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Ligature of Femoral inScarpa's triangle.. Ligature of Arteries.—In a work ofthis nature there is no room for anydiscussion of the principles whichshould guide us in the selection of case

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Author: Joseph Bell

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HOUSE SURGEONS, AND

JUNIOR PRACTITIONERS.

ILLUSTRATED.

BY JOSEPH BELL, F.R.C.S Edin.

LECTURER ON CLINICAL SURGERY, SURGEON TO THE ROYAL INFIRMARY

AND TO THE EYE INFIRMARY, AND LATE DEMONSTRATOR OF ANATOMY

IN THE UNIVERSITY OF EDINBURGH.

FIFTH EDITION, REVISED AND

ENLARGED.

MACLACHLAN & STEWART,

BOOKSELLERS TO THE UNIVERSITY.

LONDON: SIMPKIN, MARSHALL, & CO.

1883.

TO THE MEMORY OF

JAMES SYME, ESQ., F.R.C.S AND F.R.S.E.

SURGEON TO THE QUEEN IN

SCOTLANDPROFESSOR OF CLINICAL

SURGERY

IN THE UNIVERSITY OF

EDINBURGHETC ETC

THIS BOOK IS DEDICATED

BY HIS OLD HOUSE-SURGEON AND

ASSISTANTTHE AUTHOR

PREFACE TO FIFTH

EDITION.

To retain the smallsize of the work and to

keep it up to date have

been the Author's aim in

the Fifth Edition

20 Melville Street,

Edinburgh,

August 1883.

PREFACE TO THE FIRST EDITION.

Having been asked, year after year,

by the members of my Class forOperative Surgery, to recommend tothem some Manual of SurgicalOperations which might at once guidethem in their choice of operations, andgive minute details as to the mode ofperformance, I have been gradually led

to undertake the production of this littlework

My aim has been to describe assimply as possible those operations

which are most likely to prove useful,and especially those which, from theirnature, admit of being practised on thedead body.

In accordance with this plan,neither historical completeness of detail,nor much variety in the methods ofperforming any given operation, is to beexpected Hence, also, many omissionswhich would be unpardonable in thebriefest system of Surgery areunavoidable For example, excision oftumours and operations for necrosis arehardly mentioned, because for these nospecial instructions can well be given;for, while general principles may guide

us to what should be done, the special

circumstances of each case must dictate

how it is to be done.

In such a work as this, to attemptoriginality would be undesirable andintrusive; a judicious selection, a faithfulcompilation, are all that can beexpected

That the selection of operationsmay sometimes show "NorthernProclivities" is possible; and this isperhaps not unnatural to a scholar andteacher in the Edinburgh School

An earnest endeavour has beenused to make the references correct andcopious: for any mistakes or omissionsthe author would crave indulgence

The four plates which precede the

letterpress were drawn on wood (fromoriginal photographs) by Mr D.W.Williamson, Melbourne Place, and thelines of incision for the variousoperations were added by the author.

The rough woodcuts scatteredthrough the work were drawn on wood

by the author, and for their roughness he,not his engraver, is responsible He alsohopes that the references in theletterpress will be accepted as sufficientacknowledgment of the true ownership,

in those few instances in which the idea

of the diagram has been borrowed

It has been thought unnecessary tointroduce woodcuts of surgicalinstruments, as the illustrated catalogues

lately published by Weiss, Maw, andothers, are sufficiently accurate.

In excuse of the frequent baldnessand brevity of the style, the author mustpoint to the size and price of the work.Its composition would have been easierhad its dimensions been greater

Though intended chiefly to guidethe studies, on the dead subject, ofstudents and junior practitioners, theauthor ventures to hope that the Manualmay be useful to those who, in the publicservices, in the colonies, or in lonelycountry districts, find themselvesconstrained to attempt the performance

of operations which, in the towns,usually fall to the lot of a few Hospital

JOSEPH BELL

5 Castle Terrace, Edinburgh,

July 1866.

Paracentesis ofthe AnteriorChamber—

Operations forCataract byDisplacement,Solution, andExtraction—Various methods

of Extraction—Operations forArtificial Pupil—Iridesis—

Corelysis—

Iridectomy—Excision ofStaphyloma—

Operations for

Harelip, 175-187

CHAPTER VII.

OPERATIONS ON THE JAWS.

Excision of Upper Jaw

—Of Lower Jaw, 188-195

OPERATIONS ON AIR PASSAGES.

Larynx and Trachea—

On Tenotomy for Wry

Neck and Club

Foot,

296-298

CHAPTER XIV.

IV " " (dorsalview),

V Amputations

of Toes,

VI Excision ofWrist-joint—Lister's,

VII Operations forEctropium andEntropium,

IX Operation forEpiphora—Bowman's,

X Greenslade'sInstrument forabove,

XI Operations forSquint,

XII Linear

XIII Flap

Extraction ofCataract,

XIV Operation of

Corelysis—Streatfeild's,

XV Operation forStaphyloma—Critchett's,XVI Result of

above,

177181

XXIV Nelaton's

Operation forditto,

XXV Operation for

Double

Harelip,

XXVIII Operation for

Salivary

Fistula,

XXIX Operation for

Fissure in SoftPalate,

XXXI Diagram

illustratingOperations onAir Passages,

XXXII Diagram

illustratingOperations forHernia,

XXXIII Diagram of an

Artificial

XXXV Diagram of

Membranousportion ofUrethra,

XXXVI Diagram

illustratingPuncture ofBladder,

XXXVII Diagram of

Operation forPhymosis,

XXXVIII Diagram of

Amputation ofPenis,

5 Ligature of Femoral in

Scarpa's triangle

6 Ligature of Femoral

below Sartorius.[1]

14 Amputation at

Ankle-joint by internalflap—Mackenzie's.15-16 Amputation of Leg just

above the joint

Ankle-17-18 Amputation below Knee

—modifiedcircular

A Excision of Head of

B Excision of Knee-joint;

semilunar incision

3-3

Amputation at joint by triangular flapfrom deltoid—3dmethod

8 Amputation by Single Flap

—Carden's, and Pl IV.16

9-10

Amputation of Thigh—Teale's

A Excision of Hip-joint

B-B

Excision of Ankle-joint—Hancock's incisions

4 Amputation at Ankle-joint—

Mackenzie's, and Pl I.14

5 Amputation through

Condyles of Femur—Syme, and Pl I 19

6 Amputation at lower third of

Thigh—Syme, and Pl

E Excision of Hip-joint—

Gross's

F Excision of Os Calcis

G Excision of Scapula

14-15

Amputation of Leg—posterior flap—Lee's

Spence's, and Pl III 8.

A Excision of Wrist—radial

incision

B Excision of Wrist—ulnar

incision

CHAPTER I.

LIGATURE OF ARTERIES.

Ligature of Arteries.—In a work ofthis nature there is no room for anydiscussion of the principles whichshould guide us in the selection of cases,

or of the pathology of aneurism, or thelocal effects of the ligature on thevessels One or two fundamental axiomsmay be given in a few words:—

1 In selecting the spot for theapplication of the ligature, avoid as far

as possible bifurcations, or the

neighbourhood of large collateralbranches.

2 A free incision should be madethrough the skin and subjacent textures,till the sheath of the artery is reachedand fairly exposed

3 The sheath must be opened andthe artery cleaned with a sharp knife tillthe white external coat is clearly seen.The portion cleaned should, however, be

as small as possible, consistent withthorough exposure, so that the ligaturemay be passed round the vessel withoutforce

4 As the artery should never beraised from its bed, it is generally

advisable to pass the needle only so far

as just to permit the eye to be seen pastthe vessel The ligature should then beseized by a pair of forceps and gentlypulled through, the needle beingcautiously withdrawn When catgut isused, it is better to pass the unarmedneedle till the eye is visible, then threadand withdraw it, thus pulling the catgutthrough

5 As a rule, the needle should bepassed from the side of the vessel atwhich the chief dangers exist This willgenerally be in the side at which the veinis

6 The ligature should be single,and consist of strong well-waxed silk,

and should always be drawn as tight aspossible, so as to divide the internal andmiddle coats of the vessel In caseswhere the wound is to be treated withantiseptic precautions and an attempt atimmediate union made, the ligature may

be of strong catgut properly prepared,and both ends of it may be cut off

7 Before the ligature is tightened, it

is well to feel that pressure between theligature and the finger arrests thepulsation of the tumour

Ligature of the Aorta.—It has beenfound necessary in a few rare cases toplace a ligature on the abdominal aorta;

no case has as yet survived the operation

beyond a very few days, but they have intheir progress sufficiently proved thatthe circulation can be carried on, andgangrene does not necessarily resulteven after such a decided interferencewith vascular supply.

Operation.—The ligature may be

applied in one of two ways, the choicebeing influenced by the nature of thedisease for which it is done

1 A straight incision (Plate I fig.1) in the linea alba, just avoiding theumbilicus by a curve, and dividing theperitoneum, allows the intestines to bepushed aside, and the aorta exposed stillcovered by the peritoneum, as it lies infront of the lumbar vertebræ The

peritoneum must again be divided verycautiously at the point selected, and theaortic plexus of nerves carefullydissected off, in order that they may not

be interfered with by the ligature Theligature should then be passed round,tied, cut short, and the wound accuratelysewed up

2 Without wounding theperitoneum

A curved incision (Plate I fig 2),with its convexity backwards, from theprojecting end of the tenth rib to a point

a little in front of the anterior superiorspinous process of the ilium At firstthrough the skin and fascia only, thisincision must be continued through the

muscles of the abdominal wall, one byone, till the transversalis fascia isexposed, which must then be scrapedthrough very cautiously, so as not toinjure the peritoneum, which is to bedetached from the fascia covering thepsoas and iliacus muscles, and must beheld inwards and out of the way by bentcopper spatulæ The common iliac willthen be felt pulsating, and on it the fingermay easily be guided up until the aorta isreached.

The really difficult part of theoperation now begins: to isolate thevessel from the spine behind, the inferiorcava on the right side, and the plexus ofnerves in the cellular tissue all round.The cleaning of the vessel must be done

in great measure by the finger-nail, andmuch dexterity will be required to passthe ligature without unnecessarily raisingthe vessel from its bed, especially as thevessel itself may very possibly bediseased, and the aneurism of the iliactrunk for which the operation is requiredwill displace and confuse the parts, andmay have set up adhesive inflammation.

Results.—Operation has beenperformed at least ten times By the firstmethod by Sir Astley Cooper and Mr.James; by the second by Drs Murrayand Monteiro, M'Guire, Heron Watson,and Stokes, and Mr South, and Czerny

of Heidelberg All the cases provedfatal; Dr Monteiro's survived for tendays, and eventually perished from

hæmorrhage; the rest all died at shorterintervals.

Iliac.—Anatomical Note.—This short

thick trunk varies slightly in its relations

on the two sides of the body As theaorta bifurcates on the left side of thebody of the fourth lumbar vertebra, thecommon iliac of the right side wouldhave a longer course to pursue than that

on the left, if both ended atcorresponding points However, this isnot always the case, as has been pointedout by Mr Adams of Dublin, as the rightcommon iliac often bifurcates soonerthan the left does With this slightdifference, the position of the two

vessels is precisely similar, eachextending along the brim of the pelvisfrom the bifurcation of the aorta towardsthe sacro-iliac synchondrosis for abouttwo inches Sometimes the divisiontakes place a little higher, even at thejunction of the last lumbar vertebra andthe sacrum This variation dependschiefly on the length of the artery, which,

as Quain has shown, varies from oneinch and a half to more than three inches.The anterior surface of botharteries is covered by the peritoneum,and each is crossed by the ureter just as

it bifurcates into its branches

The artery of the right side is inclose contact behind with its

corresponding vein, which at its upperpart projects to the outside, and below tothe inner side The artery of the left side

is less involved with its vein, which liesbelow it, and to the inside The right is

in contact with a coil of ileum, the leftwith the colon The inferior mesentericartery crosses the left one, while to theoutside of both, and behind them, lie thesympathetic and obdurator nerves

There are no named branches fromthe common iliac

Operation.—The chief difficulties

to be encountered are—1 The closeproximity of the peritoneum, andspecially the risk there is that it hasbecome adherent to the sac of the

aneurism; 2 The depth of the parts, andtendency of the intestines to roll into thewound; 3 Specially on the right side, theproximity of the great veins With theseexceptions the passing of the ligature isnot so difficult as in some situations, thelax cellular tissue in which the vessellies generally yielding much more easilythan the tough sheath which elsewhere,

as in the femoral, requires accuratedissection

Incision.—(Plate I fig 3.)—From

a point about half an inch above thecentre of Poupart's ligament, a crescenticincision should be made, at firstextending upwards and outwards, so as

to pass about one inch inside of theanterior superior spine of the ilium, and

then prolonged upwards and inwards, asfar as may be rendered necessary by thesize of the aneurism or the depth ofparts It must extend through skin andsuperficial fascia, exposing the tendon ofthe external oblique, which must then beslit up to the full extent visible Thespermatic cord may then be easilyexposed under the edge of the internaloblique, and the forefinger of the lefthand inserted on the cord, and thusbeneath the internal oblique andtransversalis muscles, the peritoneumbeing quite safe below.

On the finger these muscles may besafely divided to the full extent of theexternal incision The deep circumflexiliac artery if possible should not be