RADICAL OPERATION FOR POLL-EVlL 333 



by means of previously heated irons may be used to excep- 

 tionally good advantage. The field is thus at once cleared 

 of masking blood and the loss, whose total will be consider- 

 able before^ the procedure is completed, is materially dimin- 

 ished. The bleeding walls are well seared by passing the 

 hot irons oven them a number of times. 



Fourth Step. — Detaching the Ligament from the Occiput. 

 — The index finger of the left hand is then passed under the 

 ligament at its point of attachment to the occipital bone to 

 serve as a guide for the bistoury, which is now slipped under 

 the ligament and drawn slowly upward until a complete der 

 tachment is effected. 



Fifth Step. — Dissection of the Ligament. — The liga- 

 mentum nuchse is not a very distinct structure.' On the con- 

 trary, it is very closely fused to the aponeuroses and tendons 

 of the cervical muscles whose attachments it receives ; and 

 besides it is generally enlarged and agglomerated with 

 plenty of new-formed connective tissue, all of which leave 

 rather indistinct outlines to follow. Anteriorly, where the 

 bursa is interposed beneath, is the only unattached portion of 

 the ligament, and it is here that the dissection should begin. 

 The first step to this end is to grasp the now detached end 

 with the tumor forceps, which is then used to lift the liga- 

 ment out as fast as it is dissected loose with the scalpel. The 

 resection includes not only the ligament but also the new 

 connective tissue and the tendinous structures of the supe- 

 rior cervical muscles. In fact, the central structures of the 

 poll (whose anatomical outlines are always indistinct) are 

 virtually all enucleated, laying bare the occipital protuber- 

 ance and the whole superior surface of the atlas. Approach- 

 ing the atlo-axoid space, the dissection is deflected outward 

 so as to leave abundant protection to the spinal cord in that 

 region. Even when the necrotic process seems to overlap 

 the atlo-axoid space, it is prudent to follow this precaution 

 and then remove the remaining portion ten days later, at 

 which time it will have separated from its relations by the 

 formation of a more distinct line of demarcation. 



Sixth Step.— Final Control of the Haemorrhage. — The 

 hot irons are now passed over the parts bleeding most co- 

 piously, haemostatic forceps fastened to any vessels bleeding 

 conspicuously and the wound packed loosely with cotton 

 soaked in antiseptic solution. The latter is retained by sev- 

 eral loosely arranged sutures. The slight bleeding that does 

 not respond to these efforts is left to flow out and arrest spon- 

 taneously. Tight packing and suturing of the wound is dan- 



