling-up. As much repairing of cut muscle tissue as 
possible, by suturing, should, therefore, be done in completing the operation. 
(3) Artificial illumination is desirable in this operation. 

Collateral Circulation.— First aortic intercostal, with superior inter- 
costal of subclavian. Upper aortic intcrcostals, with thoracic branches of 
axillary and intercostals of internal mammary. Phrenic, with musculo- 
phrenic of internal mammary. Deep epigastric, with superior epigastric 
of internal mammary. Free communication of vertebrals and internal 
carotids of o|)posite side, inside of skufl. Communication of branches of 
opposite external carotids in middle line of face and neck. (MacCormac). 



l.H;\TIQN OF INNOMINATK ARTERY. 



29 



M 



U 



p... . _ I ii,4TioK OF Innominatk »v Obliqi'e iNcisicm ,' Also of Rich r Common Carotid hit- 
LO\ ■ , \'eRtk»kai-NkarO«K.IN; and Infkkiok Tiivhoih Nhar Origin :— A, Platvsma ; B, 

Slcr •ti^cted outward and «iu\vii\vard; C, Right ^temorlnvicularaniculalion; F., Maiittbtium 

«lcTni; t omoliyuid; G. Stcniohyoid ; H, Stcrtiolhyroid ; I. Thyroid Kl^tid ; J. Innominate arttfry 
dividuix iiilo I'tmmoii carotict and «(ibcla\ ian ihrMjk is sreii rclrarliiig common carotid, w:> as to draw 
tnnoniiiiittr utmiird and iiis^tiidl; K, Thyroid axi^ ; L. Inferior thyroid , M, Nfrtebrai ; N. Right (11- 
nomiriatv vein. Yirilh !>utn.'luviMii and internal )ui;ulur (last, drawn outward); i). I'ncumo^nstric ; P, 
Kccurrrttt laryngeal, y. fhtenic; R, Ncr\'es ft<im Uwp iK-lwceii commuiiicans and dcs<.-«tidens livpo- 
i; S. S«f»rfricial c».-rvii'*»l Mcrs-f*; T. T. Aijtrrinr jui?ular vcm : V, W. Inlcfioi ttiyroid vein. The 
Kapular and transvcrsalis colli arteries arc seen crossing scalenus afilicus, lM;hind inlcnial 
rvcln 



LIGATION OF INNOMINATE ARTERY 

BY PARTIAL BONY RESFXTION-T HKOUC.H OBIJUUE INCISION. 

DeftCription. — The right sternoclavicular articulation, upper part of 
manubrium, and sternal end of first right rib are excised through an oblique 
incision — thus, exposing the artery. 

Position. — As in Moll's operation (page 26). 

Landmarks.' — Cricoid cartilage; stemomasioid muscle; manuhrium, 

Incision, —An oblique incision, beginning over the anterior margin of the 
right stemomastoid must Ic. t>n a level with the cricoid cartilage— and passing 
do^n the anterior border of the sternomastoid, over the right sternoclavicular 
tiiulation. onto the manubrium— and down to the gladiolus (Fig. 7, C, C), 

Operation.— Incise skin, superficial fascia, platysma. and deep fascia. 
Tie the anterior jugular vein between two ligatures. Protect the large veins 
by a spatula slipped behind the sternum. Having retracted the overlying 
piirts, remove, with Ciigli saw. rongeur, bone-cutting forceps, or chisel, the 
right sternoclavicular articulation, upper part of the manubrium, and in- 
sertion of the first right rib. Ligate the inferior thyroid veins. Separale 
the areolar tissue from the vessels, — guarding the neighboring .structures as 
mcntione<l in the prcce<ling operations, — when the innuminate will be fully 
exf)oseil to sight and touch. Temporary drainage is used in this, as in all 
ligations of the innominate 

Comment. — The common carotid and vertebral are also tied. 



3© OPERATIONS UPON THE ARTERIES. 



LIGATION OF INNOMINATE ARTERY 

BY PARTIAL BONY RESECTION-THROUGH TRANSVERSE AND VERTICAL 
lNCISIONS-(BARDENHEUER'S OPERATION). 

Description. — The following parts are excised through a combined 
transverse and vertical incision : — the right and left sternoclavicular articula- 
tions, sternal ends of right and left first ribs, sternal end of right second rib, 
and upper 2.5 cm. (i inch) of manubrium — thus exposing the innominate. 

Position. — As in Mott's operation (page 26). 

Landmarks. — Suprasternal notch and manubrium; sternal ends of 
clavicles; inferior margin of thyroid cartilage. 

Incisions. — (i) Transverse incision — along upper border of sternum and 
over the surfaces of the inner thirds of both clavicles, (a) Vertical incision 
— from lower border of larynx, down the median line, and well onto the 
manubrium stemi (Fig. 7, D, D). 

Operation. — Carry both incisions through skin, superficial and deep 
fasciae. In the transverse incision, divide stemomastoids, sternohyoids, 
and sternothyroids. Subperiosteally resect (with Gigli saw, rongeur, bone- 
cutting forceps, or chisel) the inner extremities of the left clavicle and left 
first rib — for about 1.3 cm. (^ inch) of their extent. Having made this 
exposure of the upper and outer portion of the manubrium upon its left 
aspect, free, through this approach, the posterior surface of the manubrium 
subperiosteally. The manubrium is then cut transversely through at a level 
about 2.5 cm. (i inch) below its upper border — the division being accom- 
plished, preferably, by a Gigli saw conducted beneath the bone, between it 
and the periosteum. The sternal ends of the right clavicle and the right 
first and second ribs, after having been well cleared, are divided close to the 
outer margin of the sternum, in the same manner as the manubrium was 
divided. The mass of bone detached by the above cuts is now removed. 
The periosteum is then incised in the median line — the inferior thyroid 
veins ligated — the left innominate vein depressed — the right innominate vein 
retracted — the right pneumogastric nerve and pleura guarded on the outer 
side and behind — the innominate arterj' cleared — and the ligature passed 
from the pleura and pneumogastric. 



LIGATION OF INNOMINATE ARTERY 

BY SPLITTING OF MANUBRIUM STERNI. 

Description. — The manubrium is exposed by a transverse incision — 
divided transversely at its junction with the gladiolus — then split vertically 
at its center— followed by the separation of the two halves of the manubrium 
and the e.xposure of the innominate. Upon completing the operation, the 
bony parts are returned to their normal positions — with or without suturing 
of the edges of the vertically divided manubrium into apposition. 

Position. — Patient supine; shoulders raised; neck prominent. Surgeon 
to right side. Assistant opposite. 

Landmarks. — Sternoclavicular articulations; lower border of manubrium 
(marked by line extending transversely across between the articulations of 
the second ribs). 

Incision. — Curved transverse incision — passing from inner third of 
anterior surface of one clavicle to the inner third of the anterior surface of 



SURGICAL ANATOMY OF COMMON CAROTID ARTERIES. 



31 



I 

I 



I 



the opposite clavicle, and passing down over the manubrium to the junction 
of its upper and middle thirds (Fig. 7, E). 

Operation.— Having incised skin, fascia, and anterior borders of the 
platysma down to the bone, clamp and tie all bleeding vessels. Free the 
manubrium subi)eriosteally over its anterior surface, downward to the junc- 
tion of the manubrium and gladiolus, and upward to its superior border. 
Follow the superior border backward and downward along its posterior 
aspect — also freeing this surface subperiostcally as far as the junction of manu- 
brium and gladiolus. Retract the overlying soft parts on the anterior aspect 
of the manubrium and divide the sternum along the manubrio-gladiolar 
junction — accomplishing the division with a GigU saw, if one can be conducted 
across beneath the bone, or by bone-rutting forceps. Through the opening 
thus made by the transverse division, carry a Gigli saw from the ccnier of 
the lower border of the divided manubrium to the center of the suprasternal 
notch — and divide the manubrium vertically in its center, cutting from the 
manubrio-gladiolar junction Ufnvard toward the free superiur border — the 
Gigli saw traveling l>etween the posterior surface of the manubrium in front, 
and its periosteum posteriorly. After the completion of the vertical section, 
retract the two halves of the manubrium laterally — incise the posterior perios- 
teum — ligale the inferior thyroid veins — depress the left innominate vein, 
retract the right innominate vein — guard the right pneumogastric and [>leura 
c.itemally and posteriorly — clear the innominate — and pass the ligature from 
the pleura and pneumogastric. 

Comment. — Where it is wished lo suture together the vertical borders 
of the split manul)rium, two or three holes should be drilled on each side 
as soon as the manubrium has been exposed anteriorly and posteriorly, and 
before its division— the soft parts below being protected by some thin, flat 
metallic instrument during the drilling. 

Comparison of Methods of Exposure of the Innominate, — Choiie 
would K»e given to methiMls of nun-division of muscles, with rt-traction — 
the obUfjue incision thus being preferable to the angular one — where these 
incisions promise sufficient room for manipulation. Where more room is 

rssani'. especially from abnormal displacement of the parts (as from 

irism), the angular incision, or the methods of partial resection, give mt)re 
mace for the safe carrying-out of the necessary steps; and of these latter, 
ific melliod of partial resection upon the right aspect of the manubrio-clavicular 
region is applicable to cases where a more limited sacrifice of bone will suffice; 
and Bnrdenheuer's operation — lur the splitting of the manubrium — where the 
RLUcimum space is required. The innominate has also been ligated through 
a trephine-opening made through the manubrium slerrii, after turning back 
flap of soft parts. 



SURGICAL ANATOMY OF COMMON CAROTID ARTERIES. 

Description.— (a) Right Common Carotid : About 0,5 cm. (3J inches) 
in length. Arises from bifurcation of innominate, behind right stemocUivicular 
articulation — passes upward and outward and slightly backward to upper 
border of thyroid cartilage (opposite fourth cervical vertebra, according to 
Morris; — third cervical vertebra, accc^rding to Gray) — there dividing into e.x- 
I Aod internal carotids. In its course it is containe<l within a common 
of connective tissue, which also includes internal jugular vein and 
pnaimogastric nerve, each separated by a fibrous seplum^ — the vein lying to 




32 OPERATIONS UPON THE ARTERIES. 

outer side and slightly overlapping artery, and the pneumogastric l)ring 
between and posterior to both. The omohyoid muscle crosses common 
carotid opposite lower border of cricoid cartilage, and divides the artery, 
surgically, into a lower part, deeply placed — and an upper part, superfici- 
ally placed, (b) Left Common Carotid: About 11.5 cm. (4^ inches) in 
length. Arises from middle of transverse portion of arch of aorta — ascends 
upward and outward behind, but at some distance from, manubrium steriii, 
overlapped by left lung and pleura, and in front of trachea, to left sterno- 
clavicular articulation — whence its course, relations, and terminations are 
same as for right common carotid. The crossing and relations of the omo- 
hyoid muscle are aLso similar. 

Relations. — (a) Left Common Carotid in Thorax: Anteriorly— 
manubrium sterni; origin sternohyoid; origin sternothyroid (above three 
structures being at some distance); remains of thymus; fatty areolar tissue 
of superior mediastinum; left innominate vein. Posteriorly (from below 
upward) — trachea; esophagus; thoracic duct; recurrent lar3mgeal nerve. 
External (to left) — left pleura and lung (slightly overlapping) ; left pneumo- 
gastric; left subclavian (both of latter being somewhat posterior). Internally 
(to right) — innominate artery; trachea; remains of thymus gland; left 
inferior thyroid vein, (b) Both Common Carotids in Neck: Anteriorly 
— skin; superficial fascia; platysma; deep fascia; stemomastoid; sternohyoid; 
sternothyroid; omohyoid; anterior jugular vein; thyroid body (often overlaps); 
middle thyroid vein; superior thyroid vein; lingual vein; facial vein; middle 
stemomastoid artery; descendens hypoglossi nerve (generally upon, some- 
limes within, sheath); communicantes hvpoglossi; lymphatic glands. Poste- 
riorly — pneumogastric nerve; sympathetic nerve; cervical cardiac branches 
of sympathetic and pneumogastric nerves; recurrent larjugeal nerve; inferior 
thyroid artery; longus colli; rectus capitis anticus major. Externally — 
internal jugular vein; pneumogastric nerve. (On right side a space is left 
at root of neck by divergence of vein, in which pneumogastric nerve and 
vertebral artery are found; on left side the internal jugular vein overlaps 
this space). Internally (from below upward) — trachea; esophagus; re- 
current laryngeal nerve; branches of inferior thyroid artery; lateral lobe of 
thyroid body; cricoid cartilage; thyroid cartilage; lower part of pharynx; 
carotid glands. 

Branches. — None, ordinarily. 

Line. — (With head turned moderately to opposite side and upward) — 
from sternoclavicular articulation to a point midway between angle of jaw 
and tip of mastoid process — that portion of this line between the sterno- 
clavicular articulation and the level of the upper border of the thyroid cartilage 
representing the common carotid. From the clavicle a little external to the 
sternoclavicular articulation would more accurately represent the line. The 
anterior margin of the stemomastoid muscle overlaps the carotid throughout. 
The omohyoid muscle crosses the carotid opposite and directly over Chas- 
saignac's "carotid tubercle" (costal process of sixth cervical vertebra) — 
which is about .6.3 cm. (2^ inches) above the clavicle. 

Indications for Ligation. — Wounds of itself and branches of external 
and internal carotid; di.stal and proximal aneurism; distal angiomata; as a 
temporary ligature; to limit growth of inoperable tumors; hemorrhage from 
areas supplied by distal branches. 

Sites of Ligation. — Above the omohyoid muscle — place of election. 
Below the omohyoid — depth of artery and nature of relations make the 
operation more difficult and more fatal (Fig. 7, F and G). 



LIGATION OF COMMON CAROTHI ARTKRV. 



33 




Viz o— l.niATioM oi» Rir.Hr Common Carotid ahovk OMOHvofD;— A. A Platvsma ; B. Sier- 
I tf«>uu.«<<>t') (rTtfu«ir<l rtiiiwjn)!. COnohytlid i ri'ini«nf«i ijowimiinli , 1). *^ienM.»lh\roi*J ; K. Common 
I c*f*'i ' ''- '-"••alli luci**-"! abuve otnoh>oiid>; P, SlfrnumaMoid anef\ ; <», Internal jiiij^ulnr vt-iii : 
I tl. -- ' loid vci«; I. lti(cnur thyroid vein; J, CummiiuiciiliiiR vein between anleriot and 

^: . K, One al traiisiversalui culli nervtsi ; L, Nerves (ruin luop between dp&ccudi;iij& nnd 
BunicAiift hypoclossi. 



LIGATION OF COMMON CAROTID ARTERY 

ABOVIi THE OMOHYOID MCSCLE 

Position. — Palient supine; shoulders elevale<l, neck prominent; chin 
upward and to tipptxsitc side. Surgetjn on side of operation, or on the ri^ht 
for both sides. 

Landmarks. — Line of artery; anterior btirdcr of sternomastoid ; cricoid 
cart i In ^'c. 

Incision. — About 7.5 cm. (3 inches) in length, with center at level of 
cricoid i.iTtilaKe — the incision lying in ihe line uf the artery (Ftg. 7, F). 

Operation.— incise skin, superficial fascia, and [ilaty^ma. Superficial 
veins connecting anterior and external jugulars, and sometimes intercom- 
niuni<^ling veins Ix'tween facial and anterior jugular, as well as cutaneous 
ncfXTs are encountered (F'ig. 9). Divide the deep fascia along the anterior 
border of the slemomasloid and o|>en up the cellular tissue. The upficr 
bofuJcT of the omohyoifl is here exposed, either by direct incision or by follow- 
ing up the anlcrior border of the sternomasttiid. Having identified the 
intersection of stemomasttjiil and omohyoid, the omohyoid is retracted 
downward (or may be diviiletl if in the way)- — and the sternomastoid outward. 
Flexing the chin aids during these manipulations, by relaxing the parts. 
The common carotid is now lotate«l as it crosses the "carotid tubercle" (sec 
.AnalomVt " Line.*' page 32), Clear its sheath, avoiding or lying the 
slemomastoid arter}' and the superior and middle thyroid veins. Carefully 
indse the sheath, approaching from the inner side, to avoid the descendcns 



34 OPERATIONS UPON THE ARTERIES. 

hypoglossi nerve (generally on the antero-extemal side of the sheath) and 
the internal jugular vein, and see that artery is freed from its sheath in its 
entire circumference. Pass the needle from the internal jugular and pneu- 
mogastric nerve. 

Collateral Circulation. — Inferior thyroid, with superior th)rroid. Deep 
cer\ical, with occipital. Transversalis colli, with occipital. Branches of 
two vertebrals, with branches of two external carotids. Circle of Willis. 



LIGATION OF COMMON CAROTID ARTERY 

BELOW THE OMOHYOID MUSCLE. 

Position — ^Landmarks. — As in the ligation above the omohyoid. 
Incision. — About 7.5 cm. (3 inches) in length, in line of artery — from 
just below cricoid cartilage to just above sternoclavicular articulation 

(Fig- h Co- 
operation. — Incise skin, superficial fascia, and platysma. Here arc 
encountered the superficial veins between the facial, anterior and external 
jugular veins, and the cutaneous cer\'ical nerves. Divide the deep fasda 
along the anterior border of the sternomastoid. Expose the inner border 
of this muscle, flexing the head to relax the parts. The sternohyoid is then 
exposed, and sometimes the underlying sternothyroid. The omohyoid is, 
ordinarily, not brought into the field of operation. These muscles, if en- 
countered, are retracted in their respective directions, or may be divided 
as far as necessary. Tie the inferior thyroid veins. The sheath is to be 
exposed as, and with the precautions, mentioned in the above operation. 
The recurrent larj'ngeal nerve and the inferior thyroid artery are to be espe- 
cially guarded in operating at this site. 

Comment. — The ligation of the common carotid is more difficult on 
the left side, owing to the nearness of the internal jugular vein (see Anatomy, 
"Relations," page 32), and the operation is less frequently done than on 
the right side. 



SURGICAL ANATOMY OF EXTERNAL CAROTID ARTERY. 

Description. — The smaller of the two divisions of the common carotid. 
About 6.3 cm. (2^ inches) in length. Begins opposite upper border of thyroid 
cartilage; passes upward, forward, and then backward, under the stylohyoid 
and posterior belly of the digastric, to the interval between neck of condyle 
of inferior maxilla and the external auditory meatus, where it divides, in 
the substance of the parotid gland, into the internal ma.xillary and temporal 
arteries. 

Relations.— Anteriorly : skin; superficial fascia; platysma; deep fasda; 
anterior border of sternomastoid; hypoglossal nerve; lingual vein, facial vein; 
posterior belly of digastric; stylohyoid; temporomaxillary vein; superior 
cervical lymphatic glands; branches of facial nerve; parotid gland. Poste- 
riorly: internal carotid artery; styloglossus; stylopharyngeus; glossopharyn- 
geal nerve; pharj'ngeal branch of pneumogastric; stylohyoid ligament; parotid 
gland ; superior laryngeal nerve. Externally : internal carotid artery. In- 
ternally: hyoid bone; pharynx; ramus of inferior maxilla; stylomaxillary 
ligament; submaxillary gland; parotid gland. 

Branches (from below). — Ascending pharyngeal; superior thyroid; 
lingual; facial; occipital; posterior auricular; temporal; internal maxillary. 



LIGATION OF EXTERNAL CAROTID ARTERY. 



35 



I 



Line. — Upper part of line of common carotid artery (page 32). 

Indications for Ligation. — Wounds and aneurism of trunk and branches; 
hemorrhage from areas of branches; palliative in malignant growths; pre- 
liminary to operations; aneurism by anastomosis in the regions of the 
trunks. 

Sites of Ligation. — Below the digastric (between the superior thyroid 
and lingual branches) — place of electiun — the operation is easier and more 
branches are thus controlled. Above the digastric — the operation is more 
difficult and more apt to involve branches of the facial nerve. Note: — The 
digastric muscle crosses the artery about 3.2 cm. (i| inches) above its origin, 
opposite the upper l>ordcr of the thyroid cartilage. The lingual arises oppo- 
site ihc great cornu of the hyoid bone. (Fig. 7, H and L) 

Comment. — (i) The external carotid may be distinguished from the in- 
ternal carotid by the presence of its branches and by being to tlie inner side 
of the external carotid. (2) The ligation of the external carotid is now 
gcntrrally done where formerly the common cnmiid was ligated for 
conditions of the former vessel and its branches — the practicability and 
de^^irability of the operation having been demonstrated bv ihe work of 
Wyeth. 



LIGAnON OF EXTERNAL CAROTID ARTERY 

BELOW THE DIGASTRIC MUSCLE. 



t Position. — .\s for the common carotid (page ^^). 
Landmarks. — Sternomastoid ; thyroid cartilage; angle of jaw. 
Incision. — About 7.5 cm. (3 inches) — along the anterior border of the 
momastoid, or slightly \n front of border — from level of middle of thyroid 
tilage, to near angle of jaw (Fig. 7, H). 

Operation. — Incise skin, superficial fascia, and platysma (Fig. 10). Tie 
any veins which may lie in the line of incision. Divide the deep fascia and 
expose the anterior border of ihe stcrnomastoid and draw it outward. Find 

I the posterior belly of the digastric at the upper angle of the wound- Next, 
locate the hypoglossal nerve crossing the external carotid below the origin 
of the ocdpital artery. LcKate the tip of the great cornu of the hyoid bone, 
opposite which the lingual artery arises. Having fixed the location of these 
three structures, and avoiding the superior thyroid, facial, and lingual veins; 
expose the artery opposite the lip of the great cornu of the hyoid. Clear 
the sheath and pass the ligature between the superior thyroid an<i Ungual 
branches — guarding the descendens hypoglossi nerve in front, and the .supe- 

Irior larj'ngcal nerve passing behind Ihe arter\- — directing the needle from 
the internal carotid. 
Comment. — (i) The operation is not an easy one, and it is often difficult 
lo recugnize the branches, (a) Jacobson advises simultaneous ligation of 
the suix?rior thyroid, the lingual, ami, if possible, the ascending pharyngeal 
branches — on account of secondary hemorrhage. (3) Through this same 
tnciiiion the superior thyroid. Ungual, facial, occipital, and ascending phar\'n- 
grnl may be ligated. 

Collateral Circulation. — Same as for the ligation of the common carotid 
above the omohyoid (page 34). 



36 



OPERATIONS UPON THE ARTERIES. 




FiR. lO.— Lir.ATION OK RlCillT EXTKRNAL CAROTID BFI.OW DIGASTRIC; AND At. SO OF K'TKRNAL 

C'aroiid. Si'PKKiOK Thvkoid. LiNGiAi., Kaciai. AND ( )(:cipi lAi., NKAR Orkhn :— A, Suprrhcii! 
fascia; B, H, Plalysma ; C, Ccrviial fascia ; M. Stcnn)mast<)id i retracted outward); E. Posterior bclly 
<>f (ligaslrir; F. Hy(i>;lossus. with liiij^tial artery disa)>|K>aiiti;>; beneath il ; (», Thy rcih void M.: H. 
Middle constrictor M. ; I, Inferi<»r con«ilriitor M. ; J, Tip fif ji^eal coniu of hyoid hone; K. External 
carotid A.; L. Internal carotid; M.Siipeiiur thyroid; N, Faci;il ; O, Occipital; P. Internal ju]iO>lar 
v.; y. Lingual and facial veins emptying into internal jnguiar; R. Superior thyroid V. ; S. Hjpo- 
glossal N. ; T. Descendens noni N. 



LIGATION OF EXTERNAL CAROTID ARTERY 

ABOVE DIGASTRIC Ml-SCLE AND BEHIND RAMUS OF JAW. 

Position. — As for the common carotid. 

Landmarks. — Line of artery; ramus of inferior maxilla. 

Incision. — From tragus of ear, to below angle of inferior maxilla, and 
placed just behind the ramus of the jaw. in the line of the artery (Fig. 7, I). 

Operation. — Incise skin and superficial fascia. Avoid, or doubly ligatc 
and incise, the tributaries of the external jugular and facial veins. Divide 
the deej) fascia. Fl.xpose the anterior border of the sternomastoid and retract 
outward. F-xpose the posterior belly of the digastric and stylohyoid and 
draw downward — partially or entirely dividing them if necessary. Avoid 
the branches of the facial nerve. FApf)se the parotid gland and draw upward 
and forward — thus exposing the vessel. Clear the artery and open its sheath 
— and pass the ligature around the artery prior to its entrance into the sub- 
stance of the parotid gland. Repair, by suturing, whatever muscles may 
have been incised. 



SURGICAL ANATOMY OF LLXGUAL ARTERY, 



57 



r 



SXJRGICAL ANATOMY OF SUPERIOR THYROID BRANCH OF EXTERNAL 

CAROTID. 

Description. — The second in order and an anterior branch of ihe ex- 
ternal carotid. Runs forward and a liule upward beneath the great cornu 
of the hyoid bone, lying in the superior carotid triangle and covered bv the 
skin, fascia, and plalysma — then runs inward and downward, passing under 
the omohyoid, sternohyoid, and sternothyrnid to the upi>er part of the thyroid 
gland. The superior thyroid vein runs beneath the artery on its way to the 
internal jug:ular vein. The superior laryngeal nerve is in close relation 
posteriorly. 



I 



UGATION OF SUPERIOR THYROID BRANCH OF EXTERNAL CAROTID. 

Position— Landmarks. — As for ligation i>i external carotid below the 
digastric f page 35). 

Incision. — .\bout 5 cm. (2 inches) in length — along the line of the 
eJfternal carotid artery, with its center on a level with the upper lumler of 
the thyroid cartilage (Fig. 7. J). 

Operation. — Practically the same as for the h'gation of the external 
carotitl below the digastric, the main trunk Ijeing first exjiosed, and the 
superior thyroid branch being then loiMicd, (luard the superior laryngeal 
ncr\e> Place the ligature between the external carotid and the hyoid branch, 
or beyond the sternomastoid branch. 



SURGICAL ANATOMY OF LINGUAL BRANCH OF EXTERNAL CAROHD. 

Description. — The third in order, and an anterior branch of the external 
canjtid. .\rises opposite, or a little below, the great ctirnu of the hyoid bone, 
about 2 cm, (J inch) above the bifurcatii»n of the common carotid, (a) First 
or <)bUque Portion: — lies in superitjr carotid triangle, extending obliciucly 
iipw'ani to the external border of the hyoglossus, — being co\'ere<J by skin, 
sufierficial fascia, platysma, deep fascia, and hypoglossiil nerve, — and resting 
cm the middle constrictor and laryngeal nerve, (b) Second or Horizontal 
portion: — lies in the digastric triangle, running horizonlally beneath the hyo- 
gloSi»us muscle, along the su|)cri«)r bvtnJer of the h\>jid bone. — ^being covered 
by the hyoglossus muscle (which separates the artery from the hypoglossal 
ncrre» posterior belly of the <lignstric, stylohyoid muscle, and lingual vein), 
— and resting upon the middle constrictor of the pharynx and gcniohyo- 
[gloHsus. (c) Third or .Vscending IVjrtion: — ascends between the hyoglossus 
jind geniohy«»gIossus to the inferior surface of the tongue, (d) Fourth or 
Terminal Portion; — nins forward to tip of tongue, lying between the lingualis 
and geiiiohyoglossus, an<l co\'ered only by mucous membrane. Two venie 
cnmites acci»mfKiny the lingual artery beneath the hyoglossus. The ranine 
vein njn«. on the supcrlicial surface «>f the hyoglossus, l»etow the hypoglossal 
ner\'t' Sexera! veins follow the dorsalis lingua^ artery. 

Sites of Ligature. — Its first or second portimis are the parts usually 
lied — ^and of these, the second is preferable (Fig. 7, K and L). 



38 OPERATIONS UPON THE ARTERIES. 

LIGATION OF LINGUAL BRANCH OF EXTERNAL CAROTID 

NEAR ITS ORIGIN. 

Position — Landmarks. — As for ligation of external carotid below the 
digastric (page 35). 

Incision. — In line of external carotid, with its center opposite the body 
of the hyoid bone (Fig. 7, K) 

Operation. — Same, practically, as for ligation of external carotid below 
the digastric, the main vessel being first exposed and the origin of the lingual 
then located. 

Comment. — The first part of the lingual may also be tied, though less 
readily, by a transverse incision extending from the level of the body of the 
hyoid bone to the anterior border of the sternomastoid, the artery being 
exposed and tied just before passing under the hyoglossus muscle. 

LIGATION OF LINGUAL BRANCH OF EXTERNAL CAROTID 

BKNF.ATH THE HYOGLOSSUS. 

Position. — Patient supine; shoulders raised; neck prominent; head to 
opposite side and chin upward. Surgeon on side of operation, cutting from 
before backward on the right, and vice versa. 





h 
G 
R 

A 



L - 




S Q M K P 

Fig. 11.— Ligation of Ric.ht Lisr.iAi. Artkry bknf.ath Hvooi.ossfs:— A, A, Plalysnia ; B, 
Transverse cervi<al la.siia over sulimaxillarv vlaml : (", Ikep iraiisverse cervical fascia under sub- 
maxillary K'it'xl ; I^). Submaxillary >;laiul ; E. Hyoid bone; P (al boiioin oj illustration), Anterior 
bcllv of digastric; C. Posterior lielly of digastric; H, Stylohyoid; I, Mylohyoid; J, Hyoglossus; 
K, Omohyoid; L, Thyrohyoid; NL Liiiijual artery seen tlirouj^h incision in hyoglossus; N. Sub- 
mental A.; O, Tributary of temporomiixiliary V.; P (at ri^bt inars^in of illustration), Tributar>* of 
anterior iugular V. ; Q. Ilypoj^lossal .\. (above) and ratline \'. (below i; K, Transverse cervical ner\'e; 



SURGICAL ANATOMY OF FACIAL ARTERY. 



39 



I 



Incision. — Cuned incision — beginning just below and external to sym- 
physis menti — and ending just below and internal to crossing of facial artery 
over inferior maxilla — it> center being just above the greater cornu of the 
hyoid bone (Fig. 7. L). 

Operation. — Incise skin, superficial fascia, platysma* and deep fascia. 
Avoid or ligate trii>uurie.s of facial, anterior jugular, or temporomaxillar}' 
veins. Incise the transverse cervical fascia over the submaxillary gland — 
exposing the gland and retracting it upward, out of its bed, over the margin 
of the lower jaw (Fig. 11). Incise transversely the deep cervical fascia 
exposed by lifting out the submaxillary gland — and identify the mylohyoid 
muscle in the anterior aspect of the wound. Expose the two bellies of the 
digastric and hrmly retract them downward at their point of attachment to 
the hyoid bone — which steafJies the parts and renders the hyoglossus more 
prominent. Clear the surface ul the hyuglossus and itlentif)' the hypoglossal 
nerve crossing its anterior aspect. The ranine vein crosses the same surface 
just below and parallel with the nerve and at about the same level as the 
artery lies on the opposite side of the muscle. Retract both hypoglossiil 
nerve and ranine vein upward. Divide the hyoglossus transversely for 
about 1.3 cm. (i inch) just above and parallel with the hyoid bone. This 
incision falls just over the artery, which generally bulges into the opening 
as soon as it is made, or through which it is easily reached. Having 
isolated the arter>', trace it backward until the tiorsalis lingua- branch 
is reached, so that the ligature may be placed upon its proximal side. 
HaNing passed the ligature, replace the submaxillary gland and close the 
wound. 

Comment. — The fascia of the submaxillary gland may be sutured over 
it, and the incision in the hyogiossus may be repaired by suturing, if either 
be considered indicated. 



SURGICAL ANATOMY OF FAQAL BRANCH OF EXTERNAL CAROTID. 

Description, — The fourth in order, and an anterior branch of the ex- 
ternal lanDtid. The Cerviial Portion passes upvvanl and forward in the 
posterior part of subma.villary triangle, under the digastric, stylohyoid, 
submaxillar}' gland, and horizontal ramus of inferior maxilla. The Facial 
Portion curves over lower border of inferior m.ixillu at the anterior border 
of masseter mu.scle — and, running forward and ujnvard, crosses the cheek 
to the angle of mouth — thence upward along side of nose to end at internal 
canlhus of eye. 

Relations,— Cervical portion rests on (from below upward) stylo- 
glossus; mylohyoid, submaxillar)' gland (in or under it); — and is covered by 
(from l>elow upward) posterior belly of digastric; stylohyoid; h>7ioglossal 
nerve (generally); submaxillary gland (beneath or in its sub.^tance); inferior 
maxilla; lymphatic glands; fascia; platysma; skin. Facial portion rests on 
(from below upward) inferior maxilla; buccinator; levator anguli oris; levator 
Ai sui^erioris (sometimes); infraorbital branches of fifth nen*e; — and is 
jvered by (from below upward) risorius; zygomatic! major and minor; 
tipramaxillar>' and buccal branches of facia! nerve; levator labii superioris; 
levator labii suf)erioris ala."t|ue nasi; infraorbital branches of facial The 
\\ portion of the facial vein is more direct than the artery, and separated 
tt by submaxillary gland, posterior belly of digastric, stylohyoid muscle, 
and h>ix)glos.<>al nerve. The facial portion of the facial vein is also more 



40 



OPERATIONS UPON THE ARTERIES. 



direct than the facial portion of the facial artery, and is separated from its 
artery by the zygomatici major and minor. 

Sites of Ligation. — Near origin (less frequently), — over lower jaw (the 
usual selection) (Fig. 7, M ). 



UGATION OF FACIAL BRANCH OF EXTERNAL CAROTID 

NEAR ORIGIN. 

Position — Landmarks — Incision— Operation.— Practically the same as 
for ligation of the external carotid below the digastric. 

LIGATION OF FAQAL BRANCH OF EXTERNAL CAROTID 

OVER INFERIOR MAXILLA. 

Position. — Patient supine; shoulders raised; head thrown back and to 
opposite side. Surgeon on side of operation, or on right for both sides. 

Landmarks. — Anterior margin of masseter muscle; horizontal portion 
of inferior maxilla. 

A G L I F H 




Fi«. ij.— l.ir.ATioN OK RKiHT Faciai, ovkk Bordkk ok Inkkrior Maxii.la : — A, Cer\ical 
fascia; B, Plalysiiia ; C, Dt-t-ji cervical fascia; I), Submaxillary j;land ; E, Mylohyoid muscle: F, 
Inferior maxilla ; C, Masseter M. ; H, Dt-picssor aiiguli mis ; [, Facial A. ; J, Facial V. ; K, Submen- 
tal A.; L,Su|iiamaxillary N. 



Incision. — .About 2.5 cm. (i inch) in length — placed along and under 
cover of lower border of lower jaw, with its center over the course of the 
artery (at the anterior margin of the masseter muscle) (Fig. 7, M). 

Operation. — Incise skin, sui)erficial fascia, platysma, and deep fascia, 
when the artery should come into view — with the facial vein just posterior 
to it. Avoid branches of the facial nerve (Fig. 12). 



LIGATION OF OCCIPITAL BRANCH OF EXTERNAL CAROTID. 41 



SURGICAL ANATOMY OF OCCIPITAL BRANCH OF EXTERNAL 

CAROTID. 

Description. — The fifth in order, and a posterior branch of the external 
carotid — passing upward and backward to the interval between mastoid 
prtxess of temporal and transverse process of atlas — thence horiiionlally 
backward in the occipital groove — thence upward unto the scalp. 

Relations. — First Part (internal to stermmiastoid) — covered by skin, 
fascia, posterior belly of digastric; parotid gland; temptiromaxiliary vein; 
hypoglossal nerve; — and rests on internal carotid artery; hypoglossal nerve; 
pneumogastric ner\'e; internal jugular vein, and spinal accessory nerve. 
Second Part (beneath sicrnomastoid) — covered by sternomastnid; splcnius 
c«tpilis; Irachelomastoid; origin of digastric; — and rests on capitis lateralis, in 
occipital grcxne of mastoid process of temporal, and on the insertion of 
superior oblique muscle. Third Part (external to sternomastoid) — covered 
by skin, aponeurosis uniting occipital attachments of sternomastoid and 
trapezius — and resting upon the complexus. It perforates this aponeurosis 
jusi mentioned, or the posterior belly itself of the occipitofronlalts, together 
^with the great occipital nerve — and follows, roughly, the line of the lambtloid 
Iture. between the integument and the cranial afMmeurosis. Two venas 
crimites accompany the occipital artery. 

Sites of Ligation. — Near its origin — and behind the mastoiil process 
of the temporal — according to site of lesion requiring ligature (Fig, 7, N). 



UGATION OF OCCIPITAL BRANCH OF EXTERNAL CAROTID 
.m:ar origin. 

Position — Landmarks — Incision — Operation. — As for ligation of the 
external carotid bdow the digastric (page 35). 



LIGATION OF OCCIPITAL BRANCH OF EXTERNAL CAROTID 

BFJIIXD MASTOID PROCESS. 

Position. — Patient supine; shoulders anrl head elevated; head turned 
well to o(»po>ite side (or patient resting slightly to one side). Surgeon -lands 
behind, on side of operation. 

Landmarks. — ^lastoid process; external occipital protuberance. 

Incision. — .\b<iut 5 cm. (2 inches) in length — beginning from lip of 

>toid process and extending toward the external occipital protuberance 
ig. 7. N). 

Operation.— Having incised skin anrl fascia. divi<le the posterior half 
c4 the ^lt■^lomasloid and its string aponeurosis — then the splenius capitis — 
then .1* many fibers of the trachelomastoid as are in the way (Fig. 13). Relax 
and retract the muscles by turning the head to the side of the operation. 
~^x[M>se the artery rlecp tjown between the mastoid process of the temporal 
,D<I the transverse process of the atla.s, resting upon the superior oblique 
and complexus muscles. Having separated from it the accompanyinj; veins, 
ami luving guarded the veins from the mastoid foramen, the ligature is 
paMrd. The lesser occipital nerve runs on the posterior surface of the sterno- 




4' 



(fVy.kAtiOSS VVOS THE ARTERIES. 

Ml D A 




;j 



! >K M < X V ^^ V > • v\n - . ^^^^' '^'^'^^ 'V.^5r.>:iN r,,x-Ess:-A. Posterior 



vipitaJ nerv-e; 



tN>,iMxN->-, ^s^t .V «Nxv;oNV X--. v: ,•.--,. :Sf err;.: .vnpi^L] iienr pierces the 



sn >^;^^^; ^wrvwv v^v posterior Ati^icajkx ssik^cs of ex- 



*Vvv^'iffN'«>r 






N v->N - — - ^^; . 



' ^^> ^ SlIOCUL 



,>5/-;:.- 



.^[^LXUK. ff 



\^ 



..sn\ n V N > V . . 



.r ^T.^v-^ <Y siraaac. 



Aw-'- -■ 



r^rmv tt aa»Bsat 



LIGATION OF TEMPORAL BRANCH OF EXTERNAL CAROTID. 43 

Incision.— About 3.8 cm. (i^ inches) in length, between posterior aspect 
of pinna of ear and anterior border of base of mastoid process. 

Operation.^Having incised skin and fascia and avoided facial and 
posterior auricular nerves, the artery is found, with accompanying vein, in 
the groove between the cartilage of the ear and the base of the mastoid process 
(Fig. 14). 




fig. M— LiGATioK OF Right Posterior Al-ricllar behind Ear :— A, Riemomostoid ; B, 
ReirxJt«n«^«urr«n: C. Posterior auricular artery and vein; D. Samv. bcncaih rvtrahcns aurcm; E. 
Biatul). u( occipilalis luiiior ner>'e,' F, Auricularis ma^iius tierve; G. Pusterior auricular branch 
ut iauAl; H, Parutid glatid. 



SURGICAL ANATOMY OF TEMPORAL BRANCH OF EXTERNAL 

CAROTID. 

Description. — The seventh in order and the smaller but more direct 
of the two terminal branches of the external carotid. Arises in substance 
of parotid gland, opposite neck of inferior maxilla — and runs upward, beneath 
parotid gland, between condyle and external auditory meatus — thence upward, 
rossing the posterior root of the zygoma — and continuing upward under the 
Ittrahens aurem muscle and temporal aponeurosis for 3.8 cm. to 5 cm. (1^ 
'to a inches), where it divides into anierior and posterior branches. A plexus 
of sympathetic nerves surrounds the vessel — it is crossed by the temporofactal 
division of the facial nen'e — ^and is accompanied by the auriculotemporal 
nerve. 

Sites of Ligation. — Just above r(X)t of zygoma. The anterior and 
(Kj&terior branches may be ligated at their bifurcation, about 3.8 to 5 cm. 
(i^ to 3 inches) above the zygoma. 



LIGATION OF TEMPORAL BRANCH OF EXTERNAL CAROTID 

JLST ABOVK ZVGUMA, 

Position. — Patienl supine; shoulders raised; head to opposite side. 
jrgeon on side of operation, cutting from above downward on right, and 
' vrrsa (or on right for both operations, cutting from above downward). 
Landmarks. — Tragus of ear; condyle of jaw; zygoma. 



44 OPERATIONS UPON THE ARTERIES. 

Incision. — Vertical, about 2.5 to 3.8 cm. (i to ij inches) in length, over 
line of artery, with center over zygoma, and extending downward in the 
interval between the tragus of the ear and the condyle of the lower jaw 
(Fig. 7, O). 

Operation. — Incise skin and dense subcutaneous tissue and parotid 
fascia — when the artery will be exposed lying quite superficial as it crosses 
the zygoma. Avoid the accompanying vein posteriorly — also avoid the 
branches of the temporofacial division of the facial nerve and the auriculo- 
temporal nerve (Fig. 15). 




KiK 15— I-KiAFKiN OK Kii.nr TKMPORAr, Ji'ST AROVK Zvr.oMA :— A, Temporal artery, with ils 
anterior :iinl |>4isiiTi<>r hiiiirLalion^, ami iu lr.iiis\irse lacial. middle teiu])<)ral, and anterior auricular 

braiuhes ; H. leiupotal \cin. \\ itii iiraiirlus i <>i u— j iiiii; lo those ol arierv ; C. Teiniioral branches 

oi aiin«uli.ilenipuial nei\e; I), Biancli ut tenipoioi.i. ial di\isi<)iiijf laiial nerve; !C, Temi)oral fascia. 

SURGICAL ANATOMY OF INTERNAL MAXILLARY BRANCH OF EX- 
TERNAL CAROTID. 

Description. — The eighth in order and the larger of the two terminal 
branches of the external carotid, arising opposite neck of jaw, in substance 
of parotid gland. 

Course and Relations.- First or maxillary portion : — passes inward 
and forward between neck of inferior maxilla and internal lateral ligament, 
surrounded by deep part of parotid gland. Runs j)arallel with and ju^^t 
below auriculotemporal nerve and external j)tcrygoid muscle, crossing the in- 
ferit)r dental nerve. Second or pterygoid portion: — takes one of two courses: 
(a^ ■■ F.itluT runs between the two pterygoid muscles and ramus of jaw, and 
then turns up over outer -urface o\ external pterygoid beneath the temporal 
muscle to gain the two heads of the external pterygoid, between which it 
sinks into the >phenomaxillary fossa — or (b) it passes behind and internal to 
the external pterygoid, and i- covered by that muscle till it reaches the inter\'al 
between its two heads, where it then often I'orms a projecting loop as it turns 
into the sphenomaxillary fo<sa " (Morris). Third or sphenomazillary 
portion:— enters si^hennmaxilKiry fossa, between two heads of external ptery- 
goitl. and is placed beneath the superior maxillary division of the fifth ner\'e 
and in relationship with Meckel's ganglion — and here it divides into its 



SURGICAL ANATOMY OF MIDDLE MENINGEAL ARTERY, 



45 



The middle meningeal branch is tied within the cranium for intracranial 
hemorrhage. 



SURGICAL ANATOMY OF MIDDLE MENINGEAL BRANCH OF INTERNAL 

MAXILLARY BRANCH OF EXTERNAL CAROTID. 

Description,— The lari^cst l)ranLh ui ihc ftrst or Maxillar)' Portion of 
the internal maxillary. Arises Ijetween inlernal lateral lij^ament and neck 
of inferior maxilla — anrl, under cnvtr <if external plcrygoid, passes upward 
between the two n»ils uf the aiiriculotempijral nerve to the foramen spinosum. 
l)einji (Tosi^d hy the chorda lym|>ani nerve, h enters the skull through 
this foramen and ascends in ihc irnvovc on ihe preal wing of ihe sphcnoitL 
where it divides into anterior anrl posterior branches which ramify between 
the bone and the dura. The fxiint of Ijifurcation is generally |];i\cn by anato- 
mists as correst5<:)ndinp;, on the exterior of the skull, wiih a i)oint 3.S cm. {i\ 
iiKhes) l>ehind the external angular process of the frontal hone, and 5.S to 
4,5 cm, (ij to ij inches) above the zyj^orna. The Anterior Branih runs in 
a groove on the great ala of the si»hcnoi«| and the anterior inferior an^le of 
the parietal. The Posterior Branch crosses the squam*»us p<»rtion of the 
lemi^oral and then enlcrs the groove on the posterior inferior angle of the 
parietal fxme. In ihe y<tung these measuremcnls are less. 

Indications for Ligation. — I ntratranial hcm<trrhagc. 

Sites of Ligation.— The common trunk, or the anient r or posterior 
branch, as indicated (Fig. 7, P, Q, R). 

Note. — Because of the practical surgical l^earing of the middle meningeal 
arteri' and its branches, and because of the wide variations from each other 
in the ilesrriplions of the intracranial portion of the middle meningeal artery 
juk) it5 branches in various anatomies, and because of the equally wide 
irariations of the artery and its branches, as aclualiy found in the skull. 
from the textbook descrif>tions. — ihe following summary is given of the oui- 
come of special research upon the subject made upon fifty dried skulls and 
thirty cadavera (representing r6o, upon the two sides) by S. C. Plummer. 
In the following data it is to be remembered that, owing to beveling, the 
lower part of the coronal sulmre is 5 mm. to i cm. {j\ U> | inch) more jkis- 
Icriur on the inner than outer side of skull, and that the stiuamoparietal 
suture is from 1 to t.5 cm. (J to § inch) lower on the inner than the outer 
side 

Covering of Artery.— Instead of lying fK?lvveen dura and bone (as 
generally understo<Mj) the artery is really covered by a thin process of dura 
on its outer surface; hence its adherence to the dura in sc|>araiion of the 

ttrr from the bone. 

Trunk of Middle Meningeal Artery.- (i) Present in 95 per cent. In 
50 per cent,, anterior ant! posterior branches entered separately, or the trunk 
(livide<l at the foramen spinosum. (2) Point of Division into Anterior and 
Posterior Branches: — 2 mm. to 5.5 cm. (little more than y\j to 2^ inches) from 
foramen spint»sum in a dircci line — (less than i cm, or ^^j^ inch) in 16 cases — 
between i and ,^ i m. (y^ anrl i ^\ inches) in 60 rases — over 3 cm. (ij*^ inches) 
in 1Q cases. Bifurcation was 58 times upon squamous part of temporal — 21 
ujxm $y>henoid — 15 upon squamosphenoidal suture — once on sphenoparietal 
future. (Steiner. another investigator, found a common trunk preseni in 
only 43 per cent. — and found that bifurcation occurred in 57 per cent, at the 
foramen spinosum.) (3) Length; — corresponds with point of bifurcation, 




46 OPERATIONS UPON THE ARTERIES. 

when point of bifurcation is not more than 2 cm. (f inch) above the foramen 
spinosum, — and from i mm. to 1.2 cm. (^ to ^ inch) greater when the point 
of bifurcation is more than 2 cm. (f inch) above the foramen spinosum (due 
to cur\'e in artery). (In Steiner's cases the length was from i to 3.5 cm., or 
f to if inches, in 43 cases — and from 3.5 to 5 cm., or if to 2 inches, in 8 cases.) 
(4) Direction: — almost invariably outward — and more frequently outward 
and fomv'ard than outward and backward. Generally runs outward for 2 mm. 
to 1.7 cm. (little more than j*^ to J inch) and thence outward and forward — 
running in a gentle curve. (5) Location : — almost always runs from foramen 
spinosum onto the temporal (sometimes first runs onto the sphenoid, or 
squamosphenoidal suture) — generally running from 5 mm. to i cm. (-^ to | 
inch) posterior to the squamosphenoidal suture; thence a long trunk generally 
runs onto the squamosphenoidal suture — and then onto the great wing of the 
sphenoid. 

Anterior Branch of Middle Meningeal Artery. — (i) Relative Size: — 
Generally the main branch and larger than the posterior. (3) Direction 
and Location: — Beginning at point at which lowest bifurcation occurs (v. s.), 
the anterior branch, after bifurcating on the squamous, squamosphenoidal 
suture, sphenoid, or on the sphenoparietal suture, as the case may be, passes 
fon^'ard and upward across the anterior and lower part of the squamous; — 
thence almost invariably crosses the upper part of the great wing of the 
sphenoid; — thence passes backward across the sphenoparietal suture onto the 
parietal — and runs thence generally upward and backward about parallel 
with the coronal suture, and generally within 2 mm. to 3 cm. (little 
more than -jV to i-j^ inches) of it. Practically, the most constant position 
of the anterior branch is where it crosses the sphenoparietal suture — the cross- 
ing may be at any part of its 1.5 cm. (nearly f inch) length, but is usually 
on its anterior half. (3) As to Branches of Anterior Branch: — ^The anterior 
branch did not divide in 44 per cent. In the 56 per cent, in which it did 
divide, it divided 25 times on the right and 31 on the left. There were 2 
branches in 49 cases — 3 branches in 5 cases — 4 branches in 2 cases; — and these 
divisions occurred 51 times on the parietal, 3 times on the sphenoparietal 
suture, and 2 times on the sphenoid. Kroenlein considers that the anterior 
branch, in the average case, divides into two branches, one of which runs 
up in front and one behind the rolandic fissure. Where the anterior branch 
divides into branches, one branch generally runs parallel with and within 
2 cm. (f inch) of the coronal suture. (4) Bony Canal: — In from 38 per cent. 
(Steiner) to 60 per cent. (Plummer), the anterior branch was found to run 
through a bony canal upon the anterior inferior angle of the parietal bone — 
the canal sometimes beginning upon the sphenoid — being from 3 mm. to 
2.8 cm. (I to I J inches) long. 

Posterior Branch of Middle Meningeal Artery. — (1) Much less con- 
stant in size and position than anterior branch. Generally smaller — often 
appearing as, and mistaken for, a branch of the anterior branch. Some- 
times appears to be a continuation of the trunk and larger than the anterior — 
and sometimes is larger without appearing to be main trunk. (2) Direction: — 
At first outward and backward, or upward and backward — rarely directly 
backward. Subsequently, in majority of cases, it passes horizontally backward 
— exceptionally, downward and backward. (3) Location: — (a) In Majority 
of Ca.ses: — it runs approximately parallel with squamoparietal suture, gener- 
ally within I cm. (| inch), never more than 2 cm. (f inch) from it — gradually 
approaching it — crossing it (unless its terminal branches are given off on the 
temporal bone) generally within 2 cm. (f inch) of its posterior end, passing 



LIGATION OF TRUNK OF MIDDLE MENINGEAL ARTERY. 47 

thence onto the parietal bone — its small branches ninning onto the occipital. 
(It may at first run parallel with the squamosphcnoidal sulure. It may 
cross the squamoparietal suture onto the parietal bone at any point-) (b) 
In Other Cases: — sometimes it runs outward and backward over the squamo- 
petrosal suture, or upon the squamous parallel with and generally within 
I cm. of the squamopetrosal suture — passing back over the base of the petrous 
bone, crossing the squamuparielal suture near its posterior end — thence back 
onto the parietal bone, superiorly to and parallel with the mastoparietal 
suture. (4) Branches of Posterior Branch: — In majority of cases the posterior 
branch divides into two branches — on the temporal bone, most frequently 
- — on the parietal bone, next most frequently — and on the squamoparietal 
suture, least frequently. 

Summary.— (I) That no parts of the middle meningeal artery or its 

r*nterior or posterior branches have fi.xed relations, e.Kcept the main trunk 

at its exit from the foramen s[>inosum, and the anterior branch where it 

crosses the sphenoparietal suture to reach anterior inferior angle of parietal. 

(a) That the common trunk is generally present. (J) That the anterior branch 

>inay be given off from the orbital branch of the lachr>"mal branch of the 

lophthaimic. (4) That a tendency to symmetry exists upon the two sides 

lof the skull, but is not constant. (S) That the anterior branch runs through 

fa bony canal in the anterior inferior angle of ihe parietal bone in the majority 

of cases. 



UGATION OF TRUNK OF MIDDLE MENINGEAL ARTERY IN THE 

CRANIUM 

THROt'GFI TRF.PKINKOI^F.NING E.Kt*OSED BV CUKVF-D OBIJQITE INCISIO.M. 

Position.— Patient supine; head supported, shaveii and turned to oppo- 
site side; surgeon on side of operation. 

Landmarks. — .\ point Is selected as the center of the irephine-opening 
[Wbich will fall over the trunk of the artery proximal to its bifurcalion,-=and 
rhich is taken to be about 3.8 cm. (lA inches) behind the external angular 
process of the frontal bone and 2.5 cm. (r inch) above the zygoma. 

Incision. — Begins at extenial angular process of frontal bone — passes 
obliquely downward and backward to the posterior end of the zygoma — and 
from this point upward and backward above the auricie (Fig. 7, P). 

Operation. — (i) Having incised -^kin and temporal fascia, ligate the 

, superhcial temporal artery and vein, guarding the auriculotemporal nerve 

[and branches of the facial (Fig. 16). Then carrv the incision along the 

iposlcrior border of the tem[)oral muscle through the periosteum to the bone. 

Ibetach the temporal muscle forward subpcriosteally, baring parts of tlie 

Isquamous, p.irietal, and sphenoid bones — guarding the deep temporal arteries. 

Firmly retract the soft parts thus freed upward and forward, (a) Using a 

tref>hine about 3.8 cm. (ij inches) in diameter, place its center over a point 

about 3.8 cm. (ij inches) behind the external angular process and 2.5 cm. 

(l inch) above the zygoma. Having removed the disc of bone (which is 

ihert Uun). CJcpose the arter}' — and pass the needle carefully, to avoid wounding 

'the brain. (3) In completing the operation, the disc of bone may be replaced, 

or not, according to the individual ideas of the surgeon. Allow the periosteum 

and >ofi parts to reoccupy their normal positions. Suture the margins of 

j>crio5tcum with buried catgut. Repair by gut-suturing any muscle 

lie which may have been cut and close the skin incision. 

Comment.~(l) This incision of Kocher, together with the subsequent 



48 



OPERATIONS UPON THE ARTERIES. 



retraction of the soft parts, involves less injury to the parts than the turning 
downward or upward of a semilunar or horseshoe flap, which is the method 
of approach most frequently adopted. (3) According to the researches of 
Plummer (v. s.), the osteoplastic flap operation of Hartley-Krause furnishes 




FiR. U).— I. n. Alios <ii Tki NK oi ki>,nr Mi nin(.k\i iHKor..n Trkphink-oj-kmnt. in Tkm- 
pf)RAi Fossa by Cikvki> Oiu ioik Incision — A, r.iiipi>v;il iiui-^i U- (its posterior bonier reiracled 
upward atul fi)r\var<l); B. Z\v;omatio aii h. ami uiii|ioral mssa just above; C, Main trunk and an- 
terior aii<l posterior l)raiiclK> ot initjillc tneniin;eil, i.\i>ose<l tlir<niu:h trephine-opcniiiij (wliich is here 
shown soniewbal too liinht; D. Decj* tiinpntal ariir> ; 1%. Superfirial temporal arter\ and vein ; F. 
Auriinloieni|M)ral nerve u^^iracted baikwaiJ); C. Bran>.hei i>i lai ial nerve irettacled downward and 
backward >. 



UGATION OF POSTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY. 4g 

raised ?subperiosieally and turned downward. A trephine of about 3.8 cm. 
(i^ inches) diameter is appliefl with its center over the above point. The 
steps of the operation are, henceforth, the same, practically, as those for 
the main trunk (page 47). 

Comment. — (i) See the surgical anatomy of the midflle meningeal 

artery and its branches for variations in the course of the anterior branch. 

(3) .According to Chipauh's method of craniocerebral localization (page 472), 

the anterior branch of the middle meningeal cnisses the second tenths of the 

Uhree primary lines. In following which method, therefore, the trephine 

Ishoulri have its center placed over a line which will cross these tenths at 

[about their middle, (3) Acc«»rding to the researches (<f Plummer (page 45), 

Nrho recommends Krocnleln's method of locating the anterior branch as the 

best of several, the following point.s are of [»ractical value: — (A) Thai site 

should l)e chosen — ((/) Which is high enough to avoid missing the anteri<ir 

branch in case it originates from the orbital branch; — {/>) which is high enouijh 

to be above the orbital branch when that liranch is only a communicating 

branch; — (<) which is least apt to fall over the bony canal in the anieriur inferior 

mgle of the parietal, and over the bony riflge along the lower [lortion of the 

oronal «.uiure: — (B) That a 2.5 cm. (i inch) trophine-o[Mi'ning placed just 

ehind any portion of the coronal suture will almost certainly strike the ante- 

'rior branch, or a branch of the anterior branch. (4) According 10 Kroenlein's 

method, Reid's base line (page 476) is first tlrawn — then a higher line is drawn 

parallel with it and on a level with the supraorbital border. On the latter 

line a point is taken 3 or 4 cm. [ij^r to i^\ inches) l:>ehind the e.xternal angular 

proces**. The center of the trephine will rest on the sphenoid in the majority 

of cAjiCs. (This corrcsjionds, practically, wiih the data often given, of fixing 

^lipon a point from 3.2 to ;?.8 cm, (ij to i^ inches), according to the size of 

ric head, behind the external angular process — and from 3.8 lo 4.5 cm. (i^ 

to ij inches) above the zygoma. 



LIGATION OF POSTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY 

IN THE CRANIUM 

THROUGH TREPH1NE4)PENING EXPOSFl) KV A HORSESHOE INCISION. 

Position.— .^s in ligating the main trunk. 

Landmarks. — A piJint is se!ecle<! as the center of the trephine-opening 
ivhirh will fall over the |)Osterii>r liranch in the gr^Mnc of the parietal bone — 
r»d is taken to l)e at the intcrsettinn «if a line drawn Imriztintally luukward 
on u \e\e\ with the rotif nf the t>rbil. and one drawn vertiially upward from 
direct ly l>chind the mastoid process — which point of inter.*;eclion lies just 
below the parietal eminence (jacobson). 

Incision. — .\ horseshoe incision with its center over the above point, 
its convexity upward* and its limbs being from 5 to 5.7 cm. (2 to 2J inches) 
ipan dig 7' R). 

Operation.— ^Performed in the same general manner as for ligation of 
the antcrinr branch. 

Comment.— (I) .Vccording to the researches of Plummer ((>age 45), 

rho recommends Steiner's meth<Kl as the best of several for Kicaling the 

jsicrior branch, the following points are of practical value: — (A) The posterior 

Dranch is iniapable of being located with as much certainly as the anterior 

^branch: — (H) The lateral sinus is to be guarded in exposing the ]»oslerior 

branch, (a) According to Steiner's method, Reid's base line is first drawn — 

4 



50 OPERATIONS UPON THE ARTERIES. 

then a second higher line is drawn parallel with it and on a level with the 
supraorbital border. A third line is drawn vertically upward along the 
anterior border of the mastoid (drawing the ear forward). The intersection 
of the third with the second line marks a convenient site for reaching the 
posterior branch. The trephine-pin rests on the squamoparietal suture. 
When the posterior branch itself is not encountered, its two branches usu- 
ally are. 



SURGICAL ANATOMY OF INTERNAL CAROTID ARTERY. 

Description. — The larger of the two branches of the common carotid. 
Arises opposite upper border of thyroid cartilage (on level with fourth cer\'ical 
vertebra) — at first comparatively superficial, and lies slightly external to 
e.\ternal carotid, then sinks more deeply in neck and passes posteriorly to 
that vessel — ascending neck in front of transverse processes of upper cer\'ical 
vertebra; to enter the carotid canal. The relations of its different portions 
are as follows: 

Relations. — (i) First or Cervical Portion :— Anteriorly (from below 
upward) — skin; superficial fascia; platysma; deep fascia; stemomastoid ; 
posterior belly of digastric; stylohyoid; hypoglossal; occipital artery; posterior 
auricular arter}'; external carotid; styloglossus; stylophar}'ngeus; glosso- 
pharyngeal nerve; pharyngeal branch of pneumogastric; stylohyoid ligament. 
Posterioriy — rectus capitis anticus major; transverse processes of three 
upper cervical vertebra?; superior cervical ganglion; pneumogastric ner\-e; 
hypoglossal nerve; glossopharyngeal nerve; spinal accessory- ner\'e; internal 
jugular vein. Externally — internal jugular vein; pneumogastric ner\-e. 
Internally — pharynx; superior constrictor; tonsil; ascending phar\'ngeal 
artery; ascending palatine artery; eustachian tube; levator palati. (2) 
Second or Petrous Portion : — \\'ithin carotid canal in petrous portion of 
temporal ])one. (3) Third or Cavernous Portion : — Between layers of dura 
mater, forming cavernous sinus. (4) Fourth or Cerebral Portion : — Enters 
inner extremity of fissure of Sylvius and gives off its branches. 

Branches. — I'rom cervical portion — none. From petrous portion — 
tym[)anic; vidian. From cavernous portion — arteria receptaculi; pituitary; 
gasserian; anterior meningeal; (Ophthalmic. From cerebral portion — anterior 
cerebral; middle cerebral; jxostcrior communicating; anterior choroid. 

Line. — Same, j)ractically, as for the external carotid, — or possibly a little 
to the outer side of that line at its lower part. 

Indications for Ligation. — Wounds; aneurism. 

Site of Ligation.— Near origin (Fig. 7, S). 



LIGATION OF INTERNAL CAROTID ARTERY 

NKAR OKICtIN. 

Position — Landmarks. — .\s for ligation of external carotid below the 
digastric (page .^5). 

Incision. — Slightly posterior to the incision for the external carotid 
artery— that is, along the anterior border of the stemomastoid, instead of 
just in front of it — with the center of the incision about 1.3 cm. (J inch) above 
the upper border of the thyroid cartilage (Fig. 7, S). 

Operation. -The steps are, at first, the same as those for exposing the 
external carotid below the digastric. This artery (external carotid) is first 



SIRGICAL ANATOMY OF SUBCLAVIAN ARTERY. 



51 



sought (all ihe structures mentioned in that ojierutfon being encountered) 
and traced to its bifurcation, and thus the inicrnai carotirl is exposed — ihe 
external carotid bein^ drawn inward and the digustrii; upward. In opening 
the sheath special care must be taken to puard the internal jugular vein, 
pneumogai^tric nerve, cervical sympiUhettc, ascending pharyngeal arter}' — > 
the needle being passed from the vagus and internal jugular vein. 
Collateral Circulation.— Cinlc of Willis, 



SURGICAL ANATOMY OF SUBCLAVIAN ARTERY* 

Description. — Subclavian artery on right side, about 7.5 cm. (3 inches) 
in length, arises from the innominate; and, on the left, about 10 cm, (4 inches) 
in length, arises from arch of aorta — arching, in both cases, across the root 
of neck, over the dome of the lung and pleura, to the lower border of the 
first rib, where it becomes the axillary artery. That portion of the subclavian 
internal to inner border of scalenus anticus being the first part — that portion 
phind this muscle being the second part — and that jxirtion external to the 
iter l>ordcr of scalenus amicus being the third part. The subclavian vein 
lies l)elovv and anterior to artery, the scalenus anticus intervening. The 
po>>terior border of the stemomastoid corresponds with the external border 
of the scalenus amicus. 

Relations.— (a) First Portion of Right Subclavian :—.\bout 3 cm. 
{i\ inches) in length — arises from bifurcation of innominate, l>ehind upper 
LtKirder of right sternoclavicular articulalion^ — curves upward and outward 
(with convexity upward) at a variable distance abo\'e clavicle, over apex 
of right lung and fileura, to inner border of right scalenus anticus, hav- 
ing following relations: — Anteriorly — skin; sufierticial fascia; platysma; an- 
riur layer of deep fascia; clavicular origin of >lernomastoid; sternohyoid; 
tcmothyroid ; deep cenical fascia; right innominate vein; internal 
Ligular vein: vertebral vein; pneumogastric nerve; phrenic nerve; su[>erior 
'Cardiac branches of sympathetic nerve: — Posteriorly — areolar tissue; longus 
colli; transverse process of seventh cerncal and I'lrst dorsal vertebra* ; sym- 
apathetic nerve; inferior cardiac nerves; recurrent laryngeal nerve; a|>ex of 
right lung and pleura; neck of first rib: — Inferiorly— pleura and limg; 
recurrent lar}7igeal ne^^•e; subclavian vein. (1)) First Portion of Left 
Subclavian : - Much longer than that of right— arises from distal end of 
ranjiVTTsc part of arch of aorta, opposite fourth dorsid vertel»ra, to left and 
rftlighily |x»ierior to left common carotid — ascending, at first, almost vertically 
— then arching further upward and outward over apex of left lung and ]>leura 
to inner Ixjrder of left scalenus anticus — having following relations: — Ante- 
riorly — left pleura and lung; sternothyroid; sternohyoid; stemomastoid; left 
innominate vein; internal jugular vein ; vertebral vein; subclavian vein; phrenic 
[nerve; pneumogastric nene; left cenical cardiac nerves of sympathetic; 
rft (<»mmon carotid; thoracic duct:— Posteriorly— esophagus; thoracic duct; 
|tfiferior cervical sympathetic ganglion; longus colli; verteliral column; left 
jileura and lung: — Externally— left pleura and lung:— Internally- irarhea; 
"rc\nirrcnt laryngral nerve; esophagus; thoracic duct, (c) Second Portions 
of Both Subclavian Arteries: — Highest part of the vessel — about 2 cm. 
(J inch) in length -lies iH'hind scalenus anticus. which separates the artery 
the subclavian vein — and has foUosving relations: — Anteriorly — skin; 
jperfirfal fawia; platyv^ma; anterior layer of deep fascia; clavicular origin 
l>f stemomastoid; deep layer of fleep fasi ia; phrenic nerve; subclavian vein; 



50 OPMKATIONS UPON THE ARTERIES. 

!liri» a hi'dJiwI hi^luT line is drawn parallel with it and on a level with the 
HUpninrliiliil iHinitT. A third line is drawn vertically upward along the 
jintciinr l»(»rdcr «if the mastoid (drawing the ear forward). The intersection 
of tlu- third with ihc st'toiid line marks a convenient site for reaching the 
ijo^itrrior hraruh. 'i'iu' trrphini- |)in rests on the squamoparietal suture. 
U'lu'ii tiu" posti"ri«)r hraiu h itself is not encountered, its two branches usu- 
tdlv arc. 



SURGICAL ANATOMY OF INTERNAL CAROTID ARTERY. 

l)f8cription. Tlu- larger of the two branches of the common carotid. 
AriM's uppiKJii' upper l>ordcr of thyroid cartilage (on level with fourth cer\-ical 
verlehra) at lusl ioni|)aratively superlicial. and lies slightly external to 
eMemal caii>liil. then sinks more deeply in neck and passes posteriorly to 
that \es>el aMemling neek in front of transverse |)roccsses of upper cervical 
Nerlehra- to enter tlie larolid canal. The relations of its different portions 
ine as f*>Uo\\s; 

RelAtions. {D lirst ov Cervical Portion : — Anteriorly (from below 
up\\.u\l^ >kin; Mipertuial fascia; plalysma; deep fascia; stemomastoid; 
jHwicvior W\\\ oi *li^a>iric; siylohxoid; hypoi:loss;d; occipital arter)-; posterior 
avnlcnlar ariei\ ; eMernal larotid; >iyloo;lo»ns; styK»phar)ngeus; glosso- 
phavvn^exd nerve; pharvniieal hraiuh of pneunu\!L:a>tric; stylohyoid ligament. 
IV^Sttfriorlv «evtn>» ^apiti^ antivu> niaiv^r; transverse pr^xesses of three 
upjvr verviv.d vetiebr.e; MiperivM" lervival i:.ir.i:lion; pneumogastric ner\'e; 
h\{sxKwv.d vevve; clo^vopharv ni^eal nerve; <pinal acce>>c»ry nene; internal 
i\5\;u'«r. Vvv.\ ExteniAlly itv.eip.al ;i:i;v.'..ir vein; pneumogastric nerve. 
lutt^rudUy '.^l^-.w-x; vv.tvriv^r vor.-'.riv '.v^r; lonsil; ascending pharyngeal 
ai\v'^\. ,',-vv-\i^.:^c :\\!,.ii^\e artorv . ev.-Mv "•:■".• v. tv.^v; levator p^lati. (2) 
N\v-\- V-. IVtrous F\>rtion : W.tiiv, v.iro: vi c..:..:! in jvtrous portion of 
tv^ .\ ■, ■ X N ^;' I ' :\ V r CAvemous Portion : — Between layers of dura 

"' s c V .\v - - > 4^ Iv :r:h vr Cerebral Portion: — Enters 

' ' \' v\. V'"' ;v >■• 'vv; "v- ^" >\"\ :;>. .;•• • i: ^c-"- v!" *> ■ ru."vhes- 

H:"*x\ches. • -. ■^- .v\ .,.'. 'v^-. /■■ "v-c K-r-.-, :^:rv^uf portion — 

V s^ ' - - X ■ .;. ' .•■ ■ '■,"•- - V', :- .\rx---.! > nic"— j.:::erior 



.i ^r.je 






iivvr.v^N v^F :\Tv:5:\c vAxOT:r aktzsy 






A-xj 






SURGICAL ANATOMY OF SUBCLAVIAN ARTERY. 5 1 

sought (all the structures mentioned in that operation being encountered) 
and traced to its bifurcation, and thus the internal carotid is exposed — the 
external carotid being drawn inward and the digastric upward. In opening 
the sheath special care must be taken to guard the internal jugular vein, 
pneumogastric nerve, cervical sympathetic, ascending pharyngeal artery — • 
the needle being passed from the vagus and internal jugular vein. 
Collateral Circulation.— Circle of Willis. 



SURGICAL ANATOMY OF SUBCLAVIAN ARTERY. 

Description. — Subclavian artery on right side, about 7.5 cm. (3 inches) 
in length, arises from the innominate; and, on the left, about 10 cm. (4 inches) 
in length, ari.ses from arch of aorta — arching, in both cases, across the root 
of neck, over the dome of the lung and pleura, to the lower border of the 
first rib, where it becomes the a.xillary artery. That portion of the sul)clavian 
internal to inner border of scalenus anlicus being the first part — that portion 
behind this mu.scle being the second part — and that portion external to the 
outer border of scalenus anticus being the lliinl i)art. The subclavian vein 
lies below and anterior to artery, the scalenus anticus intervening. The 
posterior border of the sternomastoid corrcs[)<)nds with the external border 
of the scalenus anticus. 

Relations.— (a) First Portion of Right Subclavian :— About 3 cm. 
(i^ inches) in length — arises from bifurcation of innominate, behind upper 
border of right sternoclavicular articulation — curves upward and outward 
(with convexity upward) at a variable distance above clavicle, over apex 
of right lung and pleura, to inner border of right scalenus anticus, hav- 
ing following relations: — Anteriorly — skin; su])erricial fascia; platysma; an- 
terior layer of deep fascia; clavicular origin of sternomastoid; sternohyoid; 
sternothyroid; deep cervical fascia; right innominate vein; internal 
jugular vein; vertebral vein; pneumogastric nerve; phrenic nerve; superior 
cardiac branches of sympathetic nerve: — Posteriorly — areolar tissue; longus 
colli; transverse process of seventh cervical and first dorsiil vertebra; s\m- 
pathetic nerve; inferior cardiac nerves; recurrent laryngeal nerve; apex of 
right lung and pleura; neck of first rib: — Inferiorly— pleura and lung; 
recurrent laryngeal nerve; subclavian vein, (b) First Portion of Left 
Subclavian : — Much longer than that of right — arises from distal end of 
transverse part of arch of aorta, opposite fourth dorsal vertebra, to left and 
slightly posterior to left common carotid- ascending, at first, almost vertically 
— then arching further U|nvard and outward over apex of left lung and pleura 
to inner border of left scalenus anticus— having following relations: — Ante- 
riorly — left pleura and lung; sternothyroid; sternohyoid; sternomastoid; left 
innominate vein; internal jugular vein; vcrteljral vein; subclavian vein; phrenic 
nerve; pneumogastric nerve; left cervical cardiac nerves of sympathetic; 
left common carotid; thoracic duct: — Posteriorly— esophagus; thoracic duct; 
inferior cervical sympathetic ganglion; longus colli; vertebral column; left 
pleura and lung: — Externally — left [)leura and lung: — Internally — trachea; 
recurrent laryngeal nerve; esophagus; thoracic duct, (c) Second Portions 
of Both Subclavian Arteries: — Highest part of the vessel— about 2 cm. 
(I inch) in length — lies behinrl scalenus anlicus, which se|)arates the artery 
from the subclavian vein — and has following relations: — Anteriorly — skin; 
superficial fascia; platysma; anterior layer of deep fascia; clavicular origin 
of sternomastoid; deep layer of deep fa-(ia; j^hrenic nerve; subclavian vein; 



52 OPERATIONS UPON THE ARTERIES. 

scalenus anticus: — Posteriorly — apex of lung and pleura; scalenus medius: — 
Superiorly— brachial plexus: — Inferiorly — lung and pleura, (d) Third 
Portions of Both Subclavians : — Lie in subclavian triangle (of stemomasloid, 
omohyoid, and clavicle). Extend from outer border of scalenus anticus 
downward and outward to lower border of first rib, and have follownng rela- 
tions: — Anteriorly — skin; superficial fascia; platysma; clavicular branches 
of descending portion of cervical plexus; anterior layer of deep fascia (from 
omohyoid to clavicle) ; posterior layer of deep fascia (from omohyoid to first 
rib); fatty areolar tissue between layers of d.eep cervical fascia; suprascapular 
artery; external jugular vein; suprascapular vein; transversalis colli vein; 
other tributary veins to external jugular; nerve to subclavius muscle; stemo- 
mastoid (sometimes); clavicle; subclavius muscle: — Posteriorly — scalenus 
medius; cord of brachial plexus formed by eighth cen'ical and first dorsal: 
— Superiorly — brachial plexus; posterior belly of omohyoid: — Inferiorly 
— first rib. 

Branches. — From First Portion: — vertebral, thyroid axis (inferior thyroid, 
transversalis colli, suprascapular), internal mammar)'. From Second Portion: 
— superior intercostal. From Third Portion: — no branches, ordinarily. 

Line. — A curve, with convexity upward, at base of posterior triangle- 
beginning at sternoclavicular articulation and ending at center of inlerior 
border of clavicle — its mid-point being about 1.3 cm. (^ inch) above the 
superior border of clavicle. 

Indications for Ligation. — Wounds; aneurism; preliminarj^ to extensive 
operations about the shoulder and upper extremity. 

Sites of Ligation. — Only three successful cases are recorded, as far as 
known by the writer, of ligature of the first portion of the right subclavian, 
and but one of the left — the ligation being particularly hazardous, especially 
upon the latter side. Nor is ligature of the second portion to be recom- 
mended, owing to the depth and relations of the artery. The third portion is 
the part of the artery usually selected for ligation (Fig. 7, T). 



LIGATION OF FIRST PORTION OF RIGHT SUBCLAVIAN 

BV ANGULAR INCISION. 

Position— Landmarks — Incision.— As for ligation of innominate by 

angular incision (page 26). 

Operation. — Having incised skin and superficial fascia, this triangular 
flap is dissected up, as in ligation of the innominate. The anterior jugular 
vein is doubly ligated and divided, and the external jugular similarly treated, 
if in the way. Divide the deep fascia. Expose and sever the sternal and 
clavicular heads of the stcrnomastoid. Divide the sternohyoid and sterno- 
thyroid either in whole or in ])art. Expose the common carotid, carefully 
retracting the internal jugular vein and pneumogastric nerve outward and 
displacing or doubly ligating any overlying veins. Identify the subclavian 
vein by following down the common carotid on its postero-extemal aspect 
to the bifurcation. Clear the subclavian artery, carefully guarding the 
recurrent laryngeal and phrenic nerves and \ertebral artery. Displace the 
pleura downward and outward with tip of finger, and pass the needle from 
below (from the pleura). The vertebral should also be secured at the same 
time and through the same incision — lo accomplish which, the internal 
jugular and pneumogastric nerve arc now retracted inward and the vertebral 
exposed by a few strokes of the knife as it lies between the longus colli and 



LIGATION OF SECOND PORTION OF SUBCI.AVIAN AKTER\ . 



53 



scalenus, guarding the phrenic and recurrent laryngeal nerves and the inferior 
thy mid arter}'. 

Comment. — Excision of the right slenioclavicular articulation may be 
done when necessary-, as in the ligation of the innominate by partial bony 
resection 

Collateral Circulation. — Superior tliyroid, with Inferior thyroid; one 
vertebral, with opposite vertebral. Internal mammary, with dee|> epigastric 
an<l aortic inlercostals. Superior intercostal, with aortic intercostaU. Pro- 
funcUi rervicis, with princej>s cervicis. Scapular braiuhes of thyroid axis, 
with branches of axillary. Thoracic branches of axillary, with aortic inter- 
costals. 



LIGATION OF FIRST PORTION OF LEFT SUBCLAVIAN 

tt\' ANi.ri.AR IN<'ISHtN\ 

Position— Landmarks— Incision.— As for ligation of innominate by 
langular incision, except that llie operation i.s placed upon ihc left side. 

Operation. — The stejis of the operation are similar to those for ligation 
of the first pf>rtion of the right subclavian— up to the exposure of the common 
carotid and internal jugular. Here the common carotid and pneumogastric 
are retracted inward, the internal jugular is drawn outward and downward, 
and, with it, the left innominate vein. At this stage the head is bent forward 
lo relax the parts. Special care is here given to identifying the thoracic 
duct before proceeding — ^the duct arching from the seventh cervical vertebra 
forward and downward over the subclavian artery in front of the scalenus 
amicus, and emptying into the left subclaxian vein at the junction with it 
of the left internal jugular, being embedded in the loose areolar tissue of llie 
tnarl, making it often dilTicuIl to fmd. and sometimes dividing into several 
branches. Having safeguardcfl the imiMirtunt neighboring structures, follow 
dorum ihe common carotid with the finger until the subclavian is idenlifie<l, 
on n plane posterior and external to that of the former vessel. The artery 
15 then to be freed, carefully guarfling the pleura; the sheath is opened and 
the needle passed from the pleura. 

Comment.— If more room be required than given by the above incision, 
t»r if it be required to ligate the vessel nearer the arch, an excision of the 
slemfKlavicular articulation can be done. 

Collateral Circulation. — See Ligation of First Part of Right Subclavian. 



LIGATION OF SECOND PORTION OF SUBCLAVIAN ARTERY. 

Position— Landmarks— Incision,— As for ligaiion of third pnrti(»n of 
subclavian. 

Operation. — The steps of this operation, up to the division of the deep 

Icervitvd fa^ ia ancl ihc rccc*gnilion of the outer border of the scalenus anticus 

{(which lies directly under the outer border of the sternomastoid). are identical 

l^'ith thttse f<»r the exjhosure of the third part of the subclavian. The further 

[steps consist in the inward retraction of the scalenus anticus (and overlying 

♦tcroomastoid). witli the divisitm of as many of their tibers as necessary, when 

tKe artrry* will be exposed and may be ligated. Especial care is taken to 

Kuard the phrenic nerve, which crosses obliquely the lower anterior surface 

of the scalenus anticus, — as well as the iransversalis colli and suprascapular 



54 



OPERATIONS UPON THE ARTERIES, 



arteries, which cross the scalenus anticus transversely, — and the external 
jugular vein, running parallel with the anterior scalene muscle. 

Comment. — This operation is often merely a proximal continuation of 
the operation for the exposure of the third part of the subclavian, when the 
application of a ligature to the third part is impracticable. 



LIGATION OF TTORD PORTION OF THE SUBCLAVIAN. 

Position. — Patient supine; shoulders raised; head thrown back and to 
opposite side; operated shoulder depressed by arm drawn downward and 
placed under the back (to open out the posterior cervical triangle). Surgeon 
in front of shoulder. 




Fig. 17.— Ligation of Third Part of Right SrBci.AviAS:— A, Platysma; B. Trapezius; C, 
Steniomastoid (posterior border incised); D, Scaloiuis aiiticiis; K, Posterior belly of omohyoid (rc- 
tractetl upward); F, Clavicle ; G, Third part ol siibdax iaii ; H, Transvcrsalis colli A.; I, Suprascapu- 
lar A.; J, Subclavian vein; K, Ippcr end 01 cxleiiial jugular V. (divided and retracted), with 
transversalis colli V. and cotntnuuicatiiig branch ti» anterior jugular; L, Lower end of external jugu- 
lar (.divided and retracted), with suprubcapular brunch ; M, Brachial plexus; N, N, N, Supraclavicu- 
lar nerves ; O, Deep cervical fascia. 



Landmarks. — Posterior border of sternomastoid (which correspxjnds 
with the outer border of the scalenus anticus) ; anterior border of trapezius; 
middle of clavicle. 

Incision. — With the skin of the posterior cervical triangle drawn down 
over the clavicle by the left hand, an incision about 7.5 cm. (3 inches) is 
made transversely over the clavicle down to the bone, from the posterior 
border of the sternomastoid to the anterior border of the trapezius, and with 
its center about 2.5 cm. (i inch) internal to the center of the superior border 
of the clavicle (Fig. 7, T). 

Operation. — (i) This incision will divide the skin, fascia, platysma, 
some supraclavicular nerves, and maybe a connecting vein between the 
cephalic and internal jugular — but will avoid the external jugular, which 



SURGICAL ANATOMY OF VERTEBRAL ARTERY. $$ 

passes through the deep fascia above the clavicle. The incision will lie 
about 2.5 cm. (4 inch) above the clavicle when the tension upon the skin is 
relaxed (Fig. 17). (2) The margins nf liie slernomasloid and trapezius will 
\tc exposed, and, if mare room be needed, may be divided along the clavicle 
as far as necessary. (3) The deep cervical fascia is next incised, the external 
jugular vein being carefully exp^ised and retracted, or ch'vided between double 
ligatures. Tribulan,' veins of the e.xternal jugular are to be similarly treated, 
especially the transversidis colli and suprascapular. (4) Generally the trans- 
versalis colli artery lies transversely alujve the incision, and the suprascap- 
ular transversely l>clo\v it, under the clavicle and out of the way; but one or 
both may present in the field, and are to be carefully preservefl for collateral 
circulation. Retract the [wisterior belly of the omohyoid upx\ard if in the 
way. Identify the outer margin of the scalenus (just under ihe outer margin 
of the stemomasloid) as a guide to the artery, and follow its outer border 
do%vnward until the finger reaches the tubercle on the upper border of the 
first rib, which ties between the subclavian vein in front, and the subclavian 
arler}' behind — when the artery will be recognized and may be traced upward. 
(5) Kxpcse the lowest cord of the brachial plexus — for the purpose of hence- 
forth avoiding it (as it has been mistaken and ligated for the artery). The 
s>ubclavian vein will lie anteriorly and infcriorly to the artery. (6) Open 
the sheath — clear the arter> — and [>ass the needle fn^m the brachial plexus, 
jpiarding the subclavian vein and the pleura. 

Collateral Circulation. — (When the second or third part is tied): — Supra- 
scapubr and posterior sca[jubr above, with acroniiothoracic, infrascapular, 
subscapular, and dorsidis scapula* below; internal mammary, superior inter- 
costals, aortic intercostals above, with long thoracic and scapular arteries 
below; plexiform vessels from branches of subclavian above, with branches 
of axilian' below. 



SURGICAL ANATOMY OF VERTEBRAL ARTERY. 

Description. — Largest and generally first branch of subclavian. .Vrises 
from upper and posterior [)ortion of first part of subclavian, near inner border 
of s<alenus anticus — ascends upward, backward, and outward, in interval 
between scalenus anticus and longus colli, to foramen in transverse process 
<»f sixth cervical vertebra — passes through foramina in all vertebra* above 
lhi& — emerging from foramen in transverse process of atlas, it runs in grmive 
on posterior arch of atlas, lying in the sulxxcipital triangle, and pierces the 
cxTipitt»-atloid ligament and ilura mater— and passes into cranium through 
foramen magnum — ujjward upon lateral aspect of medulla to its anterior 
aspctl, where it unites with its fellow to form the basilar. 

Relations.— (a) First or Cervical Part : — from origin to transverse 
process of sixth cervical vertebra, lying between scalenus anticus and longus 
colH. Anteriorly — vertcl>rai vein; internal jugular vein; inferior thyroid 
artery; thoracic duct (left side). Posteriorly— transverse process of seventh 
i,ervital vertebra; sym|vithctir niTvr. Externally -scalenus anticus. In- 
ternally— longus colli, (b) Second or Vertebral Portion : — runs in osseo- 
rauscular canal formed by intervertebral foramina and intertransverse muscles, 
surrounded by plexus of veins and branches of sympathetic nerve. (C) 
Third or Occipital Portion: — Itt-sin suboccipital triangle, which is formed, 
sufHrriorly and internally, by rectus capitis posticus major; superiorly and 
cxtemAlly, by obliquu*^ capitis superior; inferiorly and externally, by obliquus 



-.inin- nrnrrrr ■ »-^;r!r: :;- r-imricTii^ -niiaciei imi i:«:r 5:maed bj postoior 
v.'-n>rr.- iTjinni^ irLitein -•j?nerrrr ir-Ji if iria* laii pc^serior atlanto- 
i.^.-t. .i!Ei--nRnr. — -ne i-.i.Trt* : .ntainmit tie •'""BCtal. iraerj ±2*1 suboccipital 
niir* -.le ar?i^ -a-^rdn;! :»irve23. :3:e i r . g- inc. -irrt re rise alias. Ante- 
rittcij— r^:r.i.- -j^-itr..- iirt=:Li=: irriniar -jr:c=£= :i xdsisi ocdpito-atloid 
.ics.ren-. PTaoBrijOtfT- — -iciir-j r :riii;i:t :»c=is 3zci* pc^dcos major; 
-.-mc'e:::>. t Finr:^ IT £xc3CZ3axsL ^jcum.: — -r^m t^ccsing in dura 
V. r.n-^ -.•■.r'jsr .f -•.c-r. vnsr? x imrEi vrx ±i iili:v do form basilar 

ladscaaans 5ir Lic3±iiii- — "^ ii:ii::r. ronrmiri: loeorfis:: in coancctira 

Srea if T rgarrriir — L: :zti Itk ;r i^^-jzL ;i:rdi:ir ^laoii sxt)i in third 



LjGaI^O^ of '*r:^,fTW4" 5S.A3CH GF STBOAVIAN 

P»i«S«L,— Fitier.t T^^iiie r^i'iijierr nirei. r«t:it rfgm'nmt: head to 
''.r,o.'.-* -i.ie -^-rr-i-.r ic r-rz: -l .-.intizs :c either ^lerKbraL 

Laadnatrki.— .*j:-^.-;r -ruri^r c <i!r:-c:i:iC-L.i 

IscisaiC.— A ■.•■-:- r ;rr_ : Lz :-.^r - j;r.rJ^ eT:<nci=ar along the ante- 
• « r -r r-.er .c' -.-.ri -r.^rr.- rLi-r .,-_. -zn^Z-Z-z ■^i''^ i: tit jiav-cie. lAs for ligation 
".»' • "i* '.'.r.'.."r.''.r ■..i'Ti'i '•;•.•:"'-■ ize "i^-i'Ti-i 

Ojtratioc— i Hj. t.-z L -!:e: ^i:-. s-t erf vr!ul fiicfa. and the anterior 
.'r* ..'- -.r --..^ : -i- --~_i. '-.riz ::!:-;< :: the >-7er£--fil :«tr--:cil nerve, and com- 

- .- i ' s r".- -ttTT-rr- -ji-ir i-.-.r.":;- LZ'i eTTerrj-I /.liuLir ^Tina^ are en- 

- .1.' .*-^'. •-■: 1.-* -.rr:\-rri ir i-i. -iri a I".:i^ the 'ieep cervical fasda. 
*v;y. -/ --> -:--rr .- -. r:-rr : -z-t -:rrr. cri^t .^i. irhich is to be drawn 
'^. « j- ; :-.; ---^ - -• '.i. ~ r..:T. > : re rttrutei 'iownward and inward; 
'<'(-. ■'. f. -r -r.—. -.; ::. --_:>. if iriT^. ir.T^iri. 3 Ha\ing freed the 
■t A — ^- ■'. "r -TrT I'Zrr' f the ~— ■■- fheith. ih* carotid, internal 
../.-.- •. --: -'r.- z ■-:--;: irr in-- >.:.'■?. itz frcm o\Ter the vertebral 
^-.*- '; -^ - -* r-^'.r/. !i-.::-i .« -.r-ir !r.:::*'i venfoiily between the carotid 
•,v* - ■';- *'-rr '- .-T" ' : riith ,cr.-::il ver.ebn jind the arch of the 
,.- '*' ',- ' -• : '."■—. = T.rTt '.'. :-rr> :r.-?\iri :o the posterior surface of the 
•- " -; y '. ' . - '.rTr \:.r - -rre'r. Til ^T.tT.- ^^iLl be found ascending, partly 
' . ■--''. •, •-'- .■ ' i .- -.1;. v. :he : Tinic" :r. the iransverse process of the 

" i. '-.'-- ',.'i. hi. i'j the ir.terior scalenus muscle and phrenic 
.'.'- " *', ,• '..*'.' :': ir.'i :he ■ r.r-^ coil: mujcle and recurrent lar>-ngeal 
r ' - ^ *o . . - - ' - '.'- V r/: \:.*: ir.fer!- r th;.T ■id iner>- ind vein and the \*ertebral 
r' r. ; ' :' '. '.' ' '\^. '-j'.-f. 'tnitures. therefore, are to be displaced in the 
:r'y' ",i *•'..-.:.■ ;.:': v'-.-. a- the hriirer ?eek> the vertebral arter>- in the 
;.-,', *■ ',' ;:' 7 ■ :' :- . ':. 7 ?.*: '.Acitj. lieT^ b»elow and imemaUy. The thoracic 
'. .'• '.:. *•': .':'• "'. (.- '•:.': ,s.r.tr/ irMm wiihin outward. (4> The arter}* is 
'-', •>*■ *'/'./. *"\ ,'/: T.^- /'ji'jre jKi-re-i '.vith especial care, in order to avoid. 
'J V:' ■■: :.'• .•>.*:. ':.*■ f.h'r- 'A the >yrr.pdthetic. some of which are apt to be 
>r.' ; .':'■': .:. *'..*-. ','.'>■■.'■ .'.*• 

Comment. '\:.*- •.*rt'\,r>A artt-r. may also be ligated by an incision 
%u.\*> :'.'.'. :.'t tr,*- J,/, v-r or \,<,r<\i-x of the -lernomasioid. followed by the inward 
r<f;;i't;',f, of f|,::r rri . '1*- 'v. ith or v.iih'>ul a partial division of its clavicular 
:\\\:v \xu\tu^ , . \,.\ \ I*:-- -imple than the above. The arterj- may also be 
\\V;.\U't\ in the Jil/O' npital triangle. 



SURC.ICAL ANATOMY L>F TRANSVERSALIS COLLL 



57 



I 

I 



» 



SURGICAL ANATOMY OF INFERIOR THYROID BRANCH OF THYROID 
AXIS OF SUBCLAVIAN ARTERY, 

Description and Relations. — Largest branch of thyroid axis (which 
latter arises from first pari of subclavian). Asctnds upward and inward 
to fK>slerior surface of thyroid gkmtl — passing behind common carotid, internal 
jugular, pneumogastrir nen.'e, and sympathetic nerve (middle cervical gan- 
glion usually resting upon it) — and in front of vertebral artery, recurrent 
larj'ngeal nerve (sometimes posterior to it), longus colli muscle. The thoracic 
duct passes in front of commencement of left vertebral artery. 

Indications for Ligation. — Preliminary to thyreoidectomy; and to 
diminish goiter. 

Sites of Ligation.— Just beyond the ascending cervical branch (which 
arises shortly before the vertebral passes behind the carotid). 



LIGATION OF INFERIOR THYROID BRANCH OF THYROID AXIS OF 

SUBCLAVIAN. 

Position. — Patient supine; shoulders elevated; neck prominent; heafl lo 
opp<>sile side. Surgeon to right side, in either case. 

Landmarks. — Anterior border of sternomastoid. 

Incision. — Alxjut 7.5 cm. (3 inches) in length, along the anterior margin 
of the sternomastoid (as for the common caroticl). 

Operation. — Divide skin, superficial fascia, and the platysma, when 
branches of the superficialis colli nene and tributaries l>etween the anterior 
ami external jugular veins are met, and are to be dealt with as indicated. 
Incise the deep cervical fascia and detine the anterior border of the sterno- 
mastoid, and retract that muscle outward — the omohyoid is drawm downward 
and inward, and the sternohyipid inward. After freeing the inner attachment 
of the common sheath, the carotid, internal Jugular, and pneumogastric are 
<lrawn oulvvar<l from over the inferior thyroid artery. The artery is then 
«ought by continuing the dissection toward the vertebra-, lying a little way 
l>elow the carotid tuber* le, in the interval covered by the sternothyroid muscle, 
Ijetween the inner border of the retracted raroltd sheath and the outer border 
of the thymitl gland. The gland is rai.sed and displaced inward. The 
artery i.s e.xposc<l where it arches inward, and where the ascending cervical 
branch arises. The ligature is applied just beyond this branch— thus avoid- 
ing the recurrent lar)*ngeal nerve, which runs along the trachea and behind 
the thyroid gland; and the vertebral artery, nearly parallel with it below 
and passing liehind the inferior thyroid as the latter bends inward. The 
sympathetic nerve, which sometimes embraces the artery, and the phrenic, 
which lies to its outer hide, are to be guarded against injury. 



SURGICAL ANATOMY OF TRANSVERSALIS COLLI BRANCH OF THYROID 
AXIS OF SUBCLAVIAN. 

Description. — One «if three branches of thyroid axis. Runs transversely 
outward, crossing root of neck a little above the chuicle, and divides, beneath 
anterior Iwjrder of trapezius, into posterior scapular and superficial cervical 

Relations.— From its origin outward, it is covered by the plaiysma, 



$8 OPERATIONS UPON THE ARTERIES. 

cervical fascia, sternomastoid, omohyoid, and anterior border of trapezius — 
and rests on phrenic nerve, scalenus anticus, brachial plexus (or between its 
cords), and scalenus medius. 

Indications for Ligation. — Rare, except for wounds, when the artery, 
or its branches, are cut down upon and tied where wounded. 

Sites of Ligation. — Most conveniently exposed in the subclavian triangle, 
just below the outer margin of the sternomastoid. 



LIGATION OF TRANSVERSALIS COLLI BRANCH OF THYROID AXIS 

OF SUBCLAVIAN 

AT OUTER MAR(;i\ OF STERNOMASTOID. 

Position. — As for ligation of inferior thyroid. 

Landmarks. — Posterior border of sternomastoid, made evident by man- 
ipulating the neck so as to render the margin of the muscle tense. 

Incision. — About 5 cm. (2 inches), along posterior border of sterno- 
mastoid, extending nearly to clavicle (Fig. 7, \V). 

Operation. — Having incised skin, sujjcrficial fa.'^cia, and platysma, 
branches of the descending superficial cervical nerves may be encountered, 
as well as the tributaries of the external jugular vein. The external jugular 
vein itself has to be carefully guarded at the outer edge of the sternomastoid. 
Having divided the deep cervical fascia and exposed the posterior border 
of the sternomastoid and the posterior belly of the omohyoid, the latter muscle, 
if in the way, is retracted upward. The sternomastoid (whose outer border 
corresponds with the outer l)ordcr of the scalenus anticus) is then drawn 
inward, and the artery is foiuid crossing outward between the two muscles 
to pass beneath the posterior belly of the omohyoid to reach the trapezius. 
The cords of the brachial plexus are to be guarded in passing the ligature 
(Fig. 17). 



SURGICAL ANATOMY OF THE SUPRASCAPULAR BRANCH OF THE 



SURGICAL ANATOMY OF INTERNAL MAMMARY. 



59 



LIGATION OF SUPRASCAPULAR BRANCH OF THYROID AXIS OF SUB- 
CLAVIAN 

AT OUTER MARGIN OF STERNOMASTOID. 

Position— Landmarks— Incision,— As for ligation of transversalis colli 
arterv' (pa^c 58). 

Operation.— Practically ihc same as ihal for the transversalis colli, the 
supra t»capular artery running almost parallel with il, tiiough on a somewhat 
lower plane, and soon j^elting behind the clavicle and subclavius muscle. 
The site of ejtposing the artery is in ihe same vertical line (at the jiosterior 
border of the sternomasloid) hut nearer the cla\'iclc. The same care is 
necessary in guarding the external jugular vein, which here enters the sub- 
clavian near the site at which the artery i> ligaled (Fig. 17). 



SURGICAL ANATOMY OF INTERNAL MASIMARY BRANCH OF SUB- 
CLAVIAN. 

Description. — Arises from lower aspect of first part of subclavian, near 
to inner margin of scalenus amicus — desccntls forward and inward, passing 
behind clavicle to enter thorax posterior to cartilage of first rib — ihencc 
runs downward parallel with and about 1.3 cm. (^ inch) external to margin 
of sternum, to interspace between sixth and seventh costal cartilages, where 
it divides into superior epigastric and musculophrenic. Its two vena' comites 
unite to form one trunk in first intercostal space and empty into the innominate 
vein. The internal mammary artery, above, is 0.5 to 1.5 cm. (\ to ^ inch) 
irom border of sternum — and, below, from i to 2 cm. (| to i inch) from the 
Biemal margin. In its upper part it lies between the internal inlerco.sial 
lusde and costal cartilages, in front; and [pleura behind. In its lower jjarl 
lies between the costal cartilages in front; and triangularis slcmi behind 
(the latter structure iritcrvenini; between it and the fileura). 

Relations.— (a) Cervical Part:— Covered by .sternomastoid, subclavian 
vein, internal jugular vein, phrenic nerve. Rests on pleura, innominate 
vein, (b) Thoracic Part : — Covered by cartilages of first to sixth ribs, pecto- 
ralis major, internal intercostal mustles, anterior intercostal membrane. 
Rcfts on pleura (above), and triangularis sterni (below). 

Arterial Supply of the An tero- lateral Thoracic Wall. — (a) .As the 
ntemal mammary artery crosses the upper intercostal s])aces two branches 
(superior and inferior anterior intercostal arteries, or superior an<l inferior 
branches of the anterior intercostal arteries, where they arise from a common 
jnk) arr given off in each of the five or six upper interspaces — which pass 
•MJtward between the pleura and the internal intercostal muscles, and then 
, bciYieen the internal and external intercostal muscles, running along the 
Dwrr border of the superior, and the upper border of the inferior rib — to 
fcnaslomosc with the suj>crior and inferior branches of the aortic intcrcostals. 
1(b) In each of the same upjxT five or six spaces a single branch, the perforating, 
the anterior perforating, is given oti between the upper and lower anterior 
itrrnrysial arteries— which pierce the internal intercostal muscles, between 
ic costal cartilages, and supply the pectoralis major, mammary gland (sec- 
nd. third, and fourth branches), and skin, (c) The anterior intercostal 
|l>nini hrs fur the five or six lower interspaces are given off by the mus- 
^culophrcnic branch, which passes down behind the costal cartilages, pierc- 
ing the dixiphragm opposite the ninth rib, and ending at the tenth or eleventh 



58 OPERATIONS UPON THE ARTERIES. 

cervical fascia, sternomastoid, omohyoid, and anterior border of trapezitis — 
and rests on phrenic nerve, scalenus anticus, brachial plexus (or between its 
cords), and scalenus medius. 

Indications for Ligation. — Rare, except for wounds, when the artery, 
or its branches, are cut down upon and tied where wounded. 

Sites of Ligation. — Most conveniently exposed in the subclavian triangle, 
just below the outer margin of the sternomastoid. 



LIGATION OF TRANSVERSALIS COLLI BRANCH OF THYROID AXIS 

OF SUBCLAVIAN 

AT OUTER MARGIN OF STERNOMASTOID. 

Position. — As for ligation of inferior thyroid. 

Landmarks. — Posterior border of sternomastoid, made evident by man- 
ipulating the neck so as to render the margin of the muscle tense. 

Incision. — About $ cm. (2 inches), along posterior border of sterno- 
mastoid, extending nearly to clavicle (Fig. 7, W). 

Operation. — Having incised skin, superficial fascia, and platysma, 
branches of the descending superficial cervical ner\'es may be encountered, 
as well as the tributaries of the external jugular vein. The external jugular 
vein itself has to be carefully guarded at the outer edge of the sternomastoid. 
Having divided the deep cervical fascia and exposed the posterior border 
of the sternomastoid and the posterior belly of the omohyoid, the latter muscle, 
if in the way, is retracted upward. The sternomastoid (whose outer border 
corresponds with the outer border of the scalenus anticus) is then drawn 
inward, and the artery is found crossing outward between the two muscles 
to pass beneath the posterior belly of the omohyoid to reach the trapezius. 
The cords of the brachial plexus are to be guarded in passing the ligature 
(Fig. 17). 



SURGICAL ANATOMY OF THE SUPRASCAPULAR BRANCH OF THE 
THYROID AXIS OF SUBCLAVIAN. 

Description. — Smallest of three branches of thyroid axis. Runs trans- 
versely outward across root of neck, at first between scalenus anticus and 
sternomastoid — thence through lower part of subclavian triangle — behind 
clavicle and subclavius muscle — Ijencath posterior belly of omohyoid — over 
transverse ligament of scapular notch into supraspinous fossa (the supra- 
scapular nerve passing through the notch) — and finally winds around base 
of spine and neck of scapula to gain the infraspinous fossa. Two vense 
comites accompany the artery. 

Relations. — From its origin outward, the artery is covered by the skin, 
platysma, cervical fascia, sternomastoid, trapezius, posterior belly of omo- 
hyoid, clavicle, subclavius muscle, supraspinatus, infraspinatus; — and rests 
upon the phrenic nerve, scalenus anticus, cervical fascia from omohyoid to 
first rib, subclavian artery, brachial plexus, transverse scapular ligament, 
scapula. 

Indications — Site of Ligation. — As for transversalis colli. 



SURGICAL ANATOMY OF INTERNAL MAMMARY. 



59 



UGATION OF SUPRASCAPULAR BRANCH OF THYROID AXIS OF SUB- 
CLAVIAN 

AT OUTER MARGIN OF ST ER NO MASTOID. 

Position— Landmarks— Incision.— As for ligation of transversalis colli 

anen.' tpage 5S). 

Operation.— Praciically the same as that for ihc transversalis colli, the 
suprascapular artery niiinini; almost parallel with it, though on a somewhat 
lower plane, and so<.^n getting behind the clavicle and subclavius muscle. 
The site of exposing the artery is in the same vertical line (at the posterior 
borfler of the sternomasloid) but nearer the clavicle. The same care is 
ccssary in guarding the external jugular vein, which here enters the sub- 
iv-ian near the site at which the artery is ligated (Fig. 17). 



SURGICAL ANATOMY OF INTERNAL MAMMARY BRANCH OF SUB- 
CLAVIAN. 

Description.— .\rises from lower aspect of first part of subt lavian, near 
to inner margin of scalenus anticus — descends forward and inward, passing 
behind clavicle to enter thorax |>osterior to cartilage of tirsl rib — thence 
runs downward parallel with and about 1-3 cm. (^ inch) external to margin 
of .sternum, to interspace between sixth and seventh costal cartilages, where 
it divides into superior epigastric and musculophrenic. Its two ven.T comites 
unite to form one trunk in first intercostal space and empty into the innominate 
vein. The internal mammarj' artery. al>ove, is 0.5 to 1.5 cm. {^ to § inch) 
from b<-)rder of sternum — and, below, from i to 2 cm. (* to i inch) from ihe 
sternal margin. In its upper part it lies between the internal intercostal 
muscle and costal cartilages, in front; and pleura behind. In its lower part 
it Ues between the costal cartilages in front; and triangularis sterni behind 
(the laller structure intervening between it and the pleura). 

Relations. — (a) Cervical Part : — Covered by sternomastoid, subclavian 
vein, internal jugular vein, phrenic nerve. Rests on pleura, innominate 
vein, (b) Thoracic Part : — Covered by cartilages of first to sixih ribs, pecto- 
ralis major, internal intercostal muscles, anterior iniercostal membrane. 
Rests nn pleura (above), and triangularis sterni (below). 

Arterial Supply of the An tero- lateral Thoracic WalL— (a) ,\s the 
^internal mammary artery crosses the upper intercostal spaces two branches 
(superior and inferior anterior intercostal arteries, or superior and inferior 
branches of ihe anterior intercostal arteries, where ihey arise from a common 
truhk) are given off in each of the live or six upper Interspaces — which pass 
outward between the pleura and the internal intercostal muscles, and then 
l>etween the internal and external intercostal muscles, running along the 
lower border of the superior, and the up[>er border of the inferior rib — to 
[iastomo<« with the superior and inferior branches of the aortic intercoslals. 
>) In each of the same upper five or six spaces a single branch, the perforating, 
the anterior perforating, is given otT between (he upper and lower anterior 
Hlerto>ial arteries — which pierce the ijiternal intercostal muscles, between 
the costal cartilages, and supply the petloralis major, mammary gland (sec- 
<1, thirrJ. and fourth branches), and skin, (c) The anterior intercostal 
runrhc* for the five or six lower interspaces are given off by the mus 
j>hrcnic branch, which passes down behind the costal cartilages, picrc- 
pihe diaphragm oppiisite the ninth rib, and ending at the tenth or eleventh 



62 OPERATIONS UPON THE ARTERIES. 

subscapularis; latissimus dorsi; teres major. Externally — external root of 
median nerve; musculocutaneous nerve; coracobrachialis. Internally — in- 
ternal root of median nerve; ulnar nerve; internal cutaneous nerve; lesser 
internal cutaneous nerve; axillary vein. 

Branches. — From first part — superior thoracic, acromial thoracic. 
From second part — long thoradc, alar thoracic. From third part — sub- 
scapular, anterior circumflex, posterior circumflex. 

Line of Artery. — (With arm at right angle to trunk and hand supine) — 
from middle of clavicle to junction of anterior and middle thirds of the 
outer axillary wall, between the anterior and j)osterior folds of the axilla. 

Sites of Ligation.— Third part, by preference; — first part, if third part 
not available. Ligation of third portion of subclavian is usually considered 
preferable to that of first part of axillary (Figs. 19, C, and 7, VV). 

Comment. — (1) When the arm is at a right angle to the body, the axillary 
vein is drawn across the first part of the artery. (2) The upper and lower 
borders of the pectoralis minor correspond, respectively, with lines drawn 
from the junction of the third rib and its cartilage to the coracoid process; 
and from the junction of the fifth rib and its cartilage to the coracoid process. 
(3) Two brachial venic comites are generally found at the lower part of the 
artery — and also the basilic vein, unless it have already joined the internal 
vena comes. 



LIGATION OF FIRST PART OF AXILLARY ARTERY 

BV CURVED TRAXSVKKSK INTISIOX RKI.OW CLAVICLE. 

Position. — Patient on bnck, at edge of table; upper thorax raised; shoulder 
backward. Surgeon near thorax on left, for left operation; near head on 
right, for right operation — (or between abducted limb and body on each 
side). 

Landmarks. — Clavicle; sternoclavicular articulation; coracoid process. 

Incision. — Curved incision in infraclavicular fossa — beginning just ex- 
ternal to the sternoclavicular joint — dipping, at lowest point, about 1.3 cm. 
(J inch) below clavicle — and ending at the coracoid [)rocess (Fig. 7, W). 

Operation. — Incise skin, j)lalysma. supraclavicular nerves, and fascia. 
Carefully guard the cephalic vein and branches of acromial thoracic artery 
at outer part of wound, on account of collateral circulation. Divide the 
clavicular origin of the pectoralis major throughout the wound. Clear the 
areolar tissue beneath the f)ectoralis major. lCx[)ose the upper border of 
the pectoralis minor and draw it downward. IJivide vertically, near the 
coracoid process, the costocoracoid membrane— through which pass the 
cephalic vein, branches of the acromiothorac ic artery, and the anterior thoracic 
nerves — and displace it upward and outward. The (e|)halic vein, indicating 
the position of the axillary vein, is generally closely arlherent to the costo- 
coracoid membrane. Kx])ose the sheath and clear the artery — which lies 
between the axillary vein on the inner >idc and the brachial j)lexus on the 
outer, aided in the exposure by bringing the arm nearer the body, when the 
axillary vein will be carried from over the artery to its inner side. The 
ligature is placed above the acromiolhoracic branch. The incised pectoraHs 
major muscle is rc])aired by gut suturing. 

Comment. — This is the easiest and most frequent ligation of the first 
part, in the rare cases in which a ligation at this site i> done — a ligation of 
the third portion of the subclavian being considered preferable. The first 



SURGICAL ANATOMY OF AXILLARY ARTERY. 



6t 




— \ Jiini tioii 



I'Ue- 1^— iNCtStOKS F-'k I I .MiN*. Ki..nr Axih-ARV as ■ ■ - -\ Jurntion 

ol •ntvrk>f And niuUlli* ihinU ivi uulrr ax.ilUT> uali ; B, reiiU-r oi )H.-tkil ^'i tUio^t , C, Lii^Liuii ot thirci 
tjiart of aulbo : L>, Of biachial in muldlc of »rm ; C, Of brncliiiti al btrmi ol ekboM\ 



r 



SURGICAL ANATOMY OF AXILLARY ARTERY. 



I 

K antcT 



Description and Relations. — Otntinuiition of subtlavian — cxtenrlinpj 
through axiUa, from huver border of lirsi rib, on to the iirm, at the lower 
borrlcr of the tendon of teres maj<»r mu*-cle. where it becomes the brachial. 
li is. divided into three parts: (a) First Part : — Abi»ui 2.5 cin. (i inch) in len^rth 
— t-xiendinj; from lower border of fir^l rib to upper border of pectoralis 
minor, having following relations: Anteriorly— ski ti; superfuial fascia; 
origin of plalysma; deep fascia; pectoralis major; clavicle (when shoulder is 
depressed); subclavius muscle (when shoulder is depressed); costocoracoid 
membrane; layer of areolar fatly tissue; cephalic \ein; acromiolhoracic vein; 
anterior external thoracic nerve; axillary lymphatic trunk. Posteriorly — 
first intercostal space; first intercostal musilc; second (and sometimes third) 
aiions of serralus majjnus; part of se< onrl rib; [Mistcrior thora<ic nerve. 
temally — brachial plexus. Internally — axillary vein; anterior internal 
ihoravic nene. (b) Second Part :— about .^ cm. (ij inches) in lentith — 
lying Ix'hind pectoralis mincjr mu.scle, and hanng following relations: Ante- 
riorly—integuments; superllcial fascia; pectoralis major; pectoralis minor. 
Posteriorly— posterior cord of brachial plexus; areolar tissue and fat; sub- 
flcaputariv Externally — external cttrd of lirachial plexus; coracoid j>rocess 
. uhat removed). Internally— iniemal cord of brachial plexus; axillary 
(Cl Third Part: — about 7.5 cm. (1, inches) in length — extending from 
lower tnirder of f>ertoralis minur to lower Inirder of tendon of teres major 
up|>cr half l>eing in axilla, ihc lower half on arm), and having following 
tions: Anteriorly — integument; sujjerficial fascia; j>ectoralis major; deep 
of arm; internal root of median ner\e; external brachial vena comes, 
rly— musculospiral nene; circumflex nerve; fatly areolar tiseuc; 



62 OPERATIONS UPON THE ARTERIES. 

subscapularis; latissimus dorsi; teres major. Externally — external root of 
median nerve; musculocutaneous nerve; coracobrachialis. Internally — in- 
ternal root of median nerve; ulnar nerve; internal cutaneous nerve; lesser 
internal cutaneous nerve; axillary vein. 

Branches. — From first part — superior thoracic, acromial thoracic. 
From second part — long thoracic, alar thoracic. From third part — sub- 
scapular, anterior circumflex, posterior circumflex. 

Line of Artery. — (With arm at right angle to trunk and hand supine) — 
from middle of clavicle to junction of anterior and middle thirds of the 
outer axillary wall, between the anterior and posterior folds of the axilla. 

Sites of Ligation. — Third part, by preference; — first part, if third part 
not available. Ligation of third portion of subclavian is usually considered 
preferable to that of first part of axillary (Figs. 19, C, and 7, \V). 

Comment. — (1) When the arm is at a right angle to the body, the axillary 
vein is drawn across the first part of the artery. (2) The upper and lower 
borders of the pectoralis minor correspond, respectively, with lines drawn 
from the junction of the third rib and its cartilage to the coracoid process; 
and from the junction of the fifth rib and its cartilage to the coracoid process. 
(3) Two brachial venx comites are generally found at the lower part of the 
artery — and also the basilic vein, unless it have already joined the internal 
vena comes. 



LIGATION OF FIRST PART OF AXILLARY ARTERY 

BVcrRVF.D tr.\xsvi:rsi-: ixcisiox bki.ow clavicle. 

Position. — Palienl on biick, al edge of tabic; u|)pcr thorax raised ; shoulder 
backward. Surgeon near thorax on left, for left operation; near head on 
right, for right operatit)n — (or between abducted limb and body on each 
side). 

Landmarks. — Clavicle; sternoclavicular articulation; coracoid process. 

Incision. — Curved incision in infraclavicular fossa — beginning just ex- 
ternal to the sternoclavicular joint--dij)j)ing. at lowest point, about 1.3 cm. 
(^ inch) below clavicle- -and ending at the coracoid process (Fig. 7, W). 

Operation. — Incise skin, i)latysma. su[)ra(lavicular nerves, and fascia. 
Carefully guard the ce])halic vein and l)ranches of acromial thoracic artery 
at outer part of wound, on account of collateral circulation. Divide the 
clavicular origin of the pe(t(iralis major throughout the wound. Clear the 
areolar tissue beneath the pectoralis major. Expose the upper border of 
the j)cctoralis minor and draw it downward. Divide vertically, near the 
coracoid process, the costot oracoi<l membrane-through which pass the 
cephalic vein, branches of the acromiothoracic artery, and the anterior thoracic 
nerves — and disj)lace it uj)ward and outward. The cephalic vein, indicating 
the jK).sition (jf the axillary vein, is generally closely adherent to the costo- 
coracoid membrane. Kxj^ose the sheath and dear the artery — which lies 
between the axillary vein on the inner side and the brachial plexus on the 
outer, aided in the exposure by bringing the arm nearer the body, when the 
axillary vein will be carried from over the artery to its inner side. The 
ligature is j)laced above the ac romiothoracic branch. The incised pectoralis 
major muscle is re|)aired by gut suturing. 

Comment.— This is the easiest and most frequent ligation of the first 
part, in the rare cases in wlii(h a ligation at this site is done — a ligation of 
the third portion of the subclavian being considered ))referable. The first 



UCATION OF THIRD PART OF AXILLARY ARTERY. 



63 



part may be exposed by an oblique incision between pectoralis major and 
deltoid- 
Collateral Circulation^— When If gated between the superior thoracic 
and acromial thoracic: — Suprascapular aFid posterior scapular; with acromial 
thoracic and subscapular. Internal mammary, aortic intcrcostals, superior 
intercostal; with long thoracic and subscapular. Plexiform vessels from 
subclavian; with plexiform vessels from axillary. 




T'l; '< Tmmi Part or Rigiii AxiLtAkV — A. Coiuc-obratliialis (rdracte-d oai- 

^»«t<l )<n ; C, Trfc» ttiHiut ; TF, Tiice|»; K, Axillarv arlifry; F, Knuiltc vein. Iwcom- 

itiit *%> >-< MiM^titrt t«v4-iviti|; two btHihiiil vrtmr rotntm ; Tt, KiKhi hnichial vrtui comes; H, Miu^ 
«r«lacttt«ncnu« turrve ; I, Mctltnti N. ; J, Inlenml cutaneous N. -, K, K, L'tiiar N. 



UGATION OF THIRD PART OF AXILLARY ARTERY. 

Position.— Patient sujiinc a.t edge of table; shoulders raised; arm at 
right angle to ImmIv, and slighlly rotated outward. .Surgeon between arm 
and chr>t, on either side. Axilla to be shaved, 

Landmarks. — Junction of anterior and middle thirds of external axillary 
wall; lorarnbrarhialis. 

Incision. — .About 7.5 cm. (3 inches) in length— beginning at the middle 
of ihe oudel of the axilla, ai the junction of the anterior and middle thirds 
oi it* outer wall, and pttsv.nHr dnwinvarci jlnni? the inner bonier of the toraco- 
brachialis (Fig. 19, C). 



^mmrn 



64 OPERATIONS UPON THE ARTERIES. 

Operation. — Having incised integument and fascia, expose the inner 
border of the coracobrachiaUs (Fig. 20). Draw this muscle and the musculo- 
cutaneous nerve outward. The median nerve is exposed and also drawn 
outward. The internal cutaneous and ulnar nerves are drawn inward. 
Venae comites are generally present at the lower part of the axilla 
and sometimes the basilic vein, which have to be guarded. Again, the 
axillary vein alone may be present to the inner side of the artery. Pass the 
needle from the vein, ligating the artery as far from a large branch as 
possible. 

Collateral Circulation.— (a) If tied below the circumflex arteries: — the 
posterior circumflex above, with the superior profunda below, (b) If tied 
between subscapular above and two circunillex branches below; — the supra- 
scapular and acromial thoracic above, with posterior circumflex below. 



SURGICAL ANATOMY OF SUBSCAPULAR BRANCH OF AXILLARY 

ARTERY. 

Description. — Arises from third j)art of axillary artery, opposite lower 
border of subscapularis; — passes downward and inward along the anterior 
margin of the lower border of that muscle, under cover of the latissimus dorsi 
to the angle of the scapula, accom|)anie(l by the long subscapular nerve and 
two vena? comites. The dorsidis scapula* branch is given off about 2.5 cm. 
(i inch) from the origin of the main vessel. 



LIGATION OF SUBSCAPULAR BRANCH OF AXILLARY ARTERY 

AI.ONC. I'OSTKKIOR AXIM.ARV FOLD. 

Position. — Patient su|)inc; limb fully abducted. Surgeon between chest 
and arm. 

Landmarks. — Posterior axillary fold. 

Incision. — Begins at the arm and passes along the anterior surface of 
the posterior axillary fold. 

Operation. — Incise skin and siijierfuial fa>cia. The intercostohumeral 
nerve may be encountered here. Divide the dce[) fascia. The artery lies 
at the upper edge of the insertions of the latissimus dorsi and teres major, 
v.hich form the posterior axillary wall. Separate the artery from its venae 
comites and long sul)sraj)ular nerve an<l j)as> ihc needle. 

Comment. -Tlirough this in(i>ion the dorsilis .^capuhe artery is also 
exposed, and at the upi)cr part of this incision the circumllex nerve is seen. 



LKiATION OF BRACHIAL ARTERY. 



65 



Relations. — Anteriorly: inlegumenl; superficial and deep fascia; 
median nerve (in middle); median basilic vein and bicipital fascia (at elbow). 
Posteriorly: lies, in order, upon— long head of triceps (musculospiral nerve 
and superior profunda artery ioterveningj; inner head of triceps; insertion 
of coracobrachialis; brachialis anticus. Externally: in order — coraco- 
brachiaiis; belly of biceps (both s^lighlly overlapping ihe artery); lendnn of 
biceps; median nerve, above (crossing arter}' at middle); external vena comes. 
Internally: internal cutaneous and ulnar nerves (above); median nerve 
(below); internal vena comes; basilic vein. 

Branches. — Superior profunda; inferior profunda; anaslomotica magna; 
nutrient; muficular. 

Line of Artery. — (Arm extended and abduiied, hand supine.) From 
jiinclion of anterior and middle thirds of outer wall of axilla to center of 
bend of t\\H)w (Pig. 19. A and B). 

Sites of Ligation.— Middle of arm (preferably); bend of elbow. 




Flf. ai.— Ligation 01 Akm:— A. Biceps; B, Coracobrachi- 

■lU Odtvricd uulwsixn , ' , . . iii.L. ..:; 1 bmiii lits. ; F.. BraL-liJal vena: camilcs 

aihS rommuiifcalitiK liranche^ ; h, hHsitic vcm; i>. iininch trom basilic tocieph&lic vein; H, Mcdlaa 
IMf>«; 1. L~liui N. ; J, lntcmail cuiastcuus N. 



K 



LIGATION OF BRACHIAL ARTERY 

IN Mlhltl K (H ARM. 



Position. — Limb extended, abducted, and hand supine. Surgeon to 
outer <.ide of limb, cutting from above downward on right, and from below 
upward on left. 
5 




66 OPERATIONS UPON THE ARTERIES. 

Landmarks.— Inner border of coracobrachialis and biceps; line of 
artery. 

Incision. — About 5 to 7.5 cm. (2 to 3 inches) in length, extending along 
inner border of biceps, in line of artery, opposite middle of arm (Fig. 19, D). 

Operation. — The skin and fascia having been divided, the inner border 
of the biceps must be clearly recognized and retracted outward — when the 
artery is generally found under its inner margin — the median ner\'e usually 
crossing the front of the artery at its middle — the internal cutaneous nerve 
lying to the inner side (Fig. 21). The vena^ comites and basilic vein are to 
be separated from the artery. The needle is passed from the nerve. 

Comment. — (i) The artery is not as easily found in this situation as 
the superficial position would suggest. Its exposure is made easier by an 
assistant's holding the limb by the wrist, so that it cannot rest on the table, 
where the triceps is apt to be pushed upward and may protrude the inferior 
profunda artery and ulnar nerve, instead of the brachial artery and median 
nerve (Heath). (2) In hgaling higher than the middle third, the artery 
lies to the inner side of the coracobrachialis, the median nerve to the outer 
side, and the ulnar nerve to the inner. 




Fis;. 22.— Ligation of Right Brachial at Bend of Eirow:— A. Median basilic vein: B. 
Mc'dian it'pliali<- ; (', liilcriial < uuimlohs iicimj aiul biaiichcs; I), F'iicps; E, E, Bicipital fascia 
tliviiloci ; I', Biaihial aiu-iy; ('•. I'.iailiial \ ciiii- tuimle.s ami coniimiiiii aiiiig branches; H, Median 
nerve; I, BracIliali^ amicus nmscl*-. 



LIGATION OF BRACHIAL ARTERY 

AT hi:ni) ov elbow. 

Position. — Limb extended (not overextended) and abducted. Surgeon 
to outer side of limb, cutting from above on right, and from below on left. 



SURGICAL ANATOMY OF KAUIAL ARTERV. 



67 



Incision. — About 5 cm. (2 inches) in length— in the internal bicipital 
fosf^^ along the inner border of the biceps tendon — its center corresponding 
to the "fold of the elbow." This incisinn will be oblique and its upper end 
will commence opposite ihe tip of the internal condyle of the humerus. It is 
well to compress the veins above, to get an idea of their position at the elbow, 
and thus avoid them, if possible. Ordinarily the incision will lie above and 
to the outer side of the mc<lian basilic (t*ig. 19, E). 

Operation. — Having incised skin and supertlcia! fascia, isolate the 
median basilic vein and accompanying internal cutaneous nerve and retract 
them inward (Fig. 22). Incise, in the direction of the original wound, the 
deep fascia and the bicipital fascia — the latter (passing inward and down- 
ward) is to be incised to as limited an extent as |K)ssible. Beneath the bicipital 
fascia lies the arter>-, with itsvence comites — the median nerve generally lying 
out of the way and to the inner side, nearer the upper than the lower part 
of the wound. Pass the needle from the side of the ulnar nerve. Re^uture 
the bicipital fascia with gul. 



SURGICAL ANATOMY OF RADIAL ARTERY. 

Description. — Smaller but more direct of two divisions of brachial. 

iBegins at bifurcation of brachial, abcmt 1.3 cm, (^ inch) below bend of elbow 

— runs outward and downward alung radial side of forearm to styloid process 

of radius — thence passes around outer side of carpus over external lateral 

.ligament and beneath extensor tendons of thumb, to back of wrist — and 

fTnters palm between first and second metacarpal bones, passing between 

the two heads of tirst dorsal interosseous mustle— thence crosses metarurpal 

bones and interossei muscles, anastomosing at ulnar side of hand with deep 

branch of ulnar, to form deep palmar arch. The artery is accompanied by 

two ven;p comites. 

Relations. — (a) In Forearm : — The artery runs in outermost intermuscu- 
l;ir space, lying between sujiinator longus and prfinalor radii teres above, and 
ptwecn supinator longus and tendon of flexor carpi radialis below. Ante- 
riorly — skin; fascia; supinator longus (above). Skin; fascia; cutaneous 
vessels and nerves (below). Posteriorly — (from above downward) tendon 
of biceps; supinator brevis; insertion of pronator radii teres; radial origin 
of Ucxor subUmis digitorum; flexor lungus polljcis; pronator quatlralus; 
anterior surface of lower end of radius. Externally — supinator lonp,us 
(guide to arter>') and external vena comes (throughout); railial ner\e (middle 
liirti). Internally— pronat«»r radii teres (up[)er third); tendon flexor caqji 
idialis (lower third); internal vena comes (thniughout). (b) At Wrist: — 
l*rhe aricr)' winds over outer side of carpus, from a point Just below and 
1 10 styloid process of radius, to base of first interosseous s|>ace, entering 

I . between the two heads of the first dorsiil tniero.sseous muscle (ab- 

duitor indicis) to form the deep palmar arch. It is covered, successively, 
by extensor ossis melacarfii p^illicis; extensor brevis fK)lticis; branches of 
adial nerve; superficial radial veins; eJctensor longus pollicis; — ami rests, in 
'"onler. u|ion ejctcnial lateral ligament; scaphoid; trajjezium; base of first 
metacarpal; dorsal carpal ligaments. It is accompanied by two venae comites 
and branches of musculocutaneous ncne. (c) In the Palm: — Enters palm 
in upfier part of interval between first and second metacarpals, jiassing 
piween two heads of first dorsal interosseous muscle (abductor indicis) — 
an>i inward between adductor obliquus pollicis and adductor transversus 



68 



OPERATIONS UPON THE ARTERIES. 



pollicis — crossing the palm transversely, with slight downward curve, to 
base of metacarpal of little finger, and there anastomoses with deep branch 
of ulnar, forming the deep palmar arch. The deep palmar arch, therefore, 
extends from base of first interosseous space to base of metacarpal of little 
finger, and is about 2 cm. (f inch) nearer the wrist than is the superficial 
palmar arch. It is covered by the superficial and deep flexor tendons; ad- 




Fij?. 23.— Incisions toK Lk.aiini, Rh.iii Kadiai. and Ti nar Akt kkiks, and Superficial 
AND I)ki;p Palmar Akihi-.s ; -A. Ligation ol ladial in upper third of lorcarm ; B, of radial in middle 
Ihinl ; C. of radial in Unvt-r third; 1>, ol drcp paltn.ir au li ; i;. l.inalion of ulnar in middle third of 
forearm; F, of ulnar in lowt-r third ; C,.i<\ ^iiinrlli iai pahii.u arrli ; H. tenter of bend of elbow ; I, 
'•'•ero-internal as|>ect of slyhjid proi esi of r;i(iiu-> ; J. Kadiai sidi-ot j)isiiortn hone; K. Anterior aspect 

ner condyle of humerus; L, Toitil on inticr asjiecl of forearm ai junction of upper and middle 



LIGATION OF RADIAL ARTERV. 



«9 



ductor obliquus pollkis; part of flexor brevis minimi digiti; part of opponens 
minimi digiti; lumbricales. It rests upon adductor transversus poIHcis; 
carpal extremities of metacarpal bones; inlerossei muscles. It is accom- 
panied by two venae comites and the deep branch of the ulnar ner\'e (running 
in opposite direction). 

Branches. — (a) In Forearm — radial recurrent; muscular; anterior radial 
carpal; superficialis vola?. (b) At Wrist — posterior radial raq)al; melacarpal 
(fir>.t dorsal interosseous); dorsalis pollicis; dorsalis indicis. fc) In Palm 
— princeps pollicis; radialis indicis; palmar interosseous; recurrent; per- 
forating. 

Line of Artery. — (a) In Forearm (with hand supine) — from center of 
bend of elbow, to inner side of forepart of styloid process of radius (Fig. 
23, H and I), (b) At Wrist — from inner side of forepart of styloid process 
to base of first interosseous space, (r) In Palm — runs about 2 cm, (} 
inch) nearer wrist than does superficial palmar arch (which corresponds 
with a line continued across on level with lower border of outstretched 
thumb). 

Sites for Ligature. — Upper forearm (rarely); middle forearm; lower 
forearm (preferably); back of hand (rarely). In palm— the arch may be 
lied in cas^e of wounds, under which circumstances it may be ligated at any 
site (Fig. 23, D). 

Anatomy of the "Tabatifere," or "Snuff-box."— The triangular 
space on back of hand — boundeil, on radial siffe, by extensor ossis metacarpi 
pollicis, and extensor brevis pollicis; — on ulnar side, by extensor longus polli- 
cis; — above, by lower edge of posterior annular ligament. Its floor is 
formed by trapeyJum^ jiart of scaphoid, base of first metacarpal. It con- 
tains radial artery, cephalic vein of thumb, branch of internal division of 
radial nerve, branch of musculocutaneous nerve. 



I 



LIGATION OF RADIAL ARTERY 

IN UPPER THIRD OF FOREARM 

Position.— Hand supine; wrist extended. Surgeon stands outside of 
limb, cutting downward on right and ujnvnrd on left. Assistant holds fingers 
ilh one hand and grasps forearm with uther. 

Landmarks. — Line of artery; inner border of supinator longus. 

Incision. — From 5 to 7.5 cm. (2 to 3 inches), in line of artery^with 
center over the point to be tied (Fig. 23, A). 

Operation. — Having incised skin and superficial fascia, the radial or 
me<lian vein may be met. Divide the deep fascia and open up the space 
brtwecn the supinator longus (fibers running directly downward) and the 
pronator radii teres (fibers running downward and outward) (Fig. 24). The 
artcr}- lies under the edge of the supinator longus and upon the inser- 
tion of the pronator radii teres. The radial ner\e lies well to the outer 
smIc- 

Comment. — Unless one recognize the inner margin of the supinator 
k»ngu^, there is possibility of hitting off the wrong intermu.scular septum and 
getting t(x» near the middle of the forearm. The anterior surface of the 
supinator longus (and not iti inner border) appears at first, in operating upon 
the muscular— and this must be well retracted outward. 




70 



OPERATIONS UPON THE ARTERIES. 



H — 




r 

G 



Fij?. 24.— Lir.ATioNOK 1,'ppF.R Third OF Right Radial :— A, Anterior branch of musculocutaneous 
nerve; B, Branch of rndial vein ; C. C, Supinator longus muscle, retracted outward ; D, D. Pronator 
radii teres; E, Flexor carpi radialis; F, Radial artery ; G, G, Radial vena; comites; H, Radial nerve. 



LIGATION OF RADIAL ARTERY 

IN MIODLF-: THIRD OF FORFARM. 

Position. — As for upper third. 

Landmarks. — Line of artery (especially as inner border of supinator 
longus is not always evident). 

Incision. — From 5 to 6 cm. (2 to 2^ inches) — ^in line of artery, with its 
center opposite center of forearm, so as to fall Vjetween supinator longus 
and flexor carpi radialis (Fig. 23. B). 

Operation. — Havin«^ incised skin and superficial fascia, branches of the 
radial and median veins and anterior branch of the musculocutaneous nerve 
are generally encountered. Incise the deep fascia and recognize the inner 
margin of the supinator longus (its fibers running directly downward) and 
retract outward while ell)Ow is slightly fle.xed. The artery is found upon 
the flexor sublimisdigitorum and tlcxor longus pollicis — or. if higher up, upon 
the insertion of the pronator radii teres, with its vena' comites. Clear the 
artery and pass the needle from the nearer vein. The radial nerve lies to 
the radial side of the arlerv. ])ul mav not come into the field. 



LIGATION OF RADIAL ARTERY 

IX l.OWI'.R rillKl) ()!■• F(1RFAKM. 



Position. — .As for upper third. 

Landmarks. ^Tendons of supinator longus and flexor carpi radialis. 



LIGATION OF RADIAL ARTERY. 71 

Incision. — From 2.5 to 5 cm. (i to 2 inches), vertically, in center of interval 
between tendons of supinator longus and flexor carpi radialis (Fig. 23, C). 

Operation. — Having incised skin and superficial fascia, the radial vein, 
or a large branch, and often the superficialis volaj arterv', are met and are 





E 

G 



Fig- 25— Ligation OF Lower Third of Right Radial (Jtst above Wrist) :— A, Radial 
vein; B, Anterior branch of musculocutaneous nerve; C. Supinator lonpus tendon ; D, Flexor carpi 
radialis tendon; E, Pronator quadratus ; F, Radial artery ; (i, Superficialis volie artery; H, H, Radial 
venx comites. 

displaced to one side (Fig, 25). The deep fascia is divided, and the interval 
between the tendon of the supinator longus, externally, and the tendon of the 
flexor carpi radialis, internally, is opened up and the artery and its vence 
comites are found between them, accompanied by the anterior branch of 
the musculocutaneous nerve. 



LIGATION OF RADIAL ARTERY 

OS HACK OF" HANI). 

Position. — Limb rests on ulnar margin. Assistant holds thumb extended 
and abducted, and fingers straight, and so manipulates them as to bring out 
the boundaries of the snuff-box. 

Landmarks. — Tendons of extensor ossis metacarpi pollicis and extensor 
brevis poUicis, on radial side — and that of extensor longus ponicis,on ulnar side. 

Incision. — From 2.5 to 4 cm. (i to i^ inches), midway between the two 
ridges made by the above tendons — beginning on a level with the tip of the 
styloid process, and extending downward, but stopping short of the lower 
end of the vessel. 

Operation. — Having incised skin and superficial fascia, separate the 
divided fascia carefully. Avoid the cephalic vein of the thumb and branches 
of the radial and musculocutaneous nerves. Demonstrate the tendons 
forming the boundaries of the snuff-box. The artery is found deej)ly placed 
and closely surrounded by venae comites, which may be included in the ligature 
if necessary. 

Comment. — Guard against opening the synovial sheaths of the tendons. 



70 



OPERATIONS UPON THE ARTERIES. 




Fig. 24.— Ligation OF Uppbr Third of Right Radial :— A, Anterior branch of musculocutaneous 
nerve; B, Branch of radial vein ; C, C. Supinator longus muscle, retracted outward ; D, U, Pronator 
radii teres ; E, Flexor carpi radialis; F, Radial artery ; G, G. Radial venee comites; H, Radial nerve. 



LIGATION OF RADIAL ARTERY 

IN MIDDLE THIRD OF FOREARM. 

Position. — As for upper third. 

Landmarks.— Line of artery (especially as inner border of supinator 
longus is not always evident). 

Incision. — From 5 to 6 cm. (2 to 2^ inches) — in line of artery, with its 
center opposite center of forearm, so as to fall between supinator longus 
and flexor carpi radialis (Fig. 23, B). 

Operation. — Having incised skin and superficial fascia, branches of the 
radial and median veins and anterior branch of the musculocutaneous nerve 
are generally encountered. Incise the deep fascia and recognize the inner 
margin of the supinator longus (its fibers running directly downward) and 
retract outward while elbow is slightly flexed. The artery is found upon 
the flexor sublimisdigitorum and flexor longus poUicis — or, if higher up, upon 
the insertion of the pronator radii teres, with its venze comites. Clear the 
artery and pass the needle from the nearer vein. The radial nerve lies to 
the radial side of the artery, but may not come into the field. 



LIGATION OF RADIAL ARTERY 

IN LOWKR THIRD OF FOREARM. 



Position.— As for upper third. 

Landmarks. — Tendons of supinator longus and flexor carpi radialis. 



LIGATION OF RADIAL ARTERY. 



71 



Incision.— From 2.5 to 5 cm. (i 10 2 inches), vertically, in center of interval 
between tendons of supinator longus and flexor carpi radialis (Fig. 2^, C). 

Operation. — Having incised skin and superficial fascia, the radial vein, 
or a large branch, and often the superficialts vota; arler}% are met and are 




Fig. js— Ligation op LovtBH Third or Ktaur Radial (Just ahovk Wuist) ;— A. Radial 
«Yiii; B. Atitfetivr hraiit-h of tnusculocutanruus nerve; C. Supinator lougus tendon ; D, Flexor carpi 
r*<1i*lis imtlfMi ; E. Pronator quadratus ; F. Radial artery ; ti, Superlicialis volse artery ; H , H. Radial 
t-etuc curoiln. 

displaced to one side (Fig, 25). The deep fascia is divided, and the intenal 
between the tendon of the supinator longus, exlernally, and the tendon of the 
licxor car|)i radialis, internally, is opened up and Ihe artery and its vena^ 
comites are found between them, accompanied by the anterior branch of 
ihc musculocutaneous nerve. 



LIGATION OF RADIAL ARTERY 

ON BACK OF HAND. 

Position.— Limb rests on ulnar margin. .Assistant holds thumb e.xtended 
and aMuctefi* and hngei^ straight, and so manipulates them as to bring out 
the l>oundaries of the snulT-box. 

Landmarks.— Tendons of extensor ossis metacarpi pollicis and e.xtensor 
brevis pullicis, on rarlial side — and that of extensor longus pollicis. on ulnar side. 

Incision. — Fnmi 2.5 to 4 cm. (i to i^ inches), midway between the two 
ndges made by the alj<ive tendons — licginning on a level with the tip of the 
styloid prcxess. and extending downward, but stopping short of the lower 
did of the vessel 

Operation. — Having incised skin and superficial fascia, separate the 
di\ided fa.scia carefully. .Avoid the cephalic vein of the thumb and branches 
of the railial and musculfKUtaneous nerves. Demonstrate the tendons 
forming the boundaries of the snulT-box. The artery is found deeply plau'd 
and rlc»sely surrounde*! t)y vena? comites, which may be included in the ligature 
if ncrcssar)*. 

Comment. — Guard against opening the synonal sheaths of the tendons. 



72 



OPERATIONS UPON THli ARTERIES. 




Fil". ."I.— I.TCAIIDN OK I.KKT SlI'liRKtlM M. ANH ])<.:\:f> I»AI.M\R ARCHKS: — A, Aniiulsil Jljja- 

nu-iil : i'>. Flexor lirevis ]Hilli>is i]i:iit ni it^ ixi^;!)! ir<i:ii aiiiiiil.ii li;;:iiiiciii i in i sod I ; C. Tviuloiis «if 
flrxcir MiMiinix (lij^iiorinii and uutcr liiiiil>ri> .d -diauii iiiwaidi: I), Adiliictur uhliqiiiis |Millici»; K. 
Addiu'tm tiausvi-isus |><tl1U-is: I-", F. Hrainlu-.«- of nu-diaii iktvo ; H, II, Superficial palmar arch ; G, 
Uct-p ]).dMiar arch ami its vciue c<»mitc.>.; I, 1, Siipcrlicial vein. 



LIGATION OF DEEP PALMAR ARCH OF RADIAL ARTERY. 

Position.— Limb supine; hand extended. Assistant steadying fingers 
and wrist. Surjjeon ruts from above downward on both sides. 

Landmarks.- Obhtjue crease running downward and outward from 
junctirm of thenar and hypothenar eminences and partially circumscribing 
the thenar eminence. 

Incision. — From junction of the thenar and hypothenar eminences — and 
ninninp along the thenar crease toward the metacarpophalangeal joint of 
the inde.x-finger — with the center of the incision opposite the center of the 
ball of the thumb (Fig. 23, D). 



SURGICAL ANATOMY OF ULNAR ARTERY. 



73 



Operation. — Having incised skin and superficial fascia, expose and 
ligate the su|>erficial palmar arch (crossing the palm on a level with the lower 
border of the outstretched ihymb) {Fig. 26). The muscles of the thenar 
eminence are now exposed, and these, with the annular ligament, are incised 
at the upper part of the wound to as limited an extent as possible. The 
inlcr\'al between the flexor tendon of the index-fin^er and its accompanying 
lumbricai muscle, on the one hand, and the muscles of the thumb, on ihe 
other, is made out and opened up by deep reiracliun, guarding the branches 
of the median nerve. In the interval thus exposed by retraction is seen 
the adductor obliquus pollicis, which is tu be divided vertically, when the 
arch will be found under it. running transversely from between the adduclur 
obh'quus pollicis and adductor transversus pollicis onto the deep fascia covering 
the interossei, and about 2 cm. (f inch) nearer the wrist than dttes the supcr- 
ficiaJ arch. The needle is to be carefully passed in the deep wound, to avoid 
the nenes and veins. 

Comment. — The position for ligating can be located by feeling for the 
apex of the first interosseous space on the back of the hand. 



b 



SURGICAL ANATOMY OF ULNAR ARTERY. 



I 



Description. — Larger of two divisions of brachial arter\'. Begins at 
bifurcation of brachial, about 1.3 cm. {\ inch) below bend of elbow, and in 
middle of forearm — runs through upper half uf forearm, with .slight {:nT\t 
(convexity to ulnar side), to ulnar aspect of limb, passing beneath the pronator 
radii teres and superficial flexors— thence vertically down the lower half 
of the forearm, along its ulnar border lo the wrist, being .slightly overlajiped 
by the flexor carpi ulnaris. It crosses the annular ligament immediately 
to the radial side of the pisiform bune. and, entering the palm, divides into 
superficial and deep palmar branches, to help form superficial and deep 
palmar arches. It is accompanied by iwo vena: coraites. The ulnar 
ner\'e comes into contact with the artery at ihe junction of its upper and 
middle thirds, and remains in relation with it to the palm, being upon its 
ulnar side. 

Relations.— (A) In Forearm :- Anteriorly — (a) Above— skin; fascia; 
superficial flexors (pronator radii teres, flexor carpi radialis, palmaris longus, 
flexor sublimis digitc»nim); median nerve (separated from arter\' by deep 
head of pronator radii teres), (b) Upper part nf hwer half— skin; fascia; 
and ovcrlapj>ed by tendon of flexor carpi ulnaris. (c) Lower part of lower 
half — skin; superficial fascia; deep fascia; palmar cutaneous branch of ulnar 
ner\T- Posteriorly — brachialis anticus; flexor [profundus digitorum. Ex- 
ternally — flexor sublimis digitonim (in lower two-lhirds of artery's course). 
Internally— flexor carpi ulnaris (in lower twn-ihirds); ulnar nerve (in lower 
two-thirds). (B) At Wrist : — This part of the artery extends from the upper 
to the lower part of the annular ligament, running in a channel formed by 
the pisiform and unciform process of unciform bone and by e.\pansion of 
flexor carpi ulnaris extending frnm |M>iform to unciform process. Ante- 
riorly — skin; fascia; expansion of flexor carpi ulnaris from pisiform to unci- 
form process of unciform. Posteriorly— anterior annular ligament. Ex- 
ternally— unciform process of unciform bone. Internally— pisiform bone; 
ulnar nen'e. (C) In Palm:— On entering the jialni. the uhiar ilividcs into 
suprrficial branch and deep branch —(i) Superficial branch of ulnar— 
direct continuation of ulnar artery — descends short distance toward gap 



74 OPERATIONS UPON THE ARTERIES. 

between fourth and fifth fingers, thence curves outward (with convexity 
toward fingers) and anastomoses opposite gap between index and middle 
finger, and at junction of upper and middle thirds of hand, with superficialis 
voiae of radial (sometimes with branch from radialis indicis of radial) to 
form superficial palmar arch — having following relations: Anteriorly — 
skin; fascia; and, from ulnar to radial side, by palmaris brevis, palmar branch 
of ulnar ner\'e, palmar fascia, palmar branch of median nerve. Posteriorly 
— in order, from ulnar to radial side — annular ligament; short muscles of 
little finger; digital branches of ulnar nerve; superficial flexor tendons; digital 
branches of median nerve. (2) Deep (communicating) branch of ulnar 
artery — runs deeply inward, between abductor minimi digiti and flexor 
brevis minimi digiti — anastomosing with termination of radial to form deep 
palmar arch. 

Branches. — (a) In Forearm — anterior ulnar recurrent; posterior ulnar 
recurrent; common interosseous (anterior and posterior interosseous); mus- 
cular, (b) At Wrist — anterior ulnar carpal; posterior ulnar carpal, (c) 
In Palm — superficial palmar arch; deep (communicating) palmar. 

Line of Artery. — Upper third of artery corresponds with line from a 
point about 1.3 cm. (^ inch) below center of bend of elbow, passing to inner 
side with gentle cur\'e (convexity to ulnar side), to a point at junction of 
upper and middle thirds of following line. Lower two-thirds corresponds 
with line from anterior surface of internal condyle of humerus to radial 
side of pisiform bone (Fig. 23, H, L, and K, J). 

Sites for Ligation. — Upper third of forearm (rarely) ; middle third; lower 
third (commonly); superficial palmar arch (for wounds at that site). (Fig. 
23.) 

LIGATION OF ULNAR ARTERY 

IN MIDDLE THIRD OF FOREARM. 

Position. — As for the radial arter}-. 

Landmarks. — Line of artery. The muscular landmarks at the middle 
of the forearm are generally difficult to recognize. 

Incision. — .\bout 7.5 cm. (3 inches), in line of artery, with its center 
corresponding with the center of the forearm (E, Fig. 23). 

Operation. — Incise skin and superficial fascia. The anterior ulnar 
vein and anterior branch of internal cutaneous ner\'e are likely to be en- 
countered (Fig. 27). Divide the deep fascia somewhat to the outer side of 
the skin incision, as the flexor sublimis digitorum is generally slightly over- 
lapped by the flexor carpi ulnaris. In this deep fascia the intermuscular 
plane between the fle.xor carpi ulnaris and flexor sublimis digitorum is sought 
by exposure and by the sense of touch. A muscular branch will often lead 
to it. These muscles are retracted well apart, when the ulnar nerve is first 
encountered between them— and, following inward on the same plane, the 
artery will be found upon the flexor profundus, surrounded by the venae 
comites, and with the ulnar nerve to the ulnar side. 

Comment. — It is sometimes exceedingly difllicult to hit off the inter- 
muscular space and to find the artery when once in it. Remember that the 
anterior margin of the flexor carpi ulnaris slightly overlaps the flexor sublimis 
digitorum at this level. Also remember, when once in the intermuscular 
space, not to pass below the ulnar nerve, and thus go too deeply on the ulnar 
side of the forearm, but rather work inward from the level of the nerve. 



LIGATION OF ULNAR ARTERY. 



75 




Ifg. *?.— LiCATtoN Of Rtr.HT Ulnar in Upper Part of Middle Third:— A. AntvrioT ulnar 
v«iu ; B. Autenor branch of interrul cutaneou» m-rvc ; C, Flexor carpi lilnaris; D. Flexof suhtimis 
diffilorum, E. Flexor proiundus digilorum; F, Ulnar ner^-e; G. Ulnar artery ami ils venae coniites 
( dnt wn to ulnar side > . 




fkm. A— LlOAtioK OP LoWHH TKinn "K Right Ulnar {Ji^st arovb tmh Wrist) 

-^,^._ .,1 — . «.! v......... htRHcliol iiitcrtuil cutBneou*ner\-e; C,Te«ilon "i ii. v..i .in, 

II -ligiiortiin; F., UliMir Rjteryt F, Commumcaili' 

It, , • nerve. 



-A, An- 



76 OPERATIONS UPON THE ARTERIES. 



LIGATION OF ULNAR ARTERY 

IN LOWER THIRD OF FOREARM. 

Position. — As for radial. 

Landmarks. — Outer border of flexor carpi ulnaris. 

Incision. — About 5 cm. (2 inches) in length — ending about 2.5 cm. 
(1 inch) above the pisiform bone — and placed between the tendon of the 
flexor carpi ulnaris and the innermost tendon of the flexor sublimis digitorum. 
(As the innermost tendon of the flexor sublimis digitorum is not always 
recognizable, the incision is generally placed to the outer side of the tendon 
of the flexor carpi ulnaris.) (Fig. 23, F.) 

Operation. — Having incised skin and superficial fascia, avoid the anterior 
ulnar vein or its branches (Fig. 28). Divide the deep fascia. Partly flex 
the wrist to relax the structures, and retract the flexor carpi ulnaris outward. 
The artery will be found upon the flexor profundus digitorum, with the 
venae comites closely surrounding it, and the ulnar nerve lying closely to the 
ulnar side. 



LIGATION OF SUPERFIOAL PALMAR ARCH OF ULNAR ARTERY. 

Position. — As for the deep palmar arch. 

Landmarks. — Junction of thenar and hypothenar eminences. 

Incision. — Vertical — extending from junction of thenar and hypothenar 
eminences toward base of ring-finger, with center opposite a line crossing 
the palm transversely, on a level with the lower border of the outstretched 
thumb. The artery lies at the intersection of these two lines (Fig. 23, 

Operation. — Divide the skin, superficial fascia, and palmar fascia, 
when the arch will be found in the underlying fat, lying upon the digital 
branches of the median and ulnar nerves (Fig. 26, H, H). 

Comment.— If the arch cannot be found, ligate the artery at the pisiform 
bone. 



SURGICAL ANATOMY OF INTERCOSTAL BRANCHES OF THORAaC 

AORTA. 

Description. — The ten aortic intercostals generally supply from the 
third to eleventh intercostal spaces inclusive — the first space being supplied 
by superior intercostal alone — and the second space also by superior inter- 
costal alone, or conjointly by it and the first aortic intercostal. The tenth 
aortic intercostal runs below the twelfth rib (subcostal artery), (a) The Ver- 
tebral Portions of the Intercostal Arteries, arising in pairs from the posterior 
part of the thoracic aorta, pass around the vertebrae — the right being covered 
by thoracic duct, vena azygos major, pleura, lung, esophagus — the left, 
by vena azygos minor, left superior intercostal vein, third vena azygos 
pleura, lung. The arteries here divide into posterior or dorsal, and anterior 
or intercostal branches, (b) The Intercostal Portions run forward and 
obliquely upward in the intercostal space to the lower border of the superior 
rib, and divide near the angle of the rib into upper (larger) and lower (smaller) 
branches — the former, to run in the groove along the lower border of the 
upper rib and anastomose with the superior intercostal branch of the internal 
mammary in the upper spaces, and of the musculophrenic in the lower — the 



LIGATION OF AN INTERCOSTAL ARTERY. 



77 



latter, to run along the upper border of the lower rib and anastomose with 
the inferior branch of the internal mammary in llic upper spaces, and of the 
muscuJophrenic in the lower. At first these arteries lie between pleural 
lungs, endothoracic fascia, and infracostals internaUy — and external inter- 
costal muscles e.xtemally — then (from the angles of the ribs) between the 
external and internal intercostal muscles. The sympiithetic nerve crosses 
them opposite the head of the ribs. The intercostal vein lies above and 
the intercostal nerve below the intercostal arteries — except in the upper 
spaces, The arteries of the tenth and elevenili spaces run outward between 
the abdominal muscles. 



LIGATION OF AN INTERCOSTAL ARTERY 

BV AN INTERCOSTAL INCISION. 

Position. — Patient supine, and so turned as lu render site of operation 
prominent, and chest supported below, so as to increase width of intercostal 
ites. Surgeon stands nn side of o[>eration. Assistant oppo.'^ite. 
Landmarks. — Lower border of rib in the groove of which the special 
artery runs; or the upi)er border, in case it he the lower branch of the inter- 
coslal arter\-. 

Incision. — .About 5 cm. (2 inches), parallel with and just below the 
lower border of the indicated rib; or just above the U]iper border, as the 
rase may be. 

Operation.— Incise skin and superficial fascia. .As to what muscle, and 
Is to what amount of muscle tissue, as well as fascia, will ha\e to be further 
Jimised in the line of the oripnal incision, before the intercostal muscles are 
ljcache<i. will depend upon the site at which ihe artery is to be exposed. Ha\ing 
issctl through the overlying muscle-covering of the thoracic wall, the inter- 
stal fascia is met and incised, then the external intercostal muscle (if operal- 
ig anpvhere l>eiween the tubercles of the ribs l>ehind, and the costaJ car- 
lilu^es in frunt). The two cut marj^ins of the external iniercoslals are then 
Iravin uf>ward and downward and the artery sought as it lies partially or 
atirtJy concealed in the inferior intercostal groove, with intercostal nerve 
clow and vein above. The artery may be drawn out of its groove and down 
Ho view by the curved tip of the aneurism needle. The vessel should be 
ioubly ligated (its supply coming from l>oth directions). The incised inler- 
cosud muscle and fascia may be suiurcfl with gut in closing the wound. 

Comment. — (i) If difficulty in exposing the arteni' be exjK'ricnced. the rib 

may beexf>osed subperiosteally, as in the following operation. (2) It is to l>e 

I rrmcml)cre<i. in operating posterior to the angle of the rib, that the intercostal 

tcnr has not yet reached the inferior groove of the upper rib, but lies between 

he two ribs, and has nut divided into its upper and lower branches. 13) If it 

•iesire<l to ligate the upper and lower branches of the intCTCostal (anywhere 

' I>eiwcen the angle and costal cartilages), the incision is made midway between 

the ribs, and. after retracting the rut e.xtemal intercostal muscle, the upper 

nch is sought as above, and the lower branch is found along the up|)er 

itt of the lower rib. Both are doubly ligated. 



78 OPERATIONS UPON THE ARTERIES. 




Fiff. 29.— Ligation of Lbft Intercostal Arthry, in Lower Anterior Thoracic Region. 
BY Partial Excision of a Rib:— A. Thoracic muscles; B. External intercostal muscle: C, Rib, 
with half-button of bone bitten out with rongeur forceps; I), Periosteum, incised over ceiiler of 
rib ; E, Lower half of anterior layer of periosteum relracte*! downward ; F", F. Posterior layer of peri- 
osteum incised and retracted upward and downward, showing intercostal vessels beneath; G, Inler- 
costal artery; H, Intercostal vein ; I, Intercostal nerve. (Hartley's method.) 



LIGATION OF AN INTERCOSTAL ARTERY 

BY PARTIAL. SUBPERIOSTEAL EXCISION OF RIB (HARTLEY'S METHOD.) 

Position — Landmarks. — As in the preceding operation. 

Incision. — About 6 cm. (2^ inches), parallel with and directly over 
center of rib. 

Operation. — The above incision passes through skin, superficial fascia, 
any overlying thoracic muscles (according to site of operation), deep fascia and 
periosteum (Fig. 29). With periosteal elevator, free the lower half of the 
anterior surface, the inferior groove, and the lower half of the posterior sur- 
face of the rib, all subperiosleally. Then, with rongeur bone-forceps, bite 
out a " half-button " of bone from the bared lower half of the rib, being 
careful to insert the lower blade of the rongeur between the detached peri- 
osteum and the rib. After the half-button of bone is removed, the position 
of the artery is plainly evident — and the vessel is exposed by incising 
through the periosteal membrane, directly over it. 

Comment. — The artery may also be exposed by the ordinary method of 
subperiosteal excision of about 4 cm. (i^ inches) of rib throughout its entire 
thickness. 



SURGICAL ANATOMY OF ABDOMINAL AORTA. 

Description. — Continuation of thoracic aorta. Commences at aortic 
opening of diaphragm, opposite lower border of twelfth dorsal vertebra — and 
passes down between pillars of diaphragm, in front of lumbar ve^tebra^, at 
first in median line, but deviating to left as it descends, until it lies a little 
to left of spine at its point of bifurcation, opposite lower border of fourth 
lumbar vertebra, where it divides into right and left common iliac arteries. 
Its point of bifurcation is represented externally, roughly, by a point about 
T.3 cm. (i inch) below and a little to left of umbilicus — and, more accurately, 



SURGICAL ANATOMY OF ABDOMINAL AORTA. 



79 



by a line crossing the abdomen on a level with the highest points of the iliac 
crests. The arcompanjing vena cava is separated from ihe aorta above 
by ihe right crus of ihe diaphragm, and is on a plane anterior to it. Below, 
the vein lies in conlact with the artery, and on a somewhat posterior plane. 
The arten* is covered only by peritoneum at the site indicated for ligation, 
but between the serous covering and the artery lie important suTnpalhetic 
nene-cords from the aortic plexus (lying along the aorta between the superior 
and inferior mesenteric arteries) to the h}-pogastric plexus (lying between 
the common iliacs). 

Relations.— Anteriorly (from above downward, in order): right lobe 





I 



,V>.— Incisions rou Ligations in thk ABUoMiNtj-PELVtc Ruclow:— A, Exposure of 

»l Aon » In tr^itiv^tfrnoncnt rntifc throtiijh median itirisiuii over unibiliciUi; B. KnpiMurc of 

.il .-luria hvrrtropcritn)ieMfromc,ttiiuU);h oblique itdismn 

lire ol <-x(t.-iiitil, int<.-ni.»>. mikI toinmoii times liy t^lt«^p«^i- 

>yv unibitii.u<i ; D. u( e.vlcffuil and deep epigastric, rciro- 

■ ^[HK iiKistuit iKkiiillcl with ('uut>art'H ltK<)tnciil ; K, ol commoti, iiilciiuil, anil 

>>tirall> , throu^li vertical incision in lioea scmiluiiaris; F, of cxtem^il ili:ic, 

1' ui^ij iiitramuKUlar incision; C, G, Anterior superior iliac spines; H, Symphysis 



of liver: solar plexus; lesser omentum; termination of esophagus in stomach; 
a ' layer of transverse mesocolon; splenic vein (or beginning of vena 

p inrreas; left renal vein; third part of duodenum; mesentery; aortic 

pieAUs of «.ympalhetic; spermatic (or ovarian) arteries; inferior mesenteric 
«iiery; me<liar» lumbar lymphatic glands and vessels; small intestines, Pos- 
ttriorly: bcKlJes of lumbar vertebra-; intervening intervertebral cartilages; 
anterior common ligament; left crus of diaphragm; left lumbar veins. To 
fight: right crus of diaphragm; great splanchnic ner\"e; spigelian lobe of 
K^*rr; rcccptnculum rhyli (on a posterior plane) ; thoracic duct (on a posterior 
pbne); right semilunar ganglion; inferior vena cava; vena azygos major. 



8o OPERATIONS UPON THE ARTERIES. 

To left: left crus of diaphragm; left splanchnic nerve; left semilunar gan- 
glion; tail of pancreas; small intestines. 

Branches. — (From above downward.) Phrenic, cceliac axis (gastric, 
hepatic, splenic); suprarenals; first lumbars, superior mesenteric; renals; 
spermatics (ovarians); second lumbars; inferior mesenteric; third lumbars; 
fourth lumbars; common iliacs; middle sacral. 

Line of Artery. — From a point in the anterior median line, on a level 
with the lower border of twelfth dorsal vertebra, to a point a little to left of 
umbilicus, on a level with the highest points of the iliac crests. 

Indications for Ligation. — Iliac and inguinal aneurisms and primary 
and secondary hemorrhage — in cases where no other means are possible. 
More than a dozen cases have been reported — one case living ten days. 

Sites for Ligation. — Between the origin of the inferior mesenteric (be- 
tween 2.5 and 5 cm., or i and 2 inches, above the bifurcation) and the bifurca- 
tion (Fig. 30). 

LIGATION OF ABDOIHINAL AORTA 

BY TRANSPERITONEAL METHOD. 

Description. — The abdomen is opened in the median line, the intestines 
displaced, and the posterior parietal peritoneum opened over the artery. 

Position. — Patient supine; shoulders raised ; knees slightly flexed. Surgeon 
on right. Assistant opposite. 

Landmarks. — Median, vertical abdominal line; transverse line on level 
with highest points of iliac crests. 

Incision. — About 10 cm. (4 inches) in length, in Unea alba, with its 
center corresponding with the umbilicus — the incision passing slightly to 
left of the navel, to avoid the round ligament of the liver and the urachus 
(Fig. 30, A). 

Operation. — The peritoneal cavity having been opened in the usual 
manner, the small intestines and mesentery are well retracted upward and 
to the sides. Guided to the arter\' by its known position and by its pulsation, 
the peritoneum covering the vessel is carefully divided between the inferior 
mesenteric and its bifurcation in the iliacs. The clearing of the arteiy should 
be done with especial care, as inclusion of the sympathetic ner^'e-fibers (see 
Surgical Anatomy) is otherwise apt to take place — and is supposed to have 
been done in one case, which quickly ended fatally. A flat ligature should 
be used (kangaroo tendon, chromicized gut and silk, flat and round, have 
been used). The needle should be of special make and shape, and should 
be passed from the inferior vena cava. 

Comment. — This is the more desirable form of operation, though the 
case which sur\'ived longest was done through a posterior retroperitoneal 
incision. 

Collateral Circulation. — Internal mammary, above; with deep epi- 
gastric, below. Inferior mesenteric, above; with internal pudic, below. 
Possibly by lumbar arteries, above; with branches of internal iliac, below. 
And, if above the inferior mesenteric, by superior mesenteric, above; with 
inferior mesenteric, below. 



SURGICAL ANATOMY OF COMMON ILIAC ARTERIES. 



8l 



I 



LIGATION OF ABDOMINAL AORTA 

BV Kr:rROi^EKlTONEAI. OPF.RATiON. 

Description. — The arten' i^ here approached from the anterolateral 
ahdominal region, the peritoneum hieing pushed back from the iliac vessels 
until the aorta is reached and exposed. 

Position— Landmarks— Incision— Operation. -The operation is prac- 
tically similar to that for the exposure and ligation of the common iliac extra- 
fHfriloneally, the site being reached by an extension of those steps (Fig. 30. B). 
The patient is tilted so as to lie upon the sound side, the surgeon standing 
behind the patient, upon the side of the operation (the left). An extension 
K of the incision employed for the common iliac is carried further upward to 
^f piA*e the necessiiry room; and, if stilt required, additional room may l)e gotten 
by a second incision running parallel with the ribs, at a right angle to the 
main incision. The separation of the parts and exposure of the common 
H iliac are, otherwise, the same as for the ligation of that vessel. The incision 
™ is made upt^n the left side — its general direction being from Just within the 
anterior superior iliac spine toward the tip of the tenth rib — and the aorta 
H is reached by following up the common iliac in the peeling back of the peri- 
^P toneum from the iliac fascia. The vessel is thus less salisfaclorily exposed 
than by the intra abdominal operation, and there is greater difficulty in 
avoiding the sympathetic nerve-cords that surround the vessel. The ligature 
is placed upon the same site as in the intraabdominal operation, and the 
inferior vena cava is guarded in passing the needle. 

^B Description.— Arise from bifurcation of the alxlominal aorta, opposite 

H lower border of left side of body of fourth lumbar vertebra (corresponding, 

™ approximately, to a fwint about 1.3 cm. [i inch] below and a little to left of 

umbilicus — or, more accurately, on a level with a line pa.ssing transversely 

through the highest points of the iliac crests) — and pass thence downward 

and outward over the body of the fifth lumbar vertebra to margin of pelvis, 

■ bifurcating opfxisite upper border of sacro- iliac synchondrosis, into external 
and internal iliac arteries. The relations of right and left common iliacs 
differ slightly. 
i Relations of Right Common Iliac Artery.— Anteriorly : peritoneum; 

H right ureter (a little above its bifurcation) ; ovaries (in female) : termination of 
^" ileum; terminal branches of sup)erior mesenteric; branches of sympathetic 
to hypog;istric ple.xus. Posteriorly: right common iliac vein; end of left 
common iliac vein; beginning of inferior vena cava; and, in le.ss immediate 
relationship, the following — psoas magnus; sympathetic nerve; lumbosacral 

^co^d; obturator nerve; iliolumbar artery. Externally: beginning of inferior 
rcna cava; end of right common iliac vein; psoas magnus. Intemally : 
|||ght common iliac vein; end of left common iliac vein; hypogastric plexus. 
■^Relations of Left Common Iliac Artery.— Anteriorly : peritoneum; 
•mall intestines; ureter; ovarian arter)' (in female); branches of sympathetic 
to h^^pogaslric plexus; termination of inferior mesenteric artery; sigmoid 
flexure; sigmoid me.socolon; superior hemorrhoidal arter)-. Posteriorly: 
lower part of body of fourth lumbar vertebra; fifth lumbar vertebra; inter- 
vertebral discs; left common iliac vein; and, in less immediate relationship. 



SURGICAL ANATOMY OF C05IM0N ILIAC ARTERIES. 



82 OPERATIONS UPON THE ARTERIES. 

the following — psoas muscle; obturator nene; lumbosacral cord; iliolumbar 
artery. Externally: psoas muscle. Internally: left common iliac vein; 
hypogastric plexus; middle sacral arterj'. 

Branches. — Peritoneal; subperitoneal; ureteric; internal iliac; external 
iliac. 

Line of Artery. — Draw a line transversely across the abdomen, on 
level with highest points of iliac crests, which will cross the abdominal aorta 
at its bifurcation—draw a second line transversely across the abdomen on a 
level with the anterior superior iliac spines, which will cross the common 
iliacs at their bifurcation — draw a third line from a point on the first line about 
1.3 cm. (i inch) to the left of its center (which is the linea alba), to a point 
midway between the anterior superior iliac spine and symphysis pubis. 
That portion of the third line between the two zones represents the common 
iliac - and that portion below the lower zone, the external iliac. The right 
common iUac is about 5 cm. (2 inches) in length; and the left, about 4.5 cm. 
(if inches). 

Site for Ligation. — As nearly midway of its length as possible (Fig. 30). 



LIGATION OF COMMON ILIAC ARTERY 

BY RETROPERITONEAL OPERATION. 

Position. — Patient supine, or slightly turned to one side. The intes- 
tines are more easily displaced from the field of operation if the patient be 
in the Trendelenburg position. Surgeon stands upon side of operation. 
Assistant opposite. 

Landmarks. — Line of external iliac (v. s.); Poupart's ligament; anterior 
superior spine of ilium ; eleventh rib. 

Incision. — Begun as for exposure of external iliac (page 90) and con- 
tinued in the cleavage line of the external oblique as far upward toward 
the eleventh rib as necessary to furnish suflTicient room (Fig. 30, B). 

Operation. — The steps of the operation are identical with those for 
e.xposure of the external iliac (page 9c), with an extension upward, in the 
present operation, of the separation of the fibers of the external oblique 
and a division of the fibers of the internal oblique and transversalis as far 
up toward the eleventh rib as necessar\' — the incision of the two latter muscles 
corresponding in direction with the separation of the fibers of the external 
oblique (Fig. 31). In this higher part of the wound the last dorsal and 
other dorsal nenes are apt to be encountered between the internal oblique 
and transversalis, and are to be carefully preserved. The deep circumflex 
iliac artery and the lumbar arteries are apt to be met here above the crest 
of the ilium. Havini^ divided the transversalis fascia and separated the 
peritoneum from the iliac fascia (which overlies the iliacus muscle), detaching 
it downward and backward to the psoas muscle and then upward to the 
sacral promontory, the structures in the floor of the iliac fossa are exposed. 
The external iliac artery is first found, and this is followed up to the common 
iliac, guarding the deep ej)igastric. The genitocrural, external cutaneous, 
and anterior crural nerves, branch of the iliolumbar, and the spermatic 
arteries cross this area. The ureter crosses either the common iliac, or the 
external iliac, obliquely, opposite the first piece of the sacrum, having the 
ileum in front of it on the right, and the sigmoid flexure of the colon in front 
of it on the left; but in the peeling hack of the peritoneum the ureter usually 
adheres to the peritoneum, and is thus removed from the area of operatMA 



LIGATION OF COMMON II.IAC ARTERY. 



83 



I 



without trouble. The anery having been reached and bared of peritoneum, 
the needle is passed from the iliac vein. 

Comment. — The line of incision may begin further to the outer side 
of the external iliac than for the t^-pica! operation upon that artery, though 
that vessel is then a little less easily encountered. As to a choice between 
the extraperitoneal and intraperitoneal operations, the former is to be pre- 
ferred wherever the relations of the parts are not loo much dislurbeil by 
disease or injury. 




Kir.in Common and Intkkn.m iiiais, kKTROPKHiTONEALLV :— A. A, 

I I n(Mincur<»f4isi B, lriienti«l oblique ; C. TriiiisvcrsaHs ; D. ronjoint ten- 

M u-i( ; I'", l"ri'l<.-i , ii'irttiUHJ ,- ij. Cuniinoii iliac !irur> tshcalli incited) ; U, 

h incised I ; I, Kxtcrtuil iliac artery; J. Kxlcrnal juul intenial iliac veins; 

V ; I., I>e<t» •"Ti'iMiHi-x ili:ic ari«ry ; M. Liimliar urlery ; N, Illfiliitiih«r 

...ii.u ....<.i> ; I*. Anterior crtiral iicr>'e: Q, nig-inKUiit'il iwrve ; R, C^iiitocrunil 

>i4l CUUHCQU9 ticfvc; T, Iliac fascia ; M. LunibMr artery and iiiohypuitastric (or 



llateral Circulation. — Internal mammary and lower intercostals; 

♦H*/. with deep epigastric below. Lumbar above, with deep circumflex 

I iliolumbar below. Suj»erior hemorrhoidal above, with middle and 

hrmi»rrhoidal below. Middle s^^icral above, with lateral sacral below. 

I iV ' -^irit, obturator and epigastric l»ianches of one side, with corre- 

-ixteries nf (dlicr side. 



mti 



84 OPERATIONS UPON THE ARTERIES. 



LIGATION OF COMMON ILIAC ARTERY 

BY TRANSPERITONEAL OPERATION. 

Position — Landmarks — Incision — Operation. — The steps are prac- 
tically the same as for the transperitoneal ligation of the abdominal aorta, 
though somewhat less extensive, and with the slight modifications necessitated 
by the anatomy of the parts (Fig. 30, C). Especial care is taken to recognize 
the position of the ureter before incising the peritoneum. 



SURGICAL ANATOMY OF INTERNAL ILLAC ARTERY. 

Description. — About 4 cm. (i^ inches) in length — arising from bifurca- 
tion of common iliac, opposite upper border of sacro iliac synchondrosis. 
Descends in pelvis to upper margin of great sacrosciatic foramen, where it 
divides into anterior and posterior branches. 

Relations. — Anteriorly: peritoneum; ureter. Posteriorly: termina- 
tion of external iliac vein; internal iliac vein; inner border of psoas; lumbo- 
sacral cord; obturator nerve; sacrum. Externally: psoas. Internally: 
internal iliac vein; peritoneum. 

Branches. — From Anterior Trunk: — Hypogastric; superior, middle, and 
inferior vesical; middle hemorrhoidal; obturator; sciatic; internal pudic; 
uterine; vaginal. From Posterior Trunk: — Iliolumbar; lateral sacral; glu- 
teal. 

Line of Artery. — See under Line of Common Iliac. 

Indications for Ligation.— Gluteal and sciatic aneurism; hemorrhage; 
to cause atrophy of prostate gland. 

Sites for Ligation. — Midway between its origin and its bifurcation. 



LIGATION OF INTERNAL ILIAC ARTERY 

BY RETROPERITONEAL OPERATION. 

Position — Landmarks — Incision— Operation. — Same as for the retro- 
peritoneal ligation of the external iliac — which, hanng been exposed, is 
followed up to the bifurcation of the common iliac (Fig. 30, B). 

Collateral Circulation. — Sciatic above, with superior branch of profunda 
below. Inferior mesenteric above, with hemorrhoidal arteries below. Pubic 
branch of obturator of one side, with same of opposite. Branches of pudic 
of one side, with same of opposite. Circumflex and perforating of profunda 
above, with sciatic and gluteal below. Middle sacral above, with lateral 
sacral below. Circumflex iliac above, with iliolumbar and gluteal below. 



LIGATION OF INTERNAL ILIAC ARTERY 

BY TRANSPERITONEAL OPERATION. 

Position — Landmarks— Incision — Operation.— Same as for the tnns- 

peritoneal ligation of the abdominal aorta, with the modifications necessitated 
by the anatomy of the parts (Fig. 30, C). Recognize the positioa o* 
ureter before incising the peritoneum. 



SURGICAL ANATOMY OF SCIATIC ARTERY. 



85 



SURGICAL ANATOMY OF OBTURATOR BRANCH OF ANTERIOR DIVI- 
SION OF INTERNAL ILIAC. 

Description and Relations.— GeneraUy arises from anterior trunk, hut 
often from posterior trunk (and sometimes from ihe deep epigastric). Runs 
foncard and downward, below brim of pelvis to upper part of obturator 
foramen, with obturator nerve above, and obturator vein below, lying between 
penioneum and f>elvic fascia — piercing the pelvic fascia to enter the canal 
in the upper and outer part of the obturator membrane — being crossed in 
its course by the vas deferens — and dividing, on its e^it from the canal, into 
external and internal branches, which skirt the external and internal margins 
of the thyroid foramen. 

Sites for Ligation.— At exit from thyroid foramen. 

Comment. — When the obturator arises from the deep epigastric, it 
may pjass down in contact with the external iliac vein, on the outer side of 
the femoral ring — or it may pass along the free margin of Gimbernat's liga- 
ment, almost encircling the neck of a hernial sac, and thus be in danger in 
the usual operation. 



^" »»^- 



LIGATION OF OBTURATOR ARTERY 



AT THYROID FORAMEN. 



Position. — Patient supine; limb slightly abducted and rotated outward. 
Surgeon stands to right side, facing patient, on left — and between the limbs, 
on ihe right (or leans over from the left). 

Landmarks.— Middle of Poupart's ligament. 

Incision. — Vertical, made downward from a point about 2 cm. (} inch) 
internal to the center of Poupart's ligament. 

Operation. — Divide skin, superficial fascia, and fascia lata. Draw in- 
Urmal saphenous vein outward. Incise fascia o^er [)ectineus just internal 
to femoral vein. Expose the outer border of the pectineus muscle and draw 
the muscle inward, separating it from the os pubis and fascia of the obturator 
cjitemus — and divide the fascia over the obturator externus, exjwsing the 
muscle. Follow the upper border of the musi le to the inferior margin of 
the obturator foramen, to the groove for the oliturator vessels and nerve- 
where the arter>' will be found emerging between the nerve above and vein 
below. 



SURGICAL ANATOMY OF SQATIC BRANCH OF ANTERIOR DIVISION 

OF INTERNAL ILIAC 

Description and Relations.— Larger of two terminal branches of 

anterior trunk. Descends over >acral plexus and pyriformis muscle to lower 

part of great sacrosciatic foramen, whence it passes out of pelvis between 

p)Tiformis and coccygeus muscle.s, with pudtc arter}' anterior and internal 

10 IL Emerging through great sciatic foramen upon buttock, beneath the 

•*"*"'• "i^ximus, it descends the thigh midway between trochanter major 

•tv of ischium, resting upon gemellus superior, obturator internus, 

nuadratus femoris and adductor magnus— being to inner 

"e and accompanied l>y small sciatic nerve. 



86 



OPERATIONS UPON THE ARTERIES. 



Line of Artery. — Having rotated the thigh inward and slightly flexed 
it, draw a line from the posterior superior iliac spine to the outer border 
of the tuberosity of the ischium. A point on this line, at the junction of its 
middle and lower thirds, will represent the site at which the sciatic and pudic 
arteries emerge from the lower part of the sciatic foramen upon the gluteal 
region (Fig. 32, A, C, E). 




FiK- ;,2.— Incisions for Lir.AiiONS AnofT the Pi'ttock :— A. Posterior superior iliac spine; B. 
Croat trovhaiitcr : t'. Tiibeiositv ot iscliiiim ; I), Iiuisiori for exposure of gluteal branch of internal 
iliac at its emerj^etice from upper i)ail of great saerosciatic notch; K, For exposure of sciatic and 
internal pudic l)ranchest)f internal iliac at their emergence from lower part of great sacrosciatic notch. 

Indications for Ligation.— Wounds. 

Site for Ligation. — M its emergence onto the gluteal region, just below 
the pyriformis muscle (P'ig. 32). 



LIGATION OF SCIATIC BRANCH OF INTERNAL ILIAC 

rPON THK lUTTOCK. 

Position. — Patient upon uninvolved side, rolled nearly onto chest, with 
knee flexed and thigh rotated in. Surgeon on side of operation; assistant 
opposite. 

Landmarks. — Posterior superior iliac spine; tuberosity of ischium. 

Incision. — Having drawn the line given under Anatomy, make an in- 
cision about 10 cm. (4 inches) in length, obliquely across this line, in the 
direction of the fibers of the gluteus ma.vinnis (which run from above and 
behind, downward and forward) — with its center corresponding to the junc- 
tion of the middle and lower thirds of the line (Fig. 32, E). 

Operation. — Having incised skin and thick fatty areolar tissue, divide 



SURGICAL ANATOMY ( >F INTERNAL rUDU ARTERY. 



87 



the fibers of the gluteus maximus in their clea\ago h'ne (Fig. 33, F). Retract 
the separated margins of this muscle upward and dcnvnward, respectively. 
E.Tpose the lower margin of the jn'riformis muscle. Follow the lesser sacro- 
sdatic ligament to the spine of the ischium — when the sciatic artery will be 



- ' lOATlOX OF RlCHT InTBBNAI- PrOSr A ,ii ; . . ;... A,N fFRlK!il.'rOM THH Bt'lTOrK, ME- 

uow lOHMis — A, A, iftiiteus maximum (uiriM-d and ri?trartcd i ; B, Pyritormis (lower 

U>i.. .1 upwartl); C, Obtunuor iinernus. wiih geinfllu* superiot and InlVtinr. above and 

I , l> T'iKltf arten and veiiw cniiiitc* ; E, IntcmAl piidic ticrvc; F. Sciatic aner> and venae com- 
b; fJ, Stnall wriitliv nerve; H, I'.rcal scialic ultvv. 



md emerging from beneath the fiyriformis muscle — passing out of the 
pclvi'S al)ove the spine of the ischium, and the lesser sacrosciatic ligament 
attached to it — and lying posterior and external to the pudic arterj-. 



SURGICAL ANATOMY OF INTERNAL PUDIC BRANCH OF ANTERIOR 
DIVISION OF INTERNAL ILIAC 

Description. — Smaller of two terminal branches of anterior trunk of 
internal iliac. Descends over pyriformis and sacral plexus to lower border 
of great sacrosciatic foramen, lying in front and to inner side of sciatic artery — 
fKisses thence out of pelvis between p\Tiformis and coccygeus — crosses over 
outer surface of spine of ischium, under gluteus maximus. and re-enters 
j>elvis through lesser sciatic notch— passing, thence, forward over obturator 
intcntus muscle, along outer wall of ischiorectal fos5at afuml 4 cm. (i^ inches) 
4lbovc the lower margin of the tuberosity of ischium, and contained in a canal 
of the obturator fascia. Gradually approaching the border of the ischial 
[ ¥amu<i. it runs forward and upward — pierces posterior layer of deep perineal 
runs forAvard along inner margin of ramus of pubis, giving olT artery 
LI5 penis and artery of bulb between layers of triangular ligament — piercing 
pwierior Liyer of deep perineal fascia as the dorsal arterj' of penis. 

Relations.— (a) Within Pelvis: — descends over pyriformis muscle and 
sacral plexus to lower border of great sacrosciatic notch, whence it emerges 
lieinecn pyriformis atjd coccygeus muscles, together with .sciatic artery, 
pudic nerve, greater and lesser sciatic ner\'es, and nerve to obturator intemus 



88 OPERATIONS UPON THE ARTERIES. 

muscle, (b) Crossing Spine of Ischium : — is covered by gluteus maximus and 
edge of great sacrosciatic ligament. A vena comes is on either side, and the 
nerve to the obturator intemus to the outer side and the pudic nerve to the 
inner side, (c) On Obturator Internus Muscle: — bound to muscle by sheath 
of obturator layer of pelvic fascia (Alcock's canal), with dorsal nerve of penis 
above and superficial perineal nerve below, (d) Between Two Layers of 
Triangular Ligament: — runs near to ramus of pubis, in substance of com- 
pressor urethras muscle. 

Line of Artery. — See Surgical Anatomy of Sciatic Artery. 

Indications for Ligation.— Wounds. 

Sites for Ligation. — Over the spine of the ischium, or in the perineum. 
(Fig. 32') 

Comment. — The main trunk of the artery is the same in both sexes. 



LIGATION OF INTERNAL PUDIC BRANCH OF INTERNAL ILIAC 

UPOX THE BUTTOCK. 

Position— Landmarks — Incision— Operation.— Same as for Ligation 
of Sciatic Branch of Internal Iliac upon the Buttock — the arteries lying side 
by side at their exit from the pelvis, below the lower border of the pyriformis 
(Fig. 32, E, and Fig. ^^^ ^)- 



LIGATION OF INTERNAL PUDIC BRANCH OF INTERNAL ILIAC 

IN THE PERINEUM. 

Position. — Patient in lithotomy position. Surgeon sits facing buttock. 

Landmarks. — Tuberosity and ascending ramus of ischium. 

Incision. — Begins about 7.5 cm. (3 inches) above inner border of tuber- 
osity of ischium and ])asscs downward along the margin of the ascending 
ramus of the ischium. 

Operation. — Divide skin and fascia, avoiding inferior pudendal nerve 
beneath the superficial fascia. The erector |)enis mu.sclc is exposed (in the 
male). The transversus })erina'i is either cut or drawn downward and in- 
ward. Divide the base of the triangular ligament and adjacent parietal 
pelvic fascia — when the artery will be found running forward above the 
pudic nerve, upon the inner surface of the obturator internus muscle, and 
above the attachment of the great sacrosciatic ligament. 



SURGICAL ANATOMY OF GLUTEAL BRANCH OF POSTERIOR DIVI- 
SION OF INTERNAL ILIAC. 

Description and Relations.— Largest l>ranch of posterior division, of 
which it is the continuation. Passes backward and downward between 
first sacral nerve and lumbosacral conl — lea\ing [)clvis through upper part 
of sacrosciatic notch, above ynriformis. in osseotendinous groove formed by 
margin of bone and pelvic fascia, accoinj^anied l)y gluteal vein and superior 
gluteal nerve, — emerging from the pelvis under the gluteus maximus, where 
it divides into its branches just above the up])er border of the pyriformis 



LIGATION OF GLUTEAL BRANCH OF INTERNAL ILIAC ARTERY. 89 

Line of Artery. — Having rotated inward and slightly flexed the ihigh, 
draw a line from the posterior superior iliac spine to the top of the greal 
trochanter. A point on this Une at the junction of the upper and middle 
thirds will correspond with the emergence of the gluteal arterj- from the 
sciatic notch (Fifj. v- ■^- ^* T^)- 

Indications for Ligation. — Wounds; aneurism. 

Site for Ligation.— At emergence from sciatic notch, at upper border 
of pyriformis muscle (Fig. 32). 



I 



LIGATION OF GLUTEAL BRANCH OF INTERNAL ILIAC ARTERY 

0\ THE ni TT(H K. 

Position. — Patient on involved sitle, rolled nearly onto chest; knee flexed; 
thigh rotated inward. Surgeon on side of operation. 

Landmarks. — Posterior superior iliac spine; top of great trochanter. 

Incision. — Having drawn the line given under Surgical /\natomy, an 
incision about 10 cm. (4 inches) in length is drawn along ihis line, wilh its 
center corresponding with the junction of its upper and middle thirds, which 
will be over the site at which the gluteal arterv leaves the sciatic notch 
(Fig. 32, ^) 




C,34. — l.li^*TIOM or Rir.MT ClV-TKAt. A»T«HV«/PnN THI' Hl'TTOCK. AHOVIC TMK PVRlFOHMtS: — 

tbuclM over Klulciik tiittilimis; B. B, Gluteus ninxiniu». kiiLi»ctJ and retraiLtfd ; C, Glulrus 
irwitcil iipwunl I ; I>. P> rifurmis « rc'ttnclcii tlnwiiwiird^ ; H, FA»«^ta bclwecii gluteus iiiax- 

S;tui«-us mr<f)U4 aii.l jivfiMrmis; K, GItttcral artery rttid vetiar cumitcit; G, Su|>crior gliit«ul 
rr.iiit hirs II (VliUeus miiiiinwk. 

Rration.— .Alter dividing skin, superficial fascia, some superficial 
ficr^cs, and the fascia of the gluteus maximus. the muscle itself is met, its 
fibers running parallel with the skin incision (Fig. 34). Incise the musclc- 
6brrs of ihc gluteus ma.xdmus along their cleavage line. Having passed 
through the thickness of the gluteus ma.vimus, a branch of the gluteal artery 
will generally lead to the interval between the gluteus medius and pyriformt.<> 
(which oiher\visc is sought without this guide). Having diNTJded the fascia 
over the lower border of the gluteus medius, separate these muscles by re- 
tractors and expose the upi^er margin of the sciatic notch by passing the 



00 OPERATIONS UPON THE ARTERIES. 

Anitrr under the lower border of the gluteus medius— and through the upper 
|H>rtion of the sciatic notch, between the lower border of the gluteus meiiius 
nnd upper border of the pyriformis, emerge the gluteal artery, vein, and 
iiuiKTior gluteal nerve. 



SURGICAL ANATOMY OF EXTERNAL ILIAC ARTERY. 

Detcription. — The larger (in the adult) branch of common iliac. About 
y to 10 cm. (3^ to 4 inches) in length. Arises at bifurcation of common 
lllur lit Httcro-iliac synchondrosis— running thence obliquely downward and 
o\Hwanl along brim of pelvis, upon inner border of psoas muscle — passing 
uiuliT lower border of Poupart's ligament, midway between anterior superior 
ilitit spine and symphysis pubis, to become femoral. The external iliac vein 
lirn to inner side of artery below, and to inner and posterior aspect above. 
'Vhv deep epigastric artery arises about 6 mm. (^ inch) above Poupart's 
iiKttniCTit, and runs between transversalis fascia and peritoneum toward the 
umbilicus. The deep circumflex iliac arises below the deep epigastric, and 
pjiHWs behind Poupart's Hgament upon the iliacus muscle. The internal 
abdominal ring is situated about 1.3 cm. (^ inch) above Poupart's ligament, 
(ind midway between anterior superior iliac spine and spine of os pubis, 
mid hence just external to course of arter}-. 

Relations. — Anteriorly: Parietal peritoneum; subperitoneal fascia; encJ 
of ileum, on right; sigmoid flexure of colon, on left; genital branch of genito- 
I rural nerve (over its lower third); circumflex iliac vein; spermatic arter\^ 
and vein; ovarian vessels lin female); vas deferens; ureter (sometimes); ex- 
ternal iliac lymphatic vessels and glands. Posteriorly: External iliac vein^ 
Inner border of psoas magnus and its tendon; iliac fascia. Internally^' 
Kxternal iliac vein; peritoneum; vas deferens; ovarian vessels, in female. 
Externally: Psoas magnus; iliac fascia. 

Branches. — Deep epigastric; deep circumflex iliac; several branches to 
psoas magnus and lymphatic glands. 

Line of Artery. — See Surgical Anatomy of Common Iliac. 

Indications for Ligation. — Wounds; secondary hemorrhage; femoral 
or iliofemoral aneurisms; to arrest malignant growths; in elephantiasis arabum; 
a.s a distal ligation in aneurism of common iliac. 

Sites of Ligation. — Proximal to deep epigastric and deep circumflex iliac 
branches (Fig. 30, D). 



LIGATION OF EXTERNAL ILIAC 

BY RETROPERITONEAL ROUTE. 

Position. — Patient supine, near edge of table. Surgeon on side of 
operation. 

Landmarks. — Poupart's ligament; anterior superior iliac spine; line of 
arter)'. 

Incision. — Begins over external iliac artery, about 1.3 cm. (^ inch) 
above Poupart's ligament, and passes upward and outward parallel with 
the ligament, to the anterior superior iliac spine — and is prolonged upward as 
far as necessar\', in the cleavage line of the external oblique (Fig. 30, D). 

Operation. — (1) Having incised skin, superficial fascia — together with, 
possibly, the superficial epigastric, branches of superficial circumflex iliac, 



LIGATION OF EXTERNAL ILIAC. 



91 



vrith their veins, ligating where necessan-, exi>osc the aponeurosis of the 
external oblique (Fig. 35). (2) Divide this aponeurosis in ils cleavage line, 
without cutting ils fibers — and continue this division, or separation, in the 
cleavaKe line as far toward or beyond the anterior superior iliac spine as 
indicated to give free room for manipulation. (5) Having retracted the cut 
edges of the external oblique well apart, separate from the outer half of 
Poupart's ligament the attachment of the internal oblique. Carefully retract 
the cut edges of the internal oblique, being on liie watch for branches of the 
iliohxpogastric and ilioinguinal nerves between the internal oblique and 
iransversalis. and, if encountered, carefully displace them above or below, 
but avoid cutting them. If necessary to gain more room, the internal oblique 
is to be incised in the line of the separation of the external oblique as far as 




V 



Fi«. 3i,—t.iCi»TiOH or Right External Iuiac. Retkopkritoseali-v— tkroit.h OBuiQrK In- 

CtStOM HAJLAIXHt. WtTH PouHAftTs LlCiAMI^NT :— A. A. Siiiicrficial trpifi^aslrtc tirter> ; B. Kxtcrnal 
abU<|lMr mmrle; C. C. O, F.xtrmal uhlic)«i(r aiMtueurosis; D, liiteriial ohlicgjur ; E, ]lit>-ittieuiii»l nt!r\-«r ; 
F, Trjunvrmllf mtisete: H, Deep circumHt-x iliac artery and accom)h-itiviii|; vein; t, LK-cp <et>i;(n&- 
tric iift*ry bimI vciuTrornUcs; J, r,t-niti:h-rui4l iierve; K, Peritoneum (pecle<l luck and rctr3lct«^d up- 
ward] , L. Uisti: (Aftcia , M. KxtPinul iliac aricrs iti» slicaih iruiscd) ; N, Extenul iliac x-ein ; O, Aii- 
tetk>r ctutaI ncr>c i »ecii lliruu^li (a»^-i») ; P, Paupuri"> lij^Miticui. 



the Upper limit of the separation of the fibers of the latter muscle. (4) Having 
inrised the internal oblique and protected the nerves encountered, detach 
the iransversalis from the outer third of Poujuart's ligament, and as far beyond 
as necessar)'. incising its fibers transversely to their direction, but in the 
direction of the division <»f the internal oblitjue. .\fter ilividing the tran^- 
versalis. guard the deep circumflex iliac artery and vein and the genitocrural 
nerve, both lying between the iransversalis fascia and peritoneum. (51 
Having now separated the fibers of the aponeurosis of the external oblique, 
and divirled the fibers of the internal oblique and iransversalis in the same 
line as the separati<»n of ihe external oblique aponeurosis, and haNing safe 
guartjetj the important nerves encountered, the fascia Iransversalis is then 
exposed and is divided over the artery in a transverse direction, corresponding 




92 OPERATIONS UPON THE ARTERIES. 

with the preceding separation and incision lines. The artery is here clearly 
defined, and the deep epigastric, the main source of collateral circulation, 
is carefully guarded. (6) As soon as the artery is clearly located, the sub- 
peritoneal tissue about the vessel is carefully opened up and the artery well 
exposed — as well as the deep epigastric, for the purpose of guarding it. The 
peritoneum is then pushed and rolled backward and upward from the vessel 
with the fingers and held out of the way by retractors. (7) When sufficiently 
exposed, the sheath of the artery is opened and the needle passed from the 
vein on its inner side guarding the anterior crural nerve on its outer side. 
The ligature should be about 3 cm. (ij inches) above Poupart's ligament. 
(8) In concluding the operation, the cut edges of the transversalis are united 
by buried catgut sutures to their line of severance from Poupart's ligament, 
and as far beyond as they may have been divided. The cut edges of the 
internal oblique are similarly sutured to their former attachment to Poupart's 
ligament, and to their opposite cut margin as far beyond as divided. And, 
finally, the separated margins of the external oblique are united by a buried 
gut suture. The skin wound is then closed. 

Comment. — The incision for exposure may, if thought necessarj', begin 
about 3 cm. (i^ inches) to the outer side of the spine of the os pubis — being 
thus begun well to the inner side of the arter>', as in the modified Astley 
Cooper operation. 

Collateral Circulation. — Internal mammar>% lumbar, lower intercostals, 
above; with deep epigastric, below. Iliolumbar, lumbar, gluteal, above; 
with deep circumflex iliac, below. Obturator and sciatic, above; with internal 
circumflex below. Sciatic, above; with superior perforating, below. Gluteal, 
above; with external and internal circumflex and first perforating, below. 
Internal pudic, above; with external pudic, below. 



LIGATION OF EXTERNAL ILIAC 

BV TRANSPRRITONRAl. ROI'TE. 

Position. — As in the extraperitoneal operation. Or in the Trendelen- 
burg position. 

Landmarks.— As for the extraperitoneal exposure. 

Incision. — The incision may be in one of three sites: (a) As an intra- 
muscular incision, placed over the site of the artery to be lied (Fig. 30, F); 
(b) vertical, in the linea semilunaris (Fig. 30, E); or (c) vertical, in the linea 
alba (Fig. 30, C). 

Operation. ^The steps of the operation and the manipulation to expose 
the site of ligation are, practically, similar to those in the transperitoneal 
exposure of the common iliac, or the internal iliac. 



SURGICAL ANATOMY OF DEEP EPIGASTRIC BRANCH OF EXTERNAL 

ILIAC ARTERY. 

Description and Relations. — The deep epigastric generally arises from 
inner side of external iliac, about 6 mm. (\ inch) above Poupart's hgament. 
It descends from its origin to Poupart's litjament (thereby forming a loop 
over which the vas deferens in male, and round ligament in female, pass on 
their way to the internal ring) — thence ascends along inner border of internal 
abdominal ring, lying behind inguinal canal and slightly above and to outer 



SURGICAL ANATOMY OF FEMORAL ARTERY 



93 



I 
I 
I 



side of femoral ring — thence it continues upward and inward toward the 
umbilicus, between fascia transversa lis and peritoneum, passing above and 
to outer side of eMernal abdominal ring to inferior btirder of posterior layer 
of rectal sheath (semilunar fold of Douglas). Having passed beneath the 
fold of Douglas, it runs upward between the rectus muscle and sheath, about 
midway between its external and internal borders, to enter the muscle and 
anastomose with the superior epigasiric of the internal mammar)-. Two 
venae comites accompany the artery-. 

Comment. — The position of the artery between the two abdominal 
rings, and to the upper and outer side of the femoral ring is important. 

Line of Artery. — From a point on Poupart's ligament midway between 
the anterior superior iliac spine and the symphysis pubis toward the um 
bilicus — but after this line crosses the Hnea semilunaris it passes upward 
about midway between the external and internal borders of the rectus. 

Sites of Ligation. — Preferably, between 0.6 and 2.5 em. (4 and i inch) 
from origin. It may also be ligated in the lower abdominal wall. 



LIGATION OF DEEP EPIGASTRIC 

NEAR ORIGIN. 



SURGICAL ANATOMY OF FEMORAL ARTERY. 



^^^ Position.— As for ligation of external iliac retrnperitoneally. 

■ Landmarks.— Poupart's ligament: position of external iliac artery. 

■ Incision— Operation. — As for ligation of external iliac retroperitoneally 

■ — that artery being first exposed — and the epigasiric branch traced from it 
(Fig. 30, D, and Fig. 35, I). 

^ Description. — Cominumlion of external iliac. Begins at lower border 
of Poupart's ligament, midway between anterior sufjcrior iliac spine and 
symphysis pubis— passes down anterior and inner side of thigh to opening 
in adductor magnus, at junction of middle and lower thirds of thigh, through 
which it passes into pophteal space, becoming poj»litcat arterj'. Above, the 
artery lies near the antero- internal aspect of head of femur. Below, it is 
close to inner side of bone. Between, it is some distance from bone. In 
its upper third the arter>' [)asses from the center of liase to apex of Scarpa's 
triangle. [Scarpa's triangle is bounded, externally, by sarlorius; internally, 
by adductor longus; its base, above, being formed by Poupart's Hgamenl; 
its apex, below, at junction of sarlorius and adductor longus. Its ti<x>r 
(from without inward) is formed by iliacus, psoas, pectineus, small part of 
jiffductor brevis, and small part of adductor longus. It contains femoral 
artery (in its center), with its cutaneous and profunda branches; femoral vein 
(toward inner side), with deep femoral vein and internal saphenous branches, 
passing from middle of base to apex; anterior crural nerve (to outer side); 
lymphatic glands] In its lower third the artery pas-ses through Hunter's 
canal. [Hunter's canal is an aponeurotic canal extending from apex of 
Scarpa's triangle to femoral opening in adductor magnus, and formed, ex- 
ternally, by vastus internus; poslero internally, by adductor h)ngus and 
magnus; antero internally, by ap<meurosis stretching from vastus internus 
over femoral vessels to adductor longus and magnus, the sartorius passing 
i^fftT top of this aponeurosis. It contains femoral artery, femoral vein (each 




94 



OPERATIONS UPON THE ARTERIES. 



in its own sheath, the vein being behind and external to artery), and long 
saphenous nen-e (external to vessels).] 

Divisions of Artery.— Common Femoral — first 4 cm. (i^ inches). 
Superficial Femoral — made up by remainder (about 9 cm. — 3^ inches). Deep 
Femoral — profunda femoris branch. 

Relations. — (a) Common Femoral : —Anteriorly— skin ; superficial 
fascia; superficial inguinal glands; iliac portion of fascia lata; continuation 
of transversalis fascia into femoral sheath; crural branch of genitocrural 
nerve; .superficial circumflex iliac vein; superficial epigastric vein (sometimes). 
Posteriorly — continuation of iliac fascia into femoral sheath; pubic portim 
of fascia lata; nerve to pectineus; psoas muscle; j)ectineus muscle; capsule 
of hip-joint. Externally — anterior crural ner^'es. Internally — femoral 
vein, (b) Superficial Femoral Artery in Scarpa's Triangle : — Anteriorly 
— skin; superficial fascia; crural branch of genitocrural nerve; deep fascia; 




F'iK. .^fi.— Incisions ior Lihation of Chikf ArikkifvS oi- Thigh :— A. Anterior superior iliac 
spmc; B. SyiiipliNsih piilus ; <". Adductor tubercle ; 1>. Mid -point between anterior superior iliac spine 
an<l sympb>'^is pubis; I-', l.lKalionof lonmKjii ienioral at b;t>e of Scarpa's triauRle. by incision parallel 
witb artery; l-". Same, by iui isiou parallel with and just Inlow Toupart's ligament; <.'r,(>f profunda 
fcnioiis, near otiKin ; H. Of superficial femoral at apex of Scarpa's triangle ; I. Of sujierficial femoial 
in Hunter's canal ; J, C>t jKipliteai in upper pait of pojiliteal space, trom inner side of tbijjh. 



internal cutaneous nerve. Posteriorly — femoral vein; profunda vein; pro- 
funda artery; pectineus muscle; adductor longus. Externally — long saphe- 
nous nerve; nerve to vastus internus. Internally — femoral vein (getting 
behind artery at apex of Scarpa's triangle), (c) Superficial Femoral 
Artery in Hunter's Canal: — Anteriorly— skin; superficial fascia; deep 
fascia; sartorius; apcneurotic roof of Hunter's canal; internal saphenous 
nerve. Posteriorly— angle of junction of vastus internus and adductors; 
femoral vein (lying, in middle of Hunter's canal, behind and becoming 
slightly external and closely adherent to artery). Externally — vastus internus, 
femoral vein (at lower part of Hunter's canal). Internally — adductor longus 
(above); adductor magnus (below). 

Branches. — From Common Femoral — superficial epigastric, superficial 
circumflex iliac, sui)erlRial external pudic, deep external pudic, profunda. 
From Superficial Femoral in Scarpa's Triangle — muscular, saphenous. 



LIGATION OF COMMON FEMORAL. 



95 



From Superficial Femoral in Hunter's Canal— muscular, anastomotica 
mapna. 

Line of Artery.— (With hip slightly flexed, thigh abducletJ and rotated 
outward.) From a point midway between anterior superior iliac spine 
and symphysis pubis, lu adductor tubercle of internal femoral condyle 

§(Fig. 36. D. C). (When thigh in normal position and [larallel with its 
fellow— from midway between anterior superior iliac spine and symphysis 
pubis, to inner border of patella.) 

I Sites for Ligation.— Common femoral at base of Scarpa's triangle — 
rare (on account tif proximity of large vessels). Superfuial femoral at apex 
of Scarpa's triangle — operation of election. Superficial femoral in Hunter's 
canal — not common (Fi^. 0). 
Comment. — (•) A short common femoral is more fre<]uent than a long 
one, (2) Apex of Scarpa's triangle is from 7.5 lo cm. (,^ to 3^ inches) 
below Poupart's ligament, (3) Profunda fcmoris arises about 4 cm. (i4 

• inches) below Poupart's ligament. (4) At g:roin, femoral artery and vein 
are on same plane — at apex of Scarpa's triangle, vein is posterior — in middle 
of Hunter's canal, vein is posterior and slightly external — at lower part of 
Hunter's canal, vein is external. (5) Order of vessels at apex of Scarpa's 
triangle, from before backward, is femoral artery, femoral vein, profunda 
vein, profunda arier}\ (6) Line approximately representing course of long 
saphenous vein is one running from a point about 2 cm. (| inch) internal to 
mid point between anterior superior iliac spine and symphysis pubis, to 
posterior border of sartoriua muscle at femoral condyle. 



LIGATION OF COMMON FEMORAL 

AT BASE OF SCARPA S TKIAMVLI.-JtV IXCISinN P.\K Al.LEL WITH ARTERV. 

Position. — Patient supine; hip slightly flexed; thigh abducterl and rotated 
'outward; knee bent and lying upon its outer aspect. Surgeon stands on 
I side of operated limb, cutting from above downward on the right, and vice 
[•\"ersa. 

Landmarks.— Line of arter}-. 

Incision. — .About 5 cm. (2 inches), beginning just a. little above Poupart's 
imcnt and extending downward in line of artery (Fig. ,^6. E). 
Operation.— Incise skin and superficial fa.scia. Avoid lymphatic glands 
»lso the su[>erticial circumtlex iliac, superluial epigastric, and superticiat 
external pudit arteries and \cins. Di\ide the iliac portion of the fascia lata 
(Fig. 37). Avoid the crural branch of the geniitxrural ner\e on the femoral 
^leath. a little external to the artery . Expose and ojicn the sheath, guarding 
the femoral vein, which lies immediately to the inner side of the artery 
ami within the sheath — and the anterior crural nerve lying further to the 
<^ter side of the artery and outside of the sheath. Pass the needle from 
the vein. 

Comment. — (i) Ligation at the base of Scarpa's triangle is rarely done, 
WR to the ncames.s and number of the branches— except in such cases 
_^ wounds, and to contml hemorrh.ige at the hip-joint, or for temporary 
rontrol in operating about the ihigh. Where not otherwise indicated, ligation 
of the external iliac Is the l>elter operation. (2) The artcr} may also be 
cxptiscd, at this site, by an incision parallel with and about mm. (^ inch) 
bctow the middle third of Poupart's ligament (Fig. 36, F). 

Collateral Circulation.— Internal pudic of internal iliac; with pudic 



96 



OPERATIONS UPON THE ARTERIES 



of femoral. Gluteal; with external and internal circumflex and superior 
perforating. Superficial circumflex iliac; with external circumflex. Ob- 
turator; with internal circumflex. Sciatic; with superior perforating and 




Fijf- 37.— I-ii.AiioN oi' Ki<;nT Common I-i- moral at Kasr of Scarpa's TRiASrii.K :— A, Super- 
ficial fascia; H, H. I'u'^cia lata; D, iVitiiKMi;. : I", iSna-,; 1'. Iliaiu>: G, I'uiiiwrfs li>;ameiit and ex- 
ternal ut)li(|iic: H. CoinuHiti t'ciiKiral aiti.i> . \\ iih xinHMlicial i-piKasiric, cxU-rnal pudii . and circum- 
flex iliac liraiiclKs; 1, Icinoral vein; J, liiii-rnal >ai)lii-in>iis, witli Mi|>erficial vpiKastrio. external 
pudic. and ciicuniMvx iliac veins ; K. Antonor crural nv.>r\ o : I., (.? rural branch of genitocrurai. 

internal circumflex. Comes nervi ischiadici ; with all the perforating branches 
of profunda and articular of popliteal. 



SURGICAL ANATOMY OF PROFUNDA FEMORIS BRANCH OF GOMMON 

FEMORAL ARTERY. 

Description. — Larj^est branch of femoral, nearly equaling main trunk. 
Arises from externo -posterior aspect of common femoral, about 4 cm. (i^ 
inches) below Poupart's ligament— passinj; down thigh, at first external to 
superficial femoral — thence posterior to femoral arter>' and vein to inner 
side of femur— thence leaves femur and runs beneath adductor longus and 
adductor mapnus. 

Relations. — Anteriorly: (near origin) skin; superficial fascia; deep 
fascia; branches of anterior crural nerve; (lower down) femoral vein; pro- 
funda vein; (still lower) adductor It^igus. Posteriorly: (in order) iliacus; 
pectineus; adductor brevis; adductor magnus. Externally: vastus intemus. 



LIGA'IION OF SUPERFICIAL FEMORAL ARTERY. 



97 



Internally : pectineus; angle of junction of adductor brevis and adductor 
mapTius. 

Branches.— Kxternal circumflex; internal circumflex; three perforating. 

Site of Ligation. — At origin. 



LIGATION OF PROFUNDA FEMORIS 

NEAR ORIGIN, 

Position. — Patient supine; limb extended and parallel with fellow. 
Surgeon on outer i^ide of o|.>eraled limb, cutting from above downward on 
the right, and vice versa. 

Landmarks. — Line of artery fvvidi extended limb — see page 95); Pou- 
part's ligament. 

Incision. — .About 5 or 6 cm. (2 or 2A inches) in length, in line of artery 
— calculating to fall over its outer border, with the center of inci.-^ion over a 
point in the course of the arter>' about 4 cm. (i^ inches) below Poupart's 
ligament (Fig. .^6. G). 

Operation. — Incise skin, sujx'rficial fascia, and fascia lata. E.xpose the 
inner edge of the sartorius and retract it outward. Beneath this muscle 
lies the rectus, with branches of the anterior crural nene in close relation — 
these «re to he drawn outward. The trunk of the common femoral will 
then he exposed, with the profunda coming off from its postero external 
aspect, and running outward and downward, with the external circumflex 
arising from it and passing under the rectus. The artery is then freed and 
the ligature passed. 



LIGATION OF SUPERFIQAL FEMORAL 

AT APEX OF SCARPA'S TRIANGLi:. 

Position. — Same as for ligation of common femoral at base of Scarpa's 
triangle- 
Landmarks.— Line of arter)\ 

Incision. — About 7.5 cm. (3 inches) in length, in tine of artery — with its 
center over apex of Scarpa's triangle, that is, about 7.5 cm. (3 inches) below 
Poupart's ligament (Fig. 36, H). 

Operation.— Incise skin and superficial fascia. Draw aside, or ligate, 
branches of internal saphenous vein (Fig. .^8). Divide fascia lata. Identify 
inner margin of sartorius (fibers running <lownward and inwarc}) and retract 
outtiard. Open up the groove between the sartorius and adductor longus 
(fibers of latter running directly downward, or downward and outward) and 
retract the adductor longus internally, if nece.ssarv. The internal cutaneous 
nerve and long saphenous nerve are encountered anterior to the arter>'. and 
are to he displaced to one side, dearly identify the femoral sheath and 
incise — guarding the femoral vein, which lie^ posteriorly and internally to 
the arterv'. Pass the needle from the vein. 

Collateral Circulation,— External circumflex; with lower muscular 
branches of femoral, anaslomotica magna, superior articular of popliteal, 
:ind anterior tibial recurrent. Perforating and terminating of profunda, 
with muscular branches of femoral and muscular and superior articular 




98 



OPERATIONS UPON THE ARTERIES. 




Fijj. 3S.— Lir.ATioN OF Right Frmorai. at Apkx of Scarpa's Trianclb :— A, Sartorius; B. 
Adductor Ioiikus; C. Femoral artery and muscular branches, with its sheath incised and retracted; 
D, Femoral vein ; K, Branch of internal saphenous vein ; F, Long saphenous nerve; G, Internal cuta- 
neous ner\e. 

branches of popliteal. Comes nervi ischiadici; with perforating of profunda 
and articular of popliteal. 



LIGATION OF SUPERFIQAL FEMORAL 

IN UrNTERS CANAL. 

Position. — Same as for common femoral at base of triangle. 

Landmarks. — Line of arter\'. 

Incision. — From 7.5 to 9 cm. (3 to 3^ inches), in line of artery' — over 
middle third of thigh (Fig. 36, I). 

Operation. — Incise skin and superficial fascia. The anterior branch of 
the internal cutaneous nerve, to the outer side, and the long saphenous vein» 
to the inner side, are likely to be encountered. Divide the fascia lata. Ex- 
pose the outer edge of the sartorius (its fibers running downward and inward) 
and retract inward from its position over the roof of Hunter's canal. Hunter's 
canal is thereby exposed in the inter\al between the vastus intemus and the 
adductor magnus (the fibers of the latter running obliquely downward and 
outward). I'he nerve to the vastus intemus may be here exposed. Incise 
the roof of the canal, when the internal saphenous nerve is found between 
the aponeurotic roof and the sheath of the vessels, running from without 
inward. Open the sheath and pass the needle from the vein. 



SURGICAL ANATOMY OF POri.ITFAI. ARTFRV. 



99 






I 



Comment. — Guard against taking 
ihe vastus intemus for the sarlorius — 
the fibers of the former running down- 
ward and outward. 

Collateral Circulation. — Same as 
for the supertitial femoral at the apex of 
Scarpa's triangle. 



SURGICAL ANATOMY OF POPLITEAL 
ARTERY. 

Description. — Continuation of fem- 
oraL Extends from aponeurotic oj>en 
ing in adductor magnus, at junction of 
middle and lower thirds of thigh, down 
ward and outward through the impHteal 
space to its center behind the knee-joint 
— thence vertically downward to the in 
ferior border of the pof>litfu.s muscle, op 
posite the lower border <jf the tubercle of 
the tibia, where it <livides into anterior 
and posterior tibial arteries. 

Relations.— Anteriorly : (from above 
»wnward) popliteal surface of femur; 
erior ligament of knee; posterior 
articular surface of tibia; po[>lileus mus 
cic. Posteriorly: (above) semimem 
bmnovus; (center) skin, superlaial fascia, 
deep fascia; (below) internal head of gas- 
iTtcnemius, aponeurotic arch of s<^)leus. 
PcipUteal vein lies behind arter\- through 
out its course, crossing obliquely from 
outer to inner side, and may be double 
below. Internal popliteal nerve lies be- 
nd arxery and vein (immediately pos 
ior to latter), crossing the vessels ob 
Iqucly at their center, from outer to 
inner side. Externally: (above) ex 
condyle, biceps, internal popliteal 
e; (below) outer head of gaslroc 
ncmius, plantaris. Internally : (above) 
semimembranosus; (below) inner head 
of gastro<*nrmius, internal popliteal ner\'e. 
Branches. — Cutaneous; muscular 
(sufH-rior mustular, inferior muscular or 
^urah; articular (suf>erior external arlic 
ubr «;uperior internal articular, inferior 
r rticular, inferior internal artic- 

ui j'js articular); terminal (jM^sle- 

rior tihul. anterior tibial). 






POSIKHIOK TlHlAL, ANl» PllKOMKAI. Alt- 

TEKits — A, Outer t»otiIer uf scinimctri' 

hnHiK^us int juiivlioii uf iiiitldk- Hint lowvr 

Iliii>h <•( tliixlO : B, MiiMk- uf |Mj|»1iilcHl 

spiK>.- . <-' , Outer of iK>itlt:nur »siH-t» of fcjf 

on \v\x\ vkilh Itbiul lubvitlc; I). IViiiit 

ttittlwM)- Ijclwrcti cc»tivextty nf heel »rn\ tip 

of iiili-rnal tnallc<»li«; E, M»<l-pciinl between 

outer bonier i>( lentlo At hitl(s ,\Uf\ tip of 

e!»lerii.il malleolus; F, Im l^li.n lor (.npliicul 

' IiiikJ ; G. Same, hi lower pnn of [•ripliK'Al .^|iiicc( 

' . ill its tniiMIe tliint : J. Saiiir. In its lower third ; 

jx pcruttcul ill iniiJdlc uf leg. 



lOO OPERATIONS UPON THE ARTERIES. 

Line of Artery. — From outer border of semimembranosus (at junction 
of middle and lower thirds of thigh) obliquely down to middle of popliteal 
space, directly posterior to the knee-joint (for upper part of artery); and 
from mid-point of popliteal space vertically down to level of lower border of 
tubercle of tibia (for lower part of artery). (Fig. 39, A, B, C.) 

Sites of Ligation .^M ay be ligated either in its upper part or lower 
part— the artery being tied with difficulty in its middle, owing to its depth 
and relations (Figs. 36 and 39). 

Indications for Ligation. — Rare, other than wounds and aneurism — 
the superficial femoral usually being ligated instead. 



LIGATION OF POPLITEAL ARTERY IN UPPER PART OF POPLITEAL 

SPACE 

FROM BRHIND. 

Position. — Patient as nearly prone as feasible, resting on side of shoulder 
and chest, with limb extended. Surgeon to outer side of left limb, cutting 
downward; and to outer side of right limb, cutting upward (or inside of 
right limb, cutting downward). 

Landmarks. — Line of artery and upper boundaries of popliteal space. 

Incision. — About 9 cm. (3^ inches) in length, in line of artery, beginning 
at outer border of semimembranosus, at junction of middle and lower thirds 
of thigh, and passing obliquely downward to the middle of the popliteal 
space (Fig. 39, F). 

Operation. — Incise skin and superficial fascia. Avoid the small sciatic 
nerve. Open up the deep fascia. Retract the hamstring muscles to the 
outer and inner sides. The popliteal nerve is first encountered crossing from 
the outer to the inner side — the popliteal vein crossing similarly. Displace 
these structures laterally— when the arter>' is found, generally lying in fatty 
areolar tissue. 

Collateral Circulation. — Where the ligation is between the superior 
and inferior articular arteries;— anaslomotica magna, superior external and 
internal articular, descending branch of external circumflex, above; with in- 
ferior external and inlcrnal articular and anterior tibial recurrent (also, possibly, 
{posterior tibial recurrent and suj^erior fibular of anterior recurrent), below. 



LIGATION OF POPLITEAL ARTERY IN UPPER PART OF POPLITEAL 

SPACE 

FROM INNI R SUM-: OF THU.H-JORERTS OPERATION. 

Position.— Patient supine; thigh slightly flexed; fully abducted and 
rotated luilwanl: knee at a rit^ht angle and resting on external aspect. Surgeon 
on outside, cutting dmvnward on right, upward on left (or may stand on 
inner side of left and cut downward^. 

Landmarks. -Tendon of adductor magnus. 

Incision.— Alnnit 7.5 cm. (3 inches'^ in length, beginning opposite the 
junction o\ middle anii lower thirds of thigh, and ninning parallel with and 
immoviiatoly iK^sierior to the tendon of the adductor magnus (which is inserted 
into the aiiducior tubercle on the internal condyle of the femur). (Fig. 36, J.) 

Operation.- Incise skin anii suiH'rficial fascia. Avoid anterior branch 
of internal cuiane\^us nene ^Fig. 40). Divide deep fascia. Expose the 



LIGATION OF I'Or[.lTEAL ARTERV. 



lOI 



anterior edge of the sartorius and retract it backward, together with the 

internal saphenous vein, if in view {the internal saphenous nerve being beneath 

the sartorius. out of view). Having ihornughly divided the deep fascia the 

.adductor magnus tendon is identified and drawn forward— then the scmi- 




riif. 40— I.iGAnoM ov VvpfLK Part ov Riciit I'oplitral vbom Inner Sidh op Thigh :— A. 
AnlciKtf tvr^nrh oi iMicm.il (■ut.-iiiroii» nrrvt*; B. Iiitcrtuil >npheiinus vein ; r. Sartorius Uls anterior 
_^0»<l«:t ' ■ l>, liitcnia! sapheiiniis ht;r\e oiiaiDly under sartorius, out of si^ht) ; E. 

~ vriuflyu I, Srminii'iubraiuisu*. (drawn po^icriorly I ; G, Popliteal 

i1«ti 'NA and cxlctiial t<.> unci y). 

ani^u-- !•> identifierl and <lrawn backward — and the artery is then 
^il Ixjlween these two structures, near the bone and in considerable 
fnity areolar tissue. Both popliteal vein and nerve He on a plane posterior 
10 the artery, and arc generally not brought to view. 



UGATION OF POPLITEAL ARTERY IN LOVER PART OF POPLITEAL 

SPACE 

BY POSTERIOR MFOIAX INCISION. 

Position. — As for ligation in the upper part of the space. 

Landmarks.— Boundaries of the popliteal space (the biceps above, and 
thr )>lantaris and outer head of gastrocnemius below, forming the outer 
f —and the semimembranosus and semitendinosus above, and the 

d of the gastrocnemius below, forming the inner boundary). 




102 



OPERATIONS UPON THE ARTERIES. 



Incision. — About 9 cm. (3^ inches) in length, beginning at the middle 
of the popliteal space (on a level with the knee-joint) and passing downward 
between the two heads of the gastrocnemius (Fig. 39, G). 

Operation. — Incise skin and superficial fascia. Avoid the external 
saphenous vein and external saphenous ner\'e in the outer aspect of the 
wound, or the communicans poplitei ner\'e which helps form the external 
saphenous nerve (Fig. 41). Divide the deep fascia. Expose the inner and 
outer heads of the gastrocnemius, with the sural arteries going to them — 
and retract these and the planlaris muscle to their respective sides. Muscular 
branches of the internal popliteal nerve may be met with here, and maybe 




F'tg. 41— Lir.ATios OK Right Popi.itkal at Lower Part of Popliteal Space:— A. Inner 
head of past roiiieiii ins (retracU-tl inward); B, OuttT head of gastrocnemius (drawn outward); C, 
Plaiituris; I), External sa|ihenuus vein ; K, Communicans poplitei nerve; K, Internal popliteal ner\'e 
(diawn inward) ; G, Popliteal vein (drawn inward) ; H, Popliteal artery and muscular branches; I, 
Popliteus muscle. 



the posterior tibial nerve. The external saphenous vein is the guide to the 
popliteal vessels. The internal popliteal nerve is found most superficial of 
the three important structures — the popliteal vein next (both crossing to the 
inner side, toward which side they are further retracted) — and the artery 
deepest of all, near the bone and in much fatty areolar tissue. The needle 
is passed from the side of the vein, flexure of the knee aiding during this 
stage. 

Comment. — A continuation upward of the above incision would amount 
to ligation of the popliteal artery in the middle of the popliteal space. 



SURGICAL ANATOMY OF ANTERIOR TIBIAL ARTERV. 



103 



Collateral Circulation.— If the artery be ligated between the superior 

and inferior articubr branches, the 
collateral anastomosis would be the 
sacne as after the above operation. 



SURGICAL ANATOMY OF ANTERIOR 
TIBLAL ARTERY. 

Description. — The smaller bifur 
cation of f»oplileat artery, at lower 
border of popliteus muscle, passing 
thence forward between the two heads 
of tibialis f>osticus. through apunure 
in upper part of interosseous mem- 
brane. l)etween tibia and fibula, to 
deep part of front of leg — descending, 
at first, on anterior surface of inferos 
<«ous membrane, then on ihe tibia, 
and finally onto front of ankle joinl, 
l>^nealh anterior annular ligament, 
where it becomes dorsalis pedis. It 
is accompanied by two vena* comiles. 
The anterior tibial ner\e accompanies 
its lower three-fourths, lying upon its 
fibular side, though partly overlapping 
it in middle of leg. 

Relations. — Anteriorly : skin, 
rsuperficial fascia; deep fascia; anterior 
ihial nerve (at middle); tibialis an- 
licus (above); extensor longus digi- 
>rum (above); extensor proprius [>oJ- 
licis (below) ; anterior annular ligament 
(IktIow). Posteriorly : interosseous 
membrane (upper two thirds); tibia 
and ankle-joint (lower one -third). Ex- 
ternally : anterior tibial nerve (above 
and below) ; extensor longus digitorum 
Wupper third); extensor proprius pol- 

h (middle third). Internally : tibi- 
_ anticus (upper two thirds); ex 
tensor proprius pollicis (crosses lower 
part of arter>'). 

Branches.— Posterior liliial recur 
rent, suf>erior fibular (sometimes), an- 
terior tibial recurrent, muscular, in- 
ternal malleolar, external malleolar. 

Line of Artery.— From inner side 

head of fibula, to center of line be 
the malleoli — (according to 
iocher. from midway between ex 
Ftrmal surface of head of fibula and 
center of tubercle of tibia, to the same point below). The artery passes 




FiR. 4J.— Incisions pou Ligation or 

ANTKHIOIt TlHIAl AND DoKSAI «5 PKDIS AH- 

TKMKs. —A, liKisjoii for upprrdiirdol aiitcriur 
libtitl , B. Kur miildlc ihinl >>( Atilcriur litfttil; 
C, l*or lower tliirU oj aiileriur tibia); D, For 
diiTihaUs peilis jusl IjcIow aitklc-juitit ; li., For 
duTSRtis pcdJH in fin»t i?)lcro**i-ous sjwcc ; f. 
Inner side oi head uf fibula; C. Mid- point be- 
tween two mallet^ilL 



I04 



OPERATIONS UPON THE ARTERIES. 



through the interosseous membrane about 3 cm. {i\ inches) below the level 
of the head of the fibula. 

Indications for Ligation. — Wounds (of anterior tibial or in foot): 
aneurism. 

Sites of Ligation. — Upper and middle thirds — rarely, except in wounds. 
Lower third — most frequent site. (Fig. 42.) 



LIGATION OF ANTERIOR TIBLAL 

IX ITS UPPER THIRD. 

Position. — Patient supine; leg extended and rotated inward. Surgeon 
on outer side (cutting from alx)ve downward, on the right — and vice versa). 

Landmarks. — Line of artery. 

Incision. — About 7.5 cm. (3 inches) in length, in line of artery — beginning 
about 2.5 cm. (i inch) below head of fibula (Fig. 42, A). 




Fijj. 43— Li<;ation ok Uppkr Third of Right Antkrior Tibial:— A. Tibialis amicus muscle; 
B, Exteiivjt cmnmimis dlKitoi urn ; C, Anterior tibial artery and branches. U, L), Anterior tibial veiw 
comilcs; K. Anterior tibial nerve ; F, Branch ot internal saplienuuh vein ; G, Interosseous membrane. 

Operation. — Incise skin, superficial fascia, and deep fascia. Define the 
gap between tibialis amicus, internally, and extensor longus digitorum, 
externally, and retract these structures to their respective sides (Fig. 43). 
Open up this interval — flexing the foot to relax the parts. Aim to reach the 
external aspect of the tibia, covered by the tibialis anticus, and, when reached. 



LIGATION OF ANTERIOR TIBIAL. 



105 



follow down to the interosseous membrane, upon which the artery will be 
found. Twovensecomites lie in very close contact, in front of and behind the 
artery. The anterior tibial nerve may not )et have reached the outer side 
i>f the artery. If the vense comites be not separable, include them in the 
ligature. 

Comment.— The interval between the tibialis anticus and extensor 
longus digitorum is the key to the situation , and is rather hard to find. The 
outer edge of the tibialis anticus often overlaps the exiensfir longus digitorum. 
And also one may get into the septum between the extensor longus rligiturum 
and peroneus lonpus and work down toward the hbub, Guides to the 
pro|»er intermuscular gap, accessory to the sensation of touch, are the "white 
line" (sometimes visible) and a small arter}* leading to the anterior tibial. 



LIGATION OF ANTERIOR TIBIAL 

IN ITS MIDDLE THIRD. 

Position— Landmarks. — As for ligation of the upper third. 

Incision. — .AJMiut 7.5 cm. (3 inches) in length, in line of arten.-. with its 
center over the center of the leg (Fip. 42, B). 

Operation. —Incise skin, superficial and deep fascia. Recognize the 
interval between the tibialis anticus (its outer eilj^e still muscular) internally— 
and the extensor longus digilnrum (its inner edge tendinous) externally. A 
yellow fatty line may sometimes indicate the interval. Open up this interval, 
flexing the foot. Retract these muscles to their own sides — and, deeper in 
the wound, also retract the extensor proprius pollicis to the outer side. Fl»11ow 
down the gap toward the tibia (and not the gap between the e.vtensor longus 
digilurum and extensor proprius pollicis). The anicrior libial nerve will be 
found slightly overlapping the artery — draw it outward. The artery will be 
found on the interosseous membrane, under cover of the muscular fibers 
I of the tibialis anticus, with the extens^jr proprius poOicis on its outer side. 
The vena* comites are separated with difficulty, and, if so, may be included 
in the ligature. 



LIGATION OF ANTERIOR TIBIAL 

IN ITS l.nWEK TEIIRH 

Position. — As for ligation of the upper third — without the inward rola- 
of the foot. 

Landmarks.— Line of artery. 

Incision. — From 5 to 7.5 cm. (2 to 3 inches) in length, with center over 
center of lower thinl of leg (Fig. 42, C). 

Operation. — Incise skin and fascia. Clearly identify tendon of tibialis 
antirus. Divide the upyx^r part of the superior band of the anterior annuhvr 
ligament in the line of the wound (Fig. 44). Demonstrate the interval be- 
tween the tendon of the tibialis anticus and tendon of the extensor proprius 
pollicis — fle.xing the fiM»t and retracting these tendons to their own sides. 
The anterior tibial arter}' will be found between them, lying upon the anterior 
aspect of the tibia and held down by fatty areolar tissue — accompanied by 
Iwo vciuc comites, and with the anterior tibial nerve on the outer side. Pass 
,,0irQi99dle from the nerve. In closing the wound, suture the anterior annular 




io6 



OPERATIONS UPON THE ARTERIES. 



Comment. — If the artery were ligated after passing beneath the obliquely 
crossing extensor proprius pollicis, it would then have the tendon of the 
extensor proprius pollicis to its inner side and the innermost tendon of the 
extensor longus digitorum to its outer side. 

Collateral Circulation. — (When ligated below the malleolar branches.) 
External malleolar of anterior tibial, with anterior peroneal of peroneal and 




Fig. 44.— Ligation of Lowhr Third of Right Antkrior Tibial :— A, Tendon of tibialis 
anticus, retracted inwatil ; B. Extensor proprius hallucis, retracted outward; C. Extensor longus 
digitorum ; D. Aiuiular ligament ; K, Anterior tibial artery and branches ; K, F, Anterior tibial \ ense 
coniites; G. Anterior tibial ner>-e; H, Inner branch of musculocutaneous nerve; I, Branch of 
internal saphenous vein. 



with calcaneal of posterior peroneal. Internal malleolar of anterior tibial, 
with internal malleolar of posterior tibial. Dorsalis pedis and branches, 
with internal plantar of posterior tibial, with external plantar of posterior 
tibial, with anterior peroneal of peroneal, and with calcaneal of posterior 
peroneal. Muscular branches of anterior tibial anastomosing through the 
interosseous membrane with muscular branches of posterior tibial. 



SURGICAL ANATOMY OF DORSALIS PEDIS (OF ANTERIOR TIBIAL). 

Description. — Continuation of anterior tibial — extending from bend of 
ankle along tibial side of foot to apex of first inter metatarsal space — passing 
into sole (as communicating artery) between two heads of first dorsal inter- 
osseous. The anterior tibial nerve lies upon its outer side. The arter}- is 
accompanied by two xenx comites. 

Relations. — Anteriorly: Skin, superficial fascia; deep fascia; anterior 



LIGATION OF DORSALIS PEDIS. 



107 



annular ligament; extensor longus pollicis; innermost tendon of extensor 
brens dipitonjm. Posteriorly : (frum aljiJve downward) Astragalus; scaph- 
oid; internal cuneiform; ligament uf first and st'toncl metacarpals. Ex- 
tenudly : Innermost tendon of extensor lonj^us dlgitorum (above); innermost 

I tendon of extensor brevis digitorum (below); anterior tibia! nerve. In- 
ternally : Extensor longus poHicis. 
Branches. — Tarsal: metatarsal; dorsalis hallucis; communicating (plantar 
digitil). 
Line of Artery, — From center of line connecting two malleoli, to proximal 
end of first nietatars;d space. 
Indications for Ligation. — Rare— wounds, aneurism. 
Sites of Ligation.— At ankle-joint (involves cutting anterior annular 
ligament); below ankle-joint (general site); at first interosseous space (Fig. 42). 



LIGATION OF DORSALIS PEDIS 

jrsr hi.ntw anklf j«mm. 



Position. — Patient supine; fool resting on heel and e.xtended. Surgeon 
below ftjot. on either side, culling downward (or on outer side of both limbs, 
cutting downward on right, and upward on left). AssisUinl steadies foot. 

Landmarks. — Line of artery. 




W|fr t^.— I^H!A*no?« nr KtL.Mr D0RSAL.1S PBOtsJitsT uklow Anklk-joint '— a. A, Branches of 
vein; II, lnlcni.al branch of musruliK'ttlitficnus nctve utul ti^ <livi»iotts ; C. Tendon 
Italtucis; D. liMur Iciulun <>( iWxor tonnus dmilorum ; K, Inner Icnciou o( evtctt- 
Mii; K, lHjr<Htlis |K-ilii. arttrj- ; G, \\-n;t loiMttc* ol dursal)& pvU Is artery ; il.Anlt:- 
rtoi tibwi tMEjvci 1, Annular ItKament. 



Incision.— From 3.5 to 5 cm. (i to 2 in,), in line of artery, passing from 
lower border of anterior annular ligament— between tendon of extensor 
pollicis and inner tendon of extensor longus digitorum (Fig. 42, D), 




io8 OPERATIONS UPON THE ARTERIES. 

Operation. — Incise skin and superficial fascia. Tributaries of internal 
saphenous vein and the internal branch of the musculocutaneous nerve lie 
in the line of incision (Fig. 45). Open up the deep fascia between the tendon 
of the extensor proprius polUcis and innermost tendon of flexor longus digitorum 
— when the artery will be found upon the tarsal ligaments. The anterior 
tibial nerve lies upon its fibular side — two vense comites accompanying the 
artery. Avoid opening the tendon sheaths. 

Comment. — When the artery is tied at the base of the first interosseous 
space, an incision is made from the apex of the first interosseous space, passing 
down between the first and second metatarsals. The artery is found emerging 
from under the innermost tendon of the extensor brevis digitorum, which 
is retracted inward. 



SURGICAL ANATOMY OF POSTERIOR TIBIAL ARTERY. 

Description. — Larger and more direct division of popliteal artery — 
extending from lower border of popliteus muscle (on level with lower border 
of tubercle of tibia), down tibial side of back of leg, between superficial and 
deep muscles, to middle of fossa between tip of internal malleolus and os 
calcis — and dividing, under abductor hallucis, into internal and external 
plantar branches. It arises midway between tibia and fibula, covered by 
the superficial muscles — lower down it lies behind the tibia — and at its lower 
third it is covered by only skin and fascia, and then passes beneath the internal 
annular ligament. It is accompanied by two vena; comites. The posterior 
tibial nerve crosses the artery, from the inner to outer side, about 2.5 to 4 
cm. (i to I J inches) below inferior border of popliteus, and runs thence along 
its fibular aspect. 

Relations. — Anteriorly: (From above downward) tibialis posticus; 
flexor longus digitorum; tibia; internal lateral ligament of ankle-joint. Pos- 
teriorly: Skin; su[)erficial fascia; gastrocnemius; soleus; deep intermuscular 
(transverse) fascia binding artery to underlying muscles; posterior tibial 
nerve (crossing from inner to outer side above, and then running riong fibular 
side). In lower third, covered only by skin and fascia. Externally : Poste- 
rior tibial nerve (lower three-fourths) ; vena comes. Internally : Posterior 
tibial nerve (upper one-fourth) ; vena comes. At Ankle-joint : Posterior 
tibial artery lies under internal annular ligament and abductor hallucis — 
resting upon internal lateral ligament of ankle — having tibialis posticus and 
flexor longus digitorum in front — and posterior tibial nerve and flexor longus 
hallucis behind and externally. 

Branches. — Peroneal, muscular, medullary, cutaneous, communicating, 
internal malleolar, internal calcaneal, external plantar, internal plantar. 

Line of Artery. — Lower half — line from a point 5 cm. (2 inches) below 
center of popliteal space, to midway between tip of internal malleolus and 
center of convexity of heel. Upper half — forms a slight curve inward from 
this line. 

Indications for Ligation.— Wounds; aneurisms. 

Sites of Ligation. — Upj>er third — not frequent — difficult because of 
depth. Middle third —same. Lower third — most usual site. Behind ankle 
— also common. (Fig. 39, K.) 



liGAilUN UV PUSriiRIOR TIUIAL, 



109 



LIGATION OF POSTERIOR TIBIAL 

IN ITS L'PPER THIRD-ABOVE ORIGIN OF f'KKONIi.AL BRANCH 

Position. — As for Lgation of lower part of popliteal artery (page loi). 

Landmarks. — Popliteal boundaries (page loi); head of fibula. 

Incision. — Begins in popliteal space, on level with head of fibula, and 
passes directly down the middle line for about 7.5 cm. (3 inches) (Fig. 39, H), 

Operation. — Incise skin, superficial fascia, avoiding external saphenous 
vein and nerve. Divide deep fascia, exposing two heads of ga.strocncmius. 
Incise their connecting rapho freely and separate them fully, avoiding their 
nerves and vessels as much as possible. Kxposc the upper border of the 
soleus beneath the external head of the gastrocnemius. Retract the plantaris 
(found between the outer head of the gastrocnemius and soleus). The 
lower border of the poplileus. opjxjsite which the y>osterior tibial nerve begins, 
about corresponds with the upper border of the soleus — so that after re- 
tracting the internal popliteal nerve and vein to the inner side, draw the 
upper border of the soleus downward (or nick its upper border) and thus 
expose the bifurcation of the popliteal artery into anterior tibial (passing 
through the interosseous membrane) and po.slerior tibial (descending on 
the deep muscles). Pass the needle between the anterior tibial and peroneal 
branches. 

Collateral Circulation.— (When ligated between the bifurcation and 
origin of the peroneal.) Peroneal of posterior tibiaK with communicating 
and muscular branches of the posterior tibial; external calcaneal of peroneal, 
with internal calcaneal of external plantar; external malleolar of anterior 
tibia\ with external plantar; internal malle<ilar of anterior tibial, with internal 
malleolar of posterior tibial; dorsalis pedis antl branches, with internal and 
external plantar. 



LIGATION OF POSTERIOR TIBIAL 

IN ITS MIDDLE THIRD 

Position. — Patient supine; knee flexed; leg on outer side. Surgeon lo 
outer side, cutting downward on right, and upward on left. 

Landmarks. — Inner margin of tibia. 

Incision. — From 7.5 cm. to ro cm. (3 to 4 inches) in length, placed 
parallel with and 2 cm. (I inch) behind the inner margin of the tibia, along 
il» middle third (Fig. 39. I). 

Operation. — Incise skin and superficial fascia. .\vDid internal sap*henous 
vein and internal saphenous nerve (Fig. 46). Divide the deep fascia. The 
inner edge of the gastrocnemius should be identified here— and retracted 
outward. Having gone through the deep fascia, the soleus is exposed, and 
i% to be dixided along its attachment to the tibia, and its outer part retracted. 
The transverse intermuscular fascia (between superficial and deep muscles 
of back of leg) is now in view, and is inci.sed in the axis of the limb, whereby 
he tlr.xor longus digitorum is reached— and, by following along the surface 

this muscle until nearly opposite the outer border of the tibia, the vena 
xinne* interna, posterior tibial arter>'. vena comes externa, and posterior 
Ttibial nerve are met in order, lying upon the tibialis posticus, or lietween it 
and the flc.tor longus digitorum. Pass the needle from the nerve, including 
Jht veo:e comites if unavoidable — flexing the knee and fool lo relax the 
itruclurcs. 



no OPERATIONS UPON THE ARTERIES. 

Comment. — The knife should be held at a right angle to the surface 
of the muscle, in cutting through the soleus, pointing toward the tibia until 
the transverse fascia is reached — and thereby wandering too deeply, or in 
the wTong direction, is less likely. If one incise too near the tibia, the flexor 




FiR. 46.— Ligation OF Middlh Third of Right Postkrior Tibial :— A. Internal saphenous 
vein; B, Internal saphenous nerve; C. Soleus, incised vertically, and margins of incision well 
retracted ; D. Inner N-irdcr of gastrocnemius stronRly retracte<l outward; E, Transverse intermuscu- 
lar fascia ; F, F'lexor lonjrus diKilorum ; ("..Tibialis jKisticus; H, Posterior tibial arterj- ; 1, I, Poste- 
rior tibial veiiif c<jmites ; J, Posterior tibial ner\e. 

longus digitorum may be divided and the interosseous membrane reached. 
While incising the soleus, do not mistake its central membranous tendon 
for the transverse intermuscular fascia. The arter\' hes about 3 cm. {i\ 
inches) external to the inner border of the tibia. 



LIGATION OF POSTERIOR TIBIAL 

IN ITS LOWKR THIRD. 

Position.— As for the middle third. 

Landmarks.— Line of artery. 

Incision. — About 5 cm. (2 inches) in length, in line of artery, with its 
center over the lower third of the leg — which should fall midway between 
the inner border of the tendo Achillis and the inner border of the tibia 
(Fig. 39, J). 

Operation. — Incise skin and superficial fascia. Divide the deep fascia 
binding down the flexor tendons— when the artery will be found lying be- 
tween the flexor longus digitorum and flexor longus pollicis — the posterior 



LlGATIOiN OF I^STERIOR TIBIAL. 



Ill 



tibial nen-e lying to its fibular side^ with the venae comites surrounding the 
arten- 

Comment. — If the incision be at the upper part of the Imver third of 
the artery, the vessel will be found upon the flexor longus digitorum. If 
the incision he at the lower part of the lower third, the upper part of the 
internal annular ligament must be cut. 



LIGATION OF POSTERIOR TIBIAL 

BEHIND INTERNAL MALLEOLUS. 

Position. — As for ligation of the lower third. 

Landmarks.— Internal malleolus. 

Incision. — About 5 cm. (2 inches) in length, placed about 1.3 cm. (X 
inch) posterior to and parallel with the inner malleolu.s (Fig. 3Q. K). 

Operation.^ Incise skin and superficial fascia — rluring which branches 
of the internal saphenous vein are encountered (Fig, 47). Expose the in- 
ternal annular ligament and divide it over the vessels — the artery being found 




Fil- 47— t.KiATioN OF Right Postbrior Tirjal behind Ister.vai Malleoms :— A. Hnincli 
«4 htlentai •i*|>h('mHi» vein; B. Branch of ititertial saphenous nerve; C, Internal annular hganieiit 
tiactavdl: U. Tendon nt flrxor lontcni^ halliiciA, F. Tendon of flexor louKti^ dij^itorum ; F. Tendon 
ileus; G, Pijitcriot tibial artery ; H, H. Poi>tcrior tibial vena- comites ; 1, Poi^ierior libiat 



. the intcn'al between the flexor longus digilorum and flexor longus hallucis, 
Uttrroundrd f)v its vena* comites and with the ner\e upon its fibular side. 

Comment. — Keep the knife pointed toward the tibia, in making the 
Indston. .\void of>ening the sheaths of the tendons. Behind the internal 
»nd posterior surface of the tibia are four compartments, which, 
lip of malleolus toward heel, are — first, a canal in the annular 



112 OPERATIONS UPON THE ARTERIES. 

ligament for the posterior tibial muscle tendon — a second canal for the flexor 
longus digitorum tendon — a third space occupied by the posterior tibial 
artery, its venae comites, and the posterior tibial nerve — and a fourth canal 
for the flexor longus hallucis. 



SURGICAL ANATOMY OF PERONEAL BRANCH OF POSTERIOR 
TIBIAL ARTERY. 

Description. — Arises from posterior tibial about 2.5 cm. (i inch) below 
inferior border of popliteus — and curves (with convexity outward and upward) 
obliquely outward and downward to fibula — descending thence close to inner 
border of fibula, to lower third of leg, where the anterior peroneal is given off 
(which pierces the interosseous membrane to front of leg) — thence passes, 
as posterior peroneal, to inferior tibiofibular joint and external malleolus. 
It is accompanied by two venae comites. 

Relations.— (From origin to bifurcation.) Anteriorly: (from above 
downward) Tibialis posticus; fibrous bed between origins of tibialis posticus 
and flexor longus hallucis. Posteriorly : (from above downward) Soleus; 
flexor longus hallucis (completing fibrous canal of artery). 

Branches. — Muscular, nutrient, anterior peroneal, communicating, 
posterior peroneal, external calcanean. 

Line of Artery. — From middle of popliteal space, on level of lower 
border of tubercle of tibia, arching slightly outward and then downward 
along inner border of posterior surface of fibula. For purposes of ligation, 
the artery is represented by a line from posterior border of head of fibula 
to point midway between external malleolus and outer margin of tendo 
Achillis. 

Indications for Ligation.— Rare — except for wounds, when the vessel 
is cut down upon at the point wounded. 

Sites of Ligation. — Upper part — rare, owing to depth. Middle — usual 
site (Fig. 39). 



LIGATION OF PERONEAL BRANCH OF POSTERIOR TIBIAL 

IN MIDDLE OF LKG. 

Position. — Patient rests on shoulder and chest of opposite side; knee 
flexed; leg on antero-internal surface. Surgeon on outer side, cutting from 
below on right, and from above on left. 

Landmarks. — External border of fibula. 

Incision. — About 7.5 cm. (3 inches) in length — parallel with and just 
behind external border of fibula, with its center over the middle of the leg — 
which falls behind the peronei muscles (Fig. 39, L). 

Operation. — Incise skin and superficial fascia. Branches of the external 
saphenous nerve and external saphenous vein are apt to be encountered here 
(Fig. 48). F^xpose the .soleus (which, at this site, no longer arises from the 
fibula) and retract it upward and inward (incising its lower fibers if any be 
found attached to the fibula at this height). Divide the deep fascia behind 
the peronei. Expose the flexor longus hallucis and incise through its thick- 
ness, close to the fibula — until the fibrous canal of which it forms the roof 



SURGICAL ANATOMY OF THE EXTERNAL Pl^NTAR ARTERY. U3 




-LiCATioK OF Right Peroneal in Middle ok Leg:— A. Branch of external «aph- 
B, Krstnch of exltrnal saphenous vein; C, tlnstrocnemius, rpiracled inward; D. 
S^»l«Mi«». ruractetl iiimnrtl and inward; F., Pt-roiieus loiigus ; F, Peroncus lircvis ; <;, Tibialis jvisticus; 
11. FlvAui lijtiicu» hnllucis. iuci-scd. sltowinif root oi aponeurotic caiml «ucla!>iiij{ v«;$scb; I, Pcroi>«al 
»rl«3^- ; J. I'cmneal %WMe toniiles. 



is reached. Divide the aponeurotic canal and expose the artery lying near 
the fibula, with its venzc comites 



torn 
^ nen 

■ fifth 



SURGICAL ANATOMY OF EXTERNAL PLANTAR BRANCH OF POS- 
TERIOR TIBIAL. 

Description.— Larger of two terminal branches given otT by posterior 
ibial xl inner .inkle. Passes from bcncaih internal annular ligament, obliquely 
tA and oulward across sole of fool to base of tifth metatarsal — ihence 
curvrs forward and inward to base of first interosseous space — where it 
astomoses with communicating branch of dorsalis pedis, to form phintar 
ch Two vena* comites accompany the artery. 
Relations. —First part (from inner ankle-joint to base of fifth meta- 
t;»rsali: Rests on os caicis; flexor accessorius; Hexor minimi rligiti. Covered 
t superficial fascia; plantar fascia; abductor hallucis; flexor brevis 

<i 1 and abductor minimi digiti. Lies Ijetween — flexor brevis digi 

torum and ah<luctor minimi digiti. Accompanied by — external plantar 
ntrvt and two vena* comites. Second part: (Plantar arch; from base of 
fifth metatarsal to proximal end of first interosseous space.) Rests on — 
proximal ends, and corresponding interosseous muscles, of second, third, 
" fourth metatarsals. Covered by — skin; superficial fascia; plantar fascia; 
flexor bre%'is digitorum; tendon of flexor longus digitorum; lumbricales; 
branches of intennl plantar nerve; adductor hallucis. 




114 



OPERATIONS UPON THE ARTERIES. 



Branches. — Muscular, calcaneal, cutaneous, anastomotic, articular, pos- 
terior perforating, digital. 

Line of Artery. — First Part: from point midway between tip of internal 
malleolus and great tubercle of os calcis, to base of fifth metatarsal. Second 
Part:— from base of fifth metatarsal, to posterior part of ball of great toe. 



-■;-n 





1-\k- 4«J.— In^iskjns iok I.k.aiion 
OI-- I'l.AMAK Akikkii.s:— A. IritisiMti lt»r 
rxU-itial plantar in solf i>t' toot; U, I'or 
inU-inal planlar in M)1v ot toot; <". i-"t>i 
fxlt-i nal ]>1antar anli at bast.- ot Ur>\ in- 
lfro>sfoii«i s|»a«f ; I>. H.ill oi lu-rl ; K, 
Basi- ot ft)Uith toe; l-". Hast- of fust t<K*. 



l-'i^. 50. — I.HJATION OF Kir.HT RXTKRNAL Pl.ANTAK 

IN Sou-; Oh Imioi :— A, SujKTtjcial fasria ; R. AMiutor 
niinitni <liKili ; ('. Flexor brt'vis (liKit<irum : I>. l)tt.-;> 
l>1,iiitar t'.iscia; K. Kxternal plantar aitcry; I-, I- . F.x- 
tviiial plantar wmv cotKil«:s ; (>, Kxtornal planlar ik-t\«-. 
iTlif l<Mit lu-rc u-sls u|»oii ihf li>cs. the revtrisc ot the 
position in l-'i^- 4'>. wlicrc it rests u|K>n the hwl.) 



Indications for Ligation.— Wounds and aneurisms. 
Sites of Ligation.— At origin— more frequent site. In the sole. Plantar 
arch- rare. (Fig. 49, A, C.) 



LIGATION OF EXTERNAL PLANTAR 

AT ORIC.IN. 

Position. — As for the posterior ti])ial at the ankle. 

Landmarks. — Sustentaculum tali. 

Incision. — Begins 2 cm. (| inch) below and in front of sustentaculum 
tali and passes backward along inner border of foot, above the abductor 
hallucis prominence. 

Operation. — Incise skin, superficial fascia, exposing the abductor hallucis. 
Draw this muscle downward. Divide the dee[) fascia lying beneath the 
abductor hallucis — and the bifurcation of the artcr)' will be found just in 
front of a line let fall from the posterior margin of the internal malleolus— 
accomi)anied })y veins and the posterior tibial nerve. 



UGATION OF INTERNAL PLANTAR. 



IIS 



LIGATION OF EXTERNAL PLANTAR 

IN SOLE OF FOOT. 

Position. — Patient supine; ft>ot resting upon heel, steadied upon a sup- 
port Surgeon at fcKil of tabic. 

Landmarks. — Ball of heel; fourth toe. 

Incision. — Along arch of foot, in a line from ball of heel to fourth tf:e 
— alH»ut 6 rm- (2h inches) in length (Fig. 49, A). 

Operation. — Divide skin, sujjerluial fascia, fatty areolar tissue, and 
plantar fascia. E.x}x>se the gap between the flexor hrevis digilorum and 
abductor minimi digiti — in which the artery is found, with accompanying 
ncr>e and veins (Fig. 50). 



SURGICAL ANATOMY OF INTERNAL PLANTAR BRANCH OF POSTE- 
RIOR TIBIAL. 

Description. — Smaller of two terminal branches given off by posterior 
tibial at inner ankle — passing forward idong inner side of sole, generally 
to t'lrst inter«)sseous spare, lo anastomu.sc with tifth plantar digital of com- 
raunicaiing branch of dorsidis pe<H&. 

Relations. — First covered by abductor hallucis — then lies between 
abductor hallucis and tle.xor brevis digilorum — and, toward distal end, is 
cr>vcre<l by skin ami fascia. 

Branches.— Muscular, cutaneous, articular, anastomotica, superficial 
^digital 

Sites of Ligation.— .At origin — more frequent. In sole. (Fig. 49. B.) 



LIGATION OF INTERNAL PLANTAR 

AT ORIGIN. 

Position— Landmarks— Incision— Operation.— .As for ligation of ex- 
ternal plantar at origin. 



LIGATION OF INTERNAL PIANTAR 

tN SOLE OV rOOT, 

sition. — As for external plantar. 
Landmarks.— Heel; great toe. 

Incision. — .Mong arch of foot, in line from point of heel to great toe — 

:>ut 6 cm. (2^ inches) in length (Fig. 49, B). 

Operation.— Divide skin, superficial fascia, and fatty areolar tissue. 
Expose the gap between the abductor hallucis and flexor brevis digitonim — 

10 which interval the artery is found (Fig. 51). 



Il6 OPERATIONS UPON THE ARTERIES. 




P'ff- 51.— I-i'-ATioN OF Rtght Internal Plantar Artery in Solk of Foot:— A. SufH-rfi- 
cial fnsi-i:i ; R. Abductor lialliu-is ; (', Fk-xor hrevis diKiloium ; I>, Iiit^-niul plantar aiterv ; K. K. In- 
ternal plantar vorui' comites ; I-', Internal plantar lu-rvf. (The f<K)i here rests upon the tties. the 
rcverso of iho p«)>iliun in Fig. 49, where it rests uihjii the heel. I 



TEMPORARY LIGATION OF ARTERIES. 

Definition. — The temi)(>rarv arrest of circulation in an arter}* by means 
of a lij^ature carried beneath the vessel — whereby the artery is drawn upon 
until the flow ceases, but is not tied. 

Indications. — Where it is desired to control for a time the arterial circu- 
lation during the steps of an operation — or where a ligature is placed about 
an artery in advance of, or ])reparatory for, any emergency which may arise 
— (e. g., tem])orary ligature of common carotid in the removal of a tumor 
of the neck, t)r of the femoral in |)0|)lilcal aneurism). 

Operation. — All the steps, u|> to the exposure of the sheath of the arter>', 
are similar to those for an ordinary ligation. At this jwint, instead of opening 
the sheath, the sheath itself is isoli-terl (unless a common sheath contain 
other im|)ortant structures). A stout ligature (preferably broad) that will 
not cut is passed beneath the sheath. The two ends of the ligature are not 
tied u|)on the artery, but are simply gras|)ed by clamp-forceps in the hands 
of an assistant (or knotte<I into a Icjop). When it is desired to control all 
flow through the vessel, the assistant simply lifts the arterj- slightly from 
its position -the under wall of the artery is thereby pressed into contact 
with the upper wall by the loop of the ligature, over which the arterj' makes 
an angle, and the How ceases. On relaxing tension, the arten' falls back 
into its normal position and the flow continues. Where no further need 
exists for this control, one end of the loop is drawn upon and the ligature 
slips out from under the artery. Where the temporar\' is converted into a 
perm;ment ligature, the ligature is tigiitened in the ordinary manner — although, 
were this likeliho(Kl foreseen, it woul«l be better to open the sheath of the 



I 



ARTERIORRHAPHS. II7 

artery at first and place the temiwrary ligature directly around the artery 
proper. 

Comment. — As this secondar)'- operation is generali)' resorted to in the 
course, or in the site, of ^ome mure major and primar\' operation, ihc steps 
of the lemporarv' ligature are modified by those of the main operation. 



INTERMEDIATE LIGATION. OR LIGATURE EN MASSE. 

Definition. — Ligature en nunsc for parenchymatous hemorrhage is a 
method of conlroUing hemorrhage which comes from no definite vessels, or 
from inaccessible sources, or as a capillary oozing. 

Description. — A fully curved needle, armed with catgut, is made to 
enter the tissue to one side of the site from which the fl<nv comes — passes 
deeply into the parts, and, in emerging, more or less completely surrounds 
the area of hemorrhage — which is controlled by the tightening of the ligature. 
< )r, in hemorrhage from a larger area, a curved needle, held in a holder, 
may be made to surround the area from which parenchimatous bleeding 
comes by circumventing that area with a purse-string ligature introciuced 
by several consetnilive insertions of the needle — at, for instance, four points 
<»f a circle. The ends of beginning and ending of this catgut h'gature are 
then drawn and knottc<l — only tightly enough to control hemorrhage, and 
not tightly enough to strangulate the parts. 



ARTERIORRHAPHY. 

Definition. — Suture of an artery. 

Indications. — Arteriorrhaphy may be required in longitudinal wounds 
t»f an arier\-; in limited transverse wounds; in transserse wounds of more 
than half the circumference; and in complete division, or in division with 
partial resection (the resected portion not exceeding more than about 2 cm. 
^\ inch). 

Operation. — (a) In wounds of artery: ft) With aseptic precautions, 
ihe shc.ith uf the artery is e\|toscd and upened with minimum injury to 
iressel and surroundings. If the circulation have not been contmlletl by a 
omstrictor, t)r sf»mc form of pressure, the artery is clamped above and below 
the injun' with special forceps (r. ^.. Billruth's. with broad blades protected 
by piecc< of rubber drainage tubes drawn over them; or by means of floss 
silk lightly tictl. or looped). (2) Seize, in turn, the lips of the wounded 
milrry with a pair of oculist's rat tooth tlxation-forccps. Using a fully curved 
mnd roumi conjunctival needle (or straight tloss-needle, or cambric needle) 
thrr-idcd with twiste*! silk of exact size as eye <jf needle (that hemorrhage 
tsiAV not cxcur through the needle-hole which the silk has not fully fiileil), 
|»ene'tr.ile the tunica adventitia and muscularis, down to (but not through) 
ihr intim.-i, The lips of ihe wound are jiierced immediately ojtposite each 
other. The knots are interrupted— are from i to 2 mm. (about t/^ tu y^^- 
inch) apart — enter arten.' about 1.5 mm. (^7;^ inch) from edge of wt»und — 
•sid are lightly lie<l with a reefknot, avrtiding inversion of the lips of the 
artery The sheath of the artery is separately sutured over the vessel, if 
piuiiiQiIe. The skin wound is closed as usual. A wound in the long axis 
of the arter>' tends to gape least, and a transverse wound most. If the artery 
be tJvided through one-half of its circumference, it should be entirely divided 




ii8 



OPERATIONS UPON THE ARTERIES. 



and re-united by some method of suture, preferably by invagination, (b) 
In complete division of artery: The artery should be united end-to-end 





Fig. 52.— Artf.riorrhaphy in rf)MPi KTK CiRcri.AR Division of an Artrry (Mi'Rphv's 
Method): — A, Intuhsiisn.'ptum, with siilims iiassiiiy tlimu/^h outer and middle coats; B, Intus- 
suscipiens (split to aid invagination) with sutures iiassin>{ ilnnu.ijli all coats. 

Fig. 53. — C, Same, showing all suturt-s lic-d. 

by invagination. A piece of finely twisted silk is threaded upon two needles 
— one of which is passed through the outer and middle coats of the proximal 





Fig. 54 — <"iR<-' I -^K Arti KioRKHAPiiv in CoMri.KTK Division ok an Artkry :— A, Method of 
Salomoni and T<'inas<>lli im.M n|iii-il suumv> tlirougli all toals, 

Pip;. 51; —1!. S.iinc. nifiliod <.i ( .liii k— inlcrruptcd sutures through outer coals, protected by cyl- 
inder ot decalcified hone, ivuis , or nibber. 



end, in the long a.xis— then both needles, held side by side, are simultaneously 



ARTERIAL FORCl PRESSURE. 



119 



passed through all coats of the distal end (intussuscipiens) about 7 to 12 mm. 
(i to i inch) from its free end, passinj^ from within outward. Two or three 
of these sutures are applied equidistantly. The distal end is then sUt a 
short distance (the slit not extending as low as the sutures) to aid in invagi- 
Dation — which is then accomplished by traction upon the sutures — which 
are, after invagination is complete, tied lightly with reef-knot. Reinforcing 



T 



fN^ 



Sii-5li —Circular Artsriorrhaphv. wwa C"Mi»LiJte Division ot' am Artery:— The 

methtxis of Bougie. 



sutures are placed at the line of junction, and uniting the lips of the slit — 
but do not pass through the intima of the intussceplum. (See Figs. 52 
and 5^) 

Comment. — Besides the method of Murphy, above described, end-to-end 
union may also be accompli.«-hed by suturing through all the coats, of both 
ends, as in Salomoni's and Tomaselli's method (Fig. 54). Or one of Bougie's 
methods may be used (Figs. 56, 57, and 58) — or Gliick's method (Fig. 55)- 



ARTERIAL FORCIPRESSURE. 

Definition. — Pressure of artery by artery clam]) forceps. 
Description. — This is the onlinary method uf controlling hemorrhage 
by seizing arteries in a wound, upon an amputation stump or in the course 
of any operation — by means f»f clamp, or hemostatic forceps. The forceps 
arc allowed to remain in situ for a j)eriod of time after their application, but 
^ not twisted upon their axis (as in the following operation). The hemostat 
iUl grasp the bleetling end of the artery, and as little else as possible. 
' Where circumstances allow, the artcn' to be subjected to forcipressure should 
tlcareti of surrounding connective tissue by a stroke or two of the knife, 
ccially in the case of the larger vessels. In the case of the smaller arteries, 
; forceps maybe removed and nothing further done, with fair certainty that 
Ijcr bleeding will occur from the crushed vessels. In the case of the 
r arteries, a catgut ligature should be applied over the point of the forceps, 
just prior to their removal. 



I20 OPERATIONS UPON THE ARTERIES. 

Comment. — In some operations, as in vaginal hysterectomy by the 
clamp method, the forceps are left in the wound for twenty-four or forty- 
eight hours. 



ARTERIOSTREPSIS. 

Definition. — Torsion of an artery by means of artery-clamp forceps. 

Description. — The operation consists in the seizing of the divided end 
of an arter>' with forceps and twislinp; it through two or three revolutions, in 
the direction of its long axis — causing a rupture and retraction of its inner 
and middle coats within the outer coat. A clot forms and organizes upon 
and in the roughened inner coats and is protected by the outer coat. The 
twisting should cease short of causing a complete severance of the end of the 
artery. This is the common method of arresting hemorrhage from the 
smaller vessels bleeding in a wound or upon the surface of an amputation 
stump, and its use should be confined to such vessels, although the femoral 
artery has been successfully controlled by torsion (occurring in accidents). 
The technic differs slightly in the ap]jlication of arteriostrepsis to small and 
medium vessels: (a) Upon Smaller Arteries: — seize the extremity of the bleed- 
ing vessel with catch-forceps, including as little tissue, other than the sheath 
of the artery, as possible — draw it out from its connections and twist it around 
two or three limes and release the hold, (b) Upon Medium Arteries: — seize 
the extremity of the severed artery, in its long axis, with catch- forceps, and 
draw the vessel out of its sheath for about 1.3 to 2 cm. (^ to f inch). With 
a second pair of catch-forceps, grasp the bared artery about 1.3 cm. (^ inch) 
from its extremity, at a right angle to its long axis, and hold steadily. Then 
rotate the vessel two or three times by means of the terminal forceps, and 
let go. Thus the proximal forceps prevent the artery from being twisted in 
its sheath, which would sever its vasa vasorum in their passage from the 
sheath to the artery. Only that portion of the artery, therefore, between the 
clamps is twisted. 



LIGATION FOR RADICAL CURE OF ANEURISM. 

Description. — Several methods of a|)j)lying ligatures for the radical cure 
of aneurism have been adopted — cither as a means alone, or in conjunction 
with other ste[)S. 

Methods.— (I) Antyllus's Method ("Old Method"): — The sac is incised 
— the clots arc turned out — and the involved artery ligated above and below 
the sac. (2) Anel's Method: — Ligature of the involved artery just above 
(proximal to) the sac. (3) Hunter's Methcxl: — Ligature of the main vessel 
involved at some distance above (])roxinial to) the sac, so that one branch, 
at least, intervenes l)et\vcen sac .ukI ligature, thereby only partly cutting off 
the circulation through the sac. (4) Brasdor's ]Method: — Ligature of the 
main artery involved beyond (distal to) the sac, entirely cutting off the cir- 
culation through the sac. (5) \\ardro]>'s Method: — Ligature of one or 
more of the distal branches. (6) Kxtiri>ation: — Ligature of the main vessel 
(and collateral branches) above and below the sac, with extirpation of the 



OPERATION FOR RADICAL CURE OF ANEURISM. 



121 



^ 



OPERATION FOR RADICAL CURE OF ANEURISM. BASED UPON 
ARTERIORRHAPHY. 

.MATASS METHUO. 

Description. — The aneurismal sac is laid open — the openings of ihc 
main and collateral vessels are closed by suture — and the cavity of the sac 
obliterated by suturing its walls, and overlying integumentary parts, to its 
floor. Four cases thus far operated in the above manner by the author of 
the method have been uncomplicated and have resulted in complete cure. 
Matas further proposed to restore the circulation through the part, by 
forming a new bl(K>d-channel by suturing the lower part of ihc sac over a 
temp<jrarily placed rubber tube — which is withdrawn just before the re- 
mainder of the sac is obliterated. 

Indications.-— The method is applicable to all cases where (a) a distinct 





fvjwms ^■^«R Rakicai. C'ri. ■ .r \Nt i ki";M ( \Utass Mrthod^ ,— A. First itagc of 
•iwi »neuii»m bUiopcn, sixavmir iw. • opeHiiiRs and inicr>'Ctiiog groove, (Mfxiji'i*.! 

FiK- (m.-H. FIiiaI MAffr-^hMwiiiK wnlls uf aneurism-sac ami inlrjfumcnts sutured to fltior of sac 
r (SUlic follvia. tMixlificd frotii M»(as.) 

[ Mc exists (whether fusiform or saccular), and (b) where the proximal circula 
lion can be controlled. In the fusiform tyjie of aneurism two openings of 
the main vessel exist, one at either end, generally with a groove connecting 
them. Here both opening.s are obliterated by suture, as well as the floor of 
ihc aneurism. It has been possible to restore the circulation through these 
Iwo openings and groove in the manner above described. In the saccular 
type a single opening of the main vessel exists. Here the margin of the 
ojxrning is obliterated by suture, leaving the arterj' intact and capable of 
canying on circulation. 

Operation.— (I) Control of circulation through sac by digital or con- 



122 OPERATIONS UPON THE ARTERIES. 

stricter compression, traction-loop around vessel, or by special artery-clamps. 
(2) Free median incision of the overlying parts and of the aneurismal sac, 
from end to end. All clots are turned out. All laminated fibrin is rubbed 




Fig. 6i.— Operation for Rapicai. Cirr of Anrirism (Matas's Mf.thod) :— A, Suturing to- 
gether borders of openings in main and ojllateral arteries, in case of saccular aneurism, leaving 
channel of main artery intact. (Modified from Matas.) 

Fig. 62. — B, Same, showing openings completely closed. (Modifieil from Matas.) 

off with gauze mops from the walls of the sac. All openings into the sac are 
thus exposed (Fig. 59). (3) Obliteration of all vascular openings by inter- 



OPERATION FOR RADICAL ( URE OF ANEURISM. 



123 



rupled or continuoiis Lemberl sutures of chromic gut introduced by cun'ed 
neeflle in holder, and taking firm and deep hold of the lips to Ije approximated 
(Fi^s, 61 and 62). (4) Reinforcement of first tier of sutures, esj:>ecially in 
large aneurisms, by a second lier of Lemberts, preferably continuous. Object 



I 




F"ig *5.— Operation FOR Radical Ci'be of A.s^eurxsm (Matas's Method) ;— I, Diafirram of 

, ^.»^*» -•!«>« t ion of pans in complete oblitcmtJoii of sac nud blood-diannd ; A. Intcgumeiils; B, Anrii- 

sac; C.Walls of blotxUhaiincI . I>. First tier of sutures, apprnximatiriK borders of blo<xl- 

- 1 ; E, Second lier of sutures, appro xi mat i tig floor of sac over first tier ; F. F, SiiUirrs ihrouffh 

»nii?- **<id into floor of aneurism, apfiruximatiiiK former to latter; G, Suture ihrouab inarjftu of in- 

|gig"m«y«»*^ts and into floor of sac. over second tier. ( %fodJried frnm \fatas. ) 

B^iaf. 66l— II. Diagnim of croivsectioti of part* in complete obliteration of aneurism-sac. hut with 
(^■K«»s-aK.tion of blood-channel ; parts are <,ame a<i in abuve, except that D represents suture approxim- 
«f*«^j r- -wAllsof sac o%'er a teni|ioniry rubber tube; II, Restored blood-cbaiuiel. (ModiAed from Matas.) 



fof scr<roiid tier is to protect against leakage and for the purpose of reducing 
itte s-ize of the sac and building it up from the bottom toward the surface, 
in tHe middle line (Figs. 63 and 64). (S) In-folding of the walb of the aneu- 





^Hc. ♦r— <^riu»ATioK FOR Raixcal. CfRH OF AwBimisM (Matas's Mktiiod) :— A. Suturing lior- 
w» tvi .,., ... -,„^ connecliiiK jtroovc over lemporarj' rubber tube, In case of fusiform aneuristn. 

lira,' 



'fxy.} 



Miu., 



inie, withdrawing tulw through temporarily dispUcctl sutures. (Modifictl from 



'l^malsac. together with the overlying integumentary tissues— and the oblitera 
ll**. thereby, of the sac by complete approximation of these tissues to the 
"** of the sac and lo the central elevation formed bv the one or two tiers 



124 OPERATIONS UPON THE ARTERIES. 

of sutures just described. The two flaps thus in-turned consist of aneurismal 
wall and integumentary coverings. These relaxed flaps are sutured to the 
bottom of the aneurism by interrupted sutures deeply placed (Fig. 64) — and, 
especially in large aneurisms, the approximation is made more complete, and 
dead spaces between the wall of sac and integuments, on the one hand, and 
the floor of the sac, on the other, rendered less likely by the passage of deep 
chromic gut, or silkworm-gut, sutures — passing through all the walls of the 
sac and into the floor of the aneurism, and tied over rollers of gauze on the 
skin surface (Fig. 60). A hollow ovoid is thus left on the skin surface where 
formerly a convexity existed (Fig. 66). (6) Where a new blood-channel is 
to be formed, a rubber tube is carried through both openings and made to 
occupy the groove which usually exists between the two openings (Fig. 67). 
Over this tube the sac is sutured, as in Witzel's gastrostomy (page 769). All 
sutures are placed before any are tied. The end sutures are then tied over 
the tube — when the tube is withdrawn through the separated middle sutures. 
which are then tied (Figs. 68 and 65). The operation is then completed 
as in cases where the circulation is entirely obliterated. 

Comment. — (1) Union takes place between the serous surfaces lining 
the sac (the arteries being mesoblastic). (2) The sutures take good and 
strong hold in the walls of the sac. (3) Advantage of this method of operating 
are the following: simpler technic; less traumatism; elimination of any liga- 
turing; no disturbance of structures in vicinity of aneurismal sac; collateral 
circulation preserved ; circulation of main artery preserved, in favorable cases; 
usually prompt healing by approximation of skin to floor of aneurismal sac. 



OTHER OPERATIONS FOR RADICAL CURE OF ANEURISH. 

Acupuncture.— A method of treating aneurisms by the introduction of 
long needles into their sacs. Several long, fine needles are simultaneously 
introduced, by the safest route, through overlying integuments, into and 
through the wall of the aneurism — and on beyond, until in contact with the 
opposite wall. Here they are allowed to quietly rest for several hours, and 
are then withdrawn. Repetition of this process may be resorted to upon 
successive occasions. Coagulation is thus favored. 

Needling (Macewen*s Operation). — The introduction of one or two 
long needles into the sac, with irritation of its wall. A long, fine needle is 
introduced, by the safest route, through skin and connective tissue, into and 
through the wall of the aneurism — and is pushed on until in contact with 
the inner surface of the opposite wall. The wall of the aneurism is then 
gently irritated by a process of scratching, by means of the point of the needle 
— which is then withdrawn. The interior of the sac should be evenly irritated 
throughout, or at different sites consecutively. This direct irritation of the 
wall should be only great enough to produce a reparative exudation together 
with a deposit of fibrin— and thus white thrombi are formed upon the surface 
of the sac. Two or more needles may be used simultaneously in a large sac, 
and several hours may be consumed in the jirocess — and their use repeated 
upon successive occasions. 

Introduction of Wire. — A fine cannula is introduced, by the safest route, 
through skin, fascia, and wall of aneurism, into the cavity of the sac. Through 
this cannula several yards of fine wire (according to size of aneurism) are 
introduced and left, the cannula being withdrawn. Cure is effected by the 
clotting of blood upon this wire meshwork. Catgut, silk, horsehair, and the 



TREATMENT OF VASCULAR NEOPLASMS. 



'25 



like have been used — but silvered copper wire has pruved the most salis- 
faclor)*. 



I 

I 



THE TREATMENT OF VASCULAR NEOPLASMS BY INJECTION OF 

WATER AT HIGH TEMPERATURE. 

WYKTH'S OFERvMlON. 

Description. — This method of treatment consists in the injection into 
the substance of vascular neoplasms (angeiomata) of water at a temperature 
of from igo'' to 212° F. and over — the object being immediiilely to coagulate 
the blo<K.l and albuminoids of the tissues. The vascular tumors ihus far 
treated by the author of the operation have been arterial angeiomata (cirsoid 
aneurisms), capillary angeiomata ('* mother's marks"), and venous angeiomata 
(caxemous nitvi). 

Instruments. — SvTinge with metallic cylinder and an adjustable piston, 
and needles of various sizes. The water is usually gotten from some im- 
mediately adjacent vessel in which it has come to a boil, and under all aseptic 
precautions. In cirs*)id aneurisms and in the larger cavernous nce\'i, where 
the water should be kept at the boiling-point during the use of the needle 
and syringe, the author of the operation has devised a Umg metallic instru- 
ment under the cylinder of which a Bunsen burner is held during operation. 

Operation. — (f) 'IMie region of the injection is rendered aseptic in the 
usual manner. The operation is done umler complete narcosis. The quan- 
tity and temperature of the water will vary according lo the size and nature 
of the growth, (a) In arterial and venous angeiomata the needle is carried 
deeply into the .substance of the growth and from .^o to 60 minims of water 
are thrown out in one site— the needle is then withdrawn from 1.5 lo 2.5 
on. (i to I inch) and about the same amount injected — and the same steps 
rc|>eated in different sites until the whole tumor is solidified. While using 
water of a temf>crature sufficiently high to coagulate the bkxKJ and albu- 
minoids of the neighboring tissues, it should not be delivered into the part 
so exceedingly ht>t nor with such pressure as to cause subsequent sloughing 
of the overlying parts. Evidence of sufhcienl distention of the part to tlis 
continue the injection in that particular site is given by slight bleaching 
of the skin. (.?) In capillar)- angeiomata, especially upon delicate parts, 
water a Utile below boiUng (about 190'^ F.) should be usetl — and only abnut 
two lo six minims thrown in at a single puncture— beginning at the periphery 
of the grovi-th. Sloughing is more ai>t to occur in the capillar)' angeiomata. 
The injection may be repeated in from seven to ten days, if necessary. (4) 
A surgical dressing is then applied and the part kept at rest. 

Comment.— { I) Xo painful symptom nor septic infection has followed 
any of the cases except in one instance where the patient passctl out 
from under Ihe obsen'ation of the author of the operation. (2) Kspecial 
care is ad\ i.sed in the cases of angeiomata of the neck and scalp, because of 
odema. (3) No more than from five to six ounces should be injected at 
onr •stitfn«r 



CHAPTER II. 

OPERATIONS UPON THE VEINS. 

PHLEBOTOMY. 

Definition. — Incision of a vein, or venesection. A method, now rarely 
practised, of depiction by bleeding, for its effect upon the system. One of 
the veins of tlie elbow is usually selected. 

Indications.— Pulmonary engorgement; engorgement of the right heart; 
muFiy inflammatory states in sthenic persons. 

Preparation.— Bend of elbow shaved. 

Position. Patient, holding arm extended and abducted, sits upright, 
that warning by approaching syncope may be given. Surgeon stands in 
fnu\t and lo right of either arm. 

Instruments and Accessories. — Lancet or bistour)-; fillet or constrictor; 
round object to grasp (roller bandage); a graduated "bleeding-bowl" or 
measure; gau/.e compress; bandage. 

Operation. - Apply tlie ctnistrictor around the lower third of the arm, 
tliat tlie return venous tlow may be obstructed and veins about the elbow 
made ]>rominenl. while not firmly enough to obstruct the arterial flow. The 
grasping and manipulating of the lingers about some object will aid the 
distontit>n o( the veins. The most prominent vein at the bend of the elbow 
is t>ow seloctiHl. The nuMlian basilic vein (which is crossed by the internal 
cutaiuHHis nerve anvl is ]nirallel with and separated from the brachial artery- 
bv the bii ipital fascial is generally chosen — Ixnause of its greater prominence, 
and Invaust* of Unng steavlit\l by the underlying bicipital fascia. The median 
^Ypludic vein o^l^i^h is coveretl by skin and fascia alone and rests upon the 
rxiern.d vutanoous nervo'^ is often chosen — and is also sometimes the more 
pr\M\\ineni. rhe vein is steadii\i by pres.<ure of the left thumb just below 
the intondiHl invisi\>n. The l.vnoet or bistour\\ with its back to the arm, is 
U\nj>t thi\>u»ih the skin over the vess<'l. anvl into the distended vcm beneath 
and i> mavie iv^ cut its way upwarvl and outward at a single stroke — cal- 
culatiuj: t\^ s<*\er, in an oMio,ue vlirxvtiv^n. aU^ut two-thirds of the vein. L'pon 
iXMwninji tJu" t'Vv'.mb. the bUHV.iv.i: is allowevl to cx^niinue until approaching 
fatntr.ovs ituiivaies a sutV.vier.: Ions when the vv»nsirictor is remoA-ed. the 
j;au.-e :v\vi t^uVvwi vner :he ^\vv,:^.^l. ar.vi a Itgu^^^ol-eight bandage applied 
to the cIK^xN 

Comment, j'* It V'.txv.i^^.j: vv-.r.r.uc. the \eir. is to be entirely se\-ered 
,AV.x', the \xou:^: !v.,;\ c\x*". S^ o".„-r^:t\: ar.^i :he \iKsel doubly Ugated. (a) 
TtK* in:er,Ml s.v.^her.v^;:s \e:*.: •.v.,..\ .I'sv^ l>e U5»evi. 



PHIEiORRHAPHY. 
Pvfiaitico. Pv s^u:;;r!f v-: ,% w.u^.-i :n a N>r:r.. viibout occluding the 



LATERAL LIGATION OF VEINS. 



127 



Indications. — Where, in the case of a limited wound to one of the larger 
veins, it is desired to control hemorrhage without permanently destroying 
the function of the vein by transverse ligation — and where the wound is too 
long for lateral ligation. 

Operation. — Having well exposed the vein and controlled the hemorrhage 
from the vessel by distal compression (by constrictor, digital compression, 
or temporar}' ligature), one of the lips of the wounded vein is steadied with 
fine forceps, while a fine needle, armed with finest catgut, pierces this lip, 
including, if possible, only the external and part of the middle coat. The 
opposite lip is similarly steadied and similarly pierced, in the opposite direction 




FiK <■.— I'm. KBOKRHAPiiv:— Forceps are s«-«.-ii everting lip of wouml f«>r pu^^^;lJ;^.' oj nt-edlc and 

iiitcrrupti:d suiurcs. 

(penetrating part of the middle and the entire thickness of the outer coat). 
By tying the ligatures carefully, the two lips are brought into even apposition. 
Interrupted sutures, closely applied, will more safely repair the wound than 
continuous suture (Fig. 69). 

Comment. — This method is especially applicable where (a) the wound 
is longitudinal (and therefore the lips tend to lie parallel), and (b) where 
the wound extends in any one direction a distance greater than equivalent 
to the diameter of the lumen. Sometimes instead of approximating lip to 
lip, the edges of the wound are sutured upon themselves. 



LATERAL LIGATION OF VEINS. 

Description. — The application of a ligature to the wall of a vein for 
the f»urpose of closing a wound in the vein without obliterating its lumen. 
Indications. — Wound of one of the larger veins, where it is desired to 



128 OPERATIONS UPON THE VEINS. 

control hemorrhage without destroying the function of the vein by transverse 
ligation. 

Operation. — Having controlled hemorrhage and brought the vein well 
into the field of operation, seize the two lips of the wounded vein in a single 
bite of a pair of dissecting forceps— draw them outward from the wall of 
the vein in the form of a small cone (whose apex is formed by the forceps) — and, 
around the base of the cone, tie, with a reef-knot, a Hgature of fine chromicized 
catgut, rela.xing the tension upon the cone at the moment of tightening the 




li({ ■.« I Mi.K\i 1 ;v.vnv>s o» A V»:n :— Forceps .ire shown drawiriff outward and puckerini; 
t»»Rvllu-« ihc wvmiuUsl .,iu:u; «.i.! o: .\ \ci:i, around which a IiKaiure is being tied. 

knoi auvl ilui^ thrv^winj; inio toKl> ihe walls of the rent in the vessel very 
nuhh av ono jnukors losiolhor the mouth of a sac with a draw-string. The 
hualuir is lUt short .nul the ioni|vrary compression relaxed — and the wound 
iK»mhI av in an ot\linary lijiation vFij:. 70^. 

Comment. rhi> mothvv! i> apvlicablc where the wound does not extend 
\\\ A\\\ ouo »hivvtixM^ a viivtav.vo ix^uivalent to the diameter of the lumen. 
TianvNoiM' wour.O'^ cuv 5v.v^r<* :har. longitudinal ones and are thus especially 
M»uablo tvM ihi> ixMm v»t li»:a:urxv 



TK.\N^VF-RSE LIGATION OF VEINS, 
l^escm^tion. r*-o o'.\.-\-.tN ..c.'.v-"**- ot* a vein lin contradistinction to 

lu\ttcAtuM\s. W .^..v, V .. '..■. \^i"v^;;> .'.:uv.r.<m: simple and suppurative 



iV^. 



O^^ciAtion. \v •;,: ..<..: o- ,-. ,-.::<:,i->, :v. certcnl principle. 



)t?\U\>K\KY 1:0 Anew OF N'EISS. 

Ws»n\^t\»N« \v =,- V. 'V , .v ' ,.;v~ .-Tti'Tws jvMje 116). 

li\a\«At\«Nx^> \- - ;,.v.^^;.;;^ . ,;„i.,v- s^^ ir. AHen* if.g., temporary 



PIILKBECTOMV. 



189 



ligation of internal jugular vein in removal of tumor of neck — or while li|:;ating 
or suturing a wound of the vein). 

Operation. — Same, practitally, as for the corresponding operation upon 
the ancrics (page ii6). 



VENOUS LIGATION EN MASSE. 

Description. — For parent livma tons hcmntrrhage. 

Operation. -Practically ideiuical with intermediate ligation, or ligation 
en masse, descrit>ed under Arteries (page 117). 



VENOUS FORaPRESSURE. 

Description. — A meth(Kl of control of venous hemorrhage, corresponding 
wilh arterial forcipressure (page 119)— though of more limited application. 



PHLEBOSTREPSIS. 
Description. — Corresponding with arteriostrepsis (page lao). 

ACUPRESSURE OF VEINS. 

Description. — Pressure of vein by needle — the pressure being applie<l 
direct I v or indirectly. Rarely resorted to at present. Formerly much used 
few variooc veins, na-vi, and venous hemorrhage. 

Operation. — Several methods oi acujircssure exist, differing in but minor 
dctaib. The following is the most generally applicable melh^Ki: The needle 
(or pin) enters the skin near the involved vein — passes under the vein as closely 
as possible— and emerges from the skin on the opf>osile side. Over this 
needle, in a figure of -eight fashion, a silk ligature is wound — thus compressing 
the vein between needle and ligature. 



PHLEBECTOMY. 

Description. — Excision of a vein, in whole or in part. 

Indications.— The usual causes for which \eins are removed are vari- 
(e. j^„ excision of varicosed veins of leg. or of a varicocele) and throm- 
sb. esf>ecially suppmrative (e. g., excision of internal jugular for supi)urative 
lhr«ml>osis following middle-ear di^*ase). 

Operation,— As illustrative of the technic of phlebectomy in general, 
partial excision of the internal sa[ihenous will be descrilied for varicosity 
of thai vein and its branches — the operation consisting in the total removal 
of sections of the vein and its branches at intervals along its course (I) 
The site and coun^ of the varicose veins are previously marked with nitrate 
of silver Main (on the preceding clay, to allow of darkening), that the land- 
mark <• may not Ik* lost during operation. The limb is shaved. An Ksmarch 
is j^encrally usetl to control hemorrhage, (a) Over the course of the vein 
{or slightly to one side, or obliquely crossing it) incisions of from 8 to 1 5 cm. 



130 OPERATIONS UPON THE VEINS. 

(3 to 6 inches) are made at intervals — extending, if necessary, from the inner 
side of the foot to the saphenous opening in the thigh. These incisions are 
especially placed over the most marked groups of veins — and those nearer 
the siiphenous opening are usually the first attacked. The skin and bands 
of fibrous tissue binding down the vein are divided and the involved veins 
exposed. The vein and its branches are entirely isolated to the extent of 
the incision, by blunt and sharp dissection. The vein is then gently drawn 
upon, so as to bring into the open wound as much of itself and branches as 
possible — when it is gut-ligatured at both ends, each branch being also liga- 
tured — after which the main vein and its branches are cut away. This site 
of operation is then packed with gauze, until removal at all indicated sites is 
accomplished — to allow of cessation of all bleeding before suturing. (3) 
The edges of the skin wound are then sutured with silk, or silkworm-gut — 
after which the limb is dressed, immobilized, and slightly elevated. 

Comment. — (1) The removal of the vein in sections appears to give as 
good, or better, results as the attempt to remove the entire vein. (3) Avoid 
wounding the veins in operation, which increases the diflficulties. (3) Avoid 
including a nerve filament in the ligature, which has caused much subsequent 
pain. 



INTRAVENOUS INFUSION OF NORMAL SALT SOLUTION. 

Description. — Injection of normal salt solution into the venous circula- 
tion. 

Indications. — Hemorrhage; shock; sepsis; suppression of urine; and other 
conditions. 

Preparation of Normal Salt Solution.— The physiological salt solution 
for man is a mixture of 0.6 of i per cent, of sodium chlorid in water (approx- 
imately, one dram of stxlium chlorid to one pint of water). This mixture is 
to be sterilized and used at a temperature of 100° F. — being allowed to pass 
from an elevated funnel, or jar. through a rubber tube and special cannula 
into the vein. The salt may be sterilized first — or the solution may be steril- 
ized after preparation. The operation is conducted aseptically throughout. 

Preparation. — Patient's elbow is shaved and protected by aseptic dressing 
(if occasion allow). 

Position. — Patient recumbent; arm extended, abducted and supine. 
Surgeon on right side of both arms — or on right side of right, cutting from 
above; and on left side of left, cutting from below. 

Instruments and Accessories. — Scalpel; dissecting forceps; artery- 
clamp forceps; funnel; rubber tube; bulbous-pointed cannula; aneurism- 
needle; ligature; suture; needle and holder; constrictor for arm; gauze com- 
j)ress, cotton and bandage. 

Operation. — The most prominent vein at the bend of the elbow is chosen 
(see Phlebotomy, page 126). If the vein be prominently marked, incise 
directly over and parallel with it. If not marked, incise obliquely across 
the known course of the median basilic vein, the incision running parallel 
with the direction of the bicipital fascia. Proceed carefully until the vein is 
located. Kxpose from 2.5 to 4 cm. (i to i^ inches) of the vein. Pass two 
catgut ligatures beneath the vein, about 2.5 cm. (i inch) apart — and tie the 
distal one permanently (Fig. 71). With a pair of sharp-pointed scissors, 
curved on the flat, an oblique incision is made through one-half of the vein, 
between the two ligatures, the apex of the " V " pointing distally. Into this 



INTRAVENOUS INFUSION OF NORMAL SALT SOLUTION. 



131 



oblique opening into the vein, the cannula (after seeing that no air is in the 
instrument) is introduced — and the proximal ligature is tightened about it 
with a friction-knot. Through this is allowed to flow, by sialic pressure, as 
much fluid as is indicated (generally from one to six pints). The cannula 
is then withdrawn — the proximal ligature is tightened and tied permanently 




I IK :i. -lNiRA\hN«n s Immsion or XciKMAi. Sai.t SonTioN :— A. HandaKc touriiiqufi; H, 
M«-<li.i!i ><a>>iiii M-iii : ('. Pistal U<> licurti lii^Litiiri- tii-d about \ciii ; D, I'mxiinal (to licart) lij^aturi.- 
i'Mi-xA |i;.in-il ami hmiIv to liv lii-ti alxuit vt-iii : Iv. lMirir|)> Kiaspiiik; i(.iii};iic of wuuinl in vi-iii just 
niii«l< l>^ I iirvcfl s< ivKitis : F, tip of cannula aUiut tov-ntrr vein and aruund which ligature will htrticd ; 
I.. St<.|i.... k. 



- :ind the vein completely severed. The wound is sutured and the dressing 
a|»|>lie<i. 

Comment.— The fluid may be thrown into an o])en vein in a stump- 
er any (onvenient vein in a wound may be «)pened. The basilic vein itself 
may be used — or the internal Siiphenous. 



CHAPTER III. 

OPERATIONS UPON THE LYMPHATIC GLANDS 

AND VESSELS- 
SURGICAL ANATOMY OF THORAQC DUCT. 

Course and Relations. — (i) Abdominal portion: — (from origin to dia- 
phragm); — Begins in abdomen at receptaculum chyli, on anterior surface 
of second lumbar vertebra, lying behind and to right side of aorta and between 
aorta and right crus of diaphragm. At aortic opening in diaphragm (in 
front of twelfth dorsal vertebra) it still lies to right of aorta and has vena 
azygos major to its right. (2) Thoracic portion: — (from diaphragm to 
superior thoracic ojaening); — Runs up posterior mediastinum between aorta 
and vena azygos major, in front of sixth to twelfth dorsal vertebrae. Opposite 
to fifth dorsal vertebra it passes to left behind esophagus and aortic arch 
to enter superior mediastinum, whence it emerges through superior thoracic 
opening into root of neck, (a) In Posterior Mediastinum (from below- 
upward) — Anteriorly ; pericardium ; esophagus ; arch of aorta. Posteriorly ; 
sixth to twelfth dorsal vertebra?; anterior common ligament; right inferior 
intercostal arteries; vena azygos minor (sometimes one of left middle inter- 
costal veins and vena azygos tertia). Left; thoracic aorta. Right; vena 
azygos major; right pleura, (b) In Superior Mediastinum; — anteriorly; 
first part of left subclavian artery. Posteriorly; upper dorsal vertebrae 
(first to fifth.) Left; left pleura. Right; esophagus. (3) Cervical por- 
tion: — (from sujDerior thoracic opening to termination); — From superior 
thoracic opening it ascends on left side of neck to level of seventh cerxical 
vertebra — curves thence downward, for\vard, and outward, arching over 
apex of left pleura— passing in front of subclavian arter\', scalenus anticus 
muscle, vertebral vein — and behind left internal jugular vein, and behind 
and then externally to left common carotid arter}- — and, receiving left jugular 
lymphatic trunk, empties into left innominate vein at junction of left internal 
jugular and left subclavian veins. 

Course and Relations of Right Lymphatic Duct. — About 1.3 to 2 
cm. (i to f inch) in length — formed by union of subcla\nan and jugular 
lymphatic ducts — passes downward and inward — and empties into venous 
circulation at junction of right internal jugular and subclavian veins. 



SUTURE OF THORAaC DUCT. 

Description. — Suture of the thoracic duct is indicated in wounds of 
the duct occurrine: from external injury, or in the course of an operation. 

Operation. —The method of suturing the thoracic duct is similar to 
that employed in suturing a vein (see Phlelwrrhaphy, page 126). Ha^ing 
completed the technic of suturing the duct itself, the neighboring tissues 
should ho drawn over and sutured almut the wound in the duct, to aid in 
closing and reinforcing the sutured site -and the overlying skin should be 

132 



SURGICAL ANATOMY OF ANTKRO LATERAL A.srKCT <M'' NECK. X33 



sutured throughout and pressure applied. Minimum nourishment should 
be adminislered to the patient, to keep the duct as emffty as possible until 

^m union of the wound has occurred. 

B Commeat. — If possible, the right duct should be similarly dealt with. 



LIGATION OF THORACIC DUCT. 



Description.^ — The thoracic duct, where completely severed by accident, 
been Heated, and recover)' has folluwed — allhouj^h there has been a 
question as lo whether, in such cases, a branch of the main duct has not 
existed and maintained the circulation. Suturinp;, however, is always prefer- 
able to ligation, where p«?ssible. Where li^^ation is performed, the technic 
is the same as that for ligating a vein (pa^^cs 127 and laK). 

Comment. — The right lymphatic duct may also require ligation if its 
dindcd ends be discovered in a wound- 




SURGICAL ANATOMY OF ANTEROLATERAL ASPECT OF NECK. 

Boundaries of Antero-lateral Aspect of Neck. Superiorly : lower 
border of body of inferior maxilla, anrl imaginary line from angle of inferior 
maxilla to mastoid process. Inferiorly : uj)per border of clavicle. Ante- 
riorly : median line of neck. Posteriorly: anterittr border of trapezius. 

Subdivisions of Quadrilateral Surface of Neck. — fa) Anterior Triangle 

i\ided, by digastric muscle above and anterior Ijelly of omohyoid below, 
into submaxillary, superior carotid, and inferior carotid triangles, (h) 
Posterior Triangle — divided, by jiosterior belly of omohyoid, into occipital 
and subcla\ian triangles. 

Anterior Triangle.— Boundaries, anteriorly : median line of neck, 
from chin to sternum. Posteriorly: anterior margin of sternomastoid 
muscle. Superiorly ; lower bonier of Intdy of inferior maxilla, and line 
fn>m angle of inferior maxilla to mnsioid process (base). Inferiorly : at 
urn (apex). Thi.s triangle is subdivided into submaxillary, superior 

tid. an(l inferior carotid triangles. 

Submaxillary Triangle.— Boundaries : Superiorly — lower border of 
inferior maxilla, and line from angle of inferior maxilla to mastoid process. 
Inferiorly — posterior belly of digastric and stylohyoid. Anteriorly — anterior 
brlly of digastric (or middle line of neck). Coverings: integument; super- 
ficial fascia; platysma; deep fa.scia; branches of facial nerve; branches of 
suprrficialis colli nene. Floor: anterior belly of digastric; mylohyoid; 
hyi:iflos.*Jus. Contents : Muscles — styloglossus, stylopharyngeus. Ligaments 
— «-tylomaNillan' (separating anterior from posterior f^nrt of triangle). Ar- 
lerie*^— external taroii<l. posterior auricular. icm|Kir:d, internal maxillary, 
myIt»hvoid branch of inferior dental, facial with sulmia\illar\' and submental 
branf hr^. inten^d carotid. Veins — internal jugular, facial, submaxillary. 
Nr . iul, pneumogastric, glossopharyngeal, mylohyoid branch of in- 

ri il, Other .Structures — parotid gland, submaxilhm' gland, lym]ih- 

glands. 

Superior Carotid Triangle.— Boundaries : Superiorly — posterior belly 
of digastric. Inferiorly — anterior In-lly of omohyoid. Posteriorly— anterior 
ixirdcr of Mcmomastoid. Coverings: integument; superficial fascia; pla- 
tjnuna; deep fascia; branches of facial nerve; branches of superficialis colli 





134 OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. 

nen'c. Floor: parts of thyrohyoid; hyoglossus; inferior constrictor of 
pharynx; middle constrictor of pharynx. Contents: Arteries — comnwrn 
carotid; internal carotid; external carotid; superior thyroid; lingual; facial; 
occipital; ascending pharyngeal. Veins — internal jugular; superior thyroid; 
lingual; facial; occipital (sometimes); ascending pharyngeal. Ner\'es— 
descendens hypoglossi; hypoglossal; pneumogastric; sympathetic; spinal 
accessory; superior laryngeal; external larj'ngeal. Other Structures — larynx; 
pharynx; lymphatic glands. 

Inferior Carotid Triangle. — Boundaries: Superiorly — anterior belly 
of omohyoid. Anteriorly — middle line of neck. Posteriorly — anterior margin 
of stemomastoid. Coverings: integument; superficial fascia; platysma; 
deep fascia; descending branch of superficialis colli ner\'e. Floor: scalenus 
anticus (superiorly and externally); longus colli (inferiorly and internally); 
rectus capitis anticus major (between and superiorly); vertebral artery* and 
vein (between and inferiorly). Contents: Muscles — sternohyoid; sterno- 
thyroid. Arteries — common carotid (not strictly); inferior thjToid; vertebral. 
Veins — internal jugular. Nerves — pneumogastric; descending filaments from 
loop between descendens and communicans hypoglossi; recurrent lar>-ngeal; 
sympathetic. Other Structures — larynx; trachea; thyroid gland; lymphatic 
glands. 

Posterior Triangle. — Boundaries: Anteriorly — posterior border of 
stemomastoid. Posteriorly — anterior border of trapezius. Superiorly— 
occiput (apex). Inferiorly — superior border of clavicle (base). This triangle 
is subdivided into the occipital and subclavian triangles. 

Occipital Triangle.— Boundaries : Anteriorly — posterior border of 
stemomastoid. Posteriorly — anterior border of trapezius. Inferiorly — 
posterior belly of omohyoid. Coverings: integument; superficial fascia; 
platysma; deep fascia. Floor: splenius ca])ilis; levator anguli scapula?; 
middle scalenus; ]K)steri<)r scalenus. Contents : Arteries — transversalis colli. 
N'eins— transversalis colli. Xervcs — spinal accessory; descending branches 
of cervical ple.xus. Other Structures- -lymphatic glands. 

Subclavian Triangle. -Boundaries : -Posteriorly — posterior belly of 
omohyoid. Inferiorly— u[)per border of clavicle. Anteriorly — posterior 
border of stemomastoid (base). Coverings : — integument; superficial fascia; 
platysma; deep fascia; descending branches of cervical plexnis. Floor: — 
iirst rib, first serration of scrratus magnus. Contents : — Arteries — subcla\-ian 
fthirrl ])art); suprascapular; transversalis colli. \'eins — subclavian (some- 
times); suprasca})ular; transversalis colli; external jugular; small vein from 
cephalic to external jugular. Nerves — brachial ple.xus, small ner\e to sub- 
davius. Other Structures — lympiialic glanrls. 

Lymphatic Glands of Head and Neck. — Consist of superficial and 
ileep glands. (A) Superficial glands of head and neck: — Consist of 
transverse and vertical sets, (i) Transverse set of superficial glands: — 
Extend transversely from occiput along mastoid process, zygoma, and lower 
border of jaw. to symj)hysis menti,an(l comprise following groups; — (a) Oc- 
cipital or Suboccipital — below superior curved line of occipital bone, between 
skin and insertion of comjjlexus muscle, (b) Posterior Auricular, or Stemo- 
mastoid— behind ear, between skin and insertion of stemomastoid. (c) 
Parotid — in front of ear, between skin and parotid gland, some being embedded 
within parotid gland, (d) Buccal — on .-iurface of buccinator, between it 
and skin, (e) Submaxillary — in digastric triangle, between skin and mylo- 
hyoid and hyoglossus. (f) Suprahyoid - in middle line, between anterior 
bellies of digastric, between skin and mylohyoid. (2) Vertical set of super- 



REMOVAI. OF LYMPHATIC GLANDS OF KECK. 



135 



ficial glands (superficial cervical chain): — (a) Anterior — in front of neck, 
between hyoid bone and sternum, and between skin and sujierficial muscles, 
(b) Middle (sujjerhcial cervical chain) — chietly along external juj^ular vein. 
mainly in posterior triangle of neck, between platysma and deep ccr\ical 
fascia, (c) Posterior — over trapezius, between 11 and skin. (B) Deep glainds 
of head and neck: — Comprising those of head and neck, (i) Those of 
head: — Consisting of folUming groups: — (a) Lingual — on external surface of 
hyoglossus and geniohyoglossiis. (b) Internal Maxillary — on lateral aspect 
of pharynx, behind buccinator muscle, (c) Posterior Phar)'ngeal — between 
posterior surface of pharynx and rectus capitis anticus major, near base of 
\u[l. (2) Those of neck : — Consisting of following sets;— (a) Superior set — 
Jong internal jugular vein, from base of skull to level of thyroid cartilage. 
(b) Inferior set — along internal jugular vein, from ihyruid cartilage to near 
clavicle. 



I. 



REMOVAL OF LYHPHATIC GLANDS OF NECK. 

General Considerations. — In the case t>f diseased cervical glands, an 
oj>erjiion may be undertaken — (1) for the removal of one or a few defined 
mis. in one or more of the regions of ihe neck, in which case a single or 
vcral incision.s more or less limited, are so placcfl as most readily and 
safely to expose the involved glands; — or (2) for the removal of glands widely, 
deeply, and indistinctly disseminated throughout the anterolateral asj3ect 
of the neck, in which case one or more extensive incisions are necessar}', 
both for the removal of the glands and in order to give rtxim in which to 
safeguard important structures during their removal. Removal of dis- 
seminated ccr\'ical glands will be first described — and removal of isolated 
^bnd«i will be referred to under Cummcnt. 

Indications for Removal of Cervical Lymphatic Glands. ^Chronic 
tubenular adenitis (most frequently); acute non tubercular suppuralive 
adenitis; enlargement secondarily from neighboring malignant growths. 

Preparation.— Shaving of all hairy parts at site of and Ixirdering upon 
field of operation. 

Position. — Patient supine; shouklers raised; neck resting over a support, 
to render it {)rominent; head s<i turned as to incrca.^e prominence, length, 
ind width of neik, and in <mler to drag glands out from under protecting 
iS!>ues. Surge<>n on side of operation; assistant opposite. 
Landmarks, —The triangles of the neck. 

Instruments.— .Scal[)els; scissors, straight, curved, l>lunt and sharp; 

ting forceps; toothtnl forceps; artery- clamp forceps; blunt dissector: 

factors; lenacula; grooved director; aneuri-m neefJle; needles; needle- 

ilder; sutures; ligatua-s; sterilized water on hand to lltxxl neck in case of 

ntng brge vein in an inaccessible locality. 

Incision —Various forms of incision have Ijeen u.sed, singly or combined. 
\\ here the entire antero lateral aspect of the neck is to be ex|-posed, a ^-shaped 
Inci.^idn (Fig. 72) may be used — BC extending from over the mastoid process 
to the interval between the sternal and clavicular attachment of the slerno- 
mastoid, passing down the middle of the sternomastoid or along its anterior 
Uictier — IL\ extending transversely forward from the upper end of the 
;uc incision to the angle of the jaw, and thence along the lower border 
ic jaw to Ihe symphysis — CD extending transversely outward along the 
bonier of ihe clavicle, as far toward the acromioclavicular articulation 
IS occcssar}'. If only the anterior triangle of the neck be involved, the por- 




136 OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. 

tion ABC of the incision is alone used — if the posterior triangle, the portion 
BCD. 

Operation. — (1) Incise directly through skin, superficial fascia, platysma, 
and deep fascia — the diagonal portion of the X-shaped incision being first 
made; that is, the portion over the anterior border of the stemomastoid. 
Sever the external jugular vein between two ligatures. Branches of the 
superficialis colli nerve will be cut, but the auricularis magnus and occipitalis 
minor should be retracted backward, if exposed. This incision is carried 
down to and exposes the whole length of the stemomastoid muscle. (3) 
Carry the upper incision transversely downward to the angle of the jaw, 




Fig. 72. — Ist isTON.s I OR F.\Pf>siN(; I.^ mf'hatk" Gi ant^s oi" ("krvicai. Rkgion :— BC, Line over 
amcriur f>or<in<>f sttiiiKfiiastoid, liom mnstoid |)r<Ht--s lo jiiui\al bctwi't-ii sternal and clavicular 
origins of stLtiKniiastoid ; I'.\. I,inc iiniii niast<^>i(l piotcss t<> aiij;li' <■! jaw, and thenceforward along 
its lowt-r honlor; CL>, I.int- from sti i iiodavii nlar arti( iilalion onuvard alontj upper border of clavicle. 
Anterior trian.i;le of n<clv is exposed by raising flap AI'.C ; I'oslerifir triangle, by raising flap BCD; 
Kntire antcro latcial aspet t of niik, by raising bolii (1a))s. I'oiiowing iiuisirjn.s may be used for 
removing isolated grfmps of glands; i:i", Iii< i.,ioii j)aralkl with anterior border of stemomastoid; 
r,H. ])arailel with ])osiiiior border; IJ, Transxerse oblique in u])per j 'art of neck; KL, Transverse 
oblique in lower i>art of net k. 



and then forward ahnif^ the lower border of the inferior maxilla toward the 
symphy.sis, passing through the skin, superficial fascia, platysma, and deep 
fascia — and cxjjosinj:^, without injury, the i)arotid gland, facial nerve, tribu- 
taries of lemporomaxillary vein, facial artery and vein, submaxillary and 
submental glands. The facial artery and vein may be divided between two 
ligatures, if necessary. (3) The lower incision is now carried transversely 
along the up))er l)order of the clavicle, as far toward its outer end as necessar\' 
— passing through skin, superficial fascia, platysma, anfl deep fascia — 
dividing some of the descending su])erficial branches of the cervical plexus 
and a few minor vessels. (4) Having now completed these three incisions, 



REMOVAL 01' LYMPHATIC (iLANDS OF NIICK. 



137 



I 



two triangular flaps are carefully dissected up and lumcd aside — an anterior 
flap (ABC), having ihc same boundaries as the anterior triangle of the neck, 
is turned forward, hinging on the anterior median line of the neck— and a 
posterior llap (BCD), having the same boundaries as the posterior triangle 
of the neck, is turned backward, hinging on the anterior margin of the tra- 
pezius (or on a line jxisterior lo that, if the lower transverse incision ha\e 
been extended fwstcriorly to the acrumiochuifular arltculation). Thus. 
the superficial parts having been turned asi<le, the entire anlero lateral quadri- 
lateral surface of the neck is expose^! on a plane with the imi»ortant slmctures 
and in easy access to those structures. (5) All glands are now dissected out^ 
tc^clher with their surrounding conneclise tissue — being sought in the locali- 
ties indicated in the above summary (see Lymphatic Glands of Head and 
Xeck, page 134)— guaniing, at the s;inie time, the important anatomical 
structures enumerated under Surgical Anatomy of the Triangles of the Neck. 
(6) If avoidable, the stemomastoid shoulrl not be cut — it generally being 
possible, in such a free exposure, to retract it alternately well forward and 
iiackward in order to remove the glantls jiartly or entirely cohered by it, 
slightly flexing the chin on the sternum to lessen lensiun. Where, hmvever, 
it proves a barrier to thorough and safe work, it should be unhesitatingly 
srveretl— the emergence of the spinal accessor)- nerve from its pcjslerior 
bonier Iwing exfxi?.ed, and the muscle divided transversely below the nerve 
The upjier end of the muscle is then turned upward and backward with 
the uninjured nerve, and the lower end downward and forward — and the 
imjK*rt;tnt structures l>enealh it thus easily brought to view. (7) In com- 
pleting the operation, the cut ends of the stemomastoid should be carefully 
sutured with interrupted buried catgut sutures. The flaps are now turned 
back into place and sutured throughout — the flaps being sutured to each 
other first, then along the suiierior transverse line, an<l, last, al^ng the inferior 
transv^erse line — the wound being closcJ throughout with silkwtirm-gut or 
siJk — and firm pressure, to occlude dead spaces, made in the dressing. The 
neck and head are steadied in some form of retentive apparatus until union 
has octMrnxl. 

Removal of Isolated Lymphatic Glands of the ITeck, — Those isolated 
^landjs will Ix-loiig to <^ne of the gnnips of su|x-rficial or deep glands given. 
with their relations, upon a preceding page. The p sition, direction. an<l 
«:rtrnl of the incision for their exposure will be determined by the special 
^Tuup of glands involve<l and the extent of the involvement — the general 
rule iM'ing that the incision is so placed as to reach the site most readily and 
with greatest safety to neighboring structures — and may be a single vertical, 
irunsvcrsc, or oblique straight incision, making an o|>ening whose li})S have 
to lie relracte<l (o expose the parts; — or a combination of these; — or a curxerl 
incision, thereby forming a flap, which is temporarily turned back. The 
two most generally used forms of incision, however, are those which are 
n^^re or less parallel with one of the borders of the stemomastoid (Fig. 72, 
KF or (jH) — or more or less parallel with the natural ol>liquely transverse 
crease crossing the neck alR»ut on a level with the hyoid Inine, in the cleavage 
line of the skin (Fig. 72, IJ or KL). The incision may l*e placed over the 
subma.xillar)'. suficrior carotid, or inferior carotid triangle, of the ant.rior 
triangle of the neck, or over the occijvital or subclavian triangle, of the poMerior 
triangle -or over the jK^sterior aspect of the neck, liclween the anterior border 
of the trapezius and the posterior median tine, and between the superior 
biinlef I if the scapula — or may involve several triangles. 

Comment.— (I) Great care b necessary in removing glands from thin- 




138 OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. 

walled veins. Should a vein be wounded, the opening should be caught up 
instantly and laterally ligated, if the wound be appropriate, or sutured, or 
even transversely ligated. If so situated that closure cannot be immediately 
made, the part should be flooded with water, so that water stands over the 
open vein, to prevent the drawing-in of air until the vein can be secured. 
(2) The important nerves are to be particularly guarded. (3) The arteries 
and arterial hemorrhage give far less concern than the veins and venous 
hemorrhage. (4) It is better to dissect the glands out in masses or chains, 
together with their adherent connective tissue — invisible, impalpable glands 
being thus more thoroughly removed. (5) Glands should be removed with 
their capsules intact. (6) The sternohyoid and omohyoid may also be divided 
and subsequently sutured. (7) All bleeding should be immediately con- 
trolled as encountered, and ligated as soon as convenient. 



SURGICAL ANATOMY OF AXILLARY REGION. 

Description. — The axilla is a pyramidal space Ijelvveen the upper lateral 
wall of thorax and inner wall of arm— its apex corresponding with interval 
between first rib on inner side, clavicle in front, and upper edge of scapula 
behind; — its base, broad at chest and narrow at arm, is composed of skin 
and dense fascia, extending between inferior border of pectoraHs major in 
front, and inferior border of latissimus dorsi behind. 

Boundaries. — Anteriorly — pecloralis major (throughout); pectoralis 
minor (its center). Posteriorly — subscapulaiis (above); teres major and 
latissimus dorsi (below). Internally— first to fourth ribs; first to third 
intercostal muscles; serralus magnus. Externally — humerus; coracobrachi- 
alis; biceps. 

Contents. — Arteries : — axillary (along external wall, nearer anterior than 
posterior boundary); su})erior thoracic; acromial thoracic; long thoracic; 
alar thoracic; subscapular; anterior circumllex; ])osterior circumflex. Veins : 
—axillary (to inner side of axillary artery); receiving vena* comites of brachial 
artery and tributaries of branches of axillary artery. Nerves: — brachial 
plexus lies to outer side of tlrst part of axillary artery; — the second part of 
axillary artery has the outer, inner, and |)oslerior cords of j)lexus in the rela- 
tions ex|)ressc<l by their names; -the third part of the artery has, anteriorly, 
inner head of median nerve; ]>osteriorly, musculospiral and circumflex; 
externally, median, musculo cutaneous; internally, ulnar, internal cutaneous, 
lesser internal cutaneous. Posterior thoracic (on serratus magnus). In- 
tercosto-humeral. Kxternal anri internal anterior thoracic, crossing in front 

1 u..u:„,i „..:it ..-. — , 4:. ...I.. /-*i^-.J„ . .-__ u^i 



REMOVAL OF AXILLARY LYMPHATIC GLANDS. 



139 



REMOVAL OF AXILLARY LYMPHATIC GLANDS. 

Description.^ — The removiil of the axillary glands is drmc. in the majority 
of cases, in connection w-ith ihe rcmnval of neighboring malignant growths, 
esfwcially those involving the breast— and, in such cases, the incision for 
e-\pt)sing the axillan' region is merely a proloT^gation into ihe axilla of the 
incision for the original operation. The steps, therefore, of the ojjcration 
for ihe removal of these glands will be found sufficiently described under 
the operations for the radical removal of the breast (pages 582 to 5 85). Where 
it is planned to remove enlarge^l ax 
iUan' glands alone and as a distinct 
operation, ihe incision is pbcctl 
over the in vol ve<i glands (Fig. 73). / >*^- 



SURGICAL ANATOMY OF 
SCARPA*S TRIANGLE. 

Description.— A triangular 
ariM iu>l Ix'Iow foKl of groin. 

Boundaries.— Base (alMive); 
Pouf)art's ligament. Kxtcrnaily; 
sartorius. Inlernally; adductor 
longus. Apex fbelow); junction of 
s.irturius and adductor longus. 

Roof.— Skin; superficial fascia; 
fasiia lala. 

Floor. — (From without in 

ti.) lliacus; psoas; pectineus; 
txjui tor brevis; ad<luctor longus. 

Contents.^ Arteries; common 
ftJtu»ral (from middle of base to 
apex); su|>erior epigastric; superfi 
cial circumtlex iliac; su|>crficial ex 
lemal pudic; deep external pudic; 
profunda femoris. Veins; fennfral 
(to inner side of artery) ; profunda 
femorl^; tributaries of branches uf 
femoral; internal saphenous, 
Ncn-es; anterior crural (to outer 
^kIc of arter>); crural branch of 
gcnttoiTiiral; evtemal cutaneous. 
Lj-mnha tics; superficial and deep 
gUno^. 

Inguinal Lymphatic Glands.—Consist of two following sets; (1) Super- 
ficifti Glands; <H)li(iuc or Inguinal Set— along Foupart's ligament. up(»n 
fasou lata. \ erlical or Sa|>henuus Set— around saphenous opening and upon 
fascia lata, (3) Deep Glands; along upper part of femoral vessels, one or 
more being vritliin femoral canal. 




l-VMI-M.MIC liLAMJS :— l'.1»«UIK IhtIwccU bK«rJ« Ul»d 

l*ct.torAl muscles, iiii front, uihI thv M-apulitr musclcsi. 
iRisleriofly. lu whicli inwy •»c afl«leil uiie or mote m- 
i-i<.Um!« al ntclft alible. rutcMdkltg t'lthcr in Irolil o< or 
bcliitid iIk: main Iticiiiiuii. 



134 OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. 

nerve. Floor: parts of thyrohyoid; hyoglossus; inferior constrictor of 
pharynx; middle constrictor of pharynx. Contents: Arteries — common 
carotid; internal carotid; external carotid; superior thyroid; lingual; fadal; 
occipital; ascending pharyngeal. Veins — internal jugular; superior thyroid; 
lingual; facial; occipital (sometimes); ascending phar^'ngeal. Nen'es — 
descendens hypoglossi; hypoglossal; pneumogastric; sympathetic; spinal 
accessory; superior laryngeal; external larj'ngeal. Other Structures — larynx; 
pharynx; lymphatic glands. 

Inferior Carotid Triangle. — Boundaries: Superiorly — anterior belly 
of omohyoid. Anteriorly — middle line of neck. Posteriorly — anterior margin 
of stemomastoid. Coverings: integument; superficial fascia; platysma; 
deep fascia; descending branch of superficialis colli nerve. Floor: scalenus 
anticus (superiorly and externally); longus colli (inferiorly and internally); 
rectus capitis anticus major (between and superiorly); vertebral arter>' and 
vein (between and inferiorly). Contents : Muscles — sternohyoid; sterno- 
thyroid. Arteries — common carotid (not strictly); inferior thjToid; vertebral 
Veins — internal jugular. Nenes — pneumogastric; descending filaments from 
loop between descendens and communicans hypoglossi; recurrent lar}*ngeal; 
sympathetic. Other Structures — larj'nx; trachea; thyroid gland; lymphatic 
glands. 

Posterior Triangle. — ^Boundaries: Anteriorly — posterior border of 
stemomastoid. Posteriorly — anterior border of trapezius. Superiorly — 
occiput (apex). Inferiorly — superior border of clavicle (base). This triangle 
is subdivided into the occipital and subclavian triangles. 

Occipital Triangle.— Boundaries : Anteriorly — posterior border of 
stemomastoid. Posteriorly — anterior border of tra]>ezius. Inferiorly — 
posterior belly of omohyoid. Coverings: integument; superficial fascia; 
platysma; deep fascia. Floor: splenius capitis; levator anguli scapulx; 
middle scalenus; posterior scalenus. Contents : .\rteries — transversalis colli. 
Veins — transversalis colli. Nerves — spinal accessory; descending branches 
of cervical plexus. Other Structures— lymphatic glands. 

Subclavian Triangle.— Boundaries: -Posteriorly — posterior belly of 
omohyoid. Inferiorly — upper Ix^rder of clavicle. Anteriorly — posterior 
border of stemomastoid (base). Coverings : — integument; superficial fascia; 
platysma; deep fascia; descending branches of cervical plexus. Floor: — 
first rib, first serration of serratus magnus. Contents : — Arteries — subclarian 
(third part); suprascapular; transversiilis colli. Veins — subclavian (some- 
times); suprascapular; transversalis colli; extemal jugular; small vein from 
cephalic to external jugular. Nerves — brachial plexus, small nen-e to sub- 
clavius. Other Structures — lymphatic glands. 

Lymphatic Glands of Head and Neck. — Consist of superficial and 
dee|j glands. (A) Superficial glands of head and neck: — Consist of 
transverse and vertical sets, (i) Transverse set of superficial glands:— 
Extend transver.'^cly from occiput along mastoid process, zygoma, and lower 
border of jaw. to symphysis menti, and comprise following groups; — (a) Oc- 
cipital or Sul)(>ccipital — below superior curved line of occipital bone, between 
skin and insertion of comjilexus muscle, (b) Posterior Auricular, or Stemo- 
mastoid— l)chind ear, between skin and insertion of stemomastoid. (c) 
Parotid — in front of ear, between skin and parotid gland, some being embedded 
within parotid gland, (d) Buccal — on surface of buccinator, between it 
and skin, (e) Submaxillary — in digastric triangle, between skin and mylo- 
hyoid and hyoglossus. (f) Suprahyoid — in middle line, between anterior 
bellies of digastric, between skin and mylohyoid. (2) Vertical set of super- 



REMOVAL OF LVMPIIATrC GLANDS OF NKCK. 



135 



ficial glands (superficial cervical chain): — (a) Anlcrior— in front of neck, 
I between hvoid bone and sternum, and between skin and superficial muscles. 
(b) Middle (superticial cervical chain) — chietly along external jupular vein, 
mainly in posterior Irianjfle of neck, t>etween platysma anrl deep cervical 
fa'icia. (C) Posterior — over trapezius, between it and skin. (B) Deep glands 
of head and neck: — Comprising those of head and neck, (i) Those of 
_iiead: — Consisting of following groups: — (a) Lin|2^ual — on external surface of 
liyoglossus and geniohyoglossus. (b) Internal Maxillan' — on lateral aspect 
phar)*nx, behind buccinator muscle, (c) Posterior Phar>'ngeal — between 
oslerior surface of pharinx and rectus capitis amicus major, near base of 
skull. (2) Those of neck : — Consisting of following sets;— (a) Superior set — 
along internal jugular vein, from base of skull to level of thyroid cartilage. 
(b> Inferior set — -along internal jugular vein, from thyroid cartilage to near 
clavicle. 



REMOVAL OF LYIHPHATIC GLANDS OF NECK. 

General Considerations. — In the case of diseased cervical glands, an 

ojjeration may l.>e undertaken — (I) for the remo\al of one or a few defined 

glands, in one or more of the regions of the neck, in which case a single or 

r«everal incisions, more or less limited, arc so placed as most readily and 

safely to expose the involved glands; — or (2) for the removal of glands widely, 

deeply, and indistinctly disst^minated throughout the aniero-lateral aspect 

of the neck, in which case one or more extensive incisions are necessarj', 

Jboth for the removal of the glands and in order to give room in which to 

ftfei;uard important structures during ihcir removal. Removal of dis- 

rmtnated cervical glands will be tirsi described — and removal of isolated 

iJand*! will be referretJ to under Comment. 

Indications for Removal of Cervical Lymphatic Glands.— Chronic 
tubcnular adenitis (most frequently); acute non4ubcrru!ar sujipurative 
adenJti'«; enlargement secondarily from ncighlmring malignant growths. 

Preparation. — Shaving of all hairy parts at sile of and bordering upon 
field of operation. 

Position. — Patient supine; shoulders raised; neck resting over a supfKirt, 
to render it prominent; head st) turned as to increase prominence, length, 
nd width of neck, and in order to drag glands out from under protecting 
lv54je*. Surgeon on side of oj>eration, assistant 0|>[>osite. 
Landmarks. The triangles of the neck. 

Instruments.— Scalj>cl.s; scissors, straight, curvefl, blunt and sharp; 

ccling forceps; tmithed forceps; arter\'-clamp forceps; blunt dissector; 

imclors; lenacula; grooved director; aneuri m needle; needles; needle- 

^Idcr; sutures; ligatures; sterilized water on hand to llood neck in case of 

ning large vein in an inaccessible kx-ality. 

Incision —Various forms of incision have been used, singly or combined. 
i\\'here the entire antero lateral asjK^ct of the neck is to be expc^ed, a 3I-sha|>ed 
nci>ion (Fig. 72) may be useti — BC extenrling from over the mastoid process 
'to the interval l>etween the sternal and clavicular attachment of the sterno- 
mastoid, f>a.ssing down the middle of the stcrnomastoid or along its anterior 
|j<>r«lcr — B.\ extending transversely forward from the upper end of the 
oblique inci.sion to the angle of the jaw. and l hence along the lower border 
of the jaw to the symphysis — CD extending transversely outward along the 
upper borfier of the clavicle, as far toward the acromioclavicular articulation 
as ncccs&ar)'. If only the anterior triangle of the neck be involved, the por- 



142 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 



NEURECTOMY. 

Description. — Excision of a nerve. Neurectomy may be partial or com- 
plete. As ordinarily performed, only a small part of the length of the nerve 
is removed. 

Preparation — Position — Landmarks — Surgical Anatomy — Incision. 
— Determined by the special nerve. 

Indications. — Neuralgia of sensory nerves; spasm of motor nerves. 




FiiC. 76. — NlURHCTOMY OF StPR Af )K11ITAI. NkRVI-.. 

Operation. — The nerve liaving been exposed and brought well into 
the field, is lifted out of its bed with f()rcci)s — and from 2 to 3 cm. (i to ij 
inches) of its trunk is excised with scaljjcl (i)referable to scissors, w'hich partly 
crush). The ends are then allowed to drop l)ack into position — and the 
wound is closed (Fig. 76). 

Comment. — Total excision is most frequently done by avulsion (page 143). 



NEURECTASY. 

Description. — Nerve stretching. 

Indications. — Neuralgia of sensory and spasm of motor nerves. 

Preparation — Position — Landmarks — Surgical Anatomy — Incision. 

— Determined by the nerve operated upon. 

Operation. — The nerve is freely exposed and separated by blunt dis- 
section sufficiently for manipulation. Small nerves are stretched by means 
of a nerve-hook inserted beneath them. l-,arge nerves are stretched by being 
grasped between thumb and finger — the nerve is steadily and evenly pulled 
from its center for about five minutes — then from its periphery for about 
five minutes. The extremes of force employed may be represented by a 
pull of a half-pound for the supraorbital — and from thirty to sixty pounds 
(according to the judgment of the operator) for the sciatic. The manipu- 
lation is (lone with as limited disturbance to the surrounding structures as 
possible. After the stretching, the nerve is dropped back into place and the 
incision closed. In the after-treatment, the part should be immobilized until 
union of the wound occurs. Temporary paralyses of motion and sensation 



NERVE AVULSION. 



143 




FJp. 77.— NBt'UBCTASV OF jNpR\nKiirru Ni k\ i . 

Comment. — Sensory nerves seem more dulled by iraction in a. direction 
»y from the cord — motor nen'cs more dulled by iraction toward the cfird 



NERVE-AVULSION. 

Description. — The tearing away of a nerve from its central and peripheral 

<r«nnections. 

Indications.— Nearalj^'ia. Chielly used upon branches of the fifth nerve 
Preparation —Position— Landmarks— Surgical Anatomy— Incision. 

Determined by the s|>e€iat nerve. 




Kir. 7«».^i\i<RVE-AV»!i5in«< nr Inkp aornital 



Operation. — Having ex[?osed the ner\e involved, it is grasped by calch- 
forrq>v (rirmly. but not strongly enough lo crush and break it)— and then 
iilowly wound around the forceps (by twisting the latter between the fingcrsli 
— iintil the nerve is torn away from its connections, both proximally and 

lUy, Branches of the nerve are also sometimes avulsed, to a greater or 



144 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGUA. 

less extent along with the main trunk — as well as a part or the whole of a 
ganglion. The nene may, also, be partly cut — either distally (generally) 
or peripherally. The wound is closed throughout, in the usual manner 
(Fig. 78). 



NEURORRHAPHY. 

Description.— Suturing of nerve which has been partially or entirely 
divided. Neurorrhaphy may be primar>', or immediate, where the nerve 
is sutured at once, — or secondar}-, where the suturing is done subsequent 
to repair of injury. 

Indications. — Repair of injury to nerve. Neuroplasty. 

Preparation— Position — Landmarks — Surgical Anatomy — Incision. 
— Determined by the ner\e involved. 

Operation of Primary, or Immediate, Neurorrhaphy. — The severed 
nerve-ends are exposed in the wound and brought well within reach. See 
if they be cleanly cut. If not, gently grasp them with forceps and cut them 
cleanly, and preferably transversely, with a sharp knife, with a minimum 
sacrifice of ner\'e-tissue. The ends are brought and held in apposition, in 
their normal relations, anterior aspect to anterior aspect, and the like. If 





F'Jfs. 79-.S3.— MiuHODS of Nkrvic Siti-rinc :— I.— A. B. C, Sutures passing through entire thick- 
ness (if ticrvc* and sheath ; D, K, Sutures passing through ner>'e-shcath only. 



the ends cannot be approximated, flex or extend the limb to increase the 
length, or stretch both ends gently (preferably grasping them with the fingers). 
It is desirable that there should be no tension upon the sutures. The junction 
is made with a fine cambric needle threaded with fine chromic catgut and 
held in a needle-holder. One of several methods of suturing may be adopted; 
— (a) The sutures may be passed entirely through the sheath and ner\'e, in 
two or more directions, and about 3 mm. (i inch) from the ends. The 
needle passes from before backward through the entire thickness of the 
proximal end — then similarly through the distal end, from behind forward — 
and the suture is tied lightly, so as not to have tension. A second suture may 
be applied antero-posteriorly, or laterally— and as many as seem needed 
accurately to coapt the ends. This is the most general method of nerve- 
suturing (Figs. 79-81, A, B, C). (b) Sutures may be passed through the 



NEURORRHAPHY. 



M5 



ncnic-sheath alone, encircling ihe nerve proper. Thb is the j)referaljle 
oj^ralion — but is possible only in lar«ie nerves (Tigs. S2-83, D, E). (c) 
Part of the sutures may pa&s ihrougli the nerve and sheath (as in a) — and 
part through the sheath only (as in b) (Figs. 84-86, .\, B, C). (d) After 





FIk». %4-W.— Mkthoos OP Xkrvk StTrS-lNC:— IT.— A, B. Sutures fiassiug lhn>ug:h sheath and 
jrtkrt c»< nerve; C. Sutur« thnjugh sheath, mnfuntnl by icIaxntioti-sutitrL* thruu^h enlirt- iierv-e; l>, 
Nrr%c cut obliquely aiiU uniicU by sutuTc through sheath ajid part of nerve; E, Same with relaxatiou- 
ftuiurc. 

paring the larger end it may lie split down its center for about 1.3 cm. 

<J inch) — the smaller end maybe beveled on two sides and sutured lietween 

I Ihe Ups of the split end (Fig. 93, A), (e) One end may be beveled on its 




Mitfj'* or NebvE'SITV'RING :— UI,— A. Reiufoniui; lliruii«li-.^iid-ihrou«fi "iiiture 
:\iU |<Mip« ul 6r5l isuture; B, C. D, Union by a|>provimuliun iti Uteial a&|>ccts ul 



?.uri;ui', the other on its lower surface — the two freshene<l surfaces 
then placed in contact and sutured through and through (Figs. S7 and 
I ^"i, D, E), This requires a greater length of nerve than some of the other 
methods. Other methods are shown in Figs. 89 to 92, and 94 and 95. 



to 



146 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 



Having completed the union of the nen'e-ends, the wound is sutured and the 
limb immobilized so as to minimize tension for about ten days — the part is 
then gently massaged daily and the splint reapplied between times and not 
removed for about six weeks. Primary union is particularly to be sought. 
The restraining splint should be such as will hold the part so that the ner\'e 
will be relaxed. 

Operation of Secondary Neurorrhaphy. — Having applied Esmarch's 
bandage, one may cut directly down u\Hm the supposed site of the nerve ends. 
It is better, however, deli})erately to incise for and expose both proximal 
and distal nerve-trunks, above and below the involvement, on anatomical 
grounds. Much difficulty may be experienced in finding the nerve-ends, 
unless traced down and upward, as the case may be, from the nerve-trunks. 
The proximal end is easier to find, and apt to be buUx)us and sensitive. The 
distal end is apt to be atrophied. Sufficient freeing of the nerve-ends to 
enable them to meet is necessary. While in primary suturing the severed 

ends may or may not 
require trimming before 
suturing, in secondary 
suturing they are, in ad- 
dition to being freed 
from connective tissue, 
always to be excised. 
Having identified the 
nerve ends, dissect away 
all intervening fibrous 
tissue. With a sharp 
knife cut away trans- 
versely the proximal 
end until healthy nerve 
tissue is reached. In 
the case of the distal 
end, simply cut away 
enough of the upper 
end to afford good ap- 
proximation (for degen- 
erative processes will 
have extended far down 
this end under any cir- 
cumstances). If the ends can now be made to meet without too much ten- 
sion, tliey are sutured together by one of tlic methods described under primary 
neurorrhaphy. If greater length l)e necessary, as is almost invariably the 
case, it may generally l)e gotten by first carefully stretching the ends — after 
which they are united by suture. If sufficient length cannot be thus secured, 
neuroplasty must l)e done (i)agc i47)- l^>ll()wing secondary neurorrhaphy 
the wound is dosed, the limb splinted, and the same after-treatment carried 
on as after the primary operation — altliough results are not to be expected 
so soon. Restoration of function may require from one to two years. 

Comment. — Where stretching is resorted to to gain length in secondary 
suturing, it should he aj)plied before excising the nerve-ends — traction being 
made upon the nerve-ends themselves, which are afterward removed. And 
if tension be too great u[)on the sutured ends, relaxation-sutures may be 




l-ii;'^ »;,-<7,S.— Mil nous OK Ni-;kvk-sc riRiN<; :— I\'.— A, Sutur- 
iiiR of l>cvi'k'<l iiiil iKtwctii lips oi split vikI ; B, <,", McIIkkI oi iinit- 
iiij; souiitl upper .uid lower porti<»ns of iici\c 1)> si)liitiiig and 
suturiiijL; cotitmclcd porii<;n. 



NELROPLASTV. 



147 



NEtmOPLASTY. 

Description. — The union of severed nerve-ends by processes of plastic 
elongation of the nerve itself, — or by the interposition of nerve or other 





|b — NBV»ofi.ASTV:— I.— A, B, Union b^- splitting both ends of nerve and unitize split end* 
crtd tixrnd ; C. D, Samu, with split ends united laiemlly. 

material^in cases where the loss of nerve substance is so great that the 
severed ends cannot be brought and held tr»geiher by the ordinary methods 






Pig^ MR^lg^ — NKnort A*tV:— II.— A.Spliltini; nne end.witti union uf lateral aspect of split end 
lol iJ[*p«j*ite rnlitc ctiJ , B. Sumc. with uninn cnd-to-cnd ; C. t), Same as in B, in case 



jy, 



148 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 



\r 



of suturing. The object sought is the supplying of a substance between 
the cut ends along which the nerve-fibers may grow from the proximal to 

the distal end (as the tendrils of 
a vine grow along a trellis) 

Indications. — Where, in 
primary operations, considerable 
nerve-substance has been de- 
stroyed by the cause of the in- 
jury, — or, in secondary opera- 
lions, the retraction of the sev- 
ered ends has been very great — 
so that by no other means can 
the ends of the nerves be brought 
and kept together. 

Preparation — Position — 
Landmarks— Surgical Anat- 
omy — Incision. — Determined 
by the special op)eration. 

Operation. — Having ex- 
posed and isolated the severed 
ends, and, in the case of secon- 
dary operations, freed them from 
connective tissue and freshened 
them by partial excision, one of 
the following means of bringing 
and holding the ends in contact 
is resorted to: — ^(a) At points as far from the ends of the nerves as indicated 
by the length of the intervening space to be filled, divide each nerve half- 




Figs. 104-106.— Nkiropi \stv :— III— .\. B. Doubly 
splittiiiK l><>lli cikIs, with union <.t sj)lil ends cnd-to- 
ciid ; C, Interpolation t>f section oi lu rvc 



NERVE-GRAhTING ; NERVE-hM PLANTATION. 



149 



cut ends laterally, and approximate as shown in Fig. 105, B, (g) Com- 
bine meihod<i (d) and (e)— the cumbined methtxi of bnclging v^ith calgut 
and enclosure in decalcified bone lube. One end of the catgut bridge is 
slipped through the lube, sutured lo the other end, and drawn back within 
the tube (Figs. 108 and 109, B, C). (h) Shortening of the limb, by resec- 
tion of its bx>ne or bones, to allow of approximalion of the ends of ihe 
ner\e. (The musculospiral has been thus succtssfully treated.) Of the 
abijve methods, method (a) is the one most generally used. Having com- 
pleted the neuroplastic o[>cration, the wound is closed and the part immo- 
bilized in a position to relax the nerve. 



NERVE^RAFTINGj NmVE-IMPLANTATION. 

Description. ^The grafting of the ends of an injured nerve into the 
trunk of a neighboring nerve — the severed up7»er end being grafted into the 
intact nerve at a point opposite its level, above — and the severed lower end 
ifted into the intact trunk opposite its level, below — that is, at points where 
ey can be conveniently brought into contact with the sound nerve. The 
cl sought is to switch the interrupted nerve-stream, or nerve-impulse, 
the proximal end of the cut nerve into the neighboring sound nerve — 
thence to have it conveyed along this used nerve down to the poini where 




F|k»^ itft-its.— NKRVE-<iRAPTiKG . — I.— A. B, EngrattiitKor freshened lower end of divided median 
: I for ioMUirice) uiioii jtiucl uliwr nerve; C, D, EngmftinK o( fresihcncd upijcr and lower ciid» of 
I ntetlian nerve u|K>ti tntact ulnMr nerve. 



the distal end of the cut nerve is sutured to the utilized ner\*e— and thence 

cturaed lo the original nerve and transmitted along the distal portion of 

cut ncrv'c to its final dislril>uti(»n, as though no inierruption to ils normal 

and transmission had occurred. An illustration would l>e a divided 

in nerve and an intact ulnar nerve — where the upper end <»f the median 

nerve is suttired to the upper part of the ulnar — and the lower end of the 

lian to the lower part of the ulnar (Figs. 1 1 2 and 113. C, D). The object 

Uy sought is to have nerve fibrils grow down this nerve from the proximal 



150 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

cut end to the distal cut end. The method is of limited application, because 
of the necessity of finding large nerves in close proximity — the upper ex- 
tremity being about the only locality in which the method can be utilized 
(Figs. 114 and 115). 

Preparation — Position — Landmarks — Surgical Anatomy — Incision. 
— Determined by the individual operation. 

Operation. — Kxpose, isolate, and excise the proximal and distal ends 
of the severed nerve, supposing it to be a secondary case. Also through 





Figs. 114 and ii.s.—Nkrvfx. rafting :— TI.— A i.to left), Showing ulnar and median nervesdivided 
al diileienl licixlils ; R (to ri>;lii), I'liioii of iii>i)(>r cinl oi nxMjiaii to lower fiid of ulnar ;— followed by 
ennraflin^ of upper end ot ulnar aiul lower en<l t)f uK<li.in into this new trunk. 



the original incision, expose the neighboring nerve up<m which the grafting 
or implantation is to be made. By means of curved sc.ssors, remove a limited 
portion of its sheath, on the lateral aspect of the nerve, at the sites where 
the upper and lower severed nerve-ends are to be grafted. The obliquely 
or transversely divided ends of the involved nerve are to be sutured to the 
denuded lateral aspect of the intact nerve, above and below, by fine chromic 
sutures passing through the sheath of the nerve ends, on the one hand, 
and through the sheath and part of the thickness of the intact nerve at the 



INTRANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 151 

bared sites, on the other hand. Having completed the nerve-suturing, if 
ihc neighboring parts have been disarranged, these should be rearranged — 
by buried catgut sutures, if necessary. The wound is tlien clo.sed throughout. 
The part should be immobilized in a position of relaxation of nerve-iensinn 
until union has occurred — anil subse(|uenily treated as described under 
neurorrhaphy. 

Comment.— The intact nerve may be split at the two places to receive 
the freshened severed ends. It seems to make no difference whether a sen- 
sory nerve be grafted to a motor or to a mixed nerve — or vice versa. 



OPERATION FOR RELIEF OF NERVE COMPRESSED BY BONY OR 
FIBROUS aCATRIQAL TISSUE. 

Description. — Nerves iire sometimes involved and pressed upon in the 
processes of repair following injury of bones and soft parts, or in the processes 
of disease, and eventually become so firmly compressed as to have iheir 
function impaired--iu which case an operation to free them for pressure is 
indicuietl. 

Position— Landmarks— Incision.— Dependent ufjon nerve involved. 

Operation. — The steps of the ojieration will be determined by the position 
and nature of the compression. Where fibrous cicatricial tissue surrounds 
the nen*e, the mass is to be exposed by dissection ^the nerve is tc* he isolated 
cither above or below the mass and is to be followed through it and dissected 
out from it. The cause of compression, as far as fKissible^ is to be removed^ 
so as to avoid a recurrence. Where a bony callus surrounds the nerve, this 
is to be reached by the safest route through the muscular planes— the nerve 
being similarly isolated al>ove and below the mass — and freed through it- 
It is often necessary to chisel away as much of the callus as Imprisons the 
nepkc — and in order to render a recurrence of compre.s.sion unlikely. The 
wound is closed as u.sual. 

Comment. — Nerves may be compressed by growing tumors — their 
relief being determined by ihe treatment adopted for the lumor. 



INTRANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 

Description. — The injection of a sterilized anesthetic solution into a 
ncr\'e-trunk. The injection may be made at the site of the proposed opera- 
tion, or abo\e the site. 

Indications. — To produce anesthesia in the region supplied by the 
ner\-c, for the purpose of operating at any magnitude. Especially indicated 
in those j>onions of the bcxly which may l>e more or less isolated. — and in 
fthosc cases in which general anesthesia is contraindicated. 

Position— Landmarks Incision, -Determined by the sfx^cial opera- 
tion. 

Operation.— The anesthetic fluid may be injecle<l at the site of o[)eration 
above it; — (a) Where the Injection is made into the Nerve trunk above 
the site of Operation — the anesthesia being protiuced in the region suppiieti 
by the nen'e: — (Suppose the injection be made into the sciatic ncrvf. for 
I amputation of the leg); To prepare the way for the incision, anesthetize the 
♦kin by intradermal infiltration — and the connective tissue by subdcrmal 
(subcutaneous) infiltration. Expose the sciatic nerve above the bifurcation 



152 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

into internal and external popliteal and isolate it sufficiently for manipulation. 
Insert the needle of the syringe through the sheath of the ner\'e and into and 
among its fibers — and slowly inject the anesthetizing fluid (the amount 
determined by the nature of the solution and size of the nerve) until the entire 
extent of a transverse section of the nerve has been infiltrated or *' blocked" 




Fiji, nr'.— lNTK\MtKAL Inkit.tr ^tton for Rfciovai, Anfsthesia ;— The jjreat sciatic nen-o be- 

i'l^; hen- iiililtr.itcii. 



(Fig. ii6V It this ?inglo injeciinn be considered sufficient to last throughout 
the opiTatinn. ilie wound m.iy lie at once clo>od— othenvise it is temporarily 
packi'd wiih gauze. The linil» is elevated and e.xsanguinated by gra\aty. A 
circular constricior is apj^lioil abtn-e the site at which the nerve was infiltrated. 
Within a lew minutes of tlie intillration. the distal regions supplied by tho 



PARANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 153 



» 



I 



nerve will be completely anesthetic, and any operation may be performed 
ihereon, as long as the constrictor remains in sifu. (b) Where Inlihration 
is made into Nerve-trunks as exposed in the course of an Operation: — Anes- 
thetiite the skin by intradermal intiltration, and the connective tissue by 
subdermal infiltraiion. As each nerve is exposed, it is isolated, taken up, 
and infiltrale<^l as in the above metht>d. Where the case is a limb, a circular 
constricior is used as above. Where the region is such an one as is involved 
in the radical operation for inguinal hernia, no arrest of circulation is at- 
tempted. In this methiMl the anesthesia is complete not only at the site 
infiltrated, but in the regions supplied by the infiltrated nerves — but lasts a 
shorter time, unless the intiltration be repeated, than where a constrictor 
can t)e applied. 

Nature of the Anesthetic Solutions. — These have been of various 
constitutions and percentages — there being no recognized standard solution 
universally employed in this comparatively new field of surgery. Sterilized 




H^ Tig. 117.— MaTAS'S .\PPAHATl'S FOR PaRANRIRAL INFILTRATION OR <I>:DHMAT17AT10N :— Ait for 

V pccasurr i^ iirrr txritif* puini>eil into tlu- hoille curttairiitij; ihc atiesthrtic sulitlJMii. (Modified from 



solutions of cocain, of eucain B, of nir\*anin. of Schleich's solution, and 
others, have been used. Almost any suitable syringe may be used, though 
a special instrument is more appropriate, Malas (whose writing up'U local 
anesthesia this article largely follows) has devised a special form of injecting 
apparatus for infiltration in the paraneural method (Fig. 117). 

Comment. — If the site of operation be supplied entirely by one nerve, 
that nerve alone need be infiltralcil, at some convenient point proximal to 
the site ui intended! operation. If the site of operation, however, be supplied 
by several nerves, each has to be separately infiltrated;— for example, in the 
operation of amputation of the leg described above, if the operation is to 
be aImjvc the level of the tuberosity of the tibia, the anterior crural nen'e is 
to he also injecte<J, — if below that level, the long saphenous nerve is to be 
injected instead of the anterior crural— the sciatic being, of course, infiltrated 
in l>oth instances. The entire upper limb can be anesthetized by infiltrating 
the brachial plexus above the clavicle. 



PARANEURAL INFILTRATION FOR REGIONAL ANESTHESU. 



^^^ Description.— The injection of a sterilized anesthetic solution into the 
^^^kues immediately surrounding a nerve-trunk. 



154 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

Indications. — To produce anesthesia in the region of the infiltration and 
as far beyond as the solution is diffused. 

Position— Landmarks. — Determined by the sjjecial operation. 

Operation. — Without making any incision for the exposure of the ner\'e, 
the anesthetic solution is injected first intradermally, to deaden the site 
superficially, and then into the tissues immediately in the neighborhood 
of the nerve, and as near to the nen-e as possible. This infiltration of the 
tissues alongside of the ner\e is done ujwn a knowledge of the anatomy of 
the nerve and its relation — and is meant to "envelope the ner\"e in an anes- 
thetic atmosphere.'* In the case of dealing with an extremity, a few minutes 
after the infihration the part is elevated, exsanguinated by gravity, and a 
circular constrictor applied above the region of infiltration — subsequently 




Fijf. ii8.— Paranei-ral Inpii.tration in thk Covrsb op thk Radial Nbrvb. (Modified 

from Matas.) 

to which the parts below the infiltration will be anesthetized by the diffusion 
of the anesthetic solution (Fig. 1 18). In other localities no attempt to control 
the circulation is made. The anesthetic solutions and the spedal syringe 
for injection are mentioned under Intraneural Infiltration. 

Comment. — This method is more applicable to smaller extremities and 
part? — wliile the intraneural method to the larger. The paraneural infiltra- 
tion for regional anesthesia differs from local infiltration for regional anes- 
thesia (which may be represented by the common use of cocain h\'podermatic- 
ally) in that in the latter no attempt is made to infiltrate along the anatomical 
course of the nerves, but the injection is made almost at random into the 
cutaneous and subcutaneous tissue. 



IXTRACRANIAL EXPOSURE OF GASSERIAN GANGLION. 



ISS 



SURGICAL ANATOMY OF GASSERIAN GANGLION OF TRIFACIAL 

NERVE. 

Description and Relations. — (a) Both sensory and motor root of the 
itrifarial j»a,s> <lo\vn\var(J ami forward thnui^h an aperture in dura mater, 
Imhich lies under cover of lenkirium cerebelli and a little lo outer sifje of apex 
of («rtn>us portion of temijoral hone, to enter Meckel's space, between the 
supfKirting and periosteal layers of dura mater, in which space the sensory 
portion enlarges into the j^asserian ganglion, (h) The gasserian ganglion, of 
somewhat semilunar form, with convexity forward, rests in depression upon 
upper surface of petrous portion of temporal bone, near its aj^ex — and also to a 
slight extent upon cartilage which occupies foramen lacerum medium, Its 
upper surface is 6rmly attached to dura maler (nxjif of Meckel's space) — its 
lower surface, less firmly (lo rt(W)r of Meckel's space). Its inner part lies 
near posterior extremity of cavernnus sinus and inlernal tarotifl artery. 
The motor root and the large superficial (>etrosal nerve lie beneath the ganglion. 
From its convex antero- external border are given off the following main 
[divisions;— Ophthalmic, pas-sing out through sphem*i(lal fissure; Su|>erior 
Maxillar)-, jiassing through foramen rotundum; Inferior Maxillary, passing 
through fonimen ovale and being joined immediately after its exit by ihe 
motor root, which also passes through foramen ovale separately. 



INTRACRANIAL EXPOSURE OF GASSERLAN GANGLION AND THREE 
DIVISIONS OF FIFTH NERVE. 

HAKTl-tiV-KRAt'SK Of'KKATlUN. 

Description.— Osteoplastic resection of temporal region with lemporar)- 
.turning down of flap of bone and soft jiarts and separation r>f dura mater 
'from middle fossa of skull — the ganglion and three divisions of the fifth nerve 
being exposed without opening dura. 
Preparation . — H ea < I sha \ ed . 

Position. — Patient on back; head to one side and supported by firm 
pillow. Surgeon at side of head, either in front of or behind patient. Assist- 
ant opposite. 

Landmarks. — External angular process of frontal; tragus of ear; supra- 
temporal ridge. 

Incision. — \ horseshoe-sha[>ed incision is made over the temporal 
rrfjion, its anterior extremity being near the externai angular [>rtHcss of ihe 
I frontal bone, its posterior extremity near the tragus of the ear. and the highest 
rpari of the cun'e reaching the supralemporal ridge (Fig. 119). 

Operation. --(I) The above incision passes through all the soft tissues 
^and periosteum directly to the bone, along the entire line, (a) With periosteal 
■ele^'ator, the soft parts of the Hap are freed from the bone lo a slight extent 
only, around the entire incision line- the freeing at the two ends of the base- 
line being a little more extensive. Throughout the rest of its extent, the 
flap remains adherent to the underlying bone. (3) \^'ith a trephine of about 
t t rm (^ inch) <liamcter, two discs of bone arc removed, the anterior with 
i •" over the tip of the sphenoid wing, the posterior having its center 

"inl 2.5 cm. (i inch) vertically above the external auditory meatus. 
From these trcphine-openings the dura is separated as far as possible, both 
Hilonf; the straight basal line connecting the two openings, and in the direction 
tn which the convex bone-section is to be made. (4) A section of bone similar 



156 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

in shape to the skin incision, but smaller in size, is now made. This section 
is made from the squamous portion of the temporal and greater wing of the 
sphenoid — the basal attachment being somewhat narrower than the greatest 
transverse measurement of the convex portion. This bone-section was 
formerly made by a special chisel cutting a triangular groove — but is now 
made by a motor or other saw — the section beginning at one trephine-opening 




/ 



Fir. ii<j.— I".\i'f)srRK ok Cvsskrian Gangiion BY Ostkopi Asi ic Flap— Preparatory tothk 
Har ii.i-.v-Krai SK Opfkation :— I.— A, Fciiu.stciim ; H. Hurstshoc tlap broken back and turned 
down ; C, Dura nialer, with aiucrior and i>o>tcriur branehts of middle nicninj;eal artery. 



INTRACRANIAL EXPOSURE OF GASSERIAN GANGLION. 



157 



and bone is prized outward and downward, generally snapping direct!)' and 
evenly across the basal line just above the zygomalic arch, and remaining 
hinged by the soft parts — and exposing an area of brain (covered by dura 
mater) of about 5 lo 7.5 cm. {2 in 3 inches) in diameter (Fig. 120), (6) If 
ihe middle meningeal arter}' is found injured, it is tied as near the foramen 
^inosuro as possible. (7) The dura mater and temporosphenoiilal lobe of 




P 



^ 



/ 



F»e. tX> — EXFOSt'KB OF GaSSXRIAN GANGLION BV OSTKOPt.ASTTC Fl.Ar. HV THB HaRTJ KV- 

a: -f MMtifii> —11. — The l>tnm clcv.iicd aiul "(tnictiircK in tnicUlle (ossa shown. A. Ca*&friah 
ipgi. iiviMfii ii;i<«i<iiii<< thr<m>jli s|iilii."iuji(JnI fissurt; secoti(l,lhroii)(li foramen nitiinilnm ; 

Ihii It ovalf; It. M(<li1k" mminnvat artery pasi^in^ ihrotiK^ (otJinicn sjiinostum; C, 

P&»..,..,. ... ^.,..., ..li, ftinu-«; 1>. Pi.>si(Kin <•! vmiuimom carotid. The Ihird nerve ubovc) :intl fourth 
ncTvr (ht'Ui'M ) Ar<r xrcn (asuthK Ticiwocti Ihe fitsl <livision of the fifth nurve aikI the cavemoiu sinus. 
The itum malrr (urminK Meckel's st>ace is nui here shown. E, Ftuor of miitdlc fossa. 

the brain arc now separated from the middle fossa of the skull. This is done 
tn thr direction toward the ajH-'X of the petrous portion of the temj>oral bone, 
and h accomplished by the fingers or a piece of gau/e, or by a curved, blunt 
drt^ator. St:>metimes the dura is considerably torn, and sometimes the 
U toni whether the dura is or not, reqiuring tcmporar)' packing of 
bony groove to control the hemorrhage, where ligature is impossible. 



158 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

Injured dura should be sutured wherever possible. (8) The three divisions 
of the nerve are now seen and are traced back from their foramina. The 
positions of the carotid arter}- and cavernous sinus are located as nearly as 
possible, for the purpose of guarding them. (9) Isolate and cut the first, 
second, and third divisions close to the sphenoidal fissure, foramen rotimdum, 
and foramen ovale, respectively. Secure the proximal ends of the severed 
ner\'es with forceps or silk, and, practising traction upon them, trace them 
back to the gasserian ganglion — after incising the dura mater over them. 
Then, raising the ganglion from its bed, sever its connections with the brain 
close to the dura mater, and, if possible, without including or injuring the 
motor root. (10) At the end of the operation the dura and cerebral convolu- 
tions are allowed to fall into place — the flap of bone and soft parts is turned 
up — and sutures applied to skin and muscles. 

Comment. — (1) The width of the basal line of bone may be decreased 
by rongeur forceps, thus increasing the likelihood of a clean, transverse 
breakage — or a Gigli saw may be conducted under the bone at its base and 
made partly to divide it. (2) In the use of either chisel or saw, the inner 
tablet of the skull may be left uncut in two or three places, over a limited 
extent, so that when the flap is broken back, these parts of the vitreous are 
hft as shelves for the flap to rest upon when turned back into place. (3) 
Bleeding may be so great as compel one to pack and finish the operation in 
two stages. (4) The advisability of removing the first division is doubtful, 
because of the trophic changes which follow in the eye. The first division 
is never invohed alone. (5) The motor root should always be left undisturbed, 
if possible — to avoid paralysis of the muscles of mastication. It is more apt to 
be injured if the dura of ^Iecke^s space be oi)ened over the ganglion and the 
sensory root be cut between the ganglion and the pons. When possible it is 
best to cut the second and third divisions close to the foramen rotundum and 
foramen ovale respectively — dissect them back to the ganglion, and remove the 
parts of the ganglion corresponding to these divisions, leaving untouched the 
first division, with its corres]>onding ganglion and the motor root. (6) If the 
first division be removed, with the corresponding part of the ganglion, especial 
care is needed not to harm the cavernous sinus and the nerves to the eye — 
to aid in avoiding which, the second and third divisions should be removed 
first to give more room. If the first division be accidentally severed, leave 
the lacerated end as near the remains of the ganglion as pos.sible. (7) If 
much oozing follows packing, wick or gauze drainage is indicated for twenty- 
four or forty-eight hours. (8) The chief dangers of the operations are — 
injury to internal carotid and cavernous sinus; laceration of brain; injury 
to nerves of eye (third, fourth, and ophthalmic division); hemorrhage from 
middle meningeal arter)-. (9) In Horsley's method of intracranial exposure 
of the gasserian ganglion a large soft flap is turned down from the temix)ral 
region, the underlying bone is removed by trephine and bone forceps (not 
to be returned), the temporosphenoidal lobe exposed, the dura incised, the 
ganglion expo>ed, and the root cut on the proximal side of the ganglion. 



EXTRACRANIAL EXPOSURE OF GASSERIAN GANGLION AND THREE 
DIVISIONS OF FIFTH NERVE; 

ROSE'S MFTHOD. 

Description. — The ganglion is approached through the pterygomaxillary 
fossa, the zygoma being temporarily and the coronoid process of the inferior 



EXTRACRANIAL EXPOSURE OF GASSERIAN GANGLION. 



159 



I 




maxilla permanently resected, and the trephine applied to include the anterior 
and outer p^^nion of the foramen ovale. 

Preparation. — Head sha\ed; eyelids stitched together with horsehair or 
other sutures. 

Position. — As in preceding operation. 

Landmarks. — Ouler canthus nf eye; zygomatic arch; meatus auditorius 
cxtemus; angle and horizontal ramus of lower jaw. 

Incision. — Begins near outer canthu.s of eye, about 1.3 cm. (i inch) 
below ihe external angular process of the frontal — passes back\^'llrd along 
Ihe upper border of the zygoma to its posterior extremity — thence downward 
just in front of ear to the angle of the juw — thence forward along the horizontal 
ramus of the jaw to the facial vessels. 

Operation. — (i) Reflection of the Skin Flap; — Incise through skin and 
only, along the above line. Raise this semicircular skin flap without 
ing the facial nerve or Slenson's duct. (2) Exposure of the Pterygoid 
Space; — Incise down tlirough the j>eriosieum for the entire length of the 
zygoma, and detach the periosteum. Drill (for later wiring of the bones) 
two holes through the zygomatic process of the malar, and twti thnrngh the 
mot of the zygoma. Divide the bone (downward and forward) between the 
tMO anterior holes — and also between the two iiosterif>r holes. Displace the 
jn,*goma downward and backward, bringing the masseter with it (divitJing 
the necessary muscle- fibers). The coronoid process is exposed and cut 
ubliquely downward and forward, as low as possible, then turned upward, 
and, together with tendon, cut away (there being no object in retaining it, 
as it would waste with the other muscles of ma.sti cation supplied by the 
notor 6bers of the third divisiim). (3) Exposure of the Foramen Ovale; — 
Expose the internal pler\*goid by removing the overlying fat anrl connective 
tissue. The internal maxillary artery, which is generally found upon the 
rou*cle, is dividerl between two ligatures. 1 he inferior dental and lingual 
Ijustitor}' nerves are sought at the lower border of the external ptervgoirl, 
cut, and iheir proximal ends lied with silk, to serve as guides. Expo>e ihc 
men ovale on the under surface of the great wing of the sphenoid, by 
ly cutting away an<l partly retracting away (by scraping) the external 

-ygoid — thus exposing both the great wing of the sphenoid and the external 
pterygoid plate. The foramen ovale is sought by following up the silk liga- 
ture, drawing the ncr\cs of the third division taut, and also I»y the finger 
feeling in its known position, a little behind and external to the external 
ptervgoid pLite, remembering that just to ihe inner side and behind the 
foramen ovale lie the eustachian tube and the middle meningeal artery' about 
to enter the foramen ovale. Bleeding is apt to be considerable here, espe- 
cially from the veins of the pterygoid plexus and from veins passing through 
the foramen ovale between the pterygoid plexus and the cavernous sinus. 
This hemorrhage is controlled by gauze packing. (4) Opening the Base 
of the Skull; — A small, long-handled trei»hine is placed just in front and 
to the outer side of the foramen ovale, so that the margin of the foramen is 
inrludet) in the disc of the bone to be removed. (5) Division of Nerve- 
tnink<) and Partial Removal of the Ganglion.— The trephine-opening having 
ixcn ileared and sufficiently enlarged by chisel or forceps, the surgeon follows, 
by means of the silk ligature, the third division up to the ganglion, which is 
loosened from its bed and the second and third divisions freely resected— 
the first being left undisturbed. (6) ("losure of the Wound; — The wound 
hairing been irrigated with r : 4000 hi chlorid, dried and dusted with iodoform, 
the previously drilled zygoma is wired, the temporal fascia sutured to the 




i6o OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

cut margin of the fascia over the zygoma, and the wound closed without 
drainage. The eyelid stitches are removed in three or four days. 

Comment. — (i) The operation may be performed in two stages. (2) 
The coronoid process may be drilled (for wiring) before cutting. (3) The 
extracranial method of exposing the ganglion is preferable. 



SURGICAL ANATOMY OF SUPRAORBITAL BRANCH OF FRONTAL 

NERVE. 

Description. — Passes forward from bifurcation of frontal ner\'e and 
leaves orbit through supraorbital notch (or foramen) — and, giving off palpebral 
branches, ascends vertically upward close to bone, beneath orbicularis pal- 
pebrarum and occipitofrontalis to forehead, where it divides into cutaneous 
and pericranial branches. The supraorbital vessels lie on its outer side. 



EXPOSURE OF SUPRAORBITAL BRANCH OF FRONTAL AT 
SUPRAORBITAL FORAMEN. 

Position. — Patient supine; head slightly elevated. Surgeon on side of 
operation, or above head. 

Landmarks. — Supraorbital notch (or foramen) — ^\vhich, if not easily 
felt, lies at junction of inner and middle thirds of supraorbital margin. 

Incision. — Transverse, about 2.5 cm. (i inch) in length, along supra- 
orbital margin, with center over position of supraorbital notch (or foramen) 
— the eyebrow having been previously shaved. 

Operation. — Having steadied the brow by the first finger of left hand 
(which also draws up the soft parts so as to hide subsequent scar) and de- 
pressed lid with left thumb, carry the above incision through skin, fascia, 
and orbicularis palpebrarum — when the nerve will be found upon the peri- 
osteum, accompanied by its vessels. 



SURGICAL ANATOMY OF SUPERIOR MAXILLARY BRANCH OF TRI- 
FACLAL AND MECKEL'S GANGLION. 

Description. — .\rises from center of gasserian ganglion — runs forward 
through foramen rotundum — traverses upper part of sphenomaxillary fossa 
— enters orbit through si)henomaxillary fissure — thence courses forward along 
infraorbital groove, accompanied by infraorbital arter\', to infraorbital canal 
— along which it passes to emerge upon face through infraorbital foramen, 
as the infraorbital nerve, terminating beneath levator labii superioris muscle 
in a leash of branches. The distance of infraorbital foramen from foramen 
rotundum is about 5 cm. (2 inches). 

Sphenopalatine or Meckel's Ganglion.— Placed deeply in spheno- 
maxillary fossa, beneath superior maxillary nerve, near sphenopalatine 
foramen. Its relations are:— Superiorly, suj)erior maxillar}' ner\'e; Poste- 
riorly, sphenoifl bone and vidian canal; E.xtemally, internal maxiUar>' artery 
and external pterygoid muscle; Internally, vertical plate of palate and spheno- 
palatine foramen. 

Comment. — The posterior superior dental is given otT from the superior 
maxillary just before the nerve enters the infraorbital canal — the middle 



EXPOSURE OF SUPERIOR MAXILLARY NERVE. 



i6i 



superior denial, at the back pari of the canal — and the anterior superior 
dental just before its exit upon the face. To insure, therefore, the removal 
of ihe origin of the jju<terior superior denial ner\e, the trunk has to be removed 
as Car back as Meckel's ganglion. 



EXPOSURE OF SUPERIOR MAXILLARy NERVE AND MECKEL'S 

GANGLION BY THE ANTRAL ROUTE. 

CARNOCHAN'S OPERATION. 



l_^„ ,..„.. 

^^^Biiital foramen to the foramen rolundum. together with Meckel's ganglion — 
by following the course of the infraorbital canal, and removing parts of the 

I anterior wall, roof, and posterior wall of the antrum of High more. 
Position. — Patient supine; head elevated and turned sHghtly to one side. 
Surgeon on side of operation. 
Landmarks,— Infraorbital foramen (which is about 8 mm. — J inch — 
below the infraorbital margin, and on a line drawn from the supraorbital 
foramen to a point between the two bicuspids of both jaws). 

Incision. — V-shaped (two sides of an equilateral triangle, each side 
being about 2.5 cm. — i inch — long), placed with its leiiter over the inlraorliiial 

■ fonunen and its two limbs upward. 
Operation.— (I) This incision is carried to the bone. The Jlap is then 
turned up over the closed eye and its apex stitched to the forehead. (2) 

I The infraorbital nerve is isolated at the foramen, cut as long as possible, 
ami lied with silk — to serve as a guide and means of traction. (5) A trephine 
of alxiut 1.3 to 2 cm. (k to } inch) in diameter, or a chisel, is now ap|)lied to 
the cleared bone, and a portion of bone removed including the foramen in its 
upper half — and the mucous membrane of the antrum is incised. (4) The 
upper portion of the jKjsterior wall of the antrunT is similarly removed over 
an area of al>out 6 mm. (\ inch), either by trephine or chisel. (5) The mucous 
membrane covering the roof of the antrum is now divided in the direction 
of the infraorbital canal, followed by breaking away the bony floor of the 
canal, which may l>e done by chisel or stout scissors, while practising traction 
upon the ne^^e as a guide. (6) By this means, and by the use of long slender 
sdssors and dissecting forcejfs, the nerve is freed back atros^s the sphcno- 
maxiUar)' fossa to the foramen rolundura, until it hangs freely e.vjxtscd. 

1(7) Eff(»rt should be made to recognize Meckel's ganglion at this stage, locating 
it as definitely as jMjssible, Consideraljle bleeding may l>e exjieclcd at this 
period of the o|)eration — hemorrhage being controlled chiefly by presswre. 
Artificial illumination should be used. The nerve, while slight traction is 
being applied, should l>e dividefJ at the foramen rotundum and from its 
^_ sphenopalatine branches. The nerve an<i ganglion are then withdrawn. 
^P (8) The soft parts are now sutured— and, if much ixjzing occur, temjx»rary 
^^ dramage is to be provided for through the lower angle of the wtmnd. or tem- 
porary packing may be nece.ssar)'. with subsequent suturing of the lower 
part of the wound. 

Comillftnt. — (I) A T shaped incision may be used — the horizontal 
portion lacing j)laced under the tower margin of the orbit, and the vertical 
portion running down on the cheek to near the mouth. Or a r shaped 
incifilon may l»e use<l — the hori/.onl,vi portion along the orbit, and the vertical 
portion in the nas<.>labial groove. I'robably the best incision is a long trans- 
Uttte one Ijclow the orbital margin, with strong retraction. (2) When 
M 




l62 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

Meckers ganglion is removed, the vidian nerve is paralyzed and therefore 
the motor branches to the palate muscles. 



EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S 
GANGLION BY THE ORBITAL ROUTE. 

Description. — After subperiosteally displacing the contents of the orbit 
from the infraorbital canal and removing the roof of the canal, the nerve 
is followed back to and beyond Meckel's ganglion and cut at the foramen 
rotundum. 

Position. — As in the above operation. 

Landmarks. — Infraorbital margin and infraorbital foramen. 

Incision. — Curved incision along lower margin of orbit over infraorbital 
foramen — extending from near internal angular process to external angular 
process of frontal. 

Operation. — Carry the incision to the bone throughout. Isolate the 
ner\'e — cut as long as possible — and attach a stout piece of silk to the proximal 
end as a guide and means of traction. The bone between the infraorbital 
foramen and infraorbital margin is removed by trephine or chisel, exposing 
the anterior portion of the infraorbital canal. The periosteum of the floor 
of the orbit is raised along the orbital margin with a periosteal elevator — 
a spatula or retractor is placed beneath this and the tissues of the orbit are 
held out of the way. The roof of the canal is next broken down w^ith a fine 
chisel, or other instrument — bleeding being controlled by pressure — and the 
ner\'e lifted out of its bed by traction on the ligature — and is then traced 
back with delicate instruments to the foramen rotundum and removed, 
together with Meckel's ganglion and its terminal filaments. The orbital 
contents are then allowed to fall back into ])lace and the skin incision sutured. 

Comment. — It is exceedingly difficult, and probably impossible, actually 
to leach the ganglion by this method, especially without wounding the eye- 
structures. It is also difficult to make the section far enough back to include 
all the dental nerves. 



EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S 
GANGLION BY THE PTERYGOMAXILLARY ROUTE. 

BRArX-I.ORSSKN OPERATION. 

Description. — The nerve and ganglion are reached in the pter}-go- 
maxillary fiissa by temporarily resecting the zygoma, turning it and the 
massetcr muscle downward, firmly retracting the temporal muscle backward, 
and following the posterior surface of the superior ma.xillarj* bone into the 
pterygomaxillary fossa. 

Position. — Patient supine; head on one side and elevated; surgeon to 
right for both sides. 

Landmarks. — External angular process of frontal; zygoma; [josterior 
border of ascending ramus of lower jaw. 

Incision. — Begins at external angular process of frontal, passes downward 
and backward along upy)er border of zygoma to tragus of ear, thence down- 
ward in front of car along posterior margin of inferior maxilla to angle of 
lower jaw. 

Operation. — (i) This incision (the region having been shaved) {>asses 



EXPOSURE OF INFRAORBITAL NERVE. 



163 



I 
I 



only through skin and suii^rfKial fascia— and the flap of integumentary 
tissues thus raised by dissectJtm is turned forward and temporarily attached 
lo the nose by suture. (2) An incision is made along the zygoma, passing 
to the bone, which is then exposed subperiosieally. Two hnles are drilled 
(for wiring the bone later) through the malar Lone on a Une with a continua- 
tion of the upper part of its posterior border, and two through the zygoma 
near its nx>t. The zygomatic arch is then sawed through between the two 
anterior drill holes and between the two posterior drill holes, directing the 
saw from without inward at the two ends (forming a beveled shelf for the 
arch to rest upon when replaced). The temporal fascia has been freetl 
along its upper border in exposing the arch — and now the entire arch is 
turned down, with its attached masscter, cutting whatever fibers of that 
muscle are still holding the arch in place. (3) At this stage the mouth is 
opened with a gag and the lower jaw depressed, to carry downward and 
backward the coronoid process, with its temporal attachment — at the same 
lime drawing backward with retractors the temporal muscle and tendon 
from the anterior portion of the temporal fossa. If this do not give sutlicient 
exposure, the anterior part of the muscle and tension is divjfled transversely. 

The pierA'gomaxillary fissure is thereby e.xposed —and the internal maxil- 
arten* and vein are seen entering and leaving the pterygomaxillary 
through this fissure and are both ligated. The superior maxilbry 
nene b found leaving the foramen rotundum and is brought forward t)y 
means of a nerve-hook. The nerve and Meckel's ganglion can be nn>re 
thofmighly exposed, at this stage of the operation, by chiseling away the 
spur of bone at the base of the external pterygoid plate, projecting outward 
and forward across the pterkgomaxillarv' fissure and partially Idocking the 
entrance to the pier)'gomaxiliary fossa— and then both nerve and ganglion 
can be booked forward. (5) In concluding the operation, the tcm[>orarily 
removed zygomatic arch is wired at both ends where previously drilled. If 
the temporal muscle have been partly severed, this is sutured. The temporal 
fascia is sutured lo the cut margin of fascia over the zygoma. The skin 
incision is closed as usual. 

Comment. — fi) If the infraorbital nerve be exposed at its emergence 
upon the face from the infraorbital foramen and he severed, then by traction 
upon the ner\'e hooked up in the sphenomaxillary fossa the entire length 
of the infraorbital ner\'e may be drawn out of the canal backward and all its 
denial branches torn across in their bony canals. (2") This operation is 
similar, in principle, to Rose's method of exposing the gasserian ganglion — 
and the chief indication for its use is where it is found desirable to expof^ 
the inferior maxillary at the foramen ovale, as well as the superior maxillaryj 
with Meckel's ganglion, at the foramen rotundum. To expo.se the superior 
maxillary and Sleckel's ganglion aJone, the antral or the orliital route would 
be prrferable; — and to exjjose all three roots, or ihe second and third, the 
Hartley- Krause or the Rose operation, especially the former, would be better. 



EXPOSURE OF INFRAORBITAL NERVE AT INFRAORBITAL 

FORAMEN. 

Position.— Patient's head slightly elevated. Surgeon to side of operation. 

Landmarks.— Infraorbital foramen— which, if not palpable, lies about 8 
mm.(i inch) below infraorbital margin. and on line from supraorbital foramen 
lo a point between the two bicuspids in both jaws. 



1 64 OPERATION'S UPOX THE NERVES. PLEXUSES, AND GANGLIA. 

Incision. — About 2 cm. (f inch) in length, over the infraorbital foramen, 
parallel with the margin of the orbit. 

Operation. — Skin, fat, and orbicularis palpebrarum are indsed. The 
levator labii superioris is exposed and also incised. The nerve is found at 
its emergence from the foramen. 

Comment. — The infraorbital ner^•e may be exposed through the mouth, 
without scarring. Having made the gingivolabial fold tense, an incision is 
made through the mucous membrane and periosteum along the line of reflec- 
tion from the upper lip to the superior maxilla. The soft parts are then 
dissected away from the bone along the canine fossa, subperiosteally, and 
firmly retractefl upward — until the infraorbital foramen is reached. 

Note. — For the Anatomy of the Infraorbital, see the Superior Maxillar}* 
nerve. 



SURGICAL ANATOMY OF INFERIOR MAXILLARY BRANCH OF TRI- 
FACIAL AND THE OTIC AND SUBMAXILLARY GANGLIA. 

Description of Inferior Maxillary. — Formed of two roots — ^a large 
sensory root from the inferior angle of gasserian ganglion — and a small 
motor root which passes under the ganglion and unites with the sensory root 
just after it has passed through the foramen ovale — both roots passing through 
the foramen separately. The nerve dindes into anterior and posterior divi- 
sions 3 to 4 mm. (I inch, about) beneath the base of skull and under cover 
of the external pterygoid — the former recei\'ing the greater part of the motor 
root and the latter the greater part of the sensory root. 

Ganglia. — (1) Otic (Arnold's) Ganglion; — situated immediately beneath 
foramen ovale, having inferior maxillar}' nerve on its outer side, the eustachian 
tube on its inner side, and the middle meningeal arter\' on its posterior side. 
(2) Submaxillar)' Ganglion; — placed between mylohyoid and hyoglossus 
muscles, above deep portion of submaxillary gland, and at outer side of 
Wharton's duct. 

Note. — Foramen ovale lies on a line connecting the eminentia articularis, 
at rfK)t of zygoma, of one side, with that of the other, and about 3 cm. (it 
inches) from the eminentia — and is directly posterior and a little external 
to the external pterygoid plate. The middle meningeal arterj' enters the 
foramen spinosum just behind the foramen ovale. (3) The internal maxillary 
artery, in its second part, runs forward and upward on outer surface of external 
pterygoid muscle. (4) The pter\'goid plexus of veins lies on the external 
pter>'goid muscle. 



EXPOSURE OF INFERIOR MAXILLARY NERVE AT FORAMEN OVALE 
—OR OF SUPERIOR MAXILLARY NERVE AT FORAMEN ROTUNDUH. 

MI.XTER'S OPERATION. 

Description. — Mixter's operation consists in a temporary excision and 
downward displacement of the zygomatic arch, with the attached masseter 
— followed by a backward displacement of the temporal muscle, to reach 
the suj^erior maxillary nerve and foramen rotundum — and a forward dis- 
placement of the muscle to reach the inferior maxillary and foramen ovale. 
The inferior maxillary nerve may be exposed at its origin by any of the opera- 
tions exposing the gasi^rian ganglion, either intracranially or extracranially. 



EXPOSURE OF INFERIOR MAXILLARY NERVE. 



165 



I 
I 

I 



Position. — Patient on back; head elevated and turned lo one side. Surgeon 
on side of operation, or lo right for both operations. 

Landmarks.— Zygoma; temporal ridge. 

Incision. — Cuned, with convexity upward — beginning about 1.3 cm. 
(§ inch) below malar portion of zygomatic arch and passing upwartl along 
posterior margin of malar bone and external angular process of frontal bone, 
to commencement of temporal ridge — thciue follows lower temporal ridge 
to op|)osite anterior margin of ear — and then curves downward to pass in 
front of ear and ends about 1.3 cm. (A inch) below root of zygoma. 

Operation.— The above incision is made through J he shaved skin and 
through the fascia — and ihis flap is turned downward, guarding Steno's duct. 
The iemp<jral artery is Hgaicd, unless it can be displaced backward. The 
z.^'gomatic arch is exposed subperiosleally and sawed through in front and 
behind, beveling from without inward — and guarding against opening the 
inferior maxillary articulation behind. The zygoma, attached masseler, and 
fatty connective tissue are now well retracted downward. The temporal 
muscle and its attachment lo ihc coronoid pnicess become thereby well exposed 
— and are manipulate^i in accordance with the structure sought : — (a) To 
Expose the Superior Maxillary' Nerve and ihe Foramen I^otundum: — The 
lcm{ioral muscle and tendon are firmly retracted [>osteriorly. by a broad, 
stncKJth retractor, aidetl by an assistant's depressing the jaw — the surgeon 
bdng guided by the posterior wall of the superior maxillary bone and the 
spur of bone projecting forward and outward from the base of the external 
pterygoid plate. This spur is chiseled away to better expose the foramt-n 
rutundum, if necessary — the chiseling being done in a forward and slightly 
inward direction, to avoid going into the middle fossa of the skull. Having 
removed this spur, the superior maxillary nerve is lo he found crossing the 
plcrj'gomaxillary fossa from the foramen rolundum to the infraorbital foramen, 
with Meckel's ganglion beneath it, and near the spheii<»[<alaiine foramen. 
(b) To Expose the Inferior Maxillary Nerve and Foramen Ovale: — The 
temporal muscle and tendon are now firmly retracted forward (ihe jaw 
being now closc<l lo carry* the coronoid process fonvard)— the surgeon being 
guided to the foramen ovale by its position just posterior and e.xternal to the 
base of the external pterygoid plate, at a distance of about 3 tm. (i^ inches) 
internal to the anterior margin of the posteri(»r attachmenl of ihe zygoma 
and slightly i>osterior to this line drawn directly inward. On the way inward 
the internal ma.\illar\' artery is met on the external pterygoid muscle and 
liguted. The pterygtiid plexus of veins also lies upon this mu.scle. The 
external and internal pterygoid muscles can generally be displaced by retrac- 
tion without necessitating their incision. The foramen ovale is usually 
recognized by the tip of the finger and the nerve is exposed emerging from 
it and drawn forward by a hcjok. Free hemorrhage may necessitate packing 
one purt of the wound while working in another. In concluding the operation 
for exposure of either structure, the zygoma is replaced and the flap turned 
back into {josition. 

Comment. — (•) If tlie zygoma be drilled anteriorly and posteriorly 
and then sawed In'tween each pair of Hrill holes, it may be subsequently 
wired, (a) If sufficient rrx^m cannot be gotten by retraction of the temporal 
must Ic and tendon, it may be rlivided in jtart, transversely — the anterior 
portion being cut to reach the foramen rotundum — and the posterior portion 
m ofder to reach the foramen ovale. The muscle should be sutured on 
completing the opcralion. (3) The coronoid [>rocess could be drilled, s;twed 
between the drill holes, and the coronoid tip and temporal attachment turned 



1 66 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

upward — to be afterward wired back in place. (4) As much of the pterv'goid 
muscles (especially the external) may be divided, or drawn away from its 
origin at the sphenoid, as needed. But the less the detachment of the 
temporal and pterygoid muscles, the less the involvement of the jaw- 
articulation subsequently — except that caused by paralytic atrophy if the 
motor part of the third division be cut. (5) The motor part of the inferior 
maxillar}' is to be avoided if possible — but is generally imavoidably included 
in the destruction of the sensor}' portion. 



SURGICAL ANATOMY OF INFERIOR DENTAL NERVE. 

Description and Relations. — A sensor}' ner\e — a branch of inferior 
maxillar}' nerve, passing down under cover of external pterygoid muscle, it 
descends to outer side of internal pter}goid, to interval between ramus of 
inferior maxilla and internal lateral ligament, to dental foramen — ^accom- 
panied by inferior dental arter}- and having lingual nerve in front and internal 
to it. The mylohyoid branch is given off just before the ner\'e enters the 
dental canal, and the mental branch at its exit at the mental foramen. The 
dental foramen is surrounded by the lingula of Spix, to which is attached 
the internal lateral ligament, the groove for the mylohyoid ner\'e being just 
behind it and the attachment of the internal pterygoid muscle reaching to 
its base. The inferior dental vessels pass along behind and outside the 
nerve. The internal maxillary artery passes safely above the dental foramen. 



EXPOSURE OF INFERIOR DENTAL NERVE IN HOUTH 

PARAVICINI'S INTRABUCCAL METHOD. 

Position. — Patient supine; head slightly raised; gag in opposite side of 
mouth; cheek of operated side held open by retractors and commissure of 
mouth drawn backward. Surgeon faces patient and stands on his right for 
both ojjerations. A head-mirror should be used. 

Landmarks. — .A.scending ramus of jaw; spine of Spix; internal pter}'goid 
muscle. 

Incision. — About 2.5 cm. (i inch) in length — along anterior border of 
ascending ramus of inferior maxilla, about 7 mm. (^ inch) to inner side 
of sharp anterior border of coronoid process, and ending over the spine of 
Spix. 

Operation. — Having incised and detached the mucous membrane and 
periosteum, feel for the spine of Spix — cutting the internal lateral ligament 
with scissors if necessary in order to expose the nerve entering the foramen — 
which is then isolated and drawn forward. The inferior dental arterj' lies 
in close contact and should be avoided. In completing the operation, it is 
better to close tlie incision with sutures — though these are often omitted. 

Comment.— Kxposc the dental foramen that the lingual may not be 
taken for the inferior dental ner\e. If possible, avoid injuring the internal 
lateral ligament, which is attached to the spine of Spix. 



EXPOSURE OF INFERIOR DEiNTAL NERVE. 



167 



I 
I 



ySURE OF INFERIOR DENTAL THROUGH ASCENDING RAMUS 
OF INFERIOR MAXILLA. 

Description. — The outer asjjcct of the lower jaw is exposed and the 
nerve reached by Irephmino; the l>one. 

Position. — Patient's head turned to one side and slightly elevated. 
Sur^^con on ^ide of oj>eration. 

Landmarks. ^The four borders of the ascending ramus of the inferior 
ma^xilla. 

Incision. — Curved, circumscribinj^ the .ingle and lower half of ascending 
ramus of lower jaw — the transverse cur\e being just above the lower margin 
— -and the vertical limbs corresponding with the anterior and po*>terior borders. 
Thus Stenson's duct escapes and but few branches of the facial nerve are 
injured. 

Operation. — This incision is first carried through skin and superficial 
fascia, when whatever nerves are in line of incision are retracted (e>[)ecially 
the bucctd and supramaxillary)— then through mas^^ter and periosteum to 
bone. The soft parts are now freed from bone subperi^isteally and retracted 
strongly uf>ward, gaining room by this upward retraction without harm to 
the facial nerve or Stenson'.s duct. A window of bone, having its center 
corresprmding with this quadrilateral surface of bone, is ihen removed with 
the trephine or chisel (a disc about 1.3 to 2 cm. — J to j inch — in diameter), 
remembering that the lower and anterior part of the ascentling ramus is 
much thicker than the upper and posterior. Approach the nerve and accom- 
panying artery with care, elevating, rather than chiseling or trephining, the 
last thickness of bone. The nene is ihen isolated in ils canal. 

Comment. ^(1) The nerve can be reachetl ai ils enirancc into the dental 
canal and traced up to the foramen ovale by an extension of this operalion, 
by widening the sigmoid notch. The incision passes through skin and 
superficial fascia only — beginning at the middle of the zygoma, pas.sJng 
backward and downward in front of the tragus to the angle of the jaw, and 
ihence forward to a point just posterior to the facial artery. Raise this flap 
of skin and superficial fascia as far as the anterior border of the masseler 
and turn it fonvarcL Exp<isc .Stenst^n's duct and edge of the parotid gland 
(sufficiently to guard them). r>ivide the ma.sseter and overlying deep fascia 
down to the bone in a transverse direction, and between Stenson's duct above 
and the highest branch of the facial nerve below. Free the muscle from 
the bone at the sigmoid notch and just below. Apply the trephine so as 
to leave a slight bridge of bone between the sigmoid notch and the trephine- 
opening — and subsequently cut this bridge away with bone forceps. Expose 
the inferior dental nerve and artery — ligate ihe artery and al.so the internal 
majtillan* artery (upon the external pterygoid muscle) if necessary. Secure 
ibe nerve with silk ligature, and. by traction on silk, follow the nerve to the 
foramen ovale, retracting the external ptery-goid upward (or divide it). Sever 
the nen'c as high and as low as possible. The lingual nerve, lying further 
forward and inward, may be also reached at the same time, (a) The entrance 
to thr infcrijir dental canal may also be reached from the inner aspect of the 
ferior maxilla — by making an incision around the angle of the jaw, corre- 
«mding with the insertion of the masseter. and raising the soft parts from 
inner surface of the bones subperiosteally to the dental foramen — the 
mouth canity not being opened (Liicke-Sonnenburg operation). (3) The 
<i{»rnition of e.xposing the inferior dental nerve through the mouth is to be 
preferred, as being less disfiguring— ^allhough probably more difficult. 



i68 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 



EXPOSURE OF INFERIOR DENTAL NERVE AT MENTAL FORAMEN, 
FROM WITHIN MOUTH. 

Description. — The lower lip is everted and an incision made over the 
site of the mental foramen. 

Position. — Patient supine; head supported and to one side. Surgeon 
on side of operation, or on right for both operations. Assistant draws lower 
lip well downward. 

Landmarks. — A line drawn over the supraorbital foramen and between 
the two bicuspids of both jaws will cross the infraorbital and mental foramina 
— the mental foramen, in the adult, generally lying midway between the upper 
and lower borders of the jaw proper (exclusive of teeth). 

Incision. — Transverse, through mucous membrane along line of its 
reflection from lower lip to inferior maxilla, with its center between the two 
bicuspids, the lower lip being firmly drawn downward. A vertical incision 
may be made instead of the transverse. 

Operation. — This incision passes through periosteum to bone, upon 
slight downward freeing of which the nerve is found emerging from the 
mental foramen. 

Comment. — An incision could be made from without, through the 
tissues of the chin, over the position of the foramen, in the direction of the 
fibers of the facial nerve, if the matter of scarring be not taken into account. 



SURGICAL ANATOMY OF LINGUAL (GUSTATORY) NERVE. 

Description and Relations.^ — A nerve of common sensation — branch 
of posterior division of inferior maxillary nerve. Descends under external 
pterygoid, to inner side and anterior to dental nerve, a cord generally con- 
necting the two, and being joined near origin by chorda tympani. The 
nerve then passes between internal pterygoid muscle and ramus of lower 
jaw — inclining inward to side of tongue, and, passing over attachment of 
superior constrictor of pharynx to the lower jaw and the styloglossus muscle, 
above the deep part of sul:)maxillary gland, is continued forward between 
mucous meml)ranc of mouth and mylohyoid muscle and lies on its origin 
close to bone — then nms between mylohyoid and hyoglossus — crosses below 
Wharton's duct, and passes along side of tongue, under mucous membrane, 
to apex. 

Comment. — On widely opening the mouth, one can feel the pterygo- 
maxillary ligament, as a prominent ridge behind the last molar. The nerve 
is generally to be felt behind the plerygomaxillary ligament, about 1.3 cm. 
(^ mch) posterior and inferior to the last molar, lying just beneath the mucous 
membrane. 



EXPOSURE OF LINGUAL (GUSTATORY) NERVE IN THE MOUTH. 

Position. — Patient on back; head slightly raised; gag in opposite side 
of mouth; cheek of operated side held open by retractors; tongue of patient 
drawn out and to opposite side by assistant. Surgeon stands on patient's 
right for both operations, and uses a head- mirror. 

Landmarks. — Ramus of jaw; plerygomaxillary Hgament; last molar 



EXPOSURE OF FACIAL NERVE IN IRONT OF MASTOID PROCESS. 169 

Incision. — Vertical, about 2.5 cm. (i inch) in length. pl:icc<l in UAd of 
mucous membrane midwa> between lon^iie and pum. wilh center on level 
with last molar. The nerve lies about at the junction of the Uf>[>er and 
middle thirds of a line from the crown of the last molar to the angle of the 
javv. 

Operation. — Having incised in the above line, the nerve is found just 
f»eneath the mucous membrane, prior to dipping under the mylohyoid muscle 
— and is isiolated and drawn forward by a hiK)k. 

Comment. The linj^ual nerve may be reached from outside the mouth 
by excising a pari of the inferior maxilla, at the junction of the alveolar jirocess 
aj»d the ascending ramu5i (Locbker). Or it may be reached by dis^ectin.i; 
up under the internal surface of the inferior maxilla, displacini^ the sub- 
maxillan* pland, dividing the posterior portion of the mylohyMid and finding 
the nerve under the posterior portion of the sublingual gland (Luschka). 



SURGICAI. ANATOMY OF FACIAL P^RVE. 

Description. — Arises, superficially, at upper end of medulla oblonpala, 
in groove between olivary ami restiform bodies — passe.s, in companv with 
auditor} nerAe, forward and outward to internal auditory meatus, which it 
rnlers with auditor)' nerve, the pars intermedia intervening between the 
neT\-cs. At the IvoHom of meatus, the facial nerve enters aqueductus Fallo{)ii, 
which it follows to its emergence at the stylomastoid foramen— thence passes 
downward and fonvard through >ubstance of parotid gland— crosses external 
carotid artery and divides behind ramus of inferior maxilla, opposite upper 
m;irgin of digastric muscle, into two chief branches: — (1) Temporofacial, 
running upward and forward thr*nigh parotid gland, crossing external carotid 
^.artery and temporomaxillary vein and passing over neck of condyle of jaw, 
and dividing into temporal, malar, and infraorbital branches* — and (3) 
Cervicofacial, running downward and forward, through parotid gland, 
crossing external carotid artery, and dividing. opp<>site angle of jaw, into 
buccal, supramaxillary, and inframaxiUary branches. 



EXPOSURE OF FACIAL NERVE IN FRONT OF MASTOID PROCESS. 

BAirMS ClPERATlON. 

Position.— Patient supine; head elevated and to one side. Surgeon to 
riphl for b<iih operations. 

Landmarks. — .\nierior border of mastoid process; jMisterior border of 
ascending ramus of inferior maxilla. The point at which the nerve is sought 
bcin); from 6 mm. to 1.3 era, (J to i inch) In front of center of anterior border 
ol miisloid process. 

Incision. — Begins close l>ehind pinna of ear, o[>pnsile meatus — passes 
tiownnard to opposite lobule of car. and then downward anrl forwarrl almost 
4nglc of inferifjr maxilla. 

Operation. — This incision is deefiened through skin antl fascia, wilh 
carr. The parotid fascia is incised and the jiarotid gland is retracted forward. 
The anterior c<lge of the sternomasloid is exf)osed and drawn backward. 
The posterior belly of the digastric is exfwsed ,ind ihe nerve is sought on a 
Be with the upper Ixirder of the posterior belly nf this muscle and at the 
lint aljovc mcnlioncd^coming from the slylomasltiid foramen toward the 



17© OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

surface. The posterior auricular arterj' and vein will probably need ligating, 
and some fibers of the great auricular nerve will be cut. The internal jugular 
vein is near the deep part of the wound, but there are no other important vessels 
anterior to the plane of the digastric (behind which is the external carotid). 
If necessar}', especially in stout subjects, a small transverse incision, passing 
forward from below the pinna, may be added. 



SURGICAL ANATOMY OF SPINAL ACCESSORY NERVE. 

Description and Relations. — (i) Accessor)' portion passes outward to 
jugular foramen, where it unites with spinal portion, and is joined to upper 
ganglion of the vagus and sends fibers into its pharv'ngeal and superior lar}*n- 
geal branches and into the trunk of that nerve below the ganglion. (2) 
Spinal portion, after issuing from jugular foramen (where it unites i^nth 
accessory portion), passes backward, crossing in front of (sometimes behind) 
the internal jugular vein, descends obliquely behind digastric and stylo- 
hyoid muscles and occipital arter>' to enter upper third of stemomastoid 
about 5 cm. (2 inches) below tip of mastoid process — perforates this muscle 
in its second fourth and emerges on level with center of its posterior border 
— and runs thence obliquely across the occipital triangle, and, entering 
upper i)art of lower third of its anterior border, terminates in the deep surface 
of the trapezius. 



EXPOSURE OF SPINAL ACCESSORY NERVE AT ANTERIOR BORDER 
OF STERNOMASTOm MUSCLE. 

Position. — Patient supine; shoulders slightly elevated; head to opposite 
side; neck supported. Surgeon on right, for either operation. 

Landmarks. — Anterior border of upper portion of stemomastoid. 

Incision. — About 7.5 cm. (3 inches) in length, following the anterior 
border of the stemomastoid, with its center opposite a point about 5 cm. 
(2 inches) below the tip of the mastoid process. 

Operation. — Having cut through skin and superficial fascia, and opened 
up the cervical fascia, avoiding the external jugular vein and great auricular 
ner\'e, expose the anterior border of the stemomastoid and draw the muscle 
firmly backward. Recognize the inferior border of the posterior belly of 
the digastric — the nerve will be found passing from beneath it to the stemo- 
mastoid, crossing the transverse process of the atlas. Avoid branches of 
the facial nerve (at the upper edge of the wound) and the occipital artery 
(lying over the ner\'e). 

Comment.— If only that portion of the spinal accessor)' be involved 
which is distal to the stemomastoid. the nen^e may be exposed by an incision 
placed along the posterior border of the stemomastoid, with its center oppo- 
site the center of the posterior border of the muscle. 



SURGICAL ANATOMY OF OCaPITALIS MAJOR BRANCH OF POSTE- 
RIOR DIVISION OF SECOND CERVICAL NERVE. 

Description and Relations. — Internal branch of posterior di\nsion of 
second cervical nerve — passes upward across (not contained within) sub- 



KXPOSURE OF riJSTERIOR DIVISIONS OF CERVIfAI. NFRVES. 171 

occipital triangle (which is formed by rectus capitis posticus major, superior 
and inferior oblique) — passing across inferior oblique, between it and com- 
plcxus — piercing the comi)lexus and trapezius near their cranial attachments 
— ascending over back nf head with otcipilul arter}*, lying on its inner side, 
and dividing into two branches to supply scalp. 



EXPOSURE OF OCCIPITALIS MAJOR NERVE BENEATH THE COH- 

PLEXUS. 

Position. — Patient on side; face turned as far forward as possible, to 
make bteral occipital region prominent. Surgeon stands behind patient. 

Landmarks. — Spine of axis; posterior border of stcrn<^mastoid- 

Incision. — Transverse, passing from spine of axis directly outward to 
posterior edge of stemomastoid. 

Operation. — Divide, in order, skin, fascia, trajjezius (ascending upward 
and inward ^ splenius capitis (ascending upward and outward), and com- 
j)lrxus (ascending vertically). Beneath this last muscle the suboccipital 
»• triangle is exposed — and the nerve is found passing upward and inward 
around the inferior oblique which forms the lower boundary of that triangle. 
The small occipital ner>'e w^ill be exposed at the outer portion of the more 
superficial part of the incision. 

Comment.— The nerve is here reached before it pierces the complexus 
and before coming in relation with the occipital artery. It may be reached 
more superficially where it pierces the iiuter b«»rder of the trapezius im- 
mediately below the superior curved line. But the lower expo.sure is better, 
as ginng control of a greater number of branches. 



EXPOSURE OF POSTERIOR DIVISIONS OF FIRST, SECOND, AND 
THmD CERVICAL NERVES. 

KEEN'S OPERATION. 

Description. — The posterior divisions of the first, second, and third 
cervical ner\es have been exposed and excised in spasmodic torticollis — • 
supplying, as they do. the ywjstcrior rotator muscles of the neck. 

Position. — Patient turned to one side; neck made prtiminent. Surgeon 
at patient's back. 

Landmarks. — Middle line of neck; external occipital protuberance. 

Incision.— From 6 lo 7.5 cm. (2^ to 3 inches) in length and transverse 
in direction — passing outward from the middle line of the neck, at a point 
about 4 cm. (i§ inches) below the external occipital protuberance. 

Operation. — Divide, in the Line of incision, the skin, fascia, trapezius. 
posterior b«-)rder of the splenius capitis, until the complexus is reached, 
iftcr which the nerves are separately isolated: — (i) Find the occipitalis major 

ic (internal branch of posterior division of second cervical ner\'e) emerging 
1 llie complexus and about to enter the trapezius. DiWde the complexus 
MJSverscly, on a level with the nerve. Follow the nerve to the common 
trunk of the p«>sterior division (l>efore the external and internal branches 
are given oil). Thus the second cervical nerve is exposed. (2) Recognize 
ihe ^ubocripital triangle, — ^bounded, above and internally, by the rectus 
ipitis posticus major (from spinous process of a.xis to superior cur\'ed line 

occiput),— above and eAternuIly, by obliquus capitis superior (from upper 



172 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

surface of transverse process of atlas to occipital bone, between curved lines, 
and external to complexus), — below and externally, by obliquus capitis 
inferior (from apex of spinous process of axis to lower and back part of trans- 
verse process of atlas). Within this triangle lies the suboccipital nerve 
(posterior division of first cervical nerve), which does not divide into internal 
and external branches — lying close to the occiput and behind the vertebral 
arter}'. Trace it as near to the spine as possible. Thus the first cer\'ical 
nene is exposed. (3) The external branch of the posterior di\ision of the 
third cervical nerve is found about 2.5 cm. (i inch) lower down than the 
occipitalis major (page 171) and under the complexus. It is to be followed 
to the common trunk of the posterior division. And thus the third cer\'ical 
nerve is exposed. 

Comment. — This operation has been modified by making a vertical 
incision from the occiput downward, about 4 cm. (i^ inches) outside of 
the median line — passing through the trapezius, edge of the splenius, and 
then through the complexus. Also, the second and third divisions may be 
divided without the first. 



SURGICAL ANATOMY OF BRACHIAL PLEXUS OF NERVES. 

Formed by. — Fasciculus from anterior branch of fourth cer\'ical, anterior 
branches of fifth, sixth, seventh, and eighth cer\'ical, and greater part of 
anterior branch of first dorsal. 

Extent and Position.— From lower part of side of neck to lower part 
of a.xillar}' space, dividing, opposite the coracoid process, into numerous 
trunks, and giving off its terminal nerves at the lower axillary boundarj'. 

Relations. — (1) In neck: — First, lies between anterior and middle 
scaleni and at outer border of former muscle; — then partly behind and partly 
above and external to third part of subclavian arter\', in the posterior triangle 
of neck, crossed by posterior belly of omohyoid; — then behind clavicle and 
subclavius muscle, upon first serration of serratus magnus and subscapularis 
muscles. (3) In axilla : — IJes to outer side of first portion of axillarj' artery, 
being covered by pectoralis major — then surrounds second portion of artery, 
covered by the pectoralis minor and resting upon subscapularis muscle, one 
cord lying to inner side, one behind, and one to outer side of vessel. The 
third part of the artery has the internal cutaneous and inner head of median 
nen'e in front; circumflex and musculospiral behind; ulnar and lesser internal 
cutaneous on inner side; and trunk of median and musculocutaneous on 
outer side. 

EXPOSURE OF BRACHIAL PLEXUS IN NECK. 

Position.— Patent upon back, near edge of table; thorax raised; head 
extended and turned to opposite side; arm drawn downward and behind 
back. Surgeon stands in front of right shoulder, in operating upon either 
side. 

Landmarks. — Stcmomastoid ; trapezius. 

Incision. — Vertical, in posterior triangle of neck — beginning about 9 
cm. (3^ inches) above clavicle and passing downward to within about 1.3 
cm. (i inch) of middle of clavicle, parallel with anterior border of trapezius, 
but nearer posterior border of sternomastoid. 

Operation. — Having divided skin and platysma, the external jugular 



EXPOSURE OF MUSCUIiKUTAXEOUS NERVE. 173 

vein is either ligated and cut between nvo ligatures, or retracted. Some of 
the desrendinp branches of ihc cehvical plexus are apt to be incised, generally 
the supraclavicular. Incise the deep cervical fascia. Recognize the outer 
border of the anterior scalenus and retract inward. Retract the posterior 
belly of the omohyoid downward and expose the brachial plexus by rlissection. 
Avoid the transversiilis colli artery and vein crossing the middle of the plexus, 
dentify the cords of the plexus by following with finger to the inten-'al between 
anterior and middle scalenus muscles. 



SURGICAL ANATOMY OF ORCUMFLEX NERVE, 

Description. — One of terminal branches of posteriur cord of brachial 
plexus, lying, at first, l)etween axillary artery and subscaputaris muscle, it 
passes downward and outward to lower border of that muscle, accompanied 
by posterior circumflex artery — it then winds backward and outward around 
ihe 3urg;ical neck of humenis, ihroui^h the quadrilateral space lnuunded by 
teres mmor above; teres major below; long head of triceps internally; and 
neck of humerus externally — and divides into upi)er and lower branches. 



EXPOSURE OF QRCUMFLEX NERVE ON BACX OF ARM. 

Position. — As for exposure of ulnar nerve just above inner condyle of 
humerus (page 175). 

Landmarks. — Angle made between posterior scapular muscles and pos- 
terior b<>r<ler i)f deltoid — by pressing latter muscle toward neck of humerus. 

Incision. — Made in long axis of Hmb and placed over above inlervaL 

Operation. — Expose and draw forward the posterior border of the 
dehoi<l, ex|>«>sing the teres minor above and long head of triceps internally. 
In the angle formed by the last two muscles the circumilex nerve, accom- 
panied by the posterior circumllex artery (I\ing below), is seen coming out 
from before backward through the quadrilateral space and curving around 
the surgical neck of the humerus to enter the under surface of the deltoid. 



SURGICAL ANATOMY OF MUSCULOCUTANEOUS NERVE. 

Description.— Arising from outer cord of brachial plexus opposite lower 
[>rrier of pectoralis minor, it runs downward and outward, perforating the 
oracobrachialis and passing obliquely across the arm between the biceps 
and bnichialis anticus to outer side of biceps a little above the elbow, where 
it perforates the deep fascia, passing behind the median cephalic vein, and 
divides into anterior and i.K>slerinr cutaneous branches. 



EXPOSURE OF MUSCLfLOCUTANEOUS NERVE IN UPPER PART OF ARM. 

Position.— As for exposure of ulnar nerve just above inner condyle of 
huneru^ (page 175). , 

Landmarks.— Upper internal bicijtiial sulcus. 

Incision. — Along inner margin of biceps, beginning at prominence <^f 
coracobrachialii) and passing downward. 



174 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

Operation. — Having incised the superficial structures, the biceps muscle 
is exposed and drawn outward. The nerve is found penetrating the outer 
border of the coracobrachialis, covered by the biceps. 



SURGICAL ANATOKIY OF HEDIAN NERVE. 

Description. — (a) In Arm; Arises by a root from inner and one from 
outer cords of brachial plexus, which embrace axillary artery, uniting either 
in front or to outer side of the vessel. Descends arm on outer side of brachial 
artery at first — then crosses in front of the middle of arter}' (though some- 
times passing behind) — thence downward on inner side of artery to elbow — 
where it is separated from elbow-joint by brachialis anticus muscle and is 
covered by bicipital fascia, (b) In Forearm; Passes between two heads of 
pronator radii teres and descends between flexor sublimis and profundus 
digitorum to about 5 cm. (2 inches) above the annular ligament of wiist, 
where it lies beneath the fascia, between the tendons of the flexor sublimis 
digitorum below, the palmaris longus internally, and the flexor carpi radialis 
externally (or rather more under the palmaris longus). (c) In Hand: It 
enters palm beneath the annular ligament and rests upon flexor tendons, 
covered by fascia and superficial palmar arch. 



EXPOSURE OF MEDIAN NERVE IN MIDDLE OF ARM. 

Position. — Patient's arm is extended and abducted, with hand supine. 
Surgeon stands on outer side of right limb, cutting from above downward; 
and between body and left limb, cutting from above downward (or on outside 
of left limb, cutting from below upward). 

Landmarks. — Inner edge of bicipital muscle. 

Incision. — Along inner edge of biceps, in middle of arm — about 4 cm. 
(2^ inches) in length. 

Operation. — Divide skin and connective tissue. Avoid internal cutaneous 
nerve and basilic vein. Clearly expose inner edge of biceps muscle and 
draw the muscle to the outer side, when the median nen-e is found crossing 
the brachial artery from the outer toward the inner side (or sometimes passing 
beneath the artery). 



EXPOSURE OF MEDIAN NERVE AT BEND OF ELBOW. 

Position. — As above. 

Landmarks. — Groove between biceps and pronator radii teres muscles. 

Incision. — Between inner margin of biceps and outer margin of pronator 
radii teres, somewhat nearer the former, with center of incision opposite 
the fold of the elbow, and being about 5 cm. (2 inches) in length. 

Operation. — This incision will, in the usual disposition of the veins 
at the elbow, pass to the outer side and nearly parallel with the median basilic 
vein, which should be retracted inward. Incise the bicipital fascia in a line 
with the skin-cut. The median nerve lies just to the inner side of the brachial 
artery and its ven.T comites — all lying upon the brachialis anticus. Gut- 
suture the bicipital fascia in closing the wound. 



EXPOSURE OF ULNAR NERVE. 



175 



I 



SURGICAL ANATOMY OF ULNAR NERVE. 

Description. — (a) In Arm; Arises from inner cord of brachial plexus, 
iccn axillary artery and vein, and pasises down arm on inner side of 
axilbn' and brachial arteries to middle of arm, covered only by skin and 
fascia — thence diverges to cross inner head of triceps obliquely — pierces 
internal intermuscular septum and descends posterior to that structure, 
together with inferior profunda artery, which is upon its outer side, (b) 
At Elbow, Occupies grmne between olecranon and internal condyle, resting 
upon posterior surface of latter (rarely upon anterior surface), and enters 
forearm between two heads of flexor carpi ulnaris. (c) In Forearm; Passes 
vertically down ulnar side, upon flexor jirofundus fligitorum, its upper half 
covereiJ by flexor carj)i ulnaris, its lower half by skin and fascia (the nene 
here l^-ing external to ihxoi carpi ulnaris). The ulnar nene lies, throughout, 
to the ulnar side of the ulnar artery — the u|vper thin! lying considc*nd>ly to 
the inner side, and the lower two tiiirds near to the inner side. The dorsal 
cutaneous branch passes posteriorly Ijetween 5 and 7.5 cm. (2 and 3 inches) 
above the wrist, (d) At Wrist; Crosses front of annular Ugament between 
ulnar arter}* and pisiform bone, a little internal and posterior to the artery, 
and immediately divides into superficial and deep palmar branches. 



EXPOSURE OF ULNAR NERVE ABOVE MIDDLE OF ARM. 



I Position. — .\s for median nerve in middle of arm (page 174). 
Landmarks.— Brachial artery, which is parallel with and to outer side 
of the ner\'e for the upper half of the arm. 
Incision. —From 5 to 7.5 cm. (2 tn ;; inches) in length, with its center 
just above the mi«.l<lle of the arm — running parallel with and about 1.3 cm. 
(i inch) to inner side of line of brachial arter}' (the line for the ligation of 
the middle third of the braihial artery passing along the inner margin of the 
biceps muscle). 

Operation. ^Incise skin and fascia, which here alone cover the nerve. 

i A void the basilic vein and the vena^ comites of the brachial artery — also the 
inicmal cutaneous nene to the outer, ami the lesser internal cutaneous nerve 
A the inner side. The ulnar nerve is found diverging from its course parallel 
With I he inner side of the brachial artery to pass obliquely across the inner 
head of the triceps to pierce the internal intermuscular septum. 



"llJiri 



EXPOSURE OF ULNAR NERVE JUST ABOVE INTERNAL CONDYLE OF 

HUMERUS. 



Position. — Patient upon back at edge of table. Assistant stands on 
opp«-ifile one to be operated, and, grasping jialient's wrist, with patient's 
n ' , draws his (patient's) arm antl forearm across the chest, thus 

cxif postt-riiir surface to the ojierator — who st«inds upon the side to 

be c»|>i.f.iiid. rutting from elbow tnwnrd shoulder on l>oth sides. 
Landmarks. — Olecranon; Internal condyle of humerus. 
Incision. — .About 5 cm. (2 inches) in length, e.xtending from a jxtint 
alout 1-3 cm. (§ inch) above (10 proximal side of) internal condyle and midway 
between interna! condyle and olecranon, upward toward a ptoint at inner 



176 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

side of brachial artery opposite the insertion of the coracobrachialis muscle 
(about center of arm). 

Operation. — Incise skin and fascia in above line — when the nen-e will 
be found upon the posterior surface of the internal intermuscular septum, 
with the inferior profunda artery upon its outer side. 

Comment. — If the incision were to extend over the internal condyle, 
the nerve would be found lying upon the posterior surface of the base of the 
inner condyle of the humerus, close to the bone and along the inner edge 
of the triceps. 



SURGICAL ANATOMY OF MUSCULOSPIRAL NERVE. 

Description. — Arises, in common with circumflex ner\'e, from posterior 
cord of brachial plexus — descends arm behind axillary and brachial arteries 
and in front of tendons of latissimus dorsi and teres major, and winds around 
humerus in musculospiral groove, from inner to outer side, with superior 
profunda artery, lying between the internal and external heads of the triceps 
Arriving at outer side of arm, it pierces the external intermuscular septum 
about midway between insertion of deltoid and tip of external condyle (namely, 
at lower third) and descends between supinator longus and brachialis anticus 
to front of external condyle, where it divides into radial and posterior inter- 
osseous nerves. 



EXPOSURE OF MUSCULOSPIRAL NERVE BELOW MIDDLE OF ARM. 

Description. — The exposure is here made upon the external aspect of 
the arm and the nerve is reached anterior to the external intermuscular 
septum. 

Position. — Same as for ulnar nerve just above internal condyle (page 
175). The surgeon may also stand so as to cut from shoulder toward elbow. 

Landmarks. — Insertion of deltoid (about middle of arm); external 
condyle of humerus: upper border of supinator longus. 

Incision. — About 6 to 7.5 cm. (2^ to 3 inches) in length — crossing obliquely 
the outer surface of the lower third of the arm — so placed that its center 
will be midway between the deltoid and the external condyle — and so that 
its obliquity will follow the line of the upper border of the supinator longus. 

Operation. — Having incised skin and fascia, avoiding cephalic and 
median cephalic veins, identify the internal border of the supinator longus. 
Draw this muscle to the outer side, so as to expose the inter\'al between it 
and the brachialis anticus — where the ner\'e will be found close to the bone, 
accompanied by a branch of the superior profunda arter}*. 

Comment. — Exposure of the nerve at its bifurcation into radial and 
posterior interosseous may be accomplished (if not performed as a separate 
operation) by continuing the above incision downward. 



SURGICAL ANATOMY OF RADIAL BRANCH OF MUSCULOSPIRAL 

NERVE. 

Description. — Anterior subdivision of musculospiral. At first lies a 
short distance to radial side of radial arter}', but gradually approaches it 



SURGICAL ANATOMY OF THE INTERCOSTAL NERVES. 



177 



closely and runs parallel with it, on its outer side, covered by supinator longus 
— running along anterior border of extensor carpi radialis brevior and resting 
on supinator brevis, insertion of pronator radii teres, and radius. About 
7.5 cm. (3 inches) above the wrist the nerve quits the artery, passes backward 
beneath the tendon of supinator longus, and, piercing the deep fascia, divides 
into external and internal branches. 




SURGICAL ANATOMY OF POSTERIOR INTEROSSEOUS BRANCH OF 

HUSCULOSPIRAL. 

Description. — Posterior subdivision of musculospiral. Passing down- 
ward in intenal between brachialisanticus and extensor carpi radialis longior, 
winds around outer side of radius tu back of forearm, passing between super- 
iicial and deep layers of supinator brevis muscle. Thence it enters the 
ular interval between the superficial and deep layers of the muscles at 
k of forearm, passing onto the interosseous membrane at lower third 
of forearm — and thence under cover of tendons of extensor communis digi- 
torum to back of wrist, where it swells into a gangliform enlargement. 



I 



EXPOSURE OF RADIAL OR POSTERIOR 
OF MUSCULOSPIRAL. AT THEIR 



INTEREOSSEOUS BRANCH 
COMMENCEMENT. 



Position. — As for the meiiian nerve in middle of arm (page 174). 

Landmarks. — External bicipital sulcus. 

Incision. — Along anterior margin of supinator longus muscle, in external 
biti|»it.d sulcus — center of incision corresponding with external condyle. 

Operation. — Incise skin and fascia. Avoid metlian cephalic vein and 
mu>cul«KUtaneous nerve. Retract supinator longus to outer and brachialis 
mniicus to inner side — between which two structures the beginning of the 

Iradi^il and of the [X)sieri(jr inlenisseous will be found, accompanied by a 
branch of the superior profunda artery. 
Comment. — This is, practically, a continuation of the operation for the 
exposure of the musculosjnral below the middle of the arm. 



SimGICAL ANATOMY OF THE INTERCOSTAL NERVES. 



■ Hgar 

■8" 



Description, -(a) Pectoral Intercostal Nerves:— Pass outward, as 
the anterior divisions of ihe dorsal nervc^. in from tif superior cc>stotransverse 
ligaments, levatores costarum, external intercostal muscles, coveret^l (to angle 

ribs) by pleura and cndothoracic fascia. They then approach U|)iHjr 
of each intercostal space to accompany intercostal vessels, in groove of 
tib aljovc, to front of chest — the ncn-e lying below the vessels. Between 
juigtc of rib and middle of rib they lie between inlcrnal and external inter 
cotttiii muscles, giving off, a little {)0'^lL'nor to middle of the ribs, the lateral 
cutaneous branches— which latter bran<'hes jiass through external intercostal 
and scrratus magnus mu^iles about center of ribs and divide into anterior 
aiwl puiierior branches. The main trunk of the intercostal nerve continues 
forwanJ among fillers of internal intercostal muscles to costal cartilages— 
cbencr pas<ics lietwecn internal intercostal muscles and pleura, crossing in 
£rtint r»f iniemal mammar)' arter)' and triangularis stemi muscle — to pierce 




178 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 

internal intercostal muscles and pectoralis major and end in the anterior 
cutaneous branches, (b) Abdominal Intercostal Nerves : — Take the same 
course (as the anterior divisions of the dorsal nerves) as the pectoral inter- 
costals, from their origin to ends of intercostal spaces in which they lie — 
thence they run between the slips of origin of diaphragm to enter the abdominal 
wall, each nerve (from seventh to ninth, inclusive) crossing behind cartilage 
of rib below. In the abdominal wall they pass between internal oblique 
and transversalis, diverging from each other as they go forward, to outer 
edge of the rectus — and, piercing posterior layer of rectal sheath, rectus itself, 
and anterior layer of sheath, they supply rectus and sheath and end in the 
anterior cutaneous nerves near the linea alba. 

Comment. — (i) The exceptions in the distribution of the anterior divi- 
sions of the first, second, and twelfth nerves are not mentioned in the above 
descriptions. (2) The upper six dorsal ner\'es form the pectoral intercostal 
nerves — the lower six, the abdominal intercostals. (3) The final distribution 
of the lower dorsal nerves is as follows; — sixth, to pit of stomach; seventh, to 
lower end of ensiform cartilage; eighth, over the middle linea transversa; 
tenth, to the umbilicus; twelfth, midway between umbihcus and pubis. 



EXPOSURE OF INTERCOSTAL NERVE BETWEEN ANGLE AND HIDDLE 

OF RIB. 

Position. — Patient on side. Surgeon either in front or at back of patient. 

Landmarks. — Angle and lower border of rib. 

Incision. — Parallel with and just below lower border of rib, and lying 
between the angle and middle of rib. 

Operation. — Having incised skin, fascia, and external intercostal muscle, 
separate the cut edges of the external intercostal muscle and seek for ner\e 
in the intermuscular plane between external and internal intercostals, near 
the lower bonier of the rib above. The nerve may be drawn down into view 
from the groove in the lower border of the rib by means of a nerve-hook. If 
necessary, bite out a half-button of rib subperiosteally with rongeur forceps, 
fully exposing the nerve and intercostal vessels, when the latter may be 
divided between ligatures, if necessary. 



SURGICAL ANATOMY OF ANTERIOR CRURAL NERVE. 

.Arises from second, third, and fourth lumbar nerves and descends through 
fibers of psoas muscle — emerging from lower part of its outer border, and 
descenchng beneath Poupart's ligament into thigh, beneath the iliac fascia, 
in groove between psoas and iliacus, being separated from femoral arter)' 
on its inner side by the ])soas. It divides below Poupart's ligament into an 
anterior division, ])assing in front of the external circumflex vessels — and a 
posterior division, passing behind these vessels. 



EXPOSURE OF ANTERIOR CRURAL NERVE, BELOV POUPARTS 

LIGAMENT. 

Position. — Patient on back; limb extended and rotated slightly outward. 
Surgeon to outer side of right limb, and to inner side of left or on right, 



EXmSURE OF GREA r SCIATIC NERVE. 



179 



leaning over body; or on ouler side of left Iiinlj, cutun^ from below up- 
ward). 

Landmarks.— \fi(idle of Poupmrt's Iig;imeiU. 

Incision.— \'ertkal, alKiut 5 cm. (2 inches) in length, carried downward 
flt)m J. pnint about 1.3 cm. (J inch) external to center of Poupart's Hj^amcnL 

Operation. — Incise skin and sujicrlicial fascia, trural branch of t,'enito- 
cniral nerve may he met ruiinitij; down the thij?h. The superficial circumflex 
iliac iT.ssels will lie across the incision. Flex llie ihifjh to relax the muscles. 
The nerve will be found lyinj^ to the outer side of the femoral artery, in the 
gT»H»vc l»etween the iliacut» and psoas muscles. 



EXPOSURE OF OBTURATOR, SUPERIOR GLUTEAL. AND PUDIC 

NERVES. 

The operations for the exposure of the oljturalor nerve at the thyroid 
foramen, the superior gluteal nerve upon the buttock, the pudic nerve upon 
the buttock, and the pudic nerve in the j)erineum, are. practically, the same 
;is the ojjerations for the ligation of the obturator arteri' at the thyroid foramen 
(fiaj;^ 85), the gluteal artery upon the buttock (paj^e 89), the internal pudic 
artery up<in the buttock (page SS;. and the internal pudic artery in the 
perineum (puge 88), respectively. 



SURGICAL ANATOMY OF GREAT SCIATIC NERVE. 

Description. — Continuation of lower cord of sacral plexus— leaves pelvis 
br great sacrosciatic foramen, lielow pyrifornus — descends from hollow 
between prcat tnKiianter an<l tuberosiiy of ischium down back of ihijjh, lo 
alxmt its lower third, where it divides into externa! and internal popiliteal 
ncrvc?i (ihe division often occurring higher). The great sciatic nerve rests, 
fnim al>ove downwanl. upon the ischium, gemellus su[>erior, obturator 
inlenias. gemellus inferior, t^uadraius femoris and adductor magnus,— and 
is n>vcred by. from above downward, the skin, fascia, gluteus maximus, 
biccj>s, and small sciatic nerve, It has the sciatic artery to its inner side, 
and small sciatic ner\x* superficial to it above, anil to its inner side as it (the 
snuU «dalic nerve) descends the thigh. 



^- a di 
H^ mar 



EXPOSURE OF GREAT SCIATIC NERVE AT LOWER BORDER OF 
GLUTEUS MAXIMUS. 

Position. — Patient turned u\»*u side sufliciently to e.x]x)se field of opcra- 
ticm. Surget)n on iiide of operation, cutting downwanl on left side, and 
upward on right. 

Landmarks.- -Lower margin of gluteus, which is below fold of buttock; 
lul«'r«»sii\ of isthium; great trochanter 

Incision, -Begins over gluteal fold and passes vertically d<iwnward for 

a di?tanie of 7.5 10 10 cm. (t to 4 imhes). with center of incision over lower 

margin of gluteus maximus and placed miriway fH?t\veen tuberosity of ischium 

ureal lrt)chnntcr— although the nerve lies a little nearer the former than 

Utler. for by this incision the hamstring muscles are more easily retracted. 

Operation. — Having incised skin and fatty areolar tissue, the small 
sdatic ncr\e .ind cutaneous vessels are encountered. E.xpose the lower edge 




l8o OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA- 

of the gluteus maximus, running downward and outward, and retract upward. 
Find and retract the hamstring muscles inward, bending the knee to aid the 
retraction. The nerve is found a little nearer the tuberosity of the ischium 
than the great trochanter and under the outer edge of the biceps muscle. 



SURGICAL ANATOMY OF INTERNAL POPLITEAL BRANCH OF GREAT 

SCLATIC NERVE. 

Description. — The larger branch of the great sciatic. Extends from 
bifurcation, at lower third of thigh, through middle of popliteal space to 
lower border of popliteus muscle, where it becomes the posterior tibial ner\c. 
It is covered, above, by hamstring muscles; in the middle, by skin and fasda; 
and below, by heads of gastrocnemii. The popliteal vein inter\-enes betw^een 
the nerve superficially, and the artery deeply. In the upf)er popliteal space 
the nerve lies external to the popliteal arter>' and vein; at the level of the 
knee, the nerve crosses these vessels; and in the lower popliteal space the 
nerve lies to the inner side of the vessels. 



EXPOSURE OF INTERNAL POPLITEAL NERVE AT LOWER PART OF 

POPLITEAL SPACE. 

Position. Patient rests i>n shoulder and side of chest, as nearly prone 
as anesthesia will allow; Hmb extended. Surgeon to outer side of left, cutting 
downwaril; ami to inner side of right, cutting downward (or to outer side, 
cutting upwanh. 

Landmarks. Heads oi gaslnnnemii muscles. 

Incision. lUgins op{H»>iie the center of the popliteal space and passes 
Ncrliially downw.irvl tor about o cm. ^;^ inches), between the two heads of 
the \;a^lrvKiUMuii. 

Operation. H.ixing dixidtxl skin and sup>erlicial fascia, avoid external 
s.iplunvHi'i \oin a:ul nor\e at trio outer and lower part of the wound. Expose 
the hiMvl^ ot ihc j:,i>ti\vnettui an*i v>fvn up. by blunt dissection, the inter\al 
bolwwn ilutn. nirav'.'!:^^ 1*10 hcavis t»t the muscle to their resj^ctive sides. 
The tu:\o will Iv tvv.tui the n^v>t suix^nu ial of the important structures in 
the isv>U;oal v:v.vV 



s'^VROlCAl .WATOMY OF POSTERIOR TIBIAL NERVE. 

IVscnption, l-o v- :vv: v^v-:^u.■:•ov. of internal (K^pliteal ner\c 
Iv'.x N - ".\-" '.vWv: N \cr.- y v"i:cu> rrv.:>vlo to inler>al between internal 
»«»,»!;>\v,^ ■ ', vv". ^^ 'vtv i: ■ •. .V- i: :o ::.:err.al and external plantar ner\es. 
\\ \^ vv \s' \- «v\o \ .:.>:v\"v""iu>. : :ar.:an>. soleus. and intermuscular 
xixv^i. . .. ,- v\-% >. V •*. -V ••,■.■•• :\!.-c',i. It rests upon ( its anterior 
'\' ,•■>• \ • v^^x" .' -> >.>:vV^. .l"^i. VviO'.> . r^exc^ K>ngus digitorum. 
I. » .-' ' \- V , ' • - s • : ,. . v.:t«frA j.bo\e. but s«x«i crosaies it and 



t\>\vsvKv ov >\\^:vKvoK t:b.:ai fettee:? orkis and ankle. 

* s ^ X V o> V ■■".' -v^*;:- r r'bijil Rer\T at its origin 

> • -. X i \ . s V -v '^ " ."c ..'vvs-.::^ vi :he incemal pt^piiteal at 



EXPOSURE Ol- EXTERNAL I^OPLITEAL NERVE. 



i8l 



the lower part of the poi)liteal space (page i8o). The posterior tibial nerve 
in ihe leg may l>e exfH)se<l by the same operation as would expose the posterior 
tibial arlef)" at the same level (page 109). 



EXPOSURE OF POSTERIOR TIBIAL NERVE BEHIND INTERNA. 

MALLEOLUS, 

Position. — Patient on back; knee Jlcxct! ; lei^ resting on outer side. Sur- 
perm stands facinjj either foot, cutting from abnve downward. 

Landmarks. — Internal malleolus; tendo Achillis. 

Incision. — Curve<l, about 5 cm. (2 inches) in length, matie about 1.3 
cm. (§ inch) behind and parallel with the internal malleolus, beginning just 
in front of tip of malleolus and extending upward in a line midway !>et\vcen 
inlemal malleolus and tendo Achillis. 

Operation. — Directing the knife toward the tibia, divide skin, superficial 
fascb, and annular ligament. The order of the slnicturcs met behind the 
internal malleolus, from within outward, is, tibialis [M)sticus; llexor longus 
digitorum: |x»slerior tibial artery, vein and nerve; flexor Utngus hallucis. 
The ner\e is therefore sought between the tendons of the flexor lungus dlgi- 

Ilorum and tlexor longus hailucis. 
Description.— Smaller branch of great sciatic. Enters superior angle 
of popliteal space and passes obliquely along outer side of this space to head 
of fibula, lying near inner border of biceps (lying beneath skin and fascia, 
behind head of fibula, to inner side of biceps lenrlon). The nerve leaves 
the [wpliteal space in intcn-al between biceps tendon and outer head of 
Bi&trocnemius — winds around neck of fibula between bone and peroneus 
longus muscle — and, piercing origin of latter muscle, divides into anterior 
tibial, musculocutaneous, and recurrent articular nerves. 



SURGICAL ANATOMY OF EXTERNAL POPLITEAL (PERONEAL) 
BRANCH OF GREAT SaATIC* 



I 
I 



EXPOSURE OF EXTERNAL POPLITEAL BEHIND TENDON OF BICEPS. 

Position.— Patient on uninvolved side, rolled into slightly prone ^wsition; 
leg c.\ten<led. Surgeon stands facing back of patient's knee. 

Landmarks. — Tendon of biceps; head of fibula. 

Incision.— About 4 to 5 cm. (i^ to 2 inches), along posterior edge of 
tendon of bice()S, extending from over the prominence of the external condyle 
«f ihc femur toward the posterior border of the head of the fibula. 

Operation. — Divide skin and deep fascia. Expose the biceps tendon. 
Flex the knee to relax the tendon and search for the nerve near the attachment 
of the biceps tendon to the head of the fibula, near the outer edge of the 
gastrocnt-mius. 



i82 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA 



SURGICAL ANATOMY OF ANTERIOR TIBLAL BRANCH OF EXTEI 

POPLITEAL. 

Description. — One of the terminal branches of the external pop 
Commences between fibula and j>eroneus longus — pierces septum bei 
peronei and extensors — passing obliquely beneath extensor longus digit 
to forepart of interosseous membrane. Runs forward on interosseous 
brane between extensor longus digitorum and tibialis anticus, in uppei 
of leg — and between tibialis anticus and extensor longus hallucis, 
down. Passes under anterior annular ligament and ends in front of 
of ankle in external and internal l)ranches. The anterior tibial ner\'e re 
the fibular side of the tibial artery at the junction of the upper and a 
fourths of the leg, thence lies in front of the artery to the ankle, and t 
generally lies to its outer side. 



EXPOSURE OF ANTERIOR TIBIAL NERVE NEAR ORIGIN. 

Position. — Patient supine and inclined to uninvolved side; hip si 
flexed and rotated inward, so that knee rests u\Hm inner aspect. Su 
stands behind either limb, cutting from above on the right, and from 1 
on the left. 

Landmarks. — Outer tu])er()sity of tibia; head of fibula. 

Incision. — Hegins o])posite the most external i)art of the tibial tubei 
and about 1.3 cm. (i inch) anterior to the head of the fibula, and \ 
downward for 5 to 7.5 cm. (2 to t, inches). 

Operation. — Having incised skin and fascia, the intermuscular se 
between peroneus longus and extensor k)ngus digitorum is sought, ru 
oblifjuely (knvnward and forward, and is o|)cned up by blunt disse 
The anterior tibial nerve (and also the musculocutaneous nerve) is 
deep in this intermuscular interval, running downward and inward, 1 
the fibular head and covered by the extensor longus digitorum (the mui 
cutaneous running vertically downward). 

Comment. — The anterior tibial nerve may be exposed at any poi 
the leg below its uj)|)er fourth, by the same ()|)eration as would expos 
anterior tibial artery at the corresponding level (page 105). 



SURGICAL ANATOMY OF THE CERVICAL SYMPATHETIC GAN 

AND CORD. 

Description. — The cervical ])oriion of the gangliated cord lies (] 
in the neck, embedded in the fascia between the muscles covering the 
of the vertebral column behind, anrl the carotid sheath in front — and co 
of three ganglia, together with the connecting cord: — (a) Superior Ce 
Ganglion (largest) — lies opposite second and third cervical vertebra? (« 
times, fourth and fifth) — rests uixm rectus ca])itis anticus major, postei 
— has internal carotid artery and internal jugular vein, anteriorly,- 
pneumogastric nerve, externally, (b) Middle Cervical Ganglion (some 
wanting) — opjxKsite sixth (or seventh) cervical vertebra — upon, or clo! 
where the cord crosses the inferior thyroid artery, (c) Inferior Ce 
Ganglion— between base of transverse process of seventh cervical vei 
and neck of first rib, lying between subclavian and vertebral arteries. 



TOTAL EXCISION OF CERVICAL SYMPATHETIC. 



183 




TOTAL EXaSION OF CERVICAL SYMPATHETIC GANGLIA AND CORD. 

JUWESLOS (Jl'EKATION. 

Description. — The cervical sympalhetic ganglia and cord Imve l:»€cn 
iDiised, partially excised, ami toLilly excised— cliietly for exophthalmic goiicr 
epilep:?y — and also in hysteria, chorea, tumors of the brain, and glau- 
The cord and one or both upper ganglia of one or both sides have 
1bceo removed, — or both up|wr ganglia of both sides, with intervening cords, 
— or both corrls with all the ganglia of one or both sides. The removal of 
ihc cord and ganglia of one side will be docnbetJ below. 

Position. — Patient supine; shoulders and head raised and kilter turned 
to opposite side; neck, shaved, rests u[x)n a narrow support (to render promi- 
nent). Surgeon to right, for both sides. 

Landmarks. — Mastoid process; posterior border of slernomastoid; 
clavicle. 

Licision. — Beginning opfK^siie the jxjsterior margin of the mastoid pro- 
cess, passes downward along the posterior border of the sternomastoid to 
just below the clavicle. 

Operation. — Incise skin, superficial fascia, and platysma. Divide the 
external jugular vein between two ligatures. Displace the sternomastoid 
iward (or it may be split longitudinally near its posterior Ixtrdcr and the 

:s retracted laterally). FApose the common shuath of ihc vessels by blunt 
dissection. Lift the carotid sheath, uno|>ened, upward and retract it inward 
— when the cen'ical cord and sufwrior and middle cervical ganglia will l^e 
exposed, lying upon the prevertebral muscles. Having well retracted the 
structures to that side toward which most easily displaced, isolate the trunk 
ai the cervical sympathetic near the center of the incisifMi. Follow it up to 
the su|KTior ganglion, divide the comniunicaling branches of the ganglion 
with delicate scissors, and remove the ganglion with fine forceps. Practising 
slight traction upon the distal end oi the trunk, trace the cord down to the 
middle ganglion, which is similarly removed— carefully guarding, throughout, 
all important adjacent structures. Continuing gentle traction upon the cord, 
just sufTicJent to follow it, trace the main trunk down behind the ciavicte to 
the inferior ganglion. Ouard the spinal accessory nerve in the upfwr jxirl 
«if the neck— the nenes of the cervical plexus in the mirldle of the neck — 
the ihvToid and vertebral vessels, recurrent larynKeal and phrenic nerves 
and pleura in the lower part of the neck -and the thoracic duct on the lower 
Irfl side In closing the operation, approximate the separated mu.scles with 
burieij gut sutures — and close the superficial wound in the usual manner, 
un!ps> frmporary drainage be indicated. 



CHAPTER V. 

OPERATIONS UPON THE BONES. 

OSTEOTOMY IN GENERAL. 

Definition. — Any division of bone by cutting instrument. 

Indications. — Deformities of l)ones and joints (such as result from 
congenital conditions); diseases of bones and joints, followed by weakening 
of bone and subsequent curvature or angularity; malunion following fracture; 
ankylosis. 

Varieties. — (a) Linear Osteotomy; Sim[)le division of bone in its con- 
tinuity, by simple transverse, oblitjue or vertical section-line {e. g., linear 
osteotomy of neck or shaft of femur for faulty ankylosis), (b) Cuneiform 
Osteotomy; Removal of a wedge shaj^cd piece of bone in its continuity (f. g., 
cuneiform osteotomy for bent tibia), — or from, or including, one of its ends 
(e. g., cuneiform osteotomy of a joint for ankylosis), (c) Osteoarthrotomy; 
Though not a distinct variety of osteotomy, may be considered as an inter- 
articular osteotomy, linear or cuneiform. 

General Manner of Performing Osteotomy as to the Instrument. 
— Osteotomy, in general, may lie performed with an osteotome, an instrument 
ground evenly from lx)lh sides, and graded ui)on its blade to indicate depth 
of section, — with a chisel, an instrument beveled from one side only, and 
similarly graded uj)on handle, — or with a special saw. 

General Manner of Performing Osteotomy as to Method of Opera- 
tion. — (a) Open Method; in which the site of the bone section is exposed 
to view by a preliminary oix'ration. (b) Subcutaneous or Submuscular 
Method; in which the site of bone-section is reached through the smallest, 
simplest incision and the bone divided out of sight and by the sense of touch. 
Cuneiform osteotomy is nearly always done by the open method. Linear 
osteotomy may be done by the subcutaneous or by the open method — the 
former being more frequently done — the latter being ])referable where the 
safety of the parts can be better [)reserved by first e.\|>osing them. Cuneiform 
osteotomy should be done subperiostcally where possible, and when not 
contraindicated (as by disease). Linear osteotomy should be done sub- 
periosteally when performed by the open method, if jwssible and not contra- 
indicated. Linear osteotomy is usually performed with an osteotome or a 
saw. Cuneiform osteotomy is generally done with a chisel (sometimes with 
a saw). 

Instruments Used in Osteotomy. — Rubber tourniquet; scalpels; 
tenotomy knives; hemostatic forceps; dis.secting and toothed forceps; scissors, 
curved and straight, sharp and blunt; retractors; chisels, various sizes and 
widths; osteotomes, various sizes and widths; mallets, preferably of wood; 
saws, especially of the osteotomy type (with narrow blade and with cutting 
part' only at end, and with blunt point and large handle), and also chain- 
saws, Gigli saws, and butcher saw; periosteal elevators, curved and straight; 
rugines; raspatories; blunt dissector; bone-holding forceps; bone-cutting 
forceps; needles, straight and curved; needle-holder; chromic and plain 



LINEAR OSTEOTOMY BY THE SUBCUTANEOUS METHOD. 



r8s 



It; silkworm-gut and kangaroo tendon; bone-drills; silver wire; pegs and 
nails, ivory and metallic; sand-bag (for pari to rest upon and dissipate the 
_^ jar). 

■ Preparation of Patient.— The part shaved. 

H Position. — The position of patient, surgeon, and assistant will be deler- 

H mined by the special operation. 

■ ^ 



LINEAR OSTEOTOMY BY THE SUBCUTANEOUS METHOD. 





Steps of Operation Preparatory to Division of Bone.— Having ex- 
sanguinated the limb by elevation, follnwcd by the application of a rubber 
toumifjuet (which may generally be dispensed with), the portion of the limb 
involved is placed 
upon a sand-bag 
(previously damp 
enerl and covered 
with several layers 
of wet, sterih'zed tow- 
els, to prevent the fly 
ing o( dust), which 
forms a \nelding bed 
into which the part 
may be moulded and 
in which it may re- 
crive the jar of the 
blows from the mal- 

t- An Incision, just 
ig enough to ad- 
it the osteotome or 
saw, is made over 
the >ilc of the iame- 
section. The incision 
is as limited as |>os- 
sible, and so placed 
as to reach the bone 
by the most direct 
id safest route, and 

1th the least danger 
to important sinjc 
Cures. It should be, 
where possible, in a 
line with the nver- 
hing muscle filiers — 

tbould nvoid vessels and nen'es — and is generally parallel with the bone. 
Tlii.^ incision is usually made directly to the bnne with one stroke— it being 
Niblc, from the small size of the wound, to recognize the intermuscular 
J ti.ti,c?.. or the bone's exact level, if at any depth from the surface. Hav- 
ing made a path to the bone, the remaining steps of the operation will de 
pcnd ufxm the instrument with which the division of the bone is to be made. 
Division of Bone with Osteotome. — Having made the incision through 
the ioft parts with a knife, the knife is not withdrawn but allowed to remain 
tn siUt as a guide — upon this an osteotome (somewhat narrower than the 




Fig. UK— LiHEAR Osteotomy bv thiv Si'ncvTANeous Mbthoo: 
— A, Linear osttfotomy of anatomical tie<"k of (emur with saw ; B, 
Linear ostcolomy of surgical neck of (eniur with ofiteolome. 




i86 OPERATIONS UPON THE BONES. 

bone to be divided) is introduced, entering the wound with the length of its 
cutting-edge corresponding to the length of the wound. It is carefully passed 
down, in contact with the knife, to the bone, and the knife withdrawn. The 
osteotome, constantly held in contact with the bone, is now turned with its 
cutting-edge in the direction of the desired bone-section (which is generally 
at a right angle to the incision of the soft parts). In the act of turning the 
osteotome into position, the soft parts are levered away by the blunt sides 
of the instrument, and the bone is hugged, but care is used not to detach 
the periosteum (which the knife-incision may have cut) (Fig. 121. B). The 
osteotome is held in the surgeon's left hand near its cutting end — being grasped 
in his full hand, the ulnar margin of his hand resting on the patient's limb 
to steady the instrument. The instrument should cut away from important 
structures, and preferably toward the surgeon. After each stroke of the 
mallet, the osteotome should be shifted, traveling back and forth in the line 
of section, that it may not bind in any one place. In section of thick bones, 
if the instrument bind, it is withdrawn and a thinner (not narrower) one is 
introduced — and subsequently a still thinner, if necessary. Progress through 
the bone is determined by the skilled sense of touch. The section should be 
evenly made, as to depth, completely across the width of bone, traveling 
back and forth, no two blows being made in one site. Never remove the 
instrument from the groove in the bone when once the section has been 
commenced (unless a larger instrument catches in the section and has to 
be replaced by a thinner one), for it is often hard to regain the groove. The 
last portion of bone on the far side of the section, when important structures 
are just beyond, need not be cut with the osteotome, but may be bent or 
broken subsequently by manipulation of the limb. 

Division of Bone with Saw. — A special osteotomy saw, generally of 
the .Adams type, is used. The operation is very similar to that just described, 
except in the substitution of the saw for the osteotome. The skin incision 
is j)laced as in the above operation, but is made with a tenotome instead 
of an ordinary knife — usually cutting in the line of the muscle-fibers and in 
the axis of the limb. When the bone is reached, the blade of the tenotome 
is turned so as to cross the bone transversely and is made to cut a path for 
the Siiw across the bone — the non-cutting part of the handle of the tenotome 
doing no harm to the soft parts between the bone and wound of entrance. 
When the way for the saw has been prepared, the tenotome is left in situ 
as a guide. Upon this the blade of the saw is introduced down to the bone 
and its cutting part i)ushed on across the portion of bone to be divided (Fig. 
121, A). The bone is to be sawed with short strokes, guarding against 
thrusting tne point of the saw into the soft parts, especially at the beginning 
and ending of the section. The section may be nearly made with the saw 
and completed by manual bending or breaking. 

After-treatment.— Following osteotomy, the limb, or part, is in a con- 
dition of com])ound fracture made under the most favorable circumstances. 
Some form of sj)lint, or a plaster-dressing, must immobilize the limb and 
keep the ends of the bones in a[>position. The wound is closed by suture 
— no drainage being used in clean cases. 

Comment.— (I) In division by an osteotome, the osteotome itself is 
sometimes used to cut its way through the soft parts, instead of knife, (a) 
When the bone section is nearly complete, bending is especially applicable 
in young, tender bones. (3) The section of the bone should generally be 
completed by instrument, and not by breaking, as a splinter of bone may 
do damage to adjacent parts. 



CUNEIFORM OSTEOTOMY. 



187 



LINEAR OSTEOTOHY BY THE OPEN METHOD, 

Steps of Operation Preparatory to Division of Bone. -The site of 

the htinc-sci tion is expti.seil by :in incisinn so pLui'd as to reach the bone 
ro<ivi readily arul s;ifely. scekin}» an intermuscubr |>lane where possible. 
Havinj^ passed throu'^^h skin, fascia — and through or between muscles — ■ 
The ^»ft parts are opened up and retracted to either side — and the region 
of b<jne fully exposcfl to view. Where it is possible to do so, and where 
it b not contraindicate<l, the i>eriostcum is incised in the long axis of the 
bone, freed from its circumference, and retracted with the soft parts. The 
bone-section may then be made with an osteotome or with a saw: — 

Division of Bone with Osteotome.— The ostc«.iome is introduced at 
oni'e u(Mm the bone, in tlie direction the section is to be made — afler which it 
is manipulated as in the 
subt uLiineous method — 
mm h greater tontrol 
iti the inslnimcnt bcinj^ 
jMissible. 

Division of Bone 
with Saw.— The saw 
is similarly intnKluced 
at once upc>n the bone. 
in the direction the sec 
tion is to be made. 
The Mxtion is then 
rn.jile by short strokes, 
tlic jarls are well 
i*...»» tc<i and the entire 
rratfon exposed to 
le^v. 

After - treatment. 
— Unless con traindi 
ratc«J, the |ieriostcum 
■shnuld be sutured with 
Ifut the sutures at the 
same lime passing 
thnxigh the muscles and 
cjuilting them t«*gelher. 
iTbc wound is then 

in the visual wav— and a retentive apparatus applied, as described 
"ill the la^l o|>eralion. 

Comparison. — In subcutaneous osteottjmy the use of the osteotome is 

tlumaj:ing. and the section is cleaner than l)y the saw. In open 

the s«w is preferable. es}>ecially the chain or Gigli saw. In the 

tnelhod, while a hirjt^er wound of entrance is ma<le, the bone section 

accurately made and less damage is done to the neighboring tissues. 




FIjf. IM.— CvNEiFOHM OsTWOTOMV:— Chistfl i» «bhown removing 
U'cUlctvsliMtieU piece ul bone Itum Iient libia. 




CUNEIFORM OSTEOTOMY. 

Description. — .\ wedge shaped piece of bone is removed, the size of 
whkh 131 dciermincfl by the needs of the case — the general rule l>eing that 
the sides of the wctlge should be at right angles to the axis of the bone just 



l88 OPERATIONS UPON THE BONES. 

above and below the section — ordinarily, however, a smaller wedge suffices. 
The wedge usually extends entirely through the bone, its base being upon 
one surface and the apex upon the opposite — but it may extend only two- 
thirds or three-fourths of the way through, the balance being bent or broken. 
The operation is nearly always done by the open method. 

Operation. — Having exsanguinated the limb by elevation, followed by 
the application of a rubber tourniquet (which is much more frequently used 
than in the linear form of osteotomy) the limb is placed upon a sand-bag. 
The incision is placed over the site of the base of the wedge to be removed 
and is considerably longer than the base of the wedge — and is so planned 
as to enable the bone to be reached through the most direct and safest route, 
and to enable the muscles to be separated rather than cut. The skin and 
fascia are first incised — the muscles separated in their intermuscular cleavage 
line and retracted — and the periosteum incised in the axis of the bone, down 
to the bone, and retracted with, and adherent to, the soft parts. This clearing 
of the bone subperiosteally is accomplished with a cur\'ed periosteal elevator, 
the clearing being done more extensively at the site corresponding with the 
base of the wedge. The chisel is the best instrument with which to perform 
cuneiform osteotomy — though a chain or Gigli saw may sometimes be used 
advantageously, and even an ordinary saw may be conveniently used in 
some cases of angular ankylosis (Fig. 122). The chisel is held like an osteo- 
tome, for the sake of steadiness. The beveled edge of the chi.sel is directed 
toward the wedge of bone to be removed. If the wedge be of considerable 
size, it cannot be removed with accuracy in one piece — a small wedge, narrow 
at its base, must be first removed — and then slices may be chiseled from the 
sides of this until a cuneiform space representing a wedge of the requisite 
size is removed. Having removed the wedge of bone, the ends of the bone 
are put into position — the periosteum is sutured with gut — the wound closed 
— and the limb put up in an immovable splint. 

Comment. — In this, as in the other forms of osteotomy, additional 
means may be used for holding the divided ends of the bone in place, besides 
the special form of splint — such as wiring, pegging, suturing, and other 
devices mentioned under operations for ununited fractures. 



OPERATIONS FOR RECENT OR UNUNITED FRACTURES IN GENERAL. 

Operations for ununited fractures resolve themselves, as far as the forms 
of the bones are concerned, into three classes — those for fractures of the 
long bones — of the short bones — and of the mixed bones. The general prin- 
ciples involved are the same in all classes. Fractures of the patella and 
olecranon require special mention. 

The principles involved : — the placing of freshened ends of bones in good 
position, without too great tension, and without intervening soft parts — 
and the maintaining of these ends strictly in position by competent immobil- 
izing splint. 

Following is a brief summary of the technic employed in the majority 
of cases; — Exposure of ends of bones as nearly subperiosteally as possible 
— resection of ihe ends as nearly transversely as the nature of the fracture 
will permit — if the ends of the bones can be easily appro.ximated and easily 
retained in position, place them in apposition, suture the periosteum, ap- 
proximate the muscles by buried sutures, close the wound, and apply an 
immobilizing splint. If the ends are not likely to be easily kept in ap- 



RESECTIOX FOR FRACTLRED BONES. 



189 



proximation (especially as the result of an oblique section), one of the methods 
of holding them in ap^HJhiiion (to be described heluw) may be resorted to 
— in addition to plating the ends in contact and applying a retentive form 
of apparatus. 

In opterating, some form of tourniquet i> usually applied. The site of 
operaiit»n i> to be shaverl. The position of patient, surgeon, and assistant 
will be determined by the special operation. 

The inslruments used are those employed for Osteotomy (page 184). 






OPERATION FOR RECENT OR UNUNITED FRACTURE BY RESEtmON 

OF ENDS OF BONES. WITH RETENTION OF COAFTATED ENDS 

BY IMMOBILIZING SPLINTS, 

Description. — The ends of the bones are exposed and excised, and the 
aed ends are then brought into contact and held in apposition by a 
t or a plaster cast. 

Operation.— Ha V 
ing exsanguinated the 
limb and applied a 
tourniquet, an inci- 
sion, sufficiently free 
to allovr of protrusion 
of the ends of the 
Hones, is made in the 
long axis of the limb, 
directly over the ends 
of the bones — and 
placed so as to give 

'. access by the most 

cct and safest route 

the involved site. 
The skin and fascia 
,are divided — the mus- 
idts are separated in 
their intermuscular 
planes and retracted 
— or, if separation of 
the muscles in their 
planes be impossible, 

thcv are divided in the direction of their fibers. Important vessels and 
neri'es are carefully avoided, being retracted to one side. The wound is 
made fully large and the lateral retraction of the soft parts sufficient to 
make the necessary manipulations p^issible without adding to the trauma- 
lism. The ends of the bones are fully exy>osed an<J entirely freed of all 
Ibstte which may intervene between the fragments, whether normal or 
Scatricial. As the ends of the bones are apjiroached, care is taken to 
Rvoid injuring the periosteum— which should be split longitudinally and 
frrcd circumferentially from the ends of the bones, without othenvisc scver- 
inij its connection, and should be raised without separation of overlying 
muM^^le, that is, as a musculo periosteal covering. The end of each bone is 
dealt with in turn, and. after being thoroughly freed, is, where possible, 

truded through the wound, the limb being bent at an angle for this purpose 






C D 

Figs. r»3-l3«.— I— OpEBATtOVS FOR Ust'WITKD FRACTURES RV 
SiMPiK Suction:— At B, Simple iruiisvervr (racturc, (ollwvctl by 
tr.4M!iV(;rfie sectioti of hr>i)«.*»; C, D, Irregularly tratisvcise inicUire, 
liillowvtl by wcliun of houc itAraltcl wilti Irat lures. 



190 



OPERATIONS UPON THE BONES. 



and the soft parts well retracted, the periosteum being carefully peeled back 
during this step. A minimum slice of bone is now removed from the end 
of each bone, simply enough to insure a fresh, raw surface upon each. If 
the bones have been protruded, this section is generally best made with a 
butcher's saw. If the ends have not been protruded through the wound, 
after they have been well freed, it is best to slip a chain or Gigli saw between 
the bone and the periosteum and thus make the section. The section may 
also be made, though generally less satisfactorily, with a chisel. The direction 
of the section will depend largely upon the nature of the ends of the bone; — 
if a rather transverse fracture, the section is made transversely; — if a ver}- 
oblique fracture, the section is made obliquely (Figs. 123-126, A, B, C, D; 
and Figs. 127-130, A, B, C, D). Whether the section be made trans- 
versely or obliquely, the section is so planned as to leave a limb in correct 
position, as to its axis and as to its rotation, and is so made as to secure two 

parallel surfaces for con- 
tact. An exception to 
this is where some spe- 
cial form of section is 
made, as when the bones 
are so sawed as to have 
an angularity of one fit 
into a depression of 
another, producing the 
mortising effect — the 
great principle being that 
the ends of the bones 
should be cut so as to fit 
each other. A transverse 
section of the bones is 
always preferable, unless 
involving too great a sac- 
rifice of length. The 
ends are now approx- 
imated in the position in 
which the bones will re- 
main, and are held in this 
position during the re- 
mainder of the operation 
and until the permanent splint be applied. The periosteum is sutured 
with gut. The muscles are brought together with buried gut sutures. The 
outer wound is closed in the usual way. The limb is then placed in a per- 
manent splint, or in a plaster cast, with extreme care, so steadying the 
parts during the dressin;^ that the ends of the bones remain undisturbed. 

Comment. — (i) The operation is, practically, that of osteotomy by the 
open method. (2) In a recent case, the after-treatment is that of a compound 
fracture, with the limb put up in a j)osition to relax the pull on the fractured 
ends. (3) In old cases where bands of fascia, or tendons, are apt to draw 
the ends out of place, these should be divided. (4) Where it seems likely 
that the ends of the bones will tend to displacement, especially in such cases 
as the femur, a process of mortising may be carried out in fashioning the 
ends of the bones for appro.ximation. 





Figs. 127-130. — II. — Opkkations for I'ni'nited Fract^rhs 
BY SiMi'i.K Skction:— .\. K, Wed^jf-sli.iiKnl. and C. D, rectan- 
gular fracture, followed by section of bone parallel with fracture. 



WIRING i^UK FRACTURED BONES. 



191 



I 



OPERATION FOR RECENT OR UNUNITED FRACTURE BY WIRING OF 
ENDS OF BONES, WITH OR WITHOUT RESECTION. 

Description. — In addilujn to the retention of the coaptated ends of the 
bones by splints, the ends are previously drilled and wired into conlact. In 
the case of new fractures, where the ends are left so shaped .is likely to remain 
in position when wired, resection of the ends of ihc bones need not be done 
- — otherwise the ends should be resected. In all cases of old fracture the 
ends of the bones are always resected, so as to present freshened surfaces. 

Operation. — The steps of the operation are the same, in all respects, as 
for resection with retention by spbnls — up to the exposure and clearing of 
the emis of the lx)nes — after which the lechnic will differ, dependent upon 
whether the bones are resected or not; — (a) Wiring of the bones without 
resection: — The ends oi the bones are grasped ami steadied by some special 
form of bone-holding forceps, while holes for the passage of wire are drilled 




I 



FJg. Iji.— MrmoD op Diiilii>»c Eonb fo« Wimikc :— a, Hont.< holdinj; forccjK ; B, Hand-dritl. 

— fiuflicient in number to furnish the desired strenpih and st> planned in 
position as In retain the normal axis of the bone (Fig. 131). The holes may 
be drilled and the silver wire passed in several ways. Where the fracture 
i» practically u transverse division oi the bone, the drill-holes are usually 
made to pa>s through one wall of ihc upper and the corres)3onding wall of 
the Uywcr fragment, the wire thus passing through but a small portion of the 
mrdulJa of the Ixme (Figs. 1JJ2-134, A, B, C). In the case of an oblic|ue 
fracture, the holes may be drilled and the wire passed in the same way — 
car ihc fragments may h»e held in i>osition and the holes drilled through opposite 
walh nnd the intervening medullar) substance (Figs. i;^5, 136, and 137). 
The end* «»f the wire, in cither of ilie melho<ls above mentioned, may then 
be liristwl, cut short and pressed into the j>eriosleum and U^ie — or may 
be twisted long and brought out of the wound (Figs. 138-140 and 141-143). 
In lm>lh methods the jieriosteum is piercerl by wire, thougli elsewhere it is 
prr>cnctl as intact as f>ossibIe upon the lajncs. (b) U iring «>f the bones 




192 



OPERATIONS UPON THE BONES. 



after resection: — The resection of the ends of the bones is accomplished 
just as in the operation for ununited fracture by resection of the ends of the 




Mks. 132-134- — Operations for Un- 
i.'Niii'.ii Fracti-rks by Skctk^n and WlR- 
IM. : I -In transverse fractures ;— A, Siiif^le 
wire tlirouxh ImuH walls of each bone: B, Dou- 
filr win- tlinniKh both walls of each bone ; C, 
Wires passed throtiKh single wall of each end. 
Tiiese forms may be used without section of 




Figs. 135-137.— Operations for I'MirsiTiiD 
Fracti'rks by Skction and Wiring:— II— In 
oblique fractures ; — A, Double wires through both 
walls of each end, in axis of bone ; B, Same, cross- 
ing fracture at right angle; C, Ixtop of wire car- 
ried through drill-hole, and free ends brought 
around bone and through loop and twisted. These 
forms may be used without section of bone. 




I! i 



I'lK**- I,;S- ItO. -- OrHRAJIONS FOR Tn- 
I'NIIIli |-H\lllHIS Il^ Sl-.lTlON ANI> WlR- 

isi. Ill- I'lN siinpli- I<M)p-lif;;itun's;— .\, Hy 
• liniMr liiops aMiiiiul l>(>iu-iit liftht ;niKli'ti»axi-< 
ol lioiu-: It, pDiiliK- loop*, at liKlil umkU- lo lino 
III iili|ii|ii<- tiaituio: I", DouMv liM»ps. a^. in A. 
itiiiliiii 111 liv lau-i.ii wiiL-limps. Tlu'si* tumis 
in.iv lio a>li>pti-il wiiluiut siTlion of lK>nc. 




Figs. 141-143.— Ophrations for ITni-nitkd 
Fractirks by Shction and Wiring:— IV— By 
frame-ligature ;— A, R, C, First, second, and third 
stages of the frame-ligature. 



OPERATION FOR FRACTURE BY NAILING OR PEGGING. 



193 



I 



bones, with retention of the coaptated ends by immobflizing splints (page i8q). 
The ends of the bones are then drawn back Intu their musculo periosteal 
sheaths — and the ends are then wired as in (a) above. Following the ap- 
proximation of the ends of the bones, the periosteum is sutured with gut— 
the muscles are brought together with buried gut sutures — the outside wound 
closed as usual — and an immobilizing splint applied. The wire is nni ex- 
pected to be removed when buried, — when left long, it is subsei|uently (after 
firm union) unt\visted and drawn out, to accomplish which, it is sometimes 
ncces&ar\' to expose the parts by incision down to the bone. 

Comment. — The drill holes should be a little larger than the silver wire 
used. The wire should be fairly heavy. The holes are drilled from 8 mm. 
to i.^ cm. (^ to ^ inch) from the ends of ibe bones, penetrating obliquely 
if but one wall of the upper and one wall of the luwcr 
fragment be drilled — and penetrating at a right angle 
to the surface, if the drilling pass transver.sely through 
opposite walls. In drilling for oblique fracture, the 
suture should pass at a right angle to the line of 
fracture. 



OPERATION FOR RECENT OR UNUNITED FRAC- 
TURE BY SUTURING, WITH OR WITH- 
OUT RESECTION. 

Description. --The operation is here practically 
the same as that for ununited fracture by wiring 
except that heavy chromic gut. kangaroo tendon, or 
silk (preferably one of the first two) is used to apjirox 
imaie the ends of the bones. 

Comment. — As the chief dependence is in the ul- 
timate bony union between the fractured or resected 
ends, and as the chief function of wire, gut, tendon, 
or silk suture is temporarily to hold the ends m posi 
Don until union is sufhcienlly advanced lo fix the 
ends of the bones firmly and permanently, it »s un 
questionably best to use a material which, while ful 
filling that temporary office, will then disiippear of its 
own accord and give no future trouble — and. there- 
fore. hea%*y chromic gut or kangaroo tendon is the 
ideal material for this purpose, if the conditions of 
the c*»e |x'rmii. 




F-'iff. 144- - I'NtTIWC 
FHACri'HKlliiiM RKS|i(i;TIU) 

Bonk by N'auinl.. 



OPERATION FOR RECENT OR UNUNITED FRACTURE BY NAILING. 
PEGOING OR SCREWING ENDS OF BONES, WITH OR WITHOUT 

RESECTION. 

Description. — The ends of the fractured bones, w ith or without resection, 
ar- It and held together by means of plated nails or screws, ivory pegs, 

€*r 1^ of metallic plates held in place by nails i)r screws, or by metallic 

Operation.— The ends of the bones are exposed, freed, and, if necessary, 
re><cted. as in the above operations. If the fracture, or section be trans- 




194 



OPERATIONS UPON THE BONES. 



verse, the nails, pegs, or screws are put in obliquely, passing from without 
through the proximal wall of the upper fragment, through the medullary 
substance, and into the wall of the lower fragment, from within outward. 
Two or more nails or pegs are generally inserted, passing in diflferent direc- 
tions (Figs. 144 and 145). If the section, or fracture, be oblique, the nails 
are put in at a right angle to the surface of bone and pass transversely through. 
Where plates are used, they are placed over the line of fracture or resection- 
some of the screws passing into the upper fragment, and some into the lower 





Fig. 145.— Uniting P'ractured or Re- 
sected Bone by Pegging. 



Figs. 146 and 147.— Uniting Fracturbd or Rb- 
sectedBonebvScrrwing. Screws may be used akxK 
—or in metallic plates, as shown in diagram to left. 



(Figs. 146 and 147). As little damage as possible is done to the periosteum. 
The muscles are brought together by buried gut sutures — the wound closed 
— and the limb immobilized. 

Comment. — The nails and screws generally protrude through the skin 
and are removed in about two weeks, or remain longer. Ivory pegs are 
similarly treated, or, if very short, may be left in situ. Metallic plates and 
bands are expected to be left in situ. 



OPERATION FOR RECENT OR UNUNITED FRACTURE BY PARKHILL'S 

CLAMP. 

Description. — The fragments of bone are here held together by means 
of a special form of clamp consisting of four long steel screw-pins and an 
interlocking mechanism. 

Operation. — The ends of the bones are exposed and freed in the ordinary 



OTHER OPERATIONS FOR RECENT OR UNUNITED FRACTURES. 15 

manner — and resected, if necessary. Two holes are drilled in the long ax 
of each fragment, in direct line with each other. Four long steel scrcw-pii 
are then screwed into these holes by means of a clock-key attachment- 
after which the "wings" of the instrument are adjusted. While the en( 
of the bones are held in accurate apposition and care taken that the propi 




ffrf W' 



Fig. 148.— Operation for pRACTrREi) or 
Reskcted Bonk bv Parkiiii.i.'s Bonk-ci.amp: 
— Surface view of clamp in position. 



I-'Ir. 149.— <JPKRAriON KOR I'KACTURKn i 

RhsiiTKr) Bonk bv Pakkhii.i.'s Bone-clam 
— Side \ iew of clamp in position. 



axis of the bone is secured, the two fragments are clamped together in tl 
special manner of the instrument. The muscles and other soft parts a 
then adjusted about the screws of the clamp, which projects without tl 
wound. The dressing is then applied — and the pins of the clamp not remove 
for from four to six weeks (Figs. 148 and 149). 



OTHER OPERATIONS FOR RECENT OR UNUNITED FRACTURES. 

(I) Ligation of Bone. — One or more pieces of wire are passed arour 
the fractured portion of bone, either at a right angle to the •-•- 

nr at a riaht analp tr» thp linp of frnrtiir#^ TL 



196 



OPERATIONS UPON THE BONES. 



buried. The bone may be notched to aid in holding the wire in place. Longi- 
tudinal loops may unite the circumferential wire bands (Figs. 138-140). 

(2) Combined Ligature and Suture.— A hole is drilled through the 
fragments at a right angle to their line of fracture — a loop of wire is passed 
through, given a half-turn in the center, and the two ends passed around the 
sides of the bone and through the loop and twisted (Fig. 137, C). 

(3) Frame Ligature of Bone.— Drill two holes through the fragments, 
in the long axis of the bone — pass the free ends of a wire loop through the 
holes — pass the loop over the free ends and draw tight — then bring the free 
ends around to the holes through which the looped end originally passed and 





Firs. 150 and 15,1.— Opkkation ior Fkac- 

TIKI.L) OR RKSKCTKU HuNK RV ImRAMKIXI.- 

I.ARV Pi-f.f.iNG: — A. W'K i^ ^.fi-ii ill iiR-diillaiy 
ta\ ity ot lowt-r bone, and about lo bi- iiitrodm t-tl 
iiilo lliat of upi><.T ; H. I'rriostcuni is bciiij;; su- 
tured aloiij; m.irgiiis ol bone. 



FIr. T52. — Opi;ration for Fracturhd or 
Reskctkd Bonk bv Intramkdui.i.ary Peg- 
ging:— Where part of one hone has been ex- 
cised and periosieuin is being sutured around 



carry them under the wires emerging from those holes and twist them together 
in the long axis of the hone (Figs. 141-143). 

(4) Intramedullary Pegging. — Pegs of ivory, or of fresh, or decalcified 
hone, are lightly driven into the nieckillary canal of one bone, and the ends 
of the fractured Ix^nc so displaced, temporarily, as to enable the medullary 
cavity of the opposite fragment to he slipped over the opposite end of the 
peg (Figs. T50 and 151). Where there has been a loss of substance of bone 
and the j)eriosteuni corresponding to the ah.sent hone is preserved, this has 
been sutured over the bone peg with success, especially in the young (Fig. 152). 



STIMSON'S OPERATlOxN FOR FKACTLRKD PATELLA. 



197 




Fig. 153.— Ophration for FRAcrrRKn Patkli.a bv Stimson's Mkthod ok Mfdiatii Si'Turk : 
— A, Ht-avysilk suture (of inattrc^^ \arict> t passing ilirough j;rt'aUr thickness nf <]uaflrict|is extensor 
lendon. above, and liKainenlum patella-, below; b. Chromic k"1 suture ol lorn capsule ami fibro- 
Ijeriosleum. 



OPERATION FOR RECENT OR UNUNITED FRACTURE OF PATELLA 

KV STl.MSON'S .MKTHOD Ol- Mi:i)I.\Tl-. SUTIRH. 

Description. — The margins of bone, after being cleared, and, if necessary, 
freshened, are held in position })y a hea\y silk suture-loop passed trans- 
versely through the quadriceps e.xtensor tendon above, and the ligamentum 
patella* below. 

Position. — Patient supine; limb fully extended. Surgeon on side of 
operation. Assistant opposite. 

Landmarks. — Contour of patella. 

Incision. — Median, in long a.xis of limb, with its center over center of 
patella and extending considerably above and below the j>atella but not 
passing into muscular tissue. 

Operation. — The incision extends through skin, fascia, prepatellar bursa, 
expansion of quadriceps extensor tendon, and periosteum directly to the 
patella bone. The soft parts arc well retracted, so as to ex|)ose the entire 
extent of the transverse fracture (which is |)()ssible because of the length 
of the incision) (Fig. 153). The joint is irrigated to remove the clots. If 
the fracture be recent, no removal of fibrous tissue or })one is necessary. If 
old, each fragment is carefully seized with bone-holding force[)s and steadied 



ipS OPERATIONS UPON THE BONES. 

in such a position as to render it accessible to the saw, and a thin slice of 
bone is then removed. A heavy silk ligature, threaded upon a curved needle, 
is now carried transversely through the ligamentum patellae near its apex, 
passing through about two-thirds of its width and thickness — then trans- 
versely through the quadriceps extensor tendon, near the upper border of 
the patella, also passing through about two-thirds of its width and thickness. 
While the fragments are held in close contact this hgature is tightly tied. 
The torn capsule on either side of the patella and the fibro-periosteum are 
sutured with chromic gut. The fibrous tissues overlying the patella, and 
divided in the median incision, may then be sutured with buried gut suture. 
The skin wound is closed. No drainage is used. The limb is put up in 
full extension. 

Comment. — In some old cases the quadriceps extensor tendon has con- 
tracted to such an extent that it is necessary to lengthen the common quad- 
riceps extensor (see operation for muscle-lengthening, page 208). 



OPERATION FOR RECENT OR UNUNITED FRACTURE OF PATELLA 

HV WIKINC. OR SLTfRrxr.. 

Description. — The ends of the bones, after being cleared, and, if neces- 
sary, freshened, are drilled and wired together, the wire being buried and 
left — or they may be sutured witli an absorbable material. The joint may 
be exposed by a median vertical, transverse, or by Cheyne's oval incision — 
the last being here described. 

Position— Landmarks.— .As in the above operation. 

Incision.— Oval, outlining' a flap with upward convexity, which is raised 
from over the patella and temporarily turned downward. The incision 
l)egins 2.5 cm. (i inch) to one side of the patella, on a level a little below 
the fracture — extends vertically upward and then curves across the front of 
the thigh about 2.5 cm. (i inch) above the upper border of the patella, and 
descends on the oj)posite side to a point corresponding with its commence- 
ment. This flap-incision gives a full field and places the scar above the 
patella. 

Operation. — The fractured ends of the bones are exposed, the joint 
irrigated, and the fragments slightly everted and examined. All inteq)Osed 
periosteum, fibrous and other tissue are removed. In recent cases no removal 
of bone is ordinarily indicated. In old cases a thin slice of bone is removed 
from each fragment. Each fragment is now grasped in turn by means of 
stout bone-forceps, injuring the bone as little as possible while firmly steadying 
it (Fig. 154). One, two, or three wire sutures, as seem indicated, are now 
intro(lucecl in the following manner; — Two holes are drilled directly opposite 
each other in a vertical line, in the upper and lower fragments, a short incision 
being made for the drill through the fibrous covering of the patella, within 
8 mm. to 1.3 cm. (^ to h inch) of the fractured edges — the margins of the 
incision through the fibrous tissue being drawn aside and the drill (hand or 
motor) directed obliquely, so as to come out at the fractured margin after 
having passed through about two-thirds of the thickness of the bone. All 
the drill-holes are first made, and arc made from without inward. Care is 
taken that each pair of holes is drilled immediately <)[)posite and that their 
|)oints of emergence on the fractured surfaces are on the .same level. The 
wires are now passed, arc graspcfl with strong forceps, and. while an assistant 
firmly approximates the margins of the fragments, these wires are tightly 



OPERATION FOR FRACTURED PATELLA BY WIRING. 



199 



twisted for three or four turnst cut off about 6 mm. ({ inch) long, bent upon 
the bone, and sh'ghtly buried by one or two blows of the mallei. The peri- 
osteum which has been drawn out from between the fragments of bones 
is stitched together with chromic giit to the opposite tip of the turn penui^leum. 




^ 



B 



J 



Hlir tH — Or«*ATioN FOR Fractvurd PATm-i.A nv Wiring :— a, Lo«pr frajrmeiu ol patella 
I with Uin«-hoUliiij; (orct'ps ; li, Drill in hcI <>t m:tkitiK holes fur ixissrijfc of silver wire, oiic 
bich <* «rci» in |Misiu<>ii ; C, Chromic gul suture uf lorn capsule ami t'lluo |>rrlosteum. 



rent in the capsule ^enerallv found on each side of the fractured patella is 
«imilarly sutured with gut. The fibrous covering of the patella, incised in 
raising the oval f^ap, is sutured with l)uried put. The wound is i ioscd through- 
no <irainage fnfing usefi. The limb is f)ut up in full extension, 
, Comment.— Chromic gut, kangaroo tendon, and siik are also used in 
I Mine manner as wire. 



200 



OPERATIONS UPON THE BONES. 




FiK- 155.— Operahon kok Kkacturkd Oi.kcranon by Wikino:— A. Drilling holes for pas- 
sage of silver wire, (hk- siiiiiro liciiic; seen in position, ami one being diawn ihrougli ; B, Chromic gut 
suturing ol lorn capsule and filjro-perioslcuin 



OPERATION FOR RECENT OR UNUNITED FRACTURE OF OLECRANON 

HV \VIRI\r, OR Sr TURINC. 

Description. — The olecranon is cjuite frequently fractured at its junction 
with the .shaft of the ulna- and is repaired l)y wiring or suturing in the same 
general manner as in the case of fracture of the ])atella. 

Position. — Patient supine; forearm drawn across chest, by an assistant 
on the opposite side, presenting to the surgeon the semiflexed elbow, while 
exposing the fragments; and fully extended by the side while suturing. Surgeon 
stands opposite the ell)ow. 

Landmarks. — Contour of olecranon; shaft of ulna; condyles of humerus. 

Incision. — The site of fracture may be exposed — (i) By an oval incision; — 
beginning to one side of lateral border of olecranon, just below the fracture 
-f)asses uj)ward in axis of limb for about 2.5 cm. (1 inch) above the olecra- 
non--thence curves across arm and descends to a corresponding point on the 
opposite side — thus furnishing a free exposure of the fracture and providing 
a scar which falls out of the way of pressure. (2) By a median longitudinal 



SEQUESTROTOMY. 



20I 



incision; — beginning and ending considerably above and below ihe line of 
fmrlure, but not involving the muscles above or below — and having its center 
over the fracture. The length of this incision allows of siit^kient lateral 
retraction to well expose the parts (though less jierfectly than the incision 
just fleRribed). 

Operation, — The incisi«>n pas^s through skin, fascia, bursa, fibrous 
ision of the triceps tendon, and periosteum directly onto the bone 
'»g- 155)- The manner (»f exposing the fractured ends, irrigating the 
:tint, removing a slice of bone from each fragment in old cases, drilling the 
igments, passing and tightening the wire, suturing the torn periosteum and 
iscia, and closure of wound are similar, in all practical essentials, to the 
:)rresponding steps in the operations just described upon the paleUa (page 
198). The limb is put up in full extension. 

Comment. — (i) Chrc»mic gut, kangaroo tendon, and silk may l)e used 
instead of wire. [2) In some ol<l cases, where much retraction of the triceps 
tias (xcurred. that muscle should be lengthened, as described under muscle- 
thening (page 20S). 

SEQUESTROTOMY. 

Description. — An operation for the removal or excision of a .sequestrum 
(dcarl bone) en masse. The o|>eration might be more ])roperly termed 
]uc>treclomy. The site of the sequestrum is generally determined by the 
[>resence of one or more sinuses, together with the history of the case. 

Position and Preparation.— ^Patient is so placed as to e.xpose the in- 




Fig, t^fi.— Cboss^kction op Leg, Showimc a SeouESTietiM cavitv- 

volved site most conveniently. A constrictor is usually applied, where 
possable, to control hemorrhage. 

Landmarks. -( jenerally the existence of one or more sinuses; the known 
anatomy of the {lart. 

Incision. — (Generally placed in the long a.xis of the limb, or in such a 
as tn fall in with the intermuscular cleavage line and so as lo le.id 
the site by the safest route — with its center over the sinus, or extending 
between the two chief sinuses (Fig. 156). 

Operation.— The incision passes down to and through the periosteum. 

•soft parts, including periosteum, are then retracted laterally, fully ex[>osing 

bone in the neighborhood of the sinus, or between two or more sinuses. 

may be at once jx»ssiblc to grasp the sequestrum with strong forceps 



202 



OPERATIONS UPON THE BONES. 



introduced through the sinus-opening and draw it out — or the sinus-opening 
may be sufficiently enlarged for this purpose by rongeur forceps. If neither 
of these can be done, the sinus may be enlarged with the curved chisel — 
or the bone between two sinuses may be chiseled away — or the bone may 
be chiseled away in the long axis of the sequestrum, even where but one 
opening exists — or a trephine-opening (one or more) may be made instead 
of using the chisel. Following the removal of the sequestrum, the cavity 
of the bone should be well scraped. The periosteum and muscles are then 
united by buried gut sutures, and the skin closed with sutures of silkworm - 
gut or silk — drainage being established to the bottom of the bone cavity 
in the most favorable position. If the limb be weakened l)y the operation, 
it should be put up in a splint. 




P'K- '57- — Skqukstrotomy ; — Neuber's Operation. The aiUc-io-iiitenial aspect of the tibia is 
removed — sequestrum cavity scraped— the integumentary tissues nailed to its floor — and relaxation 
sutures placed. 

Comment. — Bone-chips may be used in the cavity — or the entire thick- 
ness of the soft parts, including periosteum, may be inverted into the bottom 
of the bone cavity from each side and held in place by a nail or peg (Fig. 
157). Or the cavity may be packed throughout with gauze. 

OSTEOPLASTY. 

Description. — Transplantation of bone— in the form of bone-chips or 
decalcified bone-fragments — which are placed in the desired site and among 
which organization of the blood -clot takes place. The transplantation of 
a larger section of bone, entirely <letached, has not yet been commonly done — 
though the success of reinserting the trephine buttons suggests the practi- 
cability of such a course. This principle will be further mentioned under 
osteoplastic amputations. 

Operation. — The site of operation having been rendered bloodless by 
a proximal constrictor, and having provided the bone-chips in advance 
(which come specially prepared by decalcification), the locality is e.xposed. 
If the chips are to be used within a bone cavity, such as a scraped medullary 
cavity, it is seen that this is thoroughly aseptic before their introduction. 
If they are to be used within a periosteal cavity (as after the partial resection 
of a bone), this periosteal cavity should l)e kept as nearly like the special 
form of the original bone as possible. In the case of the bone cavity, the 
bone chips are dropped into the cavity and the soft parts sutured as just 
described in the above operation. In the case of a periosteal cavity, sutures 



EXCISION. 203 

of gut are made to approximate the periosteal margins over the included 
bone-chips — and the muscles over the periosteum — and finally the skin, in 
the usual manner. The tourniquet is then removed and the blood allowed 
to flow into the part and fill the interstices between the bone-chips. The 
part is usually put up in an immobilizing splint. 

Comment. — If the neighboring parts do not cover the site in which the 
bone-chips have been deposited, they may be covered by sterilized rubber 
tissue. 



EXasiON. 

Excision of the bones is described under the general head of Excisions, 
including both joints and bones (pages 397 to 457). 



CHAPTER VI. 

OPERATIONS UPON THE JOINTS- 

ARTHROTOMY. 

Description. — A simple incision into a joint. 

Indications. — Kxploralion; removal of foreign body; evacuation of pus. 
or other fluid; irrigation; drainage. 

Preparation. — As for a major operation of the same joint. 

Position. — Determined by the special operation — and such as to render 
the site of incision prominent and convenient. 

Special Instruments. — Scalpel; dissecting forceps; artery-clamp forceps; 
retractors; tourniquet (sometimes). 

Operation. — The patient having been placed in a position to render 
the joint most accessible — and the overlying tissues in the best position with 
reference to the joint — an incision, of the simplest form and shortest extent 
compatible with the object in view, is made over that aspect of the joint 
which will lead into the interior of the joint-structures by the route which is 
shortest and safest, both in regard to the joint-structures and the tissues 
intervening between skin and joint. Having opened up the joint, the sub- 
sequent steps will depend upon the special object of the operation; — (a) 
Where exploration is the object; its interior is examined by some form of 
probe or sound, or, preferably, by the gloved finger-tip; — (b) Where the 
removal of a foreign btnly is sought; suitable forceps are introduced, with 
which it is grasped and withdrawn; — (c) Where drainage is indicated; a 
tube, or other drain, is inserted through the incision, with or without a counter- 
opening. In the first two cases, the wound is entirely closed. In all cases 
the joint is immobilized. 

PUNCTURE OF JOINTS. 

Description. — The exploration of the fluid contents of a joint by means 
of the needle of a suction-syringe — for the purf>ose of ascertaining the nature 
of those contents — or for the evacuation of the fluid found. 

Indications. — Collection of pus, or other fluid, within a joint. 

Preparation— Position. — .\s for arthrotomy. 

Special Instruments.- Exploratory or aspirating s\Tinge. 

Operation. -The same preliminaries having been observed as in ar- 
throtomy, the needle of the exploratory syringe is thrust, by the safest and 
shortest route, into the joint — the cylinder withdrawn and the contents 
aspirated. Following the withdrawal of the needle, the punctured wound 
is hermeticallv chased with sterilized collwlion. 



ERASION OR ARTHRECTOMY. 

Description. — Etymologically, erasion signifies the scraping or curetting 
of a joint — and arthrectomy, the cutting out of a joint. Practically, both 
expressions are used synonymously — and are taken to signify the exix)sure 
of a joint with the removal of the diseased tissue alone. While arthrectomy 

204 



ERASION OR ARTHRECTOMV. 



205 



signifies, literally, the cutting out of a joint, it is not here used as the word ex- 
cision commnnly signifies. In excision, the articular ends of the bones are 
invariably removed— in erasion or arthrectomy, while a certain amount of 
l)one may be incidentally removed (and always as much as is diseased is 
removed) in the gouging, only the articular cartilages and synovial membrane 
*rc supposed to be scra|)e<l ur curetted. When bone is removed at all, the 
least possible is removed, and that is generally done with a gouge — and the 
whole operation ccjnducled with as litllc injury as possible to the neighboring 
Structures. In extreme cases all the articular cartilage is gnugcd away, all 
ihe synovial membrane is dissected nut, and some of the bone is removed. 
An erasion or arthrectomy is, therefore, commtmly understood as the applica- 
tion of scraping to the interior of a joint — ^the laying open of a joint and the 
femoval of as many and as much of the tissues forming the joint as are dis- 
eased — synovial membrane, capsular ligaments, cartilage, and bone — the 
removal generally being accomplished by some form of gouge for cartilage 
and b<tne, and scissors and knife for soft parts. An arthrectomy, finally, 
may be regarded as a procedure the same in general purpose, though less 



B 




Fig. Ifj^.^'EKASlOM or T}IH Knkb-JOINT :— A, Rctnovsil ol iMniliiKC Of condyle of Icttikir with 
rm&paXoty . B. RermjVitI uf mrtiLiKC v>f itbiavvilh curette:. The juiiil is cxposctl by ■ Intnsvvncly 
csrvrd htci»ion and the |Mtclla tttnicd backu-anl. 



se**ere in dcj?rce. as an excision — and is distinctly a conservative measure espe- 
rially afjplicable to early cases. An arthrectomy is a part (►f every excision. 
Arthrectomy has its greatest application in joints of simple structure and easy 
.ijipr^nuh — the knee being its nn)st frequent site of ajiplication. A movable 
ioinl is always to be sought after erasion. even in the case of the knee 
(although in the latter case some surgeons jirefcr to secure ankylosis in 
preference to a probable weak joint). Arthrectum\' is always preferalde to 
excision in rhildrrn, owing to its non-interference with the growth of bone. 

Indications. — Disease of the articular strurturcs, especially tubercular. 

Preparation -Position.— As for excisions (page 397). 

Special Instruments.— Be^des those used for excisions, the following 
»re sfjccially re<(uirtd; -(lougcs. curettes; spoons — of many sizes ami sha|)es, 
dull and shaqj. Flushing-gougeii. 

Operation. — Xo form of constrictor is ordinarily use<l— ^though may be 
use*!, as in excisions. The incision is generally the same as that for the 



^m 




2o6 OPERATIONS UPON THE JOINTS. 

excision of the corresponding joint. Having exposed the interior of the joint, 
the following structures are closely examined, and, if necessar>', removed 
— the guide being that all diseased tissue should be removed ; — (a) Synodal 
membrane; where but slightly involved, is curetted, — where extensively, it is 
grasped with toothed forceps and dissected out, in as continuous a layer as 
possible, with scissors or scalpel. Every recess is sought and, if diseased, 
thoroughly curetted or removed, (b) Bursa; communicating with joint; are 
subjected to the same treatment as the synovial membrane — ojDened up 
and followed to their furthest extent, (c) Ligamentous tissue; to be scraped 
and cut away, (d) Articular cartilage; all involved or suspicious areas are 
gouged out with a sharp spoon, (e) Articular ends of bones; if actually 
diseased, or suspicious, to be removed with gouge, (f) Extra-synovial and 
extra-articular tissues; to be dissected out and removed, if involved. Finally, 
where much debris results, it is well to use a flushing-gouge and clean out 
the area of operation. Drainage is usually not necessar\' — but may be 
temporarily used where thought best. The capsular ligament, if not dis- 
sected away in removing disease, is closed by buried gut sutures. Muscles 
separated in reaching the joint are similarly brought together with buried 
gut sutures. The limb is put up upon an immobilizing splint. The after- 
treatment is practically the same as after excisions — and a more satisfactorily 
functioning joint is to be expected. (Fig. 158.) 



EXCISION. 

Excision of the joints is described under the general head of Excisions, 
including both bones and joints (pages 397 to 457). 



CHAPTER Vri. 



OPERATIONS UPON THE MUSCLES. 

MYOTOMY. 

Description. — Division of muscle — generally done as a preliminary to 
mu5i:Je-lengthening, or in the exposure of underlying parts, or in deformities. 

Operation. — The muscle is fully exposed by an apprapriatc incision — 
or is exposed in the cours^e of some 
ojxrration. Having been isolated 
from neigh tyoring structures, the 
inuscie is cleanly divided with a 
scalpel, cutting transversely, or 
very slightly oblit|uely, to the di 
rection of its fibers. A grooved 
diretior may first tie passed beneath 
the muscle, but is rarely necessan^. 
Myotomy should be done by the 
ojK-n methotl. Muscles are st^mc- 
timcs divide*! subcutaneously (as 
the slemomastoid. for torticollis), 
but this Ls even less atlvisable 
(owing lo their greater size and 
less accurately defmed contour) 
than the subcutaneous division of 
tendons, 

5IY0RRHAPHY. 

Description. — Suturing of 
muscle which has been either pur- 
pi>srly and cleanly divided (as in 
an operation) — or accidentally and 
unevenly divided or ruptured (as 
from injur>- or from excessive 
action). 

Operation.— (a) Where mus 
dc has been deliberately cut in the 
rr>ur«* of an operation, to expose 
v; • parts (as in dividing 

!J mastoid in removing the 

cervical glands); — The muscle is 
here cleanly and evenly divided, 

preferably in a transverse or \ery slightly oblique direction. At the 
tame of iiutuinng, the parts are put into a position to relax the muscle as 
Dticb as possible. WTiile the two opposing ends of the muscle are carefully 
held in easy contact, as many mu.scle -sutures are inserted and tied as the 

207 




Fig- t5<».— MvORHiiAfiiv :— The divided biceps 
h here shown $iutiired in several ways; A. Mai* 
trtss suture; B, lateral knotJeii siuurc; C. 
Peii|>lu'ral 'suliire; D, Lateral IhrLUif^h-aiid- 
Ihroujfh «.iilur*; ; K, Anlero-posUrior throu|fh-aiK|. 
through suture. The last two are here shuwti ms 
reloucalloti— or reiitforcing— *utur«. 




208 OPERATIONS UPON THE MUSCLES. 

size and form of the muscle require. Chromic gut or kangaroo tendon is 
used for suturing — and the sutures are all buried. One of several forms of 
stitch may be applied. As the muscle-sutures are practically the same as 
tendon-sutures, and applied in the same manner, they will only be briefly 
mentioned here and their fuller description given under tendons, (i) In- 
terrupted mattress sutures (Fig. 159, A). This is probably the best form of 
muscle-suturing. (The manner of its insertion is given at page 214.) (2) 
Interrupted sutures passing transversely through the upper and lower ends 
of the cut muscle (page 214). (3) Lateral knotted sutures (Fig. 159, B) (page 
2^5)- (4) Simple, peripheral longitudinal coaptation sutures (Fig. 159, C) 
(page 214). (5) Relaxation sutures for reinforcement; — In any of the above 
forms of primary or coaptation sutures, one or more relaxation sutures of 
heavy catgut may be applied passing transversely through the entire thickness 
of the muscle considerably above and below the primary sutures, and tied 
tightly enough to take the chief tension — and thus free the primary sutures 
from strain (Fig. 159, D, E). (b) Where the muscle has been accidentally 
and unevenly ruptured: — The ruptured muscle is exposed by the safest, 
most direct, and least damaging route — remembering that the ends of the 
muscles may have retracted far away from their normal position. If the 
ends of the muscle have been left ver}^ irregular, they are carefully trimmed. 
and are then sutured in one of the above manners. If they be torn almost 
transversely, they are approximated and sutured without trimming. If 
much muscle tissue have been lost, or be sacrificed in trimming, some process 
of lengthening may have to be resorted to before the ends can be made to 
meet without Ux) great tension (see muscle-lengthening, page 208). In 
order that the skin -incision, used in reaching the part, may not lie over the 
muscle wound, bringing two cicatrices directly opposite, a cur\'ed incision 
may be used — or an oval flap of overlying parts may be raised. In com- 
pleting the operation, the part should be so immobilized in the dressing 
as to relax the muscle as comi)letely as possible. 



MUSCLE-LENGTHENING. 

Description. — In old cases in which mu.scle tissue has contracted con- 
siderably (as in long-standing cases of fractured patella or olecranon) — or 
in cases in which much muscle tissue has been lost in injurj', or has been 
sacrificed in trimming muscles for suturing — it is impossible to appro.ximate 
the separated ends without too great tension, unle.ss the muscle be lengthened. 
Muscle-lengthening, therefore, is resorted to in two sets of cases, — those in 
which muscle must he lengthened to enable parts below, other than the 
muscle, to be ai)proximated without too great tension (as in the case of the 
triceps or the common quadriceps extensor, in fractures of olecranon and 
patella),— and those in which lengthening is necessar\' after an old transverse 
rupture of a muscle in which the ends are separated too far to allow of ap- 
proximation without ioo great tension (as in transverse rupture of the biceps 
muscle). In either category of cases the operation is the same. 

Operation.- The patient having been placed so as to relax the part 
completely, the site of lengthening is exposed by a longitudinal incision of 
about 7.5 to 10 cm. (3 to 4 inches) in length, placed over the involved muscle. 
The incision should he su ITk lent ly long to afford free access and manipulation 
and planned to reach the parts by the safest, most direct, and least damaging 
route. Retract the overlying soft parts and isolate the muscle. Divide the 




M use LE-t ,E NGTI \ ENING. 



209 



muscle in a zig-zag line mnning transversely, and about 7.5 to 10 cm. 
(3 lo 4 inches) above the nipturetl j)art. This is a series of bluntly rounded 
scmilions or V'!> — the incision passing tijvward about 5 cm. (2 inches) and 
downward the same distance, until the width and entire thickness of the 
muscle is traversed (Fig. 160, A). The muscle on either side of the zig-zag 
incision is now drawn apart until ihe apices of the V's luiuh. If the leelh 
or serrations are 5 cm. (2 inches) in length, when the suturing is done, nearly 
5 cm, (2 inches) in length will be 
gained. The adjacent lateral mar- 
gins of the two muscle ends are now 
sutured by the knotted sutures de 
scribed above (Fig. 161, I£, E) (pages 
214 and 215). A V from above is 
now sutured, by the same knotted 
suture, or other form of suture, to 





Wtg. HbO. — Mt Wrt-K-LKNGrHISNINCi :— I— A, By Fig. fit, — McsCI-K-tRNGTHKNINO :— II — 

nMHi' ol m ■eti« o| U-«h»p«l incHiotm ; B, by a Maimer of suturitig ihe miisLle-seciions shuwit in 
•!■()« lofig V'«iu I led liKisloii. rrhc manner of the iRst iDustration ; A. Needle (.-arryirig cnie part 
■■ilim. Iliiir »cvUoii* ts shown ill Itic (olluwirig of t Ulerql knuUcri suture through one oi the 
I.J tiinRnes of the spill muscle : B. Opposite part 

plitced ; C, Enrh half tiol unci Ihe Iree emJs being 
kiifitlc^i; t). A completeti lntcr«it knotted '»h- 
lure, E, R. LatemI knotted kuiuie» tipproxi- 
matiitg tite bnM-9 uf the tongues and at»o scrying 
as relaxAlion-itulures ; P, Suture of the tongur- 
and-gro<»ve «uture. 

below. Ui that their blunted tips are held in contact by the sutures 

through alxivc an<l IrIow their lips (unless some such form of 

turr be used, as shown in Fig. 150, A. B, C, D). Theoretically, the apex 

a V abo\-e will correspond with the base of a V heiow, but, practically, 

antCTf are so dis[>oscd in the suturing as to bring them in contact. Suffi- 

nt length having been gained, the lower oiteraJion, for which the lengthening 

prinwii-ily done, is now performed (an ununited fracture of patella or 



210 OPERATIONS UPON THE MUSCLES. 

olecranon, or ruptured biceps) — and unless this site has been exposed in 
the original incision, a separate incision is made for that purpose. Both 
wounds are then closed and the limb placed in a splint that will cause full 
relaxation of the parts during healing. Lengthening may also be accom- 
plished by a long V-shaped incision, as in Fig. i6o, B, which is then sutured 
as shown in Fig. i6i, F. 



CHAPTER VIII. 

OPERATIONS UPON THE TENDONS AND 
TENDON-SHEATHS. 

TENOTOMY. 

Description. — Division of tendons. 

Varieties. — Open Tenotomy, where the tendon is freely exposed before 




\ 






Fij?. i62.~f)PKN Tesoiomv : -ftf ill. tend.. A. hillis. 



heinj; cut. Subcutaneous Tenotomy, where the chvision is made l)cneath 
ihf skin, by the sense of touch. Complete Tenotomy, where the entire thi( k- 

21 I 



212 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

ness of the tendon is divided. Partial Tenotomy, where a part only of the 
thickness of the tendon is dix-ided, the remaining fibers being stretched. 

Indications. — Shortening of tendons. To prevent action of muscles. 

Special Instruments. — For open tenotomy; — scalpel; artery-clamps; dis- 
secting forceps ; retractors. For subcutaneous tenotomy ; — tenotomes, straight. 
cur\'ed, sharp and blunt. 

Open Tenotomy. — The tendon is here divided in an open wound. The 
incision for its exposure is generally made parallel with and directly over 
the tendon. The overlying .soft parts are retracted — the tendon is exposed 
and isolated — and its sheath, if any. is opened. The tendon is then grasped 
with forceps and divided with a scalpel. The ends retract in both directions. 




FiR. i6.^.— Si'BCfTANKoi's Tknotomy :— Of the tendo Achillis. 

The wound is entirely closed and the limb dressed upon a splint, or the part 
immobilized (Fig. 162). 

Subcutaneous Tenotomy.— The tendon is here divided subcutaneously, 
through the smallest possible wound. Having put the tendon upon the 
stretch, to render j)r()mincnt, an incision is made parallel with and just to 
one side of the tendon to be cut, and so placed as to do the least damage 
to other structures in the neighborhood. The incision is first made with a 
sharp tenotome, through skin and fascia down to the tendon — upon this as 
a guide the hlunl tenotome is passed sidewise (the sharp one being withdrawn). 
The tenot(»nie is then insinuated beneath the tendon, which it closely hugs 
throughout. Sometimes temporary relaxation of the tendon will aid the 
passage of the knife beneath it. The cutting-edge of the tenotome is then 
turned outward -the tendon put upon the stretch — the forefinger of the 



TENORRHAPHY. 



2U 



left hand being placed over the siie of section as a guard and guide — and the 
tendon cut by a short sawing movement, the hist libers being cut carefully 
as the tendon is feU to yield. Tht- knife is finally withdrawn upon its side. 
The wound is sutured and the limb dressed upon a splint (Fig. i6j). 

Comment. — (i) In simple sections where the tendons are easily accessible 
and the neighboring parts are not important, subcutaneous tenotomy may 
be done. Where the opjjosite conditions exist, open tenotomy should always 
be practise<i (3) In doing subcutanei>us tenotomy, the tenotome is some- 
times inserted between skin and tendon and the section made inward upon 
the tendon — which is more dangerous than cutting from beneath the tendon 
outwajxl. 

TENORRHAPHY. 

Description. ^Suturing of tendon. In recent cases the ends of the 
tendons can ordinarily be approximated without great difficulty. In old cases 
if the ends cannot be approximated and sutured after freshening them by 




ift4-ifi7.— Tkmorrhafiiv • — A.Siftg^le suture through entire thiclcncM of teiirlon ; B, Two 
ictfllrrly itirouKli ictHK^n, in opposite (Jirectioiis ; C, Peripheral sutures; D, Woelflcr's quili 



trimming, some method of lengthening must be used — and if their uniim 
cannot Ije accomplished by lengthening, irans])lantution to adjacent tendons 
may l)c resorted to. 

Varieties. — Primary, when the tenorrhai»hy is done near the lime of 
injur)'. Sccondar)', when done after healing. 

Operation.— In recent cases an already existing wound may be present 
fexrt-|il insuchca««s as subcutaneous ruj)turcof a tendon) and where a wound 
i I't. this is simply enlarged and the tendon more fully exposed and the 

. l.tted. Where nt) wound exists at the time <jf the tenorrhaphy, the 

itn^in tcntjon anri its cnrj* are exjKisc<l by an incision which reaches the site 
by the safest and simplest route. In primary tenorrhaphy the ends may 
rrqtnre no trimming, esjjecially in clean ruts.— or hut slight trimming. In 
icctjfxlan' tenorrhaphy, a transverse or oblique section of the lcn<lon ends 
is aJwa)** necessary, prior to suturing. In either case, the opposite ends of 



214 OPERATIONS UPON THE TENDONS AND TENDONSHEATHS. 

the tendons are brought weU into the wound and approximated. Chromic 
catgut and kangaroo tendon are the best materiak for uniting the ends. 
Several methods of suturing are used — the chief of which wiU be here de- 
scribed: (a) Interrupted sutures passing transversely through upper and 
lower ends of di\ided tendon (Figs. 164 and 165, letters A, B); — A straight 
needle enters the proximal surface of the upper portion and passes transversely 
through its thickness, about 8 mm. or 1.3 cm. (from i to J inch) from the 
cut margin — emerges at same level upon distal surface — crosses the gap — 
enters the distal surface of the lower portion, from 8 mm. to 1.3 cm. (J to J 
inch) from the cut end — passes transversely through — emerges at same level 
on proximal surface. The two ends of the suture are drawn upon until the 
tendon ends are approximated, and are then tied. When the tendon-ends 
have Ijcen cut obliquely, the sutures are so passed as to cross the line of 
division at a right angle (Fig. 173, B). (b) Interrupted mattress sutures: — 
A cur\ed needle enters the proximal surface of the lower portion, about 8 
mm. (i inch) from its end — passes a.xially through two-thirds of the thickness 




Figs. 16S-171.— Tknorrhaphy:— A, Mattress sutures; B. Same, tied; C. I.ateral ; knotted sutures; 

U, Same, tied. 



of the tendon — emerges on the cut margin — crosses the gap to the upper 
f)ortion - enters the cut margin about two-thirds its thickness from the prox- 
imal surface -emerges al)out 8 mm. (^ inch) above the end — passes over 
the outer surface of the upper portion of the tendon for from 8 mm. to 1.3 
cm. (if to i iiuh) — again enters the upper portion on a level with the point 
at which it has just emerged from the upper portion — passes through about 
two-thirds its thi( kness — emerges on the cut margin — crosses the gap to the 
lower portion - enters its cut margin about two-thirds its thickness from 
the pro.ximal surface — and emerges on the proximal surface on a level with 
the original entrance-when the two ends of the tendon are drawn upon 
until the rut surfaces come well into contact and are then tied (Figs. 168 and 
i6(), \ and H; and Fig. 167. D). (c) Peripheral longitudinal coaptation 
sutures;- A curved needle enters the lateral surface of the upper portion, 
about S mm. or i.;^ cm. (J to A inch) from the cut edge — passes longitudinally 
through the tendon and emerges on the cut margin about 6 to 8 mm. (\ to J 



TENORRHAPHY. 



31$ 



inch) from the lateral surface — crosses the j^ap — enters the cut margin of the 
lower portion, from 6 to 8 mm. (| to J inch) from the lateral surface— passes 
longitudinally through the muscle and emerges on the lateral surface, about 
mm. to 1.3 cm. (§ to J[ inch) from the cut margin. The upper and lower 
ends of the sutures are now lied, approximating the tendons. These sutures 
axe repeatetl at intervals of about 8 mm. to 1,3 cm. (^ lu h inch) around the 
entire circumference of the tendon (Fig. 166, C). (d) Lateral knotted sutures; 
— A curved needle enters the lateral surface of the upper portion about 8 
mm. to 1.3 cm. (^ to J inch) from the cut margin — passes Iransversclv through 
the tendon tissue for about 8 mm. to 1.3 cm. (^ to A inch) in width, and 8 mm. 
(\ inch) in depth — and emerges on the level of entrance. The two ends 
of the suture are now tied, care being taken to but slightly, if u\ alb pucker 
the tendon — and one end of the suture is then cut short The same kind of 
suture is applied immediately below, in the lower portion of the tendon, and 
one end of the suture similarly cut short. The two long ends of the .sutures 
are then tied together, thus approximating the two ends of the tendon. As 






17>-IT4, — TUNOiBHAPHv :— A. Rcin(ort.-irij{ or rt'taxatioii suture, applicable to any form of 
(»hown with first turn of knot); B, SuiuriiiK of uMiijucly divided end*; C. Kcinlorciiijf 
(b^tid-throuib ftuturc by lateral suture throUKli loops ot drsl suture. 



nuiny of these pairs of sutures are introduced as necessary (Figs. 170 and 

171, C and D). The extreme margins of the tendon-ends may be Jfurther 

witUTtd, between these sutures, by method *'c." (c) Relaxation sutures; — 

In any of the above forms of primary or coaptation sutures, one or more 

relaxation sutures of heavy catgut may be applied, passing transversely 

|.through ihe entire thickness of the tendon considerably above and below the 

rimary sutures — and tie*! tightly enough to take the chief tension, and thus 

the primar)' sutures from strain (Fig. 172, A), (f) Combinalion nf the 

lintciTuptcd mattress (method "b"), or lateral knotted suiures (method "d"), 

riih rcUixalion sutures (melhmi "e"). Of these various methods, either 

Inethod **a" or **b** is probably most generally applicable— the former 

iespecially in smaller tendons and the latter in larger. Having united the 

don-ends, the wound is closed and the limb put up upon an immobilizing 



2i6 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

Comment. — (i) While a constrictor is not generally necessary, its use is 
ordinarily advisable, (a) Some surgeons prefer to expose the parts by a 
cur\'ed incision, beginning and ending over the tendon, above and below 
the rupture, but not over the rupture — so that there may be no possibility 
of adhesion between the tendon cicatrix and the skin cicatrix. (3) The 
ends of the tendons often form adhesions to their sheaths, and must be freed 
before they can be brought together. (4) All tendon-sheaths opened to expose 
tendons must be repaired with catgut. (5) The upper end of the divided 
tendon retracts further, and is harder to find, than the lower. The upper 
end retracts more because of the more active shortening of the proximal end 
of the muscle. It may be found, in hard cases, by " milking " the tendon- 
sheath downward — or by incising over the tendon higher up and tracing 
downward — or by incising the sheath in the lower part of the wound and 
tracing upward. The upper end of the tendon may sometimes be brought 
into view by extending the fingers or toes, the fibro-serous vincula pulling 
down the adjacent tendons. The lower end is generally not hard to be 
found — when hard, incise over the sheath low-er down and trace upward — 
or pass a probe into its sheath from below and protrude it upward. (6) 
If the two ends cannot be found, one end must be transplanted into a neigh- 
boring tendon of the same group or function (see transplantation and grafting 
of tendons, pages 221 to 223). (7) The limb is put up so as to relax the 
tendon and muscle fully, and held so in a splint during union. After union 
has occurred, passive and active movements are begun early and persisted 
in — in order to prevent adhesion of tendon to sheath, and to get full range 
of movement. (8) It will be seen by comparing the illustrations of Neuror- 
rhaphy (pages 144 to 146) that many of the methods used in uniting nenes 
are applicable to the union of tendons, and vice versa. 



TENDON-LENGTHENING. 

Description. — Tendon-lengthening, sometimes called tendoplasty, is ap- 
plied to the lengthening of shortened tendons, or to the union of severed 
tendons, by processes of plastic elongation. 

Varieties. — Tendon-lengthening may be required in two classes of cases; 
— (I) Where the tendon is intact but shortened; — (2) Where the tendon has 
been severed and the divided ends have retracted. As to the time of per- 
forming the operation, tendon-lengthening may be either primary' (done near 
the lime of injury), or secondary (when done after retraction and healing). 

Operation. — Much tliat has been said under Tenorrhaphy, as to the 
exposure of the tendon, is equally applicable here — (see Operation, page 213, 
and Comment, page 216). Having exposed the shortened tendon, or the 
retracted tendon-ends, in the wound, one of several methods of lengthening 
may be applied — the chief of which will be here described: — (a) Operations 
for lengthening shortened intact tendons : — (i) By long oblique division 
of tendon, with gliding of beveled ends; — The obliquity of the division will 
determine the amount of lengthening — tlie ends being slid past each other far 
enough to still leave sutTicient substance for union — and then the ends are 
sutured by several transverse sutures of chromic gut or kangaroo tendon. 
An oblique incision of 5 cm. (2 inclies) will furnish a lengthening of from 
2.5 to 4 cm. (i to i^ inches) (Fig. 176, B). (3) By central longitudinal 
splitting of tendon with transverse division of the split ends and their 
approximation, surface to surface; — Having split the shortened tendon 



TENDON LENGTHENING. 



2^^ 




Ftjt*. i7i*i7«.— TKNiK>Ni.KNGTHRNiNr, :— A, SpIitlitiK iftulnn transversely ami Ion git ud in ally anil 
sntuirtnK ciidfc lAtcmity ; B^ Splitting .tml suturing; tciidmi obliquely ; C, SpliUin); UMiituri uhiiquely .nnil 
j^liiuliruilly ami f^HtuririK split ponif*iis rnd-to-citd ; D, Splitting one end obliquely and lorigitudi- 
iMUy Ainl suluriiijc the ^plil end laterally lu uppusilc unsplit «!iid. 




Flf!k Ij^ila*— Ti«»mr»*«-l-»»*»»;TM«*MNr. .— A. Splitting on« trifl lonirt^mllnnllv and iraiisvcrBely, 

iMtlM|M|'Htarabti>i iilit em) itilo rip|»r>«ilc tmsplit end : V- <i;l* 

~*' ■ wlifjc bi-nt, and '^iituruii: <ipllt |m>i: ic, 

, D.Samr ■> Inst, with diflcrvut m- nul 



irrJ 



b 




2l8 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

down its center, as far as necessarj' to furnish the needed length, the 
ends of the split portion are divided transversely, or slightly obliquely, in 
opposite directions. They are then glided past each other and fastened 
laterally near their ends by two or more sutures passing through their com- 
bined thickness (Fig. 175, A). (3) By central longitudinal splitting of tendon 
with transverse division of the split ends and their approximation, end to 
end; — Somewhat similar to the method just described, except that the extreme 
ends of the split portions are sutured end-to-end, rather than surface-to- 
surface (Fig. 177, C). (4) By zig-zag incisions; — Incisions, transverse to 
the length of the tendon, are made on opposite sides of the tendon, p>assing 
half-way across, and not placed directly opposite each other. As many as are 
deemed necessary are thus placed, and the tendon lengthened by traction 
(Figs. 187 and 188, A, B). (b) Operations for lengthening shortened 
severed tendons : — (1) By partially splitting one end, twisting the split half 




Fijfs. 1S3-1S6.— Tknu<)n-i.f.N(;thknino :— A, Double splitting of both ends, reinforcing where 
bent, and suturiti^ split portions cnd-to-end ; B, Bridj^ing with gut, or reinforcing or relaxing with 
lateral knotted sutures ; C, Bridging with twisted gut ; D, Interpolation with another pieceof tendon. 



and suturing it to itself and to the end of the opposite end. Calculating the 
required amount of tendon needed, the upper end of the tendon is partially 
split, twisted upon itself and sutured to itself — and its free end sutured to the 
opposite lower end of the unsplit tendon (Fig. 178, D; and Fig. 179, A). 

(2) By partially splitting both ends, twisting the split portions and suturing 
them to themselves and to the end of the opposite end. This is the applica- 
tion to l)oth ends of the principle applied in *'i" to one end (Fig. 180, B). 

(3) By partially sj)litting both ends, twisting the split portions and suturing 
them to themselves and laterally to the opposite end (Fig. 181, C). (4) 
By distance suturing, or bridging, with catgut; — The ends are approximated 
by lateral knotted sutures, as far as possible, then a continuous catgut suture 
is run back and forth between the ends and between the lateral knotted 



TENDON-LENGTMENING. 



319 



sutures, partially filling in the gap by catgut strands, upon which lymjih 
and blood are poured, and, together with the calgul, organized (Figs. 184 
and 185, B and C; and Fig. 189, C). Following the union of the tendon- 
vnds, the tendon-sheath, if it have been incised or othenvise injured, is re- 
paired with catgut sutures, as far as possible. In exposing the tendon, the 
sheath should not ha\'e been needlessly freed, for the vessels of the tendon 
reuvh it through the sheath. The overlying muscles are brought together 
with buried catgut sutures. The skin-wound is then closed — and the limb 
bimmobilized upon a splint, which will insure relaxation of the part. Passive 
*and active motion should be begun as stx>n as sound healing has occurred. 
Comment, — Many of the niethtxls of nerve-lengthening are equally 
applicable to tendon-lengthening (pages 147 to 149). Not only may 
tendon -lengthening be accomplished b\- processes of plastic elongation in the 




Fljt«. 187-1*).— TBwnoN-lnNcTURNiNc —A. Poncct's accordion method lin cascof Icndo AchJUi«) 
—inciMQns pnitly across tenduij ; B, Same, fthovring amount of lengthening by traction upon tendon ; 
C. Sndcing wtth gut, reinforced with decftlcified bonv-rylinder. 



of bringing into position undetached portions of tendon — but elongation 
ly l>c also accomplished by the interposition of tendon substance, in those 
where the gap is loo long to be bridged by other means, as in the similar 
■1 for nenc lengthening. The two most ordinary ways are the 
i .:, — (a) A piece of tendon of the required length and as nearly the 

^dc?urrd size as possible, taken from a human being just operated upon, tir 
rfrom a lower animal, is inserted into the interval between the severed ends, 
irhich have been freshened, and is sutured to both ends of the main tendon 
by longitudinal [>eripheral sutures, or other method (Fig. 186, D), (b) Half 
ihc tliickne^s. and as much of the length as required, of part of the same or 
oC one of the neighboring tendons of the patient is taken, and sutured, as 



220 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

above, into the gap. The wound is treated as after other forms of tendon- 
lengthening. The interpolated tendon probably disappears, as such, after 
serving as a framework. 

TENDON-SHORTENING. 

Description. — The shortening of a tendon for the purpose of increasing 
the action of a muscle which has become impaired by the elongation of its 
tendon,— or for the purpose of improving a deformity (as the shortening of 
the tendo Achillis for talipes calcaneus). 

Operation. — Having exposed the involved tendon, its shortening may be 
accomplished in one of several ways; — (i ) By excision of a piece of the tendon, 
with the union of the resulting ends by one of the methods of tenorrhaphy. 
(2) By oblique division of the tendon, followed by gliding of the ends in such 
a way as to lessen the length of the tendon, and the suturing of the ends as 




FIks. ic^o-igj^.— r»:NO()N-SHr)RTKNiNG :— a, Portion of tendon excised obliquely and se\-ered 
portions sutured fiid-to-cnd, in direci contact or ovcrhipping (reverse of Fijj. 176. Bi ; B. Z-&hap«d inci- 
sion is made, followed by excision of E F G H and IJ K L, after which K F is sutured to K L : C, Follow- 
ing excision, ends of tendon are sutured in form of mortise ; D, Excision of portion of tendon by trans- 
verse incision, followed by mattress-suturing of opposite ends (portion between circular transverse 
incisions is here excised). 

in Fig. 19c, A. (3) By division and shortening of the tendon, followed by 
the beveling of one end into a wedge, and the splitting of the other end— 
and the suturing of the wedge into the sj)Ht portion, thus using up the excess 
of length (Fig. 192. C). (4) By the figure of Z method (Fig. 191. B):— 
make a vertical incision down the center of the tendon from F to K. and 
transverse ones along E F and K L. Having drawn the cut portions apart, 
shorten each piece by removing the ends at G H and I J. E F and G H are 
then sutured together, and I J and K L — as well as the vertical line of 
division. The wound, following the operations for tendon-shortening, is 
closed and treated us after tendon-lengthening. Another form of tendon- 
shortening is shown in Fig. 193, D, where a portion of tendon is removed. 



TENDON-GRAFTING. 



a2i 



TENDON-GRAFTING. 

Description.— Tendon-grafting, tendon-lransplantalion, or tendon-im- 
plantiiiion, as liic optralion is variously termetl* is the altaihmenl of ihe 
di-^tal end of a divided tendon into a neighboring «.ound tendon of the same 
general group or function. The altarhment is Fnimetimes made laterally, 
without the division of the invohed tendon 

Indications. — ( I ) Those cases in which so much of the tendon has L>ecn 
destroyed that its reconstruction is impossible — and the damaged tendon 




Figt' i(H-— TkNOON'GKArTINC:— Of souittj cxlciisor of i;real ln«r liilo Impaiicil atilcHor tibial ; A, 
TvTMian at tthiaili* nnticus; B, ProximaJ end oj e>ilciisoi pioptius halluris, which has b«;ii ^tvered 
^ftom itwwrr r»iil. C aixt engrafted upon aiilcrior tibial tciiituii , D. Iiincniiuiit Icniioii ol extensor 
\u ditcHoruiii. 



is therefore grafted to a neighboring tendon (for instance, shiiuld one ^( the 
blotir tendons of the flexor sublimis or profundus digitorum be Ick) extensively 
(damaged for union of the pmximal and dista! ends» its distal end may be 
lattarhc<i to one of the neighboring sound tendons of the same muscle), (a) 
[Those cases in which a group of muscles, or a single muscle, has been para- 
Ij-xed— and one or more of the tendons of the paralyzed group is therefore 
[grafted to a ten<lon of an unparalyze<l group (for instance, if the tibialis 
nticus were paralyzerJ and the extensor proprius hallucis intact, the tendon 
bttrr may Ik* grafted upon the tibialis amicus) (Tig. T94). Where the 
>o of llic muscle fn^m which the power is to be derived is of comparatively 



222 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 

little importance functionally, and the paralyzed muscle is of more importance, 
the entire sound tendon may be diverted into the paralyzed muscle (Figs. 
195-198). But where the tendon of the muscle which is to supply the 
power is more important than the paralyzed tendon, then but a portion of 
the sound tendon should be diverted into the paralyzed one (Figs. 199-203). 




Figs. 193-I9.S.— Thndon-graf 1 i.w, —I— Where the teiidoti of the muscle supplying the power is of 
coiupaialively little importance (shown on the light, in light), the entire sound tetidun is grafted 
upon the impaired tendon (shown on the left, in dark). (Modified from Vulpius.) 




Figs. H/crio-j.—TKNnoN r.RMTisr; :— II— Where the tendon of the muscle supplying the power is 
of greater inijxiTtain e oiiowii on the right, iti light), onl> a pottion ol the sound tendon is grafted 
U]ion the im)iairetl tendon isho«n on the kit, in ilarki. (Modified from X'uljiius.) 



Operation. — Having exposed the field of operation l)y an incision harming 
the adjacent structures as little as possible, and having isolated the involved 
and the sound tendons, the technic of j^raftint^ may be accomplished in one 
of several ways — the chief of which will be here mentioned; — (a) Tendon- 
grafting by lateral attachment :- In the ta^e of a divided tendon, the 
distal end is freshened by an oblique paring (Fig. 204, A). In the case of a 



REPAIR OF RUPTL RKU OR DIVIDED TENDON-SHEATHS. 



223 



I 



Jyzed (undivided) tendon, it is di\ided obliquely (also A, Fig. 204). 
lat portion of the sound tendon to which the involved tendon is to be at- 
tached is freshened upon its lateral asfject — to which the i>bli<iuely divided 
distal end of the injured, or paralyzed, tendon is now sutured with gut by 
peripheral coaptation sutures, or other form of suturing. Sometimes the 
paralyzed tendon is not divided^ but its lateral aspjecl freshened, just as in 
the case of the sound tendon — these aspects being then brought together 
and sutured (Fig. 20<;, 
B). Especially wiaild 
thisbeindicatefl where it 
is possible for the struc- 
ture of the paralyzed 
muscle eventually to re 
pain its functioning, (b) 
Tendon - grafting by 
implantation: — The 
sound tendon is split en- 
tirely through its center, 
over an area sufficiently 
jnng t<» accommodate the 
tendon to be grafted. 
Freshen the distal end 
of the involved tendon 
(injured or paralN'zed) 
by paring both sides in 
a beveling or wcxJge- 
shajietl fa.-jhion. The 
wcfigc-shaped ])iece of 
tendon is then inserted 
between the li|>s of the 
split tendon and held in 
pbcc by two or more 
gut sutures passed trans- 
versely through both tendons (Fig. 206, C). The wound is finally closed 
in the usual way—and the limb put up upon a splint in such u jiosiiion 
to secure relaxation of the parts. 




F\k$. »n-anft,— TE«D€iK-GfcAFTiNr. •— a, nmUliig nid of i!»- 

vulnl triMl4in iitt" Inltral ;is|>c*-t of lUnlivJflwJ teni|>>ii; It, Grnlllrtt; 
iiii<li\ iiliMl ictxloiis hitiT;i1lv, C, Impluiit.itioit oi bc\eU'd cikI of 
lt-tid<jri iHjtWfcii itit split |Hnli(>]is ol M>uti() icrulun. 



REPAIR OF RUPTURED OR DIVIDED TENDON-SHEATHS. 

Description.— A tendon -sheath may be aci idenlally rujnured by violent 
tinn or injury, as in the case of the li)ng head of the biceps, or may be pur- 
posely clivided in an operation temporarily to expose the tendon within, or 
the underlying parts beyond (as the division of the sliealh of the tendo Achillis 
for tenorrhaphy, or the division of the common sheath of the peroneua longus 
an<l brevis tendons temporarily to retract the contained tendons in the excision 
of the ankle joint). 

Hperalion.— When the object is to expose the tendon and sheath alone, 
riv curved incision is made, coming over the shc.uh above and below 
ill- 'lat to one side at the site of rupture {m> that the citalrites of skin 

ajr 11 will not fall directly over each other). Or a straight int ision 

may itc made directly over the tendtm-shealh. \Mien the sheath is divided 
in the amrse of Ktmc other operation, the position of the incision will have 
been determined by the special o]>eratiun. The part is then put into that 



224 OPERATIONS UI*ON THE TENDONS AND TENDON-SHEATHS. 

position which will relax the tendon to the greatest extent — the tendon and 
sheath are then clearly located, and the former placed within the latter, 
while the edges of the sheath are held aside. The sheath is then carefully 
dropped together over the tendon and the sheath -margins sutured with a 
fine continuous gut suture. The wound is now closed and the limb put up 
so as comi)letcly to relax the tendon. In about ten days the limb is taken oul 
of the splint at intervals and passively moved, to prevent adhesion of tendon 
to sheath — while the surgeon's left thumb placed over the tendon during 
manipulation holds it in place within the sheath and relieves part of the 
strain upon the recently sutured sheath. 

Comment. — In cases of paralysis, the peroneus longus has been grafted 
into the tendo Achillis, into the tibialis posticus, and even into the tibialis 
anticus; — the tibialis anticus into the extensor proprius hallucis; — the sartorius 
into the rectus femoris, and the like. Tendons are sometimes appro.ximated 
by tunneling under other structures. 




I'iv;. j'17.— l",xi:isin\ tJi- riNiM^N-siiKAiH :— SlK-alh is sc-i/cd with forceps and dividcil cirouLirl* 
atniiixl tlic tciiiiiiii a( bfith iiids of the invulved area. 



EXCISION OF TENDON-SHEATHS. 

Description.— The removal of more or less of the sheath of a tendon. 
Oenorally rcsi)rtc<l to in cases of obstinate tenosynovitis. 

Operation. -Tlic spcriai tendon-sheath involved is e.xposed by an incisi<'n 
diri'dly over it, — or l>y an incision l)eginning and ending over the sheath but 
pas>inj^ to oiu* sitic of the sheath throughout the rest of its course, thus en- 



EXCISION OF TENDON-SHEATHS. 225 

abling a skin-flap to be turned to one side, so that when replaced its scar 
will not fall directly over the tendon. Having retracted the soft parts, the 
tendon-sheath is entirely isolated, with care, from the neighboring structures — 
especially from those forming its bed. The sheath of the tendon is now 
divided circularly around the tendon, above and below the diseased portion 
— but without cutting the tendon itself. Having completed the two circular 

incisions at either end, the sheath is split in the long axis of the tendon — 

and thus laid completely open — and may be removed in one piece (Fig. 207). 

Any diseased portions of the contained tendon found, should be scraped. 

The skin-flap is then united — and the limb put up so as to immobilize the 

tendon. 



«S 



CHAPTER IX. 



OPERATIONS UPON THE LIGAMENTS. 

SYNDESMOTOMY. 

Description. — Division of ligaments. Generally performed for the con- 
traction of ligaments occurring as the cause, in whole or in part, of some 
of the deformities. 

Operations. — The ligament, or ligaments, at fault may be divided by 
the subcutaneous or open method — the latter being preferable. In the open 
method the involved ligaments are exposed by the simplest and safest route 
— and divided in the same general manner as the division of tendons by the 
open method — and the wound similarly treated. 



SUTURING OF LIGAMENTS. 

The suturing of ligaments is performed upon the same general principles 
as is tendon-suturing (see page 213). 



LENGTHENING OF LIGAMENTS. 

Description. — Lengthening of ligaments which have become shortened 
through disease or injury — esi)ecially in cases of deformity. 

Operation. — Many of the same methods involved in tendon-lengthening 
are applicable to the lengthening of ligaments. Where a ligament is attached 
to a bony prominence, this has been chiseled off and displaced to a neigh- 
boring site and there nailed (as in the case of the ligamentum patellae, where 
the tubercle of the tibia has been displaced to the upper portion of the tibia 
— but with uncertain success). (See Tendon-lengthening, page 216.) 



SHORTENING OF LIGAMENTS. 

Description. — Shortening of ligaments which may have become lengthened 
through disease or injury. 

Operation. — Many of the tendon-shortening methods may also be ap 
plied to elongated ligaments. .As in the above operation, where a ligament 
is attached to a prominence of bone, this may l)e chiseled from its normal 
site and nailed to an adjacent site (as in the case of the ligamentum patella?, 
where the tibial tubercle has been dis{)laced lower down the tibia). 

Note. — Most of the work done ui)on Ligaments will be found described 
in special writings upon orthopedic surgery. (Also see Tendon-shortening, 



OPERATIONS UPON THE FASCIA. 

FASaOTOMY. 

Description. — Fasciotomy or aponeurotomy signifies the division of 
bands or planes of contracted fascia. The term is used with especial reference 
to operations upon contracted palmar and plantar fascia, in the deformities 
of those parts — and in connection with the contracted fascia lata, and the 
contracted fascia following burns, and the like. 

Operation. — The division is usually accomplished by the subcutaneous 
or open method. The general princii)les of the operations will be here de- 
scribed — the steps of the special operation will be determined by the anatomy 
and contraction of the part involved, (a) Fasciotomy by the Subcutaneous 
Method : — Where the contracted fascia is in the form of narrow bands, a 
sharp-pointed tenotome with a narrow cutting-edge (of about 6 mm., or { 
inch) is best. Where the fascia is contracted in the form of planes, a sharp- 
pointed tenotome with a longer cutting-edge is to be preferred. The short- 
bladed fasciatome, however, is the safer form of tenotome, as far as damaging 
the neighboring structures is concerned. The instrument is inserted flatwise 
beneath the fascia — the cutting-edge is then turned toward the contracted 
fascia, which is rendered further prominent by e.xtending the part, and the 
special band of fascia is divided against which the knife-edge presses — then 
another band is sought — new bands api)earing to sjjring into existence as 
others are cut — the tenotome being carefully pushed in different directions 
until all the bands are cut. Just before each band is cut, the tip of the surgeon s 
left forefinger should be placed over the tense band of fascia and make counter- 
pressure, and thereby serve as a guide of the progress of the knife toward the 
skin. Sometimes all the bands can be divided through one introduction 
of the tenotome — in other cases the tenotome is introduced at several sites. 
The tenotome is sometimes introduced between the skin and the fascia and 
divides the latter by cutting downward, which is somewhat more risky. 
When all or nearly all of the ligaments have been divided which the tenotome 
can detect and reach, the part is fully extended, breaking down the remaining 
ones if any. The tenotome wound or wounds are then closed by a suture 
or two and the limb immobilized in a splint, which is worn for a long period, 
(b) Fasciotomy by the Open Method :— A number of limited incisions 
may be made from without inward, through the skin and fascial bands, ^ 
or the involved fascial bands may be exposed through a skin-flap which is 
raised and retracted to one side, or through a long straight incision whose 
margins are retracted laterally. Following the thorough exposure of the 
parts, in the last method, the contracted fascia is dissected out wherever 
present. In either one of the open methods, the part is fully extended after 
the operation, the skin-wound closed and the part immobilized. 

Note. — Much of the work done upon the Fascia will be found described 
in special writings upon orthopedic surgery. 



CHAPTER XI. 

OPERATIONS UPON THE BURSAE. 

PUNCTURE OF BURSAE. 

Description. — Generally resorted to for exploring the nature of the 
bursal contents, or for injecting fluid for destroying its secreting surface, or 
simply for the evacuation of its contents. 

Operation. — The needle of the syringe is introduced, with the usual 
precautions, into the interior of the enlarged bursa — piercing the skin as 
directly over the cyst as possible and passing by the safest route through, or 
preferably between, the overlying tissues. The site of the introduction will 
depend upon the special bursa. 

INCISION OF BURSAE. 

Description. — Usually resorted to for the evacuation of pus, or other 
fluid; or to expose the interior for curettage. 

Operation. — An incision is made down to the bursal sac — selecting a 
site where the least important structures will be encountered and the sac 
most readily reached. The intervening parts having been retracted to one 
or both sides and the bursa steadied by the surgeon's left forefinger and 
thumb, its wall is incised with a scalpel — after which the special object of 
the operation is accomplished. The steps of the operation will depend upon 
the special bursa. In some cases the incision will pass from the skin directly 
into the bursal cavity, without any intervening dissection. 

EXCISION OF BURSAE. 

Description. — Generally done for the removal of chronically inflamed 
or diseased bursa? — the majority of the latter cases being tubercular. 

Operation. — The exposure of the enlarged bursa is accomplished as 
described under the operation for incision. The surrounding parts having 
been then drawn well aside, the entire bursal sac is dissected from its bed, 
partly by blunt and partly by sharp dissection — carefully guarding the neigh- 
boring structures, and especially those joints with which the bursa may 
communicate. Whenever possible, the communication with a joint should 
be closed by suturing together the edges of the neck of the excised bursa. 
The wound is then closed, or drained, as indicated. 



228 



CHAPTER XII. 
AMPUTATIONS. 



I 



GENERAL CONSIDERATIONS. 

Definition.^Ampuiation — the removal of a limb through its continuity. 
Disarticulation — the removal of a hmb at a joint. 

Indications. — Any injury, disease, or malformatioin rendering retention 
of the limb incompatible with life or comfort; — avulsion of iimb; compound 
fracture; compound dislocation; fracture with great comminution of bone; 
laceration of important vessels; extensive contusion; extensive laceration; gun- 
shot injuries; aneurism; effects of heat and col<l: ganj^ene; extensive bone 
disease: tumors; elephantiasis; tetanus; snakebite; deformities. Amputa- 
tions are far less frequent in modern conservative surgery than farmerly— 
limbs now being often saved by excision, and other operations, which were 
at one time sacrificed. 

Preparation of Patient.— The constitutional preparation of the patient 
— and the previous and immediate local antiseptic preparation of the part — 
are the same as for any major o})eration. The part should be shaved, where 
its condition admits of this preparation— and should come to the table with 
the preliminary dressing in position. 

Position of Patient, Surgeon, and Assistant.— (i) Patient rests upon 
back, lying near side of table, and nearer the upper end for amputations of 
the upper extremity, that the limb may be held out from the table at a right 
angle: — anr! nearer the lower end for amputations of the lower extremity, 
that the limb may be held both out from the table, and also over the end of 
the table. (2) Surgeon so places himself as to enable him to grasp with 
his left hand the patient's limb between the saw-line and the trunk— which 
irill place him upon the outer side of the right limbs, and on ihe inner side 
«f the left limbs (between the table and the left limbs) (Fig. 20S). This is 
ihe gctjcral ruJe. of almost universal application (and will not be repealed 
each o|)eration)— where exceptions occur they will be mentioned with 
special amputations. In amputations of the upper part of the left .arm 
lin<1 upt>er part of the left thigh, especially the lalter, it maybe more con- 
venient to stand to the outer side of ihe limb, in which case the left hand 
s the limb below the saw -line. This avoids wedging one's self between 

table and the upper part of the limb, which, in the case of the lower limb 
panicularly, cannot be stretched nut at a right angle from the table. (3) As- 
•isttnt : -grasps the part of the limb, wrapjxni in an aseptic towel, that is 
U> iic rrmovetl. standing facing the surgeon, so that he can better steady the 
limb against the movements of the saw than if he stCHxl at the end of tht- 
limh — his arms being thus parallel rather than at a right angle to the working 
of thr %aw. 

Instnunents. — Esmarch's rubber bandage and tourniquet; amputating 
knive!!. U»ng and short; scalF>els, various; cartilage knives; Catlin knives; 
«awft, ordinary amputating, bow, and butcher; small thin saw, for spicuhe 
vi bones; periosteal elevators; metallic retractors (for flaps); linen retractors 

22q 




230 



AMPUTATIONS. 



(for flaps) ; broad metallic or ivory spatula? and retractors to hold soft parts 
out of way; dissecting and toothed forceps; arten-clamp forceps, numerous; 
rongeur forceps; scissors, straight and cur\ed, sharp and blunt; tenacula; 
l)rohes; gr(K)ved directors; ligatures and sutures, silk, catgut, plain, chro- 
mic, silk-worm gut, tendon; needles, straight and cur\ed; needle-holder: 







X. 



l-iK. .>■■>.— Ill I siK.\iiN«; J'osniov oi- Si'Rr.i-.oN in AMPtTAiisr. :— Slaiuliiin to «>ulor «.idc ul 
ri):ht, ;iiiil t<> iimri -iilc <>t Ittt liiiiN-^- iii:mi|iulatiiij; kiiilo wiili rijihl hniui. atxl sicidx iiii; limb <al«« 
i(ti:i<lin;; ^ >it |>.iti'>< will) Icil li.uxl pKii i-<| hciwccii s.iw-liiic and irunk. — lliinds ot assistant arc 
shtiwii ill xaiii'ii'. jMi-ilions, i^kisjuml; and ><upporiiiix p.iM t<» roiiu' away. 



drainage tul)cs; irrigator and irrigation fluid; normal salt solution and in- 
struments for intravenous infu>ion; dressings for stump; splint. Special 
instruments will l)e mentioned under special amputations. 

Control of Hemorrhage in Amputations. — Hemorrhage maybe con- 
trolled in one of two general ways— by >ome form of t<nirniquet or constrictor, 
or by digital (()m|)re»ion. (A) Control of hemorrhage by tourniquet 
or constrictor: Several forms of tourniquet control are in use: — (i) Es- 
march's liroad Kul)l)er Handagc, and Tourniquet of Rublx?r Tubing or 
Narrow Hand; The>e constrictors may be used in two ways; — (a) Use of 



GENERAL CONSIDERATIONS. 



231 



Bandage and Tourniquet (Esmarch MethcKl); — The bandai^e is applied 
from the fingers or toes ufnvard, for example, nearly to the shoulder or hip 
— ihe tourniquet is then applied above the bandage — and the bandaj;e re- 
moved. This saving to the patient of the blnod in the limb is more particu- 
larly indicated when the limb is healthy and the patient anemic — otherwise a 
patient who loses a limb can also generally afford to lose its proportional amount 





rtl Uiu 



'KATi.Ni^ M»;riM)05s i>»' MiiMORKH At;»< LnvTRoi. : — \V Villi s nictlio<t by lubber 
rti.al fJKlu »lioMj«lcr-|<iiiit.— Same itl left bii>-jomt.- OniitiHry tiiMn't ti>itiiiii|iict 
'ICT-joint. rfiiiJoried (kept trnm *lipl"irig» l»v sliip*; iif r(»ncr-l»aiulnji;c'. — Same, at 
• tf K^nufili ruM>i-r l<>tiriii<jOcl al»>vf left cU«iw — KxsansiiiiKHiun t>f liinh by 
•infc, followed Viy ;*pplaation «j( mbber tubing U»r EMunrcb luhbcr t«^*uniiqurt) 
.»inpct»5!»i»i» <>l riubt lemoniJ by I'etit lyia- <>( luurnicpict. — rrclimiTuir>' 1i|;ntiaii 



of tdl ten»o(j*l.^tiiiriU> iOin|Mcs<»ioii ul ninJH artrrirs at riglit wrl»i. 



of blorxl. (Fig. 20c), left leg.) (b) U^e of Esmarch's Tourniquet Alone;— The 
ibis held elevated for about three minutes (this empties the veins mechani 

ly and causes the arteries to contract retle.xly, thus lessening the blrMKi to the 

Timb; but if the elevation be too long, the arteries recover, dilate, and let in 
inorc bIcKxIj — and, during the lime of this elevation, a healthy limb may be 
iBiafiBised downward to aid exsanguination — the tourniquet alone is then 




232 AMPUTATIONS. 

applied as high up the limb as indicated for the special operation, no form of 
bandage having been previously applied (Fig. 209, left arm). In operating any- 
where below the elbow or knee, the constriction should be applied just abo\'e the 
elbow or knee, — and in amputating anywhere above the elbow or knee, the con- 
striction should be applied as near the trunk as possible. This is the general 
method of hemorrhage control in the majority of cases. The objections 
which have been urged against the Esmarch bandage and tourniquet, or 
tourniquet alone, are — the increased bleeding following the operation, from 
temporary vasomotor paralysis; the possible lowered vitality of the com- 
pressed parts; occasional temporary paralysis of nerve-trunks from pressure; 
and the possibility of forcing pathological products into the body. The 
great advantage over these disadvantages, however, is that it controls all 
bleeding — and its use, therefore, is advisable in spite of the disadvantages. 
(3) Tourniquet of the Petit T>'pe; — The entire limb is compressed, with 
special pressure over the main artery (Fig. 209, right thigh). (3) Tourniquet 
of the Signorini Type; — No circular constriction is used — a pad on one arm 
of the tourniquet compresses the artery against a counter-pad on the other 
arm of the tourniquet opposite or beneath the limb or body. (B) Digital 
compression of the main artery : — Compression is generally made through 
the skin — but may be made directly upon the main vessel through an incision 
made immediately over it. (Fig. 209, right hand.) The office of hemorrhage- 
control by digital compression is sometimes delegated to a single individual 
in a hospital. Note : — Special methods of controlling the circulation will be 
mentioned in connection with special amputations, especially those about 
the shoulder- and hip-joints (Fig. 209, shoulders and hips). 



THE GENERAL TECHNIC IN AMPUTATING. 
LOCATION OF LINE OF BONE-SECTION. OR DISARTICULATION. 

The determination of the saw-line in an amputation, or the disarticula- 
tion-line in a disarticulation, is the first step — generally marking the upper 
limit of the operation — and is the necessarj- guide to the subsequent steps. 

Level at Which the Bone, or Bones/are to be Sawed. — Is to be deter- 
mined by the individual case — and its position should be such that enough 
healthy tissue will be provided for, between the saw-line and the upper limit 
of the diseased or injured tissues to be removed, to furnish ample covering 
of soft parts to protect the stump without undue tension. 

Level of Joint-line at which Disarticulation is to be Done.— The 
position of the articulation-line is, of course, fixed — it is only necessar}' to 
recognize it anatomically — and to determine whether sufficient sound tissue 
intervenes between joint-line and upper limit of the parts to be removed to 
afford covering satisfactory in quantity and quaHty to protect the stump. 
Otherwise the disarticulation will have to be converted into an amputation 
at a higher level. 

Relation of Saw-line to Length of Flap, and Vice Versa. — While 
the position of the saw-line determines the amount of tissue (and, conse- 
quently, length of Hap or flaps or of circular covering) which will be required 
to cover the sawed bone — so also does the choice of the method of amputation 
to be used largely determine the amount of bone to be sacrificed (and, con- 
sequently, the length of the resulting limb) — for (a), In circular amputations 
and amputations by equal llaps, the minimum amount of bone is sacrificed; 
and (b). In amputations by a single flap, the maximum amount of bone is 
sacrificed. 



LOCATION OF LIMITS OF SKIN INCISIONS. 



^33 



LOCATION OF LIMITS OF SKIN INQSIONS. 

"total co\ering of soft parts equivakni to li diameters of the limb at 
the saw-line is the general rule uf allowaiue. It is necessary, therefore, to 
determine the lower limit of the skin incision, as this forms the lower limit 
of the total covering. This hmit may be determined accurately or approx- 
imately. 

In Circular Amputations.— (a) Accurately; — Find the circumference of 
the limb at the s;»vv-line by means of a metallic tape line (say. 15 cm., or 6 
inches) — one-third of the circumference will give the diameter (say, 5 cm., 
or 3 inches). Therefore, to furnish i^ diameters (say, 7.5 cm., or 3 inches) 
the lower limit of the skin incision would have to be 3.8 cm,, or li inches, 
below the saw-line, (b) Apj)roximafel\ ; — Place the thumb at the sawdine 
on the anterior aspect of the limb (the nail facing the junction of the limb 
with the trunk) and the lip of the inde.x-fingcr immediately opposite on the 
posterior aspect of the limb (without compressing the soft parts). Now, 
keeping the thumb where first placet!, and keeping the distance between 
the tip of the thumb and tip of the index unchanged, rotate the hand around 
rraakLn^ these two fingers act as the two arms of callipers) until the tip of 



I 



I 




Fix- jto,— R»» ATiuN OK Skin Incision to Saw-link :— Methods of nmpulalion by equal 
flapa^ circular covcTinx. and unequal (laps are slKmii cacti lo furnish a covering oi i^j dtaiiierici.s uf 
limb »l Miw tine. 

the index rests upon the anterior aspect of the limb in a vertical line below 
the tip of the thumb. The distance between the thumb-tip and the finger tip 
will be the diameter of the limb at the saw line — and three fourths of this 
measurement will insure a covering of the requisite i4 diameters f)f (he limb. 
In ralculating the covering in the circular method uf amputuling. it is lo be 
retncnibercd that as the circular covering will be sutured in a straight line, 
either from before backward or from side lo side, practically the covering 
may l>c regarded as Ijcing furnishe<J liy two aspects of the limb, either the 
front and back or the two sides— that is, as though furnished by two equal 
flap!* (Fig. 210). 

In Equal Flap Amputations,— Same as fur the circular melhc>tl, whether 
calculated acciiratel\ or approximately (Fig. 21c). 

In Unequal Flap Amputations.— (say the anterior twice as long as 
the piistrrior ll ip); — (a) Accurately; -Fintiing the circumference andiltameter 
in ihc above manner (the measurements lieirig as there given) — ^the lower 
limit of the anterior flaf) would be 5 cm. (2 inches) below the s.iw line, and 
the lower limit of the [wtsterior, 2.5 cm (i inch) below, (b) Approximately; — 
Hivillg gotten the measurement of the full diameter marked out on the 
•Mcrior a.s|)ecl, as explained above, this will represent the length of the 
anterior flap—and one half of this measurement will give the length of the 
flap (Fig. 210). 



234 



AMPUTATIONS. 



INCISION OF SKIN AND FASCIA. 

In general terms, it is considered that the aspects of the limb furnish an 
average covering of i^ diameters of the limb at the saw-line — whether this 
covering consist of skin alone, or of skin and muscle combined — and whether 
furnished by one or more aspects of the limb. In the circular method of 
amputating, the covering is furnished equally from all aspects of the limb. 
In the method by equal flaps, it is furnished equally by two aspects of the 
limb. And in the method by unequal flaps, the inequality of length may 
be parceled out in any way indicated, just so the total covering is equivalent 
to i^ diameters at the .saw-line. If the covering be from one aspect alone, 
as in the single flap or in the elliptical methods, the total diameter and a half 
comes from that one aspect. Where the amputation is done through a site 
of maximum contractility of skin and muscles (as through the lower half of 




Fifj. 2ir.— iNcisiNt; Skis ano Fvscia in CiRcri ar AMPrxATiON :— I, Pdsition o» 'ong knife in 
iu(.'isiiij{ iip[)<-i , turilKT and part of lower aspects uf limb. 



the arm. or the lower half of the thigh), a somewhat greater allowance may 
l>ecome necessary (even to the extent of two diameters). Where the ampu- 
tation is done through a site of minimum contractility of skin and muscles 
(as through the dense tissues of the palm of hand and sole of foot), a somewhat 
less allowance than the average may be provided. 

Manner of Incising Skin and Fascia in Circular Amputations.— 
Whether a stump is going to be covered by skin alone, or by skin and muscle, 
the skin is invariably cut first and cut separately. Standing to the outer 
side of tlie right and inner side of the left limbs, grasp the part above the level 
of the skin incision with the left hand and retract the skin upward, either 
entirely alone or aided by an assistant (the assistant's aid being more necessary 
in large limbs) -the retraction being evenly maintained throughout. This 
is done to j)rovide as ample a skin covering for the muscles as possible, for, 
as the average contractility of the skin involved in an amputation is greater 
than the average contractility of the muscles involved, if the skin and muscles 
were di\ iiled on the same level it would subsequently be found difficult, or 



INCISION OF SKIN AND FASCIA. 



235 



I 



impossible to make the skin meet over ihe cut muscles. Therefore this 
circular division of skin, which has been well drawn up under the knife-cut 
prior to incising, means an actual division of the skin a little lower than the 
position of the knife on the limb indicates — but insures having a somewhat 
fuller measure of skin than if it were cut without retraction. Having thus 
retractef^i the skin, take a long knife with a blade one-and-a-half times the 
diameter of the limb to be removed — ^and, holding it in a full hand, like a 
pruning-knifc, pass the arm under the patient's limb and bririK the aitllng- 
edge into contact with the upper surface of the limb, the back of the knife 
being horizontal and pointing upward, the heel of the knife being over the 
center of the limb, and the point projecting beyond the limb toward the 
surgeon. Beginning the incision with the heel of the knife, steadily and 
c\Tnly draw the knife from heel to point, passing with one sweep of the knife 




, ya^-lNctsiwc Skim avd Fascia in Circi-lar Ampitatiok:— 1 1— Position of lon|f knife In 
inci&ing nearer and rctnaiittlcrr of lower uitpcct ul Viinlv. 



thnmgh three fourths of the circumference (Fig. 211). The knife is then with- 
• Imwrn and reinserted with its heel at the place of beginning of the incision 
on ihc sufiero-ex'ternal surface (In <i|>erating on the right limbs), and, with 
one sweep, passes through the remaining fourth of the circumference 
Fig. it 2). The attempt to make the complete circuit with one sweep is 
to be recommended, as the ends of the resulting wound are not apt to 
in line, and the vvoun<i. generally, imperfectly made. This circular skin 
rtsion is sometimes made with a small knife. The assistant can aid the 
srgcon by rotating the limb to meet the knife. The blade is held perpen- 
to the skin throughout. The incision passes through skin and fas- 
CHI, but not into muscles. Owing to the unequal retraction which some- 
times Ukcs place upon the different aspects of a limb, it may be necessar>^ 
to pl^n one portion of the circular incision upon a lower level than the rest 



236 



AMPUTATIONS. 



of the incision — this greater allowance of skin at this site will, however, be 
drawn up on a level with the rest of the circular incision, owing to the 
greater retraction there. So that what may appear as an oblique incision, 
will become circular and upon the same level after the division. 

Manner of Incising Skin and Fascia in Flap Amputations. — As in 




Fig. 213.— Incising Skin and Fascia in Flap Amputation :— I— In cutting rounded flaps. 




Fig. 2n.— I.NcisiNf. Skin anp Fascia in Flap A.MrrTATiONi— II — In cutting rectang^ular flaps. 



the circular method, whether the covering is to be of skin alone, or of skin 
and muscles, the skin is invariably cut first and separately — and whether 
the flap be cut from without inward, or from within outward (by transfixion). 
The preliminary steps, as to position, retraction of skin, and general prin- 



FREEING SKIN AND FASCIA. 



237 



r 



pies involved, are the same as in making the skin incision in the circular 
amputation. When all is ready, the surgeon takes an ordinar}' scalpel of 
medium size, and, holding il as a violin bow, enters its point into the skin 
vertically, at the upper limit of the base of the flap. The knife passes through 
skin and connective tissue, and as It travels vertically down one limb of the 
flap the cutting-edge is lowered until it forms less than a right angle with 
the surface being cut — when nearly the lower limit of the flap is reached, 
the knife rounds the corner of the flap — ihence passes transversely across 
that aspect of the limb from which the fla[> is being taken — then similarly 
rounds the opposite corner — and thence tra\ els vertically upward lo a point cor- 
responding with the point of beginning (Fig. 213). Care should be exercised 
that each flap should measure one-half the circumference of the limb at its base, 
and one-half of the circumference at that part of its free end just above the 
rounded corners — and that these corners should be very bluntly, and not 
sharply, roun<letl (that they should be squarely rounded, as it were), for if 
they be too much tapered al their free ends, they will cover the stumps with 
difficulty and unsatisfactorily. Instead of cutting the entire flap with one 
sweep of the knife, each vertical limb and one corner of the tlap should be 
made with one downward cut of the knife. While all flaps shoukl l>e prac- 
tically square, with merely the corners rounded, an exception is made in the 
method of unequal rectangular flaps of skin and fascia (Teale's method) — 
the corners of the flaps being here right-angled, instead of rounde<l (Fig- 
214). This is also Ihe case in the conversion of a circular method of 
amputation into a flap method by two vertical incisions placed laterally — 
and even here the comers may be rounded. 



FREEING SKIN AND FASCIA. 

Having incised skin and fascia, for either a circular or a flap amputation, 
the manner and extent of further freeing skin and fascia will depend upon 
whether the method is to be one of simply skin and fascial covering, or of 
skin, fascial, and muscular covering for the stump. 

Freeing Skin and Fascia in Simple Skin and Fascial Covering for 
Stump. — The skin and fascia, after having been divided, arc partly retracted 
and partly dissected back to the line of future tiivision of muscles. The edges 
of hkin and fascia (avoiding the separation of the one from the other, as the 
vri-scls reach the skin through the fascia) are grasped by the fingers of the 
left hand, lifted from the muscles, and <irawn upward — and, while held in 
this position, and while under slight tension, the fascia is touched here and 
there at points where it especially binds along the line of its junction with 
the muscles and deep fascial planes, by a scalpel held at a right angle to the 
surface of the muscles and with its cutting edge toward tlie part to be removed 
— and thus scoring of the skin and consequent damage to its blood-supply are 
a^T>idcd. The skin and fa.scia are, by this means, raised in one layer from 
the muscles — and the skin should be raised with all the underlying fascia 
possible — and the combined skin and fascia should be raised evenly up lo 
the future line of muscle division (Fig. 215). 

Freeing Skin and Fascia in Skin^ Fascial, and Muscular Covering 
T Sttimp. — Special care is here taken not to separate skin and fascia from 

crlying muscles, any further than simply in the immediate line of original 

in incision, and simply for the purpose of allowing of full retraction. The 

skin and fascia are here not picked up and separated from the muscles— 




238 



AMPUTATIONS. 



the only knife-touches necessary being a few where the fascia has not beezi 
thoroughly divided and where it is necessary further to divide a fascial attacl^ - 
ment here and there in order that the skin and fascia may retract as far ^i^s 




Fig. 215.— Freeing Skin and Fascia from Undkruvinc Muscles. 

they naturally will unaided by manual retraction — and this is done by touching 
the points of binding at the bottom of the original incision, by the point of a 
knife held vertically. 




Fig. 216. — Retraction of Skin and Fascia. 



RETRACTION OF SKIN AND FASCIA. 

Where Stump-coverings are to be of Skin and Fascia Alone. — Ha\'ing 

freed skin and fascia from the underlying parts, as above described, partly 
by retraction and partly by dissection, until the line is reached at which the 
muscles are to be divided, the skin and fascia are further retracted above 



DIVISION OF MUSCLES IN CIRCULAR METHODS OF AMPUTATION. 239 

this line and are held out of the way by the hands of an assistant, or by re- 
tractors (Fig. 216). 

Where the Stump-coverings are to be of Skin, Fascia, and Muscles. 

— Retraction of skin and fascia from the underlying muscles, other than that 
which occurs unaided, is not practised. It is sought, on the other hand, to 
keep in contact, as one layer, skin, fascia, and muscles. 



DIVISION OF MUSCLES IN CIRCULAR METHODS OF AMPUTATION. 

In the Ordinary, or Infundibuliform, Variety of Circular Amputa- 
tion. — (For description, see page 261)— (a) Division of More Superficial 
Muscles; — The position of surgeon, manner of holding limb, kind of knife 
and manner of manipulating it, are all the same as in making the skin incision. 




Fig. ai7.— Division of Mrsci.RS in iNKrNnnu'i.AR Variktv of Circi-lar Ampitation :— I— Di- 
viding more superficial muscles 011 k-vcl with rctiactt-d skin and fascia. 

The skin and fascia having been circularly incised and allowed to retract, 
the surgeon grasps the limb above the naturally retracted skin, and further 
retracts skin and fascia, putting, at the same time, the muscles upon the 
stretch by this upward retraction of the overlying parts, aided by an assistant 
in the case of larger limbs. The more superficial muscles are now divided 
circularly on an exact level with the retracted skin, by one sweep of a long 
knife passing, first, through three-fourths of a circle, followed by a second sweep 
through the remaining fourth (Fig. 217). It is not always possible to divide 
only and wholly what are generally understood as the superficial layers of 
muscles — it is only meant that one divides, in this first circular division, about 
one-half of the muscular covering of the limb, the knife sometimes dividing 
a group of muscles completely and sometimes only jxirtially. To allow for 
unequal retraction, the muscles may sometimes have to be divided lower 
on one aspect of the limb than on another, (b) Retraction of More Super- 



240 AMPUTATIONS. 

ficial Muscles; — This layer of muscle tissue is now retracted as the skin was 
above it. It is not expected that the first muscle layer includes all and only 
the superficial muscles, and the deep layer all and only the deep musclesr- 




Fig. 3i8.— Division OF Muscles in Infundibular Varibtv op Circular Amputation:— II— 
Dividing deeper muscles on level with retracted superficial muscles. 

the former includes simply the more superficially placed, and the latter the more 
deeply placed muscles. There is no general use made of the scalpel in freeing 
the superficial muscle layer, as in the case of separating the fascia and skin 
from the muscles, but, where indicated, a touch of the knife may be used to 




Flif. 119.— Division ok Musci.ks in Cuff Varibtv of Circular AMitTTATiON— on a level with 
the tunicd-back cuff and fascia. 

enable the more superficial muscles to be evenly retracted, (c) Division of 
Deeper Muscles;— Having retracted the divided muscles more superficially 
placed, the more deeply situated muscles are now circularly divided on a 



DIVISION OF MUSCLES INaRCULAR METHODS OF AMPUTATION. 241 
level with the retracted superficial muscles, and in a maimer similar to the divi- 




I 



Fi(. sao.— Division of Mi^scues in Modifikd Cmcvt-AR Amputation— showing flaps of skhi 
BCi» tam«<l back, the more superficial tnu&cirs dividetl, and the knife in ihe act of dividing the 
riBU>cl» in the infundibular fashion. 

sion of the first layer (Fig. a 18). It is to be planned that this circular division 
of the deep muscles will come down 
upon the bone sufficiently far beltnv the 
saW'iine to provide for a pveriositeal flap. 
(d) Retraction of Deeper Muscles; — 
This is done preparaton- to forming 
the periosteal covering. Note— it will 
thus be seen that, having divided skin 
and fascia lowest of all, the superficial 
muscles have been divided ujjon a higher 
level, and the deep muscles upon a still 
higher lexel^forming, thereby, when the 
b<:»ne h sawed, a hojiow cone, whose a[>ex 
will be formed by the sawed bone, whose 
base will be the margin of skin and 
fascia, and whose sides will be com- 
posed of the cut muscles (Fig. 242). 

In the Circular Amputation **a 
U Manchette," or Cuff Variety of 
Circular Amputation.— (For descrip- 
titm, sec page wOj.)— In tlijs method, 
all the muscles are «livided circularly 
doim to the bone al one level, which 
m that of the reflected cuff of skin — cal 
cnlating to tume down upon the bone 
iRifBricntly far below the saw line to 
farm a musculo- periosteal covering (Fig. 
»I9). 




16 



Fig. aai. — DivTsius of Mi kci i£s in Oval 
Mhthoo ur AMruTATtuN. 



242 AMPUTATIONS. 

In the Modified Circular Amputation. — (For description, see page 
264.) — After the flaps of skin and fascia have been retracted, the more super- 
ficial muscles are divided on a level with the retracted flaps — this layer of 
muscle tissue is retracted — and the deeper layer is divided upon a level with 
the retracted superficial layer — calculating to come down upon the bone far 
enough below the saw-line to allow for a musculo-periosteal covering (Fig. 220). 
The division of muscles being, in other words, just as in the ordinar>' circular 
amputation. This is the better way of dividing the muscles in the modified 
circular operation. Where, in the modified circular amputation, the muscles 
are all divided at one level (that of the retracted flaps), the muscles are di- 
vided as in the circular amputation d. la manchette. 

In the Oval Method of Amputating.— (For description, see page 265.) 
— After having made the oval incision through skin and fascia, the muscles 
are divided directly to the bone — the knife entering the muscle tissue upwn 
the line of the retracted skin and fascia. Along the queue, or vertical portion 
of the oval, which begins at, or just above, the saw-line, or disarticulation- 
line, the two lines of incision will coincide — parting below to follow the 
outlines of the oval — and meeting at the mid-point behind (Fig. 221). 

In the Racket Method of Amputating. — (For description, see page 
266). — The principle here is the same as in the oval method. 



DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 

In Amputating by Single Flap of Skin and Muscle. — (For description, 

see page 267.) — The skin-and-fascia flap having been outlined and incised, 
the muscles are cut, preferably from without inward (or may be cut from 
within outward, by transfixion), beveling inward, on a line with the retracted 
skin-and-fascia flap — the incision coming down upon the bone sufficiently 
far below the saw-line to provide for a musculo-periosteal covering (Fig. 222). 

In Amputating by a Single Skin-flap. — (For description, see page 
26q). — Having retracted skin-and-fascia flap, the muscles are divided cir- 
cularly at the saw-line, or disarticulation-line. 

In Amputating by Equal Flaps of Skin and Muscle. — (For description, 
see page 269.) — Same as by single flap of skin and muscle (Fig. 223). 

In Amputating by Equal Flaps of Skin. — (For description, see page 
270.) — Same as by single skin-flap. 

In Amputating by Unequal Flaps of Skin and Muscle. — (For de- 
scription, see page 271.) — Same as by single flap of skin and muscle. 

In Amputating by Unequal Flaps of Skin. — (For description, see 
page 272.) — Same as by single flap of skin. 

In Amputating by the Elliptical Method. — (For description, see page 
273.) — As this may be considered a variety of single flap amputation (of 
either skin alone, or of skin and muscle combined), the manner of dealii^ 
with the muscle is here the same as in that operation. 

In Amputating by Teale*s Method of Unequal Rectangular Flaps 
of Skin and Muscle.— (For description, see page 272.) — LTpon the line 
of the retracted skin and fascia, the muscles are cut through the periosteum 
along the two vertical lines. The muscles are then cut through the periosteum 
transversely along the free margin of the retracted skin and fascia representing 
the end of the longer flap— all of the soft parts are then dissected up above 
the lower limit of the shorter flap, when the muscles opposite its lower limit 
are transversely divided through periosteum to bone. 



DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 243 



I 
I 



Method of Cutting Flaps from Without Inward,— In this method 
the flaps are cut by dissection, as it Is sometimes called. The incision out- 
lining the flap having been made through skin and fascia, the surgeon, standing 
10 the outer side of right limbs and inner side of left limbs, and grasping the 
limbs between saw -line and trunk, proceeds to cut the muscle portion of 
the flap. A scalpel is made to cut the muscles along the line of retracted 
skin-and-fascia flap, the point 
of the knife entering the 
muscles at the upper limit of 
one of the limbs of the skin- 
and -fascia flaps — follows i his 
margin vertically downward, 
passing deeply through the 
muscles — as the free border 
is approached, the knife is 
given a direction obliquely 
inward, so as to broadly and 
thickly bevel the muscles 
here, leaving them thinnest 
(though not thin) along this 
aspect of the flap — continu 
tng the beveling process 
across the entire transverse 
width of the free end of the 
flap and well around its 
bluntly rounded comer — 
thence the knife passes ver 
tically up the op|X)site limb 
of the flap, sinking deeply 

the muscles, though the 
neetl not be fully 

hed in the vertical cuts at 

first stroke (Fig. 224). 
A* in cutting skin-flaps, the 
entire incision need not be 
made at one stroke of the 
knife — but is heller made 
in iwo strokes from above 
<loviivard. The surgeon 
DOW gni5ps the partly cut 
flap with the fingers of his 
left hand, and, while draw 

ing it away from the bone, proceeds to fashion the rest of it along the same 
line* upon which it was begun, beveling it toward the bone by successive cuts 
of the knife — planning that the base of the flap will contain the full thickness 
of the soft parts covering the bone— and calculating that the knife will come 
down upon the bone for hones) far enough below the saw line (or disarticula- 
tioO'line) to provide a musculo periosteal (or capsulo periosteal) covering. 
^Tiere two flaps are cut, the second is cut in the same general manner. Care 
riiould be taken that the muscles are thickly and bluntly beveled, else a thin, 
ill-nourished ending to the flap is apt to be left. No attempt is made to 
the upper part of the sides of the flap (the vertical portions) — the beveling 

tning only just alwive the rounded corners. By cutting on a line with 




Fig. 33J.— Division OF Mi scles in Amputation •vStNCLK 
FLAr Method. 




244 



AMPUTATIONS. 



the retracted skin, ample covering of the muscle-portion of the flap by the 
skin-and-fascia portion is provided (Fig. 223). 

Method of Cutting Flaps from Within Outward.— In this method 
the flaps are cut by transfixion. The skin and fascia should always be cut 
first and from without inward, as the first step of every flap (as well as of 
every other kind of) amputation — no matter what the method of doing the 




Fig. 223.— Division of Mi'scles in Ampi-tation bv Doitble Flap Method. 

Other steps of the operation. If this be not done, the muscles and skin will 
necessarily be cut upon the same, or nearly the same, level — with the inevitable 
result that there will be a deficiency of skin to cover the muscles, owing to 
the greater retraction of the former. Having, therefore, cut the skin and 
fascia flap from without, the surgeon proceeds to cut the muscles by trans- 
fixion. A long knife is taken, having a length equal to at least one-and-a-half 
diameters of the limb at the site in question. Marking the saw-line with 




Fig. 224.— Mfthod of Raising Flaps of Skin and Mi'scle by Cutting pkom Without 

Inward. 

the thumb of the left hand, the point of the long knife (whose sides look 
upward and downward and whose edge points toward the extremity to be 
removed) is entered directly in the center of the lateral aspect of the limb 
(where the flaps are to be taken from the anterior and posterior aspects of 
the limb) and oppcsite the saw-line. The knife-point should be so placed 
and pointed as to avoid imi)ortant vessels. The knife is then carefully 
pushed directly forward, until its point strikes the center of the lateral aspect 
of the bone (or, if two bones, of that one nearer the operator) — the handle is 



DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 245 

ihen lowered while the forward progress of tht* knife continues, so that its 
point is made to hug the bone closely unli! its u[>per margin is reached — 
the handle b then raised 50 us to cause ihe point to sink and follow, as nearly 
as possible, the surface of the bone (or bones) on the opposite side (which, 
naturally, can be less closely followed than the nearer quadrant of the bone's 
circumference). \\'hen the knife's point is felt tu ha\e reached a point on 
the far side of the limb corresponding with the center of the bone, the handle 
is then loweretJ to n horizontal position and the knife thrust on forward until 
it protrudes through the skin on the far side of the limb. The surj^eon stops 
here a moment to calculate the hne along which the cutting edge of the knife 
is to emerge — the guide to which being the line of the retracted skin flap. 
With a slow back-and'forth sawing movement, the knife is made to cut 
its way forward — hugging the bone (or bones) closely throughout the greater 
portion of its way— until near the free end of the flap^ when it is made to 
round its way out in such a manner as to cut a thickly beveled edge of muscle on 




Pig. aa9.'->MftTHo» oP Raistnc Flaj>s of Skin and Mpsclb bv CirmNC fxom Withim 
CKtwaba {vv T»AKsrixioN)— cutting upoik ibe line of retracted skin and faMrta, which have been 
ptmiumiy diviUcd. 



s line with the retracted free edge of skin (Fig. 225). In cutting a second flap 
from the opposite aspect of the limb» the first flap is retracted out of the way — 
Ihe knife then passes over the rut surface of the muscle along exactly the 
same course as in beginning the tran.sfixion of the first flap — until its point 
ftrikes the center of the lateral aspect nearer the surgeon (at exactly the same 
potnl as in the first mananivre). The handle is now raised, to cause the point 
to follow down the lower quarter of the circumference of bone nearer the 
opentor — when its lower margin is reached, the handle of the knife is lowered 
ftiwi the knife pushed f«^rward, until the inferior surface of the l>one (or bones) 
IS passed. The handle is now still further lowered and the knife pushed 
forward, so as to cause the pjint in follow the further inferior cjuarter of the 
bone and emerge opfwisite the center of its lateral aspect. Hut as this manoeu\Te 
b difficult to accomplish, the surgeon generally aids the knife with his left 
barvd, by partly guiding it and partly depressing the remaining soft pans on 
far Mde liclow the i)oint of the knife so that its edge escapes them. Then 
with a similar back and-forth movement, at first hugging the bone, the knife 
is made to cut its way out on a line with the retracted skin f1a[>. In order to 



246 AMPUTATIONS. 

avoid cutting the muscle-flaps too narrow and too thin, it is necessary to hug 
the bone (or bones) until about three-fourths of the flap is cut and then 
abruptly round out to the line of the retracted skin-flap. Great care is also 
necessary to avoid piercing the main vessels in making the transfixion — 
and to avoid splitting them (whether at first transfixed or not) in cutting 
forward to form the flap. Therefore, it is sometimes necessary, when forming 
flaps by transfixion, to so plan them that they will not be precisely antero- 
posterior, or lateral — but will be so formed as to be least likely to contain 
split vessels. Considerable tissue at the base of the flap often escapes division 
in cutting by transfixion and has to be cut subsequently. The method of 
transfixion may be varied by not passing the knife so closely to the bone — 
that is, by transfixing the more superficial muscles only, retracting these, 
and then cutting the deeper muscles circularly at the saw-line. A further 
modification of the transfixion method consists in cutting through skin-and- 
fascia flap from without — then transfixing the apex of the muscle-flap — 
and dissecting up the remaining soft parts. 

Comparison of Methods of Cutting Flaps. — (a) The method of cutting 
from without inward enables a flap to be cut with greater precision — makes 
the wounding and splitting of the main vessels unlikely — and provides for a 
more accurate calculation of covering for the stump, especially as to the 
relation between the amount of skin and muscle covering. It is the method 
to be chosen in the great majority of cases, (b) The method of cutting flaps 
from within outward (transfixion) is a convenient method in very large 
limbs, and in some special amputations, and where speed is necessary. Flaps 
thus cut are apt to have their arteries injured — are apt to be too thinly beveled 
at their free ends — are apt to be too narrow throughout, and too pointed 
at their ends — and, generally, less judgment can be exercised in their fashion- 
ing. Even in the larger limbs a flap can be more satisfactorily cut from 
without inward than by transfixion. Even where transfixion is used, how- 
ever, the skin and fascia should invariably be cut from without — and the 
knife should come out on a line with this retracted skin. 



FREEING AND RETRACTING OF MUSCLES. 

In Ordinary Circular Method. — After the division of the more super- 
ficial muscles by the circular sweep of the knife, it may be found that here 
and there these muscles are not divided to an equal depth. Such unequal 
division, wherever found, is completed by a few strokes of the edge of a 
small knife. This layer of muscles is then retracted upward until the level 
is reached for the circular division of the deei)er muscles. 

In Circular Amputation a la Manchette.— Here the muscles are 
divified directly to the bone, on the line of the reflected cufi", and no special 
freeing or retraction of the muscles is done, until ready to make the musculo- 
pcriosteal covering;. 

In Modified Circular Amputation.— The muscles are here freed and 
retracted as in the ordinary circular amputation. 

In Oval Method of Amputation. — Here the muscles are divided on the 
line of the oval—no freeinj^ or retraction being necessary until ready to make 
the musculo- periosteal llap. 

In Racket Method of Amputation.— Same as in the oval method. 

In Single, or Equal, or Unequal Flaps of Skin and Muscle. — (A) 
When Cut from Without; — The fingers of the left hand raise the flap away 



MAKING MUSCULO-PERIOSTEAL COVERING. 



247 



from the bone, while the surgeon cuts the vertical limbs of the flap to the 
sne, and gradually bevels the terminal portion of the flap obliquely upward 
Itoward the bone. (B) When Cut from Within by Transfixion;— No freeing 
or retraction is necessary, until ready to make ihe musculo-periostcal tovering. 
(The fingers of the left hand may grasp up the soft parts of the limb and 
lift ihem away from the bone as the knife cuts its way out.) 

In Single, or Equal, or Unequal Flaps of Skin.— The muscles are 
here divided on one level — no freeing or retraction being necestiar)-, until 
ready to make the miisvuIo-|>eriosteal covering. 

In EUlptical Method.— The muscles are handled as in an amputation 
by a single llap of skin and muscles. 

In Unequal Rectangular Flaps of Skin and Muscle (Teale's Method). 
-The muscles are here handled as in amputation by unequal flaps of skin 
ad muscle. 



«JG MUSCULO-PERIOSTEAL. OR PERIOSTEO-CAPSULAR, COVER- 
ING FOR END OF BONE. 

Description. — A covering should be provided for the end of the ampu- 
iled or disarticulated bone, or bones, which will consist of periosteum and 
jverlying muscle, raised as a single muscub-periosteal or pcriosteo-capsular 
"up or covering. Care should be e.\ercised in raising this covering, that 
nuscle is not first raised from periosteum and periosteum from bone, but 
thai muscle and periosteum should be raised In one adherent layer. Peri- 
osteum is absent over cartilaginous surfaces, hence a pure musculo-periosteal 
covering is not to be gotten in a di.-^articulation — but as much of the capsule 
^of the joint, which is practically a continuation of the i>eriosteum, should 
prcser\'ed as possible, and treated in the same way as the j>eriosleum, 
Ifiiat the articular end of the pro.ximal bune may l>e covered. The distinct 
ludvanlages trf a musculo-periosteal covering for the end of the bone are the 
following; — (i) The muscles being adherent to the (XTiosteum, when a 
r Covering of the taller is stitched over the bone, a thicker and more fixed 
covering to the end of the bone is secured than could be olherv-ise attained: 
—(3) The end of the bone being covered by periosteum, adhesion of the 
Isofi parts to the end of the bone is far less like!)', the parts covering the bone 
fgrnerally remaining freely movable, and are, therefore, both belter nourished 
ind are less likely to become painful; — (3) The medullary cavity of the lK>ne 
eing shut off by the musculo- perioslca I covering, is much less apt to become 
ivolvcd in any septic process which may arise in the stump. The only 
ibjcctions which can be raised to a musculo-|>eriosteal covering are the 
le and trouble involved — which should not Ije allowed to weigh against 
practical advantages— nor should ihe possible formalifm of osteophytes 
proliferation of bone from the turned over periosteum l>e seriously 
ded. 
Manner of Providing Musculo-periosteal Covering in all Forms 
of Circular Amputation, and in all Double-flap Amputations Cut from 
Without Inward.^— The .'^urgcon should i»lan lo have his knife pass through 
thr drrp layer of muscles surrounding the bone in such a way as lo come 
awn through these muscles and u|)on ihe periosteum without separating 
Busies from periosteum (which would alsf> detach the vascular supply 
the jicriosleum), and at such a level on the bone below the saw-line as to 
tfuol a full half diameter of the biine at the saw-line. In circular amputa- 
tiim* lhi» final cut will pass transversely through the muscles, — in flap ampu- 



348 



AMPUTATIONS. 



tations, obliquely through, in the process of beveling. As soon as the peri- 
osteum is reached in this final incision, all the soft parts are carefully retracted 
around the whole circumference of bone at this level, especial care being 
taken not to use force in the retraction, thereby separating muscle from 
periosteum by dragging the former off of the latter. A circular incision 
is now made through the periosteum around the entire circumference of 
bone, at the level of the lightly retracted muscles — cutting the periosteum 
with especial firmness where closely bound to the lineae asperae. The peri- 
osteum is then detached back to the Une of the future saw-cut, by means of 
a periosteal elevator — care being exercised not to push the muscles off the 
periosteum, but to push the periosteum back from the bone with the muscles 
attached (Fig. 226). 

In Flap Amputations by Transfixion.— The knife should be entered just 
far enough below the saw-line to equal a full half -diameter, or more, of bone at 
the saw-line. When the flaps are cut, the f)eriosteum is divided circularly 
at this level — and then the periosteum and muscles are detached back to 




K jk ."^ — K.\:s!No A Ml SCI L^^rKKiosTF.AL CovEK:Nc—;n ihe circular m«hod of amputation. 



the saw-line — c^r the |^rio>teum may l>e rai^etl as two small flaps, their 
incision l^eginning at the Mw-lino (^Fii:. rr;'. 

In Oval and Racket Modifications of the Circular Amputation. — 
The freeing bvuk of the muscles should be sioppe^i at a level equal to a full 
half diameter. *^r more, of ihe Kmio Ivlow the Sviw line — the periosteum is 
here circularly divided — and the pvriosieum and muscles detached thence 
back to the saw line. 

In Single-fiap Amputations of Skin and Muscle.— The knife comes 
down u|x>n the Ihmu" one full diameior. or more, of K^r.e below the saw-line. As 
the two venical limbs of the flap have Ix^n cut down :o the periosteum in the 
earlier p,\rt of the oi^ration. a musv;:io ivriosieal nap is now marked out, 
ha\-ing a Kise equal to half the circumfererue of the bone at the saw-line 
and a length equal to one full diameter, ornion:* of the U^neat the saw-line. 
Thc perioisieum and mus< les are row detached back to the line of bone-section 
— all the hilheno undisiurbevi ivirts or. the opposite side of the hmb are 
divided transver^ly to the K^nc and the Ix^ne Sviwed. 

hk Flap Amputations of Skin Only.— As the muscles are here diWded 



MAKING MUSCULO-PERIOSTEAL COVERING. 



249 



I 



circularly, the musculo periosteal flap is provided for just as in the ordinary' 
circular amputation. 

In the Elliptical Modification of the Single-flap Method.— The 
musculo- f>eriosteal covering is hancile<i as in the single Hap uf skin and muscle. 

In Unequal Rectangular Flaps of Skin and Muscle ^Teale's Method). 
— The muscuto-jK.Tiostcal tovering is secured as in ampulaiiun by unequal 
flaps of skin and muscle. 

In Amputating Limbs with Two Bones.— The mustulo-periosteal 
covering for the larger bone is pnn ided as described in the single-bfme limbs. 
The musculo periosteal covering for the smaller bone is provided in the 
same manner, but will be cut at a higher level (as it is circularly divided, or 
a flap is cut, which will be equivalent lo the smaller diameter of the smaller 
bone). Where the bones are of the siime size, the periosteum is divided 
at the same level in each case — which may also be dtme when the bones 
APc of une<{ual size, the redundancy of perinsleum in the ca.se of the smaller 
banc being subsequently removed with scissors, if necessary. 




FIk- »7.— RAtStKC A MescutOPEitiosTEAL CovEKiNG— in the flap nie(hr>d of ampuuting. 



Note. — The hnal treatment of the periosteal covering cannot be carried 
out until after the division oi bone. 

Comment. — (i) It will be seen that in circular amputations and in ampu- 
tation<; by double flaps, the musculo periosteal covering is furnished from 
the entire circumference of the bone — while in amputations by single 3aps« 
a single fljtp of musculo-j>eriosteal tissue is raiseil. the width of which is 
rqtiaJ to a half circumference of bone and a length equal to a diameter of 
bone. (2) As there is comparatively little retraction of fibrous periosteal 
tissue^ th*? chief retraction taking place in the aJtached antl overlying muscles, 
for the musculo periosteal covering of one full diameter of the bi)ne 
fside of the Ijone hereby furnishing one-half diameter) will, therefore, 
' Corrr ihc end of the bone, but none too full) — so that this measurement 
ibould be made ver>' full. (3) Where it is difficult to detach the musculo- 
poiosiea] covering backward after simply a circular division of the periosteum, 
two vertical incisions may be made U[>on the lateral aspects of the bone, 
from the site of the saw-line to join the circular cut— which will make the 
ftcnt easier. These vertical incisions may. indeed, be made in all 
Even vrherc the vertical incisions are not made in detaching the 
jm, they may be subsequently made before adjusting the periosteal 
or covering. In the pure Hap amyjutations the muscles have already 




250 



AMPUTATIONS. 



been divided to the periosteum, so that the knife easily makes the two vertical 
incisions in the periosteum. In the circular amputation where it is necessary 
to add the vertical cuts before sawing the bone (that is, in order to rrach thic 
saw-line), the point of the knife may be pushed into the transversely divided 
muscles, in the long axis of the limb, up to the saw-line (which will lie only 
a half-diameter of the bone above) and cut downward thence to join the 
circular cut. (4) In the case of the two-bone limbs, the interosseous mem- 
brane is also freed back in the act of detaching the periosteum. (5) Some 
hold that the periosteal covering is without value in the adult and actually 
harmful in the young, owing to the possibility of reproduction of bone render- 
ing the stump conical. The former is an error of observation. The latter 
must be very rare, the epiphysis being responsible for the chief increase of 
length of bone. 



^^ 




Fig. 228.— Retraction op Soft Parts Preparatory to Sawing of Bone— in the case of a 
single-bone limb. A single-tail retractor is shown above. 



RETRACTION OF SOFT PARTS PREPARATORY TO SAWING THE 

BONE. 

All the soft parts overlying the bone having now been divided, from skin 

to periosteum, these soft parts are to be retracted above and out of 

^^^^ the way of the saw- 

' 1 line, which should be 

seen to be clear in its 
entire circumference 
before making the 
bone-section. 

In Single-bone 
Limbs. — A double- 
tailed linen retractor 
is generally used to 
hold the soft parts 
back — the two tails 
of the retractor pass- 
ing around the bone, 
thus supporting the 
soft parts and drawing 
them upward and out 
of the way (Fig. 228). 




r"ij^'. 2.").— RiiKAi 1 i<iN or SoiT Paris I'kkparatorv to 
Sawini. Di Hi, SI -iti tin- cast- i.>l a (loubK-bonc limb. A double- 
tail triKuiur is shown altovc. 



SAWING THE BONE, OR BONES. 



25J 



I 



In Double-bone Linibs. — A three-tailed linen retractor is us^ually used 
— the central tail passing between the bones^the outer of the other two 
tails on the outer side of the outer bone, and the inner on the inner side of 
the inner bone (Fig. 229), 

Comment. — The parts may also be retracted by the hands, or by various 
forms of metallic or other retractors. 



SAWING THE BONE. OR BONES. 

General Considerations. — The surgeon, .standing to the outer side 
of right hmbs and to the inner side of left limbs, grasps the limb firmly with 
his left hand Just above the saw-line. An assistant supports the distal portion 
of the limb, holding it out over the side of the table, and on an exact line 
with the level at which the limb leaves the trunk, in the case of the arm and 
thigh; and on a level with the surgeun's left hand in the case of the forearm 




1 



Flf. 130.— Maknbh of Sawing the Bonk— in the case of a singtebone IJmb. 



and leg. If he elevates it above the common level, he will bind the surgeon's 
saw throughout the entire transverse section (because the parallel walls of 
the section will tend to approximate), — and if he depresses h below the common 
level, while he makes it easier for the surgeon to stw, he is apt to splinter 
the hone just l>efore the section is completed (because the parallel walls of 
the s^ection will tend to diverge). 

In Single-bone Limbs. — The surgeon places the edge of his thumb- 
nail down ujw.n the bone immediately above the saw-line, as a guide to the 
saw, temporarily loosening but not entirely relaxing his steadying hold with 
the other tingers and palm upon the limb. Holding an ordinary amputating 
saw in his right hand, he deliberately places its heel against his thumb and 
knuckles, and directly over the saw-line^and, with a fairly slow but firm 
and steady movement, he draws the saw backward from heel to point, thus 
jfroo>ing the bone transversely. If this groove be not distinct or deep enough, 
the first movement (from heel to point) may be repeated. The surgecjn 
now resumes his steadying grasp of the limb with his left hand and proceeds 
to saw the bone by slow, even, steady, back -and -forth strokes of the saw, 




252 



AMPUTATIONS. 



traveling the entire length of the saw-blade at each stroke — and avoiding 
uneven and too rapid sawing, the latter sometimes generating a harmful 
degree of heat. It is during the section of the latter part of the bone that 
the assistant is most careful in his manner of holding the limb and the surgeon 
in his use of the saw. Toward the last the strokes of the saw should l>e 
slower, shorter, and lighter, and the limb so balanced that there will be no 
cross-strain anywhere throughout its length — and thus are the chances of 
splintering minimized. If indicated, the larger saw may be removed towani 
the last and the section be completed with a lighter, finer saw, but this is 
ordinarily unnecessary. As the bones of both single-bone limbs are nearly 
circular, no beveling of the edges is needed (Fig. 230). 

In Double-bone Limbs. — The general manipulative method is here 
the same as in the single-bone limbs. The saw first engages the heavier 
bone, and, having passed partly through this, is dropped upon the lighter 
or more movable bone — the section of which latter bone should be first com- 
pleted, the saw all the w^hile cutting the heavier bone also, which it finalh' 
completes alone. Where both bones are of the same size (as the middle 
of the forearm), the saw grooves the one nearer the operator and is then 

dropped upon the farther one. 
Where a bone presents a promi- 
nent ridge, almost or quite sub- 
cutaneous (as the anterior border 
of the tibia), this would become 
an angular projection after sec- 
tion of the bone and would be 
apt to become a prominent point 
of pressure. To avoid this, this 
edge of bone should be beveled — 
which is best done by making an 
oblique saw-cut from above down- 
ward, beginning about 1.3 cm. (J 
inch) above the saw-line and pass- 
ing obliquely into the bone at such 
an angle as to be about 6 or 8 mm. (for ^ inch) below the level of the bone by the 
time it has reached the saw-line. Having made this 1.3 cm. (i inch) oblique 
saw-cut into the bone, the saw is then withdrawn and is made to traverse 
the bone transversely along the line of bone-section in the ordinary manner. 
When the saw, traveling transversely, reaches the short oblique section, 
the small triangle of bone will drop out — and when the section is completed, 
the prominent edge of the bone will be found beveled (Fig. 231). 

Comment. — In the very young, and es|)ecially in amputating those bones 
which grow chiefly from an upper epiphysis, it is well to saw the bone as high 
as possible — as subsequent growth from such bones may require reamputation. 




Fig. 231.— Mannkr ok Sa\vin«; the Bonks— 
in the cast- <>f a <lnuhlf-b<)iie limb. The mothod oi 
bevelinjf a prominent marjjin of bone is also here 
shown. 



REMOVING SPLINTERED BONE. 

If, in the final saw-section, whether by splintering or a transverse snapping 
of the frail bridge of bone, a fragment of bone is left projecting from the 
stump, or any other projecting irregularity should appear upon the trans- 
versely divided bone, this should be remove<l down to a level with the face 
of the bone. This is accomplished by grasping the spicula of bone with 
bone-holding forceps (such as the lion-jaw tyj)e) and steadying it, while the 
surgeon removes the spicula with a small, fine saw (Fig. 232). 



LIGATING ARTERIES AND VEINS. 



253 



Comment, — (i) Bony projections are often crudely crushed off with 
bone-cutting forceps— ihis is quickly done and is a temptation — but is not 
to be recommended, as necrosis of the margin of the bone is more apt to 
loUow crushing than sawing. (2) The splinter of bone may be upon the 




Fig. ajj.— Mansieu of Rbmovtng a Piece of Sri isterkd Bo?cr, 

portion of bone removed — there will then be a corresponding depression, 
with probably a tearing of periosteum and muscles, upon ihe bone in the 
stump — which may require to be evened off. 



LIGATING ARTERIES AND VEINS. 

As soon as the bone has been sawed, alt the chief arteries and the larger 

%*cins should be tied. The arteries arc tied in the order of their importance 

are sought in their known positions. They have frequently retracted 

ewhat, so as to be out of sight, and are to be traced by their known rela- 

The stump should be held in a good jjosilion and light — and, if 

ir)', dried of blocxl. The cut ends of the arteries are caught by catch- 

orceps and drawn out of their beds by the surgeon — while an assistant 

lies the larger vessels with chromic catgut, tying them with a surgeon's 

knot. The larger arteries may be lied with the stay-knot of Edmunds and 

^nce (page 24). AH the vessels should be clamped before any are tied. 

larger arteries shoukl be drawn out of their sheath before being tied. 

be smaller arteries with their sheaths may be included in the ligature. 

Arteries which are caught with difficulty with catch-forceps may be taken 

up with a tenaculum. \'ery small vessels may be compressed or twisted 

without ligaturing. The chief veins should be tied — as well as any others 

rhich are seen gaping. All vessels should be tied as long as possible — and 

}»ould be disturbed in their sheath as little as possible. Arteries bleeding 

5m their osseous canals in the end of (he bone cannot be tied, but may be 

^trmirollcd by plugging the vascular canal with a piece of catgut, a piece of 

Btrrilizcd wood, or with Horsley's antiseptic wax, or Hatsted's gut-wool — 



254 



AMPUTATIONS. 



or a limited portion of the canal may be crushed in upon itself. After all 
known vessels are tied, the Esmarch, or other constrictor, should be relaxed 
and all hitherto untied vessels which now bleed are to be ligated (Fig. 233, A, 
B, and C). 

Comment. — (1) See that the first knot (friction-knot) does not loosen 
before the second knot (surgeon's knot) is complete — and that the knot is 
far enough from the end of the vessel not to slip off. (a) Where hemorrhage 




Fiif. 23.^.— Sti'mp after Ampi'tatinc throl'gh Lower Part of Right Lrc:— A. Li{i:mtion <rf 
aiitetuir tibial artfry; H, Clamping of posterior tibial arter>' ; C, Plugpng vascular canal ot bone 
with piece of catgut ; D, Cutting otl tag of peroneus loiigus ; E, Cutting anterior tibial ner\-e short. 



is apprehended, vessels may be taken up immediately after dividing the 
soft parts, and before even severing the bone. Instead of taking up and 
tying the vessels seriatim, they may be immediately clamped, one after another, 
and, if not tied at once, the catch-forceps may be retracted with the flaps^ 
or with the circular division of soft parts, and the bone sawed, after which the 
vessels are tied — relaxing the original hold where vessel and sheath are in- 
cluded and taking up vessel alone. (3) Obstinate oozing may generally be 



» 



SUTURING OF MUSCULO-PERIOSTEAL COVERING. 255 

controlled by ligating en masse — or by douching with hot saline solution, or 
by pressure. This is the form of hemorrhage which is more apt to occur 
after the removal of the constrictor. 

TREATMENT OF NERVES, TENIXJNS, AND TAGS OF MUSCLE, FASOA, 

AND SKIN. 

(I) AU nerves should be cut as short as possible, to avoid entanglement 
and pressure in the process of cicatrization^to accomplish which they should 
be caught by forceps and drawn well out and then cut with scissors and 
allowed to retract out of sight. Where ihe flap methcKl has been done and 
it is likely that an important nerte may be subjected to pressure when the 
flaps are bent and sutured over the end of the bone^ the nerve should be dis- 
sected out- This is esj>ecially the case In the melhtxl of single-flap ampu- 
tation. Nerve ends are apt to become bulbous in any event, but will not 
be troublesome unless subjected to pressure. (2) All tendons should l>e 
caught with forceps, steadied, and cut short under slight tension. They are 
difficult 10 cut unless steadily held and slightly stretched — when thev may 
be cut with scissors or a very sharp knife. Tendon-ends possess low vitality, 
arc apt to slough, fulfil no useful purpose in the stump, and make l>ut poor 
covering. (J) All tags and irregularities of muscle, fuscin, and skin should 
evcnlv trimmed, so as to conform with the general contour. (Fig. 233, 
and D.) 

TRIMMING OF FLAPS. 

It is undesirable, and somewhat unsurgical, to make a miscalculation in 
the length or contour of a flap, which will require any subsequent trimming 
— but where a flap is distinctly tcK) long, or loo large, or misshapen, it is 
better to do the trimming necessary to make a gocxl fit than lo suture it in 

^pUce as it is. It is held in the left hand, or caught with forceps, and trimmed 
as one would trim a [>iece of paper. A flap may be trimmed as a whole — or 
some individual tissue composing it may be trimmed. 
■ RE-AHPUTATION FOR mPROPERLY MADE FLAPS. 

It is even more unsurgical, and much more dilTicult lo rectify, to find 
that so little allowance of covering has been made that the end of the bone 
either cannot be covered at all. t)r cannot be covered without a degree of 
tension calculated to endanger the flaps- In such a case all that one can 
do is to amputate at a higher level. If only a slight deficiency of covering 
exist, the end of the bone may be freefl of its soft parts by retraction and 
made to project and then be removed i>y the saw. Where the deficiency is 
greater, from one to several inches of the soft parts may also have lo be re- 
moved, as well as the bone. In such a case one proceeds very much as in 
the original operation, modified by the needs. 



ADJUSTMENT AND SUTURING OF MUSCUiaPEFIOSTEAL OR 

PERIOSTEO-CAPSULAR COVERING. 

The first step in the closure of the stump-lissues is the adjustment of the 

muiiculo-periosteal covering. It will be remembered that in all rirrular 

amputations, and in all double-flap amputations of skin and muscle, the 




256 AMPUTATIONS. 

musculo-periosteal covering was made by a circular division of the periosteum 
around the bone one-half of a full diameter of the bone below the saw-line 
(thus furnishing a full diameter), and that the periosteum, with adherent 
muscles, was then detached in one layer up to the saw-line. Therefore, 
after the bone is sawed and the soft parts drop down around its cut end, 
the musculo-periosteal covering will form a hollow cylinder projecting from 
the lower surface of the transversely sawed bone — the periosteum hanging 
down around the bone for a depth, approximately, of a half diameter of the 
bone, the muscles being adherent to its outer side. This cuff of musculo- 
periosteal covering may be converted into two small flaps by cutting along 
its lateral aspects with straight-pointed scissors, from its lower free margins 
up to the bone. The corners of these little flaps may then be slightly rounded, 
though this is not necessary. These two flaps are then dropped over the 
end of the bone and their edges are sutured together with catgut, the sutures 
passing through periosteum and muscles. While the above method makes 
a neater fit, it is not really necessary that the musculo-periosteal covering 

should be slit up at all on the 
sides — it suffices simply to ap- 
proximate the edges over the 
bone by a suture running either 
antero-posteriorly or trans- 
versely. Where the musculo- 
periosteal covering has been 
raised in the form of a single 
flap (as in the amputation by a 
single flap), this single flap' of 
musculo-periosteal covering is 
dropped over the end of the 
bone and its margins sutured 
to the cut margins of the peri- 
Fig. 2:w.-sihking of Mi-scrLo-PERiosTEAi. cov- osteum around the rest of the 
hRiN«;. circumference of bone, including 

the muscle overlying the j)erios- 
teum. Where the bone-section is very small, it is often difficult to adopt 
any definite plan of making and suturing a musculo-periosteal flap, the per- 
iosteum being torn in shreds in the process of detachment. In such cases 
the mass of musculo-periosteal tissue is simply gathered together and sutured 
over the end of the bone. (Figs. 234 and 242.) 

QUILTING OF MUSCLES. 

The muscle tissue which enters into the covering of the bone should, 
where j)ossible, be approximated and sutured into apposition by buried 
chromic gut sutures, placed in one or more tiers, by means of either buried 
simple sutures, or buried quilt- or mattress-sutures. Thus the cut aspects 
of the muscles are brought into contact, — less tendency for them to retract 
away from the end of the bone occurs, — in the process of cicatrization they 
become incorporated in the general pad of covering which forms the stump 
(even though the muscle tissue itself may be subsequently replaced by fibrous 
tissue). — there is less chance of adhesions forming between bone and skin,— 
and, altogether, a fuller, softer, better-formed pad of covering is pro\-ided. 
These advantages more than counterbalance the only two disadvantages— 
namely, of time and trouble involved. By the process of quilting, muscles 




Ql ILTING OF MUSCLES. 



2S7 



I 




F'fT J35---QiriLT«Nr, of MfscLKs in Circular 
M&THtiD OK AMPi'TATlt»N;-^-'irst tier of •i.uturrs 
Ims been plactnl— iiFitl is being buried by the second 
tier. 



are brought and held in contact untO united, which, in the ordinar\' method 
of simply dropping muscles aver the ends of the bones and depending upon 
the single line of marginal skin-sutures to approximate, either could not be 
made to come into contact even temporarily, or, if so, would generally retract 
apart before union. 

In Circular (Inftindibuliform Variety), Modified Circular, Oval, 
and Racket Methods.— After su- 
turing the musculo periosteal cover- 
ing the muscle surfaces are brought 
into contact immediately over the 
rauscuio-pcriosteally covered end of 
bone. The approximation of mus- 
cle tissue over the bone msLX be 
made in the way in which the mus- 
cles most naturally fall. Other 
things being equal, the approxima- 
tion should be made so as to cause 
ihe suture line to be parallel with 
the future suture line of the integu- 
^jnentary coverings. The first tier 
of sutures is placed nearer the bone, 
entering and leaving the muscle tis- 
sue at such a distance from the 
bone as to secure an easy ap- 
proximation of the muscle substance 

over the end of bone. This first row of sutures, which, if of ihe simple 
form, may be either interrupted or continuous, will conceal the end of the 
bone. A second tier, especially in heavily muscled limbs, or in thin 

limbs with large muscle 
flaps, should be applied 
— being inserted nearer 
the edge of the muscle 
tissue than the first — 
and» when tied, will hide 
the first row (Fig. 2.^5). 
In Circular 
Method a La Man- 
chette.— As the mus 
cles are here all divided 
on one level, and that 
level is that of the re- 
tracted skin, skin and 
fascia alone cover the 
end of the bone, and 
no appro.ximation and 
quilling of the muscles 
are possible. 
In All Double-flap Amputations of Skin and Muscle.— The muscles 
are <|uilted in the same manner as in the ordinary circular finfundibuh'- 
form), the process of muscle quilling being easier in the double- flap 
H mcthtxl than in the ordinari' circular, as the muscles are adherent to the 
^^^ flapi 00 either side and are more readily held in approximation while being 
^Mqtitlted (Fig. 236). 




Fig. »j^~y'V»LriH«. OK Mi.'scuts IN FLAr Method of Ampi'- 
«^-Flr«t tier ul buried sutures bas been placed and tied— 
1 Mcoad tlci i« beiiiK pU<.-cd. 



2S8 AMPUTATIONS. 

In All Double Flaps of Skin. — No quilting of muscles is here possible 
— as the muscles are transversely divided on a level with the retracted skin- 
flaps. 

In All Single Flaps of Skin and Muscle, Including the Elliptical 
Method. — As the muscles are here divided obliquely on the side of the flap, 
and transversely on the opposite side, the quilting of muscles is not done 
as in the above-described methods (where the lateral aspects of the muscles 
are sutured to lateral aspect, or ends to ends). The lateral aspect of the 
muscles in the present instance, some of which aspect is made up by the 
obliquely beveled muscles, is sutured to the transversely divided muscles 
on the side of the limb opposite to the flap — and the ends of the muscles in 
the flap are sutured to the circumferential margin of the transversely divided 
muscles in the stump. As the base of the flap comes from a full half-cir- 
cumference of the limb, the bent-over flap is only approximated to the opposite 
half of the face of the stump. Where the elliptical method is used in the 
neighborhood of an articulation (that is, in a disarticulation) where only 
tendons pass over and cover the joint, no quilting is j)ossible. It is, therefore, 
applicable only where muscles cover bones, which, in the case of the joints, is 
only at the shoulder and hip. 

DRAINAGE. 

No drainage is necessar}' in amputating through sound tissue in the 
continuity of a limb. Temporary drainage (for two or three days) may be 
instituted in disarticulating through the larger joints — to provide for the 
escape of the synovial fluid which the remaining synovial surfaces will go 
on secreting for a time. \\Tiere drainage is indicated, it is sometimes better 
to make a counter-opening than to attempt to drain through a non-dependent 
suture-line. Drainage may be temporarily used where bleeding in the 
stump-tissues is feared after prolonged use of an Esmarch, or for other reason. 
Drains of rubber- tubing, glass, gauze, or bone-tube may be used. 



SUTURING OF THE STUMP. 

The suturing of the edges of the wound should be done with silk and by 
means of interrupted sutures. W'here no great tension is likely to occur, 
silkworm-gut may be used. Catgut is also employed. The parts should 
come together without tension. The interrupted is to be preferred to the 
continuous form of suturing, for the parts may be thereby more acciu"ately 
adjusted — and if it become neces.sary to open any part of the wound for 
drainage, or other cause, only the few indicated sutures need be cut. 

In Circular Amputations. — It is optional with the operator as to whether 
the soft j)arts are so approximated as to result in a line of sutures running 
from before backward, or from side to side. The former is to be preferred, 
as the lower end of the suture-line (in the recumbent position of the patient) 
drains the wound by gravity, in case drainage be necessary. WTiere skin 
and muscle come evenly to the edge of the wound, both are included in the 
sutures. \\'here skin is longer than muscle, the sutures which close the 
wound pass through skin only — the muscles having been approximated by 
their own buried sutures. 

In Flap Amputations. — Here the direction of the line of sutures will be 
determined by the j)osition of the flaps. Where double flaps are taken 
from the anterior and posterior aspects of a limb, the suture-line will run 



THE EVOLUTION OF AMPUTATION METHODS. 



259 



I 



from side to side. Where double flaps are taken from ihe lateral aspects 
the surure-line will be anteroposterior. V\*here a single flap is approximated 
to the opposite side of the limb, its margin is sutured to the opposite half- 
drcwnference. Where the margin of the flaps is comjwsed of skin and 
muscle, both are included in the sutures. Where the skin is longer than the 
muscle, the skin alone is included in the suturing. In al! cases the muscle 
surfaces are supposed to have been quilted together prior to the final closure 
of the wound. 

Comment. — (i) Owing to the difficulty of equally dividing out the |>osi- 
tions for sutures where a large wound is lo be brought together; it is well 
10 begin by putting in a central suture and then divide each remaining half 
oi the space into quarters by two other sutures — then these smaller lengths 
can be sutured with intemipted or continuous suture — the former being 
better, as, in case it be necessary to loosen any suture for suppuration, or 
otherwise, the entire tine need not be loosened. (2) If tension upon the 
edgies be great, a few lensiori'sutures may be used. 



r 



H T 



DRESSING OF THE WOUND, 

The wound and .stump should be covered with absorbent gauze — the 
entire stump enveloped in absorbent cotton — which should be snugly bandaged 
to the end of the stump and the circumference of the limb, A padded poste- 
rior splint should be incorporaterl in the outer layers of the dressing, pro- 
jecting beyond the stump slightly — both to support the part; protect it from 
injur)", and control, or lessen, the muscular starlings which are apt to occur. 
The stimip should rest upon an inclined plane, outside of bed-covering. 



REMOVAL OF DRESSINGS. 

If all goes well, the dressings are not removctl until about the tenth day 
(or from the tenth to the fourteenth). If a drainage-tube \>c used, the dress- 
ings are often changed when that is withdrawn — although it is sometimes 
withdrawn at the end of the second or third day — and the dressings not 
removed until the usual time. 



THE METHODS OF AMPUTATION. 
THE EVOLUTION OF AMPUTATION METHODS. 



^ rei 

^m The methods of amputation have undergfme a slow process of evolution 

^m — which may be briefly staled in the following tabular form (mLKlified from 
I Kocher). 

Circular Incision. — The fundamental type of amputation. Of which 

there are two varieties, and from which all other methtxls of amputation 

may be derived; — (a) Transverse circular incision (Fig. 237, A); (b) Oblique 

cirruUr incision (Fig, 237, B). 

H Racket Incision. — Formed by the addition of a longitudinal incision 

H to the circular incision, (a) If the longitudinal incision be added to the 

H transverse circular incision, the transverse racket incision results (Fig. 237, 

^M C); (h) If the longitudinal incision be added to the obHquc circular incision, 

^1 the oblique racket incision results (Fig. 237, D). Note — The comers of the 



26o AMPUTATIONS. 

racket incision are now generally rounded off, as in the oval method, the 




Fig. 237.— Thr Evolution of Amputation Methods :— I— A, Transverse circular incision ; B. 
Oblique circular incision; C, Transverse racket incision; D, Oblique racket incision, ^fodified 
from Kochcr.) 

only practical difference between the two, as now usually employed, being 
that the queue is made longer in the racket method. 

Oval Incision. — Formed by the shortening of the queue and the rounding- 




Fi>f- 238.— The Evoli'tion ok Ampi'tation Mkthods :— II— A, Transverse oval incision: 
B, Oliliqiic oval iiii-ision ; C. Kqual rectangular (laps; D, Unequal rectangular flaps. (Modified 
from Kuchur.) 

off of the angles of the racket incision, (a) If the angles of the transverse 
racket incision be rounded, the transverse oval incision results (Fig. 238, A); 




Fir. 230.— The Evoi.rrios oi- A.mittation MHTiiuns:— III— A, Kqual rounded flaps; B, L'nequat 
t<>uii(li-(l flaps. (Mmiiticd iroin Kuchor.) 



(b) If the anplesof the oblique racket incision be rounded off, the oblique oval 
incision results (Fig. 238, B). 



ORDINARY CIRCULAR AMPUTATION, 



26t 



Rectangular Flaps. — Formed by adtiing twn lnn*;itufiinal incisions to the 
circular incision, (a) If the two longitudinal incisions be ;u1(Icj1 to the circular 
incision, equal rect.inf^lar t1:ips result (Fii^. 2^8, C) ; (b) If they be added to the 
oblique circular incision^ unequal rectangular flaps result {Fig. 238, D). 

Rotmded Flaps. ^Formed by rounding the angles of the rectangular 
flaps, (a) If the angles of equal rectangular flaps be rounded, equal rounded 
kiflaps result (Fig. 239, A); (b) If the angles of uneciual rectangular flaps be 
Grounded, unequal rounde<l tla])s result (Fig. 239, B). 

Elliptical Method. — The position of this method, in the process of 
.evolution, will be described further on (page 273). 



SUMMARY OF AMPUTATION METHODS. 

Fundamental Types. — Circular Method; Flap Methorb 
Modem Types. — (a) Circular and its modifications; (b) Flap and its 
|«lJodihcalions; (c) Irregular methods of amputation. 

As to Nature of Covering of Stump.— All methods of amputation 

either — (a) Skin Coverings— that is, skin and fascia alone cover the 

divided muscles and bone, as in the cut! methixJ of the circular amputation, 

and in the 5im{>le skin-flap in the flaj» method of amputation; — or (b) Skin- 

i-muscle Coverings — where skin, fascia, and muscles, combined and un- 

r«eparaled, including the periosteum, cover the end of the bone, as in the 

ordinarv' (infundibuliform) circular amputation, and in flaps of skin and 

< musde in the flap method of amputation. 



CIRCULAR METHODS OF AMPUTATING. 

(ft) Ordinar\' Circular Method — (amputation circulaire infundibuli- 
e); — (b) CulT Method of Circular Amputation — (amputation it hi man- 
ite): — (c) Mtxiificil Circular Mcthml of Amputation — (mixed method); — 
(d) Oval (or Lanceolate) Method;— (e) Racket Method. 



ORDINARY CIRCULAR AMPUTATION. 

(AMH'TATION tlRCtLAIRI*: INFrMUmi IFORME). 

General Description.— The soft parts are dividerl by a series of circular 
■cuts, retraction of the parts taking place between each circular sweep of the 
' life, so that they are cut partly through at ditTerent levels — the sawed bone 
i:ng the apex of the funnel left upon the proximal end of the limb, anti 
t»c skin margin the base — the distal part removefl being cone-shaped. 

Technic. — Stand ti> outer side of right and inner si<le of left limbs, so 
as to prasp limb between trunk and amputation site. Determine the saw- 
Fix the skin incision at a level below the saw-line equal to J of i| 
lime* the diameter of the limb (or three fourths of that diameter) at the 
saw-line (that is, at 11.5 cm., or 4^ inches, below the saw-line, if the diam- 
l^tcT of the limb nt the saw-line be 15.3 cm., or b inches) (Fig. 240, A). 
Jrasp the limb just above the line of the skin incis^ion with the left 
and retract the skin ujnvard, aided, if the limb be large, by an 
»nt. With a long knife, make a circular incision, at the skin incision 
Rue, through skin and superfnial fascia, entirely around the limb. Free 
ikin with iis supcrfu ial fascia from the muscles with their deep fascia, aiding 



262 



AMPUTATIONS. 



the separation in the interfascial line by touches with a scalpel, where neces- 
sary. Retract the skin and fascia evenly around the circumference of the 
limb. Divide the more superficial layer of muscles circularly, on a level 
with the retracted skin. Retract this more superficial layer of muscles. 
Divide the remaining deeper muscles circularly on a level with the retracted 
outer layer of muscles — and planning to come down upon the bone, or 
bones, far enough below the saw-line to allow of making a musculo-periosteal 
covering for the bone or bones. Retract the deei)er muscles thus cut. Divide 
with a stout knife, the periosteum circularly around the bone, or bones, at a 
distance below the saw-line equal to a good one-half diameter of the bone 




Fijfs. 240 and 241.— Ordinary (IsFrNniBrLAR) Form of Circular Amputation :— A, Position 
of incision and bonc-scrtion ; B, RcsultiriK suture-line. The skin-inctsioii and auture-line here »n 
also applicable to the cuff variety of the circular method. 



at the saw-line. Push up the periosteum from the bone with periosteal 
elevator — keej)ing the muscles adherent to the periosteum. Apply linen 
(or other) retractors to the soft parts and draw them above the saw-line. 
Saw the bone, or bones. If splintering occur, grasp the spicula with forceps 
and remove with finer siiw. Allow the soft parts to drop over the end of 
bone, or bones, the sawed ends of which will form the apex of a funnel — 
the bone being covered by periosteum — periosteum by muscle — and muscle 
by fascia and skin (Fig. 242). Tic the vessels — cut the nerves and ten- 
dons short — and remove any tags t)f connective tissue or skin. Suture 
the musculo-periosteal covering over the end of bone, or bones. Quilt the 



CLTF METHOD OF CIRCULAR AMPL'TATIo\. 



263 



< 



muscles together in one or two layers. Suture the skin and fascia antero- 
posteriurly (Fip. 24], H) — and apply the dressing and supporting splint. 

Resulting Stump» — Evenly ccjvere<l on all sides by muscle and skin 
— the bone being particularly well jirotecled and on a higher level above the 
surface of the stump than in any other 
form of amputation. The scar is ter 
minal — antero-poslerior, if the wound be 
sutured from before backward, — lateral, 
if sutured frnm side to side (Fig. 241 » B). 

Indications. — In limbs more or less 
evenly surrounded by muscles; — lower 
pan of forearm (s<jmetimes), arm. and 
thigh. 

Comment.— (I) Owing to unequal 
skin retraction in some localities (as the 
anlero-intemal aspect of the arm and 
thigh) the circular incision may have to 
be planned obliquely and only become 
circular after the incisi<in — and may also 
have to be planne<l lower. (2) A pure 
ordinary circular (infundibuliform) am- 
putation is impossible in a limb of rap- 
idly increasing girth, as it is impossible 
lo retract the st>ft parts. A single lateral 
vertical incision through skin and fascia, 
or double lateral incisions, may become 
necessar}* in order lo free the parts — 
when it ceases to be a typical infundi- 
buliform amputation. 



Ktg. xia-— Appkarance of the Parts 
Following thk IftFCNDiBiiAR Form of 
Circl-lar Ampitation-.— a (utiiiel-shaped 
cavity left proximally. and a coiie-sbaped 
mass dislally. 



CUFF METHOD OF CIRCULAR AMPUTATION 

(CIRCLTLAR AMPUTATION A LA MANCHETTE). 

General Description. — \ circular division of the skin is made, which 
is turned over and upward upon itself as a cuff — and, ujKin a level with this 
retracted culT of skin and fascia, the muscles are divided to the bone, generally 
with one circular sweep of a long knife. 

Technic. — The steps of the operation are similar to those of the ordinary 
circular amputation (page 261) up lo the completion of ihc circular incision 
through the skin and superfirial fascia. The skin and subcutaneous tissue 
arc then turned back upon themselves as a cuff — the freeing being done 
by means of the fingers of the left hand, aided by touches of a scalpel, until 
e^xnly rrtracletl all around. On a level with the retracted cuff, the muscles 
are circularly divided down to the bone^ihe site at which this division takes 
plate being such as will allow of amjile and easy covering of the transversely 
divided muscle by the skin and fascia — an average calculation l>cing that 
X one-third of the total distance from saw-line to line of skin incision 
\jc given lo skin and fascia alone. The subsequent steps of the opera- 
'faduding the musculo-ix*riosteal covering for the bone, l>eing the same 
the onlinur\'. or infundibyliform, circular amputation. 
Resulting Stump. — Apt lo be more or less irregular in contour and not 
irdl paddt*d, owing to the nature of the parts used for covering. The 
lies a& in the onlinary circular amputation (page 262). 



264 



AMPUTATIONS. 



Indications. — Most frequently used where the soft coverings are more 
tendinous than muscular: — wrist, lower part of forearm, ankle, and lower 
part of leg (in thin subjects). 

Comment. — (i) and (a) The same comments made under (i) and (a) 
of the last operation apply equally here (page 263). (3) Owing to the greater 
proportion of skin in this covering and the division of muscles in one law, 
as well as the number of tendons present in the sites where this method is 
generally used, the covering of the bones is not so satisfactory as in the ordinary 
circular method. 

MODIFIED CIRCULAR AMPUTATION 

(MIXED METHOD). 

General Description. — Two equal flaps, composed of skin and fasda. 




Fijjs. 2^i aiul 344.— M<u>iKiKn Circui ar Mktiioo of A.MPrTATioN: — A, Position of incisioti and 
boiiv-Sii.tioii ; K, Kcsultiii|; suiurc-line. 



of varying length, and having bases ccjual to one-half of the circumference 
of the limb at their upper ends, are cut and dissected up a short distance — 
followed by a cinuhir sweep of the knife through the retracted superficial 
muscIc"^ — and by a second circular sweep at a higher level, through the re- 
tracted ilec])er muscles — and completion of the operation as in the ordinary 
circular amputation. 

Technic— Having fixed upon the saw-line, and having marked a point 
below the saw-line equal to * of i^ diameters of the limb at the saw-line (that 



5, thrcc-fourths of the diameler at the ?a\v-line), two equal Ilaps of skin and 
iascia (of ihU length) are planned. These flaps have bases equal to 
bne-half the circumference of the limb at ihe level of their upfjer limit 
■^and their length will be equal lo one-third or one-half of the total distance 
between saw-line and lowest limit of skin-covering (generally one-third in 
slender, ill-formeti limbs, and often one- half in large, tapering limbs). The 
Baps are usually lateral ones, but may be anterior or {posterior (Tig. 243, A). 
Retracting the skin with the left hand, begin the incision at one mid-lateral 
ftspecl of the limb, at a level abcne the lowest limit of the skin incision equal lo 
one-third or one-half (as the case may be) of the distance belueen the saw-line 
and the lowest limit of the skin incision— pass vertically downward, through 
»kin and fascia, until nearly at the level of the lowest skin incision — thence 
round forward into the line of lowest skin incision, in a bluntly rounding 
manner — and complete the opposite end of ihe siime flap in the same manner. 
Then make the opposite tlap in the same way as the first one, corresp(>nding 
in shaf>e and size. Dissect these tiaps of skin and fascia back to just beyund 
their bases. While the flaps, and the muscles also, are retracted, divide the 
more superficial muscles circularly — retract these, and divide the deeper 
muscles similarly — making the usual provision for the musculo-[>eriosteal 
■covering. The operation is completed as in the ordinary circular ampu- 
■lation — the skin and fascial flaps being sewed over the quilted muscles — 
■the bone being at the apex of a funnel which is somewhat shallower than 
"In the infundibuiiform variety of circular amputation (owing lo the muscles 
having l>een divided at a higher level). 

Resulting Stump.— While not covering the end of the bone with quite 
«s thick a padding uf soft parts, its general features are the s;ime as thoi-e 
following the ordinary- circular method. The main part of the scar is terminal, 
but its ends are apt to be partly lateral (Fig. 244, B). 

Indications. — This is the form nf circular amputation must generally 
used and is adapted lo a greater number of sites than the ordinary circular, 
the cuH modification of the ordinary method. 

Comment. — (i) The skin -Haps may be cut of unequal lengths. (2) 
The muscles may be divided al tine level. (Jj This form of circular ampu- 
tation has largely replaced either of the other forms. 



OVAL METHOD OF AMPUTATION. 

General Description.— A modifKaiion of the circular method. The 
akin incision is in the form of an oval, with one of its ends more prolonged 

■ anil p«jinted— ihe soft parts between skin and bone being divided by cutting 
Kfrom without inward — and the lips of the wound being sutured in a single 
Bfiae parallel with the long axis of the wound. 

■ Technic. — This amputation being generally used in disarticulations, the 
npper or ]>ointed end of the oval usually begins just alx)ve a joint-tine and 
^pon its outer or anterior asjx^ct — the limbs of the oval parting at an angle 

fufficirnt lo include the head of the distal bone — and sweeping thence in 
a ctjn'c down the lateral aspects of the limb -passing, finally, transversely 
toward each other— to meet upon the inner or under surface of the distal 

Sat a distJince beneath the line of articulation calculated to furnish 
covering for the head of the proximal >)ne of the bones making up the 
;. .245, .\). Having completed the incision through skin and fascia, one 
tirses may then be adopted; — (a) The incision may then bedccjaned 



% 




266 



AMPUTATIONS. 



throughout direct to the bone, by cutting from without — the deep incision, 
from the point where the arms or limbs of the oval begin to diverge, following 
the line of the retracted skin. This is the general method in all of the smaller 

disarticulations and in most of the larger, 
(b) Or the joint may be opened by the 
more vertical part of the incision and, after 
disarticulation, the muscles may be cut 
from within outward, on a line with the re- 
tracted skin. Having tied the vessels and 
cut the ncnes and tendons short, the wound 
is sutured in its long axis (Fig. 245, B). 

Resulting Stump. — The end of the 
bone is very fully covered except where 
the head or articular end of the proximal 
bone is disproportionately large. The scar 
is termino-lateral (Fig. 245, B). 

Indications.— A form of amputation 
generally used for disarticulating a limb 
from the trunk, or a smaller limb from 
a larger limb. The method admits of 
first opening the joint for investigation 
before finally deciding upon amputation — 
and it also admits of securing the vessels 
before removing the limb. 

Comment. — The suture-line may run 
antero-posteriorly in one straight line — 
or the free, lower convex border of the 
flap may be turned over and sutured 
to the upper angular concavity of the wound. 




Fifj. 245.— Oval Mbthod of Ampin 
TATioN :— A, Form and position of oval ; 
B, Resulting suture-line. 



RACKET METHOD OF 
AMPUTATION. 

General Description.— 

A modification of the cir- 
cular method. The same, 
in principle, as the oval am- 
putation — with the addition 
of a longitudinal vertical cut 
prolonged from the apex of 
the oval forming the "han- 
dle of a racket " — thus 
giving a better exposure of 
joints without sacrifice of 
tissue and >ccuring a better 
covering for the bone in the 
Uf)pcr j)art of the wound. 
Technic. — Practically 
similar to the oval amputa- 
tion, except that the queue 
of the racket begins con- 
siderablv farther back over 





FiRs. .'4'i ami ^47.— Rackrt NfETHOD oh Ampi'TAtion :— A 
I'orm and i>osilion of incision ; B. Resulting suture-liue. 



AMPUTATION BY SINGLE FLAP OF SKIN AND MUSCLES. 267 



I 




the head of ihc proximal bone forming the juini — and along this single 
Straight line the knife travels some distance before the arms of the racket 
begin to diverge. After the beginning of the divergence of the limbs of the 
racket, the operation is completed as in the oval ofjeration (Mg. 246, A). 

Resulting Stump.— More satisfactory covering is secured by the racket 
Ihan bv the o\al melh(.xl of amputating. The scar is termiiio lateral (Fig. 

Indications. — Disarticulations of the shoulder- and hip-joints, and of 
the digits from the hand and kmt (especially, in the latter instances, where 
a metatarsal or metacarpal iK)ne is rcmovctl with the digit). As in the oval 
method, but to a much greater extent, does the racket method admit of a pre- 
liminary' examination of the joint through the vertical portion of the incision, 
before deciding u[>on amputation. The vessels may also be secured before 
entirely separating the limb. The muscles in the stump are better preserved. 

Comment. — (i) The queue of ihe racket should be placed, if possible, 
over an intermuscular septum and be deepenefl in the septum. (2) Ampu- 
tation by a T-*haped incision is, practically, a form of racket incision. (3) 
The suture line may run antero fKisterjorly (or from the outer to the inner 
a3()ect of the part), which is to be preferred. Or the upper portion of the 
queue may be sutured in this manner and the lower convex portion of the 
flap brought up and sutured to the angular concavity formed by the di- 
vergence of the lateral limbs of the racket. 



FLAP METHODS OF AMPUTATING. 

(a) Single Flap of Skin and Muscles; — (b) Single Flap of Skin; — (c) 
Equal Flaps of Skin and Muscles; — (d) Equal Flaps of Skin;^(e) Unequal 
Flaps of Skin and Muscles; — (f) Unequal Flaps of Skin; — (g) Elliptical 
Method;— (h) Unequal Rectangular Flaps of Skin and Muscle. 



AMPUTATION BY SINGLE FLAP OF SKIN AND MUSCLES. 

General Description.— A method of amputating whereby the stump 
is covered with a single flap derived from one aspect of a limb— and consists 
of skin, fascia, and muscles. Such an amputation involves the maximum 

ificc of bone. 

Tedmic— Having fixed upon the saw-line (or line of disarticulation), 
• point is determined upon below this line, and on that aspect of the limb 
which is to furnish the flap, which will represent a distance below the saw- 
line equivalent to ij diameters of the limb at the saw-line. A llap is then 
marked out with a base equal in width to a half-circumference of the limb 
at the saw-line, and a length equal to ij diameters of the Hmb at that line. 
(Fig. 248, .\). Grasping the limb as in the ordinarv' circular amputation, the 
knife is entered at the far upper en<l of tlie base of the llap. at a right angle to 
Cheskin -anti passes vertically down the mid-axis of the limb to near the lower 
Itmtl of the rtap— w here it forms a squarely or bluntly rounded corner to Ihe flap 
— ihcnce passes transversely along the lower limit nf the lla]) — and completes 
the opjMjsite limb of the llap symmetrically with the first limlj. This incision 
p«is«n through skin and fascia. When this integumentary llap has retracted, 
the muwrlcs are rut obliquely on a line with its retracted edges, so directing 
the knife as to bluntly bevej the muscular portion as the knife cuts its way 





268 



AMPUTATIONS. 



from without inward and upward. This incision passes obliquely throu^ all 
the muscles and is planned to come down upon the bone at a distance beneath 
the saw-line equivalent to a good diameter of the bone at the saw-line, thus 
providing for a musculo-periosteal covering. The knife is then carried througli 
the periosteum so as to form a musculo-periosteal flap with a base of half 
the bone at the saw-line and a length of once the diameter. The musculo- 
periosteal covering is then detached back to the saw-line. Divide the hitherto 
undisturbed soft parts on the opposite side of the limb by a circular sweep 
of the knife — passing through the skin and fascia of the half-circumference 





Figs. 248 and 249.— Amputation by Single Flap of Skin and M i;sclk :— A, Form and position ol 
incisions ; B, Resulting suture-line. 



a little below the level of the base of the single flap — and through the muscles 
on a level with the base of that flap, including the periosteum. Retract all 
the soft i)arts on the proximal side of the saw-line and divide the bone. Suture 
the musculo-periosteal flap over the bone, the free edge of the periosteal 
flap being sutured to the half-circumference of the opposite aspect of the 
periosteum. Quilt the lateral and terminal aspects of the cut muscles in the 
flap with the transversely cut ends of the muscles on the opposite side of the 
limb. Suture the terminal and lateral aspects of the skin of the flap to the 
transversely divided skin of the opposite side. 

Resulting Stump. — The stump is at first well covered with muscle— 
and. when this atro])hies, by the replacing fibrous tissue. The scar is lateral 
(Fig. 249, B). 



» 



AMPUTATION BV EQUAL FLAPS OF SKIN AND MUSCLE. 269 

Indications. — Cases of injur}' so destroying the soft parts as to leave 

those of but one aspect available. Also in such cases as Farabeuf's amputa- 

1 lion of the upper third of the leg by a singie external flap of skin and muscies, 

or Dubreuil's disarticulation at the wrist by a single external flap of skin 

and muscles. 

Comment. — (■) In all flaps, skin must he longer than muscle. (2) 
There is s»)melimes an excess of muscle in a flap, part of which should be 
removed in the prixess of beveling — but a fully muscled flap is generally 
desirable. (3) A flap of skin and muscle is more apt to live and makes a 
better covering than une of skin alone. (4) While the muscle tissue as such 
may not remain in the tissues of a stump, the muscle-fibers undergoing 
atrophy, yet the flbrous tissue matting and padding together of the parts 
is left in its place. (5) A single flap requires the maximum sacrifice of limb, 
one side of the limb furnishing the entire covering and the bone being con- 
sequently divided at a higher level. 



AMPUTATION BY SINGLE FLAP OF SKIN. 

General Description. -^The features of this operation are practically 
the same as those of the amputation by a single flap of skin and muscles, 
CJicept that the covering here consists entirely of skin. 

Technic*. — Having incised through skin and fascia, this integumcntar>^ 
flap is dissected up from the muscles throughout, including all overlying 
fascia, and is retracted above the saw line {or disarticulation-line) — when 
the b<me is sawcfi or <lisarliculatetl, and the flap dro])ped over the end of 
the limb — its terminal aspect being sutured to the transversely divided skin 
of the OfjjKjsile side. 

Resulting Stump. — V^ery thinly covered, but as the skin so utilized is 
genemily accustomed to pressure, the result is usually satisfactor}-. 

Indications. — Such localities as the knee-joint (disarticulation by a 
single anterior flap), or the elbow -joint (disarticulation by a single posterior 
flap). 

Comment. — (1) As this method is generally used in a disarticulation, a 
capsulo- periosteal covering may sometimes be provided. (2) Nutrition of 
a single flap of skin and mu.scle is more difficult to maintain than in the more 
ordinar)' methotls — and the nulriliun of a llaj* o( skin alone is even harrier. 
(3) Skin-flaps are more used now than formerly because, owing to rarer 
suppuration, their vitality can be more counted ujjon. 



AMPUTATION BY EQUAL FLAPS OF SKIN AND MUSCLE. 

General Description. — Coverings for the stump are gt)tten from two 
opposite aspects of the limb in the fttrm of two flaps comjiosed of all the 
Darts covering the limb — having ecjual ba.ses and lengths — and the 
■SBce of skin being sufficiently in excess to well cover the mu.scles. 
TBChnic. — The preliminaries being the i^me as in the ordinary circular 
amputation, two fla[>s are marked out. each having a width of base c<jual 
lo ti frcumference at the saw-line and a length equal to ihrec-ftMirths 

nf • ;«'r of the limb at that same line (Fig. 250, A). \\'ith a large seal 

I c .dong the outlined fla|is, passing through skin and connective tissue. 

icsc integumentary flaps have retracted, proceed to form the remainder 
oi the tlaps — cutting obliquely along the margin of the retracted skin, in such 



270 



AMPUTATIONS. 



a manner that the flaps will be bluntly (not thinly) beveled, directing the 
knife so that the beveling will be greatest (though not thin even here) at the 
tip, and thickest toward the base — and coming down upon the bone, or bones, 
a distance below the saw-line equal to a full diameter of the bone (or of the 
bigger bone) to allow for musculo-periosteal covering. At this level make 
a circular cut around the bone through the periosteum with a heavy knife 
— detach the musculo-periosteal covering of the bone upward to the saw-line 
— retract the soft parts — divide the bone — suture the musculo-periosteal 
covering — quilt the muscles — and suture the skin. 

Resulting Stump. — As a rule, excellently covered by substantial tissues. 
The scar is termino-lateral (Fig. 251, B). 




Figs. 350 and 251.— Amputation by Equal Mixed Flaps:— A, Form and position of incisions; B 

Resulting suture-line. 

Indications. — In the continuity of limbs (between joints) where the 
bone or bones are equally covered with soft parts. 

Comment. — (i) The simplest form of making double flaps is by two 
vertical incisions down the opposite sides of what has been begun as a circular 
method, (a) One flap may be cut from without inward, and the other by 
transfixion. (3) In ver>' muscular limbs it makes the meeting of skin ox-er 
muscles easier if about 2.5 cm. (i inch) of skin and fascia are dissected up 
from the muscle, after marking out and dividing the skin and fascia, and 
then cutting the muscles to the bone in a beveling fashion. 



AMPUTATION BY EQUAL FLAPS OF SKIN. 

This operation is the same, in general contour and dimensions of the 
flaps, as the last — except that the covering here consists of skin only. 



AMPl TATIOX BV UNEQUAL FLAPS OF SKLX AXD MUSCLES, 271 

Technic. — Ha\'ing inriR*d through skin and fascia, upon ihc same lines 
\ms in the last form of amputation, the two equal flaf)S of integumentary tis^^ues 
arc dissected up to a level below the saw line which will allow of providing 
a muscuio-periosteal covering — at this level the muscies, after retracting the 
skin, are circularly divided down to the Ijone — this circular incision is con- 
tinued, on the same level (one-half diameter of the hone below the sawfine) 
I around and through the periosteum — the periosteum is then retracted, with 
the overlying muscles, to the saw line — and the b^ine divided. The musculo 
jicriusteal covering is then sutured over the bone — and the skin margins 
sutured together. 
Resulting Stump. — Thinly covered, no muscle being present — but is 
generally satisfactory in the locaOties whrre aiJujited. The scar is termino- 
lateral. 
Indications. — Where a satisfactory muscle covering is hard to secure- 
as in the lower thin I of the forearm and leg and in the hngers — the tenfSons 
predominating in these localities. 



B 




FlBf^ 



4Sli*b4 »9^--AMPt:T*TtoN bv ITswBQrAL Mixkd Flaps:— A. Form aitd position of incisions, 
■ltd tine of bone'WClioii ; B^ Rnulling suturc-lific. 



AHPUTATION BY UNEQUAL FLAPS OF SKIN AND MUSCLES. 

General Description. — Coverings are furnished by two flaps taken 
^from opposite asj^ects of the limb — each flap having a base equal to one- 
[half circumference of the limb at the saw-line— and one flap having a length 
than the other. One flap usually furnishes one-third or two thirds 
''covering, and the opposite flap two-thirds or one-third— the longer 



272 AMPUTATIONS. 

flap generally coming from that aspect of the limb most thickly muscled. 
The flaps may bear any relation to each other in relative length — but the 
two flaps combined furnish a covering equivalent to ij diameters of the 
limb at the saw-line. 

Technic. — This amputation is identical, except as to the length of the 
flaps, with the amputation by equal flaps of skin and muscle (Fig. 252, A). 

Resulting Stump. — Generally well covered. With scar either entirely 
lateral or partly lateral and partly terminal, dependent upon the preponderance 
of one flap over the other (Fig, 253 ,B). 

Indications. — Thigh and arm throughout, and upper parts of forearm 
and leg. 

AMPUTATION BY UNEQUAL FLAPS OF SKIN. 
General Description.— Coverings are of skin and fascia alone and 
are furnished by the two opposite aspects of the limb, in the form of two 
flaps having equal bases and unequal lengths. This amputation is identical 
throughout with the amputation by equal flaps of skin, except as to the 
length of the flaps. 

AMPUTATION BY UNEQUAL RECTANGULAR FLAPS OF SKIN AND 

MUSCLES. 

TEALES METHOD. 

General Description. — The general method of performing this operation 
is similar, in principle, to that for amputation by unequal flaps of skin and 
muscles — with the exception that the flaps are rectangular (instead of rounded) 
and of special dimensions. 

Technic— Having fixed upon the saw-line, two flaps are marked out, 
having their bases at that line and extending downward as described below. 
Find the circumference of the limb at the saw-line. The longer flap is to 
have its length and its breadth equal to a half-circumference at the saw-line. 
The shorter flu}) is to be one-fourth of the length of the longer, and its breadth 
equal to the remaining half-circumference at the saw-line. The longer flap 
should be of the same width all the way down. The shorter flap will have 
a width at its free end equal to very nearly a half-circumference of the Umb 
at the level where it terminates (as that level, in the case of the shorter flap, 
is so short a distance beneath the saw-line) (Fig. 254, A). Having marked out 
these flaps, which should be accurately measured, the vertical parts of the inci- 
sion should be made from above downward, connected at their lower ends by 
the transverse incision which marks the limit of the longer flap, and by another 
transverse incision across the opposite half-circumference of the limb, at the 
proper level, marking otT the lower limit of the shorter flap. These incisions 
at first involve skin and fascia only. When retraction has occurred (making 
a ditTerence in the transverse incisions only), they are deepened throughout 
to the periosteum. The vertical limbs of the flaps are first cut to the peri- 
osteum— then the lower transverse limit of the longer flap, which is dissected 
up above the lower limit of the shorter flap — which in turn is cut transversely 
to tlie periosteum and dissected up. When a level below the saw-line is 
reai hetl equal to a half-diameter of the bone at the saw-line, a circular incision 
is maile thrni^h the periosteum and a musculo-periosteal covering raised. 
All the soft parts are now retracted above the saw-Hne and the bone divided. 
The musculo periosteal covering is sutured. The longer flap is bent over 




ELLIPTICAL METHOrt OF AMPLTATION. 



273 



the end of the bone — its end being sutured to the end of the shorter flap — 
the lateral aspects of the shorter flap are sutured to the lateral aspects of the 
longer — and the lateral aspects of the lient over portion of the long flap are 

itured to the contiguous lateral aspects of the unbent portion of the lung 
Bap. The muscles are quilted prior to suturing ihe skin. The part is well 

jpporte<l by splint, with only light pressure over the bent longer flap. 

Resulting Stump. —An H'Shaf>ed cicatrix is formed upon the aspect 
of the limb furnishing the shorter flap. The end of the bone is well covered 

I hen the long flap cuntains a preponderance of muscle — less well covered 
rhen containing a preponderance of lenduns (Fig, 255, Bj. 




. »S4 Ami 155.— AurCTATlOf* tv Unkqpal Mixi;d Rkctanoular Pij^ps :— A, Form and position 
of tocisiotts, atiil line of bone-»ectiori ; B, Resulting suture-Une. 



Indications. — In the lower part of the leg (where the longer flap is taken 
am the anterinr as|-»ecl) — and sometimes in the lower forearm (where the 
cr flap tomes from the posterior aspect), 



ELLIPTICAL METHOD OF AMPUTATION. 

General Description. — This is not a distinct form of amputation. It 
be considered a variety of the circular method (an oblique circular), 
'equally, u variety of single flap amputation — and may be held in an 
ncdiate position. It is circular, as to skin incision; and flap, as to its 
manner of covering the stump and in the suturing. The skin incision is in 
dw form of an ellipse, or a lozenge, the upper [)art of the ellipse being upon 
aspect of the limb and the lower part upon the opposite — the lateral 
of the figure crossing the lateral aspects of the limb to be amputated. 



274 



AMPUTATIONS. 



The idea of the ellipse is brought out by imagining the outline projected upon 
a flat surface. 

Technic. — Having fixed upon the saw-line (or line of disarticulation), 
a point is determined above this, on, say, the posterior aspect of the limb, 
which is just above the saw-line — this becomes the highest point of the ellipse. 
The point marking the lowest point of the ellipse is placed upon the opposite 
side of the limb, at a distance below the saw-line equal, approximately, to 
li^ diameters of the limb at the saw-line (as there is but this one source d 
covering). Between these two points the lateral limbs of the ellipse pass. 
crossing the lateral aspects of the limb to be operated obliquely, from abo\*e 
downward, and so planned as to give a well-rounded convex termination of the 
ellipse below to be brought up and fitted into a corresponding concavity above 
(Fig. 256, A). The incision first passes around the outline of the ellipse, 

through skin and fascia only. 
• Around the lower three- 
fourths of the line of this 
retracted skin and fascia a 
second incision passes throuf^h 
the muscles to the bone. The 
soft parts (skin and muscles) 
forming the lower part of the 
ellipse (the part that is to 
remain attached to the limb 
which is to be retained) are 
now dissected up from the 
bone to a point sufficiently 
below the upper limit of the 
ellipse to allow a' musculo- 
periosteal or capsulo-perios 
teal covering to be raised, and 
then on up to just below the 
upper limit of the ellipse (that 
is. to the saw-line or h"ne of 
disarticulation). This large 
single mass of soft parts is 
well retracted — and the mus- 
cles on that aspect of the limb 
opposite to the one furnishing 
the muscles in the elliptical 
covering are circularly divided — and the limb sawed, or disarticulated, pre 
serving the periosteum in the usual way. The lower convexity of the ellip 
tical flap is now sutured into the upper concavity left by the part of the limb 
removed — the musculo-j)eriosteal. or capsulo-periosteal, covering and the 
muscles being treated in the general manner by buried gut sutures — and the 
skin wounfi closed. 

Resulting Stump. — The ellii)se is generally taken from a locality which 
affords a plentiful covering for the extremity, which is thus well provided for. 
The scar is lateral (Fig. 257, B). 

Indications.— Chicny used for disarticulations — especially at the elbow 
and wrist, and in the supramalleolar amputation. 

Comment. — The muscle-jwrtion of the ellipse may be cut also by trans- 
fixion, though, as usual, less satisfactorily. 





B 



Figs. J56 and 257.— Ampi-tation by the Ei.uptical 
Mhthod-.— A. Form and jxxsilion of incision; B, Re- 
sulting suture-line. 




SELECTION OF AMPUTATION METHOD. 



IRREGULAR METHODS OF AHPUTAnON. 



27s 



■ This is a special feature of mtwJern-day surgery. P'ormcrly amputations 
were done upon hard and fast lines, Xow there is a marked tendency to 
allow the method of amputation to be determined hy the special features 
and need of the individual case — and, as a result, irregular amputations 
are more commonly done, which, while aciomjdishing the general indica- 

ktionSf are not bound by any set rule, shape, ur measurement. The practical 
tnirgcon, therefore, should, (m common-sense ground, adapt his method of 
amputation to the case in point, rather than be bound by any fixetl form of 
ampulatiiin. The greatest field for irregular forms of amputation is in 
cases of injury and deformity, rather than in disease. 



SELECTIOH OF AMPUTATION METHOD. 

[any considerations enter into the determination of the best method 
nputation in a particular case — and the choice shtjuld be given to that 
i*xj which promises to fulfil the greatest number ot the following features; — • 
Characteristics of Good Amputation Methods.— (i) Minimum sued- 
Ifice of heidlhy tissue — (2) Best permanent bone-covering — (3) Small wound 
-(4) Goo<J bl<x>d-supply to stump — (5) Favoraldy placed cicatrix — (6) 
:ient drainage — (7) Simplicity of method — (8) Wssels and muscles cut 
Eisversely — (9) Possibility of getting satisfactory musculn-periosteal covering 
tio) Ease of exposing bone at saw-line — (11) Hase of bringing soft ()arls 
' logclher over bone without tension — (I3) Adjustalnlity of artificial limb — 
1(13) largest range of adaptability — (14) Shapeliness of resulting stump — 
I (15) Rapidity of meth<xl. 

Comment.— Circumstances may determine the selection of an ampu- 
l>n mcthrKJ known in advance not to be the best — for instance, owing 
flhe incTeai^rd mortality in approaching the trunk, a limb may lie removed, 
in a case where the vitality of the patient demands that every chance be 
idvcn him. at a level which, while increasing his chances for life, may not 
furnish the best covering. Again, in amputating about the hanil, it may 
con««n*e the interest of the patient better to be satisfied with even a partial 
fliap and allow the remainder to heal by granulation, rather than remove 
an adflilionul \ cm. (| inch) of an important linger. Rapidity of meth<xl 
tuctl to be the chief consitlcration, but is now the last in imp<»rtance, except 
in special instances — other consideralitms taking precedence — the operation 
l>eing <ione with deliberation and f)rccision. 

Features of the Circular Method of Amputating, — (i) Minimum 

sacrifice of biMie and si»ft parts of any method. — (2) Hone es|jecially well 

nnercil in the infundibuliform variety. Conical slump sometimes follows 

n. especially in the culT and mollified varieties of the circular— (3) 

' wounil area of any method. — (4) Tissues of stump well supplied 

(5) Citatri.v terminal. — (6) Efficient drainage when sutured 

riorly,— (7) Most simjile of any melh«xl, — (8) Main vessels and 

muscles cut transversely. — (Q) Musculo periosteal covering well provided. 

— (lo) I'Uposure of bone at saw hne not always easy. — (li) Not always 

easy to bring <oft parts t«igcthcr over bone. — (12) Terminal cicatri.x favorable 

for hollow artificial limbs; unfavoral)le for solid limbs of lower extremity. - 

{13) Unfavurable for amputation following injur}' involving the aspects of 



276 AMPUTATIONS. 

the limb to unequal heights. — (14) Somewhat greater tendency to become 
conical. — (15) Most rapid of any method. 

Features of the Flap Method of Amputating. — (1) Greater sacrifice 
of bone and soft tissues (especially in unequal flaps). — (a) Coverings of bone 
can be more largely regulated to suit demand. Conical stumps less apt to 
follow than after the cuff and modified forms of the circular. — (3) Greater 
wound area. — (4) In long flaps the blood-supply may not be so satisfactory.— 
(5) Terminal or termino-lateral cicatrix — can be planne<l as desired.— (6) 
Drainage as efficient as in the circular if the flaps be lateral. Not so efficient 
if the flaps be antero-posterior. — (7) Not so simple as the circular.— (8) 
Muscles divided obliquely; vessels also, and latter may be split up. — (9) 
Musculo-periosteal covering well provided. — (10) Bone easily exposed at 
the saw-line. — (n) Flaps easily brought together over bone. — (12) Terminal 
cicatri.x favorable for any hollow artificial limb. Terminal portion of tennino- 
lateral cicatrix pressed upon by solid lower limb, and lateral portion pressed 
upon by any hollow artificial limb. — (13) Favorable for amputations following 
injury involving the aspects of the limbs unequally. Adaptable to any part 
of any limb. — (14) Slump apt to be more shaj^ely than that of the circular.— 
(15) Less rapid than the circular. 

Circumstances Influencing Death-rate After Amputation. — The 
death-rate is greater; — (1) The nearer the amputation is to the trunk — (2) 
In the lower than in the upper limbs — (3) For injury than for disease — (4) 
In men than in women — (5) Between the ages of five to fifteen than before 
or after. 

THE AMPUTATION STUMP. 
QUALITIES OF A GOOD STUMP. 

Firm in consistency — well covered — insensitive — of regular and symmetrical 
contour. The death-rate i\m\ the quality of the stump determine the success 
of any form of amputation. The following features are characteristic of a 
good stumj) — and also indicate the changes which follow successful ampu- 
tation : — 

Skin.— Not adherent, except at cicatrix. Capable of withstanding (and, 
preferably, accustomed to withstand) pressure. Plentifully supplied with 
blood. 

Muscles. — The muscles of a stump are not retained as such — the muscle 
tissue disapf)ears in greater part and is replaced by fibrous tissue. Ex- 
ceptionally some muscle tissue remains and continues to function. The 
mass of fibrous tissue which rey)laces it, however, ser\'es a useful purpose 
in padding over the end of the bone. In brief, muscle tissue tends to de- 
crease — and fil)rous tissue to increase. Muscles and tendons either become 
incorporated in the cicatrix, form new attachments to bone, or retract out 
of the way. 

Bone. — The cnfls of the bones become rounded and the medullary 
canals closed by fibrous tissue. The end of the bone may either dwindle 
and atrophy, or the j>eriosteum may, exceptionally, deposit an excess of bone. 
The shaft of the bone in an amputated limb also atrophies somewhat. 

Cartilage. — Following a disiirticulation, the articular cartilage left 
atrophies and sometimes entirely disappears. 

Nerves. — .\lso atrophy to a greater or less extent. The ends generally 
become bulbous, but give no trouble unless they become adherent to bone 
or cicatrix. 



COXTRACTILITV OF THK TISSUES OF THE STUMP. 277 

Vessels. — Share in the general atrophy, and dwindle to a size com- 
mensurate with the parts lo be supplied. Ligated trunks become obliterated 
to iheir nearest branch. Collateral circulation is established. 



CHARACTERISTICS OF A BAD STUMP. 

In contradistinction to the general quahlies of a good stump, a bad stump 
i may be flaccid^ s<:antily covered, sensitive, of irregular contour — anrl may 
' be further characterized l>y the following conditions: — 

Skin. — Thin, scanty, lightly drawn, adherent, puckered — cold or purple 
from improper circulation — ulcerated from the same cause, or from trophic 
[ change*. — involved with corns — and may become malignant. 
Muscles. — See the changes mentioned in the last f-ection. 
Connective Tissue. — Bursa? may form. 
Bone. — Osteitis, periosteitis. and necrosis may occur. 
Tvro special forms of bad slump are met; — 

Painful Stump. — May be flue to osteitis or periosteitis — but is generally 
I due lo compression of the nerve. The nerve may be directly pressed ujjon 
by new bone or fibrous tissue — may be stretched over the slump — or may 
be l>»e seat of neuritis. The end of a painful nerve is generally bulbous — 
but not necessarily — for often normal-looking nerve-ends are sensitive, and 
bulbous ones non sensitive. 

Conical Stump.— The end of the bone forms the apex of a cone which 

may be the result of one or more of the following causes — (i) Maps cut too 

short— or bone loo long. — (2) Sloughing or suppuration of the sofi parts. — 

(3) Post -opera live contraction of muscles. — (4) Growth of the bone from 

I an active epiphysis in the young. 

Comment. — Unfavorable changes are less apt to occur in case of primary 
union than in the reverse. 



CONDITIONS INFLUENCING VITALITY OF STUMP. 

(I) Blcxid supply — full or scani, impeded or unobstructed by position 

f»f stump ctnering. — (2) Compression by bandage, dressing or splint. — (j) 

Tightness and unnatural position of flaps, as compared with easy and natural 

position — (4) Full .dlowance of skin and non-separation of skin from muscle, 

I as compared with the reverse. — (5) Long and loose tendons and ap<jneuroses. 

I (6) Too rnpid sawing of bone. — (7) Finally, site of amputation, manner of 

] performing the operation, prior local condition, prior constitutional con- 

Idilion. anti after treatment — all influence the vitality of the stump. 

Comment. — The chief dangers to be avoided, are — over-tension in the 

and muscle covering — insufTicient b!tK:)d-supply — rough projections of 

I and laceration of the parts — and inclusion of nerves in the cicatriialion. 



CONTRACTILITY OF THE TISSUES OF THE STUMP. 

Skio. — The average contractility of the skin i.s equivalent lo about one- 
ihtrd of il.s length. It is most contractile where thinnest— where the sub- 
cillaoeous tissue is least— where its attachment to underlying parts is least 
— whcTT it b least slretche<l by movements— and where the process of healing 
lyM bcrn longest. It is least contractile where the opposite conditions exist. 




278 AMPUTATIONS. 

Muscles. — The extremes of muscular contractility vary from a sligbt 
separation of divided parts up to a retraction of four-fifths of their length. 
Contractility is primar>', where it occurs at the time of the operation— and 
secondary, where it occurs subsequent to the operation. Muscles contract 
most — which are freest between origin and insertion — w^hich have long 
fibers — and where the process of healing has been longest. The larger the 
muscle, the greater the amount left in the flap, and the younger and healthier 
the subject, the greater the contraction. Muscles contract least where the 
conditions are the reverse of those just mentioned. 

Skin, Fascia, and Muscles.— The average contractility of the mixed 
tissues of a flap, or covering, is generally equivalent to about one-thiid of 
the length of the flap, or covering. Additional length, however, should be 
allowed, in calculating the length of coverings — (1) When the transverse 
section of the bone is large as compared with the transverse section of the 
soft parts — (2) When the amputation is considerably below the origin of the 
muscle involved — (3) When secondary retraction is exj)ected. 



POSITION OF STUMP-aCATRICES. 

The cicatrix should be so placed as to be the least exposed to pressure 
after the healing of the wound. 

With Reference to Their Position.— Scars may be Terminal— at the 
end of the stump; — Lateral — on one or more sides of the stump; — ^Termino- 
lateral — occupying the end and side of the stump. 

With Reference to Their Production. — The following methods of 
amputation produce the following kinds of scars; — Circular is followed by 
terminal scar; — Elliptical, by lateral scar, if the ellipse be oblique, and terminal 
if the ellipse be nearly horizontal; — Oval, by termino-lateral; — Racket, by 
termino-lateral ; — Single flap, by lateral scar; — Double flap, by terminal scar, 
if the flaps be equal, and lateral if the flaps be unequal. 

Comment. — (1) Other things being equal, that method of amputation 
should be chosen which will bring the scar in the most favorable position 
for that particular case — and especially with reference to the subsequent 
functioning of the stump and its adaptability to an artificial limb, (a) In 
amputating in some situations the muscles of one group being so much stronger 
than those of another, will often draw a scar, terminal at the time of opera- 
tion, much higher up upon one aspect than it will be drawn on the opposite 
aspect. Calculations for such an occurrence have, therefore, to be made. 



FUNCTION OF AMPUTATION STUMPS. 

In the Upper Extremity. — The chief function of the stump in the upper 
extremity is ran^c of movement and power to wield an artificial limb, rather 
than to i)car [)ressure and weight. As the chief pressure of an artificial limb 
comes upon the lateral aspects of the stump, the scar of the stump in the 
upper extremity is best when terminally placed. 

In the Lower Extremity.— The chief function of the stump in the lower 
extcmity is to bear pressure and weight. As the chief pressure of a solid 
artificial limb comes upon the end of the stump, the scar of the stump in the 
lower extremity is best when laterally placed — in those cases in which 
a solid artificial limb is to be worn. As, however, most modem artificial 



SL'RGICAL ANATOMY OF THE FINGERS. 



279 



I 
I 



limbs for the lower extremity, for the better classes, are hollow, there is not 
now made the same ditTerente as formerly. 

The Modem Type of Artificial Limb,— While the above was particu- 
larly irue of the older, cruder forms of artilicial limbs (and is still true of the 
peg-leg), the modern forms of artificial limbs are nearly always made upon 
the basis of a light, hollow cone, and are so adjusted as to largely adapt 
themselves to the conditions found — and, generally speaking, most of the 
pressure is of the lateral aspects of the stump and living limb against the 
sides of the hollow cone of the arthu ial limb — so that jjressure is exercised 
upon the lateral aspects of the living slump and limb rather than upon the 
end — and in the lower as well as in the upper extremity. 

Comment. — A function of the slump of the upper extremity, especially 
about the hand, and more particularly of a woman, is to be as symmetrical 
and shapely as possible, in the case of partial sacrilice of that member. While 
in the case of a laborer it would certainly be better to sacrifice appearance 
to strength and utility, one might be urged to sacritke strength for appearance 
in the case of a woman of the non working class. 



AMPUTATIONS AND DISARTICULATIONS OF THE UPPER 

EXTREMITY. 

SURGICAL ANATOMY OF THE FINGERS. 



■ Bones. — Third, second, and first phalanges of the fingers; — and second 

and ftrst phalanges of the thumb. 

Articulations and Ligaments. — (a) Second Interphalangeal .Articula- 
tions; anterior; two lateral; capsule. Posterior ligament not present — [ilace 
supplied by united tendons of extensor communis digitorum and extensor 
indicis, for index; — extensor communis digitorum for middle and ring; — 
united tendons of extensor communis digitorum and extensor minimi digiti, 
for little finger, (b) First Inleq^halangeal Articulations; — anterior (glenoid); 
fv-*! lateral; capsule. Posterior ligament not present— place supplied by 
extensor longus pollicis (extensor secundi inlernodii pollicis) for thumb; — 
united tendons of extensor communis digitorum and extensor indicis, for 
index;— extensor communis digitctrum, for middle and ring: — united tendons 
of extensor communis digitorum and extensor minimi digiti, for little finger. 
(C) Metacarpophalangeal Articulations: — anterior; two lateral: capsule. 
Posterior ligament — not jiresent as distinct ligament — place supplied by 
scattered fibers from one lateral ligament to opposite lateral hgameni; ex- 
tensor brc\is pollicis (extensor primi inlernodii pollicis); extensor longus 
poUiris (extensor setnjndi intcrnmlii pollicis), for thumb; — and the same 
Uffaments for the other fingers as those for the first interphalangeal joints. 

Sesamoid Bones. — Two on palmar surface of metacarpophalangeal 

joint of thumb, developed in inner and outer heads of flexor brevis pollicis^ 

"jch here replace the anterior ligament. One or two on palmar surface 

metacarj>o-phalangeal joint of inrlex and little fingers. Rarely one on 
"palmar surface of melacarpo jihalangeal of middle and ring fingers. Rarely 
one on palmar surface of interphalangeal joint of thumb. 

Muscles and Tendons.— (A) Of Fingers in General;— (a) On palmar 

aspeii; — tlexor sublimis digitorum: flexor profundis digitorum. (b) On 

rliirsal aspect of index; — united tendons of extensor communis digitorum 

• and extensor indicis; first dorsal interosseous (abductor indicis). On dorsal 

ct of middle finger; — extensor communis digitorum; second dorsal 




28o AMPUTATIONS. 

interosseous; third dorsal interosseous. On dorsal aspect of ring finger;— 
extensor communis digitorum; fourth dorsal interosseous; second palmar 
interosseous. On dorsal aspect of little finger; — united tendons of extensor 
communis digitorum and extensor minimi digiti; fourth lumbrical; third 
palmar interosseous, (c) On ulnar aspect of little finger; — abductor minimi 
digiti; flexor brevis minimi digiti. (B) Of Thumb; — (a) On palmar aspect; 
— flexor longus pollicis. (h) On dorsal aspect; — extensor brens pollicis 
(extensor primi internodii pollicis) ; extensor longus pollicis (extensor secundi 
internodii pollicis). (c) On radial aspect; — abductor pollicis; outer head of 
flexor brevis pollicis. (d) On ulnar aspect; — inner head of flexor brexis 
pollicis; adductor obliquus pollicis; adductor transversus pollicis. 

Sheaths (Thecse). — Processes of palmar fascia extending down fingers 
from palm of hand to bases of last phalanges, being attached to lateral margins 
of first phalanges, and forming sheaths for flexor tendons. 

Synovial Membranes. — (a) Of index, middle, and ring fingers; — extend 
from base of last phalanges up to bifurcation of palmar fascia, namely, about 
opposite necks of metacarpals (corresponding, approximately, to middle 
crease on palm of hand, for index, and to lowest crease for middle and ring), 
(b) Of thumb and liule finger; — extend from base of last phalanges to and 
into great synovial sac of hand. 

Nails. — Overlie the soft parts covering the distal two-thirds of the last 
phalanges on their dorsal aspect. 

Arteries. — (a) Palmar Supply; — Four palmar digital branches of super- 
ficial arch; radialis indicis of deep arch; princeps pollicis of deep arch, (b) 
Dorsal Supply; — Second and third dorsal interosseous branches of posterior 
radial carpal branch of radial; first dorsal interosseous (metacarpal) branch 
of radial; dorsalis indicis branch of radial; dorsalis pollicis branch of radial. 

Veins. — (a) Superficial; — digital (one on each side), (b) Deep; — venae 
comites. 

Lymphatics. — One lymphatic vessel on dorsal and one on palmar aspect 
of each side of each finger. 

Nerves. — (a) Median supplies — thumb, index, middle, and ring fingers. 
(b) Ulnar supplies — ring, little, and middle (sometimes), (c) Radial supplies 
— thumb, index, middle, and ring. 



SURFACE FORM AND LANDMARKS OF THE FINGERS. 

The proximal ends of the phalanges form the knuckles — and therefore 
the joint-line is beyond the knuckle. The interphalangeal joint-lines arc 
found, with approximate accuracy, by flexing the distal plfialanges at a right 
angle with the proximal phalanges (or metacarpals) — and then prolonging 
the mid-lateral axis of the proximal bone forward — this line will pass through 
the center of the joints. More accurately, the last interphalangeal joint is 
2 mm. (-/tj inch), the first interphalangeal joint 4 mm. (J inch), and the meta- 
carpo-phalangeal joint 8 mm. (^ inch) beyond the prominence of the knuckle. 

The sesamoid bones can be felt in front of the metacarpo-phalangeal 
joint of the thumb. 

The palmar aspects of the fingers are crossed by three series of transverse 
folds; -the highest are single for the index and little fingers, double for the 
middle and ring — and are nearly 2 cm. (| inch) below the metacarpo-phalan- 
geal joints;— the middle are double for all the fingers — and are directly 
opposite the first interphalangeal joints; — the lowest are single for all the 



GENERAL CONSIDERATIONS IN FINGER AMPUTATIONS. 



281 



fingers — and arc a little above the scconO inlerfihalangeal juinls. The 
thumb has two folds — the higher, single, crosses the metacnrpo-phalangeal 
joint obliquely; — the lower, sinj^le, direclly opposite the first interi)halangeal 
joint. 

The free margin of the webs of the fingers is about 2 cm. (| inch) below 
the metacarpophalangeal joints. 

The lateral ligaments of the joints are nearer the palm than the dorsum. 

The sheaths of the tlexor tendons e.xtend from the melacarpo-phalangeal 
joints to the proximal ends of the third phalanges — are least distinct opposite 
the joints — gape when cut — and lead inU) the palm <jf the hand. 

The digital arteries bifurcate about 8 mm. (^ inch) above the free margin 
of the webs of the tingers. 

The epiphyses form the heads o( the four inner metacarpals, the base 
of the first, and the bases of all the phalanges — all joining the shaft about 
ihc ivrentielh year. 

The skin of the palm is thick, dense, and adherent — that of the dorsum, 
ibin and loosely connected to the fascia. 



\ 



GENERAL SURGICAL 



CONSIDERATIONS 

FINGERS. 



IN A]iIPUTATIONS OF THE 



Minimum sacrifice of tissue is the rule in alt amputations about the fingers 
— es{»ecially in thumb, inde.x, and lillle fingers — so that there may be left 
some length of digit, no matter how short, to approximate to other digits 
and objects grasped. The basjd principle here is — (a) Save a stump, no 
matter how imperfect — (b) provided tendons remain connected to it, or can 
be sutured to it — (C) and sound skin can be found to cover it. Indeed, the 
last may be dispensed with, if there seem fair chance that granulation will 
a»ver over the part. Amputations here, especially in cases of injury, are 
often irregular operations, and amount lo little more than trimming of mangled 
part^ — as a bony stump of irregular form, provided llexion and extension 
exist, is better than a shorter stump of more symmetrical contour. 

Sinc-e the bones of the fingers arc large, as compared with the surrounding 
soft parts, an ample allowance of covering should be made. 

In the interphalangeal region the joints are concave from side to side, 
with the concavity toward the finger tips. In the metacaq>o-phalangcal 
region the convexity is toward the tips. 

Owing to the function of the fingers, cicatrices should be planned to fall 
out of the way of pressure — should not be terminal or palmar — and are best 
placed on the dorsum. 

The stump of a phalanx is often considerably in the way unless the flexor 
and rxteastir tendons can act upon it. Formerly all <if a finger below the 
center of the middle phalanx (where the suyierficial flexor is attached) was 
tarrihced. Now, however, the flexor tendon is sutured into the mouth of 
the cut thcca and periosteum, or even the flap, therel>y securing control 
of the phalangeal stump. 

The fibmu* sheaths of the flexor tendons gape open when nit across 
md their channels lead directly into t!ie palm of the haml. and thtise of the 
tliumb and little finger into the great synovial sac beneath the annular ligament 
of the wrist, furnishing a ready avenue for possible infection. They should, 
therefore, be closed by two or three catgut sutures, passed from the palmar 
to the dorsal aspect of the sheath with a curved needle, whenever cut in the 



282 AMPUTATIONS. 

course of an amputation about the fingers. But when cut, especially when 
the finger is extended, the flexor tendons draw up into the sheath out of 
sight, and if the sheaths were then sutured the action of the flexor tendons 
upon the phalangeal stump would be lost. Therefore, to give the flexor 
tendons a firm hold upon the part, the sutures should include flexor tendon, 
theca, and periosteum — passing, in order, from before backward, through 
anterior wall of theca, flexor tendon (if distal to center of middle phalanx), 
or tendons (if proximal to center of middle phalanx), and posterior wall of 
theca, which is blended with the periosteum. Where the theca is imperfect, 
the tendons should be sutured to neighboring periosteum, glenoid ligament, 
adjacent fibrous tissue, or into the tissues of the flap. Thus the mouth of 
the sheath is closed by the tendon while anchoring the latter to the part. 
This sheath is absent over the terminal phalanx and over the distal inter- 
phalangeal joint — and is indistinct over the metacarpo-phalangeal joint. 
Where absent, the flexor tendons should be sutured into the neighboring 
structures, as just described. Where the periosteum is to be included in the 
suture, it should be stripped back before dividing the bone. 

If the base of the terminal phalanx be saved, the attachment of the deep 
flexor is preserved. If the upper third of the second phalanx be saved, the 
attachment of the superficial flexor is preserved. If the amputation be 
through the first interphalangeal joint, or proximal to it, both flexor tendons 
will be lost — unless they are sutured into the neighboring structures as just 
described (into theca, periosteum, or flaps). 

The best form of amputation for all parts below the metacarpo-phalangeal 
joint is one in which a palmar flap predominates — furnishing a covering 
of thick, sensitive skin accustomed to pressure — and a cicatrix on the dorsum. 

In disarticulations by the palmar flap method, a slight downward con- 
vexity given to the transverse dorsal incision gives a better apposition with 
the palmar flap than would a straight transverse incision over the dorsum 
of the joint. 

Disarticulation is best accomplished from the dorsum, after flexing the 
joint — cutting, in order, through the following structures — skin; fascia; 
extensor tendons (attached to the bases in the interphalangeal joints, and 
forming the posterior ligaments of the joints); dorsal portion of the capsule; 
the knife passing thence behind the base of the distal bone and cutting the 
lateral ligaments from within outward; anterior portion of capsule, from 
within; and anterior ligament, also from within. 

The glenoid ligament, the fibro-cartilaginous plate which is mainly attached 
to the Ixase of the distal bone, should be left in the stump. 

A longitudinal cut made in the mid-lateral aspect of the finger will have 
the digital arteries on the palmar side. 

All flaps should he cut from without inward — none by transfixion. 

The heads of the metacarpals should be preserved, especially in those 
who require strength in their hands. Their removal weakens the hand. If left 
in, they and their soft overlying parts eventually atrophy to some extent and 
the gap is not so apparent. If removed, somewhat greater symmetr}* is 
acquired at the cost of strength. 

Musculo-pcriosteal coverings in these small amputations through the 
phalanges arc often difficult to provide, but should be provided where possible 
— even a periosteo-capsular covering in disarticulating. 

In making all palmar incisions, the part should be extended — and flexed 
while making dorsal incisions. The fullest coverings will be thus secured. 

Guard against making flaps too narrow and pointed — the heads of the 
bones to be covered are all large, following disarticulation. 



AMPUTATION THROLGll LAST PHALANX ( >F FINGERS, 



283 




AH incisions outlining the different amputations pass through only skin 
and fascia at first. 

All ligatures should be catgut — and the skin sutures either silk or silkworm 
guL 

In all amputations aWut the finp;ers the stumjj shuuld Ijc snujiily dressed 
and bandaged, and an anterior splint should be included in the dressing. 



AMPUTAHON THROUGH tAST PHALANX OF FINGERS, IN GENERAL. 

Best Form. -Palmar Flap. 

Comiiient. -The palmar flap melhcwi furnislies the best form of cohering 
— and, owing to the presence of the nail, is about the only available form 
of amputation in this locality- 



ABIPUTATION THROUGH LAST PHALANX OF FINGERS 

BV PALMAR FLAP. 

Description.— Single palmar flap of all tissues down to bone. 





FUf. 35^.— AMriTATIoNs Aiwi'T THB FiNGBR :— A, Through first phalanx, by eqtiat palmar and 
■t t)ii|*»; it. At hr;it inier|ihatan|{ica) joint, by long p«i)nuir and short dorsal na|>6 ; Ct At »ecoiid 
liluliiiifpeal joint, by pAJhinr Hap. 

Position (for all Amputations about the Fingers).— Patient on back; 

upper cxtreniily held out from body, tir. belter, supported on a small table; 

hand pronated and fingers (lext?d while dorsal incisions are made, and hand 

suptnate<l and lingers extended during palmar incisions. Ai-^sistant st;iuds 

in front of surgeon, between him and shoulder of patient — steadying the hand 

with l)oth of hi.s own and holding the atljacent lingcn> out of the way. Surgeon 

(kis digit to l>e removed with thumb and forefinger of left hand— with 

ick of thumb downward and his haml pronated during palmar incisi»>ns— 

and with his thumb u]>ward and his hand siipinated during dorsal indsions. 

Landmarks. — The sj>ace is so limited that the saw line can only be 

placed between the matrix of nail and proximal end of second phalanx. 

Incision.- (I) Palmar incision— from saw line downward along lateral 
au^icct of phalanx, midway between dorsal and palmar surfaces, around the 
center of the pulp, and back to the saw line on the opjHjsite side. (2) Dorsal 
Inds^on— connects upper ends of palmar incision, passing transversely over 
the dorsum with slight downward convexity. (For principle, see I-'ig. 358, C, 
where disarticulation at the last interjihalangeal joint is shown.) 




284 AMPUTATIONS. 

Operation. — Having outlined these incisions, carry the palmar incision 
to the bone — dissect up all palmar tissues down to the bone — deepen the 
dorsal incision to the bone — retract the soft parts, in the entire circumference 
— and saw the phalanx with a light saw, while holding the tip of the phalanx 
with bone-holding forceps (as there is generally too little room for the fingers 
of the operator to grasp). Ligate the palmar digital artery on each side. 
Suture the deep flexor tendon to the periosteum or flap. Suture the palmar 
flap to the transverse dorsal line. 



DISARTICULATION AT SECOND INTERPHALANGEAL JOINT OF 
FINGERS, IN GENERAL. 

Best Method.— Palmar Flap. 

Other Methods. — Short Dorsal and Long Palmar Flaps. 
Comment. — Fven where the douljle flap method is adopted, the covering 
must be almost entirely palmar, owing to the position of the nail. 



DISARTICULATION THROUGH SECOND INTERPHALANGEAL JOINT 

OF FINGERS 

r,V PALMAR KLAP 

Position. — As for amputation tlirough last phalanx (page 287,). 

Landmarks. — Second intcrphaiangcal joint-line. 

Incisions. — (i) Palmar incision — begins o{)j>osite the joint-line, midway 
between dorsal and palmar surfaces— i)asses down lateral asj)ect for a distance 
equal to i^ diameters of the finger at the disarticulation-line — crosses palmar 
aspect with bluntly rounded corners — and passes upward to the corresponding 
point on the opposite side of the finger. (2) Dorsal incision — connects upper 
end of palmar incision by a transverse incision made over dorsum of joint, 
with slight downward convexity (Fig. 258, C). 

Operation. — Having outlined these incisions through skin and fascia, 
carry the palmar incision to the bone on a line with the retracted skin — and 
dissect the soft parts up from the bone. Deepen the dorsal incision to 
the bone, along the line of retracted skin — open the joint from the dorsum 
and disarticulate from within outward. There is no theca here to close. 
Suture the deep flexor tendons into the neighboring tissues. Ligate the two 
digital arteries. Suture the palmar flap to the dorsal line. 

Comment. — The joint is sometimes first disarticulated by a transverse 
dorsal incision — and the palmar flap then cut from within outward — but 
with less salisfactorv result. 



DISARTICULATION THROUGH SECOND INTERPHALANGEAL JOINT 

OF FINGERS 

l',\ SHORT DORSAL AND LONG I'AL\L\R I'LAPS. 

Position — Landmarks. — As in the last operation. 

Incisions. — (i) Palmar flap — little more than length of diameter of 
finger at disarticulation-line — begins at disarticulation-line. in mid-lateral 
aspect of finger— [)asses directly down the finger for the above distance — 
crosses the palm with bluntly rounded corners— and passes up the finger to 



AMPUTATION THROUGH SECOND PHALANX OF FINGERS. 285 

the corresponding site upon the opposite side. (2) Dorsal flap — one-third 
the length of the palmar — beginning and ending at the same points as the 
palmar — and crossing the dorsum with bluntly rounded corners at the above 
distance below the upper limit. (For principle, see Fig. 258, B.) 

Operation. — Carry these incisions to the bone on the lines of retracted 
skin, completing the palmar incision first — dissect the soft parts from the 
bone up to the joint-line — open the dorsal a?i)ect of the joint and disarticulate 
— completing the operation as in the above method. 



AMPUTATION THROUGH SECOND PHALANX OF FINGERS, IN 

GENERAL. 

Best Methods. — Palmar Flaj); Short Dorsal and Long Palmar Flaps. 

Other Methods. — Equal Dorsal and Palmar Flaps; Equal Lateral 
Flaps; Single PvXternal Flap (for index); Single Internal Flap (for little finger); 
Circular; Oblique Circular; Dorsal Flap. 

Comment. — Any single fiap, unices taken from the {)alm, brings part of 
the scar into the palm. A dorsal llap gives a ])almar scar. All equal flap 
methods and circular methods j'ive terminal scars. 



AMPUTATION THROUGH SECOND PHALANX OF FINGERS 

r.V PALMAR FLAT. 

Position. — As for amputation through last ])halanx (page 283). 

Landmarks. — Lines of proximal and distal joints. 

Incisions. — (i) Palmar incision — begins opposite saw-line in mid-lateral 
aspect of finger — passes vertically downward a distance ecjuivalent to i^ 
diameters of the finger at the saw line — crosses the j)almar aspect with bluntly 
rounded corners — passes vertically ui>ward in the mid lateral asjject of the 
opposite side to a point corresj)onding with the one of beginning. (2) Dorsal 
incision — connects the u])per limits of the limbs of the palmar incision, 
passing transversely across the dorsum with slight downward convexity. 
(For principle, see Fig. 258, C.) 

Operation. — The above incisions are now deey)ened to the bone, the 
palmar first and then the dorsal, on a line with the retracted skin. The 
soft parts are dissected off the bone back to the saw-line and are retracted 
while the bone is being sawed. Ligate the digital arteries. In am[)utating 
distally to the upper third of the second phalanx, the superficial flexor tendon 
will retain its attachment. The deep flexor tendon will, however, be 
severed and should be sutured into the mouth of the fibrous sheath (which 
ends at the middle of the .second phalanx) and into neighboring periosteum 
and soft parts, if necessary — the closure of the sheath being accomplished 
in the process of anchoring the deep fle.xor tendon. The flap is then 
sutured in the usual way. 



AMPUTATION THROUGH SECOND PHALANX OF FINGERS 

PV SHORT DORSAL AND LONG PALMAR FLAPS. 

Position — Landmarks. — As in the last operation. 

Incisions.— (I) Palmar Flap— (2) Dorsal Flap— both outlined exactly 
as in the disarticulation through the second interphalangeal joint by short 



284 AMPL'TATIOXS. 

Operation. — HaWng outlined these incisions, carry the palznar indsioc 
to the t^fjne— dissett up all palmar tissues down 10 the bone — deepen ibe 
dorsal incision to the lx»ne — retract the soft parts, in the entire circumference 
—and saw the phalanx with a light saw. while holding the tip of the piuhni 
with ly>ne-hfilding forceps fas there is generally too little room for the anjfcr? 
of the ofxrrator to grasp;. Ligate the palmar digital arter>* on each side. 
Suture the deep flexor tendon to the periosteum or flap. Suture the palirar 
flai> to the transver.se dorsal line. 



DISARTICULATION AT SECOND INTERPHALANGEAL JOINT OF 
FINGERS. IN GENERAL. 

Best Method.— Palmar Flap. 

Other Methods.— Short Dorsal and Long Palmar Flaps. 
Comment.— Even where the drmble flap method is adopted, the covering 
mu.-t \}C almost entirely palmar, owing to the position of the naiL 



DISARTICULATION THROUGH SECOND INTERPHALANGEAL JOINT 

OF FINGERS 

BY PALMAR FLAP 

Position.— As for amputation through last phalanx (page 28^), 

Landmarks. — Second interi)halangeal joint-line. 

Incisions.-- (I) Palmar incision — begins opposite the joint-line, midway 
Ix'lwccn dorsiil and palmar surfaces — passes down lateral aspect for a distance 
Cfjual to I J diameters of the finger at the disarticulation-line — crosses palmar 
aspc< t with bluntly rounded corners — and passes upward to the corresponding 
point on the opposite side of the finger. (2) Dorsal incision — connects upper 
end of palmar incision by a transverse incision made over dorsum of joint, 
with slight downward convexity (Fig. 258, C). 

Operation. -Having outlined these incisions through skin and fascia, 
(arry tin- jxdmar incision to the bone on a line with the retracted skin— and 
disscd the .soft j)arts up from the bone. Deepen the dorsal incision to 
the bone, along the line of retracted skin — open the joint from the dorsum 
and disjirli(ulat(' from within outward. There is no theca here to close. 
Suture the deep flexor tendons into the neighboring tissues. Ligate the two 
digital arteries. Suture the palmar flap to the dorsal line. 

Comment. - The joint is sometimes first disarticulated by a transverse 
dorsal iiuision and the palmar flap then cut from within outward— but 
with less satisfactorv result. 



DISARTICULATION THROUGH SECOND INTERPHALANGEAL JOINT 

OF FINGERS 

r.V SIIOKl" DOKSAL AND LONG PALMAR FLAPS. 

Position— Landmarks. —As in the last operation. 

Incisions, (i) Palmar flap - little more than length of diameter of 
finger at <iisartiiulatit)n line begins at disarticulation-line, in mid-lateral 
aspect of finger passes direitly down the finger for the above distance — 
cn>sses the palm with bluntly rounded corners — and passes up the finger to 



AMPUTATION THROUGH SECOND PS I A LA NX OF FINGERS. 



285 



corresponding site upon the oppoj^ile side. (2) Dorsal flaji — one-third 
the length of the palmar — be^iiininj,^ and ending al the same ptilnls as the 
palmar^ — and crossing the dorsum with Ijluntly rounded corners at ihe above 
distance below the upper limit. (For principle, see Fig. 258, li.) 

Operation. — Carry these incisions to the bone on the lines of retracte<i 
skin, completing the pKiimar incision first^dissecl the soft parts I'rnm the 
bone up to the joint-line — open the dorsiil asjjecl of the joint and disarticulate 
— completing the operation as in the above method. 



AHPUTATION THROUGH SECOND PHALANX OF FINGERS, IN 

GENERAL. 

Best Methods.— Palmar Flap: Short Dorsal and Long Palmar Flaps. 

Other Methods. — Equal Dorsal and Palmar Flaps; Equal Lateral 
Flaps; Single External Flap (for index); Single Internal Flap (for little fingorK 
Cinular; Oblique Circular; Dorsal Flap. 

Comment. — Any single flap, unless taken from the palm, brings part of 
the scar into the palm. A dorsal flap gi\es a palmar scar. All equal Hup 
methods and circular methods give terminal scars. 



AMPUTAHON THROUGH SECOND PHALANX OF FINGERS 

in J'ALM.XR rL.\f. 



L 

^^H Position. — As for amputation through la.'^t jihalanx (page 28^^). 
^^" Landmarks.— Lines of proximal and distal Joints. 

H Incisions. — d) Palmar incision — begins (Opposite saw-line in mid-lateral 
^■Bpcd of finger — passes vertically downward a distance equivalent to t^ 
^IPftmeters of the finger at the saw-line — crosses the palmar as[)ert with bluntly 
' rounded corners — passes vertically upward in the mid lateral aspect of the 
opposite side lo a point corresp< md ing with the i«ne of beginning. (2) Dorsal 

I incision — connects the upj)er limits of the limbs of the palmar incision, 
pAs.sin,g transversely across the dorsum with .slight downward convexity. 
(For principle, see Fig. 258. C.) 
Operation. — ^The above incisions are now deepened to the bone, the 
palmar first and then the dorsal, on a line with the retracted skin. The 
soft parts are dissected off the bone liaik to the saw line and arc retracted 
while the hone is being sawed. Ligate the digital arteries. In amputating 

■ distally to ihe upper third of the second phalanx, the superficial flexor tendon 
V will retain its attachment. The deep llf.vor lentlon will, however, be 

se%ercd and shmild be suture<l into the mouth of the fibrous sheath (which 
ends at the middle of the second phalanx) and into neighboring periosteum 

■ and soft parts, if necessary— the closure of the sheath being accomplished 
" in the process of anchoring the deep flexor tendon. The flap is then 

sutured in the usual way. 



I 



AMPUTATION THROUGH SECOND PHALANX OF FINGERS 

PV SIH'KT DokSAL AMJ I OSC. P \1MAK H.APS. 

Position— Landmarks.— As in the last operation. 
Incisions.— (I) Palmar Flap — (2) Dorsal Flap— both outlined exactly 
MS it\ the disarticulation ihntugh the second inlerphalangeal jc*jnt by short 




286 AMPUTATIONS. 

dorsal and long palmar flaps — with the necessary calculations for the change 
in position (page 284). (For principle, see Fig. 258, B.) 

Operation. — For the technic of the operation, see the disarticulation 
just mentioned. For the manner of deahng with the structures encountered, 
see the operation last described. 



DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF 
FINGERS, IN GENERAL. 

Best Methods. — Same as mentioned under amputation through second 
phalanx (page 285). 

Other Methods. — Same (page 285). 
Comment. — Same (page 285). 



DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF FINGERS 

BY PALMAR FLAP. 

Position. — As in amputation through last phalanx (page 283). 

Landmarks. — First interphalangeal joint-line. 

Incisions. — As for disarticulation at second interphalangeal joint by 
palmar flap (page 284). (For principle, see Fig. 258, C.) 

Operation. — Same, in principle, as the disarticulation at the second 
joint of the fingers. Both flexor tendons are here severed below their inser- 
tions, and the use of the proximal phalanx would be much interfered 
with unless these tendons were securely attached to the sheath, periosteum, 
or glenoid ligament of the stump. 



DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF 

FINGERS 

BY SHORT DORSAL AND LONG PALMAR FLAPS. 

Position — Landmarks. — As in the last operation. 

Incision. — Same as in disarticulation at the second interphalangeal joint 
(page 285). (For principle, see Fig. 258, B.) 

Operation. — Same as in the operation just referred to (page 285). For 
treatment of the flexor tendons, see disarticulation at first interphalangeal 
joint by a palmar flap (page 286). 

AMPUTATION THROUGH FIRST PHALANX OF FINGERS, IN GENERAL. 

Best Methods.— Palmar Flap; Short Dorsal and Long Palmar Flaps. 
Other Methods. — Same as mentioned under amputation through second 
phalanx (page 285). JTo which list may be added the oval method. 

Comment.— Same as made under the operation just referred to (page 

285). 

AMPUTATION THROUGH FIRST PHALANX OF FINGERS 

HY PALMAR FLAP. 

Position. — .As for amputation through last phalanx (page 283). 
Landmarks, — Lines of metacarpophalangeal and first interphalangeal 
joints. 



DISARTICULATION AT METACARrO-PHALANGEAL JOINT. 287 



Incisions — Operation. — Same as for amputation through second phalanx 
(page 285). For reference to flexor tendons, see under disarticulation at 
first interphalangeal joint by palmar flap (page 286). 



AMPUTATION THROUGH FIRST PHALANX OF FINGERS 

HV SHORT DORSAL AND PALMAR FLAPS. 



^J^ Position — Landmarks. — ^As in the above operation. 

^V Incision — Operation*— As for amputation thmugh the second phalanx 

by the same method {page 285). Fur reference lo treatment of the fle.xor 
tendons and sheaths, see under disarticulation at first interphalangeal joint 
by palmar tlap (page 286). 



I 

I 



DISARTICULATION OF FINGERS AT HETACARPO-FHALANGEAL 
JOINTS. IN GENERAL. 

Best Methods. — Oval Method (for fingers in general and for thumb); 
E.\lerno-palmar Flap of Farabeuf (for index) ; Intemo-palmar Flap of Fara- 
beuf (for little linger); Oblique Palmar Flap (for thumb). 

Other Methods,— Equal Lateral Flaps; Circular Incision, joined by 
vertical dorsal queue; Palmar Plap; Large External and Small Internal 
Flaps (for index); Large Internal and Small External Flaps (for little finger). 

Cooxment. — The first four are the best in the sites indicated and are 
sufierior lo the others mentioned. The oblique palmar flap for the thumb 
gives the best covering where sufficient tissue exists. 



DISARTICULATION OF FINGERS. IN GENERAL, AT METACARPO- 
PHALANGEAL JOINT. 

BV OVAL METHOD. 

Description. — The queue is placed over the dorsum of the joint and 
the center of the oval passes across the palmar aspect at the web-line. 

Position. — As for amputation through the last phalanx (page 2S3]. 

Landmarks. — Head of metacarpal; metacarpophalangeal joint-Line; 
web of linger. 

Incision.—Begins just above head of metacarpal, on its dorsal aspect 
(in the position corresponding with its neck) — passes down the median dorsal 
aspect over the prominence of the knuckle, to just beyond the base 
of the first phalanx (which is about midway between the mctacarpo- 
phalangeal joint line and the free edge of the web) — at this point the hitherto 
median incision diverges into two symmetrical limbs — each sweeping across 
the dorsolateral aspect of the finger to just below the juncti<»n of the linger 
with the web — and thence transversely across the palmar surface in the 
fine of the crease, on a level with the free border of the web, coming to the 
Opposite side jusl below the junction of the web with the finger This rather 
cxtensi%*e incision is best made with three strokes— from commencement to 
web of one side — from p<jint of divergence of median line to web of opposite 
side — and across palmar surface connecting the two limbs (Fig. 259, H). 

Operation. — The above incision through skin and fascia is now deepened. 
The paimiir portion is cut to the bone while the finger is forcibly extended. 




288 AMPLIATIONS. 

The lateral portions are carried to the bone, cutting the lumbricales and 




l'\ti. .-.S'l.— AMrirMmN"^ Ar.oir Tin: l'is(,r:KS, Hanh. anp Wrist :— A, ThmuRh second phalanx 
of little hni;iM, In ^iii^^li' iiii.rii;il ll;»i> ; 1?, At lirst iiiti'rphal;ui.ijfal joint, by oval iiiclhtHi : C, Through 
scoiiul pli.il.iiiN. h\ o|ual l.itvral tiapx : I ). Tin <i\ifjh .sooinl phalanx i>f index, by sin};k cxtt-ninl flap: 
E, Throuf^h liiM jihalaiix, In DMupii' linular; F, Thronjfh titst phalanx, by ordinary circnlar; (i. 
At nictai aiixi-iihalaiiLfial jonit nt litiK- fniRcr, by inti-rno-palmar flap; H. Ai nietacnrpo-ph.ilanceai 
joint. I'v »>\al iiuth.Kl ; 1. Al nKla<.aii>«>-phalaiiKfal joint i>f iticlex. by externu-palmar flap; J. Of little 
finpLT at larpo-nKtacaip.ii inim. by r;i< kit method; K, Same of rinjf fniRer; L. Of middle finger and 
part of iiut.it ari>al, by i.ickct iiii.thod ; M, of two inner fuifjers at caipo-mctararixil joints, by racket 
method; N. Oi thumb at canio-metnr.irpal joint. b\ racket metho<l ; O, Through metacarfM>-phaIan. 
goal joint of thumb, by obliipic i)almar llap ; V. l\ At wrist-joint, by external flap. 



intcrossci. The soft parts are retracted to the joint-line. The extensor 
tendons are then cut and the joint thus entered from the dorsum — the lateral 




\ 



METACARPO.PHALANGEAL DISARTICLLATION OF THUMB. 289 

ligaments and glenoid ligament being cut from within and the disarticulation 
completed. The two digital arteries are tied and the synovial sheath closed. 
The edges of the sides of the oval are sutured in one vertical, a ntero- posterior 
line, in continuation with the queue of the incision. The splint applied 
should include the wrist -joint. 

Comment. — (i) The joint may be opened from the palmar surface, by 
cutting the glenoid ligament transversely against the base of the metacarpal. 
In cither ca:5e, the glenoid ligament is retained. (2) No attempt is made to 
attach the flexor tendons, as the entire finger is removed and there would 
he nothing for them to Ilex. (3) The lower end of the vertical cicatrix is 
eventually drawn u(i out of the way of palmar pressure. (4) If it be desired 
to remove the head of the metacarpal, prolong the queue of the incision 
upward — free the neck of the bone of soft parts, hugging the bone in the 
process — retract the soft parts — and, while partly lifting the metacarpal 
from its bed by traction upon the finger, if still attached, or by grasping the 
head of the bone with bone-forceps, if disarticulation have occurred, pass 
a chain or Gigli saw beneath the bone and make a section^ so as to bevel the 
bone obliquely from behind downward and forward, and from the inner- 
or outer aspect toward the median aspect. (5) Where the skin of the palm 
is veni- dense and hard, as in laborers, an awkward projection of skin may 
be left on the palmar surface of the convexity of the oval, which can be removed 
and make the suturing more fiatisfactory by cutting out a V-shaptd portion 
from the palmar a.spect. This, however, amounts, practically, to lateral 
flaps, and brings part of the scar into the palm. (6) Avoid cutting into 
the web. 



DISARTICULATION OF THUKCB AT METACARPO-PHALANGEAL JOINT 

BY OVAI. Mt-:THOD. 

Position. — .\s in amputation through last phalanx (page 2S3), 
Landmarks. — N"eck of first metacarpal; metacarpophalangeal joint. 
Incision. — Begins on dorsal aspect of neck of metacarpal, to ulnar side 
of median line — passes directly down over head of bone and along median 
aspect of extensor tendons, or slightly to ulnar side, to just beyond the base 
of the metacarpal — thence the median incision diverges — each limb passing 
obliquely across the dorso-lateral borders of the thumb, so as to cross and 
meet upon the palmar aspect opposite the center of the first phaianx. (Similar 
Ut H. Fig, 259.) 

Operation. — Deepen this incision to the bone along the line of the re- 
ed skin — dividing the extens<^r l>revis pollicis and exten&or longus pollicis 
ite the metacarpophalangeal joint, and the flexor longus p<41icis 
the middle of the first phalanx. The sesamoid bones are to be 
from the base of the first phalanx and left in the stump. .\s far 
as possible ihc muscles which are attat hed lo the base of the first phalanx 
(extensor brevis pollicis, adductor obliquus pollicis, adductor transversus 
pollicis, abductor |Killicis, flexor brevis j>ollicis), as well as the long flexors 
" extensors, should be sutured into the tissues of the stump — as considerable 
of movement is thereby secured for the metacarpal bone, whereby 
may offer cimnlcrpressure to the fingers. Close the synovial sheath. Tie 
don^alis pollicis and two branches of the princeps pollicis. Suture the 
in a single straight line in continuation of ihe queue. 
Comment. — The head of the metacarpal is large and requires ample 
corcring. 
»9 





290 AMPUTATIONS. 

DISARTICULATION OF THUMB AT HETACARPO-PHALANGEAL JOINT 

BY OBLIQUE PALMAR FLAP-(FARABEUF). 

Description. — This method consists of two U-shaped incisions, the 
dorsal having its convexity upward, the palmar having its convexity do^ii- 
ward — the limbs of each U passing, and obliquely meeting, on the lateral 
aspects of the thumb. 

Position. — As for amputation through the last phalanx (page 283). 

Landmarks. — Lines of the metacarpo-phalangeal and interphalangeal 
joints. 

Incision. — The convexity of the dorsal U is upward and corresponds 
with the dorsal aspect of the metacarpo-phalangeal joint. The convexity 
of the palmar U is downward and is placed just above the interphalangeal 
joint-line. Between these two rounded extremities the lateral limbs pass 
in an oblique direction along the lateral borders of the thumb, becoming 
continuous with each other (Fig. 259, O). 

Operation. — This incision is deepened throughout to the bone, along 
the line of the retracted skin — the extensor brevis pollicis and extensor longus 
p<illicis are divided over the metacarpo-phalangeal joint, and the flexor 
longus pollicis about the center of the first phalanx — the soft parts are freed 
back to the joint-line — the sesamoid bones are detached from the base of 
the first phalanx and left in the flap — the joint is entered from above and 
disarticulation completed. The dorsalis pollicis and the two branches of 
the princeps pollicis are to be tied. The synovial sheath is closed. The 
convexity of the palmar flap is sutured into the concavity of the dorsal wound 
— bringing the cicatrix well on to the dorsum and out of the way of pressure 

Comment. — As the head of the metacarpal is disproportionately lai)(i% 
an additional allowance of covering must be made. 



DISARTICULATION OF INDEX-FINGER AT METACARPO-PHALANGEAL 

JOINT 

BY KXTKRXO-PALMAR FLAP — (FARABEIF). 

Description. — This is really an oval method, so modified as to bring 
the cicatrix upon the intemo-dorsal aspect of the metacarpo-phalangeal 
regif)n — so that fingers and objects oi)posed to that aspect may not come 
into contact with the scar. 

Position. — .\s for amputation through last phalanx of finger (page 28^- 

Landmarks.— Mctacaq)o-phalangeal joint-line; middle of first phalanx; 
web. 

Incision. — Bei^ins at metacarpophalangeal joint-line, immediately over 
the median aspect of the extensor tendon — passes vertically down the median 
dorsal aspect of the finger, in the above relation to the extensor tendon, to 
the center of the first phalanx — thence sweeps across the lateral and palmar 
aspects to the web — and thence passes in a straight line, by the shortest 
route, up the inner side of the finger to the place of beginning (Fig. 25Q. I), 

Operation.— This superficial incision is deepened to the bone — the soft 
parts retracted to the joint-line — disarticulation effected — and the operation 
comi)leted as in the simple oval meth(Ki. The digital, dorsalis indicis. and 
radialis indicis arteries are to be tied. The flexor sheath is to be closed — 
and the parts so sutured as to cause the cicatrix to occupy the position of the 
straight portion of the incision, upon the intemo-dorsal aspect. 



SURGICAL ANATOMY OF THE HAM>. 



291 



I 



Commeiit. — (i) The placing of the incision over ihe median, or even 
slightly t'l the ulnar, rather than the radia! aspect of the extensor tendon 
(as recommendefl by Faraheuf), ^\vc5 ampler c(fvenng, and a greater cer- 
tainty of the scar falling well lo the ulnar side. (2) If the head of the mcla- 
carpa] be removed, it is exposed as mentioned under the oval method (page 
289. Comment). 

DISARTICULATION OF LITTLE FINGER AT METACARPO-PHALANGEAL 

JOINT 

BV INTERNOPALMAR FLAP- (FARABEUF). 

Description. — This, also, is a mrKlification of the oval method, so cal- 
culated as to bring the cicatrix ujxm the externo dorsal aspect of the meta- 
carpo-phalangeal region — that non-scar tissue may come into contact with 
objects which press the stump. 

Position — Landmarks.— As in the last of)eraiion. 

Incision. — Begins at the metacarpo-pluilangeal joint-hnep immediately 
o\'er the median aspect of the extensor tendon — passes vertically down the 
dorsal aspect of the fmger. in the abuve relation to the extensor tendon, to 
the center of the first phalanx — ihence sweeps across the lateral and palmar 
aspects of the finger to the web — an<! thence passes in a straight line, by the 
shortest route. uf> the radiul side of the fjiiger to place of beginning (Fig. 
250. G). 

Operation. — The steps of the disarticulation are completed as in the 
corresponding operation just described upon the thumb, the reverse o( which 
this is, in every resj)ect. Two digital arteries are lo be lied. The parts 

ici be so sutured as to cause the cicatrix to occupy the position of the 
Straight portion of the incision, upon the externo-dorsal aspect of the region, 
buried in the groove formed by the adjacent finger. 

Comment. — (i) Carrying the incision over the median aspect of the 
cxten>i»r tendon insures more c<nering ihim if the incision passed down the 
uin;ir aspect, as recummunded by Farabeuf — and alsi> makes it more certain 
that the scar will fall well lo the radtal side of the stumf>, out of the way of 
prr<»sure. (a) If it be rlesired to rcm<nc the head of the metacarpal, it is 
ex^Kised as descrilxnl under the <jval methtHi of disarticulating the fmgers in 
general — the bone being here beveled from ulnar 10 radial aspect, and from 
dorsum ti. p.dm 



b 



SURGICAL ANATOMY OF THE HAND. 

Bones. — (a) Metacarpals, of thumb and lingers ;—(b) Carpals;— First 
tow-; «.raphoid, semilunar, cuneifurni, pisiform; — Second Row; iriipezium, 
trapezoid. *»s magnum, untifnrni. 

Articulations and Ligaments.— (A) Metacari^Mj- Phalangeal Articula- 
tions; — See drsrri[>tion under Surgical Anatomy of Fingers. (B) Meta- 
carpals with each other (InlennetiKarpal); — (a) Carpal ends of four inner 
nctararfials; — ilorsal, palmar, and interossetius ligaments, and synovial 
gncmbrane; — (b) Digital ends of four inner metacarpals; — transverse meta- 
carpal ligaments (on palmar asf>cct). (C) Inner Metacarpals with ihe 
c^ — l()rs;il, palmar, and interosseous ligaments, and synovial membrane. 
(I' »q>nl of thumb with trapezium; — capsular ligament. (E) Articu* 

laliun* tjJ .^ecund row of carjials with each other; — three dorsal, three ]>almar, 
and three inicrosseuus ligaments, between trapezium and trapezoid, between 




292 AMPUTATIONS. 

trapezoid and os magnum, and between os magnum and undfoim; and 
synovial membrane between each. (F) Articulations of carpals of first row 
with each other; — two dorsal ligaments between scaphoid and semiluMT, 
and between semilunar and cuneiform ; two palmar ligaments bet^'een scaphoid 
and semilunar, and between semilunar and cuneiform; two interosseous 
ligaments between scaphoid and semilunar, and between semilunar and 
cuneiform; capsular ligament between cuneiform and pisiform; two palmar 
ligaments between pisiform and unciform process of unciform, and between 
pisiform and fifth metacarpal; and synovial membrane between each bone. 
(G) Articulations of two rows of carpals with each other (medio-carpal);— 
palmar, dorsal, external lateral and internal lateral ligaments, and synovial 
membrane (between each row). 

Anterior Annular Ligament. — (a) Attachments; — Internally; pisifonn 
and unciform process of unciform bone. Externally; tuberosity of scaphoid, 
inner part of anterior surface, and ridge on trapezium. Superiorly; con- 
tinuous with deep fascia of forearm. Inferiorly; continuous with palmar 
fascia, and furnishing attachment to some of muscles of thumb and little 
finger, (b) Structures passing superficial to anterior annular ligament (from 
without inward); radial vessels and nerve, flexor carpi tadialis, palxnaris 
longus, ulnar vessels and nerve, flexor carpi ulnaris. (c) Structures passing 
beneath anterior annular ligament (from above downward); flexor sublimis 
digitorum, median nerve, flexor profundus digitorum, flexor longus poUids. 

Posterior Annular Ligament. — (a) Attachments; — Internally; styloid 
process of ulna, cuneiform and pisiform bones. Externally; outer margin 
of radius and elevated ridge on its posterior surface. Superiorly; continuous 
with deep fascia of forearm, (b) Tendons passing beneath posterior annular 
ligament (in six compartments, from without inward) ; — (i) extensor ossis 
metacarj)i pollicis and extensor brevis pollicis; (a) extensor carpi radialis 
longior and brevier; (3) extensor longus pollicis; (4) extensor communis 
digitorum and extensor indicis; (5) extensor minimi digiti; (6) extensfM" 
carpi ulnaris. 

Synovial Sacs. — Two synovial sacs lie beneath the anterior annular 
ligament, one for the flexor sublimis digitorum and flexor profundus digitorum, 
and one for the tlexor longus pollicis. Both extend upward for 3 to 4 cm. 
(i^ to i^ inches) above the anterior annular ligament. That for the flexor 
longus pollicis extends downward to last phalanx of thumb. That for the 
flexor tendons of fingers divides into four processes; the one for the littk 
finger generally extending lo base of last phalanx; — those for index, middle, 
and ring fingers ending about middle of the metacarpals — and are thus 
separated by about 1.3 cm. (^ inch) from the great synovial sac. Thus there 
is an open channel from the ends of the thumb and little fingers to a point 
3 or 4 cm. (li to i^ inches) above the anterior annular ligament. 

Muscles and Tendons.— (1) Of palmar aspect: — (a) Superficial 
Muscles from Forearm; — Flexor carpi radialis; palmaris longus; flexor carpi 
ulnaris; flexor sublimis digitorum. (b) Deep Muscles from Forearm; — 
Flexor profundus digitorum; tlexor longus pollicis. (c) Short, small Muscles 
of Thumb; — .\bductor f)ollicis; opponens pollicis (flexor ossis metacarpi 
jK)llicis); llexor }>rcvis ])<)llitis; adductor obliquus pollicis; adductor trans- 
versus ])<)llicis. (d) Short, small Muscles of Little Finger; — j>almaris b^c^^s; 
abductor minimi digiti; flexor brevis minimi digiti; opponens minimi digiti 
(flexor ossis metacarpi minimi digiti). (e) Short Central Muscles of Hand; 
— four lumbricals; three palmar intcrossei. (3) Of dorsal aspect: — (a) 
Superficial Muscles from Forearm; — Extensor communis digitorum; extensor 



SURFACE FORM AND LANDMARKS OF THE HAND. 



293 



I 

I 



I 



minimi dtgiti; extensor carpi ulnaris. (b) Deep Muscles from Forearm; — 
Extensor ossis metacarpi ixjUicis; extensor brevis pollicis (extensor primi 
internodii pollicis); extensor longus pollicis (extensor secundi internndii 
pollicis); extensor indicis; extensor carpi radialis ionj^nor; extensor carpi 
radiaiis brenor. (c) Small Mui>clc5 of Dorsal Aspect of Hand; — four dorsal 
inlcrossei. 

Attachment of Muscles to Bases of Metacarpals. — To first; cxten^ur 
ossis mftaiar[)i jjullids. To second; extensor carpi radiaiis longior; flexor 
caqii radialis. To third; extensor carpi radialis brevior. To fifth; extenstjr 
carpi ulnaris; some fibers of flexor caqji ulnaris. 

Arteries. — (a) Palmar supply; — (1) From Radial; — anterior radial 
carpal; superficiaUs voke; deep arch; princeps pollicis; radialis indicis; diree 
palmar interossei; three superior (posterior) communicating (perforating); 
three inferior (anterior) communicating (perforating); palmar carpal re- 
current. (2) From Ulnar; — anterior interosseous; anterior ulnar carpal; 
sujjerficial palmar arch; four palmar digital; deep palmar (communicating); 
three palmar interossei (from deep arch, common to radial and ulnar); three 
superior (posterior) communicating (perforating) (also common to radial); 
three inferior (anterior) communicating (perforating) (also common to 
radial); palmar carpal recurrent (also common to radial), (b) Dorsal 
supply: — (I) From Radial; — radial; posterior radial carpal; dorsalis pollicis; 
dorsalis indicis; metacarpal (first dorsal interosseous); second and third 
dorsal interosseous; three superior (posterior) communicating (perforating); 
three inferior (anterior) communicating (perforating). (2) From Ulnar; — 
posterior ulnar carpal; metacarpal. 

Veins. — (a) Superficial;— Dorsal Venous Plexus — from which arise super- 
ficial radial vein, and anterior and posterior superficial ulnar veins; — Anterior 
Median Plexus — from whith arise sujierficial median vein, (b) Deep; Two 
vcn-ae comites for each artery. 

Lymphatics. — Pass up the forearm from the lymphatic palmar arch, 
and from the dorsal plexus of lymjihatics. 

Nerves. — (a) From Median;— Median and following branches; outer 
and inner palmar cutaneous; muscular branches; five digital branches; (b) 
From Ulnar; — Ulnar and following branches; palmar cutaneous; dorsal 
cutaneous; superficial palmar branch; deep palmar branch, (c) From 
Radial;- — external branch; internal branch. 



SURFACE FORM AND LANDMARKS OF THE HAND. 

Caqial bones— two subcutaneous eminences may be felt upon the palmar 
of the hand just behw the wrist — the outer (just beneath the radial 
aid process) due to the luberosily of the scaphoid and ridge on the trape- 
(ihe ridge being just beneath the former) — the inner, due to the pisiform 
bone The unciform process of the unciform bes below and slightly internal 
to the pisiform. No other carpal bnncs are recognizable on the palmar 
[ surface — and only the cuneiform on the dorsum. 

Metacarpal bones — The heads of the metacarpals form ihc knuckles. 
f The dorsal surface of the fifth, and the heads of all are subcutaneous — all the 
other aspects of the remainder are covered by muscles or lentlons. The base 
] the metacar|.»al of the thumb can be fell— and the sesamoid bones opposite 
metacaqx)- phalangeal joint 

Skin-fokis (creases) of the hand — (a) Superior fold — begins at wrist, 
lecn thenar and hypothenar eminences, and runs to the outer border 



294 AMPUTATIONS. 

of the hand at the base of the index-finger — and is formed by the adduction 
of the thumb, (b) Middle fold — begins at outer border of hand where supe- 
rior fold ends, and runs inward and slightly upward and ends at outer limit 
of hypothenar eminence — and is formed by the simultaneous flexion of the 
metacarpo-phalangeal joints of the first and second fingers — and about 
corresponds, opposite the third metacarpal, to the lower portion of the super- 
ficial palmar arch, (c) Inferior fold — begins opposite the cleft between 
the index and middle fingers and runs almost transversely to the ulnar margin 
of the hand, crossing the lower part of the hypothenar eminence — and is 
formed by the flexion of the middle, ring, and little fingers. It crosses the 
necks of the three inner metacarpals, and approximately indicates the upper 
limit of the synovial sheaths of the flexor tendons of the three outer fingers. 
Midway between this fold and the free margins of the webs are the meta- 
carpo-phalangeal joints. 

Line of carpometacarpal joints — from base of fifth metacarpal, to carpo- 
metacarpal joint-line of thumb (both of which may be recognized). The 
inner portion of this line is regular, the outer portion irregular. 

Line of metacarpo-phalangeal joint-line — found by flexing the first 
phalanges at a right angle with the metacarpals — and then prolonging the 
mid-lateral axis of the metacarpals forward — which lines will pass through 
the center of the joints. 

Free edges of webs of fingers, on palmar aspect, are about 2 cm. (} inch) 
below the metacarpo-phalangeal joints. 

Muscles — The muscles of the thenar (thumb) eminence — and those of 
the hypothenar (little finger) eminence are recognizable, and also the ad- 
ductor transversus pollicis. The lumbricals form soft eminences behind the 
clefts of the fingers — and the dorsal interossci form similar soft eminences 
between the metacaq)als. The position of many of the extensor tendons 
can be recognized by both sight and touch — and some of the flexor tendons 
can be detected by touch while in the act of movement. 

\'esscls — the superficial palmar arch is on a level with the lower border 
of the outstretched thumb, passing down from the wrist on the outer side 
of the pisiform. The deep palmar arch lies about 1.3 cm. (^ inch) nearer 
the wrist, crossing the shafts of the second, third, and fourth metacarpals 
near their ba.ses. 



GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 

THE HANDS. 

A finger may be removed with a part, or the whole, of its metacarpal. 
In the middle metacarpals, the removal of a part, where pos.sible. is better 
than a disarticulation at the carpo-metacaq)al joint — as the end of the bone 
is not apt to pet into the way. and the strength of the hand is greater. In 
the case of the thumb and little finger, however (which are the fingers most 
frequently removed, because most exposed to injur)*), it is best to remove the 
entire metacarpal — the retention of a part of the outer metacarpals being 
of little value, and often in the way — and its removal not weakening the hand 
as much as the loss of an inner one. 

If hut a part of the metacarpal of the thumb or little finger be removed, 
however, the remaining i)ortion should be beveled obliquely away from the 
position of most pressure. 

The metacarpals should l)e divided in their continuity by a Gigli saw 
It is easier, but less surgical, to divide them with bone-cutting pliers. 



AMPUTATION OF FINGER WITH PART (IK ITS METACARPAL. 295 

Additional advantages in amputating a finger and part of its metacarpal, 
over disarticulating a finger and all of its metacarpal, are the folJmving; — 
deep palmar arch is not exposed; synovial sacs of flexor tendons may escape, 
if the bone be divided abo\'e its ceiiltr; curjio-melacuryjiil sj-novial sacs are 
not opened; and tendons attached to bases of metacarpals arc not lost. 

Where, in disarticulating at the carpo metacarpal articulation, the joint- 
Knic is not easily located before incising, begin the incision as high as thought 
Id be the articular line, and then verify the line by inserting the tip of the 
index-finger into the wound, while the opi>osite hand manipulates the special 
6nger whose metacarpal forms part of tiie articulation. 

As the metacarpal of the thumb iind, according to some, of the little finger 
do not communicate with the large synovial sac of the carpal bones, they 
can be removed in their entirety with little danger of infection— but, in un- 
clciin cases, the removal of the second, thinl, and fourth metacarpals in their 
continuity is preferable to a disarticulation at the carpo-melacarpal line^ 
with the likelihoo<i of general infection. 

The synovial sheaths should be closed with gut-suture when cut. But 
where large synovial sheaths and extensive articular surfaces are opened up, 
drainage for twenty-four or forty-eight hours is indicated. 

In partial ampulalifins of the hand, the tlexor and extensor tendons should 
be cut long enough to be sutured into the wound, so as to retain tlexion and 
extension of the stump. 

The main dangers in amputating and disarticulating about the hand 
are wounding of the deep palmar arch or termination of the radial, and in 
opening the synovial sheath of the palm or fingers. 

The stump should be dressed upon a splint which will immobilize the 
wrist. 




AMPUTATION OF FINGERS. IN GENERAL, WITH PARTS OF THEIR 

METACARPALS, 

Methods. — Racket Method — best for single fingers, in general, as well as 
for thumb and little finger; and also for two or three rontinguous inside 
fingers. Equal Dorsal and Palmar Fla|)s— best for the three inner fingers. 
Anterior Ellipse (sometimes called a Short Palmar Flap) — best for all the 
fijigcn^. not including the thumb. 

AMPUTATION OF A FINGER. IN GENERAL, WITH PART OF ITS 

METACARPAL, 

BY R \CKF;T MKTHOn. 

Description. — The finger is removed as one continuous whole at the 
line of section of the metacur])al. 

Position. — Same as for amputation through hist phalanx (page 28,^). 

Landmarks. — Outline of dorsal aspect of metacarpal; carpometacarpal 
Joint; webs of fingers. 

Incision. — Begins over dorsum of metacarpal, a short distance above 
the fHjint It which the hone is to i:»e sawed — passes thence downward over 
the midtile of the dt)rs:d aspcri until the neck of the metacarpal is reached 
— whence the median line diverges into t^vo limbs, each limb passing down 
ihc dt^rso -lateral ai^jKJct »>f the finger to just below the junction of the web and 
ingrr — whence each limb crosses immediately in front of the digito-palmar 
to meet in the center of the palmar aspect of the finger (Fig. 259, L). 




30i AMPUTATIONS. 

and extensor tendon? mto the wound — and suture the convex palmar flip 
to the cvncavo dorsal wound. 



DISARTICULATION OF FINGERS AND THUHB AT CARPOJKTA- 
CARPAL ARTICULATION 

BV PALMAR FLAP. 

Description. — Same, in principle, as the disarticulation of the hand ;t 
ihe wrist joint v]uj:e 505^ — except that the upper limits of the flap Mtend 
only to the ulnar margin oi the unriform-metacarpal articulation, on tht 
one siiio. .»nd the radial margin of the trapezio-metacarpal articulation, go 
the other side .ho lower limit crossing the necks of the metacarpals. 



Sl'RGICU. ANATOBIY OF THE WRIST-JOINT. 

Bones. K.u:;;;>: ;:!:ia; nr^i row of carpal bones (scaphoid, semilunar, 
cunoifi^rm. pi>: .'oriv. ' . 

Ligaments. Ar.Tcrfor rar.io caipal; ]X)sterior radio-carpal; extenial 
lator.d. iniorv.al l.iior.ii: ar.ii >ynovial membrane. 

Movements. I'loxior.; -accomplished by flexor carpi radialis; flexor 
carpi Tih'ar-N; :vi!:v...riv K>ngu>. Extension; — by extensor car|ii radiafo 
lon»;ior. ov'.ov.vv^: c.ir*.v; r.iviiaMs brevior: extensor carpi ulnaris. Adduction:— 
b\ ilo\vM vatp: i:l:\i::x. i'\:i:.>*t carjii ulnaris. Abduction; — by extensor osis 
moiavaivi ';V\'.:vi>. c\:c".>,'ni^«. ^revior et longior poUicis; cxtensores carpi 
radialiN Kv\i:.'*r c: l^ri-\..r; ;-t\or c;irju radialis. 

Muscles And Tendons in Neighborhood of Wrist-joint.— (a) Ant^ 
riorb , :'.c\o: ...:■.: !,.,;;,i;i>: ".viInMris lonnjus; flexor carpi ulnaris; flexor 
>\:Min'.i-. .'. !;•.:.»•. ;.". :\ \ r vr. ;i::h:i:> dicitorum: flexor longus pollicis. (b) 
l\Mor'.«v!\ . cN'.i'v, :,x ,..7. ■; r,..;i.il:> lonpior el brevior; extensor communis 
dvc.'.»"-'.::v.. o\:i>.v: -.'. . -. c\:t:-.>«T minimi digiti: extensor carpi ulnaris. fci 
K.i«:'..:! \«.;vv: -;.■...: • !.:;;.>: oxionst^r o>sis melacaqji |K)llicis; e.xtensor 
I '.i\> .•.^•. ■" ■ -.i V .\.. -s y. V >: c\:i:':><^r Kmi^us (secundi internodii) polliciN 

Arteries in NeijihbvThood of Wrist- joint.— Radial, with its anterior 

^..:. .... -.••.v: V \, :.v ... v:i7\ r c.:r.».d and metacarpal (first dorsal inter- 

v^^-i. ;.«. I ■•'..:. w : ■. s .. :ir-.. r cshmI. ]^>sterior carpal, cari)al branch 
«:..■;»: . -. ■ -.i:. -v,«. , .. .n -.ir.- :ir:r.::;.iiion of anterior interosseous. Caqwl 
re. ;.::;-: :-..-, ^ -. - . ,.; ..-/- 

Veins in Neij^hborhoc^d ot Wrist-joint.— .^Superficial — anterior ulnar: 

• -.v: .. .: ..'. ■■ ... T\^^->_•w^, vcnre comiies accompany each 

^': :"":c .■:\'\o . ::;• » - 

Nerves in Neighborhood of Wiist-joint. — >u|>erficial — anterior and 

iv-tvT- ■:....- .■ ■•..-, ..\„:.."i-.-.:>; ar.:erior and p<\<;terior branche> 

■:;■... V ... i . <. • . • , . ..:"i-, .:> br.-r.ch of meiiian; |>almar cutaneous 

* ' \ .- .:..::/.-. v"*: ulr-.-r communicating with anterior 

■" - ..-...; ..- -"ix •.;;".: ".v ..:.j<-r.i: dorsal cutanet)us branch 

■ - -• • v^ ..- .:.."/: : r.:.:i.i!: dorsal division of radial. 

I*i-i' ■';•....■■ .. ..: . :.:■".■■..:.." . ; :':^;^.•■s^4^ou>. 



Sl'RFACE FORM AN?* LANT^5L\RKS OF THE WRIST-JOINT. 

\" - :"\ " -: . ■ : - ■ .. '.t\c'. wiih the a]^x of the styloid 

•^-"' - i . s • - ::■; Ni . : -.1 ;.::•/.. To find the joint-line «tf 



SURGICAL CONSIDERATIONS IN DISARTICULATING AT 



the wrist, draw a straight line connecting the radial and ulnar styloid processes 
— ihcn draw a cuned h'ne between ihe siimc points, with the highest part of 
the ctmvexity i.;^ cm. (^ inch) above the straight line^ — thi-^^ curved line will 
represent the dome-shaped articular line. The ulnar styloid process is more 
distinct in pronation—lhat of ratlial in supination. 

Two or three skin-folds generally cross the palmar surface of the wrist 
lransversely~the lowe.^t fairly represents ihe upjier border of the anterior 
annular ligament— and is about 1.3 to 2 cm. (| to J inch) below the arch 
of the wrist- joint. 

All the muscles mentioned above under Surgical Anatomy can generally 
be felt and recognized about the wrist joint — except the flexor profundus 
digit»^rum and tlexor longus pnllicis, of the anterior group; the extensor 
carpi ulnaris, of the posterior group; and the supinator longus, of the radial 
group 

Bony prominences of ihe tubercle of the scaphoid and ritlge of the lnij)e- 
zium are generally to be felt on the anicrior aspect of the radial sitle of the 
wrist — and those of the pisiform and unciform process of the unciform, on 
the ulnar side. 

The lower end of the diaphysis of the ulna just comes to the radio-ulnar 
jo-nt. The lower end of the diaphysis of the radius comes within the synovial 
membrane- 

The tendon of the extensor longus (secundi interncwiii) i>olHcis marks 
the center of the lower end of the radius — and indicates the intenal between 
the .staphoid and semilunar. 

The ulnar artery, with the ulnar nerve to the ulnar side, lies on the anterior 
annular ligament, to the radial side of the pisiform and to the ulnar side of 
the hcxik of the unciform (in the groove between them). The deep branch 
of the ulnar arterv* arises directly below the pisiform. 

The radial artery passes under the extensor tendons of the thumb, uj'on 
the external lateral ligament, wintling over the outer side of the caqius from 
a point just l»cl"»w and internal to the stylnid process oi the radius lo the 
base of the lirst interosseous space. 

The sujK-rfirial palmar arch is on a line with the lower liorder of the 
thlrelched thumb -and the deep arch is 1.3 cm. (J inch) higher. 



GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT THE 

WRIST-JOINT. 

Disarticulation ill the wrist joint is preferable to amputation through 
the forearm, as pronation and supination are usually retained, and the stump 
b bt'iter adaptetl to an artitkial limb. 

Avoid injuring the radioulnar articulation — which is arljacent to, but 
rK>t a part of, the wrist joint. 

The styloid pntces-ses of the radius ant! u!na should r«iI be removed, 
dtpectally (hat of the radius, owing to the attachment of the sujnnator longus. 

Disarticulation of the joint is more easily done from the dorsum. 

The pisiform bone is often unconsciously removed with the thip, and it 
is < if to s*i remove it and subse<]uently to dissert it out, 

i cohering for the joint is from the palm, but the nature of the 
t»'; r which the operation is done will generally determine from 

wit ' t the covering tan be gotten. Care must be e.xercised lo ct>ver 



298 AMPUTATIONS. 

care in the palmar region. The ligaments of the intermetacarpal joints 
and carpo-metacarpal joints are di\'ided by carefully thrusting a knife between 
the sides of the bases of the metacarpals and between the metacarpab and 
the carpal bones, working from the dorsum of the hand. The disarticulation 
is a^mpleted by forcibly turning back the finger upon the dorsum of the 
hand. a>mpleiing. with the knife, the division of any undivided ligaments, 
in<erti^>n5 of tendons, or pvilmar structures. The syno\ial sheaths of the 
tWxvvr tendvHis shvuild be sutured with catgut, if f)ossible. Tie the two digital 
art«ws^anvi suture the wound in a single median line upx)n its dorsal aspect. 



DISARTICULATION OF INDEX-FINGER WITH ITS BIETACARPAL 

BY RACKET INCISION. 

Description. — The steps of this operation are practically the same as 
tor the o.>rres^xinding op)eration upon an inner finger. The incision is in 
the mid dorsal line. The addition of a short transverse incision at a right 
ui\i;le to the upper end of the queue is especially ad\isable here, owing to 
the width of the base of the second metacarpal. The outer (radial) of the 
diverging limbs below should follow the dorsal aspect a little further down 
before sweeping over the lateral aspect than does the inner (ulnar) limb, in 
order to bring the scar more out of the way of pressure. The index shoidd 
t>e exientled and abducted in clearing and disarticulating. Tie the digital, 
radialis indicis, and dorsahs indicis arteries — and suture the wound in a ver- 
tical dorsal line. 



DISARTICULATION OF LITTLE FINGER WITH ITS BIETACARPAL 

BY RACKET INCISION. 

Description. — The steps of the operation are essentially similar to those 
for the removal of an inner finger with its metacarpal by the racket incision. 
It is better to place the incision in the mid-dorsal a5p>ect than toward the 
inner (ulnar) side of the metacarpal, as objects less easily press such a scar. 
.■\t the upper extremity of the queue a short transverse incision may be added, 
not crossing the upper end of the queue (as in the case of the inner fingers), 
but running from the upper end of the queue at a right angle toward the 
ulnar as})cct of the hand, over the carpometacarpal joint — to allow of readier 
disarticulation. The inner (ulnar) of the diverging limbs below should 
follow the dorsal aspect a little further down before sweeping over the lateral 
border than does the outer (radial) limb — in order to bring the scar more 
out of the way of pressure. The little finger should be extended and ab- 
ducted (from the median line of the hand) in clearing and disarticulation. 
Carefully close the large syncnial sac of the little finger, if opened. Preserve 
the hypothcnar muscles as far as possible and suture into the wound. Suture 
the wound in a single dorsal line (Fig. 259, J). 



DISARTICULATION OF THUMB WITH ITS METACARPAL 

BV RACKET INCISION. 

Description. — Removal of the thumb, together with its metacarpal, at 
the carpometacarpal joint. 

Position. — Same as for the fingers, except that the hand is held midway 



DISARTICULATION OF FINGERS WITH THEIR METACARPALS. 299 

Landmarks. — Outline of the dorsal aspect of the metacarpal, and the 
carpo-metacarpal joint. 

Incision. — Begins just above the carpometacarpal joint-Hne, in the 
mid-dorsal aspect of the metacarpal — passing into the "snuff-box," if at all, 
with great care and, at first, very superficially, on account of the radial artery. 
The incision then passes down the center of the dorsum of the thumb to the 
neck of the metacarpal — and here divides into the two limbs of an oval, 
which part to encircle the head of the metacarpal, crossing the palmar aspect 
of the thumb on a level with the free edge of the web — the outer (radial) of the 
diverging limbs following the dorsal aspect a little further down before sweep- 
ing over the lateral aspect than does the inner (ulnar) limb (Fig. 259, N). 

Operation. — This incision is deepened on the line of the retracted skin 
and fascia. The extensor tendons of the first and second phalanges are 
cut as long as possible, so as to be sutured into the wound. The dorsum 
and sides of the metacarpal are cleared of soft parts, hugging the bone. The 
thumb is extended and abducted and the muscles attached to the base of 
the first phalanx are divided near the sesamoid bones, preserving the thenar 
muscles as far as possible. The palmar aspect of the metacarpal is cleared 
while an assistant rotates the thumb from side to side, working as near the 
bone as possible. The flexor longus pollicis tendon is divided low down, so 
that it may be sutured into the wound. Disarticulation is accomplished 
by severing the binding ligaments and the extensor ossis mctacarpi pollicis, 
while the thumb is fle.xed into the palm— opening the joint from the dorsum, 
the thumb being then rotated in different directions to complete the dis- 
articulation. Suture the sheath of the flexor tendon. Tie the arteria princeps 
pollicis, or its two branches, and the dorsalis j)ollicis. Quilt the muscles, 
suturing the flexor, extensor, and thenar tendons and muscles into the wound. 
The cicatrix will run in a dorsal median line. 



DISARTICULATION OF TWO CONTIGUOUS INSIDE FINGERS WITH 
THEIR METACARPALS 

BY KACKKT I.NCISION. 

Description. — The operation is the same, in principle, as that for the 
removal of a single finger and its metacarpal. A vertical incision begins 
just above the carpo-metacar])al joint-line and between the bases of the two 
contiguous metacarpals — passes down the back of the hand midway between 
the two metacary)als for about one half of their lenj^th — then divides into 
the two limbs of an oval, or racket— the radial limb passing to the radial side 
of the outer of the two fingers to be removed — the ulnar limb to the ulnar 
side of the inner of the two finders to be removed — to the junction of the 
fingers and webs — thence both limbs < ross and meet beneath the fingers 
in the digito-palmar crease. The incision is deepened— the metacarpals 
cleared — the tendons cut long — disarticulation a(com|)lished — and the opera- 
tion completed just as in the disarticulation of a single fini,'er and its meta- 
carpal. The flexor and exlenM>r tendon.> are to be sutured into the wound. 
(Fig. 259, M.) 

DISARTICULATION OF THREE INSIDE FINGERS WITH THEIR META- 
CARPALS 

BV K.ACk'ET INCISIDN. 

Description. — Same, in the main, as the disarticulation of any two 



3o6 AMPUTATIONS. 

below the radial styloid process and is directed downward along the radial 
border of the index. Ulnar limb of the U begins 1.3 cm. (J inch) below the 
ulnar styloid process and is directed downward along the ulnar border of 
the little finger. These limbs are bluntly rounded at their lower ends and 
pass transversely toward each other so as to meet just above the center of 
the metacarpus. Dorsal incision — crosses the carpus in a straight line, or, 
better, with slightly downward convexity, between the two upper ends of the 
palmar incision (Fig. 261, B), 

Operation. — With the hand in supination and extension, the palmar 
incision is deepened to the flexor tendons, the thenar and hypothenar muscles 
being cut through to that extent — and the palmar flap then dissected up to 
the joint-line, raising the flap from the bony prominences in the palm. With 
the hand now in pronation and the skin of the wrist drawn upward, the dorsal 
incision is deepened and the integuments dissected up to the joint-line, when 
the extensor tendons, posterior ligament, and lateral ligaments are severed 
and disarticulation accomplished. The flexor tendons and surrounding tis- 
sues on the palmar surface are now severed, while on the stretch, by di\idinp 
the anterior ligament from within the disarticulated joint and then cutting 
the flexor tendons from the dorsal toward the palmar aspect, on a line with 
the retracted palmar flap. The same arteries are to be tied as in the elliptical 
method, the deep arch and loops of the superficial arch coming away with 
the hand. 



DISARTICULATION AT THE WRIST- JOINT 

BY EXTERNAL LATKRAL, OR RADIAL FLAP — Dl'BRl'F.IL'S METHOD. 

Description. — A saddle-shaped flap of skin and muscles is raised from 
the metacarpal region of the thumb, and approximated to the disarticulated 
ends of the radius and ulna. 

Position. — As in disarticulation by the elliptical method (page 304). 

Landmarks. — Wrist-joint; first metacarpal. 

Incision. — Flap-incision — begins on back of wrist, about 6 mm. (\ inch) 
below the wrist -joint line, and at the junction of the outer and middle thirds 
of that line — passes thence downward upon the dorsal aspect of the thumb- 
thence rounds outward to cross the first metacarpal transversely about its 
middle (remaining, up to the point of rounding outward, as far from the 
outer border of the haml as at the beginning). The incision now passes 
upward correspondingly on the inner aspect of the thumb, following the 
inner part of the thenar eminence to a point about 6 mm. {\ inch) below the 
wrist-joint line, at the junction of the outer and middle thirds of that line 
on the palmar surface. Disarticulating-incision — the two upper ends of this 
flap are connected by a transverse incision passing directly around the inner 
aspect of the wrist-joint (Fig, 259, P, P). 

Operation. — The thenar incision, forming the flap, is deepened — the 
soft parts are dissected from the metacarpal, and as much of the thenar 
muscles as possible is taken. The soft parts upon the inner aspect of the 
wrist are divided to the bone by the circular incision on a level with the base 
of the flap. Disarticulation is accomplished from the dorsal and inner 
aspect, toward the palmar and outer. The following arteries are to be tied: 
superficial and deep palmar arches, dorsalis and radialis indicis and ulnar. 
The tendons and nerves are treated as in the preceding operations upon the 
wrist. The external or thenar flap is now brought transversely across the 




SURFACE FORM AND LANDMARKS (Jl" HIE FOREARM. 



307 



articular ends of the radius and ulna, and sutured ht ihe circularly divided 
parts. 

SURGICAL ANATOMY OF THE FOREARM. 

Bones, — Radius; ulna. 

Articulations and Ligaments. — (a) Superior Radioulnar Aniculaiion; 
— orbicular ligamenl; synuvial membrane, (b) Mitldlc Radio ulnar Articu- 
tlation; — oblique (nmnd) ligamenl; inlcrassenus membrane, (c) Inferior 
iRadio-ulnar Aniculaiion ;^ — aiUerior radio ulnar ligament; posterior radio- 
lulnar ligament; interariicular (triangular) fibro-cartilajjie; synovial mem- 
nine. (d) Klbow-joinl (pa<^e 312). (e) Wrist joint (page 302). 
r Muscles of the Forearm. — (a) Anterior radio-ubiar region :—{i) 
re Superficial Muscles.; — pronator radii teres; ilexor carja radialis; palmaris 
ongus; flexor carpi uinaris; ilexor .^ubli mis digilorum. (3) Deeper Sluscles; 
-flexor profundus digitorum; Ilexor longus pollicis; pronator quadralus. 
|(b) Radial region: — supinator longus; extensor carpi radialis longior; ex- 
tensor caq>i radialis brevior. (cj Posterior radio-ulnar region:— (i) 
jMorr Superficial Muscles; — extensor communis digitorum; extensor minimi 
idigiti; extensor carpi uinaris; anconeus. (2) Deeper .Mu-des; — supinator 
[brevis; extensor ossis metacar[>i pollicis; extensor brevfs fprimi intemodii) 
poilicis; extensor longus (sccundi inlernodii) pollicis; extensor indicis. 

Arteries of the Forearm.— Radial, with radial recurrent; muscular; 

Lantcrior carj^ai; superficialis voire; poi^terior carpal branches. L'Inar, with 

anterior ulnar recurrent; posterior ulnar recurrent; common interosseous; 

anterior interosseous; posterior interosseous; muscular; anterior carpal; 

posterior carj)al branches. 

Veins of Forearm. — ^Superficial — mcflian; median cephalic; median 
LbasiUc; deep median; radial cephalic; cephalic; anterior ulnar; posterior 
(ulnar; common ulnar; basilic. Deep — two ven;e oomiles accompanying each 
above arteries. 

, llerves of Forearm. — Superficial; — musculiKutaneous; intern;d cutane- 

; external cutaneous branch of musculospiral; cutaneous branch of ulnar; 

il cutaneous branch of ulnar; cutaneous branches of radial. Deep; — 

lulnar and its muscular branches; median and its muscular branches; muscular 

[irhes of must ulospiral; radial branch of musculospiral; jxjstcrior tnter- 

Qus branch of musculospiral. 



SURFACE FORM AND LANDMARKS OF THE FOREARM. 

Olecranon and posterior border of ufiper part tif ulna are subcutaneous 

— and the entire shaft is to be felt down to the styloid process, passing from 

itT i»f the forearm above to the ulnar side of the wrist below, and lying 

the tlexor and extensor c<tri»i uinaris. The ulnar styloid process is 

bc»t felt ^ilh the forearm midway between flexion and extension, being con 

^ttnamis with the pcisterior subcutaneous border of the bone. 

Head of the radius is felt just l^elow and a little in front of the posteri<ir 

ice of the external condyle, revolving in the orbicular ligamenl ami lesser 

DUMJ cavity— marked by a dimple in the skin posteriorly* best seen when 

is exlcnde<l. The lower half of the radius can be outlined, though 

Jtaneous — the outer aspect of the hmer jKirt alone being subcularveous, 

raiding in the radial styloid process. The radius is deeply covered abo\e 



3o8 AMPUTATIONS. 

and superficially covered below. Opposite a point in the forearm where 
one bone is most slender, the opposite bone is most substantial — both being 
about equal in the middle. The radius and ulna are everywhere nearer the 
posterior than anterior aspect of the forearm, and increasingly so above. 
They are nearest each other in complete pronation and furthest in complete 
supination. 

Flexor and pronator muscles form the muscular elevation upon the inner 
side of the elbow and forearm— the extensor and supinator muscles forming 
a corresponding elevation upon the outer and posterior side of the elbow 
and forearm. These two groups diverge above toward the condyles of the 
humerus and converge below toward the center of the forearm — the supinator 
longus forming the outer boundary and the pronator radii teres the inner 
boundary of the triangular space at the bend of the elbow. Of the muscles 
of the internal group, the pronator radii teres, flexor carpi radialis, palmaris 
longus, flexor carpi ulnaris, alone influence surface form, the remainder being 
unrecognizable. The external group of muscles divides into two longitudinal 
eminences, diverging from each other, with a triangular inten-al between 
them: — the outer, consisting of the supinator longus, extensor carpi radialis 
longior and brevis, descending from the outer condyloid ridge toward the 
radial styloid j)rocess; — the other, more posterior, consisting of the extensor 
communis digitorum, extensor minimi digiti, extensor carpi ulnaris, descend- 
ing from the external condyle, separated above from the anconeus by a furrow, 
and below from the pronator-flexor mass by the ulnar furrow. In the tri- 
angular interval between these two groups the extensor ossis metacarpi 
poUicis, extensor bre\ is poUicis, extensor longus pollicis, and extensor indicis 
pass downward. The anconeus forms a slight prominence external to the 
subcutaneous j)osteri()r surface of the olecranon. 

In the muscular, the transverse is much greater than the antero-posterior 
diameter of the forearm — ami the downward tapering is marked. In the 
non-muscular, the forearm is more rounded and the tapering is less. Above, 
the muscles are found chiefly at the sides and in front; — below, more equally 
along the anterior and posterior aspects — hence flap amputations are 
more adapted to the upper and circular amputations to the lower part of 
the forearm. 

The three chief pronators of the forearm are, the pronator radii teres. 
pronator (juadratus, and flexor carj)i radialis. The three chief supinators 
are, the supinator longus, supinator brevis, and biceps. 



GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 

THE FOREARM. 

For the purposes of amputation, the forearm may be divided into two 
natural regions, a lower one-third and an upper two-thirds — the former 
being ihararlerizcd by an almost even contour of similar dimensions through- 
out — tiie latter, esi)ecial]y in the muscular, by its rapidly increasing measure- 
ments up to from 2.5 to 5 cm. (i to 2 inches) below the elbow, and with a 
slight dcirease thence to the elbow-joint. Therefore, on this account, and 
because of the grouj)ing of the muscles, amputation-methods are described 
as ap})lical)]e to ''the lower third" and "the upper two-thinls." (In this 
connection, see the last paragraph from the bottom, in the alK>ve section.) 

The general type of amputation most suitable for the lower third of the 



AMPUTATION OF LOWER THIRD OF FOREARM. 



309 



ft 



is the circular method — and the general type most suitable for the 
U{>per two-thirds is the flap method. 

Saving of the smallest part of the forearm, with its movement, is preferable 
to disarticulation at the elbow. 

If possible, the bones should be sawed bcinw the insertion of the pronator 
radii teres, othenvise the radius will become supinated and rotatory move- 
meats lost- 
Owing to the tendency of the bones to project tlirough the angles of the 
flaps, the flaps at their bases and their lower ends should l)e made fully long. 
In cutting by transfixion the interosseous membrane is apt ti> be pierced. 
.\ terminal cicatrix is here desirable, as best ada|>led to an arlilkial limb. 
The stump should be dressed with the forearm midway between pronation 
and supination, and the elbow steadied by a right-angled sjilint. 



»B AMPUTATION OF THE FOREARM, IN GENERAL. 

Best Methods.— Modified Circular— 
for the lower third. Kqual Anterior and 
Posterior Flaps —for the up(>er two-thirds. 

■ Other Methods.— Long Anterior Flap 
— where the posterior tissues are defi- 
cient. Long Posterior Flap — where the 
Anterior tissues are deficient. Long An- 
terior and Short Posterior Flap. Rcc 
langular Flaps (Teale's metho<J). E.v- 
lemal Lateral Flap — wliere the internal 
ti^ii^ucs are deticient. Equilateral Skin- 
&ip&. Circular Skin-flap. Circular. 




ATION OF LOWER THIRD OF 
FOREARM 

BY MOUIMtl) CIKCIKAK MRTHOD. 

Description.— 'Two short flaps of 
skin and fascia are turned back and 
the muscles arc then circularly divided at 
th« Ic^'cl of the retracted skin and fascia 
flaps. 

Position. — Patient supine, near edge 
of table, with upper limb abducted to a 
right iingle — an<l held by an assistant in 
supination <iuring anterior incisions, and 
in pronation, or vertically, during pos- 
trrior incisions. Surgeon to outer side of 
right limbs and inner side of left. 

Landmarks.— Saw-line. 

Incision. — The total covering is to be 
i^ diameters of the forearm at the saw- 

Une. The anterior and [insterior aspects will each furnish ihree-fourths 
of a diameter. One-half of this Ihree-fourths diameter length will be of 
•leifi and fascia alone, on each side — the remaining half of skin, fascia, 




Fig. a6a. — Amm.ttations Tiinot'cii 
FoRBAKM AM> AT F.i-now :— A, TtirouKh 
lower pari of (orcartti, by nitxliftcd tifcti- 
lar. B. Thrmunh up|RM forearm, by **iuftl 
iititcriol and ixi-^tci r<ir (liips , <'. At vltufW- 
JDJnl. bv loiiji* :ititt:ri>-iiiternt(l and short 
posleroexiemal flaps. 




304 AMPUTATIONS. 

the prominent radial styloid process. In approximating the thick palmar 
to the thin dorsal skin, the sutures are to be securely tied and left amply long. 
Drainage is indicated for twenty-four or thirty-six hours. The stump should 
be placed upon a splint which will steady the part and prevent pronation 
and supination, in a position midway between pronation and supination. 

The lower epiphyses of the radius and ulna join the bones about the 
twentieth year. 

DISARTICULATION AT THE WRIST- JOINT, IN GENERAL. 

Best Methods. — Anterior Ellipse; Palmar Flap; External lateral, or 
radial, Flap (Dubrueil's Method). 

Other Methods. — Modified Circular; Circular; Equal Palmar and 
Dorsal Flaps; Dorsal Flap. 

Comment. — Anterior ellipse method forms the best covering, and amounts 
to a palmar flap. Palmar flap — rather bulky and unyielding and less ad- 
justable. External flap — a good substantial covering, and especially adapted 
to cases in which the palmar covering is not available. Circular method — 
forms a scanty covering. Dor.sal flap — warrantable when the palmar and 
external coverings are unavailable, but consists only of skin and tendons. 



DISARTICULATION AT THE WRIST-JOINT 

BY ANTERIOR P:LLIPSE. 

Description. — The covering raised is, practically, an anterior flap. The 
idea of the ellipse is appreciated after marking the outline, as given below, 
and then viewing it from the radial or ulnar aspect of the hand. 

Position. — Patient on back, forearm abducted horizontally; hand pro- 
nated or supinated, as indicated by the stage of the operation. Surgeon sits 
or stands, facing the patient's hand. An assistant steadies the limb from 
above, and holds the parts out of the way. 

Landmarks. — Line of the wrist-joint; pi.siform; base of fifth metacarpal; 
carpo-metacarpal joint of the thumb. 

Incision. — Highest point of the ellipse is upon the dorsum, 1.3 cm. (^ 
inch) below the line of the wrist-joint, and on a line with the middle finger. 
Lowest point of the ellipse is upon the palm, 6.3 cm. (2^ inches) below the 
line of the wrist-joint, and on a line with the middle finger. The inner 
portion of the ellipse crosses the ulnar border of the hand between the pisiform 
bone and base of the fifth metacar|)al. The outer portion of the ellipse 
crosses the radial border of the hand at the carpometacarpal joint-line of 
the thumb. The entire incision has, therefore, a downward convexity upon 
the palm and an upward convexity upon the dorsum, and passes through 
the four above-mentioned points (Fig. 261, A). 

Operation. — Supinating the hand while incising the palm, and pronating 
it while making the dorsal incisions, this entire ellipse, which has been made 
through the skin and fascia at first, is now deepened throughout. The 
dorsal integuments are first dissectcri to the joint-line. The hand is flexed 
and the extensor tendons, posterior ligament, and lateral ligaments are cut 
and the joint opened — and then the anterior ligaments. First one and then 
the other lateral Ijorder of the hand is made to present and the lateral parts 
of the eilip.^e carried to the bones. The knife is then carried between the 



DISARTICULATION AT THE WRIST-JOINT. 



305 



flexor tendons and the carpus, from above and within, and made to clear 
out the hollow of the carpus in the act of cutting its way obliquely from within 
downward and outward, to the margin of the palmar incision through the 
skin — and the hand thus severed from the arm. All loose tendons and 
nerves are to be cut. The following arteries are to be tied; radial, ulnar 
(below the deep branch), deep branch of the ulnar, superficialis vola?. The 
deep palmar arch and part of the superficial palmar arch are removed with 




Fig. 261.— DiSARTiCL'LAi IONS AT THE Wk iST-joiN T :— A. By anterior clliiisc; B, By palmar flap. 

( Palmar view. 1 

the hand. The convex palmar fla}) is sutured into the cfmcave wound at 
the back of the wrist. 

Comment. — The palmar covering can be entirely freed uj) to the joint- 
line before disarticulating. 



DISARTICULATION AT THE WRIST 

\\\ PAI.MAk FLAP. 

Description. — The flap is U-shai)cd. and raised entirely from the palm. 
Position. — As in the disarticulation by an anterior ellipse (page 304). 
Landmarks. — Styloid process of radius; styloid process of ulna; middle 
of metacarpus. 

Incision. — Palmar incision — radial limb of the U begins 1.3 cm. (A inch) 



3o6 AMPUTATIONS. 

below the radial styloid process and is directed downward along the radial 
border of the index. Ulnar limb of the U begins 1.3 cm. (^ inch) below the 
ulnar styloid process and is directed downward along the ulnar border of 
the little finger. These limbs are bluntly rounded at their lower ends and 
pass transversely toward each other so as to meet just above the center of 
the metacarpus. Dorsal incision — crosses the carpus in a straight line, or, 
better, with slightly downward convexity, between the two upper ends of the 
palmar incision (Fig. 261, B). 

Operation. — With the hand in sujunation and extension, the palmar 
incision is deepened to the flexor tendons, the thenar and hypothenar muscles 
being cut through to that extent — and the palmar flap then dissected up to 
the joint-line, raising the flap from the bony prominences in the palm. With 
the hand now in pronation and the skin of the wrist drawn upward, the dorsal 
incision is deepened and the integuments dissected up to the joint-line, when 
the extensor tendons, posterior ligament, and lateral ligaments are severed 
and disarticulation accomplished. The flexor tendons and surrounding tis- 
sues on the palmar surface are now severed, while on the stretch, by dividing 
the anterior ligament from within the disarticulated joint and then cutting 
the flexor tendons from the dorsal towarri the jjalmar asj)ect, on a line with 
the retracted palmar flap. The same arteries arc to be tied as in the elliptical 
method, the deep arch and k)oi)s of the sui>erficial arch coming away with 
the hand. 



DISARTICULATION AT THE WRIST- JOINT 

BV K.XTKRXAL LATKKAI., OK KAhlAl. II.AP - ninRrRIl/S METHOD. 

Description. — ^A saddle shaped flap of skin and muscles is raised from 
the metacarpal region of the thumb, and approximated to the disarticulated 
ends of the radius and ulna. 

Position. — As in disarticulation by the elliptical method (page 304). 

Landmarks. — Wrist-joint; flrsl metacarpal. 

Incision. — Flap-incision — begins on back of wrist, about 6 mm. (\ inch) 
below the wrist-joint line, and at the junction of the outer and middle thirds 
of that Une — passes thence downward uixm the dorsal aspect of the thumb — 
thence rounds outward to cross the flrst metacari)al transversely about its 
middle (remaining, up to the point of rounding outward, as far from the 
outer border of the hand as at the l)eginning). The incision now passes 
upward correspondingly on the inner aspect of the thumb, following the 
inner part of the thenar eminence to a [)()int about 6 mm. (^ inch) below the 
wrist-joint line, at the junction of the outer and middle thirds of that line 
on the palmar surface. Disarticulating-incision — the two upper ends of this 
flap are connected by a transverse incision pas.sing directly around the inner 
aspect of the wrist -joint (Fig. 259, P, P). 

Operation. — The thenar incision, forming the flap, is deepened — the 
soft parts are dissected from the metacarpal, and as much of the thenar 
muscles as possible is taken. The soft parts upon the inner aspect of the 
wrist are divided to the bone by the circular incision on a level with the base 
of the flap. Disarticulation is accomplished from the dorsal and inner 
aspect, toward the palmar and outer. The following arteries are to be tied: 
superficial and deep palmar arches, dorsalis and radialis indicis and ulnar. 
The tendons and nerves are treated as in the f)receding operations upon the 
wrist. The external or thenar flap is now brought transversely across the 



SURFACE FORM AND LANDMARKS OF THE FOREARM. 



307 






articular ends of the radius and ulna, and sutured to the circularly divided 
parts. 

SURGICAL ANATOMY OF THE FOREARM. 

Bones, — Radius; ulna. 

Articulations and Ligaments.— (a) Superior Radio- ulnar Articulation; 
— orbicular ligament; synovia! membrane, (b) Middle Radioulnar Ariicu- 
lation; — oblique (round) ligament; interosseous membrane, (c) Inferior 
Radioulnar Articulation; — anterior radio-ulnar ligament; posterior radio- 
ulnar ligament; inierarticular (triangular) Jibro- cartilage; synovial mem- 
brane, (d) Ellx)w-joint (page 312). (e) Wrist joint (page 302). 

Muscles of the Forearm.— (a) Anterior radio-ulnar region:— (i) 
More Superficial Muscles; — pronator radii teres; flexor rarpi radialis; palmaris 
longus; tlcxor car|>j ulnaris; flexor subbmis digilorum. (3) Deeper ^luscles; 
— ricxor profumlus digjtorum; flexor iongus poUicis; [ironalor quadratus. 
(b) Radial region: — supinator longus; extensor carpi raxlialis longior; ex- 
tensor cnr|)i radialis brevior. (c) Posterior radio-ulnar region: — (1) 
More Supertjcial Muscles;— extensor communis digitorum; extensor minimi 
digit! ; extensor carpi ulnaris; anconeus. (2) Deeper Muscles; — supinator 
brevis; extensor ossis metacarpi pollicis; extensor brevis (primi internodii) 
pollin's; extensor longus (secundi internodii) pnllicis; extensor indicis. 

Arteries of the Forearm.— Radial, with radial recurrent; muscular; 
anterior carpal; superficialis voKt; posterior carpal branches. Ulnar, wilb 
anterior ulnar recurrent; posterior ulnar recurrent; commtm interosseous; 
anterior interosseous; posterior interosseous; muscular; anterior caqial; 
posterior carpal branches. 

Veins of Forearm.— Supertkial—median; median cephalic; median 
_ ilic; deep median; radial cephalic; cepha!ic; anterior ulnar; posterior 
fltnar; common ulnar; basilic. Deep — two venic comites uccompannng each 
of above arteries. 

Nerves of Forearm. — Supcrlicial;— musculocuiancous; internnl cutane- 
QII&; external cutane<>us branch of musculospiral; cutaneous branch of ulnar; 
^lonsl cutaneous branch of ulnar; cutaneous branches of ra^lia). Deep; — 
lllMTand its muscular branches; median and its musiular branches; muscular 
branches of musculospiral; ratlial branch of musculospiral; posterior inler- 
is branch of musculospiral. 



SURFACE FORM AND LANDMARKS OF THE FOREARM. 

Olecranon and [posterior border of upi>er part of ulna are subcutaneous 
— and the entire shaft is to be felt dcnvn to the styloid process, passing from 
t)»e center of the forearm above to the ulnar side of the wrist below, and 1\ ing 
between the flexor and extensor carpi ulnaris. The ulnar styloid process is 
^tet felt with the forearm midway between flexion and extension, being con 
tinwms with the |x>sterior subcutaneous border of the bone. 

Hea d of the radius is felt just l^chnv and a little in front tif the posterior 

iof the external Cfmdyle, revolving in the orbicular ligament and lesser 

cavity marked by a tlimi>le in the skin posteriorly, best seen when 

arm is extended. The lower half of the radius can be outlined, though 

I FuljcuLineous — the outer as^)t't t of the lower part alone being subculanei>us, 

i ending in the radial styloid process. The radius is deeply covered above 



3o8 AMPUTATIONS. 

and superficially covered below. Opposite a point in the forearm where 
one bone is most slender, the opposite bone is most substantial — both being 
about equal in the middle. The radius and ulna are everj'where nearer the 
posterior than anterior aspect of the forearm, and increasingly so above. 
They are nearest each other in complete pronation and furthest in complete 
supination. 

Flexor and pronator muscles form the muscular elevation upon the inner 
side of the elbow and forearm— the extensor and supinator muscles forming 
a corresponding elevation upon the outer and posterior side of the elbow 
and forearm. These two groups diverge above toward the condyles of the 
humerus and converge below toward the center of the forearm — the supinator 
longus forming the outer boundarj' and the pronator radii teres the inner 
boundary of the triangular space at the bend of the elbow. Of the muscles 
of the internal group, the pronator radii teres, fle.xor carpi radialis. palmaris 
longus, flexor carpi ulnaris, alone influence surface form, the remainder being 
unrecognizable. The external group of muscles divides into two longitudinal 
eminences, diverging from each other, with a triangular interval between 
them: — the outer, consisting of the supinator longus, extensor carpi radialis 
longior and brevis, descending from the outer condyloid ridge toward the 
radial styloid process; — the other, more posterior, consisting of the extensor 
communis digilorum, extensor minimi digiti, extensor carpi ulnaris, descend- 
ing from the external condyle, separated above from the anconeus by a furrow, 
and below from the pronator-flexor mass by the ulnar furrow. In the tri- 
angular interval between these two groups the extensor ossis metacarpi 
pollicis, extensor brevis poHicis, extensor longus pollicis, and extensor indicis 
pass downward. The anconeus forms a slight prominence external to the 
subcutaneous posterior surface of the olecranon. 

In the muscular, the transverse is much greater than the antero-posterior 
diameter of the forearm — and the downward tapering is marked. In the 
non-muscular, the forearm is more rounded and the tapering is less. Above, 
the muscles are found chiefly at the sides and in front; — below, more equally 
along the anterior and posterior aspects — hence flap am])utations are 
more adapted to the upper and circular amputations to the lower part of 
the forearm. 

The three chief pronators of the forearm are, the pronator radii teres, 
pronator quadratus, and flexor caq)i radialis. The three chief supinators 
are, the supinator longus, supinator brevis, and biceps. 



GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 

THE FOREARM. 

For the purposes of amputation, the forearm may be divided into two 
natural regions, a lower one-third and an upper two-thirds — the former 
being characterized by an almost even contour of similar dimensions through- 
out — the latter, especially in the muscular, by its rapidly increasing measure- 
ments uj) to from 2.5 to 5 cm. (i to 2 inches) below the elbow, and with a 
slight decrease thence to the elbow-joint. Therefore, on this account, and 
because of the grouping of the muscles, amputation-methods are described 
as ap])licable to **lhe lower third" and "the upper two-thirds." (In this 
connection, see the last j)aragraph from the bottom, in the above section.) 

Tlie general tyi)e of amputation most suitable for the lower third of the 



AMPUTATION OF LOWER TliIRD OF FOREARM. 



309 



focearm is the circular methcxJ— and ihe general type most suilable for the 
upper two-thirds is the flap melhcxJ. 

Saving of the smallest part of the forearm, with its movement, is preferable 
to disarticulation at the elbow. 

If possible, the bones should be s^iwed below the ttisertitio of the pronator 
radii teres, otherwise the radius will become supinated and rolalt^ry muve- 
ments lost. 

Owing to the tendency of the bones to project through the angles of the 
flaps, the daps at their bases and ihcir lower ends should be made fully long. 

In cutting by transfixion the interosseous membrane is apt U> be pierced. 

A terminal cicatrix is here desirable, as best adapted to an artificial limb. 

The stump should \ye dressed with the forearm midway Jietwecn pronation 
and supination, and the elbow steadied by a right-angled s[>linl. 



AMPUTATION OF THE FOREARM, IN GENERAL, 

Best Methods.— Modified Circular— 
lor the l*)\ver third. Equal Anterior and 
Posterior Flaps— for the upper two thinls. 

Other Methods.— Long Anterior Flap 
— where the posterior tissues are defi- 
cient. Long Posterior Flap — where the 
Qterior tissues are deficient. Long An- 
lerior and Short Posterior Fhi]). Rec- 
tangular Flaps (Teales method). Ex- 
ternal Lateral Flap— where the internal 
ti^ucs are deficient. Equilateral Skin- 
Haps. Circular Skin -flap. Circular. 



AHPUTATION OF LOWER THIRD OF 
FOREARM 

hV MOLilMHlJ t.lkHfl.AK METHOD. 

Description. — Two short flaps of 

kjn and fascia are turned back and 

muscles are then circularly divtdetl at 

r level of the retracted skin and fascia 

Position.— Patient supine, near edge 
of tiible. with upper limb aliducted to a 
right angle — and held by an assistant in 
»upination during anterior incisions, and 
pnination, or vertically, during pos- 
w incisions. Surgeon to outer side of 
2;hc limbs and inner side of left. 
L«&dmarks«— Sawline. 
Incision. — The total covering is to be 
t^ diameters of the forearm at I he saw- 

littc- The anterior an<l |K»sterior aspects will each furnish three-fourths 
diameter. One half of this three-fourths diameter length will be of 
and fascia alone, on each side — the remaining half of skin, fascia, 




Fig. Jfil.— AMFtTATlONS TIIROUCH 
FORHAKM AND A I Elrow:— A, ThlUUgll 
lower |»iul of lorcanii. by moditicd rlrcu- 
lar; B, Tlirough upju'r forearm, by «'<juftl 
;iiilciior Btiil (KMittrjor flaps ; C, Al clbow- 
V It III, by loll); iiiitcio-iiitertial and short 
postcro-cJrtenial flaps. 



iAi 



310 



AMPUTATIONS. 



and muscle. Therefore a point below the saw-line equal to three-fourths 
of a diameter at the saw-line will mark the lowest limit from which the covering 
is to be provided. Two small flaps are incised, each having a base equal 
to a half-circumference, and a length equal to half (the lower half) of the 
distance between the saw-line and the lowest limit of the skin incision. These 
flaps will be bluntly rounded at their lower ends (Fig. 262, A). 

Operation. — Dissect up the integumentar\' flaps half-way to the saw- 
line — retract them, and, on a level with the retracted flaps, circularly divide 
the muscles to the bone. This circular incision also divides the periosteum 
and interosseous membrane. The muscles and periosteum are then retracted 
to the saw-line — and the bones divided, completing the section of the more 

movable radius first. Tie the radial, 
ulnar, anterior and posterior interosseous 
arteries. Stitch the musculo-periosteal 
covering over the bones. Quilt the mus- 
cles or tendons of the anterior to those of 
I the ix)sterior aspect of the forearm if pos- 
sible. Suture the integumentar>' cover- 
ings in a straight line antero-posteriorly. 

Comment. — The preponderance of 
tendinous over muscular tissues here 
makes the infundibular variety of the 
modified circular difficult or impossible. 




AMPUTATION OF LOWER THIRD OF 
FOREARM 

l\V CIRCILAK MKTHOD (CUFF VARIETY). 

Description.— The cufT variety of the 
circular amputation is here done (see 
under Comment). A cufT of skin, circu- 
larly cut, is turned back — and the mus- 
cles circularly divided on a level with the 
reflected skin — the ends of the bones 
being covered by skin and fascia alone. 
Position. — .\s in the last operation. 
Landmarks.— Sawdine. 
Incision. — Circular cut, placed three- 
fourths of a diameter (at the saw-line) 
below the line of bone-section — thus mak- 
ing a total covering of ij diameters, as 
each side may be regarded as furnishing 
one-half of the covering. (For principle, see Fig. 26;^, A.) 

Operation. — This circular incision divides the skin and fascia, which 
arc then dissected up, the forearm being vertical while the [)osterior dissection 
is done. This dissection and turning back of the flap is continued up to a 
distance below the saw-line which will leave space to provide a musculo- 
perio.steal covering. Here, after well retracting the integumentary coverings, 
the muscles are <livided circularly to the bone, — extending the hand while 
the fle.xors are cut and tlexing it while the extensors are being severed. A 
circular cut is made through the periosteum, around each bone, on a level 



F\K. 2Mv- Ami r I at ions AnotT I-oki- 

ARM AM) iM.itou :— .\, I lirutl,l,'l> llllildli- < .1 

(ortarni, by cin.Mlar tmtlio'l ; H, At i Itiou- 
joiiit, lis siii;;;ic t-Mcriial llap ; ('. At tihuu , 
by obli<|iif cimilar mclliod. 



AMPUTATION OF UPPER TWO-THIRDS OF FOREARM. 



311 



I 



and a musculo- periostea I covering is freed up lu the saw-line^ with a periosteal 
elevator, from each bone. AH stift parts are now retracted and the bones 
sawed, completing the section of the more movable radius first. Tie the 
radial, ulnar, anterior and posterior interosseous arteries. Cut the tendons 
(which are here esj^>ecially numerous) and the nerves short. Suture the 
musculo- periosteal covering uver ihe bones— and stilih the skin and fascia 
in a vertical anten.i-[K^sterior or lateral direction. 

Comment, -(i) Owing to the predominance of tendons in this locality, 
tlie jnfundibuhform variety of the circular method is impracticable. (2) 
The above oi)eration is very similar to the modified circular method just 
described, which is generally considered belter than the present form, in this 
locality. The cuff melho*], indee<i. is nut possible if the limb laj)ers very 
decidedly at the site involved. (J) A musculo- periosteal covering is specially 
indicatet:! here, as being the best means of guarding a|;ainst a fusion uf the 
cut edges of the bones and conser4uent loss of pronation and supination. (4) 
K As ihe large mass of tendons is ditbcuU to cut sfpiarely by a circular incision, 

■ a long, narrow knife may \ys sli]>petJ under ihcm, and they may then be cut 

■ directly upward from within — or they may be divided with strong, sharp 
H scissors. 

^■1 



AMPUTATION OF UPPER TWO-THIRDS OF FOREARM 

BV ligiAI. ANTERluK \M » I'OSri-.RIOK J-LAf'S, 



Description. — The anterior and posterior aspects of the forearm furnish 

equal U-shaped tlaps of skin and muscle — the anlcriorly largely compcised 

^of supinator longus and flexors,— the jwsterior largely made up of extensors. 

Position. — .\s in the modified circular method (page ^og). 

Landmarks. — Saw- line. 

Incisions. — An anterior and a posterior U shaped flap are incised on 

he resj>ertive aspects of the forearm, the base of each flap at the sawdine 

|>eing etjual to a half circumference of the limb at that line, and the length 

eacii eijual to three-fourths of the diameter — the hand being supinaif^ 
in making the anterior tla[». and the forearm vertical in making the posterior 
flap (Fig. 2h2, B), 

t Operation. — Having cut through skin and fascia in outlining the flaps, 
these tnclsi{)ns are now deepened uj3on the line of the retracted skin, beginning 
at the ulnar side of the anterior flap, in case i)f the right arm (and on the 
radial side ufxni the opposite arm) The vertical ulnar incision will involve 
the flexor carpi ulnaris and tiexor profundus — the vertical radial incision 

twill involve the two radial car|»al extensors — Ixith vertical incisions passing 
directly to the lK)nes. The muscles on the anterior and |x>sterior aspects 
of the forearm, at the lower roundai exiremiiies of the tlaj)s, are cut from 
without inward in such a manner as to bevel them slightly. The entire flaps 
are now raised from the bones up to a jxiint sutliciently below the saw-line 
to furnish a mu.sculo-periosteal covering — at which level the periosteum is 
^ drruUrly di\-idetl around the bones — the interosseous membrane rut trans- 
H versely — and the muscul«>periosteal covering ireed to the s;iw line. The 
^k^ jKirts are then retracted and the bones sawed. The radial, ulnar, anteri<ir 
^^pd p«^fcrior interosseous arteries are tied. The median, radial, and ulnar 
' ner I i Ik- cut short, or even dissected from the flap. The musculo- 

prr 'vering is sutured and the muscles quilted — and the integuments 

sutured in a lateral line. 




i^Si 



312 AMPUTATIONS. 

Comment. — These flaps may be less satisfactorily cut by transfixion — 
in which method, also, the interosseous membrane is apt to be pierced. 



SURGICAL ANATOMY OF THE ELBOW-JOINT. 

Bones. — Humerus, radius, and ulna. 

Articulations and Ligaments.— (a) Of the Elbow-joint; — anterior, 
posterior, internal lateral and external lateral ligaments, and synovial mem- 
brane, (b) Of the Superior Radio-ulnar Joint; — orbicular ligament, and 
synovial membrane. 

Muscles in Neighborhood of Elbow.— (A) Muscles arising a greater 
or lesser distance above elbow and inserted below elbow: — (a) On anterior 
aspect; — biceps and brachialis anticus. (b) On posterior aspect; — triceps 
and subanconeus. (c) On radial aspect; — supinator longus and extensor 
carpi radialis longior. (B) Muscles arising from inner condyle of humerus 
and inserted into forearm and hand; — pronator radii teres, flexor carpi 
radialis, palmaris longus, flexor carpi ulnaris, flexor sublimis digitorum. 
(C) Muscles arising from outer condyle of humerus and inserted into forearm 
and hand; — extensor carpi radialis brevior, extensor communis digitorum, 
extensor minimi digiti. extensor carpi ulnaris, anconeus and supinator brevis. 

Muscles in Direct Relation with Elbow- joint. —Anteriorly; brachialis 
anticus. Posteriorly; triceps and anconeus. Externally; supinator brevis 
and common tendon of origin of extensor muscles. Internally; common 
tendon of origin of flexor muscles. 

Arteries in Neighborhood of Elbow. — Brachial, with superior profunda, 
inferior profunda, and anastomotica magna branches. Radial, with radial 
recurrent branch. Ulnar, with anterior ulnar recurrent and posterior ulnar 
recurrent branches. 

Veins in Neighborhood of Elbow. — Superficial; — median, median 
basilic, median cephalic, deep median, radial, cephalic, anterior ulnar, poste- 
rior ulnar, and common ulnar. Deep; — Two vena.' comites accompanying 
each of above arteries. 

Nerves in Neighborhood of Elbow. — Superficial; — musculocutaneous, 
internal cutaneous, lesser internal cutaneous, external cutaneous, and branches 
of mu-scul(>sj)iral. Deep; — ulnar, median, radial and j)osterior interosseous 
branches of musculospiral. 

Bicipital Fascia. — .\ l)road a|)oneurosis given off from inner side of 
tendon of biceps, opj)osite bend of eil)ow — and passing between the brachial 
artery and superficial veins and nerves of elbow obliquely downward and 
inward to become continuous with the deep fascia of forearm, fastening 
down the flexor muscles. 

Bursse in Neighborhood of Elbow. — Between olecranon and skin, and 



SURFACE FORM AND LANDMARKS OF THF ELBOW. 



3^2 



Movements of Elbow-joint. — (i) Flexion— by biceps, brachialis amicus, 
aided by muscles having oripn from internal condyle of humerus and by 
supinator long:us. (3) Extension — Ijv triceps, anconeus, aided by extensors 
of wrist and by extensor commiinis digitorum and extensor minimi digili. 



SURFACE FORM AND LANDMARKS OF THE ELBOW. 



L position of radio-humeral hne, and hence the jinnt-linc of the elbow, may 
found by feehng for the flepreshion between the head uf the radiu? ant] 
capitellum of the humerus at the back of the elbow, marked by a dimple in 

»lhe integument in the interval between the anconeus to the ulnar side, and 
the muscular mass of supinator longus and two carpal radial extensors to 
ihe radial side. 

The humero-radial articulation is horizontal — the humero-ulnar articu- 
lation slopes slightly downward. 

The fold of the elbow, more prominent when the forearm is semi-flexed, 
is a little above the level of the joint, and forms the base '>f the triangular 
fossa below the elbow, whose sides are formed by the supinator longus and 
pronator radii teres. 

The inner condyle of the humcnis is the more prominent and is a little 
more than 2.5 cm. (i inch) abo%'e the elbow-joint. The outer condyle is 2 
^ cm. (I inch) above. 

H When the forearm is fully extended, the inner condyle, lip of olecranon. 

r and c.tlcrnal condyle are all on the Siime transverse line (in extreme extension, 

Ihc tip of the olecranon is slightly abt>ve); — when the forearm is flexed to a 

(right angle, the tip of the olecranon is directly below the contlylcs; — when 
the forearm is completely tlexed, the tip of the olecranon is below and in 
front of the condyles. 
A line connecting the two ciMidyles forms a right angle with the axis of 
the arm — and an angle with that of the forearm. 

The upper part of the olecranon is covered by the triceps — the lower 
part is subcutaneous, and separated from the skin by a bursa. 

Xhrcc eminences are present upon the anterior aspect of the e!!>o\v region; 

the biceps al>ove and in the center — the supinator longus and common 

extens*>r group on the outer — and the pronator radii teres and common 
Qexor group upon the inner side. 

The ulnar nerve and jHisterior ulnar recurrent artery lie in a deep groove 

t-lwcen tlic olecranon and inner lundyle uf the humerus. 
The anterior integument of the elbow is thin and retractile — the posterior 
tegument loose and but little retractile. 



GENERAL SURGICAL 



L 

_^ cnni 
■ ind 

Ml 



CONSIDERATIONS IN 

THE ELBOW- JOINT, 



DISARTICULATING AT 



The stump after dis-irticulating at the elbow-joint is better for the adapta- 
of an artifuial limi) than after amjmtation through the arm. 

To find the cHvow-joint— place the thumb just beneath the external 
amdyle of the humerus and. gras|>ing the wrist with the right hand, pronate 
and sujiinntc the forearm — when the upper limit of the radial head will be 
found about i.^ cm. (i inch) below the external condyle. 
"" The joint is entered and disarticulate<l more easily from the outer side. 



314 AMPUTATIONS. 

The muscles on the outer side of the elbow retract more powerfully than 
those upon the inner side, chiefly owing to the presence of the supinator 
longus. 

The lower end of the humerus is so large that a liberal allowance of covering 
is necessar>'. And a more liberal covering has to be provided for the inner 
than for the outer condyle of the humerus — incisions, therefore, are longer 
on the inner aspect. 

The skin posteriorly is used to pressure — but the muscles here are not 
so available for padding as in front. 

Temporary drainage should be used after disarticulation. The stump 
should be elevated upon a splint. 



DISARTICULATIONS AT THE ELBOW, IN GENERAL. 

Best Methods. — Anterior Ellipse— best, where ample sound tissue exists; 
well nourished and thick enough to cover bones well; cicatrix well placed; 
but requires considerable tissue; skin-i)ouch over the olecranon is apt to be 
left. Posterior Ellipse — best where anterior tissue is unavailable; covering 
thin and uneven, though used to pressure. Long Antero-intemal and Short 
Posteroexternal Flaps — cover disarticulated end of humerus well; especially 
indicated where both lateral aspects of forearm can furnish covering and 
neither anterior nor posterior can sui)ply the large amounts of tissue neces- 
sary for the elliptical methods. 

Other Methods.— Circular. Modified Circular. Anterior Flap. Poste- 
rior Flap. Long Anterior and Short Posterior Flaps. Short Anterior and 
Long Posterior Flaps. Single External Flaj). Equal Lateral Flaps. Un- 
equal Lateral Flaps. Lateral Skin Flap. Racket Method. Of these 
methods, the circular requires the least sacrifice of parts, but the resulting 
covering is not so satisfactory. 



DISARTICULATION OF ELBOW- JOINT 

HV ANTKRIOR ELLIPSE — FARABEUF. 

Description. — The covering is, essentially, an anterior flap — the idea 
of the ellipse being gotten in viewing the outlined incision laterally. The 
lower anterior convexity of the covering is sutured into the upper posterior 
concavity. 

Position. — Given in the course of the operation. 

Landmarks. — Joint-line; prominence of olecranon; eminence of supinator 
longus on anterior asi)cct of forearm. 

Incision. — The highest point of the ellipse is posterior, over the prominence 
of the olecranon. The lowest point of the ellipse is anterior, over the eminence 
of the supinator longus, just above the middle of the forearm. Midway 
between the upper and lower rounded ends of the ellipse the lateral borders 
of the ellipse i)ass along the mid-lateral aspects of the forearm (Fig. 264). 

Operation.— The surgeon stands on the left of either right or left elbow 
(which will place the patient's elbow on his right) — grasping his wrist with 
his left hand, and flexing the elbow, so rotates the limb as to make the entire 
eUiptical incision without relaxing his hf)ld of the wrist, or removing the 
knife, which passes from olecranon to olecranon. Taking the right limb, 
for instance, turn the slightly fle.xed elbow so as to present the radial aspect — 



DISARTICULATION OF ELBOW JOINT. 



315 



enter the knife at the apex of the olecranon — pass down the radial lateral 
aspect — across the lower end of the ellipse, on the anterior aspect of the 
forearm (with the forearm extended and supine) — then along the inner 
aspect (with elbow again flexed and the inner aspect of the forearm thereby 
made to present) and upward to the olecranon. The skin and fascia 
upon the proximal side of the lower end of this incision are now further 
retracted by hand. On the line of the retracted integuments the muscles are 
then cut obliquely from without inward and upward toward the joint, in such 
a manner as to bevel the anterior covering which is being raised — and, at the 
same time, raise as much of a capsulo periosteal covering as possible. This 
anterior flap is dissected and retracted upward to the joint-line. The anterior 
lateral and posterior ligaments of the joint are now cut in order. The triceps 
and any remaining posterior tissues are sev- 
ered. The radial, ulnar, interosseous, mus 
cular branches, and, possibly, the posterior 
ulnar recurrent and terminations of the su- 
perior and inferior profunda are ligated. 
Quilt the muscles in the anterior flap to the 
fascia along the margins of the upper half of 
the ellipse. Suture the integumentary tis- 
sues of the convex lower end of the flap into 
those of the upper concavity. Temporary' 
drainage is indicated. 

Comment. — After the integuments are 
incised, the muscles are sometimes, though 
less satisfactorily, cut by thru.sting a long 
knife through the Hmb opposite the anterior 
aspect of the joint and cutting from within 
outward on a line with the retracted skin. 



DISARTICULATION OF ELBOW- JOINT 

BY POSTERIOR ELl.lPSK. 

Description. — The covering is, practi- 
cally, a posterior flajD — the idea of the el]ij)se 
being seen in a lateral view of the incision. 

Position. — Given in the course of the 
operation. 

Landmarks. — Joint-line; ti]) of olecranon. 

Incision. — The highest point of the elli))se is anterior, opjwsite the lower 
margin of the joint-line. The lowest part is posterior, between 8 and to cm. 
(3 and 4 inches) below the joint-line. Midway between the upper and lower 
rounded ends of the ellipse, the lateral borders of the ellipse i)ass along the 
mid-lateral aspects of the forearm. With the elbow flexed to an angle of 
135 degrees, the lateral parts of the incision will be parallel with the prolonged 
anterior aspect of the arm (Fig. 265). 

Operation. — The surgeon stands on the right of either elbow, grasping 
the patient's wrist with his left hand (the back of his hand uppermost and 
his thumb toward the patient's fingers), and manipulates the elbow so as 
to complete the incision at one sweej) — beginning the incision at the anterior 
joint-line with the elbow flexed at the above angle — jKissing down the inner 
aspect (while that part is manipulated so as to render it ])rominenl) — crossing 




Kig. 2fa. - DlSAKI ICII.AI ION AT Fl- 

nowjoiM ;— By aiUerior ellipse. 



3i6 



AMPUTATIONS. 



the dorsal aspect (while the forearm is held vertical) — ascending the outer 
aspect (while that aspect is made prominent) — to the place of beginning. 
Upon the line of the retracted integuments, the deeper parts are now cut. 
Those along the posterior aspect of the ellipse are divided, together with 
the periosteum, and including the anconeus, and insertion of the triceps when 
reached, and are dissected up to just above the tip of the olecranon. The 
deeper parts along the anterior portion of the ellipse are then divided, corre- 
sponding with the joint-line, and the capsule of the joint divided transversely, 
followed by division of the lateral ligaments and posterior portion of the 
capsule (unless a capsulo periosteal covering can be raised). Tie the brachial, 
posterior interosseous, muscular branches and terminations of the superior 

and inferior profunda. Cut the ulnar nerve 
especially short. Quilt the muscles in the 
posterior flap to the fascia along the mar- 
gins of the upper half of the eUipse. Drain 
temporarily. Suture the integuments of the 
lower portion of the ellipse (the convexity) of 
the posterior flap, to the upper concavity of 
the incision. 

Comment. — Transfixion of the lower 
part of the posterior flap is even less advisable 
than transfixion in the anterior ellipse — as, in 
the former case, the bone is almost subcu- 
taneous. 




Fip. :65. — DiSARiicii ATioN at 
lu.Bow :— By po^lei lor tllif)se. 



DISARTICULATION OF ELBOW-JOINT 

BV LONG ANTERO INTERNAL AND SHORT POS- 
TERO-EXTERNAL FLAPS. 

Description.— .A. method of unequal lat- 
eral flaps of skin and muscles — the incisions 
themselves are lateral, the bulk of the mus- 
cles being antero-internal and postero-ex- 
ternal. 

Position. — The forearm is held in supi- 
nation during anterior incisions — and verti- 
cal during posterior incisions, or partly flexed. 
Landmarks. — H11k)\v joint-line; tip and ba.^e of olecranon. 
Incisions. — .Antero-internal incision — begins at center of anterior aspect 
of the joint-line- -passes obliquely downward and inward over the forearm, 
in such a way as to meet the mid-lateral as])cct of the forearm, on the ulnar 
side, at a distance of about 7.5 cm. (3 inches) below the joint-line — thence 
passes uf)ward and backward along a corresponding line to the base of the 
olecranon. Posteroexternal incision — a shorter incision but very similar to 
the longer, passes between the same points, crossing the mid-lateral aspect 
of the forearm, on the radial side, about 2.5 cm. (i inch) below the joint- 
line (Fig. 262, C). 

Operation. -.Mong the line of these retracted integuments the muscles 
are cut obliquely down to the bone — when they, and as much of the periosteum 
as possible, are dissected up to the joint line in front, and to the tip of the 
olecranon behind. The elbow is then flexed — the triceps is divided at its 



SURGK AL ANATUMV OF THE ARM. 



317 



attachment to the olecranon — and disarticulation completed by dividing the 
posterior, luierul and aiUcrior ligaments, in order. Tic the brachial, termina- 
tions of the superior and inferior profunda, and, possibly, some smnll muscular 
and articular branches. The large antero-tnternal Hap ioUh u\vr the articular 
end of the humerus —its muscles are to be quilted to those of the smaller tlap 
— and the inlegumcnls of the two tlaps sutured— placing the cicatrix upon 
the c3ctemo-ierminal aspect uf the joint. 



FIK- »66. — L»1SAI»TirUl ATION AT 

EtA^iW :— By long mitcrior rimI short 
pfl«lrriur flapii. 



Fig. 367. — DlSAHTrClKATtOK AT 

Ekhuw ;—!)>' long )Kisterior and short 
Anterior flaps. 



SURGICAL ANATOMY OF THE ARM. 

Bones.— Humerus. 
Muscles of the Arm. — (A) Anterior Humeral Region: — coracobrachialis, 
biceps, brachialis anticus. (B) Posterior Humeral Region: — triceps, sub- 
anconcus. (C) Muscles having their inscrtiims in upper portion of humerus: 
^-supras|>inatus, infraspinatus, teres minor, sulvscapularis, pectoralis major, 
Is&imuii dorsi, dehoid, teres major. (D) Muscles having their origin 
lower fjortion of humerus: — (a) From internal condyle and ridge: — 
pronator radii teres, flexor carpi radialis, palmaris Inngus. flexor carpi ulnaris, 
'$ublimis digitorum — (b) From e.vternal condyle and ridge :^supinator 
extensor carf)i radialis longior, extensor carpi radialis brevior, ex- 
communis digitorum, extensor minimi digiti, extensor caq>i ulnaris, 
anconeus, supinator brevis. 

Arteries of Humeral Region. — From Axillar>— acromial and humeral 
bnnche^ of acromial thoracic, subscapular, anterior circumflex, |K>sterior 
drcainflcz, and axillar>* itself. From Brachial: — superior profunda, nutrient, 



3l8 AMPUTATIONS. 

inferior profunda, anastomotica magna, muscular, and brachial itself. From 
Radial: — radial recurrent. From Ulnar:— anterior ulnar recurrent, posterior 
ulnar recurrent. 

Veins of Humeral Region. — Superficial: — cephalic, basilic. Deep: — 
two venai comites accompany each of above branches of main arteries, and 
also brachial artery. Axillary vein is formed by two brachial venae comites 
and basihc vein. 

Nerves of Humeral Region. — Anteriorly: — musculocutaneous, median, 
internal cutaneous, ulnar, lesser internal cutaneous, intercosto- humeral. 
Posteriorly : — circumflex, musculospinil. 



SURFACE FORM AND LANDMARKS OF THE ARM. 

The humerus is almost entirely covered by muscles, being subcutaneous 
only at the internal and external condyles. The greater and lesser tuber- 
osities and the head may be defined. The greater tuberosity hes just below 
the antero-external aspect of the acromion. The lesser tuberosity lies to the 
inner side of and below the greater, the bicijiital groove intervening. To 
feel the head of the lK)ne, a])duct the arm, when the head will project promi- 
nently into the axilla. 

The internal condyle and internal condyloid ridge, and external condyle 
and external condyloid ridge, can l)e felt just above the elbow-joint. The 
latter are more easily felt during semiflexion, as a depression between adjacent 
muscles. 

The greater tuberosity and external condyle are in the same straight line 
and face in the same direction. The head of the humerus and the internal 
condyle are also in the same straight line and likewise face in the same direc- 
tion. 

When the arm hangs by the side, the bicipital groove looks directly for- 
ward. 

The rough prominence uj)on the outer aspyect of the middle of the humerus, 
into which the deltoid is inserted, also marks the level of the insertion of the 
coracobrachiaUs and the origin of the brachiahs anticus — and also the 
entrance of the nutrient artery into the bone, and the level at which the 
musculospiral nerve and superior profunda artery cross the back of the bone. 

The upper epiphysis is horizontal and placed just above the surgical 
neck, joining the shaft at the twentieth year. 

The coracobrachialis and biceps above, and the biceps below, form the 
prominent muscular mass of the front of the arm. The brachialis anticus is 
discernible at the lower part of the arm, on each side of the biceps. 

The triceps determines the form of the back of the arm. The inner head 
is least distinct. The outer head forms the large prominence just below the 
posterior border of the deltoid. The long head emerges from between the 
teres major and minor and descends along the back of the arm. 

The supinator longus and extensor carpi radialis longior form a prom- 
inence on the outer side of the lower portion of the arm. 

Above the middle of the arm, the biceps, deltoid, coracobrachialis, and 
long head of triceps are more or less free and capable of retraction. Below 
the middle of the arm, the biceps is the only free muscle. It is for this reason 
that the circular method of amputation is suitable only to the lower half of 
the arm. 



AMPUTATION OF THE ARM, IN GENERAL. 



319 



and more nearly of one size throughout. In the muscular, it is less regular 
and more flattened laterally. 

On the inner and outer sides of the biceps are found the inner and outer 
bicipital furrows — the cephalic vein occupying the lutler— utid the brachial 
artcr>' and ba&iUc vein the former. 

The superior profunda artery arises just below the outlet of the axilla — 
the inferior profunda opposite the center of the shaft — and the anastomotica 
muigna about 5 cm, {2 inches) above the bend of the elbow. 

The skin is most retractile over the inner aspect oi the arm. 



I 



I 



GENERAL SURGICAL CONSIDERATIONS IN ARIPUTATIONS ABOUT 

THE ARM. 

The shortest stump of an arm, even an amputation at the surgical neck. 
is better than a shoulder-joint disarticulattofl — as such a slump will ordinarily 
be able to move an artificial limb. It is» therefore, desirable ti> retain as 
much of the humerus as possible, as leverage for the artifn ial limb. 

From the standpoint of the amimtator, the arm may be divided into two 
natural regitms— a lower third, more or less cylindrical, and where the muscles 
are largely attached to bone — and an ujjpcr two-thirds, more or less conical, 
flattened or irre^lar, and where the muscles are largely free and cafjabte 
of retraction. Therefore a circular methixl of amputation is preferable for 
the lower third, and a flap method for the upper two-ihirds. 

The surgical neck of the humerus marks the height at which a useful 
stump can be obtained, as the capsule extends down to its level internally. 
In amputating at the surgical neck, the bone is sawed between the luber 
tics, and insertions of the pectoralis major and teres major. The supra 
itus, infraspinatus, teres minor, and subscapularis are left attached to 
of the humenis. The bone is sawed Ijelow the epiphyseal line, 
synovial membrane of the joint (accompanying the biceps tendon) »s apt 
be o()ened on the inner aspect, where it is lowest. The bursa under the 
pularis tendon generally communicates with the joint and may be 
during the operation. As much of the attachment of the pectoralis 
jor, teres major, and latissimus dorsi as jjossible is raised with the pen- 
so as to be included in the musculo pjeri osteal covering of the end 
me and in the quilting of the muscles, in order to retain the attach- 
es of these muscles upon the stump and, therefore, their action upon 
ic artiticial hmb. 

In an amputation through the upper two-thirds by an anterior flap twice 
! m«i long as the p<»slerior, the scar will eventually be terminal, owing to the 
Bmuci) j^rcalcr retraction of the anterior parts — the biceps contracting most of 
Hiny muscle, A terminal cicatri.x is sought in the stumps of the arm. 
B The stump should be dressed upon a sjilint. 
H For control of hemorrhage in amputating at the shoulder joint, sec page 325. 




AHPUTAnON OF THE ARM, IN GENERAL. 

Best Methods.— Modified Circular— best for the lower third 
Anterior and Short Posterior Flaps — best for the upper two-thirds. 
fjitcmal Flap — best at the surgical neck. 

Other Methods. — Simple Circular (infundibular form). Single Anterior 



Iwong 
Single 




320 



AMPUTATIONS. 



Flap (Malgaigne's method). Anterior Ellipse (practically an anterior flap). 
Posterior Ellipse (practically a posterior flap). Lateral Flaps (of skin and 
muscles). Rectangular Flap (Teale's method). Oval Method (at the surgi- 
cal neck) 

AMPUTATION THROUGH THE LOWER THIRD OF THE ARM 

BY MODIFIKD CIRCl'LAR METHOD. 

Description. — Two short skin-flaps are cut and turned back, and l^rx< 
muscles divided circularlv in the infundibular manner. 




Fii,'. 2'.^.- .\Mri lAUiiSs iiiRr.rr.M Arm anp at Shoii.dkr :— A. Through lower part of ai 
by iiiMilifii*! lirciil.ir ; I'., l lirr.n.uli iipjxT jmit of .inn, by long anterior and sh<»rl i>ostcriur rt.i|t« ; C" 
At sbmiliifr jniiit. l^y «.Mi rnal lai ktl nuthixl i I.arri.-y's operation) ; I). I). Al shouhier. by external. o^ 

ddtoiil. fi.ip '. I>npii\tnii>. opiniticitii. 



Position. — Patient supine, at edpe of table; limb horizontally abducted 
over the edge of tai)le during anterior inci.sions, and held vertically, with 
bent elbow, or drawn over the chest, in dorsal incisions. Surgeon on CMltcr 



AMPUTATION OF THE UPPER TWO-THIRDS OF THE ARM, 321 

side of right and inner side of left limbs. Assistants steady the limb above 
and below the site of amputation. 

Landmarks.— Saw-line. 

Incision. — The lowest limit of the skin incision is placed at a distance 
l)elow the saw-line equal to three-fourths of the diameter of the limb at 
the saw-line (thus securing a covering of ij diameters). Of this total dis- 
tance the small flaps will occupy, appro.ximately, the lower one-third. These 
flaps are generally anterior and posterior (but may be lateral, or in any 
intermediate position, as the local conditions may demand). Their base is 
one-half the circumference of the limb — they pass down the lateral asi)ects 
of the limb to nearly their lower limit, when they bluntly round transversely 
across the limb to a corresponding point on the opposite side. The anterior 
and posterior flaps are similar (Fig. 208, A). 

Operation. — These flaps of skin and fascia are freed up to their base 
and turned back as culls. Here the more su])erlicial muscles are circularly 
divided, and retracted in turn. Ujjon the line of these retracted superficial 
muscles, the deeper muscles are cut to the bonc^at a level still beneath the 
saw-line. This last circular division also divides the periosteum aiound 
the entire bone. All the soft parts, including the periosteum, arc now freed 
up to the saw-line and the bone divided. Tie the brachial, superior pro- 
funda, inferior profunda, muscular, and possibly the anastomotica magna, 
branches. See that the musculospiral nerve is cleanly divided, and excise 
any portion of it apt to be pressed upon in iK'nding the flap over the end of 
bone. Suture the musculo periosteal covering. Quilt the muscles. Suture 
the flaps in a lateral line. 

Comment. — (1) The modified circular method makes it easier to free 
the bone of soft parts up to the saw line, and also furnishes a more sym- 
metrical terminal covering. If necessary, the skin-fla]js may represent one- 
half of the distance between the saw line and the lowest limit of the skin- 
incision. (2) The simple circular method (the infundibular form) may be 
done here in small limbs with llabby coverings — but would be difficult in 
large limbs with firm coverings. When the infundibular circular method is 
used, it should be an oblique circular, the circle dipj)ing lower on the antero- 
internal aspect of the arm, where, owing to greater retraction, it will be sub- 
sequently drawn up to the level with the outer part. 



AMPUTATION OF THE UPPER TWO-THIRDS OF THE ARM 

BY LONG ANTERIOR AND SHORT I'OSTl-.RIOR l-l.APS. 

Description. — Two U-shaped fla})s of skin and muscle are raised, the 
posterior being one-half the length of the anterior. 

Position. — As in the last operation. 

Landmarks. — Saw-li ne. 

Incisions. — The base of each flap equals one-half circumference at the 
saw-line. The length of the anterior flaj) is equivalent to one diameter at 
the saw-line. And the length of the posterior flap is one-half the diameter. 
Both are U -shaped flaps. Care is taken to place these flaps so that the brachial 
artery will not be apt to be split — the vessel should be in the posterior fla|) — 
and the points of junction of the two flaps on the inner and outer aspect of 
the arm should be so shifted toward the outer side as to make this certain. 
The arm is raised vertically while the posterior flap is being marked out 
and incised (Fig. 268, B). 



322 AMPUTATIONS. 

Operation. — Having incised skin and fascia along the above lines, the 
muscles are divided along the retracted integumentary coverings — cutting 
to the bone along the vertical limbs of the flaps, and cutting obliquely inward 
and upward along the rounded transverse endings of the flaps, in a bluntly 
beveled fashion — coming down upon the bone sufficiently far below the saw- 
line to provide a periosteal covering, which, with the muscles, is freed up to 
the saw line — and the bone divided. Care is taken to divide the musculo- 
spiral nerve evenly and short — as well as the nerves in the anterior flap which 
bend over the end of the bone, partially excising them if necessary. Tie the 
brachial, superior profunda, and inferior profunda, and muscular branches. 
Quilt the muscles of the anterior to those of the posterior flap — the former 
chiefly covering the end of the bone. Suture the skin margins of the flaps. 
The limbs should be steadied by a splint which also includes the shoulder. 



AMPUTATION OF ARM AT SURGICAL NECK 

BY SINGLK KXTKKNAL II.AP. 

Description. — A U-shaped llap, composed chiefly of deltoid, is raised 
from the outer aspect of the arm, while the parts on the inner aspect are 
divided transversely, or with slight downward convexity, on a level with the 
upper limit of the limbs of the flap. 

Position. — As in the above operations — the limb being drawn well away 
from the body, which will give access to l)oth outer and inner aspects. 

Landmarks. — Surgical neck of humerus (just below the tuberosities). 

Incisions. — Flap incision — the base of the fl;ip, which is U-shaped, is 
placed about 2.5 cm. (i inch) below the saw-line through the surgical neck — 
its width being equal to half the circumference of the limb at the flap's upper 
limit — its length being that of the diameter at the saw-line. The anterior 
limb of the flap passes down the mid-anterior aspect of the arm, and the 
posterior limb down the mid-posterior aspect. Inner incision — crosses the 
inner aspect of the arm, with a slight downward convexity, connecting the 
upper hmits of the vertical limbs of the flap (Fig. 269, B). 

Operation. — The above incisions pass, at first, through skin and fascia 
only. After the integuments have retracted, the external flap is cut from 
without inward, upon the line of the retracted tissues, beveling obliquely 
upward and inward toward the upper limit of the flap. The bleeding vessels 
in this external wound are clamped as met. The inner incision is now deep- 
ened — and the axillary vessels tied as encountered and before being cut — 
and the nerves cut short. The tendon of the pectoralis major is preserved, 
the periosteum l;eing divided below the bicipital groove and stripped up, 
including this tendon. Avoid opening the synovial sheath of the biceps 
tenrion, dividing it low down, together with the coracobrachialis. Detach 
the tendons of the lalissimus dorsi and teres major as subperiosteally as 
possible. Retract the outer flaj) and the parts on the inner aspect of the arm 
up to the saw-line — and divide the bone through the lowest part of the surgical 
neck possible, .\void the circumflex nerve and the posterior circumflex 
artery. The brachial artery will have been tied in the course of operation — 
branches of the anterior and posterior circumflex and muscular branches 
which have not been previously tied arc now taken up. Bring the outer 
flap across the end of the bone— (juilt the muscles of the flap to those divided 
in the inner incision — and suture the integumentary portion of the flap trans- 



SURGICAL CONSIDERATIONS IN SHOULDER DISARTICULATIONS. 325 

The center of the coraco-acromial ligament lies over the superior aspect 
of the shoulder-joint. 

The greater tuberosity of the humerus is felt externally — the lesser ante- 
riorly. To the former are attached the supraspinatus, infraspinatus, and 
teres minor, in order, from above downward. To the lesser — the subscapularis. 

With the arm by the side and the hand supine, the bicipital groove looks 
directly forward — the head of the humerus lying entirely to the outer side 
of the vertical hne from the coracoid process. The head of the humerus 
faces, practically, in the direction of the inner condyle — and the greater 
tuberosity in the direction of the outer condyle. 

The upper epiphysis of the humerus unites with the bone about the 
twentieth year — the inner part of the cartilage is within the capsule of the 
joint — the outer, anterior and po.sterior parts are subperiosteal. 

The surgical neck lies between the bases of the tuberosities and the inser- 
tions of the latissimus dorsi, teres major, and pectoralis major. 

The deltoid gives the rounded outline to the shoulder — and its insertion 
is marked by a depression on the outer aspect of the middle of the arm. 

The groove between the pectoralis major and deltoid contains the cephalic 
vein and the humeral branch of the acromio thoracic artery. 

The acromio-thoracic artery emerges from the upper border of the pec- 
toralis minor in the course of the brachial artery, where a line from near the 
junction of the third rib and its cartilage to the coracoid process crosses that 
vessel. 

The posterior circumflex artery and circumflex nerve cross the surgical 
neck of the humerus transversely about 1.3 cm. (\ inch) above the center 
of the vertical axis of the deltoid. 

The skin over the deltoid is thick, adherent, and little rctractile^that 
over the pectoralis major is fme and retractile. 

The dorsalis scapula; artery crosses the axillary border of the scapula 
opposite the center of the vertical axis of the rlcltoid. 



GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT 

SHOULDER-JOINT. 

Methods of Hemorrhage-control during operations near the Shoulder- 
joint: — (a) Wyeth's Shoulder Transfixion Pins, with tubular rubber Tourni- 
quet placed above them; — The anterior pin enters the middle of the anterior 
axillary fold, sHghtly to the inner side of the center of the fold — and emerges 
2.5 cm. (i inch) within the tip of the acromion |)rocess. The posterior pin 
enters the posterior axillary fold, at a point corresi)onding with the entrance 
of the anterior pin — and similarly emerges posteriorly 2.5 cm. (i inch) within 
the tip of the acromial process. Care is necessary to avoid striking the 
spine of the scapula with the posterior y)in. RuViber tubing of i.;^ cm. (^ 
inch) diameter is wound several times around the axilla, above the pins, and 
tied (Fig. 209, right shoulder), (b) Preliminary exposure and double ligation 
of the axillary artery, with division between the two ligatures (as in I>arrey's 
operation, page 329). (c) Digital compression of the main artery in the 
flap by an assistant, who grasps the part just prior to division of the artery 
(as in Spence's operation, page 327). (d) Hy Tourniquet and Pad: — A firm 
pad is placed in the a.xilla — over this are j>laced several turns of rubber 
tubing passing around the axilla — the enrls are then carried in a single 
figure-of-eight fashion over the clavicle of the same side, and thence across 



324 AMPUTATIONS. 

superior acromio-clavicular, inferior acromio-clavncular ligaments; inter- 
articular fibro-cartilage; synovial membrane, (b) Coraco-clavicular Union:— 
trapezoid and conoid ligaments, (c) Shoulder-joint: — capsular, glcno- 
humeral bands of capsular, coraco-humeral, glenoid and transverse humeral 
ligaments, and synovial membrane. 

Muscles Reinforcing Shoulder-joint. — Above: — supraspinatus. Be- 
low: — long head of triceps; an upward extension of p)ectoralis major. In- 
ternally: — subscapularis. Externally: — infraspinatus; teres minor. \\'itliin 
Joint: — long head of biceps. Surrounding Joint: — deltoid. 

Muscles in More or Less Direct Relation with Shoulder-joint.— (a) 
Anterior Thoracic Region: — pectoralis major, pectoralis minor, subclaxius. 
(b) Lateral Thoracic Region: — serratus magnus. (c) Acromial Region:— 
deltoid, (d) Anterior Scapular Region : — subscapularis. (e) Posterior Scapu- 
lar Region: — supraspinatus, infraspinatus, teres minor, teres major, (f) 
Muscles Passing from Shoulder to Arm Anteriorly: — bicej)s, coracobrachialis. 
(g) Muscles Passing from Shoulder to Arm Posteriorly: — triceps. 

Movements of Shoulder-joint. — Forward: — pectoralis major, anterior 
fibers of deltoid, coracol)rachialis, biceps (when elbow is flexed). Backward: 
— latissimus dorsi, teres major, posterior fibers of deltoid, triceps (when 
elbow is extended). Abduction: — deltoid, supraspinatus. Adduction:— 
subscapularis, pectoralis major, latissimus dorsi, teres major. Outward 
Rotation: — infraspinatus, teres minor. Inward Rotation: — subscapularis, 
latissimus dorsi, teres major, pectoralis major. 

Bursas in Neighborhood of Joint. — Beneath tendon of subscapularis 
— communicating with joint by opening on anterior side of capsule. Bieneath 
tendon of infraspinatus (sometimes present) — communicating with joint by 
opening on posterior aspect of capsule. Between under surface of deltoid 
and outer surface of capsule — not communicating with joint. Biceps tendon 
passes through the joint and is surrounded by tubular sheath continuous 
with synovial membrane. 

Arteries in Neighborhood of Shoulder-joint.— Suprascapular, trans- 
versalis colli, superior thoracic, acromial thoracic, long thoracic, alar thoracic, 
subscapular, anterior circumflex, posterior circumflex. 

Veins in Neighborhood of Shoulder-joint. — Two suprascapular, t\*o 
transversalis colli, superior thoracic, acromial thoracic, long thoracic, alar 
thoracic, subscapular, anterior circumflex, posterior circumflex, cephalic 

Nerves in Neighborhood of Shoulder-joint. — Acromial branch of 
cervical plexus, posterior thoracic, suprascapular, external anterior thoracic, 
internal anterior thoracic, upper subscapular, lower subscapular, middle 
subscapular, circumflex, — and following passing through axilla to arm and 
forearm; musculocutaneous, internal cutaneous, lesser internal cutaneous, 
median, ulnar, musculospiral. 



SURFACE FORM AND LANDMARKS OF SHOtlLDER-JOINT. 

To find the direction and position of the shoulder-joint — ha\nng fully 
abducted the arm, draw a slightly curved line from the middle of the coraco- 
acromial ligament, with convexity inward, to the innermost part of the head 
of the humerus felt in the axilla. 

The coracoid process is not actually within the infraclavicular fossa, but 
lies near the j)ectoro-deltoid groove, covered by the anterior fibers of the 
deltoid, and a little below the clavicle. 



SURGICAL CONSIDERATIONS lNSHOU]J>KR UISARTR LLATIONS. 325 



I 



The center of the cnraco-acrnmial ligament lies oAcr the superior aspect 
of the shoulder-joint. 

The greater tuberosity fjf the humerus is felt externally— lite lesser ante- 
riorly. To the former are attached the supraspinalu.s. infraspinatus^ and 
teres minor, in order, from above downward. I'o the lesser^the subscapularis. 

With the arm by the side and the hand supine, the bicipital groove looks 
directly forward — the head t;f the humerus lying entirely to the outer side 
of the vertical line from the coracoid process. The head of the humerus 
faces, practically, in the direction of the inner condyle^and the greater 
tuberosity in the direction of the outer condyle. 

The upper epiphysis of the humerus unites with the bone about the 
tvrentieth year — the inner part of the cartilage is within the capsule of the 
joint — the outer, anterior and posterior parts are subijeriostcab 

The surreal neck lies between the bases of the tuberosities and the inser- 
tions of the latissimus dorsi, teres major, and pecloralis major. 

The deltoid gives the rounded outline to the shoulder — and its insertion 
is marked by a depression on the outer as|>ect of the midtllc oil the arm. 

The groove l>elween the pectoralis major and deltoid contains the cephalic 
vein and the humeral branch of the acromio-thoracic arter\'. 

The acromio thoracic artery emerges from the upper border of the pec- 
toralis minor in the course of the brachial artery, where a line from near the 
junction of the third rib and its cartilage ti> the coracoid process crtisses that 
vessel. 

The posterior circumflex artery and circumflex ner^e cross the surgical 
neck of the humerus transversely about 1.3 cm. (i inch) above the center 
.of the vertical axis of the deltoid. 

The skin over the deltoid is thick, adherent, and Httle retractile — ^that 
the pectoralis major is fine and retractile. 

The dorsalis scapula.' artery crosses the axillary border of the scapula 
the center of the vertical axis of the deltoid. 



[GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT 

SHOULDER-JOINT, 
Methods of Hemorrhage-control (hiring operations near the Shoulder- 
Pjoint: — (a) Wyeth's Shoulder Tran.-.rixion Pins, with tubular rubber Tourni- 
quet placed above them;^The anterior pin enters the middle of the anterior 
axillary fold, slightly to the inner side of the center of the fold— antl emerges 
a. 5 cm. (i inch) within the tip of the acromion process. The posterior pin 
i enters the posterior axillar}' fold, at a point corresponding with the entrance 
of the anterior pin — and similarly emerges posteriorly 2.5 cm. {i inch) within 
the tip of the acromial process. Care is necessary to avoid striking the 
spine of the scapula with the posterior pin. Rubber tubing of 1.3 cm. (^ 
imeter is wound several times around the axilla, above the pins, and 
4 2og, right shoulder), (b) Preliminary exposure and doulde ligation 
ot ihc iixillary arten,*, with division between the two ligatures (as in Larrey's 
operation, page 329). (c) Digital compression of the main arter>' in the 
6ap by an assistant, who grasps the part just prior to division of the arler)' 
(as in Spcnce's operation, page 327). (d) By Tourniquet and Pad; — A firm 
Ifwd is placed in the axilla— over this are placed several turns of nibber 
pa.«<sing around the axilla— the ends are then crirrJcd in a single 
T-eight fashion over the clavicle of the same side, and thence across 



328 



AMPUTATIONS. 



glenoid cavity, by abducting and rotating the head of the humerus outward — 
the connection of the limb being maintained by the still unsevered tissues 
upon the inner aspect. (6) The surgeon grasps the disarticulated head with 




Fig. 270.— AMPfTATioNs I iiKdi f,u Arm AND AT Shoii C'KK ;— A. Tliroujjh tower arm. by oblique 
circular niclluxl ; B, At shoiikicr, by aiiUTii.r nukit nidhml iSpt-iices upcralitm) ; C, Of Upper limb, 
together with sraptila and part of >.!a\i<-lf. b> antoro-intVtior i ptctoro-axillarx ) and poslero-superior 
(ccrvicoscapular) Maps i Bt.T>;fis upcratioii-. 



the left hand and draws it outward from the trunk. As he does so, the first 
assistant, standing behind the shoulder, places the palm of the fingers of 
both hands against the axillary aspect of the still uncut inner tissues, and his 
thumbs, one from each side, between the neck of the bone and the tissues 



DISARTICULATION AT SHOULDER-JOINT. 329 

of the inner side, compressing the axillary vessels between the thumbs in the 
wound and the outspread fingers in the axilla — until he feels all circulation 
controlled. The surgeon now passes a long knife between the neck of the 
bone and the thumb-nails of his assistant, and, by a steady, sawing move- 
ment, cuts his way from within downward and outward, aiming to come out 
on a line with the retracted integuments along the original incision, along 
the inner limb of the racket. As the knife cuts its way out, the fingers of 
the assistant follow the blade closely, with the artery under his grasp. Just 
prior to the final passage of the knife, the tissues are tightly grasped and 
steadily held, until the knife emerges — when he presents to the surgeon the 
cut margin of the inner flap, with the vessels in easy evidence. (7) Tie the 
brachial artery at once, and the two brachial venaj comites and the basilic 
vein. In the vertical and external liml) of the racket, in incising and deepen- 
ing the wound, branches of the acromial thoracic, the anterior circumflex, 
and muscular branches are at first clam})ecl and subsequently tied. (8) The 
posterior circumflex nerve should not be injured. The nerves which are 
severed are cut short. (9) The margins of the capsulo-pcriosteal wound, 
w'here any appreciable periosteum has been saved, are sutured. The muscles 
are quilted by deep and sui)erficial tiers of buried catgut (chromic) sutures. 
Temporary drainage is provided. The integumentary edges of the wound 
are sutured in one vertical line. The stumj) should be snugly compressed 
against the thorax by the bandage. 

Comment. — (1) This operation is an illustration of the control of liemor- 
rhage by digital compression in the flap. (2) By saving as much of the 
attachment of the pectoralis major, latissimus dorsi and teres major, in the 
subperiosteal freeing of the humerus, connections in the stunij) are formed 
by these tendons and considerable range of movement is thereby added to 
an artificial limb. (3) The axillary vessels have been exposed where the 
inner limb of the racket crosses their course and ligatcd prior to disarticula- 
tion. (4) Where the deltoid tissues are very thick, this flap may be ad- 
vantageously thinned a Utile by making the incision of the outer limb of the 
racket in a beveling manner. (5) The more nearly the oj^eration is done 
subperiosteally, where no contraindication to the preservation of the peri- 
osteum exists, the greater the safety to the im})ortant tissues, especially the 
circumflex nerve and posterior circumflex artery. 



DISARTICULATION AT SHOULDER- JOINT 

BY EXTERNAL RACKET METHOD - LARREVS OPERATION. 

Description. — The queue of the incision is placed over the external 
aspect of the upper end of the humerus — from the center of this incision 
(which may first have been made for exi)loration of the joint alone) the two 
limbs of the racket diverge — encircling the anterior and posterior aspects 
of the arm and meeting on the inner side. 

Position. — As in Spence's operation (page 327). 

Landmarks. — Prominence of acromion. 

Incisions. — (1) Vertical incision — (arm being slightly abducted) begins 
immediately below the anterior aspect of the prominence of the acromion 
and passes thence vertically down the external asj)cct of the arm for 10 cm. 
(4 inches). (2) Oval incision— from the center of the vertical incision the 
two limbs of the oval, or racket, begin and pass obliquely downward over 



330 AMPUTATIONS. 

the anterior and posterior aspects of the limb, meeting upon its inner border 
on a level with the lowest part of the vertical incision (Fig. 268, C). 

Operation. — (i) The vertical incision passes at once through the deltoid 
directly to the bone and into the joint. The operation, which may have 
been begun as an exploratory one, may end with an investigation of the joint 
— or may proceed to an excision of the joint structures — or may end as an 
amputation. If the latter, the oval, or racket, incision, as above described, 
is added to the vertical incision. (2) The limbs of the racket are at first 
incised through skin and fascia only, and may be made at one stroke, or, 
better, by two. (3) The anterior limb of the racket is now deepened, while 
the arm is rotated outward — the incision passing through the anterior portion 
of the deltoid — the tendon of the pectoralis major is severed as near the 
bone as possible — the coracobrachialis and biceps are divided — and, next to 
these, the axillary vessels are encountered, carefully exposed and doubly 
ligatcd, beyond the posterior circumflex Ijranch. This flap is then freed 
up to the joint. For the same reasons mentioned under the last operation, 
the freeing of these flaps should be done as subperiosteally as possible. (4) 
The posterior limi) of the racket is similarly dee])ened, the arm being rotated 
inward — the incision ])assing through the posterior portion of the deltoid — 
and meeting the anterior limb ujxm the inner side of the arm. This flap 
is then also freed up to the joint as subperiosteally as possible. (5) Dis- 
articulation is accomplished (after severing close to the bone in the above 
freeing of the anterior and |)osterior flaps, the attachments of the supra- 
spinatus, infraspinatus, and teres minor to the great tuberosity, and the 
subscaj)ularis to the lesser) by cutting the capsule and the long head of the 
biceps against the head of the bone transversely. The head of the bone is 
now disarticulated and thrust u|)war(l. (6) To sever the remaining soft 
parts, the surgeon gras|)s the disarticulated head of the humerus with his 
left hand and draws it outward — then inserts a long knife between the neck 
of the bone and the remaining undivided parts, and. In* a sawing movement, 
cuts his way downward and outward 1 jet ween the severed axillar}- vessels 
and the bone, coming out on a line with the retracted inner limb of the racket 
incision (just as in the disarticulation by the anterior racket). (7) Besides 
the above named vessels, the anterior and j)ostcrior circumflex are both apt 
to be divided, as well as some muscular Ijranches. The circumflex nen*e is 
likely to be severed. All nerves are cut short. (8) The capsule is to be 
trimmed, if hanging in tags. Temjx^rary drainage is used. The capsulo- 
periosteal, or capsulo-muscular covering is sutured — the muscles quilted 
dee|)ly and superficially- -and the skin sutured in a vertical line. 

Comment. — This operation is an illustration of the control of hemor- 
rhage by the ligation of the main vessels in the line of incision, prior to dis- 
articulation. 

DISARTICULATION AT SHOULDER- JOINT 

F'.V rXTKRNAI. OR l)Kl,TOir> F1..\P. 

Description.- A U-shaped flap, consisting ])ractically of the deltoid 
muscle, is raised from the outer side of the shoulder — its upper limits being 
connected by a transversely curved incision across the inner aspect ofthe 
arm. 

PnRitinn_ — \< In "snpnrp'<; rniprntii^n ^n.ncrp ?->-^ 



INTERSCAPULO-THORACIC AMPUTATION. 331 

process, anteriorly, to the spine of the scapula at the root of the acromion 
posteriorly. In length, the flap extends nearly to the insertion of the deltoid. 
The upper extremities of the limbs of the flap are joined by a transversely 
cun^ed incision (with slight downward convexity) crossing the inner side 
of the arm about 5 cm. (2 inches) below the lower limit of the axilla. On 
the right side, the incision begins at the root of the acromion and ends at the 
coracoid, the arm having been placed across the chest. On the left side, 
the incision begins at the coracoid, with the arm abducted — and ends at the 
root of the acromion, with the arm across the chest. In both, the surgeon 
manipulates the limb with his left hand. This flap consists of the entire 
thickness of the deltoid at the base, while its margins are beveled. (Fig. 268, 
D, D.) 

Operation. — The entire length of the superficial incision outlining the 
flap is now dee])ened to the bone along the line of the retracted skin — cutting 
in a beveling fashion obliquely from without inward and from below upward. 
This mass of soft tissues is then raised from the bone, severing the attach- 
ments of the muscles of the great and less tul)erosities. The joint is now- 
opened by cutting directly down upon the capsule and long head of the biceps 
transversely against the head of the bone. The head of the bone is dis- 
articulated and thrust upward, and the operation completed as in Sj)ence's 
method of disarticulating — that is, the head of the bone is grasped and drawn 
outward — an assistant guarding the tissues of the inner flaj) as in the opera- 
tion just mentioned, a long knife is inserted V)Ctween the neck of the bone 
and the still undivided tissues upon the inner aspect and made to cut its way 
downward and outward on a line with the transversely curved portion of the 
incision connecting the upper limbs of the flap, thus severing the pectoralis 
major, latissimus dorsi, and teres major. Having ligated the vessels and 
cut the nerves short — the muscles are quilted — and the integumentary margin 
of the deltoid flap is sutured to the border of the short internal flap. 

Comment. — (i) This is the least desirable of the three methods of dis- 
articulation described. (2) Hemorrhage may be controlled by some form 
of tourniquet, or by the early ligation of the artery in the axilla. (3) An 
attempt may be made to save the circumflex nerve and the posterior circumflex 
artery — either by isolating and retracting them while incising from the skin 
downward in the posterior limb of the flap — or by approaching them from 
the anterior portion of the flap, working under the periosteum and then 
retracting them. 

AHPUTATION OF UPPER LIMB, TOGETHER WITH SCAPULA AND 

PART OF CLAVICLE, 

BY ANTERO-INFF.RFOR (OR ri-XTORO-AXILI.ARV) AND rrjSTKRn-Sri'ERIOR (OR 
CKRVICO-SCAITLAR) FLAPS — BF.RGKRS OF'FRAT[ON. 

Description. — Consists in the rcmt)val of the upper limb, together with 
the scapula and the outer two-thirds of the clavicle, en jjiussc, without dis- 
articulation at the shoulder-joint. 

Position. — Given in the steps of the operation. 

Landmarks. — Outline of clavicle; outline of scapula; line of shoulder- 
joint articulation. 

Operation. — (1) Subperiosteal Excision of middle third of Clavicle and 
double ligature and division of Subclavian .Artery and Vein: — Patient on 
back, at edge of table; shoulders raised; arm by side. Make an incision 
through the periosteum to bone, over the upper surface of the clavicle, from 



330 AMPUTATIONS. 

the anterior and posterior aspects of the limb, meeting upon its inner border 
on a level with the lowest part of the vertical incision (Fig. 268, C). 

Operation. — (i) The vertical incision passes at once through the deltoid 
directly to the bone and into the joint. The operation, which may have 
been begun as an exploratory one, may end with an investigation of the joint 
— or may proceed to an excision of the joint structures — or may end as an 
amputation. If the latter, the oval, or racket, incision, as above described, 
is added to the vertical incision. (2) The limbs of the racket are at first 
incised through skin and fascia only, and may be made at one stroke, or, 
better, by two. (3) The anterior limb of the racket is now deepened, while 
the arm is rotated outward — the incision passing through the anterior portion 
of the deltoid — the tendon of the pectoralis major is severed as near the 
bone as possible — the coracobrachialis and biceps are divided — and, next to 
these, the axillary vessels are encountered, carefully exposed and doubly 
ligated, beyond the posterior circumflex branch. This flap is then freed 
up to the joint. For the same reasons mentioned under the last operation, 
the freeing of these flaps should be done as subperiosteally as possible. (4) 
The posterior limb of the racket is similarly deepened, the arm being rotated 
inward — the incision passing through the posterior portion of the deltoid — 
and meeting the anterior limb upon the inner side of the arm. This flap 
is then also freed up to the joint as sul)j)eriosteally as possible. (5) Dis- 
articulation is accomplished (after severing close to the bone in the above 
freeing of the anterior and posterior flaps, the attachments of the supra- 
spinatus, infraspinatus, and teres minor to the great tuberosity, and the 
subscapularis to the lesser) by cutting the ca])sulc and the long head of the 
bice])s against the head of the bone transversely. The head of the bone is 
now disarticulated and thrust upward. (6) To sever the remaining soft 
parts, the surgeon grasj^s the disarticulated head of the humerus with his 
left hand and draws it outward — then inserts a long knife between the neck 
of the bone and the remaining undivided ])arts, and. by a sawing movement, 
cuts his way downward and outward between the severed axillary vessels 
and the bone, coming out on a line with the retracted inner limb of the racket 
incision (just as in the disarticulation by the anterior racket). (7) Besides 
the above-named vessels, the anterior and posterior circumflex are both apt 
to be divided, as well as some muscular liranches. The circumflex nerve is 
likely to be severed. AH nerves arc cut short. (8) The capsule is to be 
trimmed, if hanging in tags. Temfwrary drainage is used. The capsulo- 
periosteal, or capsulo-muscular covering is sutured — the muscles quilted 
deeply and superficially — and the skin sutured in a vertical line. 

Comment. — This operation is an illustration of the control of hemor- 
rhage by the ligation of the main vessels in the line of incision, prior to dis- 
articulation. 

DISARTICULATION AT SHOULDER- JOINT 

BV KXTHKNAI. OR DFTI/rOID FLAP. 

Description. — A U-shaped flap, consisting practically of the deltoid 
muscle, is raised from the outer side of the shoulder — its upper limits being 
connected by a transversely curved incision across the inner aspect of the 
arm. 

Position. — .\s in Spence's operation (page 327). 

Landmarks. — (^)racoid process of scapula; spine of scapula. 

Incision. — The base of this U-shaped flap extends from the coracoid 



INTERSCAPl'LfKTIIORACIC AMPLTATION. 



331 



|anleriorly. to the spine of the scapula al the mot of the acromion 

In length, the flap extends nearly to the insertion of the deltoid. 

Br extremities of the limbs of the tlap are joined by a transversely 

jcision (with slight downwarri c<»nvexity) crossing the inner side 

about 5 cm. (2 inches) bchiw the lower limit of the axilla. On 

tside, the incision begins at ihe root of the acromion anrl ends at the 

the arm having been placed across the chest. On the left side, 

pon begins at the coracoid, with the arm abducted— and ends at the 

lie acromion, with the arm across the chest. In both, the surgeon 

Ics ihe limb with his left hand. This flap consists of the entire 

I of the deltoid at die base, while its margins arc beveled. (Fig. 268, 

tion.— The entire length of the superficial incision outlining the 
IT dcei>ened to the l>one along the line of the retracted skin — cutting 
ng fashion ubhijuely from without Inward and frum below upward. 
of soft tissues is then raised from the bone, severing the attach- 
thc muscles of the great and less lu!x*rosities. The joint is now 
cutting directly down upon the capsule and long head of the biceps 
]y against the head of the bone. The head of the bone is dis- 
and thrust upward, and the uperation completed as in Spence's 
>f disarticulating — that is, the head of the bone is grasped and drawn 
—an assistant guarding the tissues of the inner flap as in the opera- 
i mentione<l. a long knife is inserted l>elwcen the neck of the bone 
^ill undivided tissues upon the inner aspect and made to cut its way 
rd and outward on a line with the transversely curved pjorlion of the 
connecting the upper limbs of the flap, thus severing the pectoralls 
fctissimus dorsi, and teres major. Having ligated the vessels and 
rrves short— ^the muscles are quilted — and the integumentary margin 
iltoid tlap is sutured to the border of the short internal flap. 
ment. — (i) This is the least desirable of the three methods of dis- 
on described. (2) Hemorrhage may be controlled by some form 
quet. or by the early ligation of the artery in the axilla. (J) An 
fiay be made to save the circumtlev nerve and the posterior circumflex 
Bther by isolating and refracting them while incising from the skin 
Ed in the posterior limb of the fla])— or by a(iproaching them from 
rior iKirlion of the flap, working under the periosteum and then 
5 them 

kllON OF UPPER LIMB, TOGETHER WITH SCAPULA AND 

PART OF CLAVICLE. 

BtO-lNFKRiOR roR fECTORO-AXfLLARV) AND POSTERO-StTERIOR (OR 
^ CEKVICa-SKTAPtTLAR) FLAPS- BF.RGERS OPERATION. 

ription. — Consists in the removal of the upper limb, together with 
lla and the outer two-thirds of the clavicle, en masse, without dis- 
on at the shoulder-joint. 

. — Given in the steps of the operation. 

'ks. — Outline of clavicle; outline of scapula; line of shoulder- 
ion. 

I, — (I) Subperiosteal Excision of middle third of Clavicle and 

and division of Subclavian Arter>' and \"cin: — Patient on 

of table; shoulders raiseil; arm by side. Make an incision 

e periosteum to bone, over the upper surface of the clavicle, from 




332 AMPUTATIONS. 

outer border of sternomastoid to just beyond the acromioclavicular articu- 
lation (Fig. 270, C, C, C). The vein from the cephalic to the external jugular 
is hereby cut and is doubly ligated. The periosteum is raised, with curved 
periosteal elevator, from around the entire circumference of the middle third 
of the clavicle. A chain or Gigli saw is passed between bone and periosteum 
and the clavicle is divided at the junction of its inner and middle thirds. 
The outer two-thirds of the clavicle is now grasped with lion-jaw forceps 
and drawn outward, during which outward traction whatever periosteum 
may remain is now detached from its middle third. The clavicle is then 
sawed at the junction of the middle and outer thirds, by a chain, Gigli, or 
small saw. The middle third of the clavicle is thereby removed. The 
periosteum over the subclavius muscle and the subclavius muscle are 
now divided transversely, opposite the inner section of the clavicle, and 
are dissected up and turned outward, thereby exposing the subclavian 
vessels, surrounded by more or less fascia. Having divided the over- 
lying fascia, the subclavian vein and then the arterj' are exposed. Both 
artery and vein are doubly ligated and divided opposite the lower 
border of the first ril) — the former Ijeing secured first (to lessen the 
amount of blood left in the limb). (2) Formation of Antero-inferior (or 
Pectoro-axillary) Flap: — Patient on back, with shoulder over edge of table; 
arm abducted; head to opposite side. Surgeon between arm and trunk. 
The incision begins at the middle of the clavicular incision — curves down- 
ward and outward, passing close to the outer side of the coracoid process — 
thence along the anterior jjortion of the deltoid, just external to the pectoro- 
deltoid groove, to the junction of the anterior axillary wall with the arm — 
thence across the lower border of the pectoralis major — thence transversely 
across the inner or axillary surface of the arm — to the lower borders of the 
tendons of the latissimus dorsi and teres major. Here the Hmb is elevated — 
and the incision is cauied downward and inward in the groove between 
the vertical border of the scapula and the muscular elevation formed by 
the teres major and latissimus dorsi, to end over the posterior surface of the 
inferior angle of the scapula. This incision passes, at first, through skin 
and fascia, and is then dcef)ened tiirough the pectoral and axillary tissues 
— the pectoralis major being cut where its tendinous portion commences — 
the pectoralis minor near the coracoid process — the l)rachial plexus near the 
first rib — the latissimus (h^rsi in the more posterior part of the line of incision 
— and whatever remaining axillary tissues bind the limb are cut as encoun- 
tered. The shoulder is thus freed from the trunk anteriorly — and tends to 
fall outward and backward. (3) Formation of the Postero-superior (or 
Cervico-scapular) Flap: — The patient is still supine, with shoulder over 
edge of table; the arm is now drawn across the chest to emphasize the scapular 
region. The surgeon stands to the outer side. The incision begins at the 
outer end of the clavicular incision, just external to the acromio-clavicular 
joint — passing thence backward over the spine of the scapula by the shortest 
route, to join the lower end of the antero-inferior flap incision over the inferior 
angle of the scapula. This incision at first involves only the skin and fascia, 
which are then well retracted along their upper part, thus ex^DOsing the trape- 
zius, which is now divided near its attachment to the clavicle and scapula, 
and thus severed from the whole limb. (4) Severing of Connections of 
Scapula to Trunk: — The patient lies as in the last step — and the surgeon 
stands to the inner side of the right and outer side of left limb. The anterior 
and posterior flaps are well retracted and the limb permitted to hang away 



SURGICAL ANATOMY OF THE TOES. 333 

from the side. The superior and vertical borders of the scapula are rendered 
prominent and are now freed by cutting the following muscles close to the 
bone, in order from above downward: omohyoid, levator anguli scapulae, 
rhomboideus minor, rhomboideus major, and serratus magnus. The upper 
extremity is now free from the trunk — the muscles arising from the scapula 
and inserted into the humerus (teres major and minor, subscapularis, supra- 
spinatus, and infraspinatus) are removed untouched with the limb. (5) Con- 
trol of Hemorrhage: — Preliminary ligation of the subclavian arterj' and vein 
control the chief hemorrhage. In forming the anterior flap, branches ol 
the acromio-thoracic, long thoracic and suijscapular are encountered. In 
forming the posterior flap, the muscular branches in the trapezius are met. 
In severing the scapula the chief bleeding occurs — the suprascapular artery 
is to be tied near the omohyoid as it is about to enter the supraspinous fossa 
— and the posterior sca])ular is to be tied near the u|j]>er angle of the scapula 
just after dividing the levator anguli sca])ulie. (6) Closure of the Wound: — 
All the nenes are divided short. Generally no suflScient redundancy of mus- 
cles is present to admit oi quilting, it usually being diflicult to approximate 
the edges of the wound — but. if it be possible, quilting of the muscles together 
with buried gut sutures should be done — to make a thicker stump-padding 
and to take the strain ofT the cutaneous sutures. The anterior and posterior 
flaps are brought together and suture*! in one oblique line, e.xtending from 
above, downward, outward, and l>ackward. To obliterate the dead spaces 
which tend to form in so extensive a wound. ci)nsiderable even pressure is 
applied in the dressings which Ijind the ])arts to the thorax. No drainage 
is indicated in simple cases. 

Comment. — (i) Sometimes the outer two-thirds of the clavicle is drawn 
outward and disarticulated at the acromion. (2) If the suprascapular and 
posterior scapular arteries are ligated through such a wound as is made 
in exposing the clavicle, at this stage, the chief Ijleeding of the whole operation 
will be avoided. The former is easily found. (3) One is apt to find toe 
scanty an allowance of flap covering, which is caused by not extending the 
oval parts of the incisions far enough t)ut over the shoulder. 



AHPUTATIONS AND DISARTICULATIONS OF THE LOWER 

EXTREMITY. 

SURGICAL ANATOMY OF THE TOES. 

Bones. — Third, second, anrl first Phalanges. 

Articulations and Ligaments.— (a) Second and Third Interphalangeal 
Joint: — Plantar; dorsal and two lateral ligaments. Extensor tendon rein 
forces dorsal aspect of joint, (b) First and .Second Interphalangeal Joint: — 
Same as last, (c) Metatarsophalangeal Joints: — Plantar (glenoid), dorsal. 
and two lateral ligaments. Extensor tendon reinforces dorsal asj)ect. 

Muscles. — See under Foot (page .^45). 

Sheaths of Flexor Tendons. — Tendons of flexor longus digitorum and 
flexor brevis digitorum. in their passage along the phalanges, are liound 
against the bones by fibrous sheaths attached to margins of jihalanges and 
forming osseo-aponeurotic canals lined by synovial membrane. They are 
strongest opposite the first and sec(jnd j)halanges, and weakest opposite 
the interphalangeal joints. 



334 AMPUTATIONS. 

Arteries. — Two dorsal digital, from dorsal interosseous and from dorsalis 
hallucis; two plantar from plantar digital and from princeps hallucis. 

Veins. — Superficial: — branches from the superficies of each toe. Deep: 
— accompany the digital arteries. Note — From the foot to the knee, two 
veins accompany each artery; from knee upward, one vein accompanies 
each artery, except at back of thigh and gluteal region, where there are gener- 
ally two. 

Nerves. — External saphenous; internal and external branches of musculo- 
cutaneous; internal branch of anterior tibial; digital branches of internal 
plantar; digital branches of external plantar. 



SURFACE FORM AND LANDMARKS OF TOES. 

Extensor tendons of four outer toes — the four tendons of the extensor 
longus digitorum, having been joined by the tendons of the extensor brevis 
digitorum (except that the latter muscle furnishes no tendon to the little 
toe) and by filjrous expansions from the interossei and lumbricales — all 
spread out into a broad aponeurosis, which covers the dorsum of the first 
phalanx and divides into three slips — the middle slip being inserted into 
the bases of the second phalanges of the four lesser toes — the two lateral 
slips, having united on the dorsum of the second phalanx, are inserted into 
the bases of the third phalanges of the four lesser toes. 

Extensor tendon of great toe — the innermost tendon of the extensor 
brevis digitorum is inserted into the tiorsal surface of the base of the first 
phalanx — blending with the tendon of the extensor proprius hallucis, which 
is inserted into the dorsal surface of the base of the last phalanx. 

Flexor tendons of four outer toes — the four tendons of the flexor brevis 
digitorum divide opposite the base of the first phalanges (for the passage of 
the tendon of the flexor longus digitorum) and then unite opposite the first 
phalanges to form a channel for the flexor longus digitorum — then divide — 
and are finally inserted into the sides of the middle of the second phalanges. 
The four tendons of the flexor longus digitorum are inserted into the bases 
of the plantar surfaces of the last ])halanges of the four lesser toes. 

Flexor tendons of great toe — the flexor brevis hallucis is inserted into 
the inner and outer sides of the plantar surface of the base of the first phalanx, 
a sesamoid bone being present in each of its two heads of insertion. The 
tendon of the flexor longus hallucis is inserted into the plantar surface of the 
base of the last phalanx. 

The flexor sheaths, which are not so distinct as in the fingers, have been 
given under Surgical Anatomy (page 333). 

The first interphalangeal joint of each toe is aliout opposite its middle. 

The knuckle of each phalangeal joint is formed by the head of the proximal 
bone — as in the hand. 

The joint-line of the interphalangeal and metatarso-phalangeal articula- 
tions is found l)y flexing the distal bone at a right angle to the proximal and 
extending the mid-lateral axis of the proximal bone — which will pass over 
the joint-line. 

The metatarsophalangeal joints follow, approximately, the curve of the 
toes and are about 2.5 cm. ( i inch) behind the webs. The metatarso-phalangeal 
articulation of the first and fifth toes is detectable by manipulation, and the 
line of the other joints then found hv making a curve between them about 



SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT TOES. 335 

The anterior, or glenoid, ligament occupies the plantar surface of the 
metatarso-phalangeal and the interphalangeal joints and is more firmly 
adherent to the base of the distal than to the head of the proximal bone. 
It is cut against the base of the former. 

The nail largely overlies the last phalanx. 

Each metatarsal has one epiphysis at ils head, uniting from the eighteenth 
to twentieth year — that of the great toe having it at its base, and uniting 
at the same time. Each phalanx has one epiphysis at its base — uniting 
from the seventeenth to eighteenth year. 



GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS AND 
DISARTICULATIONS ABOUT THE TOES. 

Many of the observations made concerning amj)utations and disarticula- 
tions about the fingers apply to ct)rresponding regions of the toes. But 
operations here, except about the great toe, are apt to be very irregular j)ro- 
ceedings, largely determined by circumstances. 

Minimum sacrifice of parts is indicated, often amounting to mere trim- 
mings — but this principle is not as ai)soiutcly necessary as in the fingers. 

Preser\'ation of the heads of the metatarsals increases the strength of 
the foot. 

If the base of the last phalanx be saved, all of the extensor and the deep 
flexor tendon (flexor longus digitorum) will be preserved. If the proximal 
half of the second phalanx l)e saved, part of the extensor and the su])erficial 
flexor (flexor brevis digitorum) tendon will be sa\ed. 

Presen-ation of parts of the great toe is much more imi)ortant than preser- 
vation of the four lesser toes. 

As the foot rests on the heel, heads of the metatarsals and inner margin 
of the sole, as much as possible of the anterior part of the foot and phalanges 
of the great toe is to be saved. 

It is important to .save the base of the first i>halanx of the great toe, owing 
to the number of muscles which are there inserted. If the base of the first 
phalanx cannot be saved, its many attached tendons should l)e removed as 
nearly subperiosteally as possible and be sutured into the tissues of the stumj). 

Except in the case of the great toe, a ])ortion of a toe is of little or no use; 
and, in the case of the four outer toes, a retained portion of a toe may be 
drawn permanently upward and thus l^e pressed against.' Therefore some 
surgeons remove the four outer toes at the metatarso-j)halangeal joint, if 
removed at all. 

The flexor sheaths should be closed as in the finger o[)erations (page 281). 

The flexor tendons should be so sutured as to secure their union to the 
stump, if it be \vished to retain their action. Hut, exce])t in the case of the 
great toe, this is much less imj>ortant than in the fingers. 

Musculo-periosteal coverings and capsiilo periosteal coverings in these 
small amputations and disarticulations are, theoretically, desirable, but, 
practically, difficult or impossible. 

Cicatrices should be planned not to fall in the sole, where they would 
be constantly exposed to pressure. The j)lanlar lla|>, therefore, is the best 
general type of amputation or disarticulation for the toes, bringing, as it 
does, the cicatrix upon the dorsum. 

In amputating by the plantar flap a slight downward convexity given to 
the transverse dorsal incision makes a better fit. 



SZ^ AMPUTATIONS. 



AMPUTATION THROUGH SECOND PHALANX OF TOES, IN GENERAL 

Best Method.— Plantar Flap. 
Other Method.— Oblique Circular. 



AMPUTATION THROUGH SECOND PHALANX OF TOES 

HV PLANTAR FLAP. 

Description. — The manner of performing this operation is sufl5ciently 
described in the amputation through the last phalanx (page 336), and the 
dimensions of the llap, under the disarticulation at the second interphalangeal 
joint (page 337). 

DISARTICULATION AT FIRST INTERPHALANGEAL JOINTS OF TOES, 

IN GENERAL. 
Best Method.— Oval Method. 
Other Methods.— Oblique Circular. Plantar Flap. 



DISARTICULATION AT FIRST INTERPHALANGEAL JOINTS OF TOES 

r.V 0\-AL MKTHOI). 

Description. — Queue of incision over dorsal aspect of joint — the limbs 
of the oval encircling the toe beyond the first interphalangeal joint-line. 

Position. — As in amj^ulating through the last phalanx. 

Landmarks.— First Interphalangeal joint. 

Incision. — The queue of the oval begins just above the head of the 
first phalanx, on its mid dorsal aspect jjasses vertically downward over 
the head of the phalanx, and continues down to near the middle of the first 
phalanx — where the two corre>])on(]ing limbs diverge to encircle the second 
phalanx and meet in the middle of its j)lantar aspect (Fig. 271, C). 

Operation. — Deejjen the dorsal incision to the extensor tendon. Extend 
the toe and dco[)en tlie oval to tiie bone, cutting the flexor tendons trans- 
versely. Dissect up the .M)ft parts upon the plantar and lateral aspects. 
Divide the glenoid (anterior) ligament by cutting against the base of the 
second j)halanx and opening the joint. Divide the lateral ligaments from 
within outward. Draw upon the toe and cut the e.xtensor tendon high up. 
Two plantar and two dorsal digital arteries are cut — the former may require 
ligation. Close the flexor sheath. Suture the wound vertically. The 
cicatrix will be vertical and dorso-tcrminal. 

Comment. — The head of tlie tirst phalanx may be removed, especially 
of the second and third toes — as it is large and mav be in the wav. 



AMPUTATION THROUGH FIRST PHALANGES OF TOES, IN GENERAL. 

Best Methods.— Oval ^lethod. Circular Method. 

Other Methods. — Oblique Circular. Equal Lateral. Single External 
Flap. 

Comparison. — The oval method allows readier access to the saw-line 
and the freeing of the soft parts to that line. The scar is dorso-terminal. 



AMPUTATION THROUGH FIRST PHALANX OF TOES. 



339 



The circular furnishes less easy approach, but leaves a smaller cicatrix, 
which, however, is terminal. 




Fig. 271.— Ampi'tations aboit i hi-: Toks and Foot :— A, At iiiter|ilialanKeal joint of great toe. 
by a single iiilf rnal Hap: H. At liist iihalaiiKial j..iiit. liv (.(iiial latrr;il ll.ipv ; C, ,\i first pIialaiiKcal 
joint, by oval method ; D, Through sccoikI i)halaiix. I>v ol)hi|iu' riicular ; !•;. At liisl phalangeal joint 
of little toe, by single external flap: l\ .\t itKtiitarso-phalatiiital joint ol littU- toe. hy externo-dorsal 
flap; G, At nietatarso-phalangeal joint, hy cnal nictlio.l ; II.. \t inctataiM)-ph;il.in>;eal joint of great 
loe, by interno-planlar flap ; I. Of \\\<> iiuier Utr^ .a taiso-nuiaiais.il joints. In racket method ; J, Of 
tor, with its entire metatarsid at larso-nietatarsjil joint, hy racktt nulhod. 



AMPUTATION THROUGH FIRST PHALANX OF TOES 

BY OVAL MMTHf^D. 

Description. — The operation is exactly .similar to that for disarticulation 
at the first interphalangeai joint just descrihcd — except that the queue 



340 AMPUTATIONS. 

begins just above the future saw-line, and the oval extends down the toe 
a distance that will make the covering furnished by the two lateral aspects 
of the oval about equal to i^ diameters of the toe at the saw-line. 



AMPUTATION THROUGH FIRST PHALANX OF TOES 

BY CIRCULAR METHOD. 

Description. — The covering is furnished by a circular division of all 
the soft parts down to the bone, with a vertical suturing of the covering. 

Position— Landmarks. — As for the toes in general. 

Incision. — A circular incision is made through skin and fascia around 
the toe at a distance below the saw-line equal to three-fourths of the diameter 
of the toe at the saw-line (to furnish a covering of i^ diameters) (Fig. 275, A, 
for principle, disregarding obliquity of incision). 

Operation. — Upon the level of the retracted integuments, the remaining 
soft parts are circularly divided to the bone — flexing the toe while cutting 
the dorsal, and extending it while cutting the plantar aspect. These are now 
retracted to the saw-line and the bone severed. The arteries divided are the 
same as in the last operation — and the flexor sheath is treated in the same 
manner. The cicatrix will be vertical and terminal. 



DISARTICULATION AT METATARSOPHALANGEAL JOINTS OF TOES. 

IN GENERAL. 

Best Methods. — Oval Method— best for the inside toes (second, third, 
and fourth). Intcrno-Plantar Fhij)— best for great toe. Externo- Dorsal 
Flap — be.-^t for little toe. Short Dorsal and Plantar Flaps — be.st for toes 
en masse at the metatarso-j)halangcal joints. 

Other Methods.— Lateral Flaps. Internal Flap— for great toe. Ex- 
ternal Flap — for little toe. Oval Flaj) — for great or little toe. Irregular 
Circular, with U-shaped flap for (ircat Toe (Dubrueil's method) — for toes 
en masse at the metatarsophalangeal joints. 



DISARTICULATION OF SECOND. THIRD, OR FOLTtTH TOES AT META- 
TARSO-PHALANGEAL JOINT 

PA' OV.\L MKTIIOD. 

Description. — Same, in principle, as disarticulation at first interphalangeal 
joint by the oval method. 

Position. — As for the toes in general (page 336). 

Landmarks. — Metatarsophalangeal joint. 

Incision. — The queue of the incision begins just above the head of the 
metatarsal, over its mid-dorsal aspect — passes downward in the median 
line until past the base of the first phalanx — the limbs of the oval now gradu- 
ally diverge to pass obliquely downward over the lateral aspects of the toes 
and cross the plantar surface transversely, meeting just in front of the line 
of the webs (Fig. 271, ()). 

Operation. — The vertical portion of the incision is deepened to the 
extensor tendon — the lateral portions are cut to the bone — the toe is extended 
and the plantar aspect cut transversely to the bone, thereby severing the 
flexor tendons high up. The soft parts are freed, partly by retraction and 



METATARSO-PHALANGEAL DISARTICULATION OF LITTLE TOE. 341 

partly by dissection, from the upper portion of the first phalanx to the joint- 
line, which lies about 2.5 cm. (i inch) above the web. The glenoid ligament 
is cut transversely against the base of the first phalanx and the joint opened. 
Disarticulation may be completed from below, but more conveniently by 
severing the extensor tendon and disarticulating from the dorsum, cutting 
the lateral ligaments from within outward, as the toe is rotated from side 
to side and disarticulation completed. Two dorsal and two plantar digital 
arteries are cut. The flexor sheath should be closed. The wound is sutured 
vertically — the scar becoming dorso-terminal. 



DISARTICULATION OF GREAT TOE AT METATARSOPHALANGEAL 

JOINT 

BY INTERNO PLANTAR FLAP — FARABEUF. 

Description. — A modification of the oval method, whereby the covering 
is gotten from the internal and plantar aspects of the great toe, and the cica- 
trix is brought well over to lie obliquely from the upper angle of the inter- 
digital web to the head of the metatarsal, and thus well removed from internal 
and terminal pressure. 

Position. — As for the toes in general (page 336). 

Landmarks. — Metatarsophalangeal joint-line; interdigital web. 

Incision. — Begins over the metatarso-phalangeal joint, at the junction 
of the dorsal and internal surfaces — passes vertically down the toe, in the 
line represented by the junction of these two surfaces (parallel with the 
extensor tendon), nearly to the head of the first phalanx — curves thence 
downward over the inner surface to the junction of the internal and plantar 
surfaces — passes thence obliquely across the plantar surface to the angle of 
the interdigital web — thence runs directly over the external and dorsal surfaces 
of the toe to the point of beginning, by the shortest route (Fig. 271, H). 

Operation. — This incision is now decj)ene(l to the bone in the same 
order as made, extending the toe while cutting the plantar and flexing while 
cutting the dorsal tissues. Free the soft parts up to the joint-line. Sever 
the glenoid ligament against the base of the first phalanx, thus opening the 
joint, and leaving the glenoid ligament and sesamoid bones in the stump. 
Divide the lateral ligaments and the extensor tendon. Two plantar and 
two dorsal digital arteries are cut and will probably require ligation. Close 
the flexor sheath. Include the cut flexor and extensor tendons in the tissues 
of the stump. Suture the internal and plantar portions of the oval to the 
straight incision from the interdigital web to the head of the metatarsal, 
which will represent the hne of the cicatrix. 

Comment. — If the vertical portion of the oval be placed directly over 
the mid-dorsal aspect (as in the corresponding operation upon the index- 
finger, page 291) a fuller covering will be gotten and the cicatrix will be 
more certainly protected. 



DISARTICULATION OF LITTLE TOE AT METATARSO-PHALANGEAL 

JOINT 

BY EXTERNO-DORSAL FLAP- FARABEUF. 

Description. — This is the reverse of the last operation — a modification 
of the oval method, whereby the covering is gotten from the external and 
dorsal aspectsof the little toe — and the cicatrix brought well over to lie obliquely 



342 AMPUTATIONS. 

from the upper angle of the interdigital web to the head of the metatarsal 

and thus well removed from external and terminal pressure. 

Position — Landmarks. — As in the last operation. 

Incision. — Begins over dorsal aspect of metatarso-phalangeal joint, ju^^ 
to inner side of extensor tendon — passes vertically down the inner maigv — ^ 
of the tendon to the end of the first phalanx — curves thence downward ai^ ' 
outward over the external aspect of the toe — thence obliquely across tt^^ 
plantar surface to the angle of the interdigital web — thence along the inte m^ajg 
aspect of the toe to the point of beginning, by the shortest route (Fig. 271, »•" 

Operation. — The steps of the operation are exactly similar to those c^^ 
the disarticulation of the metatarso-phalangeal joint of the great toe. Th- -* 
dorsal, external and part of the plantar portion of the oval are sutured to th^- ^ 
straight incision from the metatarso-phalangeal joint to the interdigital web^^ 
which will represent the line of cicatrix and be out of the way of pressure. 



DISARTICULATION OF TWO ADJOINING TOES AT HETATARSO 

PHALANGEAL JOINT 

BY OVAL METHOD. 

Description. — Same as the disarticulation of a single toe at the meta- 
tarso-phalangeal joint (page 340) — except that the queue of the oval is placed 
between the two toes, beginning a little higher above the metatarso-phalangeal 
joint-line — the two limbs of the oval diverging to encircle the outer and 
inner toes and meet at the margin of the web between the toes. Each toe 
is then freed up to the metatarso-phalangeal joint and disarticulated. The 
wound is sutured as a vertical cicatrix. 



DISARTICULATION OF ALL TOES EN MASSE AT HETATARSO- 
PHALANGEAL JOINT 

nV EQUAL SHORT DORSAL AND PLANTAR FLAPS. 

Description. — The covering is gotten equally from the dorsal and plantar 
surfaces and the scar is terminal. 

Position. — Patient supine; foot over edge of table. Surgeon grasps 
toes with left hand, with thumb on dorsum and fingers on plantar surface 
for dorsal incisions — and thumb on plantar and fingers on dorsum for plantar 
incisions — manipulating the foot as indicated. After the incisions are made, 
an assistant takes the toes and the surgeon manipulates the flaps. The 
surgeon stands for the dorsal and sits for the plantar incisions. 

Incisions. — (Supposing the left foot to be operated upon) — the dorsal 
incision (with foot extended and toes flexed) begins at the mid-lateral aspect 
of the metatarso-phalangeal joint of the great toe — passes vertically down 
the inner margin of the foot to the middle of the first phalanx — thence rounds 
broadly on to the dorsum of the foot and follows the line of the web, dipping 
in between the toes as they are separated, until the little toe is reached, when 
the incision again rounds broadly into the outer aspect of the foot and passes 
vertically up in the mid-lateral aspect to the metatarso-phalangeal joint. 
The i)lantar incision (with foot flexed and toes extended) passes transversely 
across the plantar surface of the foot, connecting the distal ends of the vertical 
limbs of the dorsal incision — beginning at a point where the vertical limb 
begins to round onto the dorsum, the plantar incision rounds onto the plantar 



METATARSOPHALANGEAL DISARTICULATION EN MASSE. 343 

surface at the middle of the first phalanx of the great toe, and thence follows 
the line of the web and creases of the toes, dipping in between the toes as they 
are separated, until the little toe is reached, when the incision rounds into 
the outer aspect and joins the dorsal incision at a point where the outer 
vertical limb began to round onto the dorsum (Fig. 272, A, A). 

Operation. — The dorsal incision is deepened to the extensor tendons 




Fir. 272.— Disarticulations abol'T thk Foot:— A. A. Of all the toes at mctatarso-phalanj^eal 
joints, by equal short dorsal and plantar tlap^ : B. R. Ui all the toe.-^ at larso-mtlatarsal joints, by 
short dorsal and Ioiir plantar Haps (Lisfraii ^up'.ratiun ». 



and freed half-way back to the joint-line, when the extensor tendons are cut 
transversely, each toe being prexiously forcibly flexed in turn. The flap of 
entire soft parts is then dissected back to the metatarsophalangeal joint-line. 
The plantar incision is now deepened to the flexor tendons and freed half-way 
back to the joint-hne, when the flexor tendons are cut transversely, each 
toe being previously forcibly extended in turn. The flap of entire soft |)arts 
is then dissected back to the metatarso phalangeal joint-line. Both flaps 
are well retracted to the general joint-line — the toes are flexed and the joints 
are opened from the dorsum and the lateral ligament? cut from within out- 
ward. The toes are then extended and the plantar ligaments are cut from 
the plantar surface, preserving the glenoid ligaments. The disarticulation 




344 AMPUTATIONS. 

of each toe is thus completed in turn. The flexor sheaths are dosed. T^c*^ 
plantar and two dorsal digital arteries for each toe are cut — the latter ma- "5* 
not require ligature. The dorsal and plantar flaps are sutured in one latere. "^ 
terminal line. 

Comment. — It is difficult to get covering for the large head of the 
metatarsal — special care is, therefore, given to procuring this covering 
keeping well in the mid-lateral aspect of the inner surface of the great to 
until quite to, or beyond, the middle of the first phalanx, before rounding 
into the dorsal and plantar surfaces. 



SURGICAL ANATOBJY OF THE FOOT. 

Bones. — Five metatarsals; seven tarsals (astragalus; os calcis; scaphoid;^- 
internal cuneiform; middle cuneiform; external cuneiform; cuboid). 

Articulations and Ligaments. — (A) Metatarso-Phalangeal Articula- 
tions: — See Surgical Anatomy of Toes, page 333. (B) Articulation of Meta- 
tarsals with each other: — Dorsal, plantar, transverse metatarsal, interosseous 
ligaments, and synovial membrane. (C) Articulations of Metatarsals with 
Tarsals: — dorsal, plantar, and interosseous ligaments, and synovial mem- 
brane. (D) Articulation of External Cuneiform and Cuboid: — dorsal, 
plantar, and interosseous ligaments, and synovial membrane. (£) Articu- 
lations of Internal, Middle, External Cuneiform bones with each other:— 
dorsal, plantar, and interosseous ligaments, and synoN-ial membrane. (F) 
Articulation of Scaphoid and Cuboid: — dorsal, plantar, and interossecnis 
ligaments, and synovial membrane. (G) Articulation of Scaphoid and 
three Cuneiform Bones: — dorsal and plantar ligaments, and s>'novial mem- 
brane. (H) Articulation of Astragalus and Scaphoid: — Superior astragalo- 
scaphoid ligament, and synovial membrane. (I) Articulation of Os Calcis 
and Scaphoid :— superior (or external) and inferior (or internal) calcaneo- 
scaphoid ligaments, and synovial membrane. (J) Articulation of Os Calcis 
and Cuboid: — (a) Dorsal — superior and internal (interosseous) ligaments; 
(b) Palmar — long calcaneocuboid (long plantar) and short calcaneo-cubdd 
(short plantar) ligaments. And synovial membrane. (K) Articulation of 
Os Calcis and Astragalus: — external, internal, and posterior calcaneo-astraga- 
loid, and interosseous ligaments, and synovial membrane. (L) Articulation 
of Tarsus with Bones of Leg: — See Surgical Anatomy of the Ankle, page 358. 

Anterior Annular Ligament. — Consists of two portions: — (a) Vertical 
(Superior) Portion: — Binds down extensor tendons to tibia and flbula. Con- 
tinuous with fascia of leg above, and extending from anterior border of tibia 
to anterior border of subcutaneous surface of fibula. Contains s>7iovial 
sheath for tendon of tibialis anticus. Following structures pass under it — 
extensor proprius hallucis, extensor longus digitorum, peroneus tertius, 
anterior tibial vessels and nerve, (b) Horizontal (Inferior, or Y-shaped) 
Portion: — Binds down extensor tendons to tarsus. Is connected with vertical 
portion, .\ttached. externally, to superior surface of os calcis, — anteriorly, 
to depression for interosseous ligament. It passes upward and inward in a 
superficial band (which runs in front of the peroneus tertius, extensor longus 
digitorum, and part of origin of extensor brevis digitorum), and a deep band 
(which runs behind these muscles). Having formed this loop containing 
the above muscles, surrounded by synovial membrane, these two bands 
unite and redivide into two limbs. The Upper Limb passes upward and 
inward to the internal malleolus — containing tibialis anticus muscle and itft 



SURGICAL ANATOMY OF THE FOOT. 345 

synovial sheath in its structure, but passing over extensor proprius hallucis 
and anterior tibial vessels and nerve. The Lower Limb passes downward 
and inward to the scaphoid and internal cuneiform — running over extensor 
proprius pollicis, tibialis anticus, and anterior tibial vessels and nerve. 

Internal Axinular Ligament. — Extends from inner malleolus above, 
to internal border of os calcis below, converting the grooves of this region 
into four canals, each lined by separated synovial membrane. The canals 
transmit, from within outward — tibialis posticus — flexor longus digitorum — 
posterior tibial vessels and nerve — flexor longus hallucis. It is continuous, 
above, with deep fascia of leg, and, below, with plantar fascia and origin of 
abductor hallucis. 

External Annular Ligament. — Extends from extremity of external 
malleolus to outer surface of os calcis. Binds down and transmits tendons 
of peroneus longus and brevis beneath the outer ankle, in one synovial sheath. 

Plantar Fascia. — (a) Central Portion: — Arises from internal tubercle 
of OS calcis, posterior to origin of flexor brevis digitorum — divides, near 
heads of metatarsals, into processes for each of five toes — which again sub- 
divide, opposite metatarsophalangeal joints, into superficial and deep por- 
tions. The superficial part is inserted into the transverse sulcus between 
sole and toes. The deep part redivides into two slips — which blend with 
flexor tendons and sheaths and transverse metatarsal ligament. Two vertical 
intermuscular septa are sent up by central portion — separating middle from 
external and from internal plantar groups of muscles, (b) Outer Lateral 
Portion: — From os calcis to base of fifth metatarsal — covering inferior surface 
of abductor minimi digiti — and continuous with central and dorsal fascia, 
(c) Inner Lateral Portion: — From internal annular ligament — covering 
abductor hallucis — and continuous with central and dorsal fascia. 

Muscles. — (a) Dorsal Region: — Extensor brevis digitorum; and muscles 
from leg (page 362). (b) Plantar Region: — First Layer — abductor hallucis, 
flexor brevis digitorum, abductor minimi digiti; — Second Layer — flexor ac- 
cessorius, four lumbricales; — Third Layer — flexor brevis hallucis, abductor 
obliquus hallucis, abductor transversus hallucis, flexor brevis minimi digiti; — 
Fourth Layer — four dorsal interossci, three plantar interossei. And muscles 
from leg (page 362). 

S3rnovial Membranes of Tarsal and Metatarsal Joints.— Synovial 
membranes exist for following joints; — posterior calcaneo-astragaloid joint; — 
anterior calcaneo-astragaloid and astragalo-navicular joints; — calcaneo- 
cuboid joint; — articulation of navicular with three cuneiforms, three cunei- 
forms with each other, external cuneiform with cuboid, middle and external 
cuneiform with bases of second and third metatarsals, lateral surfaces of 
second, third, and fourth metatarsals with each other; — internal cuneiform 
with metatarsal of great toe; — articulation of cuboid with fourth and fifth 
metatarsals; — (and sometimes the articulation of navicular with cuboid). 

Arteries. — Dorsalis pedis branch of anterior tibial, and following branches 
— external tarsal; internal tarsal; metatarsal and its three dorsal interosseous 
branches, with the latter's three posterior and three anterior perforating 
branches; dorsalis hallucis (or first dorsal interosseous); communicating (or 
plantar digital). Posterior tibial and following branches — anterior peroneal, 
posterior peroneal and external calcaneal branches of peroneal; internal 
calcaneal branch of posterior tibial; internal plantar branch of posterior 
tibial; external plantar branch of posterior tibial and following branches, 
three posterior perforating (between plantar arch and interosseous), four 
plantar digital, three anterior perforating (between digital and interosseous), 
princeps hallucis (fifth plantar digital). 



346 AMPUTATIONS. 

Veins. — Superficial — tributaries of internal (long) saphenous; tributaiies 
of external (short) saphenous. Deep — ti^'O venae comites for each artery. 

Nerves. — (a) From Lumbar Plexus — internal saphenous, (b) Froia 

Sacral Plexus — following from great sciatic; — external (short) saphenous 

posterior tibial and plantar cutaneous branch — internal plantar with cutanc— 
ous, muscular, articular, and four digital branches — external plantar, witia 
superficial and deep (or muscular) branches — anterior tibial, with extem.2*.- 
(or tarsal) branch and its three interosseous; internal branch (continuatic^'S 
of anterior tibial) and its interosseous branch; — and internal and extenL^s 
branches of musculocutaneous. 

Bursas About Foot. — These are variable — the following are genendiK.. 
present — (a) Above, or beneath, tendon of extensor proprius halluds, ov^^ 
instep, — (b) Between tendon of extensor longus digitorum and projectile— j 
end of astragalus (sometimes communicating with joint of head of astragalusj^ 
— (c) Between tendo Achillis and calcaneum, — And others may occur ov^^' 
any bony prominence. 



SURFACE FORM AND LANDBIARKS OF FOOT. 

Bony landmarks of dorsum — head of astragalus is felt on extension of 
foot, in front of ankle-joint. 

Bony landmarks of inner aspect of foot — internal tuberosity of os calds; 
sustentaculum tali (lesser process of os calcis), 2.5 cm., or 1 inch, below 
internal malleolus; tuberosity of scaphoid (2.5 to 3 cm., or i to i^ inches, in 
front of internal malleolus); internal cuneiform (but sHghtly); base of first 
metatarsal (obscurely); shaft of first metatarsal; head of first metatarsal; 
base of first phalanx of great toe; internal sesamoid bone. 

Bony landmarks of outer aspect of foot — outer tuberosity of os calds; 
greater part of outer surface and anterior end of os calcis; peroneal tubercle 
(when present) 2.5 cm., or i inch, below external malleolus; base of fifth 
metatarsal; shaft of fifth metatarsal; head of fifth metatarsal; base of first 
phalanx of little toe. 

Bony landmarks of plantar aspect of foot — inferior surface of os calcis; 
heads of metatarsals. 

Landmarks of medio-tarsal articulation — the joint-line runs transversely 
across the fool from the astragalo-scai)hoid articulation on the inner side, 
to the calcaneo-cul)()id articulation on the outer side. The astragalo-scaphoid 
joint lies just posterior to the prominent tuberosity of the scaphoid (forcibly 
extend the foot, when the interval between the tuberosity of the scaphoid 
and head of the astragalus will be evident). The calcaneo-cuboid joint lies 
midway between the external malleolus and the prominent base of the fifth 
metatarsal. 

Landmarks of the tarso-metatarsal articulation — the cubo-metatarsal 
joint (on the outer side) is found on a line with the base of the prcminent 
fifth metatarsal, and this serves as a guide to the remaining joints — ^the line 
of which runs obliquely forward toward the inner side of the foot, to a ]x>int 
about 2.5 cm., or i inch (extremes 3.8 to 4.5 cm., or i^ to 1} inches), below 
the posterior margin of the tuberosity of the scaphoid. Practically, the 
articulations of the fifth, fourth, third, and first metatarsals are in one line, 
while the line of the articulation of the second metatarsal with the middle 
cuneiform is from 7 mm. to 1.3 cm. (^ to ^ inch) above this oblique line. 
The tarsometatarsal articulation of the great toe can sometimes be felt as a 



SURGICAL CONSIDERATIONS IN F(X)T AMPUTATIONS. 347 

depression 3.8 to 4.5 cm. (i^ to if inches) anterior to the posterior margin 
of the tuberosity of the scaphoid, by pressure here while manipulating the 
toe — which would give an inner landmark to be used with the base of the 
fifth metatarsal on the outer aspect. 

Landmarks of the metatarsophalangeal articulations — about 2.5 cm. (i 
inch) behind the webs of the corresponding toes. 

Muscles and tendons more or less influencing surface form upon the 
dorsum of the foot, from within outward — tibialis anticus, extensor proprius 
hallucis, extensor longus digitorum, peroneus tertius — and, beneath these, 
extensor brevis digitorum and dorsal interossei. 

Muscles on sole of foot influencing surface form — abductor minimi digiti, 
abductor hallucis, flexor brevis digitorum. 



GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 

THE FOOT. 

Remove as little as possible of the metatarsals of the great and little toes 
as they largely support the weight of the body. 

Amputation of the toe, except the great toe, with part or all of its meta- 
tarsal, is of very little practical apj)licability. 

Scars should be kept from the j)lantar, internal, and external aspects of 
the foot. They should be at the end of the stumj) or dorsal. 

Plantar covering is the best form to |>rovi(le. 

In removing the metatarsal bones entirely, or in part, it is well to adopt 
the subperiosteal method as far as possible. 

There is an increasing tendency to regard the foot as a whole and to 
amputate regardless of joints. 

Sutures should remain in the thick, hard skin of the sole extra long. 

Temporary drainage is indicated when large joint-surfaces are opened up. 

Stumps should remain out from under the bed-covering when dressed. 

Patients should lie j)art of the time on their side, or flex the knee, to allow 
of drainage from the angles of wounds, if any fluid accumulate. 

If drainage be necessary, drain with two short tubes in either end of the 
wound. 

Amputation through the metatarsus is preferable to tarsometatarsal 
disarticulation, for, in the former, attachment of all the important muscles 
of the foot and all its movements are retained. 

Disarticulation at the tarso-metatar.sal joints (Lisfranc's operation) gives 
an excellent stump. Disarticulation at the medio-tarsal joints (Chopart's 
operation) gives a not altogether satisfactory result. 

Subastragaloid disarticulation gives a \ery good result, furnishing a 
long limb with ankle-movement. 

Syme's amputation (disarticulation at the ankle-joint) is generally con- 
sidered preferable to either Chopart's or Pirogoff's operation. 

In Lisfranc's and Chopart's oi)erations the uno{)])osed action of the calf 
muscles may permanently raise the heel. 



AHPUTATION OF TOES WITH PART OF THEIR METATARSALS. 

The amputation of the toes with part of their metatarsals is so similar. 
In aU essential details, to disarticulation of the toes with their entire meta- 



348 AMPUTATIONS. 

tarsals that the former will not be separately given (as was done in the case 
of the fingers). The best method of remo\4ng any of the toes with part oC 
their metatarsal, whether an inside toe or the great or little toe, is by €b/^^ 
racket method (see pages 350-352). The best method for the remo^ O^ 
two or three contiguous toes with parts of their metatarsals is by the ov^^^ 
operation (see page 353). The best methods, as well as other methoitf:^ 
for these partial operations, are the same as for the entire operations— an^^ 
will be given at the above references. 

The practical differences between the partial and complete operatioc^^ 

are — that the incision begins, in the former, just above the saw-line, instea 

of just above the tarso- metatarsal joint-line — and, instead of disarticulating^ 
the proximal end of the bone, it is sawed with a Gigli or chain saw. 

The amputation of all the toes with parts of their metatarsals will 
given. 



AMPUTATION OF ALL THE TOES THROUGH THE METATARSUS 

BY SHORT DORSAL AND LONG PLANTAR FLAPS (METATARSAL AMPUTATION). 

Description. — The height at which the amputation will be done will 
depend upon the nature of the cause and condition of the parts. The opera- 
tion resembles Lisfranc's disarticulation at the tarso-metatarsal joint. 

Position. — Patient supine; foot over edge of table. Surgeon op[>osite 
foot, standing while operating on dorsum, sitting while working upon plantar 
aspect — steadying the toes with his left fingers during the incisions, while 
assistant holds ankle; — and, as soon as incisions are made, assistant takes 
the toes, while the surgeon grasps the flaps with his left hand. 

Landmarks. — Saw-line (which is oblique, to be parallel with the ends 
of the metatarsals — its inner end being more anteriorly placed than its outer 
— the line running about parallel with the webs) ; interdigital webs. 

Incisions. — Plantar incision (supposing the metatarsals to be divided 
at their middle, in the case of the left foot) begins at the mid-lateral aspect 
of the inner side of the foot and just behind the saw-line — passes vertically 
down this side of the foot to the level of the crease between the sole and 
plantar surface of the great toe — thence rounds broadly into the sole and 
sweeps across the plantar aspect just behind and parallel with the web, to 
the crease between the sole and little toe — whence it rounds broadly into the 
mid-lateral aspect of the outer side of the foot and passes straight upward 
to just beyond the saw-line. Dorsal incision is made parallel with the plantar 
incision, and joins the vertical portion of that incision about 2.5 cm. (i inch) 
from their upper ends, rounding onto the dorsum (that is, the dorsal flap is 
about 2.5 cm., i inch long). The foot is flexed on the leg while the plantar 
incision is made and extended while the dorsal incision is made (Fig. 273, 
A, A). 

Operation. — The plantar incision is first deepened to the flexor tendons, 
is then dissected up a short distance and the flexor tendons divided trans- 
versely while the foot is forcibly flexed on the leg and toes extended on foot — 
thence upward to the saw-line, all soft parts down to the bone being raised 
in the plantar flap. The dorsal incision is now deepened to the extensor 
tendons, and dissected up a short way, when these tendons are divided truis- 
versely while the foot is forcibly extended on the leg and the toes flexed on 
the foot— thence upward to saw-line, all soft parts down to the bone " 
raised in the dorsal flap. Both flaps are now retracted — the boQCS I 



TARSOMETATARSAL DISARTICULATIONS. 



349 



of their interossei muscles — and each bone separately sawed with a fine saw. 
The following arteries are tied — six plantar digital (upon contiguous sides 
of the toes, and outer side of the little and inner side of the great toes), second, 
third, and fourth dorsal interossei, and first dorsal interosseous, or its three 
dorsal digital branches. The muscles are quilted, those of the dorsal to 
those of the plantar aspect — and the integumentary margins of the dorsal 




P"'K- 273.— Ampitations ABOiT I iiK FcK) T :— A. A. Amputation of all the toes ihrouKh the meta- 
tarsus, by short dors;il .nrid Umn jilaiitiir Hajjs (metatar>al ainputaliuti 1 ; B, B. Disarltculatioii of an- 
terior part of foot at mcdio-laisal joiiiih, b> short dorsal and lun^ |)lanlai (laps (fhoparts operation). 

and plantar flaps united in a transverse line. The slump is supported upon 
a splint. 

Comment. — If the division of the metatarsus is made nearer its base, 
the flaps will be pro])()rtionately shorter. The tlaps may also be made of 
equal length, or otherwise planned — according to available tissue. 



DISARTICULATION OF TOES WITH THEIR ENTIRE METATARSALS. 

Best Methods. — Racket — toes in general. Racket, with or without an 
additional transverse incision at ui)per end of queue — for great or little toe. 



35© AMPUTATIONS. 

Short Dorsal and Long Plantar Flaps (Lisfranc's Operation) — for the toes 
en masse. Short Dorsal and Long Plantar Flaps, with sawing oflF the end 
of the internal cuneiform (Hey's Operation) — for the toes en masse. 

Other Methods. — Internal Flap — for great toe. External Flap— foT 
little toe. Equal Plantar and Dorsal Flaps — for the toes en masse. Loofe 
Plantar Flap — for the toes en masse. 



DISARTICULATION OF TOE WITH ITS ENTIRE METATARSAL 

BV RACKET METHOD. 

Description. — The coverings are gotten from the lateral and plant-^^ 
aspects, and the cicatrix is vertical and dorso-terminal. 

Position. — As in the metatarsal amputation, page 348. 

Landmarks. — Tarsometatarsal joint; interdigital web. 

Incision. — Begins just above the tarso-metatarsal joint, in the midi:^ 
dorsal aspect — passes vertically down in the median line to the head of th -^ 
metatarsal — thence the two limbs of the oval diverge — the outer limb runnin^^ 
downward across the outer aspect of the toe to the web — the inner limt:^ 
across the inner aspect to the web — the two meeting in the digito-planta 
crease (which about corresponds to the center of the first phalanx) (Fig.^ 

271, J)- . 

Operation. — Deepen the vertical incision, dividing the extensor tendons 
as high up as encountered, while the toe is flexed. Deepen the oval incision 
to the bone, upon the lateral and plantar aspects, extending the toe while 
severing the flexor tendons transversely. Free the soft parts along the dorsum 
and lateral surfaces, with a periosteal elevator, hugging the bone closely. 
Forcibly extend the toe and its metatarsal and free the plantar surface as 
far as possible. Sever, from the dorsum, the ligaments binding the metatarsal 
to the tarsus and to the adjacent metatarsals, while the toe is being manipu- 
lated and the ligaments are put upon the stretch — thus completing the dis- 
articulation. Divide the flexor tendons high up and close the sheaths. Two 
dorsal and two plantar digital arteries are cut and are to be tied. Suture 
the wound in one vertical line. 

Comment. — (1) By hugging the bone very closely and guarding the point 
of the knife while disarticulating, minimum damage is done to the tissues 
of the sole of the' foot. (2) Disarticulation of the second toe from the tarsus 
and adjacent metatarsals is somewhat diflficult (see Lisfranc's operation). 

DISARTICULATION OF GREAT TOE WITH ITS ENTIRE METATARSAL 

BY RACKET METHOD. 

Description — Landmarks. — As in the last operation. 

Incision. — Begins just above the tarso- metatarsal joint, at its dorso- 
internal aspect — passes vertically downward along the outer margin of the 
extensor tendon to just beyond the center of the metatarsal — thence the two 
hmbs of the oval diverge — the outer limb passing across the dorso-extemal 
asj)ect of the toe to the web — the inner limb passing across the dorso-intemal 
aspect to the plantar surface at a point opposite the web — the two limbs 
meeting in the digito-plantar crease. If needed for purpose of exposing the 
joint more readily, an additional transverse incision may be added to the 
upi)er end of the vertical incision, running as far as thought necessary diitcUf 
inward j)arallel to the tarsometatarsal joint (Fig. 274, B). 

Operation. — Deepen the vertical incision, exposing and 



TARSOMETATARSAL DISARTICULATION OF GREAT TOE. 



351 



tendons of the extensor proprius and brevis hallucis near the tarso-metatarsal 
joint. Deepen the limbs of the oval, cutting to the bone along the lateral 
and plantar surfaces. Free, up to the tarso-metatarsal joint, the soft parts 
from the external, internal, and plantar surfaces of the metatarsal and phalanx 
by closely hugging the bones with periosteal elevator, rotating the toe as 
indicated. The sesamoid bones are left behind, and the structures about 
the metatarso-phalangeal joint are removed as nearly subcapsulo-periosteally 
as possible, in order to retain the attachment of the severed tendons there 
inserted. Open the tarso-metatarsal joint from the dorsum, completing the 
disarticulation by severing the remaining ligaments while under tension 




Fi^- 274.— Ampitations aboct thh Toks and Foot — Inner view : — A, At iiiterplialaiiKeal joint 
of KffiU loe, by plaiilai flap : l:. Ol jjreal loe ami its riniatarsal, al tai>o-iinialais:il joint, by rat. ket 
ini.-thu(l. with traiisvtTSi- iiu isum addod to iipi>ti tiid ; (". Iiiikt asjject of plantar and ilorsal incisions 
in Ssnie's disarticulation ot foot at ankle, h\ fu*cl-t1ap : <^'', I.ine of tibial ami lihular section ; I). Inner 
aspect of plantar anil <lorsal incisions, in f'iro;jofT s disarticiilaiimi at ankle. h\ lu-cl-flap ; D', l.iiu' of 
scctK>n of bones of kx, in same; I)". Line ot soi tioii <>f os calcis, in same ; K. Inner aspect of plantar 
and dorsal incisions in subastragaloid disarti( ulation of tVxjt, b\ heel (lap. 



during the manipulation of the toe. Divide the tendons of the peroneus 
longus and tibialis anticus. Cut the flexor tendons short and close their 
sheaths. The following arteries are divided — two dorsal digital, two plantar 
digital, and termination of internal plantar. Guard against wounding the 
communicating branch of the dorsalis pedis in the first interosseous space. 
The suture line will be vertical and fall over the dorso-external aspect of the 
toe, out of the way of pressure. 

Comment. — When the upper transverse incision is added, the vertical 
incision generally begins just below the tarso- metatarsal joint and the trans- 
verse incision is then parallel with the tarso-metatarsal joint. When the 
vertical incision alone is used, it begins over the internal cuneiform. 



352 



AMPUTATIONS. 



DISARTICULATION OF LITTLE TOE WITH ITS ENTIRE HETATAMAL 

BY RACKET METHOD. 

Description — ^Landmarks.— As in the last operation. 

Incision. — Begins just above the tarso-metatarsal joint at its dorso- 
external aspect — passes vertically downward along the outer margin of tY\^ 
extensor tendon to just beyond the center of the metatarsal — thence the fw <■ 
limbs of the oval diverge — the inner limb passing across the dorso-intem.^ 
aspect of the toe to the web — the outer limb passing across the dorso-exterrvs 
aspect of the plantar surface at a point opposite the web — the two lina'fc 




Fijf. J7.S.— AMPrTATioNS ABorxTHF. ToKS AND FooT— Oiiter view :— A, Throujth first inierph*- 
Inni^i-al joint ot little toe, by uhliqiit- tirrular method ; K, Oi little toe and its molatarsal. by racket 
nu-tluxl. with adtK'd ciirvi.-d iiaihicin at iippvr end ; (.'. Outer asi»eet of plantar ami dursal incision^, in 
Syme's disjirticulatiori o! UK>t at ankle, by a lieel-Hap ; C. Line of section throuKli tibia ami fibula, in 
same ; D, Outer ai<pect of plantar and doisiil inrisicMis. in I'iroK'^^'ii disartieulation at anklv : IV. Line 
ol section of tibia an<l I'lbula in s;ime ; I>". Line of section of os calcis, in same: E, Supramalleolar 
amputation of lej;. hy ohliijue elliptical incision: F.'. Tibial and fibular section in same; F, Outer 
asitecl of diMsal and plantar incisions in Subastragaloid Uisarticulatiun of foot by heel-flap. 



meeting in the digito-plantar groove. If needed for purpose of more readily 
exposing the joint, an additional transverse, or oblique, incision may be 
added to the upper end of the vertical incision, by prolonging the latter a 
short wav directlv outward parallel with the tarso-metatarsal joint (Fig. 

275. «)• ' 

Operation. — The steps of the operation are practically the same as in 
the corre>ponding ()j)eration upon the great toe (page 350). The metatarsal 
is di.^iarticulated from the cuboid and from the fourth metatarsal. Two 
dorsal and two plantar digital arteries are cut. 



TARSOMETATARSAL DISARTICULATION OF THE TOES. 353 



DISARTICULATION OF TWO OR THREE CONTIGUO 06 TOES WITH 
THEIR ENTIRE METATARSALS 

BY OVAL OR RACKET METHOD. 

Description. — Same, in principle, as the operation for the removal of 
a single toe and its metatarsiil (page 350). Where two contiguous toes are 
removed, the vertical portion of the incision is placed between the two toes, 
beginning just above the saw-line and diverging to include both toes — meeting 
on the plantar surface of the web between them. Where three contiguous 
toes are removed, the vertical portion of the incision is placed over the middle 
metatarsal, beginning at the saw-line, or just above, and diverging to include 
all three toes, meeting at the center of the plantar surface of the middle toe, 
in the digito-plantar crease (Fig. 271, I). 



DISARTICULATION OF ALL THE TOES AT TARSO-METATARSAL 

JOINTS 

BY SHORT DORSAL AND LONG PLANTAR F[,A1'S— LISFRANCS OPERATION. 



354 AMPUTATIONS. 

terosscous muscles. Deepen the plantar incision to the flexor tendons and free 
back the flap of superficial tissues to the hollow behind the heads of the meta- 
tarsals — and then diN-ide all the soft parts down to the bones, while the foot is 
fully flexed on the leg and the toes extended on the foot — and free the flap to» 
and verj' slightly above, the tarso-metatarsal joint-line. Both flaps contain all. 
the soft parts to the bones. Disarticulation is now accomplished from the dor- 
sum. Retract the flaps — extend the foot — and begin the disarticulation bvr 
entering the knife behind the prominent base of the fifth metatarsal, at theouto- 
side of the foot— and then, passing obliquely forward and inward, cut the 
peroneus brevis and tertius tendons and disarticulate the fifth, fourth, and third 
metatarsals. Then turn to the inner side of the foot, and sever the ligaments ©f 
the first tarso-metatarsal joint, and divide the expansion of the tibialis anticus- 
There remains the freeing of the second metatarsal, which is somewhat difi- 
cult, unless undertaken in a definite manner. Hold the knife like a dagger, 
with the cutting-edge toward the ankle, the blade pointing forward at an angte 
with the dorsum of the foot — enter the point deeply between the bases of 
first and second metatarsals, where they begin to bind — elevate the handle 
until perpendicular to the dorsum, cutting, at the same time, forward — ^and 
thus the ligaments binding the base of the second metatarsal to the base d 
the first metatarsal and internal cuneiform are severed (the mancemTe being 
called the "coup de maitre"). Repeat this manoeu\Te between the bases 
of the second and third metatarsals. Complete the disarticulation of the 
second metatarsal ])y severing, from the dorsum, the ligaments between 
the middle cuneiform and base of the metatarsal. Divide any connecting 
bands ui)on the plantar aspect of the joints. The peroneus longus tendon 
now alone holds the metatarsal — put this upon the stretch, diWding it hi^ 
up. The following arteries are to be tied — in the dorsal flap; four dor^ 
interosseous, communicating branch of dorsalis pedis; — in plantar flap; five 
plantar digital branches of external plantar (and possibly the external plantar 
itself) and the termination of the internal plantar. Suture any open sheaths. 
Quilt the muscles. Suture the plantar and dorsal flaps in one transverse 
line. Support the stump upon a splint. 

Comment. — (i) The plantar flap may be cut first. (2) The dorsal flap 
may be made and disarticulation accomplished, and then the plantar flap 
cut from within outward — which is not so satisfactory- as the above. (3) 
Freer allowance should be made to cover the thicker inner than the thinner 
outer side of the foot — which is the reason for cutting the inner aspect of the 
flap longer. (4) Guard against making the dorsal flap too short and too 
scant on the dorsal aspects — and also against making either flap too pointed. 
(5) Guard against mistaking the scapho-cuneiform joint for the metatarso- 
cuneiform joint. (6) Guard the plantar tissues while disarticulating the 
second metatarsal. (7) The dorsal flap should include most of the tissues 
upon the outer and inner aspect of the foot. (8) This method makes an 
excellent and useful stump. 

DISARTICULATION OF ALL THE TOES AT THE TARSO-METATARSAL 

JOINTS, VITH SAVING OFF OF END OF 

INTERNAL CUNEIFORM, 

RV SHORT DORSAL .VND LONG PLANTAR FLAPS- HEVS OPERATION. 

Description. — This operation is similar to Lisfranc's as to incisions, 
freeing of flaps, ligation of vessels and suturing of wound — difiTering onlv* 
in one respect — namely, after disarticulating the four outer metat* 



MEDIO-TARSAL DISARTICULATION OF FOOT. 355 

the protruding end of the innermost cuneiform is sawed off on a line with 
the others, and removed together with the first metatarsal still articulated. 



DISARTICULATION OF ANTERIOR PART OF FOOT AT MEDIO-TARSAL 

JOINT, IN GENERAL. 

Best Methods. — Short Dorsal and Long Plantar Flaps— Chopart's 
Operation. 

Other Methods. — Modified Oval (Tripier's Operation) — medio-tarsal 
disarticulation, with horizontal sawing of os calcis. 



DISARTICULATION OF ANTERIOR PART OF FOOT AT MEDIO-TARSAL 

JOINT 

BY SHORT DORSAL AND LONG PLANTAR FLAPS — CHOPART'S OPERATION. 

Description. — Disarticulation of anterior portion of foot at astragalo- 
scaphoid and calcaneocuboid joints, by means of a short dorsal and long 
plantar flap — the operation being somewhat similar to Lisfranc's tarso- 
metatarsal disarticulation. 

Position. — As for Lisfranc's operation. 

Landmarks. — Astragalo-scaphoid joint (just behind the tuberosity of 
the scaphoid) ; calcaneo-cuboid joint (midway between the external malleolus 
and tubercle of fifth metatarsal); tarsometatarsal joint-line; middle of meta- 
tarsus. 

Incisions. — (Right foot) — Plantar incision — begins on outer aspect of 
foot, little nearer plantar than dorsal surface, and at a point opposite the 
calcaneo-cuboid joint (see Landmarks)— passes straight down the outer side 
of foot to near middle of fifth metatarsal — thence rounds inward and crosses 
sole of foot, opposite the middle of the metatarsals, to the inner side of the 
foot — rounds into the inner border of the foot and passes straight up that 
border, little nearer the plantar than dorsal surface, to a point opposite the 
astragalo-scaphoid joint (see Landmarks). Dorsal incision — begins by 
cur\'ing from the outer limb of the plantar incision, just posterior to the fifth 
tarso-metatarsal joint — and ends Ijy cur\'ing into the inner limb of the plantar 
incision just posterior to the first tarsometatarsal joint — crossing the dorsum 
opposite the bases of the metatarsals (Fig. 273, B, B). 

Operation. — Deepen the plantar incision, the foot flexed on the leg 
and the toes extended on the foot, to the flexor tendons. Free the skin and 
fascia a short distance — divide all soft parts to the bones — and dissect up 
the flap of the entire soft parts to the medio-tarsal joint. Deepen the dorsal 
incision, the foot extended on the leg and the toes flexed on the foot, to the 
extensor tendons. Free the skin and fascia a short distance— divide all 
the soft parts to the bones — and dissect uj) the flap of the entire soft tissues 
to the medio-tarsal joint. Disarticulate from tlie dorsum while the foot 
is forcibly extended — rotating the forepart of the foot outward while severing 
the ligaments of the astragalo-scaphoid joint, and inward while dividing 
those of the calcaneo-cuboid articulation. The tendons of the tibialis anticus 
and posticus, and peroneus tertius, brevis. and longus, are cut among the 
deeper structures. Quilt the muscular and tendinous tissues of the two 
flaps, especially suturing the extensor tendons and tibialis anticus of the 
dorsal flap, to the tissues of the plantar flap — in order to counteract the 



35^ AMPUTATIONS. 

tendency of the tendo Achillis to permanently extend the fooL In the dorsal 
flap, the dorsalis p)edis and its tarsal and metatarsal branches are cut — and 
in the plantar flap, the terminations of external and intenial plantar arteries, 
and plantar digital branches. 

Comment. — ^i) Considerable lendencA- exists for displacement of the 
bones of the slump subsequent to heahng — either the posterior portion of 
the i>s calcis being drawn up by the tendo Achillis. thus throwing the head 
oi the OS calcis downward to be pressed upon in walking — or the stump is 
turned into the varus position and the patient walks upon the outer border 
of the i^ calcis. (2) The proportionate lengths of the flaps and the manner 
of their making may be varied, as described in Lisfranc's operation. The 
total covering required is about ij diameters at the saw-line. 



DISARTICULATION OF FOOT AT ASTRAGALO-SCAPHOID AND AS- 

TRAGALO-CALCANEAL ARTICULATI(»?S-SUBASTFAGALOID 

DISARTICULATION— Df GENERAL. 

Best Methods. — Large I n:eiT:c»- plantar Flap «Farabeuf«. Heel-flap. 

Other Methods. — C>val. or Racket Me:hc»d '.Maurice Perrin). Oval 
Method tVemeuil^ 

Comparison. — The ir/.err.o phr.tar r.sp luinishes the best blood-supply 
— the cicatrix is well : ij;e>i ar.<i :he st-rr.p is Virovi'i. Bui the method requires 
considerable heahhy. j.v:iL:alie i:f>-c — :r.e « r-e.-a^ion is somewhat difficult 
to j^erform — and the r:ap :> ?-:n:c.vr.i: ur.v^ieiiy. The heel-flap method is 
a simpler oi^eraiion anc recuiret-^ rrlrlir.in lissiie — but gives a narrower 
siumi^. 



DISARTICLXATION OF FOOT AT ASTRAG.^LOSCAPHOID AND AS- 

TRAG.\LO-C\LC\NE.\L TOINTS-SUBASTRAGALOID DIS- 

.\RTICULATION 

Fv : An -f :nt?5.n-:-? : antan :-la? — fajlxfeit 

Description. — A n.>.«::r.ei oval n:e:ho.i. The siructures below the 
astr.icalus .^re rcn. -e: — :he s:-r..p -c:-^ ::vere»i by a large flap gotten 
trvMv. The Sr > ar : :":<:r V* rior c: :he : • :— :he scar b«eing horizontal and 
uixM'i the vn::«:r .iri A":cri- r ^>:yr\:f :r :"e ::•::. 

Position.- Ai^ :- :he :rt:e::! .: v:>?r.:: r.f. :n general — the surgeon so 
mar.ipul.i::: c :he : > : '.v::h hf '.e:: har.i as :c turn :: from ade to side in 
lolK^\vi;:i; the con:: h.^i'itvi ir::-: •: 

Landmarks.— Te:. A :h /.".:>: e\:emal n:allevlas: base of fifth meta- 
lars;il; vin: Ixtween s:..: h i : ..: i ourei: ms. vjr.: line between scaphoid 
ami interna! anvi niii :!e .M-virVm-.f: :-".:-. «.: ev.enf^^r longus hallucis, 
cunev> nieta:a:^il > in: v : ': c '. ^. exTcmal :u'v^r.s:!y of c*s calcis. 

Incision. — He^:n> ..: -ter n-.rr.n -f :• 5<r.::n o: :envio .\chiUls — cur\'cs 
wpwanl :v> a ix^in: 2 ; .n: : -:h "rvo-v the evrema! malleolus — passes 
hiviAMU.ir.y iVrwarv: .1: th - '.^vt;. •.\.--.x. '^ :h the rcrcer of the fool, until 
a jx>»m is reavhevi vn .i hnt v. .r-e-jt.r^ the iMse c: the nith metatarsal with 
the i\nnts Ivtwesfr. the SvAV .: .m,: vTun:? t^mt hvnes — rhence curves sharply 
acnvss the olor^unt. ;ust antvr . r t.^ the . "t line b^rw^een ihe scaphcud with the 
intenulanvi n^Aki'e cunt- ::orn->- v.-t ". t^t t::- in v t the extensor longus hallucis 
is reached- thence cunes slightly t.r-Nari tc cress the imier border of the 



SUBASTRAGALOID DISARTICULATION OF FOOT. 



357 



foot in the line of the cuneo-metatarsal joint of great toe — thence sweeps 
across the center of the sole — and, curving into the outer border of the foot, 
follows that border to the external tuberosity of the os calcis — thence upward 
to end at the insertion of the tendo Achillis, at the point of beginning (Fig. 276). 
Operation. — The above incision is now everywhere deepened to the bone 
along the line of retracted skin and fascia, using a stout knife and cutting 
with force as the parts are put upon the stretch — cutting all tendons cleanly 
— and opening no joints. Now flex the leg upon the thigh, turn the knee 
inward, and press the inner side of the leg on the table, so that the outer 
side of the leg presents and the foot is beyond the edge and kept upon the 
stretch. Dissect up, cleanly from the bones, the outer dorsal portion of the 
flap, until the head of the astragalus is exposed in front and the tendo Achillis 




Fig. 276.— Sl-BASTRAGALOID DlSARTICn.ATlON OF FoOT BY LaRGB InTKRNO-PI.ANTAR FlAP 

(Farabei'f):— A, Omliiie of incision upon outer aspect o( foot; H, Outline of incision upon inner 
aspect. 



behind — divide the tendo Achillis — enter the astragalo-scaphoid joint on its 
dorsal aspect — keep the knife in the intenirticular line and cut backward 
between the astragalus and os calcis, passing beneath the tip of the external 
malleolus to the already cut tendo Achillis, severing all ligaments and everting 
the OS calcis as the ligaments are cut — until the under surface of the astragalus 
is free. The foot is further twisted into extreme varus, and the inner and 
under surfaces of the os calcis are bared, working from the inner toward 
the under and outer surfaces of the os calcis, by cutting with short strokes 
of a strong knife, and closely hugging the bone to avoid damaging important 
structures on the inner aspect, especially the vessels which supply the flap. 
By the time the externo-plantar border of the os calcis is reached, the dorsum 
of the foot will be looking downward. Free the skin from the posterior 
surface of the os calcis carefully so as not to score the integumentary parts. 
Sever any remaining connections. Cut the anterior and posterior tibial 



358 AMPUTATIONS. 

nerves high up. The following arteries are encountered, in the direction of 
the incision, and will require ligation — posterior peroneal, anterior peroneal* 
dorsalis i)edis, internal plantar and external plantar. Provide temporaix:- 
drainage, by puncturing the heel portion of the flap. Quilt the muscfc^s 
and tendons. Suture the flap in an external and anterior horizontal lin^ _ 
Dress the stump upon a posterior splint. 



DISARTICULATION OF FOOT AT ASTRAGALO-SCAPHOID AND 
TRAGALO-CALCANEAL JOINTS-SUBASTRAGAIjOID DIS- 
ARTICULATION 

BY HEEL FLAP. 

Description. — The structures removed are the same as in the abo"^" 
operation. In the present instance the coverings are furnished from the h< 
and sole tissues. The steps of the operation are very similar to those ""^ 
Syme's disarticulation of the foot at the ankle-joint. 

Position. — See Syme's operation (page 360). 

Landmarks. — External and internal malleoli. f 

Incisions. — Plantar incision — begins 1,3 cm. (^ inch) below the tip ^^^ 
the external malleolus — passes directly across the sole of the foot — and en^^ j 
2.5 cm. (i inch) below the posterior border of the internal malleolus. Dors-^^ 
incision — is U-shaped, connecting the upper ends of the plantar incision- 
curving across the dorsum on a level with the astragalo-scaphoid joint (Fig 
274, E, and Fig. 275, F). ^ 

Operation. — For the general steps of the operation, see Syme's di^' ^ 
articulation at the ankle-joint (page 360), which is similar in general priip ^ 
ciple, though dilTerent in detail. Deepen the incisions to the bones — disscc"^ 

t'ne lieel-flap backward and the dorsal flap upward — open the astragalo 

scaphoid joint from the dorsum and cut backward, disarticulating the astraga — 
luB from the os calcis. The extreme head of the astragalus may be sawec^ 
oiT. The operation is ctmcludcd as in Syme's — the same vessels being also^ 
ligated. 

Other Amputations About the Foot. — (1) Anterior Intertarsal Dis- 
articulation (Jaeger's Operation) — consists of a disarticulation between the 
three cuneiforms anteriorly, and the scaphoid posteriorly — the cuboid being 
sawed across in a line with the disarticulation. This would occupy a position 
between Lisfranc's tarsometatarsal disarticulation and Chopart's medio- 
tarsal disarticulation. (2) Am])utation Through the Posterior Tarsus — if 
soft parts cannot be gotten to cover Chopart's stump, the articular surfaces 
of the astragalus and os calcis are sawed off. (3) Subastragaloid Osteoplastic 
Amputation (Hancock's 0])cration) — the tuberosity of the os calcis is sawed 
off and applied to the lower surface of the astragalus, from which the articular 
cartilage has been removed. 



SURGICAL ANATOMY OF ANKLE-JOINT. 

Bones. — Tibia; fibula; astragalus. 

Articulations and Ligaments. — Anterior tibio-tarsal, posterior tibio- 
tarsal, external lateral (consisting of anterior astragalo-fibular, posterior 
astragalo- fibular, and middle calcaneo- fibular fasciculi), internal lateral (or 
deltoid) ligaments, and synovial membrane. 



SURGICAL CONSIDERATIONS IN ANKLE DISARTICULATIONS. 359 

Muscles. — See under Foot (page 345) and Leg (page 362). 

Movements of Ankle-joint. — Extension — by gastrocnemius, soleus, 
plantaris, tibialis posticus, peroneus longus, peroneus brevis, flexor longus 
digitorum, flexor longus hallucis. Flexion — by tibialis amicus, peroneus ter- 
tius, extensor longus digitorum, extensor proprius hallucis. Adduction — tibialis 
anticus, tibialis posticus. Abduction — Peroneus longus, peroneus brevis. 

Arteries. — Following branches of anterior tibial — internal and external 
malleolar and dorsalis pedis. Following branch of posterior tibial — internal 
calcaneal branch of posterior tibial: — and following branches of f)croneal 
branch of posterior tibial; anterior peroneal, posterior peroneal, and external 
calcaneal. 

Veins. — Superficial — internal saphenous and tributaries; external saphen- 
ous and tributaries. Deep — Two venic comites accompany each arter)'. 

Nerves. — From lumbar plexus — internal saphenous from anterior crural. 
From sacral plexus — following from great sciatic — external saphenous (from 
communicans poplitei and communicans peronei); plantar cutaneous, articu- 
lar, internal plantar and external plantar (from posterior tibial); articular, 
muscular and external (or tarsal) (from anterior tibial); and internal and 
external branches of musculocutaneous. 

Annular Ligaments.— See under Foot (page 344). 



SURFACE FORM AND LANDMARKS OF ANKLE-JOINT. 

The general feature of the ankle-joint is that of the prominently rounded 
superior surface of the astragalus received into the dome of the tibia, and 
bounded laterally by the descending malleoli. 

The line of the joint is transverse — crossing the front of the leg about 
r.3 cm. (i inch) above the tip of the internal malleolus. 

The external malleolus extends from 1.3 to 2 cm. (^ to f inch) lower than 
the internal — and is placed upon a plane about 1.3 cm. (^ inch) posterior 
to the internal malleolus. The external malleolus is opposite the center 
of the joint — the internal is in front of the center of the joint. The tip of the 
external malleolus is nearer the posterior border of the fibula, and the tip 
of the internal malleolus nearer the anterior border of the tibia. 

Chief structures about the ankle-joint — .Xnteriorly — (from within outward) 
tibialis anticus, extensor proprius hallucis, anterior tibia) artery, anterior 
tibial nerve, e.xtensor longus digitorum. peroneus tertius. Posteriorly — tendo 
Achillis. Internally — (from before backward) tibialis posticus, flexor longus 
digitorum, companion vein, posterior tibial artery, companion vein, posterior 
tibial nerve, flexor longus hallucis. Externally — (from before backward) 
peroneus brevis, peroneus longus, external calcaneal and termination of 
peroneal artery. 

The lower epiphysis of the tibia includes the articular surface and internal 
malleolus, and unites about the eighteenth year. The lower epiphysis of the 
fibula includes the articular surface and outer malleolus, and unites about 
the twentv-first year. 



GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATIONS AT 

ANKLE-JOINT. 

Great care should be taken of the blood supply to the heel tissues forming 
the stump — the chief vessels being the external calcaneal of the j)osterior 



360 AMPUTATIONS. 

peroneal, externally; and the internal calcaneal of the external plantax-^ 
internally. 

In section of the lower ends of the tibia and fibula most of the antoior 
and posterior tibio-fibular and interosseous ligaments are saved. 

A posterior splint is used in the dressing following disarticulation. 



DISARTICULATION OF FOOT AT ANKLE-JOINT, WITH REMOVAL O^ 
MALLEOLI AND ARTICULAR SURFACE OF 
TIBLA, IN GENERAL. 

Best Method. — Heel-flap — Syme's operation. ^^ 

Other Methods. — Modified Oval Method — Roux's operation. L**^^ 

Intemo-plantar Flap — Farabeuf's operation. Internal Lateral Flap. Mc^^^ 

fied External Racket. Dorsal Flap. 



DISARTICULATION OF FOOT AT ANKLE-JOINT, WITH REMOVAL C^ 
MALLEOLI AND ARTICULAR SURFACE OF TIBIA. 

BY HEEL FLAP -SYME'S OPERATION. 

Description. — As described in the title. 

Position. — Patient supine; foot elevated and over edge of table. A^^ 
sistant steadies leg with one hand and holds foot at right angle to leg b»*"^ 
grasping toes with other hand. Surgeon sits for plantar and stands fo^ 
dorsal incisions. 

Landmarks. — Outline of ankle-joint; malleoli. 

Incisions. — Plantar incision — begins at tip of external malleolus, on th^ 
right side (the surgeon's left palm resting on the instep, with forefinger an(^ 
thumb upon the malleoli) — passes vertically down the outer side of the foot,^* 
across the sole and vertically up the inner side of the foot to a point 1.3 cm. 
(^ inch) below the tip of the internal malleolus. This incision passes exactly 
at a right angle to the long axis of the foot, in a straight line between these 
two points — if inclined fon\'ard, the flap is very difficult to dissect from the 
OS calcis — if inclined backward, it is easier to separate but apt to form a 
scanty covering, with imperfect vascular supply. If the inner limb of the 
vertical incision passes up to the posterior border of the inner malleolus, 
the posterior tibial arter}' is more in danger of being divided before its bifurca- 
tion and the main branch of the flap, the internal calcaneal of the external 
plantar, lost. The above incision is made in two cuts, each from a malleolus 
to the center of the sole. Dorsal incision — (surgeon's left palm to sole, with 
thumb and first finger grasping the margins of the foot and extending it) — 
connects the upper ends of the plantar incision by an incision sweeping 
straight across the front of the ankle. The dorsal and plantar incisions are 
approximately at a right angle to each other (Fig. 274, C, C, and Fig. 275, 

C, C). 

Operation. — The plantar incision, made with a strong knife, passes 
directly and cleanly to the bone. The large heel-flap is freed from the os 
calcis as far as its tuberosities, partly by the use of the left thumb, partly 
by a stout knife cutting close to the bone. It is possible, but difficult and 
unadvisable, to entirely dissect and retract the heel-flap from the tuberosities 
and posterior surface of tlie os calcis, from the plantar wound. With the 



PIROGOFPS OPERATION. 361 

foot fully extended the dorsal incision is now made directly to the bone, 
cutting the tendons and ligaments cleanly. This incision cuts directly through 
the anterior Ugament of the ankle-joint and opens the articulation. The 
disarticulation is continued by cutting the lateral ligaments from within 
outward, and completed by similarly cutting the posterior ligament. The 
tendo Achillis is now cut. The foot is then drawn downward and forward 
and the posterior and lateral surfaces of the os calcis dissected free of the 
heel covering by working from behind downward and forward with short, 
close strokes of the knife while the parts are under tension. The malleoli 
are now closely cleared of their soft parts, hugging the bones and guarding 
the flaps. The soft parts are well retracted — and the tibia and fibula are 
sawed transversely at about 6 mm. (\ inch) above the inferior border of the 
tibia (which will remove the articular surface of the dome)— the malleoli 
being steadied by forceps during the sawing. Ligate the anterior tibial, 
external and internal plantar, and probably the external and internal malleolar 
of the anterior tibial, the anterior peroneal, internal malleolar of posterior 
tibial, and internal and external saphenous veins. Cut all nerves short, 
especially those of the heel-flap, which is bent over the ends of the sawed 
bones. Suture the heel flap to the dorsal incision — using tension-sutures 
in addition to coaptation-suturcs, if there be much strain upon the suture-line. 
Institute drainage through a counter-opening in the heel-flap, if indicated. 
So dress the part, with a posterior splint included, as to draw the heel-flap 
forward and upward. 

Comment. — (1) This is probably the best form of disarticulation about 
the ankle and usually furnishes a very satisfactory result. (2) It is advisable 
to free the os calcis subperiosteally, if possible — and also to leave the posterior 
epiphysis, in the young, in the flap. 



DISARTICULATION OF FOOT AT ANKLE-JOINT, WITH REMOVAL OF 

MALLEOLI, ARTICULAR SURFACE OF TIBIA, AND ANTERIOR 

PART OF OS CALaS.-IN GENERAL. 

Best Method,— Heel-flap— Pirogotl's operation. 

Other Methods.— Racket Method (Pusquier-LeFort)— racket from inner 
side, with horizontal division of calcancum. Watson's modification of Piro- 
goff's Heel-flap Method — sawing calcancum from plantar surface immediately 
after plantar incision. Sedilot's modification of PirogolT's operation — middle 
(internal) oval method, with ol)li(|ue sawing of calcancum. Others have 
sawed the os calcis in angular and curved directions. 



DISARTICULATION OF FOOT AT ANKLE-JOINT, WITH REMOVAL OF 

MALLEOLI, ARTICULAR SURFACE OF TIBIA, AND ANTERIOR 

PART OF OS CALCIS, 

P.V HKKL-FLAr-IMkOCOII-S OPKKATION. 

Description. — .\n intra-calcaneal osteoplastic amputation of the foot. 
The operation is very similar to Synie's, exce})t that the anterior and major 
portion of the os calcis is sawed olT and the remaining posterior portion, 
which is left in the heel-flap, is adjusted to the transversely sawed tibia and 
fibula. 

Position — Landmarks. — .\s in Syme's operation (page 360). 



InciskHts. — FhiTiVLT izL-'z^-^.c. riz^z f >:c — i>fc:r> -.sj zrjcicc to tbc 
Vy <A xJTjt eiusT-ii niii^je'.cj.i^ — :.tL^ier .erLiiiZy i »-n ibe it^ie skit ct ibc 

I- ; or- i ir.ih^ bek/»r i^zA i i-h -r. ii-ii:: :t Antcri-.c : :■ ibe :fj' « the imemal 
ic^Jkt'yi^ Tthiih pT/ir-i? ire i l:r.> i-'.'.eri.i- :; "Jiuie •:•:' Sv^ae's cccnncn . 
Imxt^'b ir.'ii-: '.'. — ir r«cirjeT. rLi: .t- re •: r.-tx: ih^: L?. i;ii=<< funbcr ck«"»m oo 
th* coTr-.T. *.:' -.he : . : -.r^r. c .«t^ S.-t s Fir. i-i. D. D'. D". aad Fig. 
275. D. Lr'. 1/ . 

Operation. — T-e^ L- i^i.r.- ire n-.iie ^n^ feerter.ei Lz the jAznt manner 
Slt ;' .Syr-.e.-; oper_:: r.. Tr.e hci^rl r_i: ir r.:: ireri ':^:«: :r.:c: ibe piastar 
^^i'.e <^/f the '^rr ^i.1 .:t .,u:*.e :o :i- tu'xrr -i:!f-. Tr.e i.ro.rJ :\Lli::-cc is accom- 
^/ii-rher: ar in 3»yn:,e -. Tr.e : • : :> : Li t-: .r. e -rrrr.e er:e->::r in-d ihe upper 
turiace of the '^>= cai-:- e:c>~e-:. ':.-*. :r.t :tr. - : A:h:llir r. : c--:i- The irhc4e 
of ihe '^/t '^I'ii hii vir.^ 'r*eer. fret-: t\ e; : ::i^ :• r:tri r :hlri. ihe fa-sr is applied 
<'v/;th the iV/i ;r. e?r.er.-:-..r. :-■ :r.e u: •.-er rurf- c : 'he >• -:2.Ici>. 1.5 to 2 cm. 
'\lf»\ ir.ih l/eh;r.c the i.~'.z:iz^.\i-. -i' : r:- :e *. ro~ :*-i- ~-^y 'i-biiq-jdy down- 
•AarO '^z.<\ for-'ar^: r rr. re rear-v •.cr-:;_l.y. ::. •.re e.r:er.c:e»i tc«?3ac<i of the 
i<Mt\j IT. a ;:r.e a V Mt : arailel v. ;:h the r .'. :-: r.ei heel :r.ci>i'3<; — all the 
Vfh ]/iir.- tM'ir^ '.aref^i!;. retra *e^: the v. ilc. c-^i-e iiHy the inner anerics. 
The lov-er er.'i- of the tihia ar.i hb-ila are then .'ree-i a-- in S\-n:e =■ aini are 
."ja'Ae*^] of: :r. the -<ir-.e rr.iinner. e:-. ett th^t. aftvr entenns the anierior surface 
of the }^,ne aUyjt 6 rr.rr.. i ir.^.h a'V've the infer: r S rder of the tibia, the 
-seaion i- -^j mufit that the -a v. entcrje- >-ten- r.y aS't:: :.; cm. i§ inch) 
hijfher than on the anterior -urf.: •_ t '-e t ..r..hc! v.^lth the section of the 
^alraneum,. Lizate the 5an^.e ve^-^^^h- „- en untere^i in Syme's operation. 
Cut the r.'.-rve- -h'.rt ar^i the i'-/:-e tc-ni n-. .Xt-r-roximate the sawed cal- 
f^TitUTTi to the -;i-.'.e': ti- i^— r^nd -jture the t-lantar f.aT- t- the dorsal indsion. 

Comment. — i; If tr.e -....ci er <:- ri the h'<ne <:>• n- t lie in g<x«d apposi- 
tion, a thin ?;li^e of ly^r.e n^.ay '■•<: fjr.r.er rent-ve^i with the saw where indicated 
-or the -urfares of t/'/ne rr.ay !x.- na:ie<: (t petered loeether. But when 
the ]tT<f\if:r 'al' 'jlaiion- are nta^ie the sun'a- es can generally Ve held in contact 
hy the -■.Tun'r.'^ t^/jether of the nhr<'U- tissue- si:rr< undine the sawed ends, 
with buried « hromif 'jlu\.. 2, The -tumj* thus sained is a little lonpner than 
in Syme':- ojKrration — the llap i- better noun>he<i. is tirmer. contains bone 
and ter.do .Vhiilis, an^l the m'Aement is greater. But the bone is apt to 
nerro~e. or l/ef.ome di.-r»la<-e<i. < r m,:y n<.i unite. The operation is more 
suitable to traumatir (a~e-. .\n artiricial limb is harder to fit. The method 
i.s, altr^'ether, not sui>erior to Symes. 



SURGICAL ANATOMY OF LEG. 

Bones. — Tibia; fibula. 

Articulations and Ligaments. — (sl) Superior Tibio-fibular -Articula- 
tion — antcrir)r and f>osterior superior tibio-fibular ligaments, and synovial 
membrane. Cb; Middle Tibiofibular .Articulation — interosseous membrane. 
(c) Inferif^r Tibif^-fibular Articulation — anterior and posterior inferior tibio- 
fibular and transverse ligaments, inferior interosseous membrane, and synovial 
membrane. 

Muscles. — (a) Anterior Tibiofibular Region: — tibialis anticus; extensor 
Dtmnins hallucis; extensor longus digitorum; peroneus tertius. (b) Posterior 

io-fibular Region: — (1) Superficial Muscles; — gastrocnemius, soleus, 
taris. (3) Deep Muscles: — popliteus, flexor longus halluds, flexor 



SURFACE FORM AND LANDMARKS OF LEG. 363 

longus digitorum, tibialis posticus, (c) Outer, or Fibular, Region: — peroneus 
longus, peroneus brevis. 

Arteries. — Following branches of popliteal — inferior muscular, inferior 
external articular, inferior internal articular. Anterior tibial and following 
branches — posterior recurrent tibial, superior fibular, anterior recurrent 
tibial, muscular, internal malleolar, external malleolar. Posterior tibial 
and following branches: — peroneal (with its muscular, nutrient, anterior 
peroneal, and communicating branches), muscular, nutrient, and communi- 
cating branches. 

Veins. — Sui)crficial — ^internal sa|)henous and tributaries — external saphe- 
nous and tributaries. Deep — Two vena: comilcs for each artery. 

Nerves. — (a) From lumbar plexus — (i) From anterior crural; posterior 
branch of internal cutaneous; long saj)hcnous branch and its branches, (b) 
From sacral plexus — (1) From great sciatic — anterior po[)Hteal and muscular 
branches; communicans poplitei. Posterior tibial and muscular branches. 
External popliteal (or perineal) and cutaneous branches. Anterior tibial 
and muscular branches. Musculocutaneous and muscular and cutaneous 
branches. 

SURFACE FORM AND LANDMARKS OF LEG. 

Following parts of the tibia are i>alpal)le — external tuberosity (more 
prominent); internal tuberosity (broader); tubercle; anterior border, or 
crest (for upper two-thirds); internal Ijordcr; internal surface (from tuberosity 
to malleolus); internal malleolus. 

Following parts of fil)ula are ])al])ablc — licad; lower part of external surface 
of shaft (between peroneus tertius, and peronei longus and brevis); external 
malleolus. 

The fibula is on a plane consideral^ly posterior to the tibia. 

No muscular libers are attached to the lower third of the tibia. 

The sharp crest of the tibia has l)ecome rounded in its lower third. 

The interosseous space is widest at the center of the leg, decreasing in 
width toward both ends. 

The tibialis anticus forms a muscular j)rominence nuining down the leg 
external to the tibia. The extensor longus digitorum, a smaller prominence, 
fills the rest of the interval between the tibula and the tibialis anticus muscle — ■ 
a groove intervening between these two muscles above, and the extensor 
proprius hallucis coming to the front between them below. 

Externally, the peroneus longus, brevis, and tertius form a muscular 
prominence. 

The internal aspect of the leg is formed — anteriorly, by the subcutaneous 
tibia — posteriorly, In' the projecting border of the soleus and tendon of the 
tibialis posticus. 

The fleshy mass of the calf is formed l)y the gastrocnemius and soleus, 
tapering to the tendo Achillis — and beneath them the popliteus, flexor longus 
hallucis, flexor longus digitorum, and til>ialis posticus. 

A groove exists between either malleolus and the extended tendo Achillis. 

The interosseous membrane separates the anterior from the posterior 
tibio-fibular muscles. 

Tendons predominate over muscles in the lower third of the leg. 

The gastrocnemius and soleus have joined by the time the lower third 
of the leg is reached. 

The greatest girth of the leg is at about the junction of the upper and 



364 AMPUTATIONS. 

middle thirds — tapering gradually above to the knee-joint — and rapidly 
decreasing in size below toward the ankle. 

The popliteal artery bifurcates about 5 cm. (2 inches) below the knee- 
joint — on a level with the lower part of the tubercle of the tibia. In ampu- 
tating 2.5 cm. (i inch) below the head of the fibula, one main artery, the 
popliteal, is cut — at 5 cm. (2 inches), two main arteries, the anterior and 
posterior tibials — and at 7.5 cm. (3 inches), three main arteries, the anterior 
and posterior tibials and the peroneal (Holden). 



GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 

THE LEG. 

In the lower and middle thirds of the leg, the bulk of the muscles are 
posterior — hence a posterior flap forms the best covering. 

In the upper third of the leg the bulk of the muscles are postero-extemal 
— hence a flap chiefly external furnishes the best covering. 

In all amputations through the up[)er third of the leg, it is well to cut 
the fibula at a higher level than the tibia, as it is apt to be drawn out of posi- 
tion and be exposed to pressure. 

The "place of election," especially referred to in older writings, was 
understood to be a hand's-breadth (or an average of 9 cm., or 3^ inches) 
below the knee-joint. 

The termination of the stump, in amputations about the leg, does not 
directly meet pressure (excei)t in the peg-leg) — the pressure being borne by 
the lateral aspects of the hollow modern limb — so that a terminal scar (except 
where a peg-leg is contemplated) is not objectionable. 

It is esj)ecially necessary, in amputating in the lower extremity, to dissect 
out all nerves which may be pressed upon — cs})ecially in the flap forms of 
operation. 

In sawing the bones of the leg, the prominent border (shin) of the tibia 
should be beveled, as described in the General Principles (page 252). 

The stump should be dressed upon a splint — and be kept out from under 
the bedclothes. 



AMPUTATIONS ABOUT THE LEG. IN GENERAL. 

Best Methods. — Oblique Elliptical (Guyon's Supramalleolar Ampu- 
tation) — for the supramalleolar region. Large Anterior and Smafl Posterior 
Flaps (Farabeuf) — for lower third, between supramalleolar region and lower 
limit of middle third. Large Posterior and Short Anterior Flaps (Hey's 
Operation) — for middle third. Large External Flap (Farabeuf) — for upper 
third. Bilateral Hooded Flap (Stephen Smith's Operation) — for "place of 
election," or upper part of ui)per third. 

Other Methods. — Modifie(l Circular — for supramalleolar region. Oblique 
Elliptical (Duval) — for lower third. Rectangular Flaps (Teale) — for lower 
third. Large Posterior and Small .\nterior Flaps (Henry Lee) — for middle 
third. Circular Metho<l. Ecjual Lateral Flaps. Large Posterior Flap. 
Large .Anterior Flaj:*. Long .\nlerior and Short Posterior Flaps. Oblique 
Circular, forming an anterior Hap- for upper and lower thirds. Oblique 
Circular, forming an antero-external flap — for middle thirds. Oblique 
Circular — forming a dorsal flap — for supramalleolar region. Long anterior 



AMPUTATION THROUGH LOWER THIRD OF LEG. 365 

Curved Flap. Long Anterior Rectangular Flap. Large Anterior Semilunar 
and Small Posterior Semilunar Flaps. 



AMPUTATION OF LEG THROUGH SUPRAMALLEOLAR REGION 

BY OBLIQUE ELLIPTICAL INCISION — GUVONS SUPRAMALLEOLAR OPERATION. 

Description. — An operation somewhat resembling Syme's — the tibia 
and fibula being divided below the medullary canal, and the ends of the 
bones covered by a heel-flap of skin and muscles. 

Position. — In operating upon the leg, in general, the limb projects over 
the edge of the table — the patient being supine — the surgeon standing to 
the outer side of the right, and inner side of the left — the assistant steadying 
the part to come away. In the present operation, the surgeon grasps the 
foot in his left hand and manipulates it so as to readily expose the line 
of incision. On the right, the foot is turned inward and the incision begins 
at the outer side '^f the heel — crosses the outer aspect of the foot, which is 
then turned upon its outer side, and the incision carried to the heel along the 
inner aspect. On the left, the incision may begin in front, with the foot 
upon its inner side. 

Landmarks. — Ankle-joint; malleoli; greatest prominence of the heel. 

Incision. — Begins, say, on the anterior aspect of the ankle, opposite the 
center of the ankle-joint — curves obliquely downward and backward over 
the lateral aspects of the foot, just skirting the inner malleolus, and passing 
slightly in front of the external malleolus — ending over the summit of the 
curve of the heel. The incision may be made from the instep to the heel, 
or vice versa (Fig. 275, E, E'). 

Operation. — The above incision is made through skin and fascia, and 
is then everywhere deepened to the bone — except that the ankle-joint is not 
opened, and the peronei tendons behind the external malleolus are not cut, 
until the soft parts have been cleared above the ankle-joint. The soft tissues 
are now carefully freed up about 5 cm, (2 inches) above the tips of the malleoli, 
providing a musculo-pcriosteal covering — using great care to preserve the 
vessels on the inner aspect — the surgeon standing for the anterior dealing, 
and sitting (or elevating the limb) for the posterior clearing. The tendo 
Achillis is divided. The peronei tendons are cut at about the level of the 
ankle. The ankle-joint is not opened. The anterior tibial, posterior tibial, 
termination of the peroneal, and anterior peroneal vessels arc ligated. The 
nerves and tendons are cut especially short. It is probably better to dissect 
out the posterior tibial nerve. The convex heel-fla{) is then sutured to the 
upper concave incision, and the stump dressed as in Syme's operation. 



AMPUTATION THROUGH LOWER THIRD OF LEG 

BY LARGE POSTERIOR AND SMALL ANTERIOR I- LAPS— FARABEUF. 

Description. — The operation is usually known as a large posterior flap 
method, the anterior flap supplying so small a part of the covering. Both 
flaps are of skin and muscle. The posterior tlap, which forms the bulk of 
the covering, is derived really more from the ])ostero-internal aspect, and the 
anterior or smaller flap, which is about one-fourth the length of the larger, 
from the antero-external aspect. 



^^. 



Tj^yr, '.zY-rsTt. 



K m«^ Trt —^Tw 







I'ljr y/7 Ami'i » A r fo- '. Alio' t IHI-. \.\:i, —t\. Throujjh lower third of le^, by large posterior 

ihkI ^m.ill .ml' ii'.i II. i|., l; I hi'.iij-ii ihi'Mli iIiikI, l>\ lout: |,o'.ifri<ir aii<i short anterior (Hey's opera- 
Ih.k;. ( , \\\\>t\\y,\\ ii|.|ii I iliifl I-'. I.il.iii i.il lioi.i|i<l )l.ij)K Si<pheii Sfniths operation). 

••(jUiil Id .ilxjiii r^ «li;imct<Ts of tlic liml> at the saw-line — then rounds across 
ilir )Mf.(rri(»r as|M(t of ilic Ic^- 'IHc outer limb of the incision begins, with 
iIm- Ir).', liiriKMl lo |)nN(iii ilic outer side, at the saw-line, on the outer side 
ol ilie \v\\ and passes veriic ally down just behind the fibula, for a distance 
cijUid lo alMiuf I J diamclcrs of the ie^ at the saw-Hne — then rounds across 
llir po'.icrior as|)«'i t of the le^' to meet the inner incision. The anterior flap 
i'. made bv a transverse in( ision. slij^htly convex downward, passing between 
llie two vertical int isions, at a distanee below their upper ends equal to about 



AMPUTATION THROUGH MIDDLE THIRD OF LEG. 367 

Operation. — These incisions having been made through skin and fascia, 
the tendo Achillis is divided on a line with the retracted skin and the leg 
is turned to present its inner side — and the upper part of the inner incision 
is deepened for a length of about 5 cm. (2 inches), by freeing the muscles 
from the tibia. The leg is now turned to present the outer side and the 
upper end of the outer incision is similarly deepened for a distance of aboui 
5 cm. (2 inches), by freeing the muscles from the fibula. The leg is flexed 
during these incisions. Through these two opposite openings, the left thumb 
and index are thrust, meeting in the center, and thus the soft parts are picked 
up and drawn from the bones, the limb still being flexed. A long knife is 
passed through this opening and made to cut its way out on a line with the 
retracted skin, bluntly beveling the flap. The anterior incision is now deepened 
to the bones on a line with the retracted skin. The soft parts are then freed 
back to the saw-line — the interosseous membrane being divided transversely, 
and the periosteum having been circularly divided a distance below the 
saw-line sufficient to furnish a covering of one diameter of each bone at the 
saw-line. The soft parts are retracted and the bones are sawed — beveling 
the prominent anterior border of the tibia as described at page 252. Ligate 
the anterior tibial, posterior tibial, peroneal arteries, and internal and ex- 
ternal saphenous veins. Suture the perio.steo-muscular coverings over the 
ends of the bones. Quilting of the muscles is particularly indicated, as the 
heavy posterior muscles are apt to sag l)ackward. Dissect out the posterior 
tibial nerve. Dress the stump on a posterior splint. 



AMPUTATION THROUGH MIDDLE THIRD OF LEG 

BY LONG POSTERIOR AND SHORT ANTERIOR FLAF'S — BV HEV'S OPERATION. 

Description. — The covering is by skin and muscle flaps, furnished 
almost entirely from the posterior aspect of the leg. The method is fre- 
quently termed simply a long posterior flap operation — and dilTers but little 
from the preceding operation. 

Position. — As in Guyon's operation (page 365) — and as given under 
Incision, below. 

Landmarks. — Saw-line. 

Incisions. — The posterior flap is U-shaped — its breadth is equal to half 
the circumference of the limb at the saw-line, and its length is equivalent 
to one diameter of the limb at that line. It begins 2.5 cm. (i inch) below 
the saw-line (instead of at that line). The inner limb |)asses vertically down 
the leg just behind the internal border of the tibia, rounding broadly into 
the posterior aspect of the limb — the outer limb ])assing vertically downward 
just behind the fibula, posterior to the peronei muscles, and rounding broadly 
into the posterior aspect of the leg to unite with the opposite liml) of the 
inci.sion. The anterior flap is about one-third the length of the posterior, 
and is made by joining the vertical limbs of the posterior flap, at their upper 
thirds, by a transverse incision, with slight downward convexity, acro.ss the 
front of the leg. In these incisif>ns the knee is flexed and the leg is laid on 
its outer side while the inner incision is being made from above downward, 
and vice versa (Fig. 277, B). 

Operation. — The above incisions pass through the skin and fascia only. 
With the leg flexed on the thigh and the knee everted, the gastrocnemius is 
held up by thumb and first finger and cut from without, on a line with the 
retracted skin and fascia. The upper parts of both vertical incisions are now 



368 AMPUTATIONS. 

deepened — the inner to the tibia, the outer to the fibula, behind the peronei 
muscles. The left thumb and index are inserted into these slits and the 
muscles drawn outward. The muscles having been detached from the 
bones and interosseous membrane above, a long knife is passed between the 
bones and separated muscles and is made to cut its way outward along the 
line of the retracted skin. The interosseous membrane is divided transversely 
and the periosteum of the tibia and fibula circularly — and all the soft parts 
retracted upward for the 2.5 cm. (i inch) between the saw-line and the begin- 
ning of the flaps. The flaps are now retracted — the bones divided, and the 
prominent crest of the tibia beveled. The anterior tibial, posterior tibial, 
and peroneal arteries are ligated. The musculo-periosteal coverings are 
sutured over the ends of the bones. The muscles are quilted with special 
care, owing to the tendency of the j)osterior flap to sag backward. The 
large posterior and short anterior flaps are then sutured together — and the 
stump supported upon a posterior splint. 



AMPUTATION THROUGH UPPER THIRD OF LEG 

BV LARGE KXTKRXAL FLAP— FARABEUF. 

Description. — The stump is covered by a large U-shaped flap of skin 
and muscles raised from the external aspect of the leg. 

Position. — Patient supine; \e^ projecting over side of table, with knee 
flexed and leg lying on inner side for the incision of the external flap, and 
on the outer side for the transverse incision. Surgeon to outer side of right 
and inner side of left leg. 

Landmarks. — Saw-line. 

Incision. — External flap — U-shaped, equivalent in length to one diameter 
of limb at saw-line — begins opposite the saw-line anteriorly — passes vertically 
downward parallel with and just internal to the anterior border of the tibia 
— rounds across the external aspect of the leg and passes vertically upward 
directly opposite the anterior incision — but ends about 4 cm. (i^ inches) 
below the saw-line. Transverse incision — passes transversely across the 
inner aspect of the limb, with slight downward convexity, connecting the 
upper end of the posterior incision with a point on the anterior incision 4 cm. 
(i^ inches) below its beginning. The external flap may be cut, or outlined, 
with one sweep of the knife — but it is better to complete it in two strokes 
(Fig. 278, C). 

Operation. — Beginning with the external flap, the above incision is 
deepened along the line of the retracted skin — and the large flap, of all 
the soft parts to the bones, raised. To accomj)lish this, the incision is first 
deepened alotig the anterior liml) l)y cutting down upon the anterior border 
of the tibia, from above downward. The tibialis anticus is thus freed from 
the bone. The left fingers of the operator, slipped between muscle and 
bones, draw it outward, while the short knife continues its downward inci- 
sions, beveling obliquely the lower portion of the muscular mass toward the 
extremity of the flap. Thus the entire muscle-mass is separated from the 
tibia, interosseous membrane, and fibula, by the use of the knife, fingers, 
and elevator. Care is taken that the anterior tibial artery is not divided 
before the free end of the flap is reached, the integrity of which so largely 
depends upon this vessel. If the parts arc freed up too high, especially 
posteriorly, where the vertical incision is shorter than the anterior, the anterior 
tibial artery may be severed before traversing the interosseous membrane. 



•ansversc incision crossing the inner asi>ert of ihc limb is now deepened 
ting from without inward on the line of retracted skin and fascia, 
ilcrosseous membrane is divided iransvers-ely. The periosteum is 
riy divided around the tibia and fibula. The periosteum and soft 
re then freed up to the 'iaw-linc and retracted while ihe bones are 
— the prominent margin of the tibia being beveled from above down- 




W.— AMm■ATio^5 A»orr tmk Lbc;;— A. ThruuRli }i>wtT ihinl ol leu. by olilique circular 
A. Thruuxlt middle tbifd, by modllied circular method ; C. Through upper third, by large 

md from before backward. The fibula is sawed a little higher than 

ia, and Ijcvcled from above downward, and from without inward. 

' in>ial, posterior tibial peroneal, muscular branches to the 

M- and soleus, and nutrient arteries are ligated. All nerve-trunks 

in apt to be pressed upon are dissected out. The muscles are quilted. 



37© AiMPUTATIOxNS. 

The margins of the external flap are sutured to the inner transverse incision 
— and the limb dressed upon a posterior splint. 

AMPUTATION THROUGH UPPER THIRD OF LEG 

BY BILATERAL HOODED FLAPS — STEPHEN SMITH. 

Description. — Two lateral flaps of skin and fascia are raised from the 
outer sides of the leg, by an incision extending much higher behind than in 
front — these are retracted about 2.5 cm. (i inch) — the muscles circularly 
divided and retracted to the saw-line and the bones sawed — forming a bilateral 
hood over the ends of the bones, which is sutured vertically — the scar being 
eventually drawn up behind the liones. 

Position. — Patient supine; leg over edge of table, held horizontal for 
skin incisions and vertical when freeing back the soft parts. The surgeon, 
to outer side of right and inner side of left limbs, places the right thumb 
upon the crest of the tibia, to mark the upper limit of the anterior incision, 
and the index posteriorly, to mark the ui)])er limit of the posterior incision — 
leaning over patient and cutting from behind forward on both sides, the 
incisions meeting at the highest j)()int of the anterior incision. 

Landmarks. — Saw-line, marking the upper limit of the posterior incision 
— and the point on the crest of the tibia marking the upper limit of the anterior 
incision, and placed al)out three-fourths of a diameter of the limb at the 
saw-Hne below the upper limit of the j)osterior incision (Fig. 277, C). 

Incisions. — The surgeon, having grasj)ed the limb in such a manner 
as to mark the upper limit of the anterior incision by his left thumb upon the 
crest of the tibia, and of the posterior incision by his left index in the mid- 
posterior aspect of the leg at the saw-line — bends over the patient's leg (his 
arm being abo\e and to the far side of the limb) and inserts the point of a 
stout knife, held at a right angle to the skin, into the posterior tissues opposite 
the tip of the index — cuts thence downward, through skin and fascia — 
vertically downward, at first — and then soon begins gradually to sweep to 
the side of the limb opj)osile to that on which he is standing — and continues 
to pass in this curvilinear manner until a little below the level marked by his 
left thumb — then curves transversely across the far side of the limb and 
slightly ascends to the point marked by the tip of the thumb. The knife 
is now removed and this incision is rei)eatcd upon the near side of the limb, 
the knife entering at the highest ])oint posteriorly, sweeping with the same 
curve (except that the flap may be advantageously made a little larger on 
the inner side, to cover the larger libia) to the highest point anteriorly. 

Operation. — Having incised the skin and fascia, these flaps are raised 
from their lower ends for about 2.5 cm. (i inch) and are retracted, when 
the muscles are circularly divided to the bone — and are retracted from the 
tibia and fibula up to a level far enough l)elow the saw-hne to furnish a perios- 
teal covering. Here the interosseous membrane is divided transversely — 
and the periosteum circularly around the tibia. .All the soft parts, including 
periosteum, are then retracted above the saw-line and the bone divided, 
beveling the tibia and sawing the fibula shorter than the tibia. The short 
piece of the fibula may then l)e disarticulated and excised. The anterior and 
posterior tibial, peroneal, and muscular arteries are tied. The musculo- 
periosteal covering is sutured over the tibia — the muscles quilted — and the 
flaps sutured in a vertical line — the redundancy of soft parts being eventually 
drawn up behinrl the stum]). The h(X)d of skin and muscle falls over the 



SURGICAL ANATOMY OF THE KNEE-JOINT. 371 



SURGICAL ANATOMY OF THE KNEE-JOINT. 

Bones. — Condyles of femur; tuberosities of tibia; head of fibula; patella. 

Articulations and Ligaments.— (a) External Ligaments— anterior, or 
ligamentum patellae; fibrous expansion of extensor tendons (central and two 
lateral portions); posteri