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cally, and stitch the angles to the integument. Remove the acupressure-needle, also the tape.
SHORTENING OF THE ROUND LIGAMENTS.
Place the subject on the back. Shave the hair from the mons veneris.
Begin an incision just above the spine of the pubes, and continue it three inches outward and slightly upward, parallel to Poupart's ligament. Cut the integument and fasciæ, and expose the aponeurosis of the external oblique with the intercolumnar fibers joining the two pillars of the external abdominal ring. Divide the intercolumnar fascia, and nick the aponeurosis of the external oblique, to expose the contents of the inguinal canal.
The round ligament is readily known by the direction of its fibers. It is enveloped in fat.
Carefully separate the exposed portion of the round ligament from its attachments. Draw upon the round ligament, at the same time having the uterus pushed forward by an assistant's finger in the vagina. The ligament will become relaxed. loop of an inch or more in circumference is now formed, the remainder of the ligament becomes taut.
Repeat the operation on the opposite round ligament.
Draw the loops of the ligaments inward, and stitch them to the deep fascia above the pubes.
Stitch the divided aponeuroses of the external obliques; also the pillars of the rings.
Provide for drainage, and stitch the wounds.
Place the subject on the back.
Stretch the scrotal coverings over the testis. Begin an incision just below the external abdominal ring, and continue it downward over the testis to the bottom of the scrotum. Divide the tissues over the cord. Separate the cord, and throw around it a silk ligature, leaving the ends of the ligature hanging. Divide the cord between the ligature and the testis. Seize the testis by means of forceps, and cut its attachments to the scrotum. Ligate the spermatic artery, artery of the vas deferens, and the cremasteric artery.
Separate the silk ligature from the cord. Provide for drainage from the bottom of the wound. Approximate the cut edges by means of the continuous suture. A row of quilt sutures should be made one half inch from the margin of the wound, as after resection of the scrotum.
OÖPHORECTOMY. Place the subject on the back. Shave the hair from the hypogastric region and from the mons veneris. Empty the bladder.
Perform a median laparotomy, beginning the incision one inch above the pubes, and continuing it upward four inches. (Remember that the sheath of the rectus is deficient for the lower half of the distance between the umbilicus and the symphysis.) If muscular fibers are divided in the wound, the above caution is pertinent.
Push the intestines aside, and feel along the posterior surface of the broad ligament for the ovary. Separate any accidental attachments, and draw the ovary up to the wound. Transfix the attachment of the ovary by a needle carrying a double ligature. Any large vein or the tube must be avoided. The needle should not have cutting edges. Cut the ligature from the needle, and tie each half of the transfixed tissue separately. Sever the attachment of the ovary between the ligatures and the ovary.
The contiguous portion of the Fallopian tube is generally removed with the ovary. Ligate any vessel that can be discovered. Remove with a small scoop or cauterize the lining mucous secreting cells of the Fallopian tube on the cut surface of the pedicle. Allow the pedicle to drop back into the peritoneal cavity.
The other ovary may be likewise removed.
Perform the abdominal toilet, and then close the external wound after providing for superficial drainage.
MANIPULATION OF TENOTOME, MYOTOMY, TENOTOMY,
FASCIATOMY, SUTURING OF TENDONS.
MANIPULATION OF TENOTOME.
1. How to hold.-Hold the tenotome as a pen.
2. How to use.—Enter the point of the tenotome perpendicularly to the surface. The blade must be advanced with its side parallel to the tissue to be divided. The point must reach to the distal border of, but not beyond, the tissue to be divided. When the flat of the blade is in contact with the whole tis. sue to be severed, turn the handle of the tenotome to present the edge at a right angle.
Make the edge cut with a slight sawing move. ment.
When the tissue is divided, withdraw the tenotome in the same manner that it was introduced.
Sterno-cleido-mastoid.-Place the subject on the back. Turn the head from the side to which the muscle belongs, to make it taut. Stand on the same side as the muscle.
The muscle can be clearly located. Draw the integument inward over the sternal attachment. Enter the sharp point of the tenotome over the external border of the tendon, and with a slight move. ment of the point cut the fascia along the external border. Withdraw the tenotome, and introduce a probe-pointed tenotome to the outer border of the tendon. Relax the muscle by turning the head slightly to the side of the operation. Introduce the probepointed tenotome beneath the tendon, following its posterior surface to its inner border. Place the left thumb so that the tendon will lie between it and the tenotome. Make the tendon taut by turning the head away. Divide the tendon, making pressure with the left thumb at the same time over the tendon.
The thumb can appreciate with great accuracy the advancing edge, and regulate accordingly the required movement of the tenotome and pressure of the tissue against its edge.
When the tendon is divided, begin to withdraw the tenotome. Follow the tenotome as it is being withdrawn with the left thumb, until the thumb is over the wound. As soon as the wound is uncovered, close it with a square piece of plaster, to prevent the entrance of air into the track of the knife and the space made by the retracted tendon.
To divide the clavicular attachment, draw the integument inward, and pass the tenotome as before from without inward beneath the tissue to be divided. Proceed as in the former operation.
The division of this muscle at the level of the spinal accessory nerve will be considered in the operation of neurotomy of the spinal accessory.
Flexors Sublimis and Profundus Digitorum and Longus Pollicis.-Supinate the forearm, to bring the palm of the hand uppermost. Pinch
the tissues over the middle of the proxi