NE W E LE ME NTS

O P E R A T I V E S U R G E R Y

ALF . A . L. M . V E LPE AU,

L E THE FACULTY E D NE PARIS U GE N THE H T L HA E SURGICAL N P A LA. C RITR PROF SSOR OF C I IQ U OF OF M ICI OF , S R O OF OS I OF , YA ACADE MY OF M ED NE T T T T E BE THE L _ IE N E E TC . M M R OF RO ICI , OF I S I U ,

CARE FULLY RE VISED E NTIR LY RE M DE LLE D AND AUGME NTE D WITH , E O , A TRE A TI S E O N M I N O R S UR G E R Y ;

ILLUS TRATE D B Y OV E R 200 E NGRAV INGS INCORPORATE D WITH THE TE X T

ACC OMP ANIE D WITH

AN ATLAS I N Q UARTO OF TWE NTY- TWO P LATE

T N PA . PE ATI VE P E A T T EP E EN ING THE P L E G L IN EN S &o. R R S RI CI O R ROC SS S, SUR IC S RUM ,

ICAN FROM THE LAS ARI THIRD AME R , T P S E D ITION.

TRANSLATE D B Y N E . T W P . S O S ND , M . D

’ L E P ICIAN O THE S E AM E N S RE RE I OR Y E LA NE W Y K. AT H S T T AT, STAT N S ND,

AUG-ME NTE D B Y THE ADDITION OF S E V E R A H UN D R E D P A E S O F E N T I R E N E W M A T T E R L G L Y , COMPRISING ALL THE LAT E ST IMPROV E M E NTS AND D ISCOV E RI E S IN SURG E RY IN AME RIC A AND E PE T T T UP THE P E E N E . URO , O R S IM

NDE THE PE V N OF AND WITH N TE AND B E VAT N B Y U R SU R ISIO , O S O S R IO S

V ALE NTINE M OTT, M . D . ,

P ROFE OR OF THE OPE R ION OF URG E RY WI URGIC L AND P OLOGIC L N OMY IN THE U IV E R I Y OF NE W ORK FORE IG SS AT S S TH S A ATH A A AT , N S T Y ; N O I I ROY LE D E M E D E CINE OP PARI OF 0 ? B E R I B R C E OF THE C E M C L U E L E E TC . ASS AT A AD A S, THAT N, SS S, ATH NS,

I N T H R E E V O L U M E S .

A T L A S .

N E W Y O R K S A E S W I I A W O O D M U L . L L M , 1 T E E T N . 26 E ARL R o P S .

1 85 1 . E nt r d a ccord i n to Act of n r ss in the ea r 1 847 b e e g Co g e , y , y

‘ A E L . W LL A W D S MU S I I M OO , ’ - In the Clerk s 0 5 03 of the Dlstrict Court o f the Southern Dis tric t of New York.

n c w rlm r a nd S tereo t er D . Pu ha , P e ) p ,

35 Ann c o rner of Nassa u n a ct. . e

P L A T E ' I

ANNE R IN TH I T M OF HOLD G E B S OURY .

[S E E V OLUM E i . ]

1 i ht B istour with a S rin —Those . S tra a v Fig . p g bistouries th t ha e the handle fixed g y ,

. T possess the inconvenience of not allowing Of their being shut up hose which have _ no_ spring, though they may perhaps be somewhat more easily cleaned, are handled with less facility ,

‘

one n Of . A while this might, if ecessary, be substituted for all them sliding button, such as

b M. C e for n n . exists o those made y harri re , is moreover an excellent substitute the spri g 2 C nvex r b f m Fig . . o cutting edge Of this bistou y eing uni orm fro the point b the to the heel it is more convenient than those in which the blade , roader in middle part than ,

o n one . posteriorly, has a cutting edge only half of it, or on its two anterior thirds

— ‘ wi h a n E n lish orm In E Of 3. B istour t Fig . y g f ngland they scarcely make use any other than

d . T h small convex bistouries , movable on their han les heir use, which is_ convenient w en it is a d matter of importance to keep the instrument at a very short distance from the parts to be ivided , e a w b e is never absolutely called for, and th French bistoury may l ays substituted for them . — - lun t oin ed or B utton z oin ted B istour . This 4 . S tra i ht B t Fig . g p , p y is the bistoury with which sta h lora h w h the tonsils are excised when we perform p y p y, and the one ith whic we enlarge & c . certain abscesses, fistulas , osi on o r c 5 . F irst P ti n . e Fig , the onvex bistoury held in the full hand, with its cutti g edg downwards . Th i h i s 6 . e W t t Fig . same position , or the bistoury held in the full hand cutting edge upwards.

. 7 . S econd P osition m bo Fig , the cutting edge of the bistoury held in the anner of a w a nd facing downwards . . h 8 . T e Fig . same position , with the cutting edge facing upwards . '

- 9 . hir osition a s a i i d . d P w r t n en n T . Fig , or the bistoury held g p , the cutti g e ge upwards

1 0 . S a d h . n t e i vr st. Fig ame position , point of the bistoury turned backwards or towards the y

1 1 . r h . F t P osition ou u a . Fig , the bistoury held as a pen , with the c tting edge upw rds

12 . S Fig . ame position , and the point of the bistoury turned backwards . 1 . 3. F i th P osition u Fig f , the bisto ry held as a bow , the cutting edge transversely .

S uTURE s

m r e — 1 . i le o In terr a S r A . 4 S u ted o n utu e A A N o r o f Fig p p , ( p i ts separ s) , , , ooses [ points]

B R - . B B n or the suture , , , osettes, or bow k ots , which fix fasten each of its points . — 1 . B n . 5 The usti fa ufil S uture A A E d Fig g (en ) , , xtremities of the threa , and which are o c m to be knotted separately , and which have been left free i n order t o prehend the nature Of

. B B B P the process better , , , oints Of the suture .

6 . w . 1 Fig T isted S uture. — — . 1 7 . uilted S uture A A um la stic Fig Q , cylinder of adhesive plaster wood, whalebone e or , , g ,

' on Of n B S e d lin o h - Of . c der f metal , fixed one side the wou d by the nooses each thread , con y ad e e d of sive plast r, on which is to be fastene by a knot the free extremity each point Of the suture . ’ ’ — . 1 8 . S ira l Whi or Glover s S uture A A E the t d Fig p , p, , , xtremities Of thread a li tle rawn u B . B B P pon in order to tighten their turns , , , oints of the suture .

P L A T E I I .

LIGATURE OF ARTE RIE S .

The on a - Fig. X . arteries raised up, as m ny sounds , are seen on this figure at the great majo The rity of points where the surgeon is called upon to cut down to them . patient is represented o f in a convenient position for a ligature upon each them , except that we must suppose him Th e of to be lying horizontally for that upon the external iliac . hands , instead being placed from above dow nwards should be in a contrary position for the carotid and subclavian , but if placed , The r re re- so here they would have concealed the parts Of the figure too much . other figu es p

of th e . T sent Of their natural size, each wound kind at present under consideration hey retain , its number and form .

E AD NE CK AND UPPE R E XTRE IT . H , , M Y

T A 25 . Fig . Ligature upon the emporal rtery

26 on A . Fig . . Ligature the Facial rtery

the A . 27 . on Fig . Ligature Lingual rtery

O Ar . 28 . on Fig . Ligature the ccipital tery

— - 1 Li a ture u on the Ca rotid 1 I 1 The of n m n Fig . . g p , , , lips the wou d in the integu e ts pro 2 The m oides perly separated apart . , platysma y muscle divided and drawn aside with the — - The . 4 The n skin . 3 sterno mastoid drawn outwards , omo hyoideus crossi g the artery and ,

- - - 5 Th 6 Th e d . r . e . dividing the inf a hyoid region into two triangles , sterno hyoid , sterno thyroi

7 The fi brous layer which separates the muscles from the vessels , incised vertically and turned , ’ Th the . 8 e back towards inside , that is , toward the trachea , clavicle, which the skin allows of A Th e being perceived through it . , common carotid artery disengaged from its sheath in the

- o d Th u u b f . e omo tracheal triangle and raised p y the extremity a soun V, jugular vein p shed N The - the back to the outside . , pneumo gastric nerve , situated between the vein and artery , N’ Th e s o f h and naturally concealed by these two vessels . , de cending branch the nint pair of nerves . F 2 S la i n Arter outside o the S a len us An ti us M uscle —1 I 1 I C n u i . The ubc v a c c g . y f , , , , o to r 2 7 o . C of . 7 D f and lips the wound , , irection the clavicle , ervical border of the trapezius

3 C o - 4 O - 5 S . f muscle , lavicular root the sterno mastoid muscle . , mo hyoideus . , calenus 6 The of n anticus . , aponeurosis freed of its adipose layer and the lymphatic ga glions , and then T m di r . A he u n vided and aised up , subclavian artery issuing fro the chest, raised p by a sou d or from before backwards and from within outwards, between the tubercle of the first rib the a A ’ Th a . e scalenus muscle and the lower cervical branch of the br chi l plexus , posterior cervical

o f r . artery , which passes between the nervous cords the plexus in order to reach to the ear The fa r V, external jugular vein, which is very voluminous in this subject and situated very ’ . The d to posteriorly V , subclavian vein partly concealed by the clavicle, and procee ing cross of b the the anterior surface the scalenus, in order to enter into the chest, while passing ehind

' - N B . N N o f sterno mastoid muscle , , , undles which contribute to form the nervous plexus the N’ N’ D . n v axilla , , escending superficial bra ches of the cer ical plexus, otherwise called the su ra - a cromia l p nerves . — ' D E SCRIPTION OF PLATE II C ONTINUE D .

he Axilla r Arter la id ba re rom b ore ba ckwa rds —1 1 1 1 C o f 3. T Fi . g y y f ef , , , , ontour the

2 2 The i . 3 3 3 S of wound . , , ad pose and the aponeurotic layer , , , ection the pectoralis major 4 U mi — di o di Of . nor a se divided in the rection its fibres , pper border Of the pectoralis p pelotons

- Th t . A e r and the deep seated aponeurosis orn , axilla y artery brought forward by the sound, a n s after h ving been disengaged from behind the vei , which is on the in ide, and from the nervous ’ ’ h the . A A The branch nearest approximated to the chest, whic is on outside , , acromial and a the anterior thoracic branch, which come by common trunk from the principal artery . ’ The i n arm Th e . V, axillary vein V , cephalic ve n arrivi g from the in order to join the axillary .

N The r of al xu . , fi st branch the brachi ple s — 2 - 1 1 1 1 C . 2 T 4 . h B ra h Ar er h e Fi . e c ia l t g T y , , , , ontour Of the wound , , enveloping apo

3 3 A r h - neurosis . , , nother aponeu otic layer, which serves as a common sheat to the nervo 4 The la . vascu r fasciculus , fibrous partition which usually separates the artery from the A The i e. med an nerv , brachial artery raised up from before backwards, that is , on its passage

m o . C . fro the biceps muscle t wards the inner portion of the triceps V, V, ollateral veins $ ’ N The i . N The . N Th e Th e l e . V , basi ic v in , med an nerve , cutaneous nerve ulnar (or cubital) nerve .

h B ra hia Arte in the Fold or B en d the l 1 1 C h e . Fi . 5 . T e c l r t g y of , , , ontour of wound 3 2 2 2 The a di . A , , , poneurosis vided and turned back to the outside , portion Of the brachialis Th “ . A e . 4 S internus muscle , heath of the artery , artery raised up from without inwards ,

- I s i . v . t . or abo e the aponeurotic expansion Of the biceps V, collateral [ e associate accompany ’ N A o f m usculO- cuta neo s n N The . u ing] vein . , median nerve , branch the erve , separated

Of c . aside by means a hook, at the same time with the orresponding lip of the wound —L 2 2 h l 1 1 1 Th e . o f Fi . 6 . T e Ra dia l Arter a bove g y , , , , contour of, the wound , , First layer 3 The i on . the aponeurosis, d vided and turned back its borders , inner border of the supinator

‘ u 4 S r . 5 The flexor or radii longus m scle . , econd layer of the aponeu osis , i digitorum sublimis [

6 The of i . A The or . superior superficial] muscle , tendon the pronator radi teres muscle , ’ N n . C . artery raised up between the veins . V, ollateral veins V , , superficial vei and nerve — 7 1 1 l C . 2 2 2 F i . h 1 F . T e Uln a r Arter a bove g y , , , , ontour Of the wound , , , irst aponeurotic

3 m 4 Th e fi exor . 5 5 Th e The fl x r . . e o layer , digitorum subli is , carpi ulnaris muscle , ,

u A The r . second apone rotic layer . artery disengaged from its envelopes and brought fo ward ,

N The . Th e on di . V, collateral veins situated the ra al side , ulnar nerve — - 2 2 . Fi h dia l Ar er below 1 1 The . The . 8 . T e Ra t g y , , contour Of the wound , , aponeurosis 4 The r 3 T flexo r m . , endon of the carpi radialis uscle , pronator radii quad atus muscle behind the A The . vessels . , artery separated from its veins , V — 2 2 3 The F l 1 C of . A . 9 . h Uln r Ar r w i . T e a te belo g y , , ontour the wound , , poneurosis , 4 4 Th e - t of flexor m . endon the carpi ulnaris uscle pushed back to the inner side , , deep seated

A The on . N A i th e . layer of aponeurosis , artery, accompanied its sides by the veins, V , nter or n bra ch of the ulnar nerve .

h hum b a n For n r . Fi . ween t e T d i e g 30 . Liga ture upon the Ra dia l Artery bet ef g

E TRE IT THE LOWE R X M Y. — 1 0 . Fi . The E xtern 2 2 A a l I lia c Arter 1 1 1 C o f th e w . g y , , ontour ound , , poneurosis of 4 A the b n 3 T e m . . h Obliquus a dominis exter us muscle 7 Obliquus abdo inis internus muscle , — D E SCRIPTION OF PLATE II CONTINUE D .

5 n . B ga glion which is sometimes encountered in front Of the artery , orders Of the fibrous ’ A A he - N . T c sheath which separates the artery from the nerve , and from the vein V , ircum “ $ Th - t Of . A e . Ar of inte u flex ar ery the ilium , epigastric artery V, tery and vein the g ments . —l 1 1 1 1 . r r a ov C u o . h F r 2 2 T e em o a l A te b e . The f Fig y , , , onto r of the wound , , first layer 4 Th o eu- 3 The . e a n . of the aponeurosis , border Of the sartorius muscle , second layer the p Th or . A e n on rosis, the arterial sheath , femoral artery, accompa ied its outside by the crural N on o f m a n c N’ nerve , its inside by the vein the sa e name V, d rossed by the saphena nerve , n ’ d in and the internal saphe a vein V envelope fat . — 2 h F em ora l Arter below 1 1 1 C u o f 2 The . 1 . e . . T Fig y , , , onto r the wound , aponeurosis

- The k . 4 The 3 sartorius pushed bac to the outside , deep seated aponeurosis, furnishing a , u A’ The the A n v N on . sheath to artery , the femoral vein V, and the cr ral er e , its inner side , o f - great anastomosing artery, which proceeds to ramify itself into the tendon the adductor mag nus muscle . ' — 2 1 he P osterior Tibia l Arter in the Ca l 1 1 1 1 C of . 3. . T Fig y f , , , , ontour the wound , First The 3 Th e u m . 4 aponeurotic layer . , gemellus s perior and the gemellus inferior uscles , 5 . 5 A cellular layer which separates the gemelli muscles from the soleus muscle , , section of

- he m . 6 6 The . A The b t soleus uscle , , deep seated aponeurosis , ti ial (posterior) artery, having ’ P n . The n . N a vein o each side V , , osterior tibial vei and nerve V , internal saphena vein pushed forwards .

— - 1 4 os e l w h Ca 1 1 C of . . he P t rior Tibia l Arter be o t e l . T Fig y f , , ontour the wound First

t . 3 S . 4 Th e aponeuro ic layer , econd aponeurotic layer , tendo achillis placed between the

T - of u . A he C ol two layers the apone rosis , tibial (posterior) artery situated deeper down . V, N The ’ . . B of . lateral veins , posterior tibial nerve V , ranch the saphena vein 1 s r — . he P o te ior b l 5 . i r T Ti a A ter behin d I C of d . the M a lleolus . Fig y , ontour the woun

2 2 - . 3 The i 4 The o f , , First aponeurotic layer , deep seated aponeuros s . , tendon the tibialis ‘ T S ub- . A he N T v . posticus muscle, purposely laid bare , artery . V, Veins . , ibial ner es V , cutaneous veins .

. 31 . I /i a ture on the An terior bia Fig g Ti l Artery a bove. 2 i 3 . r . L a tu e on the An terior ibia l Ar r w Fig g T te y belo . 3 Li . r h 3 . a tu e on t e r a lis P dis Fig g D o s e Artery .

N T I S RUME NTS .

The o f D curved needle eschamps .

The o f J. P . needle L . etit The or li — canulated grooved ga ture holding sound . 2 0 . O and ther curved needles for passing ligatures .

The o d - r r e e obe . needle, y p D ’ esault s needle .

A knot-ti hten r g e . Slide-for e s l c a . p , (pince cou isse )

P L A T E I I I

o f m u m 1 . O a . Fig . rdinary knife edium size, and with its cutting edge nifor ly str ight

2 . S I Fig. traight knife , without a heel , and slightly convex in approaching the point , as ’ S irhenr s P a risl prefer it, which may be had at M . y , ( ) h f . 3. S Fig . traight kni e , also without a heel , and the point of whic is blunt

4 . K . Fig . nife with a double cutting edge, or the ordinary interosseous knife 5 a 5 . B Fig. istoury with a slide ( some have in the amputating c se, but which has no real advantages over the ordinary bistoury . Of C e P s 6 . S a w . , and which may be had M harri re , ( ari )

O d to . 7 . Fig . rdinary saw, here re uced a little over half the size of the preceding o A J ff he r of or . Fig . 8 . T articulated chain saw itken e rey

A e m . 9 . ligature forceps whos for has always appeared to me to be very convenient

1 0 . . Ordinary forceps

T . Fig . orsion forceps

1 2 . . C v . Fig utting pliers , (tenaille incisi e ) 1 3 of N m . . . on Fig eedle a new for , seen its side

1 . A 4 . Fig . needle seen on its face

1 5 1 6 . A . Figs . and ncient needles

1 7 . . A Fig nother ancient needle , having the heel flattened laterally and the eye on the side. 1 8 . O . v Fig rdinary cur ed needle , with its cutting portion of triangular shape . ’

1 . J P 9 . . . d m b Fig L etit s tourniquet, as modifie , and having a ova le pelote .

P L A T E I V

T A N A M P U T I O S .

UPPE R E XTRE MITY. — 1 m uta tion a t the hod —Ordin a r roce s a The Fig . . A p The Flap m et y p s , right hand of f b to cut to m the Operator, holding the kni e , almost horizontally, the palmar flap and re ove the ‘

d 0 . e The hand , which he supports and depresses himself with his left hand , dorsal flap raised

- D a oneurOsis u on rm . Adi o se . , p the fore a f , , p layer and anterior border of the wound g orsal p o m . h h h h D e of m c . l R f the etacarpus , , , , ivid d tendons the extensor us les , adial and ulnar H r r . 10 . a te ies divided , ead Of the ulna The l h h m f m articu ation aving been divided, we perceive in front the ead, , or ed by the union

- of mi a nd . i i The v the scaphoid , se lunar pyramidal bone behind , , corresponding ca ities pre sented by the radius and ulna, and then a little farther on , three fibrous sheaths, one radial , one dl h the of c ulnar, and the other a mid e s eath , which are destined for tendons the three prin ipal bundles of muscles employed in extending the hand or the fingers .

— - . 2 Am uta tion o the h a tion which on Fig . p f The Circula r met od Also the modific c

$ sists in dividin the mu cles rom the bones to the a oneurosisé—a R h g s f p , ight and Of the Operator, Hi d the if b. 0 s d o f . e The of the hol ing kn e , left hand, supporting the wrist, , the patient , part f $ be m I h c one of d of the . ore arm which should e bra ed by the han s assistant j , ncision throug k two h b the The u W . the s in at inc es elow place here the bones ara to be sawed g, m scular n h l of n . h a of u tissues and aponeurosis de uded their integume ts , Fl p skin wit its cellu ar tiss e, ‘

f m o r P o f n a c of kn . It P c of f ud . i c dissected and raised up in the or a , la e e tr n e the ife , la e exit of the knife . A in i the be s it is the right limb , and which has to be turned pronat on, and operator to placed

For - n m be i a . f on the i ner side , the skin ust kept ra sed up by an assist nt the left ore arm it w ould be the corresponding hand Of the operator ;the assistant then takes charge of the hand o f the patient . ' — e — 3. D r . isa ticula ti n o h r o t e A m. m The i b n e ho P rocess the a uthor . Fig f t d. Qf pat ent ei g m c m seated, and the hu erus disarti ulated, the me ber 1s upon the point of being separated from the tl unk . In f b o ln 1 c . place eing front, the Operato , if it is the left limb , would pla e himself behind a The of 0 11 Th n k b. c e f cl , right hand the surgeon acting the nife , le t hand , holdi g the arm to r m in such manner as separate its upper ext e ity as much apart from the trunk as possible ,

v f vor n a - o f the u . e e e The n u fla Of d el with the iew of a i g the pass ge instr ment , , , tria g lar p the r d r d Th wOun . e b of oi , strongly depressed, in orde to expose the bottom of the j ,f, orders the v a n n l umm division reuniting abo e at acute a gle, a litt e in front of the acromion g, the s it Of h f n of u . h G v whic ordinarily orms the poi t departure for the wo nd , lenoid ca ity bordered with a

n u . i C r a o f um n rem ant Of fibro s capsule , a til ginous head the h erus, surrounded near its eck j o f . k The b with a portion the articular capsule , ody Of the humerus exposed to view by the h t e . l The o f in depression of deltoid flap , right hand an assistant placed beh d the patient, which assistant is to compress the axillary vessels while the opera tor is terminating the separation o f the limb .

T m of the o f of a rm his anner suspending course blood through the artery the , and which is the h to b c employed in almost all ot er processes, and appears date its origin as far a k as to D ff c b m n Le ran, is always e e ted y the a ipulation here described .

P L A T E V .

AMPUTATIONS .

S L WE FINGE R AND O R E XTREMITY . 1 — — . o e F r a method Fig . Amputa tion f th inge s Ova l r P rocess of M The right

’ h n 2 of t c the o era tor m and terminating the incisio , , the integumen s, which in ision p had co menced Of c 3 to n o f n on the dorsum the arpus, , in such manner as surround the e tire root. the fi ger .

4 A - o f the d . We , spect wound imme iately after the amputation perceive there from behind for w a of b flexo r rds the extensor tendon , the head the one, the cut surface of the ligaments , and the We . h tendon and its sheath . are to suppose that an assistant is present to separate the ot er of m h fingers apart, and that the left hand the surgeon acts in a proper anner on t at which he is amputating . — — Am uta tion the P ha la n es . The F la Ordin a r rocess 5 The p of g p y p , right hand of

7 . i th e i . the operator, holding the b stoury , and cutting out anterior flap , [ e the palmar,] to separate 6 m i . the second phalanx fro it, and which latter L e . the phalanx] the left hand, , causes to

. An ul vibrate , (basculer,) and endeavors to remove from the first phalanx assistant sho d t of a n mb embrace with his lef hand the root this finger d the thu , while with the right hand he k eeps the three other fingers apart and flexed . — . 2 D isa r i la h M a l 2 he n n on . t cu tion t e et ta rsus. T Fig of and , hands of the surgeo pressi g the on k 3 m m h b - point of the foot and the nife , at the o ent at whic he is a out to terminate the [plan 5 Th 4 The h . e t f . tar] flap which is to cover the ar icular sur ace , bleeding surface Of t is flap , 6 h on m b . T e ul projection which is made the inside by the first cuneifor one , anterior artic ar 7 The f b . 7 7 surface (facette) Of the same one , , , articular sur ace Of the three last cuneiform b of 1 0 o f . 8 The b of h c for e t ones , ottom t e tarsal morti e destined the rec p ion the extremity, , “ ' 9 9 9 9 The u n u of b . the second metatarsal one , , , , cartilagino s articulati g s rfaces the four other

m b 1 1 1 Th o f . . 1 e etatarsal ones , , [cut] extremities the dorsalis pedis artery 3 — m hod —P rocess M The . t . i r Ova la r e Fig D sa ticula tion (f the Thigh . of 2 Th or o f on . e haunch hip the patient, who is placed in a recumbent position his sound side , n h e 4 W 3 1 0 right hand of the surgeon holdi g t knife , hile the left hand , , supports the thigh , the Th of . 5 e separation Of which from the trunk is upon the point being accomplished , Th a nd m . 6 e superior angle and lips of the wound , head of the femur, luxated detached fro the

- 9 9 9 9 The r of l 7 8 The r ul . s coty oid cavity . inter a tic ar ligament divided , , , , cut u face the , ff We m b di erent muscles . ust also suppose here that there is an assistant stationed ehind, with his bed hi n h back turned towards the head of the , and supporting the diseased p, while a ot er assistant is charged with the leg .

P L A T E V I .

TRE P INING — T N H . E XSE C IO S .

THE TRE PHINE .

S b h 1 . Fig. . haft (ar re) of the trep ine 2 C of . m m or Fig . rown the trephine ar ed with its pyra id , ( point ) he . T . Fig 3. perforating trephine Th . 4 . e of h n in c h . Fig crown the trep i e, encased a prote ting sheat

ARTIN. THE S AW OF M. M

The handle o f the instrument . 6 The to b e b m 7 Fig . . rod, (tige,) which in order put into action y its extre ity , has this last 1 b h of 1 . ov inserted into the s aft the trephine , [see fig , a e ]

A 6 on b 9 m v in the 1 0 1 0 . . 8 . Fig concave rowel saw, which the stem ,fixed the all , o es handle , ff 1 1 1 1 . C w of Figs . , oncave rowel cro ns or saws, di erent sizes .

12 A flat c or . Fig . . rowel rown saw

H B RIE RE ’ C A S SAW.

F 13 Th i . . e h h . g andle, w ich is applied against the chest 1 h 1 n h h o . T m 7 d 4 . e k Fig cran , (manivelle,) which by eans Of the wheel , a t ose w ich foll w,

16 the m h 1 5 . put into action the saw , while left hand holds the instru ent by the andle

HE INE . THE S AW OF M.

1 8 . Th . m of e b e h . Fig handle, which is to e braced by the full grasp the and 1 9 1 9 1 9 19 The - h i b m n Figs , , , . chain saw, which is made to turn wit the r ght hand y ea s Of the crank 21 .

. 20 20 20 The d n a h o f our n Figs , , . sli i g rod, (tige coulisse ,) w ich allows taki g a fixed point near the bone to be sawed during the course of the operation .

- 22 S h fl h . . o fi n er il mb d t e Fig . cissors f r the section of a toe or g na i ed ed in es

V P L A T E I I . — TI N TE NOT M . E XSE C O S . O Y

1 he . . T Fig . exfoliating trephine

2 The or ff h . . shaft, handle sta of a trep ine

- - h e s rew d ill ire fond or . 3. T c r t Fig . ( ) turrel Th ni 4 . e . Fig . lenticular k fe

- d . . Th e Fig 5 . four si ed rasp

6 R . Fig . . asp with a point he 7 . T Fig . elevator .

9 . 8 . The m b c Fig . saw with a ova le ba k,

- 1 0 . T he . Fig . little hand saw

2 i o f M . H. L rr . 1 1 1 . The cultella re Figs , saw a ey 1 d 14 . T . Ra imb u . . 3 he of a Figs , same M

. Th 5 . e Fig 1 tenotome of M . D uval .

1 . é . 6 h Fig T e same of M . B ovi r.

. 1 7 . h ae . Fig T e same o f M . S t ss

- 1 8 . . A h bl i m M h unt o nted used b . Fig not er tenotome, wit a p extre ity, y

. 1 9 . Th e c v f of M . O r . Fig ur ed amputating kni e V . nsenoo t

P L A T E V I I I

E XSE CTION OF BONE S . — — — 1 . . E xsection o the flea d o the Humer Arm P roc ss a do ted b the a uthor. Fig f f us . Left e p y In k “a t h h b following this we ma e large riangular flap, , , with its ase above, and at the expense f o i a . The the deltoid, which flap is then raised by the hand of an assist nt stationed behind u o n o f b a s rgeon , with his left hand, g, grasps the diseased arm j divides the head the one , the of the b n ; same as for amputation lim , the capsule and tendo s which surround it luxates the v s of humerus , and exposes to iew the glenoid cavity 6 causes the border the woundf , j ,to be al i e v separated apart or depressed ;fin ly seizes with his r ght hand , the saw , in order to apply , d on low m its blade the body Of the bone, as down as is required by the disease, and then to ake in h it move a slig tly Oblique direction from below upwards . 2 — — . . E xse tion o . Fig c f the Lower Articula r E xtremity of the Hum erus . Ordina ry process The t . A figure represents the left limb , and the pa ient is lying upon his belly fter having cut a o f w t h quadrilateral flap , g, g, at the expense the triceps muscle, hich flap the lef hand raises u at the same time that it supports the a rm we detach the anterior muscular tissues In such p ,

n r l l e e o f h w or - ma ne as to be enabled to g ide between them and the bone a p ate , , t in ood paste “is or board, even a simple long compress folded several times double, and which the hand f

’ l he - a n t d . T s w c charged with keeping in p ace , c is co duc ed in such manner by the hand , that , b u of h i n on its blade falls almost perpendic larly on the body the humerus, while the and , acti g

- U u m m . the fore arm j , is prepared to adapt itself to its ove ents pon the s pposition that it were to o the o f u required excise als extremity the lna and of the radius , there would be nothing more n n rolbn to a to be do e tha to p g downwards the first lateral incisions , and make a third from

w o n - m to j , in order to have two lo er flaps instead of one only , and then to perform the fore ar d on the what we have just escribed humerus . — 3. Fig . E xsection of the Ca rpa l E xtremities of the of M amma B y means o f n n on m i e or H n - an L i cisio we first cut the dorsum of the li b a triangular flap, , f ay i g dis

of a f - engaged the contour the ulna , , rom the soft parts , we glide under its deep seated surface the

b b v n . To dismounted saw , , either by means of a grooved sound , flexible probe , or cur ed eedle a 0 o f d of put this saw into action , it is necessary that the h nd the surgeon , and the hand the m a nd assistant, which hold the handles j , j , j , j , should move concert with each other, that the hand h of the patient should be directed outw a rds and backwards by the assista nt who has f o . We charge it proceed, in the last place , but in the same manner, to the extraction of the o f head g the radius .

FORCE PS AND TE NACULUM .

4 T o f b . . b h o r Fig his forceps , which y means a ook Opening seen at , is very readily shut up , I f m m r . . a n t as is shown by fig , and is at the sa e time ope ed with g eat facility is pre erable to ost

- I of . Of the slide or ca tch fo rceps destined for the same purpose . t is found at the shop M C i harr ere . 5 . T Fig . enaculum , such as is used in France .

P L A T E I X .

CATARACT AND ARTIFICIAL PUPIL.

tra ction a t the m om en t w en the o era tor is termina tin the section o 1 . Cata ra t b E x h Fig . c y p g f —a The of the w b - the Corn ea . right hand an assistant, forefinger of hich , , raises the upper eye , The of m o ut . c lid while the other fingers re ain spread upon the temple , left hand the surgeon , , d o f a - w ritin —en c holding the keratotome , in the manner g p , and dire ting it slightly from above o f h e downwards, while the little finger the right hand , pressing upwards upon the Ophthalmostat , i Th e the s a of . d (of the author,) depresses lower eyelid, and te d es the globe the eye keratotome The he b . traverses t anterior cham er through and through cutting edge j ;of its point g, has o f n emerged from the eye and arrived at the great angle , having glided under the border the ail ’ of h d a ui a nd of the middle finger the left hand , whic nail thus serves for it as a point pp , at the m n of same time protects it fro the surrou ding tissues , until the section of the flap the cornea is completed . 2 Ca ta ra ct b D e ression —The d b b o f Fig . . y p upper eyelid is raise up y the forefinger the left

a of . The hand of an assistant, while the body of the same hand , supports the head the patient b th e rd of c of lower eyelid is depressed y forefinge the left hand the surgeon , who spreads out 6 of n the other fingers upon the root the nose , while with his right hand f he puts into moveme t o f o o T h n fo of . the needle g, the handle which is supp rted the refinger the same hand his is at the moment when the needle having arrived into the pupil and lacerated the anterior capsule of ul r c c the lens in a circ a direction , is applied by its con avity upon the rystalline , in order to b a nd draw it downwards , ackwards outwards , by a simple vibratory or oscillating movement . — — 3. rt i C ro om nd Core om . . A c a l o t ct P rocess the a uthor The a Fig ifi y a y of knife , a . W introduced in the same way as for cataract, has p ssed through and through the cornea hen Th b e . e its point has arrived at , the flap of the iris is found to be completely detached reason w h of n I s . n y the back the k ife is seen here is, because the natural pupil has been pre erved W it b a d of o f ea ithdrawing from to , we take care not to cut through the point the flap the corn , h T t e c . he b d b u c which still remains adherent to s lerotica glo e is stea ied y the ro nded point , o f 4 the Ophthalmostat, . F ’ 5 . P i . I i g hysick s forceps, such as have mod fied it .

6 . Th . e of D r. Ma unoI Fig pupil forceps r. 7 Th . e Fig . small ocular forceps . F 8 9 ’ . . F . urna ri s igs , M lance for incising the cornea . 1 0 4 . Th . e of P f . Fig , ophthalmostat the author, [ ro Velpeau ] ’

. 1 1 . D on Fig upuytren s needle, seen its face and side . 1 2 ’ . . T b B Fig enon s serpette, as modified y oyer . i 3. The F . 1 of g keratotome Wenzel . 1 4 . . The k om of B Fig eratot e eer .

P L A T E X .

I T A F S UL LACHRYMALIS . 1 T r . . The of . Fig his figure rep esents the first stage the operation surgeon , with his right 0 W a b u e d he hand, , ithdr ws the isto ry from the wound g, while with his left hand, , inserts the l i b of st let A d - canu a , y means the y f n assistant, stationed behind, stea ies the external palpe h ' h b w ith his a of t e . bral angle with his left and , and right hand supports the forehead h patient Th e whole process should be conducted in such manner that the canula shall penetrate in - $ pro b n in m portion as the istoury is being withdraw the sa e direction in which it entered, and that it should also glide rather upon the back or posterior part of the blade o f the bistoury than u pon its anterior portion .

. 2 . The o S f . o Fig catheter M erre f Alais .

s C 3. of Piro di . n Fig atheter M .

. 4 5 6 . for Figs , , Lead nails dilating the nasal canal . ’

. 7 . D of P a m a rd . Fig esault s probe, to clear out the nasal cana l through the canula T . 8 . he A Fig probe of nel .

. 9 . The of Fig syringe the same author .

- . 1 0 . C of be Fig opper capillary wire, which is kept in the tube the syphon to prevent its w coming obstructed hen not used . 1 1 Fig . . Long canula to inject the E ustachian tube through the nasal passages . 2 — Fi . 1 . The c g syphon deta hed from its syringe , Th . 1 3. e Fig canula of Laforest . ’ - - . 14 . D n ri ht a n led m ff Fig upuytre s g g shape andrin or stylet, designed for introducing the di er b s ent descriptions of canulas that have circular rims , [ ourrelet ] 1 . The Fig 5 . blunt hook of D esgranges convenient for withdrawing the conducting thread or , stylet from the nasal fossae. 1 6 J ’ . . n Fig urine s i strument . 1 a 7 . Th Th e h . e C n for . Fig plates of abanis, desti ed the same uses ey r alf Opened, and in the state in which they are placed to withdraw the stylet as soon as it is seized by them . 1 Fi . 8. The g canula and spring of Pa m a rd .

1 . Fig . 9 Another mandrin mounted on an ebony handle . ’

2 . . 0 Leca t s Fig sound, which is introduced through the nose, and the beak of which , having h w w - an eye , receives the t read in the ocular angle , in order to dra from above do nwards the di lating meche, into the nasal canal . of . 21 . The l o f Fig canu a Foubert, such as it has been preserved in the cabinets the Faculty

T S hool ' u on here exists in the museum of the c o f Medicine a golden one , which has a bo rrelet its

‘ u b t o f D . pper part, and has much more resem lance than the preceding to hat upuytren

22 . . . A b ut h Fig nother canula of the same kind , straig t and much smaller

. 2 Th 3. e Fig perforator o f M . Montain . 2 4 . . . A of n or Fig canula the atural size , with a bourrelet rim at its upper part 2 . 5 . Th . e P ellier . Fig canula of , as modified by M Malgaigne 2 . 6 . A . M . Fig canula as modified by the author, [ Velpeau ] 2 . 7. The Fig extracting hook of M . Cloquet . ‘ Fig . 28 . Th e M a nec . instrument o f M . 29 . f . 30 . N G o Figs , eedle of M . erdy, for the depression the cataract

P L A T E X 1

INS TR E N OR CATARACT ARTI IA I AND IS U A TS F FIC PUP F L L CHR ALI . UM , L L T A YM S

fo r . 1 . o Fig. Protecting canula cauterization f the os unguis

$ ‘ -kera to tome of 2 . e eedle . Th n Fig the author. ’ G oul s fo r al r m . . . ens b w Fig 3. M canula cauterizing the nas canal f o elow up ards

i . he s . F g. 4 T solid sound of the ame author

A a d . 5 . n Fig. nother sound less curved less commodious

P fo . Fig . 6 . rotecting canula r cauterizing the nasal canal ’ Pellie oin o n . 7 . r s os or Fig punch (p q ) for perforating either the unguis the lachrymal sac . d 8 . he . C u . Fig . T double keratotome of M arron Villards

9 . B Fig . utton scissors for the pupil .

10 1 1 1 2 . s o . P f r out above Figs , , robes and grooved ound clearing the nasal canal from d downwar s . ’ 1 3 or t e D u Fig . . Mandrin , stylet, with an elastic and clef h ad, for withdrawing puytren s canula. 1 S m . 4 n o . Fig . all scissors, concave their border, for artificial pupil ’

15 . D b k m Pe li . v l er s Fig ouble sil er wire, shaped into a dou le hoo , and deno inated elevator , designed for raising the upper eyelid . S ’ i 1 6 . . n a he Fig. M anson s ring for cauterizing the co junct va round t cornea .

1 h L a . . T e . uz rdi Fig 7 . elevator of M

. 1 . Th 8 e l . Fig Ophtha mostat elevator of M . Fardeau

1 9 . n . P D r . Fig . upil scissors of Mau oir 2 . K . Fig 0 . eratotome of Richter

2 . 1 . D m of Jae . l n Fig ouble s ide k ife , or keratoto e ger F 22 i . K g . ystito me of La Faye .

. 23 Th e S i ri Fig . knife of ege st. ’ . 24 . H n on . Fig ey s eedle, seen its edge

. The Fig same, seen on its face . ’

2 . r . . i Fig 5 M . Furna r s forceps for extracting the c ystalline 2 . 6 K o . f . Fig eratotome M Furnari .

2 - or v r i 7 . S f . o r n Fig traight, lance shaped needle, i cising, in a ious directions, the poster or B n capsule , after having extracted the crystalline, ( ee )

i . 2 I Th F u k . e g 8 . nstr ment for breaking up the crystalline in the operation by eratonyxis on border its stem prevents it from entering too deep into the eye .

. T he boo B . . 29 k a c f c Fig needle (aiguille cro het) of eer, seen on its a e The . on . Fig same, seen its edge

30 The ri o i on on of W . . e ne r or Fig . g c ci alker ’ h - 31 . W teet force s Fig . olf s p for the pupil , 32 o F . 33 f f igs , . Various kinds ocular orceps .

P L A T E X I I

TA H I. S P YL RA O PHY.

h s of a a é . The . 1 . T e or Fig lip the division , , have been excised, (aviv es ) three threads T e b b f m h n . o sutures have bee introduced h ir extremities , , hang out the out , and their nooses N are a little depressed towards the pharynx . othing more is to be done than to knot them , and thus close up the fissure . R m of . ec SIon Of . Fig 2 . Angular scissors M oux for co mencing the the fissure

B l n - ointed b 3. u t c Fig . p bistoury, suitable for continuing from elow upwards the in ision begun near the uvula with the scissors . —h older b R I he n edle . . s a en 4 . T e t b a Fig . preferred y M oux ranches , , Op in drawing upon b of c b of d the ring , by means the stem , which traverses the handle, j ;and y means the button . On solidlyr l e w e the contrary, the branches are compressed together;and hold the need e , when act upon this instrument in an Opposite direction .

A 1 22 . 6 A l . 8 T S d f. . . 5 . he Fig . ame nee le by itsel Fig need e used by M lcock at London in

E . 8 . N of . G . 7 . . b . N . Fig eedle of M el Fig eedle M raefe, seen on its edge

1 0 . A Of a . 9 h on . . n . . T e Fig same , seen its face Fig nother eedle the same uthor

- 1 e n dl holdin . S ottea u . 1 . Th ee e Fig . g forceps of M

2 - o r he I 1 . ne dle h lde S n . t . N e t Fig eedle and of M . chwerdt, bent at an a gle like preceding on the la teI a l b n -a i is in other respects so constructed, that by pressing stem , its poi t gs opened ,

b of flexion 0 d . y means the of the spring , which is thus brought near to the handle

- B u no 3 dl ho er of . our o F . 1 New nee e ld n . ig . M g g “ ' G o E Fi 1 4 . of r . i 1 a om e o f D i fi e b ch . . . Ur not e n a g Forceps raefe bel F g 5 . — W 1 6 Kno i ht ner o f G . a Fi . t t one g . g e raefe hile with hand we draw upon the noose , by its tw o b u sw b . branches , , the instr ment , held by its handle, is pushed forward ith the other hand

1 . Fig . 7: The same instrument seen on its side

e dl - h i 1 . dl n e e old er D o . 8 N . n es m n Fig ee e and of M g , curved, pierced , ou ted on a handle, and strongly bent at an angle upon its handle . dle-holde o 1 9 . P nee r f . B o ou . u n Fig rincipal M rg g on .

PI. II. POLY

- i n r h - Fi . 2 A n hte e or b ex re 0. k ot t t g g , w ose gutter ( groove) , changes into a canal at its two mities a a . ,

- 2 k o i h e er D n b . 1 . The n t t n a . t Fig g of esault, with its head bent to an a gle , and its plate cleft

22 A kno t- ti h ener a it . . t Fig nother g , which receives the ligature by its orifice , and fixes by means of its winch b.

- e T n C h a rrI re . a d 23. . Fi . Pol us force s g yp p of M hey are slender, elastic, also exceedingly s n a nd tro g from their peculiar tempering, crossed in such manner as to occupy but very little l space in the Opening of the nostri s .

2 - 4 . h o i h en r of M . a . T e kn t t t e M . A Fig chaplet g ayor , noose of thread passed into the b l 0 c d cl o f piece , and through the small bal s , , the two branches , , which thread, reunited in the h 6 j ;. cylinder , are fixed upon the winc g

II E XCISION F THE TONS I S . I . O L

‘ i n a nd double . 26 27 . A 2 o m o f . . . . 5. T Fig onsill to e M Fahnestock Figs , s mple erig e erigne

C . 2 . 2 o f D . . 9 . T . he Fig 8. T kiotome esault Fig onsil forceps of M haumet

P L A T E X I I I

TRACHE OTO . I. MY

1 The o f . The of Fig. . head the patient is slightly elevated lips the wound are separated a part in order to expose to view more clearly the different layers which it is necessary to divide - B re onnea d as . t u The canula is placed with its concavity in front and downwar s , it was by M

e a a a a of of i . on Mademoiselle P uys gur . , Angles and lips the division the nteguments , , ,

- - c Its . d d The b b S uperficial layer of the cervical aponeurosis . , deep seated layer , , sterno , ,

The o f . i The tw o hyoid muscles . e, lower rings the trachea , canula, with its small rings ,

- . h A r . One a nd seen at its large extremity g, of the largest infra hyoid veins divided , portion of the thyroid body laid bare and pushed upwards by the canula .

he of B a uchot of - 6 . T Fig . instrument , which is a sort flattened trochar, very short, and pro vided the m n with a canula, and designed for performing operation in a single oveme t by means of puncture .

a i h c . B retonnea u one o n . 3 Tw o fl t s Fig . t anulas of M , encased within the other, and seen their edge

R heIr enm . 4 8 . o s Figs . and epresent t p g and the rings seen in front 5 A or é v Fig . . small brush swab ( cou illon) of metallic threads, used for cleansing out the of m uco s1ties interior the canulas , when they are adjusted in their place , and for expelling all V B o G S e P fi 4 f . r ul f h . e X . . or rom t em ( late g , ivalve canula M end on, and the dinary can a,

fig .

(E PHA OTO . II. SO G MY

h - 2 . e b . T The b b e n Fig division of the parts has een completed . istoury is b gIn Ing to pene oe o f a trate into the sophagus f , facilitated as it is by the beak g the sound , which has been h previously introduced t rough the mouth and pharynx, down as far as to the foreign body, with V of (e d a nd n a e the iew making the sophagus project outwar s , in order to dise g g it from the

v u . d A a nd of Of enormous essels by which it is s rrounded , ngles anterior lip the wound the

The - o n - - . e integuments , sterno mastoid muscles the outside , and the sterno hyoid and sterno h . h T e of thyroid muscles on the inside , left lobe of the thyroid gland crossed by a branch the

Th - - . i e V of k of superior thyroid artery , omo hyoid muscle , allowing a iew the portion the primi

ba nd C or o f b . The tive carotid artery in front ofthe thumb ofthe right , on the back the istoury f,f , re ion o f th e (e trachea lying on the anterior and left g sophagus . I F 1 1 . 0 1 one d . . a a Th e igs and nstruments of Vacca, curve , the other straight , , conducting

b Th n h . . . e t e 0 catheter , ri g of elastic stem , which moves the branch

I N II. E XCIS IO O T E N I F H TO S LS .

f 7 . D o ol . C omba t. Fig epressor the tongue , ( ) m o f T . . 9 . b v d h. Fig onsilloto e M Velpeau, armed with its mo a le pique , g,

2 — - . 1 The o . m f . S a int Yves Fig inter axillary ring M .

P L A T E X I V .

HE RNIA.

l A v of u n . a a a a The m Fig . . iew the track and envelopes of ing inal her ia , , , , integu ents

on A of a s su e cia lis - v e . b ci a di ided and thrown back th ir external surface , portion thef p rfi dis

’ - oo to . c A of c of b extem us s ted and drawn the outside , flap the aponeurosis the o liquus A . d abdominis muscle turned down in order to expose to view the subjacent parts , portion of r The e . the obliquus internus abdominis muscle , cut and tu ned towards the median line fl ] , a scia tra nsversa lis m he a scia f , the upper portion of which has been re oved in order to show t f h Th v ro ri a m . e p p g, and the peritoneu , epigastric essels , passing underneath and c of a scia ro ria b - on the inner side of the ord, and situated in the tissue the f p p , etween the peri oneum s r r The tra ns er a lis t a cia t a nsve sa lis . k k i a sci a v s and thef , , spermat c cord, traversing thef , which latter is purposely denuded from it a little lower down , the cord being enveloped by the Th o m m . i e f n cremaster uscle j , as far down as to the scrotu , contour the ri g turned back

b m b d . and to the outside, and prolonging itself elow, in order to for the fi rous envelope of the cor 2 $ . . A A Fig view of the femoral portion of the crural canal . portion of the integuments has Th of b . e of f een removed g, g, g, g, contour the wound which results rom this incision the

i b Th Th s ia la ta . . u r m a c e a sci a s e cia li s . a a a e nteguments , f p fi raised up , , , falcifor layer of thef (1 cl d m 6 the c , , , Venous branches, proceeding to join the fe oral vein , through opening of the s C of the D f . h h h h . w c o f m j ; , , , , aponeuro is otted lines , sho ing the tra k the e oral artery ontour anterior opening of the crural canal .

INS TRUME NTS .

’

P . Fig . 3. ott s bistoury C ’ . 4 . b Fig ooper s bistoury, whose concave border has a extent o r six eight lines at a .

5 . h . T e Ra b a rd . Fig enterotome of M . y h 6 . T e Fig . hernial bistoury of Le D ran .

. The 7 . Fig dilating gorget of Le B lanc . 8 D ’ Fig. . upuytren s enterotome for artificial anus .

P L A T E X V

THE OPE R ' ATIONS FOR HE RNIA.

1 — — In ina l Hé ia . h nd cent . . u rn T e ri ht side S ee V ol. a a a a Fig g g ( skin subj tissues, , , w b h h of hich have been freely incised, are strongly pushed aside y the hands , , the assistant,

‘ o W w h b b. draws aside, in the same manner, the sac , ith his left hand f the surgeon glides ’ P t b 6 e n to u o t s istoury under the upper and out r angle of the ri g, in order incise pwards and The of h of o . c d utwards forefinger the right hand , whic supports the back the instrument, is be a t i . On the same time made to depress the ntestines g, g the left side it would the right hand which would conduct the bistoury, and the left forefinger which would push back the intestines . l r i — — . 2 . Crura He n a he ri ht si a a T d S ee . v Fig g e ( Vol hernial en elopes , , having of to h been divided in the direction of the fold the groin , are drawn the inner side by the hand

o f i n n i . an assistant, who depresses, a contrary direction , the intestines g with his other ha d The b o f b 0 d m h s cutting edge the istoury , held in the right hand , in a direction al ost orizontal, i G b ’ i b m placed upon the concave border of im ernat s ligament, wh ch order it incises fro without i a b Th e o f the - nw rds , and slightly from a ove downwards . e forefinger the hand f pushes intes ti m of t . nes aside , and accom odates itself to the action the ins rument F T i 3. h o f g. e enterotome B elpech . 4 . 5 C he . t . S e P X III Figs and . anulas for trachea ( e late )

‘

P L A T E X V I .

INTE S TINAL S UTURE S .

’ 1 A The Glover s S utureE—The of len thw . . ise Fig , borders the wound situated g , with the

of . . Th e tw o b b of gut, are turned inwards , after the process M Lembert ends , , the thread are o r cut off a to be brought forward and fixed outside, are to be very ne r the intestine, should we adopt the pla n of leaving everything in the belly . ’ B The f m of suture ( Le D ra n a , same or wound united together by the y , whose borders are

he b b b b of - l . T a so turned inwards nooses , , , , the ligature, which are first rolled together sepa ra tel to be n c b y, are afterwards seen all u ited together in , which forms a cord, and which is to e fastened outside .

0 A n o r . In , complete sectio division through the intestine place of invaginating them of J t of b b according to the method M . ober , the two ends f the intestine , , are simply turned ' h i o t e nt e r m uc us h . . T inwards upo coat, according to process of M Lembert, (see above ) hree The a - points c of the free suture unite the divided gut. mesentery has been divided trans versel l d fa cilIt m - y in a direction para lel with the vessels , in order to give greater y to the anipula

ions upon the wound of the intestine . D T or di o f the h h 0 The , ransverse section vision gut, through and t roug , as in the last, ( )

f . D ena n s o . T suture here is made with the three metallic rings M , placed within the gut hese o m - el i The or f u a st c . a o f rings are here g , central internal ring, the external surface which is

of . b b The perceived through a slight separation of the lips the wound , , ends of the intestine , o f each which is folded inwards upon a distinct ring, after which these ends are brought into m a e approximation upon their rings , and thus aint ined, supported as th se ends are , upon the f - . 0 A o o f internal ring , noose thread which , after having passed through the interior the inner a nd e most ring, pierces the intestine externally to the other two, has its two ends firmly knott d , We G one o f . 6 so as to keep the three rings close together see at , the ends ofthe divided intestine o f the end of - provided with its appropriate ring, and the serous or external surface the gut dou

or o f . The o f bled turned in upon the inner surface the ring f , other end the intestine , also turned in r of or upon its appropriate ing, as in the last, exhibits also a portion the common internal ring

d o n of n e . , the point being i troduced into , in order to terminate the operation R A o f o f . a A E i b a rd . , longitud nal wound the gut, treated by the process M y plate of thin m - la stic a m i i o f u e . wood or g , tr versed in its iddle by a noose of thread , , is to be first prepared T n his plate is then to be glided into the intestine, the contour and position of the plate bei g

6 e e. Its m w t designated by the dotted line , , thread is im ediately passed from ithin ou wards , of the b ’ ’ x $ H in such manner as to perforate through the walls elly atf ,j , before the e tremitiesf , ,

. a a The o f . b b The of this thread are tied or twisted together , , right lip the intestinal wound , , h he ll o f m . T e of t of . left lip the sa e wound g, g, g, g, borders the division through wa s the belly

ITHOTRIT C INS TRUME NT L I S .

- 2 . The t G i he xtre . he T e . a a T of . b Fig straight cathe er of ru thuisen , , body the catheter ,

of or e 0 . A mity the stylet mandrin g, g, uniting at with the catheter, and moved by the ring f , vacant space left to show that the instrument is shorter in the figure than in the original . — DE SCRIPTION OF PLATE XV I CONTINUE D .

h . 3. T e c in n of a h Fig same atheter, with its mandrin terminated the crow a trephine , for t e I

of in . T o purpose breaking up calculi the bladder his mandrin , which three round pieces f d cl d c u leather , , , prevent from deviating in the tube , has at its extremity a p lley which receives Th e o f the cord of the bow . opening 6 is for the purpose giving exit to the particles of the cal ’ c l The u us . e b m , in proportion as they are detached from the principal stone , space a ove entioned .

I o - . 4 . n . 4 r b Fig fig , the mandrin , which terminates in a spear lance shaped point , also has a c a d a a of b a of pulley at its extremity , n contains within it a noose , , r ss wire , the two ends

. Th cl cl 6 e . which , , are seen at the other end of the instrument , space above mentioned “ — o h b f M . i on lithotri t r D . 5 . T e a c o C n . Fig lithotritor , , , harriere, that is , the p g , with its key

6 Th e m a a zin a heter . or . H . c t Fig . g of M Leroy M eurteloup, 7 h H l Fi . T e er ussor o f . c . g . p (percuteur) M eurteloup, simp ified

h o t . . F 8 . T e a rti ula ted s o ig. c c p (curet e) of M Leroy

h - o Ra b a rd m . 9 l . T a v c n a f . Fig . e v l e a u M y for e pyema

P LA T E X V I I

LITHOTRITY .

1 he method M h al w Fig . . T of patient is laid in a orizont position , ith his

- u h a lf flex ed bed . The b m seat raised up by a c shion , and his legs out of the calculus , e braced _

three- bra n ched a a a m by the forceps , , , is seen through the bladder, at the mo ent at which the

‘ - n Th e o hea d drill r is begin ing to perforate it . left hand q f the surgeon keeps it one nul s s m steadily firm in the direction against the external ca a , , which latter, oreover, is fixed

0 of m a ndrel-la th e the on o o f - by the head the , and in other direction the free porti n f the litho

b . m A of of h la e , while his right hand puts the bow in motion , portion the rod the drill, w ich is inserted by degrees into the protecting canula o r sheath provided with its leather circular

e or - n on b c box , in proportion as the twisted cork screw spri g (ressort oudin) con ealed in the la l of o l n n . upper branch , , the mandrel, pushes its free portion , and that the bow acts its pu ley b b The of s l h 0 o , , lower part the mandrel, which an assistant holds olid y wit his two hands , ,

a n he r ure- r h d on h . T ess sc ew for t e placed underneath , which glides the portion p j is purpose of n - arresting, when we wish , the expansio of the cork screw spring which presses against the r i n two of d ill , and the screw we notice at is desig ed for adjusting the portions the instrument one m d b of against each other, in the same way as the arked at fixes the lithola e in the interior

- the external or shea th ca nula .

2 . he T m of . Fig . si ple percussor M Heur teloup.

- — 3. he o a T v la n t ston r ri i . . e brea ke b se erre Fig , ( p volant ) — - - h . . e Fig 4 The duck billed screw and percussion stone brea k r t e screw at b.

- - : 5 . The screw so cket or stone brea kers Fig box which may be adapted to the preceding , and ’ w Touzet L E stra n e h hich resembles , in some measure, those that MM . , Leroy and g ave invented .

- . 6 . The ak of . J b c d c b . Cha rriére Fig stone bre er M acobson , modified as is seen at , , , and , y M , a fter my suggestions .

. 7 An vi h . or b or 6. It Fig ebony ce, which is opened shut y relaxing tig tening the screw is in a c m b its opening , that we adjust that portion of the lithotritic apparatus whi h is e braced y the o f m a drel-la he 0 n t 1 m . . bu head the , as seen in fig , t it possesses no erit

. he 8 . T Civi . a Fig urethral forceps of M le.

. 9 . The c h m Fig per ussion a mer.

P L A T E X V I I I . — LIT AS E S OF THE URE THRA. HOTRITY. DISE

INSTRUME NTS OF DUCAMP.

I m 5 . he . ts Fi . T ar m ela s ic tu . a a Th e u t g app a s open , , graduated g T conductor vesical extre ity

b fi in c. The e is provided with a platina socket , and its other end is xed a silver tube cuvette

- o f ca ustic holder o of d . R the , pushed ut its conductor by the head of the forceps f epresents

- i h . The orte ca ustic of D uca m I . P the nstrument s ut up p p, which s still preferred by M asquier, is of metal only near the ring and near the cuvette A gum - ela stic bougie constitutes its middle

I . 8 on . a b m portion n fig , we see the exploring bougie , provided at with oulding wax, fixed of m the portion the instru ent not graduated .

- - . 1 . The blunt ointed st lette of um ela stic d Fig p y working in a catheter g , and designe for m n o f b easuring the le gth the contraction of the urethra, as had een already proposed by M .

B . \Wel n r T t lette s a e b f . s ell and M Van , for penetrating into the ladder in di ficult cases his y has

S . been eulogized by M . égalas

E ND . INSTRUME NTS OF M . LALL MA

f - . 1 A o 3. Fig portion the porte ca ustic sound isolated . 1 2 The n he of . . a a T Fig i strument complete and open . , , sheath, made platina and provided

' i m w hich a llo w s . b The ma b e w th its running ring , button, which y re oved at pleasure, and of

- - o ur o ut or o e e d orte nitra te. pushing drawing in the butt n cuv tt of the p c, a small ball armed

- with a pressure screw to graduate the movements of the centra l stem . 1 T or out . h . f 9 21 . T e l Figs and articu ated mandrin of M anchou, straightening the urethra 1 9 2 . r n h I . 1 t e . n and dep essi g prostate fig , it is seen on its side, while in fig we have its dorsal or concave face .

1 . . 4 A d Fig conical , ilated, emplastic bougie .

- . 1 5 . A um ela stic b h not . Fig g conical ougie, w ich is dilated

- . 1 8 20 . for the b Figs and Forceps extracting small calculi from urethra, or even from the lad W . e 0 o . n 2 f W fi . . a der push it in shut up , as in fig , by means the ring, he it is open [as in g 1 8 u a b c c. ] and we wish to sh t it up , all we have to do is , to draw b ck its root, , into the canula, ,

- 1 6 . Th Fi . e fo rce s fi 5 hea d d . g p (seen edgewise) of the same part, seen [obliquely] at , g

l - - 1 . Th i . 7 e g antero posterior porte ca ustic of M . Leroy .

. 2 . Th e sca rifi ca tor . the uretrotome o f Fig curved with one blade only, otherwise called simple R M . icord . ’

1 0 . . h . Ta nc ou s sca rifi ca tor h o r . Fig M conical dilated , wit three four cutting blades ' ’

. 1 - 1 . . S ta flord s sca rifi a tor c t la ncet sha ed . Fig M , wi h a p head and point

- - . 3. The lentil hea d or b ridle u Fig explorer c tter o f M . Leroy .

4 . . B . a rre s Fig M f instrument for cauterizing from before backwards .

- . 7 . A orte ca ustic m Fig p isolated fro its sound fig . 1 7 . , ’ 6 - . b u he . . tton a ded st lette o f Fig M Leroy s y , made twisted silver wire .

. 9 . An m st lette x Fig articulated scoop ar ed with a y , having a head to fix and e tract calculi B from the urethra, according to the process laid down by M . onnet, of Lyons .

P L A T E X I X .

INS TRUME NTS FOR LITHOTOMY .

1 bu - ke Fig . . A sound with an ebony handle, dilated in its curved portion, and having a tton li

m of D . extre ity, also with a wide [deep] groove upon it, like that upuytren 2 The C heselden Fig . . lithotome which employed in the beginning. f of P o mb . Fig . 3. essary for the deviation the neck the wo Fi ’ 4 D esorm a ux s . . b g . e ilboquet pessary ’ - h 5 . . Ta nch u unnel s a e . Fig . M o s f p d pessary 6 Th . e el roida l Fig . yt pessary . Fi F ’ 7 . oub ert s k his . g. angulated nife for lateral method

. 8 . The o f . C m b . r The o h C . f Fig lit otome F o e , as modified y M ha riere handle this has nei

We - . a dva n ther facettes (pans) nor numbers vary the degree to which its blade is Opened, by or al of b c cing drawing back the button which slides ong the root its as ule or movable piece, on the side of the instrument . 9 The h o f D of b of m a e u- . . b Fig double lit otome upuytren , the Opening the lades which y grad u m m ated and reg lated in the sa e manner as in the last, and which lithoto e has in various respects received important and ingenious modifications from the same cutler . ’

1 . ff 0. R . of S . Fig M oux s gorget, scarcely di ering from that carpa 1 2 i . A f 1 1 . I Figs and male and emale d lator, as formerly used n the great operation . ’

. . l tene te . 1 3. C u t s T i m Fig M harriere s tenac a, ( ) hey are so constructed that in open ng the to m but i b n b of the greatest extent possible , they never ake a sl ght separation etwee the ranches their handle in the w ound . ’ ’ 1 . . . G a n 4 . m a Fig uerin s sound , its vesical and grooved portio , al ost straight , the portion

to h b b n the h c. d d which , being united atf, the corresponding uprig t ranch , , termi ates in ead, , , h c r m f c on v a o a troc ar which passes through the head, , and at the pe ineu , alls at , the groo e , f the sound .

1 5 . . Fig . Pessary in figure of 8 1 h . T e o . Fig 6 . b ndon or bung pessary 1 Fig . 7 . The girnblet pessary .

Fi . 1 8 . Th e 5 n i s r nd . g funnel pessary (see fig . ) see at t lowe e

P L A T E X X .

T LITHO OMY . — T N TR ME NTS . SURGICAL ANA OMY. I S U

1 The b c of to oe ha t ma Fig . . o je t this figure is expose to view the parts that are wounded, y Th o m t e . e n . b e wounded, in perfor ing h operation of lithotomy subject is placed his right side l of n m n it of Al the left side the abdome , co prisi g with the hip and breech [ that side] are n o f The removed in such manner however, that the separatio is outside the median line . , , F C a ul of o f . lithotome j me , placed as it is, wo d almost unavoidably wound the termination the

- l I . The uretro a na l rectum , , should we not take care to elevate its handle in withdrawing it $ ’ k k’ It in k k i triangle , , , represents , its upper border , , the l ne for entering [the bladder,] and by he h r of its lower border t line for the wit d awal the bistoury, which has performed the n is$ f o f n . The o fice ope ing a passage for the concealed lithotome lower a gle , [of this triangle] ’ o n i - It on b l falls the anus , its deep seated angle the neck of the ladder, and its anterior angle r If o n k c h' ul of the u . on the front part perine m the instrument were placed the line , , , it wo d i io in as b o s t n . incise the prostrate without danger as far to while in the p which we see it, it th e c c' would almost inevitably wound the intestine, if we should wish to extend wound , , to ’ If d of r c . beyond the incision were commenced upon the membranous portion the u ethra, it would present some advantages for the extraction of the calculus ;but it would be difficult to b e of avoid the bul , which has the appearance here being strongly curved , in consequence of the

b . remainderf of the urethra being left pendant, and the left corpus cavernosum eing raised up

The m u - T vesicula se inalis , in reality runs no risk, except in recto vesical lithotomy . hen , in s n n b h fact, the inci ion, being restricted between the peritoneal cavity , , and the prostate , w en

of . S of we follow the original process M anson, would expose to the risk also wounding the vas

i . . . The deferens p, or the pouch , [ e the vesicula seminalis,] which runs along its outer side t r r r r r r r r the o f l l peri oneum , , , , , , , , which, from front part the rectum , , ascends upwards behind a a a o f 3 l the bladder , , , in order to line the posterior surface the abdominal muscles , eaves the ’ l T t o o of sub a cent ellu a r . ure er , , and the seminal duct outside it and in the j c tissue hey have

t to o . been raised up in his plate, in order expose the parts t the view better In lithoto r t b hypogastric ny, we first penetrate down to the cellular space , and the ladder may

o f of - afterwards be opened from the root the urachus down to the sheath the lithotome, oppo of site the section the pubis h . 2 Th of H I e . s Fig . . gorget awkins t languette [or small bl unt point] occupies the middle line

o f n . the termination of the blade, which last is regularly concave and cutti g to a great extent

- - 3. e o d a . Th s n e da rd a C . Fig of F . me

T - . 6 . he c s om bi B tot e stour of . elm a s Fig y y M ,

4 i - . The l tho ome ro a b . t t ch r of C e m . W n a Fig F . O he the point has arrived , y puncture, in

the t . 1 d h space of fig , the surgeon firmly holds its body against the pubis , while with the other h a b 0 r d u s s. and he forcibly directs its bascule , and cutting edge , towa s the mbilicus , far as

' 8 The sus ensor - é . . h a crotc e C m e . W Fig p y t of F . hen its extremity is once in the bladder,

$ it . b fi d to u b handle is con ded to an assistant, whose uty it is raise p the organ [the ladder] while it m is being incised fro above downwards . 9 1 . 0. S s Figs and uspensory cy totomes o f M . Leroy .

1 . The . 1 Fig triploid suspensory of M . Leroy .

- . 7 h . T e c stotome so nd Fig y u of M . Leroy .

- Fi . E i 5 . r ne fo rce s o r l k f of . g g p of the author, po ypi and the nec the uterus

P L A T E X X I

LATE RALIZ E D LITHOTOMY .

A i i - 1 . a ss s dnt h a 0 ncli . t Fig n placed on the right, holds with his left and , the sound , while

b . The ning it a little to that side, while with his right hand , he gently raises up the scrotum i i h h u legs , , and the thighs , , flexed and separated apart, and strongly raised p, are held in this h . W d d manner by two other assistants it their hand , , they fix the kneef , f , against their e e e b f b i b ch st;while with their other hand , , they em race the oot g, g, y its nner order and The . t plantar surface integuments and all the sof parts in this figure, are incised down to the Th m of C a . e . bladder lithoto e F me, introduced shut up, is opened, in order to incise the prostate A of m . b b from. behind forwards s the ack its sheath is ade to rest against the right ranch of the a s or of of pubes, rather than directly gainst the symphysi against the upper angle q, the wound b t a b 8 the integuments , its blade there y has almost a transverse direction ow rds the order , and I i h dl m no n r . ts n lo ger towards the angle , of that wound bascule , is held aga nst the an e , by

- k w ho l -embra ces the hand , of the operator, Opens it in this manner, while his other hand , its ar ion b The ticula t o b b of f . , laterally, etween the thum and radial order the flexed orefinger whole

I t be u in- s a li tle more depressed here and more inclined than it should , beca se the wound and m v b to b of stru ent itself would otherwise ha e een, a great extent, concealed y the hands the surgeon .

E NT INS TRUM S . — . 2 . Form o the Ordina r S oun d Its a m i n Fig f y plate , , gives much ore fat gue to the hand tha I on P X I . Its b b b no if it were armed with a handle like that late V eak , though lunted, is in

an d c c c w D u . respect dilated, its groove , , , has much less idth than in that of up ytren

. 3 & o c . f Fig . Forceps for introducing lint, , upon the neck the uterus .

- 4 . . An for m m Fig al canula preventing the rectu fro re contracting.

. 5 . The of E c Fig rectal spindle (fuseau) nglish pra titioners . S . 6 . c h e b c . Fig pe ulum ani , cleft on t a k

P L A T E X X I I .

A AN AN S E XU L ORG S OF WOM . — iva v a nd develo in s eculum M Cha rriere. This to 10 . e tr l e Fig. Th p g p Qf instrument appears It me the most perfect one we have at the present day . is opened and shut up wi thout the

n a nd b . slightest oise , with the utmost ease, almost impercepti ly 1 3 Th e r ul m the a F . . . ig speculum with fou valves and a basc e, ade by s me artist ’ ll i 1 e . 4 . B F g. ug s trellis ( trei age) speculum en ' A f or 1 1 . o . b Fig sort piston, intended for introducing pomades other medicated su stances n upon the eck of the uterus through the speculum , in which last, moreover, it may be used as a or le sort of mandrin sty tte . The o i . 3. n ts Fig womb laid open internal surface, and containing a pediculated polypus , D The m upon which the ligature is being applied by the method of esault . two instru ents on t a brought from behind forwards, cross each other the an erior region of the polypus , in such A or m e e . i anner that the thread , , may strangulate its pedicle fter hav ng turned them once

o n to one of b - twice their axis, there is nothing more be done than to loosen the threads, y push

- in h o i to . The threa d bea rin g the stem int the canula , in order open the forcepsf g tube g being

- kno t ti htener ste s . T v i removed , we apply the g , and the operation p there hough applied ery h gh in e e on up the uterus , as is seen by its situation , , the neck, the polypus nevertheless makes a

c r d d . onside able projection into the vagina ,

h . of a T . h . 4 T e . e Fig ligature applied to a polypus, after the process of M Mayor Laus nne c 0 a d b h ligature , , having been passed around the neck of the morbi mass , and supported t us far

threa d - bea rin e e e i d until by the three small g forks , , , is not nserted into the cylinder after having

h r . 24 o f P t e o f o X . been made to pass through small balls ivory the chaplet, fig late I

‘

5 . The o . f W a Fig double canula Levret . hen the noose accurately embraces the polypus , h T t e b b . a we draw upon threads , , in order to tighten it hese threads are afterwards ttached to w on the rings of the canula, hich latter also is to be turned its axis when we wish to make still greater constriction .

Li a - . 6 . ture b ea rin of D th e a Fig g g forceps esault, modified in this particular, that ring gives m b. movement to it by eans of a screw, and fixes it by means of the catch

i - . 7 L a ture bea rin Fig . g g forceps of Levret . ’ - — . 8 . D screw k i r The h not t htene . 6 Fig upuytren s g body is slit throughout its whole lengt , in e h o T order to enable the fly , w ich is lodged in it, to glide al ng freely . his fly, to which the hr b d n a d t ead is fastene , tightens or loosens the oose , as Often as we act upon the plate , and h without deranging anyt ing .

. 9 . The m m d of 6 Fig sa e instrument, ar ed with a ring , and carrying at the extremity its screw b e o f a utton , instead a plate .

- . 1 . O i ca ustic holder orte cra on Fig rd nary , (p y ,) a little longer than usual, in order to touch e s the neck of the ut ru with nitrate of silver . ’ - . 2 . . Ricord s three bra nched Fig M forceps, to introduce the nitrate of silver without danger i o f n o f nto the interior the eck the uterus . ’ . 12 . . R u Fig M oux s needles for suture of the perine m. ’ . 15 . M. V the a Fig idal s needle for s me operation .