Medical AND Operative 'fmjx-.:.'. BOUGHT WITH THE INCOME FROM THE SAGE ENDOWMENT FUND THE GIFT OF Au^&^.7£ ^ ' S/^, CORNELL UNIVERSITY LIBRARY 3 1924 099 273 645 APPLIED ANATOMY. Cornell University Library The original of tliis bool< is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924099273645 APPLIED ANATOMY: SURGICAL, MEDICAL, I AND OPERATIVE. BY JOHN M'LACHLAN, M.D, B.Sc, E.R.C.S. Eng., MASTER I^f SURGERY, tTNIVEKSITY OF EDINBURGH; LICENTIATE 01" THE SOOIBTT OF APOTH BC ARIES, LONDON, ETC. Wtvii (Birition. ILLUSTRATED WITH 238 ENGRAVINGS. VOL. I. EDINBURGH: E. & S. LIVINGSTONE, 15 TEVIOT PLACE. LONDON: BAILLlilEE, TINDALL, & COX; SIMPKIN, MARSHALL, HAMILTON, ADAMS, KENT, & CO. 18 90. K JJMr-B-iT K PRINTliD BY fe S. LIVINGSTONE 4 MELBOURNE PLACE EDINBURGH. LONDON: SIMPKIN, MARSHALL, HAMILTON, ADAMS, KtSNT, AND CO. : AND BAILLlilREj TINDALL, AND COX, OLAsaow: sime; stenhouse, DUBLIN : FANNIN AND CO. ; GILL AND RON. MANCHESTER: o. E. CORNISH. TO JOHNSON SYMINGTON, M.D., F.K.S.E., F.R.C.S.E., Lecturer on Anatomy; School of Medicine, Edinburgh, in recognition of his great skill as a teacher and as an expression of sincere regard, ®Ips ^orrk is resptclfttUg getticaied BY AN OLD PUPIL. PREFACE TO THIRD EDITION. IN preparing this Edition much new matter has been added, and the book rendered more complete in every respect, especially in the parts treating of Medical Anatomy. I trust the time is not far distant when a book such as this will be used by every Medical Student before he has left the dissecting-room, for there is nothing in it — excluding the mere details of Operative Surgery — that he could not get up much better, and more easily, during the time he is preparing for his Anatomical and Physiological examination : for Anatomy is but the handmaid of Surgery — but the dry bones, into which Surgery breathes the breath of life. Were such a course pursued, the examination in Surgery, instead of being the bugbear it is to so many Students, would become the easiest and most satisfactory part of the whole examination. A large number of new Illustrations have been added,g the plates of which have been engraved partly by Miss E. P. Hill Burton and partly by Mr David L. TurnbuU, to both of whom I now desire to express my thanks. viii Preface. My thanks are also specially due to Dr Symington for the use of Fig. 119, showing the position of the mastoid antrum, and also for the use of the bones, showing the various epiphyseal lines, from which the engravings were made by Mr Turnbull ; and to Dr Wallace, Senior Assistant to the Professor of Surgery, for photographs of the same. For Figs. 42 and 43 of the present volume I am indebted to the kindness of Professor Cunningham. I am also indebted to Dr F. M. Caird for a number of the sketches from which the Wood Engravings have been drawn. I have also- to express my thanks to Dr Aitken, who has rendered me much valuable assistance in the revision of the proof-sheets. The Second Volume will be produced with as little delay as possible. J. M'L. Edinburgh, April 1889. EXTRACTS FROM PREFACE TO SECOND EDITION. In preparing the following pages for the press, I have endeavoured to write, as a Student, to Students ; in this way I hope I have been enabled more thoroughly to meet the wants of Students preparing for the various Final Examinations throughout the Kingdom. The present book is intended to replace a small book I published some years ago, but is to be regarded as essentially different in all respects. It is intended to be sufficient for the various Higher Examinations, as well as for those of less severity, and especially is it intended for those Examinations that require actual- operations on .the dead body as part of the Final or Pass Examination. The Lancet, in its kind and favourable review of my first book, drew attention to some points wherein it was deficient — chiefly in relation to " Surface Anatomy." I trust the present book is less deficient in that respect, but there are some things that cannot be learned except beside the living, or dead, body. I have certainly pointed out the special relations of the various important bony points that can be felt, or seen, on the surface of the body ; but to learn the Surface Anatomy properly. X Preface to Second Edition. the Student mud have the actual body beside him to see and feel for himself. The greater number of the engravings are original — most of them being prepared from rough sketches by the Author; but for their elaboration and execution I must express my thanks to Mr David L. Turnbull, who has engraved all the plates, with but five exceptions. I must also express my thanks to Messrs Longmans, Green, & Co. for permission to insert Nos. 41 and 42, and to Professor Cunningham for permission to insert Nos. 59 and 60, as well as to his Publishers (Messrs Maclachlan & Stewart) for the ready and courteous manner in which they furnished the necessary electrotypes. If at times, in the drawings, I have sacrificed strict scientific accuracy, for the sake of impressing special points on the Student's mind, I must be excused, for what is the use of engravings unless they impress the idea they are intended to convey, and teach some practically useful fact. J. M'L. Edinuuroii, May 18S7. CONTENTS OF VOL. I. CHAPTER Pubface ...... List of Enokavings I. Aneurism . . II. Treatment of Aneurism III. Ligature of Arteries in Continuity lY. Aneurism of the Thoracic Aorta V. Ligature of the Innominate A'l. Subclavian Artciy .... VII. Carotid Arteries .... VIII. Branches of the External Carotid IX. The Axillary Arteiy X. Arteries of the Ahdomon XI. Arteries of the Lower Extremity XII. Amputations — Instruments XIII. Amputations of the Upper Extremity XIV. Amputations of the Upper Extremity (continued) XV. Amputations of the Lower Extremity PAGI! vii xiii 1 10 22 34 43 58 79 93 105 130 149 178 194 210 235 Contents. CHAPTEB PACK XVI. Amputations of the Lower Extremity (cfmimwd) 261 XVII. Amputations of the Lower Extremity (continued) 282 XVIII. Excision of Joints .... 305 XIX. Special Excisions 312 XX. Special Excisions (continvM) 333 XXI. Dislocations of the Upper Extremity 354 XXII. Dislocations of the Lower Extremity 385 XXIII. Fractures— rin C4eneral 415 XXIV. Fractures of the Upper Extremity 425 XXV. Fractures of the Lower Extremity 466 XXVI. Excision of Bones 502 XXVII. The Eye . 518 XXVIII. The Ear . .... 557 LIST OF ENGRAVINGS. PIG. 1. Aneurismal Varix .... 2. Varicose Aneurism .... 3. The "Old Operation" .... 4. Hunter's Method 5. Brasdor's Method 6. Wardrop's Method 7. Spontaneous Arrest of Hemorrhage 8. Wounded Artery 9. Wounded Artery 10. The Director ..... 11. CEsophagus and Thoracic Aorta 12. Collateral Circulation of the Head and Neck (after Smith and Walsham) .... 13. Subclavian Vessels (after Tukneb) 14. Incisions for Subclavian and Carotid Arteries 15. Intercostal Haemorrhage 16. Transverse Section of Left Carotid Sheatli 17. Lingual Artery .... • 18. Collateral Circulation of the Upper Extremity (after Smith and Walsham) .... 19. To show the Eelation of the Arteiy to the Humerus 20. Relation of Ulnar and Radial Arteries and Nerves 21. The Graduated Compress 22. Wounded Artery .... 23. Wounded Artery .... 24. Collateral Circulation of the Abdomen (after Smith and Walsham) .... 25. Iliac Arteries and Veins 26. Guide to Arteries of Buttock . 3 12 14 16 16 24 24 25 32 40 62 66 67 78 80 95 108 114 119 126 128 123 132 135 141 XIV List of Engravings. no. PAQK 27. Showing Relation of Artery to Femur . . . . 149 28. Formation of the Femoral Sheath . . . .150 29. Femoral Artery and Vein ..... 151 30. Collateral Circulation of the Lower Extremity (after Smith and Walsham) . . . . . .154 31. Incisions for Ligature of Femoral . .157 32. Section through Hunter's Canal, Eight Side . . .159 33. Right Popliteal Space, from. Behind . . .164 34. Section through the Calf ..... 168 35. The Hand ... ... 195 36. Bent Finger ....... 196 37. Oval Amputation of Finger ..... 201 38. Flap Amputation of Finger ..... 202 39. Professor Chiene's Amputation .... 204 40. Professor Chiene's Amputation .... 205 41. Section through Fore- Arm ..... 217 42. Section through Upper- Arm (from Cunningham)* . 223 43. Section through Upper-Arm (from Cunningham)* . 223 44. Spence's Amputation ...... 226 45. Tarsus and Metatarsus . 241 46. Incisions for Hey's Amputation 243 47. Lisfranc's Amputation . . 244 48. Incisions for Chopart's Amputation .... 247 49. Knife for Syme'.s Amputation at the Ankle Joint . . 249 50. Outer Side of Right Ankle ... 250 51. Inner Side of Right Ankle .... 251 52. Mackenzie's Amputation (after Spenoe) — Large Internal Flap 255 53. Mackenzie's Amputation (after Spence) — Incision on Outer Side 255 54. Amputation of Leg ...... 262 55. Section through the Calf . 272 56. Garden's Amputation ...... 277 57. The Stump after Garden's Amputation (Original Form) . 278 58. Spence's Amputation ...... 283 59. Amputation of Hip and Thigh , 289 60. Section through the Thigh . . 290 61. Butcher's Saw .... 310 62. Excision of Shoulder . . .313 * In Pigs. 42 and 43 on page 223, read Uppeh-Akm mUmi. of Fobe-Akm. List of Engravings. XV FIG. 63. Excision of Elbow 64. Lister's Excision 65. Lister's Excision 66. Excision of Hip by Posterior Incision (White and Langen beck's Incision) ..... 67. Excision of Hip by Anterior Incision (Htjetek and Parker' Incision) ...... 68. Excision of Knee ..... 69. Iron Suspension Rod ..... 70. Modelled Gooch Splint (WaTsok) 71. Another Form of Watson's Splint 72. Miokuliez's Operation ..... 73. Foot after Miokuliez's Operation (after MaoOormac) 74. Dislocation of botli Bones Backwards . 75. Fracture of the Neck of the Femur 76. Head of Left Tibia .....' 77. Epiphysis of Acromion Proeess 78. Upper End of Humerus 79. Upper End of Humerus 80. Lower End of Humerus 81. Fracture through Surgical Neck 82. Fracture above the Deltoid 83. Fracture below the Deltoid 84. Splints for Fractured Humerus 85. Dislocation of both Bones Backwards , 86. Upper End of Eadius . 87. Lower End of Radius . 88. Upper End of Ulna 89. Lower End of Ulna 90. Fractured Fore-Arm put uji 91. CoUes's Fracture — Side View 92. Colles's Fracture — Dorsal View 93. Anterior Splint for Colles's Fracture 94. The Innominate Bone . 95. Upper End of Femur . 96. Lower End of Femur . 97. Fracture of the Neck of the Femur 98. Fracture just below the Lesser Trochanter 99. Fracture near the Knee Joint , XVI List of Engravings. FIQ. FAQE 100. LIston's Long Splint ...... 480 101. Diagram of Mattress ...... 483 102. Head of Tibia. ...... 489 103. Lower End of Tibia ...... 490 104. Upper End of Fibnla ...... 490 105. Lower End of Fibula ...... 490 106. Fracture at Lower Part of Leg .... 492 107. Extension Plaster ...... 496 108. Dupuytren's Splint ...... 496 109. Pad for "Horse-shoe" Splint. ... 498 110. Liston's Excision of the Upper Jaw . 505 111. Excision of the Jaws . . . . 506 ll'a. Eight Cavernous Sinus . ... 519 113. Right Sphenoidal Fissure ■ . . . . .520 114. The Eyelids ....... 521 115. Antero-Posterior Section of Eyeball (from Gray's "Anatomy") 523 116. The Lachrymal Apparatus (from Gray's "Anatomy") . 531 117. The Optic Nerves ... .540 118. The Ear ....... 558 119. Position of the Mastoid Antrum (Symington) . . 576 APPLIED ANATOMY: SUEGICAL, MEDICAL, AND OPEEATIVE. CHAPTER I. ANEURISM. In introducing the subject of Ligature of Arteries, I propose to say a few words concerning Aneurism in general, and its treatment. An Aneurism may be defined as a swelling containing blood, either fluid or coagulated, communicating with the cavity of an artery. Mr Ekichsen thus classifies the different forms : — I. Fusiform — True. II. Sacculated. (a) True. (b) False. (1) Gireumscribed. (2) Diffused. III. Dissecting. The cirsoid and arterio-venous varieties are not included in this classification. Formerly, a true aneurism meant one whose wall was formed by an equal dilatation of all the coats of the vessel ; as a rule, it now means an aneurism whose wall is formed by one or more of the arterial coats. I. — Fusiform or Tubular Aneurism consists of an equal expansion of all the coats of the vessel throughout its entire circumference ; this form is most frequently met with ia the arch of the aorta. A 2 Applied Anatomy : II. — By a Sacculated Aneurism is meant a tumour springing from the side oi an artery, or from a tubular aneurism, with the interior of which it communicates by a narrow opening called the mouth of the sac. (a) In true sacculated, the sac wall is formed by all the coats of the vessel ; (&) in false sacculated, the internal or middle coat, or both, are deficient, and the wall of the sac therefore is formed by the outer and middle coats only, or else by the outer coat alone. To this latter condition the name of circumscribed false aneurism is sometimes applied; diffused false aneurism means that the sac of the aneurism is not formed by the coats of the artery at all, but by the tissues outside the vessel; the blood being either confined by the condensed tissues of the part into a circumscribed tumour, or else widely diffused in the loose cellular tissue. III. — Dissecting Aneurism. — In this form the internal coat of the artery becomes eroded, or an atheromatous abscess bursts, and the blood makes its way through the ulcer or erosion and burrows between the coats of the vessel. As a result of this, it may either burst through all the coats and be effused into the sur- rounding tissues, or, if the external coat be strong enough to resist the rupture, the blood travels along between the coats for some distance, and again opens into the cavity of the artery; or, thirdly, it may form a sac in the middle coat, which may remain for a time una,ltered, but which will, in all probability, eventually burst externally. This form of aneurism is met with most frequently in women. Various other methods of classification are adopted by different writers, e.g., some divide aneurisms simply into: — (1) True, where the sac wall is formed by one or more of the coats of the vessel; this form being associated with disease of the artery. (2) False, where the tissues outside the vessel form the sac wall; this form being caused by a wound of the artery, or else by the bursting of a true aneurism. Others again divide them into : — (1) Spontaneous, or that associated with disease. (2) Traumatic, from one of three forms of traumatism — r(a) a direct wound; (i) a strain or bruise; or (c) the sharp end of a fractured bone penetrating the vessel. (3) Arterio-venous. (4) Cirsoid. Surgical, Medical, and Operative. 3 Arterio-venous Aneurism is usually caused ty a wound which simultaneously implicates an artery and some neighbouring vein ; in some rare cases it may arise from disease. There are two varieties: — (1) Aneurismal varix (Fig. 1), wheje the wounded artery and vein have adhered closely, and the inflammatory exuda- tion, caused by the injury, has fixed them in this position, and Fig. 1. Aneurismal Varix. The arrows indicate the direction of the blood-stream. at each pulsation a jet of arterial blood is projected directly into the vein, dilating it and causing incompetence of its valves, and gradually leading to a varicose condition of the neighbouring veins, both superficial and deep. The veins become tortuous, thickened, and may pulsate, but there is nothing of the nature of an aneu- rism formed. (2) Varicose aneurism (Fig. 2), where the lymph cementing the two vessels yields and an aneurism is formed. Fig. 2. Varicose Aneurism. The Sac ,... Vein, di- lated and tortuous. ^.— -Artery. The arrows indicate the direction of the blood-stream. the wall of which consists of the new inflammatory material and condensed cellular tissue. The sac of the aneurism communicates with both the artery and vein, the blood being projected from the artery through the sac into the vein, dilating it as in aneurismal varix. By far the most frequent cause of arterio-venous aneurism is the unskilful performance of venesection at the bend of the 4 Applied Anatomy : elbow, resulting in the simultaneous wounding of the brachial artery and the median basilic vein; it is but rarely seen now-a-days, since this operation is not often performed, and only by Surgeons. Any punctured wound, however, may cause it, e.g. from small shot, or a spicule of bone in comminuted fracture. In both forms there is a pulsatile dilatation of the veins, with a well marked thrill and a loud continuous murmur, increased in intensity at each cardiac systole, like the " hruit de diable" over the internal jugular vein in anaemia, and which has been likened to "the noise made by a blue-bottle fly confined in a thin paper bag ; " the murmur is conducted with greatest intensity along the veins, and, therefore, towards the heart, and not from it, as in ordinary aneurism. The chief points of distinction between the two varieties are, that in varicose aneurism there is a more or less distinct tumour in addi- tion to the other symptoms, and probably a double murmur — one, continuous and accompanied with a thrill, such as is always found when an artery and vein communicate; the other, systolic in time, like that usually found in aneurism. A Cirsoid Aneurism is produced by the simultaneous elongation and dilatation of arteries, with thinning of all their coats; but especially of the middle, so that, in structure, they come to resemble veins. It forms an ill-defined compressible swelling, with expansile pulsation, and a soft systolic bruit (with sometimes a diastolic as well) heard with equal intensity at every part of its surface; on palpation, it is felt to consist of tortuous and sacculated tubes. The arteries most frequently affected are those of the scalp, hands, orbit, and iliac fossa. In Aneurism by Anastomosis both arteries and veins are affected. The blood is not contained in vessels, properly speaking, but in large spaces or pools into which arteries empty themselves, and from which veins take their origin; the whole resembling very closely the condition found in cavernous tissues, or in the maternal part of the placenta. There is a well-marked thrill, and loud continuous bruit, like that found in arterio-venous aneurism; pulsation is only found at spots here and there — the points where the feeding arteries enter. Causes of Aneurism.— Anything that destroys the balance between the expansive force of the circulation and the reaction Surgical, Medical, and Operative. 5 of the arterial wall ; or, in other words, whatever increases the blood pressure on the one hand, or reduces the resisting force of the arterial walls on the other, as thinning of their coats or diminished resiliency. It is specially apt to OOCUr— (1) In large vessels, because atheroma (the chief predisposing cause) is a disease of the large arteries; (2) in places subjected to great strain, e.g., the axillary artery in sailors, probably from climbing, hanging by their arms, etc.; (3) where large arteries bend or bifurcate, because the pressure is greatest at these points, e.g., the innominate, bifurcation of the common carotid, and popliteal, (a) Predisposing Causes. — Anything that gives rise to a local weakness of the vessel wall. The great predisposing cause is atheroma, but syphilis, gout, rheu- matism, Bright's disease of the kidney (especially the granular contracted form), abuse of alcohol, intemperance, and vice of every form, are also important predisposing causes; and all the more so because many of these conditions are accompanied with hypertrophy of the left ventricle, so that not only is the vessel wall weakened but the blood pressure is increased as well. All occupations where sudden and severe efforts are required irregularly, as in soldiers, sailors, and huntsmen. It is said to be most common between the ages of thirty and forty. (&) Exciting Causes. — Wounds or blows, sudden strains, irregular vascular excitement, as from violent exer- cise or emotion, fits of anger, etc., in people of a certain age, say above fifty. Symptoms of Aneurism. — The more important symptoms are — (1) The presence of a pulsating tumour near the known course of some blood vessel, and which cannot be separated, or moved apart, from the vessel. (2) Pressure on the artery above arrests the pulsa- tions of the tumour, and may cause it to subside, but when the pressure is removed it refills again, often with a thrill; pressure on the artery below will cause it to become larger and more tense. (3) The pulsation is expansile, the tumour enlarging in all its diameters at each systole, and is not a mere thrust forwards. One may determine whether the pulsation is expansile or not in two ways — {a) By placing a finger on each side of the swelling and observing whether they are separated or simply raised ; or {h) by fixing a piece of strapping, or elastic webbing, with a slit jn its middle over the .swelling, when, if the pulsation be expansile, the 6 Applied Anatomy: slit will open out at each systole. (4) The pulse in the vessel heyond the aneurism is delayed, smaller and weaker than it should be. (5) Pressure effects, e.g., pain, which may either be lancinating and intermittent, or continuous and aching, muscular weakness, and oedema from pressure on the veins. (6) Presence of a bruit and thrill. Note, that many of these signs will be absent in consolidation. DIAGNOSIS. — (1) From solid tumours placed over large arteries — (a) The pulsation is chiefly felt along the line of the artery and not in the lateral expansions, and is heaving in character, not expansile ; (6) the tumour is movable in the course of the artery as well as from side to side: aneurismal tumours are only movable laterally, not in the length of the artery; (c) it neither collapses nor is compressible when the artery above is commanded, nor is the tension increased when the artery below is compressed; (cZ) all movement is stopped at once by pressure on the proximal side of the tumour, and returns at once as strongly as ever when the pressure is removed : in an aneurism, the pulsation returns gradually, and does not attain its full force for a few seconds; (e) it may be pulled away from the artery when the pulsation is lessened, or lost altogether: in the abdomen, it may be possible to produce the same effect by making the patient support himself on his hands and knees, when the tumour will fall away from the pulsating artery; (/) bruit and thrill usually absent, and so also alterations in the arterial pulse beyond. (2) From an abscess situated over a large artery — (a) An abscess forms an incompressible and immovable fluctua,tiDg swelling, and has an ill-defined outline; (&) it began with signs of inflammation, forming a solid swelling which has gradually softened. An aneurism begins as a soft swelling, and tends to become harder, (c) When the artery above is compressed, the pulsation stops, but returns at once as strongly as ever when the pressure is removed; further, the pulsation is felt mainly in the line of the vessel. (3) Cysts are much more sharply defined than abcesses, and are more or less of a globular shape, whereas an -abscess is hemispherical, resting on a stool of condensed inflammatory tissue, and has a hard rim of the same structure round it; further, cysts are usually freely movable, and, in some cases, may be reducible, e.g., synovial cysts near the knee joint in cases of chronic rheumatic arthritis. In the Stcrgical, Medical, and Operative. case of a cyst of the thyroid, situated over the common carotid, simulating an anuerism, by asking the patient to swallow, the thyroid cyst will he seen to rise and fall with the thyroid gland during deglutition, whereas an aneurism is stationary. (4) Pulsatile Tumours of Bone: Aneurism. Situated in the course of some large artery, anil sharply defined. Pulsation felt as a wave passing through the swelling. When the main artery is com- pressed above the tumour, and the compression removed, the sac fills out again with two or three strong hounding beats, showing the filling of a cavity. When the artery below the tumour is compressed, the tension in the aneurism is increased. Aneurismal tumours are movable laterally, but not m the line of the artei'y. 6. When the artery above is com- pressed, the swelling may be partially or wholly reduced by pressure, or collapse spontane- ously. 7. Bruit well marked. 8. State of neighbouring bone— an aneurism eats through the bone, and one may feel the edges of the hole. Pulsatile Tumour. 1. May not be so. Not so well defined, and is soft, spongy and elastic. 2. Pulsation simultaneous at eveiy part, though sometimes only felt at spots here and there, where large arteries enter. 3. When so treated, the pulsation at once returns over the whole tumour, as it is only due to the movement of Mood in tubes, not to the filling of a cavity. i. Is quite unaffected by such pressure. 5. Are immovable, as they grow from bone. There will probably be signs of malignant growth else- where, e.g., in the kidney, giving rise to hematuria, and in the liver, causing irregular nodular enlargement. 6. When the artery above is com- manded, it neither collapses nor is it compressible to any gi'eat extent. 7. Bruit less marked or wanting. 8. A pulsatile tumour growing from a bone usually expands it, so that one may be able to feel a thin shell of bone covering the tumour; and elicit "egg-shell crackling" by gentle pressure. 8 Applied Anatomy : Progress of Aneurism. — (1) It may remain stationary. (2) In- crease in size : the rate of increase depends on its position and the size of the mouth of the sac. Fusiform increase slowly; but the narrower the mouth of the sac, the greater the pressure on its ■walls, the more rapid its growth, and the greater the tendency to burst. This increase in size gives rise to pressure symptoms — veins are closed, causing oedema, nerves expanded, thinned, or irritated, e.g., the superior laryngeal, causing a peculiar brassy persistent cough; the inferior, or recurrent laryngeal, causing spasmodic closure of the glottis, necessitating the performance of tracheotomy : the trunk of the sympathetic in the neck giving rise to eye symptoms : muscles stretched and wasted, bones eroded and absorbed: oesophagus or trachea pressed on, causing a difficulty in swallowing or breathing. (3) Eupture of the sac, and death from hsemorrhage, either externally or internally as into joints, pericardial or pleural cavities. (4) Spontaneous cure — (a) By coag- ulation of the blood in the sac, due to some temporary retardation of the flow, as from the growth of the aneurism causing pressure on the artery feeding it, escape of a piece of clot causing embolism beyond the aneurism, displaced clot plugging the mouth of the artery leaving the aneurism, or a -clot washed down into the feed- ing artery from some aneurism higher up. (h) Suppuration and sloughing of the sac, provided the communication between the artery and the sac is closed up before the abscess bursts ; if not, it may speedily cause fatal hsemorrhage. (c) It is believed by some Surgeons that an aneurism may be cured spontaneously by inflammation of the sac without suppuration. In the first form of spontaneous cure there is gradual deposi- tion of laminated clot, which tends to restore the resisting force of the wall of the vessel. The outer part of the clot {"active clot ") consists of numerous layers of fibrin, and is firmly attached to the wall of the aneurism ; these layers not only strengthen the part, but they tend to contract, and as they do so they cause contraction of the sac, and gradually narrow it down to the level of the lumen of the original vessel, or may even close it up entirely. In order that a clot may form, the force of the circulation must be lessened, and when the clot formation is once begun it goes on till the whole sac is full, gradually becoming denser and contracting ; it thus Surgical, Medical, and Operative. 9 enables the sac to resist pressure, and stops its further growth. That part of the clot next- the lumen of the vessel is soft, amor- phous, and red, like red ciirrant jelly {"passive dot"). In many of the cases examined this is, in all probability, only a post-mortem clot ; but there is good reason for believing that it precedes the firm, laminated external clot, and is also formed in those cases where an aneurism is cured by pressure in a few hours. It is well to bear in mind, however, that unless great care be taken it is apt to be broken down and washed away, and then the appar- ently cured disease begins again. It is most difficult to induce coagulation in vessels near the heart, on account of the difficulty in obtaining a temporary retardation of the blood current ; it is specially difficult in fusiform aneurism of the arch of the aorta. 10 Applied Anatomy : CHAPTER II. TREATMENT OF ANEURISM. The treatment of Aneurism is divided into Medical and Surgical ; but in practice it is always better to combine them. MEDICAL. This includes — (1) Rest in bed in the recumbent posture, or in such a position as to impede the supply to, but to assist the return from, the aneurism; at the same time, paying special attention to the general health, giving a light, simple, unstimulating diet, but one nevertheless sufficient for the needs of the body, and avoid- ing all excitement, either mental or physical. (2) Depletion in moderation to reduce excessive vascular action ; it also seems to increase the relative amount of fibrin in the blood. The efiect on the circulation is not lasting; but this is no objection, as all that is wanted is a temporary lowering of the force of the circulation in order to allow the blood in the sac to begin to clot. This was Valsalva's plan, only he carried it to excess, and it consequently fell into disrepute. In carrying out this method, the pulse must be carefully watched and depletion stopped at once, should there seem any tendency to syncope. (3) Gradual starvation, especially of fluids (Tufnell), with the intention of reducing the total amount of blood in the body, and also the force of the heart's action. The diet is to be chiefly farinaceous, and alcohol must not be given; by some it is recommended, after coagulation has commenced, that a liberal proportion of animal food should be allowed, in order to increase the amount of fibrin in the blood. The diet recommended is something like the following: — 2 oz. of bread and butter for breakfast ; 2 oz. of bread and 2 oz. of meat for dinner ; 2 oz. of bread and butter for supper; and a little milk-and-water (as little Surgical, Medical, and Operative. 11 as possible) sipped between times. (4) Drugs, such as iodide of potassium, to lower vascular tension, and, at the same time, to induce coagulation by breaking up the white cells of the blood and liberating the fibrin ferment ; aconite and veratria to depress and weaken the heart's action. Acetate of lead has also been recommended. It should be borne in mind, however, that drugs without rest in bed in the recumbent posture, spare diet, avoid- ance of all excitement, etc., are probably of little use ; and that if these conditions are properly carried out they are to a great extent superfluous. SURGICAL. Before performing any operation, one ought to make sure that there is no internal aneurism, and that there is an absence of wide- spread cardiac or vascular disease. I. LIGATURE.— (a) Method of Antyllus (the "old operation," dating from the third century). In this method, the artery is commanded on the proximal side of the aneurism, the sac is freely exposed and opened, the clot turned out, and then, by means of a probe as guide, the arterial. orifices opening into it are found, and the artery tied both above and below the aneurism (Fig. 3). In many cases it is a very dangerous and tedious operation to expose the sac, as it may be deeply placed and surrounded by important structures, e.g., in the popliteal space. Further, there is a great risk of secondary haemorrhage when the ligatures separate; besides, very often profuse suppuration of the deep trench-like wound thus made — it may be briefly characterised as ineffective, tedious, bloody, and dangerous. In the evolution of this operation, Antylltis made three mis- takes : — First, and most serious, he tied the vessel at a part where the coats were diseased ; hence, the great mortality and risk of secondary haemorrhage. Second, he seemed to think that in order to cure an aneurism it was necessary to cowpletely check the blood flow to and through the aneurism al sac ; whereas, aU that is necessary is to obtain a temporary decrease in the force of the blood stream. Third, he had erroneous views as to the value and uses of the blood clot. He thought the clot was a vicious thing, 12 Applied Anatomy: and that it must be got rid of at all hazards before a cure could take place; whereas, it is Nature's method of cure, and must be imitated by any Surgeon who hopes to be successful in the treat- ment of aneurism by ligature, or any other method. Fig. 3. The "Old Operation." There are still, however, certain cases in which the " old oper- ation " is specially useful. It may be regarded as the operation for traumatic false aneurisms, and for this purpose it was revived by Stme, who adopted this method for the cure of a traumatic false aneurism in the axilla, probably the result of rupture of the axUlary artery. Under these circumstances, however, the objections urged against the operation, as performed by Antyllus, disappear. Here the coats of the artery are healthy, and the operation is nothing more or less than carrying out the universal principle — that where possible, the wounded vessel should be tied at the bleeding point. The following cases may be regarded as suitable for this method: — (1) Traumatic false aneurism of the axilla, bend of elbow, gluteal artery, etc. (2) In gluteal aneurisms, not necessarily the result of a wound, in preference to the dangero,us and difficult operation of tying the internal iliac artery. Mr Stme used both methods in gluteal aneurism — one by the " old operation," the other by Sttrgical, Medical, and Operative. 13 ligature of the internal iliac — and both with success. (3) Where an aneurism has been opened accidentally. (4) Where the sac has burst, as an alternative to amputation of the limb. (5) In cases where the diagnosis is uncertain, as, for example, between an aneurism and a pulsating malignant growth ; a diagnostic incision is made into the tumour with the view of tying the artery above and below if aneurismal, and amputating if malignant. (6) The Operation of Anel (1710). — This operation only de- serves a passing notice. It consists of a careful dissection down to the aneurism, and then tying the vessel close to the sac, on the proximal side only, but without laying it open as Antyllus did. It is open to the same objections as those urged against the method of Antyllus (when applied to spontaneous aneurism), and can hardly be looked upon as an improvement on that method : — (1) It leaves no current through the aneurism, and makes no provision for utilising the collateral circulation, and the clot formed is likely to be soft and loose. (2) A diseased part of the vessel is selected for the application of the ligature. (3) It is often difficult from the depth and complicated relations of the sac; and there is a further difficulty in securing the vessel, more especially as there is no certain guide to it, like the probe passed into the vessel through the sac in the method adopted by Antyllus. I ought to mention that the "mMhode d'Anel" occupies the same place in French Works on Surgery as the " Hunterian operation " occupies in English, German, Italian, and American Works — i.e., when a French Surgeon speaks of Anel's method, he means the Hunterian operation. (c) Hunter's Method. — More than one hundred years ago (1785), Mr HuNTBii introduced a method (Fig. 4) which revolutionised the whole question of the treatment of aneurism by ligature. It was the outcome of sound reasoning, founded upon accurate observation of the methods of his predecessors, and the causes of their failures : — (1) He saw that it was necessary to select a sound part of the vessel on which to operate; he therefore tied the artery at some easily accessible point between the aneurism and the heart, but at some distance from the sac, where the coats of the vessel were healthy. (2) He believed that the clot was not an evil thing, as hitherto taught, and that it should not bo interfered with as.it was Nature's 14 Applied Anatomy : method of cure; 'but that its formation and growth ought to he encouraged. (3) He said that to cure an aneurism it was not necessary to check the flow through it completely, hut only " to take the force off the circulation " for a time. (4) He tmsted to the collateral circulation to carry blood to the limb beyond the ligature, and thus prevent gangrene ; but there should he no large vessel Fig. 4. HUNTER'S Method. The arrow shows the direction of the blood-stream. Obsei-ve the double chain of anastomoses — one over the aneurism, the other over the ligature. between the ligature and the aneurism. After the application of the ligature, the cure by blood clot begins, as the force of the stream is lessened, the aim being to produce a temporary obstruction only, and trust to the collateral circulation in the meantime. According to Mr Holmes the Hunterian operation is indicated : — (1) "Whenever an active aneurism is situated upon an artery in- accessible to pressure, but which will allow a ligature to be put Surgical, Medical, and Operative. 15 round it without excessive danger, and with a sufficient space between the part tied and the tumour, e.g., the iliac and carotid arteries. These vessels migM he compressed, but the patient very often cannot bear it. (2) Where the patient from some peculi- arity, constitutional or acquired, is intolerant of the more gradual methods of cure. (3) Where these methods have been tried and failed. (4) Where an aneurism has burst into one of the internal cavities of the body, e.g., a popliteal aneurism into the knee joint. (5) Sometimes when the rupture has taken place subcutaneously. In some cases compression may be tried for a short time, but if it is not successful amputation or the ligature is indicated. According to the same authority it is contra-indicated : — • (1) In aortic and innominate aneurisms, as ligature here has always been fatal. Try medical treatment first, and only have recourse to ligature as a last resort, when medical treatment fads, or if the sac is about to burst or has burst. (2) In an artery so situated as to admit of compression, unless it has been tried and failed, or is contra-indicated. (3) In recent traumatic aneurisms, especially when caused by fracture, without a previous trial of the resources of Nature aided by rest, position, and pressure, direct or indirect. (4) In extensive disease of the heart and arterial system : in such a case digital compression is the best and safest. (i) Another method of ligature was suggested by Bbasdor (1721-1799), although to Waedeop (1822) belongs the credit of having first performed the operation, viz., that of tying the artery on the distal side of the aneurism. It is chiefly applicable in cases of aneurism at the root of the neck, and was originally intended for aneurism at the lower part of the common carotid, or aneurisms that hold an intermediate position (as regards treat- ment) between the Physician and the Surgeon. It has also been used in innominate aneurisms, where a cure was attempted either by tying both its branches simultaneously, or by tying the right common carotid first, and then, if necessary, the subclavian some weeks or months later. In cases where it is judged expedient to adopt this method in innominate aneurism, the common carotid should be first secured, as it is found that in cases of natural cure this vessel is the first to be obliterated. It has further been tried in mixed innominate and aortic aneurisms, and in pure aortic. 16 Applied Anatomy : A distinction is sometimes drawn between the methods of Brasdor and Wardrop. Brasdoe's operation is ligature of the main trunk heyond the aneurism, e.g., the common carotid in aneurism at its lower part (Fig. 5) ; whereas "Wahdeop's operation is ligature of one or both of the main branches, e.g., the common carotid, or the subclavian, or both, in innominate aneurism (Fig. 6). Fig. 5. Brasdor's Method. Fig. 6. Wardrop's Method. Ligature. Ligature--*'' -Aneurism. "*' Ligature, The arrows show the direction of the blood-stream. II. COMPRESSION. — This may be applied, either to the aneurism directly, or to the main artery on the proximal side of the aneurism :— (a) Direct pressure {i.e., on the aneurism itself) is a method not often used, and is objectionable in many ways (1) It is apt to cause sloughing and possible rupture of the sac. (2) If this method be worth retaining, and if it be used as a means of cure, the pressxire to be efficient must, to a great extent, empty the sac of blood and keep it so, in the very nature of things j but if this is the case, then the chief factor in the formation of the blood Surgical, Medical, and Operative. 17 clot is atsent, viz., blood, and it is difficult to see how a cure can be effected under these circumstances. (3) It puts the cart before the horse, as it were, or reverses the order of Nature ; for it aims at causing contraction of the sac as a primary thing, whereas we have already seen, in discussing the spontaneous cure of aneurism by coagulation, that the contraction of the sac follows as a secondary result upon the contraction of the fibrin of the blood clot. (6) Indirect pressure (i.e., pressure on the main artery on the proximal side of the aneurism) may be applied in various ways ■ — (1) Digital, by relays of well -trained intelligent assistants, taught how to apply a proper amount of pressure, and in the proper direction. It is, as a rule, simple, easy, painless, and rapid, and statistics of results are much better than those of ligature. Pressure is further useful in many cases, e.g., in the femoral, even though the vessel may have to be ligatured afterwards, as it opens up the collateral circulation, and for this reason gangrene is less likely to follow the operation. In some cases, however, it is very painful, so that the patient must be kept under the influence of an ansBsthetic. (2) Instrumental, as Carte's tourniquet, or P. H. "Watson's weight-compressor for the femoral artery in the groin ; Skbt's or SiGNORONi's tourniquets for the brachial artery; and Lister's for the aorta or common iliac arteries. Whatever method be employed there must be no circular compression of the limb, and the pressure ought, if possible, to be elastic. (3) Flexion, (Hart) may sometimes succeed in curing aneurism situated at the bend of the limb, and on the superficial aspect of the artery, e.g., in the popliteal space and in the space in front of the elbow joint. The limb is bandaged in acute flexion, and the patient is kept in bed with restricted diet. This method may be used when the aneurism is — (a) in the flexure of a joint ; (6) not of large size ; (c) when the coverings of the sac are free from inflammation ; {d) when the joint is not involved; (e) when the aneurism is on the superficial aspect of the circumference of the artery; (/) occasion- ally when other means, such as ligature or instrumental compression, fail. (4) Esmarch's bandage (Ebid). This combines the effects of direct pressure, and the total stoppage of the circulation. Supposing the aneurism to be in the popliteal space, we are directed to bandage the limb from the toes up to the popliteal space pretty firmly, then 18 Applied Anatomy : pass very lightly over the sac, or leave it free altogether, as we do not wish to empty it of blood, and then tighten again as we ascend the thigh, and finally fasten it by an elastic tube. It should be applied under anaesthesia, and kept on for one or two hours ; and after removal digital compression must be kept up for some time. It is to he MsecZ— (1) In cases where we hope to cure the aneurism at one sitting, i.e., in small and recent aneurisms. (2) Where com- pression and flexion have failed. It is not to he used — (1) Where there is any danger of the sac bursting; (2) where the aneurism is large and rapidly increasing ; (3) where there is serious venous obstruction ; (4) where the aneurism is inflamed. The dangers of this method are — (1) Eupture of the sac ; (2) gangrene of the limb; (3) increase of pressure thrown upon other arteries and on the hearty especially dangerous in some forms of heart disease as, for example, fatty degeneration. III. MANIPULATION. — The sac is manijDulated so as to break up the fibrinous clot, and part of the broken up clot is displaced, with the intention of plugging the artery on the distal side of the aneurism (Sir W. Feegusson). In the case of aneurism of the vessels at the root of the neck it is a very dangerous and difficult proceeding and has been followed by hemiplegia, from plugging of the middle cerebral artery. In the limbs it is less dangerous. IV. COAGULATING INJECTIONS.— This method can only be employed in situations where the blood current can be arrested by pressure above and below the sac, say for one hour at least after the injection, and therefore it cannot be applied in cases of innominate, aortic, or subclavian aneurism. The dangers are inflammation and abscess, and occasionally embolism. It may be used after apply- ing Esmarch's bandage, as in Dr Ebid's method of compression, and then injecting neutral ferric chloride or the fibrin ferment into the sac. V. INTRODUCTION OF FOREIGN BODIES into the sac, e.g., fine iron wire or horse hair, through a small eanula or hollow needle. This is supposed to hasten the formation of, and entangle the fibrin of the blood, in the same way that drawn blood is defibrinated by whipping it with a bundle of twigs. It has been used in some cases of aortic and subclavian aneurism.s. Surgical, Medical, and Operative. 19 VI. GALVANO-PUNCTURE (Dr John Duncan).— This may be used in some cases of internal aneurism, or aneurism at the root of the neck where other operations are contra-indicated. At the + pole the clot is hard, small, and firm, oxygen is set free, iron salts are produced, and the fluid round the needle has an acid reaction. At the — pole the clot is soft, loose, large and frothy, hydrogen is set free, and the fluid round the electrode has an alkaline reaction, caustic potash being produced ; although the clot produced is not so firm as that at the positive pole, its effect in cauterising the tissues is much more marked. Both poles may be introduced into the sac at some little distance from each other, or the + pole alone may be inserted, while the other pole is made to rest on a broad, flat, moist sponge, on some other part of the body. In this way the tissues near the — pole are not cauterised, as the broad sponge forms, as it were, a wide door through which the electricity can pass under low pressure, just like the broad copper plate which should always form the ground termination of a lightning conductor. The needles should be insulated almost to the very point. Use a weak continuous current for ten or twenty minutes at each sitting. The same precautions must be adopted as in the introduction of coagulating injections, lest it give rise to fatal embolism. The objections to its use are — (1) That it only produces a soft coagulum, which is apt to melt, and the cure is thus rendered uncertain ; (2) it is liable to set up severe inflammation of the sac and its contents; (3) the needles may produce eschars at the points of their insertion, and thus give rise to secondary hsemorrhage. In the treatment of aneurismal varix, operation is seldom called for, as there is no true aneurism, and the disease has but little tendency to spread. It is chiefly a dilatation of veins, and it rarely tends to rupture or ulcerate — except in the lower ex- tremity where it may extend and occasionally ruptures, giving rise to fatal hsemorrhage, in the same .way that varicose veins occasionally do. This condition may exist for the greater part of a life-time with but little change, especially in the upper extremity; and the rule is that if it is npt advancing it should be left alone, so far as any operative measures are concerned. All that requires to be done is to give support to the distended vessels by IMartin's bandage, elastic or laced stockings, etc. The different 20 Applied Anatomy : operative measures recommended for radical cure are — (1) Indirect pressure, digital or instrumental; (2) flexion; but both these plans are probably of little use as there is no distinct sac, and therefore little tendency to the formation of a proper coagulum as in aneurism ; (3) injection of coagulating fluids; (4) ligature of the artery above and below its communication with the vein. If aneurismal varix occurs within the skull, it may be necessary to resort to the Hunterian method, and ligature the common or internal carotid. The Treatment of a Varicose Aneurism must be conducted on different principles. Here there is a constant tendency to increase in size, and it must not be left to take its own course as it will either become diffuse through the limb, or ulcerate and give way externally. Various methods have been proposed for its cure — ( 1 ) The " old operation," as in ordinary false aneurism answers very weU, especially if it is done early enough, before the coats of the vessel have become so altered that they will not bear a ligature. Mr Symb treated ten cases in this way — ■"■ Opening the sac and applying ligatures on both sides of the aperture.'' Some recom- mend that the sac should not be opened, but simply isolate the artery and tie it above and below (Eoux, Fbrgusson). In either case the special dangen's are — (a) Haemorrhage from the part of the artery above the sac; (&) gangrene of the limb below the sac. (2) Injection of coagulating fluids, such as a weak solution of neutral ferric chloride, with the usual precautions; (3) com- pression, direct and indirect; (4) galvano-puncture; (5) expectant, i.e., do nothing; (6) amputation. The Treatment of Cirsoid Aneurism requires great caution as the methods usually adopted often fail directly, or though for a time apparently successful, yet relapses are very frequent, and occasionally even a fatal termination has followed operations undertaken for the relief of this condition. Undoubtedly the best method of treatment is that introduced and perfected by Dr John Duncan of Edinburgh, viz. — electrolysis, or galvano-puncture. Dr Duncan, who is probably the greatest authority on the subject of electrolysis in the treatment of aneurism, nsevi, etc., has used this method with remarkable and unvarying success for very many years. The cure is produced in two ways^(l) By coagulation of the blood; (2) by cauterising the walls of the arteries. The Surgical, Medical, and Operative. 21 coagulant in this case is in small amount, finely divided, and in tlie nascent state; coagulation is principally caused by the positive pole, the cauterising action by the negative. The advantages are — (1) That it leaves no scar; (2) that the effect can be very easily graduated, for the amount of hardening can be felt as the operation proceeds. It is important not to allow the points of the needles to approach the skin too closely lest it be cauterised and produce sloughing, which wUl not only leave a scar, but also forms an inlet for the admission of septic organisms, which will lead, unless great care be taken, to breaking down of the blood clot. Many other measures have been tried, but, on the whole, with little success; some of these may be enumerated — (1) Compression, a very doubt- ful proceeding; (2) ligature of the branches passing to the affected part, usually unsuccessful, on account of the free anastomoses; also ligature of the arteries on both sides of the mass; (3) extirpation en masse, by knife or ligature; (4) injection of coagulating fluids, which may at one time cause sloughing and at another be absolutely without effect, and is, therefore, on the whole, unsatisfactory. 22 Applied Anatomy : CHAPTER III. LIGATURE OF ARTERIES IN CONTINUITY. THE ANATOMY OF AN ARTERY. Coats. — 1. Tunica interna, or internal coat — (a) A single layer of flattened endothelial cells lining its lumen, which gives to it its smoothness, and serves to lessen friction; (6) a suh-endothelial layer of delicate connective tissue, with cells, especially marked in the larger arteries; (c) an elastic layer, either in the form of a loiigitudinal elastic network, or else as a perforated membrane (the fenestrated membrane of Henle). The internal coat is very easily broken across, especially in the transverse direction, and the broken edge shows a great tendency to curl inwards ; this coat may be ruptured without rupture of the external coat, and when this is the case the edges curl inwards, a blood clot forms, the flow through the artery is checked, and finally, " organisation " of the clot, and complete obliteration of the vessel, takes place. 2. Tunica media, or middle coat, consists of bundles of non- striped niuscular fibres disposed circularly round the vessel, with a certain proportion of elastic fibres. In passing from the larger to the smaller arteries the proportion (in thickness) of the muscular fibres increase in comparison with the calibre of the vessel; but in passing from the smaller to the larger the proportion of elastic tissue increases, and hence in the aorta it is very well marked. This coat is very easily torn by any force that compresses the artery transversely — such as a ligature-;-or that stretches the vessel longitudinally. Both the internal and middle coats are divided when a ligature is applied tightly roimd the artery. The contractility of arteries depends on the middle coat, and is most marked, therefore, in the small arteries. Surgical, Medical, and Operative. 28 3. The Tunica adventitia, or external coat, consists of a closely- felted layer of white connective tissue, with a varying proportion of longitudinally disposed elastic fibres, which are specially seen towards the inner part of the coat, next the muscular fibres of the tunica media, in arteries of medium size. The arteries within the cavity of the cranium and spinal canal have very thin walls, chiefly due to the thinness of their external and middle coats. The Arterial Sheath. — In most parts of the body the arteries are enclosed in a sheath of connective tissue, to which the external coat is but very loosely connected by filaments of fibrous tissue, and' the sheath itself is but loosely attached to the surrounding structures. The arteries within the cranial cavity, and the first part of the aorta possess no such sheath, and this explains why aneurism of these vessels burst so very easily — coupled with the thinness of the coats of the intra-cranial vessels. Some arteries, such as the common carotids and femorals, have special sheaths in addition to the usual sheath, a fact which the student is perhaps apt to forget when tying these vessels for the first time. All the facts above enumerated have important bearings on the natural arrest of Tioimorrhage, the only means at present open to many of the lower animals. What takes place when a Medium-Sized Artery is completely cut across? — (1) The artery contracts, because of the circular dis- position of the muscular fibres, under the stimulus of the knife. (2) It retracts within its sheath from the elasticity of the longitudinally disposed elastic fibres in its various coats, and, in some cases, from the presence of longitudinal contractile fibre-cells. This retraction is permitted on account of the loose connection between the tunica adventitia and the sheath. (3) The sheath being now empty for a little way, falls together or collapses, and this leads to the formation of (4) the " external " clot, which temporarily seals the vessel. This collapse of the sheath is permitted because of the loose connection between it and the surrounding tissues. In many cases of severe hajmorrhage, which would not otherwise cease, cardiac syncope occurs, and this gives time for the formation of an external clot which seals the vessel for the time being. There is a great risk, however, unless the vessel is otherwise secured, that when the 24 Applied Anatomy : heart regains its vigour, the clot will be forced out, giving rise to " reactionary heemorrhage." If this does not take place, then (5) the " internal clot " is formed, which is pyramidal in shape, and extends up the hore of the artery for a short distance. The internal clot (houchon), and that entangled in the sheath (couvercle), together with the clot outside all round the severed end of the artery, has been likened, hy Professor Gross, to a glass stopper fitted into a decanter (Fig. 7). FiuaUy, the whole organises both inside and outside the artery, and also in the tissues around, and thus the perfect sealing is completed. Fig. 7. Spontaneous Arrest of H/emorrhaqe. Arterial Sheatli WaUof Ai-teiy. Intei-nai Clot. The Result of Partial Division.— (Fig. 8).— In this case the vessel can neither contract nor retract perfectly, and the attempts at contraction only serve to open up the wound transversely, while Fig. 8. Wounded Artery. 'Mlllriilillliliilli iNbiiillimilliihiillililliiiill !■ jliiiiliL/ the attempts at retraction open it up longitudinally, so that the vessel, even though small, goes on bleeding, and may even lead to 9, fetal ternjination (Fig. 9). Here, therefore, the means intended Surgical, Medical, and Operative. 25 by Nature to be unto life are found to be unto death, because they are perverted; the proper treatment for such a case is to sever the vessel completely. Fig. 9. Wounded Artery. i To show how the attempts at contraction and retraction open up the wound. The Effect of Previous Chronic Inflammation. — The effect of this is — (1) To cause adhesion between the sheath and the tissues around ; and (2) to cause adhesion between the outer coat of the artery and the sheath ; hence, therefore, the vessel can neither contract nor retract, nor could the sheath collapse even if the vessel did retract. The result is two-fold — the bleeding is very free when operating through such tissues, and is exceedingly difficult to check, as the vessels to be tied are exceedingly numer- ous, and cannot be caught by the forceps in the usual way, as the coats are so softened and brittle that they break down. In this case it is often necessary to include a portion of the surrounding textures with the artery in the noose of the ligature, and this is best accomplished either by means of the old tenaculum, or else by a curved needle, threaded with catgut or fine carbolised silk. In cases of machinery accidents, the absence of bleeding is due to a different cause ; in such cases the vessels are twisted, and the inner and middle coats retract and turn inwards into a kind of valve, which effectually prevents haemorrhage, while the outer coat is drawn out into a fine point. In like manner, the much despised and maligned cat secures the umbilical vessels of her numerous progeny, by combined chewing and tearing ; in this way also, the old-style farmer controls the bleeding when castrating certain domestic animals, for, after having cut through the tunics of the testicle, he seizes that organ between his teeth and tears it out. The Vessels and Nerves of Arteries. — The vasa vasorum are distributed to the outer coat of the artery; they are chiefly found 26 Applied Anatomy: in connection with, the sheath of the vessel which they perforate, and then divide into smaller branches between the sheath and the vessel, before ending in the outer coat. The neroes form fine plexuses in which minute ganglia are sometimes found; they penetrate as far as the middle coat, to the muscular tissue of which they are chiefly distributed. In arterial haemorrhage the blood is bright red, forced out in a jet, and 'per saltum, and pressure on the proximal side retards or stops the flow : but if the patient be inhaling ether or nitrous oxide gas the blood will be dark, and if the blood flow along a narrow sinuous wound the jetting character will be lost. In venoiis hemorrhage there is a rapid flow of purple or black blood in a continuous stream, and pressure on the distal side retards; but if the blood be exposed for a short time to the air it rapidly becomes red. Capillary hsemorrhage is recognised by an oozing of bright blood from the whole surface of the wound, and not from special points. MATERIAL OF LIGATURE. For a long time a single thread of strong waxed silk was the substance used. It was "waxed" to make it less slippery, and therefore more easily tied, to prevent the knot slipping after it was tied, and, lastly, and most important, to make it non-absorbent. Usually one end of the ligature was cut close to the knot, and the other end left hanging out at the corner of the wound, and fixed there by a small piece of plaster; at the end of ten days or a fortnight, or more, as the case might be (depending on the size of the artery tied), when the healing process was completed,- the ligature was pulled away. The security of the vessel was first ascertained by gently twirling the thread between the finger and thumb, when a yielding sensation indicated that the process was complete, and that the ligature might be safely removed without- the risk of secondary haemorrhage. Sometimes both ends of the silk ligature were cut short, and, in rare instances, it became encapsuled and gave no further trouble. The chief objections to the silk ligature are— (1) It is a foreign body in the wound ; and (2) it separates by a process of ulceration or sloughing : a ring of granulations form on each side of the noose Surgical, Medical, and Operative. 27 and cut it off in the same way that the "line of demarcation" is formed in gangrene, and, when the separation is complete, the portion of the vessel included in the noose is brought away with the ligature as a small slough. For both these reasons the silk ligature is opposed to primary union, and may lead to complete or partial failure of the " organisation " of the clot, and the other processes necessary for the permanent sealing of the ligatured artery. It is true that in favourable cases the lymph and clot organise, and the divided internal and middle coats are blended together by firm fibrous union before the external coat is ulcerated through, and in this case there is no danger of secondary hsemor- rhage. In other cases, however, the ulcerative process extends faster than the healing process, and involves the clot, which then breaks down,. and there is thus a complete or partial failure of the organising process, followed by secondary hsemorrhage when the ligature separates. Hence, in using the silk ligature there was always an uncomfortable feeling of uncertainty as to the final result, which only disappeared when the ligature had separated and the wound healed. Many operators, however, stUl use the silk ligature in securing the main artery of a limb, as in amputations ; the sUk is first boiled in a 1 in 20 solution of carbolic acid and kept in a solution of the same till required. This is known as carbolised silk, and as thus prepared is non-irritating, and either becomes encapsuled or ultimately absorbed. In septic cases, however, it is probably better to use non-absorbent material, as horse-hair, silver wire, or silkworm gut. jSText came the catgut ligature, introduced by Listbe, and for a time seemed all that could be desired ; but by and by it was put aside because it sometimes disappeared before the vessel was perfectly sealed, and secondary hasmorrhage was the result, or the knot slipped, and, further, if the wound became septic so did the ligature, and again the result was haemorrhage. It has, however,- been again revived, and is now used, but only after special prepara- tion. At first it was prepared by being soaked for some months in carbolic acid, and the longer it was soaked the better it became ; but it was found inconvenient to use a method of preparation that extended over such a lengthened period, hence the process now adopted is to soak it in a weak solution of chromic and carbolic 28 Applied Anatomy : acids for a couple of days, after which, it is removed, stretched, and dried, and preserved in carbolic oil ready for use as required. The catgut is gradually absorbed, as the process of healing is completed, by the white blood corpuscles or the granulations, and its dis- appearance is not accompanied by ulceration. In cases, however, of septic wounds catgut should not be used; it should be remembered, too, that catgut itself may be septic, and be the means of inducing septic processes in the wound. Other materials have also been used with success, such as the middle coat of the aorta of the ox, cut into thin strips, and stretched to deprive it of excessive elasticity ; it is kept in earbolised gauze, and before use it is steeped in carbolic oil to render it pliable. The small tendons from the tail of the kangaroo are used for a similar purpose, and have the advantage of not requiring any previous preparation. In using the ox aorta ligature and the kangaroo tendons, the artery is compressed very gently and tied with a strong knot. This method is said to be specially applicable in cases where there is a serious risk of secondary haemorrhage, e.g'., near large branches, as in tying the first part of the subclavian, as the internal and middle coats are not divided unless the ligature be drawn very tight, and, further, it lasts much longer than even chromic acid catgut, and is therefore to be specially recommended in circumstances when, for special reasons, the artery must be tied at a place where its coats are diseased. SPECIAL POINTS IN REFERENCE TO LIGATURE. The chief points to be attended to in the ligature of arteries are the following; — 1. To select a proper point for the application of the ligature, (a) It must not be too near the aneurism, because there the coats of the vessel are diseased; (6) it must not be too far away from the aneurism, for then the collateral circulation will be too quickly re-established through the sac and prevent the formation of a proper clot; (c) it must not be too near a large branch, for then the rush of blood would prevent coagulation at the point of ligature, and the other processes necessary for the organisation of the clot, and would ultimately give rise to secondary hsemorrhage when the ligature separated. Surgical, Medical, and Operative. 29 2. To have a thorough knowledge of the general course and relations of the vessel, the more common ahnormalities, as well as the recognised superficial and deep guides, in order to be able to mark out the vessel's course on the surface of the body ; in short, the limb or other part being operated upon ought to be tramparent tb the Surgeon. 3. To make a free incision through the skin, and an equally free dissection down to the sheath of the artery, so as to lessen the depth of the wound as much as possible. Do not look for the artery in the first instance, but search for the various "rallying points" one after the other, and the vessel will be reached in due time. The integument is to be gently stretched, without displace- ment, by the fingers of the left hand, and all large superficial veins avoided in making the first incision; the position of any large super- ficial vein is best brought out by arresting the flow through it by pressure on the cardiac side, e.g., the external jugular by pressing at the root of the neck, and the long saphenous by pressing a little below Poupart's ligament. A sharp scalpel should be used, and its point made to enter and leave perpendicularly to the surface to avoid "taiHng." Twist or tie all bleeding vessels as you proceed, and above all things never hurry, but cut through layer after layer of the tissues covering the vessel, to the full extent of the original incision, in a calm and deliberate manner, carefully examining every layer with the eye and finger before cutting it; but at the same time avoid lateral dissections as far as possible. 4. Make a very limited opening in the sheath. Having cleared the sheath carefully from the structures covering it by means of the finger or director, take hold of it with the forceps and pinch up a small piece into the form of a cone, off the artery, and then cut into this cone by means of the scalpel, held flatwise, with its edge away from the vessel, and on a plane just superficial to it. Take hold of that side of the opening in the sheath furthest from you by a pair of Plan's, or the ordinary toothed forceps, in order not to lose sight of the opening, and take hold of the other edge with your dissecting forceps and clear a portion of the artery just sufficient to pass the point of the aneurism needle below the vessel. The clearing of the vessel well is one of the most important points of the operation. It should be cleared by means of the scalpel and 30 Applied A iiatomy : forceiDS till the white external coat of the vessel comes into view, the hack of the knife in the meantime heing directed towards the artery; the opening in the sheath should he about one quarter of an inch above, and one sixth of an inch below. Too free separa- tion of the sheath from the artery will endanger the vitality, of the latter by the destruction of the vasa vasorunj, which pass from the sheath to the coats of the artery; but, on the other hand, a small channel must be cleared thoroughly in order to pass the armed aneurism needle easily. 5. On no account lift the vessel from its bed, as to do so would endanger its vitality, by destroying the delicate vasa vaso- rum, and pave the way for sloughing of the vessel and secondary hivmorrhage. The aneurism needle, with or without the ligature, is passed through the aperture in the sheath and gently insinuated round the vessel till its point is just yisible on the other side, and then the ligature is seized and drawn out by a pair of forceps, while the needle itself is gently withdrawn. The handle of the needle must on no account be depressed, as this would raise the vessel from its bed ; also great care must be taken not to slide the ligature up and down the artery, as in both cases the vasa vasorum would be destroyed. The vasa vasorum run for a little way in the sheath before entering the wall of the artery, and this probably explains why it is that in secondary hsemorrhage the blood most frequently comes from the distal side of the ligature; and the better nutritive supply on the proximal side, explains why that end of the vessel is more firmly occluded than the distal end. The needle should be passed from the side where the chief danger exists, and this, in large arteries, is usually the vein — a noteworthy exception to this rule is seen in the case of the third part of the subclavian. In cases where the artery is accompanied by two veins the needle should be passed from the side on which the nerve is placed. Many text-books recommend that the needle should be passed unarmed, except in the case of deep-seated arteries, as the iliacs; it certainly passes more easily unarmed, but I do not think the question is one of great importance. 6. Before finishing this part of the operation, compress the artery between the finger and the curve of the aneurism needle, in order to make sure that no other structure, such as a nerve, for Surgical, Medical, and Operative. 31 example, is included in the ligature as well as tlie artery, and note at the same time if this pressure stops the pulsation in the artery or sac beyond — this precaution is specially necessary in tying the subclavian in its third part. Carefully avoid in any way injuring the veins. 7. The ligature must be tied transversely. round the artery, because if placed obliquely the knot tends to slacken. In tying press down the knot with the tips of the forefingers, as over pulleys, and draw the noose moderately tight so as to divide the internal and middle coats of the vessel, and then tie again forming a reef knot, or what is probably better, use the double hitch or surgical knot, i.e., put the first loop twice through before tightening. After tying a silk ligature one end is cut off close to the knot on the vessel, while the other is left hanging out of the Avound ; if catgut be used, then both ends are cut off close to the knot. Methods of Holding the Knife. — (a) Lil-a a Pen: the position of "lightness and j)recision," the method often adopted in ligature of arteries, where the incision required is not of great extent, the hand resting on the neighbouring parts. (6) Like the Bow of a Violin: the position of "nicety and precaution." This method gives a greater range of motion, but the hand must be firm and steady, as it cannot be "rested." (c) LiJce an ordinary Dirvner- knife: the position of "firmness and strength," and used where greater force is required. In opening fascite and aponeuroses upon a director, the knife is used with reversed blade. Position of the Patient. — The patient at first is placed in such a position as to render prominent the anatomical guides to the artery — usually therefore one of extension — but afterwards, as the artery is approached, the parts must be relaxed by flexion, so as to give the operator more room. Eefore concluding this section, I ought to mention that many Surgeons adopt a slightly different method of procedure from the one above described : — 1. The knife is held like a pen, while the hand rests on the neighbouring parts; it is made to enter the skin with this inclin- ation, but is gradually made to approach the perpendicular as the incision is completed. 32 Applied Anatomy : 2. A steel director is nmch used: upon this deep fasciae and aponeuroses are divided, and it is further to he used to separate muscular interspaces, and also to separate the artery from its sheath. 3. When the sheath is opened the knife is to he laid aside and the vessel cleared by the director and forceps alone. I may here say that if a director is to he used at all to clear the vessel, the most convenient form to employ is, not the straight steel director, but the ordinary German silver one, with a short curve at the lower end, the concavity of the curve being turned towards the grooved side (Fig. 10). Fig. 10. The Director. 4. The aneurism needle is to be passed unthreaded, and any tissue preventing the easy passage of its point round the artery, is to be scratched through with the thumb nail, or the scalpel cutting against the needle with the edge away from the artery. Should the director I have figured be used, the best way to pass it is as follows: — A small opening having been made in the sheath, the external edge of the opening is to be grasped by a pair of ordinary catch forceps (Pean's forceps will do. equally well), and given to an assistant, while the operator seizes the edge next himself with the dissecting forceps ; gentle traction should then be made, and in this way, the posterior part of the sheath is gently stretched between the two pairs of forceps, and is thus steadied and prevented from rolling and doubling before the point of the director, the curved part of which then slips round the artery very readily. "When the point appears at the other side, the edges of the opening in the sheath are let go, the Surgeon takes the aneurism needle and lays its point into the groove on the director, withdraws the director, and at the same moment carries the needle round the artery, so that as the director retreats it carries the needle with it. The needle is then threaded and withdrawn, and the ligature tied in the ordinary way. Surgical, Medical, and Operative. 33 COMPLICATIONS AND THEIR TREATMENT. The chief unfavourable results that may ensue from this operation are: — (1) Continuance or return of the pulsation in the sac from misapplied or badly applied ligature, e.g., placed obliquely instead of transversely, or from the presence of a vas aberrans, or from a too free collateral circulation, or when the ligature is applied at too great a distance from the sac. (2) Formation of another aneurism at the next weakest point of the vascular system. (3) Gangrene of the limb, from the third to the tenth day, due to the too tardy establishment of an adequate collateral circulation to keep up the vitality of the limb beyond the aneurism, or from injury to the vein. (4) Suppuration and sloughing of the sac. (5) Hcemm'rhage when the ligature separates, from disease of the coats, or sloughing of the included portion of the vessel before the ends have become permanently sealed by the reparative process ; this may be caused by lifting the vessel from its bed or sliding the ligature up and down, and in this way destroying its nutritive supply. The treatment after the operation should be mainly directed to avert the tendency to gangrene. The limb should be surrounded by a thick layer of carded wool to keep up its temperature, and elevated to assist the venous return. The diet should be moderately nourishing and easily digested, with the judicious use of opium, which not only soothes the patient, but also dilates the small arteries and capillaries, and thus assists the establishment of the collateral circulation. On no account should artificial warmth, in the form of hot bottles, be applied to the limb, as this would only hasten the gangrene. 34 Applied Anatomy : CHAPTER IV. ANEURISM OF THE THORACIC AORTA. Although this part of the aorta, for oh'vious reasons, is never tied during life, still aneurism in some part of its course in the thorax is, unfortunately, the most common of all forms of aneurism, and a knowledge of its relations to the surrounding structures is absolutely essential in order to interpret the leading symptoms. To point out these relations, therefore, and the chief untoward effects likely to he produced when these relations are disturbed by disease, will form a fitting introduction to the subject of ligature of special arteries. There are many reasons why aneurism should be so common here: — (1) It is much curved; (2) it gives off large branches ; (3) the first part of the arch has no sheath, and the rest of the thoracic aorta is but feebly supported ; (4) the jet of blood driven against its upper wall at each systole is apt to bulge the coats at that point ; (5) sudden variations in pressure according to the state of the heart ; (6) the aspiration of the thorax afiecfcs it, for as the chest enlarges the vessel tends to expand. FIKST, OR ASCENDING PART.— It arises from the base of the left ventricle at the level of the sixth dorsal vertebra behind, and the third left costal cartilage in front. From this point it passes upwards, to the right, and forwards, and touches the sternum at the upper border of the second right costal cartilage. This part of the arch is contained in the fibrous pericardium, and is surrounded by a tube of the serous pericardium common to it and the pulmonary artery before its bifurcation ; this depends on the fact that both vessels are developed from the hulbus arteriosus (truncus communis arteriosus) of the embryo. Relations. — In front — Pulmonary artery, pericardium, right auricular appendix, Surgical, Medical, and Operative. 35 and chest wall. Behind — Eight pulmonaTy vessels and right hronchus. To its riajht side — Superior vena" cava and right auricular appendix. Left side — Pulmonary artery. SECOND, OR TRANSVERSE PART.— This part extends from the second right costal cartilage, passing transversely to the left, and backwards, to reach the left side of the body of the fourth dorsal vertebra. Relations. — It lies under cover of the left pleura, near its termination. Above — There is the left innominate, vein, and the three large branches of the arch — (a) The innominate artery ; (6) left common carotid ; (c) left subclavian. In front — It is overlapped by the left pleura and lung, and then from left to right by the following nerves — (a) Left vagus giving off its recurrent laryngeal branch; (6) cardiac nerves to the superficial cardiac plexus (left superior cervical of the sympathetic, and inferior cardiac of left vagus) ; (c) left phrenic, crossing in front of the other nerves. Below — Pulmonary artery bifurcating, the obliterated ductus arteriosus connecting its left division with the aorta, superficial cardiac plexus, left recurrent laryngeal nerve and the left bronchus. Behind — Bifurcation of the trachea, deep cardiac plexus, left recurrent laryngeal nerve, oesophagus and thoracic duct. THIRD, OR DESCENDINQ PART.— Extends from the lower border of the left side of the body of the fourth dorsal vertebra, to the lower border of the left side of the body of the fifth dorsal vertebra. Relations.- — In front, ^ei left pleura and lung, and partly also the root of the lung. It lies against the vertebral column, and to its right side, but on a plane anterior to it, we have the oesophagus and thoracic duct, while on the left side it is covered by the pleura and lung. SYMPTOMS AND DIAGNOSIS. . The general means at our disposal for the diagnosis of aneurism of the aorta in the thorax, as well as its probable position, have been divided into direct and indirect. Fortunately this differ- ential diagnosis as to the part affected, guides the special prognosis more than it modifies the treatment. The direct means of diag- nosis include inspection, palpation, percussion, and auscultation. 36 Applied Anatomy : Inspection may discover a bulging which may or may not pulsate, or heave. Palpation may show that the pulsation is expansile and not a mere upheaval, and may also detect thrills. Percussion indicates an increased area of dulness, and also the shape of that area, and its probahle relation to the heart and great vessels. By Auscultation we may hear the normal cardiac sounds very clearly in the sac, though they may be less clear between the sac and the heart; and valvular murmurs may 'also be well heard, being transmitted by the blood current. At times also local murmurs, produced in the sac, usually systolic iii time, are heard. A very common effect of aneurism of the arch is to produce accentuation of the second sound in the aortic area. The indirect evidences are derived from the pressure effects on surrounding structures. 1. The (Esophagus, causing difficulty in swallowing, especially of solids; on auscultating over the course of the oesophagus behind, delay in the transmission of the bolus may be detected. It may also be displaced to one side. 2. Thoracic Duct, producing rapid emaciation, ansemia, and sometimes ascites, the fluid poured out resembling chyle. On account of the pressure on the duct, the lymph and chyle that it normally conveys from the intestines to the blood is lost to the body, so far as nutrition is concerned, and hence the emaciation, on account of this great loss of fat, which may be discovered in the stools, causing fatty diarrhoea. 3. Heart and Blood Vessels. — The heart may be displaced and its movements impeded, causing palpitation and other signs of heart disease; the arteries are usually imperfectly filled, and therefore show diminished tension, and there is also delay in the transmission of the pulse wave. This accounts for the difference in strength between the two radials, and the want of synchronism usually observed in these cases ; these changes are best shown by the sphygmograph. The veins are over-filled, hence the oedema. 4. Respiratory Organs. — When the trachea is pressed on, the patient has a feeling as if he were being throttled, the respiration is noisy, and on auscultation a leopard-like growl may be heard ; this feeling is increased by exertion and excitement — this is an important aid in the diagnosis of aneurism from ordinary tumours. Surgical, Medical, and Operative. 37 There is a peculiar liarsh, brassy cough, like the cry of a gander, but no expectoration, unless there is ulceration present, when there will probably also be htemoptysis; the respiratory murmur will be feeble in both lungs. If only one bronchus is pressed upon, the symptoms wiU be somewhat similar but confined to one side ; there is also very frequently a harsh snoring or wheezing heard over the part pressed on, from the alteration produced in the size of the tube. There are no crepitations, nor is the vocal resonance increased, and therefore it differs from pneumonia. When the Pulmonary AHery is pressed on, the symptoms resemble those of asthma. From this, however, it may be distinguished by the fact that it is bad day and night, that atmospheric conditions do not specially affect it, and that it is relieved by the patient assuming a certain position. 5. Nerves. — When nerves are aifected we must distinguish two stages — (a) A stage of irritation, motor or sensory; and (h) the stage oi paralysis. In se/nsm'y nerves there is at first severe shoot- ing pains, spreading in various directions along the nerve and its communications; this may be followed by complete or partial ansesthesia. In motor nerves we first have spasmodic contraction of the muscles they supply, followed, sooner or later, by paralysis. As examples of the above, we have pressure on the cardiac nerves producing severe anginous pains; tha phrenic, first irritated, causing hiccough, later paralysed ; recurrent laryngeal, causing alteration of voice and dyspncea from spasm of the muscles of the larynx during the stage of irritation, later aphonia from paralysis of the same muscles; on the vagus, causing severe anginous pains, irregular action of the heart, nausea and retching, asthmatic dyspncea, and probably inflammation of the lungs; the sympathetic, during the stage of irritation causing dilatation of the pupil, with pallor and coldness of that side of the head and face, from vaso-motor stimu- lation, but later, when the nerve is paralysed, contraction of the pupil, with redness and increased heat of that side of the head and face, from vaso-motor paralysis. It may perhaps be as well, at this stage, to point out that it is only in cases of dyspncea from spasm of the muscles of the larynx, that tracheotomy is followed by any benefit ; if it arises from pressure on the trachea or bronchi by the aneurism, it is of no use. To diagnose the tAvo conditions 38 Applied Anatomy : the laryngoscope should be used: then, if it be due to pressure on the recurrent laryngeal nerve, the abductor will be paralysed^ and the cord of that side will be found in the " cadaveric position," but if due to direct pressure on the air tubes, the cords will be widely abducted during inspiration. Further, in laryngeal dyspnma, the larynx itself moves energetically with respiration, while in tracheal dijspnoea it is stationary. Note, that enlarged bronchial glands may cause spasm of the glottis, as from tubercular, cancerous, or lymphadenomatous affections. 6. Bones are eroded and absorbed, and during the absorption there is severe pain^ which is sometimes mistaken for rheumatism. The pain in the earlier stage is usually lancinating, intermittent, and neuralgic in character, and is probably due to pressure on the sympathetic or spinal nerves; it radiates in various directions- — left side of head and face, left arm, etc. Later, the pain is more of a burning or boring character, and seems to depend on the absorption of the bony tissue and other compact structures. In the case of the vertebrae it may cause curvature of the spine, and lead to compression of the spinal cord, at first producing symptoms of motor and sensory irritation, gradually passing into paralysis of all the body below the level of the lesion. In attempting to distinguish between solid mediastinal tumours and aneurism, the following points should be kept in mind: — (1) In the case of aneurism the symptoms vary, being worse after excitement or exertion. (2) A solid tumour may have a communicated impulse, but this impulse is never expansile. (3) Solid tumours neither reproduce the heart-sounds, nor do they give rise to sounds of their own. (4) In solid tumours it is very rare to find any difference in the pulses on the two sides of the body. DIFFERENTIAL DIAGNOSIS AS TO THE PART AFFECTED. Ascending Part. — On the anterior aspect it may appear as a pulsating tumour between the intercostal spaces on the right side of the sternum ; there is increased dullness on percussion- to the right of the sternum, and, as the aneurism increases in size, it may compress any or all of the structures in relation to it. In this Surgical, Medical, and Operative. 39 part of the arch the aneurism rarely reaches a large size before it bursts into the pericardium, since this part has no fibrous sheath like other arteries (those of the brain excepted), causing sudden death by by filling it and stopping the heart. It may also open into the superior vena cava, giving rise to a continuous murmur of a peculiar character. Should the aneurism be situated on the posterior aspect, it may give rise to no symptoms except accentuation of the second sound in the aortic area, and delay of the radial pulse. Transverse Part.— When on the convex aspect it tends to pass to the right side of the sternum, or it may present at or above the manubrium sterni in the middle line; the cardiac plexus is frequently pressed on, causing angina-like pains; and the voice is altered from pressure on the left recurrent laryngeal nerve, simulating laryngitis, or, more serious, laryngeal disease. Dyspnoea is an urgent symptom from pressure upon the trachea, bronchi, pulmonary veins, or left recurrent laryngeal nerve; it may also produce cough and haemoptysis, and ultimately burst into the trachea, producing fatal haemorrhage. It may further involve the thoracic duct or oesophagus, and cerebral disturbances are common from interruption of the circulation through the carotid arteries; and when the innominate or left subclavian are involved, there will be weakness and delay of the pulse at one or other wrists. It is very difficult to differentiate aneurism of this part from aneurism of one of the arteries at the root of the neck; but in the case of aortic aneurism the tumour is seen to have no defined lower boundary on percussion. There is usually well-marked oedema, from pressure on the neighbouring veins. Descending Part. — The symptoms are obscure. There is -dull- ness on percussion over the back or front, in both cases to the left of the median line, and later the appearance of a pulsating tumour. There is marked erosion or absorption of the vertebrae, giving rise to severe pain, referred either to back or chest, and radiating round the intercostal nerves of the left side ; pressure on the left bronchus or trachea, and displacement of the left lung; pressure on the cBsophagus causing dysphagia, probably the most distressing symptom of aneurism in this region. To these may be added the symptoms of pressure on the thoracic duct and veins of the chest- wall together with delay of the femoral pulse. 40 Applied Anatomy: THE DESCENDING THORACIC AORTA. This part of the aorta is the direct continuation of the aortic arch, and extends from the lower part of the left side of the body of the fifth dorsal vertebra (Tuenee), lower horder of the fourth (Gbat) to the anterior aspect of the last dorsal vertebra, where it leaves the thorax by passing through the aortic opening of the diaphragm. Relations. — Beliind, it lies against the vertebral column following the dorsal curve; it also crosses the vena azygos minor inferior, and sometimes the vena azygos minor superior. Fig. 11. CESOPHAGUS AND THORACIC AoRTA. 1| ., -CEsophagus. ■ Aoi'ta. In front, it is covered by the pericardium, crossed transversely by the root of the left lung, and very obliquely by the oesophagus. To the right side, we find the oesophagus (at its upper part), vena azyt^os major, and thoracic duct. To the left side, the oesophagus (at its lower part), pleura, and left lung. The relation that the oesophagus bears to the different parts of the aorta in the thorax is worthy of special note (Fig. 11). It lies behind the transverse part of the Surgical, Medical, and Operative. 41 arch, to the right of the descending part; to the right, then in front, and, lastly, to the left side of the descending thoracic aorta. These relations are to he specially remembered in cases of real or supposed stricture of the oesophagus, for both in stricture and aneurism there is marked dysphagia, and it is of the utmost importance to find out on what this depends. Occasionally in aneurism the patient has been treated for stricture of the oesophagus by the introduction of bougies, with the unfortunate and fatal result of perforation of the sac by the point of the instrument. Note. — (1) The aorta in this part of its course, it -vvill be observed, is covered by the left costal pleura; aneurism therefore in this part of the vessel is very apt to burst into the left pleural cavity by a large rent, giving rise to sudden and fatal hsemorrhage (when an aneurism opens on a mucous surface, the rent is seldom large, and death rarely so sudden as when it opens into a serous cavity). (2) The spinal column is pressed upon, the vertebrae are absorbed, and the cord may suffer, causing paralysis of the lower extremities. (3) The root of the left lung passes in front of the vessel, and in the root the bronchus is the most posterior structure; hence this tube is narrowed, the lung therefore is imperfectly filled, and peculiar respiratory sounds are heard on auscultation. (4) The heart enveloped by the pericardium is also in front, and the growth of the aneurism impedes the movements of that viscus, and the disturbance thus caused may simulate heart disease. (5) There is dysphagia from pressure on the oesophagus. (See above, p. 40, and Fig. 11.) (6) The thoracic duct is pressed on and may be obliterated, when there will be marked emaciation from the lymph and chyle lost to nutrition. Although the aorta in this part of its course is not tied by the Surgeon, yet, curiously enough, Nature herself can perform even this operation with success ; for it is by no means uncommon to find the aorta obliterated just beyond the ductus arteriosus, or at the junction of the arch with the descending aorta, and yet the patient has survived. This is very interesting from a surgical point of view, as it shows the resources of the collateral circulation, and that it is possible to live, so far as that at least is concerned, even when the aorta is tied. According to Mr Sydney Jones, the principal communications by which the circulation was carried on 42 Applied Anatomy : were — (1) The internal mammary anastomosing with the inter- costal arteries, with the phrenic of the abdominal aorta, by means of the musculo-phrenic, and comes nervi phrenici, and largely with the deep epigastric. (2) The superior intercostal, anastomosing anteriorly, by means of a large branch with the first aortic inter- costal and posteriorly with the posterior branch of the same artery. (3) The inferior thyroid, by means of a branch about the size of an ordinary radial, formed a communication with the first aortic intercostal. (4) The transversalis colli, by means of large communications with the posterior branches of the interpostals. (5) The branches of the subclavian and axillary going to the side of the chest were large, and anastomosed freely with the lateral branches of the intercostals. Surgical, Medical, and Operative. 43 CHAPTEE V. LIGATURE OF THE INNOMINATE. Instruments required in Ligature of Arteries. — Scalpel or straight Mstoiiry, director, dissecting forceps, Munt hooks, a pair of broad, bent copper spatulse, aneurism needles of various shapes, waxed silk or chromic acid catgut ligatures, a pair or two of Plan's forceps, means to command the haemorrhage, sponges, etc. In operating on the dead body the instruments required are — (1) A scalpel ; (2) a dissecting forceps ; (3) a director ; (4) retractors or blunt hooks ; (5) an aneurism needle ; (6) a pair of Well's or Pean's forceps, or the ordinary toothed artery forceps ; (7) a liga- ture; (8) scissors. These must all be selected before beginning the operation, and placed in a small tray within easy reach of the operator's right hand. Assistants required: — No. 1, to administer chloroform. No. 2, to hold and steady the limb, etc. No. 3, with a blunt hook in each hand, holds apart the edges of the wound as layer after layer of the tissues are divided; and further, tries to lessen the depth of the wound as much as possible, putting the part into such a position as to relax muscles, etc. No. 4, standing in front of the operator, and with small .sponges on the ends of sticks, keeps the wound free of blood, and assists the operator to tie the bleeding vessels. No. 5, standing behind the operator, hands him the instruments he requires. No. 6, to wash sponges and hand them to assistant No. 4. CHLOROFORM. As this is the first time I have had occasion to speak about chloroform, a few words as to its administration will not be out of place. In Edinburgh, chloroform is the agent usually employed to produce anaesthesia : it is more convenient than ether in many 44 Applied Anatomy: ■ways — the bulk required is less, it is more agreeable to tbe patient, is more easily administered as it requires no special apparatus, and the patient is more easily put under. With ether a special appar- atus is required, as it must be administered nearly pure, the stage of stimulation is more protracted, its smeU is less pleasant to the patient, and it irritates the respiratory tract much more than chloro- form; but it causes less cardiac depression, so that it should be always at hand to be used in cases where the pulse shows signs of failure, or where the heart is weak and fatty ; but it is only to be used as an adjunct to chloroform, and in special cases, when the patient may be put under by chloroform and kept under by ether, e.g., in mitral disease. It (ether) must be avoided in cases of chronic bronchitis, emphysema, and other pulmonary affections, as it causes so much irritation of the bronchial mucous mem- brane, and- its subsequent risks are much greater than chloroform; it should not be given to children, nor used in cases where the operation is conducted by the aid of artificial light, as the vapour of ether is inflammable. It should not be used in operations about the mouth, as it causes a profuse secretion of ropy mucus : it is said to be safer than chloroform, but this is stUl an open question. A towel folded in the form of a A is all that is required for the administration of chloroform; folded thus, and tightly applied to the chin and side of face, it allows the administrator to see the patient's face, and watch the respirations, as well as to observe changes in colour, and further, allows a free admixture of atmospheric air. It is not so wasteful as at first sight it seems to be, because the vapour of chloroform is heavier than atmospheric air, and hence falls down towards the patient's nostrils. It is found that 3 to 4 per cent, of chloroform, along with 97 or 96 per cent, of air, is the proper proportion to use. The objection to Skinner's inhaler is that one cannot easily feel whether the patient is breathing or not ; this could be obviated to a certain extent by leaving an opening in the flannel and inserting a valve of some delicate and easily movable material. The objection to Allis's inhaler is the gutta- percha forming its investing framework : I believe that the volatile gases given off by this material (especially when new), and inhaled by the patient, are a frequent cause of persistent vomiting after Surgical, Medical, and Operative. 45 the operation. At any rate, frequent vomiting is of very common occurrence in those who are "new hands" at rubber factories. This objection could be got rid of by substituting a thin sheet of block tin for the gutta-percha. The Risks of Chloroform, unlike ether, are immediate and not remote, and principally concern the Heart, the Lungs, and the Stomach. The last is only dangerous as it affects the air passages, I mean from sickness and vomiting. One is often told that it is most important to examine the heart carefully before giving chloroform. This is best answered in the words of Sir Joseph Lister — "Preliminary examination of the chest, often considered indispensable, is quite unnecessary, and more likely to induce the dreaded syncope, by alarming the patient, than to avert it." l^ot only is it unnecessary but it may even do harm, as it directs the student's attention in the wrong direction. The Action of Chloroform is — (1) Stimulant; (2) depressant; and (3) if its administration be continued beyond this point, it will cause death by the complete loss of all reflex excitability of the cord and medulla, the last centres to be extinguished being those of organic life — the respiratory, cardiac, and vascular centres. The order in which the various parts of the nervous system are affected is very interesting. It first affects the convolutions of the cerebrum, beginning in front and passing backwards : thus the highest centres (psychological) are first affected, then comes the motor centres and those of special and common sensation. The lower cerebral and spinal centres are affected less and later; lastly, the lowest centres of all are affected, viz., those of organic life — first, the respiratory centre, and then those connected with the heart. These last are not affected to any great extent until after the functions of the higher parts (and, therefore, all voluntary muscular efforts and ordinary sensation) are completely overpowered; it is this safe order of invasion that gives to chloroform its great value as an anaesthetic. During the first stage, the pupils may dilate slightly : during the second stage, the pupil is contracted, dilating on stimulation of afferent nerves : during the third stage (the stage of danger), the pupils are widely dilated and fixed. 'So solid food should be given for at least four hours before the operation — (1) because the patient is more easily anaesthetised when 46 Applied Anatomy : the stomach is empty; and (2) because we avoid in this way the special risk of vomiting under ansesthesia — viz., solid matters passing into the glottis and choking the patient. It is a good plan, however, to give half-an-ounce of brandy mixed with an ounce and a half of water about half-an-hour before the operation. The chloroformist should not deluge his patient suddenly and without warning with the chloroform vapour, but should first converse with him for a few minutes to gain his confidence, reassure him as to the result, and instruct him how to breathe. This, of course, does not apply to young children. No single sign can be relied upon as a sure test of insensibility; the tests usually employed are — (1) Loss of the corneal reflex ; (2) relaxation of voluntary muscular action; (3) local insensibility of the part to be operated upon : the Surgeon tries this by gently pricking the part with the point of his knife. The corneal reflex may be lost and yet the part to be operated upon be widely awake, especially if in the neighbourhood of the anus and rectum, the penis and perineum; or, again, the part to be operated upon may be completely insensible whUe the corneal reflex is still active. The Risks from the Heart are fortunately rare, because as a rule, in man, the respiration stops before the heart has ceased to beat. It may, however, fail in one of two ways — either by sudden syncope, or gradual dying out. The sudden failure is probably due in most cases to the fact that the patient is not sufficiently under to abolish all reflex action when the operation is begun ; hence, the sudden shock, produced by division of the cutaneous structures, reaches the medulla and there stimulates the cardio -inhibitory centre, and at once brings the heart to a stand-still in diastole. If this be the correct explanation, then the proper way to prevent it is to see that the patient is deeply under when the operation is commenced. For the same purpose, it has also been recommended that a mixture of atropia and morphia (one -sixtieth of a grain of atropia, and one -sixth of a grain of morphia) should be given suboutaneously a short time before the operation, as the patient then not only requires less chloroform (from the narcotic eff'ect of the morphia), but the atropia paralyses the whole inhibitory mechanism, and thus prevents, it is asserted, the passage of in- hibitory impulses from the medulla to the heart. I am not at all Surgical, Medical, and Operative. 47 sure about this, but in any case it certainly can do no harm and may possibly do some good; it is stated, however, that it predisposes to after sickness. It will certainly do harm, if the chloroformist thinks that, because it is used, he need not therefore be quite so very careful in giving the chloroform ; whatever is given, he must never relax his vigilance for one moment, but must regard every case as dangerous, and use all possible precautions to prevent accidents. Usually the respirations cease before the heart; but sometimes the heart ceases before the respirations, as it does, normally, in the dog. The operation of tooth-pulling seems to be a specially frequent cause of sudden death under chloroform. This may arise from various causes — (1) The patient not being deeply enough under when the operation is commenced, and the pain produced causing sudden reflex inhibition of the heart. There can be uo doubt that the large sensory root of the fifth nerve has intimate and extensive relations with the medulla oblongata and with the cardiac and respiratory centres there situated. If this be so, care should be taken that the patient is deeply under before the forceps is in- troduced. The temptation is merely to give them a whiff just to deaden sensation a little, but nothing could be more dangerous than this: it must be deeplij, or not at all. It would probably also be advantageous to give the patient ten to fifteen grains of butyl- chloral hydrate a little while before beginning the operation, as this substance specially paralyses the sensory part of the fifth nerve, producing anaesthesia of the parts supplied by it, before general anaesthesia is produced. (2) The tongue may fall back. This is specially apt to happen when pulling the posterior molars, as the forceps itself may push it back. For this emergency, have the toothed artery forceps ready, and pull the tongue forward at once. (3) The tooth or the gag may loosen and fall back, causing sudden spasm of the glottis. In all cases, see that the patient maintains the recumhent posture, as, otherwise, syncope may occur and induce cardiac failure. The Risks from Respiration.— It may be arrested while the heart is still beating, and this may take place either suddenly or ■ more slowly. The sloio stoppage is probably due to the toxic effects of the chloroform on the respiratory centre, while the sudden 48 Applied A natomy : is usually from falling back of the tongue, or paralysis and adhesion of the vocal cords in such a way as to make inspiration impossible, but yet allow of expiration — ^from the slightly oblique position of the cords in the vertical direction. In this condition, the move- ments of the chest are apt to mislead the unwary, as it is heaving vigorously, and yet no air is entering the windpipe. For the respiratory dangers of this class, the best treatment is to see that the tongue is pulled well forwards, and the vocal cords separated, and then use artificial respiration (Sylvester's Method). If this is not suificient, then perform laryngotomy, and forcibly blow air into the lungs, as they have stopped in fuU expiration, and after this use artificial respiration. But the respiratory process may be affected in another way — asphyxia from vomited matters or blood. To avoid this, see that the patient has had no food for some hours before the operation, so that the stomach is empty, and operate in such a way or with such precautions that no blood can pass through the chink of the glottis. There is reason to believe, as Lister, I think, points out, that sickness is often induced by administering the chloroform by fits and starts — allowing the patient almost to recover consciousness, and then to suddenly give him a great gust of the vapour. At any rate, sickness is most common when the patient is half under, whether it be just as he is going under at first, or that he is allowed to partially regain consciousness during the progress of the operation. Children are peculiarly favourable subjects for chloroform, and it is best to suffocate them at once, unless they can be coaxed into taking it. There is absolutely no danger in so doing. This has been explained on physiological principles, but I am inchned to think that it does not depend so much on physiological as upon psychological causes. The child truly takes no thought for its life, but the adult is careful and troubled about many things : in this respect, the child has chosen the better part. In the Adult, give gently and slowly at first with a free supply of atmospheric air; and should there be much struggling, remove the chloroform altogether, and allow him to take a good breath or two, and probably before he feels in need of another such breath he will have passed quietly under. Let me also give a single hint Surgical, Medical, and Operative. 49 to those who are ever ready to pin the struggling patient to the operating tahle — do not grasp the patient's wrists and legs as if you had a mad bull by the horns; do not fight with him, but let him grasp your hand, and all that will then be required will be simply to direct his movements and not to forcibly restrain them. A person under chloroform is like a drunk man — the more you try to resist him, the more he fights. In all cases, there should, as far as possible, be perfect quiet round about the patient until he is under. Alcoholics are specially bad subjects for chloroform, and require special watching and care. At first the struggling is great, and then, almost before one is aware of it, they pass suddenly and deeply under, and are in great danger of paralysis of the heart or respiration from oTer-dose; and yet, if the chloroform is withdrawn, they rapidly regain consciousness. In all cases, watch the breathing above everything else, and see that air is entering the chest. There are two danger signals, as a rule, before the case becomes very serious— (1) Snoring respiratioiis — this is due to vibration, and probably paralysis of the velum palati; and is the signal, in most cases, to remove the chloroform for a time. (2) Laryngeal stertpr or stridor, from paralysis of the vocal cords, and which then flap together like a reversed V, and make the entrance of air almost impossible. This is the signal of real danger, and requires active treatment — stop the chloroform, pull forward the tongue, and, if necessary, put a finger down and separate the cords, and then artificial respiration. The chloroformist must be prepared to give all his attention to his own duty. One of the most annoying sights I know is to see the chloroformist staring inanely at what the operator is doing, or else gazing up .at the crowded benches of the operating theatre, just as if he meant to say to the other students, "Am not I a great vds.uV' or "Wouldn't you like to be mel" — perhaps at the very moment when the life of the patient committed to his care is wavering in the balance. The patient's mouth should, if possible, be turned away from the part being operated upon. I will now give a short resume of the points that must be always kept in mind by the chloroformist under three heads, after the manner of railway signals : — 60 Applied Anatomy: I.— WHITE ( = right). 1 When the chloroformist gives all his attention to his duty. Before heginning he ought to see that the patient has nothing movable in his mouth, as false teeth, sweets, etc. 2. When he has a toothed artery forceps handy — usually attached to the left lapel of his coat. 3. When muscular relaxation is complete, and the reflexes of the conjunctiva and the 'part to he operated upon are abolished: this is determined by gently pricking the part. 4. When the heart is beating regularly. 5. When air enters the chest easily. 6. When there is neither snoring nor stertor. 7. When there is an absence of extreme pallor or marked blvieness of the face. 8. Have ether, and brandy, and capsules of nitrite of amy], always at hand; and a hypodermic syringe full of ether and ready to inject subcutaneously at a moment's notice. Above everything, -watch the patient's breathing. For this purpose, the tips of the fingers of one hand may be laid on the symphysis menti, v^ith the palm a little distance above the mouth and nostrils, so that you may be able to feel whether the patient breathes or not, as the mere heaving of the chest is not a trust- worthy guide. Use especial care and precaution in the case of alcoholics. See that the patient is deeply under, during incisions through the skin and in cutting large nerves. 11. — GrREEN ( =: proceed cautiously). 1. When snoring (= vibration of the velum palati) accompanies the respirations. Eemove the chloroform for a little, and be ready to pull forward the tongue by the toothed forceps. In these cases it is often advised that the chin be tilted upward, but this is of no use at all as it does not pull forward the tongue — the lower jaw is simply jammed against the upper. The proper plan is to place the thumbs half-an-inch or so above the angles of the lower jaw and push; in this way the chin is pushed forward, and with it the genio-hyoid, and it in turn pulls forward the base of the tongue. ; Dr HowABD denies that traction of the tongue can raise the epiglottis, but states that " the new and only way " to ensure a Surgical, Medical, and Operative. 61 clear air-way to the lungs is by sufficient extension (or rather over- extension) of the head and neck, over the end, say, of the operating tahle, at the same time tilting up the chin as far as possible. 2. When vomiting is threatened. This may very often he warded off by giving more chloroform. 3. When there are signs of cardiac failure. If so, stop the chloro- form and use ether instead, and also inject ether subcutaneously. III.— RED ( = danger: stop). 1. When there is sterterous or stridulous breathing: — This is laryngeal in its cause and is probably due to paralysis of the vocal cords; this allows them to ilap together, as I have already explained, and effectually prevents the ingress of air. For this, stop .the chloroform, pull the tongue well forwards, and if necessary pass finger down to and separate vocal cords, and raise the epiglottis, and then use artificial respiration; or laryngotomy and forcible inflation may be used as the lungs stop in expiration. Ether may also be injected subcutaneously. 2. When he vomits turn him at once on his side, and let the head hang low so that the vomited matters may pass out easily, and not pass into or through the chink of the glottis. 3. At whatever stage, when there is much struggling, the danger is very great. Such patients are often alcoholic, and during the struggle, especially when held forcibly down, the muscles being all contracted, prevent the outflow of blood from the aorta and thus over-fill the left ventricle leading to its paralysis; further, the blood is insufficiently aerated, and at the same time the deep inspiratory gasps the patient takes, quickly leads to over-filling of the lungs with the vapour, and rapid poisoning of the patient follows. In such cases remove the cloth for a little, and let him get the lungs well filled with air, guide but do not forcibly control his struggles, but keep his head down. Under Red, therefore, note these three points : — Laryngeal stridor, vomiting, and struggling. AUow the patient to sleep quietly in bed till the effect of the narcotic passes off; do not adopt the disgusting practice of slapping the patient's brow with the palm of the hand or tapping with the inger nails in order to bring him to; all you have got to do is to remain beside him till he retui'ns to consciousness. 52 Applied Anatomy : In concluding this section let me enumerate the chief risks or modes of death : — THE HEART. 1. Failure may he induced hy the fainting or syncope induced by or accompanying vomiting; this is most likely to occur when the patient is but half under, or should he suddenly assume the upright position; it may also be caused by fatty heart occasionally, or be the result of a prolonged operation. The face is very pale, and in. such cases the head should be lowered or even allowed to hang over the end of the table; the vapour of nitrite of amyl may be inhaled and ether injected subcutaneously. 2. The heart may fail suddenly from reflex inhibition. To avoid this see that the patient is deeply under, or atropia may be injected previously. 3. It may gradually fail from overdose of chloroform, the med- ullary centres and the intrinsic ganglia being gradually poisoned. 4. Sudden failure before the respirations have ceased, without evident cause ("primary failure"). This form is fortunately rare, but when it does occur little can be done. Treat the case as one of asystole — inject ether, brandy, or digitalis; inhale amyl nitrite, and keep up artificial respiration. THE EESPIKATION. 1. It may be interrupted by falling back of the tongue. 2. It may be stopped by the glottis closing; this is usually preceded by snoring, stertor, or stridor. 3. It may stop slowly from overdose of chloroform, the respira- tions gradually dying away, the centres being slowly poisoned. 4. The glottis may be blocked up or thrown into spasm by the entrance of vomited matters. ISToTE. — (1) That the chest may be heaving vigorously and yet no air enter, as the tongue may have fallen back, or the glottis closed. (2) That air may be expired and yet none be inspired, as the glottis may flap together in such a way as to prevent inspira- tion, but yet allow of a certain amount of expiration. Surgical, Medical, and Operative. 53 We may also look at this question from another point of view : the continuance of life depends on the proper and regulated action of the heart, the lungs, and the brain. These three organs there- fore form the tripod of life, and arrest of the functions of any one of them very speedily leads to the arrest of the others, so that either of the three may be the primary cause of death. Thus death may (1) begin at the heart in those rare cases of sudden and primary failure without recognisable cause, in cases of syncope, and in paralysis from over-filling. (2) Death may begin at the lungs from some impediment to the entrance of air, as falling back of the tongue, closing of the glottis from paralysis, or spasm of the glottis from the entrance of vomited matters or blood. ( 3 ) Death may begin at the brain from over-dose, gradually poisoning the respiratory and cardiac centres, or from a sudden stimulation of the inhibitory centre bringing the heart to a stand-stUl in diastole; a similar condition may also be caused by strong mental emotions. In syncope, the brain is only affected secondarily, because, as the heart has stopped or is very weak, it is deprived of its proper supply of blood. INNOMINATE ARTERY. This artery has also been named Brachio-Cephalic, from its being distributed to the arm and head. Aneurism of this vessel is extremely difficult to diagnose with certainty, as indeed are all aneurisms at the root of the neck. Many cases diagnosed as aneurism of the innominate during life, have been discovered after death, by the more perfect light of the post-mortem room, to be aneurism of the arch of the aorta. Aneurism of the innominate forms a pulsating swelling behind the sternum, or perhaps more frequently situated on the tracheal side of the right sterno-mastoid muscle, fiUing up the episternal notch, and giving rise to certain special symptoms, chiefly from pressure of the tumour on neigh- bouring structures. (1) The pulse on the affected side is small, feeble, and delayed, and so is the pulsation in the right carotid. (2) The superficial veins of the right side of the neck and face, and of the right arm, are enlarged, and hence the oedema of the right eyelid and arm. (3) There are dull aching pains (or they may be sharp and shooting) from pressure on, and irritation of, the cervical 54 Applied Anatomy : and 'brachial nervous plexuses. (4) Dyspnoea from pressure on the right recurrent laryngeal nerve, or by direct compression of the trachea. (5) Difficulty in swallowing, which usually occurs after the dyspnoea, as the nerve is first affected. (6) If the cervical sympathetic he irritated there will he dilatation of the pupil of the affected side; but, if it he covci^leieij paralysed, the pupil on that side will be contracted and there may he sweating and redness of that side of the face and neck. The same remark applies to aneurism of the common carotid. Origin. — From the right side of the transverse part of the arch of the aorta at a point corresponding to the middle of the manu- brium sterni. Extent. — -From the above point upwards and to the right, to the posterior aspect of the right sterno-clavicular articula- tion and lower cervical region, where it bifurcates into the right subclavian and right common carotid. Its entire length is from IJ to 2 inches. Course. — Upwards and to the right, behind the first piece of the sternum. Its most important Relations are: — In frorct — (1) The first piece of the sternum. (2) Lower part of the sterno-mastoid, sterno-hyoid, and sterno-thyroid muscles. (3) It is crossed by the left innominate vein, and there is also a network of thyroid veins in front of it, embedded in the loose cellular tissue. On its ri(ilit side — (1) The right innominate vein; (2) vagus; (3) phrenic; (4) inferior cardiac of right vagus; (5) pleura. On its left side, the left common carotid. Beldnd — (1) Trachea, at lower part : (2) pleura and apex of the right lung. THE OPERATION. In ligature of this vessel the patient should be in an easy recumbent posture, with the shoulders raised, the head thrown back and turned towards the left shoulder; the right arm should be well drawn down and adducted. The Surgeon should either stand in front of, or facing, the right shoulder. Superficial Guide to the Vessel. — It lies just behind the right sterno-clavicular articulation. Incision. — The incision should be V-shaped. First make an incision about two inches long over the inner part of the clavicle and sterno-clavicular articulation to- the Surgical, Medical, and Operative. 55 sternum; another, two or three inches in length, along the inner border of the right sterno-mastoid muscle, meeting the other at the sternum at an acute angle. By these incisions we divide — (1) Skin; (2) platysma and fascia; (3) sternal head and inner part of the clavicular head of the sterno-mastoid, which may he divided on a director. These are thrown upwards and outwards, and then we cut through — (4) sterno-hyoid; and (5) the sterno-thyroid. Before dividing the sterno-hyoid, look out for the anterior jugular vein, which lies on this muscle, covered hy the sterno-mastoid. The head is now drawn well back in order to draw up the artery into the neck as much as possible, the left innominate vein, which crosses the artery, being fixed by its relations to the right in- nominate vein and the superior vena cava, does not rise with the artery. Deep Guide to the Vessel. — Trace down the common carotid with the finger till the bifurcation of the innominate artery can be distinctly felt; then (6) draw the inferior thyroid veins carefully to one side, clear the vessel with the finger and director from the surrounding cellular tissue, and ligature, taking care not to wound the pleura; the needle is passed from the outer side in order to avoid the right innominate vein and right pneumo-gastric nerve, and in passing it be careful to keep its point close to the artery, - in order to avoid wounding the pleura covering the apex of the right lung. The veins are the great trouble in this operation, as they become turgid, and obscure the various steps of the operation : there is also the risk of entrance of air should they happen to be wounded. BESUME of the chief steps in this operation : — 1. Make the V-shaped incision and divide the integumentary structures. 2. Divide the whole, or part, of the sterno-mastoid on a director. 3. Secure anterior jugular vein. 4. Divide both sterno-hyoid and sterno-thyroid. 5. Draw the head well back, follow down common carotid, and turn inferior thyroid veins, fat and glands, to one side. 6. Clear the vessel and pass the needle from the outer side. 56 Applied Anatomy : The Collateral Circulation is practically the same as in ligature of the common carotid, added to that of ligature of the right subclavian (see Fig. 12). PECULIARITIES. — As a rule, the innominate gives off no branch; hut occasionally a small branch, the thyroidea ima, arises from it and runs up in front of the trachea to the thyroid body: further, it is by no means an uncommon arrangement to find the left common carotid joined with the innominate artery at its origin. In some cases there is no innominate artery, the right subclavian arising directly from the arch of the aorta ; hence, the importance and necessity of the " deep guide," viz., to trace down the common carotid with the finger till the bifurcation of the innominate artery is distinctly felt. Occasionally, its point of division is considerably above the sterno-clavicular articulation; less frequently, it divides below that point. When the aorta, as in birds, is a " right aorta," the innominate artery is on the left side of the neck instead of the right side. It will also be on the left side in cases of the rare congenital malformation of " transposition " of the thoracic viscera, when everything, as it were, lies on the wrong side. Ligature of the innominate is not a successful operation, and can hardly be regarded as justifiable, and is now practically abandoned. In a large proportion of cases (one-fifth of all) the operation has had to be abandoned, on account of unforeseen difiiculties, discovered only during its progress. To render the passing of the ligature more easy and certain, the inner end of the clavicle and the upper part of the sternum has been removed by Cooper of San Francisco. It has also been proposed to ligature the vessel through a trephine hole in the manubrium sterni, just over the vessel. It is scarcely necessary to remind the reader that there is but one innominate artery (though there are two innominate veins), and that it is on the right side. It does not look well when a student rises from the examination table and asks the examiner on which side he wishes the artery tied. It is apt to raise a siLspidmi in that gentleman's mind, which is likely to be noted for future verification, that the student must have forgotten his anatomy considerably. It is specially awkward to make such a mistake at such a time; for, if ever a student's words ought to be few and ■ffeU chosen, it is g,t aji examination. Surgical, Medical, and Operative. 57 TREATMENT OP INNOMINATE ANEURISM. For the treatment of innominate aneurism various methods are adopted. All operative measures have, as yet, been very unsuccess- ful, the patients usually dying in a short time after the operation from secondary haemorrhage, inflammation and gangrene of the lung, or inflammation of the pleura; and, in all prohability, death has in most cases only been hastened by the operation. We have — (1) Medicinal and dietetic treatment — the most trustworthy and safest method. (2) Ligature of tlie innominate artery itself — usually of little use, and only hastens death. It can only, by any possibility, be successful if the artery is healthy and the aneurism limited. In tubular aneurism, where the coats are diseased, it is worse than useless, as the diseased artery gives way in a few hours under the pressure of the ligature, with fatal haemorrhage. (3) Ligature on the distal side of the aneurism (Waedeop), We may tie — (a) the subclavian alone; (h) the carotid alone; (c) both arteries, either simultaneously, or tie the carotid first and then the subclavian, after a longer or shorter interval — should the patient be fortunate enough to survive the first operation. It is probably better to tie both branches at once, as this gives the best results, and is not a more serious operation. Mr Heath has had one successful case, where he tied the common carotid and the third part of the subclavian simultaneously in 1865 — the woman lived for four years. Excluding Mr Heath's case, and one or two other more recent cases of a similar nature, neither of these methods have been followed by any marked success, on account of the disturbance on the cardiac side of the ligature, which renders the probability of consolidation taking place in the sac all but hopeless ; and, besides, the ligature is applied so close to the aneurism that the coats at the point of application are almost certainly diseased — the danger, therefore, of secondary haemorrhage is very great. (4) Introduction of foreign ladies into the sac, such as fine iron wire, horse-hair, or catgut, through a fine canula or hollow needle, after the manner of Loreta. Mr Annandalb has suggested that the artery be compressed through a central incision, as in low tracheotomy, by inserting the finger behind the artery, and compressing it against the sternum. 58 Applied Anatomy. CHAPTER VI. SUBCLAVIAN ARTERY. Origin. — On the HgM side from the branching of the innominate artery behind the sterno- clavicular articulation. On the left side directly from the arch of the aorta. Extent (in neck). — From the sterno-clavicular articulation, or opposite the interval between the two heads of the stemo-mastoid, to the lower border of the first rib. It is divided into three parts by the scalenus anticus muscle — a part internal to (first part) ; a part behind (second part) ; and a part external to that muscle (third part). Course.— It crosses the lower part of the neck, taking an arched course over the apex of the pleura and first rib, passing between the anterior and middle scaleni muscles, and ends opposite the middle of the clavicle. It usually rises about one inch above the clavicle. The right subclavian is about three inches long, the left is one inch longer. BIGHT SUBCLAVIAN.— First Part. This part extends from the right sterno-clavicular articulation to the inner edge of the scalenus anticus muscle. An aneurism of the first part of the subclavian usually presents as a pulsating tumour external to the stemo-mastoid muscle, more or less elongated trans- versely, with bruit propagated into the axilla, which is unaltered when the common carotid is compressed. The right side is more frequently afiected in the proportion of three to one, probably because the right arm is more used than the left. Relations. — In front — (1) Skin and superficial fascia; (2) platysma; (3) deep fascia; (4) three muscles — stemo-mastoid, sterno-hyoid, and sterno- thyroid; (5) three veins — internal jugular, vertebral, and anterior jugular; (6) three nerves — vagus, branches of sympathetic (cardiac, and ansse Vieusenii), and phrenic (the phrenic is always in front Surgical, Medical, and Operative. 59 on tEe left side, and very often on the right side too, hut usually close to the inner edge of the scalenus). Beldiid — (1) Longus colli muscle separated from it by loose connective tissue, in which we find three nerves — the gangliated cord of the sympathetic, the recurrent laryngeal, and the cervical cardiac branch of the vagus. Below is the pleura and the recurrent laryngeal nerve. Above, there is nothing worth noting. There are several grave objections to the ligature of this part of the subclavian — (1) Its great depth. (2) Its complicated relations ■ for these two reasons its ligature is one of the most difficult and serious operations in surgery. (3) Its shortness and the number of branches it gives off ; it is only about one inch and a half in length, and gives off three large branches, so that its ligature is almost cer- tain to be followed by fatal secondary haemorrhage when the ligature separates. (4) When tied for spontaneous aneurism there is always the serious risk of the coats 'of the artery being diseased, so that they are unable to bear the ligature. (5) The disturbance both on the cardiac and distal side of the ligature render the formation of a suiEcient coagulum all but hopeless. On the cardiac side there is the onward rush of blood in the innominate artery, and on the distal side there is the regurgitant stream through the vertebra], thyroid axis, internal mammary and superior intercostal. In almost every recorded case in which this operation has been performed, the patient has been carried off by fatal secondary haemorrhage from the distal side, on the separation of the ligature, on account of the preseiice of these large branches. THE OPERATION. In ligaturing the first part, the patient should be in an easy recumbent posture, with the shoulder depressed, the head thrown back, and the face turned to the opposite side; the Surgeon should stand in front of the shoulder on which he is about to operate, and the corresponding arm should be well pulled down and placed close to the patient's side. An incision should be made transversely over the origin (sternal and clavicular) of the sterno-cleido-mastoid, and another, two or three inches in length, along the inner border of the same muscle, meeting the first incision at an acute angle. The V-shaped flap thus marked out, consisting of integument with 60 Applied Anal o my : the platysma and deep fascia, is then turne4 upwards and outwards. The sternal head of the sterno-mastoid, and part or whole of the clavicular head, is next divided on a director and turned outwards. Avoid the anterior jugular vein and its communications, and divide the sterno-hyoid and sterno-thyroid muscles in the same manner. Carefully separate the cellular tissue with the handle of the scalpel or the finger-nail, when the artery, with the internal jugular vein, will be brought into view. At the lower part of. the wound the internal jugular vein inclines away from the artery, leaving the pneumo-gastric nerve visible. The proper point for the application of the ligature is in the space between the vagus and the recurrent laryngeal nerve on the inner side, and the thyroid axis, phrenic nerve, internal jugular vein, and cardiac nerves on the outer side. The deep guide for the ligature of this vessel is to trace down the carotid to the bifurcation of the innominate, and then the subclavian artery is to be followed outwards till the vagus nerve is recognised by the finger. The internal jugular vein is pressed out of the way, and the nerves drawn aside in the direction indicated, the vessel cleared with the finger and director, and the needle passed from below upwards, but in doing so be careful not to injure the pleura or the right innominate vein, or include the vagus nerve. The subclavian vein is in front of the artery, and on a much lower level, being under cover of the clavicle and subolavius muscle, so that it is not likely to give any trouble during the operation. Occasionally, however, it rises in the neck as high as the artery, and in two cases it has been found accompanying the artery behind the scSlenus anticus muscle. LEFT SUBCLAVIAN.— First Part. This vessel arises from the end of the transverse part of the arch of the aorta, opposite the middle of the first piece of the sternum, and extends to the inner edge of the scalenus anticus. It diifers from the right in being — (1) Much longer; (2) more deeply placed; (3) it ascends almost vertically upwards from its point of origin to its termination. Relations. — In front — (1) Left pleura and limg; (2) left internal jugular and innominate veins; (3) the same three muscles as on right side — sterno-mastoid, sterno- thyroid, and sterno-hyoid; (4) the same three nerves as on the Surgical, Medical, and Operative. 61 right side — pneumo -gastric, cardiac, and phrenic. It lies on a plane posterior to the left common carotid. Behind — It lies on — (1) The oesophagus; (2) thoracic duct; (3) sympathetic and cervical cardiac branches of vagusj (4) longus colli muscle. To the inner side — (1) The oesophagus; (2) trachea; (3) thoracic duct. To the oitter side, pleura and lung. It is generally taught that the relations of this part are too complicated to admit of ligature. Should it he found necessary to do so, the incision and the steps of the operation resemble the ligature of the corresponding part on the right side, but great care is necessary to avoid injury to the pleura and thoracic duct. Collateral Circulation (Fig. 12). — When the first part is tied the following vessels re-establish the circulation: — 1. The superior intercostal (18) anastomosing with the aortic intercostals (30) and internal mammary (31). 2. The inferior thyroid anastomosing with the superior thyroid (10). 3. By the inosculations of the vertebrals through the circle of Willis (1). 4. Internal mammary (29) anasto- mosing with the deep epigastric (28) and aortic intercostals (30). 6. The thoracic branches of the axillary (21, 26) anastomosing with the aortic intercostals (30). 6. The princeps cervicis (6) of occipital anastomosing with the profunda cervicis (11) from sub- clavian. 7. Branches from the thyroid axis going to the scapula (14, 15), anastomosing with the thoracics of the axillary (17, 21, 26), and through them with the aortic intercostals (30). SECOND PART OF SUBCLAVIAN.— Right and Left. This part of the artery lies beneath tlie scalenus anticus muscle, and is the shortest and highest of the three divisions. It may be tied in this situation, but it is necessarily a dangerous and difficult operation. — (1) On account of the depth of the vessel. (2) Its close relations to the phrenic nerve, transversalis colli and supra- scapular arteries; and (3) because it rests on the pleura and first dorsal nerve. On the rigllt side it gives off one branch, the superior intercostal, and this is likely to interfere with the formation of a proper clot; on the left side it usually gives off no branch, the superior intercostal arising from the first part, on the left side. Relations. — In front — (1) Skin, fascia, and platysma; (2) sterno- mastoid ; (3) branches of thyroid axis (transversalis colli and supra- 62 Applied Anatomy : Fig.n2. Collateral Circulation of the Head and Neck. (After Smith and Walsham.) Surgical, Medical, and Operative. 63 Explanatiqe:. of Fig. 12. A. Aorta. B. Innominate Artery. 1. Circle of Willis, formed by the posterior cerebrals from the basilar, and the anterior cerebrals from the internal carotids, connected together by the anterior and posterior communicating branches. 2. Basilar arteiy, formed by the union of the two vertebrals. 3. Occipital artery, from the external carotid. 4. To represent the anastomoses between the corresponding branches of the two external carotids — viz., facial with facial, lingual with lingual, temporals with temporals, and occipital with occipital. 5. External carotid. 6. Princeps cervicis, from occipital. 7. Anastomoses between the princeps cervicis, vertebral and profunda cervicis in the region of the sub-occipital triangle. 8. Vertebral, from the subclavian. 9. Common carotid. 10. Anastomoses between the two superior and the two inferior thyroids in the region of the thyroid gland. 11. Profunda cervicis, from the superior intercostal. 12. Transversalis colli. 13. Its superficial cervical branch. 14. Posterior scapular artery, one of the divisions of the trans- versalis colli branch of thyroid axis ; the other division is called the superficial cervical, and enters the trapezius. 15. Supra-scapular artery from the thyroid axis, anastomosing with the subscapular from the axillary. 16. Subclavian arteiy. 17. Thoracic axis, from the axiUary anastomosing with the supra-scapular and posterior circumflex. 18. Superior intercostal, anastomosing with the internal mam- mary and the aortic intercostals. 19. The first rib. 20. Axillary arteiy. 21. Superior or short thoracic, anastomosing with the iutenial mammary. 22. Posterior circumflex, anastomosing with the thoracic axis and the subscapular. 23. Anastomosis between the supra-scapular and the subscapular. 24. Anastomoses between the posterior scapular and the sub- scapular. 25. Subscapular artery. 26 and 27. Long thoracic, anastomosing with the internal mam- mary and the aortic intercostals. 28. Deep epigastric from the external iliac. 29. Internal mammaiy. 30. Aortic intercostals. 31. Anastomoses between the internal mammary and the superior intercostal. 32. External iliac. 64 Applied Anatomy : scapular); (4) phrenic nerve; (5) scalenus anticus muscle; (6) the subclavian vein is separated from the artery by the scalenus anticus, and is on a much lower level as a rule. Behind — (1) Pleura; (2) middle scalenus; (3) first dorsal nerve. Above, we have the brachial plexus, while below it rests on the pleura. Should it be necessary to tie this part, the vessel may be reached by means of the following incisions-^a transverse one over the clavicular head of the sterno-mastoid, from two to three inches in length, and a vertical one about two inches long, rather external to the outer border of the sterno-mastoid, meeting the former at an acute angle; the position of the Surgeon and patient are the same as for ligature of the first part. The flap thus mapped out, consisting of the integu- ment platysma and deep fascia, is raised upwards and inwards, and the external jugular vein drawn outwards, if necessary; the clavicular head of the sterno-mastoid is then divided from with- out inwards, on a director, in order to expose the scalenus anticus. Lying on this muscle the following structures will very likely be seen — (a) the internal jugular vein along its inner border; {li) the transversalis colli and supra-scapular arteries, and the anterior jugular vein; (c) the phrenic nerve; {d) in some cases also the external jugular vein along its outer border. These structures must be drawn aside in the most convenient manner and carefully guarded from injury. A director is next pushed under the outer edge of the scalenus anticus, which is then to be cautiously divided for a half or two-thirds of its extent when it retracts sufficiently to bring the artery into view, and after carefully clearing the vessel the aneurism needle is passed from below upwards. As a guide to the position of the scalenus anticus it is useful to remember that the outer edge of the sterno-mastoid almost corresponds to the outer edge of that muscle, though the scalenus is slightly external, and the external jugular vein often rests on the uncovered part. Note. — (1) In dividing the scalenus anticus special care must be taken to avoid cutting or bruising the phrenic nerve, which lies on its anterior surface, inclining obliquely towards its inner border. Two cases are mentioned by Erichsen, one in which the phrenic nerve was divided, and the patient died on the eighth day, of pneumonia; in the other case, incessant hiccough followed the ojseration, and after death the phrenic nerve was found reddened Surgical, Medical, and Operative. 65 and inflamed, having probably in some way been interfered with during the exposure of the vessel. (2) The transversalis colli and supra-scapular arteries also lie superficial to the scalenus anticus, and must be carefully preserved from injury, as they play a very important part in the collateral circulation : both these vessels run parallel with the clavicle, the supra-scapular being behind it, and the transversalis colli just above it. (3) The confluence of the internal jugular and subclavian veins is also commonly in front of the scalenus anticus. (4) On the left side the thoracic duct will be found arching downwards in front of the scalenus anticus and phrenic nerve. On the right side a corresponding structure, the right lymphatic duct, may also be found, but it is usually very small. THIRD PART OF SUBCLAVIAN. -Right and Left. This is the part most frequently ligatured, because — (1) It is the most superficial part; (2) it is the longest part; (3) it is usually free from branches; (4) the first rib is interposed between it and the pleura, and, by passing the needle as the artery lies on the first rib, we avoid wounding the pleura, and wUl also usually avoid coming into contact with any abnormal arterial branches — as these usually arise close to the outer edge of the scalenus anticus. It extends, from the outer edge of the scalenus anticus muscle to the lower border of the first rib, and is contained in a small triangular space, the lower and smaller of the two divisions of the posterior triangle, bounded by the sterno-mastoid in front, the clavicle below, and the posterior belly of the omo-hyoid above (see Fig. 14). Relations. — Irv front — (1) Skin, superficial fascia, platysma, and deep cervical fascia. (2) A plexus of veins formed by the external jugular and its tributaries in this region, viz., supra-scapiJar, trans- versalis coUi, and frequently also a communication from the anterior jugular, and another from the cephalic vein. (3) The descending branches of the cervical plexus of nerves. (4) Nerve to the subclavius. (5) Clavicle and subclavius muscle. (6) The supra-scapular artery. (7) The subclavian vein, but a't a much lower level. Ahom — (1) The cords going to form the brachial plexus. (2) The posterior belly of the omo-hyoid. Behind — The scalenus medius. Beloio — The first rib, and partly also the nerve trunk formed by the union of the eighth cervical and first dorsal nerves. The same nerve cords E Applied. Anatomy . Fig. 13. Subclavian Vessels (After Tdbkek). 19 20 1. Transversalis Colli. 2. Ascending Cervical. 3. Superficialis Colli. 4. Posterior Scapular. 5. Scalenus Anticus. 6. Supra-Scapular. 7. Posterior Scapular (occasional origin). 8. Deep Cervical. 9. Subclavian Vein. 10. Inferior Thyroid. 11. Vertebral. 12. Keciirrent Laryngeal.. 13. Thyroid Axis. 14. Common Carotid. 15. Internal Mammary. 16. Innominate Arteiy. 17. First Rib. 18. Superior Intercostal. 19. Phrenic. 20. Vagus. Surgical, Medical, and Operative. 67 Fig. 14. Incisions for Subclavian and Carotid Arteries. 1. Jaw. 2. Digastric. 3. Submaxillary Triangle. 4. Omo-Hyoid. 5. Superior Carotid Triangle. 6. Incision for Carotid. 7. Inferior Carotid Triangle. 8. Sterno-Mastoid. 9. Posterior Triangle (lower part). 10. Trapezius. 11. Posterior Triangle (upper part). 12. Subclavian Artery (third part). 13. Incision for Subclavian. H. Clavicle. 68 Applied Anatomy: also lie behind it. The artery is sometimes described as lying in the lower part of a little triangle formed thus — internally it is bounded by the outer margin of the scalenus anticus, and externally by the scalenus posticus, the convergence of these two muscles forming the apex of the triangle, the base being formed by the first rib, on which the vessel rests (Spence). In the same triangle, above and behind the artery, are the cords going to form the brachial plexus. THE OPERATION. The patient should be in the recumbent position, with his shoulders supported by pillows, his head thrown backwards and his face turned to the opposite side, while the arm of the affected side is to be depressed as much as possible so as to lessen the depth of the wound. The Surgeon stands in front of the shoulder on which he is to operate. Superficial Guide. — The vessel lies beneath the most prominent part of the clavicle, and it is important to remember that, by press- ing the thumb or a padded key firmly downwards, inwards, and backwards, towards the first rib, about half-an-inch to the inner side of the middle of the clavicle, or just outside the sterno-mastoid, the vessel may be compressed during life, and the circulation through the upper limb entirely commanded : it is best carried out when the arm is well drawn down. Incision. — With the inner side of the left hand, draw down the skin over the clavicle for about one inch, and cut along the hone for three or four inches, beginning over the clavicular origin of the sterno-cleido- mastoid and ending at the trapezius (see Pig. 14). By drawing down the skin in this manner, one is less likely to cut the external jugular vein, which may be found in any part of the base of the posterior triangle, and perforates the deep fascia about half-an-inch above the clavicle, and is not, therefore, displaced downwards with the skin. This incision corresponds to the middle third of the clavicle, or base of the posterior triangle. In some cases, it may be advisable to make another incision, two inches in length, along the outer edge of the sterno-mastoid joining the former incision nearly at a right angle, more especially in cases where the shoulder cannot be depressed — in very fat people, or those with short thick necks. It is better, however, not to make this incision, if possible, but rather to extend Surgical, Medical, and Operative. 69 the first incision, inwards, or even to divide a portion of the sterno- mastoid or trapezius. Parts cut through. — While the skin is tense over the clavicle, there is divided on the bone — (1) Skin. (2) Superficial fascia. (3) Platysma. (4) Superficial nerves and vessels — the nerves are the descending branches of the cervical' plexus; the vessels are chiefly the tributaries of the external jugular vein, which, at this point, usually form a venous plexus in front of the subclavian artery. The external jugular vein should be now exposed and saved by drawing it inwards or outwards according to circumstances; but, if too much in the way, it should be secured by two ligatures and divided between them. This vein often lies at the inner end of the incision, close to the edge of the sterno- mastoid, and on the scalenus anticus. When the tension is taken off, and the wound moved a little above the clavicle, we next divide with care, on a director, if thought necessary, (5) the deep fascia in the middle of the wound — that part of the cervical fascia which binds down the posterior belly of the omo-hyoid to the clavicle. Next, seek for the interval between the omo-hyoid (posterior belly) and the clavicle which will probably be about an inch in extent, but may be more or less. If the omo-hyoid presents itself in the wound in the natural course of events, good and well ; but, if not, it is not necessary, to search for and expose it. The knife must not be allowed to pass beneath the clavicle, lest the subclavian vein or the supra-scapular vessels be injured. Take care also of the transversalis colli artery, as both it and the supra- scapular are impdrtaht agents in the collateral circulation; and, besides, if the supra-scapular be injured, it is often difficult to secure, from the dense fascia in this situation and its being partly under cover of the clavicle. Push the omo-hyoid upwards a little, and, with the finger or the handle of the knife, scratch away any intervening areolar tissue, with a lymphatic gland and the other structures lying over the artery; then identify, either by sight or touch, the outer edge of the scalenus anticus muscle, and follow it down to its insertion into the first rib. (6) The small nerve to the subclavius muscle also crosses in front of the artery near its middle. At first sight, the division of this small nerve may seem a matter of little conseqaence; stiU, it is important to remember that it very frequently has a communication with the phrenic nerve, and may 70 Applied Anatomy : give rise to unpleasant symptoms if -it be lacerated, from the reflex irritation and the summation of the stimuli, starting from the lacerated point. Deep Guide to the Vessel. — Either the tuhercle on the first rib at the insertion of the scalenus anticus, and the outer edge of the same muscle, when the artery will be found immediately above and a little behind it, but covered and bound down to the first rib by a sheath of dense cervical fascia. When the tip of the finger touches the tubercle, the pulp of the finger will rest on the artery (Spence); or, the three white cords going to form the brachial plexus, seen at the outer end of the wound, and which are placed above and a little behind the artery — the artery being between them and the first rib. To distinguish the artery from a large nerve trunk on the uninjected dead body, press the structure firmly with the finger against the first rib, when, if it is a nerve, it will retain its rounded fonn, while the artery will flatten out and become slightly concave. (7) Open the sheath, and with the forceps and director clear the vessel, and pass the aneurism needle from above, in order to avoid the nerves going to form the brachial plexus — one of which is far more liable to be included in the ligature than the vein is to be injured, which is to the front of and considerably below the artery. Still, it is but right to state that many Surgeons recommend that the ligature should be passed from below upwards. The needle most suitable for passing the ligature is "a common aneurism needle with a considerable curve " (Bell). Some prefer the doubly-curved rectangular or helix needles, introduced by Dupuyteen, of which two are required — one for each side. It should be passed as low as possible, as the vessel lies on the first rib. It is advised, in cases where it is impossible to ligature the artery for want of space, to cut through the clavicle, provided it does not form part of the wall of the aneurism. One of the principal causes of death after ligature of the subclavian is septic inflammation, starting in the areolar tissue, and spreading to the anterior mediastinum, pericardium, and pleura. This is due to the opening up of the layers of fascia prolonged from the neck into the thorax, and more or less fixed to the inner side of the first rib, and partly forming a roof to the pleural cavity. The opening up of this roof is the more likely to happen if the artery be tied anywhere else than on the first rib. In dressing the Surgical, Medical, and Operative. 71 wound afterwards, a drainage tube must be used witb great caution, its free end being protected from pressure lest the other end ulcerate its way into the artery. It must be removed in from thirty-six to forty-eight hours. Note. — (1) In thick-set, short-necked persons the artery is usually deeply seated; it may be below the level of the clavicle, or but slightly above it. (2) In thin, long-necked persons its course is usually high, and, therefore, is much more easily reached and ligatured. (3) The clavicle in some cases is very much curved. When this is the case, the depth of the vessel from the surface is increased, and is therefore more difficult to ligature. An aneurism in the axilla will produce the same effect, by raising the clavicle, and will complicate the operation considerably, as the shoulder cannot in this case be depressed ; a similar result may be produced by emphysema of the lung. (4) The artery may pass in front of, or through the anterior scalenus; the clavicular head of the sterno- mastoid, instead of being confined in its origin to the inner third of the posterior surface of the clavicle, may pass beyond its usual limit outwards along the clavicle, and conceal the artery; and the trapezius may also pass further inwards than it usually does, and overlap the vessel. In five per cent, of the cases, the omo-hyoid arises from the middle third of the clavicle, and, therefore, covers the artery. When this condition is encountered the muscle must be divided ia order to reach the vessel. (5) The posterior scapular artery frequently, and sometimes the supra-scapular, may spring from this part. (6) The external jugular vein should lie just external to the stemo-mastoid ; but, very frequently, it is more external, and passes beneath the deep fascia just above the middle of the clavicle, crossing the third part of the subclavian artery, and emptying itself into the subclavian vein. While it lies over the artery it receives the supra-scapular and transversalis colli veins, and in this region also communicates with the anterior jugular and cephalic veins. In this way a plexus of veins is formed in front of the artery. If any of the large venous trunks must be cut in the operation, a double ligature should be first applied and the vein divided between. The subclavian vein may rise as high as the level of the clavicle, or may lie with the artery beneath the anterior scalenus. (7) A cord formed by the eighth cervicle and first dorsal 72 Applied Anatomy: nerves lies immediately behind the subclavian artery — or may be between it and the first rib — and is, therefore, specially liable to be included in the ligature, or even to be tied instead of the artery — mistakes committed by several eminent Surgeons. (8) In some cases the supra-scapular artery is much enlarged, and has been mistaken for the subclavian. (9) Aneurism of the transversalis colli may simulate subclavian aneurism. (10) The artery may be pushed forwards by a supernumerary cervical rib, or an exostosis springing from the first rib, conditions which at first sight may simulate subclavian aneurism. RESUME of the chief points in this operation : — 1. Make the incision opposite the middle third of the clavicle in the way directed. 2. Make sure of the safety and position of the external jugular and other large veins. The external jugular will be found by scratching through the deep fascia, close to the clavicle, with the handle of the knife. 3. Define the edge of the scalenus anticus, and use the tubercle at its insertion as guide to the vessel. 4. Make a small opening in the sheath and clear the vessel thoroughly. 5. Pass the needle from above. 6. Take care not to include the cord formed by the eighth cervical and first dorsal nerves. The anatomical guides to this operation are well marked. We have first the outer edge of the sterno-mastoid, which guides to the outer edge of the anterior scalene; then the anterior scalene itself, and lastly the tubercle at its insertion into the first rib ; we have also the cords going to form the brachial plexus. Collateral Circulation, when the subclavian is tied in its second and third parts (see Fig. 12) — 1. The supra-scapular (15) from thyroid axis (first part of the subclavian) anastomosing with the dorsalis scapulae branch of the subscapular (25) (from third part of axillary). 2. The posterior scapular branch of the transversalis colli (14), of thyroid axis, anastomosing with the subscapular (25) and circumflex branches (22) of axillary. 3. Internal mammary (29) from first part of the subclavian, the superior intercostal (18) and Surgical, Medical, and Operative. 73 the aortic intercostals (30), anastomosing with the long and short thoracics of axillary artery (26, 21), and the deep epigastric (28). IBBEG-ULARITIES. — The right subclavian may spring as a separate trunk from the arch of the aorta, and when it does so, the first part is much deeper than usual. It may pass in front of or through the fibres of the scalenus anticus; and its point of origin varies according to the point of bifurcation of the innominate. When it springs directly from the arch it may be the first, second, third, or even the fourth branch. When it is the first it occupies the position of the innominate; when it is the second or third, it usually passes behind the right carotid to gain its usual position ; and when it is the last branch it may pass behind the oesophagus, or between , it and the trachea, to reach its ordinary position. When it passes in front of or behind the oesophagus, there is a great risk of sharp foreign bodies caught in the ossophagus, e.cj., fish bones, ulcerating through into the subclavian and causing fatal haemorrhage. The left subclavian is sometimes joined with the left common carotid at its origin. An instructive case is related by Mr Holmes, where, in a case of aneurism of the arch of the aorta, the pulsation in the right carotid was normal, but the pulse at the right wrist was obliterated. The explanation was that, in this case, the subclavian arose as the last branch from the arch, and in order to reach its usual position it passed between the arch and the spine, against which the aneurism compressed and obliterated it. Treatment of Subclavian Aneurism.^1. Medical and dietetic, combined with rest, etc. 2. Surgical measures; as a rule all opera- tive measures are more or less dangerous or uncertain — (a) In aneurism of first or second parts, pressure on the vessel at the distal side of the tumour against the first rib may be tried; (6) in the same condition, ligature of the third part above or below the clavicle may be tried — Beasdor's plan, or distal ligature; (c) ligature of the innominate, if the aneurism be limited; and {d) or amputation at the shoulder joint and tying the artery on the face of the stump (FBRGtrssoN). In aneurism of the third part we may — (a) Ligature the first part, using ox aorta or kangaroo tail tendons, so as rather to compress the vessel than to divide its coats; (&) direct pressure on the tumour with refrigeration ; and (c) amputation at shoulder joint. Other means, equally uncertain and dangerous, such as 74 Applied Anatomy: galvano-puncture, manipulation, and introduction of foreign bodies have been tried. BRANCHES OF THE SUBCLAVIAN. OF THE FIEST PART. — I. Vertebral. — It arises feom the upper and back part of the artery, passes up behind the internal jugular vein, between the longus colli on the inner side, and scalenus antieus on the outer side, to the foramen in the transverse process of the sixth cervical vertebra; sometimes it enters as low as the seventh, or yet again may enter as high as the fifth. The left vertebral is usually the larger. It is crossed by the inferior thyroid artery on both sides, and on the left side, in addition, by the thoracic duct. In the foramen it is surrounded by a plexus of sympathetic nerves, having its own vein in front, and the trunks of the cervical nerves behind it. This vessel was first ligatured by Dr Smyth of New Orleans, in 1864 ; and, more recently, the operation has been recommended by Dr Alexander of Liverpool, in epilepsy. We append Dr Smyth's description of the operation as per- formed by himself : — "The head of the patient being thrown back and sligMly turned to the left, an incision two inches in length was made along the posterior border of the sterno-mastoid muscle, commencing at the point where the external jugular vein crosses this muscle, and terminating a little below the clavicle, the edge of the muscle being exposed and drawn to the inner side, the prominent anterior tubercle of the transverse process of the sixth cervical vertebra was readily felt and taken for a guide. Imme- diately before this, and in a vertical line with it, lies the artery. A layer of fascia was now divided, some loose cellular tissue, with lymphatics, and the ascending cervical artery, were pulled to the inner side, and a separation was made between the scalenus antieus and longus colli muscles just below their insertion into the tubercle, when the artery and vein became visible, the latter was drawn to the outer side (this is important), and the needle passed around the former, from without inwards.'' In performing this operation care must be taken not to mistake the inferior thyroid artery for the vertebral. Immediate contraction of the corresponding pupil is often noticed when the vessel is tied ; Surgical, Medical, and Operative. 75 this is no doubt due to some interference with, the sympathetic filaments on their way to supply the dilator pupiUse. "Wounds of the vertebral are veiy. often mistaken for wounds of the common carotid, because pressure helow the level of the " carotid tubercle " arrests the flow through hotli vessels, and therefore arrests the bleeding from the wound, and has led in many cases to the ligature of the carotid, whereas the vertebral was the vessel at fault. Above the upper border of the axis the artery passes outwards and upwards to reach the foramen in the transverse process of the atlas; after passing through this it lies in a deep groove on the upper surface of the posterior arch of this bone (see " Sub-occipital Triangle"), pierces the posterior occipito-atloid ligament and. dura mater, enters the stull through the foramen magnum, winds round the medulla to its anterior aspect, and, at the lower border of the pons, unites with the vessel of the opposite side to form the basilar. In the groove on the posterior arch of the atlas the sub-occipital nerve lies beneath it, and in the skull it lies between the hypo- glossal and the anterior root of the first cervical nerve. On the left side the operation is more difficult and dangerous than on the right, on account of the presence of the thoracic duct. This structure rises in the neck as high as the sixth cervical vertebra, passing outwards behind the internal jugular vein and lying on the vertebral artery and vein (or very frequently between them) the anterior scalene, the supra-scapnlar and transversalis colli arteries, and phrenic nerve. It then curves downwards and inwards to enter the left subclavian vein at its junction with the left internal jugular. JfoTE. — (1) The prominent anterior tubercle of the transverse process of the sixth cervical vertebra is known as the "carotid tubercle" of Chassaignac, and by some Surgeons is used as the "deep" guide in ligature of the common carotid artery as well as in ligature of the vertebral; it is also, in Dr Drobeck's method, used as the guide for the inferior thyroid; the artery arches upwards round this process, and is about one inch above it. It is about two inches above the clavicle, or on a level with the cricoid cartilage. (2) The sub-occipital nerve is the undivided posterior primary division of the first cervical nerve. This nerve communicates with the great occipital, the vagus, and the hypo-glossal; when the vertebral 70 Applied Anatomy: artery is diseased, therefore, it may press on these various nerves, causing pain in the back of the head, along the great occipital, and has also been said to. affect speech from pressure on the hypo-glossal in the skull, leading to partial paralysis of the muscles of the tongue. II. The Thyroid Axis. — This is a short trunk which arises from the anterior and upper part of the vessel, and very soon divides into three branches — (a) Inferior Thjnroid, which passes upwards and inwards in front of the vertebral artery, recurrent laryngeal neiTe, and longus colli muscle, but behind, the carotid sheath and its con- tents, and the gangliated cord of the sympathetic, the middle cervical, or thyroid, ganglion usually resting upon it. It takes a flexuous course to the inferior angle of the thyroid body, which it enters on a level with the body of the fifth cervical vertebra, the recurrent laryngeal nerve at this point often passing between its terminal branches; at first it passes vertically upwards to a point just above the " carotid tubercle," and after that it curves inwards obliquely to the thyroid body. If this branch be ligatured in its oblique part, as it passes behind the carotid sheath, the incision and the structures divided will be nearly the same as in ligature of the common carotid at the lower part of the neck, the necessary modi- fications being evident. As the omo-hyoid partially conceals tlie vessel, it must be drawn aside or divided ; when this is done, look for the artery between the trachea and the oesophagus on the inner side, and the carotid sheath with its contents on the outer side. In performing this operation great care must be taken not to injure the descendeiis noni, or the recurrent laryngeal nerve. In excision of the thyroid body, this vessel requires to be ligatured as it enters the inferior angle of the gland. The branches of the inferior thyroid artery are — (1) Ascending cervical; (2) inferior laryngeal branch; (3) oesophageal; (4) tracheal. It may also be ligatured in its first or vertical portion, by an incision two or three inches in length along the posterior border of the sterno-mastoid (Deobeck) ; the incision begins about half-an-inch above the clavicle. Take care of the external jugular vein and the phrenic nerve; the trunk of the artery is found near the inner border of the anterior scalene. The deep guide is either the ^^ carotid tubercle" or the ascending cervical branch, which lies between the scalenus anticus and the Surgical, Medical, and Operative. *l*l rectus anticus major, and which, when found, will lead to the parent trunk. (6) Transversalis Colli — Passes outwards in front of the scalenus anticus and phrenic nerve, and beneath the sterno mastoid, into the posterior triangle of the neck, where it passes in front of the cords going to form the brachial plexus, and ends there by dividing into superficial cervical and posterior scapular arteries. Aneurism of this branch may simulate subclavian aneurism, (c) Supra-scapular, or Transversalis Humeri — This vessel is on a lower level than the last, and runs outwards in front of the scalenus anticus and phrenic nerve, but behind the clavicle and the omo- hyoid to the upper border of the scapula. In some rare cases this branch is much enlarged, and has been mistaken for the subclavian artery itself. III. Internal Mammary. — This vessel arises from the anterior and lower part of the subclavian, and passes downwards behind the inner end of the clavicle, and the beginning of the right innominate vein, and enters the chest between the first rib and the pleura; as it is about to enter the chest, it is crossed by the phrenic nerve, and covered by the internal j,ugular and subclavian veins. If this vessel were to be tied at its origin, it should be borne in mind that its anterior relations are precisely similiar to those of the first part of the subclavian (see above). For the rest of its course it lies fully half-an-inch external to the margin of the sternum, and in the interval between the sixth and seventh costal cartilages it ends by dividing into the musculo-plirenic and siiperior epigastric arteries. Relations. — In front, the internal mammary is covered by — (1) The skin, superficial and deep fascia; (2) pectoralis major; (3) anterior intercostal membrane; (4) internal intercostal muscle; (5) costal cartilages. It lies on — (1) Triangularis sterni; (2) costal pleura; (3) the terminations of the intercostal nerves. The left internal mammary is usually described as being one of the contents of the anterior mediastinal space, but such is not the case, as in no part of its cou.rse does it lie within that space (Cunningham). For the purpose of ligature the vessel may be reached by an oblique Incision downwards and outwards from the side of the sternum, the centre of the incision being half-an-inch from that bone ; then by dividing the various muscular and fascial layers already indicated 78 Applied Anatomy : the artery, with its accompanyiag veins, can he readily exposed. The vessel may also he exposed hy a transverse or vertical incision, and is most easily reached in the second space. In cases, however, of hsemorrhage from the artery, the result of a wound, the operation of securing the vessel may he more difficult, but the hleeding may be readily controlled hy compression, as in the case of an intercostal artery; a small hag of muslin or -a fine silk handkerchief, being introduced through the wound, is stuffed with lint or a piece of sponge, and then withdrawn so as to effectually compress the vesse against the costal cartilages (Fig. 15). Fig. 15. Intercostal HjEmorrhage. __ Rib. ,.. Intercostal Artery. .. Packing of Lint. Handkerchief y' When the hankerchief is pulled outwanls, in the direction of the arrow, the round ball presses on the artery and stops the bleeding. OF THE SECOND PART. — The superior intercostal artery, and arising in common with it is the profunda cervicis branch, which passes backwards between the neck of the first rib and the transverse process of the seventh cervical vertebra, and ascends in the neck between the complexus and the semi-spinaUs colli, supplying these muscles and anastomosing with the vertebral and princeps cervicis branch of the occipital artery. On the left side as already men- tioned, the superior intercostal arises from the first part of the subclavian. In either case it descends into the thorax in front of the neck of the first rib, and gives -off the posterior intercostal arteries to the first and second spaces, anastomosing with the first aortic intercostal and the internal mammary. The inosculation between the profunda and the princeps cervicis is an important agent in re-establishing the circulation after ligature of the common carotid. Surgical, Medical, and Operative. 79 CHAPTER VII. CAROTID ARTERIES. Common Carotid Artery. — Aneurism of this vessel presents as a pulsating tumour between the two heads of the sterno-mastoid, more or less elongated in the vertical direction, with a bruit propagated upwards, and not towards the axilla, and gives rise to special pressure symptoms: — for instance, if the aneurism be situated near the bifurcation of the vessel (where it usually occurs), there is a constant hacking cough due to pressure on the superior laryngeal nerve; if it be placed lower down we may get spasm of the glottis from pressure on the recurrent laryngeal nerve. On account of the dense cervical fascia the aneurism tends to press inwards, and may simulate abscess of the tonsil or pharynx, but is more rounded and circumscribed than abscess, and the swelling wUl pulsate. There may also be serious dyspnoea and difficulty in deglutition from direct pressure, and also from irritation of the pharyngeal plexus. Aneurism of this vessel occurs earlier in life than most aneurisms, and as often in women as in men; it is most common on the right side and usually at the bifurcation, as at this point the pressure is greater than elsewhere. To compress this vessel during life one may — (1) squeeze it laterally by placing the thumb at the anterior border of the sterno-mastoid, and the next three fingers at the posterior edge : in this way the vagus escapes pressure; (2) directly backwards against the "carotid tubercle." In using this second method pressure must be made on a level with the cricoid cartilage (which corresponds to the level of the "carotid tubercle"), because if below this point the vertebral will be compressed as welL This is important, because wounds of the common carotid are very common in civil practice, and must be distinguished from wounds of the vertebral, and viae versa. 80 Applied Anatomy: Origin. — On the rigM side in the bifurcation of the innominate artery opposite the sterno-clavicular articulation. On the left side it springs directly from the arch of the aorta. Extent. —From behind the sterno-clavicular articulation to a point a little higher than the upper margin of the thyroid cartilage, where it divides into internal and external carotids. Course. — Its course is in- dicated by a line drawn from the sterno-clavicular articulation to a point midway between the angle of the jaw and the mastoid process. The artery, together with the internal jugular vein and vagus nerve, are included in a common sheath derived from the deep cervical fascia, although each structure lies in a separate compart- ment; the septa are comparatively strong, especially that between Fig. 16. Transverse Section of Left Carotid Sheath. //^ \ ''•/ \^ .^Pomtatwhich the Sheath i / I / \ should be opened in IntemalJugnlar Vein ././. ji 11.^—^ \ ligaturing the Com- I / 1 1 f \ I raxm. Carotid Artery. If /l\ ■^— 1*1 Common Carotid Artery. X. / ©-Vt?/- Pneumo-Gastiic Nerve. S. Septum between the Arteiy and Vein. the vein and the artery. This is important, because the compart- ment containing the artery may be opened without interfering with those containing the vein and nerve, and in this way the vein, which is about twice the size of the artery, and often overlaps it, is prevented from bulging unduly over that vessel during the operation. In the sheath the artery is the most internal, the vein most external, and the nerve behind and between (Fig. 16). Before describing the operation itself, we will state very briefly the chief relations of the sheath to the surrounding parts. As high as the Cricoid Cartilage it is deeply placed, and is covered hy — (1) The common investments {i.e., skin and superficial Surgical, Medical, and Operative. 81 fascia, platysma and deep fascia). (2) Sternal head of sterno-mastoid. (3) Stemo-hyoid. (4) Sterno-thyroid. (5) Crossed by omo-hyoid. (6) Above this point it enters the carotid triangle, is covered by the common investments of the parts overlapped by the sterno-mastoid, and crossed about the point commonly chosen for the application of a ligature by the sterno-mastoid artery from the superior thyroid. It is also crossed by (7) three veins — superior and middle thyroids, and the anterior jugular. (8) The descendens noni lies on (some- times m) the sheath. (9) In front of the superficial part there are some lymphatic glands; it is important to remember this, as a gland may be mistaken and cleaned for the artery. Eurther, these glands are apt to suppurate, and may simulate aneurism. (For the Diagnosis between Aneurism and Abscess, see page 6.) It is usually slightly overlapped by the sterno-mastoid at its upper part. Beliind the sheath is — (1) The gangliated cord of the sympathetic; (2) the recurrent laryngeal nerve crossing obliquely inwards behind the sheath; (3) longus coUi; (4) rectus capitis anticus major; and behind these (5) the transverse processes of the cervical vertebras, against which the vessel may be compressed during life. (6) The inferior thyroid artery also crosses obliquely inwards behind both the sheath and the gangliated cord of the sympathetic. (See the " Branches of Subclavian.") (7) Behind the deep part of the sheath are some lymphatic glands. To its inner side we have — (1) The larynx and trachea. (2) Pharynx and oesophagus. (3) Thyroid body. (4) Eecurrent laryngeal nerve and inferior thyroid artery. To the outer side, a chain of lymphatic glands and the scalenus anticus. It should be noted, however, that though the glands at the lower part of the neck are behind the sheath, yet at the upper part many glands lie in front of the artery; it is important to keep this in mind as these glands may undergo chronic inflammation and suppuration, and closely simulate an aneurism. The above are the chief relations of the carotid sheath. To assist the memory, note the following points in regard to the relations of the artery itself: — 1. That there are four niuscles in front of it, viz., sterno-mastoid, sterno-hyoid, sterno-thyroid, and omo-hyoid. 2. That there are four veins in relation to the artery — two jugular and two thyroid, three of these cross it, and one (the , internal jugular) lies to its outer side. 3. That there are four 82 Applied Anatomy: nerves in relation to it — above, the descendens noni; behind, the gangliated cord of the sympathetic; on the inner side, the recurrent laryngeal (at its lower part); on the outer side, the vagus. 4. There are four chief things io its inner side — the air passages, the food passages, thyroid body, and recurrent laryngeal nerve with the inferior thyroid artery. In the living body it should be remembered that the vessel is overlapped throughout its entire extent by the sterno-mastoid, as this muscle does not pass in a straight line from the sterno-clavicular articulation to the mastoid process, but takes a curved course, the convexity of the curve being directed t^vards the middle line of the neck. This curve is maintained by a process of deep cervical fascia attached on the one hand to the deep surface of the sterno- mastoid and on the other to the angle of the lower jaw, for as soon as it is cut the anterior edge takes a straight direction (Ellis). It may be necessary to ligature this vessel for a wound, either of itself or its branches, for aneurism, for epilepsy, for erectile and pulsatiug tumours of the orbit and skull, or cirsoid aneurism of the scalp; it has also been ligatured for wounds in the mouth and ulceration of the tongue. As it gives off no branches it may be tied at any part of its course, but it is better to avoid tying it either close to its origin or to its termination — at its origin, on account of its great depth, and especially on the left side where the internal jugular vein is in front and the thoracic duct behind it; at its termination, because here there is a large plexus of veins in front of it. If for a wound, it must be tied on both sides of the bleeding point and then divided between; if for a wound of its branches, or pulsating tumour higher up, it should be tied in the most accessible position — above the omo-hyoid; if for an aneurism, the point of ligature will depend on its position, e.g., ia aneurism of the upper part, the Hunteeian operation may be iised, while in aneurism low down we may use the method suggested by Brasdoe. Ligature of the vessel for cirsoid aneurism of the scalp ("aneurism by anastomosis " of some), a similar condition of the orbit, or other forms of pulsatile simple tumours of the orbit and scalp, cannot be regarded as a necessary or even justifiable operation, since Dr John Duncan has proved the safety and certainty of cure by electrolysis. Surgical, Medical, and Operative. 83 LIGATURE ABOVE THE OMO-HYOID. The patient should be placed in the recumbent position, and his shoulders raised by means of pillows, the head being thrown back a little, and the face turned towards the opposite shoulder, in order to make the sterno-mastoid tense and prominent, and the angle of the jaw turned up somewhat. The neck should be com- pressed at the lower part, in order to make the superficial veins, as the anterior and external jugulars, turgid, and their course noted, so that they may be avoided as much as possible in making the necessary incision. The Surgeon should stand on the same side as the vessel about to be ligatured, and most conveniently behind the shoulder for the left side, but in front of the right, or in both cases facing the side of the patient's neck. Superficial Guide. — The line marking its course, or the anterior border of the sterno-mastoid. incision, — With the line of the vessel in mind, make an incision three inches in length, so arranged that its centre shall be on a level with, or rather higher than, the cricoid cartilage — the point usually selected for ligature above the omo-hyoid (see Pig. 14). The upper part of this incision will be a few lines nearer the middle line of the neck than the reputed anterior margin of the sterno-mastoid, this muscle diverging from the artery as it rises higher in the neck; this, however, is only the case when the process of deep cervical fascia, already mentioned, is divided, and therefore must not be looked for out of the dissecting room. By this incision we divide — (1) the skin, (2) superficial fascia, (3) platysma. (4) Then cut through the deep fascia and expose the edge of the sterno-mastoid, and draw it aside with blunt hooks, the head being previously turned a little towards the same shoulder and flexed by the assistant, in order to relax its fibres. (5) Expose the omo-hyoid by cutting through a dense fascia covering it and the other muscles and carotid sheath. It is of importance to note that at this part of its course there is usually a large venous plexus in front of the vessel formed chiefly by the superior thyroid veins with communi- cations from the lingual, facial, anterior, and external jugulars. (6) Draw aside the lateral lobe of the thyroid body which is now exposed, and look for the deep guide to the vessel, viz., the angle formed by the anterior belly of the omo-hyoid with the anterior 84 Applied Anatomy: border of the sterno-mastoid — the artery bisecting this angle. Draw the muscle inwards with a blunt hook, and then expose the sheath fully, by carefully turning aside any intervening structures with the liandle of the knife, using the blade as little as possible, in order that the descendens noni nerve and its communications, and sterno-mastoid branches of the superior thyroid artery, be not injured. Open the inner compartment of the sheath well to the tracheal side, since the greater part of the sheath, as thus exposed, is occupied, in the living body, by the internal jugular vein (see Fig. 16). Then clear the artery very thoroughly from the special areolar sheath surrounding it, till the white external coat comes into view, and pass the ligature (without using force) from the outer side to avoid the risk of wounding the internal jugular vein or including the vagus, holding the other edge of the opening in the sheath with a pair of artery forceps to steady it during the passage of the ligature. . BESUME of the principal steps in this operation : — 1. Centre of the incision to be opposite the cricoid cartilage, not too far forward, lest the anterior jugular be cut. 2. Expose the anterior edge of the sterno-mastoid, and secure sterno-mastoid artery. 3. Expose the upper edge of the anterior belly of the omo- hyoid, watching for the venous jjlexus, sterno-mastoid artery, and descendens noni nerve. Now flex the head, and, 4. With a finger in the wound, press towards the transverse processes of the vertebrae, and feel the artery in the angle between the omo-hyoid and the sterno-mastoid, rolling beneatli the finger. 5. Open the common sheath well to the inner side, and, if necessary, push the internal jugular outwards, or com- press it at the upper angle of the wound to empty it. 6. Open the special cellular tissue sheath of the artery, and clear it till the white external coat is seen, and then pass the needle from the outer side. Surgical, Medical, and Operative. 85 LIGATURE BELOW THE OMO-HYOID. Right Side. — The position of the patient and the Surgeon are the same as for the higher operation. If we wish to ligature the vessel below the omo-hyoid, it is necessary — (1) That the incision be extended further down along the anterior edge of the sterno- mastoid, which must be drawn well outwards, after having divided its sternal head. An incision three inches long commencing a _ little above the level of the cricoid cartilage, and extending to the episternal notch, will be found sufficient; sometimes an angular incision is used, corresponding to the lower two inches of the sterno-mastoid, and the inner two inches of the clavicle. (2) To divide the fascia binding the omo-hyoid to the muscles near it, and draw it upwards. (3) Draw the sterno-mastoid outwards, the sterno-hyoid and sterno-thyroid muscles inwards, or, if necessary, divide the sterno-hyoid, and the carotid sheath is now exposed. Proceed as in ligature above the omo-hyoid, bearing in mind the complicated relations of the parts. There is a venous plexus in front of the vessel formed chiefly by the middle thyroid veins, with communications from the anterior and external jugulars; the chief trunks must be carefully avoided, as well as the ansa hypoglossi and its branches. On the left side the artery springs from the arch of the aorta, but beyond the sterno-clavicular articu- lation, its relations are almost the same as those of the vessel on the right side, with the following differences : — (1) It is more deeply placed, as the right arises from the innominate artery which lies in front of the trachea, while the left lies rather behind that structure. (2) The internal jugular vein and the pneumogastric nerve are often placed in front of the artery in the lower third of the neck. This makes clearing the vessel for the passage of the ligature more diificult on the left side ; on the right side it is easy, because the vein and nerve incline away from the artery at its lower part, but on the left side the vein bulges right over the vessel, and in the living subject complicates the operation consider- ably. (3) Being deeper it is nearer the oesophagus, which lies on its inner side. (4) Low down, the thoracic duct lies to its outer side. Otherwise the operation for ligature of the vessel on the left side is similar to the corresponding operation on the right side. 86 Applied Anatomy: After the operation the patient should be placed in hed with the head and shoulders raised. His head should be bent a little forwards to relax the parts, and fixed in that position by a circle of bandage round it, with strips passing from it to be fixed to a' broad band round the chest. An opiate, or a mixture containing hydrocyanic acid, may be necessary to allay laryngeal irritation. r r BESITME of this operation : — 1 . An incision three inches long is made from a little above the cricoid cartilage to the episternal notch. 2. Expose the sterno-mastoid and divide its sternal head and draw it outwards, and draw the omo-hyoid up- wards. 3. Secure the anterior jugular and middle thyroid veins. 4. Expose the stemo-hyoid and draw aside or divide it; the sterno-thyroid will not require division, as a rule. 5. Press a finger backwards towards the transverse processes of the cervical vertebrae and feel for the "carotid tubercle;" the artery will be felt rolling under the finger. 6. Divide the common sheath and clear the artery from its fecial cellular tissue sheath and tie as in the high operation. Sedillot has ligatured the artery at the root of the neck^by an incision between the two heads of the sterno-mastoid; the head is flexed, the two parts of the musele separated, and the vessel exposed and tied, taking special care of the vagus nerve and the internal jugular vein. Collateral Circulation (see Fig. 12). — 1. Branches of the external carotid on the side tied, anastomosing with the corre- sponding branches of the opposite side (4), viz. — (a) Facial with facial; (h) temporal with temporal; (c) occipital with occipital; {d) superior thyroid with superior thyroid (10). 2. Anastomoses between the internal carotids of opposite sides through the anterior segment of the " circle of Willis " — anterior cerebral of the one side, with the anterior cerebral of the other, through the anterior communicating (1). 3. Anastomoses between the subclavian and the external carotid of the side tied — (a) The deep cervical (11) Surgical, Medical, and Operative. 87 with princeps cervicis of occipital (6) ; (6) the vertehral (8) with the occipital (7) ; (c) inferior thyroid with superior thyroid (10). 4. Anastomoses between the suhclavian and the internal carotid of the side tied, the vertebral (from subclavian) through the basilar and posterior cerebral, with posterior communicating from internal carotid, i.e., through the lateral segment of the "circle of Willis" (1). 5. Anastomoses of the ophthalmic, from the internal carotid, through the " circle of Willis," with branches of the external carotid on the side tied — (a) Nasal of ophthalmic with angular of facial; (b) infra-orbital, from internal maxillary, with twigs of facial; (c) supra-orbital and frontal, from ophthalmic, with terminations of the anterior temporal. The usual cause of death after ligature of the common carotid is cerebral disease induced by the operation, from the sudden inter- ference with the cerebral circulation; the symptoms are twitchings, trembUngs, convulsions, syncope, giddiness, and sometimes complete hemiplegia of the opposite side, probably due to the diminished supply of arterial blood. The softening of the brain which is apt to follow corresponds, pathologically, to gangrene in other situations; abscess . in the brain has occasionally been found. In other cases drowsiness, stupor, and apoplexy supervene, probably from the venous congestion. Besides the cerebral symptoms the lungs, in many oases, appear to be affected, probably from the interference with the blood supplj' to the meduUa oblongata, they become congested and are apt to run into a low form of inflammation, just as in injury of the trunks of the vagi. Occasionally, vascular erectile tumours are situated over the course of the carotid artery, and may indirectly communicate with it or the jugular vein : under such circumstances the diagnosis of aneurism becomes a matter of extreme difficulty. IBBECrULABITIES. — The vessel may bifurcate as low as the cricoid cartilage, or even lower, so that two trunks are met with instead of one at the usual seat of ligature. Sometimes it ascends as high as, or even higher than the hyoid bone before it divides. The carotids may arise by a common trunk, the right then passing in front of the lower part of the trachea in the neck to reach its usual situation ; in such a case it would be in the way, and form a great source of danger in the operation of tracheotomy. 88 Applied Anatomy: INTERNAL CAEOTID ARTERY. Origin. — From the ■bifurcation of the common carotid, opposite the upper horder of the thyroid cartilage. It is deeper and further from the middle line (i.e., more posterior) than the external. It is called "infernal" because it is distributed to the interior of the cranium. The internal jugular vein, the vagus, and the sympathetic nerves have the same relation to the internal as to the common carotid artery. Course. — Its course is indicated by the upper part of a line drawn from the sterno-clavicular articulation to a point just in front of the lobule of the ear. The part below the posterior belly of the digastric (i.e., the part in the carotid triangle) is the only accessible portion. Relations. — In front — (1) Skin; (2) the superficial fasciaj (3) platysma; (4) deep fascia; (5) crossed by the ninth nerve, sending down the descendens noni; (6) also crossed by the occi- pital artery, giving off some sterno-mastoid branches. Higher up we find (7) the parotid gland; (8) the stylo-glossus and the stylo- pharyngeus muscles; (9) the glosso-pharyngeal nerve and pharyngeal branch of vagus; (10) the external carotid artery. On the outer side — (1) The internal jugular vein; (2) spinal accessory nerve; (3) pneumo-gastric nerve. On the inner side — (1) The pharynx; (2) ascending pharyngeal artery; (3) tonsil. Behind — (1) The gangliated cord of, sympathetic; (2) superior laryngeal nerve (iaternal and external branches); (3) rectus capitis anticus major; (4) further back, the cervical vertebrse. An extra-cranial aneurism of this vessel tends to bulge into the pharynx, as there is least resistance to its growth in this direction. Incision. — ^^With the patient and Surgeon in the same position as in ligature of the common carotid, an incision should be made in the line of the vessel along the inner edge of the sterno-mastoid muscle, from the angle of the jaw to the upper border of the thyroid cartilage. The best position for applying the ligature is about midway between the hyoid bone and the digastric. By this incision we cut through (1) skin; (2) superficial fascia; (3) platysma; and (4) deep fascia. Draw aside the sterno-mastoid, when (5) the occipital artery with its mastoid branch, and (6) the ninth nerve with its descendens noni branch, are brought into view. Turn Surgical, Medical, and Operative. 89 these aside, open the sheath, clear the vessel, and pass the ligature. Great care is necessary in clearing the vessel on account of its close relation to the internal jugular vein on its outer side, the vagus nerve behind and to its inner side, and the external carotid above and somewhat to its inner side. The needle is to be passed from the outer side, i.e., from the vein. This is an operation rarely, if ever, performed on the living body. In cases of wound of the vessel in the neck by a stab or bullet, etc., it should, if possible, be tied at the bleeding point, but in this case, the wound is the guide. Sometimes it is very difficult to be quite sure of the position of the bleeding point, and in that case, the common carotid should be tied. In cases of intra-cranial and orbital aneurism, ligature of the common carotid is the more effectual operation. Should it be injured from the fauces, as in operations on, or in ulceration of, the tonsils, ligature of the common trunk is the proper plan of treatment. Note. — The vessel lies, at this part of its course, external to the external carotid. The internal jugular vein is to its outer side, and, therefore, the aneurism needle should be passed from this side; further, the gangliated cord of the sympathetic and the vagus, with its superior laryngeal branch, are behind it. When one internal carotid trunk has been tied the circulation is very speedily re- established by the internal carotid, and vertebral of the opposite side, and vertebral of the same side, through the " Circle of Willis." FECULIAIMTIES. — The length of the internal carotid varies according to the point of bifurcation of the common. Sometimes it springs directly from the arch of the aorta; occasionally, it is altogether absent. EXTERNAL CAROTID ARTERY. Origin. — At the same point as the internal. Extent. — From its point of origin upwards to a point opposite the neck of the condyle of the lower jaw, where it divides into temporal and internal maxillary arteries. In the child, ib is smaller than the internal; but in the adult, the two vessels are almost of equal size. It is called " external " because it is distributed to the outer aspect of the craninm. At first it is placed on the inner side of the internal carotid, but afterwards is superficial to that vessel. Course.— Runs 90 Applied Anatomy: upwards and slightly outwards, passing between the angle of the jaw and the mastoid process, lying a little to the front of the anterior border of the sterno-mastoid, very nearly corresponding to a line drawn from the front of the meatus of the ear to the cricoid cartilage, slightly arched forwards. Relations. — In the first part of its course the vessel lies in the carotid triangle, and is quite superficial, being merely covered hy— (1) Skin; (2) superficial fasciaj (3) platysma, with branches of the superficial cervical, great auricular, and infrarinaxillary branches of the facial nerve; (4) deep fascia; (5) lingual and facial veins, and may be slightly overlapped by the sterno-mastoid. In the second part of its course it is deeper, being covered by (6) the posterior beUy of the digastric and stylo-hyoid muscles, and (7) crossed by the ninth nerve. In the third part it is still deeper, for it passes beneath the deep surface of, and enters (8) the parotid gland, and under the structures in its substance. Behind the vessel we have — (1) The superior laryngeal nerve with its external branch, and the structures which separate the external from the internal carotids, viz., (2) stylo-pharyngeus and (3) stylo-glossus muscles; (4) styloid process, if long (if short, we will have the stylo-hyoid ligament); (5) glosso-pharyngeal nerve, and (6) pharyngeal branch of vagus. Note the nerves in relation with this vessel — (1) The hypo-glossal crosses it near its beginning ; (2) the facial crosses it at the upper part; (3) the superior laryngeal with its external laryngeal branch are beneath its lower part; while (4) the glosso-pharyngeal lies beneath its upper part. It may be ligatured as it lies in the carotid triangle, but its branches are so numerous that its ligature is apt to be followed by secondary haemorrhage. The best point for the application of the ligature is between the origins of the superior thyroid and lingual arteries. The patient is to be placed in the same position as in ligature of the common carotid and the Surgeon stands on the same side as the vessel to be tied. At this part of its course it is covered by a large plexus of veins, formed by the lingual, facial, and pharyngeal veins, with communications from the superior thyroid and external jugular. The incision used in ligature of the internal carotid will also do for ligature of this vessel, or the incision may be half-an-inch nearer the middle Ime of the neck, and should Surgical, Medical, and Operative. 91 extend from near the angle of the jaw to the level of the thyroid cartilage. Carefully cut through the structures covering it in the first part of its course. Turn the large veins to one side if possible, or else tie them with a double ligature and cut between. The sterno-mastoid must be pulled backwards, the digastric and stylo- hyoid muscles with the hypo-glossal nerve forwards and upwards, and the parotid gland upwards. The descendens noni is external to and somewhat behind the vessel, and is not likely to be injured, but the thyro-hyoid branch is immediately in front, and if seen should be hooked aside. The vessel is then to be cleared, and the needle passed from the outer side, and in doing so care should be taken to avoid injuring or including the descendens noni nerve, the superior laryngeal nerve, or the ascending pharyngeal artery. The external carotid may be ligatured for wounds of the main trunk or its branches, various forms of aneurism of the face and scalp, etc. In case of wounds, or aneurism the result of a wound, the vessel or its branches should be secured at the injured point. In cases of idiopathic aneurism and pulsating tumours of scalp, ligature of the common carotid is the more effectual operation, on account of the large number of branches given off by the external. Collateral Circulation (see Fig. 12). — 1. Branches of the external carotid on the side tied anastomosing with the corres- ponding branches of the opposite side (4), viz. — (a) Facial with facial ; (&) temporal with temporal ; (c) occipital with occipital ; {d) superior thyroid with superior thyroid (10). 2. Anastomoses between the subclavian and the external carotid of the side tied — (a) Deep cervical (11) from the superior intercostal, with the princeps cervicis (6) of the occipital; {b) the vertebral with the occipital in the region of the suboccipital triangle (7); (c) inferior thyroid with the superior thyroid (10). 3. Nasal of the' ophthalmic anastomosing with the angular of the facial. THE PULSE IN ANEURISM of the aorta and vessels at the root of the neck. — According to Dr Mahomed, the chief characters of the aneurismal pulse recognisable by the finger are— (1) Delay; (2) diminution in volume; (3) diminution in force; (4) persistency; (5) in some cases a thrill may be felt. In many cases the finger can perceive a want of parallelism in the beats of the radials; but sometimes the differences are too slight to be dectected by the finger. 92 Applied Anatomy: The characters of a sphygmographic tracing are — (1) A sloping upstroke, due to the delay of the pulse wave; (2) diminished volume of wave; (3) impairment of percussion, from the diminution in the force of the wave; (4) obliteration of secondary waves; (5) inequality of the pressure employed on the two sides; (6) some- times vibratUe waves, corresponding to the thrill sometimes felt by the finger. A constant dissimilarity in the pulse tracings of the two radials is the most valuable sign, and this is best of all demonstrated by sphygmographic tracings; the wave is delayed, it is smaller than the other, and there is loss of tension. The presence of the signs above enumerated in the pulse at both wrists would point to an aneurism of the ascending arch; if the right pulse be affected more than the left, the aneurism must involve the innominate; if the left more than the right, the aneurism is of the transverse arch beyond the innominate. Surgical, Medical, and Operative. 93 CHAPTER VIII. BRANCHES OF THE EXTERNAL CAROTID. An Anterior Set.— (1) Superior thyroid; (2) lingual; (3) facial. A Posterior Set. — (1) Occipital; (2) posterior auricular; (3) sterno- mastoid (sometimes). An Ascending Set. — (1) Temporal; (2) in- ternal maxillary; (3) ascending pharyngeal. The sterno-mastoid branch has three possible modes of origin — (1) From the external carotid ; (2) from the occipital ; (3) from the superior thyroid. Thyroid Arteries. — Ligature of these arteries has been practised by some Surgeons as a cure for bronchocele, with but doubtful success. "We have already referred to ligature of the Inferior Thyroid. (See page 75.) The Superior Thyroid. — This vessel is a branch of the external carotid. It is the lowest of the three branches arising from the anterior surface of that vessel, and is usually given off not far from its origin, as it lies in the carotid triangle, coming off just below the great comu of the hyoid bone. The superior thyroid itself, therefore, is at first merely covered by the common investments of the parts, and at this point it may be ligatured. Make an incision two inches long parallel with the anterior edge of the sterno-mastoid, but half-an-inch nearer the middle line, so that it shall lie over the external carotid artery, the centre of the incision being opposite the superior cornu of the thyroid cartilage, or the thyro-hyoid space, as the artery usually arises somewhat below the great cornu of the hyoid bone. Here the vessel, passing upwards and inwards, is quite superficial, being covered only by skin, superficial fascia, platysma, and deep fascia, and may be readily tied. There is a well marked venous plexus in front of the vessel, formed by the lingual, superior thyroid, and facial veins, which is the chief difficulty of the operation. After this it takes an arched cou^rse downwards, passing beneath the omo-hyoid, sterno-hyoid, and steruo-thyroid muscles to the upper part of the thyroid body. ■94 Applied, Anatomy: Branches.— (1) Hyoid branch, runs inwards lelow the hyoid bone. (2) Sterno-mastoid, passes outwards across the carotid sheath to the sterno-mastoid muscle; it is important to note the relation of this little branch to the carotid sheath, as it is in the way in the operation of tying the common carotid above the omo-hyoid. (3) Superior laryngeal, pierces the thyro-hyoid membrane and supplies the mucous membrane of the larynx. (4) Crico-thyroid, runs across the crico-thyroid membrane. This little branch should be remembered in the operation of laryngotomy, although, from its small size, it seldom gives rise to any trouble. Occasionally, however, it is of large size; I have seen it as large as an ordinary radial. (5) Terminal branches to the thyroid body. THE LINGUAL ARTERY. It may be necessary to ligature this vessel to restrain profuse haemorrhage from the tongue, e.g., in cancerous ulcers, or for the purpose of starving such growths, or preliminary to excision of the tongue, and in macroglossia. Origin. — From the anterior border of the external carotid, either just above or immediately below the level of the great cornu of the hyoid bone. Extent. — From its origin to the anterior border of the hyo-glossus muscle. Course. — At first inwards above the hyoid bone, and then upwards and inwards beneath the hyo-glossus. Relations. — In the first part of its course — from its origin to the posterior border of the hyo-glossus — it passes obliquely upwards and inwards to the great cornu of the hyoid bone, and is quite superficial, being simply covered by the skin, fascia, and platysma, and rests on the middle constrictor of the pharynx. In the second part of its course, that beneath the hyo-glossus, it runs forwards parallel with the great cornu of the hyoid bone for a little way, and then ascends to the under surface of the tongue. Here it is covered by the skin, fascia, and platysma, crossed by the posterior beUy of the digastric and the stylo-hyoid muscles, and sometimes also by the ninth nerve near the posterior border of the hyo-glossus, and lastly, it is covered by the hyo-glossus muscle itself. In its second part it rests on the middle constrictor and the genio-hyo- glossus muscle. Properly speaking the vessel ends, as such, at the anterior border of the hyo-glossus, and its continuation, the ranine Surgical, Medical, and Operative. Fig. 17. Lingual Artery. 1. Anterior Temporal. 12. Masseter. 2. Posterior Temporal. 13. Jaw. 3. Temporal. 14. Facial Vein. 4. Internal Maxillary. 15. Facial Artery. 5. Hypoglossal Nerve. 16. Digastric. 6. Occipital Artery. 17. Hyo-Glossiis. 7. Internal Carotid. 18. Sublingual. 8. Internal Jugular Vein. 19. Kanine. 9. Annandale's Incision. 20. Hyoid Bone. 10. Internal Carotid. 21. Central Tendon of 11. Common Carotid. Digastric. TKr dark li/nes indicate different forms of Incision for Ligature of the Linyual. 96 Applied Anatomy: artery, runs forwards to the tip of the tongue to end at the side of the frsenuni linguae. In ligaturing this vessel, the patient's shoulders should be slightly raised, the head thrown well back over a small pUlow, and the face turned towards the opposite shoulder. The most trustworthy superficial guide to the vessel is the great cornu of the hyoid bone. The Surgeon stands on the same side as the vessel tied, above the chin on the right side, but below it on the left (Fig. 17). Incisions. — ^To tie it in the first part of its course anincision is made horizontal or slightly convex downwards, about two inches in length, on a level with the greater cornu of the hyoid bone, and extending from the body of that bone to- the anterior border of the sterno-mastoid, its centre corresponding to the end of the greater cornu. This incision secures the vessel near its origin. Mr Annandale uses a vertical incision, following the course of the external carotid artery, and half-an-inoh anterior to that vessel. An oblique incision, passing downwards and backwards over the greater cornu, may also be used ; thus we may use one of three forms — horizontal, oblique, and transverse, — but in all cases the centre of the incision must correspond to the end of the greater cornu. Cut through the superficial structures already mentioned, and look for the deep guide, the ninth nerve, which is usually accompanied by a branch of the lingual vein. The artery is deeper than the nerve as it has to pass under the hyo-glossus, while the nerve passes over that muscle. The ninth nerve, with the posterior belly of the digastric and stylo-hyoid muscles, must be displaced upwards, and the external carotid artery backwards, by means of blunt hooks, and then, with the great cornu of the hyoid bone in view, search for the vessel in the loose cellular tissue. At first sight it might seem an easy operation to secure the vessel at this part of its course where it is so superficial, but this is by no means the case. There are three reasons for this — (1) Because behind the vessel is the soft mobile wall of the pharynx, and, for this reason, it is impossible to get the artery fixed, and in clearing the vessel great care is necessary lest the wall of the pharynx be wounded. (2) Over the vessel in this region is a large plexus of veins, formed chiefly by the lingual and facial (on their way to empty into the internal jugular), with communications from the Surgical, Medical, and Operative. 97 superior thyroid and external jugular veins. (3) Although appar- ently so superficial, yet, in the actual operation, the vessel lies at the bottom of a deep narrow pit, with the mobile pharyngeal wall forming its floor. Another ohjection to this operation is that the vessel is often joined at its origin with the facial or superior thyroid. For these reasons the next form of incision is the one usually adopted, except in cases where the operation is performed preliminary to excision of the tongue, when it is necessary to tie the vessel in its first part, and as close to the parent trunk as possible, in order to be sure that, in removing the tongue, the artery will not be cut between the parent trunk and the ligatured point. To tie it in the second part of its course, i.e., as the vessel lies beneath the hyo-glossus at the apex of the digastric triangle, a curved incision is made from a point a little below and behind the symphysis menti down to the level of the hyoid bone,, and then turning upwards till it nearly reaches the angle of the jaw. It must not be carried quite up to the angle of the jaw lest the facial vein be injured. The facial artery is safe, as it is in the substance of the sub-maxillary gland, whereas the vein is on its surface. After dividing the superficial structures and deep fascia, the sub-maxillary gland is exposed, and must be displaced upwards with a blunt hook. Then the boundaries of the triangle in which the vessel lies are to be recognised, viz., the two bellies and the intervening tendon of the digastric on each side, and the ninth nerve above the nerve is to be dissected up a little and held aside, when the hyo-glossus muscle will be exposed. The fibres of this muscle are then to be divided transversely about a couple of lines above the hyoid bone, the vessel carefully cleaned, and the needle passed from above downwards. In the dead body the muscle seems thinner than one might expect, and, unless care be taken, the operator may easily open into the pharynx. In this operation the trouble with veins is not so great as in the first form. Some operators use an incision an inch and a quarter in length, parallel with, and one-third of an inch above, the great coruu of the hyoid bone. PECULIARITIES. — The lingual artery sometimes arises from a trunk common to it and the facial ; less frequently it is joined with the superior thyroid. 98 Applied Anatomy : Branches. — (1) Hyoid, which runs along the upper border of the hyoid bone. (2) Dorsalis linguiB, which arises and ascends beneath the hyo-glossus to the dorsum of tongue. In the second method of ligature, the dwsalis lingum is usually given off between the ligature and the parent trunk j and ligature in this situation, therefore, will not stop haemorrhage from the base of the tongue. (3) Sub-lingual branches to sub-lingual gland. (4) Banine, the direct continuation of the lingual, which runs forward to the tip of the tongue, and ends in the frsenum linguae. To avoid this little vessel, in relieving the condition known as " tongue-tie,'' the prominent tight edge only of the frsenum is nicked with scissors, and as close to the jaw as possible, any further freeing must be done with the thumb or finger nail. The ranine vein is more superficial than the artery; division, or, more probably, partial division, of these vessels has led to fatal haemorrhage in children, no doubt helped by efforts at sucking. BESUME of second form of operation : — 1. Make a curved incision with the convexity downwards. 2. Take care of facial vein at the outer end of the incision. 3. Open the deep fascia and hook up the sub-maxillary gland. 4. Expose the central tendon of the digastric muscle, and then — 5. Expose the ninth nerve, which will be seen higher up passing beneath the mylo-hyoid but superficial to the hyo-glossus, and often accompanied by a lingual vein, which must not be mistaken for the artery. 6. Divide the fibres of the hyo-glossus on a director from the outer edge, and then clear and tie the artery, passing the needle from above downwards. FACIAL ARTEEY. The first of the incisions for ligature of the lingual would also expose the origin of the facial. It arises from the external carotid artery, a little above the lingual, lying at first in the carotid triangle, where it is simply covered by the superficial investments of the parts (skin, platysma, and fascia). It is then crossed by the Surgical, Medical, and Operative. 99 posterior belly of the digastric and stylo -hyoid muscles and ninth nerve. After this it passes through a groove in the posterior and upper border of the sub-maxiUary gland, where it makes a sigmoid flexure, crosses the lovjfer javr, lying on the bone, in a little hollow just about the point where the body joins the ramus, and imme- diately in front of the masseter muscle, and only covered by the skin, fascia, and platysma. Here its pulsations can be felt during life, and it may be readily compressed with the finger, or ligatured by an incision one inch in length parallel with the fibres of the masseter. The Surgeon stands on the same side as the vessel to be tied. At its origin in the neck it may be tied through an incision, similar to that used by Mr Annandale for the lingual, only a little higher up; displace the posterior belly of the digastric with the stylo -hyoid, and the sub -maxillary gland upwards and forwards, carefully work through the venous plexus, isolate and tie the vessel. After this, its general direction is towards the angle of the mouth, the angle of the nose, and the inner angle of the eye, but in a very tortuous manner. In its course through the face it is covered by the superficial structures and platysma, and that special part of the platysma known as the risorius muscle: it is also covered by the zygomatic muscles, and crossed by branches of the facial nerve. It rests on — (1) The lower jaw; (2) buccinator; (3) levator anguli oris; (4) levator labii superioris. The facial vein lies posterior to the artery on the face, and is more superficial in the neck, as the artery passes through the substance of the sub-maxillary gland, whereas the vein passes over its surface. It is further less flaccid than most superficial veins, and remains patent after it is cut across. FECULIABITIES. — The facial artery may arise by a common trunk with the lingual. Sometimes it terminates as the sub-mental, and in other cases may only supply the face as high as the angle of the mouth or nose. BRANCHES. — In necl<. — (1) Inferior or ascending palatine, which passes upwards between the stylo-glossus, and the stylo- pharyngeus muscles supplying them, the tonsil, and the Eustachian tube, and sends a branch through the space of Morgagni to the soft palate. (2) Tonsillar, which perforate the superior constrictor to reach the tonsils. (3) Glandular to sub-maxillary gland. (4) Sub- mental, given off immediately below the lower jaw to the chin. 100 Applied Anatomy: This is the largest branch, and must be kept in mind in operations about the lower jaw, such as excision, etc. ; it runs forwards on the mylo-hyoid muscle. On the face. — (1) Inferior labial, which passes beneath the depressor anguli oris to supply the lower lip and chin. (2) The two coronary arteries which pass along the free margin of each lip. They pass beneath the depressor anguli oris, and then perforate the orbicularis oris to run in a tortuous course between this muscle and the mucous membrane. When the lip is struck against the teeth, the coronary artery may be divided and bleed into the mouth without any sign of external wound, more especially in the case of drunk persons. The blood then trickles down the throat and is swallowed, and some time after may be vomited up, giving rise to a suspicion of internal injury; in all such cases, therefore, always examine the inside of the lips. The superior is the larger, and gives off the artery to the septum of the nose. In operations about the Hps, such as tlie removal of an epithelioma, these branches must be kept in mind; in this operation, performed on the lower lip by the V-shaped incision, the inferior coronary and the inferior labial are both divided. (3) Lateral nasal to side of nose. (4) Angular, its terminal branch, anastomosing at the inner angle of the orbit with the nasal branch of the ophthalmic; and this is one reason why leeches at the inner angle of the eye relieve congestion of the eye or brain. It also anastomoses with the infra-orbital branch of the internal maxillary in the same region. OCCIPITAL ARTERY. This vessel arises from the posterior surface of the external carotid, just as that vessel is about to pass beneath the posterior belly of the digastric- It may be divided into three parts — (1) -A. part that passes upwards and backwards, almost parallel with and partially overlapped by the posterior belly of the digastric and stylo-hyoid, to a point between the transverse process of the atlas and mastoid process of the temporal bone. This part is usually quite superficial at first, being simply covered by the integument; afterwards it is overlapped by the muscles already mentioned, and by part of the parotid gland. It, however, crosses the following important structures — (a) Internal carotid artery; (J) vagus; (c) in- ternal jugular vein ; (d) spinal accessory nerve ; (e) ninth nerve Surgical, Medical, and Operative. 101 (hypo-glossal) which hooks round itj (/) gangliated cord of the sympathetic. (2) A part passing backwards and inwards just below the superior curved line. At this part of its course it lies on — (a) Rectus lateralis; (6) superior oblique; and (r) complexus; and is covered by — (a) trapezius; (6) sterno-cleido-mastoid; (c) splenius capitis; (d) digastric; (c) trachelo-mastoid; and is OTerlapped by (/) the mastoid process. Under the mastoid process it lies in the " occipital groove.'' (3) The third part pierces the trapezius and turns upwards to the scalp : this part is accompanied by the great occipital nerve and a cutaneous twig from the sub-occipital as well. In the first part of its course it may be tied through an incision along the anterior border of the sterno-mastoid, with its centre opposite the angle formed by this muscle, and the posterior belly of the digastric and stylo-hyoid. In the second part of its course it may be reached by an incision an inch and a half long, a little behind and below the mastoid process, passing obliquely upwards and backwards. To reach the vessel in this region, we divide skin and fascia, aponeurosis of the sterno-mastoid, the splenius capitis, and part of the trachelo-mastoid. At this part of its course, the vessel lies a little above the superior oblique muscle. PECULIARITIES. — The occipital artery is sometimes derived from the internal carotid, or from the ascending cervical branch of the inferior thyroid. BRANCHES. — (1) A sterno-mastoid branch; (2) auricular, to concha; (3) meningeal, which enters the skull through the jugular foramen ; (4) princeps cervicis. The princeps cervicis passes down- wards and divides into a superficial and deep part. The superficial l^art runs beneath the splenius, lying on the complexus : the deep branch lies between the complexus and the semi-spinalis colli, and anastomoses with the vertebral, and the profunda cervicis branch of the superior intercostal artery, in the region of the sub -occipital triangle. This anastomosis forms an important collateral supply in the ligature of the common carotid or subclavian artery. (5) Occipital to scalp, which anastomose with the corresponding branches from the opposite side, and with the temporal arteries. Posterior Auricular. — This branch is given off above the digastric and stylo-hyoid muscles, runs along the upper border of the digastric, and passes between the facial and spinal accessory nerves. Its 102 Applied Anatomy: course must be 1811161111)616(1 in making the incision through the Integuments when about to trephine the mastoid cells, as it lies in the interval between the mastoid process and the external auditory meatus. It anastomoses with the occipital and temporal arteries. Its branches are — (1) The stylo-mastoid, which enters the stylo- mastoid foramen and supplies the middle ear, mastoid cells, and semi-circular canals; (2) the auricular, which is distributed to the back of the cartilage of the ear. Ascending Pharyngeal. — This branch arises near the commence- ment of the external carotid, and ascends by the side of the pharynx, and to the inner side of the internal carotid, to the base of the skull, beneath the other branches of the external carotid, and also beneath the stylo -pharyngeus muscle, but lying on the rectus capitis anticus major. Its branches are distributed to the muscles in this region, to the dura mater, and to the pharynx. The branches to the dura mater (meningeal) pass through the foramen lacerum medius, foramen lacerum posticus, and sometimes through the anterior condyloid foramen. The pliaryngeal branches pass through the space of Morgagni to supply the soft palate and tonsil, and anastomose with the ascending palatine of the facial. This vessel lies close to the tonsil, and a case is recorded by Mr Baker where a wound of the artery from the throat, by the stem of a tobacco-pipe, proved fatal by repeated haemorrhages, notwithstand- ing ligature of the common carotid. At the post-mortem it was discovered the pipe stem had completely divided the artery. Temporal Artery. — ^This is one of the terminal branches of the external carotid. It arises in the parotid gland on a level with the neck of the condyle of the lower jaw, and passes upwards over the root of the zygoma, in front of the ear, to the scalp, and divides, about two inches above the zygoma into anterior and posterior branches, which pass in directions indicated by their names. As it crosses the root of zygoma it is covered ( 1 ) by a dense fascia derived from the parotid gland; (2) several veins; it is also accom- panied in this region by branches of the facial and the auriculo- temporal nerves. It is on account of these relations that the operation of arteriotomy should not be performed in this situation, as the dense fascia interferes with the free flow of blood during the operation, as well as causing some diflficulty in controlling the Surgical, Medical, and Operative. 103 hsBiuorrhage afterwards. Further, one of the veins might be wounded in the operation, and subsequently give rise to varicose aneurism or aneurismal varix; or severe neuralgia might result from injury to the auriculo -temporal nerve. For the purpose of arteriotomy the anterior temporal is the branch usually selected. The vessel may be tied by a vertical incision an inch and a half in length, midway between the condyle of the jaw and the external auditory meatus. The vein lies behind it, and the auriculo-teraporal nerve lies in close relation to it ; both vein and nerve must be care- fully avoided in this operation. Branches — (1) Anterior temporal; (2) posterior temporal; (3) transverse facial, given off in the substance of the parotid gland, and runs forwards over the masseter muscle, just below the zygoma but above Stenaon's duct, and anastomoses with the infra- orbital and facial. (4) Middle temporal, which pierces the temporal fascia and supplies the temporal muscle. This vessel sometimes gives off an oi'bital branch, which runs along the upper border of the zygoma between the two layers of the temporal fascia, to the outer angle of the orbit. (5) Anterior auricular, to the anterior part of pinna, the lobule, and part of the external auditory meatus. THE INTERNAL MAXILLAB7 ARTEBY. This vessel has, so far as I am aware, but little direct surgical interest. Its branches, however, are involved in many important surgical operations, such as excision of the upper and lower jaws, haemorrhage after the removal of teeth, etc. ; and its middle menin- geal branch may be injured in fracture of the temporal region of the skull. The middle meningeal enters the skull through the foramen spinosum of the sphenoid bone, and divides into two branches, an anterior and a posterior; it is the anterior branch that possesses the greatest interest, from a surgical point of view. From the foramen spinosum it crosses the great wing of the sphenoid, and then enters a canal or groove in the anterior inferior angle of the parietal bone. At this part of its course its position may be indicated on the surface by taking a point an inch and a quarter behind the external angular process of the frontal bone, and an inch and a half above the zygoma. After this the anterior branch passes upwards and slightly backwards to the upper margin of the parietal bone. 104 Applied Anatomy : from half-an-incli to an. incli behind the coronal suture. This point is easily indicated on the surface, since the coronal suture is as nearly as possible five inches from the root of the nose, and the artery is therefore half-an-inch to an inch behind this. It may extend from one, to two and a half inches, from the external angular process and the same distance above the zygoma, i.e., at one inch it will be one inch above the zygoma; at two it wiU be two inches above it, and so on. Under an inch and a half it will usually be found in a bony canal. A line straight across the vertex from one external auditory meatus to the other just cuts the junction of the coronal and sagittal sutures. The posterior branch of the artery passes upwards and backwards over the squamous portion of the temporal bone. Should it be necessary to trephine for the relief of h«?morrhage in fracture of the skull in this region, define the position of the anterior branch of the artery in the manner already indicated, and at this point make a ±- shaped incision, the horizontal limb of which is parallel vrith and about an inch above the zygoma, the vertical limb passing upwards as far as necessary. Turn back all the structures right down to and including the pericranium in one layer, search for the line of fracture and apply the trephine. Should there be no fracture visible, even though the symptoms (signs of compression coming on, not immediately after the injury but after an interval of consciousness — paralysis of the opposite side of the body and face) point to extravasation of blood, then trephine over the course of the vessel. The Structures divided in this operation are — (1) Skin, (2) superficial fascia, and closely connected with it the superficial temporal vessels and auriculo-temporal and temporo- malar nerves, and a thin fascia prolonged from the central tendon of the occipito-frontalis, with the attolens and attrahens muscles arising from it; (3) the two layers of the temporal fascia, and between them the orbital artery, and a twig of the orbital branch of the superior maxillary nerve with its artery, and some fatty tissue; (4) the temporal muscle, with the middle temporal artery; (5) the deep temporal vessels; (6) pericranium; (7) bone, which at this point is thin and contains but little diploe. The circle of bone will probably include portions of the frontal, parietal, sphenoid, and squamous part of the temporal, i.r., the bones meeting at the pterion. Surgical, Medical, and Operative. 105 CHAPTER IX. THE AXILLARY ARTERY. Origin. — It is the direct continuation of the subclavian. Extent. — From the lower border of the first rib to the lower border of the insertion of the teres major. Course. — With the arm well abducted, its course is indicated by a line drawn from a point somewhat to the sternal side of the middle of the clavicle to the inner border of the coraco-brachialis muscle, near its insertion into the humerus. It is divided into three parts — a part above, a part beneath, and a part below the pectoralis minor. Compare this artery with the subclavian: both are divided into three parts — in both the first and second parts are deeply placed, and in both the third part is the one usually ligatured, and in both cases as near the termination as possible to escape the branches. THE FIRST PART.— This part extends from the lower border of the first rib to the upper border of the pectoralis minor. Position of the Arm. — The shoulder should be pushed weU upwards, and allowed to fall backwards as far as possible, as this will raise the clavicle and increase the space; the arm, at the same time, being well abducted, and the head inclined to the opposite side. When the superficial structures and the pectoralis major are divided, then the arm must be brought close to the side to relax the pectorals and allow them to be displaced downwards by an assistant. With the arm in the position indicated, the operator, standing on the outer side of the corresponding arm, makes an incision parallel with the clavicle, or with a slight convexity downwards, from, a point half-an-inch external to the stemo-clavicular articulation, to a point half-an-inch internal to the coracoid process. It is better not to go quite up to the coracoid process in order to. avoid cutting the cephalic vein as it lies in the groove between the pectoralis major and the deltoid. 106 Applied Anatomy : We cut through — (1) Skin; (2) superficial fascia; (3) platysmaj (4) deep fascia; (5) clavicular head of the pectoialis major, which must be divided across its fibres, taking care to avoid the cephalic vein, which is seen at the outer angle of the incision, in the groove between it and the deltoid. After this we meet with a quantity of fatty tissue, in which ramify the structures that pierce the costo- coracoid membrane, viz.^(a) The cephalic vein; (&) external anterior thoracic nerve; (c) thoracic axis, or acromio- thoracic artery; (d) superior thoracic artery; and (e) corresponding veins. The arm having been brought to the side, and the upper edge of the pectoralis minor muscle exposed and displaced downwards by a broad copper spatula, and any large arterial branch pulled inwards by a blunt hook, pass carefully through the fatty tissue, cutting as little as possible, lest the above structures be injured, tiU the axillary sheath is exposed. (6) Displace the vein inwards, and then open the sheath, taking special care not to wound the vein, which is superficial and internal to, and also overlaps, the artery. The cords formed by the union of the spinal nerves entering into the formation of the brachial plexus, lie to its outer side, or may partially overlap it. Clear the artery with a director, and pass the needle from the vein, and above the origin of the thoracic axis. At this part of the axilla, the artery,, vein, and nerves, all lie obliquely to each other — the vein overlapping the artery, and the artery overlapping the nerves. This is the position of the various structures when the arm is hanging by the side; but when it is abducted to any extent, the vein is almost right in front of the artery. Take care not to include the anterior thoracic nerve. Behind this part of the vessel is the first digitation of the serratus magnus and the posterior thoracic nerve (Nerve of Bkll). Ligature of this part of the axillary artery is a dangerous operation, because of — (1) Its great depth; (2) its relation to other blood vessels, e.g., the axillary and cephalic veins, and branches of the thoracic axis; (3) its relation to nerves, e.g., the external anterior thoracic in front, and the posterior thoracic behind — for these reasons, it is much better to tie the third part of the subclavian. RESUME of the chief steps of the foregoing operation : — 1. Make the curved incision, taking care of the cephalic vein at the outer angle of incision. Surgical, Medical, and Operative. 107 2. Expose the pectoralis major, separate tlie clavicular from the sternal head, beginning at the inner end of the wound, and then divide it on a director, or else use the finger and a prohe-pointed bistoury. Bring the arm to the side, and 3. After this expose the upper edge of the pectoralis minor, ■with the finger and handle of the knife, taking care not to wound the acromio-thoracic vessels. 4. Use the branches of the acromio-thoracic artery, or the cephalic vein, as the guide to the position of the axillary. 5. Clear the vessel as near the clavicle as possible, and well above the origin of the thoracic axis. 6. Pass the needle from the inner side. Collateral Circulation (Fig. 18). — If tied above the thoracic axis it is the same as in ligature of the third part of the subclavian. If tied below the axis, in addition to the chief collateral branches mentioned under " Collateral Circulation " (see page 72) in ligature of the subclavian, we have — 1. Branches from the thoracic axis (4), and superior thoracic (8), anastomosing with branches from the two circumflex arteries (9) from third part of the axillary. 2. The long thoracic (15), anastomosing with the aortic intercostals (18) and internal mammary (11). THE SECOND PART.— Relations.— In front— The pectoralis major and pectoralis minor, with skin, fascia, etc. Behind — The subscapularis and the posterior cord of the brachial plexus. Inner side— The vein and the inner cord. ~ Outer side— The outer cord of the plexus. The part beneath the pectoralis rninor is not tied except when wounded — (1) Because it is so short and gives off two or three branches; (2) it is too deeply placed; (3) it is so closely surrounded by nerve trunks. In ligaturing the first two parts of this vessel for a wound of the main trunk or its branches, it is customary to make the incision in the line of the artery, across the fibres of the pectorals. THE THIRD PART.— This is the longest of the three parts, and extends from the lower border of the pectoralis minor to the lower border of the teres major : it is twice as long as either of the others. Position of the Arm. — The arm is abducted to a right angle with 108 Applied Anatomy: Fig. 18. Collateral Circulation of the Upper Extremity. (Aftei- Smith and Walsham.) Surgical^ Medical, and Operative. 109 Explanation of Fig. 18. 1. Posterior scapular artery. 2. Supra-scapular artery. 3. Subclavian artery. 4. Thoracic axis. 5. Superior intercostal artery. 6. The first rib. 7. Axillary artery. 8. Superior thoracic branch. 9. Posterior circumflex artery, anastomosing with the thoracic axis. 10. Anastomosis between the posterior scapular and the dorsalis scapulae. 11. The internal mammary. 12. Anastomosis between the internal mammary and the superior intercostal. 13. Subscapular artery. 14. Anastomosis between the superior profunda and the posterior circumflex. 15. Long thoracic. 16. The superior profunda. 17. Anastomosis between the long thoracic, internal mammary, and aortic intercostals. 18. Aortic intercostals. 19. Brachial artery (B). 20. Inferior profunda. 21. Interosseous recurrent. 22. Radial recurrent. 23. Deep epigastric. 24. External iliac. 25. The posterior interosseous. 26. Anterior interosseous. 27. Terminal branches of the anterior interosseous. 28. Anterior carpal arch. 29. Posterior carpal arch. 30. Recurrent branches. 31. Deep palmar arch. 31a. Superficial palmar arch. 32. Anastomotic branch. 33. Antei-ior ulnar recurrent. 34. Posterior ulnar recurrent. B. Brachial artery. R. Radial artery. U. Ulnar artery. 110 Applied Anatomy : the trunk and rotated outwards by an assistant, and the fore-arm at the same time fully supinated; the operator stands between the arm and the trunk on both sides of the body. Superficial Guide. — The inner edge of the prominence caused by the coraco-brachialis, or else we may divide the base of the axUla into thirds, when the artery wiH be found to lie at the junction of the anterior with the middle third. Make an incision along the inner side of this muscle and parallel with the anterior fold of the axilla, for about three inches, into the hollow of the armpit. Cut through — (1) Skin; (2) fascia, avoiding the basilic vein should it be in the way, and expose the edge of the coraco-brachialis. After dividing the superficial and deep fascia, the median and the internal cutaneous nerves will be seen, with the artery behind and between them, or more correctly, the artery is really surrounded by nerve trunks : — To the outer side are the median and the musculo- cutaneous nerves; on the inner side, the ulnar and nerve of Wris- berg; in front, the internal cutaneous; behind, the musculo-spiral and cireumilex. The axillary vein lies to its inner side, and partially overlaps it. These nerve trunks form the. Deep Guide, and in the midst of them the artery will usually be found. Belax the parts by bending the fore-arm, and then, by means of blunt hooks, displace the median nerve to the outer side, the axillary vein with the ulnar and internal cutaneous nerves, and the basilic vein, if present, to the inner side. Carefully expose and open the sheath near the lower part of the artery, separate the vessel from the sheath, and pass the needle from the inner side, taking care not to include the musculo-spiral or circumflex nerves which lie behind the vessel. To give, shortly, the entire Relations of this part of the artery. — In front — (1) Integument and fascia, and this only at the lower part of its course; (2) pectoralis major (at the upper part), and internal cutaneous nerve; (3) inner head of median. Behind — (1) Subscapularis ; (2) tendons of latissimus dorsi and teres major; (3) musculo-spiral and circumflex nerves. On the outer side — (1) Coraco-brachialis; (2) median nerve; (3) musculo -cutaneous nerve. On the inner side — (1) Ulnar nerve; (2) nerve of Wrisberg; (3) axillary vein. The median nerve has a triple relation to this part of the artery^-(l) Its two heads embrace it; (2) it usually lies above it; (3) it is placed to its outer side. This part of the axillary Surgical, Medical, and Operative. Ill artery is better fitted for ligature than the parts we have previously considered — (1) It is twice as long as either of the others; (2) its lower part (half or third) is simply covered by the common tegu- mentary structures, and has no muscle in front of it; (3) its branches come off weU up towards its beginning, and are therefore out of the way at the point where the artery is usually ligatured. This is important, because, if the vessel be ligatured too near these branches, secondary hsemorrhage is apt to occur. Therefore, the ligature should be applied as low down as possible. PECULIARITIES.— (1) The artery may be covered by a muscular slip from the latissimus dorsi; (2) in one out of every ten cases there are two arteries instead of one, the second usually being one of the arteries of the fore-arm, usually the radial, some- times the ulnar, and still more rarely, the interosseous. In other cases, the circumflex, subscapular, and profunda arteries arise from the third part by a common trunk; (3) the position of the nerves vary — instead of encircling the axillary artery, they may encircle a large branch formed by the union of several of the usual branches, and, in this case, they would therefore be useless as the "deep guide." r r . RESUME of the chief points in ligature of third part of axillary : — 1. Make an incision, three inches long, at the junction of the anterior and middle thirds of the axilla, from the prominence of the coraco-brachialis to the centre of the hollow of the axilla. 2. At first the incision must go through skin and super- ficial fascia only, and, if necessary, avoid the basilic vein at the outer end of the incision. 3. Then open the deep fascia forming the base of the axilla, when probably the axillary vein and the median nerve will present ; then flex the fore-arm, and — 4. Hold the lips of the wound aside and displace the vein with the internal cutaneous nerve to the inner side, and the median nerve with the coraco-brachialis muscle to the outer side. 5. Clear the artery near its termination and ligature, passing the needle from the inner side. 112 . Applied Anatomy : Collateral Circulation (see Fig. 18). — If tied above the sub- scapular branch, it is the same as when the first part is ligatured. If tied below this branch, the collateral anastomoses are small, but usually sufficient — 1. Anastomoses between branches of the posterior circumflex (9) and the superior profunda (16). 2. Anas- tomoses between branches of the subscapular (13) and the superior profunda (16). 3. Anastomoses through the coraco-brachialis, biceps, and the long head t)f the triceps — muscular branches. 4. Through the shaft of the humerus. An Axillary Aneurism presents as a pulsating tumour im- mediately below the clavicle, under the great pectoral or at the anterior fold of the axiUa. There is pain and numbness in the arm and hand from pressure on the brachial plexus, and oedema from pressure on the axillary vein; the symptoms have been often mistaken for rheumatism of the arm and shoulder, and rubbing and other remedies recommended, without a proper examination. At first it presses principally on the nerves of the axilla, but as it enlarges it tends to curve forwards, bulging the anterior wall before it. In ligature, special care must be taken not to woimd tlie axillary vein itself, nor any of its feeders close to their junction with it, as air is apt to be sucked in by the aspirating power of the thorax, and also because the fascia in this region is adherent to the vein and prevents its collapse; and for a like reason it bleeds very severely when wounded. The Axillary Vein is formed by the union of the basilic with the vense comites of the brachial, usually at the lower border of the subscapularis muscle. Aneurism in this region is common on account of the movements of the limb, and its liability to share the effects of injuries, such as sudden wrenches and contusions. BRANCHES. — Of the First Part— (1) The superior thoracic ; (2) acromio-thoracic, or thoracic axis, situated at the ujijper border of the pectoralis minor. From the Second Part — (1) The long thoracic or external mammary, which runs along in the anterior fold oi the axilla at the lower border of the pectoralis minor to the mammary region; and (2) alar thoracic. From the Third Part — (1) The subscapular artery, which runs along in the posterior fold of the axilla at the lower border of the subscapularis muscle; (2) posterior circumflex; and (3) anterior circumflex. These two Surgical, Medical, and Operative: 113 encircle the surgical neck of the humerus, and must he carefully kept in mind in excision of the shoulder joint. The circumflex nerve accompanies- the posterior vessel, and its position should he kept in mind in cases of supposed contusion leading to paralysis of the deltoid. As a guide to the other branches of the axillary remember the position of the pectoralis minor: its Ufper border indicated by a line from the upper border of the third rib to the coracoid process; its lower harder by a line from the lower border of the fifth rib to the coracoid process. BRACHIAL ARTERY. Origin. — It is tlie direct continuation of the axillary. Extent. — From the lower border of the teres major to a point opposite the neck of the radius — about half-an-inch below the bend of the elbow — where it divides into radial and ulnar arteries. Course. — Its course corresponds to a depression along the inner border, first of the coraco-brachialis and then of the biceps muscle, or a line drawn from the junction of the anterior with the middle third of the base of the axilla to the middle of the bend of the elbow. It is at first to the inner side of the humerus, but gradually turns to the front of that bone; in apjJying digital compression this relation of the artery to the humerus must be kept in mind, e.g., if it is compressed at the upper part the pressure must be directed from within out- wards, if at the lower part from before backwards (Fig. 19). Relations of the Vessel. — In front — (1) The skin, superficial and deep fascia; (2) bicipital fascia, with median basilic vein lying ' on it; and (3) median nerve crossing from the outer to the inner side, and occasionally the internal cutaneous at its upper part. Xote the triple relation of this nerve to the artery — at the outer side, above; in front, about the middle; and at its inner side, below. Behind — (1) The long and inner heads of triceps; (2) insertion of coraco-brachialis; (3) brachialis anticus; and (4) musculo-spiral nerve, with superior profunda artery, lying between it and the long head of triceps. On the inner side — (1) The median, ulnar, and internal cutaneous nerves; and (2) basUic vein. On the outer side — (1) The median nerve; (2) coraco-brachialis; and (3) biceps. The vessel may be ligatured — (1) In the upper third of its course, above the origin of the superior profunda. Here the coraco- 114 Applied Anatomy: brachialis is the guide ; the median nerve is to its outer side, and the ulnar and internal cutaneous to its inner side. The steps of the operation are precisely similar to ligature of the third part of the axillary, low down. (2) In its middle third, below the origin of both the profunda arteries, the point -usually selected; the edge of the biceps is the guide to the vessel and the median nerve crosses it obliquely. (3) In the lower third at the bend of the elbow, and below the origin of all its branches ; it lies between the tendon of the biceps on the outer side, and the median nerve on the inner side, and covered by the bicij)ital fascia and the median basilic vein. Fig. 19. To SHOW Relation of the Artery to the Humerus. To cuniprcss the vessel .it this point hook it upwards against the neck of the IScapula At this point press outwards At this point press backwards Circumflex Vessels. Superior Profunda. Inferior Profunda. Anastomotic. On the right hand side obsei-ve how the pressure must he directed at different parts in order to control the flow through the vessel. IN THE MIDDLE OF THE ARM. Superficial Guide. — The prominence caused by the inner edge of the biceps. Position of the Arm. — It should be held, by an assistant with the fore-arm fully extended and supinated, the upper Surgical, Medical, and Operative. 115 arm rotated outwards and well abducted and not allowed to rest on any support, as this is apt to push up the triceps and displace the vessel (Heath). The operator should stand behind the arm on both sides of the body, but may, if he think it more convenient, sit between the arm and the trunk in both cases. Incision. — This should be about three inches long, and made on the biceps (and not exactly over the vessel) parallel with and close to its inner edge, but avoiding the basilic vein. We divide the skin, fatty tissue, and superficial fascia, and then define the inner edge of the biceps, nnd draw it aside and cut through the deep fascia carefully, as the basilic vein and internal cutaneous nerve are often found just below it, to the inner side of the artery, and then look for the deep guide: the median nerve close to the edge of the biceps, or crossing the vessel in the bottom of the wound from without inwards. I ought to state that manj- operators advise that the sheaih of the biceps should not be opened, as the vessel can very readily be exposed and tied without doing so. Open the fascia over the median nerve, and then by means of blunt hooks draw the basilic vein and median nerve to the inner side, and the biceps to the outer side (the median nerve may be displaced to the side found most convenient), the assistant who has charge of the arm at the same time bending the elbow to relax that muscle. Separate the sheath from the sur- rounding structures, open it, clear the vessel from its venae comites, and pass the needle from the nerve, at the same time taking care not to injure the venae comites which often surround the vessel with anastomosing loops. The mobility of the vessel, the obliquity of the various structures, as well as the relation of the artery to the basilic vein and median and internal cutaneous nerves, makes the operation sometimes a little diificult. r f RESUME of the chief points m ligature of the brachial artery about the middle of the arm: — 1. Extend, abduct, and supinate the arm, take care of the basilic vein, and then 2. Make an incision three inches long about the middle of the arm on the edge of the biceps, and then 3. Open the deep fascia over its inner edge, flex the elbow, and displace it outwards. 116 Applied Anatomy : 4. Divide the fascia over the median nerve thoroughly so that it can he displaced easily withoiit dragging the artery with it, but at the same time take care not to injure the sheath of the artery. 5. Clear the vessel and tie, passing the needle from tlic median nerve. AT THE BEND OF THE ELBOW.— ^Vith the arm well abducted, and the fore-arm freely supinated and extended, the operator, standing on the outer aspect of the arm on both sides of the bodyj ascertains the position of tlie median basilic vein and the tendon of the biceps, and then makes an incision tw^o inches in length, parallel with and a little above the veiu. The incision commences half-an-inch above the level of the internal condyle of the humerus and forms an angle of 45° with the long axis of the arm; it is to the inner side of the tendon of the biceps, and must not be prolonged too far downwards lest the median cephalic vein be cut. Draw aside the median basilic vein and the internal cutaneous nerve by a blunt hook, and thus expose the bicipital fascia; divide this on a director, and then the artery is seen lying between the tendon of the biceps and the median nerve and resting on the brachialis anticus. Bend the elbow and draw the structures on each side away from the vessel, expose and open the sheath, carefuUy clear the vessel, and pass the needle from the nerve. XoTE. — (1) Unless the incision be made close to the inner edge of the biceps, the operator may cut down upon the ulnar nerve with its companion, the inferior profunda artery, and mistake the latter for the brachial. (2) In one out of every five cases there are two arteries instead of one. (3) The biceps muscle has occasionally a third head of origin arising between the coraco-brachialis and the brachialis anticus, and when this is the case it crosses in front of the brachial artery near the spot where it is usually ligatured; in other cases a slip may be derived from the coraco-brachialis, which crosses the vessel to join the inner head of the triceps. (4) Several cases are recorded where the median nerve passed under the artery, instead of over it. (5) The artery, accompanied by the median nerve, sometimes passes to the inner condyle and curves round a prominence of bone (the " supra-condyloid process"), and then passes beneath or through the pronator radii tere» to its usual Surgical, Medical, and Operative. 117 position in front of the bend of the elbow — a condition somewhat similar to the normal condition in many of the carnivora. In those who use crutches this vessel has occasionally been obliterated by the pressure thus caused. (6) The coraco-brachialis is inserted into the inner border of the humerus near its middle, and at this point note the following facts: — (a) The brachial artery lies upon it; (6) the median nerve crosses the artery at this point; (c) the internal cutaneous nerve leaves the artery here, passing forwards to pierce the deep fascia; (rf) at this point also the ulnar nerve leaves the brachial, passing backwards; (e) here the brachial is nearest the humerus and is most easily compressed ; (/) at this point the nutrient artery enters the humerus; (g) the inferior profunda is given off at this point; and lastly, (7i) the brachial is usually ligatured about this region. Branches. — (1) Muscular; (2) superior profunda, which joins and accompanies the musculo-spiral nerve ; (3) inferior profunda, which accompanies the ulnar nerve; (4) nutrient to humerus,; (5) anastomotic branch, which is given off about two inches above the elbow joint, and divides into two branches — one passes to the front of the internal condyle, the other passes behind the joint. BrESUME of the operation at the bend of the elbow :— 1. Make an oblique incision beginning half-an-inch above the level of the internal condyle, parallel with the median basilic vein, through skin and superficial fascia only. 2. Do not prolong it too far down lest the median cephalic vein be divided. 3. Draw aside the vein and the internal cutaneous nerve and divide the bicipital fascia on a director. 4. Look for the artery between the tendon of the biceps and the median nerve. 5. Clear the vessel and pass the needle from the nerve. Collateral Circulation (see Fig. 18). — This varies according to the point of ligature. At the upper part, in a general way, it is carried on by branches from the circumflex (9) and subscapular (13) arteries, anastomosing with the ascending branches of the superior profunda (14), and muscular branches through the various muscles in the neighbourhood. Ligature above the superior profunda is 118 Applied Anatomy : sometimes followed by gangrene, on account of tlie anastomoses between the axillary and brachial being so scanty. Lower down we have the superior (16) and inferior (20) profunda above, anas- tomosing with various branches in the general anastomoses round the elbow joint, e.g., the superior profunda with the radial recurrent (22), posterior interosseous recurrent (21), and anastomotic (32), the inferior profunda (20) with the anterior (33) and posterior (34) ulnar recurrents and anastomotic (32). Besides these there is the circulation through the shaft of the humerus and muscles in the neighbourhood. It will evidently vary, therefore, according as the vessel is tied between, the profunda arteries, below both, or at the bend of the elbow where it is below all the branches. It will be well, at this point, to give a brief description of the Anastomoses round the Elbow Joint (see Fig. 18). There are seven vessels that take part in this anastomoses: — Three branches coming down — superior and inferior profunda, and the anastomotic; and four branches passing upwards — radial recurrent, anterior and posterior ulnar recurrents, and the posterior interosseous recurrent. Por convenience they may be divided into four groups : — 1. In front of external condyle, anastomoses between— (a) superior profunda, and (6) radial recurrent (22). 2. In front of internal condyle, anastomoses between — (a) the anastomotic branch (32); (6) anterior ulnar recurrent (33); and (c) inferior profunda (20). 3. Behind external condyle, anastomoses between — (a) the anas- tomotic branch ; (6) interosseous recurrent; and (c) the superior pro- funda (21) 4. Behind internal condyle, anastomoses between^ — • (a) the anastomotic branch (32); (J) posterior ulnaT recurrent (34); and (c) the inferior profunda (20). ■ EADIAL ARTERY. This vessel, like the brachial, of which it is the proper con- tinuation, is quite superficial. Origin. — From the bifurcation of the brachial at the bend of the elbow. Extent. — From its point of origin till it ends in the deep palmar arch. Course. — A line drawn from the centre of the hollow in front of the elbow joint to the inner side of the anterior aspect of the styloid process of the radius will roughly indicate its course. Relations.— In /ranf — Skin, superficial and deep fascia, cutaneous nerves (especially the external Surgical, Medical, and Operative. 119 cutaneous which, lies over the vessel at the point where the "pulse" is usually felt) and vessels, etc., and it may he slightly overlapped at the upper part by the supinator longus. On the inner side— (1) Pronator radii teres, above; (2) flexor carpi radialis, below. On the outer side — (1) Supinator longus; (2) radial nerve (but only about the middle third of the vessel). Behind — (1) Tendon Fig. 20. Relation of Ulnar and Radial Arteries and Nerves. Musculo - Spiral Nerve Posterior Interos- seous Nerve . . Badial Nerve —Ulnar Nerve. Brachial Artery, Ulnar Artei*y. 7. Radial Arterj'. of biceps; (2) supinator brevis; (3) pronator radii teres; (4) flexor sublimis (radial head) ; (5) flexor longus poUicis; (6) pronator quad- ratus; (7) end of the radius. Note that at the wrist it lies between the tendons of the supinator longus and the flexor carpi radialis, and that the nerve is only in relation to the middle third of its outer side (Fig. 20). 120 Applied Anatomy : The vessel may be ligatured — 1. In the upper third of its course, where it lies between the supinator longus and the pronator radii teres, resting on the tendon of the biceps, supinator brevis, and part of the insertion of the pronator radii teres. In a muscu- lar arm the supinator longus will overlap the vessel considerably. The radial nerve has no direct relation to this part of the vessel. Guide. — The line that indicates the course of the vessel, or the inner edge of the supinator longus muscle; find the tendon of this muscle at the wrist, and trace it up towards the bend of the arm. The arm should be moderately abducted, and the fore-arm fully supinated, and either resting on the table or supported by an assistant; when the muscles are exposed, then the assistant may flex the elbow to allow of them being held aside by blunt hooks in the charge of another assistant. The operator stands on the outer side of the arm on both sides of the body. Incision. — ^This should be two or three inches in length, and parallel with the inner edge of the muscle. Divide the skin and superficial fascia, define the inner edge of the supinator longus, and divide the layer of deep fascia under the muscle, draw it a little outwards, and the pronator radii teres inwards, and the artery will be seen immediately below this. Separate the vense comites, clear the artery, and ligature. As the radial nerve has no close relation to this part of the vessel, it matters but little how the needle is passed. RESUME:— 1. Make an incision two inches long in the course of the vessel, avoiding as far as possible the large subcutaneous veins. 2. Divide the deep fascia and define the edge of the supinator longus. 3. Flex the fore-arm and wrist, separate the supinator longus and pronator radii teres. 4. Clear the artery and ligature. % In the middle third, where it lies between the supinator longus and the fleshy belly of the flexor carpi radialis, resting on the lower part of the insertion of the pronator radii teres, flexor sublimis, and flexor longus poUicis. The radial nerve lies on the outer side of, and close to, the vessel The guide to the artery Surgical, Medical, and Operative. 121 and the steps of the operation are almost precisely similar to those of the previous operation. The incision need not be quite so long, and, as the nerve lies on the outer side and close to the vessel, the needle should be passed from the nerve. 3. In the lower tllird, where it lies between the tendons of the supinator longus and the flexor carpi radialis, resting on the flexor longus pollicis, pronator qiiadratus and the end of the radius. The radial nerve has by this time left the artery to pass to the back of the hand, and therefore lies considerably to its outer side. Make an incision two inches in length in the middle of the space, bounded by the supinator longus on the outer side, and the flexor carpi radialis on the inner side; at this point the artery may be felt pulsating. Divide the skin, fascia, cutaneous vessels, and nerves (usually one of the terminal branches of the musculo-cutaneous nerve lies over the artery). When the deep fascia is divided, the artery is seen with its venae comites ; avoid these in clearing the vessel and in passing the needle. Complete the operation in the usual manner, passing the needle from the side most convenient. 4. At the root of tlie thumb (in the '^anatomist's snuff-box"). From the anteiior aspect of the radius, the artery passes round the root of the thumb to the first interosseous space, where it disappears between the two heads of the first dorsal interosseous muscle (abductor indicis) ; it lies on the external lateral ligament of the wrist joint, scaphoid and trapezium, covered by the skin and fascia, the large radial vein, filaments of the radial nerve, and the three extensors of the thumb — ossis metacarpi, primi internodii, and secundi internodii. It is accompanied by its vense comites and a twig from the musculo-cutaneous nerve. With the hand held by an assistant in a position midway between pronation and supination, the operator makes an incision an inch and a half in length from the posterior part of the root of the styloid process of the radius to the base of the metacarpal bone of the thumb, external to the large vein, and almost parallel with the tendon of the extensor secundi. The first incision divides the superficial structures, but should not injure the vein already mentioned. Divide the deep fascia, hold the tendons aside, when the artery with its vense comites and a small nerve will be seen crossing the wound obliquely. Separate the venre comites and tie the vessel in the usual manner. 122 Applied Anatomy: FECULIABITIES. — Not unfrequently the radial takes its origin from the brachial, sometimes from the axillary. It has heen seen more superficial than usual, lying above the deep fascia and the supinator longus muscle. Branches. — Its branches in the fore-arm are — (1) The radial recurrent ; (2) superficialis volse. This vessel usually arises just as the radial is about to wind round the wrist; it is usually small, and ends in the muscles of the thumb, but sometimes it is as large as the continuation of the radial, and arises much higher up ; under these circumstances, the two run side by side for a little way, and form what has been called the " double pulse." (3) Muscular ; (4) anterior carpal. At the wrist — (1) Posterior carpal; (2) meta- carpal, or first dorsal interosseous ; (3) dorsales poUicis ; (4) dorsalis indicis. In the hand — (1) Princeps poUicis; (2) radialis indicis; (3) perforating ; (4) interosseous. Collateral Circulation (see Fig. 18). — Chiefly by the ulnar artery and its branches through the palmar arches (31, 31a). The anastomoses here are so free that, if the radial is wounded, a ligature must be applied on both sides of the wound. , ULNAR ARTERY. Origin. — From the bifurcation of the brachial at the bend of the elbow. Extent. — From its point of origin tiU. it ends in the super- ficial palmar arch. Course. — It first passes downwards and inwards, and then straight downwards. The course of the straight part may be indicated by a line drawn from the inner condyle of the humerus to the inner side of the pisiform bone. Relations. — ^This vessel, unlike the radial, is at first very deeply placed. \-a. front — (1) The superficial structures ; (2) crossed by the median nerve at its upper part ; (3) the following four muscles — (a) pronator radii teres, (J) flexor carpi radialis, (c) palmaris longus, (c?) flexor subhmis digitorum. Behind — (1) Brachalis anticus ; (2) flexor profundus digitorum. To its inner side — (1) Flexor carpi ulnaris ; (2) ulnar nerve (for its lower two-thirds). To its outer side — The flexor sublimis digitorum. Note. — At the wrist it lies between the tendons of the flexor sublimis digitorum and the flexor carpi ulnaris, and that the nerve is on its inner side for the lower two thirds (see Fig. 20). It may Surgical, Medical, and Operative. 123 be ligatured at its middle or lower third ; the upper third is too deeply situated to admit of ligature except in the case of a direct wound of the arterj'. 1. At its Middle Third. — Guide — ^.The inter-muscular septum and groove between the fleshy bellies of the flexor carpi ulnaris, and the flexor sublimis digitonim ; search for the tendon of the flexor carpi ulnaris and follow it up towards the bend of the elbow and make an incision two or three inches in length, either parallel with the edge of the flexor carpi ulnaris or somewhat obliquely across its course. We may also use the line that marks the course of the lower two thirds of the artery as our guide. The position of the arm is the same as that for ligature of the radial, and the Surgeon stands on the outer side of the limb in both cases. Divide the skin and superficial fascia only by the first incision, and then search for the inter-muscular septum between that muscle and the flexor sublimis, and forcibly separate them ; this is the first inter- muscular space found in passing from the posterior edge of the ulna round the front of the fore-arm. At this stage an assistant should flex the wrist to allow the muscles on each side to be held aside with blunt hooks by another assistant. At the bottom of the wound the ulnar nerve is exposed, and the artery, with its vense comites on each side, wUl be found to the outer side of the nerve. Pass the needle from the nerve, and complete the operation in the usual manner. RESUME :— 1. Make a slightly-oblique incision across the course of the vessel well to the inner side of the arm. 2. Divide the deep fascia, and find the first inter-muscular space from the ulnar edge of the arm. 3. Separate the flexor carpi ulnaris from the flexor sublimis. 4. Flex the wrist and fore-arm, hold the sides of the wound apart, when the artery will be found between the two layers of muscles. 5. The nerve is seen to the inner side of the artery. 6. Clear the vessel and pass the ligature from the nerve. 2. At its Lower Third. — Here the artery is quite superficial, and lies between the tendons of the flexor carpi ulnaris and flexor 124 Applied Anatottiy : sablimis digitorum. Superficial G^uide — ^Tendon of the flexor carpi ulnaris ; the pisiform bone, into which it is inserted, forms a sure guide to the tendon. Or the line that marks the course of the vessel may be taken as guide. Incision. — Make an incision two inches long parallel with the tendon, but a little external to it. By this incision the skin and superficial fascia are divided ; then divide the inter-muscular layer of deep fascia, flex the wrist and draw aside the tendons, when the artery and nerve will be exposed to view. The Deep Guide is the ulnar nerve, which lies imme- diately internal to the artery. Bend the wrist, and draw the tendon of the flexor carpi ulnaris to the inner side, and then isolate the vessel, taking care of the vense comites, and ligature in the usual manner, the needle being passed from the nerve, which lies to its inner side. PECULIARITIES. — The artery not unfrequently arises from the brachial, sometimes from the axillary. When its origin is high up it usually passes superficially to the flexor muscles of the fore-arm, just beneath the deep fascia. Brandies. — The more important branches are — (1) Anterior, and (2) posterior ulnar recurrents ; (3) common interosseous, and (4) profunda branch, which is given off just beyond the pisiform bone, and dips down between the abductor minimi digiti and flexor brevis minimi digiti, and anastomoses, with the radial, completing the deep palmar arch. For the termination of the recurrent branches see "Anastomoses round the Elbow Joint" (page 102). Other branches are (5) anterior and (6) posterior carpals, and (7) digital. Coiiaterai Circuiation (see Fig. 18).— Chiefly from the radial and its branches through the palmar arches (30, 31a). FALMAB ABCHES. (a) Superficial Arcii (see Fig. 18, Sla). — This is the direct con- tinuation of the ulnar artery. It forms an arch with the convexity downwards, and is completed on the radial side by the mp(yrjkiaUs ■voice branch of the radial artery, or, probably more frequently, by the radialis indicis branch of the same artery. It lies beneath the integumentary structures and palmar fascia, and rests on the digital arteries and nerves and tendons of the flexor sublimis digitorum. Stirgical, Medical, and Operative. 125 (6) Deep Palmar Arch (see Fig. 18, .//).— This is the direct continuation of the radial artery, and is completed on the ulnar side by the profunda branch of the ulnar arteiy. It lies deeply, and, in addition to the structures covering the superficial arch, is covered by the digital nerves and arteries, and tendons of the superficial and deep flexors of the fingers and some of the muscles of the little finger and thumb. It rests on the palmar interossei and metacarpal bones near their carpal ends. Position of the Arches. — The Superficial — Extend the thumb till it lies at right angles to the hand, and then draw a line across the palm on a level with its lower margin ; this line should touch the lowest part of the convexity of the arch. The Deep Arch lies fuUy a finger's breadth nearer the carpus. To expose the superficial arch in its ulnar portion, make an incision over it an inch in length and slightly oblique, from the radial to the ulnar side, with its centre opposite the ring finger, and parallel with the palmar outline of the baU of the thumb. Branches. — (a) From Superficial Arch are given off — (1) Four digital arteries which supply the little finger, the ring finger, middle finger, and the ulnar side of the index finger. These vessels bifur- cate half-an-inch above the clefts between the fingers. (2) The deep or communicating branch; (3) recurrent branches which pass upwards towards the annular ligament. (&) From the Deep Arch — (1) Recurrent branches which ascend and anastomose with branches from the anterior carpal arch ; (2) superior perforating, three in number, which pass backwards through the upper part of the last three interosseous spaces, to anastomose with the dorsal interosseous arteries ; (3) the palmar interosseous arteries, three in number, which He in front of the palmar interosseous muscles, and anatomose at the clefts of the fingers, with the digital branches from the superficial arch. The Anterior Carpal Arch is formed by the anterior carpals of radial and ulnar; it anastomoses on the one hand with the anterior interosseous, and on the other with the deep palmar arch. The Posterior Carpal Arch is formed by the posterior carpals of radial and ulnar. From this arch are given off descendimi branches, the dorsal interosseous arteries for the third and fourth interosseous spaces, which anastomose with the posterior perforating branches from the deep palmar arch ; it also gives off ascending 126 Applied Anatomy : branches to anastomose with the branch of the anterior interosseous artery, found on the posterior surface of the fore-arm. The Deep Palmar Arch communicates with — (1) The anterior interosseous and anterior carpal arch ; (2) digital branches of the superficial arch ; (3) with branches of the posterior carpal arch. It will be seen, therefore, that the various vessels about the wrist and palm anastomose with great freedom. If both the radial and ulnar arteries are ligatured, the blood reaches the palm from the anterior and ijosterior interosseous arteries through the anterior and posterior carpal arches, which communicate with the deep palmar arch. There is usually a small artery accompanying the median nerve into the palm (" comes nervi mediani "), but this branch is sometimes of large size, and joins the Fig. 21. The Graduated Compress. .. The Compress. -The Tissues. '/iiiyVSwi^;W^vvW.^iw^^^VH'V"Wv'v.v-i-/-A'^^^^^^^ The Wounded ^ ^•''■'""-"■•■""""'""■■-'■' "■'■/■'■i.''-'"-"-" ---■" ■ -■■' , -(i( | -;il Artery. superficial palmar arch. It arises from the anterior interosseous, and it is well to bear in mind the possible existence of this branch. Hence it is not advisable to tie the radial and ulnar arteries for wounds of the palmar arches, as the blood will stiU reach the wound. It is better to apply a graduated compress or plug (Fig. 21), together with acute flexion of the wrist and elbow joints, as we wish, as far as possible, to avoid an extensive wound of the palm, on account of the resulting cicatrix. The objections to the pal- mar incision are the following: — (1) It would have to be more extensive than in other parts of the body, because incisions made into the palm of the hand and the sole of the foot show but little tendency to gape, as the skin is firmly adherent to the fascial Stirgical, Medical, and Operative. 127 textures. (2) The resulting cicatrix, especially in the hand of a ■working - man, is subjected to constant irritation, and probably fifteen to twenty years of such irritation will result in an epithe- lioma, besides frequently being painful and showing a tendency to ulcerate in the meantime. Should this be insufficient to control the hsemorrhage, it is better at once to ligature the brachial, as it is more effectual and not move difficult than the double operation of tying the radial and ulnar arteries above the wrist. As, however, in many cases the artery is only wounded, it is evident that before resorting to severe measures, one should make certain that the vessel is completely cut across. This can easily be done through the original wound, and then very likely the artery will contract and retract sufficiently to allow the blood to clot and stop further haemorrhage. The deep palmar arch, however, may be readily ligatured from the dorsum, after excision of the upper end of the third metacarpal bone (Delorme). In the palm, the digital arteries and nerves lie on the interos- seous muscles between the metacarpal bones, and, therefore, incisions in this region should be made over these bones. The arteries are superficial to the nerves, and they bifurcate fully half-an-inch from the clefts of the fingers, or about the level of the fold in the palm formed by the flexion of the fingers at the metacarpo-phalangeal joints. The most internal branch, however, does not bifurcate, but runs along the ulnar side of the little finger ; the other branches run along the sides of the fingers, nearer the anterior than the posterior aspect, and must be avoided should it be necessary to make incisions along the sides of the fingers. The relation between the nerves and the arteries differs in the palm and in the fingers : in the palm the arteries are superficial to the nerves, but in the fingers they are deeper than the nerves. r r RESUME of the methods to be adopted in the treatment of cases of haemorrhage from the palmar arches : — 1. Make sure that the artery is more than wounded, see that it is completely divided; for, true to one of Nature's great laws, the very agencies which are appointed for the conservation of the individual become, when per- verted, his destruction. Hence, when only wounded 128 Applied Anatomy : (Pig 22), the contraction and retraction serve to make the wound larger (Fig. 23), hut when completely divided they seal up the ends of the vessel. This is Fig. 22. Wounded Artery. ji'i!i!"iin'|ii.;i:i:il'|in||lll^l]lll!™ii|!l"i;iwiM!i!i"'V!"'i'!i''l[l^ \ irJ'iiMi.liiiiHiliiiliiLiiiilMiiiiiiil Liiiiiil:lllliiiMil4ii.jii'iiilliilii\./ best seen in cases where the wound is transverse in direction ; it is less marked when the wound is ohlique, and least of all when it is longitudinal. Fig. 23. Wounded Artery. t To shuw how the attempts at contraction and retraction open up the wound. 2. Next try the graduated compress. First command the brachial artery so as to stop all Weeding, clear out the wound, and apply the pads of lint dry, because if ajjplied moist they act as a poultice and encourage bleeding. The compress must be conical in shape, the narrow end resting against the bleeding vessel, the pads becoming larger and larger as the surface is approached; then apply a mass of antiseptic wool, and a bandage over all. The compress may be kept on for twelve hours. In using this method for the artificial arrest of haemorrhage, it is necessary that there should be some- thing firm hehind the vessel ; in the case of the palmar arches we have the metacarpal bones. The pressure exercised need not be great : it has been found that pressure equal to a quarter of an ounce, properly applied, will stop the bleeding. Surgical, Medical, and Operative, 129 3. IS'ext, with or without the above, use acute flexion of the elbow joint over a pad of wool, coupled at the same time with flexion of the wrist joint. 4. Lastly, when everything else faUs, ligature the brachial artery in the middle of the arm. It might be tied at the bend of the elbow, but it is better to avoid a cicatrix near the flexure of a joint. Take care that there are not two arteries instead of one to tie. Many objections are urged against the graduated compress — that it is the cause of sloughing, septic inflammation among the tendon sheaths, etc. But the pressure required is not great, and it is possible to use an antiseptic compress. An effort can also be made, if possible without enlarging the wound, to secure the bleeding ends by forcipressure, leaving the forceps attached for twenty -four hours; but flexion of the joints, with elevation of the limb, as above described, will probably be found sufficient. Com- pression of the radial and ulnar arteries by means of acupressure needles has also been recommended. 130 Applied Anatomy : CHAPTER X. ARTERIES OF THE ABDOMEN. The Abdominal Aorta. — This vessel has been tied several times immediately above its point of bifurcation, or between that point and the origin of the inferior mesenteric artery, but without suc- cess] all the patients having died within periods varying from a few hours to ten days, the greater number having died within twenty- four hours. It is usually tied behind the peritoneum, although Sir AsTLEY GooPBB, who was the first to tie the vessel, made his incision through the peritoneum. Aneurism usually occurs near the coeliac axis, or at the bifurcation ; the genito-crural, anterior crural, and external cutaneous nerves may be pressed upon, giving rise to pain in the course of the nerves. The aneurism must be diagnosed from a mass of fteces in the transverse colon, lordosis pushing the artery forwards, from masses of enlarged glands, and abdominal tumours over the aorta. Origin. — It is the direct continuation of the descending thoracic aorta. Extent. — From the front of the body of the last dorsal vertebra to the left side of the body of the fourth lumbar vertebra, where it bifurcates into the common iliacs, a little to the left of the mesial line. Its point of bifurcation corresponds very nearly to the highest part of the crest of the ilium, or about an inch below and a little to the left of the umbilicus. Course. — From the middle line, at its origin, to a point a little to the left of the same line at its bifurcation; or, from the apex of the arch formed by the tenth rib on the left side, to a point slightly internal to the anterior superior iliac spine. Relations. — In front — (l)The transverse part of the duodenum; (2) peritoneum; (3) aortic plexus of nerves; (4) lesser omentum and stomach; (5) branches of coeliac axis and solar plexus ; (6) splenic vein ; (7) pancreas ; (8) left renal vein ; (9) mesentery and small Surgical, Medical, and Operative. 131 intestines. On its left side — The left gangliated cord of the sym- pathetic and left semi-lunar ganglion. On its right side — (1) The inferior vena cavaj (2) vena azygos major; (3) receptaculum chyli. Behind it we find — (1) The left lumbar veins; (2) the vertebral column and thoracic duct; (4) right crus of diaphragm; (5) right semi-lunar ganglion. INCISIONS. — First form, through the peritoneum (Sir Astley Cooper). Make a straight incision four or five inches long in the middle line, curving round the umbilicus, which should correspond to the centre of the incision. Divide the skin, superficial fascia, and aponeurosis forming the linea alba ; then stop every bleeding vessel, and after this cut through the transversalis fascia, extra- peritoneal fat and peritoneum. Push the small intestines to the right side, and again divide the peritoneum as it covers the aorta ; carefully separate the aortic plexus from the vessel, isolate it also from the inferior vena cava, which lies to its right side, and pass the needle from the vein. Second form, witliout wounding the peritoneum (Murray). Make a semi-lunar incision five inches long on the left side of the abdomen, commencing a little below the anterior superior iliac spine, and fully an inch above Poupart's ligament, and carry it at first upwards and outwards, and then curving slightly forwards towards the umbilicus, end a little below the tenth rib. The Structures divided and the method of operating are similar to those described under ligature of the common iliac arteries (see page 136). The operator stands on the right side. Branches. — The most important branches, from a surgical point of view, are: — (1) The cceliac axis, the origin of which corresponds to a point four or five inches above the umbilicus ; it is a short trunk, and soon divides into the gastric, hepatic, and splenic ; (2) the superior mesenteric which arises about a quarter-of-an-inch below the cceliac axis ; (3) the renal arteries, which correspond to a point three and a half inches above the umbiUcus ; and (4) the inferior mesenteric, about one inch above the umbilicus. Collateral Circulation (see Eig. 24) — 1. The deep epigastric branch (9) of the external iliac anastomosing with the terminal branches of the internal mammary branch (5) of the first part of the subclavian and the aortic iutercostals (2). 2. The deep circumflex 132 Applied Anatomy : Fig. 24. Collateral Circulation of the Abdomen. (After Smith and Walsham.) --3 Surgical, Medical, and Operative. 133 Kxplanation of Fig. 24. 1. Thoracic branches of the axillary. 2. Anastomoses between the internal mammary and the aortic intercostals. 3. Subclavian artery. 4. Aorta. 5. Internal mammary. 6. Last lumbar artery. 7. Aorta. 8. The common iliac. 9. The deep epigastric. 10. The middle sacral artery. 11. Ilio-lumber artery. 12. Gluteal artery. 13. The external iliac. 14. The lateral sacral. 15. Pubic branch of deep epigastric. 16. Anastomoses between the visceral branches of the internal iliaos. 17. Pudio artery. 18. Anastomosis between the lateral and the middle sacrals. 19. Sciatic ai-tery. 20. Deep circumflex iliac. 21. Ascending branch of the external circumflex. 22. Femoral arterj-. 23. Obturator artery. 24. Anastomosis between obturator and sciatic. 23. Pubic branch of obturator anastomosing with the pubic branch of the deep epigastric. 26. Internal circumflex. 27. External circumflex. 28. Comes nervi ischiadici. 29. Profunda artery. 30. First perforating. 31. Descending branch of the external circumflex. 32. Second perforating. 33. Nutrient artery of femur. 34. Third perforating. 134 Applied Anatomy : iliac branch (20) of tlie external iliac and ilio-lumbar (11) of the internal iliac anastomosing with the lower intercostals (2) and lumbar arteries (6) of the aorta. 3. The superior hsemorrhoidal termination of the inferior mesenteric anastomosing with the lateral sacral (14) and middle hsemorrhoidal branches of the internal iliac and middle sacral (10) of the aorta. 4. The extra-peritoneal plexus of Turner, which he describes as a wide-meshed plexus of small arteries lying in the fat outside the peritoneum. Above, it com- municates with the perforating branches of the renal arteries, small twigs of the capsular, spermatic, colic, and pancreatic arteries, and below with the lower lumbar arteries, and with the ilio-lumbar, circumflex iliac, and epigastric branches of the iliac arteries. 5. Spermatic artery from the aorta anastomosing with the branches of the internal iliac to the ureter and vas deferens. 6. In the ; female, the ovarian anastomosing with the uterine. In treating aneurism of this vessel by Compression, the vessels of the kidney, the hypogastric plexus, the intestines, and the peritoneum are aU apt to be pressed upon, giving rise to the presence of blood and albumen in the urine, suppression of urine, and peritonitis. Take care tha.t the bowels are empty, and place a soft, hoUow sponge below the tourniquet, and if the patient show signs of syncope slacken; vomiting, etc., may make it slip off the vessel. LoRETA has cured an abdominal aneurism by passing wire into the sac through a small oanula. COMMON ILIACS. Origin.— From the bifurcation of the abdominal aorta at the left side of the body of the fourth lumbar vertebra. Extent. — From its point of origin to the lumbo-sacral articulation, where it divides into internal and external iliac arteries. Each common iliac is about two inches in length, but varies from three-quarters of an inch to three inches ; the right is necessarily a little longer than the left, because the point of division of the abdominal aorta is slightly to the left of the median line. The right is also somewhat larger than the left. Course. — Its course corresponds to the upper third of a line drawn from a point three-fourths of an inch below and a little to the left of the umbilicus, to a point midway between the symphysis pubis and the anterior superior Uiac spine. Surgical, Medical, and Operative. 135 Relations. — The relations differ somewhat on the two sides. Right Common Iliac. — This vessel rests against its own vein at the lower part, and at the upper part crosses the vein of the opposite side. la. front there are — (1) The small intestines (end of the ileum and csecum); (2) peritoneum; (3) sympathetic nerves; (4) crossed hy the ureter near its termination (on the right side, however, the ureter often crosses the external iliac, not the common). On its outer side are — (1) The right common iliac vein ;" (2) the commencement of the vena cava inferior. Its internal relations are unimportant. Left Common Iliac. — The left common iliac rests on the psoas magnus. In front are — (1) The rectum and the sigmoid flexure ; (2) peritoneum ; (3) sympathetic nerves ; (4) crossed by the ureter near its termination, and the inferior mesenteric vessels. Fig. 25. Iliac Arteries and Veins. Inferiov Vena Cava. Abdominal Aoi-ta. Common Iliac Artery, Internal Iliac Artery. On its outer side is the psoas magnus. On its inner side, the left common iliac vein. The relation of the common iliac veins to their corresponding arteries should be noted (Fig. 25). The inferior vena cava is formed by the union of the two common iliac veins on the right side of the vertebral column, and both veins lie on the right side of, and on a plane posterior to, their corresponding arteries. On the right side the vein is at first 136 Applied Anatomy : beneath and then to the outer side of the artery. The left veia lies entirely to the inner side of the left artery, and then passes beneath the right common iliac artery to unite with the vein of the opposite side in the formation of the inferior vena cava, at the right side of the fifth lumbar vertebra. The relation of the veins is a great trouble, and complicates the operation very much, more especially on the right side. In ligature of the arteries of the abdomen, the bowels must be well cleared out, and all hair shaved off the abdominal wall near the site of the incision. In cases of . flatulence after the operation use a soap and water enema, containing a tablespoonful of turpentine, to dispel it. Position of Patient. — On his back with his shoulders raised, his thighs somewhat flexed, and a small pillow under the loin of the side to be operated upon. The operator stands on the side to be operated upon. An assistant at first simply keeps the abdominal muscles moderately tense, but during the later stages of the operation, when the peritoneum is stripped from the iliac fossa, he must be prepared to turn the patient round a little more on the sound side, and then with two broad copper spatulse to hold the abdominal muscles, the peritoneum, and intestines out of the way of the operator, for the wound is deep, and the intestines are apt to roll back into it and embarrass the operator. Incision. — Make a semi-lunar incision about five inches in length, beginning about an inch below and an inch and a half internal to the anterior superioriliac spine, at first passing upwards and outwards for two and a half inches, and then upwards and slightly inwards towards a point midway between the umbilicus and the ensiform cartilage, as far as may be deemed necessary. Farts cut through — (1) Skin; (2) superficial and deep fascia; (3) the aponeurosis of the external oblique muscle; (4) internal oblique; (5) transversalis muscle; (6) then the dull white transversalis fascia— in dividing this fascia, raise a small part at the lower end of the wound with the forceps, and make a small incision with the edge of the knife held horizontally, just as in opening the sheath of an artery, and afterwards enlarge this opening with a probe-pointed bistoury, a finger being introduced and the peritoneum detached, or, perhaps better, open it on Spence's hernia director. The special advantages pf this director for the operation under consideration are that it is Surgical, Medical, and Operative. 137 broad and flat, with tlie edges well rounded, and has a very blunt point, so that it is not likely to injure the peritoneum or intestines during its introduction; and, further, the groove does not go quite up to the end, so that even should the peritoneum fold a little over its end it is not likely to be injured. This care is necessary in opening the transversalis fascia lest the peritoneum be wounded ; it may, if preferred, be torn with the fingers instead of using the director and knife. The patient is now to be turned well over on the sound side, and the peritoneum is then separated carefully from the iliac fossa until the brim of the true pelvis is reached and the external iliac found, which will guide to the parent trunk, or the promontory of the sacrum and sacro-iliac synchondrosis may be taken as the guides, if the artery is approached from above. The position of the spermatic vessels and the genito-crural nerve as they cross the external iliac must be kept in mind, and also the ureter, which crosses the end of the common or the beginning of the external iliac ; but the ureter and spermatic vessels are usually more or less adherent to and follow the peritoneum as it is stripped up and pressed forwards. The needle should be passed from the vein — that is, in ligature of both vessels, from right to left. The clearing of the vessel is a difficult proceeding, but it must be done as carefully and well as possible by the finger naU or director. Some use an ordinary needle, while others prefer the helix or rectangular one ; on account of the depth of the vessel the needle had better be passed threaded. The incision must not be carried too low down or too far forwards, lest the deep circumflex iliac or the deep epigastric arteries be wounded, or even the structures passing through the internal abdominal ring. A branch of the deep circumflex iliac (or the artery itself) will be found between the transversalis and the internal oblique muscle, and must be secured at once. This vessel also serves as a useful landmark indicating the depth to which the incision has been carried. Ligature of the common iliac may be rendered necessary on account of — (1) Aneurism of the external or internal iliacs; (2) haemorrhage from the same vessels, either as the result of a wound {e.g., a gunshot wound or stab) or a surgical operation; (•3) secondary haemorrhage after amputation of the upper part of 138 Applied Anatomy : the tliigh. The operation is in itself a serious one, and in addition to the dangers dependent on the magnitude of the operation and the vessel tied, there is a further risk of inducing fatal peritonitis. The form of the incision will vary according to the point at which we wish to apply the ligature, and also upon the size of the aneurism. In every case the centre of the incision should be opposite to the point at which we wish to secure the artery. Collateral Circulation (see Fig. 24). — 1. The deep epigastric branch (9) of the external iliac anastomosing with the internal mamma,ry branch (5) of the subclavian and the aortic intercostals (2). 2. The deep circumflex iliac branch (20) of the external iliac and the ilio-lumbar (11) of the internal iliac anastomosing with the lower intercostals (2) and lumbar branches (6) of the aorta. 3. The lateral sacral (14) from the internal iliac anastomosing with the middle sacral (10) of the aorta and the superior hsemorrhoidal of the inferior mesenteric. 4. The pubic branch of the deep epigastric (15) with the pubic branch of the obturator (25). 5. The visceral branches of the internal iliac of the side tied anastomosing with the corresponding branches of the opposite side (16). THE INTERNAL ILIAC. Origin. — From the bifurcation of the common iliac at the lumbo-saoral articulation. Extent and Course. — From its point of origin it passes down almost immediately into the pelvis, and at the level of the great sacro-sciatic notch it divides into anterior and posterior trunks, which supply the pelvic walls and viscera. It is a short, thick vessel, about an inch and a half in length (but may vary from half-an-ineh to three inches), and is much smaller than the external Uiac. In the fcetus the internal iliac is called the , hypogastric artery, and is twice as large as the external. It carries the blood from the fcetus to the placenta to be purified, and might, therefore, be looked upon in the same light as the pulmonary artery in the adult. Outside the belly of the child in utero the two vessels twine round the umbilical vein, and are known as the umbilical . arteries. After birth the greater part of the vessel is obliterated, and only remains as a fibrous cordj a small part of its root, however, remains pervious, and is known as the superior vesical artery. Relations. — In front are — (1) The peritoneum; Surgical, Medical, and Operative. 139 (2) it is crossed by the ureter. BeUnd are— (1) The internal iliac vein; (2) the lumbo-saeral cordj (3) part of the pyriformis. On the outer side it rests against the psoas magnus and external iliac vein. To its inner side, at the upper part, is the internal iliac vein (the internal iliac, veins hoth lie internal to their corresponding arteries) (see Fig. 25). The steps in the operation for the ligature of this vessel are precisely similar to those for the ligature of the common iliac (see page 136); and the bifurcation of the common iliac being found, the internal iliac is traced from it down into the pelvis. Great care is necessary, when the artery is exposed, in passing the ligature, on account of the close relation of— (1) The ureter (which crosses it, but is usually turned aside with the peri- toneum) ; (2) the external iliac vein, on its outer side ; and (3) the internal iliac vein, on its inner side, or behind it. BRANCHES. — {A) Prom the Anterior division — 1. Visceral, to pelvic viscera — (a) The superior vesical — this vessel is found in the posterior false ligament of the bladder, and gives off the uflery to the vas deferens; (h) the inferior vesical; (c) the middle hsemorrhoidal — this vessel usually springs from the inferior vesical. In the female there are two additional arteries — uterine and vaginal. 2. Parietal, to walls of pelvis — (a) Obturator, (b) pudic, (c) sciatic. (B) From Posterior division they are all parietal — (a) Gluteal, (6) Uio-lumbar, (c) lateral sacral. Collateral Circulation (see Fig. 24).— 1. Middle sacral (10), from the aorta, anastomosing with the lateral sacral (14), from the internal iliac. 2. Superior haemorrhoidal, from the inferior mesen- teric, anastomosing with the middle hsemorrhoidal, from the internal iliac, and inferior hsemorrhoidal from the pudic. 3. The sciatic (19), from the internal iliac, anastomosing with the internal circumflex branch of the profunda (26), from femoral. 4. The gluteal (12), from the internal iliac, anastomosing with the ascending branch of the external circumflex (21), from the profunda. 5. The pubic branch of the deep epigastric (15), anastomosing with the pubic branch of the obturator (25). 6. The ilio-lumbar (11), from the internal iliac, anastomosing with the lower lumbar arteries (6), and deep circumflex iliac (20). 7. The other visceral branches of the internal iliac, not included in the above Hst, with the corresponding branches from the other side (16). 140 Applied Anatomy : The internal iliac has been tied for aneurism of its branches and for wounds. It was first tied by Stevens, of Vera Cruz, ia 1812, for aneurism of the nates — the woman lived for three years after the operation. He made an incision five inches long, external to and parallel with the deep epigastric artery. Considering the serious nature of the operation, it has been wonderfully successful — probably on account of the free collateral circulation preventing any tendency to gangrene. The Gluteal, Sciatic, and Pudic Arteries. — These three branches of the internal Uiac artery are found in the gluteal region, beneath the gluteus maximus muscle. They all emerge from the pelvis, through the great sacro-sciatic foramen. The trunk of the Gluteal, which is about the size of the ulnar artery, at first lies between the lurabo-sacral cord and the first sacral nerve, and then passes into the gluteal region lying between the pyriformis and the gluteus minimus muscles, where it divides into a superficial and a deep division. T^CiS, Bupevfloial part is distributed to the under surface of the gluteus maximus ; the deep divides into superior and inferior branches — the mjperior runs along the middle curved line between the gluteus medius and minimus, and anastomoses with the ascend- ing branch of the external circumflex artery; the inferior crosses the gluteus minimus to the great trochanter. The Sciatic artery appears below the pyriformis; it is larger than the gluteal artery. It anastomoses with the external and internal circumflex branches of the profunda feraoris. Its branches are — (1) Muscular, or in- ferior gluteal, to gluteus maximus; (2) coccygeal; (3) comes nervi ischiadici; (4) anastomotic. The Pudic artery is seen close beside the sciatic — this vessel is found in three regions — (1) In the cavity of the pelvis; (2) in the gluteal region; and (3) in the perineum. It winds out of the great sacro-sciatic foramen, crosses over the spine of the ischium, and re-enters the pelvis by the lesser sacro- sciatic foramen above the tendon of the obturator internus. As it lies on the spine of the ischium it has a vein on each side, the nerve to the obturator internus on its outer side, and the pudic nerve internal to it. It is found ia the outer wall of the ischio- rectal fossa, within a sheath of the parietal pelvic fascia, and lies about an inch and a half above the lower border of the tuberosity of the ischium. It is accompanied by two veins and the pudic Surgical, Medical, and Operative. 141 nerve, tlie nerve being at the lower part. The artery is next found between the two layers of the triangular ligament, and finally pierces the anterior layer, half-an-inch from the pubic arch, and ends by dividing into the artery to the corpus cavemosum and the dorsal artery of the penis. Its branches are — (1) Inferior hsemorr- hoidal; (2) superficial perineal; (3) transverse perineal; (4) artery to the bulb; (5) artery to the corpus cavernosum; (6) dorsal artery of the penis. It will be noticed that this artery or its branches arc involved in many surgical operations, as — operations on the penis, perineal lithotomy, operations about the anus, lower part of rectum, and ischio-rectal fossa. The position of these three vessels may be indicated on the surface thus: — "If a line is drawn from the posterior superior spinous process of the Uium to the tuberosity of the ischium, the gluteal artery issues from the pelvis at a jwint about an inch external to the junction of the upper and middle thirds of this line; the ischiatic and pudic arteries a couple of inches lower down" (Ciiibne). Fig. 26. Guide to Arteries of Buttock. s Incision for Gluteal. Ilio-lschiatic line. *^ ''/^IriT^. Incision for Sciatic or Pudic. Ilio-troclianteiic line Another method is to draw a line {ilio-trochanteric, which corresponds in direction to the fibres of the gluteus maximus) from the posterior superior iliac spine to the posterior superior angle of the great trochanter. The junction of the upper with 142 Applied Anatomy : the middle third marks the point of emergence of the gluteal artery from the great sciatic notch. For the sciatic and pndic draw a line (ilio-ischiatic) from the same point to the tuherosity of the ischium. The junction of the lower with the middle third marks the point of emergence of the sciatic and pudic arteries from the great sciatic notch (Fig. 26). The three vessels are simply covered by the integumentary structures and the gluteus maximus, and may be reached for the purpose of ligature by incisions, three or four inches long, in the direction of the fibres of the gluteus maximus, over the points indicating their respective positions; but in by far the greater number of cases the guide to the artery affected will be the pulsating aneurismal tumour. Of the three, the gluteal is the one most frequently affected. It is the vessel most frequently wounded in this region, from sitting down on something sharp, or, for example, from the accidental collapse of the chamber utensil. Any of the three may be wounded by a punctured wound in this region. In cases of traumatic aneurism, the best treatment to adopt is to perform the "old operation;" failing this, the internal or even the common iliac may be ligatured. The Collateral Circulation (see Fig. 24) is carried on by anas- tomoses between the gluteal (12) and sciatic (19) arteries with the ascending branch of the external (21) and internal circumflex (26), branches of the profunda femoris ; and in the case of the pudic by the anastomoses of its branches with the corresponding branches from the other side. The Obturator Artery runs along the lateral pelvic wall in the extra-peritoneal fat, between the jjeritoneum and the pelvic fascia to the upper part of the thyroid foramen, and leaves the pelvis by passing above the upper edge of the pelvic fascia; the nerve of the same name lies above it, and its vein is below it. It gives off an iliac, a vesical, and a pubic branch. Outside the pelvis it divides into an external and an internal branch that skirt the sides of the thyroid foramen and anastomose with each other, and with branches of the internal circumflex. The external branch sends a twig to the hip joint through the cotyloid notch, which ramifies on the round ligament as far as the head of the femur; it is accompanied by a branch of the obturator nerve. Surgical, Medical, and Operative. 143 TJie llio-lumbar Artery.— The lumbar branch of this vessel anastomoses with the last lumbar artery, and the iliac with the gluteal, deep circumflex iliac, external circumflex and episastric arteries. THE EXTERNAL ILIAC. Origin.— Prom the bifurcation of the common iliac at the lumbo- sacral articulation. Extent.— From its point of origin to Poupart's ligament. Course.— It runs along the brim of the true pelvis, and Its course is indicated by the lower two-thirds of a line drawn from a point three-fourths of an inch below, and a little to the left of the umbilicus, to a point midway between the anterior superior iliac spine and the symphysis pubis. The artery, with its accompanying vein, are bound down to the psoas muscle in a common sheath of fascia. Relations.— In //wif—(l) The intestines; (2) peritoneum; (3) a process of iliac fascia; (4) spermatic vessels; (5) vas deferens (4 and 5 are more especially at its lower part); (6) genital branch of the genito-crural nerve; (7) the circumflex iliac vein. To its inner side — (1) The external iliac vein; (2) the vas deferens. To its outer, side — the jDSoas magnus. Behind it — (1) The external iliac vein (on the right side); (2) the psoas magnus. On the left side the vein is to the inner side of the artery in the whole of its course, but is beneath its upper part on the right side (see Fig. 25); on the right side the ureter very often crosses the upper part of the external iliac. The patient is to be placed in the recumbent position, with his shoulders raised by pillows, and his knees semi-flexed, to relax the abdominal muscles. The colon must be well emptied by an enema, the pubes shaved and the bladder emptied before beginning the operation. The Surgeon stands on the same side as the vessel about to be tied. Abernethy's incision, — Make a curved incision, four or five inches long, with the convexity downwards and outwards, commencing about an inch external to the middle of Poupart's ligament and an equal distance above it, and carry it upwards and outwards parallel with the ligament, ending an incli internal to, and a little above, the anterior superior iliac spine. This form of incision more easily reaches the artery at its upper part away from the seat of disease — supposing it to be tied for femoral aneurism. This incision, 144 Applied Anatomy : though often called Abbknbthy'b, is not, strictly speaking, the incision he iised; he first tied this vessel in 1796, but made his incision in the course of the vessel. Abernetht's incision is said to leave a great tendency to hernia, due to the injury to, and the consequent weakening of, the muscular planes; this tendency may be partially obviated by the careful application of deep sutures. Its chief advantage is, that one may ligature the vessel at any part of its course, or even, if necessary, tie the common iliac, and it is, therefore, to be preferred when operating in cases of spontaneous aneurism. The structures divided and the steps of the operation are the same as in ligature of the common iliac. After the peritoneum is stripped up, the loose cellular tissue sheath surrounding the vessel must be carefully scratched through with the finger nail, aided by a director, or the point of the aneurism needle; wlien sufficiently cleared pass the needle from within outwards to avoid injury to the vein. The incision must not be canied too far downwards lest the deep epigastric vessels, or the internal abdominal ring and the structures passing through it, be implicated; further, it should not be too near Poupart's ligament, lest the deep circumflex iliac artery be cut. Si^ecial care must be taken not to include the genital branch of the genito-crural nerve in the ligature, as this nerve lies on the artery, or wound the peritoneum. In four cases of ligature of this artery, the patients died from' tetanus, probably from implication of the nerve in question. The chief causes of death after this operation are — (1) Gangrene, especially likely to occur when the deep epigastric is injured; (2) secondary haemorrhage, especially when the vessel is diseased, or when it is tied too near its origin, or, again, when tied too near Poupart's ligament; and (3) peritonitis. Other dangers of this operation are — injury to the external iliac vein, and ligature of the genito-crural nerve. Sir Astley Cooper's Incision.— Make a semi-lunar incision extending from an inch internal to the anterior superior iliac spine to half-an-inch external to the external abdominal ring, half-an-inch above Poupart's ligament; the incision should be about three inches in length with its centre over the artery. This incision chiefly exposes the artery at the lower part, and should be made, as nearly as possible, in the direction of the fibres of the external Surgical, Medical, and Operative. 145 oblique. This incision divides the superficial epigastric artery, wMch must be secured at once. Then divide the tendon of the external oblique on a director, and after this lay aside the knife and complete the operation with director and forceps. Scratch through the cremaster muscle and push the cord upwards, and after this tear through the transversalis fascia with the fingers. The wound must now be kept open by two copper spatulse : the internal one pulls the cord and the deep epigastric artery upwards and inwards, the outer one pulls the internal oblique and trans- versalis upwards and outwards; both also displace the lower part of the peritoneal sac upwards, as the whole operation should be extra-peritoneal. The vessel is now exposed, and must be cleared at a point an inch above Poupart's ligament to avoid the two large branches; the needle must be passed /ro?w the vein. As the vessel lies exposed in the wound, the following important relations must be noted — (1) The genito-crural nerve lies on the vessel ; (2) the deep circumflex iliac vein is crossing it ; and (3) the external iliac vein lies to its inner side. Should this method be adopted in cases of aneurism the vessel is exposed too near the seat of the disease, the deep circumflex iliac artery and vein are in great danger, as well as the vas deferens and spermatic vessels, as the outer end of the inguinal canal is opened up ; and should the vessel, when exposed, be found diseased, it is impossible to pro- long the incision upwards so as to tie it at a higher point. The chief advantages, when compared with the previous operation, are — -(1) That the peritoneum is less disturbed, and (2) there is less tendency to hernia afterwards. Coopbe's operation is usually selected when it is found necessary to ligature the external iliac for secondary hssmorrhage after a wound or amputation, and where therefore the coats of the vessel are healthy, and more especially when the abdomen is thin and flat. PECULIARITIES. — The deep epigastric may arise from any part of the external iliac between Poupart's ligament and two and a half inches above it. Not unfrequently the obturator arises by a common trunk with the deep epigastric. Branches. — Two branches are given off from this artery just above Poupart's ligament — (1) The deep epigastric, and (2) the deep circumflex iliac. 146 Applied Anatomy : The Deep Epigastric Artery. — This vessel arises from the external iliac ahout a quarter or half- an -inch, ahove Poupart's ligament; it then descends to the level of that ligament and curves forwards to reach the anterior aspect of the peritoneal hag, and after this passes upwards and inwards to enter the sheath of the rectus. At first it lies in the fat, between the peritoneum and the fascia transversalis, then piercing this fascia, enters the sheath of the rectus by passing in front of the fold of Douglas. It has many important Surgical relations. — (1) It forms the outer boundary of Heseelbach's triangle; (2) it is directly in the way in ligature of the external iliac artery by Sir Astley Cooper's incision; (3) with the internal mammary it forms a direct com- munication between the subclavian, intercostals, and external Uiac, and is therefore an important medium of collateral circulation in ligature of either of these Vessels; (4) it lies close to the inner side of the internal abdominal ring; (5) the spermatic cord in the inguinal canal lies in front of it, only separated from it by the fascia transversalis; (6) the vas deferens hooks round its outer side. Its branches are — (a) Oremasteria, to the cremaster muscle; (6) pubic, to anastomose with a corresponding branch from the obturator; (c) cutaneous; and (d) muscular. The Deep Circumflex Iliac Artery^ — Arises from the outer side of the external iliac about the same level as the deep epigastric, and runs outwards behind Poupart's ligament to the anterior superior Uiac spine, then along the crest and anastomoses with the ilio-lumbar artery. Like the deep epigastric it at first lies in the extra-peritoneal fat, between the peritoneum and the fascia trans- versalis; it then pierces this fascia and lies between it and the transversalis muscle, and lastly pierces the muscle and lies between it and the internal oblique. The branch between the internal oblique and the transversalis muscles forms a useful landmark in operations in this region, as in Abeknethy's method of securing the external iliac artery. It is also an important collateral supply in ligature of the external iliac. In aneurism of the external iliac there is pain in the lumbar region along the crest of the ilium, in the testicle and scrotum, and down along the front and outer side of the thigh, f jom pressure on the branches of the lumbar plexus. Surgical, Medical, and Operative. 147 Collateral Circulation (see Fig. 24). — 1. The deep epigastric branch (9) anastomosing with the terminal branches of the internal mammary (5) and aortic intercostals (2). 2. The deep circumflex iliac branch (20), and the ilio-lumbar branch (11) from the internal iliac, anastomosing with the lower intercostals (2), and lumbar branches of the aorta (6). 3. The gluteal artery (12) from the internal iliac, anastomosing with the external circumflex branch (27) of the profunda femoris. 4. The sciatic artery (19) from the internal iliac, anastomosing with the internal circumflex branch of the profunda (26). 5. The obturator artery (23) from the internal ihac, anastomosing with the internal circumflex branch of the profunda (26), RESUME of Abernetht's method : — 1. Use the curved incision as already explained. 2. Divide the external oblique in the direction of its fibres, with the ilio-hypogastric and the ilio-inguinal nerves. 3. Divide the other two muscles to the full extent of the external incision, and secure the branch of the deep external circumflex. 4. Open the transversalis fascia at the lower part of the wound in the same w^ay that the sheath of an artery should be opened, and enlarge on director or tear with fingers, taking care not to injure the peritoneum in any way, especially by tearing a hole in it. 5. EoU the patient over towards the sound side, and use broad copper spatulss to keep the edges of the wound apart. 6. Note the relation of the vein to the artery: also the genito-crural nerve lying on it, which must be carefully turned aside. 7. Pass over the psoas and not below it, and tear through the thin fascia prolonged from its inner edge over the vessel. 8. Scratch through the loose cellular sheath with the point of the finger and aneurism needle; thread the needle, pass it from the vein, and tie. 148 Applied Anatomy: Beware of too free disturbance of the extra-peritoneal cellular tissue, and use strict antiseptic precautions throughout the operation. With hut slight variations this resume is applicable to hgature of the common and internal, as well as to the external iliac. RESUME of Cooper's operation : — 1. Make an incision three inches long with its centre over the vessel, and about half- an- inch above Poupart's ligarnent. 2. Secure superficial epigastric artery, and divide the tendon of the external oblique, the whole length of the skin wound. 3. Scratch through the cremaster muscle and push the cord upwards and inwards, displacing or dividing the internal oblique and transversalis muscles as far as may be necessary. 4. Now hook the parts well aside by blunt hooksy or retractors, or copper spatulse — the inner one pulls the cord, the internal oblique and the deep epigastric artery upwards and inwards, the outer one pulls the internal oblique and transversalis upwards and out- wards. 5. Next, with the fingers make an opening in the trans- versalis fascia over the vessel by tearing it through from Poupart's ligament; this structure may be regarded in the same light as the femoral sheath, and it is therefore unnecessary to divide it the whole length of the external wound. Further, when divided in this way the peritoneum is less likely to be injured. 6. Clear the vessel in the usual way at a point about an inch above Poupart's ligament, in order to avoid its two large branches. The needle must be passed from the vein, which lies on its inner side. Take care of the deep circumflex iliac vein which is seen crossing the artery, and the genito-crural nerve which lies upon the vessel. Surgical, Medical, and Operative. 149 CHAPTER XL ARTERIES OF THE LOWER EXTREMITY. The Femoral Artery. — Origin. — It is the direct continuation of the external iliac artery. Extent. — It extends from Poupart's Fig. 27. Showing Relation of Artery to Femur. Point at which to apply pressure Obtiu-ator Ai*tery Internal Cii'cumflox .... Perforating Branches Anastomotica Magna. Articular Arteries Poupart's Ligament. Deep Circumflex Iliac. .Femoral Artery. External Circumflex, a-X— Profunda Branch. J Descending Branch of the External Circumflex. Popliteal Artery. Articular Arteries. ligament to the opening in the adductor magnu^s; this corresponds to the upper two thirds of the thigh. Course. — Mex the thigh upon the abdomen, and rotate it a little outwards, and the course 150 Applied Anatomy: is then indicated by a line drawn from a i^oint midway between the anterior superior iliac spine and the symphysis pubis, to the inner side of the internal condyle of the femur, or to the " adductor tubercle." The artery at first lies immediately over the head of the femur, hut as it passes downwards it takes an oblique course along the Inner side of that bone, and finally passes behind it as it enters the popliteal space through the opening in the adductor magnus. In applying pressure, therefore, to the femoral artery in the upper part of its course we ought to press directly backwards against the hody of the pubes, or the ilio - pectineal eminence (Fig. 27), but, if- applied to the middle third of the thigh, as the artery lies in Hunter's canal, the pressure must be directed out- wards towards the femur. Fig. 28. Formation of the Femoral Sheath. Fascia Transversalia— Abdominal Wall . L... Fascia Iliaca. Ilium. Iliacus Muscle. yi\ Femoral Sheath. Note that the " common femoral" of Surgeons is the femoral artery before it has given off its profunda branch, and is usually about one inch and a half in length; below this point it is known as the "superficial femoral." But the common fenwral and the superficial femoral of Surgeons form simply the femoral of Anatomists; while the " deep femoral" of Surgeons, is iliB p-ofunda branch of Anatomists. Relations. — The artery is divided into a superficial and a deep part. The superficial part is contained in Scarpa's triangle, and corresponds, in extent, with upper third of the thigh; the deep part is contained in Hunter's canal, and corresponds with the middle third of the thigh. In front of the artery, as it lies in Scarpa's Surgical, Medical, and Operative. 151 triangle, we have — (1) Skin; (2) superficial fascia; (3) deep fascia; (4) cribriform fascia; (5) some large tributaries of the long saphen- ous vein; (6) the anterior part of femoral sheath; (7) the internal Fig. 29. Femoral Artery and Vein. Anterior Ciniral Nerve Huutor's Canal. Femoral Vein. Femoral Artery. Long Saphenous Nerve, which leaves the Canal just above its teiTuinatiou. cutaiieous nerve, just at the apex of the space. The crural branch of the genito-crural is found in the sheath, lying in front of the femoral artery; it leaves the sheath by piercing its outer border. 152 Applied Anatomy : As it lies in Hunter's canal, in addition to tlie superficial structures, ■we find covering it — (8) the sartorius muscle j (9) roof of Hunter's canal; and (10) the long saphenous nerve. Behind it we find — (1) The psoas muscle, which separates it from the margin of the pelvis and the capsule of the hip-joint ; (2) the nerve to the peotineus; (3) the femoral vein; (4) the pectineus; (5) the adductor longus; and (6) part of the adductor magnus. On the inner side — (1) The femoral -vein (at the upper part); (2) the adductor longus; and (3) the sartorius. On the outer side — (1) The anterior crural nerve, which lies about a quarter of an inch from the vessel, a few fihres of the psoas muscle intervening; (2) the vastus internus; (3) the femoral vein (at the lower part) ; (4) the internal cutaneous nerve; (5) the long saphenous nerve; (6) the nerve to the vastus internus. The femoral vein (Fig. 29) is at first on the same plane, and on the inner side of and close to the artery; but in its course downwards it gradually passes behind the artery, until, when it reaches the apex of Scarpa's triangle, it lies directly behind it; it then gradually passes to its outer side. The following is the arrange- ment of vessels from before backwards, at the apex of Scarpa's triangle — (1) Femoral artery; (2) femoral vein; (3.) profunda vein; and (4) profunda artery; hence, if a person receives a stab or bullet wound at this point, these vessels are liable to be injured. The adductor longus muscle separates the femoral vessels from the profunda vessels in this region. The femoral artery may be tied ■ — (1) above the origin of the profunda, i.e., the common femoral; (2) the superficial femoral at the apex of Scarpa's triangle; and (3) the superficial femoral in Hunter's canal. The Common Femoral. — Ligature of this part of the vessel has been anything but a successful operation. There are various reasons for this — (1) It is a short trunk, the usual length being about an inch and a half, and it may be much shorter. (2) The large number of branches given off in the neighbourhood, so that it is almost impossible for a satisfactory clot to form. These branches are — (a) The deep epigastric and deep circumflex iliac, just above its origin; (&) the profunda, one to two inches below; (c) occasionally also one of the circumflex arteries, usually' the internal; {d) three or four small branches — superficial epigastric, superficial circumflex iliac, superficial external pudic, and deep Surgical, 3Iedical, and Operative. 153 external pudic. It may be said that these vessels are so small that they are not worth taking into account, hut this is by no means the case; they bleed very freely and more especially if they are cut near their origin, for then the cut end retracts so much that the wound becomes, for all practical purposes, equivalent to a wound of the common femoral itself. (3) Another possible objection to this operation is lest the cicatrix, by its contraction, may interfere with the integrity of the femoral ring. Another fact very much against the success of this operation is, that the artery is of so uncertain length. The common femoral is sometimes wounded in shoemakers when, in paring leather, the knife slips off the laprboard. The vessel may be reached either by — (1) A Vertical incision, two inches long, right over the artery, beginning at Poupart's ligament; or by (2) a Transverse Incision (Porter's), two and a half inches long, across the course of the vessel, about an inch below Poupart's ligament. The vertical incision is probably the best. The Surgeon stands on the outer side of the limb, on both sides of the body. In either case the Structures cut through are — (1) Skin; (2) superficial fascia with the superficial vessels, nerves, and lymphatics in this region; (3) iliac part of the deep fascia and branches of the genito -crural, and anterior crural nerves; (4) the femoral sheath, which must be opened over the vessel. Carefully isolate the artery from the surrounding structures and pass the needle from the inner side, i.e., from the vein, taking special care not to include the crural branch of the genito-crural nerve, which lies on the sheath of the artery. As already mentioned, the results of this operation are by no means satisfactory — (1) Gangrene has fol- lowed in several cases ; but the great cause of death is (2) secondary haemorrhage. Hence, in cases where it might be deemed expedient to tie the vessel at this point, it is better not to do so, but rather to ligature the external iliac at once. Collateral Circulation (Fig. 30).— 1. Sciatic (3), from the internal iliac, anastomosing with the internal circumflex (11), ex- ternal circumflex (36), and perforating arteries (15, 18, 19). 2. The obturator (4) from the internal iliac, with the internal circumflex of the profunda (11). 3. The gluteal (1) from the internal iliac, with the ascending branch of the external circumflex of the profunda (7). 4. The deep external pudic with the superficial peroneal artery. 154 Applied Anatomy : Fig. 30. Collateral Circulation of the Lower Extremity. (After Smith and Walbham. ) 34 Surgical, Medical, and Operative. 155 Explanation of Fig. 30. 1. Gluteal artery. 2. Anastomoses between the gluteal, sciatic, external circumflex, deep circumflex iliac, and supei-ficial circumflex iliac arteries. 3. Sciatic artery. 4. Obturator artery. 5. Anastomosis between the pubic branches of deep epigastric and obturator arteries. 6. Pubic branch of deep epigastric. 7. Ascending branch of external circumflex. 8. Superficial circumflex iliac. 9. Common femoral. 1 0. Anastomosis between obturator and sciatic arteries. 11. Internal circumflex artery, 12. External circumflex artery. 13. Superficial femoral. 1 4. Deep femoral (profwiida). 15. First perforating. 16. Comes nervi ischiadic!. 17. Descending branch of external circumflex. 18. Second perforating. 19. Third perforating. 20. Superior external articular. 21. Anastomotica magna. 22. Inferior external articular. 23. Superior and inferior internal articular arteries. 24. Anterior tibial I'ecun'ent. 25. Anterior tibial. 26. Posterior tibial. 27. Peroneal. 28. Anterior peroneal. 29. Communicating branch between the peroneal and posterior tibial. 30. Malleolar branches. 31. External plantar artery. 32. Internal plantar artery. 33. Dorsalis pedis. 34. Branch of sciatic artery. 35. Transverse branch of the external circumflex. 36. Anastomosis behind external malleolus. 156 Applied A natomy : Ligature at the Apex of Scarpa's Triangle.— The safest place at which to apply a ligature is about five inches from Poupart's ligament; this point has, therefore, been called the " seat of 'elec- tion.'' This is usually well out of the way of the profunda, as this vessel has not been known to take origin lower down than four inches from the origin of the femoral. The femoral artery has been tied by Carnochan as a means of curing Elephantiasis Arabuni. THE OPERATION. Position of ttie Patient. — He should be recumbent, his thigh abducted, flexed, and rotated outwards, with the knee bent and resting against a pillow. The Surgeon stands on the outer side of the limb, on both sides of the body. Incision. — Ascertain the position of any large superficial vein, by making pressure on the upper part of the saphena vein; stretch, but do not displace, the skin with the left hand; and then make an incision three or four inches lojng in the course of the vessel, its centre corresponding to the point at which the artery is to be tied, which must be at least five inches below Poupart's ligament, in order to be well away from the origin of the profunda (Fig. 31). This incision is not parallel with the inner edge of the sartorius, but will cross that muscle obliquely, and it must not be made too far inwards lest the long saphenous vein be wounded, or the adductor longus be exposed instead of the sartorius. The adductor longus will be recognised by the direction of its fibres — passing downwards and outwards, whereas the fibres of the sartorius pass downwards and inwards. We cut through — (1) The skin ; (2) superficial fascia and fatty tissue; (3) the deep fascia forming the sheath of the sartorius, which at this point crosses the artery obliquely. An assistant with blunt hooks now keeps the edges of the wound in the fascia apart, and the Surgeon, with scalpel and forceps, proceeds to define the inner edge of the sartorius, which is then to be gently drawn towards the outer side, and held there by a broad copper spatula. (4) Clear away any loose cellular tissue and expose the femoral sheath, and next make a small opening in it. The side of the opening furthest from the operator is then to be secured by a pair of toothed forceps and given to an assistant. This prevents the possibility of losing the opening. After this open (5) the proper Surgical^ Medical^ and Operative. 157 sheath, of the vessel, which is then cleared and ligatured in the usual way. At the point where the artery is ligatured the vein lies behind it, so that it matters little from which side the needle Fig. 31. Incisions for Ligature of Femoral. Poupart'a Liga- ment Femoral Artery.. Sartorius In Ligature at this point dis- place the %'&X' toriuso'«(«f«r(fe. Adductor Longiis. In Ligature at this point displace the Sartorius imcards. is passed; but on account of this relation, great care is necessary in clearing the artery and passing the needle ; and not only does the vein lie immediately behind the artery, but it is more firmly 158 Applied Atiatomy: adherent to it than is tlie case witli most large arteries and their companion veins, so that the artery must he completely cleared hefore we attempt to pass the ligature, which must then be passed without using force. • The vein is often rather to the inner side at this point, so that, on the whole, it might be as well to pass the needle from the intier side. Some Surgeons advise that it should be passed unarmed, and then threaded and withdrawn, as, they say, there is less risk of wounding the femoral vein by so doing. But, while the artery should be cleared completely, due care must be taken at the same time to avoid undue disturbance of the parts, lest the " vasa vasorum," supplying the coats of the artery, be unnecessarily injured, and lead to death of that part of the vessel. The crural branch of the genito-crural, the internal cutaneous and long saphenous nerves must all be carefully avoided, as they often lie in front of the vessel. This is a very successful operation. The more important untoward accidents are — (1) Gangrene; (2) wound of the vein; and (3) secondary haemorrhage. (For the Preventive Treatment of Gangrene, see page 33). 1. Gangrene is especially apt to follow if the vein be injured. The best way to avoid this is to clean a small part of the vessel thoroughly with scalpel and dissectinff forceps (Bell). No blunt instruments, such as directors, etc., are admissible. If gangrene occurs, amputate through the lower third of the thigh (Spbnce). 2. Wound of the Vein is very frequently fatal from septic phlebitis or gangrene. Should this accident occur, the ligature should be withdrawn, and a new opening made in the sheath half-an-inch higher up, and the ligature reapplied there, the hole in the vein being tied longitudinally, as complete obliteration of the vein is almost certain to be followed by gangrene. 3. In Secondary Haemorrhage there are various courses open — (a) The graduated compress; (6) ligature of the external iliac or superficial femoral — this is usually followed by gangrene; (c) tie the bleeding point — usually the distal side; and (d) i£ everything else fail, amputate. For varicose aneurism in this region perform the " old opera- tion," as ligature of the external iliac is very fatal from gangrene, secondary heemorrhage, and pneumonia. Surgical, Medical, and Operative. 159 p t RESUME of the operation at the " seat of election " : — 1. Make an incision three inches long in the line of the vessel, with its centre five inches from Poupart's liga- ment, avoiding the trunk of the long saphena vein, and securing large tributaries. 2. Expose the edge of the sartorius and turn it outwards. 3. Turn aside the internal cutaneous and the long saphenous nerves, and the nerve to the vastus internus, and open the sheath common to artery and vein. 4. Then open the sheath proper to the artery, and clean well till the white external coat is seen. 5. Pass the needle unarmed from within outwards, thread, and withdraw. 6. Do not dip the point of the needle too much, hut keep it close to the artery, so as to avoid wounding the vein. LIGATURE IN HUNTER'S CANAL, This operation is rarely performed now-a-days, as the vessel is too deeply placed, and besides, ligature at the apex of Scarpa's triangle gives better results. " Hunter's canal " is formed by an aponeurotic expansion thrown across from the adductors longus and magnus on the inner side to the vastus internus on the outer side. Fig. 32. Section through Hunter's Canal, Right Side. m ^^®^^^^^^' lying on the roof of ^3 ^^ the Canal. „ . . , ^H # ^PLljong Saphenous Nerve. Femoral Artery ■■•■••;■-■ P^ Adductor Magnus, forming the Vastus Internus, formmg..^^t _.^ .^lisissssr- inner boundary of tlie Canal. Its outer boundary. ^^H C.c3-.>j^^P- Femoral Vein. (Fig. 32). It is triangular in shape, the base being formed by the expansion already alluded to, and it extends from the apex of Scarpa's triangle to the opening in the adductor magnns, and corresponds, therefore, with the middle third of the thigh. It encloses the femoral artery and vein, and the long saphenous nerve 160 Applied Anatomy: — the vein 'being at first behind, and then to the outer side of the artery, while the nerve is above it, and crosses from its outer to its inner side (see Fig. 29). The position of the patient and of the Surgeon is the same as in the previous operation. Incision. — An incision, three or four inches long, should be made, a finger's-breadth internal to, and parallel with, the line that indicates the course of the artery, so as to cut down on the outer border of the sartorius, and at the same time avoiding the internal saphenous vein (Beck), as, it is said, we may miss the sartorius altogether, and strike the vastus internus instead, if the incision be made too far to the outer side. The vastus will be recognised by its fibres passing downwards and outwards. I am not so sure of this. I think it will be found, as a rule, more convenient and sure to cut in the line that indicates the course of the vessel, as in the previous operation, exposing the sartorius and turning it to the inner side (Fig. 31). Structures cut through — (1) Skin ; (2) superficial fascia and fatty tissue; (3) through the fascia forming the sheath of the sartorius, and expose the outer edge of that muscle, and draw it well to the inner side. Next divide (4) the roof of Hunter's canal with the point of the knife, and then enlarge the opening with a probe-pointed bistoury; the saphenous nerve is then to be drawn aside, and the proper sheath of the vessel opened, and the artery cleared to the requisite extent, and the ligature passed from the outer to the inner side, and, if possible, about an inch above the origin of the anastomotica magna. FECULIABITIES. — 1. In four cases a double superficial femoral has been found, the two divisions reuniting again near the opening in the adductor magnus to form a single popliteal. 2. The femoral has been found situated at the back of the thigh, passing through the great sacro-sciatic foramen. 3. Sometimes the common femoral is very short, or altogether absent. Brandies of tiie Femoral. — (1) The superficial epigastric; (2) the superficial circumflex iliac ; (3) the superior external pudio; (4) the inferior external pudic; (S) the profunda branch— and (6) the anastomotica magna, which is given off in the lower part of Hunter's canal ; it arises just before the femoral passes through the opening. It divides into a superficial and de&p branch — the superficial accompanies the long saphenous nerve, while the deep Surgical, Medical, and Operative. 161 descends in the substance of the vastus internus, in front of the tendon of the adductor magnus, to the inner condyle of the femur, and anastomoses with the superior internal articular, and recurrent of the anterior tibial. RESUME of the operation in " Hunter's canal " :— 1. It is probably better to make the incision in the line of the artery, as we can thus more easily reach the outer edge of the sartorius and avoid the long saphena vein. 2. Open the fascia and expose the outer edge of the sar- torius, and displace the muscle inwards. 3. Open the roof of the canal, after the manner of the sheath of an artery, and enlarge on a director, or with finger and probe-pointed bistoury. 4. Avoid the internal saphenous nerve and clear the artery as in the higher operation. 5. Clear the artery and pass the needle from the outer side, about one inch above the anastomotica magna. The only other branch which requires special notice is the pro- funda branch. The Profunda Artery (Deep Femoral). — This branch arises from the outer and posterior part of the femoral artery about an inch and a half from its commencement. At first it passes down- wards and outwards, then curves inwards behind the femoral artery and the adductor longus muscle (this muscle separating the two vessels), and then passes downwards, at first lying between the adductors longus and brevis, and afterwards between the adductors longus and magnus, and terminates by piercing this latter muscle. Relations. — It lies on — (1) The ihacus, (2) the pectineus, (3) the adductor brevis, and (4) the adductor magnus. In front of it (besides the structures covering the femoral artery) we have — (1) The femoral and profunda veins, and (2) the adductor longus. To its outer side is the vastus internus. It may be ligatured near its origin by the same incision as that used for ligature of the femoral in the lower part of Scarpa's triangle; or, lower down, by following it inwards behind the adductor longus muscle, but great care would be necessary on account of its relations to its own vein, and also to the femoral vessels. 162 Applied Anatomy: Branches of the Profunda.— 1. The external circumflex— this branch passes outwards beneath the sartoiius and rectus, and divides into — (a) Ascending branches which pass upwards and anastomose with the gluteal and the circumflex iliac arteries ; (&) transverse '-■ branches which pass outwards over the crureus, and anastomose on the back of the thigh with the internal circumflex, gluteal, sciatic, and superior perforating arteries ; (c) descending branches which pass downwards towards the knee, and anastomose with the superior articular branches of the popliteal artery. 2. The internal circumflex — this vessel passes directly backwards towards the gluteal region, and there anastomoses with the gluteal, sciatic, and superior perforating arteries. It gives a small branch to the hip joint. It arises from the posterior surface of the pro- funda, and disappears by passing between the pectineus and psoas muscles; and, continuing its course backwards, between the obturator externus and the adductor brevis, and finally appearing behind between the adductor magnus and the quadratus femoris muscles. On reaching the obturator externus it divides into two branches, one passing above and the other below the adductor brevis; the branch passing beneath appears in the buttock, after giving a branch to the hip joint. 3. The three perforating arteries, which pass backwards cilose to the femur, and appear on the posterior surface of the adductor magnus. These arteries form a regular chain of anastomoses in the back of the thigh, connected above with the gluteal and sciatic arteries, and below with the anastomotica magna and the superior articular branches of the popliteal. The position of the various branches should be kept in mind, as they are apt to be wounded in stabs and other injuries of various parts of the thigh, especially the circumflex vessels. . FECULIAKITIES. — It arises sometimes from the inner side of the femoral. It usually arises from one to two inches from the beginning of the femoral. In a few cases it was less than an inch; more rarely it may arise just under Poupart's ligament, and in one case it came from the external iliac. It has been known to arise four inches below the origin of the common femoral. Collateral Circulation (see Fig. 30). — (a) In ligature of the Superficial Femoral — 1. The descending branches of the external circumflex above (17), anastomosing with the superior articular Surgical, Medical, and Operative. 163 branches of the popliteal (20), and anastomotica magna below (21). 2. The obturator artery above (4), anastomosing with the internal circumflex artery (11), muscular branches, and anastomotica magna below (21). 3. The chain of anastomoses already mentioned, formed by the perforating arteries, inosculating a,bove with the gluteal (1), sciatic (34), and ascending (7) and transverse branches of the external circumflex (35), and below with the anastomotica magna (21) and articular arteries (23, 20, 22). 4. The terminal branches of the profunda and sciatic arteries above, anastomosing with the anasto- motica magna below (21). (6) In ligature of the Deep Femoral — 1. The descending branches of the external circumflex above (17), anastomosing with the anastomotica magna (21) and the superior articular arteries below (20, 23). 2. Branches of the internal circumflex above (11), anastomosing with the perforating arteries below (15, 18, 19). POPLITEAL ARTERY. Origin. — It is the direct continuation of the femoral. Extent. — It extends from the opening in the adductor magnus to the lower border of the popliteus muscle, where it divides into the anterior and posterior tibials. Its point of division corresponds to the lower part of the tubercle of the tibia in front. Course. — It passes obliquely from the inner side of the femur to the middle of the popliteal space, exactly behind the knee, joint, and then passes straight downwards. The artery lies deeply in the space, and is covered and crossed by the internal popliteal nerve and the popliteal vein; both vein and nerve crossing the artery from without inwards (Fig. 33). Behind the knee joint, the artery lies in the middle of the space, and is covered (as looked at from behind) by the nerve and vein, so that if a person receive a stab in this region aU the three structures may be injured, or perhaps divided, in the order of nerve, vein, artery. Reiations.— In/row^, the trigone of the femur, the posterior ligament of the knee joint, and the popliteus muscle covered by its fascia. On the inner side, semi-membranosus, internal condyle, and inner head of gastroc- nemius: to the outer side, biceps, outer condyle, outer head of gastrocnemius and plantaris. Behind, popliteal vein, the internal popliteal nerve, and the popliteal fascia, with fat, etc. Its branches 164 Applied Anatomy: are — (1) Superior muscular, (2) inferior muscular or sural, and (3) the five articular — two superior, two inferior, and an azygos. Ligature of this artery is seldom performed, but it may be rendered necessary for wound, for ruptured artery, or for sup- puration of an aneurismal sac in this position. Since the artery bifurcates on a level with the tubercle of the tibia, it is possible to wound the artery from the front by a stab, as in a case of acci- dental wound of the vessel recorded by the late Professor Spencjs. Fig. 33. Right Popliteal Space, from behind. Internal Popliteal Nerve _ Popliteal Vein Popliteal Arteiy . . . . _ Internal Superior Boundary — Semi- tendinosus and Seni i - membiano- sus / ^^^1^ "V. External Superior. |i|M \ Boundary — Biceps »''"■ ^ Femoris. ' "'' The Internal Inferior Boundary — Inner Head of Gastroc- nemius External Inferior Boundary — Outer Head of G^trop- neuiius and Plau- taris. ■ Popliteal Artery. Popliteal Vein. Internal Popliteal Nerve. It may be exposed by — (1) a median incision either over the centre of the space or over its lower angle, where it lies between the two heads of the gastrocnemius; (2) by an incision on the inner side above (Jobbrt); (3) by an incision on the inner side below (Marshall). All the incisions should be about four inches long. 1. iVIsdian Incision. — The patient should be laid on his face, and the Surgeon stands on the outer side and makes an incision Surgical, Medical, and Operative. 1G5 in the middle line four inches long, carefully avoiding the external saphenous vein, which empties itself into the popliteal vein at the lower angle of the space. We cut through the skin, superficial fascia, cutaneous vessels and nerves; displace the external saphena vein as it lies in the subcutaneous tissue, and then divide the deep, or popliteal, fascia. The limb must now be flexed, and the tendons, with the internal popliteal nerve, carefully held aside with copper spatulse. Then, by dissecting carefully down amongst the fatty tissue with the handle of the knife, the operator next exposes the popliteal artery and vein, firmly bound together; the vessels must then be separated and the vein displaced to the side most con- venient, and when the artery is cleared the needle must be passed from that side. The vein and the artery are very adherent, so that it is a very difficult proceeding to separate them and clear the artery for the 'ligature. The walls of the vein are said to be specially thick, resembling very closely, in fact, the coats of an artery. This may possibly account for the rarity with which this vein is ruptured. The Circulation will be re-established by the superior articular anastomosing with the inferior articular, and other branches around the knee joint. 2. To reach the vessel in its upper third by an incision from the inner side. The limb is to be placed in the same position as in ligature of the femoral. The guide is the posterior edge of the tendon of the adductor magnus, which is attached to the " adductor tubercle," or the outer border of the semi-membranosus which overlaps the artery. An incision, three or four inches long, is made parallel with this tendon, beginning at the junction of the middle with the posterior third of the thigh, avoiding, if possible, the long saphenous vein. After dividing the superficial structures and deep fascia, the tendons of the sartorius and internal hamstrings come into view, and must be displaced backwards by a copper spatula. Then, with the left index finger, feel for the tendon of the adductor magnus, and after this dissect carefully through the loose fatty tissue with the handle of the scalpel, or a director, till the artery is exposed. It is next to be cleared sufficiently, and the needle passed from the outer side to avoid the popliteal vein, and the internal popliteal nerve, which lie on that side of the artery in this position (see Fig. 3-3). 166 Applied Anatomy : 3. It may be ligatured in the lower third of its course by Marshall's plan, as it lies on the popliteus muscle, and covered by the gastrocnemius. An incision, three or four inches long, is made a little behind and parallel with the inner border of the tibia, avoiding the long saphenous vein. By cutting through the superficial structures and deep fascia, and displacing the inner head of the gastrocnemius backwards, the vessel may be reached and ligatured. The relation of the popliteal vein and internal popliteal nerve, both of which by this time lie rather on the inner side of the vessel (see Fig. 33), will complicate the operation considerably. This, however, matters little, as the operation is of no practical utility. Popliteal Aneurism. — Next to the thoracic aorta, the popliteal artery is the most common seat of aneurism; this arises from many causes — (1) The amount of violent movement, either of flexion or extension, to which it is subjected, and which is specially apt to injure the two inner coats of the vessel; (2) its feeble lateral support from the fatty tissue in the space; (3) its very frequent acutely bent position, so that the blood impinges with considerable ^ force against the anterior or popliteal surface of the vessel. So . great is the force that the whole leg is tilted forwards, unless it is otherwise fixed, as we see how the toe is tilted forwards at each beat of the heart, when one knee is crossed over the other. The usual history is — a feeling of something giving way during exer- tion, followed by slight lameness, "rheumatic pains" in the limb, coldness, and probably oedema of the foot, numbing pains in the calf and down the limb, and pain in the foot from pressure on the internal popliteal nerve. These symptoms are due to pressure on the popliteal vein and the internal popliteal nerve. The aneurism may either become diffused into the space, leading to gangrene of the limb, or burst into the knee joint. It must be diagnosed from — (1) Eheumatism, and (2) from rupture of some of the fibres of the gastrocnemius. It is treated by flexion of the limb and compression of the femoral. If this is insufficient, then ligature the femoral. POSTERIOR TIBIAL ARTERY. Origin. — From the bifurcation of the popliteal artery, at the lower border of the popliteus muscle. Extent. — From its point of Surgical, Medical, and Operative. 167 origin to the inner side of the os calcis, where it ends by dividing into the internal and the external plantar arteries, beneath the internal annular Ugament, about half-an-inch behind and below the internal malleolus, which corresponds to the edge of the abductor haUucis. It lies between the superficial and the deep layers of muscles on the back of the leg (Fig. 34). Course. — Its course is indicated by a line drawn from a point one inch below the middle of the popliteal space, and in the middle line of the limb, to a point a finger's breadth behind the internal malleolus. Relations. — It is covered hy — (1) Skin and fascia; (2) gastroc- nemius; (3) soleus; (4) plantaris; (5) a tendinous arch covering it, which stretches between the flexor longus digitorum and the flexor longus hallucis; (6) posterior tibial nerve which crosses it at its upper part from within outwards. It lies upon — (1) The tibialis posticus; (2) the flexor longus digitorum; (3) the lower end of the tibia (this is of importance in compression). On its inner side — The posterior tibial nerve (in its upper third). On its outer side — The posterior tibial nerve (in its lower two thirds). It may be ligatured — (1) In the middle third of the leg, or (2) behind the internal malleolus. 1. In the Middle Third of the Leg. — The vessel may be reached by two incisions — (a) The Lateral Incision (see Fig. 34, 9). — An incision, about four inches long, is made parallel with the inner border of the tibia and fully half-an-inch behind it, avoiding the internal saphena vein. The patient is placed in the recurnbent position, his knee is to be flexed, his foot fully extended, and the limb laid on its outer side, resting against a pillow; the Surgeon stands on the outer side of the limb. By this incision we first divide skin and superficial fascia and fatty tissue; the deep fascia is next opened, and the internal edge of the inner head of the gastrocnemius exposed, which must be displaced backwards by a broad copper spatula. The tibial origin of the soleus is now seen, and is to be divided along the whole length of the external incision, about half-an-inch from its attachment to the tibia. In dividing it, the edge of the knife must be turned towards the tibia, and at first only cut through its muscular fibres, exposing its deep tendon. When this is thoroughly exposed, make an opening in it after the manner of opening the sheath of an artery, and complete its division 168 Applied Anatomy . Fig. 34. Section through the Calf. 6 7 I ./ 11 1. Anterior tibial vessels and nei'ves. 2. Posterior tibial vessels and nerves. 3. Peroneal vessels. 4. Short saphenous vein. 5. Septum between peronei and posterior muscles. 6. Strong septum between peronei and anterior group of muscles. 7. Weak septum in anterior group, through which the anterior tibial artery is reached. 8. Interosseous membrane. 9. To show position of lateral incision. 10. To show position of direct incision (Gtjthme's). 11. Tibia. 12. Fibula. The names of the nmseles a/re indieaied by their initial letters. Note. — In the Anterior group of Muscles, instead of P.L.P., read E.P.P.— Extensor Proprius Pollicis vel Hallucis. Surgical, Medical, and Operative. 169 on a director, or by a prolDe-pointed bistoury. The divided soleus is next hooked aside, along with the gastrocnemius, and the space where the artery lies then comes into view. At this point it is accompanied with its vense comites, and at the upper part of the incision the posterior tibial nerve lies internal to it, then over it, and lastly, at the lower part of the wound, to its outer side. These structures rest on the fascia, covering the deep muscles (tibialis posticus and flexor longus digitorum), and are covered by a thin layer of fascia. This fascia must be opened and the artery cleared and ligatured in the usual way, the needle being passed from the nerve. This operation is characterised by Mr Guthrie as being " difficult, tedious, bloody, and dangerous." It is important not to open the fascia covering the deep muscles, for then it is very easy to pass beneath the flexor longus digitorum and so miss the artery altogether. There is often a tendinous intersection in the soleus, which must not be mistaken for its deep tendon. r t RESUME of the lateral operation : — 1. Make an incision, four inches long, half-an-inch beliind and parallel with the inner edge of the tibia. 2. Divide the superficial structures and deep fascia, expose and hook aside the edge of the gastrocnemius. 3. Divide the tibial origin of the soleus, first its muscular fibres and then the glistening tendinous structure covering its under surface, and which forms a sure guide to the vessel. 4. Flex the leg well and extend the ankle to its full extent, hold aside the muscles of the calf, and divide the fascia covering the vessels. 5. Clear the artery and tie in the most convenient way. (J) The second form was recommended by the late Mr Guthrie, and is known as the mesial or Direct Incision (see Fig. 3i,10). The patient is placed in the same position as in ligature of the popliteal artery in the centre of the popliteal space, and the Surgeon stands as before. After the superficial structures are divided, the knee should be flexed and the foot extended, in order to relax the muscles through which the operator has to pass to reach 170 Applied Anatomy : the artery. An incision, six or seven inches long, is made in the mesial line of the leg, in the course of the vessel, heginning about two inches below the middle of the popliteal space, and dividing the skin and fascia. The external or short saphenous vein is then separated arid held aside, and the s&ptum between the two heads of the gastrocnemius is divided to the same extent as the superficial incision, and the two heads separated. The muscular fibres of the soleus are next cut through, and its deep tendon opened as in the last operation; and then the aponeurotic arch covering the vessels is divided, when the posterior tibial nerve will come into view, with the posterior tibial artery and its vense comites to its inner side. The artery is then cleared, and the ligature passed from the nerve. 2. Ligature of tlie Vessel at the Inner An!ving how to find the joints between the phalanges. e — Tubercle at the base of the second phalanx, which may be taken as the guide to that articulation. stand facing the hand, and must be provided with a narrow-bladed bistoury. He next grasps the tip of the phalanx to be removed between his forefinger and thumb, and bends it to a right angle with the second phalanx, and then by a transverse sweep of the bistoury, from heel to point, opens the joint, which is concave towards the tip of the finger. The usual rule for finding the joint is a good one — the joint is on a level with an imaginary line drawn Surgical, Medical, and Operative. 197 along the middle of the lateral aspect of the second phalanx, when the finger is held as directed (Fig. 36, A B). The knife is then to be carried round the base of the phalanx, the first and second phalanges in the meantime being extended, while the terminal phalanx is still further flexed as the lateral ligaments are divided. When the knife has cleared the end of the bone, the phalanx being amputated should be fully extended and a flap of sufficient length cut from the pulp. Structures divided — Skin, superficial fascia, digital vessels and nerves, extensor tendon, ligaments of the joint, and tendon of the flexor profundus digitorum. In many cases the removal of the whole phalanx, after the manner above described, is not called for, all that is required being simply to remove the necrosed piece of bone, the joint, as previously explained, often escaping. In this way the periosteum may form a new phalanx, and the finger be comparatively little the worse. 2nd Method— By double Flaps (see Fig. 35, F).— The assistant in this case miist hold the hand supinated, the finger to be operated upon fully extended, and the other fingers turned into the palm or held aside in any other convenient way. The operator standing as before, grasps the tip of the finger between his own forefinger and thumb, and, while keeping the last two phalanges extended^ may flex it slightly at the carpo-metacarpal articulation. He then transfixes it as close to the bone as possible, taking care that the back of the knife is just a little way in front (i.e., nearer the tip of the finger) of the crease in the skin corresponding to the joint. A flap of sufficient size is then cut, and is held out of the way by the assistant. The phalanx is next to be over-extended, the joint opened, the knife passed through between the bones, and a small flap cut from the dorsal aspect. Provided he makes the palmar flap of sufficient length, the operator need not make a dorsal flap at all. 3rd Method. — By Circular Incision. — This plan may be adopted when there is not enough sound material left to form flaps. The finger may be conveniently held as in the first method, only it must be kejpt extended. The operator standing as before, makes a circular incision about half-an-inch nearer the tip of the finger than the joint. The structures are then to be reflected to the level of the articulation, the ligaments divided, and the bone removed. 198 Applied Anatomy : A very excellent method is to make anterior' and posterior semi- lunar flaps of sufficient length by dissection. THE SECOND PHALANGES. The second phalanges may be amputated in exactly similar ways. An objection, however, to the amputation of a second phalanx is that we remove the entire attachments of the flexor sublimis and the flexor profundus tendons — the sublimis being attached to the sides of the second phalanges, and the profundus to the base of the terminal phalanx. The broad expansion, how- ever, of the common extensor that covers the back of the first phalanx is left, and forma new attachments, and therefore the stump remains fixed, it is said, in the extended position, being neither ornamental nor useful, but positively in the way. One might, however, on purely anatomical grounds, suppose that it would not be quite so useless, for into this same expansion are inserted the lumbricales (the so-called "fiddler's iimscles"), and the interossei muscles. Now, the lumbricales act as flexors of the first phalanges and extensors of the other two, while the interossei also act as flexors of the same phalanges, in addition to their more evident actions of abduction and adduction. This is theoretical, and experience alone is competent to decide the question. In the case of a single finger, therefore, it has usually been the custom, in circumstances requiring the amputation of a second phalanx, to remove the whole finger; in cases, however, requiring the removal of two or more fingers, it woiild manifestly be better to leave the first phalanges. Probably, also, in the case of the index finger it had better be left to act as an opponent to the thumb, but on this point Surgeons are not agreed. No doubt, the amputation of a single finger, as usually performed, weakens the grasp of the hand considerably; but there is no reason why the ivlioh of the first phalanx should be removed, its base might be preserved, and this would leave the joint intact, and at the same time keep up the full breadth of the hand. Since writing the above, in 1887, I have had many opportunities, at the Edinburgh Eoyal Infirmary and elsewhere, of testing the correctness of the old teaching on this subject, and I think there can be but little doubt that the old teachers were wrong — I mean, laboured under a misapprehension. Surgical, Medical, and Operative. 199 I have seen a number of cases now, where the first phalanx, or only a part of it, had heen left, and in every case the flexion and extension of the stump were perfect; and not only so, but it added very greatly to the usefulness of the hand, so that even here the rule holds good — "Save as much as possible." There is, however, one condition where, I thinlc, it will always be found better to remove the finger at the metacarpo-phalangeal articula- tion at once — even Avhen, at first sight, one might be tempted to leave the first phalanx, or even the greater part of the second as well — I mean in cases where the cellular tissue of the finger is much infiltrated with inflammatory material, the result of whit- low, and this even when the tendons, with their sheaths and the bones, are unaffected. Should the finger be left under these conditions the patient will almost certainly return, if he be a working man at any rate, with the request that the finger be removed altogether, as it is useless and always in the way. This is because the tissues as they heal undergo so much contraction, and so much new fibrous tissue is produced, that the finger is rendered rigid in spite of the muscles acting upon it, although, as Mr Duncan has pointed out, the tendons and their sheaths, in almost every case, are seen to be quite healthy when a longitudinal section of the finger is made after amputation. In regard to the second phalanx, however, a compromise has been suggested. The hand being held in the' same position as in the first method for the removal of a terminal phalanx, the operator makes two short antero-posterior semi-lunar flaps (see Fig. 35, D). The dorsal flap is made by dissection, its length and breadth being each equal to one-half the diameter of the finger. The dorsal flap being com- pleted and retracted, the finger is then transfixed at the base of this flap, the knife passing in front of the phalanx, and a semi- lunar flap, equal in size to the posterior, cut from the palmar aspect. Both flaps are then retracted slightly, and the bone divided by the bone pliers at a point previously determined. The flaps, if preferred, may both be made by dissection from the lateral aspects of the phalanx. In cases where the whole phalanx is removed, the tendons, both flexor and extensor, should be stitched to the periosteum of the remaining phalanx and to each other, in the hope that they will form new attachments, and give a movable 200 Applied Anatomy: and useful stump. The rule for finding the joint is the same as in the first phalanx, or the tuhercle at the hase of the second phalanx may be used as the guide (see Fig. 36, e). AMPUTATION OF A WHOLE FINGER. The means to command haemorrhage, thev duties of the assistant, and the position of the operator, are the same as in amputation of a terminal phalanx by the first method. It should be observed that, from the palmar aspect of the hand, the metacarpo-phalangeal joints are fuUy half -an -inch behind the clefts of the fingers, thus corre- sponding very closely with the palmar furrow formed by the flexion of the fingers at the metacarpo-phalangeal joints. Note also that, Avhen the hand is clenched, the knuckles are formed by the heads of the metacarpal bones, and that the joint is midway between the posterior surface of the knuckles and the clefts between the fingers. 1st Method— The Oval Operation (Fig. 37).— This method has the advantage that it does not interfere with the palm. The bistoury is entered about half- an -inch behind the head of the metacarpal bone, and after making a short median incision, passes obliquely round the right-hand side of the root of the finger as far as the point of union of the web with the pahn, and then across the palmar aspect of the finger in the crease of the skin at its root. Up to this point the knife has not been removed from the wound, but has been gradually laid on from point to heel; but to complete the oval the knife is removed, the left arm and hand of the Surgeon raised well out of the way, and the tip of the finger being amputated so held that now his thumb lies against its palmar aspect — when he commenced the operation his thumb lay on the dorsal aspect. He then re-enters the point of the knife at the end of the median incision on the dorsal aspect of the hand, and the remaining part of the oval is completed as on the other side. This plan is more convenient and neater than the method usually adopted of re-entering the point of the knife on the palmar aspect, and carrying it up from the palm to the dorsal aspect, and completing the oval in that way; further, by the plan above advocated, one is more likely to make the two sides of the oval symmetrical. By the other plan, in making the second part of the incision, the Surgeon's right hand with the knife Surgical, Medical, and Operative. 201 is over the back of the patient's hand. The skin oval is then to ho drawn well back hy an assistant, the flexor tendons cut, and the joint opened by the division of the right lateral ligament. The knife is next passed round the base of the bone, and the structures on the other side are divided from within outwards; or the finger may be removed by twisting it round while the edge is pressed against the base of the first phalanx. In the performance of this Fig. 37. Oval Amputation of Finger. Showing the shape of the wound in the "oval" amputation, with the head of the metacarpal bone. operation it is of great importance to avoid any injury to the web between the fingers. This is best accomplished by cutting upon the base of the phalanx as the knife passes towards the palm, and in such a way that the' centre of the lateral part of the oval may be slightly convex towards the tip of the finger. By doing so the head of the bone is better covered, and there is less cicatricial 202 Applied Anatomy . contraction of the hand afterwards. If it be intended to remove the head of the metacarpal hone, the incision of the dorsum must he commenced an inch ahove the head of that bonej in clearing the bone keep the edge of the knife close to it, and do not let the point plunge blindly into the palm, lest a digital artery be wounded at a point very difficult to secure and tie. Chief Structures divided — The skin, superficial fascia, digital vessels and nerves, the extensor tendon joined by the lumbrical and interossei muscles, the flexor tendons — sublimis and profundus— r-in their sheath. Fig. 38. Flap Amputation of Finger. Showing the shape of the wound in the amputation by lateral flaps, with the head of the metacarpal bone. 2nd Method— By Lateral Flaps (Fig. 38).— Two equal lateral flaps are formed from the tissues at the base of the phalanx, the convexity of the flaps being directed towards the tip of the finger. The special advantage of this form is that it provides a free exit for the discharges, but has the disadvantage that it cuts into the palm. The assistant separates the adjoining fingers as before and pulls Surgical, Medical, and Operative. 208 the integument on the hack of the hand well up, and then the operator, standing in front of the hand, seizes the finger between his own forefinger and thumb and enters the point of the bistoury immediately over the head of the metacarpal hone, and carries the incision, "laying on" the blade as he proceeds, in a convex sweep past the inter-digital web, and ends in the palm at a point just opposite the point at which he started. This forms one flap, and the other may be made in an exactly similar manner; or, after having made the first flap, he may at once open into the joint, pass the knife round the base of the bone and cut the other flap from within outwards. The ligaments and the tendons, etc., being divided, the finger is removed. 3rcl Method — By Single Palmar Flap (Professor Ghiene) — (see Fig. 35, C). — In addition to the simplicity of his method, we believe that it more nearly approaches the ideal of what amputation of a finger should be than any other. It fulfils admirably the three essential conditions, viz.- — (a) To keep up the full breadth of the hand ; (i) to avoid the remotest approach to a cicatrix in the palm; and (c) it also provides a good covering for the head of the metacarpal bone. Before, however, describing the operation, I propose to say a few words on the treatment of the heads of the metacarpal bones of the second and third fingers. It is usually admitted now-a-days that in those who labour with their hands ("ivorkmen") they had better be left; but then there comes the difficulty of finding sufficient tissue to cover the head and fill up the ugly gap, and even when the wound is healed (often after tedious granulation), the cicatricial contraction leads to great deformity and much crippling of the hand. It was from con- siderations such as these, we fancy, more than for any other reason, that in the past it has been so universally advised to remove the head of the metacarpal bone along with the finger. But what is the result? The arch is broken, its powerful connecting transverse ligament divided, the hand becomes squeezed up as if by an incubus it cannot shake off, its free motions are hampered, and its usefulness permanently damaged. It is said, however, that in those who do not labour with their hands ("gentlemen" ), the head of the bone should be removed, chiefly for the sake of appearance, in order to secure a taper and shapely hand. 204 Applied Anatomy : Fig. 39. Professor Chiene's Amputation. Showing the appearance and position of the Cicatrix, f From a cast kindly lent by ProfesBor Chieke.) Surgical, Medical, and Operative. 205 la Professor Chiene's method (see Fig. 35, C), the hand is held in the usual manner, and the point of a sharp bistoury is entered just over the metacarpo - phalangeal articulation, and carried for ahout half-way round the lateral aspects of the root of the finger to he removed. From this point two lateral incisions are made along the sides of the finger parallel with its dorsal surface, and these are next joined hy a gently curved transverse incision across the palmar aspect of the finger just through the crease between the first and second phalanges. This flap is then held aside by an assistant ; the tendons are cut off short near the base of the flap, and the finger is cleared from its further connections and removed. The flap is then turned up and fixed to the edge of the dorsal wound by a few points of suture. "When the wound heals it leaves a neat, horse-shoe-like cicatrix on the dorsal aspect of the hand, well away from the palm (Fig. 39). Fig. 40. Professor Chiene's Amputation. Sliowing the Finger after Removal. (From a cast kiiidly lent by Professor Chiekk.) THE INDEX AND LITTLE FINGER. In the case of the index finger (see Fig. 35, B), the oval incision, or the " racket-shaped " modification, is to be preferred. The straight part of the incision may be made either on the lateral or dorsal aspect of the hand ; in either case the incision is carried forwards to the head of the metacarpal bone, and then the oval made round the root of the finger. The lateral form gives a single lateral linear cicatrix well away from the palm, and also out of sight, and is probably the best form to use in the upper classes ; but in workmen the straight part of the incision should be on the 206 Applied Anatomy: dorsal aspect of the hand, and the side of the oval towards the free surface of the hand should be made larger than the other side, in order that the scar may be placed close to the neighbouring finger. This avoids any scar on the palm or side of the hand, points of great importance to workmen. The little finger is treated in exactly the same way, the straight part of the incision being placed on the ulnar side, or the dorsum. Mr Bell, however, in both cases, advises the use of the ordinary lateral flap method, the only difference being that he makes a specially large flap on the free surface of each finger to fold over the end of the bone. In this way there is no cicatrix on the lateral aspects of the hand. As regards the heads of the metacarpal bones of the index and little finger, the usual rule ,is to cut them off obliquely, either with the bonfe forceps or a small saw, in order to avoid the square, step -like knob which would otherwise remain, and would probably get more than its own share of knocks. But, again, it is advised by some authorities that in the case of a " workman " both should be left. The better plan is, undoubtedly, to remove part of the bone ; it is cut off obliquely in such a way that the whole transverse breadth of the head is not removed. By this means the ligamentous connection joining the metacarpal bones of the index and little fingers to the other meta- carpal bones is not divided. The Structures divided are almost the same as in the other fingers. In the index finger, in addition, would be divided the tendon of the extensor indicis, attached to the expansion over the first phalanx, with the dorsalis and radialis indicis arteries. In the little finger, in addition to the ordinary structures, the extensor minimi digiti would be divided. THE THUMB. No rules can be laid down for amputation of the thumb. In all cases as little should be removed and as much saved as possible, even to half a phalanx. Each of its different segments has a com- plete set of muscles to command it, and in this respect it differs from a finger ; so that whatever is left will ultimately prove useful. In cases where it is absolutely necessary to remove a considerable part of one or more of its bones, it should, if possible, be done subperiosteally, because anything which is under the patient's control and opposable to the other digits, is of the greatest possible Surgical, Medical, and Operative. 207 value. For the sake of practice on the dead body we will give a short account of what may be styled the classical methods of amputating the thumb and its metacarpal bone. 1. The Flap or V-shaped Method. — The most convenient position to hold the hand is one midway between pronation and supination, for then it may be pronated or supinated as required, the manipulations differing somewhat on the two sides; the fingers are to be held out of the way by the same assistant. The Surgeon may most conveniently, I think, stand in front of the hand. He grasps the tip of the thumb, keeping it extended and slightly adducted, and clearly fixes in his own mind the position of the carpo- metacarpal articulation. On the left side, — The knife is entered on the dorsal aspect of the thumb about half- an -inch above the base of the metacarpal bone and then carried obliquely over its ulnar side till it divides the structures forming the web between the index finger and thumb, the point of division being rather nearer the thumb than the index finger. The hand is then supinated, and the thumb bent inwards towards the centre of the palm to relax the muscles forming the ball of the thumb; and the knife, without ever having been withdrawn from the wound, is made to transfix the ball passing close in front of the metacarpal bone, and its point brought out at the first incision at the base of the bone. The thumb is then extended and abducted to render the muscles tense, and the edge of the knife turned towards the skin and a flap cut from the muscles forming the ball, the line of the incision being made to correspond to the dorsal incision, so that when the disarticulation is completed, an elliptical and shapely wound remains. The dorsal flap should now be dissected back a little, the Surgeon himself holding the flap and giving the thumb to the assistant in the meantime, or vice versa. The thumb is now to be over-extended and the joint between it and the trapezium opened, the remaining structures divided, and the digit removed. In making the palmar flap care must be taken not to lock the knife against the sesamoid bones; to avoid this, the direction of the blade must be altered slightly, by turning its edge a little towards the palm, tiU it has passed these bones. In the final stages of dis- articulation, the edge of the knife must be kept close to the bone to avoid injury to the radial, and the ladialis indicis arteries. 208 Applied Anatomy : The Right Thumb is amputated in exactly a similar way, only in this case the Surgeon first makes the palmar flap by transfixion, and then the dorsal one by applying the heel of the knife to the web, and cuts up to the end of the first incision, at the base of the metacarpal bone. He then completes the disarticulation as on the left side. 2. Oval Method — Eacket-shaped Incision (see Fig. 35, A). — This may be used either for the .removal of the thumb at the raetacarpo -phalangeal articulation or at the carpo- metacarpal. Begin the straight part of the incision at the base of the meta- carpal bone, and carry it along its dorsal aspect (as the hand is held between pronation and supination) to within half-an-inch of the head ; from this point an oval is carried round the root of the thumb. The two sides of the incision are then drawn apart by an assistant and the operation completed as in the former method. The Structures divided. — In all the operations, the skin, superficial and deep fascia, and superficial vessels and nerves. Muscles cut in amputation through the second phalanx of the thumb — (1) Flexor longus pollicis, and (2) extensor secundi inter- nodii pollicis. Through the first phalanx — (1) Abductor pollicis, (2) flexor brevis pollicis, (3) abductor pollicis, and (4) the extensor . primi internodii pollicis, with the previous list as well. Through the metacarpal bone — (1) The opponens pollicis, (2) the extensor ossis metacarpi pollicis, and (3) the first dorsal interosseous, with the previous two lists as well. So that in amputation through the terminal phalanx, two muscles are divided; through the' first phalanx, six muscles j and through the metacarpal bone, nine muscles. In amputation through the metacarpal bone the Arteries cut are — (1) The princeps pollicis, and (2) the dorsales pollicis. The Arteries to he avoided in the same operation are — (1) The radial artery, and (2) the radialis indicis. Little need be said in regard to amputation of the metacarpal bones of the fingers. Should they require removal for injury no rules can be given. For disease any one may be dissected out by a single dorsal incision. Eemoval of both metacarpal bone and finger may be most conveniently performed by the "racket-shaped" incision — a straight dorsal incision, and then encircling the root Surgical, Medical, and Operative. 2O0 of the finger by an oval incision. It is advisable, wbere pos- sible, not to remove the base of the metacarpal bone, as in this way we avoid opening up the carpal articulations. In removal of the index finger with its metacarpal bone the following Structures are divided — skin, superficial fascia, etc.; and the following Muscles — (1) Flexor carpi radialis; (2) extensor carpi radialis brevior; (3) flexor brevis pollicis; (4) 1st palmar interos- seous; (5) 1st dorsal interosseous; (6) 2nd dorsal interosseous; (7) flexor sublimis digitorum; (8) extensor communis digitorum, with its lumbrical muscle; (9) extensor indicis. Arteries divided — (1) Dorsalis indicis; (2) metacarpal (first dorsal interosseous); (3) radialis indicis; and (4) part, at least, of first digital from the superficial arch, and probably its conamunication with the corresponding interosseous from the deep arch. 210 Applied Anatomy : CHAPTER XIV. AMPUTATIONS OF THE UPPER EXTREMITY (Continued). The Wrist. — The chief object in amputating at the -wrist, in preference to higher up the arm, is not so much for the long stump thus left, as to preserve the movements of pronation and supination unimpared. To insure this it is necessary that the inferior radio- ulnar articulation should be healthy; hence, it is no use performing ' this amputation in cases of disease of the wrist joint, for then the radio -ulnar articulation is almost sure to be implicated, and a better stump will be secured by amputating through the lower third of the fore-arm. It is specially suitable in cases of injury. In all the different methods the arm should be emptied of blood by elevation, and the brachial artery secured by an elastic tour- niquet or some other means. The Supgeon should stand in front of the patient, or on the tight side, while the assistant stands facing the Surgeon and supporting the fore-arm at a convenient height. The instruments required are, a strong-bladed and sharp-pointed knife, artery forceps and ligatures, bone pliers, and a small saw. 1. Teaie's Method ( Redangiilar Flaps). — A long posterior flap, composed of sJcin and subcutaneous fatty tissue only, is raised from the back of the hand, its length and breadth being each equal to the circumference of the arm at the wrist joint; the anterior flap is to be one-fourth the length of the posterior, and, like it, to consist only of the integumentary structures. Both flaps are to be carefully raised, doing as little damage as possible to the small subcutaneous vessels. Next, the extensor tendons are divided at the base of the posterior flap, and the joint opened ; in openiDg Surgical, Medical, and Operative. 211 tlie joiat, remember its peculiar shape: — convex, with the convexity upwards. Disarticulation being completedj both flaps are retracted, and the flexor muscles divided evenly at the base of the flaps. During healing, the elbow joint is flexed at a right angle and the fore-arm pronated, as the wound drains best in this position. 2. Long Anterior and Short Posterior Flaps. — The assistant holds the fore-arm pronated and pulls back the skin as tightly as possible. The operator grasps the hand, and, flexing the wrist, makes a semi-lunar incision on the dorsal aspect, from one styloid process to the other, and raises a flap of skin fascia and subcutaneous fat only (Bell) — the flap is to include the tendons of the back of the hand (Heath). In any case a flap is raised and retracted a little above the styloid processes, the extensor tendons rendered tense, and the joint opened. The ■palmar flap may be made by dissection from the outside, before disarticulation, or dissected off the metacarpal bones from above downwards after disarticulation, having previously outlined its edges by a deep incision on each side of the metacarpus. This flap is then retracted, like the posterior, and the flexor tendons rendered tense and divided. It is almost impossible to make the anterior flap by transfixion on account of the transverse metacarpal arch, and the prominence formed by the pisiform bone and the hook of the unciform. The vessels requiring ligature are — (1) The radial artery cut close to the radius; (2) the ulnar artery in the palmar flap ; (3) sometimes the terminal twigs of the interosseous arteries. The styloid processes are to be cut off with the bone forceps, or the saw if preferred. 3. The IVIodifled Circular IWethod. — The arm is held as in the previous operation (i.e., pronated), the skin at the same time being well retracted, and then two semi-lunar incisions, beginning two inches helow the styloid processes, are made through the skin, fat, and fascia only, and two short, equal, antero-posterior semi-lunar flaps raised. The flaps are next retracted a little above the level of the styloid processes, and the muscles divided by a circular sweep of the knife at that level, the assistant in the meantime keeping the different groups of muscles tense as the knife. passes — e.g., the anterior group by over- extension (dorsifiexion), the posterior group by extreme flexion.' The late Mr Spbncb preferred this plan to all others, as, he said, by the ordinary 'flap juethod the 212 Applied Anatomy: styloid processes tended to project at the angles of tlie incision, whereas by this plan the hones are well covered with sound skin. During healing, the fore-arm is to be kept between pronation and supination. 4. By Long Palmar Flap. — An assistant holds the arm supinated, and a large square flap, with the angles rounded off, is formed from the pahn by dissection. The base of the flap should correspond to the free edges of the styloid processes, in order to give a good broad flap; and it should extend fully half- way down the palm, the full width being kept up throughout. It is composed of skin, fat, and fascia, and must be carefully dissected from the palm, avoiding the prominences caused by the ridge of the trapezium and the hook of the unciform; but while .avoiding these it is even of more importance to avoid button- holing the flap. Join the tvvo ends of the anterior incision by a slightly curved incision across the dorsum through all the tissues down to the bones. After this, flex the wrist joint forcibly; open it, and detach the hand by dividing the flexor tendons by a single sweep of the knife. The Palmar Flap contains^-The skin, superficial fascia, fat, and palmar fascia, with the cutaneous vessels and nerves, median and ulnar nerves, superficial palmar arch, and portions of the short muscles of the thumb and little finger. During healing the arm is to be supinated and laid on an elevated pOIow, as in this position the wound drains best, and there is less tendency to displacement of the long palmar flap. But if more convenient the fore-arm may be kept midway between pronation and supination. 5. Circular {'^Mple incision"). — An assistant holds the fore- arm and hand pronated, and pulls up the integuments as tightly as possible. The Surgeon stands behind the arm (on the left side), grasps the fingers with his left hand, and makes a circular incision through the skin and subcutaneous fatty tissue, as close to the thenar and hypothenar eminences as possible. The tube of skin is then to be retracted by a few touches of the knife, to the level of the joint, and another circular incision made through the deep fascia and tendons at that level. The joint is then to be opened, the hand removed, and the operation finished by sawing off the styloid processes, or snipping them off with the bone forceps. Surgical, Medical, and Operative. 213 6. Sometimes it may be necessary to make use of a Single Long Dorsal Flap, should the parts in front be hopelessly damaged, or a lateral skin flap, as in Dubrueil's method. In amputation through the wrist joint, the following are the chief Structures divided: — 1. Integumentary structures. 2. Muscles — (a) Those towards the anterior aspect — tendons of the flexor carpi radialis, palmaris longus, flexor sublimis and profundus digitorum, flexor longus poUicis, flexor carpi ulnaris ; (b) those on the posterior or lateral aspect — supinator longus, extensor ossis metacarpi poUicis, extensor primi internodii poUicis, extensores carpi radialis longior and brevior, extensor secundi internodii pollicis, extensor com- munis digitorum, extensor minimi digiti, extensor indicis, and extensor carpi ulnaris. 3. Vessels — (a) Eadial vessels, with the superficialis volse branch; (b) ulnar vessels. 4. Nerves — (a) Ulnar, (l>) radial, and (c) median. 5. Ligaments of the wrist joint. LOWER THIRD OF THE FORE-ARM. In amputating in this situation the objects are — (1) To secure a long stump, and (2) to save the insertion of the pronator radii teres, and thus give the patient more power over any artificial substitute. The assistant had better stand in front of the limb, grasping the hand, and hold it either pronated or midway between pronation and supination, as most convenient for the operator The patient is brought to the edge of the table, the arm held at right angles to the trunk, and the elbow joint extended. The instruments necessary are — A short amputating knife, artery forceps and ligatures, a saw, bone pliers, scissors, and dissecting forceps. 1. Equal Antero-posterior Flaps. — The Surgeon should stand on the patient's right side of the limb to be removed, i.e., on the outer side of the right limb, but on the inner side of the left. The dorsal flap should be made first by dissection. The fore-arm being pronated, or else held with its dorsal surface towards the operator, he enters the knife a little to the palmar side of the ulna (supposing he is amputating the left arm; on the right arm he would begin by entering the knife a little to the palmar side of the radius) and marks out a broad dorsal flap, almost square, with the angles rounded off, consisting only of the integumentary 214 Applied Anatomy : structures, the rest of the structures heing divided close to the retracted skin. As this flap is heing made, the wrist and fingers should he well flexed, and the elhow joint hent. The Surgeon then passes the knife in front of the hones a little below the base of this incision, and cuts an equal palmar flap from within outwards. In forming the anterior flap the forearm should be supinated, the fingers straightened, and the wrist dorsiflexed, and, the operator must take care not to pass the knife between the two bones. Each flap should be equal in length to the antefo-posterior diameter of the limb at the point of section of the bones, say from two to two and a half inches. The dorsal flap may be raised before or after transfixionj the Surgeon taking hold of it with his left hand and freeing it with a few touches of the knife. Both flaps are then retracted by an assistant, and the bones cleared and divided about an inch higher up. The bones are cleared by a double sweep of the knife round both bones, in the first instance round the under segment and then round the upper, and after this in a figure-of-eight-like way between the two bones, and in doing this it is importg,nt not to allow the edge of the knife to be at all directed up the arm, lest the interosseous arteries (especially the anterior) be divided too high up, or split, and retract beyond reach. To avoid this, the rule is always to keep the edge of the knife turned towards the part to be removed. As in all operations of this kind, the large nerve trunks should be shdrtened with the scissors, to prevent their being included in the cicatrix, causing a "painful stump." Mr Spencb was in the habit of making the posterior flap a little longer than the anterior, so that it folded over the end of the bone; in this way the cicatrix is not opposite the end of the stump, and the wound drains better. As the bones are nearly of equal size at the point of section, the usual practice is to divide them together. Vessels requiring ligature are — (1) The radial artery, (2) ulnar artery, (3) anterior interosseous, and (4) posterior interosseous. The radial and ulnar are found in the free end of the palmar flap. The objection to forming the anterior flap by transfixion is that the mass of muscles and tendons protrude beyond the skin; and more especially if the amputation is perfonned for injury, for then the loosened and injured tendons yield and are pulled out by the knife and leave Surgical, Medical, and Operative. 215 a very ragged and unmanageable surface. Hence, a better result is secured wlien both, are made by dissection, and, as already explained (see page 189), it is better to make the posterior flap about twice the length of the anterior, and to take up a little of the muscular tissue towards its base if deemed necessary: in this way the long flap is made to fold over the ends of the bones, the cicatrix is placed well to the front and less likely to be injured; and further, it drains better, as the limb is to be pronated during the healing process. 2. By the Modified Circular Method. — The different steps of this operation resemble very closely the previous one. The arm is held with the hand pronated, and two equal antero-posterior semi- lunar flaps, consisting of skin and subcutaneous fatty tissue only, are made. The dorsal one is first raised with the same precautions as in the last operation to secure a good, broad base to the flap. A similar flap is next raised from the front ; this flap is marked out while the hand is held pronated, by drawing the knife under the limb ; the hand is tiext supinated, and the flap dissected up. Both flaps are then retracted and the muscles divided by a circular sweep of the knife ; the bones are then cleared and divided about three-quarters of an inch higher up. 3. By Teale's Method. — Take the circumference of the limb at the point of section of the bones and mark out the two flaps according to the rules already laid down (see page 185). Outline the sides of the long dorsal flap by incisions through the integument only, but at its apex carry the knife at once to the bones ; this flap must consist of all the structures down to the bones and interos- seous membrane. So, likewise, for the short anterior flap. During healing the fore-arm is pronated to keep the long anterior flap more easily in position, and at the same time provide a free exit for the discharges. This method has no special advantage in the arm, because there is no pressure on the end of the stump, as in the lower extremity, and has the disadvantage that the bone must be divided higher up than in equal antero-posterior flaps. Tbalb's amputation in this situation can readily be done by transfixion, instead of the usual plan. Mr C. Heath suggests a modification of this method. In this plan the posterior flap consists only of the integumentary structures 216 Applied A natorny : until the level of the upper border of the posterior annular ligament is reached, when the knife is carried through everything to the hones. This is to avoid the difficulty experienced in dissecting the tendons from their grooves on the back of the radius and ulna, without damaging them. In Mr Heath's plan there is also less difference between the length of the two ilaps — his anterior being one-third the length of the dorsal, instead of one-fourth, as in Mr Tealb's method. L As in other situations, the Circular "Triple Incision" may be used. The arm is held at right angles to the trunk, midway between pronation and supination, by an assistant, who also forcibly pulls up the integuments. The operator may conveniently stand behind the arm on the right side, and between the arm and the trunk on the left side ; by so doing he is better able to retract the integumentary sheath, as he then can take hold of it with his left hand. UPPER TWO THIRDS OF THE FORE-ARM. Amputation may be performed in this situation by — 1. Equal Antero-'posterior Flaps, made by Transfixion, or, better, the dorsal one made by dissection and the anterior by transfixion. 2. Long Posterior Flap, chiefly composed of integumentary structures with a little muscular tissue taken up at its base, and an Anterior Flap of half the length. 3. The Modified Circular method. In making the anterior flap by transfixion, the knife should be brought out rather sharply at the end, in order to keep up the full breadth of the flap, and cut the vessels and nerves transversely. It will thus be square-shaped rather than semi-lunar, and should be about three inches long. If the posterior flap is formed by transfixion, the arm is held between pronation and supination, the soft parts at the sides of the fore-arm are grasped, and as much of them as possible drawn towards the posterior aspect of the limb, so as to secure as broad a flap as possible. For the anterior flap, supinate the fore-arm and enter the knife half-an-inch lower down than the previous transfixion point, to avoid cross-cutting the base of the dorsal flap. The bones are then cleared an inch above the point of transfixion, £|,nd divided, Surgical, Medical, and Operative. 217 The Structures divided in amputations through the fore-arm will vary slightly at the different levels.. For instance, at the upper part the pronator radii teres and supinator brevis will he divided, while at the lower part they would not be included ; and, near the wrist, the pronator quadratus and the extensor indicis would be cut, but not higher up. To save unnecessary repetition, the following may be taken as a fairly complete general list : — 1. Integumentary structures. 2. Muscles — (a) The pronator teres and flexor carpi radialis, (&) palmaris longus, (c) flexor sublimis digitorum, {d) flexor Fig. 41. Section through Fore-arm. Radial Vessels and Nervo. Anterior Interosseous Vessels and Nerve. : Median Nerve. .Ulnar Vessels and Nerve. Posterior Interosseous Vessels and Nerve. The names of the Miiades are indicated hy their initial letters. carpi ulnaris, (e) flexor profundus digitorum, (/) flexor longus pollicis, {g) supinator radii longus, {U) supinator brevis, {i) exten- sores carpi radialis, longior et brevior, (/) extensor communis digitorum, (k) extensor minimi digiti, {I) extensor carpi ulnaris, {m) extensor ossis metacarpi pollicis, and (n) extensor secundi inter- nodii pollicis. 3. Vessels — (a) The radial (in the outer side of the anterior flap, and quite superficial) ; (l) ulnar (in the inner side of the anterior flap, and much deeper); (c) anterior interosseous, 218 Applied Anatomy : and (c^) posterior interosseous. 4. Nerves — correspond to and accompany the arteries — (a) The radial, (&) ulnar, (c) anterior interosseous, (c?) posterior interosseous, and (e) median. 5. Eadius and ulna and interosseous membrane (Fig. 41). AMPUTATION THROUGH THE ELBOW JOINT, 1. This is usually accomplished by cutting a long flap from the anterior aspect of the upper third of the fore-arm and a small one posteriorly. It is seldom performed, because it is rarely possible to get sufficient sound texture to cover the large condyloid end of the humerus ; the flaps, further, require to be specially long, because the articular surface of the humerus projects so far beyond the muscular attachments. The upper arm is to be well abducted and held by an assistant^ the elbow joint flexed almost to a right angle ; and at the same time the skin is to be well drawn up, especially, when making the posterior incision. The Surgeon stands on the right side of the arm on both sides of the body, if he make the flaps by dissection-^which is the better method — but if he is to transfix then he stands within the arm, when amputating on the right side; but on the outside when amputating the left arm. The line of articulation of the elbow joint is oblique from without downwards and inwards, and, therefore, the knife must not be passed straight across the arm, or else the operator will find that the tissues will not cover up the internal condyle. The tissues being held well forward by the left hand, the operator then trans- fixes the limb in a line, extending from a little below the level of the external condyle of the humerus to a point at least an inch below that level on the inner side of the arm. On the left arm the point of the knife is entered at the outer end of this line, but in the right arm it is entered at its inner end. A broad flap, three or four inches in length, is then made, the knife being brought out sharply at the finish, to cut the vessels and nerves transversely, and give the end of the flap a somewhat square form. The flap is held up by an assistant, the fore-arm flexed, and the skin behind drawn tightly up, and the points of transfixion connected behind by a semi-lunar incision through the integumentary structures, so as to form a short flap, and probably also at the same time severing the connections of the radius. The iilna is then set free by division of Surgical, Medical, and Operative. 219 its ligaments and the triceps muscle. The amputation is a good one in suitable cases, both because of the long stump thus secured, and the bulbous end for the attachment of an artificial substitute. 2. The Circular Method may also be used, but it is not so good as the flap. The fore-arm being held supinated, a circular incision is made through the superficial structures, about two inches below the internal condyle. The sheath of skin and fat and fascia is then retracted to the level of the articulation, the joint opened, the remaining structures divided, and the limb removed. Mr Bryant considers amputation at the elbow an excellent operation, and performs it by anterior and posterior skin flaps, with circular division of the muscles {i.e., the "modified circular"), the posterior flap being the larger, so that, the scar may be out of harm's way. The bases of the flaps correspond to the lower extremities of the condyloid ridges. In this amputation the following are the chief Structures divided — 1. Integumentary structures. 2. Muscles — (a) Biceps, (6) brachialis anticus, (c) pronator radii teres and flexors of the wrist and fingers, including the following muscles — flexor carpi radialis, palmaris longus, flexor sublimis digitorum, flexor carpi iilnaris, flexor profundus digitorum, and flexor longus poUicis ; (d) triceps and anconeus, (e) supinator longus, (/) supinator brevis, and (gr) the following extensors of the wrist and fingers — extensores carpi radialis longior and brevior, extensor communis digitorum, extensor minimi digiti, and extensor carpi ulnaris. 3. Vessels — (a) Eadial artery, (6) ulnar artery, (c) the common interosseous or its branches, (d') posterior ulnar recurrent, (e) the corresponding veins, and also the superficial veins of the fore-arm. 4. Nerves — (a) Median, (6) ulnar, (c) radial, and (tZ) anterior and posterior interosseous nerves. 5. Ligaments of the joint. AMPUTATION THROUGH THE UPPER ARM. This is said to be the simplest of all amputations, and may be effected with almost equal success by various methods — as the old circular, modified circular, or by antero-posterior or lateral flaps. 1. Equal Antero-Posterior Flaps by Transfixion. — By the use of equal flaps the bone can be divided at the lowest possible point, and the presence of a cicatrix at the end of the stump is not of so 220 Applied Anatomy : much consequence in the arm : and by making the flaps antero- posterior, associated groups of muscles are kept in separate flaps. The usual instruments are required, viz,: — An amputating knife, a saw, artery forceps, ligatures, and bone forceps. An assistant holds the arm at right angles to the trunk and rotated well out- wards. The brachial artery may be secured by the fingers of another assistant or by an elastic tourniquet ; or, if the amputation is high up, the axillary may be compressed against the neck of the scapula by the fingers of an assistant, or by an elastic band ; or, lastly, the subclavian may be compressed against the first rib by the thumbs, or a padded key. The brachial artery and the large nerves may be left in the flap the operator deems most convenient, usually the anterior, or at the inner angle of the two flaps; the only point is to take care not to transfix them, and to sever the vessel transversely at last. The Surgeon is to stand within the arm in amputating on the left side, but on the outer side for the right arm. He next grasps the anterior muscles with his left hand, and holds them well forward, and then enters the knife with its point directed a little upwards (*.e., the point will be on a higher plane than the handle, which is to be slightly depressed), so as to secure a broad- based flap, passes it as closely in front of the bone as possible, and then, by slightly raising the handle, makes the point emerge at a spot exactly opposite to that at which it entered. The knife is then carried downwards longitudinally for some distance by a slight sawing movement, so as to form a well-rounded ;ftap from two and a half to three inches in length — the skin being cut, if possible, longer than the muscles; for this purpose the knife must be gradually turned towards the surface, but should be brought out sharply at last, so as to cut the vessels, nerves, and skin transversely. An assistant now lightly supports the flap, not retracting it at all, and the knife is then entered half-an-inch below the former point of transfixion, to avoid cross-cutting with the heel, and carried behind the bone and made to emerge on the other side at the same incision, and a posterior flap cut of the same length and shape as the anterior. The assistant now retracts both flaps forcibly, and the bone is raised almost perpendicularly and cleared by circular sweeps of the knife for about an inch and a half above the angles of the incision ; and, finally, the periosteum is divided by a sweep of the Surgical, Medical, and Operative. 221 knife, first round the under segment of the bone and then round the upper, and the saw applied. In clearing the bone, be careful to cut the musculo - spiral nerve cleanly, as it lies in its groove on the posterior surface of the humerus; after the periosteum is divided be careful not to pull back the flaps, lest the periosteum be stripped off the bone. The large nerve trunks should be shortened with the scissors, and the artery, if cut obliquely, may be recut transversely. The vessels requiring ligature are — 1. The brachial artery, accompanied by the median nerve. 2. The inferior profunda accompanying the ulnar nerve. 3. The superior profunda accom- panying the musculo - spiral nerve. Some operators make the anterior flap longer than the posterior. This, no doubt, has several advantages, but they are purchased at the expense of a shorter stump, and, therefore, it should not be performed. It is probably better to raise the anterior flap by dissection, excluding the brachial artery, and then make the posterior by transfixion, at the same time supporting the posterior mass of muscles lightly with the left hand. 2. Circular Method. — This may be used in most cases, and is a very suitable method for the lower third of the upper arm, as the bone is so equally covered by muscles on all sides. The arm is held at right angles to the trunk, as usual, and the skin should be well drawn up during the first incision. This may either be entrusted to an assistant, while the operator stands so that he can hold the part to be removed, or the operator himself may so stand that his left hand grasps the arm above the incision and draws up the skin at the same time. The operator now places his right foot well forward, bends both knees, and places his hand and wrist, with the knife, well round the arm, and then traverses the whole circumference of the arm at one sweep, the assistant who has charge of the arm rotating it, so as to meet the heel of the knife. The tube of skin, fat, and fascia is then retracted by the assistant, aided by a few touches of the knife, though the subcutaneous tissue is so loose in this situation that it may be retracted sufficiently by the hand alone. The muscles and fascia are then divided by another circular sweep of the knife at the level of the retracted skin, the knife being held obliquely so as to cut the muscles in the form of a hollow cone, and the bone cleared and sawn at a still higher 222 Applied Anatomy : level j it is better to divide the biceps first and allow it to retract, and then cut the brachialis anticus by another sweep, as it does not retract so much. In order to retract the tissues more .easily and protect them from the saw, a two-tailed calico retractor may be used. As explained elsewhere, the circular method is not to be recommended when amputating through cone-shaped limbs. In this case a far better method is — 3. The Modified Circular. — This has already been fully described elsewhere (see page 185). In making the skin flaps, the best rule is to cut just according to your cloth — anywhere and anyway, pro- vided it gives you. sufficient healthy tissue to cover the end of the bone. This plan should always be adopted in large muscular arms. 4. Teale's IWetilod. — This may be used in certain very excep- tional eases. The long flap must be cut from the outer side of the arm, the short one from the inner side, and, as usual, containing the : large vessels and nerves. Mr Spbnce used this form of amputation in cases of disease where the muscles of the arm were much atrophied, or the tissues condensed by inflammatory exudation. 5. By Equal Lateral Flaps. — The late Professor Spbnce strongly advocfited this method when amputating at or near the middle of the arm, on account of the attachment of the deltoid muscle. "When external and internal flaps are used, the external one folds over the end of the humerus, when it is raised by the deltoid muscle; but if the flaps are antero-posterior in this situation, when the deltoid raises the arm, the bone is liable to be projected at the external angle of the incision. Observe, in passing, that it is just the reverse in the thigh ; there the flaps should be antero-posterior, not lateral, else the bone projects at the anterior angle of the incisions. In a general way the Structures divided in amputations through the upper arm are — 1. Integumentary coverings. 2. Muscles — (a) Biceps, (Z;) brachialis anticus, (o) triceps, and, above the middle of the humerus, the deltoid and coraco-brachialis. 3. Vessels — (a) Brachial vessels, (&) superior profunda vessels, (c) basilic vein, (d') cephalic vein, and (e) inferior profunda vessels. 4. Nerves — (a) Musculo-cutaneous (between the biceps and the brachialis anticus); (6) median (in close relatioa to and towards the inner side of the brachial vessels); (c) ulnar (accompanying the inferior profunda vessels); {d') musculo-spiral (accompanying the superior Surgical, Medical, and Operative. 223 profunda vessels); and (e) internal cutaneous close to the basilic vein. About the middle of the arm the brachial vessels are found on the inn&r side of the humerus; the inferior profunda vessels are found close to the brachial vessels, but a little further back; while the superior profunda vessels are found towards the posterior and outer aspect of the humerus (Figs. 42, 43). Fig. 42. Section of Fore-arm. (A short way above the middle of the Fore-arm.) Fig. 43. Section of Fore-arm. (A shoTt distance above the Elbow Joint.) e— External Intermuscular Septum. i — Internal Intei-muscular Septum. (From Cunningham.) AMPUTATION AT THE SHOULDER JOINT. This maybe rendered necessary by — (1) Disease of the joint and simple tumours; (2) malignant tumours; and (3) injury. In cases where the Surgeon can choose his flaps, the best method to adopt is either that used by Baron Laiirey, and associated with his name, or Mr Spence's method. Mr Spence's amputation is of especial value ia cases where there is some doiibt as to what is the best course to pursue — whether to excise or amputate. An incision is made as in the operation of excision, the joint examined, and, if found too much disorganised to save, then it is a simple matter to transform it into his amputation. Of course, in the case of both malignant disease and injury, it is impossible to choose the flaps. 224 Applied Anatomy: In injury, we must take them as best -we can from the healthy or least injured tissues, and in malignant disease the usual practice is to form two sldn flaps from the most healthy-looking parts, taking care not to leave any muscular tissue in them. As in amputation at the hip joint, haemorrhage is one of the most serious dangers, and, therefore, the principal methods of amputation aim at making the soft parts in the axilla, surrounding the axillary vessels, the last part to be cut through, the artery being previously grasped by the fingers of an assistant. If deemed necessary, the methods described in the operation of excision of - the shoulder joint, for the control of htemorrhage, may also be adopted here. 1. Lateral Flaps of Nearly Equal Size (the, " OmV method).— This was the method preferred by Larrey. It resembles almost exactly the amputation of a finger by the "oval" method, as described in a previous chapter. The two sides are cut slightly • convex, so that, when the operation is finished, the result is two almost precisely similar semi -lunar flaps meeting above at the acromion process, and below at the posterior fold of the axilla — as the tissues on the inner side surrounding the vessels are so cut as to form part of the anterior flap. When the flaps are brought together a straight linear wound is the result. In this amputation two special assistants are required — one, standing above the shoulder, compresses the subclavian artery with his thumbs or a padded key, and -holds himself in readiness to follow the knife behind the humerus and grasp the artery in the tissues at the inner side before they are divided. The second assistant places the patient in a proper position, by bringing him well to the edge of the table, so that the part to be removed projects over its edge; he also turns him partially over on the sound side, and supports him in that position by pillows. This assistant then holds the arm for the operator, who is to take his stand on the outer aspect of the limb. The arm being held in a position of abduction, the operator thrusts the point of a strong broad bistoury through all the tissues down to the bone, immediately below the acromion process, and makes a straight incision about two inches in length, cutting on the outer aspect of the head and upper part of the neck of the humerus. From the end of this incision he carries other incisions in a curved direction on each side to the corresponding fold of the Surgical, Medical, and Operative. i^o axilla. The two semi-lunar flaps thus marked out are next dissected up and held aside so as to expose the joint completely. These flaps shoidd, as far as possible, he separated from the bone by the fingers alone, so as not to injure the vessels on their deep surface. The only vessel of any size divided at this stage of the operation is the posterior circumflex, and this should at once be secured by a pair of Wells's forceps. The assistant now adducts the arm in order to project and render tense the structures about the tuberosities, rotating inwards and outwards, as may be required, while the operator divides the muscles attached to the tuberosities. The operator then opens the joint, dividing the capsular ligament by cutting on the anatomical neck of the humerus by a semi-circular or horse-shoe-shaped sweep of the knife, as if he intended to cut off the head of the bone at the anatomical neck. The assistant again abducts the arm, and pulls the head of the bone outwards from the glenoid cavity; the knife is then passed round behind it, dividing the remaining part of the capsule, the arm again adducted, and the knife carried down the inner side of the humerus close to the bone, followed by the thumbs of an assistant, who secures the axillary vessels before the tissues are divided. The edge of the knife is now turned towards the surface, and the remaining tissues, between the end of the first and second incision, divided obliquely downwards and inwards, so as to form part of the anterior flap. The vessels requiring ligature are — (1) The axillary artery; (2) probably the axillary vein; and (3) branches of the circumflex vessels. The principal advantages of this method are — (1) The wound drains well; (2) its cut surface is as small as^is consistent with efficient flap covering; and (3) there is less risk of haemorrhage, during the operation, than in some of the other methods. RESUME of the "Oval" method:— 1. Arm held abducted. Make a short vertical incision on the outer aspect of the shoulder, beginning at the acromion. 2. Carry incisions from the end of this short cut to the anterior and posterior folds of the axilla respectively. 3. Keflcct these flaps as far as possible. 226 Applied Anatomy: •1. iissistant then rotates the humerus outwards and adducts the arm, while the operator divides the subscapularis tendon and other structures attached to the front of, the capsule. 5. Assistant then rotates inwards, and the operator divides the structures attached to the posterior part of the capsule. 6. With the arm still adduoted divide the inner and lower part of the capsule, pass the knife to the inner side of the humerus, abduct the arm, and cut downwards, uniting the two former incisions, the vessels being previously compressed by an assistant. 2. By Large External Flap (Spbncb). — Haemorrhage being provided against in the usual manner, an assistant slightly abducts the arm and rotates the humerus outwards. The Surgeon then cuts down upon the inner aspect of the head of the humerus, with Fig. 44. Spenoe's Amputation. Clavicle -^-xrx Coracoid Process- ___Acromion Process. Humerus. a broad strong bistoury, immediately external to the coracoid pro- cess, and carries the incision down through the clavicular fibres of the deltoid and pectoralis major muscles as far as the insertion of the latter muscle, which is to bo divided ; this first cut will Surgical, Medical, and Operative. 227 divide the anterior circumflex artery, whicli must be secured at once. The incision is then carried, with a gentle curve, across and deeply through the lower fibres of the deltoid as far as the posterior fold of the axilla (Fig. 44). The course of the inner incision is next outlined from the end of the straight incision to the termination of the curved incision at the posterior border of the axilla, but must extend flirough skin and fat only. The deltoid muscle is next separated from the hone by the fingers alone, so as not to injure the trunk of the circumflex artery which enters its deep surface, and, having done so, the head and upper part of the humerus is fully exposed. The muscles about the head and capsular ligament are next divided by cutting directly down on the anatomical neck of the humerus, the assistant in the meantime rotating the bone so as to bring the various muscles within reach of the knife. The large external flap is then kept out of the way by the fingers of an assistant, or a broad copper spatula, the knife is passed behind the bone, disarticulation completed, and the arm removed by dividing the remaining soft tissues on the axillary aspect, the axillary artery and vein being previously grasped by an assistant; this prevents immediate danger from haemorrhage, and also avoids the risk of the entrance of air into the vein. In very muscular limbs the skin and subcutaneous tissues should be dissected up for a little way and then the muscles divided at a higher level. The advantages of this method are — (1) The fulness and better form of stump left after healing. (2) The posterior circumflex artery is not divided except in its small terminal twigs in front ; whereas, both in amputation by the large deltoid flap and the double flap methods, the trunk of the artery is divided in the early stages of the opera- tion often giving rise to considerable haemorrhage. In the case of the single deltoid flap, the division of this vessel endangers its vitality, as the flap depends chiefly on it for its nourishment. (3) The great ease with which disarticulation can be accomplished, and especially the division of the tendon of the subscapularis muscle. (4) As already mentioned, it is further of great value in cases of doubt as to whether the joint should be excised or amputated. The first part of the incision is made use of to examine the joint, and then the Surgeon acts according to the condition in which he finds it. 228 Applied Anatomy: BESUME. — The steps of Mr Spbncb's operation are :^- 1. "With the arm abducted and rotated outwards, make a part of the vertical incision, and examine the joint if necessary. 2. Prolong the incision down through the insertion of the pectoralis major, and then curve it across through the lower fibres of the deltoid, towards but not through the posterior border of the axilla. 3. Outline the inner part of the section through skin and fat only. 4. Separate and raise the large deltoid flap with the fingers alone, to avoid injury to the large posterior circumflex artery. 5. The assistant now adducts and rotates, while the Surgeon divides the capsular • muscles and the capsule, by cutting on the anatomical neck of the humerus, usually dividing the broad subscapular tendon first. 6. Pass the knife beneath the bone, and keep its edge close to it, divide the rest of the capsule, abduct the arm, and divide the remaining soft parts on the axillary aspect, the vessels being previously grasped by an assistant. 7. Secure the vessels. 3. Doubfe Flap by Transfixion. — Both flaps may be made by cutting from within outwards, and are nearly of equal size and gently rounded. Three special assistants are required — one to take charge of the limb ; a second to raise the deltoid flap ; and a third to compress the subclavian artery against the first rib, and be prepared to follow the knife behind the humerus and grasp the inner flap, with the vessels, tefore its division. Should the opera- tion be performed on the right side, the operator stands before his patient ; if on the left side, he stands behind. The patient is brought close to the edge of the table, turned somewhat on the opposite side, and supported in that position by pillows. The assistant then abducts the arm, to relax the deltoid muscle, and may at the same time also rotate the humerus a little inwards. The line of transfixion is from a point an inch in front of the acromion process, or midway between the tip of Ihe acromion and Surgical, Medical, and Operative. 229 coracoid processes, to another point ■within the posterior horder of the axilla, well behind the root of the acromion and ahout an inch below the spine of the acapnia. On the right side the operator enters the knife midway between the acromion and coracoid processes, passes it in front of the capsule of the joint, and makes it emerge at the posterior border of the axilla ; on the left side he must enter the knife at the posterior border of the axilla, carry it across the front of the joint, and bring it out between the acromion and coracoid processes. In either case before entering the knife it is well to make a small incision about an inch in extent at the point where the knife is to be entered, to avoid cross-cutting the tissues with its heel. Supposing the right arm is to be removed, and the patient is placed and the limb held as above indicated, the Surgeon enters the point of a long narrow-bladed transfixion knife midway between the acromion and the coracoid processes, passes it close in front of the capsule of the joint, and brings it out within the posterior fold of the axilla, and cuts a large flap, three or four inches in length, and consisting chiefly of the deltoid muscle ; the flap is then to be raised by an assistant standing above the shoulder. The assistant who has charge of the arm then draws it downwards and forwards across the chest, while the Surgeon with the heel of the knife divides the capsular muscles' and capsule, close to and against the anatomical neck of the humerus, the assistant mean- while rotating the bone so as to bring the various muscles within reach of the knife. The head of the bone being turned out of the glenoid cavity, the knife is carried round it and down the inner side of the shaft, for about three inches, with its edge kept close to the bone all the time, and is closely followed by the fingers of another assistant^ who grasps the inner flap with the large vessels ; when the artery is surely grasped, but not before, the operator cuts obliquely downwards and inwards, forming the internal flap. "While this flap is being made the arm is slightly raised and abducted. The objections to this method are — (1) To perform the operation .satisfactorily we require the leverage of the humerus, but this is often smashed in cases requiring amputation. (2) It is often impossible to find suflicient healthy tissue to form the large external flap. (3) In cases requiring amputation for malignant disease transfixion is out of the question. 230 Applied Anatomy: Double Flap by Dissection. — In cases where tlie tissues are thin, it will be necessary, and, indeed, in nearly all cases it is advisable, to form the deltoid flap by dissection ; the line of the incision will correspond to that already given, extending from the posterior part of the axilla to an inch in front of the acromion process, so as to give a broad -based flap. In operating on the right side, the Surgeon, provided with a broad bistoury, stands behind the patient. The assistant holds the arm well abducted, and the Surgeon commences his incision an inch in front of the acromion process and carries it downwards to the level of the insertion of the deltoid muscle, and then upwards and inwards to a point well behind the acromion, and about an inch below the spine of the scapula, near the posterior fold of the axilla. The flap thus marked out, and which should include the whole deltoid, is then raised, the arm adducted, the joint opened, and the knife passed along the inner side of the bone, the arm again abducted, and the inner flap cut in the iisual way with a long narrow-bladed trans- fixion knife. Should he be amputatiiig the left arm he must reverse the proceedings. He stands in front of the patient and commences the incision near the posterior part of the axilla, and ends an inch in front of the acromion process ; otherwise the operation is the same as on the right side. In both cases the axUlary vessels must be secured before division, either by an assistant, or the Surgeon himself can secure them between the finger and thumb of his left hand. r r RESUME. — The steps of this operation then are : — 1 . For the right arm, stand behind ; but for the left, stand in front of patient. 2. With the arm abducted, shape and raise the deltoid flap. .3. With the arm adducted, disarticulate by cutting on the anatomical neck of humerus, while the assistant rotates the bone to bring the various tendons within reach of the knife. 4. Pass the knife beneath the head of the bone, again abduct the arm and cut an internal flap three or four inches long, securing the vessels before they are divided. .5. Tie the vessels. Surgical, Medical, and Operative. 231 4. By Deltoid Flap.— A large flap consisting nearly of the whole of the deltoid, is raised either by transfixion or dissection, and the different manipulations are nearly the same as in making the external flap in the previous method. The base of the flap ■will extend from the coracoid process to a little behind the most prominent point, or angle, of the acromion process. Should it be made by transfixion, the arm is to be held iu the abducted position in the first instance, to allow the operator to grasp and cut the flap more easily. The flap is raised, and the assistant pushes the arm forcibly across the chest, to make the capsule tense, and rotates the humerus, while the Surgeon severs the capsule and capsular muscles. The head being turned out of the glenoid cavity, the knife is passed round it and the structures in axilla divided, so as to form a short stump of tissues to meet the long deltoid flap which is laid over it. As in the other methods, an assistant grasps the axillary vessels on the inner side, before the tissues are divided. The objections to this plan are — (1) The large surface of the wound. (2) The double line of cicatrix. (3) In many cases it would be impossible to get sufficient healthy tissue to form the large deltoid flap. The principles adopted in amputation through the hip joint might also be applied to the shoulder joint, especially in cases where the Surgeon is short-handed, so far as assistants are con- cerned. It would leave a longer stump than the other methods, and, were it done subperiosteally, a certain amount of power would be retained to control an artificial limb. The principles are — (1) Amputation through the soft parts circularly low downj (2) ligature all the blood-vessels; and (3) dissect out the bone through an incision where it is least thickly covered, and where the blood-vessels are .small and few : in the shoulder the incision should, therefore, be along the anterior aspect of the joint and upper part of the shaft of the humerus. The chief Structures divided. — 1. Integumentary structures. 2. Muscles — (fl) Deltoid, and the muscles in connection with the capsule of the joint, viz. — (J) supra -spinatus, (c) infra-spinatus, (rf) teres minor, (e) subscapularis, (/) long head of triceps. Muscles not attached to the capsule, (17) pectoralis major, (7i) latissimus dorsi, (i) teres major, (./) coraco-brachialis, and (/c) biceps (both heads). 232 Applied Anatomy: The large vessels and nerves will be fouBcl in the inner flap, and consist of the axillary vessels and the cords of the brachial plexus; in addition to these the cephalic vein and the anterior and posterior circumflex arteries are divided at some stage of the operation, as well as the humeral branch of the acromio-thoracic. The capsular and coraco-humeral ligaments and the costo-coracoid membrane are ' also cut through. Amputation of the Scapula and Arm. — In amputations higher than the shoulder joint, as for large tumours of the scapula, e.g., enchondroma, sarcoma, etc., the chief points to be attended to are — (1) To divide the clavicle, (2) to divide the muscles attached to the coracoid process (biceps, coraco - brachialis, and pectoralis minor), and then (3) to tie the subclavian, and afterwards proceed to free the scapula, securing the supra-scapular, posterior scapular, and subscapular arteries as soon as possible. The wounded surface is very large, and it is important, therefore, to observe strict anti- septic precautions. The flaps are dorsal and pectoral, semi-lunar in shape, with the convexity directed forwards. The posterior begins over the superior border of the scapula, passes down over the acromion process to the lower border of the axilla, and then back to the inferior angle of the scapula ; the anterior is begun over the clavicle, an inch internal to the coracoid process and carried down over the front of the axilla to its lower border, passing slightly towards the sternum, so as to render its anterior margin somewhat convex. For the chief Structures divided in this operation, see "Excision of the Scapula;" only in amputation of the whole upper extremity the muscles and ligaments connecting the scapula and humerus directly are not divided, while the sub- clavian (or upper part of the axillary), the posterior scapular, and the supra-scapular .vessels are divided, as well as the chief branches of the axillary, especially the subscapular and the long thoracic ; the pectoralis major is also divided. RESUME of amputations of the Upper Extremity: — In finishing the section on amputations of the upper extremity, I would add a few words, to guide the student through the mazes of the very bewildering array of " methods " and " modifications of methods " , adopted by various Surgeons, Surgical,. Medical, and Operative. 233 The following are the methods I would advise on the living body : — THE HAND. 1. A Terminal Phalanx. — A long anterior flap, or antero- posterior semi-lunar flaps. 2. The Second Phalanges. r— As the terminal ; save as much of it as possible, and do not remove the entire finger, at the carpo- metacarpal articulation, except in cases of extensive disorganisation from whitlow. 3. A Whole Finger. — For the second and third fingers, Professor Chiene's method, leaving the heads of the metacarpal bones. For the index and little fingers, the " oval " method, the straight part of the incision being made in the dorsal aspect of the hand, the inner part of the oval being longer than the outer, and cut off the projecting cwner of the metacarpal bones obliquely, but not including the entire breadth of the head. 4. The Thumb. — Adopt the method by wliich you can save most, be it regular or irregular. THE ARM. As a general rule, anywhere between the hand and the shoulder, the modified circular, i.e., two equal semi-lunar skin flaps, with circular division of the muscles, may be adopted with advantage ; the skin flaps may be taken from any side, and need not neces- sarily be equal in length, as this would often necessitate a higher amputation than really necessary, especially in cases of smash. Cut the flaps so that their combined length will give sufficient covering, and so as to leave the longest possible stump, the position of the scar being of less importance in the upper extremity, provided it is mobile. 1. The Wrist. — The modified circular as performed by the late Professor Spenob, or by the long palmar flap, so as to take a covering from the hard tissue of the heel of the hand. 2. Lower Third of Fore-arm — Modified circular, or pure circular, 234 Applied Anatomy: 3. Upper two Thirds. — The modified, circular, or equal antero- posterior flaps, made by dissection ; the method of making the anterior hy transfixion is of doubtful advantage, and certainly should never be practised in cases of amputation from injury. 4. The Elbow Joint. — By a very long anterior flap with a short posterior, or else the modified circular. 5. Just above the Elbow. — The old circular, or equal antero- posterior flaps. 6. Lower part of Humerus. — Equal antero-posterior flaps by dissection; the method of making the posterior by transfixion is of doubtful advantage, but may be practised on the dead body. 7. Just below the Deltoid Insertion. — Equal lateral flaps by dissection ; higher than this use equal antero-posterior flaps by dissection. 8. The Shoulder Joint. — ilr Spencb's or the " oval " method (Lareey's). In cases of doubt between excision and amputation, always use Mr Spencb's method (see "Excision of Shoulder"). The double flap, by dissection, is also a very good method. Surgical, Medical, and Operative. 235 CHAPTER XV. AMPUTATIONS OF THE LOWER EXTREMITY. The Foot. — Just as in the palm of the hand, it is of primary im- portance to avoid all approach to a cicatrix on the sole. Therefore, whatever amputations are performed, the flaps must always be taken from the plantar surface. Another point of importance is to leave the heads of the metatarsal bones. The foot is a tripod, resting on tlie heel, the ball of the great toe, and the ball of the little toe, and only in cases of absolute necessity should this tripod be mterfored with in any way; for whether the two anterior rests are narrowed, as in removal of the central metatarsals, or any one of the three removed, the foot is rendered unstable. By a properly shaped boot and well padded stocking any inconvenience likely to result from the prominent heads of the first and fifth metatarsals is easily prevented. In amputations of the toes and metatarsal bones the best knife to use is a stout, straight, broad bistoury. The Toes. — Partial amputation of the toes is but rarely per- formed, and only in the case of the great toe. In cases where any of the other toes are in a condition necessitating amputation, it is always better to remove them at the metatarso-phalangeal articu- lation at once ; because, if any portion be left, it is apt to be tilted up.wards and is positively in the way. Even amputation of the distal phalanx of the great toe is less frequently performed now than formerly. Formerly it was the custom to amputate this phalanx for exostosis — a form of bony growth frequently situated on the dorsal aspect of the distal phalanx of the great toe, giving rise to much pain and discomfort from pressing up the nail. At the present time, however, the treatment adopted is to snip off the exostosis, being especially careful to destroy or remove all the cartilage-covered area, and leave the toe alone. Should it, however, 236 Applied Anatomy: be necessary from other causes, such as injury, necrosis, onychia maligna, etc., to remove the terminal phalanx, this is best accom- plished in a manner precisely similar to the analogous operations on the fingers — by the formation of a flap from the plantar surface, the neighbouring toes being pulled to one side and flexed by an assistant by means of strips of narrow bandage. THE GREAT TOE. Amputation of the Great Toe at the Metatarso-Phajangeal Articulation. — This may be rendered necessary by injury or joint disease, as suppurating bunion or perforating ulcer, and is best performed by the "oval" or "racket-shaped" forms of incision. It should be borne in mind that the metatarso-phalangeal ^articula- tions of all the toes are situated at least three-quarters of an inch above the web. On account of the large size of the head of the metatarsal bone of the great toe the operator must take care to leave plenty of flap to cover it well. An assistant should hold the foot extended (toes pointed) in the first instance, with the sole resting against, and the toes projecting over, the end of the table ; the neighbouring toes are to be held aside and flexed, as already indicated, by narrow bits of bandage. The operator then enters the point of a stout bistoury over the middle line of the toe, half-an-inch above the joint, and carries it along the dorsum almost to the middle of the proximal phalaitx, opposite which point the "oval" part of the incision is carried round the toe. In doing so, the manipulations of the Surgeon and his assistant resemble those in the "oval" amputation' of a finger at the corresponding joint. By commencing the "oval" at the point indicated we do not injure the web, and provide ample covering for the large head of the metatarsal bone, and there is thus less likelihood of the wound having to heal by tedious granulation and cicatricial contraction. The tissues over the end of the phalanx and joint are then to be cleared by passing the bistoury round with a short sawing movement, holding it parallel with the phalanx and well under control, and on no account to thrust its point too deeply in the sole, lest the trunk of the anteria magna hallucis be injured, or the tissues unnecessarily punctured. After this the toe is to be forcibly Surgical, Medical, and Operative. 237 over-extended, the strong flexor tendons cut, and the joint opened from helow ; the toe is then to be twisted round as the knife divides the lateral ligaments and completes the disarticulation. "The key to easy disarticulation of the toe is complete division of the strong flexor tendons, and to effect this at once I extend the toe forcibly upwards as soon as the incisions in the soft parts are completed ; and this enables me to twist the toe so as easily to open the joint and divide the lateral ligaments" (Spencb). The head of the metatarsal bone should be left, if possible, untouched. By making the straight part of the incision on the dorsum of the foot we avoid any scar on the lateral aspect, which might prove inconvenient, being irritated and pressed upon by the boot ; it is a good plan to make the inner side of the oval larger than the outer, so as to fold over the face of the metatarsal bone. The sesamoid bones may or may not be removed. Should the operator decide to leave them, it may be more convenient to open the joint from above, and divide the flexor tendons afterwards. In the case of the other toes exactly the same principles must be followed, and it is unnecessary, therefore, to go over them in detail. In all cases the oval method is to be preferred. Of course, as in the fingers, it can be done by two small lateral semi-lunar flaps, but this has the disadvantage of opening into the sole. Again, if preferred, in the case of the great and httle toes (just as in the case of the index and little fingers), a specially large flap may be taken from the free side of each to fold over the end of the bones. Amputation of the Great Toe with its Metatarsal Bone.— This should be done by the " racket-shaped " incision. The foot is held as before, and the operator commences the incision on the dorsum, about half-an-inch behind the tarso-metatarsal articulation and carries it along the dorsal aspect to near the metacarpo- phalangeal articulation, from which point the oval is made round the toe. The integuments are then to be separated from the bone on the inner side by applying the knife nearly parallel with the toes, and using it with a short sawing movement, its edge being kept close to the bone and well under control. 238 Applied Anatomy: especially near the tarso-metatarsal articulation j but lower down it need not be kept so close, as it is better to remove most of the short muscles of the toe and the sesamoid bones (Heath). The bone is then freed behind by dividing the lateral ligaments on the inner side of the tarso-metatarsal joint, and next by inserting the point of the knife perpendicularly, with its edge directed upwards and backwards, to divide the strong inter- osseous ligament; and after this the metatarsal bone and toe are drawn forcibly inwards, the anterior end freed completely, -and the toe removed. Or the anterior end of the toe may be cleared fu'st, and then its tarso-metatarsal end, by first dividing the strong interosseous ligament between the heads of the first and second metatarsal bones and the anterior extremity of the toe, and the metatarsal bone cleared completely by sweeping the knife under the bone from without inwards. The toe is then forcibly drawn away from the others, and the poiat of the knife passed between the metatarsal bones, with its edge directed upwards (i.e., towards the anterior aspect of the leg), and the ligaments of the tarso-metatarsal articulation divided close to the metatarsal bone of the great toe, against which the edge of the knife is to be directed, lest the communicating branch of the dorsalis pedis artery, as it passes down to complete the plantar arch, be injured. In cases of 'partial excision of the metatarsal bone and toe the communicating branch from the dorsalis pedis is apt to be wounded, and .gives rise then to very serious and troublesome haemorrhage, _ as it is exceedingly diificult to secure the vessel. In such circumstances Mr Spbnce advises complete removal of the bone, when there will be no difficulty in seeing and tying the artery. The straight part of the " racket-shaped " incision may be made on the lateral aspect of the foot, the disadvantage being that the scar is apt to be irritated by the pressure of the boot. The method of removing the great toe and metatarsal bone as above described, by the " oval " method, is not so rapid perhaps as the method of lateral flap by transfixion, but has the immense advan- tage of avoiding any scar in the sole. In the flap method, the Surgeon seizes the soft tissues on the inner side of the foot with his left hand and pulls them well inwards, and transfixes opposite Surgical, Medical, and Operative. 239 the tarso-metatarsal articulation, and cuts a flap from tlio inner side as far as the middle of the first phalanx, keeping as close to the bone as possible. The assistant then pulls the soft tissues as far outwards as possible, so as to bring the incision over the space between the first and second metatarsal bones, and the Surgeon passes his knife between the bones through his former incision, cuts forwards right through the web, and then opens the tarso- metatarsal articulation as in the oval method, and completes the disarticulation. A similar flap may also be raised by dissection. As in the hand, it may be desirable not to open up the tarso- metatarsal articulations, but in the case of the great toe this is not of so much importance, as it has a synovial membrane all to itself ; and, besides, it is usually in cases of partial ampiitation of this bone that trouble is apt to arise on account of wound of the communicating branch of the dorsalis pedis artery. In partial amputations the bone should be divided obliquely, to avoid any unseemly and troublesome projection. A probable advantage is the preservation of the insertion of the peroneus longus and tibialis anticus muscles. Amputation of the Little Toe with its iVIetatarsal Bone.— This may be done by precisely the same methods — 1. The " racket-shaped " incision, with the straight part of the incision on the dorsum of the foot — the best method. 2, The same incision, with the straight part along the side of the foot — objection, the lateral scar. 3. External flap, either by trans- fixion or dissection — very bad on account of the scar on the sole. The first form is the best, and is conducted on the same lines as the corresponding operation on the big toe. Partial Amputation of the metacarpal bone of the little toe has fewer objections, and has more to recommend it, than the corresponding operation on the great toe — 1. It has not a special synovial membrane to itself, but one common to it and the fourth metatarsal bone. 2. There is no special artery in danger of being wounded. 3. It preserves the insertion of the peroneus brevis and tertius tendons. Be careful, as usual, to divide the bone obliquely. The chief Structures divided in the foregoing amputations :— In all the operations — The skin, superficial fascia, plantar fascia, 240 Applied Anatomy: digital vessels and nerves, and ligaments of the joints. The following muscles are divided in amputation of the Great Toe : — At second phalanx, two muscles — (1) Extensor proprius hallucis, and (2) flexor longus hallucis. At first phalanx, the above two muscles and in addition other five — (1) Abductor hallucis, (2) flexor brevis hallucis, (3) adductor hallucis, (4) transversus pedis, and (5) extensor brevis digitorum. At tarso-metatarsal articulation, the above seven muscles and other three — (1) The tibialis anticus, (2) peroneus longus, and (3) the first dorsal interosseous. So in amputation through the second phalanx, two muscles are divided; through the first phalanx, seven muscles; and both phalanges with the metatarsal, ten muscles. The Arteries divided are — (1) Dorsalis hallucis, and (2) the trunk or branches of the arteria magna hallucis. The Arteries to be avoided are — (1) The branch of the dorsalis pedis, and (2) the plantar communicating arch. In amputation of the Little Toe with its metatarsal bone, the following fourteen muscles are divided : — Into the metatarsal bone, six muscles — (1) The peroneus brevis, (2) peroneus tertius, (3) flexor brevis minimi digiti, (4) transversus pedis, (5) fourth dorsal interosseous, and (6) third plantar interosseous.* Into the first phalanx, four muscles — (1) The abductor minimi digiti, (2) flexor brevis minimi digiti, (3) third plantar interosseous, and (4) fourth lumbricalis. Into the second phalanx, two muscles — (1) The extensor longus digitorum, and (2) flexor brevis digitorum. Into the third phalanx, tioo muscles — (1) The extensor longus digitorum, and (2) the flexor longus digitorum. TARSO-METATARSAL ARTICULATION. Amputation of the Foot at the Tarso-Metatarsal Articulation (see Fig. 40). — This is commonly called " Hey's amputation." Disarticulation of the metatarsus is performed as far as the internal cuneiform bone, and then the projecting part of that bone sawn off (H) — but not with a " Hby's^" saw, as the facetious examiner sometimes leads the unsuspecting candidate to believe and state. The disarticulation requires to be accomplished with care, as the end of the second metatarsal bone, in its articulation with the middle cuneiform, projects backwards between the external and internal cuneiforms. Lispeanc's modification of this operation Surgical, Medical, and Operative. 241 consists in the complete disarticulation of the tarsal bones, leaving the projecting part of the internal cuneiform. The reason for this modification is the supposed advantage gained by leaving the whole of the internal cuneiform bone, to which the tendons of both the tibialis anticus and the tibialis posticus are partially attached. But even in Het's operation the attachments of these muscles are Fig. 45. Tarsus and Metatarsus. 1. Astragalus. 2. Os Galois. 3. Cuboid. 4. Scaphoid. 5. External Cuneiform. 6. Middle Cuneiform. 7. Internal Cuneiform. C. Line of Chopaet's Amputa- tion. L. Line of Lisfeanc's Amputa- tion. S. Part of the Second Metatarsal removed by Skby. H. Part of the Internal Cunei- form removed by Hey. Note. — The sigmoid curve formed by the line of Chopart's amputation ; also the mortise formed by the three cuneiform bones, into which the base of the second metatarsal juts. not destroyed ; for, although anatomists figure certain points on tc/nss as the attachments of the muscles in question, yet it is found practically that they have extensive attachments to the deep ligamentous structures in their neighbourhood ; so that this disadvantage, as urged against Hey's operation, is more imaginary than real. Another, objection urged against Hey's amputation is that a cancellous bone is divided, and that there is therefore a Q 242. Applied Anatd-ttiy : greater risk of septic absorption and osteo-myelitis. Hey's ampu- tation, however, is more easily performed and leaves a better stump than LisFEANo's. Mr Skby removes the end of the second meta- tarsal bone, but does not interfere with the internal cuneiform. The amputation may be performed in one of three ways : — In the first, the dorsal flap is made first, the bones disarticulated, and the plantar flap cut afterwards. In the second, the plantajr flap is cut first, then the dorsal, and after this disarticulation performed. In the third, the dorsal flap is first -made, as in the first method, the plantar flap is then shaped and dissected up as in the second method, and lastly the bones are disarticulated. In the first plan the leg is placed with the foot downwards, the ankle joint fully extended, and the assistant keeps the heel firmly fixed upon the table with the part of the foot to be removed overhanging its edge, and at the same time pulls the skin tightly upwards. The operator then grasps the toes firmly, keeping the ankle joint well extended, and when the dorsal flap is outlined by the first incision, the assistant retracts it while the Surgeon frees it by a few touches of the knife; he then disarticulates, and finally forms the plantar flap. In the second form the assistant grasps the toes, and holds the foot at right angles to the leg with the heel firmly pressed against the table, while the operator dissects up the plantar flap ; the dorsal flap is next made as in first plan, the assistant holding the foot as there described, and the operator grasping the toes and extending the ankle joint. In the third plan, the foot is held as in the first stage of the first method (well extended, and the Surgeon grasping the toes); it is next held as in the first stage of the second method (at right angles, and the toes grasped by an assistant), and then disarticulation performed in a manner common to all the three. A strong, sharp, stout-backed, sharp-pointed, and not too broad-bladed bistoury is the best knife to use ; the blade should be about four inches long, but the point must not be too spear-like lest it break off in opening the joints. The gu ides for this operation are ( Fig. 46) : — The projection formed by the fifth metatarsal bone on the outer side, and the tarso-metatarsal articulation of the great toe on the inner side, a groove corresponding to which may be felt by firm pressure, or, if this is indistinct, a point may be taken one inch in front of the tubercle of the scaphoid, which will indicate the articulatidii Surgical, Medical, and Operative. 243 nearly enough for all practical purposes. It is often a little difficult to find the tubercle of the scaphoid with certainty. First of all find the internal malleolus, then pass forwards and slightly down- wards and the next prominence met with is the head of the astragalus, about one inch from the malleolus ; then, still passing in the same direction, comes the tubercle of the scaphoid, about one inch further forward, lastly, and about another inch in front of this, is the articulation of the first metatarsal bone with the internal cuneiform. The beginner is apt to mistake the head of the astragalus for the tubercle of the scaphoid. Fig. 46. Incisions for Hey's Amputation. In amputating by the first method the Surgeon seizes the toes with his left hand, extends the ankle joint well, and places his forefinger and thumb on the points marking the Hne of the articulations — one well behind the projection of the fifth meta- tarsal bone, and the other over the metatarsal bone of the great toe. He then makes a semi-lunar incision, down to the bones, beginning and ending half-an-inch in front of the bony guides, forming a short semi-lunar flap, " down nearly to the heads of the metatarsal bones" (Heath). The incision should commence and end fairly in the sole. The assistant then seizes the end of the flap to retract it, while the Surgeon by a few sweeps of the knife dissects it up, taking care to keep the edge of the knife towards the bones. The articulations are then to be opened (see Fig. 45) : 244 Applied Anatomy: on the right side they are to be opened from the fifth inwards till the knife is arrested by the second metatarsal bone; the knife is then taken out and the articulation between the first metatarsal bone and the internal cuneiform opened; in opening the joints the operator should work only with the point of the knife, and confine himself to the division of ligaments. The Surgeon inserts the point of the knife obliquely between the bones, with Fig. 47. LisFRANo's Amputation. To show the method of freeing the second metatarsal hone from the mortise formed hy the cuneiform bones. its edge uppermost, and gradually raises it to the perpendicular (Fig. 47), and then presses firmly backwards between the bases of the first and second inetatarsal bones and moves it gently back- wards and forwards until he feels the strong interosseous ligament snap. The same may be done if necessary to the other side, and also between its base and the middle cuneiform, the toes at the same time being firmly depressed, and then, by giving a smart wrench the disarticulation is completed. He then places his left Surgical, Medical, and Operative. 245 thumb over the end of the disarticulated bones and dissects oft' a flap, consisting of the whole thickness of the tissues of the sole, and carries the dissection as far as the roots of the toes. Prom the layer of tissues thus dissected up, the operator shapes a neatly- rounded flap, longer on the inner than on the outer side, by transfixing the centre and cutting towards each side, and so sloping the knife that the integumentary structures are cut longer than the muscles. r r BESUME of LisFRANc's method : — 1. Poot extended, and the bony guides felt by index finger and thumb. 2. Outline the dorsal flap, beginning and ending half-an- inch in front of the bony guides; and divide the tendons by a second cut near the base of the skin flap, so that they may not project beyond the skin. 3. Make the plantar flap by carrying two lateral incisions along the sides of the foot, and join by a curved incision in front across the sole, but obliquely, so that the flap is longer on the inner side. 4. Assistant then holds foot at right angles while this flap is being raised. 5. Then disarticulate, remembering the mortise into which the second metatarsal juts. Instead of this method, the whole operation may be done as described in the resume, of Chopart. On the living body, Mr Spencb always performed Hey's method, as it was easier and left a better stump. By the second method the plantar flap is cut first. A straight incision is carried from the two bony guides along each side of the foot, reaching nearly to the roots of the toes and the inner one longer than the outer; the two lines are then united in front by a gently curved incision, thus marking out a flap with well rounded angles. The flap is then raised, and at first should consist only of integumentary and fascial structures, but after the first inch, may include everything down to the bones. A dorsal flap is next to be made as in the previous method, the joints opened, and the bones disarticulated. 246 Applied Anatomy: The third plan (see resume) is probably the best. The dorsal flap is formed as in iha first method; next the plantar is shaped and dissected up, as at the beginning of the second method ; and finally the bones are disarticulated. The vessels requiring ligature are — (1) The dorsalis pedis at the apex of the dorsal flap, (2) internal plantar, (3) external plantar, and (4) numerous branches of the plantar arch and dorsal plexus of veins. By making the short dorsal flap the cicatrix is placed rather on the front of the stump, and is thus opposed to the soft padding; whereas, were it on the dorsum, it might be injured by the pressure of the boot. The objections to the tarso-metatarsal amputation (Hey, or LiSFEANc), as thus described, are — 1. If practised in a diseased foot, probably the other bones and joints will also be diseased and lead to a return of the mischief. 2. If for accident, it is far too elaborate and complicated, and more especially as the anterior parts of the foot are smashed, and therefore we have no advantage of leverage to assist in disarticulation ; a simpler and better way being simply to dissect back a sufficient sole flap, and then saw the bones across at any convenient point, irrespective of articulations. This plan has further a special advantage, as it may leave the front of the foot a little longer, which will thus form a more effective lever to oppose the tendo achillis. MEDIAN TARSAL ARTICULATION. Chopart's Amputation (Fig. 45 C). — This operation consists in the amputation of the foot at its transverse articulation — i.e., the articulations between the astragalus and the scaphoid on the inner side, the cuboid and the os calcis on the outer side ; in other words, the removal of that part of the foot that lies in front of the OS calcis and astragalus. The shape of the articulation is alternately concave and convex — on the inner side it is convex forwards (due to the rounded head of the astragalus), but concave forwards on the outer side. The manipulations of the Surgeon, the duties of the assistant, and the three methods of raising the flaps, resemble very closely the corresponding stages of the pre- vious operation, so that they need not be repeated in detail. Surgical, Medicali and Operative. 247 The guides for this operation are the tubercle of the scaphoid on the inner side, and a point one inch behind the projecting base of the fifth metatarsal bone on the outer side; or, in fat ankles, a point midway between the projecting base of the fifth metatarsal bone and the front of the external malleolus (Fig. 48). The knife used by Chopaet was about six inches long, haLf-an-inch broad, sharp-pointed, and stout-backed. Suppose the operation is to be performed by the third method, the Surgeon places his thumb and forefinger on the two bony points already indicated, and fully extends the ankle joint, and then makes a semi-lunar. incision down to the bone, marking out a fiap about an inch and a half Fig. 48. Incisions for Chopart's Amputation. in length, commencing and ending well in the sole, and half-an- inch in front of the bony guides. The assistant retracts this fiap as the Surgeon frees it by a few touches of the knife. This being done, the assistant next seizes the toes and holds the foot at right angles to the leg and pressed firmly against the table, while the operator forms the plantar fiap by cutting along the sides of the foot as far as the " tread," and joining the two side incisions by a gently curved one in front, but taking care that it leaves the flap much longer on the inner than the outer side, as the inner edge of the foot is much deeper; the fiap should be somewhat square- shaped, with well rounded angles. When the fiap is fully dissected down, the foot is again extended, the bones disarticulated, and the 248 Applied Anatomy : operation completed by sawing off the projecting head of the astragalus and the articular surface of the os calcis. The objections to this operation are — 1. If done for disease, it leaves two bones of all others the most likely to be diseased. 2. If for injury, it is better to dissect up a sufificient flap from the sole and saw the bones at the most convenient point, irrespective of articulations. 3. The muscles forming the tendo achillis have nothing to counteract them and therefore draw up the heel, and the patient soon begins to walk on the front part of his stump, i.e., on the cicatrix, more especially in cases of amputation for disease. For this reason it is advisable, in cases where this amputation is performed, to divide the tendo achillis subcutane- ously at the same time, in order to equalise matters. The tendency to tilting, however, may be obviated, to a great extent, by stitching the extensor and flexor tendons together over the face of the stump. Symb's amputation at the ankle joint is to be preferred to either Hey or Chopart in the case of disease of the bones, and for Chopart in almost every condition. RESUME of Chopart's amputation : — 1. Foot extended and bony guides felt by thumb and index finger. 2. Outline dorsal fiap, beginning and ending a little in front of bony guides. 3. Eetract skin flap and then divide everything dowii to bones at base of flap. 4. Bend foot forcibly downwards and disarticulate. 5. Then peel off all the structures forming the sole, keeping the knife close to the bones, as far as the balls of the toes. 6. The flap is then fashioned and dressed, being cut longer on the inner side. Lateral incisions might be first made, as in Lisfrano, and the whole operation com- pleted as there described (see resume of Lisfrano). In every case it is probably better to shape and raise the plantar flap by dissection, before disarticulation, both in Hey and Ci-iopaet. Surgical, Medical, and Operative. 249 Chief Structures divided in ttie two preceding Opera- tions. — 1. The integumentary coverings and the plantar fascia. 2. Muscles — (a) Tibialis anticus and extensor brevis digitorum; (&) the extensor communis digitorum and the peroneus tertius; (c) the extensor proprius haUucis ; (rf) the peroneus longus and brevis; (e) the tibialis posticus; (/) the first layer of muscles of the sole of the foot (the flexor brevis digitorum, abductor haUucis, and abductor minimi digiti); (r/) the second layer of muscles (the tendons of the flexor longus digitorum and flexor longus hallucis, accessorius and lumbricales) ; (/i) the most of the muscles of the third layer (flexor brevis hallucis, adductor hallucis, flexor brevis minimi digiti, and transversus pedis). 3. Vessels — (a) The internal plantar artery ; (?;) the external plantar artery, with the plantar arch and its digital branches; (c) the dorsal artery of the foot, with its tarsal and metatarsal branches. 4. Nerves — (a) Anterior tibial or its branches ; (&) the plantar nerves; (c) digital branches of the musculo-cutaneous or peroneal nerve; (d) the digital branch of the external saphenous nerve. 5. The Ligaments of the various joints opened into ; and, further, we may specially mention the long and the short plantar ligaments and the inferior calcaneo-scaphoid. The structures divided in Hey's operation are almost the same as the above, with the following exceptions : — The tibialis anticus and posticus and the flexor accessorius are not divided, and part of the internal cuneiform bone is removed. In Lisfranc's operation this bone is not divided. THE ANKLE JOINT. 1. Syme's iVIethod. — As in all amputations of the foot, the tibial arteries are to be secured by the thumb and fingers of an Fig. 49. Knife for Syme's Amputation at the Ankle Joint. assistant — the thumb being pressed over the anterior tibial at a point midway between the two malleoli, the fingers over the 250 Applied Anatomy: posterior tibial about half-an-inch behind the internal malleolus — or else by an elastic tourniquet applied above the ankle joint, or at the lower third of the thigh. An assistant grasps the toes and holds the foot at right angles to the leg with the heel projecting over the edge of the table, or over a block, while the operator is making the heel flap. The only instruments required are an ordinary saw, Fig. 50. Outer Side of Right Ankle. T. Tibia. S. Line of Symb's Amputation.. F. Fibula. P. Line of Pieogofp's Amputation. Note the relation of the incisions to the external malleolus. probably a lion forceps, artery forceps, ligatures and scissors, and a knife; the blade of the knife should not exceed four inches in length, and it should have a strong back as weU as a large and strong handle (Fig. 49). The guides for this operation are — the external malleolus on the outer side, a point rather nearer its posterior than anterior edge, and a point exactly (ypposite this on the inner side, i. e., a point about half-an-inch,, behind Surgical, Medical, and Operative. 251 aud below the internal malleolus, as the external malleolus is longer than the internal and also posterior to it (Figs. 50, 51, S). Position of the Patient.— la this, as in aU amputations of the leg and thigh, he should be brought well down towards the lower end of the operating table, his sound leg being tied to one of the Fig. 51. Inner Side of Right Ankle. A. Posterior Tibial Artery. S. Liue of Stme's Amputation. T. Tibia. P. Line of Pibogoff's Amputation. Note the relation of the aDgle, formed by the two paits of Syme's incision, to the internal malleolus — below and behind ; also that the posterior tibial artery is divided in this angle, just after its division into the two plantar arteries. legs of the table. The foot being held as directed, the Su Pgeon takes his place facing the foot, and grasps the heel with the palm of his left hand, and places his thumb and forefinger on the two points already named, and then carries an incision from the one to the other across the sole, inclining slightly backwards, cutting down to the plantar fascia and bone at once — the point of bone cut. down 252 Applied Anatomy : upon should be the large internal tubercle of the os calcisj the heel flap should contain no muscular tissue. Should the flap extend in front of the tubercles, great difiiculty will be experienced in dissecting it back over the os calcis. In raising the heel flap the operator places the fingers of his left hand behind the os calcis (or rather below, as the foot is now held) and inserts the point of his thumb between the edges of the plantar incision. In the dissection he must keep the edge of the knife close to and parallel with the bone, guiding it with his thumb nail till the os calcis is fairly turned and the insertion of the tendo achillis comes into view. The nail not only guides the knife, but pushes the flap downwards, and also prevents the edge " scoring the flap." The operator then grasps the front part of the foot with his left hand, fully extends the ankle joint, and unites the two ends of his first incision by another across the front of the ankle " forming an angle of 45° to the sole of the foot and long axis of the leg " (Symb), in other words, he cuts as straight as possible across the front of the ankle, dividing all the tendons, vessels, and nerves. Mr Heath directs it to be made at right angles to the first. Mr Symb, , we believe, made this incision immediately after he made the plantar one, and therefore before the heel flap was dissected back, and this is the method still followed in the Edinburgh School. The anterior flap is then to be seized by the assistant and drawn slightly upwards, while the operator frees it a little if necessary. The ankle joint is then opened from the. front, and the lateral ligaments on each side divided by the point of the knife being carried outwards and downwards on each side between the malleoli and the astragalus; the joint is best opened by a horse-shoe shaped incision with the convexity upwards, and not in the direction of the primary incision, as this avoids locking the knife against, and sawing on the neck of the astragalus. In disarticulating, the operator must be careful not to injure the posterior tibial artery, as it lies in a groove on the posterior surface of the astragalus. The foot can now be dislocated forwards, and is pressed downwards, while the tissues behind the os calcis are divided with the edge of the knife kept close to the bone, and the removal of the foot completed by the division of the tendo achillis. It should be stated that some Surgeons form the heel flap from above, after making the anterior Surgical, Medical, and Operative. 263 cut, as they say it avoids the tedious dissection of the heel flap round the projecting os calcis, as in the other method. The knife is then to be carried round the tibia and fibula to prepare them for the saw, while the assistant retracts the flap ; the external malleolus is next to be grasped with lion forceps, and then both malleoli are sawn off, including a thin slice of the intervening part of the tibia — just enough to include all the cartUage-covered surface. The saw must be kept parallel with the lower end of the tibia, that is to say, at right angles to the axis of the limb, the blade neither being allowed to cut obliquely in the antero-posterior direction, nor yet from side to side. Both in clearing the bone and in sawing it, the operator must again be careful of the posterior tibial artery, and also the vessels that lie behind the two malleoli — the con- tinuation of the peroneal behind the external malleolus, and a branch of the posterior tibial behind the internal. In dissecting the heel flap by keeping the knife close to the bone we avoid making button holes, and also "scoring" the flap, which is especially objectionable, as it severs large numbers of fine vessels on which the nutrition of the heel flap chiefly depends, and which form long anastomosing loops nearer the bone than the skin, and running chiefly in the antero-posterior direction (as looked at in the position of amputation). These important anastomosing loops are derived from two lateral arteries of some size running along each side of the heel flapj the outer one is the continuation of the peroneal artery, while the inner one is derived from the posterior tibial artery about one inch above the ankle joint. When the incisions are made according to Mr Syme's directions the posterior tibial artery is not cut till after its division into internal and external plantars; the point of section is just in the angle where the two incisions meet on the inner side (see Kg. 51). Some difficulty may be experienced in stitching the hard edge of the heel flap to the thin skin in front of the stump. Before stitching up the wound it is necessary to secure every vessel that can be seen, as well as the dorsalis pedis (or the tei-mination of the anterior tibial) and the two plantar vessels, to avoid as far as possible any general oozing. As regards drainage we can either make a longitudinal slit in the lowest part (as the patient lies in bed) of the heel flap, so that 254 Applied Anatomy : any scar will not be on the surface on which he is to walk; or, perhaps the better and more usually adopted plan, is to pass a drainage tube through the stump transversely, bringing its ends out at the angles where the two incisions meet. This latter plan is amply sufficient, especially if the patient be taught to lie for some time on the affected side with the amputated limb flexed at the knee and in front of the sound leg, so that the discharges may escape at the fibular angle; and at the same time we may, by properly applied cotton wool and bandages, prevent any cavity forming in which the discharges can accumulate. Should all go well the tube may be safely removed in a few days. It will be observed that the general rule, about making a short posterior flap so as to facilitate drainage, is broken in this amputation, because the heel flap, thus secured, bears pressure so much better than an anterior flap would. If the plantar incision is made from malleolus to malleolus the flap is not symmetrical, and the incision in the sole extends too far forwards, which makes it very difficult to turn back the flap over the prominence of the heel ; and very likely before this is accomplished, irreparable injury has been inflicted on the heel flap. Pieeie saws through the tibia and fibula without disarticulating at all. RESUME of Syme s amputation : — 1. Foot held at right angles by assistant, and sole cut made. 2. Foot extended by Surgeon, and the cut in front of the ankle made. 3. The assistant again holds the foot at right angles,, while the Surgeon raises the heel flap till the prominence of the OS calcis is turned and the tendo achillis visible. 4. Open the joint by a horse-shoe cut, convexity upwards, divide the lateral ligaments, and detach, taking care of the posterior tibial artery, as it lies on the astragalus behind. 5. Clear the ends of the tibia and fibula and saw, again taking care of the posterior tibial artery. 6. Examine the inferior tibio-fibular articulation and gouge it out if necessary : after this tie the vessels, close the wound, drain, dress, and apply a splint. Surgical, Medical, and Operative. 255 2. Mackenzie's Method — By a Large Internal Flap (also called "Eoux's amputation"). — The foot to be amputated is laid on its outer side and firmly held by an assistant, with the foot and ankle projecting over the edge of the table or over a block of convenient height. The guides for this operation are not bony but tendinous, viz., the tendo achilUs behind and the tendon of the tibialis anticus in front, at the level of the ankle joint. The Surgeon then places his thumb and forefinger on the two tendons, at the level of the ankle joint— the tendo achillis behind, and the tendon of the tibialis anticus in front, almost over the centre of the Mackenzie's Amputation. (After Spesce.) Fig. 52. Fig. 53. Large Internal Flap. Incision on Outer Side. joint. He then inserts the point of the knife over the centre of the tendo achillis, and cuts obliquely across that tendon towards the outer and plantar aspect of the heel, along which it is continued for a little way in a semi-lunar direction, and is then curved upwards in front of the internal malleolus, till it crosses the tendon of the tibialis anticus, about an inch in front of the inner malleolus; it is better, I think, to take as much of the hard heel tissue as possible in this flap, and its base to be on a level with the internal malleolus, and as broad as possible. Another incision is then made, without removing the knife from the wound, by carrying it across the outer aspect of the ankle, forming a semi-lunar flap, uniting the two ends of the first incision ; the convexity of the flap should be about an inch below the 256 Applied Anatomy : ankle. The flaps are then to be dissected up, taking care of the posterior tibial and plantar arteries, which are found in the centre of the large internal flap ; in order to preserve these vessels it is necessary to go down to the bone at once, and dissect up muscles and all in one mass. Disarticulation is then performed, the tibia and fibula cleared and sawn as in Symb's amputation, and with the same precautions. The advantages claimed for this method are — 1. It can be performed in cases where the tissues on -the outer side of the foot have been destroyed by disease or accident. 2. When the patient lies on his side the large internal flap is kept in good position by its own weight. 3. There is a free exit for discharges, etc., from the posterior and outer side, so that there is less risk of pain and tension and putrefaction of the accumulated discharges. 4. There is no risk of sloughing,, as the posterior tibial and the two plantar arteries are in the centre of the flap. It is a curious fact that the stump in this amputation in a very short time comes to resemble the stump in Symb's amputation so closely that it is almost impossible to tell the one from the other. 3. Pirogoff's Method. — The peculiar feature of this amputation is the preservation of the posterior part of the os calcis in the heel flap, which is adjusted to the cut surface of the tibia and fibula. The foot is held at right angles to the leg, and the incision begins and ends at the same points as in Mr Symb's amputation (see Figs. 50, 51, P), but is not made directly across the foot, as in that method, but should be carried obliquely forwards, so that the centre of the incision in the sole is an inch and a half in front of a line drawn transversely across the sole from the tip of one malleolus to the other, or a little beyond the anterior end of the OS calcis. The incision must go down to the bone obliquely, and, therefore, the blade of the knife must not be held at right angles to the sole. The edge of the flap may then be freed from the bone for about half-an-inch j the foot is next to be extended, and a straight cut is made across the front of the ankle joint uniting the two ends of the first incision. Disarticulatiolii is next performed, as in Symb's amputation, by opening the thin anterior ligament of the ankle joint and then dividing the strong lateral ligaments, with the point of the knife inserted between Surgical, Medical, and Operative. 257 the malleoli and the astragalus. The foot is still further extended, and the fatty tissue in front of the tendo achillis cleared, exposing the posterior part of the upper surface of the os calcis ; the bone is also more fully cleared in the line of the first incision. The operator then draws the foot well downwards, its sole resting on the table or overhanging its edge, while the assistant grasps and steadies the heel. A narrow saw with a movable back (but an ordinary saw will do well enough) is then applied midway between the astragalus and the tendo achillis, and a section made through the OS calcis obliquely downwards and forwards in the line of the first incision. If the foot is held overhanging the edge of the table, or a block, during this part of the operation, the section will seem almost vertical. He next removes a slice from the end of the tibia and fibula, transversely and at right angles to the axis of the bone, as in Stme's amputation. The osseous surfaces are then to be accurately adjusted, and the limb laid on its outer side with the knee joint flexed, so as to relax the muscles forming the tendo achillis, and thus avoid tilting the part of the os calcis in the heel flap. The oblique section through the os calcis is to insure that the dense tissues covering its lower part are exactly at the end of the stump, and will receive the weight of the body; further, it exposes a larger surface of bone to apply against the cut ends of the tibia and fibula, and the retained part of the os calcis does not require to be tilted so much on its own axis in order to adhere closely to the tibia and fibula, and has, therefore, less tendency to be displaced by the tendo achillis. Should, however, the tendency to tilting be great, the tendo achillis may be divided, or the bones may be " wired " together. Originally, Pirogoff used a vertical cut through the os calcis, merely preserving the projecting posterior end. This, of course, necessitated a greater dissection of the heel flap, which had to be reflected a little beyond the line of the ankle joint ; further, when healed, the part supporting the patient's weight was rather the thin posterior layer of tissue, instead of the hard heel pad from the sole. The advantages claimed for this method are^l. It leaves a longer stump. 2. It is more easy of performance than a Syme, as it saves the tedious and difficult dissection of the heel flap, but the bones require more accurate adjustment. 3. There is 258 Applied Anatomy: less liability to sloughing of the heel ilap, as the vascular supply is less disturbed. 4. It is said to bear pressure better. Its disadvantages are — 1. Eetum of the disease in the fragment of bone left in the heel ilap, and therefore this method should never be chosen in the case of disease of the bones of the ankle joint. 2. Greater liability to osteo-phlebitis and pyaemia, owing to the section of the two spongy bones. 3. The process of union and consolidation of the bony surfaces is more tedious. Lastly, as compared with Symb's amputation it is not hett&r fitted to support the weight of the body, nor so well adapted for pro- gression (Spenoe). Subastragaloid Amputation (Liqnoeelles). — Kemoval of the foot below the astragalus through the joint between it and the OS calcis. The guides for this operation are : — A point three- quarters of an inch below the external malleolus, and opposite the outer tubercle of the os calcis, on the outer side, and the tuberosity of the scaphoid on the inner side. A heel flap is made somewhat after the manner of Symb's amputation, but extending rather further forwards, and a dorsal flap as in Chopart's amputation, the anterior bones removed as in that operation and the os calcis dissected out ' afterwards,-, first opening the joint between the scaphoid and astragalus, and then that between the astragalus and the os calcis. ■ Com- mencing on the outer side (right foot) the incision is carried forwards for a little way, and then downwards to the sole of the foot, passing just behind the prominence of the fifth metatarsal bone, across the sole and brought up to the tubercle of the scaphoid on the inner side. The ends of this incision are connected by another ciirved incision across the dorsum of the foot. The soft parts are next raised on the outer side sufficiently to reach the tendo achillis^ which is to be cautiously divided. The finger is now introduced into the wound, to feel for the articulation between the os calcis and the astragalus; the point of the knife is then pushed in between the bones, and the strong interosseous ligament divided, while the foot is wrenched forcibly inwards. The astragalo-scaphoid articulation is next opened, and then the parts on the inner side and the rest of the heel flap are put on the stretch by Surgical, Medical, and Operative. 259 twisting tho foot, separated from the os calcis, and the foot removed. In cases where the flaps are somewhat scanty, the head of the astragalus may be sawn ofi'. A serious objection to this method is the fact that it leaves a loose bone at the end of the stump over which the patient has no control, and which must of necessity, therefore, cause great insecurity during progression. Hancock's Amputation. — This consists of amputation below the astragalus, and at the same time leaving the posterior third of the OS calcis, which is turned up against the denuded surface of the astragalus. It, therefore, bears the same relation to subastragaloid amputation as that of Pieogoff does to Stme's. The incisions mtist extend further forwards than in subastragaloid amputation, passing on the one side to a point half-ah-inch anterior to the projecting end of the fifth metatarsal bone, and to a corresponding point on the other. These incisions are then united by a third semi-lunar incision with its convexity towards the toes. The flap thus marked out is to be reflected nearly as far back as the tuberosities on the under surface of the os calcis, and then a fourth incision is carried across the dorsum of the foot, just behind the head of the astragalus. Next, the posterior third of the os calcis is divided by the saw applied to its under surface, the other tarsal bones separated from the astragalus, and the foot detached. The head of the astragalus is sawn off, its inferior articular surfaces denuded by the bone forceps, the vessels tied, the posterior third of the os calcis turned up against the denuded surface, the flaps fixed, and the operation completed. The wound is drained from the lower angles, which are left open. The alleged advantages of this operation are — 1. It leaves a longer stilmp. 2. The greater amount of leverage afforded by the astragalus for the artificial foot. In cases of disease of the tarsal bones it is a doubtful operation, unless one could be quite certain that the retained bones were perfectly healthy ; and, as already stated, the astragalus and the os calcis are, of all the bones, the most likely to be diseased. I ought to mention Tripier's Amputation which is said, by Teipieb, to possess all the advantages of Chopart without any of its disadvantages. The os calcis is cut horizontally at rigJit 260 Applied Anatomy: angles to the long axis of the leg at the level of the sustentacTilum tali, and thus gives a flat surface to stand upon, instead of the posterior part of the os calcis and the unsupported anterior extremity of that bone. The periosteum covering the under surface of the os calcis should be preserved and turned up against the raw section. The skin incisions are made as in Chopaet's amputation. The following is a general list of the more important Structures divided in the previous amputations in the vicinity of the ankle joint : — 1. The integumentary coverings and plantar fascia. 2. Muscles — (a) The tibialis anticus ; (S) the extensor communis and brevis digitorum and peroneus tertius; (c) the extensor proprius hallucis ; {d) the peroneus longus and brevis ; (e) the tendo achillis and plantaris ; (/ ) the tibialis posticus ; {g) the first layer of muscles of the foot (the abductor haUucis, flexor brevis digitorum, and the abductor minimi digit)); and (A) part of the second layer (the tendons of the flexor longus digitorum and flexor longus hallucis, and accessorius muscle). 3. Vessels — (a) The dorsal artery of the foot, or the anterior tibial ; (6) the internal and external plantar vessels, or else the posterior tibial close to the point where it divides into these vessels ; (c) the long and the short saphenous veins ; {d) the external calcaneal branch of the peroneal artery ; (e) the internal calcaneal of external plantar ; and (/) also twigs from the tarsal artery, the internal malleolar branches of the posterior tibial, and the malleolar branches of the anterior tibial. 4. Nerves — (a) The posterior tibial or plantar nerves ; (h) the anterior tibial ; (e) the musculo-cutaneous or peroneal; and (d) the long and the short saphenous nerves. 5. The ligaments of the ankle joint and the various other joints disarticulated. 6. The ends of the tibia and fibula, and, in Pirogopp's amputation, the os calcis, and, in Hancock's amputation, the astragalus as well as the os calcis. Further, in Pirogopp, as compared with Syme, the tendo achiUis is not divided, the first layer of muscles of the sole are divided as well as the flexor accessorius, and the plantar vessels are divided much further forwards. Stcrgical, Medical, and Operative. 261 CHAPTER XVI. AMPUTATIONS OF THE LOWER EXTREMITY (Gontimied). Amputation just above the Ankle. — In all cases where amputation at the ankle joint cannot be performed, amputation immediately above the ankle should if possible be chosen in pre- ference to that at the "seat of election," for two reasons — 1. The longer stump gives greater command over the artificial limb, and instead of, as formerly, using the old " box leg'' with the stump projecting behind, the, knee being flexed and placed between the prongs, the stump is now encased in the socket of a short wooden pin in the extended position. 2. Amputation in this situation is less fatal than amputation higher up. According to Mr Duncan, Symb's heel flap may be used even when the bones are divided two and a haK inches above the ankle joint. The main arteiy is secured above the knee as in the previous operations on the foot, or by the thumbs of an assistant against the ilio-pectineal eminence. The patient is brought well down, so that the part to be removed projects over the end of the table, and is held horizontally above the level of the table, with the knee joint slightly flexed, and the foot and leg well inverted, by an assistant seated on a low stool, the Surgeon standing on the right-hand side of the leg to be amputated. The other leg is secured to a leg of the operating table. 1. Teale's Method. — Long anterior and short posterior rect- angular flap. (For a description of the principles of this method see page 185.) The chief objection to the method is that the bones are not divided at the lowest possible point, and therefore the stump is not so useful, and there is, also, a greater risk to life. The large square anterior flap may be taken partly from 262 Applied Anatomy: the dorsum of the foot, so as to bring the point of section of the bones as low down as possible, and it must include every- thing in front of the bones and the interosseous membrane. The anterior tibial artery lies in the middle of this flap, but it is very close to the interosseous membrane, and should the flap be raised in the ordinary way by the knife, the artery is very apt to be punctured during the dissection; to avoid this undesirable accident — as the nutrition of the flap depends on this vessel — we Fig. 54. Amputation of Leg. LiSTEiils Amputation. ,_Tealk's Aniputiitioii. must follow Mr Tjealb's plan, who has shown that, on account of the comparatively large amount of loose cellular tissue lying between the anterior structures and the membrane, there is no difficulty in separating the flap from its anterior surface by the finger or thumb nail, or the handle of a scalpel. To render this more easy the lateral incisions, marking the limits of the anterior flap, should go th;rough all the soft tissues down to the bone, especially on the fibular side, on account of the intimate attach- Surgical, Medical, and Operative. 263 ment of the muscles to that bone. To insure that the anterior flap shall he of the same hreadth throughout it is advisable, before beginning the operation, to measure with a tape and mark the whole extent of the anterior flap in ink, rather than trust to the eye alone, as the cone-shaped form of the limb is apt to mislead the eye. The posterior flap is then made with the same pre- cautions to avoid injury of the arteries and nerve behind. The tibia and fibula are next to be cleared to the level of the base of the flaps, or a little higher if necessary, by circular sweeps of tlie knife, first below and then above the bones, the interosseous membrane divided, and the tissues between the bones cleared, by a figure-of-eight-like sweep. To avoid cracking and splinter- ing of the fibula, both bones are to be divided together, but the fibula must be finished before the tibia. Should the angle in front of the tibia be very acute it should be removed, either by the bone pliers or a small saw. The vessels requiring ligature are — (1) The anterior tibial at the middle of the apex of the anterior fiap ; (2) the posterior tibial ; and (3) the peroneal artery, both in the posterior flap. RESUME of Teale's amputation : — 1. Mark out the flaps by the rules already laid down. 2. Make the lateral incisions, and then divide aU the soft parts down to the bone at the apex of the anterior flap : the anterior flap should be a perfect square. 3. Reflect anterior flap, using the handle of the scalpel or thumb nail to separate it from the interosseous mem- brane, in order not to harm the anterior tibial artery. 4. Divide and raise the posterior flap. 5. Saw the bones at the upper limit of the reflected flaps : assistant to turn the foot well inwards, and the operator to divide the fibula before the tibia is completely divided. 6. Fix the flaps in position and dress the stump. 2. Long Anterior Flap, slightly rounded at the corners, and made by dissection. Mr Bell recommends this method, and it was also used by Mr Syme. It is formed on the same principle and with all the precautions of Mr Teale's anterior flap, and 264 Applied Anatomy: must be long enough to fall down over the face of the bones, at the point of section, and the stump of tissue behind them. The posterior tissues are divided by a transverse incision at the base of the anterior flap. This method may be applied to any part of the leg. 3. Lister's Method (see page 187). — Take the c^mnieto- of the limb at the point where the bones are to be divided, and then make a straight longitudinal incision of that length on the inner aspect of the leg, about half-an-inch behind the inner edge of the tibia, and another similar incision on the outer aspect directly over the fibula, but extending one inch higher up than- the inner one. The lower ends of these incisions are then united by a nearly transverse incision, with the angles well rounded, where it joins the lateral ones. The knife is next carried behind the bones, and cutting somewhat obliquely, from without inwards, fashions a short posterior flap, about one-half or one-third the length of the anterior, convex downwards, extending from the upper end of the internal lateral incision to a point exactly opposite on the other side, and will be therefore about one inch below the upper end of the external incision. The anterior flap is raised as in Tbalb's method, and the bones cleared and sawn at the upper end of the Older incision. The fibula and anterior edge of the tibia must be treated in the way already indicated. The flaps are then to be stitched, up closely, except at the upper end of the external incision, which is left open for drainage, the limb being placed on its outer aspect. The reason why the lateral incision is carried further up on the outer side, is on account of the difficulty of retracting the soft parts from the fibula, as the bone is sawn an inch higher xip than the proper base of the flaps. They can be retracted without any difficulty from the tibia, and therefore the incision is not carried further up than the typical operation demands. RESUME of Lister through Calf :— 1. Measure with the eye the diameter of the limb. 2. Make a longitudinal incision equal to half this diameter along the inner side of the leg, half-an-inch behind the ' inner edge of the tibia, from a point one inch below the intended division of the bono. Surgical, Medical, and Operative. 265 3. Make a similar incision on the outer aspect, directly over the fibula, but beginning one inch higher up than the one on the inner aspect. 4:. Join the lower ends of these incisions across the front of the leg, forming a square-shaped flap •with well-rounded angles. 5. In the same way form a posterior flap about one-half or two-thirds the length of the anterior. 6. Eeflect both flaps to the level of the upper end of the inner incision. 7. Eeflect all the soft parts one inch higher up, clear the bones, and saw them with the usual precautions — fibula thrown well forwards, and divided before the tibia, and the sharp anterior angle of the tibia to be removed. Other methods are sometimes employed, as — 4. A Short Anterior Semi-lunar Flap made by dissection, and a long posterior by transfixion, the bones being divided a little above the base of the flaps. 5 Modified Circular. — But of all others the best method is by some form of long anterior flap and short posterior, as in the operations already described; as this affords the best covering, since the bones are placed nearer the anterior aspect of the limb, and the cicatrix is out of the way of pressure, so that the patient can bear a part of the weight of the body on the end of the stump, the rest being supported by the prominence of the calf muscles, and the heads of the tibia and fibula. For the Structures divided see " Amputation through the Calf," but adding to the list there given — (1) The peroneus tertius muscle, and (2) anterior peroneal artery. UPPER TWO THIRDS OF THE LEG. The limb is to be drained of blood, and haemorrhage provided against, as in the previous amputations — either by the elastic tourniquet applied above the knee, or else by the thumbs of an assistant pressing on the femoral artery below Poupaet's ligament. The patient is placed as in the previous operations. In this situation the bones lie nearer the anterior aspect of the limb, and. 2G6 Applied Anatomy : therefore, it is not necessary to provide so long an anterior flap in order that the line of the cicatrix be placed well behind. 1. Long Anterior and Short Posterior Flaps. — The flaps at first consist of skin and subcutaneous fat only, with muscular tissue taken up towards their bases ; in the case of the posterior do not take too much muscle. The limb is held in a way similar to that of the previous amputations, and rotated loell inwards, so as to throw the fibula well forwards. The operator takes his stand on the right side of the limb to be removed, so that he can grasp the Hmb above the point of amputation, and, in the case of the right leg, places his thumb on the fibula, and his forefinger at a corresponding point on the opposite side, which will, therefore, be considerably behind the inner edge of the tibia. On the left side the position of the thumb and finger will be reversed, as the operator then takes his stand inside the limb. He then marks out a broad skin flap, equal in length to two-thirds of the diameter of the limb, the heel of the knife commencing well behind the tibia, its blade sweeping across the front, and its point ending a little behind the thumb ; next, without removing the knife from the incision, he transfixes the limb behind the bones, taking care not to pass the knife between them, and making it enter and emerge through the angles of his former incision, so that the blade wiU pass close behmd the fibula, but at some little distance from the tibia. A short posterior flap, about half the length of the anterior, . is then cut from within outwards; while the posterior flap is being cut, the assistant holding the foot must keep the muscles tense by dorsiflexing the foot forcibly, while the operator or another assistant puUs up the skin as far as possible. This insures the skin being cut longer than the other tissues, and avoids redundancy of muscle. The operator must next raise the anterior flap, which at first should consist entirely of integumentary structures, but, as its base is approached, as much muscular tissue as possible should be taken up, to insure its nutrition; both flaps are then to be well retracted by the assistant standing opposite the Surgeon, while the knife is swept circularly round the hmb at the base of the flaps. The interosseous structures are then to be divided by the usual figure-of-eight-Uke sweep of the knife, taking care not to allow its edge to be directed upwards in the least, lest Surgical, Medical, and Operative. 267 the anterior tibial artery especially, or any of the other vessels, be split, and retract beyond the reach of easy ligature. The bones are then to be sawn, and the sharp angle removed from the anterior edge of the tibia. In order to do this, it is usual to commence sawing the bone obliquely from a point half-an-inch above the place where the bones are to be sawn transversely, and when the oblique section has crossed the line of the transverse one, then withdraw the saw and apply it transversely half-an-inch lower down than the commencement of the oblique cut. "When the saw is about half-way through the tibia, then alter the direction of the blade, so that it will take up the fibula, which is to be completely divided before the tibia, to avoid cracking and splintering of the weaker bone. The fibula is apt to project at the outer angle, and to prevent this Mr Duncan divides it nearly an inch higher up than the tibia. The sharp angle of the crest of the tibia may be removed with the bone forceps, or a small saw, after the limb is removed, should the operator so prefer it ; this method probably disturbs the periosteum less than the other way. It is well, in order to lessen the risk of necrosis, to split the periosteum along the crest and turn aside two little triangular flaps of that membrane, before the saw or forceps is applied, so that it may not be stripped off to a higher level than that at which the saw is actually applied. The vessels divided are — (I) Anterior tibial, (2) posterior tibial, (3) peroneal artery, and (4) the long and short saphena veins, all of which may require ligature. By this amputation the vessels are cut transversely, and the cicatrix is placed behind. 2. Lister's Amputation. — Take the diameter of the limb, by spanning, at the point of the intended division of the bone, and then make a straight longitudinal incision equal in length to two- thirds of this diameter, along the inner aspect of the leg, com- mencing one inch below the point at which the bone is to be divided, and half-an-inch posterior to the inner edge of the tibia. A similar incision is made on the outer aspect, directly over the fibula, but is to be prolonged an inch higher up than the internal incision {i.e., up to the point of section of the bone), for reasons already stated. The two incisions are then united by a transverse cut, with well-rounded angles, at the points where it meets the lateral incisions. A posterior flap is then made from the upper 268 Applied Anatomy : end of the internal incision to a point exactly opposite that in the external incision — that is, one inch below its upper extremity. This flap should be half the length of the anterior, and is made by carrying the knife round the back of the limb with the blade at an angle of forty-five degrees to the horizon, through the integumentary structures only, and dissecting it up to the level of the upper end of the internal straight incision. By this means we get rid of the heavy mass of muscles of the calf. The anterior flap is dissected up to a similar point, both flaps retracted, and the bones cleared as high as the line of the external incision, and the operation finished as described ia the previous amputation (see Fig. 54). 3. The Modified Circular. — The leg is held, as in the previous amputations, supported horizontally, and well rotated inwards, so as to throw the fibula well forwards; the assistant must also extend the toes fprcibly as the operator's knife divides the muscles in front, and dorsiflex forcibly as he divides the jDosterior group of muscles. In this way the muscles are rendered tense and more easily divided. Another assistant, standing opposite the Surgeon, pulls up the skin well, both before and after the first incisions. The Surgeon stands so that his left hand grasps the limb to be removed above the level of the amputation, i.e., on the riglit side ; and then cuts two equal semi-lunar flaps of skin from the outside by dissection. In order to cover both bones equally, and avoid their projecting at either of the angles of the incisions, the flaps may be placed rather antero-external and postero-intemal. In raising the posterior, the limb should be elevated to enable the Surgeon to see better what he is doing. Both flaps are then retracted and the skin at their bases turned back for a little way, and the muscles divided at that level by a circular sweep of the knife, and the bones cleared for an inch or an inch and a half higher up, and there divided with all the usual precautions. As the posterior muscles, especially the superficial layer, retract further than the anterior (being divided at a greater distance from their origin), they should be divided at a lower level, say, a couple of inches below the base of the skin flap. Instead of making the skin flaps anterior and posterior, Mr Bryant uses lateral skin flaps, with circular division of the muscles. This is objectionable — 1. Because the tendon of the quadriceps Surgical, Medical, and Operative. 269 extensor cruris tilts the sharp angle of the tibia into the anterior angle of the incision, and is, therefore, likely to interfere with the healing process. 2. Because the scar must necessarily he opposite the end of the bone, and it also extends up both back and front of the stump ; hence the patient can neither bear his weight on the end of the stump, nor can he very well manipulate an artificial leg, because of the anterior and posterior scars. In the " modified circular," with anterior and posterior flaps, even though the flaps are equal, the scar is well behind the tibia — (1) because the tibia is so near the anterior surface of the leg, and (2) as the stump heals the posterior muscles contract and drag the scar still further backwards and upwards, so that the patient can bear a great part of his weight on the end of the stump. Instead of using the pure " modified circular,'' the anterior skin flap may be made equal to two-thirds of the diameter of the limb, and the posterior half that length. The flaps are then retracted, and the operation finished as above directed. The " modified circular " gives a good stump out of the smallest amount of material, and with the smallest possible wound, and provides an exceedingly useful limb, the patient either being provided with a properly-fitting socket, in which to put the limb, retaining the use of the knee joint, or else resting his whole weight upon the bent knee, as in the old, artificial " box leg." 4. The Old Flap Operation. — This is recommended by maiiy Surgeons, especially in cases of chronic disease, where the muscles of the calf are much wasted. It gives a well-covered stump, with the cicatrix in front, on which the patient can bear a considerable part of his weight. In this operation the Surgeon stands so that he can grasp the limb below the seat of the amputation— on the inner side, on the right leg, and the outer, on the left. An assistant takes his place opposite the operator, and must be prepared to pull up the integument, steady and support the upper part of the limb, and retract the flaps when they are formed.' The operator then places his forefinger ^nd thumb on the fibula on the one side, and half-an-inch behind the inner edge of the tibia on the other, and then places the heel of his knife (on the right limb) over the outer margin of the fibula, carries it down- wards for about an inch and a half, then sweeps the blade across 270 Applied Anatomy: the front of the limb in a semi-lunar manner, and then upwards till it reaches a point a little behind the inner edge of the tibia, and opposite the commencement of the incision on the outer side. Then, without removing the point of the knife from the incision, he transfixes the limb, the knife entering and leaving a little below the angles of the former incision, and forms a gently rounded flap from the calf, by cutting first downwards for some distance and then gradually outwards ; in cutting this flap he should support the mass of calf muscles with his left hand. The anterior flap is then dissected upwards, the assistant holding it whUe the operator frees it by a few touches of the knife — if preferred, the anterior flap may be dissected up before the posterior flap is made. Both flaps are next retracted, the bones cleared and sawn a little higher up than the point of transfixion, with all the previous precautions. The great objection to this amputation is the great mass of muscle left in the posterior flap, which is therefore apt to bag and drop, owing to its great weight, and leads to tension and sloughing; for the same reason it must be kept in position by strapping, etc., and this is a source of great discomfort and pain to the patient, as well as being likely to interfere with primary union of the wound. To get rid of this difficulty to a certain extent, Mr Spbnce advised that the skin of the posterior flap should be retracted and the redundant muscle removed by a single sweep of the knife, thus leaving little more than a skin flap. No doubt this is a great improvement; but even this does not give the advantages of the large anterior flap, viz.: — (1) Cicatrix placed behind; (2) a depen- dent opening for drainage during healing; (3) the long anterior flap is kept in position by its own weight; and (4) the tendency to protrusion of the bone is less and ulceration of the flap is rare, as the heavy muscular mass in the posterior flap is avoided. 5. Lee's Amputation through the Calf. — This amputation resembles, in a general way, Tb ale's amputation, only the long rectangular flap is made from the tissues behind instead of from the front. The incisions are made at first through the ■ skin and cellular tissue only, and when this has retracted, by virtue of its own elasticity, the muscles are divided ; the superficial muscles only are included in the posterior flap, the deep muscles with the large vessels and nerves are cut at the base of the flaps. It was Surgical, Medical, and Operative. 271 hoped by this method to combine all the advantages of Tbalk's amputation together with the ease of performance of the old flap method. But, as already pointed out, the question of ease and time is not of so much importance now-a-days, as it is to secure a good, useful stump. 6. The Circular Method ("triple incision") may be used in cases where there is not sufficient skin to form a long anterior flap. The steps of the operation resemble very closely those of the modified circular, the only difference being that the skin is divided circularly instead of in the form of two short equal semi-lunar flaps; the skin should be divided three or four inches below the point at which the bone is to be divided. The foregoing six methods may all be employed either in the middle third of the leg, or at the old "seat of election." The " seat of election " is about a hand's-breadth below the knee joint, and leaves just sufficient tibia to retain its tubercle, with the insertion of the ligamentum patellas. In practice, however, it will be found more convenient to go a little lower down if possible. If the bones are divided at the "seat of election," some difficulty will probably be experienced in securing the anterior tibial artery, which at that point is just passing through between the bones, and is therefore apt to retract after division, beyond the reach of easy ligature (see page 181); but, by going a little further down, the artery is fairly through and lying on the anterior surface of the interosseous membrane and may be iaore readily secured. The head of the fibula should always be left, because, as a rule, its synovial membrane is but a part of the general synovial membrane of the knee joint. In regard to arteries divided in amputations a little below the knee, Mr Holden has pointed out that in amputations one inch below the head of the fibula 07ie artery is divided — the IDopUteal; at two inches below the head, tivo arteries — the anterior and posterior tibials; at three inches below the head,- three arteries — the anterior and posterior tibials and peroneal. The Chief Structures divided in the foregoing amputations through the calf (Fig. 55) are — 1. The integumentary coverings. 2. Muscles — (a) Tibialis ?inticus, (6) extensor communis digitorum, (c) the extensor proprius hallucis, (d) the peroneus longus, (e) the peroneus brevis, (/) the gastrocnemius, (g) the soleus, (h) the 272 Applied Anatomy . Fig. 55. Section through the Calf. 6 7 .'8 ,11 1. Anterior tibial vessels and nerves. 2. Posterior tibial vessels and nerves. 3. Peroneal vessels. 4. Short saphenous vein. 5. Septum between peronei and posterior muscles. 6. Strong septum between peronei and anterior group of muscles. 7. Weak septum in anterior group, through which the anterior tibial artery is reached. 8. ■ Interosseous membrane. To show position of lateral incision. To show position of direct incision (Guthkie's). Tibia. 9. 10. 11. 12. Fibula. The names of the Muscles are indicated by their initial letters. Note. -In the Anterior group of Muscles, instead of P.L.P., read E.P.P. — Extensor Pvoprius Pollicls vel Hallucis. Surgical, Medical, and Operative. 273 plantaris, (i) the flexor longus digitorum, (,/) the flexor longus hallucis, and (/<;) the tibialis posticus. 3. Vessels — (a) The loDg saphenous vein, (6) the short saphenous vein, (c) the anterior tibial vessels, lying on the interosseous membrane; (cZ) the posterior tibial vessels, lying on the tibialis posticus; and (e) the peroneal vessels (about the middle of the leg these will be found in the substance of the flexor longus hallucis, higher up they will be found lying ' on the tibialis posticus). 4. Nerves — (a) The short saphenous or the branches going to form it, (6) the anterior tibial nerve, (c) the posterior tibial nerve, and (d) the peroneal or musculo-cutaneous nerve. 5. The tibia and fibula. 6. The interosseous membrane. THE KNEE JOINT. Amputation at the Knee Joint Proper (leaving the Condyles). — ^This is an amputation but rarely performed, although of recent years it seems to be reviving, being specially advocated by Mr Bbyant. The difficulty is to get sufficient covering, on account of the large size of the lower end of the femur. In the case (1) of diadase of the joint there can be no doubt that the amputations of Caedbn or Geitti are immensely superior to amputation at the knee joint, for the pyoper performance of which it is necessary that the articular surfaces of the condyles and patella should be healthy Many Surgeons, however, operate thus — even in disease of the joint — and after disarticulation is completed, use a fine-bladed Butcher's saw and cut round the end of the bone, thus removing the diseased surface without shortening the stump or lessening its breadth. An objection to this proceeding is that the cancelli may be opened up and predispose to osteo-phlebitis and pyaemia. For this reason, when the cartilages are healthy they should be left undisturbed on both femur and patella; and the cartilage, if removed from the one, should also be removed from the other. In the case (2) of injury, when the integuments are uninjured for five inches below the patella (the length of the anterior flap in amputation by the long anterior skin flap — the best method), it is better to amputate by the " modified circular " at the old seat of election. It may, however, be practised in the case of malignant disease of the head of the tibia, provided the femur and knee joint are healthy, and in gun-shot wound of the same bone. 3 274 Applied Anatomy : 1. By Long Anterior and Short Posterior Flap. — This is tlio method usually preferred. The patient is hrought well down on the table, so that the knee projects beyond it, while his other leg is secured to a leg of the operating table. One assistant holds the leg in an extended position while the anterior flap is fashioned, another supports the thigh and pulls back tlie skin. The guides • for the anterior flap are the lower and back part of each condyle, and a point an inch or more below the tubercle of the tibia. The flap should be broad and somewhat square-sha;ped, with its lower angles well rounded, and must be at least five inches long. It will be convenient for the Surgeon to stand on the right side of the limb to be amputated, so that he may himself raise up the large anterior flap with his left hand; he should be provided with a short, broad-bladed, amputating knife. The anterior flap is then marked out in the manner indicated, the ligamentum patellte divided, and the. integument, with the patella and capsule, are dissected up in front of the joint ; in this way the articulation is opened. One assistant now flexes the knee joint, and another supports the thigh, while the operator divides the lateral and crucial ligaments, and passes the knife straight backwards between the bones, turns it down behind the tibia, and cuts a posterior flap fully one-half the length of the anterior. This flap may be made by cutting from behind forwards, instead of from before backwards. In both cases the knife must be made to enter or leave the tissues abruptly, so as to keep the end of the flap squarish and divide the popliteal artery transversely. The flap must not be made any shorter than the length given, as it shows a considerable tendency to retract. The treatment of the patella is a disputed point. On the whole, I think, Surgeons are inclined to leave it, as it fills up the hollow between the condyles, to which it may ■ or may not become ankylosed; in any case, it protects the end of the stump, and the position of its bursa makes it useful in supporting the patient's - weight. The only objection to this is that it is occasionally drawn up in front of the thigh by the quadriceps extensor cruris ; this may be prevented either by cutting the tendinous insertion of that muscle into the patella, or by " wiring " the patella to the condyles by silver wire or strong catgut. If the patella is to be removed, it may cither be done during the formation of the anterior flap, by Surgical, Medical, and Operative. 275 dissecting it off and cutting above it when opening the joint, or it may be dissected out after the flap is raised j but by removing it the bursa is lost, and the flap is so thinned that it is apt to perish by sloughing. A most important part of the after treatment is the proper drainage of the wound, as in all cases where large synovial pouches are opened. This is best accomplished by. the introduc- tion of two long drainage tubes, inserted into ' the extreme upper • corners of the pouches and their ends brought out at the two angles of the wound. They must not be interfered with till the third day, and must never on any account be completely removed during the dressing of the wound, as it would probably be impossible to replace them ; they must simply be withdrawn half-an-inch or so at each dressing, and the projecting piece cut off, as the wound heals. An objection to this method is the very long anterior skin flap, which may possibly slough, as compared with amputation at " the seat of election " by the " modified circular,'' where the skin flajjs have no tendency to slough. An advantage of amputation at the knee, is that there is no sawn bone surface, which is a great advantage if by any chance the wound were to become septic*- 2. Short Anterior and Long Posterior Flap. — The leg is held as in the previous operation, and the Surgeon inay either stand on the right or left side of the limb. A slightly curved incision is made from the lower and back part of one condyle, passing just below the patella, and ending at the lower and back part of the other condyle. This flap is then dissected up, the knee flexed, and the joint opened above the patella, by a semi-circular sweep of. the knife. The lateral and crucial ligaments are next divided, the bones fully separated by dividing the posterior ligament, and the knife passed behind the tibia with its edge directed downwards, and a large flap about four or five inches long cut from the upper part of the calf of the leg. In making this posterior flap the assistant must flex and displace the tibia a little forwards till the knife is fairly behind it ; then the skin is to be drawn well upwards and the leg extended as the knife cuts the flap. As usud, the knife must be carried down close to the bone for some distance, and then brought abruptly out so as to make the end of the flap rather square than round. The great objection to this amputation is the tendency of the posterior flap to retract. 276 Applied Anatomy : 3. By Lateral Skin Flaps (Stephen Smith, New York).-^Two convex lateral incisions are made from a point on the anterior edge of the tibia, one inch below the tuhercle, and carried down- wards and backwards, round the two sides respectively, over the most prominent part of the side of the leg, and are then directed upwards, reaching the median line posteriorly at a point opposite their commencement. From this a single straight incision is carried directly upwards to the centre of the popliteal space. The flaps are then raised, the ligamentum patellae divided, disarticula- tion performed, and the limb removed. The patella is left, and the internal flap is rather larger than the external. It will be observed that this somewhat resembles the " oval " method of amputation, with the muscles divided obliquely towards the bones. The flaps here form two lateral hoods, one over each condyle ; the covering thus provided is good, and the drainage is free behind. According to Mr Bhyant, the advantages of this amputation over amputation through the thigh are — (1) Less shock; (2) less section of tissues, and the muscular interspaces of thigh are not opened up ; (3) femur is not cut, and, therefore, the risk is much less ; (4) the stump is mobile, because the attachments of the muscles of the thigh are preserved ; and (5) a very useful stump is left. This method may also be used for the leg and lower part of the thigh. I have only seen amputation at the knee performed once, and that was hy Professor Chiese, in a case where the leg was useless, being too small and partially luxated backwards from previous disease. Two straight lateral incisions were made from a point a little below the condyles of the femur, and then two rectangular flaps formed, the anterior being about twice the length of the posterior ; the flaps were then carefully dissected up — the anterior especially rec[u.iring great care — to the level of the articulation, the joint opened, and the leg removed. The result was excellent, a most useful and heautiful stump resulting. In amputation at the knee joint the Structures divided are — 1. The integumentary coverings. 2. Muscles — (a) The lower part of the quadriceps extensor cruris, (&) the adductor magnus, (c) the gracilis, {d) the hamstrings, (e) the sartorius, (/) the gastrocnemius {g) the plantaris, (/*) the solous, and («') the popliteus. 3. Vessels — (a) The popliteal artery (in the posterior flap) with its lower Surgical, Medical, and Operative. '277 articular branches, (6) branches of the anastomotica magna of the femoral, (e) long and short saphena veins, and (d) the popliteal vein. 4. Nerves — (a) The internal popliteal with its ramus communicans tibialis, (p) the external popliteal with its ramus communicans fihularis, (c) cutaneous nerves of this neighbourhood, and {d) branches of the obturator nerve supplying the knee joint. 5. The ligaments of the knee joint. AMPUTATION THROUGH THE CONDYLES. This is often spoken of as amputation at the knee joint, and is more frequently performed than that operation. 1. Garden's Amputation (slightly modified J. — This is analogous to Symb's amputation at the ankle joint, and was introduced by Mr Garden in the year 1864. The guides are the two condyloid eminences of the femur, towards their posterior part, and which correspond to the broadest part of the articular end, and the tubercle of the tibia. Garden himself simply made an anterior Fig. 56. Garden's Amputation. The original form. The present form with Posterior Flap. flap, removing the patella, and cut through everything on the posterior aspect straight out at the base of the anterior flap, not making a posterior flap at all (Fig. 56). Other operators, however, have found that without a posterior flap the covering is frequently insufficient, especially in eases where the leg has been fixed in the flexed position by disease. The patient is placed as in amputations through the knee joint, and an assistant holds the limb with the knee joint slightly flexed, as in this way we get a longer anterior flap than when it is flexed to a right angle at once. The Surgeon stands on the right side of the limb, and places his finger and 278 Applied Anatotny: thumb on the two condyloid, eminences of the femur, and, there- fore, nearer the posterior part of their lateral aspect than the anterior. He then marks out a long anterior flap, reaching as low as the tubercle of the tibia — the knife being entered behind, and close to his finger, and brought round to a point, close to and behind his thumb, or vice versd, according to the limb. The flap should be broad, and its edges at first straight, and its lower angles well rounded. It is then dissected up, with or without the patella ; if without, when the dissection has proceeded as far as the centre of that bone the assistant forcibly flexes the knee to a right angle; this pulls the patella downj and then the operator cuts into the joint by a semi-circular sweep of the knife aboTe the upper edge of the patella and immediately above the condyles. Fig. 57. The Stump after Garden's Amputation. fOrigindl Form..} When the soft parts are much thickened and matted by disease the patella may be turned up with the flap and dissected out afterwards. The lateral, crucial, and posterior ligaments are next divided, the knife passed behind the femur, and a posterior flap cut from within outwards nearly equal in length to the anterior ; it is better to make it pretty long, because it contains the hamstring tendons, and will retract considerably. Mr Bell makes a skin flap about an inch and a half long, allows it to retract, and then divides the muscles by a circular cut down to the bone at the level of the retracted skin. Both flaps are then retracted, the bone cleared to the highest point of the articular surface, and then sawn through at the broadest part of the condyles, or just below the " adductor tubercle j " the saw must be applied parallel with the articular surface of the femur, and not at right angles to the long Surgical, Medical, and Operative. 279 axis of the bone, and to avoid injurious pressure on the anterior flap, the. sharp anterior edge of the condyles may he rounded off by a narrow-bladed and iine-toothed Butchee's saw. It is not necessary to adhere strictly to the order of the operation as above described ; the anterior flap may be cut and raised, the knee joint examined if the Surgeon is undecided between excision and amputation, the bone sawn as in excision, and then, should amputation be deemed necessary, the posterior flap of skin is marked out, allowed to retract, and then the muscles and vessels divided last of all. By this plan the patella is raised with the anterior flap, and will require to be dissected out before completing the operation. In performing this amputation, Mr Heath at once flexes the knee to a right angle, makes the first incision and reflects the anterior flap, then transfixes the limb behind the condyles, and forms the posterior flap. As compared with amputation through the lower third of the thigh. Garden's amputation has the following advantages : — 1. It is less serious because further from the trunk, and there is therefore less shock, etc. 2. The parts divided are not vascular, and there is, therefore, less risk of haemorrhage. 3. The tendency to protrusion of the bone is less, because of the ample coverings, and less tendency to necrosis, osteo-myelitis, osteo-phlebitis, and pysemia, as the medullary canal is not opened. 4. A longer stump, and therefore greater command over the artificial limb. 5. The end of the stump is well adapted for bearing pressure, being of great breadth; and, further, because the skin forming it is accustomed to bear pressure, and the cicatrix is situated behind. 6. In cases of doubt as to whether amputation or excision is -the proper mode of procedure, the anterior flap can be raised, the joint examined,, and the further proceedings decided; for, just as at the shoulder, it is very easily transformed into an amputation. RESUME of Garden's amputation: — 1. Assistant to hold the limb slightly flexed — probably already so by disease. 2. Operator stands on the right side and defines bony guides — tuberosities of the femur, at their upper and posterior part, and the tubercle of the tibia, 280 Applied Anatomy : 3. With these points in view, shape the anterior flap; it should be square-shaped with the angles rounded off, the base being on a level with the femoral tuberosities, and the apex almost on a level with the tubercle of the tibia. 4. Eeflect this flap to the centre of the patella, then flex the knee forcibly, and let the knife sink into the tissues above the patella, down to the femur. 5. Eeflect the soft parts to the level of the adductor tubercle, and divide the lateral and crucial ligaments. 6. Pass the knife behind the femur, again extend the limb, and cut a posterior flap from within outwards about half the length of the anterior. 7. Clear the femur, and divide it through the condyles, just below the adductor tubercle. 2. Gritti's Amputation (slightly modified). — This to a certain extent resembles very closely Garden's amputation. We have the same guides for the anterior flap, which is dissected up with the patella. The operation is finished as in Garden, the articular surface of the patella is sawn off, and the denuded surface hangs over the end of the femur. The femur is divided about one-third of an inch higher up than in Garden, to insure that the patella will hang flatly over it and not tilt. The point of division is just above the " adductor tubercle." It has been advised, just as in amputation at the knee joint proper, to divide the tendon of the quadriceps extensor cruris, or "wire" the bones to keep it from tilting. This amputation, therefore, has the same relation to Garden's as Pubogopf's has to Syme's amputation at the ankle joint. Its great advantage is that the bursa patellae is retained, upon which the patient can bear a great part of his weight; there is probably also less risk of sloughing of the anterior flap. An alleged disadvantage is that, the femur being divided higher up, the medullary canal is mo:fe apt to be opened, and the patient therefore runs more risk of osteo -myelitis and its consequences, as section through the medullary canal is more risky than section through the spongy tissue, and this again is more risky than where the end of the bone is covered with cartilage, as amputation at the knee joint. Further, for the same reason, the end of the stump is Surgical, Medical, and Operative. 281 not quite so broad as in Caedbn. In denuding the patella of its cartilage, an assistant must at first grasp it transversely with a lion forceps, and hold 4t vertically down upon the femur till the saw has made a groove for itself. After that he changes the direction of the forceps and grasps the patella vertically, hut only taking a very narrow bite so that the teeth of the saw may not come into contact with the lower blade; or the operator himself may hold the flap and patella with his left hand and saw vertically downwards. Another plan is to lay the flap and patella into the palm of the left hand and there denude it, the hand being first covered with a towel. Stokes's Supra-Condyloid Amputation of the thigh differs from Gbitti's amputation in that the femur is divided about an inch higher up. Stokes divides the femur at least half-an-inch above the upper edge of the trochlear surface, whereas Gritti saws through the condyles just above the "adductor tubercle," but in both cases the patella is denuded of its cartilage and applied to the cut surface of the femur. Lister's IVIodifioation of Garden (a form of " modified circular"). — He suggested this method to lessen the risk of sloughing of the large anterior skin flap in Garden. The integuments behind are also made to take a larger share in forming the covering, and therefore it is not necessary to go so far down the limb in front, and hence it might be used. in cases of injury. The incisions he advises are the following: — The limb being extended, the Surgeon stands on the right side and cuts almost transversely across the front of the tibia from side to side, at the level of the tubercle of the tibia, and joins the horns of this incision by carrying the knife at an angle of forty-five degrees to axis of the leg through skin and fat. The leg is then elevated and the posterior flap dissected up, and the ring of integument reflected as in the circular operation, dividing the hamstrings as they are exposed. The knee is next flexed, and the upper border of the patella exposed, when he cuts into the joint above it by a semi-circular sweep of the knife. The bones are now cleared and sawn as in Garden's amputation. For the Structures divided in the three foregoing amputations, see " Amputation through the Knee Joint Proper." Of course, the section through the femur must be added in all, and in Gritti, section of the patella as well. 282 Applied Anatomy; CHAPTER XVII. AMPUTATIONS OF THE LOWER EXTREMITY (Gontinued). The Thigh. — In all amputations through, the thigh the amount of llap length allowed should never he less than twice the diameter of the limb at the point where the bone is sawn, and, if possible, the anterior flap should be longer than the posterior. THE LOWER THIRD. 1. Spence's Method (1856), by long anterior flap (see page 186). — An assistant, seated in front of the patient on a low stool, holds the limb firmly below the knee, so that the thigh shall be horizontal and projecting from the buttock over the edge of the table; another assistant takes his place opposite the Surgeon. The Surgeon stands on the right side of the Umb to be ampu- tated. Mr Spence, however, directs him to stand on the left side, so as to comn^and the bone whilst he is sawing. He then measures, with his eye, the breadth of one-half the circum- ference of the thigh, and inserts his knife into the side of the limb furthest from himself, well towards the posterior part, and about three inches nearer the trunk than the patella, carries the incision downwards to a point on a level with or below the lower edge" of the patella, sweeps across the front of the knee with a gentle curve, and then straight upwards, and ends at a point exactly opposite to that at which he commenced, the assistant standing opposite him, retracting the skin and fascia all the while. The leg is still kept in the extended position, and the Surgeon dissects up the flap from off the patella, taking care not to button-hole it, and, on reaching the upper border of that bone, he cuts deeply and obliquely upwards, so as to take up the Surgical, Medical, and Operative. 283 muscular tissue as well, towards the base of the flap; the flap should be nearly as broad at its apex as at its base, and is at first composed of skin and fascia only. He next shapes a posterior flap, beginning three inches below the base of the anterior flap, making a convex incision through the integuments, and outs the other soft tissues obliquely upwards towards the bone; or better, first dissect back the skin for about an inch before dividing the muscles. The leg assistant now elevates the limb to a right angle with the table, retracts the soft parts gently, and the bone is cleared by a couple of sweeps with the knife, two inches higher up than the base of the flaps, immediately above the condyles. By elevating the thigh, the bone is projected Fig. 58. Spenoe's Amputation. ^^^«._ Point where tlie Bone is divided. Its present fonii. Tbe original Posterior Incision^ Professor Spenoe's later Posterior Incision. to the utmost, and, when the limb is brought down again after sawing, it will be found to be deeply buried among the soft parts ; as soon as the bone is divided all fuHher retraction must he avoided, lest the periosteum be stripped off the bone that remains, and lead to necrosis. The younger the patient the more necessary is this precaution, as the deep layer of the periosteum is more cellular and therefore less adherent in the young than it is in the old. The femoral artery will be found towards the inner side of the posterim- flap when the operation is properly performed, and should not, on any account, form part of the anterior flap ; the other vessels requiring ligature are the terminal 284 Applied Anatomy : branches of the profunda among the adductors, the descending branches of the external circumflex, the comes nervi ischiadici beside the great sciatic nerve, and probably branches of the anastomotioa magna. f > RESUME of Spence's amputation: — 1. Measure with the eye the half circumference of the limb. 2. Recognise the guides to the operation^ a point just above the femoral tuberosities ("condyles") for the bases of the iiaps, and lower margin of patella for its apex. 3. Sweep the knife through these points, forming a broad, square-shaped flap, with well-rounded angles. 4. Dissect up this flap from off the patella and front of the knee joint ; at the upper edge of the patella cut deeply and obliquely towards the femur. 5. Apply the edge of the knife to the skin on the posterior aspect, about three inclies below the base of the anterior flap, forming a convex flap, and then divide the tissues obliquely to the bone. 6. Retract the soft parts, clear and saw the femur a little way- above the condyles. Teale's Amputation (1856). — This is performed according to the rules given elsewhere. Measure the circumference of the limb at the point where the bone is to be divided, and then mark out the long flap, making its length and breadth each equal to one-half of the circumference of the limb. Trace out the inner longitudinal line flrst, making it as near as possible to the femoral vessels, without including them in the anterior flap. If the tissues are healthy, the anterior flap may be taken from the front of the knee joint and patella. The posterior flap is next marked out, and its length is to be one-fourth that of the anterior. The lateral incisions are first made, and must only go through the integumentary structures. The anterior flap will probably at first only consist of skin and fascia, but above the upper border of the patella it must include everything down to the thigh hone. The posterior flap is made by a single sweep of the knife down to the bone through muscles, vessels, and nerves. The bone is then cleared and sawn close to the base of the flaps. Surgical, Medical, and Operative. 285 3. The Circular op Modified Circular may also be used. In the modified circular two equal anterior and posterior semi-lunar flaps of skin are cut according to the method explained elsewhere ; they are then retracted to a distance equal to half the diameter of the limh, and the muscles divided obliquely down to the bone by a circular sweep of the knife. On account of the unequal retraction, the posterior muscles must be cut much lower than the anterior. All the tissues are then retracted, the bone cleared and sawn. 4. By Lateral Flaps (Vebmale). — He introduced this method because the muscles in this part of the limb are chiefly lateral, the central parts in front and behind being tendinous, and, therefore, if anterior and posterior flaps were used they would be thin and tendinous in the middle. Lateral flaps are not so, but have the disadvantages — (1) Of leaving the cicatrix over the end of the bone; (2) they are difficult to keep in position; (3) the bone tends to be tilted forwards by the psoas and Uiacus, and projects at the anterior angle of the flaps; just as the deltoid tilts the humerus in amputation through the middle of that bone by anterior and posterior flaps. It has one advantage, however, namely, that it provides a free exit for discharges during the process of healing. The limb is held as described under Spence's amputation, and the Surgeon in all cases stands on the outer side of the limb, and the outer flap is always to be made first, as it contains no vessels of consequence. The Surgeon grasps the soft parts on the outer side with his left hand, and draws them outwards, enters the point of the knife perpendicularly in the middle of the thigh, about three inches above the upper border of the patella, thrusts it downwards^ passing closely round the bone, and brings it out in the centre of the ham; the flap is then cut downwards and outwards. The knife is again entered at the upper angle of the incision, carried closely round the inner side of the bone, taking care not to transfix the femoral artery, and brought out through the lower angle of the first incision, and a flap cut equal in length to the external one. The limb is then elevated, the flaps retracted, the bone cleared, and the saw applied about four inches above the condyles. In certain cases where the tissues are damaged on one side only, it may be found advantageous to use the lateral flap method ; in other cases, however, it ought to be avoided. 286 Applied Anatomy: 5. Lister's Method. — See under " Ampittation of Middle and Uijpei Thirds of Thigh'' for description. 6. Skin Flaps. — This is hardly a separate method, but should be ado'pted in cases of malignant disease. The flaps should, if possible, be anterior and posterior, and are to be made by dissection, and the other tissues divided circularly above the diseased part. The posterior flap should be raised first, otherwise the bleeding from the anterior will embarrass the operator. The method of amputation by double transfixion is not usually adopted in the lower third of the thigh. The muscular flaps — the necessary result of this method — tend to retract too much and lead to protrusion of the bone ; the posterior one especially retracts, as the ha,mstrings are cut so far from their origin, and leave a gaping wound to heal by granulation. This is specially manifested when the limb is flexed^ the position of greatest comfort to the patient. For the Structures divided see next set of amputations. THE MIDDLE AND UPPER THIRDS. For the different methods of restraining lisemorrhage in ampu- tations through the ufper part of the thigh, see " Amputations at the Hip Joint." In amputating in these situations we must save as much as possible, for it is of more importance to preserve the life of our patient than to secure an artistic stump, and statistics show that every inch nearer the trunk increases the mortality. In all probability therefore the best method is the — 1. Modified Circular. — By this method we can secure the longest possible stump out of the structures at our disposal. The operator stands on the right side of the limb, and three - assistants are required — one seated in front of the patient, to support the limb below^ the seat of amputation, a second to support the thigh and retract the integument, and a third to command the femoral artery. The patient is brought well down towards the end of the table, and his other leg is secured to a leg of the operating table by a clove hitch. The two short skin flaps may be taken from the most convenient position; if it is a matter of choice, then make them anterior and posterior. Ketraet the flaps of skin and divide the muscles, Surgical, Medical, and Operative. 287 taking care that the posterior ones are divided at a lower level thau the anterior. Next retract all the tissues and saw the bone higher up. Lateral flaps are not good in the thigh as the hone tends to project at the upper angle between the flaps. In wasted and almost cylindrical limbs the ordinary circular, or "triple incision," may be adopted. In the Circulap IVlethod the operator stands on the outer side of the limb. One assistant supports the limb horizontally, while another encircles the limb with both hands above the seat of the amputation, and retracts the integuments ; and, in the living body, a third must compress the femoral artery against the brim of the- pelvis. In all cases of thigh amputations, the patient is laid upon his back, with his buttocks close to the edge of the table, the leg to be amputated projecting horizontally from it, and the other secured to a leg of the table. 2. Double Flaps by Transfixion. — The anterior flap must be equal in length to two-thirds of the diameter of the limb at the point of section of the bone; the posterior, half that length. The position of the patient and the assistants required are the same as in the previous operation, and the Surgeon stands, most con- veniently, on the right side of the limb. The assistant, standing opposite the operator, places the palm of his hand on the posterior part of the thigh to be amputated, so as to press up the soft parts and relax those in front. The operator then grasps and raises the anterior structures with his left hand and transfixes the limb an inch and a half below the point where the bone is to be sawn, passes the knife close in front of the bone and femoral artery (below the middle of the thigh), so as to give a broad flap, as nearly as possible equal to half the diameter of the limb. The knife "is again re-entered one inch helow the point of the first transfixion, lest the heel cross-cut the tissues at the angle, and the posterior flap cut from the back of the thigh. The assistant then raises the thigh and retracts the flaps, while the operator prepares the bone for the saw, about an inch and a half above the base of the flaps. In sawing the femur the linea aspera must be regarded as a separate and small bone, and the femur must, therefore, be divided in the same manner as the tibia and iibula, the sa-\v first entered well on the dorsal aspect of the bone. 288 Applied Anatomy : and tlien brought nearly vertical, so as to divide the linea aspera early. The assistant must at the same time support the leg evenly, so as neither to lock the saw nor snap and splinter the bone and to secure this the assistant should be directed to make gentle traction in the long axis of the bone being divided. After the bone is divided the assistant holding the thigh must avoid retracting the flaps any more lest the periosteum be stripped ofl^ the bone. The Anterior Flap may be raised by dissection, the first inch or so consisting only of the integuments, and its base an inch lower than the point where the bone is to be sawn. This flap is then retracted by the assistant and the Surgeon passes the knife beneath the bone, places his left hand under the muscular mass and cuts the posterior flap ; the knife is carried down parallel to the bone for some distance and then brought sharply out. The bone is then cleared for an inch higher up, and sawn. As regards the vessels divided — (1) The femoral vessels at any point below the middle of the thigh will be found at the inner side of the posterior flap ; above the middle of the thigh they will be at the inner side of the bone, and at the upper part they will be in front of the bone. (2) The termination of the deep femoral, towards the outer aspect of the posterior flap, close to the bone. Besides these (3) the perforating and (4) muscular branches may also require ligature. The position of the femoral artery matters but little, provided the operator takes care not to transfix it, which he is very liable to do about the middle of the thigh, but this can be avoided by not going too close to the femur on the inner side, and leaving the vessels to be divided by the circular incision (Heath). 3. Lister's Method. — The limb is held as in previous ampu- tations of the thigh, and the Surgeon stands on the right side of the limb to be amputated, as by so doing he can better raise the flaps with his left hand. He then makes two straight incisions through the skin and fat, along the lateral aspects of the limb parallel with its anterior surface, and each equal in length to two-thirds of the diameter of the limb. At the lower ends they are united by a transverse incision curved upwards at its extremities, where it joins the longitudinal ones. In this way a square-shaped flap is formed with well-rounded angles. Surgical, Medical, and Operative. 289 The knife is tlien passed round the back of the thigh at an angle of forty-five degrees to the axis of the limTj, marking out a short posterior skin flap ; the assistant then elevates the limb, and the posterior flap is dissected up at once (Mg. 59). By making the posterior flap of skin only there is but little danger of its retracting too much, as it is freed from the hamstring muscles. The anterior flap is next raised, and at first consists only of skin and fascia, but, as the bone is approached, a moderate amount of muscle is Fig. 59. Amputation of Hip and Thigh. Jordan's Amputation. (LiSTEE's Modification.) IjIster's Amputation. included. The assistant now retracts the soft parts, the knife is swept circularly through the muscles so as to expose the bone about two inches above the angle of the flaps, where the saw is applied and the bone divided secundum artem. It has been suggested by M'Gill that two short periosteal flaps should be cut to cover in the end of the bone : the flaps are cut, held aside, and the bone divided, and then the flaps brought over the sawn surface. T 290 Applied Anatomy: RESUME of Listee's amputation through the middle of the thigh : — 1. Make internal and external lateral incisions, each equal to two-thirds of the diameter of the limb, from a point about two inches below the point where the bone is to be divided. 2. Join the lower ends across the front of the thigh, forming a square-shaped flap with well-rounded angles. 3. Shape the posterior flap, making it fully half the length of the anterior, cutting at an angle of forty-five degrees to the axis of the limb. 4. Eaise both flaps to the upper limit of lateral incisions. 5. Then retract all the tissues for fully an inch, clear the femur, and saw it. After the periosteum has been divided, do not pull back the flaps any move ; and in sawing the bone direct the assistant to make gentle traction in the axis of the limb, to avoid splintering. External Cutaneous Nerve. Fig. 60. Section through the Thigh. Anterior Crural Nerve. \ Femoral and Profunda VesseU. Great Sciatic Nerve and Vessels. :'-"ii!a [^Small Sciatic Nerve. The names of the Muscles are indicated by their initial letters. Surgical, Medical, and Operative. 291 In amputations through the thigh, the following Structures are divided, speaking generally (Fig. 60): — ^1. The integumentary coverings. 2. Muscles — (a) The quadriceps extensor cruris, (6) the sartorius, (c) the adductor longus, (d) the adductor magnus, (e) the gracilis, and (/) the hamstrings. 3. Vessels — (a) The femoral vessels (about this point these will he found at the inner side of the posterior flap) ; (6) the profunda vessels with the perforating branches (these will also be found in the posterior flap, close to the posterior surface of the femur) ; (c) the long saphenous vein, and branches of the external circumflex ; and (c?) the comes nervi ischiadici. The position of the femoral will vary with the point of section ; for, as has already been pointed out, the vessel as it passes down the thigh gradually inclines from the anterior to the posterior aspect of the bone, so that it may be found at some parts in the inner side of the anterior flap. 4. Nerves — (a) The great sciatic; and also small branches of- — (Z>) the obturator, (c) the anterior crural, (d) the small sciatic, and (e) the external cutaneous. 5. The femur. AMPUTATION AT THE HIP JOINT. As haemorrhage is one of the most serious dangers of this operation, various measures are employed, or have been suggested, to overcome this danger : — 1. Lister's or Panooast's Aortic Tourniquet. — Previously this was the method usually adopted, but, as Lister himself points out, it has two defects — 1. On account of the occasional devia- tion of the arota from its median, or almost median, position, the adjustment of the pad, and its retention when adjusted, is rendered a diificult matter, and it is apt to slip to one side, and in order to prevent this the constant attention of a very trustworthy and steady assistant is required. 2. The Surgeon, especially if inexperienced and nervous, is apt to screw down the pad too tightly and damage the intestines and peritoneum ; a soft hollow sponge placed under the pad will, to a certain extent, prevent this. It is compressed immediately above its bifurcation, a little above and to the left of the umbilicus, as the aorta bifurcates a little to the left and telow the umbilicus, or on a level with the highest points of the iliac crests. 292 Applied Anatomy: 2. Esmarch's Elastic Tourniquet, applied to the Aorta.— A pad of sufficient size is adapted over the aorta, a little above the highest points of the iliac crests, and pressed down by elastic bands. To avoid circular compression of the body, a narrow piece of board, or some such contrivance, is placed transversely beneath the back and made to project beyond the sides of the body; lateral notches are made in it, or hooks are attached to it, at a sufficient distance to protect the sides from com- pression, and at the same time to serve to fix the elastic bands. EsMABCH himself recommends, in absence of any other instru- ment, the following plan : — A common roller bandage, about two and a half inches wide and eight yards long, is to be rolled round a stick about the thickness of- the thumb, and nine inches long. The pad thus formed is held in proper position by the ends of the stick, while several turns of elastic bandage are passed round the body, so as to press it forcibly against the spine. An assistant keeps the pad in proper position by means of the stick. An objection to this plan (and all plans) of elastic compression is, that should the patient vomit, cough, or struggle, the forcible contraction of the abdominal muscles lifts the pad from the avota and relaxes the compression. 3. Esmarch's Elastic Tourniquet, applied to the Extreme Upper Part of the Thigh. — The limb is emptied of blood by vertical elevation for a few minutes, and then an elastic band, strong enough to require the whole strength of the Surgeon to stretch it twice its length, is applied. A piece of bandage is first laid upon the middle of the groin in thei line of the limb, and a similar piece placed behind, well below the great trochanter, over which the tube is to be applied. These are to be held by an assistant, who thus prevents the band from slipping downwards over the flaps during disarticulation j the assistant must be warned not to pull too hard lest he stretch the elastic band and thus raise it off the vessel. The scrotum being held aside, the middle of the tube is then placed against the perineum, between the anus and the tuber ischii, and the ends pulled forcibly and crossed as high above the trochanter as possible, and afterwards carried round the body immediately below the iliac crests. If the elastic baud is applied firmly enough, it is not necessary to have a pad over the Surgical, Medical, and Operative. 293 artery. The front part of the band passes parallel with Poupart's ligament and compresses the artery against the pelvic bone, the posterior turn runs across the great sciatic notch and compresses the vessels passing through it — especially the sciatic and gluteal. This is the method chiefly to be recommended in what is known as Jordan's amputation at the hip joint, or its modifications. 4. Davy's Lever. — This is used to compress the common iliac artery, as it lies in the groove between the last lumbar vertebra and the psoas muscle. It is a smooth, round, wooden "lever," shaped like a poker, and about two feet long. Two ounces of olive oil are first injected, and the lever is then passed into the rectum sufficiently far to permit its point to press the vessel at the spot mentioned, while the other end is carried towards the thigh of the opposite side and its handle raised, when it acts as a lever of the first order, the anus being the fulcrum. Two precautions are necessary in the use of this instrument — 1. It must not be used where the coats of the rectum are diseased, as it may easily perforate them and lead to a fatal result. 2. In cases where the meso-rectum is abnormally short it may be impossible, without unnecessary force, to compress the artery on the right side. 5. By a Steel Skewer. — "A long sharp-pointed steel skewer is passed across the upper part of the limb well behind the great vessels. A piece of india-rubber tubing is applied in the form of figure-of-eight, so as to constrict the parts on the posterior aspect of the limb, and then a separate piece of tubing is applied so as to constrict the textures on the anterior aspect, so that the circulation is thus completely commanded " (Spenob). 6. Digital Compression of the femoral artery as it lies on the ilio-pectineal eminence. The assistant stands on the side of the patient on which the vessel is to be compressed, and grasps as much of the limb as possible with both hands, fixing the tips of the fingers of the one hand below the adductor muscles, and those of the other on the posterior border of the great trochanter, while the thumbs are placed one above the other over the vessel as it lies on the above-named prominence of bone. In the antero- posterior flap amputation this assistant must be prepared to follow the knife into the first incision and grasp the flap firmly, so as to compress the femoral artery before the knife cuts its way out. 294 Applied Anatomy : Anterior and Posterior Flaps (long anterior and sliorter posterior). — The patient must be brought well forwards upon the end of the table, so that the nates project beyond it, and he is further to be steadied by strong bandages — one passed between the sound thigh and the perineum and attached to the upper end of the table ; another is to be carried across the pelvis to the lower end, and the sound limb is to be tied to a leg of the table. Three special assistants are required — No. 1 has to take charge of the aortic tourniquet ; No. 2 compresses the femoral artery against the brim of the pelvis, and follows the knife and secures the artery in the anterior ilap ; and No. 3 takes charge of the limb. A long amputating knife, with a blade at least twelve inches long, is necessary, and it is well to have a pair of lion forceps and periosteum elevators at hand. The doubtful advantages of this method are its simplicity, ease, and rapidity of performance, and, should the patient survive, a shapely stump. Formerly rapidity of execution was chiefly trusted to, to diminish the risk of shock and loss of blood. In many cases the rapidity was surprising; the late Professor Spencb states that he has completed disarticulation in one case in ten seconds, in another in fifteen seconds, and even in complicated cases in less than thirty seconds ! The landmarl In effusion into the joint, Surgical, Medical, and Operative. 383 as in Acute Synovitis, the swelling is best seen on the dorsal aspect of the wrist, showing a general fulness, and some bulging between the tendons. The pain is very acute, and, as the joint is so superficial, there will be heat and redness j it is fixed in, a slightly-flexed position, and any attempt at movement causes great pain. When, however, the wrist joint is firmly fixed, the fingers may be moved without causing pain; this shows that the inflammation is not in the sheaths of the tendons {tenosynovitis). But if, on the other hand, when the wrist joint is fixed, the move- ments of the fingers give rise to pain, there is strong reason for believing that the synovial lining of the sheaths of the tendons is inflamed. The wrist joint may be dislocated — 1. Backwards. 2. Forwards. The usual cause is a fall on the palm, or by the hand being bent forcibly backwards. 1. Bacl Other useful Measurements in injuries of the lower extremity are : — (1) The total length of the limb from the anterior superior iliac spine to the tip of either malleolus. (2) The length of the thigh, from the same point to the upper edge of the patella, ; or to the adductor tubercle. (3) The length of the leg, from the upper edge of either tibial condyle to the tip of the corresponding malleolus. Surgical, Medical, and Operative. 393 THE BACKWARD DISLOCATIONS. > 1. Upon the Dorsum ilii. — In dislocation on to the dorsum ilii (backwards and upwards), which is the most common form, the limb is shortened one or two inches, the knee is inverted, sHghtly flexed, advanced, and adducted, and rests against the lower third of the opposite thigh, and the great toe rests on the upper surface of the tarsus of the opposite foot j the heel is a little raised, and the thigh is flexed, and there is a great bulging at the hip from the projection of the great trochanter, which is directed forwards, and lies nearer the anterior superior iliac spine than natural. There is marked fixedness of the joint, and the head of the bone rests on the Uium, a little above and behind the acetabulum, under the glutei muscles. It is made to lie at this point partly by the force causing the dislocation, but is also pulled up by the glutei, hamstrings, and adductor muscles. Abduction and eversion are impossible, but there is still a slight amount of inversion, adduction, and flexion possible. Another symptom, first noted by Syme, is that if the patient be laid flat on his back on a hard couch or table, the knee of the dislocated side is raised, but the patient's back rests evenly on the table ; but if the knee be brought down flat on the table there is a marked lumbar curve produced, just as in hip joint disease. On pressing the fingers into the groin it will be found that the femoral vessels have lost their firm posterior support and seem to lie over a' hollow; when compared with the sound side, the sense of lessened resistance is very marked. The short muscles covering the joint behind are much lacerated; the ilio-psoas muscle is very tense, and the pectineus may be torn as well as the glutei. According to Bigelow, the head of the bone passes between the tendon of the obturator internus a,nd the innominate bone, and finally comes to rest above that tendon ("backward dislocation above the tendon "). This dislocation is caused when the limb is in the position already explained (abduction, flexion, and internal rotation), and the patient receives a blow on the back, the result being either a dislocation or a fracture of the shaft of the femur, as in miners ; it may also occur when a person is carrying a heavy weight and falls down. 394 Applied Anatomy: 2. Into the Sciatic Notcli (backwards). — The Symptoms of this form resemble very closely those of the previous dislocation, only they are less marked — it is simply a less advanced form. The limh is shortened about half-an-inch, the knee is inverted and touches the opposite knee, but does not tend to cross over it, and the ball of the great toe rests on the head of the metatarsal bone of the great toe of the opposite foot. There is less flexion and less bulging at the hip than in dislocation on to the dorsum ilii. The head of the bone rests, not in the sciatic notch, as the name would imply, but on the back of the ischium, opposite, or a little above, the level of the spine, and below the tendon of the obturator internus muscle (" haclaoard dislocation below the tendon"). This dislocation is produced when the limb is in the same position as in the last form, but with greater flexion and internal rotation. The backward dislocations must also be distinguished, from — (1) Fracture of the necJc with inversion. In ordinary cases of frac- ture there is usually marked eversion, which at once distinguishes it from ordinary forms of dislocation. This form of fracture is rare, and the increased mobility, the extension of the limb, the marked loss of power, the pain, and the existence of crepitus will aid the diagnosis. (2) Impacted extra-capsular fracture, loith inversion. Here the limb will probably be extended; Bryant's line shortened from half to one inch, approximation of the great trochanter to the middle line, as shown by the " bitrochanteric " measurement. There will be great pain over, and probably broad- ening of, the great trochanter, but the joint will permit movement freely in all directions, though the great trochanter will not move in so large a circle as on the sound side. Further, there will be the usual feeling of resistance in the groin behind the femoral vessels, but on pressing the hand against the outer side of the thigh the ilio-tibial band will be found to be less tense than on the sound side. Great care is necessary in performing th-ese manipulations, lest an impa£ted fracture be converted into an unimpacted one. Reduction of Baclcward Dislocations by Manipulation.— The great object is to make the head of the bone pass back to the acetabidum in exactly the same direction as it left that cavity, and, therefore, the limb must be put into the same positions as that in which the dislocation occurred — viz., flexed, abducted, and rotated Surgical, Medical, and Operative. 395 outwards. The success of the method depends on the integrity of the ilio-femoral band ; it is to act as the fulcrum of the lever, of which the shaft of the femur below it is the long arm, while the: part above it is the short arm. The manipulations are — (1) Flex the leg on the thigh to relax the hamstrings, and the great sciatic nerve, if need be, and also ilex the thigh upon the abdomen, carrying it at the same time into a position of adduction, so as to relax the untorn part of the capsule. (2) Circumduct outwards (a combination of abduction and external rotation) so as to render the Y-ligament tense, and distend the rent in the capsule ; also to make the head pass round the way it came, and turn it through the opening in the capsule. (3) Quickly extend and bring the limb to the side of its fellow, so as to make the head pass at once into the deepest part of the acetabulum. When the dislocation is reduced the legs may either be tied together with a pillow between the knees, or the long splint applied. The splint is to be kept on for a week or ten days, and after this the joint should be supported by some fixed apparatus, as a leather splint or a plaster of Paris spica, for two weeks longer. THE FORWARD DISLOCATIONS. 1. Into the Foramen Ovale (fm-wards and downwards). — The head of the bone rests in the thyroid foramen. Causes. — Sudden and violent abduction, unaccompanied either by external rotation, or fixed flexion or extension ; jumping or falling from a height, with the feet widely apart, as sliding over the end of a loaded waggon or cart ; or the sudden movement of a carriage, when one foot is on the step and the other not yet off the ground; and also getting out of bed quickly, when one foot is caught in the bed-clothes, while the other descends suddenly to the floor. The pectineus, gracilis, and adductors longus and brevis are torn, and the psoas, iliacus, glutei, and pyriformis are put on the stretch ; the ligamentum teres and capsule are ruptured as before. The obturator nerve is stretched or torn. Symptoms. — The limb seems lengthened, the toes point downwards and are a little everted, and the foot is separated some distance from the other one — the thigh being flexed and abducted, and in front of the opposite one, 396 Applied Anatomy : on account of the tension of the ilio-psoas muscle. The hip is flattened, the prominence of the great trochanter absent, and the gluteal fold is lowered ; the head of the bone may be felt under the adductor muscles. The apparent lengthening is believed to be due to a tilting of the pelvis over to the injured side; to make quite certain whether it is lengthened or not, the use of Bryant's test, or careful measurements must be made from the anterior superior iUac spine to some fixed bony point in the limb, 6.g., the tip of the internal malleolus. The movements of adduction and extension are impossible without using great force, and giving rise to severe pain from pressure on the obturator nerve; the limb, however, may still be flexed. 2. Upon the Pubes (forwards and v,pwards). — The head of the bone rests on the ilium, rather than the pubic bone, close to its junction with the horizontal ramus of the pubes and on the outer side of the femoral artery. It is caused by violence similar to that producing the thyroid variety ; but where extension and external rotation of the limb accompany the application of the violence. Symptoms. — The limb is shortened and abducted, and there is marked eversion of the foot and knee, and the heel inclines towards the opposite one. The great trochanter lies nearer the middle line than the anterior superior spine. The limb cannot be rotated inwards, but may be slightly flexed. There is sometimes pain and numbness down the thigh from pressure on the anterior crural nerve, and congestion and oedema from pressure on the vessels. This form is said to resemble fracture of the neck of the femur; but it may be distinguished from this by the greater immobUity, and by the situation of the head of the bone in the groin. Reduction of the Anterior Dislocations. — (1) Flex the leg upon the thigh and the thigh upon the abdomen, as in the previous dislocations, but, at the same time, abducting the limb. (2) Circumduct inwards {i.e., adduct and rotate inwards) until the knee is brought nearly to the middle line of the body; these movements relax the rent in the capsule, render the Y-ligament tense, disengage the head of the bone, and bring it round to the opening by which it escaped. (3) Extend and rotate outwards, so as to make the head of the bone re-enter the acetabulum. Surgical, Medical, and Operative. 397 THE IRREGULAR FORMS. There are many irregular forms of dislocation, and in all some part or the whole of the Y- ligament is torn through. The following are a few of the better marked varieties : — 1. The Everted Dorsal. — This has all the usual signs of dorsal dislocations, except that there is eversion instead of inversion, and there is but slight adduction and the limb may be extended. It is supposed by some that the outer band of the ilio-femoral ligament is ruptured. 2. The Supra-Spinous. — The limb is shortened to the extent of two or three inches, a little abducted and everted, and the head of the femur is felt just below the anterior superior spine of the ilium, above and to the outer side of the ilio-femoral ligament. As in the last form, the outer head of the ilio - femoral ligament is believed to be torn. 3. The Subspinous. — The hip is flattened, Bbtant's line is shortened about two inches, there is extreme eversion and the head of the femur is found below the outer part of Poupart's ligament, a little to the inner side of the anterior inferior iliac spine. 4. In the Perinseum. — This occurs when the limb is greatly .abducted at the moment the violence is applied. There is extreme abduction and marked flexion, and the head of the femur can be felt in the perinseum. The foot may be either inverted or everted. THE KNEE. The Knee Joint. — GIosb, Diarthrosis; Sul-Glass, Ginglymus. The Bones entering into its formation are — 1. The Femur, with its trochlear surface, which is highest and most prominent on the outer side; and the articular surfaces of the Condyles, of which the inner is the more elongated from before backwards. 2. The Tibia, with its two surfaces, of which the internal is the longest, narrowest, and deepest — the external being the reverse. 3. The Patella, with its seven facets. The Synovial Membrane is the largest in the body. It forms a large cul-de-sac beneath the extensor muscles of the thigh, extending upwards for one or two inches above the articular surface. At the sides it passes beneath 398 Applied Anatomy: the vasti and ascends higher on the inner than on the outer side of the limb beneath these muscles (being the reverse, therefore, of the articular surfaces); it also covers the lateral aspects of the tuberosities of the femur for about half their extent, extending further back on the inner condyle. This large pouch is supported during the movements of the joint by the sub-cruieus muscle, which is inserted into its upper part. Above the pouch there is some- times an independent bursa extending upwards for another inch, but very often it communicates with the cavity of the knee joint. The membrane also covers both surfaces of the semi-lunar cartilages, and on the back part of the external one sends a tubular prolonga- tion round the tendon of the popliteus muscle for some distance. It further surrounds the crucial ligaments by tubular prolongations, lines the whole interior of the capsule, and lastly very frequently extends into the superior tibio-fibular articulation. The Arteries are seven in number — anastomotica magna, five branches from the popliteal artery, and the recurrent branch of the anterior tibial. The Nerves are nine in number — branches from the obturator, from the nerve to the vastus externus, and from the nerve to the vastus internus (both from the anterior crural), three from the in- ternal popliteal, two from the external popliteal, and the recurrent articular from the termination of the same nerve. The Ligaments of this joint are very numerous, and are divided into internal and external sets. External Ligaments. — 1. The internal lateral, a broad flat band, from the back part of the inner tuberosity of the femur to the inner tuberosity and upper part of the shaft of the tibia. Beneath it pass the inferior internal articular vessels. 2. The external lateral — the long part, passing from the back part of the outer tuberosity of the femur to the outer part of the head of the fibula. It pierces the tendon of the biceps, and under it pass the tendon of the popliteus and the inferior external articular vessels. The short part is more posterior, and is attached below to the apex of the styloid process of the fibula. 3. The posterior ligament, or ligament of Winslow, a broad flat band principally derived from the tendon of the semi- membranosus. 4. The ligamentum patellae, the continuation of the tendon of the quadriceps extensor cruris, passing from the apex of the patella to the lower part of the tubercle of the tibia ; between Surgical, Medical, and Operative. 899 it and the upper part of the tubercle is a small bursa, and a large mass of fat (the infra-patellar pad) separates it -from the synovial membrane of the knee joint. 5. The capsular, which is a strong fibrous membrane filling up the gaps left by the other ligaments, and is strengthened by fibres from the various muscles surrounding the joint. Interior Ligaments. — 1. Crucial, anterior and posterior — (a) The antero - external is attached below to the ianer part of the pit in front of the spine of the tibia ; above, to the inner and hinder part of the external condyle of the femur. Its direction is upwards, backwards, and outwards ; it is rendered tense when the joint is extended, when the leg is rotated inwards, and in cases where the tibia tends to be displaced forwards, {h) The postero- internal is attached below, to the back of the pit behind the tibial spine; above, to the fore-part of the inter-condyloid hollow and side of the inner condyle. Its direction is upwards and a little forwards; and it is made tense under conditions opposite to those that tighten the anterior ligament. 2. The semi-lunar cartilages — (a) The internal forms almost a semi-circle, and embraces the ends of the external. Its anterior end is attached to an impression towards the front part of the internal articular surface; its posterior end is attached to the inner edge of the hollow behind the spine of the tibia along with the posterior crucial ligament. (&) The external forms about three-fourths of a circle, and its anterior and posterior ends are interposed between the attachments of the internal cartilage, in front of, and behind the spine of the tibia ; this cartilage is more movable than its fellow and less firmly attached to the head of the tibia. 3. The transverse ligament, which passes between the two cartilages. 4. The coronary liga- ment, which connects the convex borders of the cartilages with the head of the tibia. 5. The ligamentum mucosum, which is simply a process of synovial membrane. 6. The ligamenta alaria, its fringed borders. The following Structures are found upon the Head of the Tibia from before backwards (I"ig. 76): — (1) Transverse ligament; (2) anterior extremity of internal semi-lunar cartilage; (3) anterior crucial ligament; (4) anterior extremity of external semi -lunar cartilage; (5) posterior extremity of external semi-lunar cartilage; (6) posterior extremity of internal semi-lunar cartilage; and (7) the 400 Applied Anatomy : posterior crucial ligament. The key to the position is to remember that the internal cartilage embraces both ends of the external, and that the anterior crucial is placed between the two anterior ends, but the posterior is behind both the posterior ends. Fig. 76. Head of Left Tibia. Transverse Ligament ^ ^^ — ^ ^^^"*^*^^^p^^ -^— Anterior Crucial ^ ^^"^ \ Ligament. External Semi-lunar I I Cartilage _l I — Internal Semi-lunar I I Cartilage. Posterioi' Crucial ^ ^^ ^^ ^^? ^^ Ligament -^^*^^^- €^^<^^^^^ The Movements of this joint are in some respects peculiar: — 1. It is not a pure hingesTJoint, but has in addition a gliding and rolling movement. In these movements the semi-lunar cartilages (which may be regarded as inter-articular fibro- cartilages) form movable and accurately fitting wedges. It is of great practical importance to keep this gliding movement in mind in the case of distortion of the joint due to strumous arthritis; in this disease the joint becomes markedly flexed, the tibia lying against the posterior part of the condyles having glided backwards. For this reason forcible straightening can do no good, unless in recent • cases, as it will not restore the bones to their normal position, the tibia retaining its backward displacement, even after the leg is straightened. 2. The movement is through an oblique plane, the axis of the femur is downwards and inwards, but when the leg is flexed it is parallel with the thigh. 3. There is a move- ment of rotation at the completion of extension which is called the "locking" or "screwing honie" of the joint. 4. When the knee is partly flexed, the joint admits of internal and external rotation. Another point worthy of notice is the movements of the patella on the articular surface of the femur. This is a move- ment partly of gliding and partly of co-aptation. The patella has seven facets on its articular surface — three pairs, and one internal Surgical, Medical, and Operative. 401 perpendicular facet. When the knee is extended, as in the erect position, the two inferior facets are in contact with the upper part of the trochlear surface of the femur; in semiflexion, the middle facets come into contact with the femur; in still greater fl.exion, the superior pair are brought into contact; while in extreme flexion, the patella leaves the trochlear surface of the femur altogether, and the internal perpendicular facet then lies in contact with the outer margin of the inner condyle. Further, at the completion of extension, there is a slight rotation outwards to " lock " the joint ; and, at the heginning of flexion, there is a slight rotation inwards of the leg and foot to " unlock " it. The centre of gravity of the body, in the erect attitude, falls in frord of the axis of motion of the knee joint, and there is a tendency, therefore, to over-extension ; but this is impossible, because of the tension of the lateral, posterior, and anterior crucial ligaments (the posterior crucial being tightened in flexion). In this way the erect attitude is maintained without the expenditure of muscular energy. Professor Humphry states that the semi-lunar cartilages do not follow the tibia in the move- ments of rotation (pronation and supination), these movements taking place between the head of the tibia and the cartilages, while the chief movements of the joint take place between the femur and the cartilages. This probably explains the production of the "Internal Derangement of the Knee Joint," which is usually produced during some sudden wrench of the leg, that is of the tibia on the femur, or of the femur on the tibia. Flexors. — Direct — (1) Biceps, (2) semi-tendinosus, (3) semi-membranosus, and (4) popliteus. Indirect — (1) Gastrocnemius, (2) plantaris, (3) sartorius, and (4) gracilis. Extensors. — Quadriceps extensor cruris (formed by the two vasti, the rectus femoris and the crureus). External Rotator. — (When the limb is partly, flexed) — The biceps as a whole, but especially its short head. Internal Rotators. — (1) The popliteus — (this is the chief one, but it only acts when the knee joint is flexed, and the tendon of the popliteus lying in its groove), (2) semi-tendinosus, (3) semi-membranosus, (4) sartorius, and (5) gracilis. To lock home the joint at the completion of extension — The extensor muscles as a whole cause a slight rotation outwards. To unlock the joint at the commencement of flexion — (1) The sartorius, (2) gracilis, and (3) semi-tendinosus. 2c 402 Applied Anatomy: The different movements of the joint are limited in something like the following manner : — Flexion is checked hy the contact of the- soft parts of the leg and thigh; hut during this movement the posterior crucial ligament and the ligamentum patella are also tightened, hut all the other ligaments are relaxed. Extension is limited hy the lateral, the posterior ligament, and the anterior crucial; during this movement the j)osterior crucial and ligamentura patellse are relaxed. "When the limb has been brought into a straight line, over-extension is mainly checked by the tension of the posterior crucial and posterior ligaments. Forcible over-extension of the joint may rupture the posterior crucial, e.g., when the leg is supported horizontally on a chair and some heavy weight falls forcibly upon the anterior aspect of the knee. Internal rotation, or pronation (in the semi-flexed position of the knee), is checked by the anterior crucial ligament. External rotation, or supination, is checked by the posterior crucial. The crucial ligaments are also important agents (probably the chief) in the prevention of lateral movements of the joint; hence, in cases where the bones move laterally in the extended position of the limb, there is good reason to believe that the crucial ligaments are destroyed. In effusion into the joint, as in Acute Synovitis, the swelling assumes a horse-shoe sliajje, and first shows itself at the sides of the ligamentum pateUee, because at these points the synovial membrane is least supported and nearest the surface. The swelling gradually extends upwards under the quadriceps extensor, to the extent of two or three inches above the upper border of the patella, the swelling being higher on the inner than on the outer side of the limb. Fluctuation is readily detected by placing the fingers and thumb of one hand over the pouches at each side of the ligamentum pateUse and pressing on the large supra-patellar pouch with the other; and if there is much fluid the patella is floated up off- the surface of the femur, and by firm, sudden pressure it may be made to tap against it, provided the fluid is not in too small quantity, or if in large quantity, not too tense, and that the quadriceps extensor is relaxed. This floating of the patella is a very valuable sign of effusion into the joint, and may be detected' before either fluctuation or swelling is very evident. To obtain this test the knee must be extended aud the hip iiexcd to relax the quadriceps extensor and allow the Surgical, Medical, and Operative. 403 patella to lie free; in cases where the amount of effusion is small, the large pouch above the patella should be emptied by pressing over it with the palm of the hand, as this will press what fluid there is more directly under the patella. The position of the limb is one of moderate flexion, combined with external rotation of the head of the tibia, as in this position the cavity holds most fluid, and it, at the same time, relaxes the more powerful ligaments of the joint (posterior ligament, posterior crucial, and lateral ligaments). Should, however, the joint remain long in this position, there is a tendency for the head of the tibia to be partly dislocated backwards and rotated outwards, from the continued action of the hamstrings, conjoined with softening and yielding of the crucial and lateral ligaments ; and for the same reasons there will be shght lateral movement of the joint. In eifusion into the prepatellar bursa (Housemaid's Knee) the swelling does not assume the shape of the synovial cavity, but forms a prominent globular swelling in front of the pateUa, thus obscuring it; whereas, in synovitis, this bone can readily be felt surmounting the swelling. Above the synovial pouch of the knee joint there is very frequently a separate bursa about an inch long, between the quadriceps and the femur, and which may become filled with effusion, but without affecting the knee joint; very frequently, however, it communicates with the synovial membrane of the knee joint. The following muscles act on both Hip and Knee Joints: — (1) The biceps, (2) the semi-membranosus, (3) the semi-tendinosus, (4) the rectus femoris, (5) the sartorius, (6) the gluteus maximus (through the ilio-tibial band), (7) tensor fascise femoris (through the ilio-tibial band), and (8) the gracilis. It is evident, therefore, that in disease of either the hip or knee joints, both will require to be kept rigid, in order that the diseased one may be at rest. There are three circumstances which tend to make the knee joint insecure — (1) The configuration of the articular surfaces of the bones; (2) the fact that it is between the two longest bones in the body, and, therefore, powerful leverage is brought to bear upon it; and (3) its great mobility. Nevertheless, dislocation of this joint is rare, its great strength being due to its very powerful ligaments. 404 Applied Anatomy : DISLOCATION OF THE KNEE JOINT. This is a rare form of accident, for reasons already stated, and when it does occur, it is usually complicated with such injury to the popliteal vessels as to necessitate amputation. Other complica- tions are also likely to arise from the force required to dislocate it, such as rupture of ligaments and muscles, and gangrene may result, or the Joint may fall into a state of suppurative or destructive inflammation, so that dislocation of the knee joint is more liahle to complications than any other joint. Diastasis of the condyloid part of the femur in young children may resemhle dislocation of the knee joint. It may he dislocated to either side forwards or backwards. 1. The Lateral dislocations are most common and always in- complete, and usually combined with a certain amount of external rotation, due to the action of the biceps. One or other condyle slips over to the opposite half of the tibial surface ; the knee is always slightly flexed. To reduce, flex the thigh on the abdomen, extend the knee, and rotate slightly. 2. Backwards. — This may be either complete or incomplete. If complete, the ligamentum posticum and the posterior crucial ligament are ruptured; the limb is shortened and semiflexed, and" the head of the tibia can be felt in the ham. 3. Forwards. — This form occurs more frequently than the last- named dislocation. It is more dangerous also, from pressure on the popliteal vessels by the lower end of the femur, which is found projecting into the popliteal space. There is shortening of the limb and a certain amount of rotation. To reduce, the thigh is semiflexed and held firmly by one assistant, while another makes extension from the ankle joint, and the Surgeon manipulates the bones into position. In all cases of dislocation, the joint must be kept at rest for two or three weeks by lateral splints. In cases which resist all the ordinary means of reduction, division of the lateral ligaments has been practised. 4. "Subluxation" of the Knee (Hey's "Internal Derangement of the Knee Joint. ") — It is due to partial dislocation of the internal semi-lunar cartilage usually; the cartilage slips away from its proper position under the internal condyle, so that the surfaces of the Surgical, Medical, and Operative. 403 tibia and femur are brought into direct apposition. Cause. — The displacement of the internal cartilage is caused either by a wrench outwards of the foot, or, the foot being fixed, of the body inwards ; and the external is displaced by movements of an opposite nature, i.e., a wrench of the foot inwards, or of the body outwards. There is sudden, severe, sickening pain felt in the knee, and the joint remains semiiiexed. The edge of the cartilage can sometimes be felt projecting under the skin. To reduce, flex the joint, and when the patient is off his guard, forcibly extend, rotating slightly, either to the inner or the outer side, and at the same time press the thumb firmly on any tender spot. When the cartilage is reduced the power of extending at once returns. The synovitis induced by the accident must be treated on general principles; after it has subsided the leg must be used freely. This condition must be distinguished from that due to a loose body in the joint. Displaced Cartilage. 1. In the first instance is caused by some sudden wrench or twist when the knee joint is partially flexed. 2. May feel a hollow or projection over the displaced cartilage, and the pain always felt at the same spot. 3. Passive movement is easy, short of extreme limits. 4. When any projection can be felt, matters have gone wrong in the joint. 5. Is a chronic condition. 6. Eadical Cure. — Some means to prevent pronation and supina- tion of the joint for a long period till the cartilage adheres to the head of the tibia again. In suitable cases Mr Annandale opens the joint and stitches the displaced cartilage to the head of the tibia. Loose Body. 1. The impaction of a loose body occurs during the ordinary move- ments of flexion and extension. 2. The loose body cannot be felt when impacted, and the site of the pain may vary from time to time. 3. The joint is locked and rigid. 4. When the loose body is felt exter- nally, the joint is all right. 5. Is always acute. 6. Radical Cure. — Removal of the foreign body through a direct incision into the joint with strict antiseptic precautions. Before making the incision the "body " should be transfixed with a long needle, otherwise it may slip away into the cavity and cause much trouble. 406 Applied Anatomy : THE PATELLA. This bone may be dislocated : — 1. Outwards. — Tbis is the most common form, from the slope of the femur and quadriceps extensor, which pass downwards and inwards, making an angle with the ligamentum patellae, which passes vertically downwards. "When, therefore, the quadriceps is suddenly brought into play it tends to assume a straight line with the ligamentum patellae, and jerks the patella itself outwards. The causes, therefore, are sudden muscular contraction, especially in those who have a tendency to knock-knee, or a blow on the inner side of the patella during extension — a similar blow during flexion would cause fracture. The patella rests on the outer surface of the external condyle with its inner margin directed forwards. The leg is usually slightly flexed; very frequently the dislocation is only partial. 2. Inwards. — This form is almost unknown. To reduce lateral dislocations— Place the patient on his back, flex the thigh on the abdomen, and extend the knee joint, so as to relax the quadriceps extensor, and then depress the edge of the patella which is further from the middle line, so as to raise the other edge and free the bone, when the quadriceps will at once pull it into position. 3. Vertically. — Usually the outer (Malgaigne), sometimes the inner edge, of the patella is twisted into the inter-condyloid notch, and there fixed. The joint is completely extended. It is usually caused by sharp blows or severe falls on one side of the patella. To reduce is often a difficult matter, probably from the wedging of the bone in the notch, or else from its being held by a slit in the capsule. Chloroform will be necessary, so as to paralyse the muscles, when flexion, combined with sudden extension and rotation of the tibia, will probably replace the bone. Division of ligaments and tendons should be avoided, as the division does no good, and may do a great deal of harm. 4. U pwards. — This can only occur when the ligamentum patella3 is ruptured, or torn from its attachment, when the quadriceps extensor pulls the bone upwards. It may also be displaced downwards, from rupture of the quadriceps extensor. The Treatment is the same as that for fractured patella (quod vide). Surgical, Medical, and Operative. 407 THE ANKLE. The Ankle Joint.— Ctes, Diarthrosis; Sub-Glass, Ginglymus. Ligaments — (1) The anterior, (2) posterior — these two are very thin; (3) internal lateral or deltoid, from the apex of the internal malleolus to the scaphoid, os oalcis, and astragalus; and (4) external lateral, -vvhich consists of three strong fasciculi — (a) the anterior passes from the anterior part of the external malleolus to the front part of the astragalus ; (6) the middle passes from the tip of the external malleolus to the outer surface of the os calcis; and (c) the posterior passes hackwards horizontally from the pit on the inner side of the malleolus to the posterior surface of the astragalus. The Nerves of the joint are derived from the internal saphenous and anterior tibial. The first is derived originally from the lumhar plexus, the second from the sacral. Movements. — The movements at the ankle joint are chiefly flexion, and extension, and dorsiflexion. The normal position of the foot is supposed to be at right angles to the leg ; extension is pointing the toes, flexion is bringing the foot back again to a right angle, and dorsiflsxion is when the foot passes the right angle and its upper surface approaches the front of the leg. There is also a certain amount of movement from side to side when the foot is extended, because the posterior part of the articular surface of the astragalus is narrower than the anterior, but in the erect position there is no lateral movement possible. There are other two movements spoken about as occurring at the ankle — viz., eversion and inversion ; the first of these movements is not very free, the second form is much freer. In Eversion, the outer border of the foot is raised and drawn outwards. In the production of this form of club-foot (talipes valgus) there is, in the first instance, an obliteration of the arch of the foot, so that the sole becomes perfectly flat (talipes planus, or flat-foot), and as the disease advances, eversion of the foot takes place. The flattening of the foot is due to the relaxation of the ligaments that support the arches of the foot ; the ligaments that support the transverse arch are chiefly the interosseous ligaments, between the cuneiform and the cuboid bones ; those that support the longitiidinal arch are — (1) the long plantar ligament (the inferior calcaneo-cuboid) ; (2) the 408 Applied Anatomy : short plantar ligament (the short calcaneo-ouboid) j (3) the inferior calcaneo-scaphoid ligament, which supports the head of the astra- galus; (4) the plantar fascia also assists to maintain the archj- (5) the tendon of the tibialis posticus ; and (6) the tonic contraction of the muscles of the sole. When these structures are relaxed the head of the astragalus passes downwards, forwards, and inwards, producing the condition known a:s flat-foot, which is often associated with a peculiar straight and rigid condition of the great toe at the metatarso-phalangeal articulation, and which has heen designated " hallux rigidus." Inversion is a much freer movement. It takes place at three points — (1) to a very slight extent at the ankle joint proper ; (2) a little at the articulation between the astragalus and the OS calcis; hut chiefly at (3) the transverse articulation of the foot, i.e., at the astragalo-scaphoid and calcaneo-cuboid articulations. We have an example of this form of movement in talipes varus, where the foot is twisted inwards and the sole is contracted. Flexors of the anlde joint. — Direct — (1) The tibialis anticus, (2) the peroneus tertius. Indirect — (1) The extensor longus digitorum, and (2) the extensor proprius hallucis. Extensors. — Direct — (1) The muscles of the calf (gastrocnemius, soleus, and plantaris); (2) the tibialis posticus; (3) the peroneus longus; and (4) the peroneus brevis. Indirect— {V) The flexor longus digitorum; and (2) the flexor longus hallucis. Note that the indirect flexors of the ankle joint are extensors of the toes; while the indirect extensors are flexors of the toes. Evertors. — (1) The peroneus longus, (2) the peroneus brevis, and (3) the peroneus tertius. Inverters. — (1) The tibialis anticus, and (2) the tibialis posticus. It should be noted that in ordinary extension movements of the ankle, when a person is sitting or lying, the muscles of the calf are not used, but the move- ment is performed by the, flexors of the toes (indirect extensors). It is only when the movement is resisted, or when greater force is required that the muscles of the calf are used. Flexion of the joint is limited by the posterior part of the deltoid ligament, by the pos- terior fasciculus of the external ligament, by the posterior ligament, and by the contact of the head of the astragalus with the tibia. Extension is limited by the anterior fibres of the deltoid ligament, anterior and middle fasciculi of the outer, by the anterior ligament, and by the contact of the astragalus with the tibia behind. Surgical, Medical, and Operative. 409 The position of the Malleoli and the Scaphoid Tubercle. — The internal malleolus is more prominent and more anterior than the external ; hut the external extends lower down, and its tip is ahout half-an-inch behind, and half-an-inch below the tip of the internal. The tubercle of the scaphoid is nearly two inches in front of the internal malleolus, and the sustentaculum tali is an inch below it ; between these two points is the inferior calcaneo- scaphoid ligament and a band from the tibialis posticus — the position of the early pain in flat foot. In effusion into the joint, as in Acute Synovitis, the swelling first shows itself in front beneath the anterior tendons, and at each side in the interval between the anterior edges of the lateral ligaments and the tendon of the peroneus tertius on the outer side, and that of the tibialis anticus on the inner; further, when looked at from behind the joint has an appearance of increased width, from fiUing up of the hollows on each side of the tendo achiUis. In severe cases it may be possible to detect bulging of the thin posterior ligament, and obtain fluctuation on the two sides of the tendo achiUis. The foot usually assumes a position of slight extension (pointing of the toes), and some amount of inversion. In effusion into the hursa heneath the tendo aehilUs there is a swelling about an inch above the point of the heel, the tendon is more prominent and fluctuation may be obtained from side to side. DISLOCATIONS. By dislocation of the ankle is meant displacement of the trochlea of the astragalus, from the tibio-fibular mortise, the astragalus still retaining its natural relations with the rest of the foot. It may be dislocated in five directions — outwards, inwards, backwards, forwards, and upwards (in the order of frequency). They are usually caused by some violent and sudden twist of the foot, as treading on the edge of the kerb-stone, or alighting from a height upon a lower level than expected, with some part of the foot, but not flatly on the sole. The antero-posterior are produced by the sudden arrest of the foot during some violent impulse of the body, as in leaping from a carriage in motion, or by some great force applied to the foot when the leg is fixed.. 410 Applied Anatomy: 1. Outwards. — Caused by a forcible twist of the foot out- wards, as in suddenly slipping oif the edge of the kerbstone, when the weait fibula first snaps, and then the internal lateral ligament of the ankle, or else the tip of the internal malleolus is torn off. (a) The Incomplete Form (same thing as "Poifs fracture"). In French works on Surgery this injury is called "dislocation of the foot hacltmards, loith fracture of the fibida; " in English text-books, on the other hand, it is called "Fott's fracture, with backward displacement of the foot." The astragalus is partly displaced from the tibia by a rotation on its own horizontal axig, so that the outer edge of its superior articular surface is higher than the inner, and rests against the under surface of the tibia. It is always caused by indirect violence, usually from a twist of the foot outwards, or else, the foot being firmly jammed, by the body falling outwards over the ankle. The displacement of the foot is usually a double one — outwards and backwards. The fractured point of the fibula is from one and a half to three inches or more, above the external malleolus, that is, through the upper part of its triangular sub- cutaneous surface. The foot is everted principally by the force that caused the dislocation, but also by the three peronei muscles, as well as the weight of the limb, so that the foot almost looks directly outwards, the outer border being raised, and the heel drawn up by the muscles of the calf. There is a marked projection on the inner side, due to the internal malleolus; and on the outer side, in the site of the fractured fibula, there is a depression, as the broken ends are forced inwards. The strong inferior tibio- fibular ligament is not ruptured, (b) The Complete Form (same as "Bupuytren's fraeture"). In this form either the inferior tibio- fibular ligament is torn, or else a strip of the tibia, to which it is attached, is torn off, while the deltoid ligament escapes rupture. It is believed that the forcible eversion of the foot causes the outer border of the astragalus to act as a wedge, separating the lower end of the fibula from the tibia, the interosseous ligament usually tearing off its attachment to the tibia. The trochlear sur- face of the astragalus is completely displaced to the outer side of the bones of the leg and drawn upwards ; the internal malleolus is sometimes forced through the skin, thus making the disloca- tion compoiind. There is increased breadth of the ankle, with Surgical, Medical, and Operative. 411 shortening of the leg, but very little eversion of the foot. The internal malleolus is further down and more prominent than it should he; the external malleolus goes up with the astragalus, and is also prominent but too high. The whole foot has a tendency to be rotated outwards.' 2. Inwards. — This is caused by violence, the reverse of that which produced the previous dislocation. It is much rarer, however, as the powerful internal malleolus resists the twist and very frequently, therefore, the only result is a " sprained " ankle. Should this dislocation occur, the tibia, and sometimes the fibula as well, is broken from the sudden wrench given to the strong external lateral ligament, which, rather than give way itself, often snaps the fibula, the broken ends of which in this case are displaced outwards. It is always incomplete, and the astragalus rotates on its antero-posterior axis. The sole of the foot is in- verted, and the external malleolus is very prominent and almost touches the ground, and there is a depression on the opposite side of the ankle. 3. Backwards. — It is caused by jumping from a carriage in motion, or falling backwards while the foot is fixed ; the foot being fixed the inertia of the body carries the leg bones forwards. It may be complete or incomplete ; if complete, the anterior and posterior ligaments are torn, and the lower end of the tibia rests on the neck of the astragalus and scaphoid, with the trochlear surface of the astragalus behind it. The whole foot is fixed, and the anterior part seems too short, and the heel too long with a depression above it; the tendo achillis is tense, and the toes are pointed downwards. The lower ends of the tibia and fibula are prominent in front ; but the fibula is broken about the same place as in Pott's fracture, and the internal malleolus is also very frequently broken. 4. Forwards. — Less common tlian the last. It is usually incomplete, the tibia resting on some part of the articular surface of the astragalus, and not entirely behind that bone. The foot is elongated, and the heel shortened and less prominent. The space in front of the tendo achillis is occupied by a hard mass— the ends of the tibia and fibula; both the malleoli are usually broken. The tendo achillis is lax, and not so prominent as usual. 412 Applied Anatomy : To reduce these dislocations, flex the leg on the thigh, extend the ankle joint so as to relax the muscles of the calf and the tendo achiUis ; one assistant must now hold the thigh firmly, another seizes the foot and pulls in the direction of the long axis of the leg, while the Surgeon, by manipulation and pressure, endeavours to replace the bone. In difficult cases it may be neces- sary to divide the tendo achiUis, and probably always at once in the forward variety. After reduction, the leg is to be placed in the box splint (see " Fracture of the Bones of the Leg"). In some cases it may be necessary to resect or even amputate. 5. Upwards. — In this case the two bones are separated, the inferior tibio-fibular ligaments being ruptured and the astragalus forced up between them ; the anterior and posterior ligaments are torn. It is caused by falls on the feet from a great height, the foot being at right angles to the leg, and neither flexed nor extended ; the characteristic appearance is the increased width of the ankle joint, due to the separation of the malleoli. It is to be reduced in a similar way to that adopted in the other, cases of dislocation. Sometimes it may be found impossible to do it; nevertheless, by patience, a useful foot may result. OTHER DISLOCATIONS OF THE FOOT. Dislocations of the Astragalus. — In all dislocations of this bone the malleoli are nearer the sole than they should be, but are not separated from each other more than the normal distance, and there is little, if any, alteration in the length of the heel or of the anterior part of the foot. The astragalus is thrown out of proper relation, both with the bones of the leg and the other bones of the tarsus ; there is an entire loss of flexion and extension at the ankle joint. The ligaments connecting the astragalus with the other bones of the ankle are torn. 1. Forwards. — The most common form. The astragalus is shot forward like an orange pip from between the finger and thumb, and rotated slightly at the same time — ^usually to the outer side. It may be complete or incomplete. A swelling is noticed to one or other side, which is the round, globular head of the astragalus covered by tense skinj it maybe possible to distinguish the outline Surgical, Medical, and Operative. 413 of the head, as well as the saddle-shaped articular surface. This dislocation is usually caused hy a fall or twist on the extended foot ; it is very often compound. 2. Backwards. — This is caused by falls or twists on the flexed foot ; it is rare. There is a hard prominence felt just above the heel, between the tendo achillis and the malleoli. The foot seems shorter, and there is a prominence in front caused by the ends of the tibia and fibula. 3. Lateral. — If complete, must always be compound. If to the outer side, the foot is turned inwards, and there is a great projection of the external malleolus. If to the. inner side, the appearances are reversed. 4. Version. — A rotation of the astragalus on its horizontal or vertical axis. The history of severe injury, and the loss of movement must guide. To reduce, give chloroform and attempt reduction as ia the previous dislocations, by flexing the leg on the thigh, extending the foot, and then by extension, counter- extension, and manipulation, forcing the bone back to its place. It may be advisable to divide the tendo achillis or any other tense tendon, such as the posterior tibial. In impossible cases, put up in the best position, wait and watch, and act accordingly. Should the skiu threaten to slough over the head of the bone, it must be excised. Do not be in too great a hurry to amputate. Subastragaloid Dislocations. — These are dislocations at the calcaneo-talo -scaphoid articulation. The astragalus maintains its normal relations with the tibia and fibula, whilst the rest of the foot is partially or completely disarticulated from it ; the malleoli are not so depressed as in dislocation of the astragalus, nor is the rigidity of the joint so great. The foot may thus be displaced forwards, backwards, or laterally; the usual form is backwards, from a strain or twist. It is seldom, however, directly back- wards; the foot is usually at the same time twisted outwards or inwards. If backwards and outwards, the foot is everted and abducted, the sole looks outwards, and there is great prominence of the heel ; the inner malleolus and head of the astragalus are prominent, but the outer malleolus is not so prominent. 414 Applied Anatomy : If backwards and inwards, the symptoms are reversed. The ligaments connecting the astragalus with the os calcis and scaphoid are more or less completely ruptured; the malleoli are often fractured, and the lateral ligaments of the ankle joint more or less torn. Laterally. — These are usually incomplete and often compound; they are more common than the antero -posterior forms. In the inward form the appearance resembles that of talipes varus — the foot is inverted, its inner border is raised, shortened, and rendered concave, while its outer border is lengthened and convex. The head of the astragalus and outer malleolus form a marked projection on the outer side of the foot; the inner malleolus is buried, and the whole limb seems shorter than natural. In the outward form the reverse holds true. The appearance resembles that of talipes valgus; the foot is everted, its outer border is raised, shortened, and concave, while the inner i.s lengthened and convex. The outer malleolus is buried, while the tibia and head of the agtragalus form a marked projection on the inner side. Tlie Treatment must be conducted on the same principles as in dislocations of the astragalus. Surgical, Medical, and Operative. 415 CHAPTER XXIII. FRACTURES. Before describing fractures in detail, I will give a short account of the ANATOMY OF A BONE. Taking a long bone, such as the femur, we see it consists of a shaft and two extremities. The shaft consists of a thick layer of compact tissue externally, with a thin lining of cancellous tissue, and encloses the medullary canal, and this in turn contains the yellow marrow, which consists chiefly of fat and blood-vessels ; in some cases of fracture this fat passes into the circulation and causes fatty emboli in the pulmonary capillaries. The articular ends of the bone consist almost entirely of cancellous tissue, with a thin covering of compact bone which gradually becomes thinner until it ceases at the margin of the articular cartilage ; this spongy tissue contains the red or hlood-forming marroio, although the larger cancelli contain principally yellow marrow. It is in this part also that the " myeloid," or " giant cells," are found, which jarobably explains their presence in sarcomatous tumours of the articular ends of bones. The Periosteum. — This is a fibrous membrane, forming a complete external covering to the bones, except where they are covered with cartilage and at the insertion of strong tendons. It consists of two layers — {a) an outer layer, composed of elastic and white fibrous tissue, running longitudinally for the most part, and (&) an inner layer which is soft and cellular, and in which the blood-vessels break up before entering the bone. The cells next the bone are caUed osteoblasts, or bone-forming cells, and the whole inner layer is sometimes called the odeo(jenetic layer; 416 Applied Anatomy: this layer is also prolonged into the Haversian canals. In young subjects it is very cellular and soft, hut as age advances it becomes more fibrous and contains fewer osteoblasts; in amputations per- formed on young persons, therefore, one must be very careful, after the bone is divided, not to strip back the periosteum by pulling on the flaps. Further, since the periosteum, from the arrangemept of its fibrous layer, tends to split longitudinally and not circularly, it is necessary in subperiosteal resections, not only to divide the periosteum longitudinally, but to make transverse cuts as well, otherwise the membrane will strip up far beyond the part required; this is well shown in resections of the ribs, the upper part of the femur, and in many other situations. The Haversian canals contain blood-vessels for the nourishment of the bone, fine connective tissue, lymphatics, and nerves, and a lining of osteoblasts or bone-forming cells. In the medullary canal of a long bone the vascular fibrous tissue is condensed into a kind of membrane called the endosteum. The periosteum serves a double purpose — (a) from it the compact tissue of the shaft receives its principal blood supply ; and (6) by it the shaft of the bone increases in thickness, while the medullary canal is being hollowed out ; in fact, the entire shaft of the permanent bone is produced by the periosteum, for the part originally formed in cartilage is all removed to form the medullary canal. The bones increase in length by .progressive ossification of the layers of cartilage which intervene between the ends of the shaft and the epiphyses ; growth continues, therefore, as long as the cartilage remains unossified. Sometimes, from an injury causing separation of the epiphysis, or setting up simple or tubercular inflammation, one epiphysis may unite sooner than its fellow of the opposite limb, and in this way one limb will gradually become shorter than the other ; this is of special importance in cases of injuries to the hip joint in young people (up to eighteen years). But bones also grow slightly in length by interstitial deposit; this is well seen in cases of interstitial ostitis attacking a bone during the growing period. In this way one limb gradually becomes longer than its feUow ; the bone is usually at the same time thickened, as well as lengthened, from the presence of periostitis ; but the periostitis, while it accounts for the thickening, could not account for the Surgical, Medical, and Operative. 417 lengthening of the bone. In young bones the periosteum is always firmly adherent to the epiphyseal cartilages. The mode in which bones grow in length was first proved by Hales, Huntee, and others, who introduced shot, or ivory pegs, at definite distances into the shaft of the growing bone of a common fowl, and examined them a fortnight or three weeks later ; it was then found that the distance between the two pegs was only half as much increased as the distance between a given peg and the end of the bone. The Nutrition of a Bone. — A long bone has three sources of blood supply : — 1. The articular ends are supplied by the articular arteries, being cut oif from the shaft proper in early life by the epiphyseal cartilage. Hence it is, therefore, that the articular ends of the bones seldom perish in the disease known as diffuse infective suppurative xjeriostitis ( = the so-called " acute necrosis," which probably also includes the circumscribed and less extensive form, as well as the diffuse), while the whole slmft may perish, from epiphyseal line to epiphyseal line. This is very fortunate, for were it otherwise the joints would be speedily involved, and amputation would be required almost in every case ; whereas, as a matter of fact, amputation is seldom required, because the pus rarely finds its way into the articulation. When this unfortunate accident occurs, it is because the pressure of the septic pus separates the strong attachment between the periosteum and the epiphyseal cartilage, and thus finds its way into the joint; the importance, therefore, of a free and early incision down to the hone will be at once evident. The veins, in the spongy tissue of bone especially, are peculiar — c. g., in the diploe, vertebrae, ends of long bones, etc. In the first place, they run in canals by themselves ; and, in the second, their walls are very thin, and do not collapse when the bone is broken across, since they are attached to the bony tissue around them, and they often contain pouch -like dilatations. Further, they are exceedingly numerous. Now, these facts explain two interesting pathological points — (1) How these open mouths in fracture of the bone readily take up floating oil globules, giving rise to fat embolism. This is most apt to occur in cases where the bone is broken into a number of fragments (comminuted) and usually from twenty-four hours to three days after the accident ; 2d 418 Applied Anatomy: the signs resemble acute lobar pneumonia. There is sudden dyspncBa, rapid, laboured breathing and cyanosis, rapid weak pulse and turbulent heart, but on auscultation the air is heard to enter and leave the lungs freely; sometimes fat is observed floating on the surface of the urine. (2) It also helps towards an explanation of the origin of pya3mia — e.r/., following compound fractures of the bones of the head. The mouths of the veins are, as I said, patent and non-collapsable, and the usual steps of the process are probably the following — (a) Osteo-phlebitis with thrombosis in the open mouths; (6) this thrombus is septic, or readily becomes so, and therefore (c) tends to break down (= the old " suppurative phlebitis"), and {d) forms minute septic emboli, which are carried far and wide by the blood -stream, and are caught at points where the vessels break up into capillaries, as in the lungs and liver, and when the little plugs come to rest, the micro-organisms they contain begin to multiply, and hence we have (e) the secondary abscesses. But the same series of changes may occur even though the veins in the bone be not torn across, as their walls are so thin that septic processes readily spread from the bone into the vein, forming a true septic phlebitis, as iu idiopathic osteo-myelitis, which often exists along with " acute necrosis." 2. The shaft of a long bone is supplied chiefly by the periosteum. If we look at the surface of the shaft of a long bone we can see a large number of minute longitudinal grooves, in which the vessels lie before entering ■ the substance of the bone ; at the ends of the grooves, by the aid of a pocket lens, we can also see very fine oblique openings — in fact, the ends of Haversian canals, into which the vessels pass. It is usually taught that if the periosteum be stripped from a bone the bone will die, but this does not neces- sarily follow, and for various reasons^(l) If the periosteum is not raised too fur from the bone, the vascular connections will not be torn, because many of the capillaries run for some distance along the surface of the bone, in the grooves already mentioned, before they enter the Haversian canals, and the effusion between the bone and the periosteum simply raises them from the horizontal to the vertical position ; further, the vessels can be pulled for some distance out of the Haversian canals without tearing across. (2) Then again, oven if the vascular connections are torn across Surgical, Medical, and Operative. 419 ill the first instance, if the separation of the periostetiin from the bone be not too long continued, the periosteum may fall down and become again connected with the vessels in the compact tissue. (3) But still further, even though the vascular connections are torn, and the periosteum be separated from the bone for an indefinite period, still the bone may not necrose, because the vessels in the compact tissue are still filled with blood on account of the anastomosis between the vessels of the marrow and the "endosteum" with those in the compact tissue from the peri- osteum. (4) The question, too, of septicity has a very important bearing on this point ; even though the periosteum be extensively stripped up, if the wound be kept free from septic micro-organisms it will very likely unite again without a trace of necrosis, but this cannot possibly occur should the wound be septic. 3. The so-called " nutrient artery " passes into the interior of the hone and supplies the marrow and endosteum ; it woidd be better therefore to call it the medullarij artery. It reaches the interior through a distinct bony canal which runs obliquely through the shaft, near its middle ; in the bones of the upper extremity the nutrient arteries are directed or run towards the elbow, while in the lower extremity they run from the knee. Another curious point is, that in young bones the epiphyses of that end towards which the nutrient artery runs, are the last to begin to ossify, but are the fii-st to unite after they have begun ; the lower end of the fibula, however, is an exception to this rule. When the artery reaches the interior of the bone, it divides into ascending and descending branches, which, on the one hand, anas- . tomose with the vessels from the periosteum, and on the other, with the articular vessels at the spongy ends, after the epiphyses have completely united. The Growth of New Bone. — By means of experiments with madder, which, when mixed with the food of young animals, renders the bone produced during its administration of a deep red colour, it was shown by Duhambl, that a coloured ring was pro- duced under the periosteum, a coloured layer under the epiphyseal cartilage, and coloured circles in the Haversian canals ; at these points, therefore, new bone is laid down. Symb, in 1840, showed that if a silver plate be inserted between the periosteum and the 420 Applied Anatomy: bone, that the periosteum produced a layer of bone outside the plate, and further, proved that a bone may be regenerated after its removal, provided the periosteum be left. Olliek, further, in 1867, showed that the periosteum produces bone, even when it is excised and planted beneath the skin. The sources of bone regeneration ia disease or fracture are — (1) The osteoblasts of the deep layer of the periosteum ; (2) the bone itself, probably from the osteoblasts contained in the Haversian canals, which sprout forth in the form of bone-producing granulations ; (3) the soft tissues near the periosteum, as tendons and interosseous membranes and fascia ; and, (4) doubtfully, the endosteum. Re-absorption of Bone. — Howship was the first to observe small pits on the fangs of the milk teeth during their absorption, and also on the surface and interior of any bone undergoing absorption ; these little spaces have been called Howsliip's foveolce. Tomes and De Morgan discovered cells lying in these foveolse, and gave birth to the theory that these cells absorbed the underlying bone; the cells in question are multi-nucleated masses of protoplasm, and have been named myeloplaxes, by Kqbin, and osteoclasts, by KoLLiKEB. In the madder experiments, while a red layer is found under the osteoblasts, the ban^j und^r the osteoclasts, is unstained, showing at least that they do not produce bone. But while the osteoclasts may be the cause of bone absorption in physiological processes, I very much doubt if they have much to do with it in pathological processes, as in rarefying ostitis or acute inflammation of bone; here the compact tissue becomes opened out and rendered . spongy by absorption of the walls of the Haversian canals. Now, if one examines the contents of an inflamed Haversian canal, the cell elements are found to be increased, the vessels enlarged and tortuous; in fact we find granulation tissue — masses of indifferent cells round loops of blood-vessels. But the property of granulation tissue is to eat up everything in its neighbourhood, and hence it attacks the walls of the Haversian canals, eating them away and rendering the compact bone porous or cancellous. This is the essential process in rarefying ostitis, and it is also observed in the ends of a fractured bone previous to the laying down and organisa- tion of callus. Now compare the different effects of inflammation on bone : — (1) If it is very acute the bone at once dies en masse Surgical, Medical, and Operative. 421 (necrosis = gangrene of the soft parts), because the extra blood demand cannot be supplied in time to keep the bone alive, as it takes a week or ten days before the compact tissue can be opened up suifioiently. (2) If it is not quite so acute the bone becomes rarefied. (3) If at this stage, instead of beginning to subside, the inflammation continues, the bone becomes so rarefied that the trabeculse give way and now we have the condition of caries .( = ulceration of the soft parts, which is in turn = supisuration on a free surface), the broken trabeculse fiow away with the de- generated cells, and tissue remains ( = pus). Hence it is that the pus in this case feels gritty, and so also when a probe is passed it enters soft, spongy, and very sensitive bone. This same series of changes also occurs in the formation of the "line of demarcation," which cuts off a dead mass of bone from the living, in cases of necrosis. (4) But suppose the inflammation is chronic, what takes place? The bone becomes sclerosed, the Haversian canals are filled up, and the whole bone may become hard and heavy as ivory ; witness, for example, the hard polished articular ends of bones in chronic rheumatic arthritis, and the nodes on the surface of the tibia in syphilis, due to the localised chronic periostitis so common in the later stages of that disease. FRACTURE IN GENERAL. Fractures may be divided into Simple, Compound, and Com- pMcated. 1. A Simple Fracture is one where the bone is merely broken across, split, or fissured, but where there is no wound of the soft parts communicating with the broken bones, nor yet near the injured point. 2. A Compound Fracture is one where the bone is not only broken, but the soft parts are torn through, so that the fracture communicates by a wound with the surface of the body, either through the skin or through the mucous membrane, as in the case of the lower jaw. The wound in the soft parts may be caused in two ways : — (a) By the sharp end of the irolcen bone being forced through the skin, as in fractures caused by indirect violence — e.g., fracture of the tibia by a twist ; (b) by tJie injury that breaks the bone, as in the different forms of direct violence. 3. A Complicated Fracture, wh6n with the fracture is conjoined some other condition or injury which has no immediate connection with the fracturec" 422 Applied Anatomy : point — e.g., fracture of the tibia with a wound of the calf, fracture of the pelvis with rupture of the urethra, fracture of a rib with injury of the pleura or lung ; also where the fracture is associated with injury of a neighbouring nerve, artery, or joint. As regards the direction of the fracture, it may be transverse, as from direct violence ; oblique, longitudinal, or spiral, from indirect violence, as from sudden twists; aomminuted, when it is broken into a number of fragments at one place. An Incomplete or Green-stick Fracture is when the bone is merely bent, with a crack extending across the convexity of the curve, similar to that produced in a green stick when it is bent across the knee. It usually occurs in children, and especially in the fore-arm and clavicle, and, in many cases at least, the periosteum is not torn ; the bone is bent, but there is neither mobility nor crepitus. It must be distinguished from the curvB of a rickety bone, which, however, is a chronic thing, not produced suddenly, is symmetrical, and not accompanied with marked pain. It is possible, of course, to get a green-stick fracture in a rickety child. An Impacted Fracture is where one fragment is wedged into the other,' the compact tissue being driven into the cancellous ; in this condition there is an alteration in contour and length, but neither mobility nor crepitus. It is usually met with at the lower end of the radius (Colles's), and at the upper end of the femur. It is distinguished from green-stick fracture by the age of the patient, and the fact that the fractured point is angled, and not a rounded curve. A Multiple Fracture is where there are two or more fractures, either in different bones or in different parts of the same bone, as at the lower end of the humerus and femur, or both wrists (double Colles). A Diastasis is the separation of an epiphysis ; it is met with in persons under sixteen or twenty years of age, and, of course, occurs at the ends of bones near the joints, and is often difficult to diagnose. It is usually seen at the lower end of the radius or femur, and at both ends of the humerus. This is usually followed by a certain amount of shortening of the limb, as the life history of the epiphysis is suddenly hurried on to com- pletion; it does not entirely stop growing at this end, however, as the'attachment of the epiphysis to the shaft may be left imdisturbed. In cases where there are' two bones, the after effects are well marked — e.g., after separation of the radial epiphj'sis the hand tends to grow Surgical, Medical, and Operative. 423 towards the radial side, as the uhia, growing faster than the radius, pushes it overj or, if the ulnar one be affected, the hand will be pushed to the ulnar side. Epiphyseal injury may be produced in three ways: — (l)From actual separation of the epiphysis; (2) from tubercular ostitis near the growing line; and (3) from a blow or fall jarring it, even though the injury be too slight to cause separation, yet an inflammation, it may be of a simple nature, is set up which causes premature ossification of the growing line. The Causes of Fracture are either predisposing or exciting: — 1. The exciting causes are — («) Direct violence, when the bone gives way at the point struck, and usually in a transverse direc- tion; (6) indirect violence, such as a strain, when the bone gives way at the weakest part, and not where the force is applied; and (c) muscular action, as in the patella. 2. The predisposing causes are very various — as exposed position, age, sex, season of the year, tumours, and bone diseases, as gummata, sarcomata, etc. The General Signs of fracture are — 1. Alteration in the normal outline of the limb: this may arise from three causes — (a) The force which broke the bone, as the chief cause; (&) muscular action, as a secondary cause; and (c) the weight of the part. All these causes are illustrated very well in Pott's fracture. 2. Mobility in the continuity of the bone. 3. Crepitus or grating between the broken ends. Of course, other signs, such as swelling, pain, shock, etc., might be added to this list. In examining a limb for a supposed fracture, remember that the very last thing the Surgeon is to do is to handle the parts : learn everything else before touching, so as to give the patient as little pain as possible, and remember always to compare with the sound limb. He is first to look at it well, then compare it with its fellow, then measure ; next gently run the fingers along the most prominent surface or edge; and lastly, if necessary, try for mobility and crepitus. As a rule, the presence of a fracture should be diagnosed without crepitus ; for just as the last part of the Surgeon's examination is to handle the limb, so the very last part of handling should be the attempt to elicit crepitus. All the signs of fracture enumerated above may be due to other causes, except mobility in the continuity of the bone, e.g., deformity may be due to a previous injury, crepitation, to the movement of tendons in their sheath, from lymphy exudation, and fluid in the 424 Applied Anatomy : cellular tissue. Further, deformity may be absent in transverse fracture, and in cases where there are two bones side by side and only one is broken. Crepitus is absent in impacted and green-stick fractures, and obscure in diastasis. The indications for Treatment are — 1. To remedy the dis- tortion as completely and as gently as possible ; this is the most important part of the whole treatment. 2. To keep the fractured ends steady and in good position by the use of means that wiU command the joint above and below the fracture; in most cases, however, this wiU not be enough, notably in the case of the humerus, where the muscles that move the wrist and fingers take their origin from the lower end of that bone, and it is necessary, therefore, to command all the muscles, from origin to insertion, that are in any way attached to the broken bone, in order to avoid the risk of non- union. 3. In special cases, where the fracture is near a joint and surrounded by tendons, great care must be taken by judiciously early passive movement to avoid adhesion and stiffening of the tendons — e.g., in Colles's fracture of the wrist and in Pott's fracture of the ankle. This is specially important also in fractures near the elbow in young persons, with or without separation of the epiphysis, lest new bone be thrown out and render the joint stiff. In every case the splints ought to be looked to on the second day, lest the blood extravasation and serous oozing cause so much swelling of the limb that the splints become too tight and produce gangrene. Surgical, Medical, and Operative. 425 CHAPTER XXIV. FRACTURES OF THE UPPER EXTREMITY. THE CLAVICLE. Development. — The clavicle is developed from two centres — one for the shaft which appears very early (before any other centre, it is said ) ; so early does the ossification begin and so rapidly does it proceed that the whole shaft is bony at birth. The other centre is for the sternal end, and appears from eighteen to twenty years, and joins the shaft about twenty-five. The clavicle is subcutaneous, and any irregularity therefore, as in the case of fracture with displacement, is readily felt. It is more frequently broken than any other single bone in the body, although the radius almost runs it neck to neck, and it is more frequently the seat of green-stich fracture than any other bone. Statistics show that one-half the total number of fractures of this bone occur before the age of five years. Green-stick fracture is very often subperiosteal in children on account of the very thick and strong periosteum that covers the bone ; it is important to keep this fact in mind, as there may be little or no displacement, and the incautious practitioner may state to the parents that there is no fracture. In a few days " callus " is thrown out, forming a lump round the bone and leaving no doubt as to the nature of the accident. Should the case then fall into the' hands of an unscrupulous brother practitioner, qualified or otherwise, the first is very likely to be severely blamed and probably lose his patient as well. Therefore be cautious, and take care to explain well to the parents the probable or possible result. It is also well in aU eases where a child has had a fall, and continues crying, for no app9,rent reason, to ex9.njine the clavicle. Fracture of this bone 426 Applied Anatomy: is very common, because — (1) It is much exposed to direct violence; (2) it is the only osseous connection of the upper extremity with the trunk. Its shape enables it to withstand, to a certain extent, indirect violence, the force being partially broken at each curve. Causes.— (1) Direct Violence — Fracture from this cause happens comparatively seldom; when it does take place, the fracture is transverse and at the point struck. (2) Indirect Violence — This is the usual cause, as in falls on the shoulder, elbow, or hand; the direction of the fracture is oblique from without inwards and from before backwards, and as a rule is situated where the two curves meet, at the junction of the middle and outer thirds of the bone, as at this point the bone is more slender than elsewhere. In chndreu and infants the usual cause is falling out of bed, or being dropped by a careless nurse. (3) Muscular Action has been known to break the bone, as in using a whip ; in this case the fracture is usually on the right side and about the middle of the bone. FRACTURES OF THE CLAVICLE. 1. Fracture at the Sternal End. — Fracture at the sternal end takes place about three-quarters of an inch from the end of the bone, internal to the rhomboid ligament, and is usually transverse. This may resemble a dislocation. The outer fragment is drawn inwards towards the sternum by the subclavius, and the pectoralis major and minor muscles. The inner end of the outer fragment is displaced downwards and inwards and can be felt moving on the front of the sternum. 2. At the Junction of the Two Curves.— This is by far the most common seat of fracture. The outer fragment is drawn downwards, forwards, and inwards — downwards, by the weight of the arm and scapula, and the action of the deltoid and other muscles acting on the scapula, as the pectorals and latissimus dorsi; forwards, by the pectorals and serratus magnus rotating it; and inwards, by the pectoralis major and minor, subclavius and trapezius, and muscles attached to the posterior border of the scapula— levator anguli scapulae, and the rhomboids, major and minor, also the latissimus dorsi. At the same time the outer end is rotated forwards, whilst the inner end points backwards. Surgical, Medical, and Operative. 427 The inner fragment seems raised, but this is because the outer one is depressed; it is practically kept in its natural position by the sterno-mastoid above, and the pectoralis major, subclavius, and the rhomboid ligament below. In this fracture the patient cannot raise his hand to his head ; he keeps the injured arm semiflexed, and supports it with his other hand, and leans his head and body to that side to relax the muscles. The slightest movement of the shoulder causes intense pain. The special features of this fracture then are — (1) Apparent projection of the outer end of the inner fragment, (2) depression of the outer fragment, (3) falling down of the arm, (4) narrowing of the chest, and (5) intense pain on the slightest movement of the injured shoulder. 3. At the Coraco-Clavicular Ligament. — If the fracture takes place between the conoid and trapezoid ligaments, there will be little, if any, displacement. This fracture is often caused by direct violence, and it comes to be a question of diagnosis of this fracture from a mere hruise of the periosteum. In a hruise the pain is diffused and dull, there being no specially tender spot, and no sign on indirect pressure. In fracture the pain is severe and strictly localised to one spot, which can readily be detected by carrying the finger along the bone from the sternal side; the tender spot is situated about the deepest part of the anterior concavity, immediately above the coracoid process. Further, there will be pain at this spot when firm pressure is made on the great curvature of the bone, at some distance to the inner side of the injured point, as the pressure makes the broken ends rub against each other (the indirect method). In a bruise, as the bone is not broken, there is no pain on. applying this test. It may be possible to elicit crepitus on moving the shoulder. 4. It maybe broken to the outer side of liie Coraco-Clavicular Ligament, when the small fragment is gradually drawn round by the pectoralis minor and major, and serratus magnus, these muscles depressing and rotating forwards the point of the shoulder, until the broken fragment lies at right angles to the rest of the bone. By this means the shoulder is narrowed, and may drop a little from the weight of the arm ; but, as a rule, there is little, if any, down- ward displacement of the outer fragment, as it cannot fall without the scapula moving with it; but the scapula is slung up by the 428 Applied Anatomy : coraoo-clavicular ligament, and therefore cannot fall down. This fracture is usually caused by direct violence. Comminuted fracture of the clavicle is dangerous because of its close relation to important vessels and nerves. The structures most likely to be wounded in fracture are the veins and the cords going to form the brachial plexus. The late Sir Eobeet Pebl in this way got a diffused false venous aneurism from a fall from his horse in Hyde Park, which was ultimately fatal. Accidents of this kind are, however, fortun- ately rare, probably on account of the dense fascia which underlies the clavicle, and the subclavius muscle, protecting the vessels from injury. TREATMENT OF FRACTURED CLAVICLE. The most certain method to secure union without deformity, is to keep the patient ilat on his back in bed with a small pillow between the shoulders, for about three weeks, till the fracture unites ; the head is placed on a thin pillow, and the arm bound to the side, with the fore-arm across the trunk. In this position the blade of the scapula is pressed close against the ribs, and in this way its outer angle, with the humerus and acromion process, is pulled outwards and backwards, and the recumbent posture removes the weight of the arm, which is the chief cause of the downward displacement. This plan may therefore be adopted in cases where it is specially desirable to avoid deformity, e.g., in the case of young ladies. This plan m/ust be adopted also in complicated and comminuted fractures, and in cases where both clavicles are broken at once. I. For Fractures internal to the Coraco-Clavicular Ligament. — Whatever plan is adopted it must fulfil three conditions ; as to the exact method there are no hard and fast rules, provided the deformity is remedied. The conditions are that the shoulder must be drawn — (1) outwards, (2) upwards, and (3) backwards. 1. The shoulder may be drawn haekwards by a figure-of-eight bandage round the shoulders and stitched behind. But this is objected to, because the front turns of the bandage may press on and displace the inner end of the outer fragment. 2. The inward displacement may be overcome by an axillary pad, which acts as a fulcrum to the upper end of the humerus. Surgical, Medical, and Operative. 4211 the shoulder being carried outwards wheii the elbow is pressed to the side. This also is objectionable, because of the compression it exerts on the axillary vessels and nerves, causing great pain and oedema at first, and probably paralysis afterwards. 3. The downward displacement is best counteracted by raising the elbow. The arm is firmly fixed to the side by a broad domett bandage, so guided that it will also support the elbow of the injured side. Or a special sling may be used. (a) By Three Handkerchiefs. — 1. One, folded diagonally, is rolled round a pad of wool, and the pad is placed in the axilla of the injured side, the ends being crossed on the top of the opposite shoulder over a small pad, and thence under the axiUa, which is also padded, and the ends tied in front over a small pad of wool. 2. The second, also folded diagonally, is applied as a sling over the opposite shoulder to support the elbow, and the base of the triangle is therefore applied to this point; the fore-arm is flexed at an acute angle and laid so that the fingers almost touch the shoulder of the opposite side. 3. The third, is applied round the trunk and elbow, so as to fix the arm to the side. In order to get rid of the axillary pad we may adopt VELrEAu's plau' — viz., to carry the elbow of the injured side well across the chest, pushing it upwards at the same time, so that the hand rests on the opposite shoulder, and fixing it there by bandages in the same way that the arm is fixed up in cases of excision of the breast. By this means the point of the shoulder is pushed directly backwards, upwards, and outwards — the side of the chest being the fidcrum, and the humerus the lever. (ft) Say re's Method. — Two pieces of adhesive plaster spread upon strong calico or moleskin, about three and a half inches wide, or less, according to the size of the patient, and for an adult, about two yards in length. On one of the pieces a loop is made and stitched, which is passed round the arm of the injured side about its middle third; the loop must be quite loose, so as not to compress the vessels, and the non-adhesive side of the plaster next the skin, so that the adhesive side of the rest of the plaster may be next the body. By means of this piece the arm is drawn well laehwards, and then the plaster is carried round the body one and a half times and the end stitched to the first turn. The second piece passes from 430 Applied Anatomy : the sound shoulder obliquely round the chest, the injured arm being drawn well forwards, when the loop round the arm acts as a fulcrum, and the shoulder is thrown backwards and outwards; a slit is cut in this piece for the point of the elbow, which is at the same time pushed well upwards. The second piece is then fastened to itself over the sound shoulder; it must be long enough to com- plete this circumference once and leave about eight inches more. By these means the blade of the scapula is pressed close to the ribs, and in this way the point of the shoulder is thi'own outwards and backwards. It is better, at the same time, to apply a domett bandage to fix the arm more securely to the side, and support and steaidy the elbow. II. Fractures at the Copaco-Clavicular Ligament. — All that is required is simply a broad domett bandage to fix the arm to the side for a couple of weeks. III. Fractures External to the Coraco-Clavicular Ligament. — In this case there are only two displacements to counteract, forwards and inwards ; and for this purpose the shoulder must be braced back and the arm fixed to the side — (a) By figure-of-eight bandage round the shoulders and fastened behind. This counteracts both the inward and the forward displacements ; or (J) two padded handkerchiefs may be used, carried round the axillte from behind, over the tips of the shoulders, and tied or stitched at the back over a pad. The arm is then secured to the side as usual. In adults, fractures internal and external to the coraco-clavicular ligament will unite in about four weeks; at the ligament, a rest of two weeks will be sulficient. Fractures of the clavicle in children will unite in thi'ee weeks, and in infants in tioo weeks. FRACTURES OF THE SCAPULA. Fractures of the Body of this bone are rare. When they occur aU that is required is a thick, soft pad, and a broad bandage to steady the parts. The Anatomical Neck, that is, of the glenoid cavity, external to the root of the coracoid process. A fracture through the anatomical neck is usually caused by direct violence, and may simulate a subglenoid dislocation of the humerus; but by raising the arm the parts resume their natural appearance, with the production of crepitus probably, but become displaced again Surgical, Medical, and Operative. 431 when the support is removed. The Treatment is to raise the elbow, place a pad in the axilla, and hind the arm to the side. Fracture through the Surgical Neck, that is, of the glenoid cavity, and passing through the supra-scapular notch, and internal therefore to the root of the coracoid process. As the powerful , coraco-clavicular ligament is not ruptured, there can be no displace- ment, as the broken fragment is slung to the clavicle; hence there will be crepitus, but no deformity. One can only diagnose this condition by a process of exclusion (Chiene). AU that is required in the way of Treatment is to place the fore-arm across the chest and hind the whole arm firmly to the side. Fracture of the Acromion Process. — Many of the cases of sup- posed fracture of this process are believed to have been instances of non-union of its epiphyseal centres, which appear, one at fifteen. Fig. 77. Epiphysis of Acromion Process. Articular Surface for Clavicle. Unites from 22 to 25 years of age. and the other at sixteen years, and unite sometime between twenty- two and twenty-five years of age (Fig. 77). The cause is usually direct violence, as a blow on the tip of the shoulder, or it may result from the head of the humerus being forced upwards from a fall on the elbow. It is necessarily associated with dislocation of the acromio-clavicular articulation. The broken fragment is drawn downwards by the deltoid, though the strong periosteum and the trapezius oppose the tendency to great deformity; the arm feels as if it were dropping ofii and is, therefore, supported by the other hand. The patient can neither raise nor abduct the arm. As the bone is subcutaneous, by running the finger along the spine of the scapula, the fracture may be readily detected, and, by raising the arm, the deformity is removed, probably with the production of crepitus. The Treatment is to support the elbow in a sling and fix the arm to the side. 432 Applied Anatomy : Fracture of the Goracoid Process. — Fracture of this process is rare, because of its depth, and because it is so well protected by neighbouring bones. Occasionally, however, fracture is produced by direct violence, though Mr Lane believes that it is usually broken by indirect violence, as a fall with the arm fully flexed at the shoulder joint, so that the coracoid process is jammed against the under surface of the clavicle ; the same thing would also take place when a person falls from a height and catches hold of some thing with his hands — the sudden check would jam the process against the clavicle. This injury is often associated with dislocation of the shoulder. Like the previous process, it may be merely the separation of an epiphysis; a centre appears during the first year near the tip of the bone, and unites with the rest from twenty-two to twenty-five years of age. If the fracture is external to the coraco-clavicular ligament, the detached fragment will be displaced downwards and inwards by the short head of the biceps and coraco- brachialis on the one hand, and the pectoralis minor on the other. If internal to the ligament, there will be no displacement, as it will simply be slung up to the clavicle by the strong coraco-clavicular ligament. The Treatment will be to bend the arm to an acute angle, to relax the biceps, support the elbow, and bind the whole arm to the trunk. THE HUMERUS. This bone is developed by seven centres; that for (1) the shaft appears about the fifth week of foetal life, and at birth the shaft is pretty weU ossified though the ends are cartilaginous. (2) A centre for the head appears during the first or second years, and unites with the tuberosities in the line of the anatomical neck, about the age of five (Fig. 78). Before five years of age, therefore, it will be possible to have a separation of this epiphysis. (3) There is a centre for the tuberosities which appears during the second or third years, and after being joined by the head of the bone, unites with the shaft at twenty years of age (Fig. 79), the line of union being considerably above the surgical neck, so that from five to twenty years of age we are more likely to have a separation at this line than fracture of the surgical neck (Fig. 78). The length of the bone is mainly due to growth from this upper epiphysis. At the lower end there are Surgical, Medical, and Operative. 433 Fig. 78. Upper End of Humerus. Surgical Neck. Epiphyseal Cartilage in the line of the Anatomical Neck, which joins the Tuberosities at five years of age. Epiphyseal Cartilage be- tween the Tuberosities and Shaft, and which unites with the Shaft at twenty years of age. rgical Neck. Lesser Tuberosity.. Fig. 79. Upper End of Humerus. Unites at 20 years of age. .Greater Tuberosity. .Bicipital Groove. 2b 434 Applied Anatomy: other four centres appearing at various ages, and all, save that for the internal condyle, unite with the shaft at sixteen or seventeen years of age. That for the internal condyle is the last to unite, union taking place a year or so later — at eighteen years (Fig. 80). Fig. 80. Lower End of Humerus. Internal Epicondyle ^External Bpicondyle,4J,-§; -JEpiphysis for Trochlea and Capitellum. Complete union at 18 years of age. The humerus is most thickly covered hy muscles on its anterior and posterior aspects, and fractures are hest detected by running the fingers and thumb along the sides of the bone. The shaft is very often the seat of ununited fracture; this was well seen in the case of the late Dr David Livingstone, the African Missionary and Explorer, about the middle of whose left humerus a pretty complete false joint had formed. The cause of non-union of the humerus is doubtful, but it is probably to a great extent due to imperfect fixing of the joints above and below the fracture, and of the muscles that act on the wrist and fingers. Some say it is because the elbow is usually left unsupported during the after treatment of the case; and others, that it is due to the inclusion of some muscular tissue between the broken ends, which is very likely to happen since the bone is so closely enveloped by muscles — the brachialis anticus in front and the triceps behind — and Surgical, Medical, and Operative. 435 especially wliere the fracture is caused by direct violefice, for then the tissue is directly driven in between the broken ends. The causes of these fractures are — (1) Direct Violence, the usual cause of fractures at the upper end ; (2) Indirect Violence, as falls on the hand or elbow; and (3) Muscular Action — the humerus is said to be more frequently fractured from this cause than any other bone in the body. It is usually the shaft that is thus broken, as in throwing a ball or striking a blow straight from the shoulder, when the humerus gives, either from the actual force of the blow or else from the object having " dodged " it. Anatomical Neck. — Fractures of the anatomical neck mayTae impacted or non-impacted. In the first case the head of the bone is driven into the cancellous tissue of the upper end of the humerus; in the non-impacted the head lies loose, like a foreign body in the joint, and will almost certainly necrose, a condition far less favourable to union than the impacted variety. Before five years of age it is merely a separation of the head at the epiphyseal line. Fractures of the anatomical neck are mostly caused by severe direct violence, as falls or blows on the shoulder, usually in old people. The exact way in which this occurs is doubtful, but Dr Caird has pointed out that there is probably a partial dislocation in the first instance, and the anatomical neck is then jammed against the sharp anterior edge of the glenoid cavity which splits it off. The signs are not very definite : by the finger in the axilla the surgical neck can be felt entire, but stiU crepitus is elicited on moving the shaft of the humerus, and it may be possible to feel the detached head. It is often partly extra-capsular at the upper part, running obliquely through the greater tuberosity ; under these circumstances there will probably be some broadening of this tuberosity, as the upper fragment is driven into it. There is further, pain, slight flattening of the shoulder, loss of movement, and probably slight shortening. Observe that in impacted intra-capsular fracture the upper fragment is driven into the lower ; in extra-capsular, the lower is driven into the upper. In fractures of the upper end of the femur the reverse obtains. Fracture of the Surgical Neck, that is, below the great tuber- osity, but above the muscles inserted into the bicipital groove. It may be impacted or non-impacted ; it is the most frequent fracture 436 Applied Anatomy: in this regioft, and is usually transverse in direction. It is usually caused. by direct violence, as severe falls or blows on tlie shoulder, in elderly people. As already stated, separation at the epiphyseal line between the tuberosities and the shaft can only occur before the age of twenty. This line does not correspond to the surgical neck, but is considerably above it. In this case the upper fragment of the bone remains in the glenoid cavity, while the upper end of the lower fragment is drawn inwards and upwards, and forms a marked projection just beneath the coracoid process, rounded and smooth in outline, and when crepitus can be detected it is softer in character than ordinary crepitus; the upper fragment (the epiphysis) is held in position by the muscles attached to the tuberosities, which are inserted above this epiphyseal line. Fracture proper through the surgical neck is recognised by the shortening, crepitus, distortion, the axis of the bone being directed downwards and outwards, and loss of power of the arm, while the shoulder is rounded and swollen. The shaft of the bone moves independently of the head when the elbow is rotated, and by pushing the fingers up into the axilla the upper end of the lower fragment may be detected. The elbow can be brought to the side while the hand is placed on the opposite shoulder. The upper end of the lower fragment can be felt under the coracoid process, especially when the elbow is pushed up and rotated. The uTp^er fragment, together with the head of the bone, is rotated outwards, abducted, and raised by the muscles attached to the greater and lesser tuberosities — snpra-spinatus and infra-spinatus, teres minor, and subscapularis ; still, the displacement is not great, because the muscles of the two tuberosities almost counterbalance each other. The only muscle not balanced is the supra^spinatus, which may, therefore, and sometimes does, cause persistent abduction of the fragment. The lower fragment is drawn upwards, inwards, and forwards — upwards by the biceps, triceps, and deltoid; inwards and forwards by the pectoralis major, latissimus dorsi, and teres major. The axis of this part also is altered, the elbow being tilted outwards by the action of the deltoid (Fig. 81). At first sight this injury may seem to resemble subglenoid dislocation of the head of the humerus; but the head of the bone can be felt in its natural position, the limb is shortened, and there is increased Surgical, Medical, and Operative. 437 mobility, and we may easily elicit crepitus. Further; the depres- sion in fracture is not immediately under the acromion process, as in dislocation, but at some distance below this point — below the lower end of the upper fragment, a little above the insertion of the deltoid. In impacted fracture there is no mobility, displace- ment, nor crepitus. In this case the lower fragment usually penetrates into the cancellous tissue of the superior — the reverse of impacted fracture of the anatomical neck. The signs of this condition are obscure, and chiefly of a negative character. Fig. 81. Fracture through Surgical Neck. Anatomical Neck Forces that displace the Bone upwards— Biceps, Triceps, Coraco-BracmaliB, etc. Forces that pull the Bone inwards — Pectoralis Major, Latissimus Dorsi, and Teres Major. Axis of unbroken Humerus, Acromion Process. Deltoid Muscle. Imaginary Pivot round which the Humerus is rotated by the Del- toid, throwing the Elbow outwards and the Upper End in wards. Axis of unbroken Humerus. Treatment of fractures and diastasis of the necks of the humerus — (1) "Set" the bones by extension; (2) place a pad in the axilla to keep the upper end of the lower fragment outwards; (3) bend the elbow to a right angle, and keep the upper arm parallel with the side of the chest, and rather in advance of the mid-axiUary line, so as to counteract the forward displacement of the upper end of the lower fragment; (4) use a sling to support the hand only, so that the weight of the limb may overcome the 438 Applied Anatomy : upward, displacement. The late Professor Spbnce taught that the dhow should he m;^m-ted, so as to keep the ends of the bone in apposition, and secure firm union; (5) the arm must then bo firmly bandaged to the trunk by a broad domett bandage, but must not be carried across the chest, as in fracture of the clavicle, as this would bend the bone at the seat of fracture, and cause angling. Some advise that the hand and fore-arm should be bandaged lightly so as to avoid venous congestion, but this is unnecessary, and may even be injurious. No splints are required, but if necessary a gutta-percha cap may be moulded over the shoulder and upper part of the humerus, to steady the parts, especially iu the case of children or restless patients; or the cap may be made of moulded " poroplastic " material, with a rect- angular splint attached, of the same material, to pass along the outer side of the arm and fore-arm to the tips of the fingers; this will insure perfect rest to the injured bone. Splints are of no use as regards co-aptation of the fragments, for it is im- possible to put the internal splint so high as the fracture, and one splint alone is useless. In cases where the upper fragment is persistently abducted, and it is consequently impossible to bring it iato line with the lower, the lower fragment must then be abducted, to bring it into line with the upper, some such means as " Middledorpf 's triangle" being used for this purpose. T^e fracture unites in from four to five weeks in youth, but requires longer in old age — two to five months. THE GEEAT TUBEROSITY. Separation of the Great Tuberosity. — This may be caused by falls or blows on the shoulder, or from powerful contraction of the muscles inserted into it ; it may also accompany dislocation of the shoulder. The separated fragment is carried outwards and upwards by the three muscles attached to it — supra-spinatus, infra-spinatus, and teres minor; while the other part of the head with the shaft of the bone is drawn upwards and inwards by the muscles passing from the trunk and scapula, to the arm — subscapular! s, pectoralis major, latissimus dorsi, and teres major — as well as the flexors and extensors — triceps, biceps, and coraco-brachialis. There is flatten- ing and great widening of the shoulder, with a double projection Surgical, Medical, and Operative. 439 and a groove between. The anterior projection rotates with the shaft of the humerus, but the posterior projection does not. The Treatment is to pad the axilla, to throw the anterior fragment into its proper place, and then, by a compress behind, the detached fragment is pressed into apposition ; or the patient may be kept in bed, and the muscles displacing the parts relaxed by raising and abdvicting the arm. SHAFT OF HUMERUS. Fractures of the shaft of the humerus are usually transverse, but may be oblique from above, downwards, and outwards, when the brachialis anticus and biceps muscles in front, and the triceps behind, will cause a certain amount of displacement and shortening, Fig. 82. Fracture above the Deltoid. Anatomical Neck. . Forces displacing the lower ._ end of the upper fragment inwai-ds — The Pectoi-alis Major, Latissimus Dovsi, and Teres Major. Axis of unbroken Humei*us. Acromion Process. Deltoid Muscle, tilt- ing the lower frag- ment outwards. Forces that displace the Bone upwards — Biceps, Triceps, etc. Axis of unbroken Humerus. by making the parts glide over each other. The shortening, how- ever, is not usually great, on account of the weight of the arm; the usual amount is about three-quarters of an inch. The usual causes are direct violence, indirect violence, as a fall on the elbow, or muscular action. If the fracture be transverse there may be 440 Applied Anatomy: no displacement, only a slight angling. If fractured at a point between the insertion of the deltoid below, and the muscles in the bicipital groove above, the lower fragment will be drawn upwards by the deltoid, biceps, and triceps, and glide to the outer side of the ujyper fragment, which will be drawn towards the chest by the muscles in the bicipital groove — pectoralis major, latissimus dorsi, and teres major (Fig. 82). Fracture below the Deltoid impression. — The upper fragment is abducted by the deltoid and supra-spinatus, while the lower Fig, 83. Fracture below the Deltoid. Muscles in the Bicipital Groove — Pectoralis Major, Latissimus Dorsi, and Teres Major Forces that displace the, lower fragment up- wards and inwards — Biceps, Triceps, Cor- aco-Brachialis, and Brachialis Antlcus. Axis of unbroken Humerus. Acromion Process. The Deltoid Muscle, displacing the lower end of the upper fragment outwardSjin spite, of the Muscles inserted into the Bicipital Groove. Axis of unbroken Humerus. fragment is drawn upwards and to its inner side by the biceps and triceps (Fig. 83). Tlie great sign of fracture of the shaft of the humerus is moUUty in the length of the lone, as in all cases where there is but one bone in a limb, or if two, where both are broken : fix the upper fragment, and then try to move the elbow laterally. Treatment of Fractures of the Shaft.— Two Gooch splints, sufficiently broad to almost completely surround the arm when padded. From, the upper and anterior angle of the outer one a Surgical, Medical, and Operative. 441 triangular piece should be cut off in order to allow the splint to he carried well up over the point of the shoulder, which could not be done were the upper end cut square, as the anterior corner would hitch against the anterior fold of the axilla. This external splint must be long enough to reach from the tip of the shoulder to the lower end of the elbow when the arm is bent ; a rectangular slice must be cut out of its anterior inferior corner — i.e., fr.om its inner side. The inner is cut nearly square at the top, or slightly scooped out, but a like slice, to that cut from the outer splint, is Splints Fig. 84. FOR Fractured Humerus. External Splint — V 1 — Internal Splint . i 1 i Gap into -which the Fore-Arm fits. The student must carefully note that these two splints alone are not sufficient for fractures of the shaft of the Humerus. It is absolutely necessary to carry a splint from the shoulder to the tips of the fingers. cut from its outer and lower corner (Fig. 84). Both splints are to be well padded, especially the upper end of the inner splint. The elbow is bent at a right angle, and the fore-arm fits into the gap at the lower ends of the two splints, to which it is fastened by a few figure-of-eight turns of bandage. The splint above this is to be fastened with slip-knots, the fore-arm slung, but the elbow left unsupported. Instead of using two splints of the same shape, the external one may be made like the above, and the internal simply a narrow, straight piece of board with a piece cut from its lower 442 Applied Anatomy : end to avoid pressure on the internal condyle. The arm must not be put across the chest, as in fracture of tlie clavicle, as this would bend the bone at the seat of fracture. It is important, however, in all cases to fix both the elbow and shoulder joints either by an external or internal rectangular splint or both, the external reaching to the tipn of the fingers, to command the muscles acting on the wrist and fingers, since they mostly arise from the lower end of the humerus, and every time the fingers are moved the fractured point is disturbed. The neglect of this precaution very often leads to an ununited fracture. Should an internal one be used, care must be taken not to press unduly on the axillary vein, or the internal condyle; a hollow pad must be placed over the internal condyle, or else a hole cut out of the splint. If an external one be used, it must be carried from the acromion process to the finger tips, and its upper part expanded in order to envelope and steady the shoulder. It is most convenient to make the rectangular splints of poroplastic. In some books great stress is laid on the fact that the elbow is to be supported in cases of fracture of the shaft of the humerus, as otherwise, it is stated, non-union is apt to take place. But probably the real cause of non-union in most cases is, because the joint on each side of the fracture, as well as the fore-arm and fingers, have not been thoroughly kept at rest. Fractures of the shaft unite in from four to six weeks, according to the age of the patient. FRACTURES NEAR THE ELBOW. Fracture just above the Condyles.— This fracture occurs chiefly in young persons. The usual cause is a fall on the semi-flexed elbow. It may be confounded with separation of the epiphysis in children, or dislocation of both bones of the fore-arm backwards; but the presence of crepitus, the fact that the limb assumes its normal appearance on extension, but becomes distorted again when the extension is discontinued, the increased mobility, and the guide already mentioned — viz., the relation between the intema,l condyle of the humerus and the olecranon process — will aid the diagnosis, both in fracture and separation of the epiphysis. In separation of the epiphysis there is no crepitation, or, if there is, it is very soft in character. The deformity is easily reduced, but difficult to Surgical, Medical, and Operative. 443 retain, the bony points maintain their proper relationship, and the patient will probahly be under sixteen years of age. The lower fragment is carried backwards and upwards behind the upper fragment by the triceps, biceps, and the brachialis anticus muscles, just as in fracture proper, but the anterior projection is broader and more rounded than in fracture. In fracture, separation of the epiphysis, and dislocation of both bones backwards, the general appearance is the same (Fig. 85) ; but in fracture and separation of the epiphysis the bony points about Fig. 85. DiSLOOATION OF BOTH BONES BACKWARDS. Position of the An- terior Swelling in Fracture / y Position of the Anterior Swelling in Dislocation. the elbow joint are the same as on the uninjured side, which is not the case in dislocation. Since, however, the epiphyseal line is wholly idthin tlie capsule, the displacement is not likely to bs great unless there be a partial fracture through the lower end of the humerus as well. In Fracture proper the displacement is very similar to the above, the lower fragment is prdled upwards and backwards behind the upper, and carries the fore-arm with it; so that the olecranon projects unnaturally, and there is a hollow above it (Fig. 85). 444 Applied Anatomy : The lower end of the upper fragment is tilted forwards, forming a prominence in front, above the crease in front of the elbow joint (in dislocation of both bones backwards the prominence is 6efo«(; this crease). In fracture, also, the distance between the acromion process and the condyles is lessened, but not so in dislocation. So also the mobility, crepitus, and the fact that the deformity is easily reduced by extension, and the absence of any change in the rela- tive i)ositions of the various bony points around the joint, should prevent the student mistaking this accident for dislocation of .both bones backwards. The fracture is transverse from side to side and oblique from behind downwards and forwards ; the muscles displacing the lower fragment are the triceps, biceps, and brachialis anticus. The median and ulnar nerves are apt to be injured. Treatment. — Set the bones by extension of the arm and fore- arm, and press the lower end of the humerus backwards and the lower fragment forwards, and then bend the elbow to an acute angle. In this way the triceps behind acts as a posterior splint, and keeps the lower fragment pressed forward; next, place a pad of cotton wool 'in the bend to exert counter-pressure, and keep the lower end of the upper fragment backward. The elbow is then to be bandaged by successive divergent figures-of-eight sufficient to secure it in this position, and the arm then carried in a sling midway between pronation and supination, or else bound firmly to the trunk. Begin gentle passive movement early; the seat of the fracture can be secured between the fingers and thumb of the one hand, while the other moves the fore-arm. Being near the spongy end of the bone there is but little danger of non-union. Fractures of the Condyles. — Fractures of the condyles are usually caused by direct violence, such as falls or blows, or from muscular action. The inner one is more often fractured, and the detached piece (when the " epicondyle " alone is broken) is carried downwards and outwards by the muscles attached to it. The signs are pain, impairment of motion, mobility of the fragment, and crep- itus. In cases where the articular surface is involved in fractures at the lower end of the humerus, they are almost always followed by some permanent damage to thB joint, unless very great care be exercised in their diagnosis and after "treatment. The joint may be involved by fracture of either condyle, or transverse fracture Surgical, Medical, and Operative. 445 of the lower end of the humerus, with a vertical fissure between the condyles running into the joint— the T-shaped fracture; in this case, it is said that the tip of the olecranon acts as a wedge, producing the transverse part of the fracture; while the ridge along the middle of the greater sigmoid cavity also acts as a wedge, and produces the vertical fracture into the joint. The various forms are usually produced by falls on the bent elbow. In fracture of the external condyle the fissure is usually situated between the capitellum and the trochlea ; of the internal, it runs through the centre of the trochlea. In the T-shaped fracture the width between the condyles is increased, and by grasping the condyles each can be moved independently of the other with the production of crepitus. In fracture of the internal condyle into the joint, the fragment is dragged upwards and inwards, and carries the ulna with it, so that the relation between the internal condyle and the olecranon process is normal, but not so its relation to the external condyle ; there is also a marked increase into the antero-posterior breadth of the condyle. This is very frequently associated with dislocation of the head of the radius backwards. The different Fractures of the Lower End of the Humerus, then, are: — (1) An oblique fracture just above the condyles; (2) separation of the lower epiphysis; (3) a transverse fracture across the lower end of the humerus, with a vertical split into the joint — " the T- shaped fracture " ; (4) fracture of the internal condyle, involving the joint ; (5) fracture of the external condyle, involving the joint ; and (6) up to eighteen years of age, separation of the internal " epicondyle,'' which is wholly extra-articular. Treatment of Fractures of the Condyles. — As there is usually considerable swelling and inflammation of the joint, the ordinary means must be taken to allay the inflammation ; after this get the bones into proper position by extension, counter-extension, and manipulation, and then put up the limb with the arm at right angles to the fore-arm and the hand midway between pronation and supination. For this purpose some use a jointed rectangular splint on the inner aspect of the fore-arm. But, probably, the best way is to apply two moulded poroplastic rectangular splints of such a size as almost to envelope the arm when padded, the posterior one reaching to the tips of the fingers. The arm is then supported 446 Applied Anatomy: in a sling. Begin passive movement vary early, within seven days (Hamilton), in case the joint be stiffened either by fibrous adhesions, union of the detached parts in wrong positions, or else by the excessive production of callus adhering to the articular surfaces. Another way (which is suitable in all cases of injury about the elbow joint except fracture of the olecranon) is to bend the arm to an acute angle, place a pad in the bend, and retain it thus by a figure-of-eight bandage, and afterwards to sling or bind tlie arm to the side (Spencb). NERVE LESIONS. Nerve Injuries following fractures of the humerus. — In fractures of the shaft of the humerus, the musculo-spiral nerve may be injured, either directly, at the time of the accident, or later, by the "ensheathing callus.'' Lower down, at the external condyle, the posterior interosseous branch alone may be injured. If the trunk of the muscUlo-spiral be injured, supination is imperfect, extension of the hand and fingers is entirely lost, and the hand becomes pronated, and "wrist drop," somewhat resembling that seen in lead palsy, ensues ; extension of the elbow will probably be impaired, or altogether lost. As the biceps, however, is not paralysed, a certain amount of supination is still possible. Further, the lumhricdles and the interossei are not paralysed, so that the upper two joints of the fingers, if forcibly bent, may be again extended, as these muscles are supplied by the median and the ulnar nerves, and their function is to flex the first phalanx and extend the other two ; the fingers are flexed, and cover the thumb, which is also flexed and adducted. It is to be distinguished from lead-poisoning by the history of the case — occupation, blue line on gums (from the sulphide of lead), colic, trembling of the muscles previous to their actual paralysis, and by the early appearance and well-marked character of the "reaction of degeneration," as shown by the continuous current. In lead-poisoning too, curiously enough, the supinator longus muscle is not aflfected ; this can readily be shown by placing the hand midway between pronation and supina- tion, and pressing down the upper edge of the hand while the patient attempts to bend the elbow, when the muscle will be seen as a distinct resisting band. "When the trunk of the musculo-spiral Surgical, Medical, and Operative. 447 is paralysed, as i» " crutch palsy," in " Saturday night palsy," and by pressure of the axillary pad in cases of fracture of the clavicle, this muscle is paralysed to the same extent as the rest of the group. The "reaction of degeneration," and atrophy (from the loss of trophic influence, and not from disuse alone), also result from lesions of the nerve trunks, but not so rapidly as in lead-poisoning. The following fourteen muscles are supplied by the musculo- spiral nerve, either directly or indirectly — (1) Biceps, (2) triceps, (3) the anconeus, (4) supinator longus, (5) extensor carpi radialis longior, (6) extensor carpi radialis brevior, (7) extensor communis digitorum, (8) extensor minimi digiti, (9) extensor carpi ulnaris, (10) extensor ossis metacarpi pollicis, (11) extensor secundi inter- nodii poUicis, (12) extensor primi internodii pollicis, (13) extensor indicis, and (14) supinator brevis. In paralysis of the posterior interosseous alone, in injuries involving the external condyle, there is only partial loss of supina- tion and extension, as the supinator longus and extensor carpi radialis longior are not aifected, being supplied directly from the trunk of the musculo-spiral. Should this condition last any length of time, the paralysed muscles tend to increase in length from the constant tension of the still healthy muscles, while the latter in like manner shorten, as they have nothing to oppose them, conse- quently the fingers become flexed, and the hand crumpled up into a " duh-hand," somewhat resembling that seen after bad cases of teno-synovitis, or in contraction of the palmar fascia. The muscles supplied by the posterior interosseous nerve are from 6 to 14, inclusive, of the list given under the musculo-spiral nerve. In fractures of the internal condyle the ulnar nerve may be implicated in a similar way. In this case there will be great loss of power in the ring and little fingers, adduction and flexion of the thumb will be imperfect, and adduction and abduction of the index and middle fingers impaired, as the interossei are paralysed. The position the hand assumes in lesions of the ulnar nerve is known as the " clawed hand," or " main en griffe ;" it is due to paralysis of the interossei allowing the opposing muscles to have it all their own way, the result being extension of the first and flexion of the second and third phalanges, the hand thus assuming the bird-claw position. It must be distinguished from a similar appearance found 448 Applied Anatomy: in the disease known as " progressive muscular atrophy ; " in this disease all the fingers are equally aifected, but in paralysis of the ulnar, the ring and the little fingers are much more bent than the others, since the first two lumbrical muscles, which are supplied by a branch of the median nerve, escape. In traumatic cases of lesion of the ulnar nerve, the onset is sudden, not progressive, and the paralysis precedes the atrophy. Sensation is lost in the little finger and on the ulnar side of the ring finger; the paralysed muscles undergo rapid atrophy, and show the " reaction of degeneration." The atrophy is first and most clearly seen in the abductor indicia (first dorsal interosseous), and next in the short muscles of the little finger. In addition to these symptoms we have the usual trophic lesions of the skin and its appendages- — glossy skin, loss of hair and nails, blebs, and chilblain -like ulcerations. The muscles paralysed are — (1) The flexor carpi ulnaris; (2) half of the flexor profundus digitorum ; ( 3 ) the three short muscles of the little finger — abductor, flexor brevis, and the opponens minimi digiti ; (4) one and a half muscles of the thumb — the abductor poUiois, and deep head of the flexor brevis ; (5) all the palmar and dorsal interossei ; and (6) the two inner lumbricales. To treat these conditions, mechanical means must be used so as to prevent further deformity and remove that already existing, passive motion, massage, and galvanism to the paralysed muscles. In cases where the nerve is actually enveloped in bony outgrowths, it will be necessary to cut down and set it free. The musculo-spiral nerve may also be paralysed, partially at least, in those who use crutches (" crutch palsy") from pressure of the upper end of the cratch upon the nerve trunk : also by the axillary pad, in cases of fracture of the surgical neck of the humerus: sometimes also in coachmen, who fall asleep on the box with the reins twisted round the upper arm : and lastly, in those who have imbibed too much of the cup that cheers (1) and most certainly does inebriate, and have fallen asleep in consequence, with one arm hanging over the back of a chair, in that position of good-natured abandon and free-and-easy carelessness so characteristic a result of the too free imbibition of this beverage. This last form (" Saturday nigJit palsy") is usually first discovered on Sunday morning, the patient, as a rule, applying for advice and explanation on the following Surgical, Medical, and operative. 449 Monday. Duchenne has collected a large number of cases of sudden paralysis of this nerve, usually due, he believes, to cold, from sleeping with the arms exposed to a draught of cold air. While not denying the possibility of its being caused by draughts of cold air, still the usual cause, in this country at anyrate, would seem to be draughts of CaHeO. The best immediate treatment for this last condition is to apply electrical stimulation to the muscles; to stimulate the nerve trunk by applying some counter- irritant to the skin along its course — e.g., iodine ; and, for the future, to avoid " draughts." BONES OF THE FORE-ARM. Each of the bones of the fore -arm is developed from three centres. The centres for the shafts appear very early in foetal life. Fig. 86. Upper End of Radius. Fig. 87. Lower End of Radius. Bicipital Tubercle. -Epiphysis. Si^iioid Cavity for Ulna _ .-- Tubercle for Supinatoi: Longus. Unites about Puberty. Unites about 20 years of age. The Radius has also a centre for the head that appears at five years of age, and joins the shaft about puberty (Fig. 86), and another for the lower extremity which appears about the second year, and joins the shaft at twenty years of age (Fig. 87) ; the length of the bone is probably chiefly dependent on the lower epiphysis, although the contrary has been stated. The Ulna has a centre for the olecranon process, appearing at the tenth year and joining 2p 450 Applied Anatomy : the shaft ahout puberty (Fig. 88); and another for the lower extremity, appearing at the fourth year, and, like the radial one, joining the shaft at twenty (Fig. 89). The ulna grows in length chiefly from the lower epiphysis. Hence, it will be noticed that in both cases the upper epiphyses join the shafts at puberty, and the lower at twenty; and that the two centres for the ulna appear at exactly double the age as that for the radial centres — radial, five and two ; ulnar, ten and four. The upjjer epiphysis of the radius is entirely within the orbicular ligament ; the lower includes the facet for the ulna and the insertion of the supinator longus. As regards the upper end of the ulna, the eoronoid process and the chief part of the olecranon are formed from an extension of the shaft) of the bone into it; the upper part only of the olecranon is Fig. 88. Upper End of Ulna. Fig. 89. Lower End of Ulna. ..JBpipbyeis. Unites aljout Puberty. Epiphysis j Unites about 20 years of age. developed from a separate centre. Next to the clavicle, the bones of the fore-arm more frequently present examples of green-sUcJc fracture than other bones, usually the result of a faU on the hand or a twist of the arm in a young person. In adults either may be broken alone, but fracture of both together is more common. The lower end of the radius is not included in the previous statement, of course; if it were, then fracture of the radius alone occurs more frequently than fracture of any other bone — the clavicle, perhaps. Surgical, Medical, and Operative. 451 excluded — and at the lower end the fracture is very often impacted. The bones are throughout nearer the posterior than the anterior surface of the limb, and as the wrist is approached the nearer the two bones come to the surface of the lateral aspects of the arm. The posterior edge of the ulna is subcutaneous from the olecranon process to the wrist, and can, therefore, be readily examined in eases of supposed fracture. The upper third of the radius is pretty deeply covered, though its head is quite superficial, just imme- diately below the external condyle of the humerus ; in the lower two thirds it is quite subcutaneous on its outer aspect. However, fractures of this bone are best detected by noting whether the head of the bone follows the movements of the wrist during pronation and supination, the Surgeon placing his left thumb on the head of the radius. The Olecranon Process. — Fractures of the olecranon are usually the result of direct violence, and may be divided into — (1) Those with displacement, and (2) those without. The latter variety is the more common. Of the latter there are three forms — (a) The transverse, where the periosteum and ligaments are intact and efieetually resist the action of the triceps to separate the fragments; (ft) where the process is split obliquely, or longitudinally, or almost stellate ; and (c) where the tip is broken off obliquely from behind forwards and downwards, leaving the unbroken posterior part attached to the triceps. The fracture may be caused by the actioi) of the triceps muscle, or by a fall or a blow with a stick on the bent elbow. It occurs most frequently in men during the middle period of life. When the fragment is carried up by the triceps there is a hollow at the back of the joint, which is increased during flexion; and there is partial or entire loss of extending power. In other cases the dense periosteum, strengthened by a ligamentous expansion from the triceps muscle and the internal lateral ligament ( = " Uffament of Sir Astley Cooper"), is not torn, and in these cases there will be little or no displacement; the only symptom being special tenderness at one spot, or in the line of the fracture, and probably mobility and crepitus — the upper fragment moving on the lower. The line of fracture is usually about the middle of the process, often across the constriction or groove in the middle of the greater sigmoid cavity. 452 Applied Anatomy: Treatment. — The indications are — (1) to keep the triceps muscle relaxed, to enable (2) the detached portion to be brought into and kept in its natural position by mechanical means — in other words, the arm must be kept extended during the healing of the bone. This is the otHy injury in the region of the elbow joint that should be treated in this position; all other injuries here are best treated in the flexed position. A splint, not exactly straight, but cut so as to correspond to the angle made by the fore-arm with the upper arm, is required; it may be made of wood, Gooch splint, or gutta- percha, and should be long enough to reach from the middle of the upper arm to the wrist. The splint, as usual, must be well padded. Before applying the splint, in this special fracture, the fingers must be carefully padded, and the hand and fore-arm bandaged in the ordinary way, from the tips of the fingers upwards, finishing off with a very lightly applied figure-of-eight round the elbow, merely to retain the end of the bandage, and not to exert any pressure upon the joiat; remember that this is the only fracture where it is lawful to apply a bandage beloio, the splint, and it is advisable before applying it. to. encase the limb in a layer of boracic lint. The arm is to be thus bandaged to prevent venous congestion, which is apt to take place since the limb is kept in the extended position; and as the joint is wounded, blood is probably poured into it, and in any case synovitis, with extensive effusion, will almost certainly take place, hence the importance of avoiding tight bandages round the joint under the splint. The splint is then to be applied along the front of the limb, and bandaged to it in the usual way ; and lastly, apply a few turns of a convergent figure-of- eight bandage above and below the olecranon, so as to press the fragments together, at first not very tightly, but as the swelling and effusion into the joint subside, more firmly. The tips of the fingers are left uncovered, so that the Surgeon may be, able to judge of the condition of the circulation in the ann; blueness, coldness, and swelling wiU indicate that the bandages are too tight. The splints must be looked to on the second day to see if all is well. Passive movement must be gently tried from a fortnight to three weeks after the injury, the broken parts being firmly supported with one hand while the arm is moved with the other. Probably some form of gentle elastic traction brought to bear on the upper Surgical, Medical, and Operative. 453 fragment alone, as it only is displaced, would be the most effective plan — something of the nature of Manning's splint for fractured patella. The splint may be kept on for two or three weeks, and after this, gentle passive movement practised, and a week or so later the splint may be entirely abandoned. The union is usually fibrous, bony being rare, except in cases where there has been no separation of the fragments. In cases where the fibrous medium is too long, it may be removed by operation, and the fragments wired together. Fracture of the Coronoid Process. — This is very frequently associated with dislocation of the ulna alone, or of both bones backwards, as, when broken, the ulna during flexion is readily projected backwards. When the ulna is brought into position again and the elbow flexed, crepitus is produced, but when the extending force is withdrawn it quickly passes back again to its former position. As already pointed out, this process is developed as a part of the shaft, and therefore can never be separated as an epiphysis. It is caused by falls on the palm with the elbow slightly flexed. The detached fragment wiU be pulled upwards by the brachialis anticus muscle. Fractures of the head and neck of the radius are very rare forms of accident. In fractures of the neck, the upper end of the lower fragment will be pulled forwards by the biceps muscle. The upper epiphysis may also be separated before the age of puberty; this epiphysis is entirely within the orbicular ligament and we must not therefore expect much displacement. The head may also be split or starred. The Treatment of these injuries is the same as that for fracture of the condyles of the humerus (see page 445). Fracture of the Radius alone above the insertion of the pronator radii teres.— When the radius alone is fractured it is usually the result of indirect violence, as a fall on the hand. The upper fragment is flexed by the biceps, and fully supinated by the same muscle, and the supinator brevis ; while the lower fragment is fully pronated by the pronator radii teres and the pronator quadratus. Hence the upper part is fully supinated, while the lower is fuUy pronated. It is important to bear this in mind while treating the case, as first pointed out by Lonsdale. The fracture is best diagnosed by gently pronating and supinating the hand, while a finger or thumb is placed over the head of the 454 Applied Anatomy: radius just below the external condyle j if the head moves with, and as fast as, the hand and lower end of the radius, there can be no fracture. Fracture of the Radius below the insertion of the pronator radii teres. — Here the fracture is between the two pronators and the upper fragment is drawn upwards; or, rather, it tends to be tilted forwards and supinated by the biceps, and inwards by the pronator radii teres. The displacement inwards, however, may not be great, as the pronator radii teres is powerfully opposed by the supinator brevis and biceps, so that the bone retains a position midway between pronation and supination. The upper fragment is therefore held between the supinator brevis and biceps on the one hand, and the pronator radii teres on the other, nearly in its proper position. The lower fragment is drawn towards the ulna, and pronated by the unopposed action of the pronator quadratus, while the supinator longus tUts up the styloid process and depresses the upper end of the fragment; the lower fragment therefore usually lies in front of the upper. There is a swelling in front and behind, and the hand falls in and is pronated (compare with ColIjEs's fracture). Fracture of the Ulna alone near its middle. — This is usually the result of direct violence, because the bone is so superficial, as in carrying something in the hands, e.g., a tray, when the foot slips, and, to save the contents of the hand, the whole force of the fall is received on the posterior edge of the ulna. So also it may be broken by a blow from a stick when the arm is held up to protect the head ; or in falling against the edge of a door-step. In this case there is but little displacement of the upper fragment, except that it is drawn a little nearer the radius by the pronator radii teres and forwards by the brachialis anticus ; the lower fragment is drawn towards the radius by the pronator quadratus, and the extensors and flexors tend to draw it upwards. Although the displacement, due to muscular action, may not be great, yet the force that breaks the bone may cause a good deal, as it forces the broken ends towards the radius, narrowing the interosseous space. It is very difficult to treat this fracture, as the ends fall inwards and we have no power to act directly upon them to bring them into a proper position. Surgical, Medical, and Operative. 455 Fracture of both Bones. — The bones of the fore-arm are more frequently broken together than either the radius or ulna alone. The usual cause is direct violence, as a severe blow, or the passage of a wheel over them, and they, therefore, give way opposite each other. But it may also be caused by indirect violence, when the bones gave way at their weakest parts. One case is quoted, on the authority of Malgaigne, where muscular action, during digging, was the cause of the fracture. The usual position of the fracture is about the middle or lower thirds. As regards the displacement this wiU necessarily depend a good deal on the cause of the fracture; in a general way, something like the following will happen : — ^The Upper Ends. — The radius is tilted forwards by the biceps, and inwards by the pronator radii teres, and the ulna is tilted a little forwards by the brachialis anticus. The Lower Fragments. — The radius is pronated, and the two bones are approximated by the pronator quadratus, and are drawn upwards and forwards, or upwards and backwards, according to the obliquity of the fracture, by the Hexors and extensors. The diagnosis depends on the pain, loss of power, unnatural bend of the fore-arm, crepitus, and the ease with which we can obtain mobility in the continuity of the bones, after fixing their upper ends. Treatment of Fracture of the Shafts of one or both Bones. — The great objects are — (1) To keep up the fuU breadth of the in- terosseous space throughout, as this is essential to the movements of pronation and supination ; (2) to command the elbow, wrist, and finger joints, in order to prevent non-union ; and (3) carefully avoid pressure in the flexure of the elbow joint, and on the ball of the thumb. The bones are to be set by extension and counter- extension, applied to the upper arm and wrist by two assistants, while the Surgeon manipulates the bones into position. Two splints are required, rigid, and broader than the arm; Goooh, or ordinary wooden splints may be used; but if Goooh be used, the splints must be padded on the wooden side, and not on the leather side, as in most cases of fracture — e.g., of the humerus. They must be broader than the arm so as to prevent pressure by the bandages on the lateral aspects of the bones, as this would force them together and narrow the interosseous space (Fig. 90). The posterior one must reach from the olecranon process to the 456 Applied Anatomy . tips of the fingers J the anterior one must reach from the elbow to the roots of the fingers, and have a portion removed, if necessary, at the outer side of the lower end to avoid pressure on the ball of the thumb. Before applying the anterior splint the elbow joint should be bent to a right angle, otherwise this splint is apt to be carried too for up, and when the arm is bent afterwards the end of the splint presses injuriously in the flexure of the joint and may cause gangrene. They must be weU padded as usual, but in addition a small " graduated compress "-like pad is to be placed lengthwise in front and behind, so that it may press the muscles of the fore-arm into the interosseous space and tend, at least, to keep the bones from falling together. The hand is then Fig. 90. Fractured Fore-Arm put up. Bandage . Beversed Gooch Splini;. Special Pad in Inter-_ Bandage, weU away ,from the side of the Arm, Special Interosseous... Pad. -Ordinary Pad. -Fore- Arm. ^Ordinary Pad. -Reversed Gooch Splint. placed midway between pronation and supination, as in this posi- tion of the bones the interosseous space is widened to nearly its fullest possible extent; the elbow is next bent to a right angle, the graduated compresses applied over the front and back of the interosseous space, and the splints applied and fastened by a con- tinuous bandage, to finish off by a lightly applied figure-of-eight round the elbow — if preferred slip knots may be used instead, as in the upper arm. The arm must then be slung in a position midway between pronation and supination — the thumb uppermost, and pointing towards the patient's face. Over all an external rectangular splint extending from the shoulder downwards to the tips of the fingers should be applied to insure perfect immobility of the broken ends, by fixing the elbow, wrist, and finger joints. But inasmuch as the power of supination is sometimes lost, it is said from the union of the radius in a bad position, the upper Surgical, Medical, and Operative. 457 fragment being fully supinated while the lower is fully pronated, it was first recommended by Edwaed Lonsdale, in 1832, and more recently by Malgaignb, that the arm should be put up in com- plete supination. It is impossible to bring the upper fragment of the radius into good position with the lower, and therefore, the next best thing to be done is to put the lower fragment into as good position as possible with the upper, otherwise the use of the supLnator brevis and biceps, as supinators, is entirely lost, as they have already fully supinated the bone and are fixed in that position. The difficulty is best overcome by putting up the fractured arm in the position of full supination. The limb must be kept perfectly rigid for at least two or three weeks, when the fingers and wrist may be allowed some freedom of movement. But as the fracture is not near a joint, there is less danger of adhesions forming in the sheaths of the tendons ; indeed, absolute and, long continued rigidity rather is indicated, as the fracture is through the compact tissue of the shaft, to avoid non-union. The bones unite in about five weeks. COLLES'S FRACTURE, Fracture of the Lower End of the Radius. — The fracture in this ease is for the most part below the origin of the pronator quadratus, and is usually about three-quarters of an inch, or rather more, above the articular surface, as seen from the front, but extends higher up on the posterior aspect, as it is usually oblique from before backwards. The cause is usually indirect violence, as a fall on the pahn of the outstretched hand, the whole weight of the fall being transmitted through the ulnar side of the hand to the lower end of the radius, as it is three-quarters pronated, so that the ulnar border first touches the ground, and the hand is thus driven to the radial side ; when caused by a blow on the palm, there is no lateral displacement. The fracture may be non-impacted, but is usually impacted. Varieties. — 1. Where it is very near the lower end of the radius, comminuted, and non- impacted, and therefore easily reduced. 2. Higher up (the usual site) and not comminuted. This may be — (a) Impacted, or (&) non- impacted. Any fracture of the lower end of the radius, within 458 Applied Anatomy : two and a half inches of the wrist joint, is called a " Colles's fracture." Next to fracture of the clavicle, the lower end of the radius is most frequently broken; and fracture of hoth wrists ("double CoLLEs's") forms the commonest double fracture. From thirty years of age onward it occurs with increasing frequency in women. The great sign of this fracture is deformity, being caused in the first instance by the force that breaks it, and kept up by the impaction and by the extensors of the wrist and thumb, as well as all the other flexors and extensors passing over the broken radius. The radius is very frequently splintered into the ■wrist joint (Chiene). The lower fragment is drawn upwards and backwards and to the radial side by the supinator longus, flexors, Fig. 91, CoLLES's Fracture— Side View. (To show the "Spoon-shaped" Deformity.) Prominence on the back, caused by tbe lower fragment, with a hollow above it Prominence on the Anterior Aspect, caused by the lower end of the upper fragment, with a hollow below it. and extensors of the thumb and carpus; the upp&)' fragment is not displaced (Chiene), though it seems to project forward. Thus we have a prominence on the back of the wrist and a hollow above it, caused by the lower fragment, and a projection in front, where there ought to be a hollow, caused by the lower end of the upper fragment, the whole forming a peculiar spoon-shaped deformity (Fig. 91). It resembles dislocation of the carpus backwards, but may be distinguished from it by the fact that the deformity is removed by extension, and by the presence of crepitus in fracture, and the normal relation of the styloid processes to each other in cases of dislocation. It also simulates^ separation of the epiphysis of the lower end of the radius, but the age of the patient will aid the diagnosis. It should be noted, in cases of separated epiphysis Surgical, Medical, and Operative. 459 in young persons, when the hone unites, that this end of the radius will not grow to its usual length, while the ulna grows normally, and therefore the hand will be gradually pushed to the radial side, probably simulating a badly-treated Colles. This fracture must also be diagnosed from fracture of the lower end of both radius and ulna ; in this case there is greater mobility, and the whole hand, with the lower ends of the radius and ulna, is carried straight backwards, and lies in a straight line with the fore-arm, and is not abducted, as in ColIjEs's fracture. This injury more closely simulates dislocations of the wrist backwards. It must Fig. 92. CoLLEs's Fracture— Dorsal View. Prominence caused by the Head of the Ulna. also be diagnosed from sprain of the wrist joint ; in sprain the tender area is over the line of the joint, whereas in fracture it is some distance above the joint. But the lower fragment, besides being displaced upwards and backwards, undergoes a rotation on its transverse axis, whereby the carpal articidar surface comes to have an inclination backwards instead of forwards, as in the normal bonej hence the difficulty in flexing, though extension is easy. It is also slightly rotated on its antero- posterior axis, whereby the outer (radial) side of the bone is more shortened 460 Applied Anatomy: than the inner (ulnar) side, as the strong inferior radio-ulnar ligaments oppose the displacement at that side, and it is in this way that the hand is inclined to the radial side, as well as being slightly dorsiflexed. The head of the ulna seems unduly pro- minent (Fig. 92), hut this is not due to any displacement of the hone, but is due to the hand being displaced to the radial side and carried away from it, so that the styloid process seems carried forwards, as well as being too prominent. Very frequently there is a specially tender spot over the articulation between the radius and the ulna. The fracture is to be recognised by the appearance of the hand, history of the case, age of the patient, and by the fact that he is unable to supinate the fore-arm; and, by passing the fingers gently along the posterior surface of the lower end of the radius, the ridge formed by the displaced upper end of the lower fragment will usually be felt. Also the prominences and depressions about the wrist, the flexion of the fingers, and pro- minence of the head of the ulna, and, above all, the position of the styloid processes — in health, the styloid process of the radius is on a lower level than- that of the ulna; but in fracture the position is reversed, the ulnar being on a level with, or below, the radial. Another symptom of some importance is the obliteration of the natural hollow on the front of the lower end of the radius, its place being occupied by a prominence. According to Professor Chiene, when a person falls on his palm, if the angle between the fore-arm and the ground is less than sixty degrees, the whole shock is borne by the lower end of the radius, and a Collbs's fracture is the result ; but if the angle be greater than sixty degrees, the shock passes up the bones of the fore-arm, and the result is either a severe sprain of the wrist, or a dislocation of both bones backwards at the elbow. When a person, with the wrist in extreme flexion, falls upon the knuckles and dorsum of the metacarpus, a fracture is sometimes produced the very reverse of CoLLEs's ; it is usually known as " Smith's fracture." Treatment. — The bone, in ordinary cases, is placed in position by extension, counter-extension, and manipulation ; in difi&cult cases it may be necessary to employ forcible and full flexion with twisting, before it is replaced, and sometimes it will require to be forcibly bent over the Surgeon's knee. The backward rotation of the lower Surgical, Medical, and Operative. 461 fragment m'ml be corrected, else the patient will not be able to flex his wrist afterwards to any extent. Even in well set cases the styloid process of the nlna usually remains too far forwards. Two splints (Goooh) are required — the anterior one (Fig. 93) must not extend further than the centre of the palm, so that the fingers may be freely flexed from the very first ; on its radial side a large piece must be cut out for the prominence of the muscles of the thumb, and also extending upwards as far as the lower end of the upper fragment (some Surgeons only bring the anterior splint as far as the lower end of the tipper fragment). This gap is to allow the lower fragment to be pushed forwards, in order that the natural Fig. 93. Anterior Splint for Colles's Fracture. A X 1 2 b 1. That part of the splint that runs along the front of the uhia, and extends as far as the centre of the palm ; the splint is sometimes used without this part. 2. The gap for the mnsoles of the thumb, OMd, to allow the lo-wer fragment to he pushed forward. A and B — This line must not come further down than the lower end of the xipper fragment. hollow of the radius may be reproduced when the bones have united. The posterior splint extends to the knuckles. Both splints are to be well padded and applied; but a specially thick pad must be placed under the posterior splint opposite the lower end of the radius, in order to push the lower fragment well for- ward towards the palmar surface, into the gap in the anterior splint. The splints are then to be fastened on, first by a couple of slip-knots and then by a roller bandage, secundum artem, and the arm slung midway between pronation and supination. ' On account of the large number of tendons around this fracture it is most important to begin passive movement very early, especially 462 Applied Anatomy : in old persons. The fingers and thumb are left free, and moved regularly from the very first, and at the end of the fourth or fifth day the splints are to be taken oif, and the Surgeon, placing his index and middle finger over the upper end of the lower fragment, and his thumb on the lower end of the upper fragment, keeps the bones in position, while he gently moves the wrist with his other hand. This must be done every second day till the bones have united — at the end of three or four weeks. There is little or no danger of non-union, as the fracture is through the cancellous tissue, but there is great danger of a stiff and useless wrist result- ing, especially in old persons. There are many other forms of splints used J but the results of the above simple method, that generally adopted in Edinburgh, arc so satisfactory that it is quite unnecessary to seek refuge in more complicated, expensive, uncomfortable, and less efficient apparatus. Among them may be mentioned, the " pistol "-shaped splint, Goedon's splint, Cabb's splint, etc. One objection, it seems to me, to most of these special splints, is that the hand is displaced as far in the opposite direction by the splint, as that caused by the force that broke the bone in the other direction. That the wrist is extended and the hand displaced to the radial side, is no reason, surely, why it should be unduly flexed and turned as far to the ulnar side — unless, indeed, it be to test the truth of the parallelogram of forces ; but in this case it is scarcely necessary to point out that the two forces must act slmultaiwously on the point in question. The " pistol" splint is specially objectionable, as it almost invariably leads to a stiif wrist — the very thing we most wish to avoid. RESUME of the fractures about the wrist joint : — 1. CoLLEs's fracture, known by the marked deformity and the altered position of the styloid processes to each other. 2. Smith's fracture, where the deformity is reversed. 3. Separation of the lower epiphysis of the radius, known by the age of the patient — below twenty. -1. Fractures of both bones just above the wrist — marked de- formity, but hand in a straight line with the fore-arm. 5. Fracture just above the pronator quadratus; the hand turns in and is iully prmiated. Surgical, Medical, and Operative. 463 These must be distinguished from dislocatioiis of the wrist) by the fact that in dislocation the styloid processes maintain their proper relations to eacli other, but are altered with respect to the metacarpal bones, as weU as other signs. Fracture of the Metacarpal Bones is usually caused by direct violence, as by striking a blow with, or falling upon, the closed fist ; it is more often met with in men, and in them during the period of active adult life, and usually towards the end of the week (pay-day), or about Christmas and the Il^ew Year. There are two varieties of this fractu.re — (1) The oblique, and (2) the transverse. In the obliqice form there wiU very likely be shortening of the finger connected with the injured metacarpal, but in the transverse form there is no shortening. The fracture is to be diagnosed by running a finger along each metacarpal bone and carefully watching for any tender spot or marked deformity; this can easily be managed, as the bones are so subcutaneous. We may also grasp the two ends of the bone and try for mobility in its continuity ; then place the hands palm to palm, and observe if the corresponding finger of each hand is of the same length as its fellow. Next, we may press the end of each finger towards the wrist ; this wiU cause pain at the fractured spot should such exist, but if it be merely a bruise, there will be no pain felt at the injured spot. Lastly, make the patient clench his fists, and compare the line of the knuckles in the two hands, noting any fulness or depression. It should be noted that a " stave " of the thumb may produce a contusion of the meta- carpo-phalangeal joint or split the head of the metacarpal bone. Fractiire of the metacarpal bone of the thumb usually presents no difficulty in diagnosis, as it is free on all sides ; the metacarpal bones of the index and little fingers are more difficult, and those of the middle and ring fingers the most difficult of all, on account of their relation to the other bones. Treatment. — First Method, to be used in the case of transverse fracture of the metacarpal bones of the middle and ring fingers. Direct the patient to grasp a ball of soft worsted in the palm of the injured hand, and bandage it in that position thus: — Carry an ordinary bandage in a figure-of-eight, beginning at the carpo-meta- carpal articulation of the thumb, over the back of the fist, and then round the front of the second phalanges of the fingers, but not 464 Applied Anatomy: including the thumb, then over the back of the hand to the ulnar side, and then take a turn round the wrist, thus completing and fixing the figure-of-eight. On reaching the spot where we com- menced, the roller is then carried forwards over the first and second fingers, taking care to leave a free margin hanging over the radial side of the index finger; now carry the bandage back over the palmar aspect, to meet at the same spot as before, and complete by a turn round the wrist. Eepeat this three or four times, bringing each turn nearer the ulnar side, and at last leaving a free margin there, as on the radial side. Then carry the bandage round the wrist, as in the first figure-of-eight, being careful to catch and secure the free margins left at each side of the hand. Eepeat this two or three times, and then take a turn round the wrist, and fasten. Second Method, to be used in cases of transverse fracture of the metacarpal bone of the thumb, and probably also in the case of the index and little fingers as well. In the previous method, the neighbouring bones act as lateral splints to the ring and middle fingers. In the case of the others, however, it will probably be better to keep the hand straight and apply a well-padded splint along the anterior aspect, and bandage the injured digit in that position ; and certainly always do so in the case of the metacarpal bone of the thumb — the one most frequently broken. Were they treated like the middle or ring fingers, the bandage would force the broken ends towards the other bones and lead to marked deformity. Transverse fractures of the Phalanges must be treated by a well-padded, straight, anterior splint, with a specially thick pad opposite the middle of the broken phalanx, to fill up the hollow that naturally exists opposite the middle of the phalanges. In the case, however, of oblique fracture of the phalanges, or of the metacarpal bones, it will be necessary in every case to put up the fracture in the straight position and apply some form of extension. This may be accomplished by the use of an internal rectangular splint, passing- some distance beyond the tips of the fingers, together with an elastic band brought over the lower end of the splint and then fastened to its upper end, while the other end is attached to a more or less complete finger-stool of sticking-plaster, which is in turn to be attached to the injured finger. Surgical, Medical, and Operative. 465 The Metacarpal Bones are developed Tby two centres — the four inner hones, one for the shaft appearing ahout the sixth week, the other for the head appearing about the third year, and uniting with the shaft at twenty. The metacarpal bone of the thumb 'has also two centres, one for the shaft and the other for the base, in this respect resembling the phalanges. The dates of appearance are the same as the others. The Phalanges are also developed from two centres, one for the shaft appearing about the sixth week, and one for the base from the fourth or fifth year, and uniting between the eighteenth and twentieth years. 466 Applied Atiatomy: CHAPTER XXV. FRACTURES OF THE LOWER EXTREMITY. THE PELVIS. The innominate bone is developed by eigbt centres — three primary and five secondary; tbe three primary — one for the ilium, the ischium, and the pubes respectively — unite through the Y-shaped piece at the bottom of the acetabulum, about puberty; the secondary centres appear about puberty and unite about the twenty-fifth year (Fig. 94). The secondary centres are — one for Fig. 94. The Innominate Bone. Pubos , Ischium lY-sbaped Epiphysis. . llima. the iliac crest, one for the tuberosity of the ischium, one at the Y-shaped junction of the three bones; one for the anterior inferior spine, most frequently seen in males ; and one for the symphysis pubis, most frequently seen in females. It is important to remem- ber the Y-shaped piece, as before its consolidation, pus, in hip joint disease, may readily pass through into the pelvis. Surgical, Medical, and Operative. 467 The pelvis may be broken by crushes between a cart and a wall, mining accidents, in railway collisions, etc. (a) The False Pelvis is usually broken by lateral crushes ; but fracture of this part is not so serious as fracture of the true pelvis. (6) The True Pelvis — This is most likely to suffer from antero-posterior com- pression ; the great danger of this fracture is injury to the various pelvic viscera, especially the urethra, bladder, and rectum. The membranous part of the urethra is most apt to be injured, as the fracture very constantly passes through the rami of the pubes and ischium, and is therefore very near the urethra. To detect fracture of the false pelvis, grasp and try to move the iliac crests. For the true pelvis, feel the rami of the pubes and ischium; but in every case it wiU be wise not to make a too exact diagnosis, lest a sharp spicule of bone be pushed into the urethra or bladder. The Anterior Inferior Spinous Process may be torn off by the rectus, in running or jumping, more especially before complete consolidation — the twenty-fifth year. Treatment. — ^The chief point in the treatment of the case is never to let the patient attempt to pass water, but the Surgeon should at once try to pass a catheter into the bladder — gum-elastic if possible. If the urethra is ruptured, the patient would simply make water into his perinseal tissues on any attempt at micturition, unless, fortunately, the centres for that act were paralysed by the shock. If, when the catheter is passed, clear urine is drawn off, it shows that the bladder is not ruptured. Should the urine be bloody it may point to various accidents, but at any rate, in all cases of doubt a soft catheter should be tied in and a syphon arrangement attached to it, so that the urine may drain away as soon as it enters the bladder. In passing a catheter, keep its point well against the upper wall of the urethra, as this part is less likely to be torn than the lower part of the circumference The pelvis is then to be steadied by a broad flannel bandage with plenty of wadding below, and a double spica over all. The prognosis is fairly good, so far as immediate danger to life is concerned; hut ever afterwards the patient will be the subject of the worst possible form of organic stricture — the traumatic — with all its secondary risks to the genito-urinary organs, situated behind the stricture. 468 Applied Anatomy. Fig. 95. Upper End of Femur. Head. -^Great Trochanter. '. .Small Trochanter. The " Third Trochanter.' Union complete about 18 years of age. Fig. 96. Lower End of Femur. Articular Sui-face - A.dductor Tubercle. Joins the shaft at 20 years of age. Surreal, Medical, and Operative. 469 THE FEMUR. This bone is developed from five centres, that for the shaft appearing soon after the centre for the clavicle. At the upper end there are three centres — one for the head, vehich appears at the end of the first year; another for the great trochanter, which appears during the fourth year; and a third for the lesser trochanter, which appears between the thirteenth and fourteenth years. All the three join the shaft about eighteen (Fig. 95). There is only one centre for the lower end of the bone, and that appears two leeeks before birth and joins the shaft at twenty years of age (Fig. 96). The presence or absence of this centre is an im- portant sign of the maturity or otherwise of newly-born children, found dead, in medico-legal cases. For medico-legal purposes also, compare the development of the femur with the humerus: the lower end of the humerus is complete at eighteen, the upp&i- end at twenty ; in the femur it is the reverse, the lower end is complete at twenty, and the upper end at eighteen. A knowledge of these facts, together with the dentition — all the teeth being present except the wisdom, and the presence of an ossifying centre in the epiphysis of the clavicle, which appears about eighteen, — would enable one to speak with considerable assurance upon the age of a body, say of eighteen years, though reduced to a skeleton. Observe the great number of epiphyses in the neighbourhood of the hip joint — three in the femur, and the Y-shaped one at the bottom of the acetabulum. This, no doubt, explains the very great frecLuency of hip disease {strumous arthritis) in early life, as probably in most cases the disease begins at the growing line of the bone, as there the tissue is nearest the embryonic type, and the vascularity is great, so that any slight stimulus is enough to convert the physiological hypersemia into pathological congestion. It also explains why it is that the femur should be attacked more frequently than the acetabulum : one would expect the femur to be attacked three times as often as the acetabulum. It will be noticed, therefore, that, as usual, the order of union of the centres is the reverse of their appearance. The femur grows in length chiefly from the lower epiphysis. The line of this epiphysis just passes through the "adductor tubercle" and immediately above 470 Applied A natomy : the highest part of the articular surface, being deeper, in vertical extent, on the inner side than it is on the outer (Fig. 96). It includes, therefore, part of the tendon of the adductor magnusj practically all the inner head of the gastrocnemius, probably all the outer head too, as it is attached at a lower level and more external than the inner, and the tendon of the popliteus; the plantaris is attached to the shaft of the femur. In the adult the neck of the femur forms an angle of 125 degrees with the shaft; in. children the angle is even more oblique; and in old age the neck drops nearly to a right angle with the shaft, and not only so, but its cancellous tissue undergoes fatty degeneration and interstitial absorption (" osteoporosis"), and its compact shell is also thinned. The femur is thickly covered by muscle throughout its entire extent ; it is perhaps least thickly covered on the anterior aspect of its lower third. Fractures of the Neck. — These may, be — (a) Intra-capsular, and (6) extra-capsular. The following table will assist the diagnosis between intra-capsular and extra-capsular fractures of the neck of the femur-^(From Erichsen) : — Intra-Capsular. 1. Cause — generally slight and in- direct, such as catching the foot in the carpet or slipping off the kerb-stone. i. Force — ^usually applied longitudi- nally or obliquely. 3. Age — rarely "below fifty, most com- monly in feeble, aged persons. i. Pain and constitutional disturb- ance slight. 5. No apparent injury to soft parts about the hip. 6. Crepitus often obscure. 7. Shortening usually at iirst not more than one inch. Extra-Capsular. 1. Cause — usually severe and diiect violence, such as falling from a height or blow on the hip. 2. Force — usually applied trans- versely. 3. Age— usually below fifty, chiefly in vigorous adults. 4. Pain and constitutional distiu'b- ance usually considerable. 5. Considerable extravasation, ecchy- mosis, and signs of direct injury to hip. 6. Crepitus (when not impacted) jeiy readily felt. ^ 7. Shortening (when not impacted) at least two inches or more. Surgical, Medical, and Operative. 471 The limb lies extended and helpless, and there is usually marked everdon in both cases, partly perhaps because this, is the natural position of the limb, but chiefly from the action of the psoas and iliacus muscles, the adductors, the glutei and other external rotators of the hip joint. The shortening of the limb is caused by the glutei muscles, rectus femoris, and hamstring muscles (biceps, semi-tendinosus, and semi-membranosus). The cause of eversion in impacted extra-capsular fracture is probably due; as Bigblow has pointed out, to the thinness and less resisting nature of the compact shell of bone on the posterior surface of the neck of the femur, as compared with the anterior. It therefore yields more readily, " crushes up and becomes impacted. "- Intra-Capsular may be either impacted or non-impacted. In impacted the lower fragment is driven into the upper. The predisposing cause is the changes already mentioned as occurring in the direction and internal structure of the neck of the femur j the exciting cause, some very slight indirect violence, as tripping on a stone, turning in bed, etc., and, as a result of the snapping of the neck of the bone, the patient drops down. It is especially apt to occur in women beyond a certain age. There are no signs of bruising in the first instance, but in three or four. days a characteristic staining often appears in Scarpa's triangle, when the effused blood has had time to reach the surface. In some cases, probably from the nature of the cause, the fracture is, in the fiist instance, sub-periosteal, so that there would be little or no shortening, as the fragments are held in position by the periosteum, and the cervical reflection of the capsular ligament; but later, these structures soften and yield, either from the movements of the limb, or from inflammatory softening, as wUl also the capsular ligament itself, which is not, in the first instance, torn. In a few rare cases there may be inversion of the limb probably because more of the anterior part of the neck is crushed up than of the posterior, or else the anterior part of the cervical reflection is not torn. These facts explain the slow appearance of the shortening, so often noticed in intra-capsular fracture, and which is apt to mislead the incautious Surgeon; or, again, the sudden increase of shortening under manipulation. The limb lies helpless, extended and everted, but can be moved freely by the Surgeon in all 472 Applied Anatomy . directions, probably with the production of crepitus; for this purpose the Surgeon places his hand flat over the great trochanter, while an assistant grasps the foot and gently rotates the whole limb. The great trochanter is raised as shown by Bryant's test, or the still simpler and more effective method used by Professor Chiene (Fig. 97). On rotating the foot it will be noticed that the trochanter rotates round a smaller circle than the trochanter of the sound side. As the patient stands the knee is flexed some- what and the heel raised. In the usual state of the parts, in health, blood is brought to the head of the bone by the ligamentum Fig. 97. Fracture of the Neck of the Femur. Anterior Superior Spine. Anterior Superior Spine. Fractured Side. Middle Line. llealtliy Side. Observe on the Fractured Side, that not only is the Trochanter raised, but it is also nearer the Middle Line. teres, synovial membrane surrounding it, the thick periosteum and the cervical reflection of the capsular ligament. In non-impacted fracture of the usual kind, all these sources, save the ligamentum teres, and, perhaps, the synovial membrane, are cut ofi' ; for this reason it is said, and, perhaps, also because the parts are not kept in proper apposition, the union is usually by fibrous tissue only. In those that heal by hone it is presumed that the fracture has probably been impacted, or sub-periosteal, or not strictly intra- capsular. Surgical, Medical, and Operative. 473 Extra-Capsular Fracture is usually impacted, but may also be non-impacted. In the impacted variety the upper fragment is driven into the great trochanter, splitting it up and increasing its breadth, and the trochanter itself is carried nearer the middle line. It is equally common in both sexes, and most often met with during vigorous adult life from a severe direct blow to the outer side of the hip, but in older persons may result from a simple fall on the great trochanter. In the non-impacted form there is distinct crepitus, severe pain on attempts at movement, and great shortening; on rotating the foot the trochanter rolls round a smaller circle than on the sound side. In the impacted form there is great pain, but the patient may possess a considerable amount of power over the limbj there will also be eversion, slight shortening, usually about three-quarters of an inch only, and another very characteristic sign, viz., broadening of the great trochanter in the antero-posterior direction (Chiene) together with free passive motion in all directions. Hence, given a case, where the patient has had a fall on the hip, with slight eversion, three- quarters of an inch of shortening and broadening of the great trochanter, there can be no doubt as to what has taken place — impacted extra-capsular fracture. These simple tests further avoid all disturbance of the limb, save the patient from needless pain, and one escapes the risk of un- impacting an impacted fracture. If further confirmatory evidence is wanted then we can use the previous simple test for the position of the great trochanter. From the fact that the anterior part of the capsule is attached to the anterior inter-trochanteric line, and as this point also marks the junction of the neck of the bone with great trochanter, it is therefore anatomically impossible to have an extrorcwpmilar fracture of the neck, at least on the anterior aspect; but, at the lower and posterior part, the capsule is attached about three-quarters of an inch internal to the inter-trochanteric line. In addition, of course, to these tests others may be used, as Betant's, IffeATON's, and Moeeis's : Betant's line will be shortened from half to. an inch, and the trochanter is nearer the middle line, as shown by Moeeis's test. In fractures of the neck the ilio-tibial band is also relaxed (Allis). 474 Applied Anatomy : Diagnosis. — Fractures of the neck must be distinguished ;(1) from bacltward dislocations. In dislocation we have marked mwersjcw (except in the rare form of the everted dorsal), the rigidity of the limb in certain directions, the absence of resistance when the fingers are pressed into the upper part of Scarpa's triangle, the presence of the head of the bone in an abnormal position, and other signs of dislocation; specially note, therefore, the marked deformity and rigidity of the articulation. Sometimes, however, there is inversion in fracture of the neck, some say as a result of muscular action — the adductors, because the external rotators are torn off or paralysed by the injury — but it is more likely due to impaction in that special position, from the attitude of the limb at the time of the injury, or from the direction of the force. But in any case there will be the usual feeling of resistance in the groin; and, as the head of the bone is in its proper place, the Surgeon will be able to obtain passive movement freely in all directions, and there will probably be broadening of the great trochanter. It must also be distinguished (2) from the condition of the hip, met with in chronic rheumatic arthritis, where the appearance and symptoms closely resemble those met with in fracture. There is pain, loss of power, and rigidity, especially on passive rotation, shortening of the limb, and elevation of the great trochanter ; but in this condition there is no history of injury to account for it, though, of course, a person suffering from chronic rheumatic arthritis may also be the subject of fracture of the neck of the femur, when the diagnosis becomes very difficult. In chronic rheumatic arthritis it may be possible to detect enlargement of the lips of the articular bones, and creaking during passive movement. The Surgeon must also be on his guard, and warn those who have received a fall or blow on the hip of the probable result — ^viz., a shortening of the limb taking place in the course of a few weeks, more especially in old persons, otherwise he may be unjustly blamed for having overlooked a fracture of the neck of the femur. It is a curious fact that this (3) interstitial absorption of the neck of the bone often foUows blows on the hip, coming to resemble, after some weeks or months, a fracture of the neck, not only in the old, ltd in young persons as well, probably from some injury to thei epiphysis, which has caused Surgical, Medical, and Operative. 475 it to ossify too soon, and hence the limh becomes shorter and shorter until growth is completed. But in this case there will he no broadening of the great trochanter ; the shortening does not take place at the time of the accident, but after the lapse of some weeks, and comes on gradually, the patient being probably able to walk about aU. the tiqje. In any injury of the hip therefore, especially in the aged, give a guarded prognosis, and tell them the possible, and even probable result. Charcot's Disease. — This is a trophic lesion, depending on disease of the postero-external column (Bdhdach's) of the spinal cord, and is but a symptom of locomotor ataxy. In many respects it resembles chronic rheumatic arthritis; but however close the resemblance may be, there are usually two marked differences — one is the absence of pain in the part, the other is the excessive mobility of the articulation. Charcot's Disease. 1. Very rapid and extreme wearing away of the articular bones, often leading to spontaneous disloca- tion. Often rapid and great collection of turbid serum, forming a large fluctuating tumour, filling up Scarpa's triangle and bulging behind as well. 3. Its onset is acute, and its course is rapid and irregular, and it may subside partially or entirely. i. Absence of pain and stiffness of the affected joint ; patient can readily move it. 5. Peculiar scrunch on moving the joint passively, 6. Formation of osteophytes the ex- ception. Chronic Rheumatic Arthritis. 1. Chronic in its course, and the wearing away is accompanied with excessive gi-owth of osteo- phytes round the lips of the articulation; dislocation rare. 2. This is essentially a dry disease — the cavity of the joint is usually veiy dry, though neighbouring bursse may be enlarged from effusion, and sometimes^ the joint itself. 3. Is essentially long-continued, and steadUy progressive from bad to 4. Joint rigid, and there is great pain, especially at night. 5. Dry creaking or crackling crepita- tion on passive movement. 6,- The rule in this affection. 476 Applied Anatomy : Accompanying Charcot's disease we may likewise find some or all of the following symptoms — (1) Lightening and girdle pains j (2) loss of co-ordinating power, usually first ohserved by the patient in the dark, as in rising at night, or when his eyes are shut, as in washing himself in the morning, when he is apt to fall into the basin. It is also seen when he stands with hi^eyes closed and his heels close together, for then he sways from side to side, and will probably fall ; he staggers also when he turns sharply round. (3) Loss of the patellar reflex; (4) Argyll Eobbrtson symptom; (5) temporary paralysis of the ocular nerves; (6) various forms of parsesthesia, such as numbness and formication, and delayed conduction of sensory impressions, especially of pain; and (7) crises of various organs, such as the stomach, intestines, and kidneys, but especially the stomach. Treatment of Fractures of the Neck. — In all cases treat as if we meant to get bony union. The old plan was simply to keep the patient a week or two in bed, then allow them to rise and hobble to the end of life (often not far distant), with the aid of a friendly stick or crutch, as best they could. Many Surgeons soem to think that this is still the best method of treatment, with the addition, perhaps, of a well-fitted Thomas's hip splint. In spite of this treatment it occasionally happens that the fracture unites by hone, as some museum specimens show ; and in cases where no union takes place, the capsule becomes so thickened in many cases that the patient may be able to walk about fairly well. Formerly the mortality from this accident was greater than that of amputation at the hip joint, the causes of death being failure of the general health, hypostatic congestion of the lungs, and bed sores; these, combined with imperfect nursing, very quickly finished the patient. Be careful to keep the buttocks and back dean and dry, the sheets smooth, and, if necessary, use a water bed ; the use of the weight and pulley, too, with a single or double long side splint to prevent eversion, will do much to obviate the former dreaded and fatal dangers. In impacted fracture, provided the shortening and eversion are not greater than usual, all that is reqiiired is simply to steady the limb by a double long splint, without the use of any extension apparatus at all. The bone must on no account be unimpacted, as it is in the very best possible Surgical, Medical^ and Operative, 477 condition for bony union. (For the metliod of putting up the limb by the long splint, or weight and pulley, in fractures of the neck, see end of " Fractures of the Femur.") Fig. 98. Fracture just below the Lesser Trochanter. To represent the action of the Psoas and the Iliacus _. ..Muscles acting on the lower end of the hone — The Gastrocnemius, the Flantarls, and the P'opliteus. FRACTURES OF THE SHAFT. Fracture of the shaft is very common in children, and is often transverse ia direction and incomplete (green-stick). Excluding fractures of the neck, one-third of all fractures of the femur occur in children under ten. In adults the fracture is usually oblique, being caused by indirect violence, the bone giving about its middle 478 Applied Anatomy: third. If the fracture be through the upper part of the shafts below the lesser trochanter, the upper fragment is tilted forwards and everted by the psoas and iliacus, and drawn outwards by the external rotators and glutei muscles (Fig. 98); the lower fragment is drawn upwards behind the upper by the rectus femoris in front, and the hamstring muscles behind, and drawn inwards by the pectineus Fig. 99. Fracture near the Knee Joint. Axis of tlie mibrokeu Bone. — To represent the action of the Gastrocnemius, etc., in tilting the lower frag- ment backwards, into the popliteal space. Axis of the unbroken Bone. and adductor muscles. Hence there is marked shortening, eversion, and crepitus. In treating this fracture it is very difficult to place and keep the upper fragment in proper position; this is because we have no power to act upon it directly, nor overcome the muscles- attached to it. In fracture through the middle of the shaft, which is by far the most common situation, the lower fragment is drawn inwards and upwards behind the upper fragment by the adductor Surgical, Medical, and Operative. 479 fibres attached to it, and rotated outwards, probably by the weight of the limb and the adductor magnus; while the upper fragment projects forwards, usually from the same causes as in fracture of the upper part of the shaft, and is probably also tilted in this direction by the lower fragment slipping in behind it. In fracture in the vicinity of the Condyles the lower fragment is tilted backwards by the gastrocnemius, plantaris, and popliteus muscles, and can be felt deep in the popliteal space (Fig. 99), the upper end being tilted a little outwards by the tendon of the adductor magnus ; the upper fragment is drawn inwards by the pectineus and adductors, and tilted forwards by the psoas and Uiacus, but in many cases it remains very nearly in its natural position. In all cases of oblique fracture of the shaft of the femur there is shortening and external rotation— shortening being caused by the contraction of the flexors, extensors, and adductors of the limb, while external rotation is caused by the external rotators being more powerful than the internal. In children fractures of the shaft of the femur are frequently transverse, and, in such cases, the well-marked displacement is absent; and, in connection with fractures in the vicinity of the condyles in children, it should be borne in mind that diastasis of the condyloid end of the femur may take place^the lower epiphysis of this bone not uniting with the shaft till the twentieth year. Just as in the humerus, the great sign of fracture of the sliaft of the femur is mobility in its length; fix the upper part of the thigh and get some one to move the leg gently from side to side. METHODS OF TREATING FKAOTURES AT ANY PART OF THE FEMUR, 1. The Long Splint. — I begin with the "long splint," which is usually named after Liston, not because it is the best method, but because it will be more convenient to describe it first, as the same apparatus may be used, but for a very different purpose, along with the weight and pulley; and doing so will, therefore, save repetition. In some cases, too, it may be impossible to use the weight and pulley — e.g., where patients are cooped up in the time- honoured, but sadly defective (for the purposes of the Surgeon, and from a hygienic point of view as well) " box-bed." For the long 480 Applied Anatomy : splint we require a board, four or five inches broad, long enough to reach from the axilla to six inches beyond the foot ; through its upper end are two holes, and its lower end is cut into a three- pronged-like fork. This is rolled up in a sheet, so folded that it will reach from the tuber ischii to the malleoli, thus leaving the last six inches of the splint bare ; enough of the sheet must be left free to surround both limb and splint afterwards. The splint is then laid along the injured side with the free part of the sheet under the limb. The " perineal band " is next placed in position, but left slack ; this consists of a padded handkerchief, or one covered with gutta-percha, passing under the perineum and tied Fig. 100. LisTON's Long Splint. Broad Chest Bandage. Observe, that to lengthen the limb we must tighten the pcriiical band, which then forces down the long splint. If the hwndkerehief at tlufoot is tightened, the splint is pushed up and the limh shortened. through the holes in the upper end of the splint, The foot should now be fixed to the lower end of the splint by passing a padded handkerchief in a figure-of-eight round the ankle and foot, twisting the ends round each other in' front of the sole, and then tying them to the horns of the splint; the objection to this plan is that it is apt to cause pressure on the instep or ankle, and cause eversion of the foot, as the pull is oblique— this last might be remedied by fastening a little square of wood to the splint in front of the sole round which the handkerchief could be brought (Fig, 100). To avoid these defects the late Professor Spence used plasters applied to the limb, as in the weight and pulley method, and attached to a Surgical, Medical, and Operative. 481 square foot-piece, and then the foot-piece fastened to the horns of the splint ; in this way all pressure is avoided on the instep and ankle, and extension secured in a straight line, thus avoiding eversion of the foot. Thick pads of boracic lint are then to be placed along the side, and " bird-nest " pads applied over all prominent points, as the hip, knee,. and malleoli. Then bring the free end of the sheet round over the limb, and fasten tightly to the folds of sheet round the splint, by means of long pins, thrust vertically across the line of the splint ; the pins should be made of steel, spring-tempered, otherwise they are apt to snap, and should have large round heads. The upper end of the splint is now to be fastened to the trunk by means of a broad flannel bandage, or kitchen roller, folded once or twice. The foot having been already secured to the horns of the splint, finally make extension by pulling on the perineal band and fastening it tightly to the two holes in the upper end of the splint. This is the most important part of the whole apparatus; by pulling on the perineal band the splint is forced downwards, and with it the leg, as the foot is firmly fastened to the splint. On the other hand, should we try to extend by tightening the handkerchief or tapes at the foot, the splint is forced upwards, and with it the lower fragment of the femur. It is very tempting, indeed, to have a pull at the handkerchief at the foot j and, as a rule, nine students out of every ten will tell you that this is how the Hmb is to be lengthened. The above is aU that is required in fracture of the necks of the femur. But in fractures of the shaft we require, in addition, padded Gooch splints ; in fractures of the upper and lower parts of the shaft, the splints must beantero-posterior; in fractures through the middle part of, the bone, the splints should be lateral. The splints are fastened by slip-knots, which must be tied over the inner side or front of the thigh; because if tied on the outer side they could not be tightened or loosened without undoing the whole apparatus. Some use a continuous roller to fasten the splint instead of the sheet, but it is better not to do so, because the fracture cannot be seen without undoing the whole bandage, thus causing unnecessary trouble and pain, and disturbing the fractured bone. There is no objection to using a "many -tailed" bandage ("'a ScuUetus"), but the sheet, used as above directed, is better than .anything else. 482 Applied Anatomy: 2. By Weight and Pulley. — For this purpose we require two isosceles triangles of strong sticking-plaster with the selvage removed, each long enough to reach from the malleoli to helow the seat of the fracture, or to the middle of the thigh in fractures of the upper part of the femur, or in hip joint disease. In cutting the plasters they should always be cut across the web — i.e., the way in which it tears most easily — and not along it; otherwise the apices of the plasters wUl not be able to bear the strain. If in doubt as to the proper way, cut a short strip from both directions and try the effect of pulling on them. The difficulty in many cases will be to find a web broad enough for the purpose. The bases are split into three tails, and pieces of strong tape are stitched to the apices. The first thing to be done is to shave the leg, if necessary, and then to pad the heel and the malleoli well and bandage the foot and ankle by figures-of-eight in the usual manner, covering the malleoli well ; also place a layer of boracic lint over the sides of the knee under the plasters. Now apply the plasters, bandaging the leg and thigh over them, placing plenty of padding around the knee; this is to be continued tiU the base of the plasters is almost reached, when all or one (the central) of the tails must be turned down over the bandage, and then the bandage continued upwards over the others, and downwards again as far as may be deemed necessary. In applying this bandage avoid creases and reverses, and leave the plasters for an hour or so to become firm before applying the weight. The tapes at the apices of the plasters are next passed through buckles attached to the sides of a square piece of wood, slightly broader than the sole of the foot. Through the hole in the centre of this piece pass the end of the cord that supports the weight and secure it there, either by simply knotting it, or by a little bar of wood. The pole bearing the pulley is then to be fastened to the end of the bed in some way so as to project from it at an acute angle, and directly in a line with the broken limb. Eaise the lower end of the bed and place two blocks, about nine inches high, under its feet; this transforms it into an inclined plane, and a part of the weight of the patient's body acts as the counter-extending force, and obviates the necessity for the irksome perineal band. The weight is now attached to the cord, and the cord placed over the pulley, and the extension is completed. A sand-bag is to be placed Surgical, Medical, and Operative. 483 on each side of the limb to prevent eversion, and the whole pro- tected by a wire cage. This is all that is required in fracture of the neck ; but in fractures of the shaft we require, as usual, padded GoooH splints to prevent antero-posterior or lateral displacements. At first a weight of from 12 ib to 15 lb is usually sufficient, and this at the end of a fortnight or three weeks may be slowly decreased, but carefully watching for shortening in the meantime. It is better in the first instance to make the fractured limb fully half-an-inch longer than the sound one, to allow for the yielding of the knee and ankle joints. In the case of transverse fractures, the weight is not so great a necessity ; but as fractures of the shaft are usually oblique, it is a most important means of treatment. Another important point is to have a Jirm mattress below the patient ; it should be divided transversely into thirds, and the middle third should be divided in the middle vertically, so that one-half can be pulled out for the use of the bed-pan, without raising the patient or disturbing the fracture. Thus : — Fig. 101. Diagram of Mattress. No. 3 is pulled out and No. 4 pushed a little outwards, or also pulled out, and then the bed-pan can easily bo placed in position. The use of sand-bags, however, is troublesome, and the long splint is now generally used instead, with some special foot-piece to prevent it from tilting. In every case Professor Chiene uses a double long splint for the same purpose, with the most satisfactoiy results. The patient can absolutely move nothing except his head 484 Applied Anatomy : and his arms; this, of course, gives the fracture the very hest possible chance to unite. The splints may be fastened to the limb by ordinary roller bandages, but the sheet is much better. The limb must be kept in this position for six or eight weeks, and after that encased in a starch, or plaster of Paris bandage. The patient may then be allowed to go about on crutches, either with the injured limb slung to the neck, or else the sole of the sound foot raised so that the injured limb may hang free. In out-of-the-way places it may not be always possible to procure at once the proper weight and pulley ; but an ordinary cotton reel, with a strong steel knitting-needle for an axle, a pail containing water for the weight, will form very efficient substitutes. Eemem- ber that " a pint of water, weighs a pound and a qua'ter." 3. M'Intyre's Splint as Modified by Listen. — Although the great majority of fractures of the femur are best treated in the straight position of the limb, in some rare cases it has been found that the fragments could only be kept in position by flexing the leg and thigh, e.g., in fractures of the shaft just below the lesser trochanter, and again, just above the condyles. This method is advised in cases of transverse fracture immediately above the condyles, where the upper end of the lower fragment is tilted directly backwards by the gastrocnemius, plantaris, and popliteus muscles; hence, when the leg is fixed up in the extended position, the knee joint is really flexed, and the result is either non-union, or union in a useless position. It is for cases such as these that Beyant recommends division of the tendo acMllis before putting the limb up in the straight position, in cases where the double inclined plane fails to remove the deformity. The splint used for this purpose is M'Intyee's splint as modified by Liston. I subjoin a short description of the splint and its mode of application. It has also been used in cases where, in the straight position, the sharp end of the bone threatens to come through the skin ; and in certain fractures of the leg, especially when compound or comminuted. In this splint the weight of the body acts as the counter-extending power. The splint, then, is a double inclined plane with a move- able joint at the knee, and a foot-piece; the foot-piece is fixed in a slot so that it may be drawn forwards if desired, and its angle to the axis of the splint can be shifted by means of a screw. The Surgical, Medical, and Operative, 485 angle at the knee can be altered in like manner. At the lower end there is a piece cut away, opposite the heel and tendo achillis, to prevent undue pressure. In applying this splint, the first thing to he done is to fasten a strip of handage or a handkerchief across the space at the lower end to prevent the heel falling backwards through the gap. The splint must now be very well padded, so that the limb may rest on rather than in it ; but the foot piece must be padded separately. The limb is now laid on the splint, and the foot fixed to the foot piece by a handkerchief or roller bandage passed behind the splint at the heel, then, making a figure-of-eight round the ankle and foot, the ends being fastened to a button on the sole of the foot-piece. The foot-piece is then to be screwed to a rigM angle, and the limb fastened to the splint by interrupted circles of broad bandage or plaster. If a continuous roller is used, then we cannot examine the fracture without undoing the whole bandage. Screw the knee into such a position that the fractured ends are in apposition — ^in fracture at the lower end of the femur this will be nearly a right angle. Cover up the screw behind the knee joint, lest the patient meddle with it, and change the angle into a less irksome position, and swing the limb, splint and all, or else fasten the iroii bar behind the heel firmly to a wooden block, so as to get the required height, and also for the purpose of steadying the splint. This splint is also used by some in fracture of the bones of the leg. For Children. — (1) The Double Long Splint may be used, connected at the bottom by a transverse bar; this is necessary because of the restlessness of the patient. The two splints should be wider apart at their lower ends, and not parallel with eiach other, for the use of the bed-pan. (2) Beyant's method of Vertical Suspension of the broken limb. A posterior splint is applied froni the heel to the nates, and short splints on the sides and front of the thigh, strapping having been previously attached to the leg for the purposes of extension. The limb is then slung ■ up to a hook in the ceiling, or some other convenient point, so as to keep the limb at right angles to the body. By this means ' the bandages are kept clean, and the weight of the body acts as a constant counter-extending force ; one or both legs may be so placed. 486 Applied Anatomy: THE PATELLA. This is merely a sesamoid bone developed in the tendon of the quadriceps extensor. It has one centre which appears about the second year, and is fully ossified about puberty. There are two varieties of fracture — (1) Transverse; (2) stellate, Y-shaped, or some other form, but not transverse. It may be broken by direct violence when the knee is flexed, and the fracture may then be comminuted, transverse, vertical, stellate, etc. The usual cause of fracture, however, is muscular action, as when the patient slips backwards, and, to save himself from falling, throws the quadriceps suddenly into action, when the patella snaps in the- same way that a stick is broken across the knee; the patient falls down because the patella is broken; it is not the fall that breaks it. The fracture resulting from muscular action is always transverse, and in all pro- bability always into the knee joint and also into the prepatellar bursa, unless the fracture merely involves the peak below the arti- cular surface. For this reason the joint swells up from the eflFusion of blood into it, which, however, usually subsides after a few days' rest. When due to direct violence, the fracture is very often starred or vertical, and then bony union, it is said, is common enough, as the aponeurotic covering is not ruptured ; but when due to muscular action, the fragments are often widely separated on account of rupture of the fibrous expansion at the sides of the bone, and the union is usually by fibrous tissue only. Treatment. — At first, in almost all cases, as there is severe inflammation and great effusion into the joint, rest in the easiest position, and evaporating lotions are indicated, or removal of the fluid by antiseptic aspiration. Whatever method of treatment is adopted, the patient must be semi-recumbent in all cases, with the foot raised to relax the muscles that displace the upper fragment— the quadriceps extensor, but especially that part of it formed by the rectus femoris; after this, the fragment may be brought down by some special appliance. As the upper fragment is chiefly displaced, the special treatment should be brought to bear on it alone without any circular constriction of the joint. Whatever plan be adopted it must be kept up for six or eight weeks at least, and better still, for three months; and after that the limb may bo Surgical, Medical, and Operative. 487 encased in plastei of Paris, or else the patient must constantly wear a posterior straight leather splint, so as to prevent the joint from being bent for at least three months more, else the fibrous uniting medium will stretch unduly. Many Surgeons believe that the best results are obtained by cutting down on the patella by a vertical incision, and pulling the fragments together by wire or catgut. The objection to this plan is that it opens into the knee joint. It is, no doubt, better for osseous union, but more dangerous, as regards the life of the patient, than the other method. 1. By Posterior Inclined Plane. — This is a straight wooden splint with or without a foot-piece, with notches or hooks opposite the knee joint to give a fixed point from which to puU on the pateUa. The splint is well padded, its lower end well raised, and then the limb placed upon it and bandaged to it from the foot upwards. When the knee is reached take two or three figures-of- eight from the notches on the side of the splint above and below the patella, gradually pressing the fragments together. If there is much swelling and effusion into the joint do not forcibly drag the broken parts together, but first wait till the efiusion has subsided. The thigh is then bandaged to the splint, and lastly the foot raised and swung. It will probably be found more convenient to fix the leg and thigh to the splint first and then to use a separate bandage at the knee joint, as this can then be tightened from time to time without disturbing the rest of the splint. The objection to this plan is that the vessels supplying the fractured patella are com- pressed and the fragments starved. 2. By IMalgaigne's Hooks. — Two pairs of steel hooks, of which the pair next the skin work in a slot in the other pair, and which can be screwed together or loosened by a screw and nut arrangement, worked by means of a handle. They may be used as Malgaignk himself used them, simply passing them through the skin into the broken fragments, only with strict antiseptic precautions ; or they may be used in the way practised by the late Professor Spence : — Two large pieces of stout plaster, each seven inches long by five broad, with a semi-circular piece cut out of the upper and lower ends respectively, are prepared ; also a number of smaller rectangular pieces three inches by two. The posterior inclined plane is applied as before described, and the leg and thigh 488 Applied Anatomy: bandaged to it. Then stretch the skin and apply the long pieces of plaster so that the notches fit round the edges of the patella; the smaller pieces are next fastened on to the front of these. The points of the hooks are. then stuck into these smaller pieces and screwed to the required tightness. In this plan there is no circular constriction of the limh; it was spoken of very highly by the late Professor Spenoe. 3. Manning's Splint. — This splint acts on the upper fragment of the fractured patella by elastic, and therefore constant traction, and, at the same time, avoids circular constriction of the limb, so that the articular arteries are not compressed. It consists of a wooden back-piece, a little wider than the knee joint, and long enough to reach from the sole of the foot to the gluteal fold, and provided at the lower end with a- foot-piece. At the junction of the middle and lower thirds is a transverse oblique slit one and a half inches long. Strips of strong plaster, two inches broad, and long enough to encircle the thigh and overlap by some inches, are attached to a calico band. The free end of this band is carried through the slit, and the strips of plaster are open on the upper part of the splint. A piece of wood is attached to the lower part of the splint, and another piece of corresponding size is attached to a loop at the end of the calico band, so that, when drawn down and the splint adjusted, these pieces may be five or six inches apart. The foot and the leg having been previously bandaged as far as the lower edge of the patella, and the splint padded so as to leave the slit uncovered, the strapping is heated by means of a bottle of hot water, and, while an assistant draws down the upper fragment by grasping the muscles of the thigh, the strips of plaster are carried firmly round the limb from above downwards, extending from just below the gluteal fold to within three inches of the upper border of the patella. It beiug important that the band of calico should be kept in the middle line, the upper part of the thigh is then secured to the splint by a few turns of a roller. Lastly, elastic rings are passed over the projecting ends of the pieces of wood, on each side of the splint, so as to exercise sufficient traction on the muscles pulling on the upper fragment and approximate the fragments. In the drawing given in Erichsen's "Surgery," the limb appears to be lying flat ; if this is the case a better plan, we Surgical, Medical, and Operative. 489 think, would be the usual position for fractured patella — the heel raised some distance above the level of the buttocks. 4. The plan adopted at the Middlesex Hospital seerus to be a good one. A broad piece of plaster cut out at one border some- what horse-shoe-shaped, but with the ends of the curve prolonged, is fixed to the thigh, so that the curved edge is level with the normal position of the patella, and is fixed by a few turns of a roUer bandage. The limb is now placed on the posterior inclined plane, with foot-piece, or a M'Inttrb's splint. The lower frag- ment is fixed by means of a pad of lint and plaster bandage. To the ends of the plaster, tapes are stitched, which are attached to india-rubber " accumulators," which are in turn fastened by means of strips of bandage to the foot-board of the splint. The requisite amount of tension is obtained by loosening or tightening these strips of bandage. THE BONES OF THE LEG. Like the bones of the fore-arm, both these bones are developed from three centres, that for the shafts appearing about the usual Fig. 102. Head of Tibpa. Tongue-shaped pro- cess forming the Tubercle. Unites at 25 years of age. 4,90 Applied Anatomy : time. The centre for the head of the tihia appears at the time of hirth, and that for the fibula about the fourth year; both join their Fig. 103. UowER End of Tibia. Unites at 20 years of age. Fig. 104. Upper End of Fibula. Fig. 105. Lower End of Fibula. .-Kplphysis. Ai-ticulav Surface.. Pit at Posterior Border. Unites at 25 years of age. Unites at 20 years of age. respective shafts at twenty-five (Figs. 102, 104). The centres for the lower ends of both appear during the second year, and join the shaft at twenty (Figs. 103, 105). It will be noticed, therefore, Surgical, Medical, and Operative. 491 tliat, opposed to the usual custom, the lower epiphysis of the fibula appears first and unites first. The tibia grows in length chiefly from the upper epiphysis. This epiphysis includes the facet for the fibula on the outer side, and the groove for the semi-mem- branosus on the outer side; in front it slopes down obliquely so as to include the whole of the "tubercle" of the tibia, the insertion of the ligamentum patellae (Fig. 102). The lower epiphysis of the tibia has no muscles attached to it, but includes the inner malleolus and the facet for the fibula. The fibula is surrounded by a thick pad of muscles for the greater part of its extent, which thus gives an otherwise weak bone great support; its lower fourth, however, is subcutaneous. The anterior border and inner surface of the tibia are entirely sub- cutaneous, hence any irregularity in outline can be readily detected, and for the same reason the fracture is more often compound and comminuted than any other bone ; it becomes compound in two ways — either from the force that breaks the bone in direct violence, or else from a sharp fragment being forced through the skin in indirect violence. Each of the bones may be broken separately, but usually both are broken together. If the tibia alone be broken, or if the fibula alone be broken, there is usually little displacement, because the sound bone acts as a splint to the fractured one, and especially if the fracture be transverse. The weakest part of the shaft of the tibia is about its lower third, and the weakest part of the shaft of the fibula is about its upper fourth, and at these points, therefore, the bones usually give way in fracture from indirect violence; the fracture, further, is usually oblique from behind, downwards, forwards, and a little inwards. In direct violence the fracture will be transverse and at the point struck. In transverse fractures of one bone there will be little displacement, muscular action simply keeping the fractured ends in apposition ; if, however, the fracture be oblique and both bones broken, the lower fragment is drawn upwards and backwards by the muscles of the calf (gastrocnemius, plantaris, and soleus), and this is more marked if the fracture be situated at the lower part of the shafts of the tibia and fibula (Fig. 106), and rotated outwards by the weight of the foot; while the upper fragment is tilted forwards by the teiido patelhc (the tendon of insertion of the quadriceps extensor 492 Applied Anatomy: cruris — the rectus, the two vasti, and crureus) — and rotated inwards by the sartorius, gracilis, and semi-tendinosus; and this displacement of the upper fragment is more evident if the fracture be at the upper part of the shaft of the tibia. All fractures of the bones of the leg occur with extreme rarity in infancy and childhood. Fig. 106. Fracture at Lower Part of Leg. Axis of the unbroken Bones. Muscles of the Calf draging the Heel backwards. ,»_.The Muscles forming the Ligamentum Patellae, displacing the upper fragment forwards. Axis of the unbroken Bones. Tibia Alone. — This is usually the result of direct violence, as a kick or a blow. In transverse fracture, when the fibula is intact, the fracture may be missed unless great care be exercised, as there is no displacement, and the patient may be able to walk wonder- fully well. But the existence of a tender spot at the seat of tte Surgical, Medical, and Operative. 493 crack, and the fact that firm indirect pressure on the hone above and helow this point will probably produce a yielding and crepitus, and certainly cause pain at the seat of the fracture, should prevent any mistake in the diagnosis. Fibula Alone. — This bone may be broken either by direct or indirect violence. The usual seat is from two to five inches above the malleolus, especially if caused by indirect violence. It may be caused by a twist of the foot, either outwards or inwards, and is then very often associated with partial or complete dislocation of the ankle joint; but in that due to inversion of the foot there is often no displacement at all. If due to eversion, the broken ends of the fibula are driven inwards towards the tibia (see "Disloca- tions of the Ankle — Pott's Fracture"). There is also a fracture of the fibula occasionally met with, through or just above the malleolus, caused by direct violence, where there is also an absence of displacement. Here again, in diagnosing such fractures, the great guides must be the existence of a tender spot, sharply defined (differing therefore from a braise or sprain, though both may be present), and the indirect method of pressure applied to the upper part of the fibula, pressing it towards the tibia, when pain wiU be caused at the fractured spot. If it be merely a bruise, there will be no pain as thus tested. The -only source of fallacy in this test is the possibility that the lower tibio-fibular articulation be inflamed, and when pressure is made upon the upper part of the fibula, the pain might be due to squeezing the inflamed articulation, and not to a fracture. Both Bones. — This fracture maybe caused by direct violence, as kicks, blows, wheels passing over the limb, etc., when the hones give way at the point struck; or indirect violence, such as jumping from a height, severe twists, etc., when the bones yield at their weakest parts. The limb is usually everted from the weight of the limb, from the force breaking the bones, and probably also from muscular action. Both bones of the leg require about eight weeks to unite firmly ; the tibia alone requires seven, and the fibula alone six. Treatment. — In cases of fracture of the shaft of a single bone, with little or no displacement, any simple apparatus will be sufficient, such as Clink's side splints, for the first few days, till the swelling has subsided, when the limb may be encased in a starched 494 Applied Anatomy: bandage, the Bavarian plaster splint, Croft's dressing, or it may be treated by the " Edinburgh box splint" (Spenct's)j to be described immediately. The chief objection to all immovable dressings is that the fracture cannot be examined from time to time to correct any possible error of position. "When both bones are fractured, or, indeed, in any form of fracture, the most simple and convenient splint to use, and one by which perfect apposition can be secured, is that known as — The " Edinburgh Box Splint."— This consists of— (1) Two narrow pieces of board, long enough to reach from the knee to a few inches beyond the sole, so that when applied they should command both knee and ankle joints, and broad enough to pre- vent the slip-knots pressing on the leg; (2) a sheet folded a little shorter than the length of the splints ; and (3) two small towels to form pads for the front of the limb. In addition to this we require slip-knots, roller bandages, padding, etc. In applying this apparatus, roll up the splints from different sides of the sheet till there is just enough room left for the leg. AVe have thus a "box," the sides of which are formed by the splints covered by the sheet, the posterior part of the box simply consisting of several layers of the folded sheet. If desired, this may be rendered rigid by introducing a strip of pasteboard between the layers of the sheet. Now bend the knee, and lay the leg in the box thus made, taking care to pad the prominences about the knee and the malleoli well. If preferred, the leg may be laid on the middle of the sheet in the first instance, and the splints rolled up from either side ; this will obviate the necessity of lifting the leg afterwards. The foot is then to be fastened at right angles to the leg by a few turns of a figure-of-eight round the ankle aiid splint — the bandage being carried from the inner to the outer side of the foot across the dorsum, so as to guard against any possible eversion ; then lay the towel pads on the front, so as to overlap at the fractured part, after which secure the splint to the leg by slip-knots, one of which is to be carried over the double pad of towel in the region of the fracture. If one towel only be used, then the fracture cannot be examined without undoing all the slip-knots ; whereas, if two be used, as described above, by simply undoing the central slip-knot, the ends of the towels can be turned Surgical, Medical, and Operative. 495 back, and the fracture examined without slackening the rest of the dressing. By this plan the fractured point can he examined very easily without disturbing the rest of the splint, which could not be done were an ordinary roller bandage used ; all that is required in this case is simply to undo the middle slip-knot and turn back the ends of the two towels. The limb is now to be laid on a couple of pUlows, or swung, with the knee considerably bent, to relax the muscles of the calf. The fracture can be examined from time to time without disturbing the limb. The most important points to be kept in mind are — (1) To keep the foot at right angles to the leg ; and (2) to guard specially against any eversion of the foot — a little inversion is not so objectionable, although this should also be avoided. Both these conditions can be readily carried out by using the "box splint." To keep the foot at right angles a figure-of-eight of elastic, or ordinary domett bandage, is passed round the foot and fastened to the sides of the box. To judge whether the foot is properly placed as regards eversion and in- version, it should be noted that when the foot is in the proper position the hall of the great toe, the internal malleolus, and the inner edge of the patella, are all in one vertical plane, and the patella loolcing directly upwards. Even in health, however, there . is a slight tendency to inversion of the foot. In methods of treating these fractures, where the knee joint is flexed and the leg laid on its outer side on a pillow, it is impossible to judge of the eversion and inversion ; hence the usual result is that the patient rises with the foot very much everted, the toes probably pointed, and consequently a crippled and useless foot — a condition not only bad at the time, but one likely to induce disagreeable secondary consequences, e.g., flat-foot, with all its aches and pains. In cases where the fracture is very oblique, and accompanied with much shortening, it will be necessary to employ the weight and pulley. In eases where the fracture is low down, there may not be sufficient room to apply the extension plasters, but a short elastic sock, laced to the foot should be used, with side straps to fasten to the buckles on the square of wood to which the cord is attached. We may also use two pieces of plaster cut into a number of short tails, to grasp the dorsum of the foot, and the sides and posterior aspect of the heel, as shown in Fig. 107. The 496 Applied Anatomy: " box splint" may be used in almost every case of fracture of the bones of the leg, even for fracture low down, where the chief diificulties are, the aversion of the foot and the drawing back of the heel (see Fig. 106), although special splints have been devised for both these displacements— Dupuytren's splint for the eversion, e.g., in "Pott's -fracture;" and the "stirrup splint" (Syme), for the falling back of the heel. Fig. 107. Extension Plaster. Dupuytren's Splint. — This may occasionally be useful in "Pott's" fracture. It is a most troublesome splint to apply properly, and equally difficult to keep in proper position when it is applied, as it always tends to shift ; if it is to be used the Fig. 108. Dupuytren's Splint. O O (The "Short, Long Splint") knee must be flexed and the limb laid on its inner side on a pillow, and not swung. Further, the same objection may he urged against it as against the special splints used for CoLiBa'^ fracture; it causes excessive inversion, thus displacing th.6 iooi Surgical, Medical, and Operative. 497 as far iu tlie opposite direction as the injury did in the other. It consists (1) of a tri-furoated wooden splint, with two holes at its upper end, long enough to reach from the head of the tibia to four or five inches beyond the sole (Fig. 108). (2) A pad of towel or sheet the width of the splint, and doubled on itself at its lower end. Fasten the split ends of a roller bandage through the holes at its upper end, as this will steady the splint and prevent it from being forced upwards. Apply the pad over the splint, so that the doubled end of the towel may be over the internal malleolus, forming a soft fulcrum round which the foot is to be inverted; fasten it to the splint by slip knots or a continuous bandage. As the object is to invert the foot and throw the broken ends of the fibula outwards, the splint, thus prepared, is applied along the inner side of the limb on the same lie as the bones of the leg, and secured firmly to the head and upper part of the tibia, but not carrying the bandage above the knee joint, as the knee has to be flexed. The knee must be bent so as to rela.x the muscles of the calf which pull back the heel and point the toes; the foot is then brought to right angles and inverted. At the lower part of the leg, the bandage securing the splint to the leg and inverting the foot, must not go above the external malleolus, otherwise it will press the broken ends of the fibula towards the tibia. The splint is firmly fastened to the leg at the lower end, and the foot is then to be inverted to the desired extent by means of a few properly applied figure-of-eight turns of a bandage; the figures-of-eight must be led round from the inner side and across the dorsum of the foot, and then inwards across the sole, and secured round the prongs of the splint. The part of the foot to be acted upon in producing the inversion is just above the projection of the fifth metatarsal bone, and not on the heel. Lastly, the knee being well flexed, as already indicated, the limb should be laid on its inner side on a pillow, and secured thereto by strips of bandage. In applying this splint, therefore, for Pott's fracture — (1) Mount the splint; (2) lay it along the inner side of the leg; (3) fasten it to the head of the tibia; (4) fasten it to the lower end of the tibia; and (5) invert the foot by figures-of-eight round the horns of the splint and foot. 2i 498 Applied Anatomy : The "Stirrup Splint" (Syme). — This is a wooden splint with one end like a horse -shoe, and two holes through the upper end; it is mounted in the same way as Dupuytrbn's splint. A sheet or large towel is also required, rolled up from each side towards the centre, forming a pad very thick at each side but less so in the middle, so that when applied along the front of the sharp edge of the tibia, the splint may rest on the rolled up thick parts of the pad, in this way fulfilling two purposes, first steadying the splint, and secondly protecting the sharp edge of the bone from pressure (Fig. 109). This splint was formerly used to prevent retraction of the heel in fracture of both bones of the leg low down ; it may also be used at the same time to overcome excessive inversion or eversion. Like the last splint it is most difficult to fasten on and keep in position ; and very often the patient could not bear it, as the soft parts in front are sometimes injured. Fig. 109. Pad for "Horse-shoe" Splint. 33- Splint. ..Special Pad. ^Hollow for tlie Crest of the Tibia. Fasten a pad, like that used with Dupuytrbn's splint, firmly to the splint by slip knots, so that the doubled end is level with the middle of the arch of the horse-shoe. Place the special pad along the front of the tibia, and then lay the splint along the front of the- tibia with the prongs on either side of the foot. Then a handkerchief, or bandage, is brought under the tip of the heel, neither above nor below that point— if brought in front of the sole it would push the heel backwards, and if applied higher up it would simply cause greater displacement. It is then carried round the shoulders of the prongs, there crossed, and the figure-of- eight completed round splint and ankle, and fastened. The object is simply to lift up the heel and hang it to the end of the horse- shoe. Lastly, the upper end of the splint is fastened to the leg by a turn of bandage passed through the two holes there, so that Surgical, Medical, and Operative. 499 the splint may not slip; and a strip of bandage is passed from one horn of the splint to the other in front of the foot. Before the "stirrup splint" came into use, in cases of great retraction of the heel, DrPUYTitEn's method was generally adopted, viz., a posterior splint to ^ms7i the heel forwards. A well padded GoocH splint may be used for this purpose — this keeps the heel in position, and prevents any possible retraction. The pressure on the heel, however, should be made as diffuse as possible in ord«r to prevent ulceration. I wiU now give a short resume of the different methods used in the treatment of " Pott's fi-acture " — which method to choose in any given case will depend much on the special displacement present, the presence and position of blisters, abrasions, or wounds complicating the fracture. Whatever plan is adopted, the first and by far the most important part of the treatment is to put the fractured bones into as good position as possible before applying the splints. 1. The "Box Splint," properly padded to overcome the dis- placement, e.g., to overcome the eversion, place one special pad just above the internal malleolus, and another over the external malleolus. See that the heel is kept well forward. 2. Dupuytren's Splint may be used in cases where the eversion is excessive, and provided there is no wound or blister over the inner aspect of the leg. 3. Double Poroplastic Splints moulded to the limb, the bones being first carefully set, and the leg being retained in proper position tUl the splints become rigid. 4. The " Stirrup Splint," wlicre the backward displacement of the heel is the most marked symptom. Have a specially prepared pad along the crest of the tibia, lest the splint cause ulceration of the soft parts — this method pulls the heel forwards. 5. Dupuytebn's Posterior Splint to push the heel forwards. See that the pressure over the heel is diffused properly, lest a pressure ulcer be formed. 500 Applied Anatomy : RESUME of fractures near the ankle joint : — 1. Fracture of both bones: great trouble by the falling back of the heel. 2. Fracture of the internal malleolus, Avith rupture of the external lateral ligament; foot displaced inwards. 3. Pott's fracture — fracture of the fibula about an inch and a half or more above the external malleolus, with rupture of the internal lateral ligament, or snapping across of the internal malleolus; foot markedly everted, and heel often much retracted. 4. Dupuytrbn's fracture — fracture of the fibula and rupture of the internal lateral ligament, as in Pott's fracture ; but also rupture of the inferior tibio-fibular ligament, or else the part of the tibia to which it is attached is torn off ; foot displaced outwards, as a whole, without marked eversion or inversion. 5. Fracture of the fibula in the same position as in Pott's fracture, due to inversion of the foot; the fractured ends tilted outwards. In Pott's fracture it is due to eversion of the foot, and the broken ends are driven in towards the tibia. 6. Fracture of the fibula, just through the malleolus, from direct violence; Uttle displacement, but foot may be slightly invei-ted. In diagnosing this fracture trust chiefly to the existence of a tender spot and pain on indirect pressure — pressure at the upper part of the fibula — and the nature of the violence. I miist be pardoned if I have, for the most part, described the Edinburgh methods of treating fractures. I have done so, not merely because they are the Edinburgh methods, but because of their simplicity and efficiency. I do not write this as an apology, because the methods require no apology. The lecturer on Surgery has no right to waste his time teaching the student — who will probably by-and-by drift into general practice in some out of the way place — the use of complicated methods, which it will probably be out of his power then to procure, or his patients to pay for, and which are, for the most part, of advantage only to the instrument Surgical, Medical, and Operative. 501 maker. It is better to describe the use and application of simple methods and means — methods that can be applied anywhere, and splints that can be made in a few minutes by any carpenter, or even by the Surgeon himself, if he be at all conversant with the use of such tools as a pair of scissors, a pocket-knife, and saw. The principles I have endeavoured to lay down, and the methods I have described, may be applied with equal facility in the sequestered vaUeys of "Wales, on the hillsides of Scotland, among the ancestral homes of England, in the humble cabins and among the bogholes of Ireland, in the Australian bush, and in the back- woods of the Far West. 502 Applied Anatom^y: CHAPTEE XXVL EXCISION OF BONES. THE UPPER JAW. The upper jaw articulates with nine bones — viz., the frontal, the ethmoid, the nasal, the malar, the lachrymal, the inferior turbinated, the palate, the vomer, and, lastly, with its fellow of the opposite side. This bone assists in the formation of three cavities — the roof of the mouth, the floor and outer wall of the nasal fossae, and the floor of the orbit ; it also helps to form two fossce, the zygomatic and the spheno- maxillary — and two fissures, the spheno -maxillary and the pterygo-maxillary. A knowledge of these facts has a most important bearing in the matter of diagnosis. In the case of malig- nant disease, the bone must only be removed, provided the Surgeon convinces himself that he can remove all the diseased tissue and, at the same time, cut wide of the disease. In examining a tumour of the upper jaw, the Surgeon must look at it from five points of view — (1) From the face, (2) from the orbit, (3) from the nose, (4) from the mouth and pharynx, and (5) from the temporal and zygomatic regions, and then ask himself the questions — (1) Where did it begin 1 and (2) What, are its attachments now ] Should it implicate the basi-sphenoid, the frontal or ethmoid cells, as shown by separation and divergence of the eyes, and broadening of the root of the nose, it will be better to leave it alone. Among the early signs of malignant tumour of the upper jaw may be noted — ■ (1) Overflow of tears from pressure on the nasal duct; (2) shooting pains in the supra- orbital region from implication of the fifth nerve ; and (3) blocking of the nostrils. As in all operations about the mouth, ha;mor:rhage is one of the chief difficulties and dangers, not merely from the actual loss of blood, but from the danger of asphyxia from the blood passing into the pharynx; another very Surgical, Medical, and Operative. 603 serious danger, should it reach the lungs, is that it is apt, at a later period, to set up a suppurative form of pneumonia ("Interlobular Suppurative Pneumonia"), probably from the coagulated blood becoming septic and putrifying in the vesicles. This danger, how- ever, is not so great in excision of the upper jaw as in many other operations; stUl, if great hsemorrhage is expected, some of the following special means may be adopted. The risk of the operation itself is small, and in this respect it contrasts very markedly with excision of the tongue, where the risk is very great and the prognosis grave. Note on Diagnosis. — If the tumour — e.g., a sarcoma— 1. Begins in the malar bone, it pushes the cheek into a conical projection, and bulges into the mouth between the gums and the cheek. The line of the teeth and the palate are normal. 2. If it begins behind the upper jaw, it pushes that bone forwards as a whole; the line of the teeth and the antrum are normal. 3. If it begins in the antrum, it expands the walls of that cavity, bulging into the nose, mouth, and orbit, and causing a projection on the face. The line of the teeth is also irregular. 4. , If it begins in the ethmoid cells, it causes broadening of the root of the nose and projection of the eye outwards, rather than forwards. There will also, probably, be a history that the swelling began higher up than the antrum. Mere protrusion forwards of one eye is not so bad, but when the eyes are separated it indicates that the growth has either begun in, or spread to, the ethmoidal sinuses, and is, therefore, too far gone for operation. One plan to obviate the risks from haemorrhage is to keep the source of the blood lower than the opening of the larynx, by allowing the patient's head to hang over the end of the table and sponging out the accumulated blood from time to time (Annandale); or Teendelenbueg's " trachea-tampoon " may be used, or some modi- fication of it; or, as Macewen suggests, one may pass a rigid tube 504 Applied Anatomy : through the glottis, after which the entire pharynx is tightlj' filled with a sponge; or, a still simpler and more efficient plan, adopted by Professor Chiene, in cases demanding such severe measures — a preliminary tracheotomy is performed, and the pharynx filled with a sponge, and an elastic tube, passing from the end of an ordinary funnel, is inserted into the inner part of the tracheotomy tube, and through this the patient inhales the chloroform; over the mouth of the funnel a fold of domett bandage is stretched, and on this the chloroform is dropped as required. Besides its simplicity this plan has another advantage — namely, that the chloroformist is well out of the way of the operator. Instruments required. — The usual instruments required in all major operations, also tooth forceps, a narrow saw with a movable back and a large handle, bone forceps, lion forceps, gouges, hair-lip needle or silver wire suture, retractors, chisel and mallet at hand lest they be required, wire nippers ; and perchloride of iron, or the actual cautery for the haemorrhage; solution of zinc chloride, to touch up doubtful parts afterwards ; and lastly, some of the special means for the management of the haemorrhage, and the administra- tion of chloroform. The Surgeon stands on the same side as the bone to be removed in the first instance, but during the sawing of the bony points he will probably find it most convenient to stand always on the right side. The usual number of assistants may be made use of, and their duties require no special mention. (1) Place the patient in a semi-recumbent position, shave the parts if necessary, compress the facial artery as it passes over the lower jaw, exti-act the central incisor tooth of the diseased side, and then make the incision — (a) Liston's (Fig. 110). Enter the knife opposite the external angular process of the frontal bone {i.e., a little above the zygoma), and carry it in a semi-circular manner downwards and forwards to the angle of the mouth. Another incision is then made from the nasal process of the superior maxillary bone down the side of the nose, round the ala, and through the centre of the upper lip into the mouth; this flap is then dissected upwards and inwards. This is the most convenient incision when the tumour is of large size. (6) By External Flap (Fig. Ill, fl). Cut horizontally from the outer to the inner canthus of the eye, then straight down to the ala of the- nose, round it Surgical, Medical, and Operative. 505 and through the centre of the upper lip into the mouth j this flap is then dissected downwards and outwards. The great advantage of this incision is that the arteries and nerves of the face are cut close to their terminations, and not through their larger branches, as they are more likely to he by Libton's method. (2) Having divided the mucous membrane and dissected the flap off the jaw, separate Fig. 110. Liston's Excision of the Upper Jaw. A — Position and direction of the additional incision when the malar bone is to be removed as well. the soft parts from the floor of the orbit, including the periosteum, and should the case admit of it, the orbital plate of the superior maxilla as well, using a thin copper spatula to protect them and the globe of the eye. Before going any further, it will be well to tie all the bleeding vessels, such as the coronary and angular; after which (3) divide the bony points. 506 Applied Anatomy: There are four bony attachments to divide. The following order will be found convenient : — (1) The malar attachment ; this is first to be deeply notched with the saw, parallel with, and immediately in front of, the masseter muscle, passing into the spheno-waxillary fissure. (2) The palate attachment to the opposite bone and the palate bone ; the saw is passed into the nostril, and the hard palate and the alveolus divided. The saw should be kept (a) Excision of the Upper Jaw by External Flap. Fig. 111. Excision of the Jaws. (i) The Line for the Excision of the Lower Jaw parallel in the nostril, as there is but little danger of injuring the soft palate, as it hangs down perpendicularly from the end of the hard palate. It is useless to attempt to dissect off the soft tissues from the hard palate. (3) The nasal process of the superior maxilla, articulating with the nasal, frontal, and lachrymal; the bone forceps alone is usually sufficient for this purpose, one blade being placed in the orbit, the other in the nose, with the flat side, Surgical, Medical, and Operative. 507 as usual, next the part to be left. If preferred, this process may first be notched with the saw like the other two, or complete division may be accomplished by a chain saw. Some Surgeons divide these points with the saw in the following order: — Palate, nasal, malar, and then complete the division with the bone forceps in'the reverse order. The forceps are now used to completely divide the malar attachment, and, lastly, the palate process and alveolus; in dividing this last part the forceps can also be used as a lever to prise the bone from its bed, thus preparing the way for the next part of the operation. Dr Duncan completes division of the malar attachment by the bone forceps last of all, as he says it is easier to loosen the bone by working downwards and inwards than by prising it upwards and outwards, as is done when the palate attachment is divided last. (4) Everything being now ready for the gush of blood likely to follow removal of the bone, and the patient brought fully under the influence of the anassthetic, and the soft palate separated from the hard by a transverse incision, the jaw is firmly grasped with the lion forceps, and with a firm, sudden wrench downwards and outwards the bone is torn from its posterior attachments; in this way its attachments to the palate bone and the pterygoid processes behind, and the ethmoid bone above are torn away. As the bone is wrenched out, any soft tissues must be divided with the fingers or bistoury, such as the origin of the temporal muscle in the zygomatic fossa, the buccinator muscle, and the infra-orbital nerve, etc. When the bone is removed there is great hajmorrhage, and the cavity must be at once packed with a dry antiseptic sponge, or strips of lint, till the vessels (which are mostly of small size) have had a little time to close themselves by retraction and contraction; the vessel that gives most trouble is the posterior palatine artery, which is torn just at the last moment. After this the packing is removed, the vessels tied, and some strips of lint dipped in zinc chloride or iodoform are introduced to support the cheek flap, and which are to be left in for two or three days. Iodoform, or a solution of chloride of zinc, is the most effective antiseptic to use in the first instance, and afterwards continuous irrigation with some warm antiseptic — e.g., boracic acid. The incision must be very neatly and carefully stitched up with horse-hair sutures ; these may be used throughout, and will be found 508 Applied Anatomy: very efficient, bat when the lip is reached another plan may be adopted — \ hair lip needle passed deeply through the tissues of the lip to act as a splint, or a deep silver suture may be used for the same purpose. Before putting in the needle or silver wire, how- ever, a silk suture should be passed through the mucous membrane, but left iintiedj after this horse-hair sutures are passed and tied to hold the skin edges in apposition, then the silver one is tightened, and, lastly, the silk suture through the mucous membrane is tied, first removing all blood clots from between the edges of the mucous membrane. In this way neat apposition of the cut edge is insured. If the hair lip needle be used, its point must be cut off with the wire nippers. Mr Bell advises that, in making the incision through the skin, we should make plenty of corners and not rounded curves, as the corners act as guides and enable us to stitch like parts to like, whereas, in curves, it is often difficult to tell exactly the cor- responding parts of the two sides. Should it be necessary to remove the malar bone, then from the end of the upper incision carry another cut, one inch in length, along the zygoma (see Fig. 110, A). In this case also it will be necessary to divide the zygomatic process, and the external orbital angle of the frontal bone into the spheno-maxillary fissure by first using a small saw, and then completing the division with the bone forceps. It is better, if possible, however, to preserve the malar bone, as this leaves the prominence of the cheek. In cases also of simple tumour and sarcoma confined to the alveolar edge, leave the orbital plate of the superior maxilla, as this gives support to the eyeball ; where this plate is removed the eye falls down and is apt to be destroyed by subsequent inflammation. Chief Parts Cut Through. — 1. The skin and fascia; part of the orbicularis palpebrarum, orbicularis oris, and temporal fascia; part of the masseter and temporal muscles, zygomatici, buccinator, and other muscles of expression ; the lachrymal sac or nasal duct, levator labii superioris et alse nasi, compressor naris, depressor alse nasi, orbicularis oris, inferior oblique of eye, and tendo-oculi ; and the mucous membrane of the lip. 2. Nerves — Chiefly branches of facial and branches of second division of the fifth that appear on the face, as well as the infra-trochlear, and in the end the trunk of the second division of the fifth itself in front of Meckel's ganglion. Surgical, Medical, and Operative, 509 3. Tlic various bony points already mentioned. In tearing the bone from its posterior attachments, the vertical plate of the palate bone, pterygoid fossa, and internal pterygoid muscle, are usually torn away as well. 4 Arteries^— (a) Branches of the temporal — (1) Orbital ; (2) middle temporal; and (3) transverse facial. (&) Facial near the angle of the jaw and several of its branches — (1) Superior coronary ; (2) lateral nasal; and (3) angular, (c) Termination of the internal maxillary artery, probably, and certainly many of its branches — (1) The buccal; (2) posterior dental; (3) infra-orbital; (4) descending palatine ; and (5) spheno-palatine. 5. Corresponding veins. f r BESUME of this operation : — 1 . Extract a central incisor tooth. 2. Make the incision through the soft parts. 3. Secure all bleeding points. 4. Eaise the flap upwards and outwards, and again secure bleeding points. 5. Separate the soft from the hard palate by a transverse incision; don't bother about the soft covering of the hard palate. 6. 2fotch the palate process deeply with the saw, and then do the same to the malar junction. 7. With a large bone forceps complete the division of the malar attachment, entirely divide the nasal, and com- plete the division of the palate process, at the same time giving the bone a prise outwards, using the bone forceps as a lever. 8. With the lion forceps wrench the bone suddenly and forcibly downwards and outwards. 9. Quickly plug the gap thus made to control hEemorrhage. 1 0. Lastly, carefully stitch up the external wound and lip. THE LOWER JAW (One-half). The same principles must guide as in the last operation. If the tumour be a simple one, then keep close to it during the operation; but if, on the other hand, it is malignant, cut wide of iti The instrumehts required are. tJie same as in the previous operation;, in cases where a part only of the bone is removed, a match, or 510 Applied Anatomy : some similar piece of wood, partially sharpened, should always be at hand to plug the foramen in the bone, where the inferior dental artery lies, in order to stop the bleeding. The Surgeon stands on the right side. (1) Place the patient in a recumbent position, with the shoulders slightly raised; shave the part if necessary, extract an incisor tooth, fix the point of the tongue, and make the incision (Fig. Ill, h). The usual directions are to begin the incision above and immediately behind the articulation of the lower jaw, but in front of the temporal and external carotid arteries, and carry it deeply down to the bone along the ascend- ing ramus of the jaw, and then forwards und.er the horizontal ramus, so that the resulting scar may be hidden, till oj)posite the point where the bone is to be divided, and then carry it upwards towards, but do not divide the lip. The lip, however, may be divided if necessary, as it really does not matter since it unites readily enough, and the saving of it might embarrass the operator. An important point is to endeavour to have every- thing separated from the jaw on the outer side and below, and the bone divided before opening through the mucous membrane into the mouth; this will help greatly to prevent blood passing into the trachea. For the same reason it is probably better not to draw a tooth as the fint step of the operation. In the case of a simple tumour of limited extent; or in the case of a female, an attempt may be made to do the whole operation by an incision under the jaw. Secure the facial artery, before or as soon as divided, by a catch forceps (Wells's), and at once tie it. (2) Dissect this flap upwards and inwards to expose the bone, and clear the inner side of the jaw from contiguous structures, using a narrow bistoury, and keeping its edge close to the bone. (3) Saw through the jaw partially, close to the symphysis, and complete the division with the bone pliers. (4) Depress the divided ramus with the left hand or lion forceps, tUl the insertion of the temporal muscle into the coronoid process is seen, and then divide it at its insertion. IT this be impossible then snip off the coronoid process in the meantime, and remove it afterwards if necessary. (5) Turn the jaw horizontally outwards, still depressing it, to make the external ligaments of the joint tense, and open the joint /ro??i the front, and Iteep the edge of the knife close to the bone to avoid wounding the Surgical, Medical, and Operative. 511 internal maxillary artery. In depressing the jaw it must not bo rotated, lest the artery in this way be stretched round the neck of the bone and be torn or divided. (6) Divide the insertions of the internal and the external pterygoids; evert the bone, and carefully separate all the soft parts from its inner surface, taking care not to injure the submaxillary gland or lingual nerve, and remove it. Secure the bleeding points and close the incision, and drain from the lower and posterior angle. IToTE. — In making the incision it is better not to carry it too far up behind the ascending ramus (if the jaw can be disarticidated without doing so) lest the trunk of the facial nerve be severed, and the various facial muscles be therefore paralysed (the portio dura — facial — being the motor nerve of the face), but only curve it slightly over the angle of the jaw, and dissect up beneath this ilap very close to the bono. If, however, the nerve must be divided, its main branches should be sutured afterwards with fine catgut. In closing the wound it is better to stitch the two edges of the divided mucous membrane together in order to shut the wound off from the cavity of the mouth; but if this cannot be done then a drainage tube must be passed through into the mouth. The wound and lip (if divided) must be sutured in the same way, and the after-treatment conducted on the same principles as in excision of the upper jaw — continuous irrigation with warm antiseptic fluid. In the case of simple tumours, whenever possible, the alveolus should be divided and the lower border of the jaw preserved. Chief Structures Divided. — (1) Superficial structures, fascia, and platysma. (2) Muscles — viz., the masseter, platysma, part of buccinator, insertion of digastric (anterior belly), genio-hyoid, genio-hyo-glossus of the side excised (if the incision be through the symphysis), mylo-hyoid, a few fibres of the superior constrictor of the pharynx, internal and external pterygoids, depressor labii inferioris, temporal, levator menti, and orbicularis oris. (3) Pro- bably a part of parotid gland. (4) The stylo-maxillary ligament. (5) Nerves — viz., inferior dental, small twigs of the facial, part of the auriculo-temporal, mylo-hyoid, and masseteric. Care must be taken to preserve the conjoined chorda tympani and lingual from injury. They lie on the internal pterygoid, and are covered by the external pterygoid ; the chorda being the nerve of taste to the 512 Applied A natoinf : anterior two-thirds of the tongue, while the lingual is the nerve of common sensation to the same part. (6) Arteries — viz., inferior dental, facial and its submental branch, inferior coronary, inferior labial, mental and masseteric, and other small muscular branches. The internal maxillary may be cut, or even the external carotid near the point where it divides into the temporal and internal maicillary, if the operator be not sufficiently careful. The care necessary in disarticulating the jaw will at once be evident when one remembers the close relation of various important structures to it — such as the internal maxillary artery, temporo- maxQlary vein, auriculo-temporal nerve with the middle meningeal artery between its two heads of origin, and the chorda tympani close to the Glaserian fissure, and the other branches of the third division of the fifth. Avoid also the facial nerve as far as possible, the external carotid artery, and the lingual nerve. The excision of the central part of the lower jaw is always a dangerous operation. There is the risk of sufifocation, from the retraction of the hyoid bone and tongue, when the attachments of the mylo-hyoid, genio-hyoid, and genio-hyo-glossi muscles are divided from the bone. To prevent this as far as possible, the tongue must be fixed by a strong ligature passed through its tip, and held well out by an assistant. Tor the same reason it is better in excision of one side of the lower jaw not to cut through the symphysis exactly, but a little external to it, so as to leave the insertions of the genio-hyoid and the genio-hyo-glossus muscles. ' BESUME of this operation: — 1. Extract a central incisor tooth. 2. Make the skin incision : do not go too far up lest the facial nerve be unnecessarily divided, or too far back lest the external carotid artery and temporo-facial vein be divided; secure the facial artery before it is divided by a double ligature, also secure its submental branch. 3. Kapidly dissect up the flap and expose the outer surface of the bone,. and secure bleeding points. 4 Clear the inner surface of the bone as far as possible, and then Surgical, Medical, and Operative. 513 5. Divide it by saw and bone forceps a little to one side of the symphysis. 6. Depress the divided ramus, and divide the attachment of the temporal muscle into the coronoid process — " tlie. hey of the operation." 7. Open the joint from the front, taking care of the internal maxillary artery and vein and their junction with the temporal vessels ; also the auriculo-temporal nerve and the middle meningeal artery. 8. Complete the disarticulation by depressing the jaw and at the same time carrying it horizontally outwards : secure all bleeding vessels and stitch up the external wound,, if possible suturing the edges of the mucous membrane together to shut out the saliva. THE OS CALCIS. In excising this bone avoid making any incision in the sole. For this purpose the best form of incision to use is the following : — The patient is laid on his face, and a horse-shoe-shaped incision is carried from a point a little in front of the calcaneo-cuboid articulation round the heel and along the side of the foot to a corresponding point on the opposite side. The flap thus outlined is then dissected down over the prominence of the os calcis, keeping the edge of the knife close to the bone, exposing the whole of its under surface. Then a perpendicular incision is made, about two inches long, behind the heel and through the tendo achillis, opening into the former incision; the tendon is then divided, and the flaps dissected up, and the knife passed between the os calcis and the astragalus, and the strong inter- osseous ligament divided ; and lastly, its attachment to the cuboid is divided and the bone removed. Great care is necessary in clearing the inner side of the os calcis from the large number of vessels, nerves, and tendons at that side. Structures Divided. — (1) The skin, superficial and deep fascia, and cutaneous vessels and nerves. (2) Muscles — the tendo achillis, extensor brevis digitorum, abductor minimi digiti, flexor brevis digitorum, plantaris, accessorius, abductor hallucis, and the pro- longation of tibialis posticus to the lesser process of the os calcis ; 2k 514 Applied Anatomy: some also divide tlie peroiieus longus and brevis. (3) Arteries — chiefly malleolar and calcanean twigs. (4) Ligaments — the superior calcaneo-cuboid, the internal calcaneo-cuhoid, the superior calcaneo- scaphoid, the external calcaneo-astragaloid, the middle fasciculus of the external lateral ligament of the ankle joint, the posterior calcaneo- astragaloid, part of the deltoid ligament, inferior calcaneo-scaphoid, the long and short calcaneo-cuhoid ligaments, and lastly, the strong interosseous ligament. THE ASTRAGALUS. This hone may he excised by an external incision, similar to that used in excision of the ankle joint, with, if necessary, a short straight incision over the internal malleolus, sufficient to allow division of the internal lateral ligament. Some divide the peroneus brevis and tertius, but it is better not to do so. The steps of the operation resemble closely those of excision of the ankle joint. It is important to clear the bone on all sides before separating the structures on the posterior edge — the flexor longus hallucis tendon, posterior tibial vessels, and posterior tibial nerve. The various Ligaments connecting the bone with its fellows must be divided as they present themselves : — To the bones of the leg, OS calcis, and scaphoid — (1) to the hones of the leg — the anterior ligament, posterior ligament, and the lateral ligaments of the ankle joint (the middle fasciculus of the external lateral may be saved); {2) with the scaphoid — one, the superior astragalo- scaphoid; and (3) with the os calcis — the strong interosseous, and external and posterior calcaneo-astragaloid. THE CLAVICLE. The more important Relations of this bone are — In Front — The skin, superficial fascia, platysma, and descending branches of the supra-clavicular nerves — the sternal, clavicular, and acromial, from the third and fourth cervical, — the deep fascia, and communi- cation from the cephalic to the external jugular vein. Behind — (1) Vessels — Subclavian vein, internal jugular vein, and probably the junction of these two to form the innominate vein ; external jugular vein, internal mammary artery, and supra-scapular artery and vein ; the subclavian artery, common carotid artery, and partly Surgical, Medical, and Operative. 515 tlie innominate artery. (2) Nerves — the vagus, phrenic, the great cords going to form the brachial plexus, the nerve of Bell, nerve to the subclavius, and cardiac nerves. (3) Muscles — sterno-hyoid, sterno-thyroid, omo-hyoid, scalenus anticus ; (4) apex of the pleura and lung ; (5) thoracic duct ; (6) trachea ; and (7) the oesophagus. The last two are not exactly behind, but they are not far from the inner end. In excising this bone, an important point is to secure free access. After the bone is exposed, one of three courses may be pursued — (1) to disarticulate at the sternal end, and gradually turn the bone outwards ; (2) disarticulate at the acromial end, and turn the bone inwards ; or (3) divide the bone with chisel and mallet at some convenient part of its length, if possible so that the outer fragment is the longer, as that end is the most difficult and dangerous to deal with, and remove it in two parts. I have only seen this operation performed once — for malignant disease of the bone; on this occasion Professor Chiene was the operator. He exposed the clavicle by a free crucial incision, but, according to his custom, made in such a way that the four angles do not all meet at one point. The flaps were then raised, and the bone divided about one inch from its sternal end. Round the inner end of the outer and larger fragment, a strip of bandage was tied, by which the clavicle was gradually raised, as it was freed from its surround- ings. The difficult part of the operation was the division of the coraco-clavicular ligament; this he divided by a probe- pointed bistoury, after which the removal of the bone was an easy matter. The inner end was then freed from its attachments, the joint opened, and the bone removed by division of the strong costo- clavicular, or rhomboid ligament. The only vessel of any size cut during the operation was the supra-scapular artery ; twigs of the superior thoracic and acromio-thoracic would probably also be divided. In this operation great care is necessary lest any of the large veins be cut; the great risk of this accident would be the entrance of air, and probably fatal syncope on account of the aspirating_ power of the thorax. The care requisite is all the greater, since the veins are most anterior. The wound is then closed, and drainage secured from the outer angle; this is the deepest part of the wound, and at the bottom lies the third part of the subclavian artery. One must therefore be careful to 516 Applied Anatomy: avoid pressure on the end of the tube, lest the other end ulcerate into the vessel. The arm must be bound firmly to the side during the after treatment, pretty much in the same way as is done in fracture of the clavicle. The Structures Divided. — (1) Skin, superficial fascia, platysma, sternal, clavicular, and acromial twigs of supra-clavicular nerve, twigs of acromio-thoracic artery, communication from cephalic vein to external jugular, and deep fascia. (2) Muscles— pectoralis major, deltoid, clavicular head of sterno-mastoid, part of the sterno-hyoid, trapezius, and subelavius. (3) Ligaments— of the sterno-clavicular articulation, including the rhomboid; of the acromio-clavicular articulation, including the conoid and trapezoid. In this case also the supra-scapular artery, on account of the position and nature of the tumour. In injuries to the clavicle the veins behind it are very apt to suffer as they are most anterior, but the dense costo-coraooid membrane and the subelavius muscle in most cases protect them from all harm. The descending branches of the third and fourth cervical nerves passing over the bone are important, as they may be implicated in bruises or fractures of the clavicle, or be the seat of reflected pains in disease of the upper cervical vertebrae. THE SCAPULA. This may be removed by a crucial or — i-shaped incision. By the H-incision, an incision is made from the acromial end of the clavicle downwards along the axillary border of the scapula to its inferior angle ; from the middle and upper third of this incision another is made at right angles, extending to the posterior border of the bone near the root of the spine. The patient is placed in a semi-prone position, and an assistant commands the subclavian artery by digital compression or a padded key. The flaps are then dissected up, and the acromio-clavicular joint opened. The supra-scapular artery is next found (by feeling for the notch iu the upper border of the bone and the transverse ligament, over which the vessel passes) and secured ; then the posterior scapular is looked for under the levator anguli scapulae, and also secured. . The attachments of the posterior border are then divided and the bone drawn backwards and outwards ; then the muscles attached Surgical, Medical, and Operative. 517 to the coracoid process are divided. Next the shoulder joint may- be opened by dividing the subsoapularis tendon and the other tendons surrounding the neck of the bone. In doing so avoid the trunk of the subscapular artery and the posterior circumflex. Structures Divided. — (1) Skin, superficial fascia, branches of dorsal nerves, and deep fascia. (2) Muscles — the supra-spinatusj infra-spinatus, teres major, teres minor, deltoid, trapezius sub- soapularis, serratus magnus, the rhomboids — major and minor, levator anguli scapulae, onio-hyoid, long head of triceps, pectoralis minor, coraco-brachialis, short head of biceps, long head of biceps, and, in some cases, the latissimus dorsi. (3) Arteries — the supra- scapular, posterior scapular, the acromial branch of thoracic axis, dorsalis scapulae, and termination of subscapular. (4) Ligaments — of the shoulder joint, of the acromio-clavicular joint, also the conoid and trapezoid ligaments. 518 Applied Anatomy: CHAPTER XXVII. THE EYE. THE OEBIT. The cavity of the orbit resembles a four-sided pyramid, the antero- posterior diameter of ■which is slightly greater than either the vertical or transverse. Its apex is formed by the optic foramen; the base is surrounded by the frontal, malar, and superior maxillary bones. The roof is formed by the frontal bone and lesser wing of the sphenoid; the roof is very thin, and sharp-pointed bodies may easily pass through it accidentally, or be forced through with homicidal intent, and injure the brain. The floor is formed by the orbital plate of the superior maxilla, the malar bone, and the orbital surface of the palate bone. On the inner wall we find the nasal process of the superior maxilla, the lachrymal bone, the OS 'planum of the ethmoid, and the body of the sphenoid. The outer wall is formed by the malar bone and the gi-eat wing of the sphenoid. The openings into the orbit are nine in number: — (1) The optic foramen, which transmits the optic nerve and the ophthalmic artery; (2) sphenoidal fissure (for structures passing through, see after); (3) spheno-maxillary fissure, which transmits the superior maxillary nerve with its orbital branch, the infra- orbital artery, and the ascending branches from Meckel's ganglion. This fissure opens a communication between three fossse and the orbital cavity — the temporal, zygomatic, and sphenq-maxillary. It will therefore be readily understood how malignant growths can so easily and rapidly spread in both directions— ^e., 9., the rapidly growing forms of sarcomata, which are the tumours most frequently met with in this situation. (4) Supra-orbital foramen, for supra- orbital vessels and nerves; (5) infra-orbital canal, for infra-orbital vessels and nerve; (6) anterior ethmoidal foramen, for nasal nerve Surgical, Medical, and Operative. 519 and anterior ethmoidal vessels; (7) posterior ethmoidal foramen, for posterior ethmoidal vessels; (8) malar foramina, for temporal and malar branches of orbital nerve; and (9) the lachrymal groove, for lachrymal sac and nasal duct. Cavernous Sinus and Sphenoidal Fissure (foramen lacerum anteriiw). — The .cavernous sinuses are situated at the sides of the body of the sphenoid bone, and are so named from their present- ing a reticulated or cavernous structure. Each sinus begins at the sphenoidal fissure, receiving the ophthalmic vein, and ends at the apex of the petrous portion of the temporal bone by dividing into the superior and inferior petrosals; they are connected by means of the circular sinus, and sometimes also by the transverse sinus. On the inner wall of each sinus is found the internal carotid artery. Fig. 112. Right Cavernous Sinus. ^*^ Third Nerve. \ ^^^ Pourth Nerve. , _ ^^^^. 'St Division of Sixth Nerve.. /~\* ^^^^k^ 'iffch Nerve. Internal Caret '_ ^*N^ aous Channel. surrounded by the carotid plexus, and with the sixth nerve to its outer side. On the outer wall are the third, fourth, and first division of the fifth nerve, in that order from above downwards (Fig. 112). Through the centre of this sinus the blood flows in an irregular channel lined by endothelium. Pressure on the sinus will be indicated by venous engorgement of the eyeball and orbital cavity, and paralysis of some of the ocular nerves, especially the third and fourth. The pressure may be produced by anything that causes enlargement of the tip of the tempore -sphenoidal lobe of the cerebrum, as a gumma or an abscess ; also by aneurism of the internal carotid in the sinus. In the splienoidal fissure the position of parts is considerably altered — ( 1 ) The fourth nerve to the inner side; (2) the frontal branch of the fifth ; and (3) the lachrymal branch of the fifth. These three nerves are above all 520 Applied Anatomy : the muscles, and lie nearly on one level, just under the periosteum, the fourth being to the inner side. Then comes (4) the upper division of the third nerve ; (5) the nasal branch of the fifth ; (6) the lower division of the third nerve; (7) the sixth nerve; and lastly, and most internal of all, (8) the ophthalmic vein. The various nerves may be pressed upon by growths, involving this fissure, and also by syphilitic or rheumatic periostitis. Note. — The structures named from 4 to 8 inclusive are all found between the two heads of the external rectus (Fig. 113). Fig. 113. Right Sphenoidal Fissure. Fourth Nerve, Frontal of Fifth Laohiymal of Fifth. . - Fourth Nerve. m Fifth Nerve. Superior Division of Third Nasal of Fifth Structures between the Two Heads of External Bectus. Inferior Division of Third. Sixth Nei-ve Third Nerve. - Sixth Nerve. -Ophthalmic Vein. THE EYELIDS. The eyelids are opened by the levator palpebrse, svipplied by the third nerve, and shut by the contraction of the orbicularis oculi, supplied by the facial nerve. Structure— (1) The skin, (2) the orbicularis muscle, (3) loose connective tissue, (4) tendon of levator palpebrse (in the upper lid only), (5) the tarsal cartilage, into the anterior and lower part of which the levator palpebrse is inserted ; Surgical, Medical, and Operative. 521 (6) palpebral ligament, (7) Meibomian glands, (8) conjunctiva, the mucous membrane of tbe eye, which lines the inner surface of the eyelids, and is reiiected from them over the fore part of the sclerotic and cornea (Fig. 114). In the palpebral part of the conjunctiva there are many nodules of adenoid tissue, also mucous follicles and papillsa ; in the condition known as granular lids, or Trachoma, these structures are much hypertrophied, and cause great irritation of the upper half of the ocular conjunctiva, leading directly to Fig. 114. The Eyelids. Tendon of Levator , Palpebraj Orbicularis Palpe- brarum -, Tbe Skin / Tarsal Cartilage — - ^ - The Eyelashes /^^ ^ Palpebral Ligament. y^ j/^^r\ Conjunctiva. ' -^ ^ ■'^^^^ir. Meibomian Glands. . , „ ^ S Sclerotic. C Cornea. L6v,ator Palpebrse Muscle. pannus, and, after cicatrisation, to inversion of the eyelashes and entropion. The common tarsal cyst is a retention cyst developed in one of the Meibomian glands, and should be removed from, the inside by everting the lid, cutting through the conjunctiva, and shelling it out. A dermoid cyst is often met with at the upper and outer angle of the orbit, under the orbicularis muscle j 522 Applied Anatomy : it is very thin walled, and contains epithelial cells and fine hairs. It is attached to the periosteum, and very often causes a depression in the bone as well, but the superficial structures move freely over it. The wall of the sac is usually very thin, and a very careful and tedious dissection is required to remove it; occasionally, it is connected with the dura mater. These cysts are developed in the situation of the inner end of the embryonic fronto-orbital fissure. Dermoids are also met with occasionally at the inner and lower angle of the orbit, in the situation of the upper end of the embryonic naso - maxillary fissure ; the nasal duct represents a persistent portion of the same cleft or fissure. One must be very careful not to confound a meningocele, in this situation, with a dermoid cyst. The Eyeball (Fig. 115). — The eyeball consists of three coats and the refracting media. The outer COat is formed by the sclerotic and cornea, (a) The sclerotic forms five-sixths of the circumference of the globe, and is composed of strong fibrous tissue, being thicker behind than in front ; its weakest part is about a quarter-of-an- inch behind the cornea. (6) The cornea forms the anterior sixth of the circumference of the globe, forming a small projection in front, being the segment of a smaller sphere than the sclerotic. It consists of five layers — (1) Anterior epithelium — squamous and stratified, (2) anterior elastic lamina of Bowman, (3) the corneal tissue proper, (4) posterior elastic lamina of Descemet or Demours, and (5) the posterior epithelium — a single layer of squamous cells. The corneal tissue is continuous with the sclerotic, but the opaque sclerotic overlaps the cornea very much in the same way as a watch-glass is overlapped by the edge of the groove that receives it. It is important to remember this in making incisions abouttlie comeo-sclerotic junction. The middle coat consists of the choroid, ciliary body, and iris, (a) The Choroid is the vascular and pigmented coat of the eyeball, and is often the seat of melanotic sarcoma. It consists of— (1) The lamina supra-choroidea and the lamina fusca, which connect it with the sclerotic, and between which is found a lymph space. (2) The venae Torticosse, which end in the ophthalmic vein and return the blood from the globe; in cases of increased intra-ocular tension, as in glaucoma, pressure on these veins is indicated by the dilated Surgical, Medical, and Operative. 523 and enlarged veins observed on the surface, of the sclerotic. (3) A closely-set capillary plexus, formed by the short ciliary vessels, known as the tunica Eusychiana. (4) The lamina vitrea, and (5) the layer of hexagonal pigment cells, which may be regarded as belonging either to this coat or, more properly, to the retina. The choroid is the nutritive tunic of the eyeball, having an especial Fig. 115, Antero-Posterior Section of Eyeball. (From Okay's "Anatomy.") TENDON OF RECTUS SCLEROTIC' CHOROID' RETINA CILIARY MUSCLE K LIGAMENT CILIARY PROCESS CIRCULAR SINU CANAL OF PETIT relation to the vitreous humour. Disease of the choroid may be primary, that is, beginning in the choroid (choroiditis), or secondary to iritis, the mischief spreading backwards and involving the choroid (irido-choroiditis). There are two clinical signs that point very strongly to choroidal disease, the first is diminished tension of the globe, and the second is the presence of floating opacities in the vitreous, (6) The Ciliary body consists of the ciliary processes and 524 Applied Anatomy: the ciliary muscle — the muscle of accommodation ^ it arises from the posterior surface of the cornea and sclerotic junction close to the canal of Schlemm and the spaces of Fontana, and is inserted into the choroid, opposite the ciliary processes. The vascular supply, like that of the choroid, is derived from the short ciliary arteries, (c) The iris — this is also a muscular structure, and forms a self- acting diaphragm, excluding or. admitting light as required, like the diaphragm of a microscope, becoming narrower during active accommodation (equal to high 'power of microscope) and widening during passive accommodation (low pmeerj. It consists of the following structures : — (1) In front, a layer of epithelial cells, con- tinuous with those on the posterior surface of the cornea. (2) A stroma, formed of cells and connective tissue bundles arranged in a radiating manner towards the pupil, and which gives the iris a striated, fibrous look; when the iris is inflamed this fibrous look is lost, and the iris seems smooth and dull in appearance. (3) Non- striped muscular fibres arranged in a circular and radiating manner; the circular fibres form the sphincter pupillm and surround the margin of the pupil, the radiating form the dilator pupillm. (4) The posterior surface is covered with pigment of a deep purple tint, known as the uvea. The vascular supply of the iris is derived, for the most part, from the two long ciliary arteries which form the greater and the lesser arterial circles of the iris; it also receives blood from the anterior ciliary arteries, which are derived from the muscular branches, and which join the great arterial circle. The iris is very vascular, almost resembling erectile tissue, and it often affords important information as to the state of the cerebral circu- lation ; thus, when the brain is ansemic, as in typhoid fever, the pupil is dilated, but when the brain is engorged, as in typhus fever, the pupil is contracted. For the same reason it is also slightly contracted in iritis. The circular fibres are supplied by the third nerve, and the radiating by the sympathetic. In the foetus the pupil is closed by a delicate vascular membrane, which thus divides the chamber of the aqueous into two separate compartments — ^the menibrana pupillaris; it begins to disappear about the seventh month, and has usually quite disappeared, vessels and all, before birth. Occasionally traces of it remain after birth, and occasionally it is permanent, causing blindness. In some animals it remains Surgical, Medical, and Operative. 525 apparent for a few days after birth, such heing said, in popular parlance, to he horn hlind, hut to compensate for this few days' hlindness, it is said they see in the dart ever afterwards. Its remains in the human eye are apt to he mistaken for old iritic adhesions; they form thin shreds of the same colour as the iris, and are attached to its anterior surface close to its pupillary border. They are longer and more slender than posterior synechise, and are not attached to the lens capsule. The entire membrane is the anterior portion of the capsulo -pupillary memhrane, which at one time forms a complete fibro - vascular ' covering of the lens; the capsulo-pupillary membrane is developed from the enclosed meso- blast, and is supplied by a branch of the central artery of the retina, which passes forward in the axis of the globe in a canal in the vitreous humour (Canal of Stilling), and breaks up at the back of the lens into a brush of capillaries. At its circumference the iris is connected to the cornea by the ligamentum pectinatum iridis, which is derived from the posterior elastic lamina of that tunic. Passing through this ligament are a number of cavernous spaces, known as the spaces of Fontana ; these communicate with the canal of Schlemm, a sinus tunnelling the choroid near its corneal junction. This sinus is either a vein or a lymph canal, having a very intimate relation with the veins of the globe, and in this way, therefore, the aqueous humour is brought into very direct relation with the venous system. The pupillary margin of the iris is free, and floats in the aqueous humour ; in cases, therefore, of penetrating wounds of the cornea, the iris is apt to prolapse, being carried out with the gush of the aqueous fluid. This is an exceedingly troublesome and serious complication, and unless reduced, may give rise later to recurrent attacks of iritis, or even to sympathetic ophthalmia, from the irritation caused by the adhesion of the iris to the corneal cicatrix. Sometimes prolapse occurs in the case of wounds, made by the Surgeon, in the ciliary region for the puri^ose of removing an opaque lens (cataract); to avoid this as far as possible, a small bit of the iris is removed opposite the wound, but, even with this, one must be careful to see that no part of the iris is included in the wound, as this will delay healing very much. The iris is a muscular structure, and, therefore, may be made to contract or dilate 526 Applied Anatomy: like other muscles; this fact is made use of in corneal wounds to prevent prolapse : for example, in wounds situated near the circum- ference of the cornea, whether the result of accident or made by the Surgeon, a solution of Calabar bean (eserine) is dropped into the eye, since this causes contraction of the iris, and will, therefore, draw it away from the wound; whereas in wounds near the centre of the cornea, a solution of atropine is used to dilate the pupil, and . thus again carry the iris away from the wound. The inner coat consists Tif the retina, which is formed by the expansion of the optic nerve, and is the seeing part of the eye. It is thickest behind, and becomes gradually thinner as it passes forwards ; it ends by a jagged margin, the era serrata, just behind the ciliary body. From within outwards it consists of the following layers : — (1) Internal limiting membrane, next the vitreous humour; (2) layer of nerve fibres; (3) layer of nerve cells; (4) inner mole- cular layer; (5) inner nuclear layer; (6) outer molecular layer; (7) outer nuclear layer; (8) external limiting membrane; (9) layer of rods and cones; and (10) layer of hexagonal pigment cells. At the yellow spot, however, the structure is a little different — the layer of nerve fibres is absent, but the layer of nerve cells consists of - several strata; the rods are few, and absent altogether in its centre, but the cones are many and large. All the other layers are thinner, and there are scarcely any blood-vessels, only a few capillaries. When looked at, by the aid of the opthalmoscope, the following parts may be recognised : — (1) The optic disc or blind spot, one- tenth of an inch to the inner side of the axis of the eye; (2) the macvla lutea or yellow spot, as nearly as possible in the axis of the eyeball : in its centre is a slight depression — the fovea centralis ; (3) the arteria centralis retime, which enters through the optic disc and divides into four or five branches, which pass over the retina in various directions, but seem to avoid the macula lutea ; and (4) sometimes the vessels of the choroid may be seen. The fundus itself is bright ferrety red, the depth of the colour depending on the complexion of the individual ; this red appear- ance does not come from the retina — which is invisible except under rare conditions — but from the choroid. When the lens is opaque, as in cataract, this redness is obscured more or less, and when it cannot be seen at all the cataract is said to be "ripe." Surgical, Medical, and Operative. 527 The optic disc is of a lighter pink than the rest of the fundus, and is circular or slightly oval, and very markedly so, should the patient be astigmatic ; the centre of the disc is still paler, and into this the greater number of the blood-vessels dip. This central white spot represents a hollow cup — the physiological cup — left by the optic nerve fibres as they radiate from the centre of the disc towards the periphery. Compare this with the large, deep pathological cup seen in glaucoma ; in health the cup does not extend to the edge of the disc, whereas in glaucoma it does, and is also very deep. In atrophy of the optic nerve, the cup though wide is very shallow. In health the edge of the optic disc is sharply defined, and it is often surrounded by a white ring — the scleral ring — which corresponds to the edge of the sclerotic. In cases of myopia a greyish white crescentic patch is often seen on the apparent inner side of the optic disc, in indirect examination {i.e., next the yellow spot). This is known as the "myopic crescent," and is due to atrophy of the choroid ; it is also known as a "■posterior staphyloma." In some cases the lamina cribrosa may be distinguished like a number" of dots at the bottom of the physiological cup. The veins of the retina are easily distinguished from the arteries by their larger size, deeper colour, and single outline; the arteries have a double outline and pursue a straighter course. The visible retinal vessels are few in number, widely spread, and are what are known as terminal vessels, as the arteries do not anastomose with each other, while the choroidal vessels, if seen, branch and anastomose freely, forming a closely set network ; in embolism, therefore, of the retinal vessels, an infarct is produced. In cases of glaucoma and aortic regurgitation one may sometimes be able to see the vessels pulsating. As the optic disc lies to the nasal side of the posterior pole of the eye, in the indirect method of ophthalmoscopic examination, the cornea must be turned a little inwards, towards the patient's nose, to bring the disc opposite the pupil ; in this movement, of course, the back of the eye is carried outwards, and the patient must be directed to turn his eye, not his head. Advantage is taken of the red reflection of the fundus, but especially of the pale disc, in examining for floating opacities in the vitreous. The Surgeon sits about twelve to eighteen inches in 528 Applied Anatomy : front of the patient's eye, and directs him to move his eye sharply and freely from side to side, and up and down, and then quickly to fix it so that the disc will he opposite the pupil, when the floating particles will be seen passing across the optic disc, like figures in a magic lantern, as they continue to move through the vitreous from their inertia, after the eye has come to rest. In this way, too, they are distinguished from opacities in the cornea and lens, or pigment spots on the fundus, which come at once to rest when the eye stops. Anatomically, the Refracting Media of the eye are— (1) The Cornea. (2) The Aqueous Humour, which fills the space between the cornea in front, and the lens with its suspensory ligament behind j this space is partially subdivided into two by the iris — the anterior and posterior chambers of anatomists. It should be noted, however, that oculists call the whole cavity the anterior chamber — their posterior chamber being the cavity containing the vitreous humour. In infants, the anterior chamber is very shallow, the lens being close behind the cornea; this probably explains the occurrence of anterior polar or pyramidal cataract, which is caused by a localised inflammation of the lens capsule and the layers immediately below it, and is usually the result of ophthalmia neonatorum, which has probably caused a central perforating ulcer of the cornea. (3) The Lens with its Capsule, which are held in position by the suspensory ligament. (4) The Vitreous Humour with its Hyaloid Membrane. Physiologically, however, refraction only takes place at three surfaces — the anterior surface of the cornea, the anterior surface of the lens, and the posterior surface of the lens. The eyeball lies in the orbital cavity, and is surrounded by much fine;ly granular fat, which forms a soft elastic packing for it. Coursing through this fat are many arteries and veins, going to and returning from the globe, and it occasionally happens that we find here some one of the many forms of aneurism. The conditions giving rise to "orbital aneurism" are very numerous and of a most varied character, and extremely difficult to diagnose with certainty; and sometimes, even at the post- mortem, nothing abnormal is found to account for the symptoms during life. Surgical, Medical, and Operative. -529 Symptoms. — Pulsation, displacement of the eyeball, and some- times loss of sight, from pressure optic neuritis; in .the arterio- venous forms we have the iisual thrill and bruits. Conditions present in some cases — Cirsoid aneurism, aneurism by anastomoses, arterio-venous aneurism of the orbit, pulsatile dilatation of the vessels of the orbit — as in exophthalmic goitre, communication between the internal carotid artery and the cavernous sinus, aneurism of the internal carotid, tumours pressing upon the termination of the ophthalmic vein, thrombosis of the cavernous sinus, dilatation of the carotid artery, aneurism of the ophthalmic in the cranium, and occasionally true aneurism. As regards the diagnosis^note (1) that ordinary aneurism and varicose aneurism tend to grow larger, so also would pulsating malignant tumours; and (2) that aneurismal varix does not tend to increase in size. The arterio-venous varieties are caused by wounds implicating simultaneously an artery and vein ; the author has seen two such cases, one caused by a knitting-needle, the other by an umbrella wire. This fat in the orbit is often the seat of abscess, due either to a primary septic cellulitis, or from disease of the neighbouring bones, especially . strumous caries of the lachrymal or ethmoid ; in this condition there may be no redness of the skin as the abscess is so deep, but there is usually oedema of the lid. At the inner angle of the orbit the facial and ophthalmic veins communicate, and in cases of malignant facial carbuncle, the septic thrombosis readily extends along the facial veia and through the ophthalmic to the cavernous and other sinuses, speedily setting up a condition of septic embolism and pyaemia. In young people also, soft rapidly growing sarcomatous tumours may start in the cellular tissue round about and behind the globe, from an injury, as a blow with a snowball. Ivory exostosis, and enostosis growing in the frontal sinus, are also sometimes found in the inner wall of the orbit, displacing the eyeball. Tumours of purely local origin, pressing upon the optic nerve and displacing the eyeball, will cause uni-lateral optic neuritis {" eholced disc"), followed by atrophy of the nerve pressed upon ; in tumours of cerebral origin, the same appearances are usually found in hoth eyes. Between the packing of the cavity and the globe itself, however, we find a membranous sac, which is known as the capsule of Tenon or the tunica vaginalis 2l 530 Applied Anatomy. ocuU. It is regarded as a distinct serous sac, ■with, a parietal layer covering the fatty tissue, and a visceral layer enclosing about three- fourths of the entire globe, extending from the base of the orbit to the optic nerve, with the sheath of which it blends. Just as in the case of the peritoneum, lymphatic vessels begin on the epithelial- lined surface- by stomata. The ocular muscles pierce this capsule as they pass to their insertion into the choroid y in operations there- fore for strabismus, this capsule must be opened before the tendon is thoroughlyexposed ; and since a serous cavity is thus opened, the necessity for strict antiseptic precautions is very evident. THE LACHRYMAL APPARATUS. This consists of — (1) The lachrymal gland and its ducts opening around the outer canthus, especially on the upper lid ; (2) puncta lachrymalia, which are the openings into (3) the canaliculi, which lead into (4) the lachrymal sac, from which (5) the nasal duct descends to open into the inferior meatus of the nose (Fig. 116). Puncta Lachrymalia and Canaliculi.— The puncta are two small apertures, situated one on the free margin of each lid, about- one quarter of an inch from the inner canthus j they are the openings of two small ducts — the canaliculi. Each canaliculus takes a curved course inwards — the upper first passing upwards and then curving downwards ; the lower first passing downwards and inwards, and then curving upwards and inwards; and therefore, in introducing a probe, or in slitting open the canaliculus, the lid should be drawn outwards, to make it as straight as possible. The lower canaliculus is shorter, wider, and not so much arched as the upper, and is the one usually opened, both because it is easier, and also because it carries off most of the fluid. In doing this the edge of the knife is directed inwards, and passed first a little downwards and a little inwards, and then inwards and very slightly upwards, tUl it touches the lachrymal bone. Lachrymal Sac. — If from any cause this sac requires to be opened {e.g., when suppuration has occurred in it), it should he opened from the outer side,' because the angular artery (the termination of the facial) and the large angular vein are on its inner or nasal side. The sac is placed in the inner angle of the orbit, and crossed in front by the tendo-oculi and some of the Surgical, Medical, and Operative. 531 inner fibres of the orbicularis muscle, a little above its niiddlo : while on its orbital surface is the tensor tarsi mu^scle. If the finger be placed on the inner edge of the orbit, this little tendon wiU be felt to tighten every time the eye is closed, and still more so if the eyelid be drawn outwards. In this way the tendon serves a most important purpose in helping to drain away the tears, as its pressure empties the lachrymal sac, and then, when it relaxes, the sac sucks up the tears through the canaliculi^ — resembling, in fact, an ordinary injection syringe. In opening an abscess of the lachrymal sac, the knife must be entered just below this tendon, and towards the outer side, to avoid the angular vessels. Fig. 116. The Lachrymal Apparatus. (From Gra'y's "Anatomy.") f / Nasal Duct. — This duct leads from the lachrymal sac to the inferior meatus of the nose. The edges of the canal through which it passes may be felt on one's own person, by pressing the finger on the inner edge of the orbit on its lower aspect. To pass a probe through it, it should be directed downwards, outwards, and a little backwards (the direction of the duct). Obstruction of this duct leads to distension, and consequently to irritation 532 Applied Anatomy : and disease of the lachrymal sac, and, unless properly treated, inflammation and suppuration follow, which may end in fistula lachrymalis. It is also a cause of "Epiphora" or " Stillicidiura Lachrymarum," trickling of tears over the cheek, or "Watery Eye." Each duct opens into the anterior part of the inferior meatus of the nose, immediately below, and about a quarter of an inch behind, the anterior end of the inferior turbinated bone, or an inch behind the orifice of the nostril, and about three-quarters of an inch above the floor of the nose ; they are about half-an-inch long, and they are narrowest about the middle. "Watery Eye." — This condition may be due to excessive secretion of fluid, when it is known as "Epiphora;" or to some obstruction preventing the proper drainage of a normal quantity of fluid, and it is then called " Stilliaidium Lachrymarum." Causes of Watery Eye. — (1) Obstruction of the nasal duct from chronic thickening of the mucous and submucous tissue, tumours and polypi of the nasal cavities and antrum ; (2) from increased secretion; (3) from obstruction of puncta or canaliculi, due to chronic inflammation or waxty growths; (4) in cases where the puncta are displaced, as in facial paralysis ; (5) suppuration of the sac from acute inflammation, probably following chronic thickening of its lining membrane, with increased secretion of mucus, forming a little tumour (mucocele or chronic dacryo- cystitis), which is very apt to inflame and suppurate ; (6) chronic conjunctivitis of the lower lid, causing increased thickness and eversion of the lid, leading to displacement of the punctum ; and (7) congenital narrowness of the puncta. In chronic cases the usual treatment is to open the inferior canaliculus. It is true, probes might be passed, and the opening gradually dilated, just as in ordinary stricture of the urethra ; but this plan is exceedingly slow, painful, unnecessary, and not satisfactory even when performed. The quickest and best way is to open the canaliculus, thus transforming it from a round pipe into an open gutter. After twenty-four hours rest probes are passed down from the lachryrftal sac into the nasal duct. Each ''probe must be kept in for ten or fifteen minutes (one probe at each sitting will usually be sufficient) and a larger size passed every second or third day. Before passing the probe, Dr Argyll Surgical, Medical, and Operative. 533 EoBERTSON curves it slightly, so that it may enter the duct more easily; he judges of the proper amount by placing the curved part against the side of the patient's nose and eyehrow just over the sac and duct, and when it lies level with the skin it is sufficiently curved. It is then passed along the opened canaliculus till the point comes into contact with the lachrymal bone, when the handle is raised tiU it lies over the supra-orbital notch, and the probe is then to be pushed in the direction above indicated — downwards, backwards, and a little outwards. SURFACE VESSELS OF THE EYEBALL. By this is meant vessels that can be seen, more or less distinctly, with the naked eye in certain diseased conditions. 1. The Vessels Proper to the Conjunctiva. — These vessels are usually known as the posterior conjunctival branches, and are derived fi;om the palpebral and lachrymal arteries. In health they are too small to be well seen, but in simple conjunctivitis they can be seen to perfection. They are of a bright brick-red colour, superficial, moving with the conjunctiva when it is slid over the globe, can be emptied for a time by gentle pressure, are tortuous, forming open loops, largest at the circumference of the globe, and growing smaller and less marked as they approach the edge of the cornea. 2. The Vessels of the Iris. — These are chiefly derived from — (a) The two Long Ciliary arteries which pierce the posterior part of the sclerotic, and run forwards along each side of the eyeball, between the sclerotic and the choroid to the ciliary ligament, where they each divide into two branches and form the great arterial circle of the iris, from which smaller branches pass to form the lesser circle at the pupillary margin. (J) The Anterior Ciliary arteries, which are derived from the muscular branches, and lie in the suh-eonjunetival tissue, and divide into two sets of branches — (1) The perforating hiATLches, which pierce the sclerotic about a line from the edge of the cornea, supply, the sclerotic and ciliary body, and end in the great arterial circle of the iris; and (2) the episcleral non-perforating branches, which are too small to be seen in health, but in Iritis, and in some deep-seated inflammatory affections of the cornea, they form a zone ( " circumcorneal zone ") about an 534 Applied Anatomy: eighth,-of-an-inch wide surrounding the cornea, pinli in coloiir, and consisting of closely packed, straight, and very fine radiating vessels. This injection is suh-conjunctival, and the vessels do not therefore move when the conjunctiva is slid over the globe, nor can they be emptied or affected in any way by pressure. Marked as these differ- ences are between the injection of iritis and that of conjunctivitis, yet iritis itself must not be diagnosed on these grounds alone, as other conditions produce the same injection. Besides the congestion in iritis, there is the altered colour of the iris, and sluggish action of the pupil to light ; there is slight narrowing and irregularity of the pupil, and the iris loses its fibrous look and becomes smooth, dull, and muddy. There is deep-seated pain shooting up the side of the head, nose, and eyebrow, which is usually worst in the early morning ; the pain is conveyed along the supra-orbital, the supra-trochlear, the infra-trochlear, and the nasal branches of the ophthalmic division of the fifth. There is further impairment of vision, and often great watering of the eye, and photophobia from irritation of the lachrymal nerve. In Conjunctivitis the pain is smarting and superficial (like sand in the eye), the secretion is rather sticky than watery, and gums the lids together during the night, and the vision is not impaired except for the moisture in front of the eye. It is very important to distinguish between conjunctivitis and iritis, as the treatment is so different, and the result of a mistaken diagnosis might be serious for the patient. 3. The Veins corresponding to the anterior ciliary arteries (tlie episcleral venous plexus) are sometimes found to be engorged, forming a scanty reticulated zone of dusky colour, with sometimes the larger trunks standing out in a sharply defined manner on the surface of the sclerotic. When this is the case it usually points to the serious condition known as glaucoma — a condition characterised by increased intra-ocular tension, the increased pressure obstructing the venous return through the vorticose veins of the choroid. 4. In Sclerotitis (rheumatic ophthalmia) there is usually some conjunctival and subconjunctival injection, but the characteristic feature is the peculiar bluish or violet tint of the sclerotic itself, due to the injection of numerous minute vessels in its substance. This dusky pink injection is most marked at the edge of the cornea and shades off as we pass backwards, but there is no visible Surgical, Medical, and Operative. 535 anastomoses. . There is also some thickening of the sclerotic from inflammatory effusion. This condition is found in middle-aged patients of a rheumatic constitution and is usually limited to a small area close to the edge of the cornea; in young adults it is usually gonorrhoeal in nature, and resemhles, as regards its pathology, a similar condition attacking certain large joints, and other fibrous, tissues, such as the tunica albuginea of the testicle. It is apt to involve the ciliary processes and iris; when this takes place there will be deep-seated pain and injection, and great sensitiveness of the eye to touch in the ciliary region, together with slight irregularity of the pupil. When the condition passes off it leaves the sclerotic thinned and of a bluish tint from, deep-seated pigmefitation, and may even be a cause of anterior staphyloma. ■ The Cornea itself is non-vascular, but in interstitial keratitis, where the cornea becomes like ground glass, a condition so frequently associated with congenital syphUis, blood-vessels from the periphery often penetrate into its substance at some little distance from the surface. This gives rise to a patch of peculiar colour — the " salmon patch" of Hutchinson; with a lens, the "patch" can be seen to consist of a fine, straight, and closely packed plexus of vessels. To confirm this, look for the signs of congenital syphilis, such as — (1) The notched, pegged, and widely separated upper central incisors ; (2) sunk bridge of the nose ; (3) hazy cornea from old interstitial keratitis ; (4) radiating scars at the angles of the mouth ; (5) prominent forehead; (6) the patient probably the eldest of the family; and (7) the presence of cliaroiditis disseminata. Myopia is a not uncommon result of interstitial keratitis; this is caused by the projection forwards of the cornea, due to thinning of its layers as a result of the inflammation, but is also partly the result of increased intra-ocular tension. Further, in the condition known as "pannus," there is a new growth of very vascular tissue just beneath the corneal epithelium, over part of the surface (usually the upper part) of the cornea. The usual cause of pannus is granular lids (glranular conjunctivitis or trachoma) where the conjunctiva of the lids is studded with minute elevations which constantly irritate the cornea. This con- dition of the lids is caused hy exposure to heat and glare, and is much more common in Palestine than in this country. 536 Applied Anatomy: MOVEMENTS OF THE EYEBALL. There are, in all, seven muscles acting on the globe^the four recti, the superior and inferior obliques, and the levator palpebrss superioris. Their nervous supply is as follows — The external rectus is supplied by the aixth nerve; the superior oblique by the fourth; and aU the rest by the third or motor oculi — viz., levator palpebrae superioris, superior rectus, internal rectus, inferior rectus, and the inferior oblique. Movements. — (1) To raise the eyeball, the superior rectus and inferior oblique act together; the superior rectus pulls upwards and inwards, the inferior oblique pulls upwards and outwards, but acting together the eye is raised directly upwards. (2) To depress the eyeball the inferior rectus and superior oblique act together; the inferior rectus displaces the ball downwards and inwards, the superior oblique downwards and outwards, but acting together the ball is displaced directly downwards. (3) The external rectus abducts the eyeball, while (4) the internal rectus adducts it. "Fire" in the Eye. — This is a condition of irritative con- junctivitis, due usually to a foreign body sticking in the eye, or else a recent abrasion produced by a foreign body, as bits of metal, spots of freshly slaked lime, etc. The usual history is, that it is in a working man in good health ; the onset is sudden, and only one eye is affected. First, gently separate the lids and examine the exposed part of the globe with the unaided eye, and after- vi'ards, if necessary, with an ordinary pocket lens ; then make the patient face a window and ask him to follow with his eye the movements of your finger, while you watch the reilection of the window on his cornea. Should there be an abrasion or foreign body sticking in the cornea, the image of the window will be broken and irregular at the abraded part. Small foreign bodies embedded in the cornea become surrounded by a hazy zone, and are then easily detected; they are apt to adhere to the inner surface of the lids, .especially the upper, and the next thing therefore to be done is to examine the inner surface of the lids. By gently depressing the lower lid its inner surface will be exposed; but for the upper, the lid must be completely everted over a probe or the handle of a pen. Lay the probe on the upper Surgical, Medical, and Operative. 537 lid, direct the patient to look down, and then gently take hold of the ciliary margin of the lid; press the probe downwards and draw the lid forwards and then upwards, when the cartilage will tilt over. In doubtful cases we must use oblique illumination by the aid of a lamp in a dark room, and a lens of about three inches focal length, such as is used with the ophthalmoscope; by this means we concentrate the light on the cornea, and any abrasion or opacity will be readily seen. This may also be supplemented by examining the illuminated cornea by the aid of a pocket lens. An abrasion may be the starting point of spreading septic ulcer of the cornea and of pus in the anterior chamber (hypopyon keratitis). The treatment is to destroy the septic condition by antiseptic appli- cations or the thermo-cautery, when the pus readily disappears from the anterior chamber, and the ulcer stops spreading. Treatment. — In many cases the foreign body can be easily removed, but when it is embedded in the cornea, drop a solution of cocaine into the eye, and then use a small spud, and passing it behind the foreign body, jerk it out; and afterwards, if there be much irritation, use a solution of cocaine or atropia. In the case of quicklime, wash the eye with a weak solution of vinegar (a teaspoonful to a cupful of water) and afterwards, to lessen the friction, use a drop of castor oil every half-hour, or else a solution of atropia or cocaine. In penetrating wounds of the cornea, the aqueous humour escapes with a gush, and carries the iris with it (prolapse) ; the iris sticks between the lips of the wound and delays healing, and also, because the iris is a very sensitive structure, gives rise to great pain and irritation. The first thing to be done is to reduce the prolapsed iris if possible; for this purpose close the eye and rub the lid gently against the globe, and afterwards use a strong solution of atropia or eserine, accord- ing to the position of the wound. If it is not yet reduced, then the prolapsed part must be snipped off. Penetrating wounds of the " dangerous zone" of the eye {ciliary region) are specially dangerous, not only to the wounded eye, but to the other eye as well ; in the wounded eye it is apt to give rise to iritis, eyclitis, and irido-choroiditis, and in the other eye, sympathetic ophthalmitis in three to six weeks after the injury, especially if the injured eye contains a foreign body, or if the iris be attached ^3S Applied Anatomy : to the cicatrix. The secondary inflammation usually takes the form of an irido-cyclitis or irido-choroiditis ; the injection is hut slight, but there is great sensibility of the eye to touch over the ciliary region. The exact cause is doubtful; it may be purely reflex, or spread through the optic nerve by continuity of tissue, or have a microbic origin; one thing is certain, that it most often follows wounds of the ciliary region, and that its first efi'ects are observed in the same region of the other eye. A somewhat similar phenomenon is, I believe, observed in the case of dental caries; a tooth on one side is carious, and if it is not removed, stopped, or 'else kept well dressed with some antiseptic substance, the corresponding tooth on the other side wUl very often quickly become carious too. The change may possibly be trophic in its nature. NERVES OF THE EYEBALL. 1. The Optic Nerve. — The deep origin of this nerve is from the posterior part of the optic thalamus (pulvinar), the anterior pair of corpora quadrigemina, the corpora geniculata, and, according to some authors, from the angular gyrus, where, according to Fbrribr, the visual centre is situated; but Munk, on the other hand, places the centre on the outer convex surface of the occipital lobe. From the deep origin each tract winds obliquely across the under surface of the corresponding crus, and afterwards join each other to form the optic commissure. The optic nerves take origin from the commissure, pass through the optic foramina, pierce the sclerotic and choroid a little to the nasal side of the centre, and expand into the retinse. The white sheath of Schwann should cease at the lamina cribrosa, but in rare cases it does not do so, but is continued through the disc into the retina forming " opaque nerve fibres " as seen by the opthalmoscope; it usually affects tongue-like processes round the circumference of the disc. The processes are pure white, striated, and the free edge is feathered, or like carded wool. The rest of the fundus is normal, the vision is not at all affected, and the vessels crossing the white patch are not tortuous, as in patches of choroidal atrophy. Surgical, Medical, and Operative. 589 The exact course and origin of the fibres passing to each retina is still a disputed point. It is generally admitted that there is a partial decussation at the optic commissure, each tract supplying the corresponding half of each eye, e.g., the left tract supplying the left half of each eye. Should, therefore, this tract be destroyed by disease, there will be blindness of the left half of both retinoe (which will thus correspond to the right half of each visual field). This is known as Homonymous hemianopsia. On the other hand, a lesion situated in the anterior part of the optic commissure will produce blindness of the inner half of each eye (the right half of one eye but the left half of the other). Thi^ is called internal Hetei-onymoics hemianopsia. In the very rare and doiibtful condition of external Heteronymous hemianopsia (blindness of the external half of each retina) there must be a double lesion situated at the outer margins of the sides of the optic commissure. But hemianopsia may also be caused by other conditions, su.ch as detachment of the retina, and in Coloboma iridis — a congenital cleft or deficiency in the iris, due to the imperfect closure of the choroidal cleft of the foetus, usually afiecting the choroid as well, always found at the lower and inner aspect, and therefore the upper and outer part of the visual field is deficient. It is very often symmetrical; the white patch is bounded by a dense line of pigment, and over its surface the choroidal and retinal vessels may be seen. Occasionally small dermoid cysts of the iris are due to the unobliterated remains of this cleft ; such cysts look like small white currants, semi-transparent, protruding into the anterior chamber, and partly occluding the pupil. Similar cysts may also arise as a result of a perforating wound of the cornea, whereby small pieces of Dbscemet's membrane, epidermal scales, or eyelashes are transplanted on to the iris, and form the germs of cysts — " implantation dermoids " (HuLkb). Detachment of the retina is due to serous exudation between it and the choroid ; it may begin at any part, but always gravitates by-and-by to the lowest part of the fundus. It is doubtful what would be the result of a lesion situated in the visual centre. Chaecot believes that the fibres that do not decussate at the optic commissure have already decussated in the corpora quadrigemina, so that the right centre would in this way 540 Applied Anatomy: entirely supply the left eye. Others believe that each centre presides over the corresponding half of each eye; this arrange- ment seems to receive most support both from pathological and anatomical research (Fig 117). Hypertrophy of the pituitary body may cause blindness by pressing on the optic chiasma and tracts, as in some fatal cases of acromegaly, where this body has occasionally been found much enlarged. Fig. 117. The Optio Nerves. Globe Lesion of Tract. Optio Thal- amus. . Goulciilate Body. Corpora Quadri- gemina. Angular Gyrus. The optio nerve is one of the excito-motor nerves of sneezing, as is sometimes shown upon sudden exposure of the eye to a bright light ; in paralysis of the first division of the fifth, where the other excito-motor nerve of sneezing is paralysed (the trnml branch of the fifth), irritation of the nose does not produce sneezing, yet exposure to a bright light will. The optic nerves are very constantly aff'ected both in cerebral and cerebellar tumours, the condition produced being double optic Surgical, Medical, and Operative. 541 neuritis ("choked disc'' ), and finally atrophy of the ojjtic nerve and gradual loss of sight, more or less complete; they may also be pressed on directly by tumours, either at the tract, chiasma, or optic nerve proper. They are also affected in injuries and diseases involving the optic foramina : in fractures through the anterior fossa of the skull, either from a fissure involving the optic foramen of that side, or from hsemorrhage into the sheath of the nerve; from tumours beginning in the orbital cavity, as sarcoma and exostoses; or from tumours invading the orbit from other parts, as sarcoma of the antrum or of the ethmoid cells, and large enostoses of the frontal sinus. 2. The Third Nerve (Motor Oculi). — The deep origin of this nerve is from a grey nucleus in the floor of the aquseductus Sylvii, and vphich is the continuation of the grey matter of the anterior horn of the spinal cord. It is also connected with the locus niger and the corpora quadrigemina. At its superficial origin, on the inner side of the eras, close to the pons, it lies between the superior cerebellar and the posterior cerebral arteries. It then lies in the outer wall of the cavernous sinus, where it receives communications from the fifth and sympathetic, after which it enters the orbit, through the sphenoidal fissure. The extrinsic muscles supplied by this nerve have been already named. It also supplies two muscles within the eye — the sphincter pupillm, and the ciliary muscle, by which the eye is accommodated for near objects. In looking at a near object three distinct events take place — (1) Contraction of the ciliary muscle; (2) contraction of the pupil; and (3) convergence of the eyeballs (by the internal recti) — all accomplished by the third nerve. In health a definite relationship exists between these three movements, which, if disturbed, will lead to defective sight. The centre for the reflex contraction of the pupil is in the corpora quadrigemina or medulla oblongata. The third nerve may be paralysed by cold, rheumatic inflammation or periostitis, syphilitic periostitis, gummata about the inter-peduncular space and pons, disease of the posterior cerebral artery or of the internal carotid in the cavernous sinus, and abscesses or new growths in the tip of the temporo-sphenoidal lobe, pressing on the outer wall of the cavernous sinus. It is very frequently, also, a result of central nervous disease. 542 Applied Anatomy: Results of Paralysis. — (1) Ptosis, drooping of the upper eyelid, because the levator is paralysed; (2) external squint, as there is nothing to oppose the external rectus, which is supplied by the sixth nerve, and which is, therefore, not affected ; (3) double vision, as the images are not thrown on corresponding parts of the two retinae; (4) dilatation of the pupil, as the sphincter is paralysed, and, further, it is insensible to light; (5) loss of accommodative power for near objects, as the sphincter pupilte, ciliary muscle, and internal recti are paralysed; (6) immobility of the eye in all direc- tions; (7) giddiness will probably also be present, as the patient has a false idea of the relations of external objects to himself; (8) the globe is slightly more prominent, due to the action of the superior oblique (fourth nerve), which is not paralysed. Paralysis of the third often only affects a part of the nerve — e.g., ptosis, and a fixed dilated pupil are frequently met with, without other signs. The squint in this case is paralytic, and the movements of the squinting eye are extremely limited (in contra -distinction to con- comitant squint, where the squinting eye retains its full range of motion). It is also divergent, and the double images are therefore crossed — i.e., the image belonging to the right eye appears to be to the left of the other (Heteronymous squint); in other words, the right hand image belongs to the left eye, and vice versa. This is ascertained, in a darkened room, by means of a candle held about eight or ten feet from the patient, and a strongly-coloured red glass placed in front of each eye successively, by means of which one can tell which of the two images belongs to each eye. As the paralysed eye cannot move upwards or downwards, as the candle is moved the height of the images will vary according as the candle is above or below the horizontal plane, and the position of the images will be understood by remembering that the lower part of the visual field corresponds to the upper part of the retina, and vice versa. The image formed by the squinting e3'e is fainter than that formed by the "working" eye, and is called the /aZse image; patients by-and-by learn to disregard this image, and thus get rid of the inconvenience arising from the double vision. To find out the working eye, let the patient look steadily at the tip of one index finger placed about a foot in front of the eyes, and then screen each eye successively and watch the unscreened eye. When the Surgical, Medical, and Operative. 543 working eye is covered the squinting eye makes an effort to fix the tip of the finger and moves towards the visual line; hut the working eye remains quite stationary when the squinting eye is screened. If the working eye he watched hehind the screen it will he seen to squint as soon as the affected eye "fixes" the object; this is known as secondary squint, and its direction and extent (unless the primari/ squint be due to paralysis) are the same as those of the original, ov primary squint The Fourth Nerve. — The deep origin of this nerve is partly from the nucleus of the third in the aqueduct of Sylvids, and another nucleus below this point. It also communicates with the motor nucleus of the fifth. It passes through the outer wall of the cavernous sinus, and enters the orbit through the sphenoidal fissure, and then enters the orbital surface of the superior oblique. The function of this muscle is to turn the eye downwards and out- wards. It may be paralysed by central disease, conditions causing pressure on the cavernous sinus, periostitis — simple, rheumatic, or syphilitic — of the sphenoidal fissure. Paralysis of the nerve gives rise to little sign, unless the patient looks below the horizontal level, when the paralysed eye lags behind the other, and is also twisted inwards by the inferior rectus, producing diplopia. The squint is paralytic and convergent, and, therefore, the images are not crossed (Homonymous squint) — i.e., the right hand image belongs to the right eye, and vice versa. As the eye is turned downwards, the false image is always below the true and leans towards it, and also seems nearer to the eye than the true one. The Fifth Nerve. — The fifth nerve arises by two roots : the small, aganglionic motor root, arises from a nucleus just below the lateral angle of the fourth ventricle and from the grey matter at the sides of the aqueduct of Sylvius : the large, ganglionic sensory root arises from the nerve cells of the formatio reticularis of the pons and medulla. Only the first or ophthalmic division concerns the eye. It is the sensory nerve of the eyeball, and probably trophic in function as well; it also supplies the lachrymal gland, eyebrow, forehead, and nose. This explains why in deep-seated affections of the globe, such as iritis, there is pain over the eyebrow and down the side of the nose, and also the increased lachrymation. It also supplies the mucous membrane of the nose, and hence 544 Applied Anatomy : irritation of this surface, as by snuff or the volatile oil of mustard, is often accompanied by increased lachrymation. The terminal branches of this division — the supra-orbital, supra-trochlear, and nasal — are frequently implicated in the disease known as Herpes Zoster, probably a form of neuritis. The nasal branch of this nerve takes a very remarkable course ; it enters the orbit between the two heads of the external rectus, and between the two divisions of the third nerve, passes obliquely across the optic nerve to the inner wall of the orbit, and enters the anterior ethmoidal foramen. It then enters the cranial cavity, lies on the anterior part of the cribriform plate of the ethmoid, passes down through a slit by the side of the crista galli into the nose, where it divides into branches to supply the septum and the outer wall of the nose with common sensation. It gives brandies to the ciliary ganglion, gives off the two long ciliary nerves to the eye, and an infra-trochlear twig to the lower part of the inner angle of the orbit; this latter branch supplies the skin, the conjunctiva, the lachrymal sac, and the caruncula lachrymalis. The ophthalmic division of the fifth appears on the face five times — (1) As the supra-orbital (2) the supra- trochlear, (3) the nasal, (4) infra-trochlear, and (5) the lachrymal. When this division of the fifth is paralysed there is loss of sensa- tion in the various parts supplied, dryness of the eye from paralysis of the secretory fibres of the lachrymal gland, and also destructive inflammation of the cornea, partly from the loss of trophic influence, but also because foreign bodies do not f)roduce sensible irritation or winking, and are, therefore, not expelled as foreign bodies, because they are not felt. The conjunctiva covering the lower eyelid is not affected, as this is supplied by a twig from the infra-orbital of the second division of the fifth. The Sixth Nerve.— This nerve arises from a nucleus in the upper part of the floor of the fourth ventricle, beneath the fasciculus teres, continuous with the grey matter of the anterior horn of the cord, common to it and the portio dura of the seventh. It passes along the inner wall of the cavernous sinus close to the internal carotid artery, and enters the orbit through the sphenoidal fissure and supplies the external rectus. The result of paralysis of this nerve is internal squint (convergent). Being convergent it is therefore homonymous, i.e., just as in the paralysis of the Surgical, Medical, and Operative. 545 fourth, the right hand image belongs to the right eye and viae versa. There may also be contraction of the pupil in paralysis of this nerve, because some of the sympathetic fibres pass along with it to reach the radiating fibres of the iris. The patient ■wiU also feel giddy when the healthy eye is closed, as he has then false ideas of the position of external objects, because one judges of their position, to a great extent, by the degree of effort required to bring the eye to look at any given object. Also, if the patient close the good eye and strike at an object, he misses it by going too far to the outer side; and in like manner he cannot walk in a straight line, but takes a curve outwards as he attempts to reach any given point. The causes of paralysis of the ocular nerves are very various. We have such causes as rheumatism, syphilis, and locomotor ataxy ; pressure on the cavernous sinus, due to cerebral abscess, carotid aneurism or dilatation of the internal carotid. The third nerve passes between the posterior cerebral and the superior cerebellar arteries, and is, therefore, very apt to be compressed in old people where the arteries are diseased. Malignant tumours, aneurisms, and gummata at the base of the skull, also cause paralysis; very often one or more nerves being simultaneously affected. The common causes of ophthalmoplegia externa are locomotor ataxia, syphilis, diphtheria, and exposure to cold; if from syphilis, it is seldom Tery regular, one or more muscles usually escaping. Paralysis of accommodation is sometimes noticed after " slight sore throat," so slight as to be overlooked at the time. The Sympathetic Nerve in relation to the eye. — In addition to its ordinary vaso-motor action, the sympathetic is the motor nerve to the dilator pupillse, and also to Muller's muscle — a layer of non-striped muscular tissue bridging across the sphenoidal fissure. The centre is probably situated in the medulla, but the fibres pass down the cord some little distance {cilio-spinal region), leaving it through the last cervical or the first two dorsal nerves, and entering the corresponding ganglia of the sympathetic trunk, up which they pass to the base of the skull, then along the plexus around the internal carotid artery {carotid and cavernous plexuses), pass along the sixth nerve, and then join the ophthalmic division of the fifth, forming part of its nasal branch, and thence through 2m ^*^ Applied Anatmny: the long ciliary twigs of the nasal nerve to the radiating fibres of the iris. The stimulus for these fibres is the absence of light; they are also stimulated by the stimulation of other sensory nerves, e.g., severe pain dilates the pupil, and also by the venous condition of the blood, as seen in the dilatation of the pupil in dyspnoea. Mr Hutchinson, in his "Illustrations of Clinical Surgery," shows very beautifully the efi'ect on the eye, produced by paralysis of the cervical sympathetic— (1) The eyeball is retracted within the orbit, probably from paralysis of the muscle of MtJLLER. (2) The pupil is contracted in the shade, although it responds to atropine; the paralysis simply prevents dilatation, but does not cause contraction. (3) The palpebral aperture is apparently narrowed from the slight drooping of -the upper eyelid, probably from the paralysis of some smooth muscular fibres situated there, and also from the recession of the globe. The Argyll Robertson Symptom. — By this is meant the failure of the pupil to react to light, while it still alters with accommodation. It is found in disease of the dlio-spinal region of the cord (a region extending from the third cervical to the second dorsal vertebra) and is often a very early sign of locomotor ataxia. Disease in this region involves the sympathetic fibres on their way from the medulla down the cord to make their exit at the last cervical and first dorsal nerves, and thence up to the pupil. These fibres being involved, the pupil is somewhat contracted and insensible to light, but stiUr further contracts when a near object is looked at, though the strongest mydriatic wiU only produce a medium dilatation. GLAUCOMA. This disease is so named because of the greenish reflection observed in the interior of the eye. It is characterised, in the later stages, by great increase of the intra-ocular tension, so that the globe feels like a marble in hardness, with blindness or great limitation of the visual field. The premonitory symptoms are — (a) Greatly increased presbyopia, so that the spectacles must be changed often; (6) intermittent attacks of dimness of sight, like a fog in front of the eye — the patient seeing well enough in the morn- ing, but from midday onwards the vision is occasionally obscured ; Surgical, Medical, and Operative. 547 (c) dull aching in tlie eye, forehead, and temple ; (d ) the pupil is dilated, sluggish, or fixed; (e) prismatic hales are seen surround- ing bright objects, such as a gas flame, the moon, etc. These symptoms may last for a variable time, and then an attack occurs, usually at night. There is intense sickness, vomiting, and severe neuralgic pain in the eye, forehead, side of nose, and temple ; great lachrymation, almost complete blindness, injection of the conjunctival and sub-conjunetival vessels, and large tortuous veins are seen over the sclerotic, the corneal epithelium is uneven and dull in appearance, and there is a great increase of the tension; a shallow anterior chamber, concentric limitation of the field of vision, and cupping of the optic disc. The attack nearly always occurs in patients beyond middle life, who seem pale and un- healthy, and look as if they had suifered much; and it must be distinguished, in the first instance, from a " bilious attack." It is usually in hypermetropes, rarely in myopes ; in persons pre- disposed to this condition, one must not use atropia, as it is very apt to bring on an acute attack, and will certainly aggravate an existing attack. In chronic cases, the premonitory symptoms gradually pass into glaucoma without the onset of any acute attack. The fogs in front of the eyes may clear off for days or weeks, but by-and-by there are only remissions, and at length it passes into a well- marked state of glaucoma. There is a very acute form of glaucoma (Glaucoma fidminansj which may produce blindness in a few hours ; but in ordinary acute cases blindness is not usually caused before eight or ten days. All the above symptoms are to be explained by the increased intra-ocular tension. This causes the hardness of the globe; the dilated and sluggish pupil is due to the paralysis of the nerves of the iris by the increased pressure, and also because the lens is forced through the pupil ; the shallow anterior chamber, because the parts behind are pushed forwards ; ansesthesia of the cornea, due to paralysis of the first division of the fifth, from the great pressure; the distension of the subconjunctival and the sclerotic veins, because the pressure obstructs the flow through the vorticose veins; the intense pain is due to pressure on, and irritation of, the sensory nerves; the coloured spectra, from the pressure of 548 Applied Anatomy : tlie vitreous humour on the retina irritating it ; contraction of the field of vision, from the paralysing effects of pressure on the retina, -which is thinnest at the periphery, and also because the vascular supply is obstructed ; the cupped disc, because it is the point of least resistance, and it therefore yields to the increased pressure. By the ophthalmoscope one may see — (a) Cupping of the optic disc, the cup is very deep, and extends right up to the edge of the disc ; and over the edge, the vessels seem to dip with an abrupt curve, like a shepherd's crook, as the pressure has pushed them from the centre towards the periphery; (J) pulsation of the retinal arteries, especially if the globe be pressed upon; (c) the full and tortuous veins, and (d) there may also be small hsemorrhages. The cause of the increased tension is doubtful. It has been supposed to be due to increased secretion of fluid from irritation of the fifth and inhibition of the vaso-motor branches of the sympa- thetic ; or else due to the damming back of the fluid ordinarily secreted, by the closure of the spaces of Eontana, from adhesion between the iris and the cornea at that angle, thus preventing permeation of fluid from the aqueous chamber through the canal of ScHLEMM, and thence into the veins. Treatment. — ^The sulphate of eserine, or nitrate of pilocarpine, as palUative measures. Radical— (1) Iridectomy (see page 550), the best radical cure. (2) Myotomy, or the division of the ciliary muscle, as it has been supposed to be due to spasm of this muscle. ,, (.3) Sclerotomy, or division of the sclerotic at its junction with the cornea, to open up the spaces of Fontana ; prolapse of the iris is the usual result of this operation, but it may be tried after the failure of iridectomy. Before dividing the sclerotic, introduce eserine, to contract the pupil and so lessen the risk of prolapse ; if done after iridectomy, of course this risk is removed. CATARACT EXTRACTION. The method usually adopted at the present day is Graefe's modified linear, or something closely resembling it. Instruments required — (1) Gbahpb's spring speculum; (2) a toothed fixing forceps; (3) Graefe's narrow-bladed cataract knife; (4) a curved and finely-toothed iris forceps; (5) scissors, to snip off a portion Surgical, Medical, and Operative. 549 of the iris ; (6) a curette or scoop ; (7) a cystotome or pricker, to lacerate the capsule of the lensj and (8) a special scoop, to lift out the lens if necessary, as in a diseased eye, where pressure might be dangerous, or where the vitreous humour is very fluid or is beginning to escape at the corneal wound. The patient reclines on a table or couch with a support behind his head; the Surgeon stands most conveniently behind the patient's head, and should be ambidextrous, as it is more convenient to use the right hand for the right eye in making incisions, etc., and the left for the left eye. An assistant takes his stand on the patient's left side, opposite the Surgeon. The steps of the operation are four — (1) The incision, (2) the removal of a part of the iris, (3) the laceration of the lens capsule, and (4) the expulsion of the lens. The eye is rendered insensible to pain by means of a solution of cocaine, dropped in occasionally for ten minutes before the opera- tion; it is then washed with a weak solution of corrosive sublimate (1 in 5000), and the spring speculum introduced and set. The Surgeon then fixes the eye by pinching up the conjunctiva close to the lower edge of the cornea. The knife is then introduced through the cornea and sclerotic junction, about half a line beyond the apparent edge of the cornea, and about a line and a half above its middle; the knife must be introduced perpendicularly till it has gone through into the anterior chamber, and then the plane of the knife must be made to correspond to the surface of the iris. It is then passed through a counter puncture, the edge turned upwards and forwards, and the knife made to cut its way out by slight sawing movements; the point of exit is just beyond the apparent edge of the cornea. The iris forceps is then introduced, the iris drawn out, and a little bit snipped off with the scissors. The pricker is next introduced, and the capsule lacerated in a crucial manner, beginning at the lower part. The scoop is now to be pressed against the lower edge of the cornea, when the lens wiU usually be extruded. The anterior chamber is then to be emptied of blood and lens matter, and the edges of the wound placed closely in apposition, taking care that neither lens matter nor any part of the iris is between its lips. A solution of eserine is then introduced to draw the iris away from the wounded region, the eye douched with 550 Applied Anatomy : corrosive sublimate and then put up. The risks of iritis and prolapse of the iris are not so great as in the old flap, and by means of strict antiseptic precautions suppurative inflammation can usually be avoided. IRIDECTOMY, This operation consists in the removal of a portion of the iris. This may be required — 1. To form an aHificial pupil, in cases where we wish — (a) to get a new opening after prolapse of the iris where the natural one is displaced; (6) to reopen or enlarge a pupil obstructed by previous inflammation; and (c) to displace the pupil towards a transparent part of the cornea, or opposite a clear part of the lens, in cases where the cataract is stationary and central. 2. To influence the course of some diseases as — (a) Glaucoma, {h) recurrent gouty iritis, (c) irido-choroiditis, {d) purulent iritis, (e) advancing staphyloma of cornea, and (/) ulcer of the cornea with pus in the anterior chamber (hypopyon keratitis). 3. For occlusion or exclusion of the pupil after iritis. 4. Sometimes preliminary to cataract extraction, in order to ripen the cataract. The position and preparation of the patient, and the position of the Surgeon and his assistant are the same as in cataract extraction. Instruments required — (1) A spring speculum, (2) fixing forceps, (3) curved scissors with elbow bend, (4) fine-toothed iris forceps, and (5) a bent triangular keratome — ^like a br<5ad needle. The opening for artificial pupil must be made where the media are clearest; if a choice be allowed, then the lower and inner part should be chosen, as this will cause least deformity and also be in the most usefuL position. The globe being fixed, an incision is made through the cornea and sclerotic junction at the part where the artificial pupil is to be; it should not be all in the cornea, lest the cicatrix con- tract and alter its curvature. The iris forceps is then introduced closed, the iris seized and drawn out, and a little bit snipped off with the scissors, forming a pupil somethiag between square and round in shape. The iris should be grasped at the pupillary border, lest a button-hole be made in it, and then cut off with a single snip. In Glaucoma a Geabpe's cataract knife is used and a good large incision made (resembling that for cataract, but not quite so large,) Surgical, Medical, and Operative. 551 at the cornea and sclerotic junction, so as to open np, if possible, the angle hetween the iris and the cornea, where the spaces of FoNTANA lie. The portion of the iris removed in this case is always at the wpiper part, because the disfigurement is less and the optical defect also less, as it is covered by the upper lid, since the operation in this case is not performed for the purpose of securing an artificial pupil, but for curing the disease. A large bit of iris is removed; it must be pulled well out and cut away from the very ciliary edge. It is done during the acute stage of the disease. When for artificial pupil, only after the condition has become chronicor subsided altogether. OPERATION FOB STRABISMUS. The patient is prepared as before, but probably had better bo under the influence of chloroform, or cocaine may be injected deeply. The Surgeon and assistant stand as before. Instruments required are — (1) A spring speculum, (2) straight, blunt-pointed scissors; (3) a toothed fixation forceps, and (4) a strabismus hook. The operation is performed very often more for appearance than to improve vision, as the patient has probably become accustomed to suppress the image of the squinting eye. 1. The Subconjunctival, or English Method. — A fold of the conjunctiva is pinched up lelow the level of the insertion of the tendon to be divided, and then- incised with the straight blunt- pointed scissors. The capsule of Tenon is now exposed, and must be divided by thrusting in the point of the scissors below the conjunctiva. The probe -pointed strabismus hook is then passed into the wound, with the concavity downwards and the point backwards, through the opening in the conjunctiva and capsule, and carried along the surface of the sclerotic ; the concavity of the hook is then turned upwards, its point being kept close to" the sclerotic, and slipped between the tendon and the globe. The hook is then pulled forwards, the tendon raised off the surface of the globe and divided by the scissors, between the hook and the globe; make sure that all the fibres are divided by passing the hook back and then drawing it forwards again, when it will slip forwards beneath the conjunctiva as far as the edge of the cornea if the tendon is completely divided. 552 Applied Anatomy: 2. The Direct, or Continental Method. — A vertical incision is made right over the tendon close to the cornea. By this method the tendon can he seen, so that the Surgeon can see what he is doing, and can make certain of dividing all the fihres. In dividing the capsule of Tenon, pass the scissors towards the inner canthus and free it well there, so as to lessen the risk of unsightly retrac- tion at that part. A horse-hair suture requires to he introduced into the conjunctiva to hring its edges together, and the wound prohably does not heal so readily as in the other method. Little after treatment is required. The eye is tied up for a few hours, say, till hedtime, when everything is removed; for a day or so longer the patient may wear a shade and remain in a darkened room, but the sooner the eye is brought into use the better, so that the tendon may be moulded while it is yet plastic. READJUSTMENT OR ADVANCEMENT. This operation consists in bringing forwards to a new attach- ment the tendon of a rectus — usually the internal, sometimes the external — which has become attached too far back after a previous tenotomy, or has become weakened, as in myopia. The instruments required are — a stop speculum, straight scissors with blunted points, a toothed fixation forceps, a strabismus hook, and two or three double-needled sutures. Critchett's Operation— 1. Make a vertical incision, exposing the internal rectus, about one-sixth of an inch from the edge of the cornea. 2. Divide the tendon in the usual way. 3. Pass the two or three needles, from within outwards, through the flap formed by the tendon, fascia, and conjunctiva, at some distance from its free edge. 4. Shorten this flap by cutting off its free edge. 5. Pass the other ends of the sutures, from within outwards, through the fascia and conjunctiva, close to the edge of the cornea, taking as broad a hold as possible. 6. Divide the external rectus in the usual way, and intro- duce a stout traction suture at the outer side of the eye, by which it can be drawn inwards. Surgical, Medical, and Operative, 553 7. Tighten the tendon sutures first introduced. 8. Fasten the traction suture to the nose hy plaster, pulling the eye inwards as far as possible. This suture soon cuts its way out : the tendon sutures are left in for a week or so. Prince's Operation. — For this operation it is better to have Prince's special advancement forceps, and a special curved and handled needle with the eye in point is sometimes necessary, though, as a rule, the usual curved needles are quite sufficient. We also require one double -needled suture, one single -needled suture, as well as the ordinary strabismus instruments. 1. Expose the internal rectus as in last operation. 2. Hook it up on strabismus hook, or grasp it with special forceps. 3. Pass sutures through the tendon, using the double- needled suture — passing both needles from behind forwards, through the rectus, its sheath, and the conjunctiva. This is the " loop suture." 4. Divide and remove part of the tendon. 5. Divide the external rectus in the usual way. 6. Pass a suture through the conjunctival and subconjunc- tival tissue near the edge of the cornea, opposite the tendon to be advanced. This suture should be passed in the vertical direction, and is the "pulley suture." 7. Tie this suture tightly, making it include one of the ends of the suture through the tendon. This suture is to act as a puUey, or point d'apjpui, by means of which the tendon is pulled forwards by the other suture. 8. Tie the two ends of the suture through the tendon, pull- ing the tendon tightly up against the former suture. 9. Bring the edges of the divided conjunctiva together by means of a suture. Brudenell Carter's Operation. — By this operation the sheath of the optic nerve is opened for the relief of pressure. It is said that fluid in the arachnoid space is forced through the optic foramen, between the two coats of the optic nerve, in certain cases where the intra-cranial pressure is increased. The fluid passes along the nerve up to its insertion into the eyeball, but there it 554 Applied Anatomy: is stopped because of the sclerotic ring ; the pressure thus caused produces strangulation of the contents of the optic sheath — nerve fibres and vessels — causing disturbance of vision and secondary atrophy of the optic nerve. The nerve is exposed and reached from the outer side. The conjunctiva and subconjunctival tissues are divided, the external rectus hooked up, and sutures inserted at two points, and the muscle divided between them. Texgn's capsule is next divided, the intervening tissue scratched through, and the optic nerve exposed ; after which the sheath is pinched up and incised, when some fluid will escape. The two ends of the divided rectus are then tied together by the sutures previously introduced, and the conjunctival wound closed. EXCISION OF THE EYE. This may be rendered necessary for — 1. "Sympathetic" oph- tlmlmia (ophthalmitis), usually due to some wound, accidental or operative, in the cUiary region of the eye — a zone about a quarter of an inch wide surrounding the cornea, often spoken of as the " dangerous zone " of the eye. 2. In cases of wounds, where the vision is destroyed and the foreign body cannot be found. 3. In pan-ophthalmitis. 4. In general staphyloma of the globe, or large staphyloma of the cornea. 5. For the removal of tender irritable stumps. 6. Tumours of the interior, e.g., glioma of the retina, or melanotic sarcoma of the choroid. Instruments required— (1) Spring speculum; (2) blunt-pointed scissors curved on the flat ; (3) fixation forceps ; (4) strabismus hook ; (5) sponges, lint, and wool ; (6) ice-cold water ; (7) styptic, such as perchloride of iron ; (8) fine needle and silk sutures ; and (9) chloroform, etc. The operator may most conveniently stand behind the patient. Introduce the speculum and divide the ocular conjunctiva all round close to the edge of the cornea, beginning at the upper part, with the scissors. Then raise up the conjunctiva and divide Tenon's capsule also with the scissors, and then with the strabismus hook, hook up and divide the recti one after the other, capsule and all ; the superior oblique may also be divided on the hook, but the inferior is left for the present. Now make the eye start forwards by pressing the spring speculum behind the Surgical, Medical, and Operative. 555 globe, and then pass the curved scissors from the outer side, round the sclerotic, and divide the optic nerve and remove the globe hy dividing the inferior oblique, and any remaining soft tissues. Then at once plug up the opening by compresses of cotton wool wrung out of some cold antiseptic ; this is for the purpose of controlling hajniorrhage by pressure. The cut edges of the conjunctiva may or may not be brought together by sutures, according to the inclination of the operator. Pressure must be kept up for six or eight hours by means of sponges or cotton wool. If this operation be performed for malignant tumours of the orbit (sarcomata) the whole contents must be cleared out ; for -simple conditions a less radical method will suffice,, the chief thing to be kept in mind being that whatever else is left, the corneal tissue must be all removed. Structures Divided. — The ocular conjunctiva; the capsule of Tenon ; the four recti ; the two obliques ; the ciliary arteries and nerves ; the optic nerve with the arteria centralis retinas ; branches of the third and fifth nerves ; and twigs of the ophthalmic artery and vein. INJURY TO EYE. The possible results of a blow on the eye are: — 1. Temporary paralysis of accommodation from concussion. 2. Commotio retinse, and possibly also detachment of the retina. 3. Effusion of blood into the anterior chamber, or into the vitreous. 4. Superficial septic ulcer of cornea, with pus in the anterior chamber. 5. Dislocation of lens. 6. Detachment of the iris from its ciliary connections (the zonule of Zinn). 7. Eupture of the lens capsule and traumatic cataract from the lens imbibing the aqueous. 8. Inflammation of the iris and ciliary processes. 9. Growth of a sarcoma. 10. Fissure through the optic foramen, causing blindness from injury to the optic nerve, which is followed at a later date by atrophy of that structure. 556 Applied Anatomy: 11. Cataract, from injury to the frontal or infra - orbital nerves, setting up a neuritis that spreads hagkwards and affects the nutrition of the globe. 12. Eupture of the sclerotic, usually about a quarter of an inch behind the cornea; the choroid may also be ruptured. 13. Haemorrhage into the space between the lamina supra- choroidea and the lamina fusca. A curious train of Eye Symptoms are often observed in the disease known as Locomotor Ataxia, a disease consisting in chronic inflammation, followed" by sclerosis of the postero-extemal tract of the cord (Buedach's), spreading to the postero-internal column and probably to the direct cerebellar tract as well. The symptoms observed are — (1) The Argyll Eobertson symptom (see page 546) ; (2) temporary paralysis of the various ocular nerves with accom- panying symptoms; (3) marked myosis, the pupil being often contracted to a pin point; (4) frequently unequal size of the pupils; (5) colour blindness; and, lastly, (6) atrophy of the optic nerve and gradual loss of sight. A remarkable train of symptoms is frequently observed to follow " Concussion of the Spine," e.g., in railway injuries; we may find any one of the following five :— (1) Asthenopia; (2) amblyopia; (3) loss, or failure, of the power of accommodation ; (4) irritability of the eye and photopsia, from neuro-retinitis; and, lastly, (5) atrophy of the optic nerve and gradual loss of sight. Surgical, Medical, and Operative. 557 CHAPTER XXVIII. THE EAR. EXTERNAL AUDITORY MEATUS. This canal is about an inch -and a quarter in length ; the lower wall is the longest on account of the oblique direction of the mem- brana tympani, which forms an angle of forty-five degrees with the horizon in the adult. In the child, however, the membrane is more nearly horizontal, forming only an angle of ten degrees with the horizon; but as age advances this gradually increases. The meatus passes obliquely forwards and inwards, and is curved upon itself, the concavity pointing downwards, so that its floor is convex ; it is also curved a little forwards. Its shape is oval, with the long axis vertical, and it is narrowest about the middle, and, therefore, the ear speculum should not be introduced beyond this point. Eather less than one-half its length is formed of cartilage, the rest of bone. In youiig children, however, there is practically no bony part, and in them, therefore, the meatus is very short. In examin- ing the membrana tympani, by means of the speculum and mirror, the pinna or auricle, should be pulled upwards and backwards in order to straighten the meatus as much as possible. In health, the membrana tympani is transparent, smooth and shining, and has a slate-blue colour, or delicate bluish grey, and it is concave from the outside; from its transparency it is possible to see serous collections in the middle ear through it. Besides seeing the membrane we also see the handle and short process of the malleus (which are situated between the outer and middle layers of the membrane) and that appearance known to aural surgeons as the "triangle of light," with its apex at the end of the handle of the malleus, an appearance due to the peculiar curvature of the membrane, the rays from the two sides crossing each other at the anterior and lower 558 Applied Anatomy: part. The handle of the malleus runs from, above downwards and backwards to a little below the centre of the membrane. From the short process there are two folds, one passing forwards, and the other backwards, and the part of the. membrane above this is very thin, consisting only of cutaneous and mucous layers.; this part is called Sheapnell's membrane. Fig. 118. The Ear. 1. External Auditory Meatus. 2. Membrana Tympani. 3. Malleus. 4. Incus. 5. Stapes. 6. Membrane shutting off the Tym- panic Cavity from the Vestibule. 7. Membrane in the Foramen llo- tundum, shutting off the Tympanic Cavity from the Soala Tympani of ^ the Cochlea. 8. Tympanic Cavity. 9. Eustachian Tube. Surgical, Medical, and Operative. 559 Structure of the Membrane. — It consists of tliree layers — (1) The outer, or cutieular layer, a continuation of the skiu of the meatus. (2) The internal, or mucous layer, which is continuous with the mucous membrane of the tympanic cavity; in a fold of this layer the chorda tympani nerve lies concealed. (3) The middle, or fibrous layer, consisting of connective tissue fibres arranged both radially and circularly — the radial are the more numerous, and radiate from the point of attachment of the handle of the maUeus; the circular form a dense ring near the circum- ference, and are lodged in a bony groove which is deficient at the upper anterior part {notch of Rmmis). The layer itself is also defective above, and here, therefore, the membrane is only composed by the cutieular and mucous layers ; this part is known as the menibrana flaccida, or Shrapnbll's membrane. Nerves of the meatus. The principal nerves are derived from the auricula-temporal, which is a branch of the third division of the fifth nerve, and supplies the outer layer of the membrana tympani; the great auricular from the cervical plexus, and the auricular branch of the vagus (Aenold's nerve). These nerves and their communications explain the occasional peculiar results of irritation of the external auditory meatus — such as coughing and sneezing from irritation of Arnold's nerve, and the auriculo-temporal nerve respectively, and yawning from irritation of the auriculo-temporal nerve, the impulse passing to the muscles that open the jaws. The vessels of the meatus are derived from the posterior auricular, internal maxillary, and temporal arteries. Incisions through this membrane should be made at the lower and posterior part, as by so doing we escape the ossicles, the chorda tympani, and other important structures. Just as in other serous membranes, the early signs of inflammation are congestion and loss of polish, and it also becomes less concave from the accompanying Eustachian obstruction. The Cysts of the Auricle. — "We may find — (1) Simple serous cysts; (2) sebaceous cysts; (3) the traumatic hsematoma of foot- ball players; (4) the hsematoma of lunatics {Hcematoma auris, or Othaematoma) — the hsematoma consists of an effusion of blood between the cartilage and the perichondrium. From its frequent occurrence in lunatic asylums, it has been termed " insane ear.'' (5) We may also find abscesses; and, lastly, (6) dermoid cysts. 560 Applied Anatomy : Supernumerary Auricles are occasionally found. They are sometimes represented by small tags of skin near the pinna ; or again, they may be found in the neck, in association with branchial fistulae. The pinna is first indicated in the embryo by six small tubercles, which arise on each side of the hyo-mandibular cleft. When any of the tubercles fail to coalesce the result may be congenital fistulse, or supernumerary auricles. Sometimes also bits of epithelium become buried during their coalescence and form the germs of dermoid cysts. THE MIDDLE EAR OK TYMPANUM. This is a small six-sided cavity, somewhat compressed from side to side, situated in the substance of the temporal bone, and containing air. It communicates with the pharynx, by means of the Eustachian tube. It is placed immediately above the jugular fossa; in front is the carotid canal, with the internal carotid artery j behind are the mastoid cells and the internal jugular vein; externally the membrana tympani and external auditory meatus, and internally the labyrinth. Boundaries.—!. The roof is a thin plate of bone separating the cranial from the tympanic cavity; the bone is only separated from the temporo-sphenoidal lobe by the dura mater. 2. The floor is formed by the meeting of. the outer and inner walls, and is immediately above the jugular fossa ; in the floor is a small aperture for the entrance of Jacobson's nerve (from the glosso-pharyngeal). 3. The outer wall is the membrana tympani. At the lower part of this wall there are three openings— the Glaserian fissure, which gives passage to the laxator tympani muscle, the tympanic vessels, and lodges the processus gracUis of the malleus ; and the iter chordae posterius et anterius, being the apertures of entrance and exit of the chorda tympani nerve. The iter chordm anterms is the beginning of the canal of Huguier. The chorda tympam is the nerve of taste to the anterior two-thirds of the tongue, and passes across the cavity from back to front, close to the outer wall,,; between the handle of the malleus and the long process of the' incus, being invested by a fold of the mucous membrane formmg Surgical, Medical, and Operative. 661 the most internal layer of the membrana tympani. It is easy to understand, therefore, how this nerve may be implicated by disease of the middle ear, and its function consec[uently stimulated, causing an excessive flow of saliva, or altogether destroyed. . 4. The inner wall is vertical, and looks almost directly out- wards. On this wall, note — (a) The Fenestra ovalis, a depression wMch leads to the vestibule, but which is closed by a membrane similar in structure to the membrana tympani; the depression is occupied by the base of the stapes. (6) The Fenestra rotunda, a depression which leads to the scala tympani of the cochlea. It is also closed by a membrane resembling the tympanic membrane in structure, (c) The Promontory, a hollow prominence formed by the first turn of the cochlea ; it is placed anteriorly, and between the two fenestras, and is grooved by the nerves of the tympanic plexus, (d) The rounded eminence of the Aquceductus Fallopii, which lodges the facial nerve, -(e) The Pyramid; it contains the stapedius muscle, and has a small opening at its apex for the exit of the tendon of that muscle ; there is also a minute canal for the nerve to the stapedius, from the facial. 5. In the Posterior wall are the openings of the mastoid cells, one large (the mastoid antrum) and several smaller openings j the openings are near the roof of the cavity. 6. In the Anterior wall we find — (a) The canal for the tensor tympani ; (6) the processus cochleariformis, a process of bone which separates the above from (c) the Eustachian tube, which is the lower and larger of the two openings. By this tube the middle ear communicates with the nasal part of the pharynx. The external auditory meatus, the tympanic cavity, and the Eustachian tube, are aU developed from the upper part of the first branchial deft. The arteries of the tympanum are— (1) Tympanic branch of the internal maxUlary, which enters the tympanum through the Glaserian fissure; (2) the stylo-mastoid branch of posterior auricular, which enters at the stylo-mastoid foramen ; (3) petrosal branch of meningeal, entering through the hiatus FaUopii; (4) a branch from the ascending pharyngeal, passing up the Eustachian tube ; and (5) a small twig from the internal carotid artery, enter- ing through the anterior wall of the cavity. Its Nerves are — Is ^62 Applied Anatomy. (1) The tympanic branch of the glosso-pharyngeal (Jacobson's nerve), which enters through an aperture in the floor of the cavity, and is distributed to the Eustachian tube, foramen ovale, and foramen rotundum, and communicates -with (2) twig from the carotid plexus, (3) twig from the great superficial petrosal, and (4) sends a twig to join the lesser superficial petrosal. It is thus distributed to three parts, and has three communications. EUSTACHIAN TUBE. The Eustachian tube is a canal from one and a half to two inches in length, and its direction is downwards, forwards, and inwards. It consists of— (a) An osseous part about half-an-inch in length, situated in the temporal bone ; it begins in the anterior wall of the tympanic cavity, and is directed downwards and forwards; and (J) a cartilaginous part about an inch in length, of triangular shape, and composed of yeUow elastic fibro-cartilage. The open part is below, and it is completed by a fibrous membrane and a layer of voluntary muscle; it ends in a trumpet-shaped mouth nearly on a level with the inferior meatus of the nose. It is lined by ciliated epithelium, the cilia of which lash downwards ; it is usually closed, but is opened at the moment of swallowing by the dilator tubse, levator palati, and salpingo-pharyngeus muscles. The mucous membrane is supplied by the glosso-pharyngeal and the second division of the fifth; the muscles by the facial and the third division of the fifth. The blood-vessels are derived from the internal maxiUary, the ascending pharyngeal, and the internal carotid. Its use is to get rid of secretions from, and to ventilate the tympanic cavity. By its means the pressure of air in the cavity is kept the same as in the external auditory meatus, so that the pressure on each side of the membrane is the same, a condition necessary for the clear perception of sound waves. The open trumpet-shaped mouth of this tube is situated on a level with the posterior extremity of the inferior turbinated bone. According to Tillaux, the opening is about half-an-inch below the basilar process ; half-an-inch "in front of the posterior wall of the pharynx; half-an-inch behind the posterior extremity of the inferior turbinated bone; and half-an-inch above the soft palate. In this way the nasal part of the pharynx of one side may be Surgical, Medical, and Operative. 563 regarded as a little box one inch square, and in the centre of its outer side is placed the opening of the tube. Immediately behind the orifice of the Eustachian tube is a depression known as the fossa of EosENMULLBE, into which the point of the catheter may- be inadvertently slipped. Obstruction of the tube gives rise, if not to deafness, at least to considerable impairment of hearing, from indrawing and rigidity of the membrana tympani, and it will be necessary to adopt some means to get rid of the obstruction. 1. This may be attempted by Valsalva's Method, directing the patient to hold his nose between the finger and thumb of one hand, close the mouth, and expire forcibly. If at the same time the patient is directed to swallow, the effect will be aU the more evident. 2. Politzer's Method. — This method for forcing air up the Eustachian tube takes advantage of the physiological fact, that during deglutition the opening from the mouth into the upper part of the pharynx and posterior nares is closed, and also at the same time the Eustachian tube is opened by the dilator tubas or tensor palati, and by the Salpingo-pharyngeus. Every time one swallows it is possible to hear a "click" in the ear due to the air being forced up the Eustachian tube and impinging against the membrana tympani, and this is rendered much more evident if at the same time the nostrils are closed by grasping the nose between the finger and thumb. By these means we have really an air-tight chamber, and if any of its walls are squeezed or forced inwards, or if more air be driven in, the air being practically incompressible is driven in the direction of the least resistance, e.g., up the Eustachian tube. The patient is directed to take a mouthful of fluid, and at a given signal from the operator, to swallow it. The operator intro- duces the end of a tube (the other end of which is in communication with a small reservoir of air) into one nostril, and closes the nostrils with the finger and thumb of one hand, while with the other hand he grasps the air-bag. He then directs the patient to swallow, and as he does so, the operator projects into the nostril a quantity of air, which increases the pressure, and some of it passes up the Eustachian tube into the tympanum. It will be seen that this method resembles Valsalva's very closely, only by means of the air- bag greater pressure can be brought to bear upon any obstruction ^64 Applied Anatomy: that may be present in the tube. Instead of taking a mouthful of water other plans may be adopted, such, for example, as asking the patient to say " Huck " (Geubee), or a still more convenient plan of simply directing the patient to puff out the cheeks (Holt). In cases where the patient, or Surgeon, is doubtful whether the air has or has not entered the cavity, one of the patient's ears must be connected with that of the Surgeon by a flexible rubber tube. In this way the Surgeon will be able to tell whether the air enters the cavity in the usual amount and with the usual force, or feebly, or not at all, according to the presence or absence of stenosis of the Eustachian tube ; he will also hear in this way whether there are superadded sounds, such as bubbling or crackling from the presence of fluid in the cavity, or whether a whistling sound is heard, due to the air passing right through the membrane and tube into the Surgeon's ear, from the presence of a perforation in the membrana tympani. 3. If the above means faU, then recourse must be had to the Eustachian Catheter, The catheter may be made of various materials, hard rubber, vulcanite, silver, etc. It is curved at the end which is passed into the tube ; at the other end it is expanded so as to fi.t the nozzle of the air-bag, and also has a ring, which corresponds to the concave side of the curve at the point, so that it thus indicates the position of the point of the instrument when it is lost to sight. The Surgeon connects his ear with the diseased ear of the patient by means of the flexible tube. The patient sits facing the light, with his head leaning slightly backwards, the mouth open and breathing easily. The Surgeon stands in front of the patient, with the air-bag under his left arm, and with his left hand slightly raises the tip of the patient's nose, and with the right passes the catheter along the floor of the inferior meatus, with its point downwards, and pushes it gently onwards till the posterior wall of the pharynx is reached. After this, the method recommended by Dr MoBridb, is to turn the point of the instru- ment inwards, towards the median line, through a quarter of a circle, and then withdraw it till the cixrve at the point is caught by the nasal septum, when it is again rotated, through half a circle this time, so that its point is brought at right angles to the lateral wall of the pharynx, and then, if it is not in th.e tube, a little Surgical, Medical, and Operative. 565 pressure of the beak outwards, produced by moving the other end of the tube inwards, will cause it to enter the orifice. To place the point of the instrument into the exact axis of the tube, the ring at the outer end should point to the outer eanthus of the corresponding eye. It is necessary to pass the catheter along the floor of the nose, as otherwise it might very easily be passed into the middle meatus. THE INNER EAR OR LABYRINTH. The osseous part simply consists of certain cavities scooped out in the petrous portion of the temporal bone. The whole is lined by a thin periosteal membrane, and filled with peri-lymph (Liquor Gotunnii). The membranous parts are much smaller than the osseous, being contained in the osseous parts, and surrounded by the peri-lymph. The membranous labyrinth consists of a system of tubes and bags, which are all connected together, forming a completely closed system, the cavities of which have no direct communication with the osseous cavities ; anteriorly is the cochlea, posteriorly the semi-circular canals, and between the two is placed the vestibule, which consists of the utricle and saccule. The saccule is connected with the scala media of the cochlea by the canalis reuniens, and to the utricle by the ductus vestibuli; the three semi-circular canals are also connected with the utricle. The membranous labyrinth contains endo-lymph (Liquor Scarpoe). The Nerve of Hearing {auditory or portio mollis of seventh) is distributed to the different parts of the internal ear. The vesti- bular division is distributed to the utricle and saccule, and to the three ampuUaj of the semi-circular canals, where it can be traced to peculiar elevations known as the cristas accousticse. The portion supplying the utricle and saccule probably end in the hair cells of the cristas accousticse, with their otoliths and jelly, the whole being similar to the structures forming the entire hearing apparatus of the invertebrata J this part enables us to appreciate the sense of sound, whether low or loud — absolute silence or noise — but does not discriminate the quality. The part passing to the semi-circular canals ends in a similar manner, and seems to be concerned in the co-ordination of muscular movements, probably because the fibres convey to the brain impidses that, in some way, give us correct S'^G Applied Anatomy : notions of our equilibrium or relation to external objects. In all probability, therefore, it is this part of the nerve that is over- - whelmed, and unable to grasp the situation, for the time being, when an individual is sea-sick. If this be so, it wiU be at once evident how useless every drug must be, and how effective my drug may be, and this may explain the curious circumstance that every new drug in turn is discovered at last to be the remedy for sea-sickness, and hailed with gladness by a suffering humanity. The cochlear part is distributed to the scala media of the cochlea, being believed to end there in the " organ of Corti." This part of the nerve enables us to discriminate the quality of sounds, giving rise in the mind to a distinct musical impression ; and the curious part is that one can distinguish a great many musical sounds at the same time. Sound waves can reach the auditory nerve in two ways — (1) through the external auditory meatus, membrana tympani, and ossicles, to the peri-lymph, and thence to the endo- lymph ; or (2) through the bones of the head, and, possibly, also the bones of the trunk, and hence the origin and use of the Audiophone, whereby a deaf person (provided the nerve of hearing is not destroyed) is enabled to hear, to a certain extent, by placing it against the teeth. EXAMINATION OF THE EAR. The hearing power may be first tested by ordinary speech, whispering, or the ticking of a watch. Deafness may be due to faults in the sound-perceiving or the sound-conducting parts of the ear. The internal ear, where the sound-perceiving part is placed, is beyond our reach, but the condition of the nerve can be tested by applying the tuning-fork to the middle of the forehead or to the teeth. In health, the fork should be heard in both ears with equal intensity. If, then, it is heard well in both ears, the fault cannot lie with the auditory nerve, and the cause of the deafness must be sought for in the sound-conducting part (the external and middle ear). In cases where the fault lies in this part of the organ, then, curiously enough, the tuning-fork is heard best in the deafer ear. When the tiining-fork is applied to the forehead or teeth, the vibrations of the bones of the head conduct the sound waves to a healthy cochlea, even when the aerial vibrations are prevented Surgical, Medical, and Operative. 567 from passing ; but if no sound is perceived when thus applied, it shows that the nerve of hearing is destroyed, or at least functionally External Ear and Membrana Tympani. — This part may he viewed by the unaided eye, by the mirror alone, by the mirror and speculum, and tested by the tuning-fork. In examining the mem- brane, any change of colour can be noted, whether it is red, or has lost its glossy appearance; also whether it is concave and shows more clearly the various processes of bone in relation with it, from deficient internal pressure, or whether it bulges outwards from accumulation of fluids in the tympanic cavity, from obstruc- tion in the Eustachian tube, or the results of inflammation. Also whether it is movable, as by Valsalva's method, or by Siegle's Pneumatic Speculum, or whether it is perforated, or entirely or partially hidden by wax. The meatus is often attacked by small boUs, which are really circumscribed acute inflammations of the parts; they cause great pain and suffering, and form one variety of acute earache. Occasionally the inflammation is diffuse, and when it attacks the bony part it resembles an acute periostitis in its symptoms and course; this also would probably be called acute ear-ache. "Wax" impacted in the ear is often a cause of sudden deafness, either from the mass being displaced so as to block up the canal completely, or from the entrance of water making it swell up so as to cause a complete block. The presence of wax may also cause severe tinnitus, or sounds in the ear, fits of coughing from irritation of Arnold's nerve, or sneezing or persistent yawning from irritation of the auriculo-temporal nerve. The wax should be softened by putting in a few drops of a warm weak solution of bicarbonate of soda (five grains to the ounce) two or three times a day for a few days, and then syringe out the ear with warm water. The fluid is injected parallel with and along the upper wall; this is sometimes accompanied with vertigo and faintness from irritation of the membrana tympani. The ear must then be dried out with cotton wool, and a plug of dry wool worn for the rest of the day. Middle Ear and Eustachian Tube. — Much information can be gathered from the examination of the membrana tympani as to the condition of the middle ear. As it is transparent one may be able to see fluid in the middle ear through it. Also note whether it is 568 Applied Anatomy : thickened from fibrous changes in the middle ear, convex from accumulations in that cavity, or concave from an obstruction in the Eustachian tube, whereby the air has become rarefied, or absorbed. The other avenue of information as to its condition is to examine the throat, as disease of the middle ear often begins in the throat and passes upwards along the Eustachian tube to that cavity. Any condition therefore capable of setting up acute naso- pharyngeal catarrh may also produce acute inflammation of the middle ear; it is often secondary to a cold in the head, or sore throat, either simple, or after measles or scarlet fever. Further, obstruction of the tube is very often due to hypertrophy of the pharyngeal tonsils (adenoid vegetations of the naso -pharynx) blocking its orifice. Then, by some of the means already described, the Surgeon should examine whether the tube is patent or not. Adenoid Vegetations of the Naso- Pharynx are common in scrofulous children, and especially so in cold damp climates and dwellings. Besides being partially deaf the child usually keeps the mouth open to breath through, and has a very characteristic expression of face; he snores loudly during sleep, and in some cases there may be difficulty of breathing from the co-incident hypertrophy of the tonsils. The voice is peculiarly altered, the letters m and n being pronounced like b and d, no, no, sounding like dodo, and words beginning with com and con like cob and cod, as in common and conversation. There is also a characteristic flattening of the nostrils, as well as noises in the ears, and slight discharge of blood into the pharynx in the morning, with trouble- some morning cough and sanguineous expectoration, and sometimes also vomiting. It is very often accompanied by " chronic atrophic rhinitis." The pharyngeal tonsils stretch across the back of the pharyngeal cavity, between the orifices of the two Eustachian tubes (Kollikee). Chronic Suppuration of the IWiddle Ear is usually caused by inflammation spreading up from the throat (naso-jiharyngeal catarrh), and a large number of cases usually date their com- mencement from an attack of measles or scarlet fever — probably again from the inflammation spreading up from the throat. This is the origin of the " running ear," and when examined the mem- bfapa tympani is jisuaUy found to be perforated; the condition Sttrgical, Medical, and Operative. 569 is usually bi-lateral. The acute stage of this condition forms the acute earache of childhood in a large proportion of cases ; it should be watched for during the course of an attack of measles or scarlet fever as well as afterwards. Besides perforation, other and more serious complications are apt to follow suppuration of the middle ear — such, for example, as inflammation of the mastoid cells, caries of the bone, facial paralysis, inflammation of the membranes of the brain, local or difi'use, and simple or suppurative, especially diffuse purulent arachnitis, pysemia, granulations and polypi blocking up the meatus, inflammation of the brain, cerebral abscess, perforation of the internal carotid artery, thrombosis of the lateral sinus or internal jugular vein, and, lastly, destruction of the chorda tym- pani nerve. To explain these phenomena one has only to keep in mind the relations of the tym pan ic cavity. On the inner wall lies the facial nerve, covered only by a thin crust of bone; and immediately beyond this wall lies the internal ear, hence inflammation and suppuration may be readily set up in the labyruith, and may possibly reach the cerebellum, or medulla oblongata, through the internal auditory meatus. On the outer wall the chorda tympani nerve lies in a fold of mucous membrane. The roof is very thin, and inflammation can readily pass through the bone to the dura mater and then to the brain itself, especially in young persons where the petro-squamous suture has not as yet solidified. This fact has probably given rise to the impression that cerebral abscess is much more common in children than in adults, as compared with cerebellar. Only a thin layer of bone separates the floor from the internal jugular vein j the mastoid cells communicate with the cavity, and are also in close relation with the lateral sinus j and, lastly, the internal carotid artery is only separated from the anterior wall by a thin plate of bone. The orifice of the Eustachian tube and the lower edge of the tympanic membrane, it should be remembered, are not on a level with the floor of the tympanic cavity, but some little distance above it; a well is thus formed in which pus may collect and ferment, even though the membrane be perforated. Hence the importance of frequently washing out the cavity with a solution of warm boracic lotion, and the daily use of Poutzeb's bag for a week or ten days. •'570 Applied Anatomy: CHREBRAL ABSCESS. Cerebral Abscess following Ear Disease. — Cerebral abscess is one of the most serious complications of disease of the middle or internal ear. It may be situated either in the temporo-sphenojdal lobe of the cerebrum, which it reaches by passing in some way through the roof -of the tympanic cavity, or in the cerebellum, which it reaches either from the mastoid process, or by passing through the internal ear and internal auditory meatus; from the latter source it may occasionally attack the pons and medulla. Contrary to the usually received statement it appears that cerebral abscess is much more common than cerebellar at all ages; but, as a matter of fact, this is what might naturally be expected. As regards the exact nature of the abscess it is impossible to say with certainty; there can be no doubt, however, that the two conditions under which it is most likely to arise are — tendon and sqms. The abscess itself may be due— (1) To direct spread of the inflamma- tion from the ear; (2) it may be reflex, or "sympathetic," in nature; (3) it may be due to minute venous or lymphatic septic emboli ; or, lastly, (4) the septic inflammation beneath the brain substance has rendered that part of the brain a point of least resistance, and the septic organisms absorbed into the blood from the increased tension find it a suitable soil for their growth and development. In cases of middle ear suppuration, when the tympanic membrane gives way by a large opening, the tension is relieved, but the chances of the admission of septic organisms are very much in- creased; the pus tends to pass backwards and involve the mastoid cells, which form a specially favourable seat for the reception and lodgment of fermented and fermenting pus. It is also evident that tension will be increased when, as not unfrequently happens, granulations and polypi spring up from the carious cavity and block up the openings of the mastoid cells, or even the external auditory meatus itself. This is now, par excellence, the condition that is most likely to result in cerebral abscess. It has been observed that the temperature is often abnormally low in cerebral abscess, and the pulse unnaturally slow; the pupils are dilated, and there is much mental confusion and torpor, usually passing on, unless relieved, to coma and death. Surgical, Medical, and Operative. 571 Sometimes there is a spot tender to jsressure, or percussion over the temporo-sphenoidal lohe. Further, weakness of the muscles of the angle of the mouth, ataxic speech, word deafness, and optic neuritis have been observed. Hemiplegia coming on with signs of compression many weeks after a head injury, is said to point to cerebral abscess. Cerebral abscess may also arise from disease of the nasal cavities; it is often present in pyaemia, and not un- frequently follows injuries to the head. Diagnosis. — It is impossible to distinguish with certainty between this condition and diffuse suppurative meningitis, and thrombosis of one or other of the cerebral sinuses. In meningitis, however, there is, in the first instance at any rate, high tempera- ture and rapid pulse, intense headache, tenderness to pressure or tapping over the cerebrum, contracted pupils, and probably hemi- plegia or unilateral spasm; and in phlebitis and thrombosis of the sinuses these symptoms would be accompanied with signs of pysemia, such as repeated rigors, high temperature, profuse sour- smelling perspiration, peculiar waxy tint of the skin, peculiar odour of the breath and metastatic abscesses, as well as swelling in the course of the internal jugular vein and side of face. If the internal jugular vein be the seat of the thrombosis there will be signs of pressure on the glosso - pharyngeal, vagus, 9,nd spinal accessory causing spasm of the sterno- mastoid, and also on the hypo -glossal nerve, together with tenderness at the side of the neck ; should the thrombus be situated in the cavernous sinus there will be signs of pressure on the third, fourth, and sixth nerves, causing paralysis or spasm of the muscles supplied, and also on the ophthalmic vein, causing suffusion of the eyes and possibly unilateral optic neuritis. In a series of cases collected by Dr M'Bride, he found that when the abscess involved the tympanum and mastoid, cerebral abscess was much more common than cerebellar, but that when the tympanum and labyrinth were involved, then cerebellar abscess was the rule. Diffuse purulent meningitis is also common, " especially when the tympanum and labyrinth are the seat of suppuration. To distinguish between the cerebral and cerebellar forms is by no means easy. In the cerebellar form there will probably be severe occipital headache, vomiting and vertigo following long existent 572 Applied Anatomy: ear disease; there will also probably be double optic neuritis, with an absence of bone conduction as tested by the tuning fork applied to the forehead or teeth (M'Bridb). This last fact would seem to show that the nerve of hearing is destroyed by the suppurative process having spread to the labyrinth, and thence, through the internal auditory meatus, to the cerebellum; one would also expect some signs of irritation or paralysis of the facial nerve. Mastoid tenderness points rather to cerebellar abscess. In the cerebrum one must chiefly trust, for purposes of diagnosis, to the slow pulse and low temperature, history of previous ear disease, together with signs of pressure on the cavernous sinus and parts near it, especially on the third nerve and venous canal, as well as the probable existence of unilateral optic neuritis — or it may be bilateral ; also paralysis of the third nerve, oedema of the retina, cireumorbital congestion and exophthalmos. One would also expect some interfer- ence with hearing, smell, or taste, according as the first, second, or third temporo-sphenoidal convolution is the seat of the abscess. In abscess of the brain the prognosis is so grave, when left alone, that the general rule is — "When in doubt trephine." The only question is where. In a case of Professor Greenfield's, suc- cessfully operated upon by Dr Gated, Professor Chiene advised the opening to be made in the skull near the tip of the temporo- sphenoidal lobe, in the region of the pterion, from the belief that the pus would tend to gravitate downwards and forwards, and also from the fact that there were signs of pressure on the cavernous siuus; the result fully confirmed the correctness of his conclusions. In another. case of abscess of the temporo-sphenoidal lobe, success- fully operated upon by Mr Barker, the trephine was entered an inch and a quarter behind, and the same distance above, Kbid's "base line." Dr M'Bride thinks that the trephine should be entered so as just to expose the roof of the tympanum, and for this purpose proposes that a curved incision should be made over the ear, the auricle dissected downwards, and the trephine entered just above and in front of the external osseous meatus. This incision is advised, both for the purposes of drainage, and also to attack the abscess as near as possible to its source. In order to reach the cerebellum, Mr Hulkb perforated the occipital bone about three quarters of an inch behind and inwards Surgical, Medical, and Operative, 573 from the mastoid process, the crown of the trephine encroaching upon the inferior curved line; this point is sufficiently removed from either the horizontal or the descending portion of the lateral sinus, and also forms a dependent point for drainage. A horse- shoe incision is made through the tissue at this spot, the ends of the incision heing a little ahove the external occipital protuherance, and the hend slightly helow the level of a line joining the apices of the mastoid processes. The occipital artery is divided, and must he secured at once. Mr Bakkee advocates a point an inch and a half hehind the centre of the meatus, and an inch below Eeid's " base line." r r EESUME of the various possible sequelse of chronic middle- ear suppuration (otitis media) : — 1. Disease of the Mastoid Cells (see page 574). 2. Phlebitis and Thrombosis of lateral sinus. Signs — High temperature, rigors, swelling, and pain in the course of the internal jugular vein and side of face, from venous obstruction. 3. Subdural Abscess. — This is not common in the adult, and is accompanied by high temperature, probably caries, and Potts's puffy swelling. 4. Meningitis.— Sighs of imtation of the motor and sensory functions of the brain, as well as the special senses, ~ gradually passing into paralysis, coma, and death. Note especially the excited state, the high temperature, the intense' headache, and the tenderness to pressure, or tapping, over the cerebrum. •3. Pyaemia. — The usual signs of this disease, with secondary abscesses. G. Cerebral Abscess. — Slow pulse, low temperature, great mental torpor, but absence of marked headache or tenderness to pressure or tapping. 7. Cerebellar Abscess. — Symptoms supposed to point to this condition are — (1) Occipital headache, (2) cerebral vomiting, (3) retraction of the head, (4) loss or im- pairment of balancing power, (5) persistent dilatation . of the pupil (mydriasis), and (6) tonic muscular spasm, most marked on same side as the abscess. 574 Applied Anatomy : 8. Granulations and Polypi blocldrg up the external auditory meatus. 9. Caries and Necrosis of diiferent parts of the temporal hone, other than the mastoid process. 10. Erosion of large vessels, as the junction of the lateral sinus and internal jugular vein {sinus or gulf oi the internal jugular) or the internal carotid artery. 11. Spontaneous Perforation of the Mastoid Process under soft tissues, and the formation of a pneumatocele or tumour containing air, the air of course coming from the pharynx up the Eustachian tube to the middle ear, and then through the mastoid cells. It is known by its soft feel, is probably, reducible, can be increased ill size by forcing air up the Eustachian tube, and is resonant on percussion. 12. Disease of the Temporo-Maxillaxy Articulation, leading to ankylosis more or less complete, and consequent inability to open the mouth. This is more likely to happen in children on account of the presence of the suture between the auditory process and the squamosa- zygomatic portion of the temporal bone. 13. Suppuration of the Upper Cervical Glands. — When the deep glands are affected, and if at the same time there is a suspicion of mastoid disease, it may be a matter of considerable diiiiculty to make out the cause of the constitutional disturbance, for the symptoms may strongly suggest intra-cranial mischief. MASTOID DISEASE. Mastoid disease resembles other bone diseases, being either a periostitis and superficial ostitis, or else deep ostitis. In the first there will be great pain, tenderness to pressure, redness and swelling over the bone, as it is comparatively superficial — the swelling making the auricle stand out from the head; in the second form there will also be great pain, but no swelling nor red- ness, though there may be. tenderness on tapping or deep pressure. In both the great danger is pysemia, as in all bone disease where Surgical, Medical, and Operative. 575 there is putrid pus under high tension, osteophlebitis, and septic thrombosis, which thrombi break down and form minute septic emboli, with all their secondary results. The question is, when to interfere'! It is doubtful whether one ought to trephine without first having signs of tenderness to pressure, superficial or deep; and again, it will probably do little good if there are already signs of widespread septic infection, or diffuse suppurative meningitis. Still, even in such a condition, opening and washing out cannot place the patient in any worse a condition than before, and may do a great deal of good. In trephining the mastoid antrum, a small-headed trephine should be used, and it must be entered on a level with the upper wall of, and as near the meatus as possible, and it should be directed forwards, inwards, and slightly upwards. Probably a less complicated form of instrument, such as a gimlet or gouge, is all that is required, and will be equally efficient in cases demand- ing this operation. In either case, were the instrument directed at right angles to the mastoid process, there is great danger of going too deeply and opening the lateral sinus, and yet missing the object of the operation. An incision should be jnade from below upwards, parallel with the attachment of the auricle and half-an- inch behind it, so as to avoid the posterior auricular artery. After having made an opening it must be treated in the same way as any other suppurating cavity — viz., introduce a drainage tube through the mastoid cells, or antrum, into the tympanic cavity, and wash it out occasionally with some warm antiseptic fluid, such as boracie acid, in both directions, from the external audi- tory meatus, and also from the drainage tube. For the relief of superficial inflammation, or abscess of the mastoid process, a similar incision should be used. Fig. 119, from a specimen in the possession of Dr Symington, shows very well the relation of the mastoid antrum to the attic, or upper chamber, of the tympanic cavity, and to the external auditory meatus. In the specimen in question the squamosa- mastoid, or external petro-squamous suture, M'as persistent, so that the temporal bone consisted of two parts — one, formed by the united petro-mastoid, tympanic, and styloid elements; the other, by the squamosa. In the figure the squamosa has been disarticulated 576 Applied Anatomy. from the rest of the temporal bone; in this way the attic, or upper chamher, of the tympanic cavity and the mastoid antrum have been exposed, as the squamosa forms the outer wall of these spaces. Fig. 119. Position of the Mastoid Antrum. (Symington.) m. a. — Mastoid Antrum. It should be remembered, as Dr Symington has pointed out, that there are no mastoid cells, properly so called, in infants ; in them the mastoid simply contains a single air cell, which com- municates with the upper chamber or attic of the tympanum. It is known as the mastoid antrum. It has also been shown that up to puberty the mastoid ^ process is finely cancellous, but after this time air cells are developed ; in many adults, however, the development of air cells is imperfect^ and in some entirely absent. In all cases, however, both in children' and adults, the mastoid antrum is present, and, according to Mr Barker, is the point to be aimed at in suppuration of the mastoid process. END OF VOL. :. INDEX. Atscess, cerebral, 670 Diagnosis from aneurism, 6 In mastoid cells, 574 Orbital, 529 Acromio-olavionlar joint, 361 Dislocations of, 362 Acromion process, fracture of, 431 Adenoid vegetations, 568 Advancement, operation of, 562 Amputation in general, 178 Assistants required, 182 Garden's method, 187 Circular method, 182 Flap methods, 183 Hsemorrhage during — How prevented, 178 Instruments for, 179 Lister's method, 187 Modified circular, 185 Oval method, 188 Principles of, 189 Spence's method, 186 Teale's method, 186 Amputations, special, 194 Arm, 219 Ankle, 249 Elbow, 218 Fingers, 194 Foot, 235 Ghopart's, 246 Hancock's, 259 Hey's, 240 Lisfranc's, 240 Mackenzie's, 266 Pirogoff 's, 256 Sub-astragaloid, 268 Syme's, 249 Tripier's, 259 Fore-arm, 213 Lower third, 213 Upper two thirds, 216 Hand, 194 Hip joint, 291 Knee joint, 273 Garden's, 277 Gritti's, 280 Lister's, 281 Stokes', 281 Leg, 261 Above the ankle, 261 Upper two thirds, 265 Lower limb, 235 Metacarpo-phalangeal joints, 200 Metatarso-phalangeal joints, 236 Shoulder joint, at, 223 Tarsus, through, 240 Thigh, 282 Lower third, 282 Middle third, 286 Upper third, 286 Vermale's, 285 Thumb, 206 Toes, 236 Upper Limb, 194 Wrist, at, 210 Anastomotica magna, 160 Anatomical neck of the humerus— Fracture of, 436 Anatomist's snuff-box, 121 Aneurism in general, 1 By anastomosis, 4 Arterio- venous, 3 Causes of, 4 Cirsoid, 4 Treatment of, 20 Classification of, 1,2 Definition of, 1 Diagnosis of, 6 From abscess, 6 From cysts, 6 Pulsating tumours of bone, 7 Solid tumours, 6 Dissecting, 2 Fusiform, 1 Gangrene after ligature, 33 Medical treatment of, 10 Pressure effects of, 8 Progress of, 8 Sacculated, 2 Spontaneous cure of, 8 Surgical treatment of, 11 578 Index. Symptoms of, 5 Traumatic, 2 Treatment of, 10 By compression, 16 Digital, 17 Instrumental, 17 Constitutional, 10 Esmarch's method, 18 Flexion, 17 Foreign bodies, 19 Galvano-punoture, 19 Injection, 18 Ligature, 11 Anel's, 13 Antyllus's, 11 Brasdor's, 15 Hunter's, 13 Wardrop's, 16 Manipulation, 18 Tubular, 1 Varicose, 3 Symptoms, 4 Treatment, 20 Aneurisms, special — Aorta, thoracic, 34 Diagnosis of, 35 Differential diagnosis of, I Pressure effects of, 36 Symptoms of, 35 Tracheotomy for, 37 Axillary, 112 Innominate artery, 53 Diagnosis of, 54 Pressure effects of, 64 Symptoms, 54 Treatment of, 57 Popliteal, 166 Diagnosis of, 166 Symptoms of, 166 Aneurismal varix, 2 Treatment of, 19 AnMe joint, amputation at, 249 Dislocations at, 409 Excision of, 348 Its movements, 407 Anterior chamber of the eye, 628 Aorta — Abdominal, 130 Thoracic, 34 Aqueduct of Fallopius, 561 Aqueous humour, 528 Arches of foot, 407 Argyll Eobertson symptom, 646 Arm, amputations of, 219 Arteries, or artery — Anatomy of, 22 Aorta — Abdominal, 130 Thoracic, 34 Auricular, posterior, 101 Axillary, 106 Brachial, 113 Brachio-cephalic, 53 Carotid, common, 79 Ligature of, 83, 85 Carotid, external, 89 Carotidj internal, 88 Oentrahs retinse, 526 GircumJ9ex iliac, deep, 146 Chronic inflammation — Effects of, 25 Deep epigastric, 146 Division of, effects — Complete, 23 Partial, 24 Dorsalis pedis, 176 Facial, 98 Femoral, 149 Ligature of common, 152 Deep, 161 Superficial, 156 For elephantiasis, 156 Deep, 161 Foot, 176 Fore-arm, 118 Gluteal, 140 Hand, 124 niac, common, ligature of, 136 External, ligature of, 143 Internal, ligature of, 138 Ilio-lumbar, 143 Innominate, 63 Ligature of, 54 Internal mammary, 77 Ligature of, 78 Ligature of, 22 Lingual, 94 Ligature of, 96 Maxillary, internal, 103 Meningeal, middle, 103 Nerves of, 26 Obtm'ator, 142 Occipital, 100 Ophthalmic, aneurism of, 528 Palmar, 124 Peroneal, 171 Ligature of, 171 Pharyngeal, ascending, 102 Plantar, 176 Popliteal, aneurism of, 166 Ligature of, 164 Prinoeps cervicie, 78 Profunda cervlois, 78 Pudio, 140 Kadial, 118 Ligature of, 120 Sciatic, ligature of, 140 Sheath of, 23 Subclavian, 59 Ligature of, 60 Index. 5^9 Supra-scapular, 77 Temporal, 102 Thyroid, ligature of — Inferior, 76 Superior, 93 Tibial— Anterior, ligature of, 173 Posterior, ligature of, 167 Transversalis colli, 77 Ulnai-, 122 Ligature of, 123 Vertebral, 74 Ligature of, 74 Vessels of, 26 Arterio-venous aneurism, 3 Arthreotomy, 806 Arthrotomy, 311 Astragalus, dislocations of, 412 Excision of, 614 Auditory meatus, external, 557 Nerve, 565 Auricle, cysts of, 559 Auricles, supernumerary, 660 Axillary artery, 106 Bend of elbow, 116 Biceps tendon in arm, dislocation of, 370 Bifurcation of aorta, 130 Bone, anatomy of, 415 Box splint, 494 Brachial artery, 113 Compression of, 113 Ligature of, 113 Brasdor's operation, 15 Bryant's triangle, 391 Bursa under psoas, 388 Bursse about knee, 403 Buttock, arteries of, 140 Oalcaneo-scaphoid ligament, 408 Canal of Schlemm, 525 CanaJicuU, 530 Capsule of Tenon, 629 Carbuncle, facial, 529 Garden's amputation, 187 Carotid artery, 79 Aneurism of, 79 Ligature of, 83 Wounds of, '79 Tubercle, 75 Carter's operation, 653 Cataract extraction, 548 ' Catheterism of Eustachian tube, 564 Oavernous sinus, 519 Cerebral abscess, 570 Diagnosis of, 571 Cervical sympathetic, paralysis of, 645 Charcot's disease, 475 Chiene's amputation, 204 Chiene's measurement, 391 Chloroform, administration of, 43 Chopart's amputation, 246 Chorda tympani nerve, 560 Choroid, 622 Diseases of, 523 Chronic rheumatic arthritis, 475 Ciliary muscle, 524 Zone, 637 Gircumoorneal zone, 633 Cirsoid aneurism, 4 Clavicle, 425 Dislocations of, 358, 361 Fractures of, 426 Green-stick fracture, 425 Movements of the, 368 Ossification of, 425 Belations of, 614 Eemoval of, 514 Structures behind, 614 " Clawed hand," 447 Club hand, 447 Ooeliac axis, 131 Collateral circulation in ligature of— Abdominal aorta, 131 Axillary — First part, 107 Third part, 112 Brachial, 117 Carotids — Common, 86 External, 91 Femoral, Common, 153 Deep and superficial, 162 Gluteal, 142 Iliac, common, 138 External, 147 Internal, 139 Innominate, 66 Peroneal, 172 Pudic, 142 BadiaJ, 122 Sciatic, 142 Subclavian — First part, 61 Second part, 72 Third part, 72 Tibial, anterior, 175 Posterior, 172 Ulnar, 124 OoUos's fracture, 457 Coloboma iridis, 539 Congenital syphilis, signs of, 536 Conjunctiva, vessels of, 533 Conjunctivitis, 533, 534 Ooracoid process, position of, 370 Cornea, wounds of, 525 Se;ptic ulcer of, 537 Coronoid process of ulna, 453 Cranial nerves — Fifth pair — first division, 543 580 Fourth pair, 543 Second pair, 538 Sixth pair, 544 Third paii-, 541 Oi'itchett's operation, 662 Crutch palsy, 448 Davy's lever, 293 Deltoid, atrophy of, 370 Digital arteries, 125 Dislocations, special, 364 Ankle joint, 409 Astragalus, 412 - Clavicle, 360 Inner end, 360 Outer end, 361 Elbow, 377 Foot, 412 Fore-arm, bones of, 380 Hip, 389 Knee, 404 Patella, 406 Scapula, 363 Shoulder joint, 366 Subastragaloid, 413 Thumb, 383 Wrist joint, 383 Dorsalis pedis artery, 175 Double pulse, 122 Drop wrist, 446 Dupuytren's fracture, 410 Splint, 496 Ear, the, 657 Abscess of, 668 Ear-ache, acute, 667, 669 Bar, cough, 567 Examination of, 566 Hsematomata of, 559 Inner, 565 Polypi of, 570, 674 Sneezing, 667 Yawning, 667 Elbow joint- Anastomoses round, 118 Dislocation of, 337 Excision of, 318 Fractures near, 442 Enostoses of frontal sinus, 629 Epioondyles of humerus, 434 Epigastric artery, deep, 146 Epiphora, 532 •Epiphyses of pelvis, 466 Upper, of femur, 469 Epiphysis of acromion, 431 Lower, of femur, 469 Fibula, 490 Humerus, 432 Olecranon, 450 Badius, 449 Index. Tibia, 489 Ulna, 449 Esmarch's bloodless plan, 178 Eustachian catheter, 564 Tube, 662 Excision of — Ankle, 348 Astragalus, 514 Clavicle, 514 Elbow, 318 Eye, 654 Hip joint, 333 Joints, 306 Conditions of success, 308 Indications for, 306 Instruments for, 310 Knee, 339 Lower jaw, 509 Os calcis, 513 Scapula, 516 Shoulder joint, 312 Upper jaw, 602 Wrist jojnt, 325 External auditory meatus, 667 Extra-capsular fracture of femur, 473 Eye, the, 518 Blow on, results, 556 Excision of, 554 Sympathetic nerve in relation to 646 Eyeball, the, 522 Coats of, 622 Dangerous zone of, 637 Movements of, 636 Muscles, 636 Nerves of, 538 Refractive media of, 528 Vessels of, 533 Eyelids, the, 520 Dermoid cysts of, 621 Facial artery, 98 Vein, 99 Fascia, bicipital, 114 Iliac, 160 Femoral artery, ligature of, 166 Femur, dislocations of, 389 Fractures of, 470 Fenestra ovalis, 661 Botunda, 561 Fibula, fractures of, 493 Fifth cranial nerve (1st division), 543 Nasal branch of, 644 Fingers, amputation of, 194 Fire in the eye, 636 Fistula lachrymalis, 632 Foot, amputations of, 235 Dislocations of, 412 Fore-arm, amputations of, 213 Fractures of the, 449 Index. 581 Fossa subclavicular, 368 Of Eosenmaller, 663 Fracture in general^ — Causes of, 423 Oomminuted, 422 Complicated, 421 Oompound, 421 Diastasis, 422 Direction of, 422 Green-stick, 422 . Impacted, 422 Incomplete, 422 Multiple, 422 Predisposing causes, 423 Signs of, 423 Treatment of, 424 Varieties of, 421 Fractures, special, 425 Acromion process, 431 Arm, 432 Clavicle, 425 CoUes's, 457 Ooracoid process, 432 Coronoid process of ulna, 453 Dupuytren's 410 Femur — Lower end of, 479 Necks of, 470 Shaft of, 477 Fibula, lower end, 493 Fore-arm, 449 Humerus, 432 Great tuberosity, 438 Lower end, 442 Necks, 436 Nerve iujiu^es in, 446 Shaft, 439 Leg, 489 Metacarpal bones, 463 Olecranon, 451 Patella, 486 Pelvis, 466 Phalanges, 464 Pott's, 410 Badius, 463 Scapula, 430 Smith's, 460 Tibia, 492 Ulna, 464 Frseiium linguae in tongue-tie, 98 Fourth cranial nerve, 643 Galvano-puncture, 19 Gangrene after ligature, 33 Glaucoma, 646. Glaucomatous cup, 527 Gluteal aneurism, 140 Artery, 140 Graduated compress, 126 Granular lids, 621 Heematoma on the pinna, 559 Haemorrhage, spontaneous arrest of, 23 Arterial, 26 Capillary, 26 FSeut of chronic inflammation on, 25 Intercostal, 78 Hancock's excision of ankle, 349 Hand, amputation of, 194 Hemianopsia, 639 Herpes Zoster, 544 Hip-, ankylosis of, 334 Dislocations of, 389 Hip joint, 386 Amputations at, 291 Fractures about, 470 Movements of, 387 Housemaid's knee, 403 Humerus, dislocations of, 366 Fractures of, 432 Non-union after, 442 Hunter's canal, 169 Hypogastric artery, 138 Hypopyon, 537 Inferior maxilla, excision of, 609 Innominate artery, 63 Bone, 466 Insane ear, 559 Intercostal artery, wound of, 78 Internal carotid artery, 88 Mammary artery, 77 Intra-oapsular fracture of femut, 471 Iridectomy, 650 For glaucoma, 660 Iris, 524 Dermoids of, 539 Inflammation of, 533 Muscles of, 624 Vessels of, 633 Iritis, 533 Jaw, lower, excision of, 609 Upper, excision of, 602 Sarcoma of, 503 Joints, description of — Acromio-clavicular, 361 Anatomy of, 354 Ankle, 407 Classification of, 358 Disease, diagnosis of, 357 Elbow, 372 Hip, 385 Knee, 397 Loose bodies in, 405 Eadio-ulnar, 373 Shoulder, 363 Sterno-clavicular, 358 Wrist, 381 Joints, effusion of fluid into — Ankle, 409 582 Index. Elbow, 375 Hip, 388 Knee, 402 Shoulder, 365 Sterno-clavioular, 359 Wrist, 382 Joints, excision of — Ankle, 348 Elbow, 318 Hip, 333 Knee, 339 Shoulder, 312 Wrist, 325 Knee joint — Amputation at, 273 Arteries of, 344 Arthreotomy of, 340 BurssB about, 403 Dislocations of, 404 Excision of, 339 Subluxation of, 404 Labyrinth, 565 Lachrymal abscess, 531 Apparatus, 530 Canals, 530 Gland, 530 Sao, 530 Laohrymation from irritation of nasal nerve, 544 Lamina f usca, 522 Supra-ohoroidea, 522 Leg, amputation of, 261 Fractures of, 489 Lens, 528 Levator palpebrse, 620 Ligamentum pectinatum iridis, 525 Ligature for aneurism — Above and below sac, 11 Anel's, 13 Brasdor's, 16 Gangrene, after, 33 Treatment of, 33 Hunter's, 13 Material of, 26 Catgut, 27 Carbolised silk, 27 Kangaroo tendon, 28 Ox aorta, 28 Waxed silk, 26 Separation of, 27 On cardiac side, 13 On distal side, 15 Eeourrent pulsation after, 33 Wardrop's, 15 Suppuration of sac, after, 33 Ligature of Arteries — Aorta abdominal, 131 Arteria dorsalis pedis, 175 Axillary arteries, 106 Brachial artery; 113 Brachio-cephalic artery, 56 Carotid artery, 79 External, 89 Internal, 88 Dorsalis pedis, 175 Facial, 99 Femoral artery, 149 Common, 152 Deep, 161 Superficial, 156 Gluteal, 140 Iliac, common, 136 Iliac, external, 143 Abernethy's method, 143 Cooper's method, 144 Iliac, internal, 138 Instruments required, 43 Internal mammary, 77 Knife, to hold, 31 Lingual artery, 94 Meningeal, 103 Occipital, 100 Palmar, 124 Peroneal artery, 171 Plantar, 176 Popliteal, 163 Position of patient, 31 Pudic, 140 Eadial artery, 120 Sciatic, 140 Special points in reference to, 28 Subclavian artery, 69 Behind Scalenus anticus, 64 In third part, 65 Temporal, 102 Thyroid strteries — Inferior, 76 Superior, 93 Tibial arteries — Anterior, 172 Posterior; 166 Ulnar, 122 Vertebral, 74 Lingual artery, 94 Lisfranc's amputation, 240 Lister's bloodless plan, 178 Locomotor ataxy — Eye symptoms in, 556 Long splint, 479 Machinery accidents, 25 M'Intyre's splint, 484 Malleoli, position of, 409 Manning's splint, 488 Mastoid antrum, trephining of, 576 Disease, 674 Medio tarsal amputation, 246 Index. 583 Meibomian glands, 521 Melanotic growths of choroid, 554 Meatus of ear, nerves of, 659 Vessels of, 559 Membrana pupillaris, 624 Tympaui, 557 Examination of, 567 Incisions in, 559 Perforation of, 568 Meningeal artery, 103 Meningitis from abscess of ear, 569, 573 Mesenteric arteries, 131 Metacarpo-phalangeal joint of thumb, 383 Mickulicz's operation, 351 Middle ear, suppuration of, 569 Complications, 669, 578 Middledorpf's triangle, 438 Miner's elbow, 375 Morris's measurement, 391 MuBoulo-spiral nerve, 446 Paralysis of, 446 Myopic orescent, 527 I^asal duct, 531 Nerve, 644 Naaton's line, 391 Notch of Kivinus, 559 Obturator or thyroid dislocation, 396 Ocular nerves, causes of paralysis, 545 CBsophagus— relation to aorta, 40 Olecranon process, position of, 376 Fractures of, 451 Opaque optic nerve fibres, 538 Ophthahma, sympathetic, 654 Ophthalmoplegia externa, 646 Ophthalmoscopic appearance of the fundus, 526 Optic disc, 626, 627 Cupping of, 527 Optic nerve, 538 Orbicularis palpebrarum, 520 Orbit, the, 518 Dermoid cysts of, 621 Pulsating tumours of, 528 Orbital abscess, 529 Aneurism, 528 Cavity bones of, 518 Fat, 629 Tumours, 529 Walls, 618 Os calcis, excision of, 513 Osseous ankylosis of hip, 334 Otitis media, 568 Possible results of, 573 Palmar arches, wound of, 126 Treatment of, 127 Pannus, 521, 635 Paralysis of cervical sympathetic, 545 Mueculo-spiral nerve, 446 Orbital nerves, 638 Ulnar nerve, 447 Patella, dislocation of, 406 Fracture of, 486 Patient, position of, 192 Peroneal artery, 171 Phrenic nerve, 64 Pinna, 559 Pirogoff's amputation, 256 Pituitary body, hypertrophy of, 540 Plantar arch, wound of, 176 Treatment of, 176 Pneumatocele, 574 Politzer's method, 663 Popliteal aneurism, 166 Artery, 163 Pott's fracture, 410 Prince's operation, 553 Profunda arteries in arm, 117 Femoris, 161 Ptosis, 642 Pulse in aneurism, 91 Puncta lachrymalia, 530 Pyramidal cataract, 528 Badial artery, 118 Badins, dislocations of, 380 Fractures of, 453 Head of position, 337 Readjustment, operation of, 552 Eeonrrent laryngeal nerve, pressure on, 37 - Betiua, 526 " Salmon patch," 535 Sartorius muscle, 157 Saturday-night palsy, 448 Scalene muscles, 66 Scaphoid tubercle — Position of, 409 Scapula, fractures of, 430 Eemoval of, 516 Sclerotitis, 634 Semilunar cartilages, 404 Shoulder, bursas near, 366 Dislocations, 366 Fractures, 435 Shoulder joint amputation, 223 Sixth cranial nerve, 644 Skewer, steel, 293 Spaces of Fontana, 525 Sphenoidal fissure, 519 Spine, concussion of — Eye, symptoms in, 666 Squint, 642 Sterno-clavicular joint, 368 Disease of, 369 Dislocations of, 360 584 Index. Stillicidium ladirymarnm, S32 Stirrup splint, 498 Strabismus, operation for, 651 Student's elbow, 375 Stump, dressing of, 192 Subacromial bursa, 366 Subastragaloid dislocation of foot, 418 Subclavian artery, 59 Subclavicular fossa, 368 Subluxation of knee, 404 Superior maxilla excision of, 502 Thyrpid artery, 93 Surgeon, position of, 191 Syme's amputation at anlde, 249 Sympathetic nerve in relation to eye, 545 Effects of lesion in neck-, on eye, 645 Sympathetic ophthalmitis, 537 Sympathetic, pressure on, 37 Synechise, 525 Synovitis (see Joints, effusion of fluid iuto) Tarsal cartilage, 620 Tarsal cysts, 521 Tendo oculi, 631 Thigh, amputation of, 282 Fractures, 479 Third cranial nerve, 541 Thumb, amputation of, 206 Dislocation of, 383 Tibia, structures on head, 399 Tibia and fibula, fractures of, 492, 493 Tibial arteries, 167, 173 " Tongue-tie," 98 Tonsil, bleeding from, 102 Trachoma, 521 Transverse arch of foot, 407 Transverse cervical artery, 77 Tubercle for adductor magnus, 150, 278, 468 Tubercle of tibia, 489 Tumours of orbit, 628 Tympanic cavity, relations of, 569 Tympanum, the, 560 Arteries of, 661 Nerves of, 561 Eolations of, 569 Ulna, dislocations of, 380 Fractures of, 454 Ulnar artery, 122 Nerve, 122 Nerve, paralysis of, 447 Valsalva's method, 568 Varicose aneurism, 3 Varix, aneurismal, 3 Vertebral artery, 74 Ligature of, 74 Visual centre, 539 Vitreous, floating opacities in, 527 Wardrop's operation, 16 " Watery eye," 632 Wax in the ear, 667 Weight and pulley, 482 Wing scapula, 363 Wrist joint, 881 Amputations at, 210 Dislocations of, 388 Excision of, 325 Fractures about, 462 Movements at, 882 Yellow spot, 526 E, & S. 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THE Topographical Anatomy of the Child JOHNSON SYMINGTON, M.D., F.R.S.E., F.R.O.S.E., Frofeuor of Anatomy, Queen'a College, Selfaet; formerly liecturer an Anatodjl, School of Medicine, and MxaWimer m Anatomt/, XTnwersity of Bdinburgh. ILLtrsTKAtEb BY FOUKTEBN BEAUTIFUL A»J> OOKKEOTLY COLOURED PLATES (NEAKLY ALL OF WHICH ARE LIFE StZEl AND THIRTY-THREE WoODOUlS. E. &'^. LIVINGSTdNES' PUBLICATIONS: THE TOFOGBAFHICAL ANATOMY OF THE CHILD. OPINIONS OF TSE JPBE8S. This magnificent work forms one of the most important and most valuable of the recent contriGuEions to human anatomy: . Topographical Anatomy is usually considered independently of the^age and sex of the subject, and there can be no question that maiiy of its data require re'cohsideratloh.' The present work is founded upon the examination of a series of firozen sections of the bodies of children . It is illustrated by fourteen life-sized coloured Plates, and by a number of Woodcuts. Of the excellence and fidelity of the Plates it is impossible/to 8])eak too highly. They reflect the "greatest credit upon the publishers. _ - . The vertical medial s^ctiqiis and^^soihe eoronalsections of the thorax are the most valuable. Sections are given o^all parts of the trunk; of the skull, to show the orbits and nasal fossae ; of the neck, to show the position of the lai7nx; of the thorax, abdomen,' and pelvis. The First Part of the work is devoted to a critical explanation of tbe Plates. The Second Part deals systematically with the more conspicuous results of the author's investigations. The topographical anatomy of the auditory meatus and tympanum, the condition of the spinal curve in children, the topography of the brain, and the relational anatomy qf the male and female genital organs, are-all dealt with in an able and original manner. ^ Dr^Symington's .book abounds in original material. It is a- work that no anatomist can afi'ord to overlook.. It adds mateiially to our knowledge of the most practical branch of anatomy, and is a credit to modern scientific research. —The Intet'nationalJownal of tTie^ Medical Sciences^ October 1887. l>r Johnson Symington has well filled a gap in our Topographical Anatomy. This department of anatomical science has been worked at most extensively and ably by Pirogoff, Braune, Luschka, and others, in the adult ; but the method of ftvzen sections has hitherto been systematically applied to the child, in one case only, by Professor Dwlght. Dr Symington has added to our knowledge by presenting ns in this work with fourteen coloured lithographic illustrations, all life-size, and'thirty-three woodcuts taken from sections of male and female children, aged fbnr years and a half, fire years, six years, and thirteen years, and has given us a large number of very acpnj'ate, observations-tm the positipn-of iI^iev-aTions organs and visceral and .the.cha^ges^whic'hiihey uudergcun the earlier periods otlife. The horizontal sections have been taken fVom a girl six years of age. whilst the vertical sections (both coronal and sagittal) are from children of both -sexes and various ages. In addition to the illustrations^ the work is n^ost valuable for excellent letterpress, treating very fiiUy and minutely of the pbsition of structures at all periods of early life, and'it is evident that-jnany of theviews generally held in regard thereto willJ^ve to undergo considerable alteration. For example, Df Symington show's "tnkt the extertial auditory meatus is relatively as long in the child as iii the adult, when ek^mlned in the fresh state in si^bjects with the entire head frozen; that the spinal cord in the newly-born child ceases at much the same point as in the adult ; that the child's nec^ is not relatively short, but that it is higher in relation to the vertebral column than in the adult. The common assumption that the position of the stomach in the child is vertical is also shown to be erroneous, and is proved by figures taken from an infant four days old, and from a girl six years of age. The portion of the book devoted to the position of the pelvic viscera in male children is of great impoiiiance to surgeons, and will be carefully studied in view of operations on the urinary organs in early life. Too much praise cannot. be bestowed upon the author ibr the obvious care and industry with which he has pursued hfs investigation, and the accuracy and fidelity with which he has reproduced its results. Its dedication to Professor Braune is a most graceful compliment'to anf anatbmist who has done more to advance the knowledge of Topographical .^natomy than any other worker, in- this, special branch.— T'Ae Lancet, 22hd October 1887. ' - . . :^ E. & S LIVINGSTONES' -PUBIiIOATIONS. IN THE PRESS. NEARLY READY. THE Conservative Treatment ...V_. iA^ "-i . -OF - --^---^ Tubercular Joint Disease andXold Abscess AS CARRIED OUT AT BRESLAU BY Prof. J. VON MIKULICZ, LL.D.Edin. BY ;,, ; ,:.r;, r ;dr a; henxe, -:-. Chief Assistant at the Surgical Klinik, Breslau. .■A ,. .' '■ \o ■'. ; o . ■ ;v.::..-.. WITH PREFACE BY PROFESSOR J. Von 'MIKULICZ. ,,: ; ., .- TRANSLATED FROM THE GERMAN BY , .J .,, CHARLES ,W. CATHCART, F.R.C.S., -" ' ; '., Senior, Assistant SurgfoK, Royal IttfirtrCary, ' - Edinburgh. - B. JE S. LIVINGSTONES' PtTBLICATIONS. Third Edition, in 2 vols,, price 18s. ILLUSTRATED WITH 238 USEFUL ENGRAVINGS. APPLIED ANATOMY BY JOHN M'LACHLAN, M.D., B.Sc, F.E.C.S.K, etc. The Book includes what is usuaify known as — 1. SURGICAL ANATOMY. 2. MEDICAL ANAT0M7. 3. OPERATIVE SURGERY. USED AS A TEXT-BOOK IN THE PRINCIPAL UNIVERSITIES & MEDICAL COLLEGES. The modiis operandi of all the more important Surgical Operations — Instruments required. 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With systematic courses of lectures constantly increasing in nimiber and severity, with tutorial classes, with extra fees and extra hours, to assist him in assimilating the indigesta moles that is spooned into his unlucky brain, by the constant yearly deciphering of ancient manuscripts, with text-books to be mastered which contain not only all that is really known on any subject, but also all the facts which the respective authors have evolved from their own conceit, and there- fore believed to be valuable, — no wonder the poor victim appears at the examination stuffed, not taught, with material, crammed, not digested. 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' The work deals with both Organic and Inorganic Chemistry, and much information has been compressed into small compasa It is well adapted as a hand-book for medical students, being furnished with a copious index, and the text is given in such a form as will render it readily accessible to the student. We commend the -vork to the attention of Canadian students.' — Canadian Lancet E. & a. LIVINGSTONES' PUBLICATION B. Fifth Edition, Eevised and Enlarged, price 6s. lateria ledica and Therapeutics FOR THE USE OF STUDENTS AND PRACTITIONERS. By WILLIAM CRAIG, M.D., C.M,, F.E.S.E., F.E.O.8.E., etc., Lecturer on Materia Mediea in the Edinftwrgi, Scliool of Medicine, Exaimner at the Royal College of Surgetms, Edi/ntmrgh Examiner at Edinbwrgh Uruiversity. Used as a Text-book in the principal Universities and Collegesrin Great Britain, India, and the Colonies. ! As the work stands it forms a very clear and complete guide to the study of the properties and uses of the pharmaoopoeial preparations, and we can endorse thoroughly the good opinion we were enabled to pass upon the previous edition. The excellent Posological Table is very valuable, as are the hints on Prescription Writing, and the very succinct Index of Diseases with their Eemedies. As a compendium of Materia Medica and Therapeutics, of moderate size, but full of information, we know few to surpass, even if to equal, the Manual before us. We have ourselves made a constant companion of the former edition, which has never failed ns.' — Students^ Journal. ~ ' This book contains sound sense and original information, and wDl prove a good pocket compajoion for the student.' — Medical Times and ' Tour " Manual " will be useful to me in various ways, teaching included, and I should think it will be regarded as a boon by students preparing for their examination.' — Professor Habvby, Aberdeen. ' This concise little Manual, though intended primarily to assist students attending the author's own classes, possesses several charac- teristics which have rendered it more generally popular. Special emphasis is laid upon alterations in nomenclature which might other- wise escape attention. The volimie concludes with a Posological Table, a Schedule of Poisons and their Antidotes, together with an Appendix of Contracted Terms in Common Use. It is beautifully printed, and is altogether a very handy and convenient volume for the use of students preparing themselves for examination.' — British Medical Jouumah ' This being a fifth edition, calls for very little remark. The amount of condensation of material is truly surprising; useful facts are stated so briefly that, a priori, it would give the impression of a peculiarly dry and uninteresting introduction to a very difficult subject. The author's hope that the book would be of service to students preparing for their professional examinations can surely only be realised when a concise epitome is required in the few weeks immediately preceding examination,and wl-«n the student i» already familiar with the subject.' — Lancet. E. & S. LIVIHGSTONES' PUBLICATIONS. Demy 4to., price 7s. 6d. lUusirated -with lO Coloured Pistes NERVES OF THE HUMAN BODY BY ALFRED W. HUGHES, M.B. & CM. Edin.; F.E.C.S.Edin.; M.R.C.S. Eng.; Professor of Aimtomy, SovM Wales Medical College, Ca/rdiff, ' An excellent work of reference for students, quite in place in a Medical School library. The drawings are large and bold, demon- strating the distributions and connections of the cranial and spinal nerves with clearness and accuracy. The cranial nerves in particular are well represented. .... The preparation of " Nerves of the Human Body " must have cost its author much trouble, and Dr Hughes may be congratulated on the result of his labours.' — Brttuh Medical Jowmal. ' As regards the work little is left to be desired. As far as the diagrammatic and literal description of the nerves goes, this work is undoTibtedly good ; and there is no doubt that the anatomical details are an improvement on those usually given. It will be found a help to students in their practical work, and of equal help to the prac- titioner in his pathological and therapeutic investigations.' — Proviacial Medical Journal. ' The diagrams are very clear. The text contains a well arranged summary of the main facts of the origin, course, and distribution of the cranial, spinal, and sympathetic nerves. It is a work that may be con- sulted with confidence by the student, and which he wiU find a useful aid in gaining a knowledge of the nervous system.' — Edinburgh Medical Joum^' ' A thoroughly excellent contribution to anatomical literature, will be valuable to those struggling hard with the most difficult subject in human anatomy. The diagrams cannot be praised too much.^ — The Student. ' Dr Hughes' book, " The Nerves of the Human Body," simplifies the task in a way unknown to the student of Gray and Quain. The diagrams are beautifully executed.' — Scotsman. ' Mr Hughes has shown more daylight into that dark subject than any of his predecessors. The book can be safely recommended to all students.' — College Colrnim. ' The special feature of the book, is a series of ten beautifully executed Plates of Diagrams, in which the different nerves are very distinctly figured. The work is intended as a special adjunct to the standard text-books of Practical Anatomy, and as such it can scarcely fail to be of great assistance to students who will use it intelligently.' — Scottish Leader. K. S S. LIVINGSTONES' PUBLICATIONS. Second Edition, Price 6s. Revised and Enlarged, with 12 Tinted Plates and 40 Woodcuts. OJ? IHB linor Qynecological Operations and Appliances By J. HALLIDAY CEOOM, M.D., F.R.C.P.E., F.R.C.S.B., Lecturer on Midwifery and Diseases of IVomen, School of Medicine ; President of the Obstetrical Society, Edinburgh ; and Examiner in Midwifery in the University of Edinburgh and Royal College of Physicians, Edinburgh. ' The descriptions and recommendations of Dr Oroom seem entirely familiar, intelligible, and wholesome. A number of well-executed lithographic plates, giving various relations of the pelvic organs, add to the value of the book.' — Amencam, Journal of Obstetrics. ' The work is admirably adapted as a practical guide to obstetric clinical clerks, house surgeons, and physicians, as well as medical practitioners. It is well arranged throughout, and will, no doubt, retain the hold it has already taken.' — London Medical Record. ' The Second Edition is considerably modihed, and forms almost a completely new book. The clearness and conciseness of the author make his Manual most useful both for practitioners and students.' — Bulletin General de Therapeutique. ' All that is of doubtful value is pmrposely omitted, and only the methods of examination and treatment recognised as the best are described concisely and with capital illustrations. The book, which embraces all the gynecological operations with the exception of the abdominal, is in a high degree likely to fulfil its aim for students.'— Ceniralblatt fur Gyncekologie. ' "We are glad to see that this valuable Manual has run into a Second Edition. Its arrangement is such as will commend itself both to the student and busy practitioner. We finish the perusal of this work impressed with its simplicity of arrangement and lucidity of expression.' — Liverpool Medico- Chirurgical Jowmal. ' This is an admirable book, for which we are sure the student in midwifery and the diseases of women wiU be very grateful. We commend it heartily to students, for whose use it is chiefly written, and even practitioners will find it very handy and suggestive in many of the emergencies of practice.' — Lancet. ' Both students and practitioners will find in it descriptions, hints, and directions— clear, practical, and usefuL' — Practitioner. B 3,o- E. ft S. LIVINGSTONES' PXTBLICATIONS. THIRD EDITION. Fifth. Thousand, price 5s. net. Illustrated by about 40 Plates (many Coloured) or 109 Figures. Anatomy of the Brain and Spinal Cord J. RYLAND WHITAKER, B.A., M.B. (Lend.), F.R,C.P., L.R.C.S.(Edin.); Lecturer on Anatomy, Surgeons' Ball, Edinburgh; Examiner for the Triple QucUi/lcation. Used as a Text-Book in the principal Universities and Medical Colleges in Great Britain, India, the Colonies, U.S.A., and Italy. 'The book is an excellent Manual for the use of Students and makes a good introduction to the heavier text-books. This Edition is made more valuable by the inclusion of some new matter in the text, and by the addition of many new figures and tables.' — Scotsman. ' The book consists of an exceedingly clear account of the central nervous system.' — British Medical Journal. ' For a clear and concise description of the nervous centres it has not been surpassed.' — Journal of Mental Science. ' We are pleased to see that Mes.irs E. & S. Livingstone have issued a Second Edition of Dr Whitaker's admirable Anatomy of the Brain and Spinal Cord.' — Edinburgh Medical Journal. B. & S. LIVINGSTONES' PUBLICATIONS. Price 4s. 6d. net. Notes on Pathology By J. EYLAND WHITAKEE, B.A., M.B.(Lond.), F.R.C.F., L.It.C.S.(Ediu.); Lectwef on Anatomy^ Surgeons^ Hall, Edinburgh; iSxamin&r for Oie Triple QualiflffaUon. AUTHOR OP ' ANATOMY OF THE BRAIN AND SPINAL CORD,' Vol. I.— GENERAL. Vol. \\.—S?^C\kL {in preparation). Used as a Handbook in tlie principal Universities and Colleges. ' These " Notes," which traverse the whole range of General Pathol- ogy, have evidently been compiled with great care. Together, they form an outline of the subject of which it will not be difficult for the student to fill in such details as he gathers from his lecturer or His text- book. The author himself recognises this as the main object of his publication, and we may say at once that he has done his work well, and that it should prove of much utility. In these days of "compendia" of knowledge, where the aim often seems to be to condense into as small a space as possible the facts of science, so that the student may be saved the trouble of learning them step by step, it is gratifying to find a writer who takes a higher view of the kind of assistance that the student needs. The information he conveys ic his little work is con- siderable, and also accurate ; in parts even — e.g., in the sections deal- ing with Inflammation and the Parasites — it is almost, if not quite, as full as is to be found in many a text-book. But it would be difficult for the student to use the work simply for the purpose of "cram." We believe, moreover, that teachers also may be glad of so concise a summary of the subject as Mr Whitaker has given.' — Lancet. ' This is evidently the first part of what may be described as a useful synopsis for students, and it deals purely with General Pathology. The author has attempted to outline the causationand pathological characters of disease ; and in a neat, concise way every subject is dealt with so as to give a concentrated idea of the varieties of disease and the nature of their pathological processes. The arrangement of the hook is in Sections — the first of which is devoted to Altered Conditions of the Circulation ; another treats of Inflammation and its Eesults ; a third of Retrogressive and Progressive Changes ; and the last of Parasites and Parasitic Diseases. As a digest it is a remarkably good book, without padding or unnecessary verbiage, and with a comprehensive survey of causation and the varieties of allied or similar pathological processes. For the student it will prove an admirable memory help, and for the practitioner it will frequently be sufficient when he does not require to dip exhaustively into a subject.' — Glasgow SeraM. 20 E. 6 S. LIVINGSTONES' PUBLICATIONS, Price 10s. 6d. THE STUDENTS' Handbook of Medicine AND Therapeutics. By ALEXANDER WHEELER, Clinical Assistant^ Out-Fatient llepartment, EdinhurgTi IRoyal InfWmwry, Author of- "Our Unseen Foes," &c. Used as a Text-Book in the principal UniTersities and Colleges. ' It is distinctly designed to refresh the memory on salient points, as well as to enunciate the leading principles of treatment. These aims have been faithfully carried out, and that too with an originality for which it might be thought there could be little scope. Clear, concise, and accurate.' — Lamcet.- 'This excellent little volume . . . Many good coloured and unooloured diagrams illustrate the book, and we think the young practitioner can hardly make a better investment than the purchase of Mr Wheeler's work. It is up to date in pathology and treatment, and is a model of clear, terse writing.'— JlfedicaZ Press and Circulwr. ' This is an exceedingly good little work, unpretentious, it is true, but fulfilling far more than it pretends. We have nothing but praise for the work. As a whole, it shows a remarkable power of imparting information in a clear and easily remembered style ; and the author's practice of giving explanations and reasons for every step in the treat- ment of disease strikes us as being particularly suitable for the needs of the men to whom he appeals. We heartily recommend it to the overworked final man.' — The Student. 'The volume is carefully compiled and well written, and is, in our opinion, destined to take high rank amongst its competitors. It can be profitably read either by the student on the eve of an examination to refresh his memory, or by .the busy practitioner for the same pur- pose. We venture to predict that a Second Edition will shortly be called for.' — The Quarterly Medical Journal. B. & 8. LIVINGSTONES' PUBLICATIONS Price 4s. 6d. net. ILLTTSTSATEB WITH 8 GOLOTJBED PLATES, MANUAL ot SURGICAL ANATOMY BY ALFEED W. HUGHES, M,B., CM., P.E.C.S. Bdin. ; M.E.O.S. Eng. ; Frofensor of Anatomy^ Sing's College, London. Author of 'Nerves of the Human Body,' ^c. Used as a Handbook in all the Universities and Medical Colleges. ' This little book contains very terse descriptions of the anatoniical facts most important to students about to present themselves for their Final Examination in Surgery. Clearness sometimes, and elegance of diction often, have been sacrificed to brevity. It will commend itself to those for whom it is specially prepared.' — Lancet. ' Di Hughes evidently possesses the faculty of condensing a large amount of information into a small space in a clear and methodical manner. The student will find it a very reliable guide. The work contains a number of excellent illustrations, which will greatly assist the student in learning the relative positions of various structures which he would euooucter in the ligature of the principal arteries.' — Edivhurgh Medical Jowmal. ' No book could be better adapted for Examination purposes. The book may be'safely recommended.'— SbspsiaZ. ' Here is a simple book plainly written with the main facts of the subject' clearly exposed,; it is easily understood, easily remembered; it can be read through in half-a-dozen hours. We recommend it to you, its perusal will supply you with many excellent and useful anatomical facts which you ought to know.' — Dvhlin Jowrnal of Medical Science. ' Dr Hughes' book will supply the gap existing betwixt the more elaborate Manuals of Surgical Anatomy on the one hand, and the mere outlines, used for "cramming" purposes, on the other. The work is a useful one, and we have perused it with the result of finding that most of the important points involved in the common work of the Surgeon have been duly noted. The section on Hernia in particular strikes us as being excellently done. The Plates illustrating the book ■have the relations of Arteries, Veins, and Nerves printed in colours, this plan facilitating easy reference to the details they expound.' — Glasgow Berald. ' A brief concisely-written handbook, covering that department of Anatomy which concerns students who seek only the usual Surgical qualifications. ' — Scotsman. E. & S. IJVINGSTONES' PUBLICATIONa Demy 8yo, price 4s. 6d. net. Vaccination Eruptions: :By THOMAS DOBSON POOLE, M.D., Master in Surgery^ TJnwereiiy ofBdinhwrgh; Fellow of the Obstetrical Society. 'The author- classifies eruptions as follows: — (1) Those due to pure vaccine inoculation, (2)- those due to mixed inoculation. He enters at length, and very properly, into the question of the qualities of the lymph itself, of its origin and cultivation, and here is the crux of the whole question. The question of the artificial cultivation of the lymph is a very important one, and the author suggests a method which we trust may either solve the problem or mature its consideration. The work is one well worthy of consideration.' — Glasgow Herald. 'The title of this very interesting work concisely, indicates its con- tents. A good acquaintance with the literature of the subject is sliown on every page, and the cited cases are of great interest, especiaUy those in connection with the subject of generalised vaccine eruption {vaccine jlniralisee). The differential diagnosis between vaccination ulcers and primary chancres, also between vaccination eruptions and secondary syphilitic manifestations, is given in extenso from Portalier's summary of Foui-nier's lectures. The author concludes from a study of tuber- culosis, including his own experiments, that its transmission by means of official vaccination is "beyond the limits of possibility." In con- clusion, this work deserves perusal by all who are interested in the subject of vaccination, therefoie by all medical practitioners.'— ^riiisA Medical Jowrnal. 'The author of this little work has made himself well acquainted with Efiost of the reliable literature of recent date bearing on lii« theme, aid has put into a convenient and useful form a great deal of information that could otherwise be obtained only by hunting through a variety of medical periodicals and other publications. The work ought therefore to be welcomed by all who have much to do with vaccination, and especially by public vaccinators, who are the only persons likely to have the opportunity of meeting with some of the very rare vaccinal sequelse of which he principally treats. A chapter is very profitably devoted to vaccine syphilis. The chapter on tuber- culosis is one of the best in the book. Other subjects shortly dis- cussed are leprosy, erysipelas, vaccinia gangrenosa, etc. The work forms a really useful addition to the literature of vaccination, and ought especjally to be read by every public vaccinator in the kingdom.' — Glasgow Medical Jownal. E, & S. LIVINGSTONES' PUBLICATIONS. Price Five Shillings. THE STUDENTS' HANDBOOK OF GYNECOLOGY. profusely |Ilustrat«ii. THE MOST PRACTICAL HANDBOOK EVER PUBLISHED. Used as an Introductory Text-Book in all the Universities and Medical Schools. ' Everything is stated in a most clear and concise way, and as the volume is nicely illustrated, it should be of great assistance to final men especially.' — Dispatch. 'There are many who have serious doubts -as to any real value being obtainable from such condensed forms of imparting infor- mation, but they are clearly very popular among medical students. The present volume makes no pretensions to compete with more exhaustive works, but it is hoped it will prove useful to beginners and to those who wish to synopsise and focus the knowledge obtained from larger works. It is clearly and concisely written, and it is surprising to find that it has succeeded so well, in the small space at its disposal, in covering the ground necessary for an ele- mentary knowledge of this progressive and important branch of medical learning. '^jScotemnK. 24 E. & S. LIVINGSTONES' PUBLICATIONS. 4to, price Sixpence net, SCHEDULES FOR PLANT DESCRIPTION (HUnatrateit) By JOHN WISHART, Lecturer on Zoology and General Biology in Mohert Gf-ordon's College, Aberdeen / Serbo/rium Medallist of the Pharmaceutical Society of Great Britain. USED IN ALL UNIVERSITIES AND COLLEGES. ' The use of these Schedules by pupils will train their powers of otiservation and reasoning, and prevent them from being .contented with book knowledge.' —-J)ublin Journal of Medical Science. ' These tables are admirably adapted and arranged on a scientific principle for building up an instructive record of plant examination.' — Aberdeen Daily Free Press. B'S" THE s-A-3yLE .A-xrmioie-- Price Two Shillings net. THE Botanists' Yade Mecum. ' A very handy little pocket guide to the classification of plants, intended for use during botanical excursions. The matter is very concise and well arranged, and the value of the book is very materially enhanced by an ingenious and novel form of index.' — Guy's Hospital Gazette. ' This little manual, of a size suitable for the pocket, will form a useful com- panion to students of botany in their fleld-days. ■ Its arrangement is concise, and its information conveniently scheduled. A useful ledger-index adds to the convenience of the manual.'— Glasgow Herald. 'We commend this Vade Mecum as a very useful guide to all botanical excursion students, who will find it an invaluable aid to recognising the char- acters of the various divisions and natural orders.' — Briiish and Colonial Druggist. E. & S. LIVINGSTONES' PUBLICATIONS. Price 2s. 6d. net. The Rotatory Movements OF The Human Vertebral Column AND THE So-called Musculi Rotatores. By ALFRED W. HUGHES, ' M.B. & CM. Edin,; F.R.C.S. Eng. ; F.R.C.S. Edin, ; Professor of Anatomy, King's College, London; Author oj • Nerves of the Human Body^ and ^Manual of Swgical Ajiatomy.' 'The entire work bears evidence.of careful observation, and forms a useful con- tribution to the mechanism of the human skeleton.' —Edinbztrgh Medical Journal ISTE^VV^ EJDITIOISr. Revised in accordance with the British Fharmacopceia, 1898. Price One Shilling net. POSOLOGICAL TABLES; Appendix on Poisons ; Index of Diseases ; and Medicines arranged according to their Actions. By WILLIAM CEAIG, M.D., ^O-M., F.R.S.B., Lecturer on Materia Medica, Edinhwrgh School of Medicine ; Examiner in Materia Medica, Edinhui'gh University; Examiner^ Royal College of Swgeons. Being a Tabular Arrangement of all the Medicines contained in the British PharmacopcEia, with Dose, &c. * This is a useful little book, containing; a tabular arrantrement of all the Phar- macopceial preparations, with their doses and methods of administration, A table on Poisons and an Index of Diseases with Appropriate Remedies are included.* — Lancet. E. & S, LIVINGSTONES' PUBMOATIOKS. Price Is. 6d. net. Materia Medica Tables. Designed for the Use of Students. BY A. HERBEET BUTCHER, L.R.C.P., L.B.C.S. & L.M., HonoTwry Surgeon to Birkenhead Borough Hospital. 'This is a small WQrk intended to supply a longracknowledged want, and will be found to contain much information arranged in an admirably simple manner.' — 'Publisher's Circular. Price 2s, 6(3. net. THE STUDENTS' Haiidl)ook of Diseases of the Skin. lIluatratEb bii ColontEb f kfee anb Woob (Sngrafamjs. ' It is clearly and systematically, arranged, and the student who masters its contents will have acquired a useful general knowledge of the pathologioW classification, course, and methods of treatment of all but the rarest diseases of the 6\m.'— Manchester Chmrdimi. • It will prove of service to the young practitioner, and also to older men m country practices, whose work leaves them but little tiine for the sjjidy of boots of greater pretensions. A number of well-executed illustrations increase the working value of the book.'— r/ie Publisher's Circular. Second Edition. Price 6d. net. Revised in accordance with the British Pharmacopoeia, 1898. Dose TaMes of Materia ledica Containing all the Doses required for Examinations and Prescribing. By T. HOMER, L.R.C.S., L.R.C.P.Edin. E. & S. LIVINGSTONES' PUBUCATIONS, Price Is. 6d. in Paper Boards; or in Cloth, 2s. THE CHILD-HOW TO IJTJRSE IT; Or the Management of Children and their Diseases, By ALEXANDEE MILNE, M.D. ' Dr Milne not only describes how the Child should be managed from the hour of birth, but he notes the distinctive characteristics of all the ailments to which Children are liable, and gives instruction as to their proper treatment- A great many works have been published of late years, but there is certainly not one which is more likely to be of use to inexperienced or conscientious parents.' — Scotsman. ' This little work will be found to contain copious details on the management of infancy, expressed in language singularly free from technicalities.' — Comani. ' We heartily recommend the careful study of Dr Milne's invaluable work.' — Ladies Ovm Journal. * To emigrants and others who are at a distance, from medical aid, we believe the book -will be a "present help in time of trouble.'" — North Metropolitan. Price Threepence. The Monthly Nurse: A FEW HINTS ON NURSING. By H. AUBEEY HUSBAND, M.B., CM., B.Sc, etc. ' It can scarcely be said that a handbook of this kind is not jequired, and it is certain that a more clearly-arranged little work of the kind could not be foujid.' — Scotsman. ' A little Manual written in the simplest possible style, but contain- ing invaluable advice and instruction for those who have to act as midwives. Bistrict visitors who should distribute copies of this , pamphlet to poor mothers would save them much unnecessary misery.' — IMercury World. ' We have very great pleasure in bearing testimony to this excellent little pamphlet. Monthly nursing, as it at present exists, is not at all in a satisfactory condition, and it is a relief to be able to get at some sensible advice and suggestions— Dr Husband supplies them here,' — Medical Review. VJe supply the above two VV^orks on special terms to District Visitors and Institutions using quantities for distribution. E. & S. LIVINGSTONES' PUBLIGATIOHS. Second Edition. Price Two Shillings net. Bevised in accordance with the British Pharmacopoeia, 1898. 96 pp. Crown 8vo. Bound in Cape Morocco. The Students' Practical Materia Medica. Miss GRACE HAXTON GIFFEN, L.E.O.P.B., L.E.C.S.B., L.F.P.&S.G.J ' Bathgate ' Gold Medallist in Materia Medica, Royal College of Surgeons; Senior Demonstrator of Anatomy, Ladies' School of Medicine, Edinburgh.- ' We recommend this little book.' — Dublin Journal of Medical Science, ' It contains a vast amount of information in small compass. MisB Giffen has produced a work which is likely to become popular with students preparing for an examination.' — Edinburgh Medical Journal, 'Medical students for whose use this book has been prepared will find it of great assistance. The work is clearly arranged, and is of a handy size for the pocket. ' — Publishers' Circular. ' This is a, very concise and practical manual, a summary and resume of the principles of pharmacology, and the nature and uses of drugs with their doses. The method of the arrangement of the chapters is simple and intelligible and the doses ol officinal pre- parations are stated under a system of classification which prevents reiteration aud more readily impresses the memory.' — Glasgow Herald. ' It is at present the most succinct, lucid, and suggestive of all the manuals on the subject.' — Scotsman. 'It contains much useful information for those wishing to arrange and revise their knowledge for examination purposes.' — Medical Press. E. & S. LIVINGSTONES' PUBLI0ATION8. 29 FOTT:Ei,1'-E3: EDIT'IOJir. Price 2s. net. BOTANY NOTES Specially adapted for Students preparing for Professional Examinations in Medicine and Science. The various divisions considered in accordance with the several University Syllabuses, By ALEXANDER JOHNSTONE, F.G.S., AUTHOR OP 'zoology NOTES,' Lecturer on Botany y Sohool of Medicine, ^dinhwrgJi ; and Natmral Science Mastery JBlair Lodge. In reviewing 'Botany Notes,* and 'Botany— a Manual/ The Lancet says 'This little volume entitled " Botany Notes" traverses the same ground as tbe other book, but is rather more suitable for use on the evening preceding Exam. It is not too much to believe that, if the student does not receive material aid from the "Botany Notes" now before us, he bas but small prospect of receiving assistance from any printed matter whatever.'— Zancrf. Price 3s. 6d. net. ZOOLOGY NOTES Specially adapted for Students preparing for Professional, Examinations in Medicine and Science. The various divisions considered in accordance with the several University Syllabuses. By ALBXANDBB JOHNSTONE, F.G.S., AUTHOR OF 'botany NOTES," Jjecturer on Sotany, School of Wedicine, Edinburgh ; and Natv/ral Science Master, JBlavr Lodge. 'This useful little manual is divided into three parts. The first part la devoted to General Morphology, Histology, and Physiology, and to the Protozoa and Vermes; the second part treats of Vermes, Mollusca, and' Arthropoda; and the third is occupied with Classes from Arthropoda to Man. The plan pursued is that a brief account of each class is given, then in succession the! sub-classes and divisions are described, and finally a detailed account of some animal, as the anodonta amongst mollusca, and nephrops amongst crustacei. The descriptions, though short, are accurate.' — Lancet. 3D E. ft S. LIVINGSTONES' PUBLICATIONS. THE CATECHISM SERIES . (NEABLY ALL THE FABTS ABE ILLUSIBAIED.) Price One -Shilling net, each Part. ANATOMY. Part 1 — Upper Extremity. ic 2-^Lower Extremity. .1 3— Head and Neck, Part 4— The Abdomen. „ 5_The Thorax. II 6— Bones and Joints. BOTANY. [In the Press,'] Price One Shilling net, each Part. CHEMISTRY. Part 1 — Inorganic. | Part 2 — Inorganic and Organic. Price One Shilling net. FORENSIC MEDICINE. [ONE PAET.] ' The aim of the Series is to help the student in preparing his works for examination without the aid of a. tutor. The Questions are very suggestive, and are such as are likely to be given at examinations. The Answers are concise and clear. The reading of these books just before going in for an examination will be of considerable use in recalling the most important points to memory.' — Illustrated Medical News. ' The arrangement of questions and answers seems to be admirably adapted for fixing the facts in the mind of the student, and for a busy man preparing for examination nothing could be handier than these booklets.' — Glasgow Herald. E. ft a MVINGSTONEB' PUBLICATIONS. THE CATECHISM SERIES. Price One Shilling net, each Part, MIDWIFERY. [TWO PARTS.] ' Messrs E. & S. Livingstone have made a desirable addition to their Catechism Series of Medical Handbooks. The little work just issued deals with the all-important subject of Midwifery, and is complete in iwo Parts of the usual size and price. Within this small compass there is no inconsiderable amount of useful matter relative to amongst other things— menstruation, pregnancy, parturi- tion, instrumental deliveries, prseternatural and complex labours, foetal complications, puerperium, and the feeding of the infant. This information, conveyed in answers to the many questions set, is intelligently put, carefully prepared, and accurate in detail. The letterpress is interspersed here and there with sketches. To say that these small books will be of help in memorising important points, and of special service when preparing for an examination, is but to reiterate what has been so often expressed in regard to other volumes in this capital series.' — Dispatch College Column. ' Like some of our famous medical contemporaries, we are not altogether in love with the pernicious cram-book. Some men think that by vigorous grinding of a cram-book, for a week or two previous to an exam., work can be easily got up. No greater mistake can be made : slow but sure "absorption" is the only royal road to the happy condition of knowing one's work. After work lias been properly got up, we know of no better way of refreshing one's memory of details than by a judicious use of books such as those produced by Messrs E. & S. Livingstone in their Catechism Series. Midwifery, Part I,, is a very commendable little volume, and its sections bearing on the pathology of pregnancy and the pelvis, normal and abnormal, are first-class. Part IL is very good on instrumental delivery and the pathology of puerperium, whilst a short chapter on the feeding of the young.ster contains much valuable information for men hoping soon to be let loose on the public. As an aid to systematic reading to seniors, we can really recommend those little volumes. 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Price One Shilling and Sixpence net. THIS DISEASES OF THE EYE. A Manual for Senior Students and Young Practitioners. Bt J. AETHUR KEMPE, F.E.C.S., Late Senior Demonstrator of Anatomy, Sttrgeons' Sail, Edinburgh. USED IN THE EDINBURGH MEDICAL SCHOOLS. * It is a hook for those who now require to show a knowledge of the more common eye diseases before passing the final examinations. The arrangement is good, the information explicit, and after the student is done with it as an exami- nation guide he will find it veiy useful in general ^T&cticQ,'— Olasgoto Sirald. 'This book givesapithy digestof thesymptomBanddiacnomsof the commonest diseases of the eye with practical hints as to treatment.*— Z?ai7|/ Frte Pnrss^. E. & S. LIVINGSTONES' PUBLICATIONS. New Edition. Revised and Greatly Enlarged. Price Is. 6d. net. The Students' Pocket Prescriber By H. 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Price 2s. 6d. net. [An EDITION DE LUXE, printed on Dutch hand-made paper and bound in half-morocco, price 5s. net— only loo copies printed.] Illustrated WITH over 100 CHARACTERISTIC SKETCHES & PEN & INK PORTRAITS, TAe Awful and Ethical Allegory OF BEUTEEOIOIY SMITH Or, The Life History of a Medical Student. BY A STUDENT OF MEDICINE. ' Metjsra E. ^ S. Livingstone have favoui'ed us with a copy of tlie above bi'ochui'e, and we have great pleasui'e in commending it to our readers. . . . The chequered career of " D. Smith " is profusely illustrated by a master-hand. Thumb-nail sketches of .the Castle. Artlmr's Seat, Prini-es Street, Torchlight Processions ("for behold the keepers of these houses were men of power and riches, and Meuteronomy heard with awe tliat the greatest of them w'as as a King in tlie land"), the sign of the Tliree Balls, and tlie Elders of the 'J'emple, are only a few of the moi'e noticeable ones. 'Ihe vicissitudes of l»euteronomy's Life were many, and will,, no doubt, strike a sympatheticchord in the hearts of our readers. Let them gather themselves together witliin the temple of Thespis, and sit in the high places therein; yea, even in the "gods" on Students' Nights, as diU our hero. "Last stage of all" (as the Bard of Avon says) is the brass- plate of iJeuteronomy Smith, M.I)., F.H.C.S., etc., and we would wish our readers no better luck, even if they have, like our ft-iend, made occasional aberrations from the paths of virtue.'— 2%e Student. 'This excellent series of University wketches are a sort of Pilgrim's Progress of Edinburgh University stndentdom, recording the gradual development of the medicalj from the crude and chrysaliH stage to that of his full-giown and perfect butterfly existence, and the moral of the tale lies in this, that it is of universal application ; and the medical of to-day can read in it lessons for himself just as sound as the generation for whom it was written. Thehumour of the narrative lies largely in this, that it is written in the Biblical style, which gives to the incidents related a naivete that is often iiTesistihle.' - Colleye Column. Price Threepence. DEUTEEOIOIY SMITH UB, The Life History of a Medical Student. 'This is one of the sinaite&r brochvres that has emanated from the University for a long time.'— Evemnu Exprees. E, & S. LIVINGSTONES' PUBLICATIONS. Crown 8vo., 411 pp., price .3s. 6d. CLAUDE GARTON % Storg of gralrm-jg;^ Mntmi fife. THOMAS J. HENRY, F.R.C.S.E., AUTHOR OF * DEUTBROKOMY SMITH.' ' This highly interesting story by the author of " Deuteronomy Smith,' itself an excellent testimonial, deals with the life and adventures of an Edinburgh medical student. It is written obviously by a man who knows all the ins and outs of our University. Our Professors and customs are faithfully depicted in a skilful and interesting nianuer. Claude Garton conies up to Edinburgh, or Duuburgh, as it is'called in the book, and goes through the usual life of a man up here. We have been unable to find any instance of his being the worse for drink, thereby upholding the well-known sobriety of medical students. He experiences a Symposium, a Eectorial, and Professional Examinations, and finally gradpates. One of the best and most faithful descriptions in the book is that of a Police Court the day after a torchlight pro- cession, Garton falls in love with a damsel called Gipsy, who resides in an establishment known as the Eoyal Britannia, and shortly termed " E.B." It will be seen that the book is well up to date, and deals with incidents of much interest to Edinburgh men. We are introduced to many whose names are curiously familiar. The story is interestingly written, and will be read with avidity by Edinburgh men in partiovilar and medical students in general.' — The Student, ' Mr Henry has given us a very striking book, even more powerful, in its way, than George Moore's masterpiece, " Esther Waters." It describes the experiences of a medical student in Edinburgh, from his entry to the day when he is " capped" for his diploma, and each scene stands out distinct and clear, a triumph of detailed and effective realism. " The dissecting room," " The Eectorial election," " The setting of a star," " The mysteries of quackery," " A chloroform case," " Professor Prean performs an operation," — to read these chapters, and they are a sample of the rest, is never to forget them ; it is as though we had been present at the scenes described. Conan Doyle has done nothing B. & S. LIVINGSTONES' PUBLICATIONS. better, aud they stand comparieon with Mr Henley's poems. The weak points in the book are the story and the hero, but these are throughout subordinate, and their weakness merely goes to show that the author's sense of humour is defective. The defect is not one to be regretted, for, probably, it is the necessary accompaniment of the rare gift which goes along with it. Mr Henry has done for the Medical School of Edinburgh what Tom Hughes did for Eugby ; in the work of either there is something to condone, but the sometMug is as nothing when we regard the whole. The book should be in the hands of all medical students, and of all who are interested in the science of medicine. It does not address itself to others, and the " general reader" had, pei-haps, better keep away from it.' — Sheffield Daily Telegraph ' In "Claude Garton" the career of a medical student during his Ave years' course at Dunburgh University — the indentity of which with the chief of Scottish Universities is thus thinly veiled — is related with unusual ability. So perfect an acquaintance with the customs and routine of the University is revealed as to warrant the belief that the author is describing none other than his own alma mater. Some of the descriptions — especially those of the operating rooms aud a couple of operations therein — are, perhaps, rather too realistic to be pleasant > and we can imagine that not a few sensitive readers will turn from the further perusal of the book with disgust. But they will do well to persevere, for the story is one of extraordinary fascination and dramatic power, and it is, moreover, written in excellent, if somewhat grandilo- quent English. It is not, however, a book for boys ; it will be better appreciated by grown-up readers.' — St Jaines' Gazette^ ' The career of a medical student is a subject that does not suggest material for an attractive story, yet here we have not only a readable but really an admirable book. The ways aud methods of the budding doctor the author has hit off to a nicety, and Claude Garten's connec- tion with Dunburgh University is a refreshing episode of life that is strong in its realism. Many types of character are to be found in its pages that have their counterparts in real life. One dwells with appreciation in the society of Maolvor, Mostyn, and Murchiston ; though sadness describes the feeling at the fate of poor White. The love entanglements of Claude lend interest, at times pathetic, to the work, while the light that is thrown on the ordinary life of the medical practitioner with his difficulties and disappointments, is lucid and entertaining. Jack Lasting, the champion boozer of the University, serves to illustrate the quackery of to-day in all its hideousness. Mr Henry is to be congratulated on this excellent contribution to the season's literature.' — Manchester Cowier. ' As a story this can be recommended to all who like their literature clean and wholesome, and yet with a thorough spice of life and sensa- tionalism. It is the career of a medical student as lived at the great university, interwoven with a thrilling and romantic love story. The action never lags, and the glimpses of science we are allowed to get now and again in the operating theatre and dissecting-room, are up-to-date, and redolent of the newest discoveries. It is" not only a book to amuse, but one from which something of profit may be gained.' — LloycPs Weekly News. K, & S. LIVINGSTONES' PtTBLICATIONS. PUBLISHED ANNUALLY. Crown 8vo, price 2s.; by post, 2s. 3d. IKFMral )3r|ooI (JHlFniiflF FOR SCOTLAND, Is the only hoole that contains all the information required for Oraduatimi in Medicine, Surgery, and Public Health at Edrni- hurgh, A berdeen, Glasgow, and St Andrews Universities; Feliowship, ■ Membership, and Licence of Royal College of Physicians; Fellowship, Licence, and Licence in Dented Surgery; Diploma in Public Health of Royal College of Surgeons; Triple Qualification of Scottish Conjoint Board; Classes in the Universities and Schools of Medicine, with short Syllabus of each Class; Classes and Schools for Women; Dis- pensa/ries, Students' Societies, &c.; also the FBOrESSIONAL EXAMINATIOX aV^STIOXS set by the Universities, Royal College of Physicians, Royal College of Surgeons, a/nd the Triple Board, for several years past; the Universities Prdirnvtuwy Examination Questions set in October and March, and the Prelimina/ry Examination Questions set by the Educational Institute of Scotlamd. ' It is full of the most useful information. It ought to be a most valuable work of reference for the medical studen (.'—Edinburgh Medical Journal. ' Much time and money may be saved by a, careful perusal of this book.'— Medical Press tmd Circular. 'The Medical School Calendar maintains its leputation for comprehensiveness and accuracy of inlormation. - Scotsman. The book is crammed with information on all subjects wliich a student requires to know m pilotmg his way through a course of medical study A naie of well compiled advice to the student as to the most advantageous methSd of study IS given. A glance throuKh the pages of the Calendar shows the extensive provision for medical education in Kdinburgh, and is itself the most pomWin^ argumest for the necessity of the publication.' -.Brfi„6„rff» Evmi^gNem