Columbia toiber.«itp gj^j \ . in tfjeCitp of i^ctogorfe College of ^fjpsicians anb ^urgeong Reference Ititirarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/operativesurgeryOOhors OPERATIVE SURGERY OPERATIVE SURGERY BY J. SHELTOX HORSLEY, M.D., F.A.C.S., Attending Surgeon, St. Elizabeth's Hospital, Eichmond, Va. WITH 613 ORIGINAL ILLUSTRATIONS Illustrated by Miss Helen Lorraine ST. LOUIS C. V. MOSBY COMPANY 1921 Copyright, 1921, By C. V. Mosby Cojipaxy (All rights reserved) Printed in U.S.A. I^ 3)iX Press of C. V. Mosby Company St. Louis THIS VOLUME IS AFFECTIONATELY DEDICATED TO MY EIGHT CHILDREN '"yiuuL. PREFACE In this book particular stress has been Laid upon the preservation of phys- iologic function and the interpretation of the biologic processes that follow surgical operations. Naturally, a knowledge of anatomy is essential for operative surgery, but in many regions of the body an etfort to conserve or to restore as far as possible the physiologic function of the tissues involved in the operation has often been neglected. Merely following anatomical landmarks and making a beautiful dissection with accurately placed ligatures and sutures should not be the sole aim of the surgeon. These things, of course, should be included in the surgeon's ideals, but it is even more important that the operation re- sults in the extirpation or correction of the pathology, and in the restoration of the physiology of the tissues or organs. One of the chief aims of this book is to emphasize those physiologic and biologic principles which, to some extent, obtain in every surgical operation. The biologic processes that follow the application of surgical drainage, for instance, have been too frequently not considered at all and surgical drain- age has been regarded as solely or chiefly mechanical. The treatment of frac- tures by metal plates or screws produces excellent immediate mechanical re- sults, but a little study of the biologic processes following the use of metal plates should convince the surgeon that this is not a satisfactory operation. Physiologic principles, if logically followed, in operations for ulcer of the stomach and for resection of the intestine, appear to lead to certain definite technics, even though others may be anatomically and mechanically unob- jectionable. The development of collateral circulation around an aneurism by partial or intermittent occlusion of the artery, as has been practiced by Hals- ted and by Matas, is often a much safer procedure than the immediate and permanent occlusion of the vessel. Developing a blood supply in the pedicle of a flap by the gradual dissection of the flap in dit^erent stages, insures against gangrene and makes possible better plastic results because it brings more nu- trition to the reconstructed tissues. There are many other examples that might be cited. No attempt has been made to include in this volume all surgical opera- tions. Such an enclycopedia of operations is found in many excellent text books and systems of surgery. Every operation that I have described is either one that I have done or else an operation that appears to me to be the one best suited for the disease. Frequently, conditions are such that different operations may be indicated for what appears to be the same affection. In order to meet this situation, I have often described several operations, each one of which I believe, under certain conditions, would be appropriate. In this Avay the book is to a considerable extent a record of my personal experience. 9 10 PREFACE All of the drawings are by ]\Iiss Helen Lorraine, exee])t the illustrations of Dr. J. AV. Long's enterostomy, Avhich were drawn l)y William F. Didusch. It is a pleasure to acknowledge my obligation to Mrs. A. C. Norris, my former secretary, -who, in spite of her domestic duties, consented to help in the preparation of the manuscript for this book. She has greatly lightened the labor of its preparation. jNIy thanks are due Dr. W. T. Graham for many helpful suggestions about the sections dealing with orthopedic surgical operations. J. Shelton Horsley. Eichmoiul, Ya. CONTENTS PAGE CHAPTER I Gexekal Considerations 29 CHAPTEE II Surgical Drainage 35 Classification of Surgical Drainage, 36; Drainage Material, 41; Encapsulated For- eign Bodies in the Peritoneum, 42; Criticisms, 42. CHAPTER III Technic, Sutures, and Instruments 44 CHAPTER IV Complications of Operations; Infection, Shock, and Hemorrhage 51 CHAPTER V Transfusion of Blood 59 Technic for Direct Transfusion of Blood, 62. CHAPTER VI Suturing Blood Vessels 69 Lateral and Incomplete Transverse AVounds of Blood A^essels, 90. CHAPTER VII Reversal of the Circulation 92 CHAPTER VIII Ligation of Blood Vessels 97 Ligation of the Innominate Artery, 100; Ligation of the Common Carotid Artery, 101; Ligation of the External Carotid Artery, 102; Ligation of the Superior Thy- roid, 104; Ligation of the Internal Carotid Artery, 105; Ligation of the Subclavian Artery, 105; Ligation of the Vertebral Artery, 107; Ligation of the Inferior Thy- roid Artery, 107; Ligation of the Axillary Artery, 108; Ligation of the Brachial Artery, 109; Ligation of the Radial and Ulnar Arteries, 109; Ligation of the Ab- dominal Aorta, 110; Ligation of the Common Iliac Artery, 110; Ligation of the Internal Iliac Artery, 111; Ligation of the External Iliac Artery, 112; Ligation of the Femoral Artery, 113; Ligation of the Popliteal Artery, 115; Ligation of the Anterior Tibial Artery, 116; Ligation of the Dorsalis Pedis, 116; Ligation of the Posterior Tibial Artery, 117. CHAPTER IX Aneurisms 118 Operation for Aneurisms of Special Arteries, 126. 11 12 CONTEXTS PAGE CHAPTER X Arteriovenous Aneurisms 133 CHAPTER XI Operations for Repair of Nerves 141 CHAPTER XII Operations on Bones 157 CHAPTER XIII Plastic Surgery 172 CHAPTER XIV Operations on the Face and Mouth 187 Cleft Palate, 195; The Lips, 198; The Eyelids, 210; Ears, 222; The External Nose, 224; The Forehead, 236; Tumors of the Face, 238; The Parotid Gland, 240; The Tongue, 245; Upper Jaw, 252; Lower Jaw, 254; Peripheral Operations on the Fifth Nerve, 258. CHAPTER XV Operations on the Scalp, Skull and Brain 261 Operations for Epilepsy, 268; Operations for Hydrocephalus, 272; Operations on the Hypophysis, 275; Congenital Hernias of the Brain or Its Membranes, 276; De- compression Operations, 279; Operations on the Gasserian Ganglion, 283. CHAPTER XVI Operations on the Spine 288 Laminectomy, 290; Spina Bifida, 296. CHAPTER XVII Operations on the Neck 303 Cystic Hygroma and Congenital Cysts, 304; Cervical Ribs, 308; Torticollis, 308; Tubercular Glands of the Neck, 309; Malignant Growths of the Neck, 310; The Larynx and Trachea, 316; Pharynx and Esophagus, 321; The Carotid Gland, 323; Diffuse Lipoma of the Neck, 324; The Cervical Sympathetic, 325; The Thyroid Gland, 326, CHAPTER XVIII Operations on the Upper Extremities 331 Amputations, 331; Excisions, 350; Arthrodesis of the Elbow, 355; Infection of the Hand, 356; Deformities, 358; Subacromial Bursitis, 369. CHAPTER XIX Operations on the Lower Extremity 370 Am.putations, 370; Tendons and Muscles, 385; Deformities of the Ankle Joint, 401; Ingrowing Nail, 406; The Joints, 407; Osteotomy, 417; Arthroplasty, 420; Osteo- myelitis, 421; Elephantiasis, 427; Varicose Veins, 428; The Sciatic Nerve and Branches, 430. CONTENTS 13 PAGE CHAPTER XX Operations on the Thorax Except the MammaPv-y Gland 432 The Ribs, 4;?2 ; Empyema, 437; The Lung, 443; The Pericar.liuni and Heart, 452; The Heart, 453; Paralysis of Muscles of tlic Tlioiax, 4.1S; Tlie Scapula and Clav- icle, 460. CHAPTER XXI Operations on the MamjiapvY Gland 462 CHAPTER XXTI Operations for Hernia 477 Inguinal Hernia, 479; Femoral Hernia, 493; Umbilical Hernia, 499; Incisional or Ventral Hernia, 502; Epigastric Hernia, 504; Diaphragmatic Hernia, 505. CHAPTER XXIII Abdominal Incisions 508 Closure of Abdominal Incisions, 514. CHAPTER XXIV Operations on the Liver, Gall Bladder, Bile Tracts, Pancreas, and Spleen . . 520 CHAPTER XXV Operations on the Stomach 543 CHAPTER XXVI Operation on the Intestines 585 The Technic of Suturing Wounds of the Stomach and Intestines, 585; Enterostomy, 589; Intestinal Resection, 603. CHAPTER XXA'II Operations on the Appendix, Pericolonic Bands, the Loavef^ Sigmoid, the Rectum, AND the Anus 623 Appendicitis, 623 ; Pericolonic Bands, 637 ; The Terminal Sigmoid, the Rectum, and Anus, 639; Hemorrhoids, 654; Pruritus Ani, 659; Sacral and Coccygeal Dermoids, 661. CHAPTER XXVIII Operations on the Kidney, Ureter and Bladder 663 The Kidneys, 663; The Ureter, 675; The Bladder, 684. CHAPTER XXIX Operations on the Prostate Gland, the Testicles and the Penis 690 The Seminal Vesicles^ the A'as Deferens, and Testicles, 700. ILLUSTRATIONS FIG. P^^«^ 1. Eoef or flat knot •^'' 2. "Granny" knot ■*" 3. Grant's method of tying knot with forceps 49 4. Second stage of Grant's method of tying knot with forceps 49 5. Tliird stage of Grant's method of tying knot with forceps 49 6. Fourth stage of Grant's method of tying knot with forceps 49 7. Fifth stage of Grant's method of tying knot with forceps 50 8. Sixth stage of Grant's method of tying knot with forceps 50 9. Seventh stage of Grant's method of tying knot with forceps 50 10. The knot completed 50 11. Incision of abdominal wall 53 12. The author's method of transfusion of blood with the arterial suture staff .... 60 13. Crile's cannula for transfusion 61 14. The vein is drawn through the cannula with a line suture 61 15. The vein is cuffed back over the cannula 61 16. The vein has been cuffed back and tied, and the artery is about to be drawn over the cuff ... 61 17. The last stage of application of Crile's cannula 61 18. Bernheim's cannula for transfusion 64 19. Kimpton and Brown's cannula for transfusion 65 20. Kimpton and Baown's cannula, in horizontal xjosition, showing the trap which prevents the entrance of air iu the cannula 65 21. Incision in skin to expose vein 67 22. Incision in vein for intravenous infusion 67 23. First stage of Carrel's method of suturing blood vessels 71 24. Second stage of Carrel's method of suturing blood vessels 72 25. Third stage of Carrel's method of suturing blood vessels 73 26. Operation of Carrel completed 73 27. The lumen of a blood vessel immediately after suturing by method of Carrel ... 75 28. The lumen of a blood vessel several weeks after suturing by method of Carrel ... 75 29. The lumen of a blood vessel immediately after suturing by author 's method ... 75 30. Special instruments used in the author 's method of end-to-end suturing of blood vessels 76 31. The artery is exposed, blood stripped from it, and serrefine clamps are placed ... 77 32. The artery has been severed by sharp scissors and the adventitia is pulled down and cut away with scissors 77 33. The thumb and finger of the left hand grasp the end of the artery after the adven- titia has been cut away and olive oil is dropped on the artery 78 34. The first suture has been placed and is wrapped around the lowest button on the long shaft and cut short , 78 35. Inserting a second suture 79 36. Inserting a third suture 80 37. The third suture is wrapped around a button on the short shaft 81 38. The three guy sutures have been inserted 82 39. Suturing in the first third is begun S3 40. Suturing of the second third 84 15 Jl 6 ILLUSTRATIONS ^^^- PAGE 41. Suturing the last third gg 42. The suturing has been completed 86 43. External appearance of the femoral artery of a dog after eiul-to-cnd suturing . , 87 44. Internal appearance of the carotid artery of a dog after end-to-end suturing ... 87 45. Internal appearance of arteriovenous union thirty-nine days after operation ... 88 46. Internal appearance of transplantation of a segment of vein sixty -three days after operation gg 47. Photograph of a specimen in ^vllic•ll a rubber tube was sutured into a defect in tlie abdominal aorta of a dog 89 48. A roentgenogram of reversal of the circulation in a dog's hiud extremity .... 9.3 49. A roentgenogram of cinnabar mass which was injected into the reversed circulation . 9.3 50. A roentgenogram of cinnabar mass injected into reversed circulation 93 51. A roentgenogram of the same dog shown in Fig. 50, but with the systemic arterial system injected with a bismuth mass through the carotid 93 52. Binuie 's method of passing a stout catgut ligature 98 53. Ligation of the femoral artery, showing method of applying two ligatures .... 99 54. Ligation of the common carotid, external carotid, and the first four branches of the external carotid 103 55. Ligation of the superior thyroid artery 104 56. Ligation of the subclavian artery 106 57. Ligation of the internal iliae artery 112 58. Ligation of the right femoral artery just below Poupart 's ligament 114 59. The operation of Antyllus for aneurism 121 60. The operation of Anel for aneurism 121 61. The operation of John Hunter 121 62. The operation of Brasdor 121 63. The operation of Wardrop 121 64. The operation of Pasquiu 121 do. The operation of Purmann 121 66. Obliterative endo-aneuiismorrhaphy of Matas 123 67. Eestorative endo-aneurisniorrhaphy of Matas 124 68. Eeconstructive endo-aneurismorrhaphy of Matas 124 69. Traumatic aneurism of the temporal artery 131 70. The excised sae of the traumatic aneurism shown in Fig. 69 131 71. The second case of traumatic aneurism of the temporal artery 132 72. Drawing of the excised sac shown m Fig. 71 132 73. The author's forceps for lateral blood vessel suturing 136 74. Method of applying the forceps 136 75. The vein and artery have been clamped with the forceps 136 76. The communication betAveen the artery and vein has been severed 136 77. Arteriovenous aneurism of the left femoral, near Poupart 's ligament 137 78. Ligatures applied to femoral artery and vein 138 79. Quintuple ligature in arterio\enous aneurism 139 80. Appearance of nerves after suturing 144 81. Dissection of binding scar tissue from a nerve 145 82. Pedicle flap applied around the old site of scar contraction 145 S3. Excision of neuromas from a divided nerve 146 84. Application of a tube of fat and fascia between ends of a nerve 146 85. Elsberg's method of cutting sections of a small nerve for cable transplantation . . 147 86. Cable shown in Fig. 85 is being sutured into the defect 147 87. Appearance of nerve after cable graft has been completed 148 88. Eud-to-side suturing of a nerve 149 ILLUSTRATIONS 17 FIG. PAGE 89. The iiu'tlHiil of bridging a clffcet m a nerve by flaps 150 90. Suturiiio- tlie hypoglossal nerve to tiie facial nerve 152 91. Diagram ot tlie brachial plexus. (After Gray.) 154 92. Injury of tlie upper trunk of the bracliial plexus 154 93. Excision of the injured j)ortion of the brachial plexus 155 94. Placing an intramedullary bone graft 163 95. Hoglund's method of placing an intramedullary graft 163 96. Albee 's method of inlay bone grafting 164 97. Inlay method of bone grafting of bones of the forearm 165 98. A method of extension that can be used after operation on tlie bones of the arm or forearm 167 09. Diagram showing the action of bone graft in Pott's disease of the spijie .... 168 100. Albee 's method of bone graft in Pott 's disease of the spine 169 101. The size and shape of the graft as determined by a malleable probe 169 102. The bone graft has been cut^ molded, and placed in position 170 103. Closure of a triangular defect by the method of Jasche 176 104. Closure of a triangular defect by the method of Szymonowski 176 105. Closure of a triangular defect by the method of Amnion 176 106. Closure of a triangular defect by the second method of Szymonowski 176 106-A. Third method of closure of triangular defect according to Szymonowski . . . . 176 107. Closure of a triangular defect by the method of Burow 176 108. Second method of closure of triangular defect according to Burow 176 109. Closure of oval defect by method of Lisfranc 176 110. Closure of oval defect by method of Szymonowski 176 111. Closure of oval defect by method of Celsus 176 112. Closure of oval defect by method of Dieffenbaeh 176 113. Closure of oval defect by double flap method 177 114. Closure of oval defect by method of Weber 177 115. Closure of circular defect by first method of Szymonowski 177 116. Closure of circular defect by second method of Szymonowski 177 117. Closure of circular defect by third method of Szymonowski 177 118. Closure of quadrilateral defect by method of Cole 177 119. Closure of quadrilateral defect by first method of Szymonowski 177 120. Closure of quadrilateral defect by second method of Szymonowski 177 121. Closure of quadrilateral defect by method of Dieffenbaeh 177 122. Closure of quadrilateral defect by method of Lexer-Bevari 177 123. Closure of quadrilateral defect by method of Burow 177 124-A. "Tubed" pedicle flap of defect in face 178 124-B. Second stage of operation of Fig. 124-A 179 124-C. Final result of operation shown in Fig. 124-A 179 125. "Tubed" pedicle which has been Thiersch grafted on the raw surface 180 126. The flap with the "tubed" pedicle shown in Fig. 125 180 127. Method of taking Thiersch graft 183 128. Thiersch graft is cut with a long amjiutating knife 183 129. The method of Esser for preventing a sunken scar 186 130. A modified Rose incision for a single harelip 189 131. The sutures have been placed and all are tied except the tractor sutures .... 189 132. An incision for harelip according to the method of Owen 190 133. Sutures in the vertical incision of Owen are placed 190 134. The last sutures are placed in the operation of Owen 190 135. Line of incision for excision of nasal septum 191 136. Lines of incision for double harelip 192 ] 8 ILLUSTRATIONS FIG. PAGE 137. Double harelij) (ipci-;itioii comiileted excejjt for insertion of additional sutures . . . 192 138. David R., ten montlis old. Photograiili taken liefoi'e operation 193 139. David E., shown in Fig. 13S. Photograpli taken four montlis after opeiaf ion . . . 193 140. Bessie H., three weeks of age. Harelip and complete cleft of palate 193 141. Same patient shown in Fig. 140. I'liotograph taken two years and seven months after the operation 193 142. Herbert T., age seven months. Double harelip and cleft palate 194 143. Same i^atient shown in Fig. 142. Photograph taken two years and tluee months after ojieration r . . . 1^*4 144. Lines of incision for relaxation in operation for cleft palate 197 145. Cleft palate operation completed 197 14G. Lines of incision for repair of upper lip by method of Denonvilliers 198 147. Operation of Denonvilliers completed 198 148. Operation of Sedillot for repair of the upper lip 199 149. Lines of incision for repair of defect in upper lip by method of Abbe 199 150. The flap from the lower lip has been turned into the defect in the upper lip. ac- cording to Abbe 199 151. The pedicle has been cut, and the operation of Abbe completed 199 152. Lines of incision for the operation of Gurdon Buck in repair of the upper Up . . 200 153. Operation of G-urdon Buck completed 200 154. V-shaped excision for cancer of the lower lip , 201 155. V-shaped incision closed with sutures 201 156. Lines of incision for operation of Bruns in repair of lower lip 201 157. Operation of Bruns completed 201 158. Lines of incision for operation of Estlander for repair of lower lip 202 159. Operation of Estlander completed 202 160. Lines of incision for operation of Dieffenbach in repair of lower lip 202 161. Operation of Dieffenbach completed 202 162. Lines of incision for "visor" operation in repair of lower lip, according to Viguerte- Morgan 203 163. Lines of incision for operation of Sedillot in repair of the lower lip 203 164. Lines of incision for second method of Sedillot in repair of the lower lip .... 204 165. Second method of Sedillot completed 204 166. Method of securing a flap from the arm for repair of lower lip 204 167. Ultimate result after repair of lower lip following injury from burn in the patient that is shown in Fig. 166 ... ^ 204 168. Lines of incision for operation of Montet in repair of angle of the mouth .... 205 169. Lines of incision for the operatio]i of Szymonowski for repair of the angle of the mouth 205 170. Oj^eration of Szymonowski completed 205 171. Lines of incision for correction of downward contraction of the angle of the mouth 206 172. Completion of operation for correction of downward displacement of angle of the mouth 206 173. Lines of incision for operation of Schulten for repair of mucosa of lower lip . . . 206 174. Section showing location of flap taken from the upper lip 206 175. The flap, according to Schulten, has been sutured into position 206 176. Lines of incision for repair of mucosa of lower lip according to the method of Nelaton and Ombredanne 207 177. Operation of Nelaton and Ombredanne completed 207 178. Lines of incision for reconstruction of vermilion border of lower lip 207 179. The vermilion border of the lower lip reconstructed according to the method of Tripier 207 ILLUSTRATIONS 19 FIG. PAGE ISO. Koi'onsti'iU'tinn of defrt-t in llic lowci' j;i\v l)y ;i iicdiclc ll;i|) incliidinji' ;i jKirtioii iif tlio clavicle 208 Isl. Jjiiios of incision for rt'imir of dofcM-t in the niidliiio of lower jaw 208 182. Tlio llap witli its jjraflod bono is tnrni'd into tho defect of the lower jaw .... 208 IS.'). Lines of incision for repair of defect in the check and angle of the mouth .... 209 154. Tiie ilap indicated in the previous figure has been dissected and placed in the defect 209 IS."). Line of incision for rel(>asing contraction of tlie np|H'r lid according to operation of Gillies 211 ISO. Dissection of contraction of ujijicm' lid . 211 1S7. The upper lid is freed and turned down 211 155. Thiersch giaft is placed on a mold of wax (Gilli?s) 211 ISO. The mold, with the Thiersch graft placed with the epithelium next to the mold, is sutured into the raw surface 211 190. The sutures which catch the skin of the lids and the graft are tied 211 191. The late result of operation of Gillies for eversion of u^iper lid , 212 192. Lines of incision for the Wharton Jones operation for ectropion of the lower lid . 212 193. The operation of Wharton Jones completed 212 194. Lines of incision for operation of Dieffenbaeh for ectropion of lower lid .... 212 195. Operation of Dieffenbaeh completed -12 190. Lines of incision for operation of Knapp for repair of lower lid 21.3 197. Operation of Knapp completed 21.3 198. Operation of Monks for repair of lower lid 213 199. The flap is freed and caught with forceps 213 200. The operation of Monks completed 213 201. Operation of Gibson for repair of lower lid 215 202. Thiersch graft is placed in position 215 203. The growth on the lower lid is excised 215 204. Ten days after the grafting the flap Is drawn over the defect in the lower lid . . . 215 205. The operation of Gibson completed 215 206. Lines of incision for operation of Syndacker-Morax for repair of both lids . . . 216 207. The pedicle has been sutured into position to the upper lid 216 208. Deformity following a burn in a boy, J. M 217 209. The patient shown in Fig. 208 217 210. Patient shown in Fig. 209 217 211. Excision of V-shaped section of lower lid for senile ectropion 218 212. Lengthening the outer canthus of the eye according to von Ammon-Agnew . . . 218 213. Narrowing the outer canthus of the eye according to Walthers 218 214. Eeconstruction of the eyebrow by turning down a flap from the forehead .... 219 215. Reconstruction of the eyebrow^ by turning down a flap from the temporal region . 219 216. Painful and contracted scar left after removal of an eye 220 217. A flap dissected from the abdomen according to the method of J. S. Davis . . . 220 218. The abdominal flap has been sewed to the incision in the hand 221 219. The painful scar in the eye socket has been removed and the flap on the hand sutured in position 221 220. The operation of Monks for prominent ears 222 221. Operation of Luckett for prominent ears 222 222. Method of reconstructing ears that are too large 222 223. Lines of incisions for the operation of iSzymonowski for reconstruction of the ear . 223 224. The flap is dissected up and folded on itself 223 225. Lines of incision at A and B show outlines of flap 223 226. Faps A and B are raised and the extremities of the new ear are brought forward . 223 227. The flaps A and B are transferred posteriorly 223 20 ILLUSTRATIONS FIG- PAGE 228. Lines of incision for operation of Roberts for ]-eeonstructing tlie ear 224 229. The flap is dissected up and attached to tlie body of the ear 224 230. Tlie lobe for the ear is dissected up and attached to the body of the ear .... 224 231. Lines of incision for operation of Esmarch for reconstruction of a la of nose . . . 225 232. The pedicled flap is turned into position 225 233. Operation of Esmarch completed 225 234. Lines of incision for operation of Dieft'cnbacli for defect of ala of nose 225 235. Operation of Dieffenbach completed 225 236. Photograph showing defect in the nose caused by application of paste 22G 237. Lines of incision for correcting defect shown in Fig. 236 226 238. The small bridge of tissue is cut away 226 2.59. A flap is formed, constituting the lower border of the ala 226 240. A flap from the mucosa of the septum as indicated in Fig. 238 is turned into the wound 226 241. The pedicle to this flap is severed and the flap sutured into position 226 242. A flap from the forehead has been turned into a defect in the tip of the nose . .227 243. Lines of incision for operation of Xelaton for correction of defect of the ala . . 227 244. The operation of Nelaton completed 227 245. Lines of incision for the operation of Lexer for the restoration of the columna . . 228 246. A flap is taken from the mucous surface of the under lip 228 247. The operation of Lexer completed 228 248. Lines of incision for operation of J. S-. Davis for restoration of the columna . . . 228 249. The flaps outlined in the previous figure are turned into position 228 250. Lines of incision for the operation of Langenbeck for reconstruction of the nose . 229 251. Lines of incision for the operation of Labat-Blasius for reconstruction of the nose . 230 252. Flaps outlined in the preceding illustration have been dissected and sutured to con- struct the alae of the nose 230 253. Lines of incision for ox^eration of Keegan for reconstruction of the nose .... 230 254. Lines of incision for operation of Thiersch for reconstruction of the nose .... 231 255. Lines of incision for operation of Israel for reconstruction of the nose by a flap from the forearm 232 256. The flap from the forearm has been dissected free and is sutured into piosition on the face 232 257. Dissection of a flap from the finger as the first stage in the operation of Baldwin for reconstruction of the nose from a finger 233 258. Lines of incision for the operation of Joseph for reconstruction of the nose . . . 233 259. The denudation according to .Joseph for the elevation of a drooping ala .... 235 260. Operation as outlined in the preceding illustration is completed 235 261. Lines of incision for operation of Diettenbach for elevation of one side of the nose . 235 262. Operation of Dieffenbach completed 235 263. Lines of incision for operation of Pirogoff for lowering the tip of the nose . . . 235 264. Operation of Pirogoff' completed 235 265. Lines of incision for operation of KoUe for reconstruction of nostrils 235 266. Operation of Kolle completed 235 267. Lines of incision for closure of defect in frontal sinus of tlie patient shown in Fig. 270 236 268. After suturing the edges of flaps C and D, flaps A and B are freed 236 269. Flaps A and B are sutured as shown 236 270. Photograph of patient E. W. S., taken before operation 236 271. Photograph of E. W. S., two weeks after operation 236 272. The incisions for repair of defect in the frontal sinus when there is no depression . 237 273. The forehead has been mobilized and the wound is sutured with a suljcutieular stitch 237 ILLUSTRATIONS 21 riG. PAGE 274. Pholoi>T;ii»li of jiatiriit S. IT., two weeks after operation as deseribocl in llie two preceding ligures 237 275. Lines of incision for e.Kcision of a benign tnnior of tlie face 239 276. The growth has been exeised and the skin and subcntaneous tissnc are thoroughly mobilized 239 277. The superficial fascia and fit is approximated with a continnous suture of plain catgut 239 27S. The deep layer of tlie skin is united witli a subeutienlar suture of fine silkworm gut 239 279. The epithelial layers are united with a superficial stitch of very fine silkworm gut or of arterial silk 239 280. Method of Deguise for closing salivary fistula of Steno 's duct 240 281. Operation of Grouse for closure of salivary fistula of the parotid 241 282. The pedicle of a flap of mucosa is formed from within the mouth 242 283. The pedicle of mucosa with its base backward has been brought through with the forceps 242 284. The operation of Sedillot for excision of the tongue 244 285. Liue of incision for operation of Ashhurst for excision of the tongue 245 286. A block dissection of the upper neck is made 246 287. The incision has been continued to the cavity of the mouth 247 288. Liue of incision in operation of V. P. Blair for excision of tongue in advanced cancer 249 289. The dissection of the neck is begun and the facial vessels are doubly clamped and divided 250 290. Operation of Blair completed, except suturing the wound 251 291. Lines of incision for op)eration of Weber for excision of upper jaw 252 292. Lilies of incision for operation of Binnie for excision of the ux^per jaw 253 293. Eeflection of flap in operation of Binnie for excision of upper jaw 253 294. Operation of Y. P. Blair for correction of retracted chin 255 295. The line of incision of the lower jaw is shown 255 296. The ramus of the lower jaw is completely divided 256 297. The line of incision for approach to the temporomaxillary joint according to J. B. Murphy 257 298. Lines showing the excision of bone for the Esmarch operation 258 299. Incision for resection of second division of the fifth nerve from within the mouth . 259 300. Method of Rinkenberger for cerebral localization 265 301. "Cross bow" incision of Gushing for exposure of the cerebellum 267 302. Lines of incision for operation for exposure of the dura and brain after an old depressed fracture 269 303. The adherent dura and tissues are removed and the brain is exposed 2/0 304. A fatty fascia flap from the thigh has been sutured over the defect in the dura . 271 305. The flap of pericranium is transferred over the fatty fascia graft 272 306. Photograi)h of a baby with meningocele in the lower part of the occipital bone . . 277 307. Lines of incision for excision of the meningocele shown in preceding figure . . . 277 308. A cuff of scalp is turned back, the opening in the skull is thoroughly exposed . . 278 309. The neck of the sac is ligated 278 310. The flap of pericranium is sutured into position 279 311. Line of incision for subtemporal decompression 279 312. The fibers of the temporal muscle are separated and the pericranium and skull are exposed 280 313. The skull is perforated with a drill or burr 280 314. The dura is incised after picking it up with the point of a needle 281 315. The dura has been split and the bulging brain is exposed 281 22 ILLUSTRATIONS ^^«- PAGE 316. The woiincl is closed by suturing first tlie fibers of tlie teuipoi-al unisc-le, then tlie galea^ and finally the skin 282 317. Lines showing the incision in tlie operation of Fra/.ier for removal of tlie sensory root of the gasserian ganglion 284 318. The flails are reflected and the skull is perforated with a burr 284 319. The sensory root of the ganglion is exposed and is about to be avulsed 285 320. Operation of Adson showing ligation of the middle and exposure of the sheath of the j)osterior sensory root 286 321. The posterior sensory root is divided in its sheath 286 322. The incision for laminectomy according to Frazier 291 323. Spinous processes have been partly removed 292 1^24. The dura of the cord is incised 293 325. The dura has been incised and the cord is exposed 294 326. The dura is sutured 29o 327. The sac of a spina bifida has been exposed by a U-shaped flap. (Frazier.) . . . 298 328. The stump of the sac is being sutured 299 329. A fascia flap is formed to turn onto the stump of the sac 299 330. The lines of incision for a flap of fascia to slill further cover in the defect . . . 299 331. The flap of fascia outlined in the preceding figure is being sutured in place . . . 299 332. Operation of Babcock for sj)ina bifida 300 333. Second stage of Babcock 's operation 301 334. Section showing the various layers of tissues that are sutured in the operation of Babcock for spina bifida 302 335. Cross section showing the relations of the cysts and fistulas of the thyroglossal tract, according to Sistrunk 306 336. The middle segment of the hyoid bone is removed and the thyroglossal tract is dissected 307 337. The dissection has been completed, and the foramen cecum is exposed 307 338. A completed block dissection of one side of the neck 315 339. Lines of incision for laryngectomy 318 340. The larynx has been exposed and partly mobilized 319 341. The trachea has been divided and brought to the skin 320 342. The laryngectomy completed 321 343. Photograph of a patient with a large diffuse lipoma of the neck 325 344. Photograph of patient shown in jjreceding illustration a few weeks after operation for removal of difl'use lipoma . .~ 325 345. Exposure of goiter 328 346. The goiter has been partially mobilized 329 347. Line of incision for amputation of distal phalanx of finger 337 348. Showing the method of forming long palmar flap in amputation of finger .... 337 349. Amputation of the finger 338 350. Amputation of the finger by different methods 339 351. Disarticulation of the hand 340 352. Amputation of the hand 340 353. Lines of incision for amputation of forearm 342 354. Lines of incision for amputation at elbow by posterior elliptical flap 344 355. Lines of incision for amputation of the arm 345 356. Wyeth's method of hemostasis for amputation at shoulder 347 357. Lines of incision for amputation of shoulder 348 358. Lines of incision for excision of the wrist 352 359. Lines of incision for excision of elbow 3,52 360. Lines of incision for excision of the shoulder joint 354 ILM'STKATIONS 23 FIG. I'A'iK ,".()I. LiiU's (if incision for i-('nio\;il ol' din nioiid sli;i |ii'il area at ciliow 355 l\&2. Wotlioil of Doiranci' fni' incision of foloii and plnciMg ot' diaiiiaf^e .550 363. Lino of im-ision for opciation for webbed fingers, palmar surface 359 ',l(U. Line of incision for operation for webbed fingers, dorsal surface -5*50 365. The flajis as outlined in the two preceding drawings have been dissected and are being sutured "561 366. Method of applying the tendon suture of Frisch 362 367. Transplantation of tendon of the flexor carpi radialis for paralysis of the extensor muscles of the forearm according to J. B. Murphy 363 368. A skin incision is made and the tendon is drawn thvougli 364 369. xV third incision is made on the back of the wrist 365 370. Last stage of operation shown in three preceding figures 366 371. Placing of silk threads on anterior surface of arm and forearm to relieve swelling of the upper extermity. (Handley.) 367 372. Placing of silk threads on the posterior surface of the arm and forearm .... 367 373. Lines of incision for operation of Kondolcon along outer border of the upper ex- tremity 368 374. Lines of incision for operation of Kondoleon along inner border of the upper ex- tremity 368 375. Lines of incision for amputation of the toe 372 376. Lines of incision for amputation of the tarso-metatarsal joint (Lisfrane's am- putation) 373 377. Lines of incision for amputation of Syme at the ankle 375 378. Lines of incision for amputation of leg. (Hey.) 377 379. Lines of incision for amputation of leg. (Farabeuf.) 378 380. Lines of incision for amputation of Stephen Smith at the knee joint 378 381. Lines of incision for amputation of the thigh 381 382. Lines of incision for amputation of the hip and thigh 381 383. The method of Wyeth for hemostasis in amputation at the hip joint 382 384. Lines of incision for amputation at the hip joint by the anterior racket incision . . 384 385. Open tenotomy by the zigzag or step method 386 386. Points of entrance of the tenotome in subcutaneous tenotomy of the plantar fascia (Soutter) 386 387. Transplantation of the tendon of the peroneus muscle 389 388. Tendon and muscle have been drawn through the second incision and are ready to be transj)lanted 389 389. The tendon of the peroneus has been transplanted 390 390. Transplantation of the tendon of the peroneus longus into the tendo Achillis, (Jones) 392 391. The peroneus tendon divided and the tendo Achillis is being split 392 392. The peroneus tendon is drawn through the slit in the tendo Achillis 393 393. The peroneus tendon is drawn through the second slit in the tendo Achillis . . . 394 394. Excision of a diamond-shaped area of skin on the dorsum of the foot . . . . . 395 395. Exposure of tendon of the extensor proprius hallucis 395 396. Drilling a hole in the head of the metatarsal bone for transplantation of the extensor proprius hallucis 396 397. The method of drawing a tendon through a drill hole in the head of the metatarsal bone ^"^^ 398. Transplantation of tendon of the biceps femoris 398 399. A tunnel has been made and the biceps tendon is to be drawn through to the second incision 399 400. The tendon of the cpuidriceps has been split and the tendon of the biceps is drawn through 400 24 ILLUSTRATIONS FIG. PAGE 401. Correction of club foot 402 402. Line of incision for the oj^eration of Ober for correction of club foot 402 403. Mobilization of the periosteum and ligaments in the operation of Ober 40.3 404. Mobilization of anterior portion of periosteum and ligaments in the operation of Ober 404 405. Lines of incision for operation for ingrowing toe nail 406 406. Insertion of braided silk for correction of flail ankle joint. (Bi-adford.) .... 408 407. The drill has entered the tibia 408 408. The drill hole has been made in the tibia and the silk is being pulled through . . . 409 409. A tunnel has been made on the outer side of the foot, and the silk is being pulled through the tunnel 409 410. The loop is being pulled through the drill hole in the tarsus 409 411. A tunnel has been made on the inner side of the foot and the second end of the silk is being pulled through to the first end 409 412. The knots have been tied 410 413. Lines of incision for operations about the ankle joint 411 414. Incision for bone grafting in intractable club foot 412 415. Club foot has been straightened and is ready to receive the bone graft 412 416. Osteotomy of the neck of the femur with the saw 419 417. Osteotomy of the internal condyle of the femur for knock knee. (Ogston.) . . . 419 418. Osteotomy of the internal condyle of the femur for knock knee. (Eeeves.) . . . 419 419. The dark portion of the involucrum shows the part to be removed 424 420. Another method of avoiding cavity formation in the bone 425 421. The mobilized wall of the involucrum shown in the preceding figure 425 422. Lines of incision for tiap to fill defect in the bone (von Eiselsberg) 426 423. The flap has been mobilized and is ready to be turned down in position 426 424. The flap is sutured in position 426 425. Lines of incision for operation of Kondoleon on outer surface of lower extremity . 427 426. Lines of incision for operation of Kondoleon on inner surface of lower extremity . 427 427. Lines of incision for excision of varicose veins of the leg 429 428. Mobilizing and stripping the varicose vein. (C. H. Mayo.) 430 429. A method of drainage of empyema by negative pressure 438 430. A rubber tube for drainage of empyema 489 431. Operation of Estlander for chronic empyema 440 432. The muscle flap is dissected and is sutured into the wound 441 433. The skin flap is sutured in position 442 434. Diagram showing method of injecting local anesthetic for operation on abscess of the lung. (Bevan.) 444 435. An incision has been made down to the parietal pleui-a, and the wound is packed with gauze 445 436. Several days later the abscess is opened with an electric cautery Avhich follows the aspirating needle 445 437. The lines of incision for closure of a fistula following abscess of the lung. (Bevan.) 446 438. The ribs have been resected and the fistulous tract is being dissected 447 439. The dissection of the fistulous tract has been almost completed 448 440. The line of incision for excision of a lobe of the lung. (Robinson.) 449- 441. The lung has been exposed and the adhesions to the diaphragm are being separated 450 442. The lobe of the lung is excised after clamping the pedicle 451 443. Lines of incision for the operation of Trendelenburg for pulmonary embolism . . 454 444. Incision into the pulmonary artery, which is held open by self-retaining forceps . 445 445. Forceps are withdrawing the embolism from the pulmonary artery 456 446. The incision in the pulmonary artery is closed by a clamp and sutured with fine silk 457 447. Incision of Dean Lewis for removal of the mammary gland in intracanalieular papilloma _ ... 464 ILLUSTRATIONS 25 PIG. PA«E 448. The maniniai^v gland is being freed 465 440. The mammary gland has been excised and pursostring sutures are ins:?rted in the surrounding fat -iOG 450. The pursestring sutures have been tied, so obliterating tlie cavity left by removal of the mammary gland 466 451. lanes of incision for operation of Jackson for cancer of the breast 469 452. Lines of incision for operation of Rodman for cancer of the breast 470 453. The axilla is exposed and dissected from above downward 471 454. The incisions are extensively undermined in order to remove as much of the sub- cutaneous fat and fascia as possible 473 455. The breast with its adjoining structures has been removed in one mass .... 474 456. Photograph of patient of the author on whom the Rodman operation was done . . 475 457. Line of incision for exposure of the inguinal canal in the Bassini operation for in- guinal hernia 480 458. The external inguinal ring is exposed 481 459. The inguinal canal is exposed by splitting the libers of the external oblique . . . 482 460. The sae is being freed 483 461. The neck of the sac is ligated 484 462. The cord is mobilized 485 463. The conjoined tendon and the internal oblicjue and transversalis muscles are sutured to Poupart's ligament beneath the cord 486 464. The incision in the aponeurosis of the external oblique is closed with a continuous lock stitch 487 465. The skin is closed with a continuous mattress suture of fine tanned catgut . . . 488 466. A flap is formed from the sheath of the rectus muscle, according to Halsted . . 488 467. The fibers of the rectus muscle can also be transplanted according to the suggestion of Bloodgood 489 468. Exposure of the neck of the sac from within the peritoneal cavity. (LaRoque.) . 490 469. Suturing the neck of the sac from within the peritoneal cavity 490 470. Method of inverting a large sac from within the peritoneal cavity 492 471. Suturing the neck of a large sac from within the peritoneal cavity 492 472. Exposure of neck of the sac of a femoral hernia by the method of Seelig and Tuholski 495 473. The neck of the sac is ligated, the sac excised, and sutures are placed to obliterate the femoral canal 496 474. Lines of incision for reconstructing Poupart's ligament 498 475. The flap has been sutured into x^osition so as to reinforce Poupart 's ligament . . 498 476. The neck of the sac of an umbilical hernia is exposed and is ready for incision . . 500 477. Mattress sutures for imbrication of the margins of the opening in the aponeurosis of the abdominal wall are placed 500 478. The mattress sutures have been tied snugly 501 479. An epigastric hernia is exposed 504 480. Lines for abdominal incisions 509 481. The incision of Judd for double inguinal hernia 513 482. Method of closing incisions above the umbilicus • 517 483. Exposure of the cystic duct in cholecystectomy 523 484. Double ligation and clamping of the cystic duct 523 485. The cystic artery has been clamped and the gall bladder is being dissected out from below upward 524 486. The cystic artery has been tied and the bed of the gall bladder is sutured . . . 525 487. A rubber tube is carried to the stump of the cystic duet 526 488. The author's method of cholecystenterostomy 531 489. A double row of sutures unites the gall bladder to the duodenum 532 490. Excision of the head of the pancreas. (Cofl'ey.) 536 "26 ILLUSTRATIONS FIG. PAGE 491. Second stage of excision of head of pancreas 537 492. Transi^lantation of common bile duct. (Coffey.) 537 493. The common bile duet is sutured in a new position 537 494. The transplantation of the common duct is complete . 538 495. A sectional view of the transplanted duct 538 496. Exposure of the pedicle of the spleen in splenectomy. (Balfour.) 540 497. Another method of treating the pedicle of the spleen. (Balfour.) 541 498. Shortening the gastrohepatie omentum in ^^tosis of the stomach 544 499i The gastrohepatie omentum is shortened and sutures are jalaced in the gastrocolic omentum 545 500. The sutures in the gastrocolic omentum are x^laced and tied 546 501'. Lines of incision for pyloroplasty of Finney 550 502. The margins of the wound are being united with a continuous lock stitch . . . 550 503. Lines of incision for the author's pyloroj^lasty 552 504. Second stage of author's operation 553 505. Correction of pocket formation with marked stenosis 554 506. Correction of pocket formation completed 554 507^. Third stage of author's operation 555 507B. Fourth stage of author's operation 555 508. Fifth stage of author's operation 556 509. Sixth stage of author's operation 557 510. Seventh stage of author 's ojieration . 558 511. Author's opei'ation completed 558 512. A roentgenogram of a patient, Miss E. D. H., taken four and one-half months after this pyloroplasty was done 560 513. A drawing of the stomach removed postmortem from a patient who died twenty- one days after jDyloroplasty 561 514. Diagram of the incisions, and direction of the opening in posterior gastroenteros- tomy. (W. J. Mayo.) 565 515. Posterior gastroenterostomy. First stage 566 516. Posterior gastroenterostomy. Second stage 567 517. Posterior gastroenterostomy. Third stage 568 518. The gastroenterostomy of Eoux to prevent vicious circle 569 519. Incision through the gastrohepatie and gastrocolic omentum to expose ulcer in posterior wall of the stomach 571 520. Gastroenterostomy. (Polya-Balfour.) 575 521. The duodenal stump is sutured over with a right angle continuous suture which is drawn tight after the clamp is removed 576 522. Additional pursestring sutures are added still further to invaginate the duodenal stump 576 523. The stomach is then severed at its cardiac portion and a loop of jejunum is brought uj) and sutured to the stomach 577 524. The second row of sutures is placed as the second row in gastroenterostomy . . . 578 525. Gastrostomy, according to the Senn method 580 526. Gastrostomy according to the method of Witzel 581 527. The ojieration of Eammstedt for congenital pyloric stenosis 582 528. Operation for congenital pyloric stenosis, according to Strauss 583 529. Operation for congenital pyloric stenosis. Second stage 584 530. Enterostomy of J. W. Long 590 531. A rubber tube is introduced and held snugly Ijy a pursestring suture 591 532. The wound is packed lightly with gauze and the tube fastened with adhesive plaster 592 533. Enterostomy, using the principle of Coffey 593 534. A catheter is inserted in the puncture and the pursestring suture is tied snugly . . 594 ILLUSTRATIONS 27 FIG. PAGE 5oo. Tlie enterostomy is completed 595 536. Enterostomy according to the iiiiiiciple of Witzid witlidut ;in iiieision to the imieosa oSHi 537. Sections of tlie enterostomies by ditt'erent methods 597 538. The enterostomy of John Young Brown with sliglit modification 599 539. Sigmoidostomy according to tlie method of Mixer 600 540. Sigmoidostomy with the bridge of skin sutnred in position 601 541. Sigmoidostomy completed 601. 542. The author's method of intestinal resection 60.j 543. Author's method of intestinal resection. Second stage 606 544. Author's method of intestinal resection. Third stage 607 545. Author's method of intestinal resection. Fourth stage 608 546. Author's method of intestinal resection. Fifth stage 608 547. Author's method of intestinal resection about completed 609 548. Author's method of resection of cecum and ascending colon 611 549. Author's method of resection of cecum and ascending colon. Second stage ... 612 550. Longitudinal section of the completed operation with the enterostomy tube inserted through the ileum 613 551. A roentgenogram of the yah-e made after resection of the cecum and ascending colon by the method just described 614 552. Lines of incision for excision of the bowel and mesentery in cancer of the cecum or ascending colon 615 553. Lines of incision for excision of the bow-el and mesentery in cancer of the hepatic flexure of the colon 615 554. Lines of incision for excision of the bowel and mesentery in cancer of the splenic flexure of the colon 615 555. Lines of incision for excision of the bowel and mesentery in cancer of the descend- ing colon 615 556. Lines of incision for excision of the bowel and mesentery in cancer of the sigmoid 616 557. Lines of incision for excision of the bowel and mesentery in cancer of the terminal sigmoid 616 558. Meckel's diyerticulum in the lower ileum 619 559. Lateral anastomosis of the intestine 620 560. Lateral anastomosis between the jejunum and dilated duodenum for obstruction at the terminal duodenum 621 561. The skin incision for the McBurney muscle splitting operation 624 562. The aponeurosis of the external oblique is split in the direction of its fibers . . . 624 563. The aponeurosis of the external oblique has been split and drawn aside with retractors 625 564. The fibers of the internal oblique and transyersalis are held apart with retractors . 625 565. The peritoneum is closed with a pursestring suture or a continuous mattress suture 626 566. The fibers of the internal oblique and transversalis muscles are approximated by a suture of plain catgut 626 567. The aponeurosis of the external oblique is brought together with a continuous lock stitch of plain catgut 627 568. The skin is closed with a subcuticular suture of fine tanned catgut 627 569. The appendix and its mesentery are tied with tanned catgut . 628 570. The appendix is severed with an electric cautery 628 571. The eschar and the mucosa in the stump are curetted 629 572. The stump of the appendix is tied and a pursestring suture for inyagination of the stumj) is placed 630 573. A sectional view shows the result of the invaginating method . 630 574. The simple method of treating the stump of the appendix 631 575. A sectional view showing the simple method of treating the stump of the appendix 631 576. Reproduction of illustration by Bunts, showing diverticulum following burying the stump of the appendix 632 28 ILLUSTRATIONS FIG. PAGE 577. Drawing of a clivertieiilinn that we liave seen following burying the stump of the appendix 6.32 578. A roentgenogram of late results after appendectomy. (Case.) 633 579. The Kraske operation for excision of the rectum. (W. J. and C. H. Mayo.) . . 641 580. The peritoneum has been opened and the lateral attachments of the rectum have been severed 6-i2 581. Operation of Bevan for early superficial cancer of the anterior wall of lower rectum 646 582. The cancer has been exposed and is removed with an electric cautery 647 583. The posterior wall of the rectum is united with interrupted sutures, tying the knot within the lumen of the boAvel 648 584. The prolapse of the rectal mucosa is cauterized with electric cautery 649 585. Clamp and cautery operation for hemorrhoids 656 586. Clamp and cautery operation for hemorrhoids completed with the insertion of a tube 657 587. A sinus in the anal canal. (E. H. Terrell.) 659 588. A large pocket or diverticulum in the anal canal 660 589. Removal of the covering of one of the anal pockets, according to the method of E. H. TerreU 661 590. The incision of W. J. Mayo for operation on the kidney 664 591. Nephropexy 665 592. The pelvis of the kidney has been opened and a forceps is thrust through to the cor- tex, where it grasps a soft rubber catheter 672 593. The catheter is drawn through so that its tip barely rests in the pelvis of the kidney 673 594. A stricture of the lower end of the ureter 675 595. A method of transplanting the ureter 680 596. Second stage of transplantation of ureter 681 597. Cross section of the first stage of the suprapubic prostatectomy of Squier ... 692 598. The finger has broken through the prostatic urethra and the prostate is being enucleated, beginning at its apex on the right side 693 599. The prostate has been removed 694 600. The operation of H. H. Young for cancer of the prostate 696 601. Operation of H. H. Young for cancer of the prostate. Second stage 697 602. Operation of H. H. Young for cancer of the prostate. Third stage ...... 698 603. Operation of H. H. Young for cancer of the prostate. Fourth stage 699 604. Operation of Lespinasse for anastomosis of the vas and the epididymis .... 702 605. Operation of Lespinasse for anastomosis of the vas and epididymis. Second stage 702 606. Operation of Lespinasse for anastomosis of the vas and epididymis. Third stage . 702 607. The first stage of circumcision .... - 707 608. The circumcision is completed 707 609. The operation of Cantwell for epispadias 708 610. The Thompson-EusseE operation for hypospadias 709 611. The flaps are dissected and are united, so forming the new urethra 710 612. The lower skin incision is sutured over the new urethra 710 613. The completed operation 721 OPERATIVE SURGERY CHAPTER I GENERAL CONSIDERATIONS* Surgical operations are performed on living tissues and must be considered with regard to physiology and pathology in the living as well as from an anatomi- cal point of view. Operations that look well on a cadaver will sometimes be unsuccessful on a patient. A beautiful operation that results in the death of the patient is not satisfactory surgery. AVhile the mechanics of a surgical operation is important, it should not entirely dominate the situation. The object of a surgical operation is to save life, to relieve pain, and to restore function, and these three things in the order named should always be kept in mind. The technic of an operation should be chosen not solely because it appeals to a mechanical sense, but because it is biologically correct. The changes and reactions of tissues after operation must be borne in mind when selecting the technic for any surgical procedure. It cannot be too often emphasized that surgery should be more a science than an art. A surgeon who is a dexterous operator and who skilfully ampu- tates a leg that wdth patience and scientific application could be saved, is merely a good artisan, and is distinctly inferior to the surgeon who could save the leg even though he should be a bungling operator. The ideal is to be thoroughly imbued with the principles of the biologic sciences, thought- fully to apply these principles, and at the same time to be mechanically skilful. The science of anatomy is essential to the mechanics of surgery. He would be a poor locomotive mechanic who did not understand the construc- tion of his engine ; and in operations on the neck, for instance, a surgeon who is ignorant of anatomy would be like the proverbial bull in a china shop. A knowledge of anatomy is essential to good surgery, but in the ever shifting problems of tissue repair and metabolism, physiology is just as necessary. The principles underlying an operation are correct only if they conform to the laws of physiology and to the laws of repair of the tissue or organ that is affected. If we could get away from blindly following what some one says merely be- cause he says it, and do things because of reasons that have sound biologic foundations, we should undoubtedly do work more satisfactory to our patients and to ourselves. Let us take an illustration from the practical work of a surgeon and see *Much of this chapter is from a paner entitled "The Value of Biologic Principles in Surgical Prac- tice." Horsley, J. Shelton: Jour. Am. Med. Assn., May 3, 1919. 29 30 operatrt: si^rgery how tliouglitful application of physiologic principles Avould have rendered a problem that appeared difficult easier to solve. Hyperemia is connected in one way or another with all surgical questions, whether they concern treatment of inflammation or repair of a wound. It has long been known that blood is an enemy of the tubercle bacillus, and that obtaining a good supply of healthy blood is the only satisfactory method of combating tuberculosis. About two decades ago when a patient with tuberculous peritonitis and ascites sought surgical treatment he might have been subjected to one of several procedures. One surgeon would have advised opening the abdomen and letting the sunlight in; another thought it was best to dust the intestine with some special powder; still another believed in drainage with a single tube, others with multiple tubes. All these methods secured more or less satis- factory results. Each surgeon, seeing his patient recover after using his own method, earnestly thought that this was the only correct procedure. The situation resembled very much that described in a poem in an old school reader in which four blind men went to see an elephant. One fell against its side and thought the elephant was like a Avail ; another embraced a leg and declared it resembled a tree ; the third grasped its tail and said the animal was constructed like a rope, and the last felt a tusk and concluded that the elephant was very like a spear. The moral was that though each was partly in the right they all were in the wrong. So all of these surgeons who were using different methods were unconsciously working on a principle that produced hyperemia, and it was this hyperemia, induced partly by draining off the fluid and so relieving pressure, and partly by handling the intestines, that cured the tuberculosis. It was many years, however, before this fact was acknowledged by the various partisans. The surgical treatment of slow or threatened gangrene has also been much discussed. Carrel and Guthrie,^ after two experiments, concluded that the blood circulation in the leg of a dog could be completely reversed within six hours. They severed the femoral artery and vein just below Poupart's ligament and united by suture the cardiac end of the artery to the distal end of the vein, and the distal end of the artery to the cardiac end of the vein. After a few hours, when red blood was seen returning, they assumed that the circulation was reversed. I think it can now be stated, however, that it is impossible to reverse the circulation in this manner. In a series of experi- ments which have been reported elsewhere,- we have shown that when the severed femoral artery and vein of animals are sutured together in a reversed direction there is no real reversal of the circulation, and the arterial blood never goes more than a short distance below the knee and is then quickly switched hack to the iliac veins through the dilated collateral vessels. Evidently what happened in Carrel's experiments was that dissection paralyzed the vaso- constrictor nerves, and the dilated capillaries permitted red arterial blood 'Carrel, Alexis, and Guthrie, G. C: Ann. Surg., 1906, xliii, 203-213. =Horsley, J. S., and Whitehead, R. H. : A study of Reversal of the Circulation in the Lower Ex- tremity, J'our. Am. Med. Assn., March 13, 1915, Ixiv, 873-877. Horslev, J. S.: Reversal of the Circulation of the Lower Extremity, Ann. Surg., March, 1916, Ixiii, 277-279. GENERAL CONSIDERATIONS 31 to i\o\y tlirougli luiclunio'ed. AVhen llio sciatic and crural nerves are divided in a dog', red Llood appears in the femoral vein l)ecause of the ex- treme dilatation of the capillaries. Clinically this is often seen to follow an application of the elastic tourniquet which, if left on for even a short time and tlien removed, produces an intense flushing of the limb until the tempora- rily i^aralyzed vasoconstrictors have resumed their function. Many useless operations have been done attempting so-called reversal of the circulation in threatened gangrene. The only good accomplished was damming back the Aenous blood and forcing the small amount of arterial blood that reached the tissues to stay longer than it normally would, and so deliver to the tissues more nutrition than would be possible when the arterial blood was quickly drained ot¥ by unobstructed veins. This can be very simply effected by ligat- iiig the femoral vein. Surgery of the gastrointestinal tract suffers from the lack of appli- cation of physiologic principles. Take, for example, the popular operation of gastroenterostomy. It does relieve the symptoms of many patients with duodenal or gastric ulcer. Many, however, still have their symptoms, and restoration of the normal channels by undoing a gastroenterostomy is an operation not infrequently performed. The cases that are cured by gastro- enterostomy have never been fully explained. Some say it is a drainage operation, and yet in draining other hollow viscera we do not open at the lowest point. We drain the gall bladder and the urinary bladder from the part opposite the most dependent portion, and we do an enterostomy in the distended loop of bowel that is nearest the incision, because we know that normal contraction or peristalsis will keep the bladder or bowel empty if an opening is made. By some it is claimed that gastroenterostomy cures because the acidity of the gastric juice is lessened, and still others assert that by short circuiting the course of food, rest is given the ulcer ; yet roentgenoscopy reveals that unless the pylorus is closed a considerable portion of food continues to go by this route, and no pyloric closure seems to be permanent unless a re- section is made. Recent physiologic research by Cannon and Washburn,^ which has been confirmed by Carlson* and others, has demonstrated that the hunger pains, or so-called pangs of hunger, m a normal stomach are due to excessive peristaltic contractions of the stomach. It has also been shoAvn that the pains that come on with clocklike regularity after meals in duodenal or gastric ulcer, are not produced by acid erosion of the ulcer by the hyperacid gastric juice, as was formerly taught, but are due to the contraction of peristalsis on gastric nerves made sensitive by the inflammation of the ulcer. The character of the gastric juice has nothing to do with the pain except so far as it excites an abnormal amount of peristalsis. Food or sodium bicarbonate lessens peristalsis for a while and so relieves pain. Investigation seems to show that the stomach has a limited 'Cannon and Washburn: An Explanation of Hunger, Am. Jour. Physiol., 1912, x-xix, 441. ^Carlson, A. J.: The Control of Hunger in Health and Disease, University of Chicago Press, 1916, pp. 62-83. 32 OPERATIVE SURGERY supply of nerves that conduct pain,^ and these nerves, which are deep in the stomach wall, are made more sensitive than normal by the inflammation around an ulcer. Consequently, they register impulses of pain from the pressure of peristalsis that in a normal physiologic condition they would not register. It is probable that gastroenterostomy relieves pain by facilitating the emptying of the stomach and so lessening peristalsis. This, however, is largely the treatment of a symptom and not an effort to remove a pathologic condition and to restore tissues to their physiologic state. In the surgery of the intestine, the work of Cannon and Murphy in their studies of peristalsis after resection of the bowel has not received proper at- tention. Lateral anastomosis is still the method employed by many surgeons, though, as shown by Cannon and Murphy, peristalsis is practically abolished in the region of such an anastomosis. Food can be pushed through only when a column of it extends into a proximal (oral) loop where peristalsis is unim- paired. Postmortems in dogs with lateral anastomosis showed that there was always an accumulation of food at the site of the lateral anastomosis even when the rest of the intestinal tract was free, because severing the circular fibers, in this operation, abolished peristalsis, and the blind pouches could not be completely emptied. They found that in an end-to-end union there was not the slightest stasis of intestinal contents at the site of operation. Merely because the lateral union usually gives no disagreeable symptoms, its use has been continued. If the patient did not die it was assumed that he had sufficiently recovered. With attention to the triangular mesenteric spaces and careful closure of these and of other raw surfaces before the bowel is opened, together with disinfection of the bowel ends after opening, as good technical results are obtained in end-to-end union as after the lateral method, with the advantage of securing normal peristalsis and normal emptying. There are many problems in neurologic surgery that require some knowl- edge of physiologic principles in order to be settled satisfactorily. Spiller and Frazier have demonstrated that section of the posterior sensory root of the gasserian ganglion produces what is called ''physiologic extirpation" of the gasserian ganglion. It has been known for years that a nerve which is injured on the central side of its ganglionic cells does not regenerate; yet when the operation of division of the posterior sensory root for tic doulou- reux was suggested, it was received with some skepticism. This operation is safer than surgical extirpation of the gasserian ganglion, and is followed by less trophic disturbance. The plugging of foramina in the skull from which neuralgic sensory nerves have been removed in order to prevent regrowth of the nerves, has sometimes been done with metal screws. Because an iron screw can stop a hole in a piece of wood is not necessarily a reason why it should be employed in living tissue. On the other hand, some substance that does not cause reaction in bone is preferable. What happens after an iron screw is applied? Nature in an effort to extrude the irritating substance removes ' sic^st and Meltzer: Med. Rec, New York, Ixx, 1017; Rittcr : Zentralbl. f. Chin, 1908, xxxiv, 609. Langley: Brain, 1903, xxvi, 23. GENERAL CONSIDERATIONS 33 liiiu> salts ill ils ii(Mernheim is very satisfactory. It can be done almost as easily as the citrate method. One half of the cannula may be inserted in the donor in the oper- ating- room and the donor taken to the patient's room after the other half of the camnila has been tied into the patient's vein. The donor is placed Fig. 19. — Kiinpton and Brown's cannula for transfusion. I'ig. 20. — Kimpton and Brown's cannula in horizontal position, showing the trap which prevents the en- trance of air in the cannula. in a comfortable chair and the two halves are connected. The blood goes directly over unmixed with chemicals and if the proper grouping of blood has been made there is never any reaction. The technic is simple. I am now using this method almost exclusively. The indirect method of transfusion has in recent years dominated the field. Without anticoagulant mixtures this method is represented by a type of container such as the Kimpton and Brown, or the Percy apparatus, which is coated with paraffin, filled with blood from the donor, and then 66 OPERATIVE SURGERY emptied into the vein of the patient. (Figs. 19 and 20.) Another indirect method consists in the aspiration of blood from the vein of the donor into a syringe Avhieh is immediately emptied into the vein of the patient. This is called the method of Lindeman, who inserts a small cannula in the vein of the donor and a similar one into the vein of the recipient. Blood is rapidly drawn out by the syringe from the cannula in the donor and quickly emptied into the vein of the recipient. This requires skillful assistance and a series of syringes, Avhich must be cleaned with salt solution after each emptying. There are many theoretical objections to indirect methods because very little is known of the actual physiologic changes in the blood. Even so gross a change as clotting has not been thoroughly explained. It seems prob- able then, that when blood is withdrawn from contact with its vascular en- dothelium and, particularly, when it is mixed Avith foreign chemicals, changes occur, which, though too fine to j)ermit of chemical detection, alter the bio- logic function of the blood. That some such changes do occur is evidenced b}^ the fact that when citrated blood is used the coagulation time of the pa- tient's blood is markedly decreased. As coagulation is dependent upon certain definite chemical changes and as these in turn require the presence of some materials which result from injured cells, it is evident that destruc- tion or injury of cells occurs, which therebj^ releases thrombokinase, or pro- thrombin, that is essential to the fibrin ferment of coagulation. This element of fibrin ferment is always derived from injured cells, probably chiefly from the platelets of blood. However, as the important constituents of transfused blood seem to be preserved intact in the citrate method and as clinically the citrate method gives about the same results as other methods in restoring the hemoglobin of the recipient, theoretical objections should not militate too greatly against the very simple method of citrate transfusion of blood, as devised by Lewisohn. The marked reaction is the chief objection. The technic of introducing this blood is identical with that of intravenous infusions of salt solution or Locke's solution. Unless the hemoglobin is too low or the condition of the patient too desperate, intravenous infusion of Locke's solution should be applied before resorting to transfusion. The recipient should be prepared for the blood before the blood is drawn from the donor. The patient needing the transfusion is usually so anemic and the veins are so collapsed that it is best to insert a cannula into his vein through a short incision. This is made under local anesthesia, lifting with thumb forceps the skin over a vein near the elbow and cutting away the apex of this elevated cone of skin. (Fig. 21.) This leaves an oval wound. A ligature is applied around the vein at the lowest portion of the wound and tied. Another ligature is placed around the vein at the upper portion of the wound but is left untied. The wall of the vein is grasped with a small thumb forceps or mosquito forceps and incised obliquely. (Fig. 22.) The intravenous cannula or, in an emergency, a medicine dropper which is at- tached by a rubber tube to a glass container or to an irrigating can contain- ing about 100 c.c. of Locke's solution, is then inserted into this opening TRANSFUSION OF BLOOD 67 in the vein wliile the sohition is flowing. The ligature at the upper end of the wound, wliieh was thrown around the vein hut not tied, is tiglitened around the cannuhi. The cannnhi is inserted, flowing, to avoid the introduction of air. Some- times when tlie insertion is a little difficult the opening in the vein can ])e made Fig. 21. — The skin is caught up over a prominent vein in front of the elbovv and the apex of the skin is cut awav with scissors. Fig. 22.— A ligature has been tied on the distal side of the vein, another ligature placed but not tied on the proximal side, and the vein has been opened with an oblique incision. more conspicuous by inserting a closed mosquito forceps and opening the forceps, or by catching the edges of the opening with two mosquito forceps and pulling the wound open, or by inserting a grooved director and pushing the cannula along the grooved director. Sometimes one of these manipulations is easier 68 OPERATIVE SURGERY than another and sometimes none of them is required. It is always well, however, to be prepared for any one of them. After about 50 c.c. of Locke's solution have run into the vein the citrated blood is poured into the container and the flow continued. If the flow is too rapid it is checked at intervals. When only 25 c.c. remain in the container, more Locke's solution is poured in so that all of the citrated blood will flow into the vein Avithout the danger of the entrance of air. If the amount of blood is not sufficient more blood can be obtained in a similar way and introduced through the same cannula. As a rule, however, 500 c.c. of citrated blood are sufficient. In obtaining blood for the citrate method a cannula within a cannula is introduced into the donor's vein, Avhich is distended by applying a tourniquet lightly to the arm. There are special cannulas for this purpose on the market, which consist of a very small cannula containing a wire that does not reach the end of the cannula. This is fitted into a large cannula. After introduction, the wire is withdrawn and if the blood flows through the small cannula, this is withdrawn, leaving the larger cannula in position. Usually the median cephalic vein in the region of the elbow is selected. The large cannula must be of suffi- cient caliber to permit the blood to flow freely and not to drop. If it drops from the cannula it is likely to clot. Sometimes the donor's vein, if not large, is transfixed with a straight round needle to hold it steady. If there is difficulty in introducing the cannula into the donor a short incision may be made and the vein exposed. If the vein has been rendered sufficiently prominent by cording and the cannula has been introduced obliquely in the general course of the vein, usually there is no trouble in securing a good flow, which can be increased by having the donor work his fingers or by adjusting the tourniquet. The blood is collected into a graduated glass jar containing 50 c.c. of 2 per cent citrate of sodium and 1 per cent sodium chloride solution. This is sufficient for 450 c.c. of blood which will make a total bulk of 500 c.c. of citrated blood. The inside of the graduate is thoroughly moistened with citrate solution, so that when the blood touches its side it will not coagulate. The flow of the stream is directed to the center of the graduate as nearly as possible and the blood is thoroughly mixed as it flows, by stirring it gently with a glass rod. Care should be taken to draw no more than 450 c.c. of blood to the 50 c.c. of 2 per cent solution of citrate of sodium, otherwise coagulation will take place. To be on the safe side it is better to draw a little less than 450 c.c. of blood. It will also be found that if the donor is excited the blood ma}^ have a greater tendency than normal to coagulate and an additional allowance of citrate solution should be made. The chief clinical objection to the citrate method is that there are more chills than after other methods. Lewisohn thinks that about 20 per cent of citrate trans- fusions are followed by chills. Others find a larger percentage of reac- tions. It is, of course, taken for granted that the proper tests have been made for agglutination and hemolysis between the donor and the recipient. CHAPTER VI SUTURING BLOOD VESSELS The field of blood vessel suturing has eontracted considerably in recent years. The indications for suturing wounded blood vessels have been con- sidered as follows: 1. AVounded blood vessels where direct suture instead of a ligature is used. 2. Excision of malignant tumors that have heretofore been considered inoperable because of involvement of a large blood vessel. 3. Aneurisms in which the collateral circulation would not be sufficient to sustain the nutrition of the limb if the vessel is tied. 4. Transfusion of blood. 5. Reversal of the circulation. (1) In the treatment of a wounded blood vessel, particularly a vein, Avith a lateral wound, direct suture is indicated instead of a ligature. It has been found, however, as an experience of the Avar, that in young men, Avho Avere previously healthy, and in whom the loss of blood Avas not too great, ligation of the ends of a large Avounded vessel close to the in- jury is, in the great majority of cases, satisfactory. The objections to usnig blood vessel suturing in military surgery are that in many cases it seems, to be unnecessary, and usually, Avhen indicated, the exigencies of the situa- tion are such as to make the teehnic of blood vessel suturing difficult or im- possible to perform. Undoubtedly, in traumatic surgery Avhere cases can be treated in Avell equipped hospitals and by surgeons Avho have acquired the proper teehnic, there Avill be occasional instances in Avhich suturing of in- jured blood vessels will be the best treatment for the patient. (2) In excision of malignant tumors involving large vessels the indi- cations for removing the vessels are not so clear as it Avould appear. If the vessel has been gradually pressed upon by the extension of the groAvth and its circulation gradually decreased, collateral circulation Avill have formed and the involved blood vessel can be excised AA^th much less danger of gangrene than if the vessel had been excised before the collateral circulation had l^een developed. This is the same principle that is taken advantage of by Halsted and by Matas in the gradual occlusion of large vessels by the use of mallea- ble metal bands, Avhich can be so adjusted as to produce a greatly decreased flow through the vessel. But if the tissues around the vessel are infiltrated and the vessel itself is not materially pressed upon, it Avould be safer to ex- cise the artery and then suture betAveen the divided ends a segment of vein, (3) In the treatment of aneurisms the endo-aneurismorrhaphy of Matas 69 70 OPERATIVE SURGERY can be applied in almost all aneurisms in which the circulation can be tem- porarily arrested. In other instances, ligation according to some of the standard technics or the gradual occlusion of the vessels by a malleable band, is usually satisfactory. There may, however, be occasional instances in which on account of enfeebled collateral circulation, excision of the aneur- ism and suturing a segment of vein between the divided ends of the artery is indicated. (4) In transfusion of blood, the ideal method would be to transfer the blood from the donor to the patient over a continuous surface of vascular endothelium. The objections to this are the difficulty of the technie, the dan- ger of dilatation of the heart, and the inability to measure the dosage of blood. The indirect method of transfusion by citrate of sodium, which ap- parently renders the blood incoagulable by combining with the calcium ele- ments in the plasma, is simple, and the cannula of Bernheim seems to be clini- cally so effective, that there is but little place for suturing blood vessels in trans- fusion of blood. (5) The so-called reversal of the circulation for threatened gangrene has been proved to be a fallacy and there is no indication here for suturing vessels. There are, however, occasional instances in which blood vessels should be sutured or a segment of vein transplanted and it w^ould be well for the surgeon to acquire, knowledge of this technie which can only be gained by ex- perimental work. He will find too, that it improves his general surgical technie and teaches gentleness in handling tissues. The chief difficulty to overcome in suturing blood vessels is occlusion by clot- ting, and the whole technie is intended to prevent an excessive amount of clotting while at the same time repairing the walls of the vessel in such a manner that they will withstand the normal blood pressure. If a vessel becomes occluded by clot- ting at the site of operation it might as well have been ligated. Indeed, a ligature would be safer because a part of the thrombus at the site of clotting in a sutured vessel may become dislodged and interfere with collateral circulation. In order to appreciate the necessity for certain steps in suturing blood vessels, it is necessary briefly to review the physiology of thrombus formation. The physiology of thrombus formation is still somewhat vague, though certain general reactions are acknowledged by all physiologists. The forma- tion of a clot or thrombus is due to the action of a material called fibrin fer- ment, or thrombin, on fibrinogen. Fibrinogen exists normally in the blood plasma. Fibrin ferment is built up of various substances and is formed from the action of a thrombo-plastic substance, called by some thrombokinase, upon thrombogen in the presence of a solution of calcium salts. Thrombo- kinase is not a true kinase in the sense of acting solely as a ferment, for it is used up in the process of clotting. Thrombokinase is the key to the situa- tion, and whether it acts directly, or indirectly, as Howell claims, by com- bining with antithrombin in the blood and thus liberating prothrombin (throm- bogen), it nevertheless is essential to clotting and to a large extent regu- SUTURING BLOOD VESSELS 71 lates the amount of thrombus formed. Thromljolviiiase is supposed to be present in all tissues of the body and also comes from disorganized blood corpuscles, particularly the platelets. It seems abundant in the adventitia of blood vessels, probably due to the fact that this coat of a blood vessel is loose and areolar, and entangles the platelets or blood cells in its sub- stance when bleeding occurs. This seems a provision by which nature at- tempts to stop hemorrhage. The practical bearing of these facts upon blood vessel surgery is evident, for thrombokinase can only be liberated from injured cells. As the amount of clotting is directly proportionate to the amount of thrombokinase, it is read- ily seen that any undue injury to blood vessels by rough handling, or by drying of the endothelial cells of the intima, or by the presence of too much foreign substance in the lumen, or by chemical or bacterial injuries, will result in the liberation of so much thrombokinase that excessive thrombus Fig. 23. — The three tractor sutures are placed. (Carrel.) is formed and the vessel is occluded. Even the most successful suturing of blood vessels is accompanied by some clotting; but a limited amount is es- sential, as it serves to fill the punctures from the needle holes and to bridge over the line of contact. In successful vessel suturing, however, the injury is so slight that very little thrombokinase is released and consequently only a small amount of thrombus is formed, just enough to plug the punctures made by the needle and not enough to obstruct the lumen. We recognize, then, as the principles for successful blood vessel suturing that a continuous surface of vascular endothelium must line the lumen of the blood vessels and that as little injury as possible must be done this en- dothelium. Probably the best known method of suturing blood vessels was published by Carrel, in 1902. It differs in no essential particular from the work of others, but is a combination of the best features of other work. The results 72 OPERATIVE SURGERY obtained were much better than those secured by any one else. He used very fine, No. 16, round, straight needles, threaded with fine silk impregnated with vaseline. The adventitia is thoroughly removed and the ends of the artery are washed out with salt solution, or Kinger's solution. The ends of the A^essels are then united by three traction sutures inserted around the artery at equidistant points (Fig. 23). Traction on the sutures converts the circum- ference of the artery into a triangle, approximates the intima, and facilitates the suturing. (Fig. 24). The operator holds one traction suture, the assist- ant holds another, and the third is caught in a small hemostatic forceps, so as to pull the artery away from the region that is being sutured. After sutur- ing one-third Avith a continuous overhand stitch the operator takes the traction suture held by the assistant, the assistant takes the one to which the hemostat Fig. 24. — The three sutures are tied and the upper third is ready for suturing. (Carrel.) was fastened, and the hemostat is placed upon the traction suture that the operator originally held. (Fig. 25). After the second third is finished the traction sutures are again changed, the operator taking the one held by the assistant, who makes tension on the suture that Avas clamped by the hemostat and the hemostat is placed on the suture just released 1)y the operator. The last third is sutured and the blood current is turned on gently. (Fig. 26.) Slight pressure usually stops the oozing from the needle holes, and then the full force of the blo(jd stream is released. The objections to the method of Carrel are: (1) it is complicated, diffi- cult and requires trained assistants; (2) the sutures are placed under A-ary- ing conditions of pressure at different points along the line and the trans- ference of the guy or traction sutures during operation is confusing; (3) a A'ery small surface of the Avascular endothelium is approximated. In an effort to overcome these difficulties I have devised a technic that in my SUTURING BLOOD VESSELS 73 hands lias proved satisfactory and seems to meet the objeetions that have been stated. In sntnrinp: bh)od vessels it is essential to have the least possible trauma Fig. 25. — The suturing of the upper third is completed. (Carrel.) Fig. 26. — The suturing has been completed and the current of blood has been turned on. (Carrel.) and irritation to vascular endothelium. In order to avoid drying of the endothelium and to prevent contamination of the sutured surfaces with juices from the cut ends of the artery, which contain thrombokinase, it has been 74 OPERATIVE SURGERY customary to smear the exposed ends of the vessel with vaseline or with paraffin oil, and the stitches are impregnated in this material. Cubbins and Abt^ have shown that A'-aseline, alboline and lanolin are irri- tating to the peritoneum, as is paraiftn oil, though in a lesser degree. These substances appear to promote adhesions instead of preventing them. They show that olive oil, Mdiile not preventing adhesions, has no irritating effect and is absorbed. If this is true of the peritoneal endothelium, it is probably also true of vascular endothelium. Besides the irritating effect which would follow clotting, these substances act as foreign bodies, do not dissolve in the blood stream and may cover injured cells or thrombokinase which will later cause local thrombus formation. To avoid these objections I have abandoned the use of vaseline in blood vessel suturing, except that the arterial needles and threads are boiled in vaseline. This seems necessary for the arterial sutures are so fine that they will not run smoothly through the tissues unless lubricated and vase- line is an excellent lubricant for this purpose. Olive oil is a poor lubricant. The small amount of vaseline that adheres to the thread is largely covered by the approximated vessel walls when a double mattress or cobbler's stitch is used and so very little or none of it appears in the lumen of the vessel. The importance of presenting to the lumen of the vessel a continuous surface of vascular endothelium, is appreciated when we recall what has been learned in a somewhat coarser fashion in intestinal suturing, where it is a well recognized principle, as it is in blood vessel suturing, that the endothelial surfaces must be approximated accurately. In the bowel, the endo- thelium is on the outside and it is necessary to turn in a small flange or shelf to secure accurate apposition of the peritoneal endothelium. In blood ves- sels the endothelium is on the inside and it is essential to turn out a flange in order to approximate the endothelial lining of the blood vessel. The usual method of suturing blood vessels consists in first placing three guy sutures and then whipping the edges of the vessel together by an overhand stitch. This necessarily cannot approximate the endothelial surface on the inside as accurately as would a mattress stitch which turns out a flange and compels the apposition of the intima. No one would think of suturing a bowel in a similar manner and claim that the peritoneum could be accurately brought together by merely whipping over the margins of the bowel wound as in suturing skin. If this cannot be done in intestinal surgery, the same thing holds equally in blood vessel surgery. The presence of foreign substances in the lumen of a blood vessel promotes clotting. Some substances favor clotting more than others. Other things being equal, however, the larger the amount of foreign substance or raw surface in the blood vessel, the greater the likelihood of extensive clotting. A mattress suture that turns out a flange not only approximates the intima more accurately but leaves almost no thread exposed in the lumen; whereas the continuous overhand stitch leaves a considerable amount of thread in the iSurg. Gynec. & Obst., May, 1916, pp. 571-579. SUTURING BLOOD VESSELS 75 lumen. This is readily seen from the accompanying cut (Figs. 27 and 28) which is reproduced from (iuthrie's work on blood vessel surgery and shows the inside of the vessel soon after being sutured by the usual method. The mattress suture which is parallel to the wound also secures a better hold upon the tissues than the overhand stitch which is at right angles to the wound, and the mattress stitch is, consequently, less liable to cut (Figs. 27 and 29). This is due to the fact that in the mattress suture the tension is more equally distributed along the whole loop of the stitch, whereas in the overhand stitch the tension is concentrated at one point, that is, at the end of the suture farthest from the wound. This fact has been brought out by Lexer, who excised an aneurism and sutured a piece of the saphenous vein into the defect. He said:^ "The wall of the artery markedly changed by arteriosclerosis allowed the threads of the running suture of Carrel to cut through. On the other hand, the continuous protruding mattress suture Fig. 28. Fig. 29. Fig. 27. Fig. 27. — This drawing, reproduced from Guthrie, shows the lumen of a blood vessel immediately after it has been sutured by the method of Carrel. Note large amount of thread exposed in the lumen. Fig. 28. — ^This drawing, also from Guthrie, shows the lumen of a blood vessel several weeks after successful suture. The stitches have been covered by endothelium, which is still transparent. The older the specimen, the thicker and more opaque is the covering over the sutures, until after several months the stitches are completely hidden. This seems true of any method of suturing, but it is the first few days after suturing that the amount of thread exposed in the lumen is important. Sutures seem to work away from endothelial surfaces toward the lumen in the intestines and toward the surface in blood vessels. Fig. 29. — This drawing shows the eversion produced by the double mattress stitch and the consequent absence of any raw surfaces in the lumen of the vessel. Note the small amount of thread exposed to the blood current, as compared with Fig. 27, and the strong grip that the loop of the mattress stitch has on the tissues. gave very good service; the thread not only held well but also prevented hemorrhage." Asepsis in blood vessel suturing should be as nearly perfect as possible, just as it should be in abdominal surgery, brain surgery or bone surgery. If the tissues around the blood vessels are infected no suturing can be expected to be satisfactory. Yet even in the presence of infection blood vessel suturing is not invariably a failure, as I have one successfully sutured femoral artery in a =^Lexer: Jour. Am. Med. Assn., May 10, 1913, p. 1474. 76 OPERATIVE SURGERY dog in which the tissues around the vessel suppurated for several weeks. As a rule, however, infection will result in failure and the proper aseptic technic should be insisted upon. Particularly should dust be avoided. The operator should wear a mask over his mouth and the floor of the operating Fig. 30.^^Special instruments used in the author's method of end-to-end suturiuR of blood vessels. On the left is^the arterial suture staff, and next to it is a small thumb forceps called '"frog" forceps. On the right is a "mosquito" hemostatic forceps, and ne.xt to it two scrrefines, or "bulldog" forceps. room should preferably be moist. In laboratory work the floor should be flushed Avith water an hour or two before operating. The manner of hand- ling tissues is most important, for gentleness is an absolute essential. No matter Iioav careful the aseptic technic, good results cannot be secured by SUTURING 151 .OOn Vi:SSKTiS 77 one who nsos tlio sniiic indlinds of luiiullino; tissue in l)lood vessel surgery as would be adopted in ))()iie surgery. Tlie vascular endothelium must not be permitted to di'y, or shouUl it l)e touched with any instrument. As for instruuuMits, 1 use No. K) straig'ht needles threaded with 00000 twist black silk. They are threaded with silk about fourteen inches long and a single knot is tied on the eye of the needle to prevent it becoming unthreaded. The short end should be cut within half an inch of the needle to avoid unnecessary loose ends dangling about. Five of these threaded needles are run through a piece of gauze of double thickness about two inches Avide and as long as the thread. This gauze is then placed in a small can or Fig. 31. — The artery is exposed, blood stripped Fig. 32.— The artery has been severed by sharp from it, and serrefine clamps are placed. Plain scissors and the adventitia which curls over the ends of gauze is under the artery. The dotted line shows the artery is pulled down and cut away with scissors, the proposed incision. ointment jar that is one-half full of white vaseline, and the jar is closed and sterilized. The needles are not removed until they are to be used, when they are taken from the gauze. To place the cobbler's stitch satisfactorily, it is necessary to have an instrument called ''an arterial suture staff" which I have devised in an effort to simplify the technic. This instrument (Fig. 30) consists of a small steel shaft which curves at one extremity into a shorter shaft. The long shaft, or handle, is six inches long, and the short shaft is one and three quarter inches long and is placed at an angle of about sixty degrees to the long 78 OPERATIVE SURGERY shaft. The curved portion is flattened to form a spring. There are five buttons; one on the main shaft as close as possible to the curved spring, one at the extremity of the short shaft, one just below this, and two on the main shaft at points about opposite the buttons on the short shaft. These but- tons hug the instrument closely and are so constructed that the guy sutures are securely held by simply wrapping them twice around the buttons. In order to occlude the vessel, either a rubber covered Crile clamp is used, or the ordinary serrefine, or bulldog clamp, uncovered, which has a spring- so weakened that the clamp can grasp the skin of the forearm without Fig. 33. — The thumb and finger of the left hand grasp the end of the artery after the adventitia has been cut away, and olive oil is dropped on the artery. Fig. 34. — The first suture has been placed and is wrapped around the lowest button on the long shaft and cut short. pain. The inside of the blood vessel should never be caught with forceps, though sometimes it is necessary to grasp the outside. For this .purpose the ordinary thumb forceps called "frog forceps" by the instrument dealers and sold for biologic dissection are excellent. Several mosquito hemo- static forceps are needed (Fig. 30). Aside from these special instruments, the usual instruments may be employed. The knife and scissors should be sharp. The vessel is exposed, keeping the tissues as dry as possible. A serrefine is placed on the portion of the vessel nearest the heart, and the vessel is gently grasped between the thumb and finger and stripped of blood to the SUTURING BLOOD VESSELS 79 other angle of the m'oiukI, -where another serrefine is ])hiee(l. This leaves the artery dry and flat like a ribbon. Dry gauze or ganze wet with salt solution now is placed beneath the vessel (Fig. 31), after stopping all bleeding in the wound, and the artery is divided with one stroke of sharp scissors. The fingers are wiped free of blood and moisture on a dry towel and the left finger and thumb grasp one of the ends of the artery firmly and pull the adventitia over its cut end. The adventitia is cut off on a level with the rest of the artery (Fig. 32). It then retracts, leaving the middle and inner coats exposed. Any remaining clots in the vessel are stripped out with the thumb and finger and the end is held firmly between the thumb and finger of the left hand and I **-_ Fig 35 — The handle of the arterial suture slaff is depressed away from the operator and the short shaft may be turned flat and caught so as to manipulate the ends of the artery into a convenient position for inserting the second suture. The second suture is inserted, tied, and wrapped around one ot the upper buttons on the long shaft. sponged with dry gauze. As the artery is collapsed and its end held between the finger and thumb the gauze cannot touch the intima, but merely ^^dpes the wounded portion and so removes any excess of thrombokinase. Olive oil is dropped on the end of the vessel with a medicine dropper (Fig. 33). This washes away the tissue juice containing thrombokinase, and pre- vents drying of the intima.^ All of these manipulations are done rapidly for it is essential to com- plete the suturing as quickly as possible after the intima has been exposed. ^Horsley, J. S.: Olive Oil in Blood Vessel Suturing, Ann. Surg., April, 1918, pp. 469-471. 80 OPKRA'I'IVI': SrRGF.RY One of the sutures, which has Ix'cii jn-epared as directed, is inserted from without inward at one end of the artery and from within outward at the other end. An artery is quite tough and a small bite will he sufficient. If too big a bite is taken, the intima cannot be properl}^ everted. The first loop of a knot is tied, bringing the ends of the vessel together. The second loop of the knot is tied while holding the ends of the suture taut, running the knot down in this manner to prevent the first loop slipping. Olive oil is dropped on the vessel ends every 20 or 30 seconds to prevent drying. After tying this suture, the arterial suture staff is placed under the artery Fig. 36. — The threaded end of this second guy suture is left long for future suturing. The un- threaded end is cut short. The vessel can now be lifted on the staff and the apex of the retracted mar- gins indicates the point of insertion for the third guy suture. The staff makes the insertion of the sec- ond, and, particularly, the third guy suture much easier. with the short shaft pointing toward the operator. Each of the buttons of the staff is daubed with vaseline to make the sutures hold better when wrapped around the buttons. The vaseline should not touch the intima of the vessel. The guy suture is fastened by wrapping it two or three times around the lowest button on the long shaft, and is cut short (Fig. 34). The length of the suture from the button to the vessel should be about half an inch. The second suture is placed about one third of the distance around the circum- ference of the vessel and should be on the side away from the operator. The suture staff is laid flat so that the short shaft is not in the way and the vessel ends rest upon the long shaft, thus making it easier to place the second SUTURING r.T-OOD VESSELS 81 suture (Fig. 35). The second suture is inserted and tied in the same manner as the first and is wrapped around one of the upper buttons on the long shaft. The threaded end is left long for future suturing, l)ut the other end is cut close to the l)ult()n. As two guy sutures are now fixed to the long shaft, the third one is easily inserted by raising the long shaft, when the point of in- sertion of the third suture is indicated by the retraction of the margins of the artery. The needle is inserted at the apex of the retracted margin (Fig. 36). Fig. 37.— After insertion of the third guy suture, it is tied m the usual manner and 'he staff is grasped by the handle as indicated in this drawing, and, while the short shaft is slightly compiessea lo- ward the long shaft, the third guy suture is wrapped around one of the buttons on the end ot ttie snort shaft. After this suture is tied, the short shaft is slightly compressed toward the long shaft and this guy suture is wrapped around one of the buttons on the end of the short shaft (Fig. 37). The threaded end is left long and the unthreaded end is cut close, as was done in the second suture. It is im- portant to have no unnecessary ends hanging loose. The short shaft is re- leased and the spring makes tension on the margins of the artery, converting its circumference into a triangle, and everting the intima (Fig. 38). Olive 82 OPERATIVE SURGERY oil should be dropped on the vessel ends from time to lime diiriii.<>' these manip- ulations and during the suturing. The three guy sutures are inserted in tlie same way when an artery is joined to a vein of much larger caliber as when a divided artery is united. Sometimes it is a little more dil^cult to place the guy sutures properly when a small artery is sutured to a large vein as in direct transfusion, but after the guy sutures are once inserted, the rest of the procedure 1*8 identical, whether vessels of equal or unequal caliber are to be united. "We now have two needles from the two guy sutures last inserted. A Fig. 38. — When the tension of the spring of the shaft is released by removing the hand, the spring makes traction on the three guy sutures, so converting the circumference of the vessel into a triangle, and everting the intima. needle is taken in each hand and thrust through both margins of the artery in the region where the second suture was tied. The threaded needle from the third guy suture at the end of the short shaft, will, of course, carry a little loop of thread which is of no consequence. The instrument is lifted so as to elevate the upper third of the arterial wound and increase the eversion. The suture is then applied in the manner of tlie double mattress, or cobbler's stitch, going from the second guy suture to the third (Fig. 39). At the angles par- ticular care should be taken to go beneath the insertion of the guy sutures ; otherwise, the tension of the guy sutures ma.y produce a Avound in the endothelium which would be exposed to the lumen of the vessel. After the SUTURING BI.OOD VESSELS 83 first tliii'd has been sului'od, tlio liaiuUc of llic suture s1alT is dcjii-essed away from the operator and the staff shoved toward the operator so as to increase the eversion of this third of the margin of the vessel (Fig. 40). The suturing is continued as a eo1)l)lcr's stitch. AVhen tlie second third is finished, the instrument is brought to its original position aiul each needle is carried under the vessel so as to be ready for suturing the hist third. The handle is then depressed toward the operator and held in such a manner as to lift up the last third and so increase its eversion (Fig. 41). The suturing is continued through the last third and when this is finished the instrument is brought Fig. 39. — The handle of the staff is upright and the whole instrument is lifted up so as to increase the eversion of the intima. The continuous double mattress or cobbler's stitch is begun by using the threaded ends of the last two guy sutures. The needles are thrust through the margins of the artery near the second guy suture and are inserted at right angles to each other, so they can be more readily handled. The suturing in this third is done toward the operator — that is, from the second to the third guy suture. to its original position and the suturing carried about two stitches beyond the point of beginning, where the threads are tied to each other. Each stitch must be drawn snugly when it is placed, else the intima Avill not be securely approximated and there will be leakage. In the carotid of a dog of medium size about five stitches are put in each third of the artery. Sometimes retraction of the ends of the artery is marked and the sutures cannot be properly placed, as they wall tend to cut out or break under the tension. If the adventitia of the vessel is grasped with curved mosquito for- ceps about one and one-half inches from the severed ends, the two ends of the 84 OPERATIVE SURGERY vessel can be shoved together hy an assistant, withont tension on the sutures and without his hands being in the way of the operator. This is better than trying to approximate the ends by tlie serrefine clamps which may either come off or loosen and flood tlie vessel Math blood. After the suturing has been completed, the short sliaft is slightly compressed toward the main shaft so as to relax the tension on the guy sutures and the distal clamp on the vessel is slowly released (Fig. 42). If there is marked spurting at any point, an extra suture is placed there. With a little experience spurting rarely occurs, though there is usually oozing of a few drops of blood. The guy su- Fig. 40. — The handle of the staff is depressed until it is horizontal and points away from tlie oper- ator. Then the whole instrument is shoved toward the operator so as to increase the aversion of the second third. The suturing is continued as a cobbler's stitch. tures are then cut and the instrument is removed. The sutured vessel is very gently compressed with drj^ gauze and the distal clamp is entirely removed. After about three minutes the proximal clamp is slowly removed. In this time the needle holes should be plugged with fibrin and there should be no leakage. The vessel must not be returned to its bed until leakage has ceased. The whole procedure of suturing the vessel from the insertion of the guy sutures to the last stitch, can easily be done in from ten to fifteen minutes and often in less time. Any competent surgeon who tries this technic experimentally a few times can master it (Figs. 43 and 44). SUTURING BLOOD VESSELS 85 The traiisplaiitatioii of a segment of a vein, or of an artery, involves the same teehnie as suturing a divided vessel. It is best, however, to have two arterial suture staffs instead of one. Three guy sutures should be placed at one end, but only the first two fastened to the staff. Then the other end of the transplant can be sutured with another staff in the usual way. After this is completed, the first staff is taken up, and the third guy suture fastened to the end of the short shaft, and the suturing completed. In this way there is no inconvenience from the presence of two suture staffs in the wound at the same time, for if all three guy sutures w^ere placed in posi- tion on the first suture staff, the short end of the staff Avould project so as Fig. 41.— The handle of the staff is brought over to a horizontal position, pointing toward the opei- ator. The instrument is lifted up so as to increase the eversion in the last third. The suturing is con- tinued from the first to the second guy suture. to interfere with the suturing at the second suture staff. A transplant can be taken from either a vein or an artery. For practical purposes the. vein is better. In experimental work the external jugular of the dog is the most suitable vein to transplant. It is readily accessible, is large, and has but few branches. Transplantation after resection of the carotid is more likely to be successful in experimental work than transplanting in the femoral because the neck is much less likely to be infected than the leg (Figs. 45 and 46). This has been jjointed out by Stephen Watts. Some attention must be given to securing a section of the vein that 86 OPERATIVE SURGERY is to be transplanted. The saphenous is the best A'ein to use as a transplant in man. The vein must be exposed and handled gently. A much longer portion should be taken than is supposed to be necessary, for it contracts greatly after being removed and it is a simple matter to cut off any excess if it is too long. The vein is dissected free while it is distended with blood and the adventitia of that portion of the vein to be cut is very carefully removed while the vein is distended; otherwise it retracts within the adven- titia and as the vein is exceedingly thin, cleaning away the adventitia ls Pig, 42. The handle of the instrument is brought to a vertical position and the sutures, having been carried about two stitches beyond the point of commencement, are tied to each other. The distal clamp is slowly removed and the staff somewhat compressed in order to relax the guy sutures and dem- onstrate if there is any spurting point along the suture line. After a minute the other serrefine is re- moved if no spurting occurs, and the guy sutures are cut. If there is spurting, the clamps can be re- applied and an extra stitch taken at the spurting point. difficult after the collapsed segment has been removed. When the adventitia has been sufficiently removed, the serrefine that caused the vein to become distended is released and a ligature is placed on the distal portion of the vein. The blood is then gently stripped out of the vein and another ligature SUTURING BLOOD VESSELS 87 placed at the proxiuial cud. The vein is severed witli sliarp scissors, with one stroke if possible. After the blood has been stripped from the vein it is en- tirely collapsed and like a ribbon. ^N]\en the end is cut it is sponged with dry gauze and thoroughly anointed with olive oil, as mentioned in the tech- nic for vessel suturing (page 79), only more olive oil should be used here. The other end is then divided and treated in a similar manner. The vein should be used as quickly as possible. The vein should not be removed until the other dissection has been completed, so that suturing of the vein into the defect can be proceeded with at once. The segment of vein should not be washed out or kept in salt solution. If for any reason it is necessary to keep the segment a while, it may be placed on a towel or piece of gauze that has been wrung out in salt solu- tion, and another piece of gauze similarly wrung out, is placed over it. It is not Fig. 43.— A femoral artery of a dog removed a few minutes after suturing, after the blood had been turned on and no leakage appeared. Note the eversion of the mtima which makes a flange without dim- inution of the caliber. . Fig. 44.— The lumen of the carotid artery of a dog after suturing according to the author's technic. The blood had been turned on and allowed to run a few minutes. Note the small amount of tiiread in the lumen. necessary for the salt solution to be warm. It has been proved that cold tends to retard thrombus formation, and segments of vessels can be kept in cold storage for weeks and then sutured successfully. I have used experimentally rubber tubing of various kinds to replace an arterial segment. This, in most instances, becomes readily covered w^ith tissue that resembles the adventitia of a blood vessel. It is well known that rubber when properly prepared is very slightly irritating to the tissues. Dentists make frequent use of it. If, then, adventitia can be thrown around the rubber tube as an encapsulation, it would probably support the blood 88 OPERATIVE SURGERY current after the rubber had degenerated. The high reproductive power of vascular endothelium is frequently observed in the rapid lining of aneur- isms that have suddenly enlarged, and it seems possible that this endothelium might cover the inner surface of the rubber tubing. Theoretically, in this way a strong adventitia and an intima may be secured. Experimentally, however, I have not been able to obtain such a result. Though the tube is often encapsulated with a membrane that resembles adventitia, its internal Fig. 45. Fig. 46. Pig. 45. — The end of the carotid artery was sutured to the distal end of the divided external jugular vein in a dog, and this specimen was removed after thirty-nine days. The sutures are distinctly buried, though the endothelium over them is transparent in places. The line of suturing is smooth. A short dis- tance from the line of suturing are the crumpled up valves which were broken down by the blood stream. Fig. 46. — A segment of the external jugular vein was sutured in the place of a resected portion of the carotid of a. large dog. The valves are about the middle of the specimen, and at this point the trans- planted vein was dilated. Otherwise, the intima is smooth and the sutures mostly buried from view. The specimen was removed sixty-three days after operation. Burfaee has so far been invariably blocked, sooner or later, by thrombus. Tubes have varied from thick, black rubber to very thin rubber, and have been coated with vaseline or paraffin. "While it Avould be impossible to suture tubes, especially thick tubes, by the overhand stitch, and at the same time SUTURING BLOOD VESSELS 89 make an aeeurate a])proxiinati()ii and avuid sharp edges of the tiil)e pointing inward, by using a mattress suture, and preferably the double mattress with the staff, that has been described, sharp edges are everted. While so far I have not met with success in having the rubber tube remain permanently patent, the thrombus formation in some instances at least must have been slow. Clinically it is almost as satisfactory to have a slowly forming thrombus in a tube Fig. 47. — Photograph of a specimen in which a rubber tube was sutured into the defect caused by- excision of a portion of the abdominal aorta of a dog. This specimen was removed after six months, and the tube, which had been sutured according to the method described, was completely encapsulated, though 90 OPERATIVE SURGERY of this character, which would permit collateral circulation to form, as it is to have the tube remain permanently open. The possibility of using a rubl)cr tube in this manner clinically has been suggested by an experiment in which a portion of the abdominal aorta of a dog was resected and a piece of rubber tube transplanted to fill the defect. The portion resected was below the renal arteries. The tube Avas a soft, black rubber tube coated with paraffin. It was much thicker than was really necessary, and the suturing was more difficult than if a thinner tube had been used. The dog was a medium sized female mongrel. There was very little leakage, which was easily controlled by pressure. The peritoneal tissues were sutured over the tube. The dog made a satisfactory recovery, there being no paralysis of the hind legs. As function had apparently not been interfered with, it was hoped that the tube had remained patent. Six months after this operation the dog appeared in perfect health. The dog was then photographed, killed with chloroform, and the specimen removed. The lumen of the tube, however, was occluded with a thrombus. There was no dilatation nor any evidence of formation of an aneurism. The outline of the tube is plainly seen in the photograph. The external caliber of the tube was con- siderably larger than the external caliber of the artery (Fig. 47). Ligation of the aorta in man has been universally fatal. This experiment suggests a possible substitute for ligation. LATERAL AND INCOMPLETE TRANSVERSE WOUNDS OF BLOOD VESSELS The preliminary steps in suturing lateral or transverse wounds of blood vessels are the same as those outlined under the description of end-to-end suturing. The wound should be a clean cut. If ragged or bruised, the mar- gins are trimmed with sharp scissors. If a transverse wound involves more than half the circumference of a vessel, the vessel should be completely di- vided and then united by the end-to-end method. If the whole circumference is contused or lacerated, the damaged section must be excised, and if the ends of the vessel cannot be sutured together without too much tension, a trans- plant of vein may be used. The method to be adopted in suturing these wounds depends partly upon the nature of the wound, but largely upon the accessibility of the blood vessel. AVhen possible, the vessel should be freely exposed by a long ex- cision. The adventitia along the edges of the wound is trimmed away with sharp scissors, blood clots are removed, and the edges of the wound and the in- tima are waslied with Locke's solution. If the wound is parallel with the vessel, it may be grasped Avith the forceps used for lateral anastomosis of blood vessels or arteriovenous aneurism and sutured with a cobbler's stitch, using fine, straight needles (Xo. 14 or 16) and fine black silk sterilized in vaseline. If the wound is transverse, the suture staff may be placed under the vessel, a guv suture of the usual material is inserted at one end of the wound and SUTURING BLOOD VESSELS 91 wrapped around an upiier button on the long sliaft, and anotlicr guy sutnre is placed at the opposite end of the wound and fastened to a button on the short shaft Avhile it is being compressed toward the long shaft. When the short shaft is released, it Avill make tension on the wound and evert the intima. A cobbler's stitch can then be placed with the thi'eaded ends of the gny sutures, as in suturing the first third of an end-to-end union. Care should be taken to secure the beginning of the suture line by going Avell beyond the wound and taking a back stitch. Occasionally a transverse or a lateral wound may be so inaccessible that neither of these methods can be used. Here a long guy suture may be placed at each end of the Avound and held by an assistant while the wound is closed with a continuous overhand stitch of black silk in a fine curved, round needle. There wall be more leakage from the needle-holes after this method and thrombosis is more frequent, but in deep wounds it may be the only technic applicable. CHAPTER VII REVERSAL OF THE CIRCULATION The therapeutic value of attempts to reverse the circulation in the ex- tremities has been freely discussed since this work was first brought to the attention of surgeons by the experiments of Carrel. Carrel and Guthrie^ reached the following conclusions as the result of two experiments; "(a) The valves prevent, at first, the reversion of the circulation in the veins, (b) After a short time, the valves gradually give way and the red blood floAvs through the veins as far as the capillaries, (c) Finally it passes through the capillaries and the arteries are filled with dark blood. Probably dark blood also returns from the capillaries towards the heart through some veins, (d) Practically complete reversal of the circulation is established about three hours after the operation." The clinical indication for reversal of the circulation has been thought to be threatened or slow gangrene of the foot or occasionally of the hand. The lower extremity is far more frequently threatened with gangrene than the upper extremity. This may be due to the fact that it is longer and the distance from the base of nutrition is consequently greater and that the cir- culation has to overcome the weight of the column of blood that must be lifted from the foot, which is far greater than would be the pressure of the returning blood circulation from the upper extremity. The diseases in which slow or threatened gangrene usually occurs are; (1) arteriosclerosis, (2) intermittent claudication, (3) Raynaud's disease, and (4) thromboangiitis obliterans. In all of these diseases the artery is usually more profoundly affected than the vein. It has been suggested as a result of the ^experimental work of Carrel and Guthrie that the vein could take on the function of the artery, and in slow or threatened gangrene of the foot the femoral artery could be divided in its upper portion, the femoral vein also divided at a same level and the cardiac end of the artery sutured to the distal end of the vein, the distal end of the artery being sutured to the cardiac end of the vein. In this way the blood in the femoral artery enters the femoral vein and is supposed to overcome the obstacles of the valves in the vein, gradually to reach the terminal veins and capillaries, and then is returned through another system of veins that would anastomose with the branches of the iliac veins. In order to determine the exact course of the reversed circulation, a series of experiments on dogs was undertaken, the results of which have been reported elsewhere.- The late Dr. R. H. AVhitehead, who was Professor of ^Ann. Surg., February, 1906, p. 212. 2Jour. Am. Med. Assn., March 13, 1915, Ixiv, 873-877; Ann. Surg., March, 1916. 92 REVERRAT. OF THE CIRCULATION 93 Anatomy in the University of Virginia, dissected the specimens and reported that the dissections corresponded in all essentials with the roentgenograms. DeWitt Stetten, of New York, worked on the same problem nsing liml)S that had l)een amputated for affections in which reversal of the circulation Fig. 48. — A roentgenogram of reversal of the circulation in a dog's hind extremity which was injected with cinnabar mass a half -hour after operation. The mass goes only a little below the knee and returns in the back part of the thigh toward the branches of the internal iliac vein. Fig. 49. — A roentgenogram of cinnabar mass which was injected into the reversed circulation of a dog's hind extremity twenty-two days after the operation. Note the very large collateral veins that conduct the mass easily to the iliac veins and the vena cava. Fig. SO. — A roentgenogram of cinnabar mass injected into reversed circulation of the hind ex- tremity of a dog sixty-nine days after the oper- ation. Fig. 51. — A roentgenogram of the same dog shown in Fig. SO, but with the systemic arterial system injected with a bismuth mass through the carotid. Note the excellent circulation in the foot. The black shadow in the body is due to rupture of some abdominal vessel toward the end of this injection which permitted the peritoneal cavity to be filled with the bismuth mass. 94 OPERATIVE SURGERY had been formerly recommended."' In liis excellent article, which goes very fully into the literature of the subject, he arrived at the same conclusion Avhich Ave had reached by our exiDcrimental work on dogs. Briefly summarizing the results of these experiments, thirteen dogs were operated upon by severing the femoral artery and femoral vein just below Poupart's ligament and suturing the cardiac end of the artery to the distal end of the vein by the teehnic described in the previous chapter. This tech- nic stands infection better than the teehnic of Carrel, as it apposes a broader surface of endothelium and makes a firmer and more resistant union. These dogs were killed within periods of time, varying from half an hour to sixty- nine days after the operation. The femoral artery just above the point of the anastomosis was injected with a cinnabar and gelatine mass under con- siderable pressure. Eoentgenograms w^ere then taken and afterwards the general arterial circulation was injected with a bismuth mass either from the aorta or the carotid. Both bismuth and cinnabar are impervious to x-ray and the ditference in color prevents confusion in dissection. In no instance did the reversed circulation, as shown by the injection of the cinnabar, go as far as the foot and in every case except one it extended but a short distance below the knee. The tendency of the arterial blood in the reversed femoral vein is to return to the vena cava by the nearest anastomotic route (Figs. 48, 49, 50 and 51). The longer the period of time after the operation, and the more abundant the collateral circulation, the easier is the return to the vena cava. Evidentl}^ what happens is that the large valves in the large veins are first quickly broken down. The arterial blood in the reversed vein then rushes into smaller veins. The smaller valves in the smaller veins require relatively more force to overcome them than the larger valves in the large veins, because of the relation of cubic contents to square surface. The ex- periments show that the reversed circulation went but little further doAvn the leg in a dog sixty-nine days after operation than it did in the dog that Avas injected a half hour after the circulation Avas rcA'ersed. This seems to show that the A'ah^es AAdiich are not broken doAvn in the first feAV minutes Avill probably hold permanently. Collateral circulation quickly increases, and large veins are formed Avhich readily carry the reversed blood to the branches of the iliac A'ein. In this Avay the pressure upon the obstructing A^alves is re- duced and probably some thickening of these vah^es occurs. Instead, then, of the constant pounding of the heart tending to break cloAvn these A'ah^es, it seems to do just the opposite. Valves that are not overcome AA^thin the first fcAV minutes haA^e less and less pressure upon them until the collateral circulation dcA^elops to its maximum. HoAv, then, can avc account for the apparent improA'ement in many of the reported cases of reversal of the circulation in patients? Certainly not all of these reports can be argued aAA^ay, and they must rest on some basis of fact. In the successful cases reported, it has been usual to find that the day after the operation the foot appears Avarmer and the color is better than ^Surg. Gynec. & Obst., April. 191S. REVERSAL OF THE CIRCULATION 95 before operation. It has been asserted, tlierefore, tliat tlie improvement must be accounted for by the operation and by the fact that the arterial blood is reaching the distal part of the foot through the reversed vein. A great many reversals of the circulation have been done b}' surgeons untrained in blood vessel surgery who liave used the end-to-end method, and it is natural to ex- pect that there will be a large percentage of occlusions by thrombosis fol- lowing sucli work. In no other branch of surgery is laboratory experience so essential as in preserving a patent lumen after suturing blood vessels. It is easy enough to unite the artery and vein so that the line of union will not •bleed at the conclusion of the operation, but the technically successful opera- tion is the one in which the lumen remains permanently patent. These tem- porary improvements may be explained in the following manner : The cause of the impending gangrene for which these operations are done is a diminished lumen of the artery, while the veins are but little if at all affected. An artery that would normally carry 100 per cent of its ca- pacity is under these altered conditions carrying only, saj" 25 per cent, but the capacity of the vein has been but slightly altered. Nutrition for the tissues is taken from the arterial blood in the capillaries and depends not only on the quantity and quality of this blood and the ability of the tissues to absorb it, but also to some extent on the length of time during which the arterial blood bathes the tissues. With the artery working normally and the veins normally, a definite period of time during which the arterial blood remains in the tissues is maintained ; but with the capacity of the artery cut down to about one fourth of normal or even less, and the capacity of the vein but slightly interfered Avith, the small amount of arterial blood that does reach the tissues is drained away by the unobstructed veins more quickly than normal. The arteriovenous anastomosis stops the venous current in the femoral vein either by the force of the reversed arterial blood stream or, more probably, particularly Avhen done by those inexperienced in vascular surgery, by throm- bosis at the site of the operation. This, of course, obstructs the vein and more nearly restores the balance between the venous and the arterial cir- culation. In other words, the operation dams back the arterial blood in the capillaries so that instead of being drained off too rapidly, the arterial blood is compelled to stay the normal time, and possibly even somewhat longer than normal, and so gives up to the tissues more of its nutrient properties. In this manner the improvement as to the color and warmth of the affected limb can be accounted for. But if the occlusion has been caused by thrombus formation at the arteriovenous anastomosis, the thrombus may extend until too much of the venous system is plugged, and gangrene will follow. The same results can be obtained much more accurately and with less danger simply by ligation of the femoral vein under a local anesthetic. This pro- cedure has been recommended and carried out by von Oppel, Coenen, Lilien- thal and others. In operation for threatened or slow gangrene of the foot, the femoral vein should be ligated below the point at which the saphenous vein enters it. in 96 OPERATIVE SURGERY order not to obstruct too much of the returning venous circulation. As the condition of the patients with threatened or slow gangrene is serious the operation should be done under local anesthesia. An incision of about three inches in length is made over the upper por- tion of the femoral artery beginning just below Poupart's ligament. The dissection is carried down until the femoral artery is fully exposed in the lower half of the incision. The femoral vein is identified internal and slightly posterior to the femoral artery and should be cleanly dissected in front with a sharp knife. Bj^ the method of inserting closed, curved scissors and then opening the blades the vein can be readily isolated. Care is taken to ex- pose the femoral vein clearly and to have the incision sufficiently long to prevent any confusion of the anatomical structures. A ligature is passed around the femoral vein with an aneurism needle. It is best to apply two ligatures of moderately stout catgut. The skin is sutured with silk or silk- worm-gut. The leg is slightly elevated and kept warm. Within twenty-four hours there is often marked improvement in the condition of the limb. This im- provement is usually not permanent. The beneficial results, however, are fully as great as those obtained from anastomosing the artery and vein, and the danger of the operation is far less. CHAPTER VIII LIGATION OF BLOOD VESSELS One of the chief indications for ligation of the blood vessels in preanti- septic days Avas secondary hemorrhage following suppuration. This indication is infrequent noAV, so the elaborate operations that were formerly devised for ligation of almost every artery in the body are largely unnecessary. On account of aneurisms there is often occasion for tying in continuity the larger arteries, as the carotid or its branches, subclavian, axillary, bra- chial, iliac, femoral. Occasionally, on account of hemorrhage from the palmar arches it is necessary to tie the radial and the ulnar arteries. Ligation of arteries in continuity requires a clear knowledge of the anat- omy of the site of operation. The general technic of ligating vessels holds good for the tying of any artery. The incision should be made as directly over the vessel to be ligated as possible. This should be determined in ad- vance and is based upon the anatomy of the parts. Any probable or possible variation in anatomy from the normal must be borne in mind and the anatom- ical changes that may be produced by the pathology present, as in ligating in the presence of great swelling, must be given due consideration. The incision should be sufficiently long to expose the vessel freely and, as a rule, should be so placed that the proposed site of the ligation of the artery wdll be in the center of the incision. The skin incision is made by holding the skin firmly with the fingers and thumb of the left hand and cutting through the skin in the proposed line of the artery with one stroke of the knife. The superficial fascia and deep fascia are then divided. All vessels that are in the way are retracted or else doubly clamped and ligated, so as to give a clean access to the artery. When approaching close to the artery, the loose connective tissue and areolar tissue are caught with thumb forceps and lifted and cut with a sharp knife. It is dangerous to dissect around a big vessel wdth a dull knife, because the stroke of a dull knife cannot be gauged with accuracy. The artery is usually distinguished by pulsation if no tourniquet is used, or, if a tourniquet is used, by the fact that the artery is thicker and not collapsible as the vein is. Below the axilla and below the knee each artery has two com- panion veins, the venae comites, which may serve as an identification, whereas the larger arteries in the head and neck are accompanied by single veins. The nerves appear as white solid cords. Occasionally, a nerve may trans- mit pulsation because it rests on an artery, but if grasped gently between the finger and thumb it can be easily seen that this is not an expansile pulsa- tion but merely transmitted. Only the main larger arteries have a distinct sheath. Usually when there is a sheath, the accompanying vein and nerve are enclosed in a common sheath 97 98 OPERATIVE Sl'RGERY with the artery. The smaller arteries have no distinct sheath, but are merely surronnded by areolar tissue. In the large arteries the sheath should be opened at least half an inch from any branch. The sheath is opened by pick- ing it up Avith thumb forceps, making traction upon it so as to pull it away from the artery and dividing it by a stroke of a sharp knife in the axis of the vessel. It must, of course, be accurately ascertained before divid- ing the .sheath that the forceps does not include the vessel Avail also. This is not likely to occur but can be easily demonstrated by moving the sheath to and fro. It is best not to make an incision into the sheath longer than is neces- sar}" to ligate the vessel clearly, as too extensive a separation of the sheath from a large arterA* maA^ interfere Avith the nutrition of the Avails of the ar- Fi? -Binnie's method of passing a stout catgut ligature. tery. If necessary, it is better to open the sheath by making tAvo short incis- ions at different points than to make one long incision. The ligature is passed preferably Avith a curved aneurism needle. It may, howcA^er, be more convenient to use a small right angled pedicle clamp. The only objection to the clamp is that, AA'hen its jaAvs are opened to receive the ligature and then clamped on the ligature, it is possible that some tags of tissue in the neighborhood may also be caught in the forceps and prevent the free moA'ing of the forceps. This can usually be prevented by opening and clos- ing the forceps scA^eral times before placing the ligature in its grasp. In a deep Avound, hoAvcA^er, the aneurism needle is preferable to the right an- gled forceps. The aneurism needle should ])e passed around the artery be- ginning on the side of the vein. In the larger arteries, moderately stout cat- LIGATION OP BI.OOD VESSELS 99 gut is used. If tliis is threaded into tlic aneurism needle before the ueedle is passed, it maj^ interfere with passage of tlu^ needle. It is a good idea to follow the suggestion of Binnie and arm the needle with a fine thread of silk or linen which does not hamper the manipulation of the aneurism needle. When the eye of the aneurism needle has appeared on the opposite side of the vessel from that under which it was inserted, the loop of small silk or linen is drawn up and the stouter catgut is passed through this loop and so drawn around the vessel (Fig. 52). Ligatures of catgut are usually best and if tied properly the knot will hold. The so-called surgeon's knot should never be used because it is im- possible to tell how much pressure is being taken up b}" the friction of Fig. 53. — Ligation of the femoral artery, showing method of applying two ligatures. The ligature nearest the heart takes the chief strain of the arterial pressure. the double tie and how much by the vessel. The first tie can be held by grasping it with small forceps, such as mosquito forceps, while the second tie is being run down, and a third tie should always be placed in order to make the knot more certain. It is not necessary to rupture the intima but sufficient pres- sure should be made by the first tie in order firmly to occlude the vessel. If too large a strand is used there is much more likelihood of the knot slipping than with a smaller strand. It must be recognized, however, that a very small strand may not stand the strain of the pulsation of the vessel or may tend to cut through the vessel w^alls. Tw^o ligatures should always be placed at a distance of about one-fourth of an inch from each other. This consumes but little more time and adds greatly to the safety. If only one ligature is passed there is constant pounding 100 OPERATIVE SURGERY upon it by the impact of the arterial current and healing is consequently more difficult. When two ligatures are placed, the one nearest the heart takes up the strain of the arterial impulse, while the tissues within the grasp of the second ligature can heal more readily because they are at rest and freed from the constant pounding of the heart. Then, too, if the first ligature should loosen it will at least probably hold long enough for a clot to form between the two ligatures and this clot will act as a buffer between the impulse of the arterial current and the second ligature and so reduce the strain on the second ligature. (Fig. 53.) In tying the ligature and in all manipulations of the artery it is important to move the artery from its bed as little as possible. This is true of all vessels, but it is particularly important when the vessels are diseased, as the slightest interference with the nutrition of the wall of a diseased vessel may result in secondary hemorrhage. The Avound should be closed as after any operation, so as to eliminate as far as possible dead spaces but not to place too great a bur- den upon the tissues by unnecessary suturing. An artery should be tied as far as possible from a large branch or else the branch should be ligated also. If a large arterial trunk of an extremity is ligated the limb should be wrapped in an abundance of cotton and slightly elevated so as to favor the return venous flow and consequently prevent passive congestion. LIGATION OF THE INNOMINATE ARTERY This artery is sometimes, though very rarely, ligated for aneurism. It is the largest branch of the arch of the aorta and is about two inches in length. It rises opposite the fourth dorsal vertebra, runs upward, forward, to the right, and divides into the right common carotid and the right subclavian. It termi- nates on a level with the upper border of the right sternoclavicular articulation. In front of this artery are the manubrium with the muscles that arise from this bone, the right sternoclavicular joint, the remains of the thymus gland, the left innominate vein, the right inferior thyroid vein and the lower cervical branches of the right vagus to the heart. Posterior are the trachea and right pleura. To the right are the right innominate vein, the right vagus nerve and the right pleura. To the left are the left common carotid, the remains of the thymus gland, the left inferior thyroid vein and the trachea. There are several operations for tying the innominate artery. One is by 'the angular incision of Mott, Avhich is made along the upper margin of the clavicle, the sternomastoid muscle being cut, and another incision from the inner end of this goes upward about three inches along the anterior border of the sternomastoid. An excellent approach can be obtained by an oblique incis- ion along the lower part of the anterior border of the sternomastoid which is carried over on the manubrium. The common carotid is exposed and followed down to the clavicle and then a portion of the manubrium may be divided or resected. A sufficient amount of the bone is taken away in order to give a sat- LIGATION OF BLOOD VESSELS 101 isfaetoi'v exposiii'c. II has Ix'cii ])r()p()S(Ml to si)lii the luamihi-imii and paii: of the sternuiu with a saw, protecting the tissues beneath 1)y a flat retractor, slipped under tlie l)one. The important point is, first to recognize the com- mon carotid and then follow down to the innominate. It is best to tie bolli the common carotid and the vertebral artery after tying the innominate in order to avoid secondary hemorrhage and to reduce the circulation in the aneu- rism as much as possible. LIGATION OF THE COMMON CAROTID ARTERY The right common carotid is about three and three quarter inches in length and arises from the innominate artery. It contains in its sheath the internal jugular vein, which lies to the outer side, and the vagus nerve, which lies between and behind the artery and the vein. The omohyoid muscle crosses the common carotid and the portion of the artery below the omohyoid muscle is deeper than the portion above it. The left common carotid is longer than the right, being about four and one- half inches long, and arises from the middle of the arch of the aorta and courses upward and outward. It is overlapped by the left lung and pleura in its first portion. The omohyoid muscle crosses on the left side as on the right. The left common carotid has in its deep portion in front, the manubrium with the muscles that arise from this bone, the remains of the thymus and the left in- nominate vein. Behind the left common carotid in the chest are the trachea, esophagus, the thoracic duct, and the recurrent laryngeal nerve. To the left are the pleura and lung, the left vagus nerve and the left subclavian artery. Internally are the innominate artery, the trachea, remains of the thymus gland and the inferior thyroid vein. In the neck both common carotids have a similar relation, being covered by skin, platysma, fascia, the neck muscles that arise from the sternum, the anterior jugular vein and several superficial veins, which are sometimes irregular, as well as the lingual and facial veins as they course across the artery. In front also is the descending branch of the hj'-pogiossal nerve. Behind are the vagus nerve, the sympathetic nerves and the cervical branches of the sympathetic to the heart, the recurrent laryngeal nerve, the inferior thyroid artery and the deep muscles of the neck, the longus colli and the rectus capitis anticus major. Externally are the internal jugular vein and the vagus nerve. Internalhj, is the trachea below, then come the esophagus, recurrent laryngeal nerve, branches of the inferior thyroid artery, the thyroid gland, the larynx and the lower part of the pharynx. The line of the common carotid artery can best be expressed by a line drawn from a 23oint just external to the sternoclavicular articulation to a point about the middle of a line between the angle of the jaw and the tip of the mastoid process. The first portion of this line as high as the upper border of the thyroid cartilage represents the common carotid. Normally there are no branches from the common carotid except the terminal branches. If the common carotid is to be ligated below the omohyoid muscle an incision about 102 OPERATIVE SURGERY three and one-half inches in length is made in the line of the artery from just below the larynx to the sternoclavicular articulation. After cutting through the skin, fascia and platj^sma, the superficial veins that are encountered are pushed aside or doubly clamped and divided. The deep fascia is incised along the anterior border of the sternomastoid, which is retracted outward. The sternohyoid muscle is either retracted inward or divided. The inferior thyroid veins are doubly clamped and tied. The sheath of the artery is then exposed. The recurrent laryngeal nerve which lies to the inner side must be guarded against as well as the vagus nerve and the internal jugular, or the outer side. Above the omohyoid, an incision of about three and one-half inches in length is made along the anterior border of the sternomastoid muscle with its center on the level of the cricoid cartilage. Superficial veins are retracted or clamped and divided. The anterior jugular and facial veins should be looked after. They are of considerable size and are doubly clamped or tied and di- vided. The sternomastoid muscle is retracted outward and the omohyoid down- ward and inward, or the omohyoid may be divided. The sheath of the artery is carefully cleared and divided from the inner side to avoid the descending branch of the hypoglossal nerve and the internal jugular vein. Ligatures should.be passed from the internal jugular vein inward (Fig. 54). LIGATION OF THE EXTERNAL CAROTID ARTERY The external carotid artery is the smaller of the two terminal divisions of the common carotid and is about two and one-half inches in length. It lies behind the upper part of the line of the common carotid artery and terminates in the substance of the parotid gland, just in front of the ex- ternal auditory meatus, where it divides into the internal maxillary and the temporal arteries. The important structures in front of this artery are the anterior border of the sternomastoid muscle, the hypoglossal nerve, the lingual and facial veins, the posterior belly of the digastric muscle, and, higher up, the branches of the facial nerve and the carotid gland. Externallj', besides these structures, is the internal carotid artery. Behind are the internal carotid artery, the styloglossus muscle, the glossoi^haryugeal nerve, and the pharyngeal branches of the vagus and the superior laryngeal nerve. Jnternalhj are the hyoid bone and the pharynx, the submaxillary gland, the parotid gland, and the ramus of the inferior maxilla. It is well known that the Ijranches of tlie external carotid are irregular. It was formerly considered that they were so irregular that ligation of this artery should not be undertaken. John A. AVyeth, of New York, in a series of brilliant dissections proved that this was not true, but that the variations of these branches were definite and according to regular laws, and that ligation of the ex- ternal carotid could be safely undertaken. Before he established these facts it was customary to ligate the common carotid when tying the external carotid seemed indicated. LIGATION OF BLOOD VESSELS 103 This artery may l)e ligated either above or below tlic digasti-ic muscle, tlie iilaee of election being below the digastric. An incision is made about three inches long just behind the anterior border of the sternomastoid mus- cle and from the level of the middle of the thyroid cartilage to near the angle of the jaw. If the sternomastoid muscle is large, approach to the artery is made easier by splitting the fibers of the muscle and so going di- rectly down to the artery. If the sternomastoid muscle is small it can be readily retracted outward. The posterior belly of the digastric is seen at the upper angle of the wound and then the hypoglossal nerve, crossing the ex- Fig. 54. — Ligation of the common carotid, external carotid, and the first four branches of the external carotid. If the common carotid is to be tied permanently, two ligatures should be placed. ternal carotid. The thyroid, lingual and facial veins should be avoided, but if too much in the way, they may be doubly clamped and tied. The liga- tures should be placed below the superior thyroid. When tying the external carotid, it is best to ligate at the same time the superior thyroid, the lingual artery and other accessible branches of the external carotid as the collateral circulation is very abundant. Through the same incision, continued slightly upward, the external carotid may be tied above the digastric muscle, though this ligation is rarely indicated (Fig. 54). 104 OPERATIVE SURGERY LIGATION OF THE SUPERIOR THYROID The superior thyroid artery is ligatecl for the therapeutic effect on the thyroid giaiid in hyperthyroidism. It has been found that the best results are obtained by ligating this artery and its branches, as Avell as the venous branches at the upper pole of the thyroid gland just as it disappears into this gland. The incision for this ligation is a transverse incision, if possi- ble in a natural crease of the neck, about two inches long and on a level with the central part of the thyroid cartilage. The level of this incision is affected to some extent by the size of the thyroid gland. When the gland is large the incision should be made at a higher level. If both superior thyroid arteries are to be tied at the same sitting, an incision about three inches long is made across the larynx on the level with the middle of the Fig. 55. — Ivigation of the superior thyroid artery. In the actual operation the incision is only about two inches long unless both superior thyroids are to be tied at the same operation, as shown in this drawing. thyroid cartilage, with its center in the midline of the neck. The inner border of the sternomastoid muscle is retracted outward which exposes the omohyoid muscle. This muscle is rather deep and dissection for it had best be done bluntly by inserting the scissors closed and opening them so as to stretch the tissues apart. When the omohyoid is well identified it is re- tracted inward, retracting also the sternomastoid outward. This exposes the terminal branches of the superior thyroid artery along with the upper pole of the thyroid gland. These branches are surrounded by a ligature, pref- erably linen or silk, as catgut in hyperthyroid patients might be absorbed too soon. The ligature is tied as closely as possible to the upper pole of the thyroid gland. It is probably better to place a second ligature a short distance from the first one. The technic of this operation has been developed by C. H. Mayo (Fig. 55). LIGATION OP BLOOD VESSELS 105 LIGATION OF THE INTERNAL CAROTID ARTERY The internal carotid is li<>ated tliroii<>li an incision similar to that nsed in lig-ating the external carotid, except that it may ])e placed slightly farther externally. The bifurcation of the common carotid is identitied and the external carotid exposed and identified by its location and by its branches. The internal carotid does not give off branches in the neck. The internal carotid at its origin is slightly external to the external carotid and then sinks more deeply in the neck. It is tied near its origin, the ligature being passed from the side of the internal jugular vein, care being taken to avoid this vein, the vagus nerve, and the ascending pharyngeal artery (Fig. 54). LIGATION OF THE SUBCLAVIAN ARTERY The subclavian artery is usually ligated in its third portion but sometimes in its first part. The ligation of the first part of the subclavian carries a high mortality. The subclavian on the right side arises from the innominate and is about three inches in length, whereas on the left side it arises from the arch of the aorta and is one inch longer. It is divided into three portions, the first portion extending from its origin to the internal border of the scalenus an- ticus muscle. On the right side this part is about one and one-fourth inches long and on the left side tAvo and one-quarter inches long. The important structures in front of the first portion on the right side are the sternomastoid muscle and the sternohyoid and sternothyroid muscles, the right innominate vein, the internal jugular vein, the vagus and phrenic nerves, and the superior cardiac branches of the sympathetic nerve. Behind are the sympathetic nerves, the infe- rior cardiac nerve, and the recurrent laryngeal nerve, the longus colli muscle, the transverse process of the seventh cervical and the first dorsal vertebra, the apex of the right lung, the pleura, and the neck of the first rib. Below are the pleura and lung, the recurrent laryngeal nerve, and the subclavian vein. On the left side the first portion of the subclavian is much longer than on the right, but the relations are much the same as of the first portion of the right subclavian, except that the thoracic duct and the subclavian vein are in front and the com- mon carotid artery is in front and the trachea, the recurrent laryngeal nerve, the left common carotid, the esophagus and the thoracic duct are internal. The second portion of both subclavian arteries is about three-fourths of an inch long and lies behind the scalenus anticus muscle, which separates the subclavian artery from the subclavian vein. Both the first and the second portion of the artery are overlapped by the sternomastoid muscle. The phrenic nerve crosses obliquely the lower anterior surface of the scalenus anticus muscle. The second portion of the left subclavian is very rarely ligated. The third portion of the subclavian is the part that is chosen for ligature if the circumstances will per- mit. This lies in the subclavian triangle whose borders are the sternomastoid, the outer belly of the omohyoid and the clavicle. The important structures 106 OPERATIVE SURGERY in front of the third portion of the subclavian are some branches of the cervical plexus, the suprascapular artery, the external jugular vein and its communica- tions, together with the suprascapular and transversalis colli vein and the clavicle. Behind are the scalenus medius muscle and the lowest cord of the brachial plexus. Atove are the brachial plexus and the omohyoid, and helow is the first rib. The subclavian artery terminates at the lower border of the first rib. The ligation of the first portion of the subclavian can be done by the same angular incision that is used for exposing the innominate. An in- cision is made along the anterior border of the sternomastoid muscle about three and one-half inches long and terminates at the right sternoclavicular joint. This is joined at its lower end by an incision of about three and one-half inches along the upper border of the clavicle. The sternomastoid muscle and Ligation of the subclavian artery. sternothyroid and sternohyoid muscles are divided near the clavicle aud the common carotid is exposed. The common carotid is traced down to the bifurcation of the innominate artery. The pleura is protected and pushed downward. The internal jugular vein and the vagus nerve are retracted either inward or outward, depending upon which appears to afford the best access to the site of the ligature. The ligatures are passed from below. It is safer to secure the vertebral artery and the common carotid at the same time. The third portion of the subclavian artery is ligated by making an in- cision about four inches long over the clavicle, first drawing the skin down and cutting dowai on the clavicle, beginning the incision from the posterior border of the sternomastoid muscle. "When the skin is relaxed the incision will be found to be about one-half inch above the clavicle. The margins of the sternomastoid and trapezius muscles are identified and divided if LIGATION OF BLOOD VESSELS 107 necessary. Tlie external jugular vein is retracted or d()ul)]y divided and the veins Avliicli empty into the external jugular, as well as the subscapular and transversalis colli veins are divided or retracted. The transversalis colli and the suprascapular artery usually run near the field but they should be carefully preserved if possible for collateral circulation. The outer margin of the scalenus anticus muscle, which lies just under the sternomastoid muscle, is identified and followed down to the artery. The lowest cord of the brachial plexus is exposed and the subclavian vein which lies in front of and below the artery. The pleura must also be guarded. The sheath is opened and the ligature passed from the brachial plexus, avoiding the pleura and the sub- clavian vein (Fig. 56). LIGATION OF THE VERTEBRAL ARTERY The vertebral artery sometimes requires ligation and it should be tied if there is occasion to ligate the subclavian in its first branch. The vertebral is the largest and usually the first branch of the subclavian and is exposed by the same incision as would be used in ligating the common carotid in its first portion. After exposing the sheath of the common carotid this vessel with the internal jugular vein and the vagus nerve is retracted outward and the prevertebral fascia is cut vertically just below the transverse proc- ess of the sixth cervical vertebra. A short distance below this point the vertebral is crossed by the inferior thyroid artery. The vertebral artery should be tied a short distance below the transverse process of the sixth cervical, where the artery enters the foramen in this vertebra. The inferior thyroid artery and the recurrent laryngeal nerve are retracted to the inner side and doAvnward and the outer structures are retracted outward. LIGATION OF THE INFERIOR THYROID ARTERY In ligating this artery the first portion of the common carotid should be exposed as though it were to be ligated. A vertical or a transverse in- cision in the skin is made. The transverse incision is half of the ''collar" incision for thyroidectomy. Below the omohyoid muscle the carotid artery in its sheath is retracted outward and the tendon of the omohyoid muscle is pulled upAvard while the thyroid gland and trachea are retracted inward. The inferior thyroid artery will be seen opposite the carotid tubercle, which is the transverse process of the sixth cervical vertebra. The inferior thy- roid artery runs behind the common carotid artery at about the same level as the omohyoid tendon crosses in front of the common carotid. The in- ferior thyroid is ligated as far as possible from the thyroid gland so as to avoid injuring the recurrent laryngeal nerve, which runs behind the thy- roid gland. This nerve and the middle cervical sympathetic ganglion should be carefuUv avoided. 108 OPERATIVE SURGERY LIGATION OF THE AXILLARY ARTERY The axillary artery is a continuation of the subclavian and begins at the lower border of the first rib and ends at the lower border of the tendon of the teres major muscle, where it becomes the brachial. The axillary ar- tery is divided into three parts by the tendon of the pectoralis minor muscle, which covers the middle or the second part of the artery. The first part of the artery, which extends from the lower border of the first rib to the upper border of the pectoralis minor, has in front the major pectoral muscle, the cephalic vein, the external anterior thoracic nerve, together with lymphatic trunks. Behind are the posterior thoracic nerve and the first intercostal space. Externally is the brachial plexus, and interndlij is the internal anterior thoracic nerve. The second part which lies behind the pectoralis minor muscle, has posteriorly the posterior cord of the brachial plexus and externally the exter- nal cord, while internally are the internal cord of the brachial plexus and the axillary vein. The second part is about one and a quarter inches in length. The third part which is the longest, and is three inches in length, ex- tends from the border of the pectoralis minor to the lowest border of the tendon of the teres major. In front are the pectoralis major muscle and the inner root of the median nerve, as well as an external brachial vein. Behind are the musculospiral nerve, the circumflex nerve and the subscapularis, the latissimus dorsi and teres major muscles. Externally are the outer root of the median nerve, the musculocutaneous nerve and the coracobrachialis muscle. Internally are the inner root of the median nerve, the ulnar nerve, the internal cutaneous nerves and the axillary vein. The part of the axillary artery usually ligated is the third part. When ligation of the first part seems indicated it is usually best to tie the third part of the subclavian. Ligation of the first part, however, can be done by an incision below the clavicle extending from near the outer portion of the sternoclavicular joint to the coracoid process of the scapular. The branches of the acromial thoracic artery should be carefully protected on account of collateral circulation. The major pectoral muscle is divided and the branches of the anterior thoracic nerve with the veins in its neighborhood are retracted upward and outward. The artery here lies between the axil- lary vein on the inner side and the brachial plexus on the outer side. The third part of the axillary artery is ligated by an incision about three inches long, which begins at the front part of the apex of the inner wall of the axilla and passes outward and downward along the inner border of the coracobrachialis muscle, the arm, of course, being extended and elevated. The coracobrachialis muscle and the musculocutaneous nerve are retracted out along with the median nerve. The internal cutaneous and ulnar nerves are retracted inward. Yenge comites are generally present at this portion, as well as occasionally the basilic vein. The axillary A'ein alone may be present at the inner side of the artery if it does not form farther in. The ligatures should be passed from the side of the A'ein. LIGATION OF BLOOD VESSELS 109 LIGATION OF THE BRACHIAL ARTERY The brachial artery extends i'rom the beginuiiig' of the axillary, at the lower border of the tendon of the teres major muscle, to about opposite the neck of the radius. The chief relations are anteriorly, the median nerve in the middle course of the artery ; posteriorly, in the upper portion of the artery the musculospiral nerve, then the superior profunda artery and the inner head of the triceps muscle, the insertion of the coracobrachialis muscle, and the brachialis anticus muscle. Externally are the coracobrachialis, which slightly overlaps the artery and the median nerve above, and the belly of the biceps, which also slightly overlaps the artery. Internally are the internal cutaneous and ulnar nerves above and the median nerve below. The cephalic vein is constantly internal, as well as the one of the venae comites. The middle of the arm is the elective point for ligation of the brachial artery and the course of the artery is indicated by a line from the junction of the anterior and middle thirds of the outer wall of the axilla to the center of the bend of the elbow. An incision about three inches long is made with its center about opposite the middle of the arm and extending along the inner border of the biceps muscle in the line of the artery. The belly of the biceps must be recognized and retracted outward. The median nerve crosses the front of the artery about the middle of this incision and the internal cutaneous nerve is on the inner side of the artery. If the patient has a well developed biceps muscle it is sometimes rather difficult to expose the artery unless the biceps is well retracted. LIGATION OF THE RADIAL AND ULNAR ARTERIES There is practically no occasion to ligate the radial artery except just above the wrist when there is an injury to one of the palmar arches. The two palmar arches, deep and superficial, anastomose so freely that when there is a serious injury to either of these arches it is best to ligate both the radial and the ulnar arteries at the wrist, though sometimes the ligation of the radial artery alone will control the deep palmar arch, which is a contin- uation of the radial artery; or ligation of the ulnar artery alone will con- trol the superficial palmar arch, which is a continuation of the ulnar artery. The lower portion of the radial artery in the forearm is covered only by skin and fascia in front, and behind are the pronator quadratus and the anterior surface of the lower end of the radius. Externally the radial nerve is at some distance from the artery in the lower part of the forearm. The tendon of the brachioradialis lies to the outer side of the artery and is inserted into the radius external to the superficial portion of the radial artery in the lower part of the forearm. An incision about two inches long is made over the artery in the lower part of the front of the forearm, extending from the wrist upward. The artery is superficial here and can easily be felt. It is accompanied by two veins, which 110 OPERATIVE SURGERY should be dissected free as the tissues along these veins often contain small nerves. In the upper portion of the incision, the tendon of the brachioradialis will be to the outer side and the tendon of the flexor carpi radialis will be to the inner side. The artery is accompanied by a small branch of the musculo- cutaneous nerve, which should be avoided. The ulnar artery is ligatcd in the lower part of the forearm on about the same level as the radial artery. It, too, is largely superficial at this point, being covered only by skin and fascia. Some cutaneous branches of the ulnar nerve are in front. Internally is the tendon of the tlexor carpi ulnaris, and externally, to the radial side, are the tendons of the flexor sublimis digitorum. The low^er portion of the artery corresponds to a line drawn from the anterior portion of the internal condyle of the humerus to the radial side of the pisiform bone. An incision is made about two inches long beginning at the pisiform bone and extending upward. The tendon of the flexor carpi ulnaris is retracted inward and if necessary the tendons of the flexor sublimis digitorum are re- tracted outward, though usually they are not in the way. The artery lies upon the flexor profundus digitorum and is closely surrounded by venfe comites. The ulnar nerve is in close relation to the inner side of the artery. LIGATION OF THE ABDOMINAL AORTA Ligation of the aorta in the abdomen is hardly a justifiable operation, in view of the fact that of the twenty cases that have been ligated all have proved fatal. One patient lived forty-eight days (Keen). It may be possi- ble that in some cases with a markedly sacculated aneurism the neck of the aneurism itself could be clamped, or ligated, or a rubber tube might be su- tured in between the ends of the resected aorta and held by flaps of fascia lata. Such procedures, however, are still in the experimental stage and would hardly be justified at present on the human body. The technic of ligating the abdominal aorta in its lower portion would consist in making a median abdominal incision, in Trendelenburg position, and a close dissection of the aorta so as to prevent thejnclusion of sympa- thetic nerves or lym]3hatic trunks. LIGATION OF THE COMMON ILIAC ARTERY The abdominal aorta bifurcates opposite the lower border of the left side of the fourth lumbar vertebra about one-half inch below and a little to the left of the umbilicus. Its two branches, the common iliacs, pass outward and bifurcate into the external and internal iliac arteries about opposite the upper border of the sacroiliac joint. On the right side, the common iliac artery near its termination is crossed by the ureter and is covered with peri- toneum and subperitoneal fascia. Behind are the right common iliac vein, the termination of the left common iliac vein, and the beginning of the in- ferior vena cava. Still further posteriorly are the psoas magnus muscle with LIGATION OF BLOOD VESSELS 111 tlic obturator nerve and the iliolmnhar arlery. Exiern<(]hj are tlie beginning of the lower vena cava, the end of the right common iliac vein, and the psoas magnus muscle. Internally are the right common iliac vein and the hypogastric ])lexus. On the left side, the common iliac artery has near its termination in front the ureter and tlie ovarian artery in the female, the termination of the inferior mesenteric artery, the sigmoid mesocolon, and the superior hemorrhoidal artery. Posteriorly are the lower part of the body of the fourth lumbar vertebra, tlie fifth lumbar vertebra and the intervertebral disc, the left common iliac vein, the psoas magnus muscle, obturator nerve and iliolumbar artery. Exter- iiaUy is the psoas muscle, and internally are the left common iliac vein, the hypo- gastric plexus and the middle sacral arter}-. Tlie right common iliac is about two inches long and the left about one and three-quarters. The arteries should be ligated as near their middle as pos- sible. Formerly, when the danger of sepsis was great it was thought best never to open the peritoneum. In those days the extraperitoneal operation of Sir Astley Cooper Avas employed in order to avoid peritonitis. This danger does not now exist. The common iliacs, as well as the internal and external iliacs, can best be tied through an abdominal incision in the midline, extending from about the navel to the pubes. The patient should be put in the Trendelenburg position and the intestines packed away out of the pelvis, affording good ex- posure. The termination of the abdominal aorta is identified and the common iliacs are located. The peritoneum is incised over the middle of the common iliac and the ligature is passed from the side of the iliac vein. As elsewhere, there should always be two ligatures placed about a quarter of an inch to a half an inch from each other. LIGATION OF THE INTERNAL ILIAC ARTERY The internal iliac artery is about one and one-half inches in length and arises from the bifurcation of the common iliac opposite the upper part of the sacroiliac joint. The important relations are, anteriorly the ureter, poste- riorly the external iliac vein, and internally the internal iliac vein. Behind is also the obturator nerve. The psoas muscle is external. This artery, which is frequently ligated to control bleeding in cancer of the uterus, is exposed by the same incision used for the common iliac. The bifurcation of the common iliac opposite the upper border of the sacroiliac joint should be lo- cated. The ureter is identified as it crosses about this region. On the left side the lower part of the sigmoid makes the operation slightly more complicated than on the right side. On the right side the peritoneum can be divided directly over the vessel. An incision about one and one-half inches long is made through the peritoneum, the ureter identified and retracted out of the way, and the bi- furcation of the common iliac and its two branches, the external and internal iliacs, are thoroughly identified. The fascia over the internal iliac is incised and the ligatures are passed from without inward, hugging the artery close to avoid injury to the external iliac vein and also avoiding injuring the internal iliac 112 OPERATIVE SURGERY vein that lies close behind and to the internal surface of the artery. On the left side the ligation is carried out in the same manner as on the right, except that if the sigmoid is short and has a short mesentery it will be necessary to Fig. 57. — Ligation of the internal iliac artery. pull the sigmoid dov^^n to note the vessels in the mesentery so as to avoid them, and make an incision through the mesosigmoid (Fig. 57). LIGATION OF THE EXTERNAL ILIAC ARTERY The external iliac artery is three and one-half to four inches in length. It arises at the upper border of the sacroiliac joint, runs outward, and ter- minates beneath the loAver border of Poupart's ligament. The external iliac vein lies to the inner side of the artery below and to the inner side and be- hind above. The genital branch of the genitocrural nerve lies in front of the artery over its lower third. It is crossed by the spermatic artery and vein in the male, and the ovarian artery and vein in the female, as well as by the vas deferens in the male near the termination of the artery. At this point also the deep epigastric artery, which is important for collateral cir- culation, lies in front of the vessel and adherent to the peritoneum as it courses forward and upward. Behind are the external iliac vein and the inner border of the psoas magnus muscle. Externally is the psoas magnus LIGATION OF BLOOD VESSELS 113 muscle with the nerves it contains. The external iliac artery can be reached by the same incision by which the common and internal iliacs are reached, or if it is desired to ligate this artery nearer to Ponpart's ligament, this can be done either by a mnscle splitting incision or by the extraperitoneal operation in which an incision is made parallel to Ponpart's ligament and about half an inch above it. The peritoneum is reached and stripped up and the external iliac artery is exposed. Care should be taken to preserve its branches, particularly the deep epigastric, for the collateral circulation. Although the peritoneum is not opened in the extraperitoneal operation, the Trendelenburg position is a great help. After the peritoneum is stripped up with dry gauze, the sheath of the external iliac is opened from the outer side to avoid the vein Avhich is internal to the artery. Care is taken to avoid injury to the genito- crural nerve. A ligature is passed about one and one-half inches above Pon- part's ligament. LIGATION OF THE FEMORAL ARTERY The femoral artery is a continuation of the external iliac and begins at the lower border of Ponpart's ligament about half w^ay between the anterior superior spine of the ilium and the symphysis pubis. It passes down the anterior and inner side of the thigh to the junction of the middle and lower thirds of the thigh, where it becomes the popliteal. The superficial part lies in Scarpa's triangle, which is bound externally by the sartorious muscle and internally by the adductor longus with its base formed by Ponpart's liga- ment. The apex of Scarpa's triangle is where the sartorius crosses the adduc- tor longus. The lower third of the femoral artery passes through Hunter's canal, which is an aponeurotic channel that extends fro|iu the apex of Scarpa's triangle to the opening in the adductor magnus. The common fem- oral artery, which is that portion from the origin of the femoral to the origin of the profunda femoris, is about one and a half inches long. The important structures in front are the crural branch of the genitocrural nerve and the superficial circumflex iliac vein. Behind are the psoas and pectineus muscles; externally is the anterior crural nerve, and internally the femoral vein. The relations of the femoral artery from the origin of the profunda femoris to the apex of Scarpa's triangle are, in front, the crural branch of the genitocrural nerve and heJdnd, the femoral vein, profunda vein, and profunda artery in the order named, then the pectineus muscle and the adductor longus. Externally are the branches of the anterior crural nerve, the long saphenous nerve and the nerve to the vastus internus, and internally is the femoral vein, which becomes posterior at the apex of the Scarpa's triangle. The third divi- sion of the femoral artery is that in Hunter's canal where it is deep. Behind is the femoral vein, which- becomes slightly external at its lower portion; heliind also, are the vastus internus and adductor muscles. Externally is the vastus internus and internally are the adductor longus above and the adductor magnus below. 114 OPERATIVE STTRGERY The favorite point for ligation of the femoral is at the apex of Scarpa's triangle, which is called the operation of election. The apex of Scarpa's triangle is about three and one-half inches below Poupart's ligament and the profunda artery arises about one and a half inches below Poupart's liga- ment. At the apex of Scarpa's triangle the relation of the vessels from be- fore backward is the femoral artery, femoral vein, profunda vein, profunda artery. The artery lies behind a line drawn from a point about midway be- tween the anterior superior spine of the ilium and the symphysis pubis, to the tubercle of the inner condyle of the femur. Ligation of the common femoral, or the femoral in its first portion, is considered dangerous because of the former frequency of secondary hemor- Fig. 58. — Ligation of the right femoral artery just below Poupart's ligament. rhage and because of the danger of gangrene. If ligation of the common femoral seems indicated it would probably be safer to ligate the external iliac. The common femoral can be ligated by an incision about three inches long beginning just above Poupart's ligament and extending down in. the line of the artery. The superficial circumflex iliac, superficial epigastric, and superficial external pudic vessels, should be avoided, also the crural branch of the genitocrural nerve, Avhich is in front of and a little external to the artery. The anterior crural nerve lies further to the outer side of the artery and outside of the sheath. The ligature is passed from the inner side, avoiding injury to the femoral vein (Fig. 58). The common femoral artery can also be exposed by an incision parallel to Poupart's ligament and about one-half inch below it. 1,1(!AT10N OF liLOOn VE8SEI>S 115 Lisi'ation of llie femoral at tlic point of election, the apex, of Scarpa's tri- aiigie, is made throul . — Restorative endo-aneurismorrhaphy of Matas. Fig. 68. — Reconstructive endo-aneurismor- rhaphy of Matas. drainage. The blood current is gradually turned on before the skin is sutured and the infolded sac is pressed upon. Usually there is but little, if any oozing, though if it is marked the tourniquet should be reapplied and the leak stopped by additional sutures. The smooth membrane lining the inside of the sac is vascular endothelium and requires no freshening or injury to heal, but merely snug approximation just as the peritoneum requires. Restorative endo-aneurismorrhaphy (Fig. 67) is applicable Avhen the sac is tough and resistant . and when there is only one opening. In other words, when the aneurism springs from one side of the artery and the whole of the artery's circumference is not involved. This does not occur very frequently. In such cases the opening is sutured either by surrounding it with a purse- string suture or by whipping it over with a continuous stitch. The rest of the procedure is identical with the obliterative method. ANEURISMS 125 Reconstructive eiido-aiieurisiuorrliapliy (Fig. 68) is recommcJided by Matas in cases in wliicli the two openings are close together, where there is but little athe- roma, and where the sac is tough and holds the sutures well. The sac is cleaned of clots and washed out with salt solution. Matas recommends that a soft rubber catheter, well anointed Avith vaseline and which fits snugly into the arterial opening, be inserted and interrupted sutures of chromic catgut be placed at close intervals over the catheter. After the sutures have been placed the catheter is withdrawal and the sutures are tied snugly. The rest of the sac is obliterated as in the other methods. In all of these methods care should be taken not to take a deeper bite with the suture than is necessary to secure a firm hold. The needle may wound the accompanying vein or nerve, or if inserted too deeply, may occlude some collateral vessel. Reconstructive endo-aneurismorrhaphy probably sooner or later either be- comes obliterative or fails to cure. The fact that, in several instances, thrombi which formed after the reconstructive operation were later dislodged and acted as emboli, is also a serious objection to this method. In the light of modern blood vessel suturing, we can hardly expect the reconstructed artery to remain patent. In experimental work under the best conditions with comparatively healthy blood vessels and using the finest sutures of silk and the finest needles, it is impossible to avoid occlusion of the artery in a considerable number of cases even after some experience in this work. We can hardly expect, then, that suturing with comparatively coarse needles and catgut in diseased tissue will produce a permanently patent artery. If there is merely a small open- ing the restorative method may be indicated, but the eventual result will probably be better if the obliterative method is always used instead of the reconstructive type. The only advantage in the reconstructive operation is that for a short time blood flows through its natural channel and the con- sequent strain upon collateral circulation will not be so great. This advan- tage, however, seems offset by the dangers of sudden emboli from the breaking loose of a thrombus, by the fact that sooner or later the channel in all probability becomes obliterated, and by the further fact that recurrences are much more common after the reconstructive than after the obliterative method. Matas has collected statistics which prove beyond doubt that wherever endo- aneurismorrhaphy can be applied it is far more satisfactory than either liga- ture or extirpation; not only is the mortality rate less but gangrene is exceed- ingly rare. Extirpation of aneurisms has been done with direct suture of the ar- tery by the end-to-end method. This is only applicable Avhere the site of the aneurism involves a very short section of the artery and Avhere the ends of the artery are comparatively healthy. It has been done by Lexer, Stich, and Enderlen in popliteal aneurisms. The limb is flexed and kept in this position for several weeks by plaster of Paris. After the sixth week the knee may be gradually extended. This method has, of course, a very limited application. 126 OPERATIVE PT'RGERY The ideal treatment of aiieiu'isni is to excise the sac and at tlie same time to restore the arterial channel. This may l)e accomplished by substituting a segment of vein. The A'cin that accompanies tlie artery has been used, though it -would 1)0 much better to utilize some other vein. Obviously, when the direct circulation is deficient on account of the aneurism, and collateral circulation is poor, closing the main artery by ligature or obliteration of the sac — even by the method of Matas — is fraught with great danger and the indications are, if possible, to reestablish the circulation by the ideal method. In a diseased arterj^, arterial sutures would not seem to be satisfactory, and it is certainly more desirable to suture healthy arteries as in traumatic aneurisms than the diseased vessels of spontaneous aneurisms. However, the brilliant case of Lexer, already referred to (p. 75), in which he excised an aneurism in- volving a portion of the external iliac and femoral arteries and sutured into the defect a segment of the saphenous vein with perfect success, shows the great possibilities of this operation. Bernheim, of Baltimore, has successfully excised a popliteal aneurism and sutured in a segment of vein. If success is to be attained in suturing diseased arteries the best possible technic should be used. As already pointed out, it is not likely that recon- structive endo-aneurismorrhaphy, in which comparatively coarse needles and catgut are used, will result in a perinanently open channel. Certainly in ex- perimental work such technic Avould invariably be followed by thrombosis in healthy arteries, and in diseased arteries we have no right to expect better results. It is practically impossible, however, to use the technic of arterial suturing in the bottom of a sac where the tension on the stitches must be considerable, but after the sac is excised a segment of vein can be sutured to the ends of the artery with the regular technic for end-to-end suture. While there is some danger of the segment becoming occluded by thrombus, it seems for the reasons mentioned that if it is necessary to reestablish the current of the blood, it should be done not by the reconstructive method of Matas, but by excision of the sac and suturing into the defect a segment of vein. Ee- versing the circulation and then excising the aneurism has been tried. This has none of the advantages of transplantation of a venous segment. OPERATION ON ANEURISM OF SPECIAL ARTERIES Aneurisms of the thoracic aorta are by far the most freciuent aneurisms, which would naturally be expected from the strain to which this great ves- sel is subject. The proper treatment is medical treatment though in saccu- lated thoracic aneurisms the Moore-Corradi method may be used. The technic employed by Finney is probably the most satisfactory (pp. 118, 119). A thorough examination by x-ray should be made before this operation is at- tempted. The average course of a thoracic aneurism is a little more than a year. There has been one ei¥ort to cure a thoracic aneurism by ligating the aorta. This was done by Guinard, of Paris, in 1904, the chest being opened posteriorly by an osteoplastic flap and a ligature placed on the thoracic aorta ANEURISMS * 127 just l)elu^\• llie (MkI of llic ;ircli. When llic lit;';itiire was 1 i^litciied, pulsation in tlie femoral artery stoppi'd and the lower i)art of tlie ])ody became pale and cold, but in a few minutes the eireulation was rcestal)lished throug-h the in- tercostal and other vessels. However, the blood pressure throug-h the collat- eral circulation was not sufficient for the renal arteries and the patient died. Aneurisms of the abdominal aorta are scarcely amenable to other direct treatment than the Moore-Corradi method. If the aneurism is above the renal arteries or involves the mesenteric, its obliteration will necessarily result fa- tally on account of interference with the function of the kidney's or from gan- grene of the intestines. BeloAV the inferior mesenteric artery, the outlook seems more hopeful, but the results are practically equally as disastrous. Of about twenty cases of ligature of the abdominal aorta none has been success- ful. The strain thrown upon the heart by the increased blood pressure after such a ligature is enormous and this high pressure and a competent heart are essential to the proper establishment of collateral circulation. Most of these jiatients have hearts that are far from competent, and even in healthy animals ligation of the abdominal aorta usually results in a cardiac death. Even if the heart should survive the strain, which it does not do in the vast majority of cases, there is still the risk of hemorrhage and the possibility of sepsis and shock. The iliac arteries have been ligated for abdominal aneurisms, follow- ing the principle of Brasdor and AYardrop, but this too has proved fatal. Various methods of compression have been advocated and even endo-aneuris- morrhaphy has been tried, but unsuccessfully. The aluminnm band of Hal- sted or of Matas which would produce a partial but not a complete occlusion of the aorta seems to offer the most satisfactory method of treatment, if wiring and galvanism are not indicated. If this did not cure the anenrism after a few weeks, the collateral circulation it encouraged might justify ligation of the aorta. Various problems, particularly the strain npon the heart, render treatment of aneurisms of the aorta a very unsatisfactory procedure. Experimentally, a portion of the abdominal aorta has been resected and a tube sutured into the defect (p. 90). Aneurisms of the innominate seem to offer a field for the Moore-Corradi method, though they have been treated successfully by ligatures. Apparently the best operation is distal ligation after Wardrop or Brasdor. Ligation of the right common carotid and the right subclavian is done during the same operation, tying the carotid first to avoid the possibility of a cerebral embolus. Aneurisms of the external carotid are ciuite rare, but occasionally occur. Treatment by ligatures, placing the ligatures as far as possible from the bi- furcation of the common carotid, may be employed. The injection into the external carotid of boiling water after the suggestion of AVyeth might be indicated, as the collateral circulation with the carotid of the other side is so free as to render simple proximal ligation much less likely to cure here than in most other arteries. Aneurisms of the common carotid or of the internal carotid are of grave significance because of the disastrous effect on the brain that often follows when these arteries are tied. The danger of ligation of the 128 "" OPERATIVE SURGERY common carotid increases enormously after forty years of age and is due to the danger of a diminished blood supply to the brain. In the young with elastic arteries ligation of the common carotid is comparatively free from danger, but after forty years of age, and particularly in the presence of arteriosclerosis, the occurrence of cerebral symptoms, from the inability of other arteries to dilate sufficiently, is frequent. The operative measures that have been used are the classical methods of ligation, though of these extirpa- tion with the double ligature has proved most successful. Proximal ligature is particularly liable to cause thrombi in the sac with the possibility of a piece of thrombus becoming loose and causing an embolus in the brain. This, of course, is in addition to the danger of cerebral symptoms from the mere occlusion of the artery. Distal ligation or extirpation to a large extent avoids the danger of embolus. It has been found that when cerebral symptoms occur, serious danger may often ])e avoided if the channel of the artery can be re-established within a few hours after occlusion. The problem in connection with the carotid artery is different from that in other parts of the body, not only because of the immediate danger to life by impairing the blood supply to the brain, but because we have a method of determining from the patient's sensations and symptoms whether occlusion of the artery is safe. Before applying a liga- ture to the carotid, except in cases of grave necessity, the common carotid should be exposed under local anesthesia and gradually occluded, prefera- bly by a rubber covered Crile clamp. If this is followed by cerebral symp- toms of a psychic nature, by paralysis or convulsions, the artery should be opened at once. If no immediate symptoms occur, the clamp may be left on for forty-eight hours and then a ligature applied to occlude the artery with comparative safety. However, cerebral symptoms sometimes appear after several days, though they are usually manifest within twenty-four hours after occlusion of the artery. If complete closure is not possible the metal band of Halsted may be rolled around the artery in such a manner as par- tially to occlude it. If this is sufficient to cure the aneurism no further treat- ment is necessary: but if not, the band may be left in place for one or two weeks until the other arteries have taken up the circulation, and then a liga- ture can be applied. If even a partial occlusion is not borne the outlook is almost hopeless, though the possibility of excision and the substitution of a segment of vein should be considered. Subclavian aneurisms have been subjected to numerous methods of treat- ment including the intrasaccular ligation of Syme. They have been treated by ligature, both distal and proximal, and the innominate artery has also been ligated in efforts to cure. The results have usually been unsuccessful, the mortality being large, though since 1890, the mortality has fallen from about eighty per cent in preantiseptic days to twenty-two per cent. The metal band may also be used here. Excision of the sac seems to have been followed by quite satisfactory results as compared with other methods of treatment. ANEURISMS V2!) Endo-aiieurisiiioi'i'li;ipliy li;is 1)0(mi altcni])t('(l, tliou^ii in not a great luimber of cases, and the results usually have been satisfactory. Axillary aneurisms may be treated by ligature, by band, or by the opera- tion of IMatas. In certain cases where the circulation can be controlled, ex- cision of the aiKMirism Avilh tlie substitution of a piece of vein may be con- sidered. This has been done by Lexer and while the patient died from gan- grene of the limb it Avas found that the occlusion from thrombus occurred where the clamp was placed, the transplanted section of vein being patent and in good condition. The treatment of aneurism of the iliac arteries is subject to somewhat the same objections as the treatment of aneurism of the aorta, for ligation of these large arteries produces great strain upon the heart. The intrasaccular method of Matas offers in certain cases excellent results, though hemostasis may be difficult or impossible except by compression of the aorta. The aluminum metal band is particularly applicable in aneurisms of the iliac arteries. By this means the current can be reduced to a minimum with- out being obliterated and the danger of gangrene of the extremity is greatly lessened. At a second operation after a few weeks the artery can be perma- nently occluded near the site of the band by ligatures. This principle is appli- cable to aneurisms anywhere when there is a reasonable doubt that the collat- eral circulation will not be sufficient if the artery is entirely occluded by a ligature or if the endo-aneurismorrhaphy of Matas is contraindicated. The common and external iliac arteries may be regarded as practically an extension of the aorta. Aneurisms affecting all of the iliac arteries are lined in front with peritoneum. They tend to dilate quickly as there is but little resistance in front and they rupture easily for the same reason. When rupture occurs it is usually immediately fatal, though occasionally the blood may form a large hematoma under the peritoneum. The treatment of aneurisms of the iliac arteries may be some form of ligature, a partial constriction by the aluminum band, or endo-aneurismorrhaphy. Digital compression is not practical, though it may be tried by opening the abdomen and compressing the common iliac or the aorta. In extirpation or in endo-aneurismorrhaphy, temporary hemostasis can be effected by digital pressure on the abdominal aorta, or else upon the trunk of the common iliac near the bifurcation. Even pressure upon the aorta may not give an entirely dry field as some blood comes through the distal end of the deep epigastric artery. Pressure upon the iliac is often unsatisfactory because of the free anastomosis with the inter- nal iliac of the other side. Aneurisms of the external iliac have occasionally been treated by digital compression. Compression of the abdominal aorta through the abdominal w^all is possible in thin patients, but is best done within the abdomen. In a thin patient the method of Momburg, constricting the abdomen with a rubber tube, has been tried. This will give a dry field, but there is always danger from an abdominal tourniquet, such as injury to the intestines, though the originator of this method claims otherwise. The treatment of aneurism of the iliacs has been largely by the ligature. 130 OPERATIVE SURGERY Double ligation, distal and proximal, Avitli extirpation has given satisfac- tory results. The iliaes should be ligatod intraperitoneally. Tlie older method of stripping up the peritoneum and nialdng an extensive raw surface is unnecessary. The patient may ])e ]nit in the Trendelenburg position with the intestines packed o&, and ligation of either the common iliac or its two branches can be readil}- done. Endo-aneurismorrhaphy has been tried in a few cases with satisfactory results. Ligation of the common iliac carries a heavy mortality rate. Matas says that in modern times, since 1880, the death rate is nearly fifty per cent. This high mortality rate, as explained by Hal- sted in an article on aneurisms of the iliac, is largely due to complications and would probably noAV be considerably lower. The fact, however, that the mortality from simple ligation is much higher than from extirpation or endo- aneurismorrhaphy should cause the later method to be employed wherever possible. Aneurisms of the Upper femoral artery require a similar hemostasis to aneurisms of the iliac, as it is impractical to place a tourniquet at this level. The external iliac gives off but few branches whereas the upper part of the femoral has a verj^ abundant collateral circulation. For this reason in pre- antiseptic days ligation of the femoral just below Poupart's ligament was avoided whenever possible. The collateral circulation is so free at this point that formation of a thrombus is prevented or retarded and as suppuration usually took place in those days, secondary hemorrhage would occur in about half of all cases; consequently, the external iliac whose branches are few could be ligated much more safely. With absorbable ligatures and careful asepsis, these objections are no longer so serious. In aneurisms of the upper or common femoral it is exceedingly difficult to obtain even temporary hemostasis unless the same measures are employed as in aneurisms of the iliac ; that is, direct compression of the abdominal aorta or the common iliac after opening the abdomen. The communications of the profunda, which is almost always in the sac of an aneurism in this region, together with other collateral branches make the field very vascular. The necessity for controlling bleeding by intraabdominal pressure on the iliac in such cases should be seriously considered whenever it is desired to open the sac of an upper femoral aneurism. Aneurism of the branches of the internal iliac practicalbv alwaj's occurs either outside of the pelvis or else partly without and partly within the pel- vis. It usuall.y involves the sciatic or the gluteal arteries. Formerly, the most satisfactory treatment was the method of Antyllus, in vrhicli the vessel is ligated both proximally and distally and the sac incised. The better method is endo-aneu/ismorrhaphy with either temporary or permanent closure of the internal iliac by ligature. When the aneurism begins in the pelvis, which is very unusual, merely ligating the internal iliac may be all that is necessary. Aneurism of the lower femoral can be treated most satisfactorily by endo- aneurismorrhaphy and here as elsewhere the obliterative operation is better than the reconstructive. If after testing the collateral circulation it appears ANEURISMS l:U deficient and tlio patient's condilion is otlierwise good, the possibility of excising the aneurism and Rnl)sti1nrm;il1liy iiuisele, I'jiseiji or I'al, alont;' llie iioriiial eourse ol' the iier\-e and it' there is no lar<;'e amount of sear tissue in the nei<>li- borhood, nothing' else is desired. J I! tlie ends of the nerves cannot: l)e made to meet, liowever, some form of tnbc construction prefei'a])ly a tul)e either lined aaIIIi or eonstrueted of fat can l)e used. Dean Lewis has secured satisfactory results with a tube of fascia lined Avith fat, fastening the ends of tlu^ nerve that could not be approximated into each end of the tube. If around the site of nerve suturing there has been consider-able scar tis- sue, the sutured nerve should be jirotected. This is best done by first dis- Fig. SI. Fig. 82. Fig. 81. — Dissection of binding scar tissue from a nerve, with outline of a pedicle flap. F'ig. 82. — Pedicle flap applied around the old site of scar contraction. secting away the scar tissue around the nerve as freely as possible, control- ling bleeding, and then shifting the nerve so it Avill lie in a normal plane of intermuscular fascia. If this is impossible the sutured nerve may be protected by a pedieled flap of fascia and muscle or fascia and fat, placing the fat next the nerve (Figs. 81 and 82). If the pedicle is well nourished the flap will aid in blood supply to the injured nerve and so tend to avoid excessive scar tissue formation. No bleeding surface such as cut muscle, should ever be placed in contact with the sutured nerve. The interposition of tissue as a free graft around the sutured nerve tends to isolate the nerve from the nutrition that can be derived from the blood supply of its adjoining tissues. Every effort should be made to secure an end-to-end union of healthy nerve tissue. If a reasonable dissection cannot give satisfactory approxima- tion, sometimes a change of position of the limb will make it possible to 1^6 OPERATIVE SURGERY bring the nerve ends together. Thus the hand may l:)e flexed in suturing the median nerve or the knee in suturing the sciatic. The limb must be put up in splints or i)laster of Paris and kept in tlie flexed position for at least two months after the operation. Occasionally, however, in spite of manipulation of the nerve and of the limb there will be a gap between the ends of the nerve, and the problem arises of what is to be done to bridge the defect. Four courses have been recommended: (1) suturing the ends of the nerve into a tube of fat and fascia, (2) free transplantation of a nerve graft from an uninjured nerve, (3) transplantation of the distal end of the nerve into another healthy nerve of somewhat similar function, and (4) flaps taken from the injured nerve. (1) This method of using a fatty fascia tube and suturing the ends of the nerve into the tube so that the fibers will more readily reunite has been de- Fig. 83. I'ig. 84. Fig. 83. — U.Kcision of neuromas from a divided nerve. Fig. 84. — Application of a tube of fat and fascia between ends of a nerve that cannot be approxi- mated. (Method of Dean Eevvis.) veloped by Dean Lewis and has given good results in some cases in his hands, though its place in surgery according to Lewis has not been definitely es- tablished (Figs. 83 and 84). Edinger states that the fibers of human nerves grow best in a medium of agar and after filling a segment of an artery or a vein with agar he sutures the ends of the nerves into this segment. This has not proT"ed satisfactory. Foreign material such as rubber tubes should not be usecL (2) A free graft of a nerve may be taken from a nerve of different function. A gap in a motor or mixed nerve, such as the facial or musculo- spiral, may be bridged by a segment from a purely sensory nerve as the radial or the internal cutaneous. A segment of the nerve is removed, taking i;i;i'AIK OP XKRVES 147 c';ire tliat il sliouhl ])c of ample Iciiulli and sului'cd to the ends of the nerve with llie same leehiiic thai wmdd he used in unilinu' the nei'X'e en(hto-end. The g'raft is usually luueh smaller than the nerve and the supply of material from -whieli the ' has been described. By elevating the slunilder and inclining the head and neck to the af- fected side, a gap of one ineli in the upper trunks of the brachial plexus can be readily overcome (Pigs. 91, 92 and 93). If the lesion is in the lower portion of the plexus it may be necessary to divide the clavicle and a portion of it may be resected permanently if it adds to the relief of the tension. If in spite of posture, it is impossible to approximate the ends of the cords or trunks or if the lesion seems to extend into the spinal column, Mple-p) l.o-iTTai'^e Fig. 93. — Excision of the injured portion of the brachial plexus. Insert (a) shows the sutures applied. The ends can be approximated as the sutures are tied by elevating the shoulder and turning the head and neck to the affected side. the healthy distal portion of the brachial plexus is cnt across and the stump sutured end-to-side into the nearest cord after incising the sheath and a few nerve fibers in order to make contact with the axons. Here, as in all nerve surgery, the wound must be kept as free of blood as possible. An excellent posture for the postoperative treatment is to bring the hand on the affected side over the head until it touches the opposite ear and to fasten the arm in this position by adhesive and bandages. Some surgeons, as Tubby and Hildebrand, have endeavored to correct the deformity caused by brachial palsy by transplanting mnscles, Tubby transplanting a portion of the triceps muscle and Hildebrand the pectoralis major. It has been shown experimentally that if the nerve supply of a muscle is maintained nninjured the muscle can be transplanted freely with but little regard for its blood supply, except that portion that affects the nerve. The muscle will probably partially degenerate, but with its uninjured nerve supply it 156 OPERATIVE SURGERY will regenerate. Hildebrand's operation takes advantage of this and maintains the nerve supply of the major pectoral muscle which comes through the an- terior thoracic nerves. He dissects free the major pectoral at its origin and turns up the muscle, suturing it to the outer third of the clavicle and to the acromion process, leaving its insertion and nerve supply intact. After all operations for restoration of motor function it is essential to carry out after-treatment in which massage and electricity are intelligently applied for a number of months. Such treatment not only hastens regenera- tion of the nerve but keeps the muscles in a healthy condition, prevents their atrophy and renders them better able to function when the nerve regenerates. Neurolysis means freeing a nerve from pressure and adhesions. The process is the same as when preparing a nerve for suture by dissecting away surrounding scar tissue. Sometimes the nerve fiber bundles are freed by longi- tudinal incisions made in the nerve with a fine sharp knife. Precautions are taken to prevent reformation of adhesions as after nerve suturing. CHAPTER XII OPERATIONS ON BONES The results of operations on bones illustrate very strikingly the great value of the application of the knowledge of the biologic reaction of bone to infection and to foreign substances. To plan intelligently operations upon bones it is necessary to have in mind the biologic processes of bone repair. AVhile the discussion still goes on as to some of the details of repair of bone, the fate of bone grafts, and the part played by the periosteum, there are certain fundamental principles that are well established. Whether the periosteum takes active part in the reproduction of bone, or, as MacEwen claims, is merely a limiting membrane, depends largely upon the definition of perios- teum. If the cambium layer on the cortex of the bone is included with the periosteum, it is undoubtedly true that this layer contains osteoblasts and will reproduce bone. If this layer is not considered as a part of the perios- teum proper, the periosteum then is only a limiting membrane. In infection of the bone, however, which is not too rapid many osteoblasts migrate from the bone and may penetrate all of the layers of the periosteum. In such instances even the more superficial part of the periosteum may actively participate in the reproduction of bone. When the infection is very virulent and overwhelming or when the nutrient artery of the bone is early occluded by inflammation, there may not be time for the osteoblasts to migrate and here the periosteum will react in the same manner as would the periosteum over a normal healthy bone and will only reproduce bone from the cambium layer. A knowledge of these facts is particularly important in operating upon osteomyelitis, because if the infection is not too virulent many osteo- blasts may have time to escape to the periosteum Avhere they Avill live be- cause of the good blood supply, though practically all of the shaft of the bone may eventually be destroyed by the inflammation. This also explams the development of an involucrum which encloses wdiat seems to be a com- pletely necrotic shaft of the bone. The reproduction of the shaft of a long bone from the periosteum, is not infrequently seen and, as has been pointed out by Nichols, if the necrosed shaft is removed at the proper time when the activity of the periosteum is at its height, reproduction from the perios- teum is very satisfactory. If, however, this is attempted in a normal bone, reproduction of the shaft will not take place unless a thin layer of the cortex or the full cambium layer is permitted to adhere to the periosteum. In bone grafting, as in transplanting other tissue, the grafts should be taken from the patient. It seems quite certain that grafts taken from lower 157 158 OPKRATIVE SI'RGERY animals act only as a foreign body and it is doul)tful wliclhcr crafts even from individuals of the same race "will be satisfactory. It is best to have the bone grafts in contact Avith other living bone, ])ut tliis is not essential, as Carter^ shoMs. Carter reported twenty cases in Avliicli bone grafts were nsed to elevate the nose and in many of these cases the grafts were not in contact with the bone of the face, but imbedded in soft tissue. Two to three years after the operation these transplants were still in place and some of them larger than when they were implanted. Wolff's law is important to bear in mind when grafting bone. Accord- ing to this laAv change in the form, position or function of bones is followed by definite changes in their internal structure and also by alteration of their external conformation in accordance with mechanical laws. The workings of this laAv are observed Avhen a small graft is inserted in the defect of a large bone and gradually develops to the size of the large bone. When a graft is taken from one tibia to fill a total defect in the other tibia, it has been frequently observed that in the course of time both tibias appear of nor- mal proportions. If the fibula is grafted to make up the defect of a tibia it will hypertrophy to the size and general contour of the tibia. This only happens, hoAvever, if the strain and stress to AAdiich a normal tibia is sub- jected are gradually applied to the graft, Avhich seems to react from the stimulus of the giadually increased function of the leg. In spite of the similar construction of bone as observed histologically, there is a considerable variation in its function. Some bones, as those of the fingers, receive quick and numerous though light strains. Others, as those of the leg, are capable of great Aveight bearing and of active motion. Still others are comparatively fixed and merely serve to hold the contour of the soft tissue they support. It seems that in grafting bone it is Avell to consider its function. If an active bone accustomed to motion and strain is to be repaired it Avould be Avise to take a graft from a bone of similar function. The bones of the arm, for instance, could be repaired from the bones of the leg. For bones of the face or skull, hoAvever, Avhose function is passive, grafts may be taken from bones of similar function Avhich Avould correspond to the ribs more nearly than to the bones of the leg. Whenever possible the periosteum should be attached to the graft. This is not only because the layer of the periosteum next to the bone, the cambium, is capable of reproducing bone, but because the nutrition of the graft is much better if the periosteum is preserved. McA¥illiams particularly has called attention to the fact that the nutrition of a bone graft can be carried on more readily Avhen the periosteum is preserved because anastomosis of the vessels in the surrounding soft tissue Avith the vessels of the bone occurs much more ciuickly and freely through the medium of the periosteum than Avith the bone graft Avithout periosteum. In this latter instance bone salts must be absorbed before definite connection AA'ith the vessels of the interior of the bone can be established, Avhereas there is no obstacle to the connection betAveen ^Med. Rec., New York, February 7, 1914. BONES 159 the vessels of sol't tissue iiiul those of the periosUMini. Tlie vessels in the periosttnnu lun'e Iheir iionual nnatoinie coininiiniciitioii Avith the vessels of the hone. The aetion of hone g'rafts dei)ends upon a numher of hiologic factors. In some individuals there is an idiosyneracy for the deposit of calcium and hut little callus is ever formed, even though the patient may be otherwise healthy. The presence of syphilis and other diseases is supposed to interfere Avith the deposit of lime salts in the callus. The free use of irritating anti- septics, the presence of infection, or certain infectious or contagious diseases nuiy interfere with the repair of bone after a fracture or grafting. The nutrition of grafts and of the bone to be repaired is of great im- portance. Here as elsewhere in surgical operations, the nutrition to the parts affected should be preserved. Other things being equal, tissues with the best nutrition repair most readily. The blood vessels to the parts should be respected and preserved. It is best to do the operation without a tourni- quet so that the nutrition of the limb is not interfered with during the oper- ation and because hemostasis after the operation is more satisfactory if the wound is closed dry, Avithout a tourniquet bei]ig used. The problem of nutrition concerns not only the supply of blood to a part but the amount of tissue that has to be nourished. A lack of consideration of this feature may lead to erroneous conclusions. The surface of a solid body varies as the square, and the cubical contents as the cube of its dimensions, so the smaller the graft the greater is its surface in proportion to its cubical contents and the less the burden of the nutrition to the graft. It is, of course, necessary to have a graft of sufficient size to bear the strain that is required but this does not mean that the strain of the full physiologic func- tion of the bone must be provided for by the graft. Due consideration must be given to the hypertrophy of the graft under moderately increased func- tional strain and the smallest graft that will meet these demands should be selected. A i-mall graft that offers a small mass to be maintained from the nutrition of the local tissues will undergo more active growth than a large graft placed under similar conditions, which Avill add a much greater burden of nutrition to the surrounding tissues. We know that physiologic function is in many instances altered to a large extent by the supply of nutrition that tissues receive. It is natural, then, to expect that when a definite amount of nutrition is divided among cells of a large graft, osteogenesis Avill not be so rapid or so satisfactory as when the same amount of nutrition is distributed to the smaller number of cells in a small graft. While it is essential to maintain a bone graft immobilized much longer than a simple fracture, gradually increasing exercise or massage should be begun as soon as possible after the period of immobilization has ceased. Grafts in the limbs should ahvays be kept immobilized for a minimum of eight weeks and in the large bones, as the femur, this period of time should be greatly extended before weight bearing is begun. Splints or braces should ahvavs be used to take up a part of the strain on the neAAdy united graft. 160 OPERATIVE f;T'ROERY A knowledge of the reaction of bone to foreig-n material is essential to a satis- factory performance of operations on bones. As has been mentioned in the chap- ter on Surgical Drainage, bone tends to extrude irritating foreign substances. Iron is one of these substances. The first reaction is absorption of the lime salts in the neighborhood of the iron in order to loosen Hie liold of the iron on the bone. This occurs even when there is no infection ]jut in the presence of infection this process of absorption of the lime salts or osteoporosis is ac- centuated. There are, too, diseases in which so much demand is made for calcium in the body or in which there is such a deficiency of calcium that the bones are not properly supplied with this essential element. There are great variations in the power of different individuals to deposit lime salts in the repair of bone. In some apparently healthy and vigorous persons this ten- dency is very slight while in others and the majority of healthy individuals there is a marked tendency for a deposit of more callus than appears to be necessary. The presence of iron, then, or any material that is irritating to bone, causes osteopcrcsis in its neighborhood. Infection produces at first softening of the bone because dilatation of the vessels and local leukocytosis cannot be so readily accomplished in the rigid tissues of normal bone as in soft tissue, and so nature tends to remove the rigid obstruction. "When an iron plate or iron screws are used in bone operations it has been frequently noted by careful observers that there is but little if any callus near the iron, and if union of the bone occurs it is by callus formation in that portion of the bone most distant from the site of the iron screws or plates. It seems a little strange, then, that in repair of bone, which can only be made by the deposit of calcium containing callus, a material is deliberately used which not only prevents the deposit of callus in its neighborhood but actually induces an absorption of the lime salts that were already there. In the usual provision by nature for much more callus than is necessary, this handicap in the repair of bone is often overcome and sufficient callus is thrown down in the part of the bone distal from the plate to make a union that is firm enough to remedy the weakness of the bone at the site of the plate. Occasionally, too, the callus may be so abundant as to limit the weakening influence of the metal to the immediate layer of bone with which it is in contact. Bearing these facts in mind it is easy to see wh}- the application of metal to bone is so frequently followed by nonunion. It is more difficult, however, to understand why, when these facts are known, metal plates are ever used. Even if the immediate repair appears satisfactory the patient is never free from the danger of complications as long as a heavy metal plate is fastened to the surface of the bone. Bone grafts taken from the same individual not only do not act as a foreign irritating substance, but actually encourage the local os- teoblasts to produce callus and reconstruct bone. In nonunioiT, the graft and the groove for its bed should be made sufficiently long so that the graft will touch healtliv bone at each end. If it is too short the BONES 161 exliauslod and scliM'osed bom- in llic innncdiale i'('^■^>^ it is ])()ssil)li' In do so i1 is Ix'st to ciii-ry tlic incision down to tlie bone throiigli an inh'rnmsi'ulai- s('])tuin rallici' tlian lliroiijih the muscle itself, tliouo'li this cannot always be done. When the fracturecl bone has been fully exposed in a fresh fracture the ends are reduced by manipulation with heavy forceps or long periosteal elevators havino' considerable leverage power. It can then be determined what is the best method of holding the fragments in position. In some eases an intramedullary graft will be sufficient. This can be secured from either end of the fracture l)y a chisel or a saw. A motor rotary saw is of great aid in this Avork and adds to the accuracy and shortens the time of the Fig Placing an intramedullary bone graft. -Iloglund's method of placing an intra- medullary graft. operation. The periosteum is first peeled back and a graft taken from either end of the bone about two or three inches long. It should contain the full thickness of the bone. It is not necessary to have periosteum with an intramedullary graft. The graft should be sufficiently thick to make firm bony contact with as much of the interior of the shaft as possible, though it should not fit too tightly as this may cause pressure necrosis. Sometimes a fragment from a fracture may be sufficient. The medullary cavity is cleaned out with a curet and a transplant two or three inches long is secured from the most convenient end of the bone. If a motor sa^v is used the trans- plant can be cut beginning about an inch from the end of the bone. This will leave an inch of the circumference of the bone at the point of fracture 164 OPERATIVE SURGERY intact. Ill this way more stability is obtained than if the graft were cut to the end of the fracture. The graft is fitted, as a rule, to the distal end of the fracture first and driven into the medullary canal lightly for about half of its length. The distal end of tlie fractured bone with the graft projecting from it is placed at an angle to the axis of the proximal end of the bone and so manipulated as to introduce the graft into the medullary canal of the upper end of the fractured bone (Fig. 94). The bone is then swung into its proper alinement. The method of Hogiund can often be used if a motor saw with parallel blades is employed. The graft is taken from one end of the fractured bone, beginning aliout an inch from the end, and is cut with parallel saw blades so the graft will drop into the medullary cavity. It is then driven down with a punch through the site of the fracture and sufficiently far into the medullary cavity of the other frag- ment so the fractured ends will be satisfactorily immobilized (Fig. 95). After closing the wound, suitable splints or a plaster of Paris support are applied. In many instances, particularly in fresh fractures, the intramedullary graft Fig. -Albee's method of inlay bone grafting. may be all that is necessary, but the inlay bone graft as developed by Albee- has many advantages, particularly in nonunion (Fig. 96). In fresh fractures if there is any reason to suspect that the callus will not be satisfactory the inlay method of Albee should be used. If the inlay method is employed the periosteum is not stripped back on the fragment from which it is pro- posed to take the graft, as it is best to have the inlay graft with perios- teum attached. The incision must be generous and the exposure satisfac- tory without too strong retraction. In fresh fractures the graft can al- ways be taken from the fractured ends. The strength of the graft should be sufficient to keep the bone in position, but it should not be made any larger than to fill this indication, for, as has already been pointed out, a small graft has more opportunity for nutrition than a large graft and con- sequently its osteogenetic powers are greater. In small bones, as those of the forearm, it may be necessary to secure the graft from the tibia. By cutting an inlay graft much longer from one end of the bone than the other, it can be slid down and made to bridge the 2Albee, F. H.: Bone Graft Surgery, Philadelphia, 1915, W. B. Saunders Co. BONES 165 fracture willi alxtiit two iiu-lics of the bone -raft is to be taken from tlie fractured bone it should be largely from the proximal fragment because of the greater sclerosis in the distal fragment. If the sclerosis is extensive, or if the bones are small, as in the bones of the forearm, it is best to secure the graft from the internal surface of the tibia. The graft is fastened in position by bone pegs or kangaroo tendons, as has already been described. The wound is closed by suturing lightly the fascia and muscles and closing the skin accurately but without ten- sion. As these cases are usually supported by plaster of Paris, it is best to use absorbable catgut stitches in the skin so that there will be no need to remove the stitches. In any repair of a fracture, whether it is a fresh fracture or nonunion, care should be taken to secure immobilization and usually traction. Noth- ing is superior to properly applied plaster of Paris. The dressing should be thin and the bony prominences should be protected by extra padding. The Fig. 98. — A method of extension that can be used after operation on the bones of the arm or forearm. cast may be snugly applied if the patient is in a hospital where it can be promptly cut if there is too much swelling. When in addition to fixation, traction is necessar^^, it can be maintained by embedding into the plaster of Paris tAvo strips of wood that project about six or eight inches below the lower part of the foot or the hand. Before applying the cast, adhesive plas- ter strips are placed on the limb as for a Buck's extension. The limb is well padded below the knee or the elbow and here the plaster is loosely applied if the fracture is above the knee or the elboAv, so that the traction will be ex- erted on the fracture itself and not on the bony protuberances about the joints distal to the fracture. A small crosspiece of wood connects the two ends of the strips that have been embedded in the plaster of Paris. A rub- ber tube is passed through a perforation in the ends of the adhesive plasters that have been previously fastened on the limb. The rubber tube is tied over the cross strip of wood as shown in the illustration (Fig. 98). In this man- ner constant elastic traction is maintained on the limb without the necessity of weights or pulleys. In operations for fractures of the femur or of the humerus, especially in mus- 168 OPERATIVE ST'RGERY cular individuals, some arrangement for traction is necessary, else the spasm of muscles will be so great as to make undue pressure and strain on the graft. Albee's inlay method of bone grafting is applicable to many fractures besides those of the long bones. In fractures of the patella, for instance, if the excavation is cut with a straight groove connecting the two fragments of the patella and a transverse groove at each end, a graft can be so fashioned from the tibia as to fit in this groove and j^roduce fixation of the patella. In fractures or defects in the lower jaw the inlay method maj' be utilized by obtaining a graft from the tibia which may be made to bridge over a consid- erable defect as after partial resection of the lower jaw. Fig. 99. — Diagram showing the action of bone graft in Pott's disease of the spine. Albee has secured very gratifying results by the use of the inlay method in Pott's disease of the spine (Fig. 99). His technic'^ consists in making a sufficiently long incision with the patient prone, starting well above the diseased area, going to one side of the midline and coming back to the mid- line below the diseased portion. In this way a flap of skin is formed with its border well away from the midline so as to avoid pressure and to prevent the skin wound coming directly over the graft. After dissecting up the skin and its subcutaneous tissue the tips of the spinous processes and the supraspinous ligament are exposed. The supraspinous ligaments are split with a knife over the tip of the spinous processes and the intraspinous ligaments are also split. ^Albee, F. H.: Bone Graft Surgery, Philadelphia, 1915, W. B. Saunders Co. BONES 169 taking care to avoid tlie niuselc or the attaclinients of muscle to the spinous processes. "Witli a broad, tliin, sluirp osteotome the spinous processes are split from a depth of one-third to two-thirds of an inch, and half of each Fig. 100. — Albee's method of bone graft in Pott's disease of the spine. Spinous processes have been ex- posed and split, and a malleable probe is ready to be placed in the defect. Fig. 101. — A malleable probe has been forced into the defect so as to present an accurate shape and size of the graft to be transplanted. spinous process is fractured at its base and set open for a sufficient distance to make a groove large enough to receive the graft. All of the fractured halves of the spinous process should be on the same side. Bleeding iDoints 170 OPERATIVE SL'RGERY are tied or compressed with iiaiize. The graft is obtained from the internal subcutaneous surface of the tibia. The groove for the reception of the graft consists of the split spinous processes and the cut supraspinous and inter- spinous ligaments Avith their osseous attachments undisturbed. This leaves the muscles and ligaments intact save for the split and fractured halves of the spinous processes (Fig. 100). The length and shape of the graft is de- termined by careful measurement Avitli calipers and a flexible probe, which is applied to the gutter bed (Fig. 101). With the patient in the same prone position the leg from Avhich the graft is to be taken is flexed to an acute angle on the thigh and an incision is made along the inner border of the inner surface of the tibia. It should be so placed that the skin incision will. not lie directly over that portion of the bone from which the graft is taken. The skin is dissected from the periosteum and the pattern of the graft is outlined on the periosteum by placing the molded probe on the periosteum and cutting the outline of the graft on the periosteum along the margins of the probe, just as a tailor cuts the cloth by laying the pattern on it and cutting along Fig. 102. -The bone graft has been cut, molded, and placed in position between the split spinous processes. It is being sutured in position with interrupted sutures of kangaroo tendon. the edges of the pattern. If the graft is to be curved the two ends should lie posterior, so that the apex of the curve is at the crest of the tibia, which is the strongest part. A straight graft is obtained by cutting the cortex of the tibia through to the marrow cavity with a motor circular saw along the in- cisions in the periosteum that have already been made. A curved graft can be cut in a similar manner, using the motor saw. A molded graft is made by sawing, at regular intervals, partly through the surface of a straight graft and then bending the graft into the proper curve. This is best done by the motor saw, which has a guard so set that it will cut a definite depth and no deeper. The ends of the graft may be loosened by saw cuts made by a very small motor saw or by a thin osteotome. The graft is removed by prizing it up with a thin osteotome, taking care to jireserve the attachment of the periosteum. A graft can be made with a chisel or hand saw, but the motor saw is far preferable. After removing the graft it is immediately transferred to its gutter bed and is held in place by strong kangaroo tendon sutures through the split halves of the supraspinous ligament (Fig. 102). The suture should be so adjusted as to secure a firm grasp on the ligaments and to BONES 171 keei) the g'raft lii-iuly in iiositiou. At the points of fixation at the ends of the graft, sharp (.-orners are removed by rongeur foreeps and these cliips are placed around the ends of the graft where it is in contact with the spin- ous process, before tying the sutures. Kangaroo tendon sutures are placed at intervals of about half an inch. If the graft is a curved one and not molded, the periosteum should lie on one side next to the spinous proc- ess and the endosteum on the other. The skin is closed in the usual way and sterile dressings are applied. It is important to prevent pressure on the graft, particularly if there is a marked kyphosis. Albee's method of inlay grafts for Pott's disease of the spine is largely founded on the fact that the spine is made up of a series of levers, each vertebra being an individual lever with its fulcrum at the lateral facets. The anterior arm of the lever is the body of the vertebra and the posterior arm is the spinous process. In destruction of the vertebral body that portion tends to collapse, but by fixing the spinous processes at their extremities the strain of the pressure on the diseased body of the vertebra is taken up by the poste- rior end of the lever and the parts are put at rest (Fig. 99). In the postoperative treatment the patient is placed on a fracture bed for five or six weeks with no other restraint than a towel across the chest, which is fastened to four strips of a broad muslin band, tied at each corner of the bed. If there is marked kyphosis abundant pads must be placed on each side to take up the pressure. No external fixation is applied to the spine dur- ing the convalescence except in unusual cases, where a light brace or plaster of Paris support may be worn for five or six weeks. CHAPTER XIII PLASTIC SURGERY Plastic surgery is that branch of surgerj' which is concerned with correct- ing defects that result from trauma, disease, or errors of development. While in a broad sense it may be applied to operations on any kind of tissue, as bones, tendons or nerves, affected by trauma or disease, it is usually em- ployed in reference to correction of defects involving the skin or mucosa either entirely or in a large part. Plastic surgery is chiefly concerned with the face though, of course, any portion of the body in which there are defects from injury or disease or from errors of development may be the subject of plastic operations. The principles of plastic operations are concerned, first of all, Avith the nutrition of the corrected tissue, and, secondly, with a mechanical reconstruc- tion that will bring the j)arts as nearly as possible to a normal condition. Operations that apply to particular regions will be discussed in the chapters devoted to regional surgery, but there are many underlying principles that must be borne in mind if success is desired in this branch of surgery, no matter in what portion of the body it is applied. Plastic operations are of two types : that in which the margins of the wound are prepared for a fresh union and sutured without transplanting tissue or Avithout the intervention of flaps, and that type in which flaps or grafts, free or pedunculated, are necessary. The former type is appli- cable in harelip and cleft palate or in defects that follow a small or nar- row injury. Usually after burns or extensive traumas the resulting de- formity is so great that it is impossible to reconstruct the tissues by excision of the affected part and union of the edges of the wound. In such cases several procedures are open. One is to undermine the margins of the wound for a con- siderable distance and determine if the additional elasticity obtained l)y the undermining will permit approximation of the edges of the wound. If this is impossible the raw surface can at least be diminished by sutures at the cor- ners or angles of the raw surface. Davis^ has secured excellent results by gradual excision of the scar tissue. If a scar is too broad for total excision and approximation of the edges of the wound, an oval area is excised from the center of the scar and the edges of the wound are approximated. After this has healed firmly, which is from a few weeks to two months, another mass of the scar tissue is excised. In this way the elasticity of the skin will permit approximation of the healthy j^ortion of the skin by gradual traction Avhicli would be impossible if all of the scar tis- iDavis, J. S.: Plastic Surgery, Philadelphia, 1919, P. Blakiston's Son & Co., p. 212. 172 PLASTIC SURGERY 173 sue wore excised at oiiee. Often, liowever, even this will not suffice, for tlie de- fect or deformity is too great, lu sucli cases, flaj)s or grafting must be re- sorted to. The operation to be performed depends largely upon the part of the body affected and also upon the function of this region. If, for instance, there is a large raw surface on the back of the legs where a scar will not be conspicuous or annoying, the chief indication is to heal'the raw surface even if there results a marked scar. It is always desirable to have as little scar tissue and as nearly a normal skin as possible, but if a large defect on the body or limbs can be so healed as to give the patient no discomfort and not to interfere with function, the main indication will have been fulfilled and it will hardly be justifiable to undertake prolonged and complicated operations to render the scar less jirominent when a simple procedure will fill every other indication. Plastic surgery chiefly concerns the face and the hands. Methods that not only restore function but remove deformity completely are chiefly desira- ble. Flaps of living whole skin Avith a pedicle usually give the best re- sults from every standpoint. They should be matched with the texture of the skin around the defect as far as possible. As a rule, flaps taken from the margins of the deformity come nearer to corresponding with the texture of the skin in the region of the defect than flaps taken from some distant part. Esser^ has called particular attention to this feature. Sometimes, hoAv- ever, it is impossible to obtain flaps at the defect and they have to be trans- planted from a distance and the pedicle cut .after the flap has been in position a sufficient length of time to obtain its nutrition locally. A flap of the wdiole skin with a pedicle can often be obtained from the region of the defect with a view to remaining permanently in position. The flap should be so shaped that the pedicle will form part of the reconstructed field. A flap may also be obtained from distant portions, as from the arm, and allowed to remain in position for about two weeks. The pedicle is then cut. A free transplant of whole skin may be used if the defect is not too large. The wdiole skin method is called the Wolfe-Krause method. Wolfe insisted upon the removal of the subcutaneous fat. The subcutaneous fat in a trans- plant of wdiole free skin is of no advantage but probably an additional bur- den. J. S. Davis, of Baltimore, has developed this method quite extensively. When the appearance of the scar is of secondary importance and the healing of the wound is the main object, thin grafts of epidermis, the so-called Thiersch grafts, are very satisfactory. When properly applied on a clean field such grafts usually take wdthout trouble and large raAV surfaces that would require months to heal or would probably never heal are closed in ten days or tW'O weeks. Thiersch grafts would be universally used instead of free transplants of whole skin or flaps except for two disadvantages; the scar resulting is conspicuous, for the skin of the scar does not appear to be normal, and there 2Surg., Gynec. & Obst., June, 1917, pp. 737-748. 174 OPERATIVE SURGERY is often a marked tendency to contraction after tlie nse of Thiersch grafts. This is partienlarly true if applied after a burn, and the reason is that in the Tliiersch grafts nothing but the epidermis or the epithelial elements are used. The contraction after an injury to the skin of the face, for instance, is not in the epithelial elements of the skin but in the connec- tive tissue that underlies the epithelium. In other words, the contraction lies in Avhat corresponds to the corium, which is composed largely of con- nective tissue and on Mhich rests the epithelial layer. If, in the healing proc- ess, this is made up of scar tissue, particularly of the dense scar tissue that follows a burn, contraction deformity will probably result even though the surface may be covered by healthy epithelium. It is contraction in this subepithelial layer that produces the striking deformities following burns of the face or hands Avith the eversion and twisting of the features, while con- traction in the submucous layer causes the strictures of the urethra that fol- low ulceration. In all of these instances, the contraction is due not to the epithelial elements, which may be perfectly healthy, but to the connective tissue elements on which the epithelium rests. If, then, a scar contraction is excised and Thiersch grafts are used to heal over the surface, the scar contraction will almost invariably recur beneath the Thiersch graft. In order to avoid this it is necessary to use the whole skin which contains not only the epidermis but normal healthy corium that does not contract. Often incisions may be so made or flaps so shaped as to secure tissue from the neighborhood, which at first sight might seem impossible. Due re- gard must always be had for nutrition of flaps, and the pedicle should pref- erably be located in the general direction of the blood supply of the skin of which the pedicle is formed. The flaps should be handled as little as pos- sible and as gently as possible. It must be borne in mind that unnecessary trauma not only destroys in a flap living tissue that might serve, but adds an extra burden to the blood supply which must absorb the injured cells and bring nutrition for repair of the defect left by their removal. In very vas- cular regions, such as the face, it is often possible to disregard the direction of the blood supply in making a flap because the blood supply is so abundant here and the collateral circulation is so great that a flap may be sufficiently nourished if the pedicle is large enough, even though the blood must come from the opposite direction of the normal blood supply. Besides handling the flap gently and providing sufficient nutrition through its pedicle, care must be taken to insert the sutures in such a manner that too much tension will not be made. No matter how carefully the pedicle may be handled or shaped, if it is sutured so that there is too great tension, the blood supply will be obstructed and the flap will be partially or totally destroyed. Occasionally when tension in a flap is unavoidable, it is best to concentrate it upon one or two tension sutures that w^ill produce pressure only in one place and relax the rest of the flap so there will be enough nutrition along the margins for satisfactory union. The nutrition of a flap may also be im- PIvASTIC SUROKRY 175 jii'I'iKmI l»y \(Mi()\is stasis. C. 11. JNlayo lias ol'lcii ciiipliasizcd iliis j)()iii1. Not infreqiUMitly llie blood supply to a llap would he sufficient except tluit the venous return is imperfect and this blocdvs the capillaries which in turn prevent the feeble arterial current from being effective. In one instance in Avhich 1 1rans[)lan1ed a Ihi]) from the forehead, preserving the temporal artery, the arterial nutrition of the flap was abundant, hut gangrene of a large portion of it occurred because the venous return Avas not sufficient. Whei-ever a large flap with a narrow pedicle is transplanted this condition nuiy obtain and should be carefully avoided. This is done by several short stab wounds in the substance of the flap and by leaving small gaps be- tween the stitches along its margin through Avhich the venous blood is emp- tied, so relieving the passive hyperemia. Many of the procedures used to close defects have become almost classical. The chief methods are given in the accompanying illustrations, which are self-explanatory (Figs. 103, 104 and 105). The methods of Szymanowski are ingenious and usually satisfactory (Fig. 106). Often a simple relaxation in- cision parallel with the wound will be all that is necessary. An oval defect can be closed by any one of a number of different procedures. Lisfranc's method is simple and useful. In many instances the sliding of flaps not in- frequently causes puckering, which is often conspicuous. This is eliminated wdienever possible either by suturing or l}y incision of a triangular area that includes the puckered portion (Figs. 107 and 108). Oval, circular or quad- rangular defects may be closed as shown in the illustrations (Figs. 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122 and 123). If the flap cannot be carried to the affected part, which is done in defects about the face, the affected part can sometimes be carried to the flap, as Avhen plastic operations are performed on the hands or on the loAver extremities. Defects about the hand, forearm, or elbow, may be repaired by a flap from the abdomen, which is dissected up as a bridge of tissue between two parallel incisions and is left attached at each end. The defect on the hand is pre- pared for a graft and the hand is inserted under the bridge and the edges of the skin of the bridge of tissue are united to the margins of the wound on the hand by sutures. After about tAvo weeks the flap is cut away. By making a flap with its broad base from the upper part of the abdomen the whole por- tion of the flap except its base can be sutured to the defect. In this Avay lesions of the palm of the hand are satisfactorily repaired and the pa- tient is much more comfortable than Avhen the hand is carried to the back. When a pedicle must be cut, it is necessary to see that the flap is suffl- ciently nourished by its ncAV location before severing the pedicle. When the pedicle is flrst severed the flap ahvays becomes somcAvhat paler, but if the pa- tient is young and in good health and the flap in good condition, a pedicle can usually be safely cut at the end of twelve days or two weeks. If in doubt, it is advisable to compress the pedicle Avith a soft clamp for an hour a day for several days before cutting it. In this AA^ay collateral circulation is deA'eloped. 176 OPERATIVE SURGERY 'S Fig. 103. — ClosLire ot a triangular defect by the method of Jasche. / / Fig. 104. — Clos '.re of a triangular defect by the method of Szymonowski. \/\^ - Fig. 1C5.— Closure of -j. triangular defect by the method of Amnion. \ ^ n , M f 1 Fig. 106. — Closure of a triangular defect by the second method of Szymonowski. Fie 106-^.— Third method of closure of trian- . gular defect according to Szymonowski. , .fijo Fig. 107. — Closure of a triangular defect by the method of Burow. jficr. 108. Second method of closure of triangular defect according to Bur 4-5- Fig. 109. — Closure of oval defect by method of Lisfranc. u )^ Fig. 110. — Closure of oval defect by method of Szymonowski. Fig. 111. — Closure of oval defect by method of Celsus. \ -U' Fig. 112.— Closure of oval defect by method of Dieffenbach. PLASTIC SURGERY 177 W J Fig. 113. — Closure of oval defect by double flap method. Fig. 114. — Closure of oval defect by method of Weber. T f r r r .* T r r f r r Fig. 115. — Closure of circular defect by first method of Szymonowski. • T r w T r r n Fig. 116. — Closure of circular defect by second method of Szymonovi'ski. r r r r r r r T. r r r r \ V r r Fig. 117. — Closure of circular defect by third method of Szymonowski. ■ <; r V r r r \\ \ \ ■k K Fig. lis. — Closure of quadrilateral defect by method of Cole. Fig. 119. — Closure of quadrilateral defect by first method of Szymonowski. f r lUi^r . w r 1" \ Fig. 120. — Closure of quadrilateral defect by sec- ond method of Szymonowski. t T t t f r f f t f f t - Fig. 121. — Closure of quadrilateral defect by method of Dieflfenbach. -5-M- 4-W- -i-i-!- - T r r - X \\ \ \ ■\ \ ^\ ^ 1° r t ij — <— ;- "\, Fig. 122. — Closure of quadrilateral defect by method of L,exer-Bevan. Fig. 123. — Closure of quadrilateral defect by method of Burow. 178 OPERATIVE SURGERY If it is desired to transfer a long narrow (la]) from the neck to a region on the face it is often too risky to imperil the nutrition liy doing the opera- tion in one stage. Tiie nutrition from the pedicle of the flap, however, can be improved by first outlining the fhi]i l)y incisions and then the l)ridge of tis- sue for the pedicle is undermined and sepai'ated by ruliber tissue or some imper- vious dressing from the underlying raw surface. In this manner the nutri- tion at the tAvo ends of the flap will be developed. The end that is to l)e severed is divided in sections at intervals of several days so that all of the nutrition will be gradually developed from that end of the flap which is to be the pedicle. One of the most interesting and valuable principles in plastic surgery is Fig. 124-A. — "Tubed" iiedicle flaij. Tht- iialieiit, a young boy, bad a severe defect following noma, which resulted in the sloughing away of the cheek and a large portion of the superior maxilla. There was complete bony ankylosis of the lower jaw and he was fed through. the defect. The illustration is a photo- graph which shows the defect and the "tubed" pedicle flap which was gradually dissected free at intervals of several days, so developing a blood supply in the pedicle. the development of the blood supply from a comparatively small pedicle. In extensive reconstruction work about the face this is essential for success. "Tubing" of the pedicle, introduced by H. D. Gillies," is a valuable aid in carrying out this principle. A flap is outlined from the chest and lower part of the neck of such a size and shape as may be best suited" to the facial defect. The pedicle extends from just beloAv the angle of the jaw to the main body of the proposed flap. It is about one and a half or tAvo inches broad ='Surg., Gynec. & Obst., February 20, 1920, pp. 121-134. J'LASTIC SrUdKHV 17i) and is raised nwv an cxlcnl of I'onr indies oi' lon.-i'er, depending' upon the loealion lo wliirli Hie Hap ninst be 1 ranst'erred. After dissecting the ped- icle from its base P. Ihe margins of the pro))osed flap, II10 edges of tlic skin of tlie ])edieh> are sninred together with a eontinuoiis sntnre. In lliis way the raw snrfaee of th(> pediele is free from infection and also from the trauma and h)ss of bb)od wliieh an exposed granulating surface is likely to undergo. The margins of the wound from wdiieh the pedicle has been dissected are undermined and united beneath the tubed pedicle so there is a mininuim of raw surface exposed. About a week later one-third of the flap is dissected from its bed (Figs. 124 A, B, and C, and 125) . If the flap is to cover part of the cavity of the mouth its raw surface is grafted with Thiersch grafts, or two flaps may be developed with tubed pedicles and one turned with the epithelial surface within the mouth and the other with the skin external. At intervals of r p*^ ■ "^ 1 «• 1 K%^ ''^^.- Fig. 124-B. — Photograph of the patient shown in the preceding illustration three months later. The flap from the neck had been turned wi'h the skin side inward and the flap from the forehead with the skin side outward. The pedicles were severed after clamping the pedicles with soft for- ceps for half an hour a day for about ten days. Fig. 124-C. — Photograph of the patient shown in the two preceding illustrations. This photo- graph was taken about seven months after that shown in Fig. 124-B. The ankylosis was overcome by the Esmarch operation and the Hp was repaired by using the mucosa that extended on the left side up to the nose, the technic being similar to that of the Owen operation for harelip. The photo- graph shows the extent to which the mouth can be opened. about a Aveek the flap is again dissected in three stages covering a period of three or four Aveeks until it is entirely divided. This wdll develop a lilood supply through the pedicle so the flap can be transferred without fear of insufficient nutrition. Sometimes, as recommended by Gillies, a large flap to cover an extensive defect of the face can be raised from the front and up- per part of the chest by having tw-o tubed pedicles, one on each side of the neck. AVhen the pedicle is to be severed it can be cither gradually cut, 180 OPERATIVE SURGERY severing about one-third at a time, at intervals of a week, or it may be compressed with a soft clamp or a rubber band for an hour twice a day for a Aveek before being severed. In this way the blood supply is gradually thrown upon the new attachments of the flap in such a manner that the local nutrition is surely established, whereas a complete severing of the pedicle without pre- liminary preparation might result in such poor nutrition that the flap would break down (Fig. 126). These principles of gradual development of the blood supply of a flap are exceedingly important in repairing an extensive defect and will enable deformities to be corrected much more satisfactorily than by the old method of a two stage operation in which the flap is completely dissected at one stage and the pedicle severed at another. Fig. 125. — "Tubed" pedicle which has been Thiersch grafted on the raw surface and is ready to be turned into the defect in the face. Fig. 126. — The flap with the tubed pedicle shown in Fig. 125 has been sutured into the de- fect in the face. A soft-nosed clamp is placed on the pedicle at intervals to develop blood supply to the flap. ''Jumping" and "waltzing" flaps may sometimes be resorted to. A flap may be turned, for instance, to the margins of the wound and kept there un- til the nutrition is well established. Then its pedicle is cut and turned over the defect; or a flap from the abdomen may be sutured into a wound made on the hand for its reception and, after it has taken, the pedicle to the abdomen is cut and the hand with the transplanted flap carried to the face. The flap is sutured into its new position, the pedicle to the hand being severed at the proper time. PLASTIC SURGERY 181 Transplantation of whole skin is always desirable because of the better scar that results and the absence of contraction, but it is more difficult than Thiersch grafts, Avhieh consist only of the epidermis. In whole skin grafting the corium occupies relatively much more of the graft than the epidermis and consequently requires much more nutrition to keep it alive. The epi- dermis graft, which is the Thiersch graft, is very thin, has a large surface and small cubical contents, and consequently requires but little nutrition. The whole skin graft if reduced to many small masses, as in the Reverdin method, or the small deep skin grafts of J. S. Davis, can be used more successfully than if the Avhole skin is transplanted in one mass. However, this method, while promoting rapid healing, leaves a very conspicuous scar. In the small deep skin graft of Davis, not only is the epidermis taken but also a consider- able portion of the corium. Whenever skin grafts are used it is always best to take them from the patient. Autografts, as these are called, are much more likely to be success- ful than grafts taken from others of the same race, which are called iso- grafts or homo grafts. Zoo-grafts are grafts taken from lower animals and invariably fail completely, though there may be an appearance of success at first. Masson, of the Mayo Clinic, has had considerable success with isografts, when the donor's blood and that of the patient have been tested and proved to be of the same group. His results in using isografts when the red blood cells of the do- nor were agglutinated by the serum of the patient were always unsuccessful, but where this agglutination did not occur, the results w^ere satisfactory. As a rule, however, it is always possible to get the grafts from the patient and no material can be more satisfactory than this. The wound on which grafts are to be placed must either be a fresh clean wound or a healthy granulating surface. When the wound is fresh and clean Thiersch grafts will live whether placed on fat, fascia, tendon, muscle or bone. If the granulations are clean, firm, pink in color, and if the bacterial count from the wound secretion is very low or negative, grafts can be transplanted directly to such a granulating surface without any further preparation. If, however, the granulating wound is infected or if the granulations are too exuberant the wound must be prepared. This may be done by painting the granulations with tincture of iodine or by wet dressings of boric acid or salt solution. If, after treating the wound in this manner for a few days, satis- factory progress is not made, the patient can be given a general anesthetic, the granulating surface thoroughly painted with a tincture of iodine, and the surface cut away with a sharp knife. This is much better than curetting, which bruises and may force infection deeph^ in the tissues. Firm pressure Avith a dry gauze compress for at least five minutes usually controls most of the bleeding. Any special points that bleed at the end of this time may have a little longer pressure or may be sutured over with fine plain catgut. It is highly important that the surface to receive the graft should be 182 OPERATIVE SURGERY dry. The wound is prepared in tliis niainicr for tlic deep ^'■raf'ts of J. S. Davis, for Reverdin grafts, or for large wliole skin grafts. If the Reverdin method is used, pieces of epithelium are removed by sticking the point of a straight intestinal needle into the epidermis and shav- ing off the small piece of epidermis that is picked up by the needle. In using the method of Davis of small deep skin grafts somcAvhat the same technic is employed. Davis uses a straight intestinal needle held in an artery clamp. He has a series of these needles caught in clamps and picks up a Int of the skin, raising it so that a little cone is formed. The base of the cons is cut through with a sharp knife, going deep enough to secure not only the epider- mis but the corium also. The graft while still on the needle is transferred to the wound, placing the raw surface next to the Avound. A space of about one-fifth of an inch is left between each graft. They are laid in definite rows. When two rows have been jolaced they are covered by strips of dry, sterile rubber protective, which is pressed firmly over the grafts with a piece of gauze. The ends of the protective extend beyond the wound. The protective may be covered with gauze kept moist with salt solution, or a paraffined mosquito netting may be laid on the grafts and the latter covered Avith a dressing. Boric acid ointment may also be used. A moderate amount of gauze is i^laced OA'er the Avound and the part is immobilized as much as jDossible. It is best to keep the patient in bed for a feAv days. The first dressing should usually be done about the third day, but in a fresh AA'ound Avithout granulations it may be postponed until the fifth or sixth day. The method of taking Thiersch grafts is to shave off the epidermis Avith a long sharp knife or razor. In order to do this the skin must be taut. Thiersch grafts are best taken from tlie thigli, the front, inner, or outer sur- faces being used. The skin can be made tense Ijy liolding it Avith dry gauze on the upper part of the thigh, pressed firml\- upward Avith the open hand of an assistant, Avhile the operator Avith his left hand pulls doAvn the skin of the thigh Avith dry gauze and Avith his right hand shaves off the grafts. If it is desired to take a large graft a long amputating knife or long kniA'es made especially for this purpose may be used and it will be nec- essai'y to have the skin of the thigh fiat. Tliis is l^est accomplished l)y using tAvo boards, the skin being held flat Avith one, at a point Avhere the graft is started and the other being pressed just in front of the advancing knife. The knife should alAvays be kept moist by solution dripping salt over it just before the graft is cut and during the process of cutting. Very large grafts can be secured by this method of using a long knife Avith tAvo boards, Avhich originated at Johns Hopkins Hospital. The graft, if it is smooth, is transferred directly to the Avound for Avhich it Avas intended and pressed into position bj' smooth moist gauze. The pressure should be firm and a sloAV rubbing motion is made over the gauze to cause the graft to ad- here to the raAV surface and to exclude air bubbles (Figs. 127 and 128). The grafts are laid as closely together as possible, preferably Avith the edges OA'erlapping. If the graft curls up it may l)e spread out on sca'- eral laA-ers of smooth gauze, which lias been Avet in salt solution. It is PLASTIC SURGERY 183 placed -willi llic r;n\- side up and \\illi llie lin^'cr it can l)e readily inicurled and spread out. It is iIumi iiuiiiediately transferred lo the area that is to be grafted and pressed liriuly into position. The gauze is gently removed, tak- uedLTav/n iroTn jj. Fig. 127. — Two boards used to keep the skin tense while taking a Thiersch graft, according to the method of Johns Hopkins Hospital. Fig. 128. — Thiersch graft is cut with a long amputating knife while the wooden boards keep the skin tense. ing it up first at one corner. Usually the gTaft Avill adhere to the wound. If, however, there is any tendency for the graft to stick to tlie gauze, an 184 OPERATIVE SURGERY edge is loosened from the gauze with the end of a i^robe or mosqnito forceps and held on the wound, and then the gauze can be removed, leaving the graft in place. Some operators prefer to lay the grafts smoothly on a piece of rubber protective, spread over a board, and then transfer the grafts in this man- ner after enough has been cut to cover the whole surface. The raw sur- face of the graft should not dry and the sooner it is x^laced in contact with the wound the better. After the grafts are in position, if there are any bubbles caught under them in spite of the precautions to prevent this, they are nicked with the point of sharp scissors and pressure is made to expel the air. There are a number of methods of dressing Thiersch skin grafts. Some surgeons prefer narrow strips of rubber protective. Silver foil also makes a good dressing, but it is likely to break up and if any of the grafts fail to take the silver becomes entangled in the granulations and may discolor the scar. The most satisfactory dressing for Thiersch grafts in my experience is sterile strips of zinc oxide adhesive plaster. Zinc oxide adhesive can be sterilized before the crinoline is removed by putting it in a steam sterilizer with the dressings. It is cut into strips about an inch wide and of a length to extend beyond the margins of the wound for about one inch. The strips are laid on carefully, beginning from the center and placed so that they barely touch each other and do not overlap. In this way drainage is provided. The strips must be applied carefully, for after they once touch the grafts the grafts will adhere to them and if the strips are not applied smoothly the grafts will be disarranged. After the wound is covered in this manner dry sterile gauze is placed over the adhesive and fastened in position by a snugly fitting bandage. The outer gauze dressing is removed three or four days later, as the serum, from the wound makes the dressing stiff and may predispose to infection. The gauze dressing must be taken off carefully so as not to pull up the adhesive strips. The adhesive strips are removed about ten days after operation, when the grafts will have taken firmly. In this manner the numerous dressings and the necessity of moist gauze is clone away with and at the same time advantage is taken of the fact that adhesive itself seems to stimulate epidermization. Boric ointment is applied for a week and then a dusting powder. In certain instances where contraction is likely to be a chief feature the whole skin must be used. As has been said the deep skin or corium is the connective tissue layer and it is here that contraction occurs. Thiersch grafts being only the epithelium layer do not prevent the tendency to contraction in a wound where there is an excessive amount of scar tissue. The technic of using the whole skin graft, or the method of "Wolfe-Krause, has been brought into considerable prominence recently by the excellent work of H. D. Gillies, of England and of J. S. Davis, of Baltimore. The method of pre- paring the field for the reception of whole skin grafts is similar to that for other grafts. All oozing must be checked and it is even more important to PLASTIC SURGERY 185 stop bleediiis^' here than when applying tlie Thiersch grafts. If the oozing of the raw snrfaee cannot be stopped it is best to wait a few days before applying the graft. It must be remembered that the whole skin graft is several times thicker than the Thiersch graft and consequently requires a much greater blood supply for its nutrition. The whole skin grafts may be applied on healthy granulations which are level with the skin edges. If pressed firmly in position on the granulations no sutures are necessary. The technic as given by Davis is to mark out lightly with the scalpel an elongated ellipse, Avhich is considerably larger than the raw surface it is desired to cover, because the graft contracts greatly when separated. The graft is so shaped that the wound from which it is removed can be approximated by sutures without great tension. The skin and fat are removed down to the fascia. Fat is trimmed from the grafts with curved scissors and the grafts are perforated in several places with a knife or a saddler's punch to allow the es- cape of serum that may collect under the graft. It is best to secure the graft in position after pressing it firmly on the wound by four interrupted su- tures and if necessary by a continuous suture of horse hair or silk. Some- times the graft adheres so firmly that no sutures are required. It should be handled as little as possible and is placed in position immediately after it has been removed and prepared. The graft may be cut in the gen- eral size and shape of the wound but it is best to have it not too wide. It should not be more than one and one-half or two inches in width at its broad- est portion. If a larger surface is to be covered a long strip of skin should be taken and cut into segments and the grafts laid side by side. Veins, if exposed, even though they are not injured, should be excised. Otherwise they may cause pain from thrombosis later on. It is much more difficult to secure success with a whole skin graft than with the Thiersch graft for reasons that have already been mentioned. Gillies thinks it best to cut the graft in one piece and of the same size as the defect to be covered. In this way, he believes the skin is slightly stretched, the vessels are held open and the transplanted skin is kept at its normal tension. The graft is accurately held in place by sutures, and firm pressure made over it, for which he recommends dental wax. The graft is perforated with a knife in several places to give exit to serum. An adhesive plaster dressing, as described for Thiersch grafts is a good dressing for whole skin grafts. Abundant gauze and firm pressure must be used. Whole skin grafts free should not be applied to bone or cartilage, be- cause they require too much nutrition. Either Thiersch grafts or a whole skin graft with a pedicle should be used in such a wound. About two weeks after the graft has thoroughly taken, gentle massage should be started upon it so as to soften the graft. In wounds w^here the normal skin is hair bearing a w^hole skin graft of this kind is made with the same technic that has just been described. A hair bearing graft can be taken froii] reo-ipjis of the body in which hair normally appears, as the scalp or the 186 OPERATIVE Sl'RGERY pulses. It can be shaped for an eyebrow and Avill jn-event a conspicuous deformit}' wlien the eyebrow has been destroyed. A g-raft transferred to Ijone, as on the skull, may not live if the wound is not very vascular or is extensive,. The wound should be prepared for the grafts a few weeks in advance by drilling through the outer table of the skull, a series of holes at close intervals. From these holes granulations will spring and upon them grafts can be laid. The granulations will furnish much more abundant nutrition to the grafts than would the undisturbed bone. This method has been developed and used successfully at the ]Mayo Clinic. In plastic work where the whole skin free graft, or the pedicle graft, or sliding method is used a depressed scar along the line of union adds greatly to the deformity no matter how accurately the skin incision is made and sutured. If there is a depression and a groove the scar will spread and be- comes very conspicuous. It is exceedingly important to prevent this. If there is the slightest tension and the sutures are improperh' inserted, though the immediate et¥ect may appear satisfactory, as healing and contraction takes place it will be seen that the scar becomes wider and is depressed. -t ^.^ fig 129. The method of Esser for preventing a sunken scar. The subcutaneous fat and fascia is so in- cised as to form a roll in the middle of the wound. Esser* has laid particular stress upon this and calls attention to the im- portance of building up the underlying fat and fascia before suturing the skin. This may be done by inserting the sutures so as to catch a small mar- gin of the skin and a deep bite of the subcuticular tissue on each side of the wound, thus approximating the subcuticular tissues firmly. If the ten- sion is considerable or the desirability of an exceedingly small scar great, it is best to undercut the subcuticular fat and fascia on each side of the wound and bring the fat and fascia together by fine plain catgut sutures, so forming a slight ridge just under the line where the skin is to be sutured (Fig. 129). This procedure will make the line of incision apparently bulge a little, but as healing and contraction occur the ridge will disappear and the scar will be on the normal level of the skin instead of being depressed and contracted. This is a highly important point when excising any scar that has been depressed and is adherent to the tissues underneath. If the depres- sion is too great to be corrected in this manner, there should be transplanted a small amount of fat, preferably on a pedicle from the undermined skin in the region of the wound, or, if necessary, a free transplant of fat from the thigh can be used. *Surg., Gynec. S: Obst., June, 1917. CHAPTER XIV OPERATIONS OX THE FACE AND MOUTH Suryery of the face consists largely of either plastic surgery or the excis- ion of tumors. The congenital defects of the face and mouth most frequently reiiuiring operations are harelip and cleft palate. Operations for harelip have an ancient and honorable history. There has not been the same change in technic that has occurred in abdominal and closed Avounds where aseptic surgery can be practiced and where sepsis as a complication is avoided by the proper technic and after-treatment. In operations on the mouth and lips no dressing can be applied. Much can be done, however, by preparing the mouth and lips and by treating the teeth for several days before the operation by careful cleansing with water and mild antiseptics. Of course the regular te:-hnic of aseptic surgery is followed, but particular care is taken to maintain the nutrition of the tissues, to make a sharp clean dissection wherever possible, and to avoid injury to the lines of the wound. As the wound cannot be sealed against infection from food or air, partic- ular reliance must be placed upon these measures in order to maintain the resist- ance of the tissues against infection and their maximum ability for satisfac- tory and rapid repair. The principles that underlie operations for harelip and cleft palate are those that have already been discussed in the chapter on Plastic Surgery. The parts must be mobilized as thoroughly as possible. An occasional drawn or unnatural fixation of the upper lip is due to the fact that the tissues were not thoroughly mobilized before suturing. Any operation on a harelip must be preceded by a dissection of the ala of the nose and the adjoining por- tion of the lip from the maxillary bone until the sides of the cleft fall easily in contact with each other without tension. The mucosa under the lip on the outer side of the cleft is cut with scissors or knife. The rest of the mobilizing dissection is done partly by spreading the blades of the scissors when there is little resistance, and partly by sharp dissection. A plug of dry gauze is inserted immediately after dissection and pressure is made to stop the bleeding. The pressure can be maintained by the fingers of an assistant until the bleeding has ceased. There is no occasion for any apparatus to clamp the lip in order to reduce the flow of blood from the coronary arteries. This is best done by the fingers of an assistant. The lip should not be pared until the operator is ready to insert sutures. In incomplete clefts often a transverse incision which is sutured in the opposite direction from that in which it is made will give satisfactory re- 1S7 188 OPERATIVE SURGERY suits. This depends, hoAvever, upon the character of the lip. If the tissue just above the notch of the cleft is thin and poorly developed it will be much better to excise this tissue and convert the incomplete harelip into one ex- tending into the nostril. The tissues should be cut widely enough to reach a lip of normal thickness. Nothing is more disfiguring than to unite thin tissue while on either side of the sear is a lip of normal thickness. Paring of the cleft is done with a view to securing a broad raw surface for apposition. If there is any doubt about this the lip is pared farther from the cleft until well de- veloped tissue is found or else the pared wound is split with an incision so as to flare it open, turning the mucosa in and the skin out, and thus giving a wide raw surface for approximation. Such a procedure, however, is not often necessary. The anesthetic is ether, given during the operation by pumping ether vapor through a bent, perforated metal tube which is placed in the corner of the mouth. Aside from the simple procedure of a transverse incision above the notch in the lip which is sewed up in the opposite direction to the in- cision there are a number of operations for harelip. This transverse incision can sometimes be made just below the nostril, as advocated by C. H. Mayo, and the scar will be less conspicuous than if made close to the margin of the mucous membrane. In spite of the multiplicity of more or less complicated operations for harelip usually two or three can be made to fill any require- ment. The important points to be borne in mind are to approximate the tissues without tension, to have the vermilion border of the lip a continu- ous smooth line, and to have the lip at the line of incision slightly longer than normal to allow for subsequent contraction when the wound heals. If there is a reasonable abundance of healthy lip tissue of normal thick- ness on either side of the cleft probably no operation is more satisfactory than the Rose operation or some of its modifications. The Eose operation re- quires a curved incision which is more difficult to make than an angular in- cision. After thoroughly mobilizing the lip an incision is made with a sharp- pointed knife from the apex of the cleft along the outer margin downward and outward to a point about one-eighth inch above the vermilion border. From the lower extremity of this incision another cut is made almost at a right angle to the first incision and going sharply inward and downward. The first incision is about one-eighth inch shorter than the length of the proposed upper lip. Similar incisions are made on the other margin of the cleft and the bleeding is controlled by pressure on the lip with the fingers and thumb of an assistant (Fig. 130). The incision gees well through the skin and down to the mucosa. It is difficult to cut the under surface of the mucosa smoothly with a kjiife and this part of the incision can best be finished with sharp scissors. A tractor suture of fine silkworm-gut is inserted into the lowest portion of the mucosa of the lip. This suture is not tied, but tlie ends are left long and clamped with a mosquito forceps. It is used as a tractor suture and by gen- tle traction the rest of the lip is thrown into easy apposition. A suture of fine silkworm-gut is then inserted, beginning close to the margin of the wound FACE AND MOUTH 189 and at the angle made by the junction of the two incisions. The insertion of this suture is exceedingly important. It is made with a small sharp needle, preferably a curved needle, and the suture, after penetrating the skin close to the wound, goes well out into the tissues of the lip and then comes back taking a small margin of the mucosa. The bite this stitch takes in the mucosa is im- portant. If it catches the mucosa too far toward the nostril it will force the vermilion border to the lower end of the skin incision ; consequently, the mucosa should be caught near the lower portion of the w^ound to prevent the forcing of a redundant amount of mucosa toward the skin part of the incision. This suture is carried over to the other side and inserted in a similar manner, only it goes from the mucosa to the skin, taking care on this side also to catch the mucosa at the proj^er place near the lower end of the incision, to take a large bite of lip tissue and a small bite of skin. It emerges at the angle made by the two incisions. This suture is tied snugly but not too tightly and the ends Fig. 130. — A modified Rose incision for a single harelip. Fig. 131. — The sutures have been placeil and all are tied except the tractor snture. are left long until the next suture is applied. The third suture, also fine silk- worm-gut, is placed near the nostril and penetrates the whole thickness of the lip. The next suture unites carefully the vermilion border of the lip. This is done while making traction on the tractor suture. This suture may be of silk- worm-gut or fine silk, preferably arterial silk. As many other sutures of fine arterial silk are inserted as is necessary to secure satisfactory approximation. The stitches in the skin are placed first, then those in the mucosa (Fig. 131). Lastly, the tractor suture is tied, if tissues which it embraces have not been too much damaged by the traction. If so, sutures of fine arterial silk are in- serted near the tractor suture to maintain apposition of the mucosa and the tractor suture is removed. The nostril should be approximated accurately. Sutures are often carried too far into the nostril and so occlude it. The nostril should be made symmetrical with the normal nostril, but it is better to have it flare open slightly, a defect which can be easily remedied by a subsequent 190 Ol'ERATIVE RrnOKRY stitch, than to have it too tiylit, as this is much more difficult to correct. Al- lowance should always be made for contraction along tlie line of scar and the lip should be made slightly louger than appears to be normal. If the tissues in the neighborhood of the cleft are quite thin and too much tension would result if thin tissues were entirely sacrificed, the Owen operation can be done. This operation is also indicated when the cleft of the harelip is iiiiipiii Fig. 132. — An incision for harelip according to the method of Owen. Fig. 133. — Sutures in the vertical incision of Owen are placed. Fig. 134. — The last sutures are placed in the operation of Owen. unusnally wide. The method of procedure is best indicated in the accompanying illnstrations. The lip is well mobilized as already described. The outer margin of the cleft of the harelip is pared from the nostril to the corner of the month, the incision making a decided angle at a point about halfway between the nos- tril and what would be the vermilion border of a normal lip. The incision on the other side of the cleft begins at the nostril and goes downward along the FACE AM) MOI'I'II 191 cleft to about opposite tin' aii^lc of the incision on tlic outer side, tlieu it turns transverst'ly away from tlie eleft, ondin-i' alxiut midway between the normal nostril and the lower border of the upper lip (Fig. 132). A suture for fixation is inserted in such a manner that it brings together these two ineisions just at the i)oint where they turn outward from tlie cleft of the liarelip (Fig. 133). A second fixation sutui'e unites the tip of the flap containing the mucous membrane to the corner of the mouth. The nostril is approximated hy a third fixation suture and the rest of the wound is closed by interrupted or contiiui- ous sutures of fine silk or horsehair (Fig. 134). Double harelip is often accompanied by a prominent intermaxillary bone. In such instances, it will be necessary first of all to replace the intermaxillary bone, which should never be cut away. This is done by making a submucous resection of a part of the septum which supports the intermaxillary bone. An incision is made along the lower border of this septum, the mucosa is stripped up on each side and a sufficient amount of the septum is cut away with scissors or bone forceps to enable the intermaxillary bone to be pressed into position between the two maxillary bones (Fig. 135). The outer edges of the inter- Fig. 135. — Line of incision for excision ot nasal septum. maxillary bone are pared with a sharp knife and the corresponding sides of the maxillary bones are similarly freshened. The lip on the outer sides of the cleft is freely dissected from the maxillary bone. With a stout perineal needle, with the eye at the point, in infants, or with a drill in older children, a hole is made about one-fourth to one-half inch from the margin of the cleft above the al- veolar process and through the maxillary bone into the mouth, coming out about the junction of the hard palate with the alveolar process. The direction of the perforation is slightly downward, as well as inward and backward. In this w^ay a good hold is obtained on each maxillary bone and at the same time the matrices of future teeth are uninjured. A wire is passed through these perforations. If a perineal needle is used the wire is threaded into the eye of the needle as it appears in the mouth. A moderately stout bronze ware may be used, though braided or cable bronze wire is preferable and is easily tied. One end of the wire is carried across the front surface of the intermaxillary bone with the perineal needle, going just beneath the lip tissue that covers this bone. The bone is pressed into position and the wire adjusted accurately either by twist- 192 OPERATIVE SURGERY ing, if it is solid wire, or by tying, if it is braided or cable wire. The double harelip can then be repaired or this can be done at a different sitting. The intermaxillary bone should not fit too far into the defect that exists between the anterior portions of the maxillary bones because it will pull the nose doAvn too low, and also because the intermaxillary bone will gradually be pressed further in after the double harelip is repaired. If there is a marked cleft of the alveolar process and hard palate in an infant with single harelip, an effort should be made to close the front of this cleft in a somewhat similar manner before repairing the harelip. The wire is inserted as has just been described and is twisted or tied while the margins of the cleft in the alveolar process are forced together by the hands of an assistant on each cheek. In this way the anterior part of a cleft in the hard palate can be brought together or greatly reduced, and a single wire suture thus placed will secure much of the benefit Avithout the added danger that is derived from multiple Avire sutures inserted farther back through the cleft. Fig. 136. — Lines of incision for double harelip. Fig. 137. — Double harelip operation completed ex- cept for insertion of additional sutures. Practically all double harelips can be repaired by a slight modification of the operation for single harelip. The only differences are that the margins of the lip on the intermaxillary bone are pared to make a broad wounded sur- face and an outward relaxation incision of about one-fourth inch is made from the angle formed by the meeting of the two incisions used for paring the mar- gins of the cleft, as has been described under single harelip (Fig. 136). In this way two flaps consisting of the vermilion border of the lip with the ad- jacent skin are. mobilized and can be readily sutured together just under that part of the lip on the intermaxillary bone. Fixation sutures are placed at each nostril and also at the points connecting the lower margins of the lip on the intermaxillary bone to the adjacent portions of the pared lip (Fig. 137). After repairing a double harelip in this manner the columna is markedly pulled down by the new position of the intermaxillary bone so that the tip of the nose is drawn forcibly down to near the level of the lip. There is a great FACE AND MOUTH im tcmi)ta1i()n 1o t'orrcL't this by an immediate operation on the cohnuiia. Blair, however, has caUed attention to the t'aet tliat the colnnma will gradually lengthen and release the tip of the nose and that such operations are usually unnecessary, particularly in infants. 138. — David R., ten months old. Photograph taken before operation. Pig. 139.— David R., shown in Fig. 138. Photo- graph taken four months after operation. The patient also hat' a complete cleft of the palate which was cured by operation. Fia 140. — Bessie H., three weeks of age. lip and complete cleft of palate. Hare- Fig. 141. — Same patient shown in Fig. 140. Photograph taken two years and seven months after the operation. Palate had also been closed by operation. No dressing is i)laced upon the wound which is merely dusted with boric acid powder. This becomes incorporated with the serum, hardens and forms a protective sealing. The tension on the harelip is largely taken up by the fixa- tion sutures and no appliance to relieve tension is necessary. The fine stitches 194 OPERATIVE SURGERY are removed after four or five days. The fixation sutures, however, should not be removed under seven or eight da3^s and unless the wound is quite firm maj^ be left even longer. While less scar from the stitches occurs if they are removed soon, the tissues need the support of the stitches and will stretcli unduly without them, so that the scar along the line of incision will be made more conspicuous if the fixation sutures are removed too soon (Figs. 138, 139, 140, 141, 142 and 148). There is much discussion as to the age at which harelips and cleft palates should be operated upon. A harelip should be corrected early. If the baby is vigorous it msLj be done even a few hours after birth. "When the baby is two or three weeks old, however, seems to be almost an ideal time. If a cleft palate extends through the alveolar process the anterior part should be cor- -Ilerbert T., age seven months, harelip and cleft palate. Double Fig. 143. — Same patient shown in Fig. 142. Photograph taken two years and three months after operation. rected at the same time the harelip is repaired. This will -greatly narrow the cleft. The rest of the cleft can be repaired from two to six months later if the patient is in good condition. None of these patients should be operated upon until their general health has been brought up as much as possible. The hare- lip patient should be examined a few months after the operation. Not infre- quently a slight irregularity of the lip will then be noticed, which was not ap- parent immediately after healing. The contraction in the line of the scar may be unduly great and may produce a slight notch or sometimes one side will pull up where it has been mobilized and elevate the vermilion border. All of these changes will occur within a few months after the operation and they can be readily remedied by a simple procedure which will make the lip practically nor- mal. If the mucosa of the lip has pulled up into the incision this can be cor- rected by the excision of a small, broad, diamond-shaped area, so planned and sutured that the excess of mucosa is removed and the margins of the skin FACE AND MOUTH 195 are brought together in siieli a manner as to make the vermilion l)order of the lip continuous and straight. The sutures used are fine arterial silk or horsehair. If the skin on one side has pulled up more than on the other, excision of the triangular redundant portion of the mucosa with a slight extension of the incision upward along the line of the old skin incision, and undercutting the skin in the neighborhood will enable the defect to be corrected by drawing the skin to its normal level. All these defects should be somewhat overcorrected. CLEFT PALATE The great majority of cleft palates can be repaired by adapting the flap sliding principle of plastic operations. This, the Langenbeck operation, has been developed and emphasized by Berry and Legg and by Blair who have ob- tained excellent results. It is particularly applicable in clefts with a high arch. It undoubtedly comes nearer returning tissue to their physiologic nor- mal than complicated plastic procedures in which flaps are inverted, such as the method of Lane. The anterior portion of a cleft in the hard palate in an infant or a young child should be closed or diminished as much as possible while the bones are soft by the insertion of a single wire suture as described under operations on harelip. If a harelip is present this wire is placed before repairing the harelip. The whole cleft in the bony palate, and particularly that in the front part, is greatly diminished by this single wire suture. It seems to accomplish most of the good that is obtained by the multiple wire sutures and is followed by less danger of necrosis than w^ien multiple wire sutures are applied. The operation of Lane in which a wide flap is taken from one side of the cleft with the hinge on the margin of the cleft and turned over and into a pocket made by dissecting up soft tissues on the opposite side of the cleft, at one time had many advocates. There are serious objections to this operation, how- ever. It exposes a large amount of raw surface and is, consequently, followed by extensive scar tissue. While union is more likely to occur after such an operation than after the flap sliding operation of Langenbeck as advocated by Berry and Legg, the late results are frequently unfortunate and the exces- sive scar tissue, while closing the actual cleft, probably functions but little better than would a rubber obturator. The late results of the Lane operation, at least in my hands, have not been satisfactory so far as obtaining good func- tional use of the soft palate is concerned. The difficulties in using the Langenbeck flap sliding operation are in cases with a low palate arch and those with a wide defect. In such instances, how- ever, as has been shown by Blair, much can be accomplished by making an in- cision in the hard palate just internal to the alveolar process, stripping up the mucoperiosteal flaps from the bone, and separating the attachment of the soft palate to the bony palate as though a complete palate operation would be done, but instead of paring the edges of the cleft and placing sutures, these in- cisions are packed with gauze saturated in ten per cent solution of colloidal 196 OPERATIVE SURGERY silver and stitched in place. After doing this Blair advocates operating four days later at which time there is a maximum amount of approximation of the flaps. If the operation is still further postponed shrinkage of the flaps will occur. Probably the best suture material for cleft palates is fine silver wire No. 29 or Xo. 30. This can be inserted with fine curved needles held in the tip of a hemostat or a small needle holder. If the needles are sharp the}' can be manipulated satisfactorily. The advantage of silver wire is that it is mildly antiseptic and so tends to prevent infection, which is the bane of cleft palate work, and also it can be very accurately adjusted. It is, of course, impossible to use coarser silver wire for such work, but the fine wire can be accurately twisted and if a suture appears too tight it can be relaxed, while if it is not tight enough it can be tightened by au extra twist. Mosquito forceps are very useful in this work. These and a sharp-pointed knife, together with a periosteal elevator, one end of which is bent at a right angle, are the chief instruments that are needed. The patient is placed with the head well back and in a good light. The tip of each half of the uvula is caught with a mosquito forceps. One side is held taut and with a sharp-pointed knife the mucosa at the front angle of the cleft, if it is not a complete cleft, is transfixed and a thin ribbon of tissue is cut off from this point to the tip of the uvula. The same procedure is repeated on the opposite side. An incision is then made just internal to the posterior portion of the alveolar process of the upper jaw. This hugs the alveolar proc- ess closely and is extended slightly around its posterior portion. In this manner the descending palatine artery is avoided and the nutrition of the flap, which is essential to successful union, is preserved (Fig. 144). A small peri- osteal elevator is inserted into the incision and the mucoperiosteal flap is raised. This is done as gently as possible so as to separate the tissues without too much injury to the flap. The tip of the elevator is pushed through to the cleft and is carried by a rocking motion, first forward and then backward to the soft palate. It is very important to separate the attachment of the soft palate to the bone of the hard palate. This is best accomplished with curved scissors, injury to the soft palate and the mucoperiosteal flap being -prevented by re- traction of this flap with a hook or with the tip of the finger. Division can also be made with the tip of a sharp knife which cuts from below upward. Some- times the division can be made by curved scissors through the relaxation in- cision. It is vital for the success of the operation that this attachment be thor- oughly separated. The suture.s are noAv placed, inserting the first suture about the point of junction between the soft palate and the mucoperiosteal portion of the hard palate. This suture of fine silver wire is not tied but the two ends are clamped and aid in exposing the margins of the cleft for further sutures. Tliree or four other sutures are placed in the soft palate and as many more anteriorly. They may be twisted as they are placed. At the tip of the uvula a suture is twisted and cut. Sometimes the sutures are more easily placed by having a needle on FACE AND MOUTH 197 eacli ciul. It is liiulily iinpoi'taiit that the sutures aj)pr()XLniatiiig the edges of the wound should not be under tension. If the general tension appears too great the original relaxation incision should be continued either forward or backward and the flaps more thoroughly mobilized (Fig. 145). It may occasionally be wise to insert one relaxation stitch in a large curved sharp needle about where the soft palate joins the mucoperiosteal portion of the hard palate. This should be of silver wire and twisted to one side of the wound. This suture is very infrequently required and diminishes the nutrition to the margins of the wound. The ends of the wire are cut and are left slightly protruding. In this way the wound, particularly in infants, will be protected from the tongue. The mouth should be systematically cleaned for some days before operation but it is doubtful if the application of any antiseptic at the time of operation is Fig. 144. — Lines of incision for relaxation in the operation for cleft palate. A ribbon of tissue is being cut from the margins of the cleft. 145. — Cleft palate operation completed. beneficial and it may be irritating. The anesthetic of ether is maintained by a curved metal tube, which is placed in the corner of the mouth while ether vapor is sprayed through the tube. This also has an antiseptic value. If the cleft is complete and the bones are too well developed for the anterior portion to be closed by a wire suture, this portion is left for a subsequent operation, because if too much is undertaken at first the nutrition of the flaps will be imperiled. After about four weeks the anterior portion of the cleft is repaired by turning over a limited flap after the general method of Lane. In this portion of the cleft, where the only function of the palate is to act as an obturator, there is not the same objection to the operation of Lane as in the posterior portion where muscular action is essential for the proper functioning of the palate. Here a pocket is created by undermining one side of the cleft from an incision along its edge. A flap is taken on the op- 198 OPERATIVE SURGERY posite side with its hinge along the margin of the cleft and is tiii'ned over and tucked into the pocket and fastened in position with sutures. If a cleft is so wide or the arch so low that the flap sliding method of Langenbeck cannot be applied, the Lane operation may be attempted. If the patient is an infant and the teeth have not erupted a wide flap can be obtained from the buccal mucosa and the alveolar process. In older patients with teeth, a flap from the anterior portion of the buccal surface of the cheek is impossible, but a flap may be turned down from the mucosa with a pedicle posterior to the alveolar process or, as practiced by Blair, a flap may be taken from the neck, carried into the mouth between the teeth, and fastened across the cleft. A permanent gag is placed between the teeth to prevent injury to the flap, and after a few weeks when the nutrition of the flap is established in the mouth the pedicle is severed. The cleft is closed by the transplant after a series of readjustment operations. THE LIPS Surgery of the lips consists largely of plastic surgery. Operations for congenital deformities have already been considered. Plastic operations on the lip may be for acquired deformities, either from accidental trauma or from removal of malignant disease. Operations for cancer should be planned (/^f^^ Fig. 146. — Eines of incision for repair of upper lip by method of Denonvilliers. Fig. 147. — Operation of Denonvilliers completed. primarily with a view to curing the cancer and the cosmetic effect should be a secondary and a different consideration. Halsted has observed that if the surgeon who operates for cancer did not attempt to close the de- fect, but left this for someone else, all temptation to leave conditions favor- able for a closure of the wound would be removed, more cancers would be cured, and plastic operations after removal of cancer would fall into the same general category as accidental trauma. The upper lip is rarely the site of malignant disease, whereas cancer of the lower lip is common, so reconstruction of the upper lip aside from con- genital deformity is called for usually on account of accidental trauma. A very satisfactory operation for reconstruction of the upper lip is that in which flaps are taken on each side, either extending upward with the base downward, according to the method of Denonvilliers, or extending downward with the base FACE AND MOUTH 199 upward cU'coi'din^u' to the method of Sedillot. The method of Denouvilliers consists of two vertical tiaps that are made through the full thickness of the cheek with the pedicle below (Figs. 146 and 147). The external incision ex- tends from the lower border of the jaw to the level of the ala of the nose and the internal border of the flap is the margin of the defect in the upper lip. A transverse cut is made to loosen the flap, which is turned down and sutured in the midline beneath the nose. The mucous membrane lining the flaps, must be arranged to form the vermilion border. The flap contains the whole thick- ness of the cheek. In the operation of Sedillot the flaps are reversed, taken Fig. 148. — Operation of Sedillot for repair of the upper lip. Fig. 149. — Lines of incision for repair of defect in upper lip by method of Abbe. Fig. ISO. — The flap from the lower lip has been turned into the defect in the upper lip, ac- cording to Abbe. The flap is kept in this position for about two weeks, when the pedicle is cut. Fig. 151. -The pedicle has been cut, and the oper- ation of Abbe completed. with the base above. These flaps are turned upw^ard and inward and the ver- milion border is made along the lower margins of the flaps (Fig. 148). The upper lip may be constructed from hair-bearing tissue by taking a long flap from the temporal region which includes the scalp and turning it down. A similar flap is taken from each side and the pedicle cut after the local nutri- tion seems to make the flap viable. In asymmetrical deformities of the upper lip, the general principles of plas- tic work, Avhich have already been discussed, can be applied. If there is too great contraction of the upper lip the method of Abbe may be utilized and a pedicle flap turned up from the lower lip. According to this method, the de- 200 OPERATIVE SURGERY feet in the upper lip is prepared and a flap from the lower lip with the pedicle on one side (as shown in the illustrations) is turned up and sutured in posi- tion. The lips are held together with sutures and the patient is fed through a tube for twelve or fourteen days, when the pedicle is cut. This is a very valuable method, particularly when the lower lip is someAvhat redundant (Figs. 149, 150 and 151). Gurdon Buck's operation involves the same prin- ciples, but a more extensive flap is taken, involving- probably a third or even half of the lower lip and including the angle of the mouth (Figs. 152 and 153). In any operation upon the lip, particularly upon the upper lip, it is neces- sary that the internal surface have a satisfactory lining, preferably of mucosa. If this is not possible a lining may be made with skin by a flap turned up from the neck. If the raw surface left within the mouth is verj^ extensive, contraction is sure to occur and so much scar tissue may involve the flap that a secondary operation will be necessary later. If possible, a flap of mucosa from the Fig. 152. — Lines of incision for the operation of Gurdon Buck in repair of the upper lip. Fig. 153. — Operation of Gurdon Buck completed. tissues in the neighborhood should be utilized to line the skin flaps. Contraction Avill be less marked in well-established tissue from which the mucosa flap is taken than in the raw surface of the new flap if left unprotected. The lower lip may be reconstructed from flaps in its neighborhood or from flaps from the arm. The lower lip is frequently the site of cancer and recon- structions are often necessitated by operations for this disease. The simplest method of removing cancer and reconstructing the lip after its removal is by the V-shaped excision. If the cancer is extensive this method cannot be used, but in man}' early cases of cancer the V-shaped excision is entirely satisfactory. Care is taken to keep a safe distance from the margins of the cancer. The cancer should be cauterized with a thermocautery just before the operation, in order to avoid the possibility of transplantation of cancer cells. The incision is made so the V will be deep and not too shallow (Figs. 154 and 155). This results not only in a more extensive removal of tissue, but at the same time the closure of the wound is more satisfactorv. The incisions are made FACE AND MOUTH 201 tlironiih the skin niul (lowii lo Ili(> imu'osa. Two llii-()U,L;li-jiiul-tlirou<;h sutures of silk\\()nn-<:ul ;ire inserted, one just below tlie veruiiliou border and one farther down. The lo()])s of the suture are held out of the way, the mucosa is quickly cut and Ihe lii) is approximated. In this way not only is bleeding lessened, as it can he controlled satisfactorily hy the sutures, hut there is a minimum exposure of the wounded surfaces to the secretions of the mouth. The rest of the incision is accurately approximated with interrupted sutures Fif 154. — \'-sIiaiiecl excision for cancer of the lower lip. Fig. 155. — V-shaped incision closed with sutures. of arterial silk or horsehair for the skin, and arterial silk for the mucosa. By making a transverse incision at each corner of the mouth, the V-shaped incis- ion can be applied in a much larger number of cases and this may be com- bined with the Burow-Stewart principle of excising a triangle of tissue down to the mucosa just above the angle of the mouth on each side (Fig. 108). In this manner a considerable portion of the lower lip can be removed with com- paratively little deformity. In extensive cancer of the lower lip the operation of J. Clarke Stewart is ■a ,*^~— ^ — (, ^ Fig. 156. — Lines ot incision for operation of Bruns in repair of lower lip. Fig. 1S7. — Operation of Cruns completed. excellent. The first incision is just below the jaw from one angle of the lower jaw to the other. The skin and platysma are dissected down and a block dis- section is made of the upper neck, including both submaxillary glands. This dissection is made from below upward. Incisions are then made on each side of the cancer at a sufficient distance from the growth and are carried down to the original transverse incision. The lateral flaps are freely dissected, from the jaw, keeping close to the skin at the lower part to avoid the lymphatics. 202 OPERATIVE SURGERY The cancer and the tissues of the block dissection of the neck are removed in one mass. If most of the lower lip is removed with the cancer, the mouth is broadened by a straight incision outward from each angle of the mouth, car- ried down to, but not through, the mucosa. A triangular incision is then made in the cheek just above the angle of the mouth (Fig. 108). This triangular in- cision goes down to the mucosa, but does not go through it. The mucosa is cut a half inch above the level of the lower lip and turned down to make a ver- milion border. The lateral flaps are brought forward and sutured together in the midline, suturing also the new chin to the soft tissues on the jaw to pro- tect the neck wound from the contents of the mouth. The lower lip may also be reconstructed by turning down flaps with the Fig. 158. — Lines of incision for operation of Estlander for repair of lower lip. Fig. 159. — Operation of Estlander completed. Fig. 160. — Lines of incision for operation of Dieffenbach in repair of lower lip. Fig. 161. — Operation of Dieffenbach completed. base below, the flaps so placed that the incisions to close them will lie in the fold running from the outer portion of the ala of the nose to the corner of the mouth (Figs. 156 and 157). The operation of Abbe or of Gurdon Buck for reconstruction of the upper lip can be reversed for the lower lip (Figs. 158 and 159). The principle of Dieffenbach which has been referred to in the chapter on plastic surgery can be applied here in securing two flaps, one from each side of the defect, and bring- ing them together in the midline (Figs. 160 and 161). This leaves a triangular raw surface at the outer portion of each flap, which can be taken up by sliding further flaps, by undermining and suturing, or by grafting skin. In complete absence of the lip a visor of skin may be turned up from the neck just below the chin and sutured in position (Fig. 162). This, however, FACE AND MOUTH 203 is likely to contract, thoiig'li this tendency may be lessened by nailing the flap to the jaw with small wire nails or brads and holding it in this position until it becomes firmly fixed. The operations of Sedillot may also l)e nscd in some cases (Figs. 163, 16-1: and 165). In extensive bnrns when the mucosa of the lip is not affected but where contraction is marked and scar tissue so abundant that no flap can be secured Fig. 162. — Lines of incision for "visor" operation in repair of lower lip, according to Viguerte-Morgan. in the neighborhood, the method of obtaining a flap from the arm offers a solution of the problem. This is the same principle that is known as the Italian method of reconstructing the nose. The flap is best taken with its base near the axilla and the incisions for it are carried around the arm so that the apex of Fig. 163. — Lines of incision for operation of Sedillot in repair of the lower lip. the flap lies in front and a little to the outer side of the elbow. Such a flap is well nourished, as it contains vessels that run in the general direction of the blood supply of this part and there is very little twist in the pedicle. If a flap is taken with the apex toward the axilla and base farther down the arm the nutrition is somewhat imperiled and a larger raw surface of the arm is kept in contact with the face than w^ould be with a flap having its base toward the axilla. The mouth is first prepared for the reception of the 204 OPERATIVE SURGERY flap by thorough excision of its scar tissue and the flap wliich will furnish ample skin covering is dissected with some underlying fat and sutured in posi- tion by interrupted sutures of fine silkworm-gut. The raw surface of the arm is covered Avith rubber protective, oiled silk, or some of the recent im- pervious transparent materials that are on the market. The arm is put over Fig. 164. — Lines of incision for second method of Sedillot in repair of the lower lip. Fig. 165. — Second metliod of Sedillot completed. the head after covering it with a flannel bandage and is fastened in position by plaster of Paris bandages which run over the head. The hair is protected by a rubber cap. It is unnecessary, as a rule, to put plaster of Paris around the Fig. 166. — Methoa of securing a flap from the arm for repair of lower lip. Photograph taken just before cutting the pedicle of the flap. Fig. 167. — Ultimate result after repair of lower lip following injury from burn in the patient that is shown in Fig. 166. neck, wiiich makes dressing the w^ound ditficult (Figs. 166 and 167). At the end of two weeks the pedicle is cut. The flap is undisturbed for about a month after the pedicle is cut and is then refashioned and smoothed to fit accurately FACE AND MOUTH 205 willi tlu' ;i(l,)(tiiiiiiii' tissues. Pai't iciilar rare is i)ai(l In llic Jiiiictiou of the fiap with the skill of the t'aet' in oihUm- that there may l)e no (h'i)ression along the line of union. The |)iMnc'ii)los for ])innent ing this hax'e heen discussed in the chapter on i'laslie Suri>ery. The nerve supply to these flaps in young patients develops rapidly and within two months from the time the transplant has been made sensation of pain and touch in the transplanted flap becomes perceptible. Fig. 168. — Lines of incision for operation of Montet in repair of angle of the mouth. In a lesion of the angle of the mouth in which both lips are affected the operation of Montet is applicable. He uses two quadrangular flaps, one from the cheek and the other from the chin with the base of each outward. The mar- gins of the flap, which are to form the edge of the lip, are lined with mucosa (Fig. 168). If the corner of the mouth is drawn uj^ward it may be corrected by an operation of the type of Sz^-monowski, in which a triangular flap is made with the base downward and the apex external to the ala of the nose (Figs. Fig. 169. — Lines of incision for the operation of Szymonowski for repair of the angle of the mouth. Fig. 170. — Operation of Szymonowski completed. 169 and 170) . This flap is turned into an incision just above the mucous border of the upper lip and so lowers the outer angle of the mouth. The method may also be used when the angle of the mouth is depressed. Here a triangular flap is made which includes the depressed angle of the mouth and this is trans- ferred into a horizontal external cut in the cheek (Figs. 171 and 172). The vermilion border of the lip can be restored by flaps of mucosa from within the mouth. These are sometimes taken from the inner sides of the up- per lip, turned down like a visor after the method of Schulten (Figs. 173, 206 OPERATIVE SURGERY 174 and 175), or if all of the vermilion border has not been destroyed the remaining portion can be dissected free as a flap and stretched to cover the defect (Figs. 176 and 177). In protrusion of the lower lip, when the mucosa is excessive an oval sec- tion may be taken from the mucosa near the point where it is reflected from the inferior maxillary bone and the wound sutured. This will remove the redun- Fig. 171. — Lines of incision for correction of downward contraction of the angle of the mouth. Fig. 172. — Completion of operation for correc- tion of downward displacement of angle of the mouth. dancy and leave no external scar. Contraction of the mouth is dealt with on the general principles of plastic surgery. Excision of the scar tissue, reserv- ing the mucosa if it is healthy, is an operation that can be done in most in- stances. The mucosa is used to form a vermilion border for the newly con- structed lip (Figs. 178 and 179). In severe burns both lips may be fashioned from the arm, as has already been mentioned. Defects of the cheek are remedied by flaps from the neighborhood when Fig. 173. — Lines of incision foi operation of Schulten for re- pair of mucosa of lower lip. Fig. 174. — Section showing lo- cation of flap taken from the upper lip. * 11 '''^" Fig. 175. — The flap, according to Schulten, has been sutured into position. The pedicles are cut ten days or two weeks later. the defect is not too great. It is necessary to provide an internal lining of either mucosa or skin. If the defect in the cheek also includes a bony defect in the lower jaw^ a flap may be turned up from the neck contain- ing a section of the clavicle; or a piece of rib may have been previously transplanted beneath the skin of the neck in such a position that it can be in- cluded in the flap and turned into the defect. Great care is taken during the dissection to prevent dislodging the attachments of the bone graft or FACE AND MOUTH 207 the section of (.'lavicle. AVlu'ii llic clavicle is used it is sawed to the depth of about oiu>-t'()urth of an incli on each side of the flap before the flap has been completely dissected free, and the bone is severed from the clavicle by a sharp chisel or fine saw. Holes are drilled in the two ends of the bone from the clavicle before it has been severed, protecting the under surface of the clavicle by a retractor slipped behind it to avoid injury to the deeper tissues if the drill should perforate the clavicle (Figs. 180, 181 and 182). It is best to keep the bone Fig. 176. — Lines of incision for repair of mu- cosa of lower lip according to the method of Nelaton and Ombredanne. 177. — Operation of Nelaton and Ombredanne completed. firmly fixed to the flap by clamps until it has been secured in the defect. It is fastened to the edges of the defect in the jaw bone with kangaroo tendon passed through drill holes. The skin flap is sufficiently long to turn over and protect the bone from the mouth. Defects of the cheek that cannot be corrected by sliding flaps from the neighborhood may be repaired by turning flaps up from the neck or by secur- ing flaps from the arm, or from the forehead. If flaps are taken from the neck they will necessarily be long and should be lined by mucosa or else doubled Fig. 178. — L,ines of incision for reconstruction of vermilion border of the lower lip. Tissues from "A" to "B" should be excised and the flap indicated by the lines of incision pulled down. This is the operation of Tripier. Fig. 179. — The vermilion border of the lower lip reconstructed according to the method of Tri- pier. over so as to have an epithelial lining on each side, or if this is impossible a flap may be turned into the mouth with the skin side inward and another flap used to cover the raw surface. If a flap from the neck is used, it being long and in. the reversed direction of the blood supply, gangrene may occur. It is best to separate the flap except at its extremities, as has been mentioned in the chapter on Plastic Surgery, "tube" the pedicle, and then gradually di- vide the end opposite the pedicle. This procedure may take several weeks, 208 OPERATIVE SURGERY but it will greatly develop the blood supply and will lessen the possibilities ol' sloughing. The flap can then be doubled on itself before being transplanted, so that it will be abundantly nourished when it is finally fit into the cheek (Figs. 183 and 184). ■ Fig. ISO.^Reconstruction of defect in the lower jaw by a pedicle flap including a portion of the clavicle. The flap is long enough to reach over the section of clavicle into the mouth and completely en- velopes the bone. Fig. 181. — I^ines of incision for repair of defect in the midline of lov.'^r jaw. A piece of rib has been previously grafted under the skin of the flap. Fig. 182. — The flap with its grafted bone is turned into the di^fect of the lower jaw. The skin is long enough to fold over the grafted bone. In defects in the upper part of the cheek in which there is no need for mucous lining, I have turned doAvn a flap from the forehead using the an- terior temporal artery as the pedicle. The defect is prepared and a flap of proper size is outlined on the forehead in such a way that it is supplied by the FACE AND MOTTTII 209 anterior temporal artery, wliieli is disseeted out aloii^' willi any adjoin in<^' veins and some surroundin-. ^_.--j^*- - ■ - "'■^■(t m ..^,-..:'^*^ H-LL. Fig. 191. — The late result of operation of Gillies for eversion of upper lid. Fig. 192. — I^ines of incision for the Wharton Jones operation for ectropion of the lower lid. Fig. 193. — The operation of Wharton Jones completed. Fig. 194. — Lines of incision for operation of Dieifenbach for ectropion of lower lid. Fig. 195. — Operation of Dieffenl.ach completed. same as has been described in the chapter on Plastic Surgery. In order to prevent infection from the secretions of the eye, it is necessary to keep the graft covered with moist saline gauze, which should be changed several times a day. FACE AND MOUTH 213 Gillies' iiiuls that wlieii the saw contraction oi' a lid is very superficial and all of the eorinni has not been destroyed, the nse of Thiersch <>'rarts may be siiecessful. The eyelid is mobilized and the scar dissected away (Figs. 185, 186, and 187), then the graft is applied to a mold of dental wax made to .;;yf -"-"'! -wi^t''r _-^ _ ^L-^:-^^-^" ^ Ul L. Fig. 19(1. — Lines of inci.sion for oiiciation of Knapp for repair of lower lid. Fig. 197. — Operation of Knapp completed. Fig. 198. — Operation of Monks for repair of lower lid. A flap is dissected from the forehead witli the temporal artery as pedicle. Fig. 199. — The flap is freed and caught with forceps, to be drawn, through a tunnel from the lower lid to the temporal artery. Fig. 200. — The operation of Monks completed. fit the defect, with the raw surface of the graft external (Fig. 188). The mold covered with the graft is fastened in the defect with sutures which catch the margins of the graft (Figs. 189 and 190). The sutures and the mold are removed in a week or ten days (Fig. 191). ^Surg., Gynec. & Obst., February, 1920, p. 133. 214 OPERATIVE SURGERY In all operations upon the eyelid the lids are sewed together after trimming the eyelashes, or a better plan still is to overcorrect the lids by overlapping them. If, for instance, the lower lid is to be operated upon, it may be folded over the upper and the sutures in its edge are fastened to the forehead hj adhesive plaster. This method has been made use of by a number of sur- geons to obtain overcorrection while the lid is healing. It is highly essential to overcorrect the lid in any plastic operation, because there is a tendency to contraction. If the whole skin graft cannot be used satisfactorily, the method of sliding flaps from the neighborhood must be considered. The operation to be selected de- pends to a large extent upon the character of the contraction. If the contrac- tion is linear or very limited the operation of Wharton Jones is excellent. Here a V-shaped incision is made, beginning at each extremity of the lower eyelid and uniting at an acute angle some distance below the lid. If the con- tracting band is in the midline or near a line of the incision it is thoroughly excised. The skin is well undermined along the margins of the incision and the wound is sutured, converting the V-shaped incision into a Y and so push- ing up the lower lid (Figs. 192 and 193). The method of Dieffenbach can also be used. This consists in taking a quadrangular flap whose upper end is about on the level of the normal upper border of the lower lid when the eye is closed, but external to the outer canthus of the eye. The base is below and inward. After excising the scar tissue or the growth below the eyelid, this flap is slid inward to replace the excised area and the triangular denuded area left by the graft is partly sutured and partly covered by a Thiersch graft (Figs. 194 and 195). A flap can also be taken with its base near the outer canthus and extending either downward or upward, or with its base near the inner canthus and extending downward. This flap may be turned into the raw surface left by excision of the scar tissue of the lower lid. The general principles of plastic operations as described under Plastic Surgery are followed here. A quadrangular flap may be slid according to the method of Knapp on a horizon- tal plane with the defect caused by excising the scar tissue of the lower lid (Figs. 196 and 197). If the deformity is confined to the lower lid and there is a redundancy of tissue in the upper lid a flap of skin may be turned down, visor-like, from the upper lid to the lower lid. Here a strip of skin is cut from the upper lid by two parallel incisions, which form a bridge of tissue attached at its two ends, one above the outer and one above the inner canthus of the eye. This bridge is turned down according to the method of Landolt to the lower lid and sutured in position. The method. of Monks consists in outlining the eyelid on the forehead and dissecting out a pedicle containing the anterior branch of the temporal artery and vein with some surrounding connective tissue. This flap is carried under a tunnel burrowed from the lower end of the incision, so the anterior temporal artery nourishes the reconstructed lower lid (Figs. 198, 199 and 200). As described on p. 209 I used the same principle in supplying a flap from the forehead for defects of the cheek. At the time I reported this I was unaware PACE AND MOUTH 215 tig. 201. — Operation of Gibson for repair of lower lid. A pocket is made for tlie reception of Thiersch graft. Fig. 202. — Thiersch graft is placed in position. Fig. 203. — The growth on the lower lid is excised. Fig. 204. — Ten days after the grafting the flap is dissected according to the method of Gibson and drawn over the defect in the lower lid. Fig. 205. — The operation of Gibson completed, 216 OPERATIVE SURGERY Fig. 206. — Lines of incision for operation of Sj'ndacker-Morax for repair of both lids. Fig. 207. — The pedicle has been sutured into position to the upper lid. Ten days later (A) the pedicle is cut and the lower portion of the flap turned into the defect of the lower lid. FACE AND MOUTH 217 of tlie oi^eration of ]\Ioiiks and iiiicoiisciously used the principle tliat he had established several years iirevionsly. On aeeount of defective venous circula- tion I have found this principle unsatisfactory in laroer flaps. Gibson uses a (|uadrilateral flap wliieh is best explained by the accompanying- Fig. 20S. — Deformity following a burn in a boy, J. M. Note marked eversion of both lids, par- ticularly on the right side. Fig 209— 11k lali.m -li ' 11 I u' 208. The mouth has been lepaued by pedieled flap from his arm. Both hds of the right eye have been freed, sutured together, and covered with a pedicled flap from the forearm, which was left in position about two weeks before the pedicle was cut. Fig. 210. — Patient shown in Fig. 209. The flap which covered both lids of the right eye has been split. The patient is shown with his eyes closed as tightly as possible to demonstrate lack of eversion. illustration (Fig. 201). A horizontal incision is made from the outer eantlius of the eye aud a Thiersch graft tucked iu (Fig. 202). This tissue is shaped into a quadrangular flap after the graft has taken and is slid inward to supply the defect 218 OPERATIVE SURGERY in the lower lid (Figs. 203, 204 and 205). Only the outer half of the lower lid can be reconstructed by this method. For the inner side of the lid a flap may be taken from the bridge of the nose and turned down. It must constantly be borne in mind that if the operation is for recon- struction of the lower lid, and not for correcting eversion, whole skin grafts cannot be used, for it is necessary to cover the raw surface next the eye with a Thiersch graft. This should be dene on a flap two weeks before the flap is Fig. 211. — Excision of V-shaped section of lower lid for senile ectropion. Operation of von Ammon. Fig. 212.— Lengthening the outer canthus of the Fig. 213.— Narrowing the outer canthus of the eye eye according to von Ammon-Agnew. according to Walthers. turned into its position. On account of the secretions of the eye it is difficult or impossible to graft the flap after it is in permanent position and if it is not thus covered contraction of the raw surface will interfere with the success of the operation. Flaps from a distance are obtained from the neck or from the arm. If from the neck, a long narrow flap is cut according to the method of Syndaeker- Morax, with the base about the mastoid region and the tip of the flap over the PACE AND MOUTH 219 sternoelaviciilar articulation (Figs. 206 and 207). As sneli a flap is long and narrow it would be safer to utilize the principle mentioned in the chapter on Plastic Surgery and first make a bridge of the tissue for the flap, "tube" the pedicle, and gradually cut the distal end so as firmly to establish the circula- tion. A pedicle flap from the arm may be obtained for the eyelids. It should be from the inner surface of the arm or from the inner surface of the forearm. Skin from these regions matches well with the eyelids and should be used when the whole skin graft is indicated. A pedicle flap from this region is taken with a broad base and with a flap large enough to have an abundance of tissue. The eyelids are denuded by dissecting away the connective tissue thor- oughly and sewing the lids together. If only the lower lid is everted a flap is sewed in this position, but if both lids are affected a large flap is made to cover Fig. 214. — Reconstruction of the eyebrow by turn- ing down a flap from the forehead. Fig. 215. — Reconstruction of the eyebrow by turn- ing down a flap from the temporal region. both lids (Figs. 208, 209 and 210). The pedicle is severed in about two weeks, after compression for an hour at a time for five days, and a week later the flap is split to make both upper and lower lids. The accompanying photo- graph shows this method after the pedicle has been cut and before the flap has been split to form the eyelids. In eversion of the eyelids which has existed for a long time, either as a result of cicatricial contraction or because of a paresis of the tissues as in senile ectropion, a V-shaped section of the lid should be removed. This in- cludes the conjunctiva and the tarsal cartilage, as well as the skin. The wound is sutured carefully with fine sutures of arterial silk, bringing the tissues into accurate approximation (Fig. 211). At the margin of the lid where there is the greatest strain it is wise to insert a somewhat stouter silk suture. This may be all that is necessary for atonic ectropion, but in ectropion from scar tissue contraction, it is only one step of the operation and should be followed by either a whole skin graft or a flap operation. Deformities that involve shortening or lengthening the palpebral opening can easily be corrected along the principles of plastic surgery. If the opening 220 OPERATIVE SURGERY is to be lengthened, the onter eantlius is split or a triangular area excised and the conjunctiva is sutured to the skin (Fig. 212). In shortening the pal- pebral tissue, a triangular area including the outer canthus, is denuded and sutured as a straight line (Fig. 213). In reconstruction of the eyebrows whole skin grafts may be used, taking the skin from some hairy region of the body as the pubes and transplanting Fig. 216. — Painful and contracted scar left after removal of an eye. (J. S. Davis.) ,'fl'.'''' u Fig. 217. — A flap dissected from the abdomen according to the method of J. S. Davis. it according to the technic of whole skin grafting, which has been described. A pedicle flap can be used by turning down a flap from the scalp (Fig. 214) with its base in the temporal region (Fig. 215), or, if the defect only involves one eyebrow and the other eyebrow is well developed, this eyebrow can be split to form a flap with its base on the bridge of the nose and the flap containing half PACE AND MOUTH 221 an eyebrow luriiccl over to the r(\uioii oi' the defect. A liairy flap should be shaved before it is transplanted. After extensive operations for cancer of the lids, involving the eye- ball, it is sometimes difficult to close the socket of the orbital cavity. The bone furnishes scant nutrition for the scar and frequentl}' the contraction and Fig. 218. — The abdominal flap has been sewed to the incision in the hand, and two weeks later the pedicle of the flap is cut and the hand transferred to the region of the eye. (Davis.) Fig. 219. — The painful scar in the eye socket has been removed and the flap on the hand sutured in posi- tion. Ten days later its connection with the hand is divided. {] . S. Davis.) 222 OPERATIVE SURGERY pulling on the surrounding tissue cause great deformity and pain (Fig. 216). After denuding the cavity a flap from the forehead may be turned into this de- feet, or the operation of J. S. Davis may be done. A flap of skin with a thick pad of fat from the abdomen (Fig. 217) is sutured into an incision in the palm of the hand. After about twelve days the attachment of this flap to the abdomen is severed and the hand containing the flap (Fig. 218) is trans- ferred to the region of the eye where the flap is sutured in position. "When its nutrition has been established in its new location its connection with the palm of the hand is severed (Fig. 219). EARS Deformities of the ear which consist of congenital enlargement or mal- position of the ear are comparatively easily corrected, but the construction of an ear when it is congenitally absent or when it has been removed by trauma is a very difficult and unsatisfactory procedure. Ears that stand out from \ r- ^ v/ ST- • 1 ^ ~ — ^ cf> ^^ / ,-^ \ / --'1 Fig. 220. — The operation of Monks for prominent ears. Fig. 221. — Operation of Luckett for prominent Fig. 122. — Method of reconstructing ears that are ears. too large. PACE AND MOUTH 223 tlie liead in iimisujil iiroiniiiaiiee ave reduced by the operation of Monks, in wliieli an elli]-)se of skin and snI)eutaneons tissue is removed from the back of tlie ear, and the skin ed.ucs of tlie wound are sutured togetlu'r (Fi<^'. 220). If c/ \'' y^y Fig. 223. — Lines of incision for the operation of Szymonowski for reconstruction of the ear. Fig. 224. — The flap is dissected up and folded on itself. Fig. 225. — Lines of incision at "A" and "B" shov outlines of flap. Fig. 226. — Flaps "A" and "B" are raised and the extremities of the new ear are brought for- ward. Fig. 227. — The flaps "\" and "B" are transferred posteriorly. the deformity is more extensive and the ears are large the operation of Luekett is more satisfactory. Here incisions are made in the posterior surface of the ear to remove a crescentic area of skin, and also a similar area of cartilage after undercutting the skin. Care is taken not to carry the incision through the 224 OPERATIVE ST'RGERY ear, so there will be no scar visible on the anterior surface of the ear. The carti- lage is sutured with interrupted sutures of catgut inserted somewhat like the Lembert intestinal sutures, turning the edges of the cartilage forward to form a ridge, which is usually absent in these large ears (Fig. 221). When the ear is unduly large it can be reduced by excision of a triangular area, which may be accompanied by excision of smaller triangles in order to reduce the size of the ear not only from above down'' ircl but from before backward (Fig. 222). The size of the lobule of the e. can be lessened by excision of a triangular area. Fig. 228. — Lines of incision for operation of Roberts for re- constructing the ear. Fig. 229. — Tlie flap is dis- sected up and folded upon itself. Lines of incision for construc- tion of lobe of the ear are shown. Fig. 230. — The lobe for the ear is dissected up and attached to the body of the ear. Complete reconstruction of an ear is difficult and unsatisfactory. The op- eration of Szymanowski has had considerable vogue. The incisions are made according to the illustration (Figs. 223, 224, 225, 226 and 227). If the hair is too abundant in this region the operation of Roberts may be used (Figs. 228, 229 and 230). Here a flap is raised, as shown in the illustrations, and the posterior part is folded back to give thickness and a rim for the ear. After this has taken, an independent flap is formed lower down to construct the lobule and is connected with the original flap. THE EXTERNAL NOSE Operations on the nose, like the surgery of other prominent portions of the face, consist largely of plastic operations, intended to correct defects, either congenital or resulting from disease or trauma. An occasional type of de- formity is that which unfortunately folloAvs the use of a paste in removal of malignant growths from the nose. These cancers can be removed much better and with less pain and resulting deformity by the electric cautery, but the superstitious dread of an operation wdll often cause a patient to suffer great agony and the conspicuous deformity which results from the paste rather than have the simpler, more effective, and less deforming operation. FACE AND MOUTH 225 Occasionally llicrr is a marked liypci'l I'opliy of llic skin of Hie nose result- ing froiii acne. 'Phis hypertrophy, wliieh is leriiied rhinophyma, is best reinox'ed by excision of the skin down lo the cai'tilasie. The finger is placed in the nosti'il to previ'iit injury to the carlilai^e and a clean excision is done. It is best to split the growth in the middle and remove it in two halves so that the outline of the cartilage can be readily distinguished, each half being dissected from the middle line. The raw surface is then grafted. In repair of small or partial defects of the ala of the nose, without ex- tensive sear tissue in the neighborhood, flaps can be taken from the skin in the region of the ala. If the defect consists of partial destruction of the ala with the edge of the ala drawn high up, it is best to take a flap from the margin of the defect after making an incision to lower the ala. This Fig. 231. Fi.a:. Fig. 231. — Lines of incision for operation of Dsmarch for reconstruction of ala of nose. Fig. 232. — The pedicled flap is turned into position. Ten days later the pedicle is severed. Fig. 233. — Operation of Fsmarch completed. Fig. 234. Fig. 235.- Fig. 234. — Lines of incision for operation of Dieffenbach for defect of ala of nose. Fig. 235. — Operation of Dieftenbach completed. can be done by the operation of Esmarch, in which a flap is taken from the nasolabial fold and turned up into either the defective ala (Figs. 231, 232 and 233), or better still into the incision by wdiich the ala has been shoved ^down. This usually leaves but little scar because the raw surface from which the flap is taken can be sutured to correspond -with the naso- labial fold. The principle of the Wharton Jones operation on the eye can sometimes be employed, making a V-shaped incision, shoving doAvn the edge of the ala and suturing the resulting wound as a Y (Figs. 234 and 235), Sometimes a flap of mucosa can be taken from the septum of the nose with its base at the tip of the nose. If considerable cartilage is destroyed, or if a large hole is left it will be 226 OPERATIVE SURGERT necessary to line the nasal surface of the flap with epithelium. This can sometimes be done by a flap of mucosa from the septum of the nose. I have done this with considerable satisfaction in a case in which there was a de- fect in the ala following the application of a paste. The procedure is shown in the accompanying illustrations (Figs. 236, 237, 238, 239, 240, and 241). This flap is turned into the defect and the pedicle is subsequently cut. This mucosa often matches the skin verv well. If the defect is large and there is Fig. 236. — Photograph showing defect in the nose caused by application of paste. Fig. 237. Fig. 238. Fig. 239. Fig. 240. Fig. 237. — Lines of incision for correcting defect shown in Fig. 235. Fig. 238. — The small bridge of tissue is cut away. Fig. 239. — A flap is formed, constituting the lower border of the ala. Fig. 240. — A flap from the mucosa of the .septum as indicated in Fig. 238 is turned into the wound. Fig. 241. — The pedicle to this flap is severed and the flap sutured into position. much surrounding scar tissue the skin flap is first raised and then covered with a Thiersch graft, or a flap from the skin along the margin of the defect is turned into the wound so that it hinges on one margin of the defect and is sutured with its raw surface outward to the other margin of the defect which has been previouslj^ freshened by cutting off a small ribbon of tissue with a sharp-pointed knife. Another flap is turned up from the nasolabial fold to cover the raw surface of the first flap. Sometimes with extensive scaring and sinking of this portion of the nose it is best to remove the scar tissue and skin FACE AND MOUTH 227 from tiie siiiikiMi jnirtioii of the nose that lies between the tip of the nose and the nasal bone, and transfer a flap from the forehead. As operations for defects resulting from cancer are usually done in elderh' people, great care must be exercised in making a flap with a long narrow pedicle. In securing a flap from the forehead the flap should first be outlined with its base near the bridge of the nose to include an angular artery. This flap ex- tends obliquely across the forehead and that portion which is to be used for reconstructive purposes should be as near the hair line as possible so that any undue scar on the forehead can be covered bv arrangement of the hair. This Fig. 242. — A flap from the forehead has been turned into a defect in the tip of the nose, which also resulted from the application of paste. The tip of this flap is being gradually severed. ISiote the in- cision on a level with the ej'e, through two-thirds of flap. Fig. 243. — Lines of incision for operation of Xela- ton for correction of defect of the ala. Fig. 244. — The operation of Nelaton completed. flap is dissected free except at its two extremities and tlie principle of gradual incision that has been already discussed (p. 178) is utilized. The part of the flap that is to be severed is cut by short incisions beginning about the fourth daj^ after the operation (Fig. 242), or else it is clamped for an hour at a time wdth soft clamps that will not injure the tissues, beginning about the fourth day after operation. In this way the blood supply is developed from the pedicle of the flap and its distal attachment can be completely severed in about twelve days. It is turned down with some periosteum and, if desired, small chips of attached bone, 228 OI'ERATIVE SURGERY wlii;:;li are removed from the skull with a chisel. It is sutured into the defect and after ten days or two weeks the pedicle is severed, cutting a third every two days, and returned to fill up as much of the defect in the forehead as possible. A flap to correct a defect in the ala can sometimes be taken with its base near the angle of the eye so that the incised wound will lie in the fold between the nose and the cheek (Figs. 243 and 244). The columna of the nose can be restored by taking a flap of skin from the tip of the nose and turning it down, or by the method of Lexer, who obtains a flap from the mucosa of the upper Fig. 245. Fig. 247. Fig. 245. — Lines of incision for the operation of Eexer for the restoration of the columna. Fig. 246. — A flap is taken from the mucous surface of the under lip, with the base toward the nose. Fig. 247. — The operation of Lexer completed. The flap is brought through the transverse incision in the lip and is attached by two sutures to the nose. 248 Fig. 249. Fig. 248. — Lines of incision for operation of J. S. Davis for restoration of the columna. Fig. 249. — The flaps outlined in the previous figure are turned into position. lip with its base at what would be the normal base of the columna. The lip is perforated at this point and the flap drawn through and sutured to the tip of the nose (Figs. 245, 246 and 247). The operation of J. S. Davis for restoring the columna consists in taking two quadrangular flaps from the upper portion of the upper lijD with their pedicles close to the midline near the anterior margin of the floor of the nose and with the free ends beyond the alae. The flaps are turned inward with the raw surfaces approximated to each other and the tips of the double flap attached FACE AND MOUTH 229 to the tip oC i\w nose (Fi^'s. 248 and 24!)). This opci'ation is only suited for individuals avIio have a very lonr lip. Recoustruetion of the nose in which all, or a major portion of the nose has been destroyed is au operation that requires skill and patience. Too frequently the illustrations, in order to show the steps of the operation, give the impression that it is comparatively easy and that the desired results can be obtained with one or two operations. This is far from true and unless any plastic operation upon the nose is well planned, skilfully executed, and followed by a number of minor operations for corrective purposes, the results will be unsatisfactory to the patient and somewhat humiliating to the surgeon. This is particularly true when operations are undertaken for reconstruction of practically the whole nose. Such plastic Avork necessarily is done by flaps, and flaps from the cheek while furnishing abundant material for partial defects are insufficient for all Fig. 250. — Lines of incisiuu for the oiJuiaUou of Languubcck for reconstruction of the nose. of such an extensive repair. The two practical methods are by securing a flap from the forehead, called the Indian method, or obtaining a flap from some dis- tant part, as the arm or neck, called the Italian method. Wherever the flap is obtained it should be carefully outlined, preferably with a pattern that can be cut from rubber dam, which is easily sterilized. The flap should be at least a third larger than appears necessary in order to allow for shrinkage. The Indian method, taking flaps from the forehead, has numerous modi- fications. The principle, however, is illustrated in operations such- as those of Langenbeck (Fig. 250) or Labat-Blasius (Figs. 251 and 252). In these opera- tions the base of the flap is so placed that it will secure the nutrition of the angular artery from the inner corner of the eyebrow and the flap is carried either straight up or to one side, depending somewhat upon the length of the nose and the character of the forehead. The flap should be so placed that the twisting to bring it in position will not be too great. It is best to outline a 230 OPERATIVE SURGERY columna in the flap. If the patient is old and there is reason to snspeet in- snffieient nntrition the flap can be first outlined and dissected free except at its pedicle and at its tip. Rubber tissue is carried beneath the flap, and the distal portion is gradually severed to develop a blood supply at the base, a prin- ciple that has already been emphasized. Some operators, as Lang-enbeck or Fig. 251. — Lines of incision for the operation of Labat-Blasius for reconstruction of the nose. Fig. 252. — Flaps outlined in the preceding illus- tration have been dissected and sutured to con- struct the alas of the nose. Labat-Blasius, prefer to construct the columna and the alse of the nose at the extremity of the flap about ten days or two weeks before turning down the flap so that the nostril has a lining of the tucked edges of the flap. If the bony framework of the nose has been destroyed it will be necessary to provide some cartilagenous or bony support. This is done preferably before the flap is turned down though it can be done after the soft tissues have been Fig. 253. — Lines of incision for operation of Keegan for reconstruction of the nose. placed. If it is done beforehand, a thin section of the skull may be chiseled up along with the flap. This is difficult of execution and it is even more difficult to prevent displacement of the bone from the flap. Such a flap, too, must be in- variably turned onto the raw surface of another flap having its epithelial surface internal and lining the cavity of the nose. It is an essential principle in any complete reconstruction operation on the FACE AND MOUTH 231 nose tliat tlie flap ^vitll which tlio nose is made nnist have an epithelial lining on its internal snrface. The older operations which did not provide for this were seldom satisfactory. Great improvement has been made in reconstruction of the nose by first lining the flaps with epithelium by Thiersch grafts, before they are put in position, or by turning in a pedicle flap from the cheek, and by forming a supporting frame work preferably by the insertion of strips of cartilage. If there is a small amount of tissue left at the bridge of the nose two flaps can be turned down according to the method of Keegan (Fig. 253) with their bases at the upper margin of the defect of the nose, or we may use the method of Thiersch, in which preliminary flaps are turned in from the cheek with the base of each flap hinging on the lateral margins of the defect (Fig. 254). This can be done at the same time that the frontal flap is turned in position so that both raw surfaces can be approximated, which will prevent infection and at the same time will be mutually helpful to both flaps in the Fig. 254. — Lines of incision for operation of Thiersch for reconstruction of the nose. blood supply. After turning the flaps in position they are sutured with inter- rupted fine silkworm-gut, horsehair, or silk. The pedicle of the frontal flap is cut in from ten to fourteen days. Eeconstructive operations under local anes- thesia should be done at intervals of a few weeks until a satisfactory result is obtained. The Ifolian method of obtaining flaps from the arm or neck has the advan- tage of not leaving a conspicuous scar on the forehead, but the disadvantage of causing considerable discomfort to the patient who is forced to keep the arm to the head for several da.vs. These flaps are outlined on the arm with the base near the elboAV. The arm is first placed on the head and the flap is marked out in such a manner that the arm can be held in as comfortable a position as possible after the flap has been applied to the nose. If the bony frame-work of the no.se is lacking it is best to transplant cartilage under the flap and dissect the flap partly free three or four weeks before the flap is applied to the nose. The flap can be taken from the forearm. Israel recom- mends a flap from the forearm with the pedicle up and the tip near the lower end of the ulna (Fig. 255). He removes the subjacent portion of the ulna bone, taking a strip of the ulna one-third of an inch wide by about two and one-half 232 OPERATIVE SURGERY inches long-. This is remoA^ed with a fine saw in order not to fracture the iihia. The skin tlap with the ulna attached is first outlined and the bone is separated except at its upper end which is left attached for about nine days. The nose is modeled as well as possible on the forearm and about twelve days after the graft from the ulna has been separated the flap is sutured to the nose, the arm being held in position for two weeks (Fig. 256). The flaps from the arm for complete reconstruction of the nose, like those from the forehead, should contain cartilage, if bone is not provided for as in the method of Israel. The cartilage is inserted between the skin and the deeper layers of fat and is permitted to stay in this position for at least two or three weeks before attempting to outline the flap or suture it to the nose. Carti- lage appears to be much better than bone, as it can be molded satisfactorily and unlike bone does not tend to atrophy and absorb. Cartilage is obtained from the costal cartilages. Fig. 255. — Lines of incision for operation of Israel for reconstruction of the nose by a flap from the forearm. Fig. 256. — The flap from the forearm has been dissected free and is sutured into position on the face. Mandry has suggested a flap from the neck which includes a portion of the clavicle. A few operations have been done in w^hich the finger has been used as a substitute for the nose. Davis- says: ''I have noted that a surgeon seldom re- ports more than one case operated upon by this method. This may be due to the fact that only one patient requiring this kind of operation has come under his care, but my feeling is that it is unnecessary to lose a finger when better results can be olrtained by other methods." If this operation is done the tech- nic of Baldwin appears to give the best results. Baldwin uses the ring finger of the left hand, which is split in the midline on the palmar surface, and trans- verse incisions are made at the level of the nail and at the base of the finger (Fig. 257). The tip of the finger including the nail and its matrix is removed aplastic Surgery, by Davis, J. S. Philadelphia, P. Elakiston's Son & Co., p. 467. FACE AND MOUTH 233 aiul the fin level of the secoiul iii)])er molar tooth, the pedicle of the flap being beliiud (Fig. 282). A closed curved hemostatic forceps is introduced througli the external incision, burrows forward close to tlie surface of the mas- seter muscles, and is forced into the mouth just in front of the pedicle of mu- cosa. The forceps is opened to dilate the tunnel and the end of the flap is grasped, pulled through the tunnel and fastened into the posterior edge of the incision into the fascia of the parotid gland with a fine chromic catgut suture. This suture is passed like the Lembert intestinal suture to tuck the end of the mucosa under the incised parotid fascia. The ends of this suture are left long. A mosquito forceps is then passed into the external wound and through the tunnel into the mouth, and seizes the middle of a strand of No. 5 chromic cat- gut, which is pulled through the wound and tied with the long ends of the fine catgut suture so as to have the ends of the stout chromic catgut in the mouth i«H| BIHM B' ^1 ■r / ^ ^ ^! f^, . Hele^ Lc)-t'-/3 ) -T^ G . Fig. 281. — Operation of Grouse for closure of salivaiy fistula of the parotid. The first incision has been made and the forceps are tunneling the tissue. (Fig. 283). This makes the flap of mucosa assume a tubular shape around the stout chromic catgut. The external wound is closed in the usual way for skin incisions. Tumors of the parotid may be small, round, and rather movable, or may be of a malignant infiltrating nature. The small movable tumors can usually be readily excised through a transverse incision through the skin and fascia par- allel with the direction of the branches of the facial nerve. This incision is carefully carried flown to the tumor and constant watch is kept for any branches of the facial nerve, not only watching for the fibers but noticing any contraction of the muscles of the face. Any suspicious strand is gently seized with a del- icate forceps to test whether it will be followed b}^ contraction of the facial muscles before it is cut. This, of course, should be carefully done because a rough handling of the branches of the facial nerve may result in their perma- 242 OPERATIVE SURGERY nent injury. "When the capsule of the tumor is readied the tumor can usually be enucleated by blunt dissection Avith curved scissors, introducing the closed scissors close to the tumor and spreading them open after they have been intro- duced. This Avill gradually stretch the tissues and permit the enucleation of the growth. Bleeding points are seized with mosquito forceps and tied with fine catgut. Tlie fascia should receive a separate row of catgut sutures before Fig. 282. — The pedicle of a flap of mucosa is formed from within the mouth. Fig. 283. — The pedicle of mucosa with its base backward has Deen orougnt luiougn with the forceps from the external incision and is fastened into the parotid gland. closing the skin. If for any reason the oozing cannot be controlled the wound is packed with gauze for five or ten minutes, the gauze removed and the wound closed. It may be necessary to insert a fine drain into the cavity left by the removing of the growth, but it is best to avoid this if possible because it may leave a point of dimpling in the scar or be followed by a parotid fistula. If the tumor is large and cannot be removed by an incision immediately FACE AND MOUTH 243 over it without makiii.u- tlio incision so lou^i' as lo ciulaii^'or the branches of the facial nerve, it can be approached by an incision nnder the angle of the jaw, which begins abont the tip of tlie mastoid process, runs down to the level of the angle of the jaw, and then forward and slightly upward. Tlie skin and superficial fascia are turned up in the form of a flap. The tumor in this way is approached from below and if it does not present readily at this point an incision is made into the gland substance over the tumor. This incision into the parotid should be transverse, in the general direction of the branches of the facial nerve. If tlie tumor is solid and the capsule strong it may be enucleated by blunt dissec- tion, but if it is friable with a weak capsule and contains semisolid material the contents of the capsule is removed, piecemeal. The tumor should be attacked first along the anterior border, then the posterior, the dissection being car- ried from below upward. If fragments of the tumor are left behind they can be touelied with the fine point of an electric cautery, though the burning should be made with caution to avoid injury to the facial nerve. The cav- ity left by the removel of a large tumor will require drainage. If sutures are necessary to check bleeding they should be of fine plain catgut so they will be readily absorbed. In malignant growths of the parotid it is necessary to remove the entire gland along with the facial nerve. The patient should always be informed be- fore the operation of the necessity of causing a facial paralysis on the side of the face in which the tumor is located. It is often necessary to dissect out the glands of the neck when a malignant growth of the parotid is re- moved, and if this is to be done the incision for removal of the parotid is so modified as to afford an ample exposure for a block dissection of either the upper portion of the neck or the whole side of the neck, according to the indications. In malignancy- in the parotid, as in malignancy elsewhere, the incision should be so shaped as to enable the operator to remove the gland and its sur- rounding tissues in one mass. The chief aim to be kept in mind is to cure the cancer. A straight incision is made from the zygoma just in front of the ear, downward over the anterior border of the sternomastoid muscle. If it is in- tended to dissect the upper triangle of the neck at the same time an incision is carried beneath the border of the jaw to the midline of the neck about one inch below- the chin. The technic of block dissection of the neck is discussed in the succeeding chapters. If the malignant growth in the parotid appears to be attached to the skin the first incision should be made at a safe distance from this point and another incision should circumscribe this area in such a manner as not to touch the tis- sues at this point. The lower end of the cut over the sternomastoid muscle is deep- ened until the external carotid artery is exposed. This artery is ligated a short distance above the superior thyroid branch. It is best to put another ligature on the external carotid just above the facial branch and to tie the facial, the lingual and the posterior occipital branches if they can be . readily exposed. This not only decreases the bleeding, but on the principle of starvation of ma- licrnant o-powths as advocated by Dawbarn, it may somewhat retard the ten- 244 OPERATIVE SURGERY dency of reciirreuce of the cancer. The edges of the wound are then thoroughly undercut to expose the parotid and its contained growtli as full}' as possihle. If the dissection of the parotid is undertaken with a cutting electric cautery that has a stout enough hlade to allow some pressure the operation will be greatly facilitated. The parotid can then he readily enucleated with the red hot cau- tery by dissecting from before backward. The cautery follows readily the line of cleavage, lessens the bleeding, destroys cancer cells in its way, and closes the lymphatics which might otherwise take up cancer cells. AVhen the temporal vessels are reached they are doubly clamped and divided with the cautery. After getting well under the parotid growth from in front and above, the cau- tery is pushed posteriorly, hugging the capsule of the parotid fairly closely, but taking care not to enter the capsule. The dissection is then carried down to Fig. JS4. — The operation of Sedillot for excision of tlie tongue. the neck and the external carotid is again clamped and tied just below the parotid and the parotid gland and tumor are cut away with the cautery. Care should be taken in this latter step not to 'svound the internal jugular vein. If a complete block dissection of the neck is necessary the incision extends from the zygcma downward over the anterior border of the sternomastoid mus- cle and terminates in front of the sternoclavicular joint. The dissection is made from below upward and the parotid gland is dissected cut along with the mass of tissue from the neck in the manner that has just been described. The wound is closed, placing a drainage tube through a stab wound or at the lower angle of the incision, for drainage should always be used after every extensive opera- tion for cancer. FACE AND MOUTH 245 THE TONGUE In operations on the ton an* many different operations for removal of the toiif^'ue. Thai iiictliod should be chosen wliicli a])p(>ars to lend itself best to the purposes of a bk)ek dissection not oidy of the tongue and its adjacent tis- sues but of the tissues of the neck. Dissection of the tongue with electric cau- tery is always done wherever possible, particularly in cancerous affections, not only because it lessens bleeding but because it diminishes the chances of recur- Fig. 2S7. — The incision has been continued to the cavity of the mouth, the flap has been reflected, and excision of the tongue is being completed. (Ashhurst.) rence. If there is an ulcerated lesion it should be thoroughly cauterized as the first step in the operation in order to prevent implantation of cancer cells. The question of anesthesia in these cases is highly important. If the cau- tery is to be employed it is dangerous to use ether about the face. The rectal anesthesia of Gwathmey is excellent here. A malignant lesion that is sufficient to demand excision of the tongue will also require dissection of the neck. It is best to do this first as it enables the surgeon to control the blood supply of the tongue by ligating the lingual or the external carotid artery, and at the 248 OPERATIVE SURGERY same time it subjects the patient to the dangers of inlialation pneumonia during only that portion of the operation in whicli the mouth cavit}' is entered to re- move the tongue. According to the method of Sedillot, a median incision is made in the lower lip, chin and neck as far down as the hyoid bone. The lower jaw is divided with a saw in the midline and the two halves of the jaw are pulled apart. The tongue is pulled out with a tractor suture and the mucosa in the floor of the mouth is divided from before backward (Fig. 284). If the lingual artery has not been previously tied during the neck dissection it is recognized as lying be- tween the hyogiossus and genioglossus muscles and is clamped and tied. The hyoglossus and mucosa behind it are divided with cautery while making trac- tion on the tongue. If the disease extends to the palate or pharynx the affected tissue in this neighborhood is excised in one mass if possible. The base of the tongue is divided, preferably with a cautery, taking care to preserve as much muscle and as many nerves as possible so as not to interfere too greatly with deglutition, but at the same time going a reasonable distance from the cancer. The bone is drilled and wired together. The patient is kept in the Trendelen- burg position until he is able to sit up. The operation of A. P. C. Ashhurst is designed to combine a block dissec- tion of the neck with excision of tlie tongue. An incision is first made from the chin downward to the hj'oid bone and then backward to the tip of the mastoid process (Fig. 285). The lower edge is retracted and the upper portion of the neck is cleared with a block dissection from below upward leaving the tissues attached to the upper skin flap. The dissection extends from below the bifur- cation of the common carotid to the floor of the mouth. It reaches the muscles of the neck and the hypoglossal and superior laryngeal nerves (Fig. 286). The neck wound is packed with gauze and the anterior end of the incision is prolonged through the midline of the lower lip into the mouth. This forms a flap which is dissected backward, so exposing the tongue. The tissue of the block dissection of the neck is then cut away from this flap. The tongue is held forward by a tractor suture. The mucous membrane between the lip and the lower jaw is divided with scissors or cautery from before backward. The masseter muscle is not cut. Another tractor suture is now passed through the glosso-epiglottidean fold, which facilitates drawing the tongue forward. The frenum of the tongue is divided and the dissection continued backward on the other side of the tongue, separating the tongue from the floor of the mouth, first on the side opposite to the disease and then on the diseased side (Fig. 287). The anterior pillow of the fauces is divided on both sides, the tongue is draAvn well out. It is cut across at its ba^e at least three-fourths of an inch beyond the visible signs of cancer on the diseased side and then on the health}^ side backward along the floor of the mouth to the transverse section of the diseased side. The lingual artery on the healthy side is watched for and caught. The tongue is then completely cut across and the stump of the tongue is sutured to the mucosa that may still be remaining on the inner side of the alveolar process of the lower jaw or from the inner side of the cheek. "Wherever possible the FACK AND MOUTH 249 raw sui'fai'O is roveri'd by niiu'o.sa. After tlie eonipletion of the operation a few buried sutures attaeli the cheek to the body of the jaw. The skin wound is accurately closed and a i-ubber drainage tube is inserted at the most dependent portion of the external ineisioii. Ashhurst'^ advises the removal of all the molar teetli on llie diseased side of the tongue before the wound is sutured as well as the (.'orresponding alveolar process of the lower jaw if it seems at all likely that this has been affected by the cancer. The method of excision of the tongue practiced by Blair'^ is well conceived and will probably replace other operations for advanced cancer of the tongue. M .^^mmm.'. V P .^^^^m" 1 I t >- ^--.. v^nMl ^ -%-'. ' He\e-T^ loorxainne 2.0 Fig. 288.- -Line of incision in operation of \. P. Blair for excision of tongue in advanced cancer. A tracheotomy had been done several days previously. He advises a low tracheotomy, preferably done under local anesthesia one or two days before the operation on the tongue (Fig. 288). The incision begins behind the angle of the jaw, curves do\\aiward to just below the lower border of the hj'oid bone in the midline, and is carried upward behind the angle of the jaw on the other side of the neck to a point corresponding with its begin- ning. The incision is carried through the platysma muscle and the npper flap, consisting of skin and platysma, is dissected from the deep cervical fascia to the lower border of the jaAv. The facial vessels at the lower border of the jaw ^Ashhurst, A. P. C: Ann. Surg.. 1915. Ixii, 238-245. ^Blair, V. P.: Surg., Gynec. & Obst., February, 1920, pp. 149-153. 250 OPERATIVE SURGERY are doubly clamped and divided. The facial vein is doubly clamped and divided on the level with the skin incision. The submaxillary gland is drawn upward and the facial arterj^ is doubly clamped and divided just as it enters the gland and as far as possible from its origin (Fig. 289). The artery is tied and the branches within half an inch of its end are also tied. Blair thinks it is impor- tant to leave a long stump of the facial artery with its branches ligated in order Fig. 289. — The dissection of the neck is begun and the facial vessels are doubly clamped and divided. to prevent secondary hemorrhage. The submaxillary gland with its surrounding tissue is dissected out. Behind the upper and outer part of the digastric ten- don the fibers of the hyoglossus muscle are separated bluntly and the lingual artery is exposed and tied. The submaxillary gland with its surrounding tissue having been removed on each side and the blood controlled, the muscles beneath the symphysis are divided with a sharp electric cautery. The periosteum and mu- cous membrane are stripped from the inner surface of the jaw and the cancer, if an ulcer, is thoroughly cauterized. The tongue is drawn through the open- FACE AND MOUTH 151 por- The iiig beneath tlie symphysis of the lower jaw. This exposes the pharynx. The tongue is severed Avith an electric cauterj- at the hyoid bone. The lower tion of each parotid gland is also removed, preferably with the canter5^ lower border of the digastric muscle on each side is sutured to the sterno- mastoid muscle witli fine tanned catgut. The stumps of the facial artery are left standing out fi'eo into the pharynx. By having a long stump and tying Fig. 290. — Operation of Blair completed, except suturing the wound. the little branches there is rarely secondary bleeding from the facial (Fig. 290). For feeding purposes a catheter is passed through one nostril into the pharynx and fastened to the upper lip by adhesive plaster or a suture. This is done before the wound is closed as the larynx drops back after the operation and makes it more difficult to pass the catheter into the esophagus. The wound is closed with silkworm-gut. The tracheotomj^ tube is left in for a week or ten days until danger of edema of the larynx is passed. The day before its removal it is plugged with a cork to test whether the patient can breathe satisfactorily through the larvnx. 252 OPERATIVE SURGERY UPPER JAW If a growlli is IJiniU'd to the alveolar proeess it may be removed by first cutting- the mucosa and stripping it back to the point at which the section of the bone is to be made. The bone is removed by a small sharp chisel or a small finger saw, Schlange's method is to drive several gouges in the proposed line of re- section of the alveolus and leave them in position to control hemorrliage until the last gouge is driven in to separate the final attachment. Then the wound is quickly packed. If a solution of epinephrin is injected into the mucosa be- fore the incision is made the bleeding is greatly diminished and the operation is facilitated. Fig. 291. — lanes of incision for operation of Weber for excision of upper jaw. Excision of the upper jaw is done for malignant tumors. A number of incisions have been devised as it was a standard operation of preantiseptic days. Probably the most satisfactory incision for excision of the upper jaw is Weber's, This begins at the inner canthus of the eye, goes downward in the groove be- tween the nose and cheek, skirts the ala of the nose, curves inward to the mid- line of the upper lip and divides the upper lip vertically (Fig. 291). From the upper extremity of the incision a slightly curved cut is made outward following the lower margin of the orbit. The flap is reflected outward and the superior maxillary bone is exposed. Unless the indications of the operation demand it, it is best to leave the orbital plate of the superior maxillae, but if this cannot be safely preserved the periosteum should be stripped up and the orbital contents lifted gently upAvard and outward with a retractor. The FACE AND lAIOUTH 253 malar bone is dixidcd with roi'('('])s oi- a wire saw, and tlion tlic nasal and orl)i- tal processes of the snix'rioi- maxilla arc (li^■id('d 1', SKULL, AND BRAIN 269 Acllicsioiis hctwccii the t'oi-tcx of the hriiiii lo liic tlura, oi', if llie dura is desti'oy(Ml, to tlu> structures ovorlyiu<>' the brain, are responsible for many cases of foeal epilepsy. Mereh' separating these adhesions and suturing the tissues does only temporary good. The}' will almost certainly re-form and the trauma of the operation may even add to their extent. The problem is some- what ditt'erent from that in the abdomen when the separation of adhesions is sometimes accompanied by removal of the cause of the adhesions, or at least by the opportunit}' to cover the two opposing raw surfaces with peritoneum. The mobility of the abdominal viscera also aids in the prevention of adhesions. The complicated tissues of the brain have poor regenerative powers and the cortical cells and their dendrites never regenerate. All of these things greatly favor not only the formation of scar tissue after any injury to the l)rain but the adhesions of the cortex of the brain to its overlying tissue. Fig. 302. — Lines of incision for operation for exposure of the dura and brain after an old depressed fracture. The adhesions may be from the arachnoid or the piamater to the dura. Naturally the physiologic expansion and contraction of the brain makes such adhesions a source of considerable irritation and in individuals who are predis- posed to convulsive seizures epilepsy may occur. The methods of preventing adhesions of the cortex of the brain to the dura have been numerous. Most of them unfortunately have not been consid- ered from a biologic viewpoint, but solely mechanically. It has apparently been conceived in some instances that if a piece of rubber tissue, or a strip of celluloid, or a gold or silver leaf would prevent two objects from touching each other, the same method would prevent adhesions of the brain to its over- lying structures. As a rule, the interposition of foreign material between the cortex of the brain and the dura and its overlying tissues means not a preven- tion but an increase of adhesions. It maj^ for a time be physically impossible for adhesions to penetrate the center of this foreign material and there are some foreign substances that are less irritating than others. The logical out- 270 OPERATIVE SURGERY come of these procedures, however, can easily be anticipated by anyone who has followed a small amount of experimental work in burying foreign sub- stances in any portion of the body. If the foreign substance is absorbable and no infection occurs, it may be absorbed if not too large, and its place is usually taken by organized connective tissue. If it is nonabsorbable, as gold or silver leaf, rubber tissue or celluloid, nature tends to encapsulate the material and adhesions are formed around the edge of the foreign substance. The contrac- tion of the adhesions not infrequently results in the crumpling up of the foreign substance until it may be broken into smaller pieces or rolled up in a Fig. 303. — The adherent dura and tissues have been removed and the brain is exposed. A flap of scalp and a flap of pericranium witli some bone attached are mobilized. mass. Anyone who has seen a sponge or a piece of gauze accidently left in the abdominal cavity and removed weeks or months later can draw a very good mental picture of what happens in a smaller way when foreign substances are left on the cortex of the brain. The transplantation of fascia or muscle over the denuded cortex is followed by adhesions. The only substance which seems to give satisfactory results that justify transplantation of tissue is fat, which has been employed successfully by Lexer, Dean Lewis, and others. This may be obtained either from the abdomen or from the thigh. A satisfactory flap can be removed from the fascia of the thigh, taking SCALP, SKULL, AND BRAIN 271 a coating of fat on the fascia lata and transplanting the fat and fascia to the brain, placing the fat next to tlie cortex. The fascia is united to the edges of the dura by a few catgut sutures. It is best to split the dura in several di- rections and to insinuate the edges of the fat under the edges of the dura. It is highly important in such cases to remove sufficient bone from the skull so that the replacement of an osteoplastic flap will not produce too much pressure upon the fatty transplant, which is normally much thicker than the dura (Figs. 302, 303, 304 and 305). In performing such operations the lesion is usually indicated by the scar on the scalp and it is best so to shape the flaps of scalp as to enable the operator Fig. 304. — A fatty fascia flap from the thigh has Ijeen sutured over the defect in the dura. to excise the scar in the scalp and to enter the skull on the margin of the supposed area of adhesion and not in its center. The skull immediately over these adhesions, if the area is not too extensive, should be removed entirely, so when the scalp is replaced there is no bone over the fatty flap to produce compression. In three cases of epilepsy following trauma to the skull and brain I have used this method of transplanting a fatty fascia flap. Two of these patients have so far made a very satisfactory recovery. The third has been considerably benefited, but is not cured. It may be that the operation in this instance merely produced a temporary alleviation. In one of the two cases in which the result 172 OPERATIVE SURGERY was considered satisfactory the patient liad been previously operated upon for general epilepsy elsewhere and a large osteoplastic flap had been turned down over the motor area. For several years he appeared to be relieved of his epilepsy, but later began having convulsive seizures of his left forearm and hand. These were not accompanied by unconsciousness. They would recur at intervals of fifteen minutes to half an hour. Operation showed marked adhe- sions of the piamater and arachnoid and of the cortex of the brain to the dura Fig. 305. — The flap of pericranium is transferred over the fatty fascia graft. over the arm and hand center. Elsewhere the cortex of the brain appeared to be normal and nonadherent. The adhesions were divided wath a sharp knife and a fatty fascia transplant was made with the fat next to the surface of the brain. The arm and hand were paralyzed for several days and then weak mo- tion began and finally the motion appeared about normal. When last heard from about two years after the operation, the patient had had no further con- vulsive seizures in his arm and hand and the motion had returned satisfactorily. OPERATIONS FOR HYDROCEPHALUS Many years ago, Hilton, in "Eest and Pain," stated that hydrocephalus was due to obstruction of the outlet of the cerebrospinal fluid from the brain. Recent research seems to emphasize Hilton's views. SCALP, SKULL, AND BRAIN 273 The cerebrospinal tiiiid coiiu's from tlie choroid plexus. About three-fourths of the choroid i)lexus lies in the two lateral ventricles, the third and fourth ven- tricles containing the remaining fourth. The cerebrospinal fluid makes its way through the aqueduct of Sylvius to the fourth ventricle, through the foramina of Luschka and Magendie to the subarachnoid space. Absorption of the cerebro- spinal fluid is practically entirely from the subarachnoid space. The existence of fanciful stomata and the absorptive powers of the pacchionian bodies have been disproved. Normal absorption of cerebrospinal fluid takes place slowly by osmosis through the membrane of the subarachnoid space. The subdural space has but little absorptive capacity. The communication bef-ween the fluids of the ventricles and the subarachnoid spaces normally exists only through the fourth ventricle and the foramina of Luschka and Magendie. In the absence of these normal openings this communication can apparently be satisfactorih' main- tained only through openings made in this region. Operations for hydrocephalus that are designed to cause absorption of the cerebrospinal fluid by transferring it to other portions of the body cannot in the nature of things be successful. The only benefit is the temporary reduc- tion of pressure by removing the cerebrospinal fluid during the operation and the decompressive effect of removal of a portion of the skull. It is Avell known that forced absorption of fluid in tissues of the bodj^ as illustrated by a continuous hypodermoclysis of salt solution is temporary. The blockage of lymphatics in the region of the hypodermoclysis produces such a condition in the tissues that but little fluid is absorbed after a few^ days and that only under great pressure. If sufficient pressure existed within the ventricles of the brain to force the absorption of the cerebrospinal fluid after it has been conducted into the tissues of the neck, scalp or chest, the pressure itself would cause de- struction of the brain. Operations for creating a channel between the ventri- cles of the brain and the sinuses of the dura sooner or later result in closure of ■ the channel. Hydrocephalus should be differentiated from acute inflammation of the brain in which there is an exudate from va[rious tissues. This exudate ceases when the irritation of inflammation or trauma has subsided. For practical pur- poses it may be said that there is only one type of hydrocephalus, the obstructive form. The obstruction may exist along the aqueduct of Sylvius or in the roof of the fourth ventricle or in the subarachnoid space, which permits only a limited amount of absorption of cerebrospinal fluid, but is not a complete blockage as would be in obstruction of the aqueduct of Sjdvius. In the form of obstructive hydrocephalus in which the obstruction is located at some dis- tance from the fourth ventricle, the fluid communicates with this limited area of subarachnoid space and with the spinal cord. It can readily be seen, then, that an operation which merely conducts the cerebrospinal fluid into tissues of the scalp or neck cannot succeed for reasons that have been mentioned. Operations such as puncture of the corpus callosum merely transfer the cerebrospinal fluid from the ventricles of the brain to the subdural space where almost no absorption takes place, the cerebrospinal fluid 274 OPERATIVE SURGERY being absorbed from the subarachnoid space. The problem, then, particularly in the communicating type of hydrocephalus, in which a small portion of the subarachnoid space near the fourth ventricle is still left but is shut off by ad- hesions from the larger subarachnoid space, consists in so reducing the forma- tion of cerebrospinal fluid that the amount that is secreted can be absorbed. Walter E. Dandy,- of Baltimore, has devised an operation for removal of that portion of the choroid plexus vi^hich lies in the lateral ventricles. It is im- practicable to remove the choroid plexus from the third and fourth ventricles and, as three-fourths of the amount is in the lateral ventricles, the absorption of the cerebrospinal fluid formed from the twenty-five per cent of choroid plexus left in the third and fourth ventricles can probably be done by the limited amount of subarachnoid space remaining. Before attempting the operation, however, it should be determined that the hydrocephalus is of the communicating type, in which the obstruction is in the subarachnoid space. This is done by injection of one cubic centimeter of neutral phenol- sulphonephthalein into either of the lateral ventricles of the brain. This solution is especially prepared and the drug that is ordinarily used to test kidney func- tion is not satisfactory. If the hydrocephalus is of the communicating type a lumbar puncture done half an hour later will demonstrate the dye in the spinal fluid, but if the obstruction exists in the ventricular system the spinal fluid will remain colorless. If the operation of Dandy is indicated, it is done as follows: A small circular bone flap is made over the parietal eminence with the base toward the midline and so located that it is well posterior to the Rolandic area. The flap of bone and then of dura is turned up, and the vessels in the cortex of the brain are tied with fine silk and the cortex of the brain is incised down to the ventricle. Into this incision is inserted a nasal dilating speculum, or if the ventricle is very large a spatula may be used. After removing all of the cere- brospinal fiuid the choroid plexus is recognized as a brownish-red flocculent substance and is picked up with forceps at the foramen of Monro. The vessels are ligated with a silver clip, clamping a small piece of silver wire on the vessel with especially constructed forceps. A small pledget of moist cot- ton is inserted gently into the foramen of Monro to prevent blood from gaining access to the third ventricle. The choroid plexus is cut and gently stripped back to the floor of the body of the ventricle. When the glomus is reached, the choroid plexus is then picked up again at the tip of the descend- ing horn of the ventricle and similarly stripped backward from this point to the glomus when the attachment to the glomus is liberated and the entire choroid plexus removed. Bleeding is slight but should be completely controlled by cotton pledgets soaked in salt solution. Great care must be taken to leave no bleeding points. The cavities that are left would cause collapse of the brain and are filled with salt solution. The opening in the cortex of the brain is 2Ann. Surg., Dec, 1918, pp. 569-580. SCALP, SKULL, AND BRAIN 275 closed Willi iiitornipted sutures oC fine silk in the piaraeter and araehnoid. The dura aud sealp are closed with sillv, taking care to have no leakage. A similar procedure is carried out on the other side at a different time. Four cases operated up)on in this manner by Dandy have all survived the immediate effects of the operation, though three died from two to four weeks after the operation. One was living and showed no evidence of return of the disease ten months after operation. The operation is, of course, a severe one and should not be lightly under- taken but it is founded on scientific knowledge of the etiology and pathology of hydrocephalus. Puncture of the corpus callosum may relieve temporarily the tension of the fluid in the ventricles of the brain and in instances in which this fluid is due to inflammation or trauma may be advisable, as has already been explained. It can hardly be curative in true hydrocephalus, because the fluid is drained into the subdural space instead of the subarachnoid and there is but little absorption in the subdural space. This operation is done pref- erably in the anterior third, or at least in the anterior two-thirds, of the corpus callosum, because the corpus is thinner at this portion. A small U-shaped flap of scalp is made with its base at the midline, or a straight incision can be used. The exposure of the skull is so located that the bone can be reached about half an inch from the midline and the same distance posterior to the coronary su- ture. The dura is opened, and a blunt malleable needle is passed downward and inward until it reaches the falx cerebri, which serves as a guide to the corpus callosum. The needle is then gently pressed through the corpus and fluid should immediately flow. The opening in the corpus callosum is enlarged by moving the needle forward and backward for about half an inch. The wound is closed in the usual manner without drainage. A probe may sometimes be used in- stead of a needle. Either instrument should have a scale marked upon it. The lateral ventricle can also be punctured by the method advocated by Keen. Here a point is indicated about one inch behind and one inch above the external auditory meatus and in the posterior part of the first temporal convolution. After removing a small piece of skull and opening the dura the needle is di- rected inward and toward the top of the ear on the opposite side. The ventricle is about two inches from the surface of the brain. OPERATIONS ON THE HYPOPHYSIS Operations for removal of tumors of the hypophysis have been performed through the nasal route or through the region of the frontal bone. This latter has been developed into a standard operation and appears to be the method of choice. The method that gives most satisfactory approach seems to be an attack by a frontal osteoplastic flap. This operation has been devised by Mc Arthur. A flap is made with its pedicle in the temporal region. An incision outlining this flap goes from the midpoint between the eyebrows up the middle of the 276 OPERATIVE SURGERY forehead to the region of the normal hair-line. The incision is carried outward and a third incision is begun at the lower end of the frontal incision and goes outward along the upper part of the eyebrow to the outer margin of the orbit. Care is taken to keep the periosteum intact and as closely connected with the bone in the region of the flap as possible. The skull is perforated at the upper outer angle of the flap with a burr or a small trephine. The ujiper and middle portion of the bone flap is separated with a DeVilbiss forceps. The lower part of the vertical cut in the bone is deflected somewhat toward the base of the flap so as to avoid the frontal sinus. The lower horizontal cut in the bone ends just above the outer angle of the orbit, invading slightly the temporal fossa. The external angular process of the frontal bone is divided with a sharp chisel or a saw. The internal bony portion of the supraorbital arch is also divided, going through well into the orbital plate of the frontal bone. This ridge of the frontal bone is removed and kept in salt solution until the operator is ready to replace the flap. The bony roof of the orbit is then removed with rongeur forceps until the optic nerve is exposed. The dura is separated from the bone in its neighborhood. The anterior clinoid process is recognized. A transverse incision about an inch long is made in the dura between the clinoid processes about three-eighths of an inch above the level of the floor of the ante- rior fossa. Through this opening the optic nerve, the chiasm, and the pituitary tumor come into view. After removing the tumor or evacuating the fluid the frontal lobe is permitted to fall into place. The ridge of bone removed from the upper margin of the orbit is replaced and held in position by sutures. The osteoplastic flap is turned in position and fastened in the usual manner. This operation has been modified and greatly improved by Adson and by Heuer. The osteoplastic flap is made by Adson with the base in the temporal region and the incisions placed much farther back, so the flap is largely in the hair region. The frontal sinus is thus avoided. The dura is incised freely as a flap and the brain, protected with strips of rubber tissue and moist cotton, is gently elevated with a broad spatula until the optic chiasm and the tumor are seen. The tumor is removed gently from within its capsule, if possible, leaving no bleeding points. CONGENITAL HERNIAS OF THE BRAIN OR ITS MEMBRANES There are occasionally found protrusions or hernias of the membranes of the brain or of the brain itself. They come through a congenital opening in the bones. If much of the brain is involved and the opening is large but little can be done except general compression, w^iich must not be too great, with the hope that if this defect occurs in young children or infants the development of the growing child may remedy the defect. The prognosis is usually bad. When the sac consists solely of the membranes of the brain and contains fluid, and when there is no hydrocephalus or spina bifida, an attempt at radical cure may be made. If the opening in the bone is small there is considerable prospect of cure, though the operation must be carried out with care as to the details SCAT.P, SKULL, AND BRAIN 277 and must be midei'takoii before tlie sac lias ruptured, and, if possible, before the skin on the sac has become ulcerated. It is best to use local anesthesia. Flaps with broad bases are dissected from the base of the meningeal sac. They should include healthy skin. The incision is made with a sharp knife and great care is taken to avoid opening the sac. Every bleeding point is caught with forceps. After reaching the bone the neck of the sac is cleared around Fig. 306. — Photograph of baby with meningocele in the lower pari of the occipital bone. Fig. 307. — Lines of incision for excision of the meningocele shown in preceding figure. the bony margin. If the neck of the sac is thin it should be very gently sep- arated from the bony margin. If it is thick careful dissection with a sharp knife removes the excessive tissue and leaves the sac at its neck consisting al- most entirely of the protruding dura. "When the sac has been thoroughly freed from the margins of the opening in the bone and, if possible, from the bone for a short distance under the margin, a ligature of tanned catgut is tied around the sac as closely as possible to the normal surface of the brain. While tying this ligature no pressure is made upon the sac which would force an undue amount 278 operatrt: st-rgert of cerebrospinal fluid back onto the brain. After this ligature has been securely placed the sac is cut away. The stump of the sac is transfixed with catgut in a needle slightly distal to the ligature and whipped over and tied in order still further to secure the stump from leaking. A flap of pericranium is turned over Fig. 308. — A cuft of scalp is turned back, the opening in the skull thoroughly exposed, and a ligature is placed around the neck of the sac. Fig. 309. — The neck of the sac is ligated. The lines show the incision for turning over a flap of pericranium. the pedicle and sutured in position to the pericranium on the other side of the opening in the bone. The flap of scalp that has previously been formed should be abundant and is placed in position by suturing the galea or by everting two flaps of scalp and using a series of mattress sutures to give a lateral ap- proximation to the galea. The skin is approximated with a continuous epithelial SCALP, SKUIiL, AND BRAIN 279 stitch of fine sillc. AVhetlier one or two flaps of scalp are formed depends upon the condition of the scalp at the base of the meningocele (Figs. 306, 307, 308, 309 and 310). In a bah}' three months old with the meningocele in the lower part of the occipital bone, I performed the operation just outlined and the baby made a Fig. olO. — The flap of pericranium is sutured into position. satisfactory recovery. When last heard from, about twenty months after the operation, the baby was improving and seemed to be developing mentally in a satisfactory manner. DECOMPRESSION OPERATIONS Operations for decompression of the brain have become popular since Harvey Gushing established the principle of performing this operation in the subtemporal region in such a manner that the fibers of the temporal muscle Fig. 311. — Line of incision for subtemporal decompression. Where the decompression is to be more extensive, the incision may incline farther backward. 280 OPERATIVE SURGERY iii|| r^ \ .>! ^' T^H H ■>(^- f:., '-'^ ^m H I ^tj ':$ rill 1 H flli^. .flHyiH "" ■~"-^— jHHIbj^^ 'IS'^^^hI^^I M T^ / ■ r^ i# nk. ssfipi [^ ■^^- 1/ .,.'# Fig. 312. — The fibers of the temporal muscle are separated and the pericranium and skull are exposed. Fig. 313. — The skull is perforated with a drill or burr. serve as a restraining influence to the protrusion and so prevent the enormous hernia that occurs when the decompression is made near the vault of the skull, where there is nothing to inhibit the protrusion of the brain except the skin and fascia of the scalp. According to Gushing 's original technic a curved incision is made about SCALP, RKI'LL, AND BRAIN 281 one ineli liclnw t1io tcnipoi"il ridiii' in the oriillii■ '1 "vcr with caliiul. Self-retainiiig' retractors may be used but llie ortliiiary hand retractor is usually satisfactory. The interspinous ligaments are separated Avitli a knife both above and below the spinous i)roce.ss, several of whieh are removed with bone for- ceps. 4Mie lamina' are removed with roni^enr forceps (Fig. 323). In the lower part of the spine, in the lumbar region, it is sometimes difficult to Fio-. 322. — The incisiuu lor laminectomy according to Frazier. find an opening. Here, if a small rongeur forceps cannot be insinuated un- der a lamina, an opening may be made with a burr as in the skull and enlarged Avith a DeVilbiss forceps until sufficient bone has been removed to enable the rongeur forceps to be used. Care is taken not to injure the dura and the cord during these manipulations. Before the dura is opened all bleeding points are stopped. Those in the bone can be controlled by the application of bone wax. At other points either pressure or whipping over with catgut 292 OPERATIVE SURGERY will suffice. Before opening the dura the wound should be completely cov- ered with fresh gauze wrung out of salt solution. The dura is carefully inspected for irregularity of contour or color before it is opened. It is caught up with the point of a small curved needle held in hemostatic forceps and in- cised, or, as practiced by Frazier, two small black silk sutures are inserted on each side of the midline and the incision is made between them. These su- Fig. 323. — Spinous processes have been partlj^ removed. tures should not perforate the dura. The incision is carried down through the dura with the intention of not cutting the arachnoid (Fig. 324). If the arachnoid is not wounded it bulges into the wound like a fetal membrane before the waters have broken. A groove director is inserted and the dura is further opened both upward and downward from this midpoint. Two more sets of small silk sutures are inserted at the distal ends of the incision in the dura and are clamped by hemostatic forceps at a sufficient distance from the THE SPINE 293 M'oiiiul not to be in the way. A small cylinder of cotton about one-third of an inch in iliainotor is placed on eaeh side of the incised dura at the depth of the wound to eateh any blood that may accumulate. When this cotton roll becomes saturated with blood it is replaced by a fresh one (Fi liyo'ul bone nuikin^ii' witli the iiicdiaii cut a T-shajx'd incision (Fig. 339). If necessary a similar transverse incision can he made at the h)wer end of the vertical one. If a tracheotomy has not been previously done tlie same steps of dividing the isthmus of the thyroid gland and control- ling the bleeding surface by whipping it over with catgut as has been de- scribed under the teclmic of tracheotomy are taken. The tissues are dissected freely from each side of the larynx, separating and dividing the sternohyoid and sternothyroid muscles on each side, as well as the thyrohyoid at its in- Fig. 3t0. — The larynx has been exposed and partly mobilized. In the next step of the operation the trachea is severed from the larynx. sertion into the thyroid cartilage. The larynx is completely freed as far as possible on each side (Fig. 340) and then after infiltrating the space between the upper ring of the trachea and the cricoid cartilage in order to lessen bleed- ing, a few drops of a two per cent solution of cocaine are injected into the lumen of the trachea with a hypodermic syringe. After a few minutes the mucosa of the trachea and larynx is anesthetized. Then the trachea is cut across. The dissection is continued and the larynx is separated from the esoph- agus behind. If a tracheotomy tube is not used, the trachea, after being divided, is separated from the esophagus for a distance of an inch or more, and brought forward and sutured to the skin. Great care is taken to see 320 OPERATIVE SURGERY that there is no oozing or trickling of blood into the traeliea. ( Jan/e is lightly packed just behind its posterior cut margin to control l)leeding. Bevan thinks that patients do much better without a tracheotomy tube. After disposing of the stump of the trachea the larynx is seized with forceps and pulled upward toward the chin and the dissection from the esoph- agus is continued to the upper extremity of the larynx behind. The esophagus is incised and the larynx is cut away at its upper portion, dividing ligaments and muscles that are attached laterally to the larynx, and finally, the thyro- hvoid membrane. The entire larynx, usually with the epiglottis, is removed Fig. 341. — The trachea has been divided and brought to the skin. The larynx is being dissected out from below upward. in one mass (Fig. 341). The wound in the esophagus and pharynx is closed by continuous silk or linen sutures. The sutures are applied as snugly as possible in an effort to prevent leakage, but if made too tight or too numerous necrosis will occur and the wound will break down. Wherever possible the sutured opening in the pharynx is reinforced by drawing soft tissues in its neighborhood over it. The skin wound is closed, leaving iodoform gauze drain- age at the lower portion of the wound just above the stump of the trachea and at each end of the transverse incision along the hyoid bone (Fig. 342). The patient is put to bed in the Trendelenburg position if the operation has been THE NKCK .. 321 (lone uiulri- a liciicral aiirsllu'tic, l)iit as soon as lie rocovei's tlio head of llic bed is elevated or he is placed in a seiui-sillinii' ])osilioii in hed. AVater is snp- plied by rectal enemas, or if necessary by hypodernioclysis. After two days, feedinii' is undertaken by introducing a large soft rubber catheter through the mouth into the esophagus well below the level of the larynx. Through this catheter, which is attached to a funnel, liquid nourishment can be gradually Fig. 342. — The laryngectomy completed. poured. In this way leakage of food through the pharyngeal wound is avoided. This method of feeding can be kept up for about two weeks. PHARYNX AND ESOPHAGUS Occasionally it is necessary to have access to the pharynx from the neck. This is obtained by an incision above the hyoid bone and parallel to it. The submaxillary gland is retracted and the digastric muscle is recognized and preserved. Other muscles of the neck, that is, the mylohyoid, geniohyoid, and the hyoglossus are divided transversely. The posterior part of the tongue is pulled into the wound with sharp retractors. The pharynx may also be entered by an incision below the hyoid bone and parallel to it. If entrance to the larynx is desired a short incision of two inches is sufficient but if the pharynx farther back is to be reached the incision should be much longer. The thyrohyoid membrane is divided along the posterior portion of the hyoid bone, but enough of this membrane is left attached to the bone to hold the sutures. The mucosa is divided, taking care to avoid injury to the epiglottis. Sutures in the mucosa along the edge of the wound act as retractors. The epiglottis is pulled into the wound and a tractor suture is inserted into it. The wound is closed by uniting the thyrohyoid membrane and the muscles in separate layers with catgut. It is best to insert a small drain. To remove a tumor or a foreign body that has lodged in the esophagus an incision is made on the left side beginning at the upper level of the larynx and going down along the anterior border of the sternomastoid muscle for three or four inches. The incision is deepened and the omohyoid is divided or retracted. The thyroid gland and the trachea are retracted toward the midline, and the common carotid, internal jugular vein and vagus nerve 322 OPERATIVE SURGERY are retracted outward in their sheath. The esophagus is exposed and if a foreign body is present and can be felt an incision is made in the axis of the esophagus down to tlie foreign bodj^ Before incising the esophagus it is best to fix its wall by tenacula forceps or by insertion of sutures that will act as tractors. If the incision is made for a tumor and the esophagus is not readily exposed an esophageal bougie is inserted through the mouth to make it prominent. To avoid the recurrent laryngeal nerve, the incision is made in the side of the esophagus and not in front of it. The wound is closed by interrupted sutures of fine catgut in the esophagus, which should not be tied too tightly. The rest of the wound is partially closed, leaving abundant drainage down to the esophageal wound in order to provide drain- age if the Avound in the esophagus leaks, which it frequently does, and also to guard against mediastinitis, Avhich is a considerable danger in these cases. An esophageal diverticulum may occur from pressure Avithin the esoph- agus or from traction without the esophagus, as from a contracting adhesion that involves its Avails. The latter form of diA^erticulum is rare, but oc- casionally occurs in that portion of the esophagus within the chest. The most common site of esophageal diverticulum is at the lateral and poste- rior portion of the junction of the esophagus and pharynx. Here there seems to be a Aveak spot as there is a Aveak spot at the internal opening of the in- guinal canal where hernia often occurs. Pressure from swallowing makes a pouch at this weak spot at the beginning of the esophagus and the pouch may con- tinue to enlarge until it attains considerable dimensions. When A^ery large a diverticulum may interfere seriously Avith the passage of food. In operat- ing, an incision is made as for esophagotomy, Avhich has just been described. The tissues are retracted and usually the diA^erticulum is readily found. It is dissected free bluntly and brought into the wound. The safest plan is to pack the Avound AA'ith gauze for about a week until granulations in the tissues have established a defense against infection and the occurrence of mediastinitis. If the diverticulum is a large one it is brought out of the skin Avouncl and left in this position surrounded by gauze. A small cliA^erticulum can sometimes be pulled up so that it stands at a right angle from the esopha- gus. A small amount of packing is placed beloAV it and most of the skin AVOund is closed. At a second operation, a week or ten days later, care must be taken not to break through the barrier of granulations and coagulated lymph, par- ticularly in the loAver portion of the wound. The neck of the sac is cut aAvay, the margins of the Avound in the esophagus being clamped or sutured as the incision is made so as to prevent too great retraction of the esophagus. Care must be taken so to cut off the diverticulum as to leaA^e no pouch AA'hen the stump is sutured. If, hoAvcA^er, too much of the esophagus is removed a stricture may result. The stump is sutured preferably Avith catgut, and if pos- sible this 'layer of sutures is iuA^erted by a second layer. Iodoform gauze drainage is carried doAvn to the Avound in the esophagus and the skin Avound is partially closed. When the diA''erticulum is small it may sometimes be iuA^erted into the THE NECK 323 esophagus by a series ol' i)ui'sesti'niG,' siilures, llie lii'st sutures being in- serted near the tip of tlu' divertieulum, inverting the tip, and the second farther down, inverting still more of the diverticulum, and so on until the last pursestring suture merely closes the dimple in the esophageal wall. This is the method practiced by A. D. Bevan, and if the diverticulum is small and thin and can be readily inverted the operation is done safely at one sitting, as the esophagus is not opened. The inverted diverticulum is sup- posed to atrophy or to slough off. In a large diverticulum or in one with thick walls this operation cannot readily be done and the two-stage operation with excision of the diverticulum, which is the method described by Judd and usu- ally followed at the Mayo clinic, is preferable. After any operation upon the esophagus the patient should be nourished as recommended after excision of the larynx. He is given enemas for the first few days and afterwards nourished through a small stomach tube passed through the mouth. Where the esophagus has not been opened, however, as when a diverticulum is inverted, there is no occasion for the use of the stomach tube though the swallowing should be restricted as much as possible for the first week by giving liquids by enemas and by administering only liquid nourishment by mouth. In an esophageal stricture a pouch often forms above the stricture and renders the passage of a sound or bougie very difficult. When the stricture cannot be entered from above. Abbe has practiced gastrotomy and the inser- tion of a small whalebone bougie from below. This passes into the mouth and two stout threads are tied to the end of the bougie and drawn through from the mouth into the stomach. The threads act as a guide to an esophageal bougie, which is tunnelled and threaded over the end of the thread that pro- trudes from the mouth. After the esophageal bougie has engaged the stric- ture the second string is pulled upon with a see-saw motion so as to cut the stricture. Ochsner advises drawing a rubber tube under tension through the stricture so that when the tension is relaxed the tube expands and dilates the stricture. The tube is left in position for several days when a larger one is inserted, and so on until the stricture has been overcome. The patient, of course, is fed in the meantime through the gastrotomy wound. Occasionally a fine silk thread can be passed through a stricture by floating it in water and taking the water through a tube. After several days the thread may pass through the stomach and into the duodenum in such a way as to fix the end of it and the thread can be made taut and serve for the introduction of a bougie. S. J. Mixter, of Boston, has practiced this method with much success. THE CAROTID GLAND The carotid gland varies considerably in size and is found near the bifur- cation of the common carotid artery. It is closely attached to the internal carotid and contains groups of epithelial cells which have a function through internal secretion probably connected with the function of the adrenal gland and 324 OPERATIVE SURGERY the sympathetic nervous system. Tumors of this gland have been found. Some- times the tumors are quite malignant, l)ut usually tliey grow slowly and are mildly malignant if not actually benign. The treatment of such tumors is very difficult to determine. If operation is deferred until the growth is large it will almost invariably be necessary to resect a portion of the carotid arteries involved in the growth. When the tumor is small the operation is less difficult, but even then the intimate association of the carotid gland with the carotid vessels makes it frequently impossible to remove the gland without serious in- jury to the walls of the carotids. Aside from hemorrhage the chief danger of the operation is in cutting off the blood supply to the brain by the ligation of the common and internal carotid arteries. This serious objection to the operation may be partially overcome by the employment of malleable bands that have been described in the treatment of carotid aneurisms, or by the use of Crile's clamp which can be nicely adjusted by a screw. By either of these devices the circulation through the internal carotid is gradually cut off until it is found that the common carotid can be completely occluded Avith safety. This may be weeks, but then it will be reasonably safe to tie the common carotid below and the external and internal carotids above and excise the growth. If it is found that the circulation to the brain cannot be sufficiently developed by this method after it has been given a satisfactory trial, and if the tumor appears to be malignant and endangering life, an attempt might be made to resect the carotid arteries and suture between the stumps of the common and internal carotid arteries a segment of the saphenous vein which is taken from the same joatient. Indications for this operation will be very unusual, but such a condition may conceivably occur and if the surgeon can suture blood vessels satisfactorily the operation may give a chance in an other- wise hopeless situation. The suturing should be done as described in the chapter on Blood Vessel Suturing. DIFFUSE LIPOMA OF THE NECK Occasionally a diffuse lipoma of the neck is so large as to indicate oper- ation. Often this is accompanied by S3anmetrical lipomas elsewhere and by nervous disturbances that would contraindicate operation upon the lipoma of the neck. If, however, the diffuse lipoma of the neck is the chief or only growth and there is no contraindication, the tumor may be removed through a long transverse incision over the most prominent portion of the growth. The dissection required is very extensive and the vessels are often greatly displaced. The. dissection begins at one of the tAvo extremities of the in- cision over the edges of the trapezius muscle, and extends forward after freeing the tumor above and below as much as possible. Care is taken to identify the large veins at the root of the neck and to guard against the en- trance of air into the veins (Figs. 343 and 344). For this reason the vessels in the lower portion of the growth are identified and clamped before dissecting those at the upper portion. The external jugular veins are usually buried in THE NECK 325 the mass of fat wliieli extends into the cre^'ices between the muscle plains and around the deep vessels of the neck. It is often impossible to remove all of a large diffuse lipoma in one mass, but if there is no distinct capsule it can be removed in sections if this renders the operation easier. The wound is washed 1 BPE^vSx^ ■ jitt^ Jt V t7 r i 1 K^--_ I 343. — Photograph of a patient with large diffuse lipoma of the neck. Fig. 344. — Photograph of patient shown _ in preceding illustranon a few weeks after operation for removal of diffuse lipoma. out with salt solution and dried Avitli gauze to remove the fat that may be licjuefied and scjueezed into the Avound during the course of the dissection. Drainage with tubes through small stab wounds on each side of the neck should be established. THE CEEVICAL SYMPATHETIC Bemoval of the cervical sympathetic ganglia was formerly recommended by Jonnesco for exophthalmic goiter. It is no longer used for this purpose but has been occasionally done for unimproved exophthalmos after the thy- roid gland has been operated upon and the other symptoms have disappeared. The operation has been done by C. H. Mayo in those cases of extreme exoph- thalmic and nervous symptoms that are out of proportion to the size of the thyroid. He removes the superior and sometimes the middle sympathetic ganglia, and at the same time ties the superior thyroid vessels. The operation is done through an incision whose center is on a level with the bifurcation of the common carotid artery. The sternomastoid muscle is retracted outward and the sheath containing the carotid vessels and the vagus and internal jugu- lar vein is retracted inward. The superior sympathetic ganglion is about one-eighth to one-fourth of an inch wide and has many branches. After dividing the branches the upper ganglion is removed. The connecting nerves of the middle f^ervical p,'anglion are cut, or this ganglion may also be re- moved. 326 OPERATIVE SURGERY In Jonnesco's operation the incision is made behind the mastoid process along the posterior border of the sternomastoid muscle to just below the clavicle. The external jugular vein is doubly ligated and divided, the fibers of the sternomastoid muscle are split, and the ganglion is approached through this muscle splitting incision. The inner portion of the sternomas- toid muscle along with the vessels and nerves in the carotid sheath is re- tracted inward, and upward. The sympathetic nerves are found either on the posterior surface of the sheath containing the vessels which have been re- tracted inward or on the vertebral column in a special sheath. The sympa- thetic nerve is followed upward until it is seen to communicate with the supe- rior sympathetic ganglion. The ganglion is dissected bluntly from below up- ward, its branches are divided with scissors and the ganglion is removed. The inferior thyroid artery, as it crosses under the common carotid, is surrounded by a dense nervous plexus which consist of the sympathetic trunk with its branches. At this point enlargement of the sympathetic nerve forms the middle cervical ganglion. By making traction on the nerve trunk it is fol- lowed downward and the nerve is elevated and separated from the inferior thyroid artery. The inferior ganglion is the most difficult to remove and its removal is usually unnecessary. It lies deep in the base of the neck, just above the pleura, behind the clavicle and against the head of the first rib between the scalenus anticus and longus colli muscles. The trunk of the sympa- thetic is the guide to the ganglion which lies sometimes internal and some- times external to the vertebral artery. The inferior sympathetic ganglion is adherent to the vertebral artery which makes its separation difficult. After exposing the vertebral artery the ganglion is caught with forceps and isolated from the artery externally and the rib and spine internally. Its nervous con- nection is severed and the ganglion removed. The wound is closed carefully without drainage. This extensive operation is rarely if ever indicated, though removal of the upper and possibly the middle, cervical sympathetic ganglion as prac- ticed by C. H. Mayo, may sometimes be beneficial under conditions that have been described by him. THE THYROID GLAND A simple goiter may be removed with the same general precautions ob- served in operating on any tumor of the neck, but a goiter with hyperthy- roidism introduces, a distinctively different problem. In the exophthalmic type of goiter thyroidectomy should not be done during the acute exacerba- tion of the disease when the pulse is running 120 or more and the symptoms of hyperthyroidism are pronounced. Here one superior thyroid artery is ligated, preferably under local anesthetic. If after five or six days but little reaction occurs, the second superior thyroid is tied, but if marked reaction shown by rapid pulse and elevation of temperature, occurs a few days after the first ligation, the second operation should be postponed, preferably for THE NECK 327 several weeks. If the second ligation is followed by little or no reaction a thyroidectomy can be done in a week or ten days after the second ligation. If there is any marked reaction after the second ligation it is safer to send the patient home with instructions to return in two or three months for thyroid- ectomy. If after this time the patient has not improved materially, thyroid- ectomy should not be attempted, but the inferior thyroids may be ligated, or the goiter injected with a solution of quinine and urea, as has been very suc- cessfully done by Leigh Watson, of Chicago, or by hot water, as practiced by Miles Porter, or treatment by a competent roentgenologist should be in- stituted. The technic of ligating the superior thyroids has been described in a preceding chapter on ligation of blood vessels. This is usually done under local anesthesia. The technic of thyroidectomy, or partial thyroidectomy as it should more properly be called, for some of the thyroid tissue must always be left, is prac- tically the same for goiters accompanied liy hyperthyroidism as with the simple type, except that the former are as a rule, more vascular and smaller. The operation is best done through the transverse collar incision of Kocher. In a symmetrical goiter this is made from one edge of the sterno- mastoid muscle to the other, about one inch above the sternum. The outer portion of the incision bends slightly upward. The incision, of course, has to be modified according to the shape and size of the goiter, and may be made higher or longer to render the thyroid more accessible. The flap is dissected to the larynx and the lower margin of the wound is freed to the sternum. The muscles of the neck are divided in the midline from the lower border of the larynx to just above the sternum and down to the true capsule of the thyroid gland, which is recognized by the large veins and vessels of the thyroid cours- ing within it. The goiter is thoroughly separated from the ribbon muscles of the neck by blunt dissection. Occasionally when the veins are large they may be ruptured and considerable hemorrhage will occur. If the separation is carefully done with the finger, and the proper line of cleavage is obtained, hem- orrhage is usually avoided. It is important to recognize the thin muscles of the neck, otherwise the muscles may be seriously injured and the dissection will not follow the capsule of the thyroid, so that it will be difficult or impossible to mobilize the goiter. Many goiters, particularly those of moderate size, can be delivered through this incision, but if difficulty is encountered the muscles are cut across after doubly clamping them with heavy Ochsner forceps in their upper portion, as advised by C. H. Mayo, in order not only that the line of incision in the muscle will be at a different level from that in the skin, but to preserve the nerve supply of the ribbon muscles which enters below (Fig. 345). The clamps should be close together and division so made that when the muscles are united by suture but one line of trauma remains. If the Ochsner forceps are placed at some distance from each other and the division made be- tween them there will be three lines of trauma, Iavo made by the forceps and one by the cut. If the forceps are placed side by side the injury made by them and the incision will be so close that the muscles which have usually 328 OPERATIVE SURGERY been stretched by tlie bulging of the goiter can be reunited Ijv a continuous suture of catgut, wliieh will include both lines of trauma made by tlie forceps. In this way a reef is taken in the overstretched muscles. With increasing experience the surgeon finds less necessity for cross cutting the muscles, though in many instances it adds not only to the ease of the technic, but permits delivery of the goiter with much less trauma than Avould be necessary if simply the midline incision in the muscle was employed. After freeing the goiter from its surrounding tissue with the finger and deliv- ering it into the wound, the upper pole is doubly clamped with stout Ochsner Fig. 345. — Exposure of goiter. The superficial muscles are clamped and are about to be divided. forceps. The pole is well isolated and care taken to include all the branches of the superior thyroid in the grasp of the forceps. Many surgeons advise using three forceps, so placed that tAvo will remain on the stump of the upper pole after its division, because it may retract and cause annoying hemorrhage. The tissue that is adherent to the goiter posteriorly is put on a stretch and any large vessels -are clamped near the goiter (Fig. 346). After clamping and dividing the upper pole the dissection is carried from above downward, so releasing the low^er pole. The posterior capsule of the goiter is left along wdth a small attached portion of thyroid tissue in order not to wound the recurrent laryngeal nerve. The trachea and thyroid are identified and an effort is made not to expose the trachea but to dissect close to the thyroid Avhile removing it THE NECK 329 from the Iraeliea. In this Avay a thin layer of tissue is left over the trachea and small nerves in the tracheal Avall, which might cause irritation if exposed, are protected by this layer of tissue. If the goiter extends on each side, dis- section is carried across the midline and the goiter on the other side is well mobilized. The vessels are clamped first from above downward, taking care to leave some thyroid tissue at the upper pole and around the region of the entrance of the inferior thyroid artery, which will also protect the recurrent laryngeal nerve. The vessels are tied carefully with catgut. All oozing sur- faces must be thoroughly controlled before closing the wound. If the raw Fig. 3-46. — The goiter has been partiallj' mobilized. The superior thyroid vessels are ready for clamping and division. surfaces of the thyroid that are left continue to bleed they are whipped over with catgut. If the muscles have been cut across they are united by a con- tinuous suture of plain catgut. The incision in the muscle in the midline is similarly sutured and a small drainage tube is inserted at the lowest end of the midline incision in the muscle. This appears to be necessary to prevent a large accumulation of serum that would otherwise occur. The platysma and subcutaneous tissues are united by a continuous suture of fine plain catgut. The skin is brought together in two sections by a subcu- ticular suture of fine silkworm-gut. The tube, which is a very small one, pro- trudes from the middle of the incision. The continuous suture of each section 330 OPERATIVE SURGERY ends at the tube and when the tube is removed about the third or fourth day after operation the skin wound falls together without further suturing. Sometimes the conformation of the goiter may be such as to make it wise to approach the growth from the midline. D. C. Balfour has described a technic in which this type of operation may be done. Willard Bartlett has special forceps for compressing the thyroid near its poles. The goiter is divided in the midline, dissected from the midline outward, clamped by for- ceps and excised in a wedge-shaped manner so that the raw surfaces in the goiter are approximated with continuous sutures which control the bleeding. Bartlett 's technic does not necessarily include division in the midline, though in the operation described by him this may be done if it facilitates matters. He first clamps and divides the superior thjToid at the goiter and then com- presses the vascular margin of the goiter with his forceps introduced from below. CHAPTER XVIII OPERATIONS ON THE UPPER EXTREMITIES AMPUTATIONS Amputations were formerly the glory of surgery because in preantisep- tic days they were the chief operations that were performed. With the progress of surgery, however, efforts to save a limb instead of to destroy it, have been greater, so gradually amputation has come to be looked upon as a confession of failure to save the limb and of inability to conserve its function. Amputation of the upper extremity or of a portion of the upper extremity may, however, be indicated either as a result of extreme trauma or of gan- grene, infection, or malignant growths. Amputation for infection and trauma is done much less frequently than formerly because the modern treatment of wounds often succeeds in saving a limb even when infection is severe. The same is true of severe injuries. Probably the greatest contribution to mili- tary surgery during the AVorld War was debridement, which is excising the injured tissue. If this is done a few hours after the wound is made or dur- ing the period of contamination before infection has set in, the raw surfaces may be sutured, or if that is impossible the wound may be treated as though it were a clean wound, and infection will seldom occur. After the first few hours, however, when the period of infection has begun and bacteria are multiplying in the tissues, debridement will merely expose freshly cut sur- faces to the infective germs with which the tissues are infiltrated. Here, fre- quent dressings of antiseptics or treatment by the Carrel-Dakin method will often result in cure in cases that appear to admit only of amputation. It must be borne in mind that it is much easier to amputate a limb than it is to save it, and while the patient's life should not be too greatly risked in order to save his limb, the operator should be reasonably sure that amputation is distinctly indicated before resorting to it. In malignant growths amputation is not frequently justified. Bone cysts and so-called giant cell sarcomas can be treated conservatively by resec- tion with bone grafting if necessary, or by thorough curetting and packing the cavity. If the growth is a periosteal sarcoma, amputation does but little good, for hardly more than four per cent of periosteal sarcomas are eventually saved by amputation. In amputation there are certain general principles which should be discussed. Controlling hemorrhage is one of the chief problems. This be- comes increasingly grave the nearer the site of amputation approaches the body. A tourniquet is the standard orthodox method of controlling hem- 331 332 Ol'ERATIVE SURGERY orrliage and may iLsiially be employed. It should be placed sufficiently far above the site of operation not to be in the way of the operator and preferably at some distance from a joint if it is a large joint. A touriii(iuet on the upper arm and thigh is more satisfactory than on the leg or forearm, because the presence of two bones in these latter regions sometimes prevents the action of the tourniquet from constricting the soft parts. It is best to place a towel next to the arm if a tourniquet is used so that the skin will not be injured. An excellent tourniquet is a broad thin rubber band, which is wrapped around a number of times and controlled by tying the ends together or by fastening Avith a clamp. A large, soft, black rubber tube also makes a good tourniquet and in amputation about the shoulder joint is superior to any other kind of tourniquet. In an emergency a handkerchief or a towel can be used very satisfactorily. After tying the handkerchief or towel tightly, a cane, or a long stick, is inserted just beneath the towel and twisted until sufficient pressure is obtained. A pair of suspenders makes an excellent tourniquet in an emergency. In operations on the fingers or thumb a small soft rubber tube or a soft rubber catheter may be used for a tourniquet. An ordinary rubber band is a good tourniquet for the finger. If a soft rubber catheter is to be used, it is best applied by wrapping it once completely around the base of the finger and then carrying the ends across the back of the hand and around the wrist in a figure-of-eight turn and clamping the two ends together with a hemostatic forceps. Tourniquets, however, are by no means free from danger. For this rea- son many industrial surgeons do not recommend them. A tourniquet may often be uselessly applied and if not tight enough will merely constrict the venous circulation and promote bleeding while if it is too tight actual damage may be done. The use of a tourniquet is also unwise in those cases in Avhich the patient's resistance is at the lowest ebb, but in which amputation is clearly necessary because of gangrene. Here with low general vitality and impover- ished circulation to the limb, particularly in arterial disease, the blood vessels may not only be injured by the application of the tourniquet, but the complete cutting off of nutrition from the tissues of the stump even for the short time that is necessary to perform the operation, has an injurious effect upon the resistance of these tissues and may embarrass the healing of the flap. In the presence of marked inflammation a tourniquet should be applied well above the inflammation, or if this is impossible it should not be applied at all. The Esmarch method of controlling bleeding has largely fallen into dis- use. This consists in beginning at the fingers with a rubber bandage and encircling the limb upward from the fingers, appljdng the l)andage so snugly as to drive out all the blood. When the bandage reaches above the elbow a tourniquet is applied and then the Esmarch bandage is released. This method secures a bloodless field, but if amputation is done for infection the application of Esmarch 's bandage would, of course, be exceedingly dangerous and would force into the circulation the products of the inflammation. Even in aseptic THK iri'i'iat KXTRianTiES 333 injuries llic ascplic products ol' injured tissues, Avhieli iire now regarded as tlie eliiel' cause of sliocd-c, may he dislodged and forced into tlie circulation in ovorwhelmiug' amounts. In malignant diseases the Esmai'cli bandage would, of course, force cancerous cells into the circulation. Before applying a tourniquet the lind) sliould be elevated for a few minutes so that the venous 1)lood that wovdd naturally drain out of the limb because of gravity can be saved. If but little blood is lost during the amputation and the patient has not bled previously the total amount of blood in proportion to the tissues wdll probably not be changed, because with am- putation of the extremity there is less tissue to be supplied with blood. With a good knoAvledge of anatomy and a reasonably careful dissection even amputation at the shoulder-joint or at the hip-joint can be done without a tourniquet and wdth no large loss of blood, particularly in patients who are not very stout. A tourniquet in these regions, however, is as a rule, desirable. If a tourniquet is not to be used, the incision should be so shaped that the large vessels will be exposed at an early stage of the operation. They can then be doubly clamped, divided, and ligated and thus the main source of hemorrhage is controlled. A good knowledge of anatomy is essential in amputating. The flaps should be cut as broad as possible so the nutrition w-ill be abundant and the vessels should be ligated, preferably wdth catgut, before the tourniquet is removed. In amputations near the body where the vessels are large there should be two ligatures on the vessels, as recommended in the ligation in continuity. The ligature nearest the heart absorbs the impulse of the arterial current and makes the conditions of healing at the second ligature distally placed much better, as this second ligature is not subjected to the strain and impulse of the arterial current and the tissues it encircles are relatively at rest. In amputations, particularly the larger amputations, it is best to use drain- age. This may be removed after tw^enty-four or forty-eight hours in cases that are clean, but there is usually considerable outpour from the severed lymphatics, which, if not drained away, is absorbed with some diiftculty by the tissues and interferes wdth the nutrition of the flaps, because it prevents them from coming in contact with raw surfaces having a good blood supply. In amputation of the finger, drainage is not necessary. If it is felt that the stump is probably infected, or if the character of infection for which the amputation is done is highly virulent, the flaps may be either not sutured at all, or, better still, sutures of silkworm-gut can be placed but not tied and the flaps left open and packed loosely with iodoform gauze. As has been explained in the chapter on drainage, this will cause a reversal of the circula- tion of the lymph channels and so Avill prevent the absorption of much of the septic material that would otherwise be carried along the regular channels of the lymphatics toward the body. After five or six days if the tendency to infection has been overcome the gauze is loosened by soak- ing it in a mild antiseptic solution and by the application of peroxide of hydrogen. It can then be removed and the sutures tied. 334 OPERATIVE SURGERY The treatment of the bone in amputations involves a very definite pro- cedure. If the amputation is through a joint, or in other words, is a disarticu- lation, care must be taken not to injure the cartila^'inous coating of the joint. If the amputation is through the continuity of the bone the end of the bone is scraped out thoroughly Avith a curet, to remove the endosteum and the medulla, for a distance of about an inch. The periosteum is also removed from the external portion of the bone for about the same distance and the sharp margins are trimmed "with forceps or with a coarse file. The method of using a periosteal flap in amputation has been discredited. While it is now known that the outer layers of the i^eriosteal flap have nothing to do with regeneration of bone, the periosteum often promotes unnecessary callus and painful nodules ; for when the periosteum is stripped up to make a flap small portions of the cortex of the bone and the cambium layer of the perios- teum are removed and these cause deposits of bone at irregular points. The so-called guillotine operation has been used in severe infections, or when there is great need for haste. In this method the limb is practically chopped off, all of the tissue being divided at about the same level. Naturally the muscles contract considerably and the bone protrudes. Often a secondary amputation has to be done later on. While indications for the guillotine ampu- tation in the arm or forearm do not usually exist, it is sometimes a good procedure in amputating the finger where an effort is made to preserve as much of the finger as possible. In every amputation the nerves should be cleanly divided with a sharp knife. The nerve should be pulled down and as much of it cut off as possible in order that the stump may retract and not be caught in the scar of the healing flaps, which is the frequent cause of painful stumps. The neuroma which forms on the end of a nerve after its section is usually not painful if there is no infection and if the scar tissue in the neuroma is not excessive. One of the most unfortunate complications of the stump is a painful stump, which may be due to adhesions to the bone or to neuromas. Neuromas consist of connective tissue about the end of the nerve into which grow the neu- raxes from the central portion of the nerve. If the end of the nerve is near the other scar tissue, or if there is considerable irritation, there is an abnormally large amount of scar tissue which produces a large neuroma that will almost certainly be painful. Huber and Dean Lewis have shown that if the last inch of a nerve be injected with alcohol at the time of amputation no neuroma Avill form, as the injection destroys the axones and does away with the tendency for them to grow downward into the end of the stump. This practice is simple and should be carried out. While there are many types of amputations, there are general principles applying to them all which reduce the matter to the selection of that operation best fitted for the particular case. Often the character of an injury Avill make it necessary to modify the shape of the flaps. It must be borne in mind that the flap should be well nourished and not too long, and THK UI'l'KR EXTRKMITIES 335 }>;n't ic'iilai'l\' not too slioi't, and it' an arliCicial liiub is to be worn llie scar pi'ot'orably slionid not be at the apex ol' the st\itii|). The amount of soft tissue necessary to cover a bone in amputation is, in rlie eirenhir amputation, a distance of about three-fourths the diameter of the limb from the point of division of the bone to the end of the flap. This is equivalent to about one-fourth of the circumference of the limb. When a single flap or unequal flaps are used, the total length below the bone should be equivalent to about one and one-half times the diameter of the limb, which is one-half of the circumference, as the diameter is about one- third of the circumference. The skin and superficial fascia always con- tract considerably after incision, so full allowance should be made for this in any amputation. In amputating a large limb retraction is greater than in a small limb. It is better to have a flap a little too long than too short, because swelling makes tension and often contraction occurs later on. If, however, there is markedly redundant tissue it can be easily excised before the flap is sutured. In the lower part of the thigh and in the arm the ten- dency to retraction of the soft parts is very great and here flaps should be made equivalent to about twice the diameter of the limb or two-thirds of the circuniference. In a circular amputation in this region the distance between the skin incision and the point of division of the bone should equal the diameter of the limb. When an incision is made the skin is firmly grasped and retracted upward to make as much allowance as possible for the natural retraction. After the skin and fascia have been cut the muscles are incised. If a flap opera- tion is made, as much fat and superficial fascia is turned back wdth the skin as possible in order to provide nutrition for the flap. If it is intended to use a muscular flap, the muscles are cut obliquely from without inward by dissection after the fascia has been incised. It is best, as a rule, to have a muscular covering for the bone. A circular amputation is quickly done and has many advantages. It is applicable in the middle of the arm, of the forearm, and of the thigh. The skin is divided circularly down through the fascia and is retracted, exposing the superflcial muscles wdiich are divided by a circular incision. This layer of muscles is retracted and the deep layer of muscles is divided at the level at which the bone is to be sawed. This makes a funnel shaped wound with the bone at the bottom and a satisfactory muscular covering. The skin has a maximum amount of nutrition as its vessels are not even interfered wdth by a longi- tudinal incision. Sometimes a cuff of skin and superflcial fascia is rolled back in order to get a sufficient amount of covering. This is called the cuff operation and is merely a modification of the circular method. The old method of transfixion Avith a long knife is but seldom used, the flaps now being dissected from without wdth a sharp scalpel. The chief ob- jection to the transfixion method is that it often splits and divides vessels and nerves and makes their identification difficult and at the same time does not fashion the muscular flap as accurately as a careful dissection would. 336 OPERATIVE SURGERY Modifications of the circular and various forms of flap amputations are, of course, often necessary because the flap should he so fashioned as to secure the best nuti-ition, and as amputations are often done for injury it may frequently be necessary to do an atypical amputation in order to secure a satisfactory flap without sacrificing too much of the stump. After the flaps have been cut an incision is made through the periosteum down to the bone, about half an inch above the desired point of section with the saw. In order to expose the bone the flaps are retracted by placing two towels over them snugly against the bone. Where there are two bones, as in the forearm and in the leg, three towels or three special pieces of cloth are necessarj^ After retracting the flaps the periosteum is divided with a circular incision and scraped down and the bone is divided about one-half an inch below the incision in the periosteum. The medulla and endosteum are carefully curetted away to about one-half an inch from the end of the bone. This makes a much better and a much less painful end of the bone than by using periosteal flaps. The vessels are identified, clamped, and care- fully tied, preferably with catgut. The larger vessels are tied at two places about one-fourth inch from each other. If a tourniquet is used it is removed and other bleeding points are clamped and tied. If muscular covering is possible the muscle is sutured over the bone with interrupted sutures of catgut. The sutures are not tied tightly and no more are placed than necessary to obtain approximation. Sometimes the suturing of the fascial covering of the muscles brings the muscles into position. This fascia is sutured wherever possible. If there is redundant tissue either in the muscle or skin it is trimmed away but this ought not to be done until it is quite certain that the tissue cannot be utilized in the stump. If a flap amputation is done the flaps are, if possible, so placed that a drainage tube in the angle of the flap will be at the most dependent portion. If a circular amputation is performed it should preferably be sutured in an anteroposterior direction so drainage can be inserted at the dependent por- tion of the wound. The skin is best closed with interrupted sutures of silk or silkworm-gut. The drainage tube of rubber is removed at the end of forty-eight hours if healing is satisfactory. Besides the standard flaps and the circular method, other modifications are used, such as the racket incision, which is a circular or slightly oval incision combined with a straight vertical incision. The oval method of amputating is a modification of the circular in which the incision is made in an oval manner and brings the scar to the side of the stump instead of being at the apex. Elliptical amputation is practically the same as the oval, but is somewhat more inclined to the form of a flap and is chiefly used in amputations or disarticulations at the joints. In amputation of the fingers or hand the palmar flap should always be longer because the skin of the palm is thick and bears usage better than the skin on the dorsal surface of the hand, and also because it is better nour- ished (Figs. 347 and 348). In amputation of the fingers a tourniquet may THE UPPER EXTREMITIES 337 be placed, as has already been described, using a ru1)ber band, or a soft rubber catheter. As a rule it is best to amputate here through a joint. It must be borne in mind that the distal ends of the metacarpal bone of the phalanges form the knuckles so that the plane of the joint is distal to the knuckle, and the flaps should be shaped accordingly. The webs of the fingers are about three-quarters of an inch below the metacarpal joints. In planning an amputation of the finger the palmar flap should always be the longer Avherever possil)le. It may be long enough to cover the whole stump and be united to the dorsal incision of the amputation, or there may be a short dorsal flap and a long palmar flap. The anatomy of the finger and the in- sertion of the flexor and extensor tendons should be borne in mind. The superficial flexors of the fingers are inserted into the sides of the middle phalanges and the deep flexors, after splitting the superficial flexors, are in- serted into the bases of the last phalanges. The extensor tendons, however, are inserted along the whole of the back of the dorsal surfaces of the phalanges. Where it is thought best to save as much of the finger as possible a Fig. 347.— Line of incision for amputation of Fig. 348. — Showing the method of forming long distal phalanx of finger. palmar flap in amputation of finger. guillotine operation can be done, dividing all the tissues at the same level. This, however, usually results in a painful stump. J. S. Davis, of Baltimore, has placed a celluloid ring around the stump, which appears to promote granulations and to give a thicker covering for the end of the bone than is ob- tained without this treatment. It is particularly desirable to save as much of the index finger and of the thumb as possible. The flexor tendons of the thumb and of the little finger have a sheath that communicates with the large palmar synovial sac, and infection from these two points is more serious than would be infection from the other fingers. The flexor tendons, particularly of the index or little finger, should be at- tached to their sheath or to the periosteum by a few sutures when the sheath is opened so as to preserve the action of these tendons. The finger should be flexed when cutting the dorsal flap and extended when cutting the palmar flap. When an amputation is made through a joint as much as possible of the capsular ligament should be saved in order to cover the end of the bone (Fig. 349). In amputating through a joint, the joint is opened on the back first, cutting the extensor tendon, then dividing the lateral attachments, and 338 OI'KRATIVE SI'RGERY last of all C'iittiiii>- the flexor toiulon. The tendons should be cut long enough to allow them to be reattached. Amputation throufrh the last phalanx should be done if possible by a single palmar flap. After outlining the flap with a knife the extensor tendon is cut and the joint opened on its back, as has just been described. The lat- eral attachments are cut and lastly the flexor tendon. The flexor tendon is fixed to its sheath or to the periosteum in its neighborhood by fine tanned or chromic catgut. After tying with catgut the digital arteries which are on the sides of the stump, the palmar flap is sutured to the dorsal flap by interrupted fine silk or fine silkworm-gut sutures. If amputation is done through a joint, that is, if a disarticulation is done, it will require a longer flap to cover the bone than where the bone is divided. If it is impractical to take a long palmar flap, the flaps should at least be so fashioned that the palmar flap will be longer than the dorsal flap. The same method is used in amputating the second phalanx. The flaps, as shown in the illustration, should not have sharp corners, but should be rounded. Occasionally it is necessary to take a flap from the lateral a.spect of the finger instead of the palmar. This variation in the technic may be Fig. 349. — Amputation of the finger; A, through first phalanx by equal flaps; B, through first phalangeal joint by long palmar and short dorsal flaps; C, amputation by long palmar flap. demanded by the situation of the lesion. The bone is divided with a saw, as bone forceps may splinter the bone. Amputation or disarticulation of the finger at the metacarpophalangeal joint may be done by the oval or by the racket incision. The racket incision resembles a Y-shaped incision when looked at from the back of the hand (Fig. 350). It begins on the back of the metacarpal bone, a short distance proxi- mal to its head, passes downward crossing the knuckle and then goes obliquely around the palmar aspect of the finger a short distance distal below the web of the finger. It is then carried around the other side of the finger in a symmetrical manner to the point of beginning. This may be made in two incisions, as in cutting a flap, so that the incisions diverge downward from the back of the knuckle. After the skin and fascia have been cut and are retracted the extensor tendon and then the capsular ligament are di- vided, saving as much of the ligament as possible. The flexor tendons are divided, as has been described, and are fastened to their sheaths with sutures. The digital arteries are tied. The wound is closed by suturing together the edges in an anteroposterior direction so that the scar forms a line leading from the back of the hand over the head of the metacarpal Till'; 1!|'Im:i: iixtjikmith:;-; 339 hoin' 1(1 llic palmar siirrarc. The llap iiu'lliod can also Ix' used licrc, particu- larly ill llu- lliimil), llic index and llic little fingers, but the oval or racket method is best in the middle and rino- fiugei's. If it is desired to make the hand smaller, the head of the metacarpal l)one may be excised, as its presence adds prominence to the defect because it accentuates the empty space, but it oivos considerably more strength to the hand. Amputation or disarticulation of several fingers with a portion or all of the metacarpal bones is done by a circular or oval incision. This may be converted into a flap method or into a racket incision by a single longitudinal incision. Amputation at the wrist joint should not be done if amputation at the carpo- metacari:»al joint is possible. (Figs. 351, 352.) Amputation of a single finger Fig. 350. — A, amputation of last phalanx by palmar flap; B, amputation of thumb at the proximal joint by long palmar flap; C, disarticulation of iirst metacarpal bone and thumb by oval method. with its adjoining metacarpal bone is done by a circular or an oval incision around the base of the finger through the webs of the finger which is joined by a straight incision over the back of the metacarpal bone through its whole length. If the ring or middle fingers are infected often disarticulation of the correspond- ing metacarpal bone adds symmetry to the hand but at the expense of strength. Amputation at the wrist, if done with a palmar flap is begun with an incision starting about half an inch below the styloid process of the radius. It is carried down and across the palm of the hand about the middle of the metacarpal bones and ends one-half inch below the stjdoid. process of the ulna. The incision on the back of the wrist curves slightly upward 340 OPERATIVE SURGERY ].'ig. 351. A, disarticulation of the third, fourth, and fifth metacarpal bones; B, disarticulation of all metacarpal bones except the thumb. Pig 352 A and A', amputation of the hand at wrist joint by equal flaps. B, disarticulation of third and fourth metacarpal bones. ' Tin: rri'EU extremities 341 so Hull llu' pnliiKir ll;i|) coNcrs well llic wIidIc ol' Hie slum]). The dorsal iiu'isioii is I'jirricd down lo I lie lioiic iiiid llic tissues are dissected as fai- ns till' ,j.)iiit. The long tendons are divided either at the extreme level of the incision to allow them to retract or, if a motor stump is planned, they are made lono> and tlie extensor tendons are united to the flexor tendons across the ends of the bone after the joint has been divided. After complet- ing the disarticulation of the joint the palmar flap is turned back and sutured to the dorsal flap. Drainage is provided for the first forty-eight hours. If impossible to secure a long palmar flap at the wrist a double flap can be used, making the palmar flap and the dorsal flap of about equal length. Great care should be taken to see that the flaps are not too narrow. (Fig. 352.) Sometimes flaps may be secured from the side, either from the radial or ulnar side, depending upon the emergency of the situation. Amputation of the forearm can usually be satisfactorily done either by the circular method or by an anterior and posterior flap, as has been de- scribed. In the lower third of the forearm the circular or cuff method is good or a double flap may be used. In the upper two-thirds of the forearm the circular method or equal flaps are satisfactory. The muscle can best be cut in tAvo layers, superficial and deep. Particular care must be taken to see that the median, radial, ulnar, and interosseous nerves are identified, injected w^th alcohol and divided as high as possible, so that they will not form attachments to the scar of the stump (Fig. 353). A motor stump, or a cineplastic, amputation may be done through the forearm. Here a double motor stump is made. The circular incision through the skin and subcutaneous fascia is made as low down on the forearm as possible, and the muscles and tendons are divided to the bone at a level with the retracted skin. Vertical incisions are made on the radial and on the ulnar side down to the bone extending up from the circular skin incision about six inches. In this manner an anterior and a posterior flap are formed and are dissected up so that each flap contains all the tendons, muscles and other tissues between the skin and the bone. The radius and ulna are divided at the upper end of the vertical incisions. In this manner one flap contains the extensor tendons and the other the flexor tendons. The skin and fascia are freed from the muscle of the flap for about half the length of the flap and the tendons in each flap are divided into two groups. Each group is sewed together so as to make a loop. The skin of each flap is then sutured over the flap to cover the bundles of tendons, and a longitudinal incision is made in the skin of the flap opposite the loop of the tendons. A second incision is made in the folded over skin opposite the first incision. These button-hole incisions are about one inch long. A similar procedure is carried out with each flap. In this manner the anterior flap contains the flexor tendons and the posterior contains the ex- tensor tendons. In each of these two flaps the long tendons, which have been sewed together in a loop, surround a perforation that is made in the skin covering the flaps. A rubber tube is placed through the perforation in the 342 OPERATIVE SURGERY anterior flap and another rubber tube in the posterior flap. No traction is made upon these tubes for about ten or twelve days when gradual traction is begun. The patient can voluntarily move the anterior or flexor flap or the posterior or extensor flap. An apparatus fitted over the forearm and con- nected with these flaps in front and behind can be worked voluntarily by cords running from the flaps to the flngers of the artiflcial hand. A motor or cineplastic stump can also be constructed by having tlie group of anterior flexor tendons attached to a piece of bone, as to the end of the radius, and the posterior or extensor tendons to the end of the ulna. About two inches of the bone is resected, just proximal to the end, leaving the y^ Fig. 353. — I^ines of incision for amputation of forearm; A, by cuff method; B, by equal flaps; C, by oblique circular method; D, by circular method. ends of the radius and ulna unconnected. A slight constriction is placed on the stump behind the ends of the bones and when healing takes place a ring is fitted, which is capable of transmitting motion to an appliance that is connected with it. This works on the same principle as the perforated cine- plastic flap. If there is infection the cineplastic amputation should not be attempted, but all of the tendons and muscles of the stump should be saved and after healing has occurred and infection has been overcome the cineplastic ampu- tation may be done. Cineplastic amputations producing a motor stump have been used in THE ITPPEK EXTREMITIES 343 ll.ilv, bill \\\c iiH'tliod lias iiol hccii widely adopted. It ap])areiilly lias not been sat isfat-lory in Anieriea. It ixMinires very considerable sacrifice of the bdiie in okKm- to produce tlu' motor stuiiii) and consequently greatly shortens the st 11111]). The llai)s are dil'tieult to ki'cp in good condition, but the most ini|)ortaiit objection seems to be that it is difficult to obtain in America the proper apparatus to be applied and, of course, Avithout the proper apparatus the cineplastic stump is of no more value than the simpler amputation. If attempted in amputation above the elbow the same principle would be adopted as in the forearm. In any amputation about the arm or forearm as much tissue as possible sliould always be saved. An effort should be made to provide a stump as nearly ideal as it can be made. This means that the scar should l)e linear, sliould not be adherent to the bone, and should not have too much redundant tissue. In amputation about the hand ever}'^ effort must be made to preserve as much of the hand, and particularly of the fingers, as possible. To leave one finger, however, when the tendons are destroyed is doubtful wisdom, as it becomes ankylosed and painful and better service may often be obtained by providing a hook or some similar device that can be attached to the end of an artificial arm. The stump of the forearm is valuable for leverage and should be left long except that, when the bones of the carpus are seriously injured, it may be better to amputate at the wrist joint than through the carpus or at the carpometacarpal junction. If the bones in the stump of the forearm measure less than three inches from the tip of the olecranon it will be difficult or impossible to adjust a satis- factory artificial arm, though if it is contemplated not to use an artificial arm even so short a stump is of considerable service. The possibility of the use of an artificial arm must always be borne in mind when amputating in the arm or forearm, though many patients do not wear artificial arms, whereas after amputation in the lower extremity an artificial leg is always* most desirable. An amputation through the elbow is difficult to fit with an artificial arm, so if an artificial arm is contemplated and a satisfactory stump cannot be se- cured, from the forearm, it will be better to amputate about one inch above the condyles of the humerus. In amputation of the forearm the stump should be as long as possible. The anatomy of the parts must be borne in mind as in operations elsewhere. The main nerves of the forearm, which are the median, the ulnar, the inter- osseous, and the radial, should be identified as well as the arteries. The re- lations of these structures to the muscles vary at different levels of the forearm. Amputation at the elbow may be done by any operation that permits sat- isfactory covering of the end of the bone. It must be recalled that am- putation or disarticulation through the elbow is not satisfactory if an arti- ficial arm is to be worn, and also that the end of the humerus requires a laro-e flap of skin to cover it satisfactorily. The anatomical structures of importance about the elbow are important. The largest artery is the brachial. 344 OPERATIVE SURGERY Avitli the superior and inferior profunda, and the anastomotica magna. The flaps will usually contain the radial with its recurrent branch and the ulnar with its recurrent branches. The position of the ulnar nerve, the musculo- spiral, and the median, the last of which lies internal to the brachial artery at the elbow joint, must be borne in mind. Probably the most satisfactory method of amputation at the elbow is the elliptical, or oblique circular, method ; though a long posterior flap and a short anterior flap make a satisfactory amputation as the skin on the back of the forearm is thicker and tougher than tlie skin on the front of the fore- arm. The necessities of the occasion, however, ma}' demand a longer flap from the front of the forearm or an external and an internal flap. Fig. 354. — Lines of incision for amputation at elbow by posterior elliptical flap. If the amputation is to be done by the elliptical method, this is begun by marking out the skin flap and making the upper limit anteriorly about oppo- site the condyles (Fig. 354). The lower limit is posterior and about one and one-half diameters of the arm below the condyle, that is, about one-half of the circumference of the arm. The flap is about four inches long in the av- erage case. The incision is begun with an ordinary scalpel at the upper limit with the .joint flexed at a right angle and passes down the inner side of the joint and obliquely down to the lower limit, then upward on the outer por- tion of the limb to the point of beginning. The skin and fascia are cut through and when retraction has occurred the muscles are divided on the line of the retracted flap. The posterior muscles are dissected free from the bone and when the dissection has reached the ligaments of the joint the ligaments are TilE UPPER EXTREMITIES 345 divided and left atlarlird to llif muscle. Disarticulation is completed by an incision in front and llu> posterior muscle flap is turned forward and sutured over the articular surface. The skin flap is then separately sutured. The convex lower end of the flap is fitted into concave upper part of the ellipse. If the disarticulation is done hy a long posterior and a short anterior flap the incisions are marked out beginning about an inch below the condyles. The posterior flap is shaped by carrying the incision down and then backward across the back of the forearm. .This joins a similar incision on the other side. The anterior flap is about one-half the length of the posterior flap. The length of both flaps is equal to about one-half the circumference of the arm at the condyles. The fascia is incised and allowed to retract and the muscles are cut on the level of the retracted flap. They are dissected from the bone Fig. 355.— Lines of incision for amputation of the arm: A, by lateral flaps; B, by long external Hap; C, by circular method. up to the ligaments of the joint and the ligaments are divided as in am- putation by an ellipse. As much of the ligaments as possible is left attached to the muscle flap. This is a rule in amputation at any joint. The ligaments of the head of the radius are divided behind as the elbow is flexed, and in this manner the joint is opened. The capsule of the joint is divided around the olecranon and the elbow is then extended and division completed anteriorly. After tying the vessels the muscles are sutured over the joint and the skin is closed as in amputation by the ellipse. Amputation o'f the arm may be done at any level but if an artificial arm is to be employed the stump should be not longer than results from the section of bone about one inch above the condyles (Fig. 355). Every 346 OPERATIVE SI'RGERY inch of good stump that can be saved above this adds to the strength of the stump and makes the artificial arm more efficient. The anatomy of the arm must be thoroughly considered before undertaking an amputation. At the upper part of the arm all the important cords and vessels are on the inner portion of the arm. The musculospiral nerve about the middle of the arm is closely connected with the humerus, and it is particularly important to guard against the possibility of the stump of this nerve being involved in the healing of the bone after amputation. This nerve should be identified, pulled doAvn, injected with alcohol, and divided so that it may retract. This treatment, of course, should be given all nerves that can be recognized but it is particularly important in the musculospiral. Amputation in the lower third of the arm may be done satisfactorily Avith the circular method, or any form or shape of flap can be used that suits the emergencies of the situation. An external and internal flap give better drainage. If the circular method is used it is done as recommended for other circular methods and the wound is sutured anterior-posteriorly in order to secure satisfactory drainage. The modified circular method with short flaps or a short anterior and a long posterior flap may be used. If flaps are used they are so fashioned as to provide satisfactory covering for the stump. All the nerves must be treated as mentioned for the musculo- spiral. Amputation of the middle third of the arm may be done with flaps that are equal or unequal. Usually a long anterior and a short posterior flap are used. The flaps should be equal in length to one-half the circumference of the limb and the anterior flap is twice the length of the posterior. The bra- chial artery should lie in the anterior flap. It is highly important that the nerves be identified and properly treated. Amputation of the upper third of the arm is best done by a single exter- nal flap, though anterior and posterior flaps may be used. If the external flap method is adopted the vertical incisions are begun at opposite points, anterior and posterior, and are about an inch below the point of division of the bone. These incisions pass downward and curve to a point on the outer side of the arm so that the flap is equal in length to the diameter of the limb, which is a third of the circumference. An inner incision connecting the upper ends of the two vertical incisions is made and passes obliquely downward and inward on the portion of the arm next to the thorax. It is best to save the tendon of the major pectoralis muscle. If the bone is to be divided above its insertion, the periosteum with the insertion of this tendon is stripped up and left in the flap and is sutured to structures on the outer or front side of the stump of the bone. The tendons of the latissimus dorsi and the teres major muscles are also preserved if possible. The cir- cumflex nerve and the posterior circumflex artery are kept from injury by making the incision along the thorax side of the arm low down. After the muscles have been divided to the bone the outer flap is retracted and then the soft parts of the inner portion of the arm are also retracted to expose the THE UPPER EXTREMITIES 347 bone. A iiiallruMc rcl ractor is jilacccl internally in order to protect the ves- sels ■while the bone is being sawed. Amputation or disarticulation at the shoulder joint can be done by the external racket incision of Larrey, by the anterior racket incision of Spence, or by the U-shaped tiap. The great problem in all of these operations is the control of hemorrhage. The ditTiculty ^vith a tournifiuet lies in the fact that a tourniquet will slip after disarticulation at the shoulder by any operation unless it is fastened by some special method. Sometimes preliminary liga- Fig. 356. — W'yeth's method of hemostasis for amputation at shoulder. tion of the subclavian artery is advisable if the amputation is done because of a tumor that encroaches upon the joint and makes the application of a tourniquet so near the lines of incision that too small a margin of healthy tissue will be left. If the metal pins of Wyeth are used to hold the tour- niquet in position the anterior piu enters at the middle of the lower margin of the anterior axillary fold and emerges about an inch internal to the tip of the acromion process. The posterior pin enters the corresponding point on the posterior axillary fold and emerges posterior to the first pin and about the same distance internal to the tip of the acromion process. A large soft 348 OPERATIVE SURGERY rubber tube is wrapped arouud the shoulder internal to the pins after the tips of the pins have been protected by cork to prevent injury to the oper- ator's hands. The tube is wrapped around tightly four or five times and securely fastened by tying the ends with a bandage, and also by a stout clamp. The ends are placed posteriorly so they will be out of the way during the manipulation of securing the vessels and severing the nerves, which are at the anterior and inner portion of the upper arm (Fig. 356). If the external racket method is to be used the incision begins just be- low and in front of the acromion process and is carried down vertically on the outer surface of the arm for about four inches. From the center of this incision an oval incision is begun which is carried around the arm down- ward and then upward in such a manner that the lowest point of the oval Fig. 357. — Lines of incision for amputation of shoulder by anterior racket method of Spence. incision is on a level with the lowest end of the vertical incision. The oval incision is carried only through the skin and subcutaneous tissue at first. The anterior structures are then divided down to the bone and after this the posterior structures. The capsule is cut over the head of the bone and the arm rotated outward when the tendon of the subscapular muscle is cut. Af- ter this the arm is rotated inward and the supraspinatus, the infraspinatus and the teres minor muscles are divided. The rest of the capsule of the joint and the ligaments are divided, saving as much of these structures for the flap as possible. The axillary artery is doubly ligated with catgut and the nerves are treated in the usual manner, being injected with alcohol. All vessels are clamped and tied and the tourniquet is gradually loosened to see if any bleed- ing vessels have escaped. The muscles and fascia are sutured together and the skin is closed in the usual manner. The anterior racket incision (Fig. 357) is done by a vertical incision THE UPPER EXTREMITIES 349 ■\vhicli begins at 1lu' \v\v\ of llie upper portion of the head of the liunierus betAveen the coraeo'ul and acromion processes and passes down through the del- toid and nuijor pectoral muscle to the insertion of the major pectoral mus- ch', which is divided. Here the incision branches and one passes downward and inward and the other downward and outward, forming an oblique incision and surrounding the arm about on a level with the insertion of the deltoid muscle. The vertical part of the incision exposes the joint and the bone. The muscles are cut on a level with the retracted skin and fascia, dissecting up the inner portion of the flap toward the axilla first. The outer portion of the incision, which divides the deltoid muscle just above its in- sertion, is then carried down to the bone, taking care to avoid the circum- flex nerve to the deltoid, by making the outer limb of the incision as Ioav as the insertion of the deltoid muscle. This incision is then carried down to the bone and the muscles are separated from the bone by periosteal elevators. Much of this can be done through the vertical incision by rotating the arm first inward and then outward. The muscles inserted into the head of the humerus are divided and as much of the capsule of the joint is preserved as possible. After securing the vessels and treating the nerves the stumps of the muscles are sutured together to protect the acromion process and the glenoid cavity. Amputation through the shoulder joint may also be done by inner or outer flaps or by other combinations that may appear advisable under the circumstances. Crile makes an incision along the outer margin of the sterno- mastoid just above the clavicle, divides the deep fascia, retracts the omohyoid downward and the trapezius muscle backward, and exposes the trunks of the brachial plexius and also the subclavian artery. The trunks of the brachial plexus are injected with novocaine or with cocaine. A clamp whose blades are protected with rubber is applied to the subclavian artery. Ampu- tation is then carried out without a tourniquet, according to any of the methods that may seem desirable. Amputation of the complete upper extremity, or interscapulothoracic amputation, is occasionally indicated. The method of LeConte is satisfac- tory. The incision begins at the inner end of the clavicle and is carried along the bone to its middle, then curves downward to the anterior axillary fold. The skin and superficial fascia are dissected exposing the inner two- thirds of the clavicle. The clavicle is disjointed from its attachm^ent to the sternum and the sternomastoid muscle is divided Avhere it is inserted into this bone. The clavicular portion of the pectoralis major is separated bluntly from the costal portion of the muscle as far as the anterior axillary fold. The clavicle is pulled upward and forward and the subclavius muscle, which is put on a stretch, is divided at the first rib. The pectoralis minor is next di- vided and its outer portion reflected up with, the clavicle. The axilla and its vessels are fully exposed. The sheath of the vessels is opened, the vein separated from the artery, and two ligatures are passed around the artery. The arm is then held up to empty the blood into the veins as much as possi- 350 OPERATIVE ST'RGERY ble and two ligatures are placed on the vein. If the cephalic vein enters the axillary vein above the point of ligature it will also require a ligature. The vessels and the brachial plexus are divided. The costal portion of the pecto ralis major is severed, which completes the division of the anterior attach- ments of the arm. The posterior incision is then carried from some point on the anterior incision, as near the tumor as it is thought safe to go, back- w^ard and downward to the lower angle of the scapula and then to the pos- terior axillary fold. The skin and fascia are dissected for a short distance, the trapezius muscle is divided, and the transversalis coli and the posterior scapular arteries are secured and divided. " The muscles attached to the inner border of the scapula are divided close to the bone, the seratus magnus mus- cle is severed, and the latissimus dorsi is divided at the posterior axillary fold. The arm is now held to the body only by the skin of the axilla. If there is enough flap to cover the wound the anterior and posterior incisions may be sutured over the axilla, but if more skin is needed a flap should be fashioned from the under surface of the arm with its base at the axilla before completing the amputation. The skin and the superficial fascia are united in the usual manner and a drain is inserted at the lowest angle. No effort is made to suture the muscles. Crile advises dividing the clavicle and resecting the inner half of the bone to expose the subclavian vessels and the brachial plexus. He then injects the brachial plexus with cocaine, or novocaine, ligates the subclavian artery and then the subclavian vein. The rest of the operation may be com- pleted according to the method of LeConte. The chief advantage of the method of LeConte is in exposing the subcla- vian artery and vein so that the artery can be readily tied before the vein is divided. In this manner much loss of blood is prevented. EXCISIONS Excision of the wrist joint may be partial or complete. In partial ex- cision the region to be excised is exposed by an incision tliat injures the ten- dons, vessels, and nerves as little as possible. In complete excision the oper- ation may be done by a single dorsal incision, by two dorsal incisions, or by two bilateral incisions. The styloid processes of the radius and ulna and the base of the second metacarpal bone are identified. When a single dorsal in- cision is used it is placed along the outer border of the extensor indicis tendon. The incision is about four inches long and begins over the lower end of the radius and ends about the middle of the second metacarpal bone. The dorsal structures are freed while extending the wrist to relax the exten- sor tendons. The bones of the wrist may be excised subperiosteally through this incision by making strong retraction. AVhen the structures are large and the tendons strong two dorsal incisions are more satisfactory. Here a radial incision starts over the lower end of the radius about half way between the styloid process of the ulna and the styloid process of the radius. The THE UPPER EXTREMITIES 351 iiu'isioii is t'jirrit'd ()l»li(|ii('ly dowiiw;! fcl lo 1lu' oiifci- side of the luiddlc of the second metfu-arpal l)oiu'. Tlu' upper end of the ineision may be proloii<;'od on the forearm if it facilitates the operation. The tendon of the extensor indicis is retracted outward, thus exposing the metacarpal bones. The dorsal branch of the radial nerve must be protected. The posterior annular liga- ment is divided and the wrist joint is opened. The second incision begins about one and one-quarter inches above the tip of the styloid process of the ulna and goes downward to the base of the fifth metacarpal bone. It is on the outer side of the tendon of the extensor carpi ulnaris and exposes the ulna and the unciform bone. The dorsal branch of the ulnar nerve to the little finger must be avoided. The carpus is removed by stripping the bones from their ligaments and periosteum and removing them with forceps or a curet. The ends of the radius and ulna can be removed by pushing them through the wound, stripping back the periosteum, and sawing off the diseased portion. Drainage tubes are inserted and the hand is put in a splint. Bilateral incisions are sometimes used for excision of the wrist joint. Here the outer incision begins at the middle of the loAver end of the radius about on a level with the base of its styloid process. The incision goes down- ward and outward, parallel with the tendon of the extensor longus pollicis to the inner side of the first carpometacarpal articulation. From this point it is carried down the outer side of the second metacarpal bone to the middle of this bone. This incision is four inches long. The radial artery should be avoided. The incision will divide the insertion of the tendon of the extensor carpi radialis muscle but no other tendons. The soft tissues on the ulnar side of the incision are dissected while the wrist is extended. The trapezium bone is not removed until last and should be left unless its removal is neces- sary. The second lateral incision, about two inches long, begins at the loAver front end of the ulna and goes down between the bone and the tendon of the flexor carpi ulnaris as far as the middle of the fifth metacarpal bone on its palmar surface. The inner side of the wound is retracted and the insertion of the tendon of the extensor carpi ulnaris is cut. The posterior soft tissues are dissected from the bone while the wrist is strongly extended. The pos- terior ligaments are divided, though the connection of the tendons with the radius is left (Fig. 358). In excisions by any method it is wise to remove diseased bone and leave healthy bone wherever possible even though a typical operation cannot be done. Excision of the elbow may be performed for active disease or for anky- losis. In the presence of active disease the pathology is removed as thoroughly as seems necessary. When the operation is for ankylosis a more typical pro- cedure can be followed. One type of operation, however, cannot well meet all indications. By whatever method of approach the operation is done, an effort should be made to remove no more bone than is necessary and it must always be borne in mind that a stiff elbow joint ankylosed at an angle is pref- erable to a flail joint (Fig. 359). 352 OPERATIVE SURGERY In the typical operation the humerus is sawed through at its epicondyle, the ulna at the base of the coronoid process, and the radius at its neck. Some- times more bone than this must be sacrificed. Sometimes much of the ole- cranon can be saved and this is always desirable, as it contains the insertion of the triceps muscle. The insertion of the brachialis anticus muscle in the ulna and the biceps in the radius should be preserved if possible. The pos- terior part of the joint is subcutaneous. All of the important vessels and nerves lie in front of the joint, except the ulnar nerve, which must be carefully protected, particularly that portion which lies behind the inner con- dyle of the humerus and along the inner side of the olecranon. Excision may be done by a long posterior incision, by a lateral incision on the radial side, or by a right-angle incision. After the operation the arm is put in a splint with the elbow slightly flexed. Extension can be placed upon the forearm by boards in a plaster of Paris case. Adhesive plaster Fig. 358. — Lines of incision for excision of the wrist: A and A', two dorsal incisions (Oilier); B, single dorsal incision of Boeckel; C and C bilateral incisions of leister. Fig. 359. — Eines of incision for excision of elbow: A and A', long external and short internal incisions; B, a right angle incision. strips are first applied to the forearm in someAvhat the same manner as is used on the leg in Buck's extension. These are connected by elastic tubes to a cross piece over the ends of the boards as they protrude beyond the hand. This apparatus is removed at the end of two Aveeks and passive motion is begun (p. 167). When the radial, or bayonet incision of Oilier, is made the upper arm is placed in a vertical position with the forearm slightly flexed. The incis- ion begins about two inches above the upper portion of the olecranon in the space between the supinator longus and the triceps about one and one- quarter inches above the external epicondjde. The incision is carried down- v^^ard parallel with the humerus to the epicondyle and then downward and in- ward to about the middle of the outer side of the olecranon. From this point it goes over the back of the olecranon and downward for about two inches. THE UPPER EXTREMITIES 353 Oil JU'eoiiiit of its sliiipi' it is ol'ten callcil the hjiyoiiet incision. The ti'ieeps on tlu- inner side is sepai'atecl from the nuisek's on its outer side and the eapside of the joint is exposed and opened. The periosteum and capsular ligaments are divided at the outer edge of the articular surface and the at- tachiiieiits of the muscles are raised with a periosteal elevator. The perios- teum of the ulna with the tendon of the triceps is raised from the other edge of the articular surface. The external condyle of the humerus is de- nuded and the periosteum and muscular and ligamentous attachments are raised. The elbow joint is flexed and the lower end of the humerus protrudes into the wound. The periosteum is completely separated and the lower end of the bone is sawed off. The head of the radius and the ulna are also removed. The posterior median incision has been a very popular one for excision of the elbow joint. It is about four inches long and. is in the direction of the long axis of the forearm. It begins two inches below the tip of the olecranon ijroeess, passes over the posterior border of the ulna upward and across the center of the olecranon, splits the triceps tendon and is carried down to the bone. The joint is opened and the parts are retracted, taking par- ticular care to protect the ulnar nerve on the inner side of the olecranon and ulna. The periosteum is divided over the humerus and stripped up, keep- ing close to the bone. The ligaments are raised in the same manner. The tissues on the outer side are also separated from the bone until the outer condyle is reached. The posterior interosseous nerve must be avoided in this region. The joint is strongly flexed and the lower end of the humerus protrudes through the wound. The bone is sawed in the usual manner. Excision by a right angle incision is done by beginning a longitudinal incision three inches long on the outer side of the joint about one and one- half inches above the tip of the olecranon. This is carried doAvn behind the outer condyle at a point just behind the neck of the radius. A second incision is carried inward at a right angle and crosses back of the ulna. This triangular flap with the periosteum of the ulna is dissected, the external liga- ments are divided, and the head of the radius is removed. Then the ulna is exposed and sawed across and the humerus finally is dislocated into the wound. After any of these operations, muscles or fascia may be interposed be- tween the ends of the bones. A flap of fascia or muscle from the brachialis anticus or from the anconeus may be taken. A strip of fascia lata from the leg may also be utilized. This is fitted over the lower end of .the humerus as a hood or cap with the fatty surface toward the joint. In any excision of the elbow enough bone should be removed to permit the hand of that side readily to be carried to the opposite shoulder after the interposition of fascia. Excision of the shoulder joint usually requires the removal only of the head of the humerus, though sometimes it may be necessary to remove the glenoid cavity also. The excision may be done through the anterior incision of Oilier, through the vertical incision of Langenbeck, or through the curved 354 OPERATIVE SURGERY flap incision of Senn. (Fig. .360.) It may also be done through a po.sterior approach, according to the method of Kocher. The anterior incision is about four inches long and begins at the outer side of the tip of the eoracoid process and passes downward and slightly outward along the anterior margin of the deltoid muscle. The capsular liga- ment is opened to the outer side of the tendon of the long head of the biceps. The periosteum and the capsular ligaments are raised from the bone with a periosteal elevator as far outward as possible while the arm is rotated in- ward. The insertion of the muscles into the greater tuberosity is raised along with the periosteum. This may be done by a periosteal elevator or with a chisel if the condition of the bone permits. The tendon of the biceps Fig. 360. — Ivines of incision for excision of the shoulder joint; A, curved incision of Senn; B, anterior incision of Oilier; C, vertical incision of Langenbeck. is retracted outward, and the periosteum is elevated toAvard the axilla. The head of the humerus is dislocated through the wound, the periosteum of the posterior surface is completely elevated and the head of the bone is saw^ecl off. Drainage is best made by a posterior stab wound. In the vertical incision of Langenbeck the arm is rotated inward and the incision begins at the anterior border of the acromion process and goes down about four inches in the line of the bicipital groove. The incision splits the deltoid muscle to the tendon of the biceps. The sheath of this tendon is divided, the tendon retracted, and the joint opened through the posterior portion of the sheath. The periosteum and capsular ligament of the .joint are ele- vated while first rotating the arm outward and then inward. The bone is removed as in the previous operation. This operation has not the advantages of the preceding one because the incision is deeper and some of the nerve supply to the deltoid is destroyed. Senn practiced approach to the shoulder joint by raising a large U-shaped THE UPPER EXTREMITIES 355 Hap \vitli its base over llie shoulder joint and eoiisisliiig largely of the deltoid muscle. This gi\es an exetdleiit exposure hut divides the deltoid and makes an extensive Avound. Excision of the shoulder joint can be done posteriorly by the method of Kocher. This incision begins at the acromioclavicular joint, goes backward along the acromion and spine of the scapula, dividing the trapezius muscle. From about the middle of the spine of the scapula the incision is carried doAvnward toward the posterior fold of the axilla ending about one and a half inches from the lower border of this fold. The infraspinatus and supraspinatus muscles are separated from the acromion and the acromion proc- ess is divided with a saw or chisel about where it joins the spine of the scapula. Holes are drilled in the bone for future suturing before it is divided. The acromion Avith the deltoid muscle attached is retracted over the head of the humerus. The joint is opened along the line of the bicipital tendon, which Fig. 361. — Lines of incision for removal of diamond-shaped area at elbow. is retracted forward as the external rotators are retracted backward. The head of the bone is thus readily exposed and when the operation is com- pleted the acromion is sutured to the spinous process of the scapula. ARTHRODESIS OF THE ELBOW The operation for immobilizing the joints, arthrodesis, is but seldom indi- cated in the joints of the upper extremity. Occasionally it is needed to fix the elbow joint. This is best done by the procedure of Sir Robert Jones. A diamond- shaped area of skin is excised (Fig. 361). The upjDcr extremity of the diamond- shaped incision is at the junction of the middle and lower thirds on the an- terior surface of the arm. The lower extremity of the incision is at the junction of the middle and upper thirds of the anterior surface of the forearm. The lateral angles are" in front of the condyles of the humerus. The area of the skin surrounded by these incisions is excised down to the fascia. 356 OPERATIVE SURGERY The arm is flexed and the upper extremity of the incision on the arm is su- tured to the lower extremity on the forearm. In tliis manner the arm is flexed and kept in this position without interfering with the bone. INFECTION OF THE HAND Infections of the hand and fingers are common. Incisions for infection should he made down to and including the infected tissue, but preferably the periosteum and bone should not be incised unless they have become in- volved. If infection is superficial to the bone and an incision is made through it to the bone, infection may thus be carried to the bone. The incision is made by blocking the nerves on the proximal side of the infection well out of the region of the inflammation, or it may be done under light gen- eral anesthesia, as nitrous oxicl anesthesia. The incision should be suffi- ciently ample to evacuate the inflammatory products, but it is best not to Fig. 362. — ^lethod of Dorrancc for incision of felon and jjlacing of drainage. carry it out of the infected region, for if this is done the natural defenses that haA^e been formed around the infected focus as barriers of lymph and leukocytic inflltration will be broken through by the knife. The bacteria will then have free access to unprotected tissue. The incision should preferably be made on the side of the finger instead of directly in the palmar surface so as to interfere as little as possible with the action of the tendons. It should be in the long axis of the finger and should not disturb the tactile area. For infection of the tip of the finger, Dorrance makes an incision parallel to the nail and a short distance toward the palmar side. This separates the nail and its supporting soft tissue from the tip of the finger and the tip of the bony phalanx, practically turning doAvn a palmar flap consisting of the tip of the finger. Por drainage a thin piece of rubber tissue is placed across the bottom of the incision to prevent pocketing and to facilitate the discharge of pus (Fig. 362). The resulting scar interferes but little with the function of the tip of the finger. THE UPPER EXTREMITIES 357 Inllaminatioii ai-ouiul llie nail, or jiaroiiycliia, l^egins around the site of the nail. Tlie inllaiinnatory products may be liberated l)y an incision that goes downward on each side of the root of the nail, turning back the soft tissue as a liap to expose the infection. It is important to remember that the bed of the nail near its root should be disturbed as little as possible, and any incision should be so placed as to avoid this. In deep infections of the hand and fingers, if recovery is not prompt after the proper application of hot water dressings, an incision should be made. This, however, should not be done until it is evident that either the condition is not improving under the wet dressing, or that there is localization of the inflammatory process. In deep infection of the hand incisions can only be satisfactorily made under a general anesthetic. The anatomy of the hand, particularly of the bursae, should be borne in mind, and the significance of the fact that the tendon sheaths to the thumb and to the little finger communicate with the bursa of the palm of the hand and wrist should be appreciated. Consequently, infection in the thumb and little finger is potentially more dangerous than infection of the other three fingers. When the index, middle or ring fingers are infected the sheath of the flexor tendons should be incised where the in- fection appears most pronounced. The length of incision will depend upon the condition. Sometimes two or three incisions of one-half inch in length are more satisfactory than a long incision. When the tendon sheaths of the thumb and little finger are infected the incision should open the bursa in the palm of the hand if the infection has shown the slightest tendency to travel in this direction. Sometimes, however, the inflammatory products will wall off the rest of the bursa and it should not always be taken for granted that if one end of the tendon sheath is infected therefore the whole of the bursa is involved. Infection of the middle palmar space is taken care of by short incisions, preferably in the creases of the palm. If the infection is very deep and appears to involve the back of the hand as well as the palmar aspect, a pair of forceps is carried through a metacarpal space and pushed to the back of the hand. A small rubber tube is drawn through, transflxes the hand, and affords drainage from both the palmar and the dorsal surfaces. Infection of the thenar space may be reached by a dorsal incision on the radial side of the metacarpal bone of the index flnger. Sharp-pointed forceps are passed from this point into the infected area and drainage is in- serted. Infection above the annular ligament of the wrist should include not only longitudinal incisions in this region, but incisions in the palm of the hand. These infections are best opened by inserting closed forceps, after incising the skin, and when pus is reached spreading the forceps widely. As shown in the middle of the last century by Hilton, this is much better than cutting into the inflammatory tissue. It is best not to use too much drainage material for the pressure may cause necrosis and lead to adhesions. If the pus is abundant, however, and rubber tissue is not sufficient, it may be necessary to place a small, soft rubber tube. 358 OPERATIVE SURGERY DEFORMITIES A rather common lesion is wliat is known as Dupuytren's contraction, which is a contraction of the palmar fascia and of those extensions of the palmar fascia that lead to the fingers. The thumb is not often affected. If the skin is adherent it is thrown into wrinkles. The condition has been remedied by different types of operations, depending npon the severity of the disease. Usually only one or two fingers are involved. Occasionally all of the fingers are affected. The ring finger is most commonly involved. Subcutaneous incisions with a tenotome are almost never curative, as the condition rapidly recurs. The most satisfactory operation is complete ex- cision of the diseased portion of the palmar fascia. This is best done by an incision preferably placed so that it will not result in a longitudinal scar in the palm of the hand. Often a triangular flap can be formed by a trans- verse incision across the palm of the hand which follows the crease of the skin. On the ulnar side another incision is made at a right angle to the transverse incision and triangular flaps of skin are turned back. If this does not afford sufficient room another longitudinal incision can be made on the radial side which will convert the incision into an H with two flaps, one to be turned downward toward the flngers and the other upward toward the wrist. It may be necessary to split the distal flap in order to excise the contracted portion of the palmar fascia which is prolonged on to the finger. The dissection is carefully made, taking care not to wound the tendons. It is essential to close the wound completely, leaving no raw surface. After excising the contracted band the skin itself may retract to such an extent that it is impossible to bring it together without too much tension. Here flaps can be taken from the radial side of the hand or from the back of the hand and turned into the skin defect. In aggravated cases in which a large defect of the skin is left in the palm after dissecting aAvay the con- tracted tissue, the proper skin covering is best obtained by procedures that have been described in the chapter on Plastic Surgery, such as raising a flap from the abdominal Avail, leaving the base attached, and suturing the apex of the flap into the wound. The pedicle is gradually divided. Such a procedure, of course, is only indicated in extreme cases. The extensor tendon of the finger is occasionally torn in injuries, a condi- tion which is particularly common in baseball players. This renders complete extension of the terminal phalanx impossible and results in what is known as ''hammer" finger or ''drop" finger. If the finger is seen soon after the in- jury a splint should be applied, placing the finger in an overextended posi- tion until healing has occurred. The splint is left on for a period of two or three weeks. If the condition is not markedly better after this treat- ment operation is indicated. A transverse incision is made on the dorsal surface along the crease of skin on the distal portion of the affected joint. The ends of the incision curve slightly downward toward the nail so that a flap of skin is turned down which exposes the distal portion of the joint. A short longitudinal incision is made beginning about the center of this trans- THE UPPER EXTREMITIES 359 verse incision, at a ri<>lit anti;le to it, and going upward in lli(3 median dorsal portion of the second phalanx. The two ends of the extensor tendon are dissected and united with sutures of fine tanned catgut. The wound is closed with silk or fine silkworm-gut and a finger splint is used to keep the finger in extension for three weeks. "Trigger" finger, or "snapping" finger, occurs when flexion or exten- sion has reached a certain point and the finger appears locked. By an extra exertion the obstruction is overcome, a snap occurs, and the flexion or ex- tension is completed. This condition is caused by some obstacle to the ac- tion of the tendons which is usually an enlargement of a tendon, or a nar- Fig'. 363. — L,ine of incision for operation for webbed lingers, palmar surface. rowing of the tendon sheath. This lesion is found in the flngers and is al- most always in the space between the palmar fold at the base of the fingers and the first crease of the skin on the palm. The tendon is exposed by an in- cision over it and if the trouble is due to a fusiform swelling of the tendon, or to thickening of the sheath, the sheath is split, according to Weir, and left open, and the skin over it is closed. If the obstruction is due to a crumpling up of the flexor tendons by a transverse band of fascia in this region, as suggested by Abbe, the fascia should of course, be divided by a longitudinal incision in the region where most of such trouble occurs, that is, between the palmar creases at the base of the fingers and the next crease in the palm of the hand. 360 OPERATIVE SURGERY Web fingers may be treated on the general principles of plastic opera- tions. Usnally a flap can be obtained from the dorsal surface of one finger with its base on the adjoining finger and a palmar flap made in a reversed direction. If the flaps are not sufficiently long to cover the raw surface of the finger with skin they will at least prevent reunion at the site of the former lo- cation of the web and the raw surface on the dorsal or on the palmar aspect of tlie finger can be covered with skin grafts or permitted to heal by granula- tions (Figs. 363; 364 and 365). Fig. 364. — Line of incision for operation for webbed fingers, dorsal surface. Transplantation of tendons of the forearm is sometimes indicated be- cause of trauma or paralysis. The principles of tendon transplantation in the upper extremity are the same as in the lower extremity, where this operation is more common because of the deformity which follows infantile paralysis. Occasionally after traumatic paralysis of some nerve, as the musculo- spinal, or following severe infection or trauma where the tendon may have been destroyed it becomes necessary to transplant a tendon to a different insertion from the normal anatomical insertion or to reconstruct a section of the tendon that may have been destroyed. Certain general principles in THE UPPER EXTREMITIES 361 transplaiUatiou of tendons liave been eini)lia.size(l by ]Meyer^ and should be followed. These embrace the adjustment of a transplanted tendon in such a maimer that when the muscle is relaxed and the origin of the muscle and the insertion of the tendon are as near together as possible, the tension on the tendon is zero. Thus it becomes necessary to fix the tendon in its loca- tion so that wlien the limb is in such a position as to approximate the origin of the muscle and the insertion of the tendon as closely as possible there will be no tension on the transplanted tendon. Another principle is that wherever possible the sheath of the paralyzed tendon should be used as a pathway for the transplanted tendon or the tendon should be invested with loose gliding- tissue. Wherever possible it should run in the intermuscular Fig. 365. — The flaps as outlined in the two preceding drawings have been dissected and are being sutured. plane of fascia. If the tendon perforates this fascia it is sure to acquire ad- hesions. When such tissue is impossible, as about the wrist joint for in- stance, a fatty bed is provided. If the neighboring subcutaneous tissue does not afford sufficient fat, a flap with subcuticular fat can be raised from the abdomen, as described in the chapter on Plastic Surgery, and the ten- don or tendons to be transplanted are carried through a tunnel of the fat by severing the tendon and then suturing it together. After about tw^o wrecks the base of the pedicle of the flap is gradually severed, the tendon together with the skin and subcuticular fat is adjusted on the forearm, and the flap is su- tured into its new location. The insertion of the tendon must be buried beneath the periosteum. Function should be begun as early as possible in order to avoid adhesions in the transplanted tendons. ■ In injuries or infections about the wrist or hand the tendons are often destroved and it becomes necessary to reconstruct them. Dean Lewis,- of lAm. lour. Surg., 1918, xxxii. No. 1. =Surg., Gynec. & Obst., February, 1917. 362 OPERATIVE SURGERY Chicago, lias done excellent work in reconstruction of tendons of the hand. The tendon of the palmaris longns is often used to bridge defects though it frequently does not afford sufficient material and the transplanted tendon may undergo degeneration and become adherent. AVith early institution of function, however, satisfactory results are likely to be obtained. Passive or active motion should begin three or four days after the transplantation of tendons. According to Lewis the transplanted tendon at the end of three weeks is two or three times as large as normal. It becomes fusiform, being largest in the middle and diminishing toward both ends. The enlargement is great- est in the third Aveek and is due to proliferative changes in the peritendineum as well as to swelling in the transplant from insufficient circulation. While there is some degeneration in all transplanted tendons the transplant as a Avhole is viable and does not act as a bridge to convey tenoblasts from one end of the resected tendon but ncAV tissue is formed from the transplant it- self. If, however, the tendon is transplanted experimentally Avhere it can- not function the proliferative changes do not occur, but the tendon atrophies without any attempt at proliferation. Function greatly stimulates the pro- liferative changes. Fig. 366. — Method of applying the tendon suture of Frisch. A strip of fascia lata may serve as a tendon and, in the opinion of Lewis, is preferable to tendon for repair of defects in the tendons of the hand. Where the injury is extensive and the scar tissue dense it is best first to transplant a flap of skin from the abdomen containing much subcutaneous fat. This should be abundant enough to make a bulging or "humping" in the region in which it is transplanted, for if enough fat is not provided it is difficult for the tendon to function on account of adhesions. Some of the excessive fat will be absorbed and if objectionable, some may be removed later. After the skin and fat flap from the abdomen has become acclimated and its nutrition established in its new location, reconstruction of the tendons is begun, [f this is done with strips of fascia lata, as Lewis prefer.s, the .sub- cutaneous fat is tunnelled with an artery forceps so that the transplant of fascia lata will run entirely through a fatty tunnel. AYhen the muscles are thrown into action the sutures should hold the ends of the transplant well approximated 'to the tendon that is its host. Tendons cannot be sutured by simple interrupted sutures as they Avill cut out. The tendon suture of Frisch^ is very satisfactory (Fig. 366). The play of the flexor tendons of the forearm is greater than the play of the extensors, so interference by adhesions is more marked with the flexor tendons. In the flexor tendon a tube of fascia 'Surg., Gynec. & Obst., February, 1917, p. 132. THE UPPER EXTREMITIES 363 lata is used inslead of a strip \vhicli will suffic^e Tor an extensor tendon. When the skin on the llexor side of the fingers has l)een destroyed and is replaeed by scar tissue, new skin is first transplanted along Avith subcutane- ous fat after ]-emoving the scar. When this has become well established the fascial tube used to reconstruct the defect in the flexor tendon is carried Fig. 367.— Transplantation of tendon of the flexor carpi radialis for paralysis of the extensor muscles of the forearm according to J. B. Murphy. The tendon is divided and a tunnel is formed under the SKin. through small incisions and a tunnel is made in the fat of the transplanted skin. The fascial tube should surround the end of the tendon on the proximal side and can be firmly attached by the Frisch suture to the tendon. The fascial tube is made with the fat side internal. The end of the reconstructed tendon, after being carried through the subcutaneous fat, is sutured to the pei'iosteum in the region of the normal insertion of the tendon. In order 364 OPERATIVE SURGERY to simulate the bands that prevent the tendon from strutting with tiexion a ring may be worn over the finger. McArthur suggests implanting the fascial strip in the fat before it is removed. The strip of fascia to be transplanted is dissected up but left attached at both ends, subcutaneous fat is placed about it and the wound closed. Six weeks later the wound is reopened and the strip of fascia along Fig-. 368.— A skin incision is made four inches higher and the tendon is drawn through. with its surrounding attached fat is transferred to the forearm and hand and sutured in position. This seems to be an excellent procedure. John B. Murphy transplanted tendons from the flexor surface of the forearm to the extensor tendons in order to overcome paralysis of the muscu- lospiral nerve. This was accomplished in the f oUoAving manner : The tendon of the flexor carpi radialis is divided .just below the annular ligament through TIIK UPPER EXTRF.MITIKS 365 a short loiiiiiliidiiKil im-isioii. lilunt dissection willi ]()iii>' scissors is carried up about four iiu-lies beuciilli the skin as far as tlie muscle of the tendon. This is done by inserting' the scissors closed and spreading' the blades, then witlulrawing and inserting- the closed scissors again (Fig. 367). Another in- cision is made at the upper point of this blunt dissection about four inches above the annular ligament and the tendon of the flexor carpi radialis is Fig. 369.— A third incision is made on the back of the wrist and the tendon of the flexor carpi radialis is pulled through. drawn through this incision (Fig. 368). This gives the tendon the proper angle for its maximum amount, of contraction. A short vertical incision is then made on the back of the Avrist over the extensor tendons of the fin- gers and closed forceps are pushed through from this incision to the upper incision on the forearm, grasping the end of the tendon of the flexor carpi radialis and pulling it through the tunnel made by the forceps to the incision 366 OPERATIVE SURGERY on the back of the wrist. This tiuniel is made in the suljcuticuhir i'at (Fig. 369). The tendon passes through the split tendons of the extensor longus and extensor brevis poUieis, the two extensor tendons of the index finger, and the extensor tendon of each of the other fingers. This insertion is made in such a way that the tendons of the thumb and index finger receive the greatest amount of pull, though when full extension is made all five fingers are extended (Fig. 370). The thumb and index finger, however, can be slightly extended without extending the other three fingers. Obstruction of the lymphatics of the arm produces marked swelling. This occurs not infrequently after cancer of the breast and if it appears several weeks or months after a radical operation for cancer it is probably due to the blocking of the lymphatic channels with cancer cells. Operations Fig'. 370. — The tendon is inserted into the extensor tendons of all five fingers in such a manner that the pull will be first exerted on the thumb and index finger. for edema of the arm and forearm following cancer give but temporary relief, but occasionally even this is justifiable. In the rare instances in which the blockage is not due to malignant disease, operation may be indicated. According to the method of Handlej^ an incision about one inch long is made through the skin in the front of the forearm immediately above the wrist, A long probe with an eye at the proximal end is introduced through this incision and -is pushed upward and outward beneath the skin to a point near the elbow. It is cut down upon and exposed. The probe is threaded with a long line of doubled stout silk and this is drawn through from the lower incision to the upper incision. The thread is clamped at the level of the lower incision so that only one-half of it can be drawn through. The probe is reintroduced in the incision at the elbow and pushed under the THE UPPER EXTREMITIES 367 skill 1<) ;i point on llic iiriii over 1lu> iiisciiioii (if 1lu' deltoid ;iiid tlic silk is cari'icd witli it and is unthreaded. The i)rol)e is again iiitrodueed at the original ineislon above the wrist, threaded with tlie other end of tlie silk and is inished inward and u])\vard and made to appear through a short in- eisioii ill the skin on the inner side of the elbow. The probe carries the other end of the thread (Fig. 371). From this point it eari-ies the thread throngh to the upper incision over the insertion of the deltoid and from there liotii probes are introduced under the skin and carry both threads to the back of the arm to an incision made in the posterior border of the deltoid. By a similar procedure silk is buried under the skin on the back p[g 37 1_ — Placing of silk threads on anterior surface of arm and forearm to relieve swelling of the upper extremity. (Handley.) Fig. 372. — Placing of silk threads on the posterior surface of the arm and forearm. of the forearm and the silk made to appear throngh the incision in the skin at the posterior border of the deltoid. The ends of the four threads are now cut so they will be shorter than the probe and one of the four ends that emerge through the npper posterior incision is threaded into a probe and the probe is thrust full length, eye first, through the npper poste- rior incision nnder the skin of the back over the region of the scapnla, and so the probe is unthreaded and leaves the silk in the tunnel made by the probe. The probe is then withdrawn and the procedure is repeated till all four of the silk threads have been placed in different directions. In this way the threads are carried in a radiating manner under the skin of the back (Fig. 372). The incisions are closed Avith sutures. This operation of Handley is 368 OPERATIVE SURGERY devised to create new lymphatic cliaiinels al()ii<>' llie llircads and so 1o iiici'ease the flow of lymph along the newly created lym])li cliaimcls as 1o rclicxc 1lic edema. The operation of Kondoleon depends upon a different principle. While the operation of Handley seems to create new lymphatic channels that of Kon- doleon promotes anastomosis between the superficial and deep lymphatics. If both sets are blocked the operation of Handley is indicated but if the swelling Fig. 373. — Lines of incision for operation of Kondoleon along the outer border of the upper extremity. is due to obstruction in the superficial lymphatics, when the deep set is free from obstruction, the operation of Kondoleon is best. Sistrunk,* of the Mayo Clinic, has obtained very satisfactory results from the Kondoleon operation. A long narrow elliptical incision is made on the outer aspect of the limb extending from the wrist to a few inches below the shoulder joint (Figs. 373 and 374). The skin incision is so made that the wound can be readily closed. The skin is retracted and under each edge of the retracted skin a long cut is made through the edematous fat Fig 374.— Lines of incision for operation of Kondoleon along inn:r border of the upper extremity. down to and through the deep fascia. A piece of tissue including the skin, much of the undermined fat, and a strip of fascia, is removed. The vessels are carefully clamped. The edges of the fascia may be turned under and sutured to the -muscle, though if a sufficient strip of fascia has been removed this is not necessary. The skin is approximated in the usual manner without drainage. If this is not satisfactory a similar incision can be made on the inner side of the arm a few weeks later. ^Jour. Am. Med. Assn., 1918, Ixxi, p. 800. THE UPPER EXTREMITIES oiii) SUBACROMIAL BURSITIS CodiiKui, of Boston, has described an inllammation of the subacromial bursa, which is often responsible for trouble with the shoulder joint. This affection is frequently accompanied by deposits of lime salts in the tendon of the supraspinous muscle and Brickner thinks that tears or bruises of this tendon are often followed by the deposit of lime salts on its surface. When these deposits are present with subacromial bursitis it is necessary to remove them. Codman advises operation by making an incision from a point midway between the coracoid and the acromion processes downward about two and one-half inches, splitting the fibers of the deltoid muscle. The bursa should be cut down upon carefully as in entering the peritoneum and its surface is recognized and incised. As much of the adherent or thickened bursa is re- moved as possible and the wound is closed in layers. Motion should be begun in about ten days. Brickner opens the bursa from an incision which goes downward from the outer border of the acromion over the greater tuberosity of the humerus toward the external condyle. The fibers of the deltoid muscle are split and retracted. The bursa is carefully opened and adherent bands are divided. By rotating the arm the whole subacromial bursa is explored. The floor of the bursa is then incised in the same line as the skin incision over the greater tuberosity of the humerus and the insertion of the supraspinatus tendon is exposed. The bursa is dissected from the tendon and any deposits of lime salts are removed. If the tendon shows evidence of an injury this re- gion is trimmed away and the tendon is sutured. If the roentgenogram has shown deposits of lime salts in the tendon these should be removed by splitting the ten- don dow^i to the deposits, and after removing the lime salts the tendon is sutured with catgut. The wound in the floor of the bursa is closed with fine catgut stitches and the roof of the bursa is similarly closed. The deltoid and the skin are sutured separately and the arm is placed in the position of abduction until healing takes place. Codman operates to restore the supraspinatus tendon if it has been in- jured by being pulled from its insertion into the head of the humerus, by making an incision as in his operation for subacromial bursitis and then continuing the upper end of the incision over the root of the acromion process directly back over the shoulder. The acromio-clavicular joint is divided. The base of the acromion is severed with a wire saw, care being taken to avoid injury to the suprascapular nerve. A small portion of the trapezius muscle is divided and the acromion process along the deltoid and the outer half of the w^ound is retracted outward. If the supraspinatus muscle has been torn the articular portion of the joint is visible, but if the operation is merely exploratory, this muscle must be divided before the joint can be seen. The tendons are sutured with tanned catgut and the acromion process is united by tanned catgut or tendon sutures passed through drill holes on either side of the saw line. CHAPTER XIX OPERATIONS OX THE LOWER EXTRE:\riTY AMPUTATIONS The same general principles that have been emphasized in amputations of the upper extremity also apply to amputations of the lower extremity. The problems are slightly different, however, because of the necessity of weight bearing on the stump of the leg, for which there is no occasion after ampu- tation of the arm. The ^Yorld War has thrown much light upon the problem of amputation, particularly concerning the most efficient stump. Starr^ speaks of the desirability of having an ideal stump in leg amputa- tions. He defines such a stump as one that is best suited for an artificial ap- pliance for that portion of the leg. The ideal stump should have a linear scar, be free from puckering or infolding of the skin, and with sufficient flap but no redundancy. There should be a pad of fat and subcutaneous tissue over the head of the bone, but it should not be adherent. The joint next above the amputation must have a full range of motion. Such a stump is not often obtained, but it should be kept in mind and an effort made to secure it whenever amputation is necessary. The guillotine operation is even more unsatisfactory in the lower extremity than in the upper extremity and should but seldom if ever be done. It probably provides but little if any more against infection than the other types of amputa- tions and it makes a secondary operation, as a rule, imperative. The better meth- ods of dealing with infection have caused the guillotine operation to be discarded. Stumps may harbor infection either in the soft tissues or in the bone, and in military surgery there is very apt to be a foreign body which will cause an ulcer or a sinus. A stump which shows a persistent ulcer or sinus should be operated upon under a tourniquet, the sinus or ulcer excised well into healthy tissue, and diseased bone or foreign body removed if present. This is much better than blindly scraping with a euret in a bloody field. Spurs of bone are sometimes the cause of pain and may be due to the snapping off of the last portion of the bone before sawing has been completed, or to the lack of proper removal of the periosteum and endosteum. Painful neuromas are best avoided by following the suggestion of Huber and Lewis, which has already been mentioned, and injecting tlie nerve trunk with alcohol just above the point of section. The nerve should be well pulled down so that after section it will retract into the soft tissues. Starr finds that ampu- tation of the toes with a plantar flap causes almost no disability. One toe should never be left, for it becomes deformed and is of no use. The tarso- ijour. Am. Med. Assn., Nov. 22 1919, pp. 1585-1590. 370 THE LOWER EXTREMITY 371 metatarsal ainputation is satisfactory, aceorclijig to Starr, if the peroneus muscles are lel't intact on the outside aud the tibial on the inside. The midtarsal amputation, hoAvever, results in an unbalanced foot with elevation of the heel and gives a stump that cannot be properly fitted either with an artificial foot or boot. This method of amputation, which is known as the classical Chopart, should never be done. In its stead the Syme operation gives excellent results when properly performed. Amputation of the leg should not be done within four inches of the ankle joint, because a stump too near the ankle will make it impossible satisfactorily to fit an artificial leg. Above this point, however, the longer the stump the more helpful will be the application of an artificial appliance, because there is greater leverage and, consequently, better walking and less limping. According to Starr the term ''site of election," as applied to leg ampu- tations should be dropped, for it is a source of confusion. Below the knee the stump may be so short as to be useless. In the thigh the lower the stump the better the leverage. The Gritti-Stokes amputation is one of the best thigh am- putations when an artificial limb is to be used. In elderly people with gan- grene of the foot or leg the Stephen Smith operation through the knee is exceedingly good and easily performed. The chief fault of the Gritti-Stokes operation is that the approximation of the patella to the end of the femur is often unsatisfactory and unequal. A stump shorter than five inches from the perineum can rarely be fitted with an artificial leg without a pelvic band. After amputation at the trochanter minor or above this point, includ- ing amputation at the hip joint, it is necessary to have a ''pelvic cradle" or "tilting table", as it is called by the English manufacturers, which has an automatic lock both at the hip and the knee. Aside from the Syme amputation at the lower end of the tibia and the Gritti at the lower end of the thigh, a complete end bearing stump is rarely possible, according to Starr, though by a hammock suspended in a bucket the stumps may take much of the weight. Amputation through the knee joint is difficult to fit with an artificial appliance, as the joint must necessarily be much lower than the normal knee joint ; but if good covering is provided for the condyles, preferably with an anterior flap, it will make a fairly good end bearing stump. Because of the liability of infection in military surgery some operators prefer this type of amputation to the Gritti-Stokes, thinking that in the latter operation it is difficult to obtain satisfactory results in the presence of infection. Amputation of the toes may be done in the same general way as amputa- tion of the fingers (Fig. 375). The insertion of the tendons and their general arrangement in the foot are similar to the insertion in the hand. As much tissue as possible should be saved if it can be sufficiently nourished. The great toe is exceedingly important and is far more valuable than any other toe. The distal end of the first metatarsal bone should also be preserved wherever possible, as it constitutes the anterior pedestal of the plantar arch. It is 372 OPERATIVE SURGERY essential that in all ^imputations of" tlic toe the sear should fall on the dorsum of the foot and not on the plantar surface. As the toes are short, disarticu- lation is usually done and there is not often occasion to amputate through the bone. The length of the flap is one and one-half times the diameter of the toe and it should be a plantar flap. If a full plantar flap cannot be ob- tained the racket or oval method may be used. Amputation or disarticula- tion of the great toe at the metatarsophalangeal joint is best done by a type of racket incision that begins over the middle of the joint on the dorsum of the foot and is carried along the junction of the upper and inner sides of the great toe to the distal end of the first phalanx. From this point the incision curves around the inner surface of the toe, then the under surface, and finally along the outer surface of the toe to the Aveb and to the point of be- ginning of the incision. It must be remembered that in speaking of inner or outer portion of the tee in an anatomical sense the outer portion is that nearest Fig. 375. — Lines of incision for amputation of the toe: A. disarticulation of the middle toe with its metatarsal bone; B, disarticulation of the two outer toes with their metatarsal bones; C, amputation of the first toe; D, E, F, and G, the lines of different types of incision for amputation of the toes. the little toe. The flexor and extensor tendons are divided about the middle of the first phalanx so that these tendons can be sewed together across the end of the stump. The joint is opened on the dorsum and the capsular liga- ment is divided close to the phalanx in order to leave as much as possible to cover the end of the bone. The flexor tendons may be sutured to the ex- tensors. If this cannot be done the sheath of the flexors should be closed with sutures. If this type of operation is not desirable on account of the in- jured tissue, a long plantar flap serves an excellent purpose. Any one of the other toes can be disarticulated or amputated at the metatarsophalangeal joint and if a long plantar flap cannot be secured the racket incision with the straight incision on the dorsum of the toe and extending down over the metatarsal bone gives good results. If possible the flexor and extensor tendons should be cut long so they can be sewed over the stump. THE LOWER EXTREMITY 373 If it is neeessai-y to amputate four toes tlie remaining one sliould also be amputated. In disease of a metatarsal bone the metatarsal bone and the corresponding toe can be removed by a long dorsal incision over the metatarsal bone which ends in an oval iiu'isiou surrounding tlie toe and forming a sufficiently long plantar Ihi]) to prevent the sear from lying on the bottom of the foot. The incision begins on the dorsum of the bone to be removed about opposite the metatarsotarsal joint. It must be remembered that the metatarsal bone of the second toe fits back slightly farther in the tarsus than do the Fig. 376. — Lines of incision for amputation at the tarsometatarsal joint (Lisfranc's aminitation) . other metatarsal bones. The extensor tendon is divided through the upper portion of the incision. In the great toe or the little toe, however, the ten- dons are divided if possible at a point sufficiently below the site of am- putation to permit the flexor and extensor tendons to be sewed together, or at least to be attached to the periosteum. In the other toes the tendons are of no great importance when the metatarsal bone is to be removed. If the bone is to be divided and not disarticulated a wire saw should be used, being careful to protect the soft tissues. Amputation or disartic- ulation of two or more toes with their metatarsal bones can be done with a racket incision that is merely an extension of the same type of incision used for amputation or disarticulation of a single toe. It must always be borne in mind to secure as much of the plantar flap as possible. It may be necessary to afford exposure of the base of the metatarsal bones 374 OPERATIVE SURGERY by an additional T-shaped or L-shaped extension at the end of the long racket incision. If the outer metatarsal or the inner metatarsal bones are to be removed along with the toes the incision should be so shaped as to have a long plantar and a short dorsal flap. Amputation at the tarsometatarsal joint, or Lisfranc's amputation, gives very satisfactory results (Fig. 376). The incision begins with the foot in plantar flexion at a point just posterior to the base of the metatarsal bone of the little toe and is carried in a slightly curved direction forward along the outer side of the foot about one inch. Then the incision curves across the dorsum of the foot one-half an inch below the line of the tarsometatarsal joint and is carried backward to the inner side of the foot a short distance behind the base of the metatarsal bone of the great toe. Care should be taken to protect the insertions of the peroneus muscles and of the tibialis anticus on the outer and inner sides of the foot. The extensor tendons are di- vided and the incision is carried down to the joint. As this is done the foot is bent forward so as to expose the joint. The dorsal flap contains as much of the subcutaneous tissue as possible and is dissected up just above the tarsometatarsal joint. The plantar flap begins at the point of beginning of the dorsal flap, that is just posterior to the base of the fifth metatarsal bone, and is carried forward and slightly iuAvard. It curves across the sole about op- posite the heads of the metatarsal bones and is carried to the point of ter- mination of the dorsal flap on the inner side of the foot. The plantar flap should be somewhat longer on the inner side than on the outer, because there is more bony surface to cover in this region. The incision for the flap is carried down to the bone, taking care to protect the plantar arteries. The flap is dissected back to a point just above the tarsometatarsal joint and includes all the flexor tendons and other soft parts down to the bone. The joint is disarticulated by first dividing the dorsal ligaments with a strong, narrow bladed knife, beginning at a point between the first meta- tarsal bone and the internal cuneiform. The knife is then firmly inserted be- tween the first and second metatarsal bones, carried backward to the base of the second metatarsal bone, and a similar cut is made between the second and third metatarsal bones. Then the joint between the second metatarsal and the middle cuneiform is severed by a transverse incision. The rest of the metatarsal bones are separated from the tarsus by opening the joint from above downward. If there is any difficult}^ about disarticulating the second metatarsal bone on account of its deep insertion its base may be sawed across. This will give a very satisfactory stump. It is much better to do this than to adopt the suggestion of Hey and saw off a part of the internal cunei- form bone, as this may affect the insertion of the tibialis anticus to such an extent as to jeopardize the usefulness of the foot. The arteries are tied. They include the dorsal interosseous, the communicating branches of the dorsalis pedis, the four digital arteries in the plantar flap, the two terminal communicating branches of the dorsalis pedis, the internal plantar and some times the external plantar. The flexor and extensor tendons are served to- THE LOWER EXTREMITY 375 gether over the bone in order to give better control of the stump, and then the plantar and dorsal flaps are approximated. If there is too great a ten- dency for the heel to be pulled up, the tendo Achillis should be cut. The operation of Chopart, or disarticulation of the foot through tlie midtarsus, has been practically discarded as the insertion of the anterior ten- dons are cut away, and tliere is nothing to oppose action of the tendo Achillis. This operation makes an unbalanced foot and it should not be done. The Pirogoff amputation, in which the posterior portion of the os caleis is fixed to the lower end of the tibia, and the malleoli have been sawed off, has not given satisfactory results and is difficult of execution. The modification in whicli the os caleis is sawed transversely instead of vertically, as in the Piro- goff operation, seems theoretically better, but practically the results are no better. The Syme operation seems to be the most useful of any operation in the region of the ankle joint. If amputation cannot be done at the tarso- Fig. 377. — Eines of incision for amputation of Syme at the ankle. metatarsal joint, the Lisfranc operation, the next site would be just above the ankle according to the method of Syme. In Syme's ami3utation an incision is made to the bone from the tip of the external malleolus down across the sole of the foot to a point about one- half inch below the internal malleolus. The center of the incision is curved very slightly toward the heel. The upper ends of this incision are joined by a straight incision carried across the front of the ankle joint. (Pig. 377.) The foot is bent strongly downward and the ankle joint is freely opened from the front, dividing also the lateral ligaments. Great care should be taken in dissecting the soft parts on the inner side of the ankle to avoid injury to the posterior tibial artery and its branches, as this is the most important supply of nutrition to the flaps. As the joint is further opened the tendo Achillis and the heel flap are dissected from the os caleis from above downward, keeping as close to the bone as possible. The flaps 376 OPERATIVE SURGERY are retracted and both malleoli together with a very thin slice of the tibia are removed Avith a saw. The posterior or heel flap is brought forAvard and sutured so that it will bear all the pressure on the stump. If the SA-me amputation cannot be done the next point of amputation should be on the leg about four inches above the ankle joint, because of the difficulty of fitting an artificial leg or foot at a point closer to the ankle joint. This may be done by flaps or by the oval method. A long posterior and a short anterior flap make an excellent stump. If the long posterior flap is taken it should be more from the posterointernal aspect than from a strictly po.sterior surface. The incision begins on the inner side of the tibia and is carried down below the sawline for a distance about equal to one and one-fourth diameters of the limb. It then goes back across the leg and upward to a point opposite its beginning. The anteroexternal flap is formed by an incision which goes forward and slightly downward half- way around the leg and is so placed as to make the short flap about one-third to dne-ha1f the length of the long flap. The incisions are carried through the skin and fascia and are then deepened to the bone. The flaps are retracted above the level of the saw line and the bone is divided. The crest of the tibia, which is sharp, is beveled so as to prevent pressure. The periosteum and en- dosteum are removed and the nerves treated as has been described* in ampu- tations of the arm. In amputations of the lower extremity the stump must bear great strain and weight. Eemoval of the periosteum and endosteum, as has been described in the general remarks on amputation of the upper extremity, together with the treatment of the nerves in the stump is, for these reasons, particularly appropriate here. The tendo Achillis and the muscular structure in its neighborhood are brought forward and sutured across the bone to the tendons and muscles of the anterior portion of the leg. The long flap is so sutured to the short flap that the scar will not lie over the end of the bone, but will be anterior. This is u.sually called Fara- beuf's operation. In the middle third of the leg a long posterior and a short anterior flap amputation is excellent (Fig. 378). This is called Key's operation. The circu- lar or oblique method or equilateral flaps may be used. In amputation through the middle or the upper third of the leg the flbula should be cut about one-half inch shorter than the tibia. Through the upper third of the leg some operators prefer to disarticulate the fibula entirely. In making the incis- ion for amputation through the middle third of the leg by a long poste- rior and a short anterior flap the posterior flap should be broad and U-shaped, its breadth being equal to one-half the circumference of the limb at the saAv line and its length equal to one-third of this circumference. The incision begins one inch below the saw line, is carried doAvn the leg just behind the inner border of the tibia, and curves back^vard broadly on the back of the ie^. The outer incision passes doAvuAvard just liehind the fibula and back of the peroneus muscles and cur^-es onto the back of the leg. uniting with the inner incision. The anterior flap is one-third the length of the pos- TIIK LOWER KXTKKMITY 377 terior Ihip and is foniu'd by joiniiiu' llu' N'ciiical iiu'isioiis lo I'oi'iii tlie pos- terior llap about llu> jimctiou of tludr middle and n])p('r Ihii'ds l)y an incision across the front of the leg', which curves slightly downward. These incisions are made while the knee is flexed. The incision is carried dowii through the skin and fascia and the posterior muscles are cut while tlie Haps are retracted. The vertical incisions are deepened and the anterior muscles are divided. The muscles are detached from the bone and the interosse- ous membrane above and the interosseous membrane is divided. The perios- teum is removed either before or after the bone is sawed. The endosteum is removed. The crest of the tibia is beveled. The nerves are treated as usual and the muscles are carefully sutured over the ends of the bones as there is a tendency for the posterior muscles to pull backward. The skin flap is sutured in the usual way. Fig. 378. — Lines of incision for amputation of leg: A, Hey; B, Stephen Smith Amputation through the upper third of the leg may be made by a large external flap according to the method of Farabeuf, or by a bilateral hooded flap according to the method of Stephen Smith. In the operation of Farabeuf a U-shaped flap, whose length is equal to the diameter of the leg at the saw line is outlined by beginning the incision about opposite the saw line in front, carrying it down just internal to the crest of the tibia and curving across the outer portion of the leg (Fig. 379). The incision then passes vertically up- ward opposite the anterior incision but terminates about one and one-half inches below the saw line. The transverse incision is carried across the inner aspect of the leg, curves slightly downward, and unites the upper end of the posterior incision with a point on the anterior incision about one and one-half inches below its beginning. The external flap is dissected up along the lines of the retracted skin and fascia, carrying the incision to the bone. 378 OPERATIVE SURGERY The anterior incision is deepened to the anterior border of the tibia and the tibialis anticns is freed from the bone. The entire mnsele mass is separated from the tibia, the interosseous membrane, and the fibula by knife and ele- vator. It is important not to injure the anterior tibial artery after it has been severed at the end of the flap. If the flap is dissected too high behind where the vertical incision is short the anterior tibial artery may be cut be- fore it penetrates the interosseous membrane. The transverse incision is carried down on the line of the retracted skin and fascia and the interosseous membrane is divided. The periosteum is divided and dissected down about one-half inch above the saw line and the bones are divided after retracting- Fig. 379. — lyines of incision for amputation of leg: A, Farabeuf; B, amputation by modified cir- cular method. Fig. 380. — Lines of incision for amputation oi Stephen Smith 'at the knee joint. the soft parts. The crest of the tibia is beveled and the endosteum at the end of the sawed bone is removed. The fibula is sawed about one-half inch higher than the tibia. The nerve trunks and vessels are treated in the usual way and the muscle flaps are sutured together over the ends of the bones. The edges of the external flap are sutured to the transverse internal incision. Amputation through the middle or upper portion of the leg should be followed by the application of a posterior splint in order to prevent flexion of the stump. Amputation through the upper third of the leg may also be done by the bilateral hooded method of Stephen Smith (Fig. 378). As has already been stated, however, the amputation should not be made too near the joint as too THE LOWKH KXTRKMITY 379 short a sluiiii) iiialvos it imi)()ssi))le to fit an arlilicial leg satisfactorily. The surgeon grasps the leg so as to mark the upper limit of the anterior incision with his left thumb about three-fourths of the diameter of the leg below the saw line on the anterior border of the tibia and the upper extremity of the po:;- terior iiieision by his left index finger about opposite the saw line of the bone. lie begins by incising the posterior tissue at the tip of the index finger, then cuts downward and curves the incision gradually to the side of the leg, carry- ing it curving slightly upward to the end marked by his thumb. A similar incision is repeated on the other side of the leg, except that the flap is made a little larger on the inner side than on the outer. The flaps of skin and fascia are dissected up for about an inch and are retracted and the muscles are di- vided in a circular manner to the bone. The interosseous membrane is divided and the bone is sawed across as in the operation of Farabeuf. The muscles are sutured across the stump of the bone and the skin is closed in the usual manner. Amputation or disarticulation at the knee may be done by the bilateral hooded method of Stephen Smith (Fig. 380), though an elliptical or oblique circular incision, or a long anterior flap may be employed. The operation of Stephen Smith at the knee joint is similar to that of Stephen Smith in the upper third of the leg. The original technic calls for a covering of only skin and fascia, but this can sometimes be advantageously modified by first dissecting the lower ends of the flap for about an inch and then dividing the muscles and soft parts by a circular incision and retracting these struc- tures to the joint. The incision begins behind, in the midline, at a point about opposite the line of the knee joint in the midpopliteal space and is carried downward vertically for about two inches, then gradually downward and forward over the outer part of the leg, and finally upward, ending at a point about one inch below the tibial tubercle. The internal flap is similar, but is slightly larger to cover the larger internal femoral condyle. The tissues are dissected for about an inch and the muscles and soft tissues are divided to the bone and retracted to the level of the joint. As much of the capsule of the joint is included as possible. The semilunar cartilages are kept with the ligaments of the joint so as to afford greater protection to the condyles. The joint is entered between the head of the tibia and the semilunar cartilage. The knee is then flexed and the crucial ligaments are divided. The knee is extended and the other ligaments holding the knee are severed. The vessels and nerves are treated in the usual way and the flaps so sutured that the scar is posterior and in the intercondyloid notch. This operation is an excellent one for amputation through the knee, par- ticularly in the old when the amputation is done for gangrene of the foot. It makes a broad stump which bears well, but it is objectionable because the broadness of the stump makes it difficult to fit an artificial leg and because the joint of the artificial leg has to be at a lower level than the normal joint. In amputating through the thigh as much stump as possible should be saved on account of the leverage. Most of the weight of an artificial limb is borne not on the end of the stump but on other portions of the stump and on 380 OPERATIVE SURGERY the tuberosity of the i.sciiium. A finu, painless stump, however, is most desirable. As a rule, a long anterior and short posterior flap amputation is preferable. The retraction is greater on the posterior and inner part of the thigh than elsewhere, so allowance must be made for this, and it should also be borne in mind that the lower the amputation the greater the retraction. The circular method of amputation in the thigh, however, often gives very satisfactory results, though the advantage of the long anterior flap is that it drops over the end of the bone and does not permit the tissue to sag back as with equal flaps or a long posterior flap. Above the knee the most satisfactory amputation close to the knee is not the transcondyloid, but the supracondyloid operation, or the Gritti-Stokes, in which a long anterior and a short posterior flap are employed. The trans- condyloid operation is unsatisfactory from the standpoint of fitting an arti- ficial leg. In the supracondyloid amputation, or the Gritti-Stokes, the operation is so planned that the division of the femur is made about three-fourths to one inch above the adductor tubercle, so the patella can be applied to a trans- verse section of bone about its size (Fig. 381). The incision for a long anterior flap in this operation begins one inch above the prominence of tlie internal condyle and is carried downward and slightly forward making a broad curve and crossing the upper part of the leg just below the tubercle of the tibia. It curves upward and outward to a point one inch above the external condyle. The incision for the posterior flap, which is shorter than the anterior flap, begins at the upper portion of the incision for the anterior flap, curves backward and downward, ending at the corresponding point on the opposite side of the leg. It is so fashioned that the posterior flap is about one-third the length of the anterior flap. These flaps are dissected upward and the skin and fascia of the anterior flap are freed until the ligamentum patellae is reached, which is divided and wdth the patella turned up with the anterior flap. The posterior flap is dissected up and consists solely of the skin and fascia. Both flaps are retracted to the saw line, which is about three-fourths to one inch above the adductor tuber- cle and all tissues are divided to the bone by a circular incision. The perios- teum here is not removed as in the usual amputation. The bone is sawed. After the vessels and nerves have been treated in the usual way the patella is seized with a heavy forceps and its articular surface is sawed away or re- moved with bone forceps The denuded surface of the patella is applied to the stump of the femur. It may be held in position by splinters or pegs of bone taken from the end of the femur and driven through holes that have been drilled through the patella into the end of the femur, or it may be fastened by two stout kangaroo tendon sutures passed through drill holes in the patella and in the end of the femur. If there is too much forward pull of the ten- don of the quadriceps the tendon may be partially divided. The periosteum and the tissues about the femur are fastened to similar tissue over the patella and the anterior and posterior flaps are sutured together in the usual manner. Amputation through the lower third of the thigh may be done by a long THE LOWER EXTREMITY 381 ;iii1(.M'iui' aiitl a slioi'l post ciMdf llap, or l)y the cii'cular oi' ol)li(iiie circular mctliod, or by ('({iial Haps, I'oi- soiiict iiiics on accoiiiil of the cliaradcr of the injury one of these methods may be necessary to secure satisfactory flaps (Fig. 382). Probably the best method for amputation of the thigh anywhere, except in immediate proximity to the joint, is by a long anterior and a short posterior Jla]>. Tlu> length of the anterior flap is equal to one and one-half times the diameter of the thigh at the saw line and its breadth is slightly greater. The incision begins opposite the saw line, about the middle of the inner surface of the thigh, and passes down the iinier portion of the thigh, curving forward Fig. 381. — Lines of incision for amputation of the thigh: A, by long anterior and short poste- rior flaps; B, by the method of Gritti-Stokes; C, by lyister's modification of Garden's operation. Fig, 382. — A, lines of incision for amputation of the hip joint by the method of Wyeth. (The external racket incision.) B, lines of incision for amputation of the thigh by modified circular method. broadly over the anterior surface to a distance below the saw line equal to about one and one-half times the diameter of the thigh at the saw line. (Fig. 381.) It then broadly curves upward on the outer portion of the thigh to a point about opposite its beginning. The incision for the posterior flap begins at the upper end of the incision for the anterior flap and is carried over the posterior portion of the leg, curving so that the posterior flap is only about one-third as long as the anterior flap. Because of the great amount of retraction it is well to make generous allowance for flaps in amputation of the thigh. After the skin and fascia of the anterior flap have retracted the muscles under this 382 OPERATIVE SURGERY flap are divided obliquely from -without inward, forming a flap of the muscles of the anterior portion of the leg. The dissection is carried through the mus- cle down to the level of the saw line in an oblique manner. The thigh is raised and the posterior flap is dissected and a short flap of muscle is made by cutting the muscle obliquely from the surface down to the bone as in the anterior flap. In this way the anterior and the posterior flaps consist of bev- eled tissue with the sharp edge downward and the l)ase al)0ut the level of the saw line of the bone. The muscles are fully divided down to the bone and are retracted. The periosteum is removed from the bone for about half an inch above the saw line and the bone is sawed. The endosteum is removed and the irregularities on the end of the bone are treated in the usual manner, partic- ular care being taken to smooth the bone along the line of the linea aspera. Fig. 383. — The method of Wyelh for hemostasis in amputation at the hip joint. The nerves and vessels are treated in the usual manner and the muscles in the anterior flap are sutured to the muscles in the posterior flap Avith heavy mat- tress sutures of catgut. The fascia is also approximated and the skin flaps are closed in the usual manner. Amputation just below the trochanters may be done by the external oval method, or by the racket incision, which is used in amputation at the hip joint. The incision begins over the great trochanter in the outer portion of the thigh, is carried down the outer portion of the thigh for about four inches, then anteriorly along the front, and then across the inner aspect of the thigh in an oval manner. The posterior incision begins about four inches below the point of beginning of the vertical incision and passes downward and backward, meeting the anterior incision on the back of the thigh at a point about six inches below the level of the trochanter major. The skin and fascia are dissected up for about two inches along the lines of the incision and the shaft THE I.OWER EXTREMITY 383 of the bone is exposed tlirnuph the vertical incision. Tlie muscles are then divided by a circular cut on a line with the retracted flap. The soft tissues are retracted and the femur is sawed just l)elow the trochanter. The muscles are sutured together with mattress sutures of catgut and the skin flap is sutured in a liorizontal line from within outAvard. The great problem of amputation at tlie hip joint has been the control of hemorrhage. In individuals who are thin and where there is much disease about the hip joint this can be done by an anterior racket incision, which first exposes the femoral vessels so they may be controlled and divided in the early stage of the operation. With careful dissection the bleeding points may be clamped as they are reached and but little blood is lost. When, however, there is no pathology at the level of the hip joint which may be adversely affected by the tourniquet, or when the patient is large and muscular the bleeding should be controlled by the application of a rubber tourniquet ac- cording to the method of Wyeth (Fig. 383). In this method pins or mattress needles about two-sixteenths to three-sixteenths of an inch in diameter and ten inches long are inserted through the thigh. One pin, entering the outer portion of the thigh just below and to the inner side of the anterior superior iliac spine, passes through the superficial muscles and fascia on the outer side of the hip and emerges about three inches from, and on the same level with, its point of entrance. The second pin is introduced on the inner portion of the thigh about one-half inch below the perineum and internal to the saphenous opening. It traverses the adductor muscles and emerges about one inch below the tuberosity of the ischium. Sterile corks are placed on the sharp ends of the pins or mattress needles to prevent injury to the hand of the operator. A small compress of gauze is placed over the femoral artery and rubber tubing about one-third of an inch in diameter is "s^Tapped tightly four or five times around the thigh just above the needles and is fastened by tying the ends with a bandage and by clamping them with pedicle forceps. A circular incision is made around the thigh about six inches below the anterior part of the tourniquet and then a vertical incision begins above the great trochanter just below the tourniquet and passes downward, joining the circular incision. The circular incision goes only through the skin and fascia, which are dissected to the level of the lesser trochanter about two inches (Fig. 382-A). Here the mus- cles are divided to the bone by a circular incision and the vertical incision which has previously been made is deepened to the bone. The large vessels are then clamped and tied. Through the vertical incision which is carried to the bone the tissues are separated from the shaft and tuberosity of the femur and the soft parts are retracted. The muscular attachments to the trochanter are divided with scissors while the limb is rotated alternately in- ward and outward. The capsular ligament is divided at its outer front border and the cotyloid ligament is incised to let in the air and overcome the suction of the joint. The posterior portion of the capsule is divided. The head of the femur is then twisted out of position by rotating the thigh. If this proveT in anv way difficult, which is unusual, the margin of the acetabulum may be 384 OPERATIVE SURGERY chipped away with a chisel to let in the air, or if the vessels have been caup'ht and tied the toni'ni(piet may be removed and the disarticnlation c(mipleted. After ty- ing all the vessels that can be found the tonrniqnet is loosened to see if any ves- sels have been overlooked. The muscles are approximated by mattress sutures of stout catgut. Drainage by a rubber tube carried to the acetabulum is estab- lished, the tube being removed in forty-eight hours. The skin wound is sutured from within outward, making a continuous line. An abundant dressing is ap- plied with firm compression. If, because of the pathology about the hip joint, or the thinness of the pa- tient, it is advisable not to use a tourniquet, the anterior racket method is satisfactory. The method of Wyeth is an external racket incision. The ante- rior racket incision begins about the center of Poupart's ligament and passes Fig. 384. — Lines of incision for amputa'.ion at the liip joint by the anterior racket incision. down over the femoral artery for three inches, then curves inward and crosses the inner portion of the thigh about four inches below the perineum (Fig. 384). From this point it is carried across the posterior and outer aspect of the thigh a short distance below the great trochanter, and then curves upward and in- ward to join the lower end of the vertical incision two inches below Poupart's ligament. Through the vertical portion of the incision the femoral artery and vein are exposed, carefully ligated, and divided. Two ligatures at distances of about one-fourth to one-half an inch are placed upon the femoral artery, as has been insisted upon in the general description of amputations. This is particularly important here because of the large size of the vessel and the great pressure within its lumen. The skin and fascia are freely dissected along the entire incision and the muscles on the outer side of the thigh are divided, the external circumflex artery being doubly clamped and tied. The thigh is TUI', LOWICR EXTREMITY 385 elevated aiul the dissect ion is carried l)aclx\var(l, dividing' tlie insertion of the giuteus maxinms muscle. The thigh is tlieii i-otated and the muscles on the posterior and inner portion of the thigh are divided. Carefully clamping the bleeding points and searching if possible for the internal circumflex artery, the muscles in the internal portion of the thigh are divided on a level with the retracted shin. Tlie tliigli is adducted and rotated imvard and the mus- cles attached to the great trochanter are severed. The femur is then adducted and rotated outward and the capsule cut and any tendons that have not been divided are severed. The capsule is divided with a long knife or with curved scissors. The muscles and skin are sutured together as after the amputation by Wyeth's method, except, of course, the line of sutures runs from before backward instead of from within outward, as with Wyeth's method. By a careful technic this incision by the anterior racket method in suitable cases can be carried through with but little loss of blood. TENDONS AND MUSCLES The three types of operations on tendons are lengthening a tendon, short- ening a tendon, and transplanting of tendon and muscle from its normal inser- tion to another position to take the place of a paralyzed or weakened muscle and to produce a proper balance between the flexors and extensors of a jonit. Tenotomy may be open or subcutaneous. The regeneration of a tendon is practically perfect, particularly of such a tendon as the tendo Achillis. This regeneration is facilitated by the presence of a part of the tendon sheath, so it is important not to divide completely the whole of the ten- don sheath in doing a tenotomy, for if it is cut entirely across, this portion of the repaired tendon may become adherent and composed largely of scar tissue that does not blend readily with the normal tendon. Subcutaneous tenotomy should not be done where there are important blood vessels or nerves that might be accidentally injured. If the open operation for tenotomy is done the skin and subcutaneous fat over the tendon are incised, the sheath of the tendon is opened and the tendon split in its middle for a half inch, separating its fibers vertically. At one extremity of the incision half of the tendon is cut across at a right angle to the slit and at the other extremity of the slit the other half on the opposite side is divided. In this manner the tendon resembles a step and the ends may be sutured together or left free. The open operation is sometimes done by cutting the tendon diagonally from side to side. If it is sutured, fine tanned or chromic catgut or silk is used. The incision in the skin is made some- what to one side of the prominent line of the tendon so that the scar in the skin will not fall on the most prominent position. The tendon should be handled carefully and should not be clamped unless it is intended to cut away the portion that is clamped. In subcutaneous tenotomy, such as tenotoni}^ of the tendo Achillis, the tendon is divided by the insertion of a small sharp-pointed tenatome through 386 OPERATIVE SURGERY the skin beside and beneath the tendon. This is done from the inner side of the leg when the tendo Achillis is divided, which is the usual structure on which this operation is done. After puncturing the skin it is safer to use a dull pointed tenatome passed beneath the tendon. The blade is then turned so that the cutting edge faces the tendon and the foot is strongly flexed dor- sally. This makes the tendon very tense. It is divided by a sawing motion, care being taken not to cut the skin. "When the fibers are completely divided it gives way with a popping sound and the heel is immediately lowered. There need be no fear that the tendo Achillis will fail to unite after a properly done tenotomy, for in large clinics wdiere thousands of these opera- tions are performed lack of union is almost never seen and is then probably Fig. 385. -Open tenotomy by the zigzag or step method. Fig. 386. — Points of -entrance of the tenotome in subcutaneous tenotomy of the plantar fascia. (Soutter.) due to the fact that the sheath of the tendon has been completely divided. By keeping close to the tendon and using a blunt-pointed tenatome after the initial puncture there is but little danger of total division of the sheath. Open tenotomy is sometimes used for relief of contraction of the flexor longus digitorum. Here an incision about tw^o inches long is made half an inch back of the internal malleolus through the skin and fat. The ten- dons of the flexor longus digitorum are exposed and pulled upon to assure the surgeon that they are connected with the toes. The tendons may be lengthened by the step method, or zig-zag tenotomy as it is sometimes called, or by an oblique incision (Fig. 385). They are then sutured with fine chromic or tanned catgut. The sheath and the subcutaneous tissues are brought to- TlIK LOWER i:XTREMlTY 387 gether with catgut and the skin is closed. Usually skin closures over a tenot- omy or transplantation are more satisfactory when done with silkworm-gut than with catgut, as this causes less reaction in the skin. In club foot operations subcutaneous tenotomy of the plantar fascia is often performed. The tenotome has a narrow blade and is sharp-pointed. The surgeon holds the ball of the foot in his left hand and inserts the tenotome perpendicularly through the skin at the inner edge of the tense plantar fascia and between the skin and the fascia Avhich is demonstrated by flexing the foot dorsally and bringing out the strong contracting bands. The fascia is divided in various directions until the contracting bands are all severed. Care is exercised not to cut the skin for the wound may be torn in subsequent manip- ulations. The deep tendons are also avoided. If all the bands cannot be reached by division from the inner edge of the plantar fascia the tenotome can be inserted at the outer edge (Fig. 386). Contraction of the tendons of the tibialis posticus and the peroneus mus- cles is best treated by open tenotomy. The tendon of the tibialis anticus may be divided subcutaneously at the inner side of the foot. It may be brought into prominence by adducting and pronating the foot. Tendons are shortened in different ways. If the tendon extends into the muscle it may be shortened over the belly of the muscle by a step or zig-zag incision, as described in open tenotomy, cutting the ends of the tendon to make it shorter and then suturing the two halves together laterally. It must be recalled that any suturing of tendons should be of the mattress type or else the suture should be quilted in because the ordinary interrupted suture placed in end-to-end union of the tendon will split its fibers and will not hold. If it is desirable to secure a particularly strong union and if the extra bulk is not objectionable, the ends of the tendon may be overlapped without cutting away any of it and sutured to each other laterallj^ The amount to be excised is judged by lifting the tendon and taking a fold, if it is small, until an idea can be had of the amount necessary to be removed. The principles of transplantation of tendons have been discussed in de- scribing tendon operations in the upper extremity. The same principles apply in the lower extremity, except that the tendons and tissues are more powerful and extra care should be taken to secure the sutures. The transplanted ten- don should be sutured with medium size braided silk in which there is no antiseptic to irritate the tissues. This silk is sterilized solely by heating. It is tested with the hands before being used in order to be sure that there are no weak spots. If it is clamped at its ends the knot must be so tied that the clamped portion is not included in the portion of the silk that is left in the tissues. The knot is tied three times and the ends should be just long enough to be tucked singly in the tissues without being erect. The method of tendon suture called the Frisch suture described on p. 362 is excellent when uniting tendons to each other by the end-to-end method. If a tendon is to be trans- 388 OPERATIVE SURG]':RY planted into a bone or periosteum the hraided silk is quilted into it for a dis- tance of about two inches above the end. The suture is started at the end of the tendon and is threaded in a straiglit needle, usually a round needle, un- less there is considerable scar tissue in the tendon. It is passed back and forth at a right angle to the fibers and at short intervals for about five insertions and it is then returned in a similar manner. If the tendon is to be trans- planted into the periosteum, one end of the braided silk is threaded into a curved needle and quilted through the periosteum three times. The other end of the silk is similarly quilted through the periosteum and the end is tied. Sometimes a notch or a groove is cut in the bone and the end of the tendon is buried into the groove and sutured to the periosteum or ligaments in the neighborhood. If the bone can be drilled through and the drill opening en- larged with a burr the tendon can sometimes be carried through the hole in the bone and fastened to the periosteum on the opposite side. This is the technic employed in the operation of Sir Robert Jones of transplantation of the extensor proprius hallucis to the head of the first metatarsal bone. An excellent method of securing the end of a transplanted tendon is to insert it through a slit in the paralj'zed tendon near the insertion of the latter. After pulling the transplanted tendon through this slit it is fastened with sutures at the point where it transfixes the paralyzed tendon. A second slit is then made in a somewhat different direction lower down and the end of the transplanted tendon is also brought through this second slit and fastened. In this manner the transplanted tendon is brought through a slit made in the paralyzed tendon anteroposteriorly, through another slit made laterally farther down, and is then fastened securely with sutures. Where it is possible to do so it is well to transplant the tendon sheath along M'ith the tendon, as it adds additional protection and promotes the nutrition of the tendon. If, however, its course is in the subcuticular fat, the fat will soon form a sheath. It is important that the tunnel be abundantly large, for there is a tendency to contraction which will bind and cause adhesions to the transplanted tendon if the tunnel is not of sufficient size. Paralyzed muscle usually has a greyish or greyish pink color, but healthy muscle is a deep red. It is highly important that the healthy and paralyzed muscles be thoroughly differentiated before any operation is undertaken. This may be done by electrical reaction and sometimes it is necessary to have the services of a neurologist in order to be certain that the motion that exists is not due to the compensating action of some adjoining muscle or group of muscles. The so-called trick motions, especially after paralysis due to nerve injuries, may be very deceptive. In all tendon transplantations it is best to have a tourniquet so the operations may be done in a bloodless manner. The Esmarch bandage is first applied from the toes to where the tourniquet is to be placed so as to make the field entirely bloodless. In all transplantations the deformity for which the operation is done should be thoroughly overcorrected before the tendon is transplanted, else THE LOWER EXTREMITY 389 the tension Avill be so great lliat tlie transplant Avill not l)e placed in a favor- able condition for healing. When the tibialis anticus muscle is paralyzed, which is common after infantile paralysis, the tendon of the peroneus muscle may be transplanted to give dorsal motion to the foot. The incision, according to the Lange method, begins one inch above and half an inch posterior to the tip of the external Fig. 387.— Transplantation of the tendon of the peroneus muscle. The tendon and muscle have been freed and are about to be drawn through an anterior incision. Pier 388 — A suture is inserted in the tendon according to the method of Frisch, a tunnel is made from the^dorsum of the foot to the upper anterior incision, and the tendon is about to be drawn through the tunnel. (I.ange method after Soutter.) malleolus and goes upward to the middle of the leg parallel to the fibula. The strong fibrous sheath about the malleolus is not opened or divided as this will weaken the joint unnecessarily. If the peroneus muscles appear to be vigor- ous and of deep red color the lower end of the incision is pulled downward by a retractor to permit access to the tendon below the lowest point of the incis- ion. Both the long and short peroneus muscles may be transplanted at the same time, though transplantation of the long peroneus is the only one that 390 OPERATIVE SURGERY is necessary. The peroneiis tendon is cut as low clown as possible after pulling it up, retracting the avouiuI down, and catching it with a hemostat as Ioav down in the wound as possible (Fig. 387). This clamped portion of the tendon at the tip should always be cut away in any transplantation, as union is made much better if this bruised portion is cleanly cut away. The muscles are dis- sected from the bone with a sharp scalpel until a line of cleavage is reached and then dissection may be continued bluntly. Care must be taken to avoid injuring the branch from the external popliteal nerve, which lies near the bone anterior to the peroneus muscle. Another incision is made about two inches in length over the anterior middle portion of the leg down to the fibers of the tibialis anticus muscle. A tunnel is made in the subcutaneous fat connecting the two incisions at the upper portion of the long incision and the tendon of the peroneus muscle is passed through this tunnel. The tunnel should be abun- danth' wide (Fig. 388). Stout braided silk is quilted into the tendon, as Fig. 389. — The tendon of the peroneus has been transplanted and sutured into the tissue over the dorsum of the foot. (Soutter.) has already been described, after cutting off its clamped end. The tips of the silk ligature are clamped and a tunnel is made in the subcutaneous fat down to the front of the midtarsus region (Fig. 389). The point of insertion into the tarsus depends upon the deformity. If the tibialis anticus is the chief or only muscle that is paralyzed the insertion should be about the middle of the tarsus, but if the tibialis anticus has some power the insertion may be a little further to the outer side. A curved incision is made over the tarsus and a flap is formed with its base internal which will overlie the point at which the tendon is to be transplanted. The base of the flap should be abundantly broad so as not to interfere with its circulation. The tendon is then carried through the tunnel from the second incision to the tarsus by a pedicle forceps, a tendon carrier, or a long uterine dressing forceps. Whatever instrument is used is inserted from below upward and an abundantly large tunnel is made in the subcutaneous fat. The silk is then quilted into the periosteum and ligaments of the tarsus, as has been described in the general remarks on tendon trans- THE LOWER EXTREMITY 391 plantation, by threading each end of the silk into a curved needle, passing it at least three times in the periosteum and ligaments and tying the ends three times. The tension should, of course, be properly regulated so that it is certain that the tendon or muscle has free play in the tunnel and will slide easily and that the tendon when the silk is tied holds the foot in about the desired position without marked tension. After tying the silk the other tendons of the foot that have been retracted are permitted to cover the in- sertion of the silk, the deeper tissues are closed with fine tanned or chromic catgut, and the skin is sutured with silkworm-gut. The leg and foot are held in such a position as will relax the transplanted tendon and should be kept strictly in this position for about ten days, when the patient may be permitted on a bed rest, but the foot is kept quiet for six weeks. After about tM'o months the patient can walk on crutches and a small amount of weight bearing with plaster of Paris holding the foot in position is permitted. Usually in this transplantation it is wise to weaken the opposing muscle by a subcutaneous tenotomy of the tendo Achillis. The tibialis posticus can also be transplanted to take up the action of the paralyzed tibialis anticus. Here an incision is made parallel to the tibia beginning about one inch above and one-half inch posterior to the internal mal- leolus and extending to the middle of the leg. The tendon of the tibialis posticus is isolated and distinguished from the flexors of the toe by pulling on the ten- don and noting the action on the toes. The tendon of the tibialis posticus is clamped with a hemostat as far down as possible, divided, and the tendon and muscle are dissected to the middle of the leg. The end of the tendon is quilted with braided silk, an incision is made over the front of the tibia about its mid- dle, and a subcutaneous tunnel is formed connecting the two incisions. The tendon and muscle of the tibialis posticus are passed through this tunnel and the tendon is inserted in the tarsus as described in the operation of transplant- ing the peroneus. The flexor longus digitorum, the extensor longus hallucis, or the extensor longus digitorum may also be transplanted for a weak or paralyzed tibialis anticus. "When the peroneus muscles are paralyzed half of the tendo Achillis may be transplanted forward. The incision begins half way between the outer malleolus and the outer edge of the tendo Achillis and is carried up the mid- dle of the leg exposing the outer portion of the tendo Achillis with its mus- cle and the peroneus muscle and tendon. The outer half of the tendo Achillis is divided at the os calcis, split up, and carried forward Avhere it is attached to the peroneus tendons through a slit in these tendons. This half of the Achilles tendon is quilted with a silk suture which is then quilted into the peroneus tendon; or it may be held in position by chromic or tanned catgut sutures which fasten it securely to the peroneus tendon after the proper amount of tension has been estimated. In total paralysis of the tibialis posticus half of the tendo Achillis may be brought forward into the tendon of the tibialis posticus in the inner side of the leg as described in transplantation of half of it in the peroneus. 392 OPERATWE SURGERY p;g_ 390. Transplantation of the tendon of the peroneus longus into the tendo Achillis. (Sir Robert Jones.) Fig. 391. — The peroneus tendon is divided and the tendo Achillis is being split. (Jones.) In paralysis of the extensor of the great toe_, after an incision is made in the lower anterior third of the leg the extensor tendons are exposed, and the extensor tendon of the great toe is isolated and sutured into a slit made in the tendon THE LOWER EXTREMITY 393 of tlie tibialis aiiticus. Care sliouUl be lalu'ii not to make the tension too great as "lianniu'i'" toe nii^iit result. In paralysis of the calf muscles, which results in talipes calcaneus, trans- plantation of the peroneus longus tendon into the tendo Achillis has given excellent results in the hands of Sir Robert Jones. Here, as elsewhere, the det'ormily should be overcorrected as far as possible before transplantation of the tendon. The patient is placed so that the tendo Achillis is uppermost and an incision is made slightly to its outer side and extending upward from its insertion four inches. After exposing the tendon thoroughly a second incision is made beginning about half an inch above the lower end Fig. 392. — The peroneus tendon is drawn tlirough the slit in the tendo Acliillis. (Jones.) of the first incision and passing beneath the external malleolus for about two and one-half inches along the outer portion of the foot. The triangular flap thus made is dissected up and the peroneus longus tendon is exposed just below the external malleolus (Fig. 390). The peroneus brevis tendon lies just external to the tendo Achillis and behind the tendon of the peroneus longus (Fig. 391). The peroneus longus tendon is isolated and divided as close to its insertion as the incision permits. The tendo Achillis is split laterally with a knife about one and one-half inches above its insertion. A long pair of forceps is passed through this slit in the tendo Achillis, going from within outward, and the end of the tendon of the peroneus longus is grasped in the forceps and pulled through this slit (Fig. 392). According to the method of Jones the peroneus longus is now anchored in this slit with two sutures of chromic 394 OPERATIVE SURGERY catgut, which transfix the teiulo Achillis and the tendon of the peroneus long-US as it passes through the slit. A second slit is made in the lendo Achillis lower doAvn and just above its insertion. A pair of forceps is passed through this slit from without inward and the end of the peroneus longus tendon is grasped and drawn through this lower slit in a reversed direction from that in which it was drawn through the upper slit (Fig. 393). The tip of the tendon which has been grasped with forceps is cut away and the ten- don is fastened in position with sutures of tanned or chromic catgut. The peroneus longus will then pull upon the tendo Achillis and so will correct the talipes calcaneus. The skin is closed with silkworm-gut and the leg is put up in gauze with a padded posterior flexible splint, which is curved well down over the sole so as to hold the foot in a marked equinus posi- tion to take the strain from the transplanted tendon. Fig. 393. — The peroneus tendon is drawn through the second slit in the tendo Achillis. (Jones.) The extensor proprius hallucis may be transplanted to the head of the first metatarsal bone to overcome a moderate degree of claw foot due to a paralysis of the short flexors of the foot. Before this operation is done the deformity should be overcome by stretching and by subcutaneous tenotomy of the plantar fascia, and also by excision of an oval portion of the skin from the dorsdm of the foot in front of the ankle (Fig. 394). After these preliminary procedures have been done a two-inch incision is made over the tendon of the extensor proprius hallucis, beginning at the level of the web be- tween the great and the second toe and going upward (Fig. 395). The tendon with its sheath is isolated and mobilized by blunt dissection as thor- oughly as possible, a hemostat is applied as close to its insertion as can THE LOWER EXTREMITY 395 Fig. 394.— Excision of a diamond-shaped area of skin on the dorsum of the foot. (Sir Robert Jones.) Fig. 395. — Exposure of tendon of the extensor proprius hallucis. be done after extending the toe and the tendon is divided. About one and one- half inches of the tendon is now freed from the surrounding tissue and an in- cision beneath it is carried down to the periosteum, which is divided and turned 396 OPERATIVE SURGERY back, exposing the bone just ])ehind the liead of the first metatarsal bone. A small hole is drilled throiiyli the first metatarsal just l^ehind its head and this hole is enlarged with a burr until it is such a size that the tendon can be carried through the opening (Fig. 396). A half-inch incision is made through the plantar surface of the foot opposite the under surface of the head of the first metatarsal bone and is carried down to the bone. The end of the tendon is transfixed with catgut in the straight needle and the catgut is brought through the hole in the metatarsal bone by the needle, Avhich is passed downward and emerges through the plantar incision (Fig. 397). The catgut draws the ten- don through the hole in the metatarsal bone and the tendon is fastened in this position by passing one end of the catgut through a part of the plantar fascia Fig. 396. — Drilling a liole in tlie head of the metatarsal bone for transplantation of tendon of the extensor proprius hallucis. (Sir Robert Jones. j and tying the ends of the catgut. In this manner the end of the tendon is attached to the plantar fascia and is prevented from slipping back through the hole in the metatarsal bone. The incision in the plantar surface of the foot is closed with a suture of silkworm-gut. In the Avound on the dorsum of the foot the tendon and periosteum of the dorsum of the meta- tarsal bone are united by a suture of catgut to give additional fixation and the skin is closed with interrupted silkworm-gut. A padded splint is placed along the back of the leg and the sole of the foot to keep the foot at a right angle. This takes the s^train from the transplanted tendon Avhile it is healing and so gives it physiologic rest. The stitches are removed in ten days and massage is instituted in about three Aveeks. The splint is removed entirely in six Aveeks and the patient may then begin to Avalk. For paralysis of muscles about the knee joint transplantation of the ham- string muscles, inner or outer, or of the sartorius, is usually done. The indica- THE LOWER EXTREMITY 397 tioiis are ijaralysis or paresis of tin; ciuaelriceps i'c'inoris. If all of the muscle is totally paralyzed it avouIcI probably be better to transplant both the inner and outer hamstring muscles, or at least the biceps and the semitendinosus and graeilis. The mnscle to be selected also depends upon the extent of the paralysis or paresis. The muscle to be transplanted should be a deep red or at least a pinkish red. A grey muscle, which of course is para- lyzed, will be of no service if transplanted. If the outer hamstring muscle, Fig. 397. — The method of drawing a tendon through a drill hole in the head of the metatarsal bone. (Sir Robert Jones.) the biceps, is used it should be inserted into the inner border of the pa- tella to stabilize the joint, likewise the inner hamstring muscles should be placed in the outer portion of the patella. The muscles should always be dis- sected up one-half their length. According to Sir Robert Jones, transplantation of the biceps tendon is done by first making an incision about five inches in length over the biceps, the lower portion of the incision reaching not quite to the insertion of the tendon. The external popliteal nerve lies just internal to the biceps tendon and must be carefully avoided. After the tendon is dissected down nearly to its insertion by retracting the lower angle of the incision, it is grasped 398 OPERATIVE SURGERY with a pair of forceps and thoroughly freed with knife dissection. It is care- fully cut, bearing in mind the proximity of the external popliteal nerve (Fig. 398), and is turned upward, dissecting the under surface, and the muscle and tendon are covered with gauze Avrung out of warm salt solution. The second incision, about three inches in length, extends from the center of the upper edge of the patella upward and outward toward the upper end of the first wound. A tunnel superficial to the muscles but just beneath the deep fascia, is made from this wound to the first. This tunnel must be so large that there is no possibility of the muscle being caught and bound by it. A pair of large Fig. 398. Transplantation of tendon of the biceps femoris. Exposure of the tendon, showing proximity of the nerve. (Sir Robert Jones.) forceps is passed through the tunnel from the second incision and the end of the biceps tendon is grasped and drawn through, taking care not to twist the muscle in this procedure (Fig. 399). The tendon of the quadriceps is split about half an inch above its insertion into the patella and the tendon of the biceps is drawn through so that its end appears on the surface of the quadriceps tendon (Fig. 400). The biceps tendon is here united to the quadriceps ten- don by three sutures of tanned or chromic catgut. The aponeurosis be- low the tunnel is split downward as far as the upper edge of the patella and the end of the biceps tendon is sutured into this field with tanned or chromic THE LOWER EXTREMITY 399 patg-ut. The skin Avoniid is closed in the usual manner. Splints are applied to yive the leg and thigh eomi)lele rest during healing. Usually where the inner hamstring muscles are vigorous and it is not necessary to transplant tendons from botli the inner and the outer side, the semi- tendinosus and gracilis are transplanted in preference to the biceps. An in- cision is begun about one inch above and a half inch posterior to the inner condyle of the femur and is carried through the skin and subcutaneous tissue parallel to the femur to about the junction of the middle and upper third of the thigh. The muscles are examined to see that they are in good condition. The bellv of the semimembranosus first comes into view, then its tendon, and Fig. 399. — A tunnel has been made and the biceps tendon is to be drawn through to the second incision. (Jones.) underneath this is seen the semitendinosus and the gracilis, both of which have long thin tendons and are more suitable for transplantation than the semi- membranosus. The skin at the loAver angle of the wound is retracted in order not to carry the incision far enough down to weaken the structures around the knee joint. The semitendinosus and the gracilis are dissected out and their tendons clamped and divided as near their insertion as possible, while retract- ing the lower angle of the wound. The tendons and muscles are dissected freely to near the upper angle of the wound. A second incision is made on the anterior portion of the thigh about its middle and down to the quadriceps muscle. A tunnel is made from this incision backward, connecting with the upper 400 Ol'KRATIVE SURGERY portion of the tirrst incision. Tlic ends of the tendons of the semitendinosus and gracilis are drawn through and quilted with braided silk. The mnsele and tendon are always protected with gauze wrung out of moist salt solution wliile the other incisions are being made. A third incision begins about one inch below the upper edge of the pa- tella and is carried upward in the midline about two and one-half inches and goes through the superficial fascia and fat. A long probe, or a pair of forceps, or a tendon carrier is inserted into this last incision and makes a broad tunnel between it and the second incision. The silk having been quilted in the tendons of the semitendinosus and the gracilis, they are pulled down into the third in- Fig. 400. — The tendon of the quadriceps has been split and the tendon of the biceps is drawn through. (Jones.) cision and the ends of the silk are threaded into a needle and sutured to the quadriceps tendon just above the patella. The muscle tissue itself is also attached to the quadriceps muscle and tendon just above the patella after slightly scarifying the quadriceps. These sutures may be chromic or tanned catgut or silk. The ends of the silk sutures from the transplanted ten- dons are again threaded into needles after the silk has been tied just above the patella and are carried beneath the skin to a fourth small curved incision over the external portion of the head of the tibia. Here the silk sutures are quilted into the periosteum, tied three times, and the knot is pressed doAvn TTIE LOWER EXTREMITY 401 Hal. Till' ileeprv st nii'l iirrs arr lii'oiiglil I o^rl lici- by cliroiiiii- ov tanned cat- tiiit aiul the skin is elosed in the usual nianner with silkwonn-gut or silk. Oeea.sionally it may be necessary to transplant both the inner and the outer hamstring' muscles into the tendon of the quadriceps. Here it may be best to quilt the end of the biceps with silk, suture it into the quadriceps tendon, carry the silk doAvn to the head of the tibia on the inner side, and qnilt it into the periosteum. In the technic of Sir Robert Jones, however, he relies upon splitting the tendon of the quadriceps, drawing the biceps tendon through, and fastening it lower doAvn with tanned or chromic catgut. Either of these methods is excellent, but the braided silk, if the knots are tied to lie flat, Avill probably afford a firmer insertion where on account of the paralysis it appears that the union may not be strong. If the sartorius muscle is to be transplanted its insertion is exposed and the muscle divided near its insertion, quilted with silk at its lower end, and brought through an incision in the middle anterior surface of the thigh, as in transplantation of the semitendinosus and gracilis. The end of the muscle with the silk quilted in is brought through a wide subcutaneous tunnel from an incision just above the patella to the second incision and is sutured by the silk in the usual manner into the tendon of the quadriceps just above the patella. The silk can also be carried down and quilted into the periosteum in the midline of the tibia just below the patella. The quadriceps muscle and the sartorius are scarified and sutured together. After all tendon transplantations the leg should be placed in such a position that there will be the least possible strain upon the tendon. Slight passive motion is begun after three weeks, but no active strain should be put upon the tendon for three or four weeks longer. DEFORMITIES OF THE ANKLE JOINT Before a tendon transplantation is done any defect in the joint over which the tendon acts must be corrected so far as possible. In club foot the foot must be brought to its normal or to an overcorrected position. Club foot may usually be straightened in a newborn infant by manual manipula- tion and holding the foot in position with adhesive plaster and straps. In older children a Thomas foot wrench or a Bradford wrench is used. The patient lies on the abdomen with the leg flexed and in this position the maxi- mum amount of force can be most conveniently brought to bear. A common form of congenital club foot is an equinovarus, in which the heel is drawn up and the sole of the foot is turned in. In pronounced cases the patient w^alks upon the dorsum of the foot. Formerly, for this type of club foot, the Phelps operation was much in vogue. This operation consisted in cutting all of the resisting structures on the inner side of the plantar sur- face of the foot. The original operation left a large deep raw surface which filled with granulation tissue and formed a large scar. An improvement w^as introduced in Avhich a Y-shaped incision was made into the skin with its base 402 OPERATIVE SURGERY about the middle of the sole of the foot and the apex in front of and below the internal malleolus. Subsequent manijpulations, however, are likely to open the wound. The preferable procedure is first to correct the foot as far as possible by manual manipulations or the foot wrench. When the equinovarus is extreme it may be necessary to remove a small wedge of bone from the anterior end of the os calcis and the astragalus. This is not necessary in the paralytic type of club foot. After manipulating the foot tenotomy of the tendo Achillis is done and then a subcutaneous tenotomy of the plantar fascia. If after this procedure an overcorrection is not obtained a small wedge of bone is removed from the os calcis and the astragalus through an incision just in front of the external malleolus and extending tow^ard the base of the fifth metatarsal bone. This incision is carried down to the bone, the tendons are retracted, and the prominent part of the astragalus is exposed. A small wedge of bone is removed from the astragalus with an osteotome, which should enter Fig. 401. — Correction of club foot by excision of bone from the os calcis and the astragalus. The bone to be excised is represented by the shaded area. Fig. 402. — lyine of incision for the operation of Ober for correction of club foot. the bone at some distance from the tibia so as not to interfere with the ankle joint. If this proves insufficient a small amount of bone is removed from the front end of the os calcis (Fig. 401). When the os calcis is markedly tilted the operation of Ober is indicated. Here the foot is manipulated and stretched as far as possible and an incision is made on the inner side of the tibia from two inches above the internal malleolus, curving slightly downward and forward to the scaphoid (Fig. 402). The incision is carried to the bone and the periosteum over the inner malleolus is exposed and incised transversely about one inch above the tip of the malleolus while the skin incision is strongly retracted. The periosteum is THE LOWER EXTREMITY 403 also incised on each side of the malleolus so it can be raised from the bone. The lower and front portions of the periosteum remain attached to the liga- ments of the ankle joint. The periosteum and the ligaments are separated from the bone with an osteotome and this separation is carried to the ligaments of the astragalus and os calcis and the astragalus and scaphoid until the foot can swing outward freely (Figs. 403 and 404). After loosening the upper end of these ligaments the foot is manipulated. The tendo Achillis is cut last of all and the foot is then again manipulated, if necessary with a wrench, in order to place it in an overcorrect position. The periosteum is not sutured but Fig. 403. — Mobilization of the periosteum and ligaments in the operation of Ober. the deeper structures are brought together with tanned or chromic catgut and the skin is sutured as usual with silk or silkworm-gut. A plaster of Paris bandage is applied over the dressing. A liberal amount of wadding is used when the plaster is applied and care is taken to prevent squeezing together the toes. It is probably best to apply plaster over the foot and over the leg sep- arately and after these casts have slightly hardened to secure the proper position and then apply plaster to connect these two segments of the cast. The equinovalgus or the calcaneovalgus type of club foot is usually due to paralysis, while the equinovarus type is almost always congenital. In the valgus club foot the balance of the foot should be restored by overcorrecting 404 OPERATIVE SURGERY the deformity and then transplanting tendons, as lias been described. When there is marked lack of stability at the ankle joint the astragalus may be excised with displacement of the foot backward. When the extensors of the toes are very active and "hammer" toes result, it may be well to transplant a tendon of the great toe into the head of the metatarsal bone and attach the other extensors to the tarsus after dividing them below. In extreme valgus, whether ealcaneo or equinovalgus, Avith a flail joint, astragalectomy is a satisfactory procedure. The correction of the valgus may, however, be possible with the use of wrenches and the transplantation of tendons. When Fig. 404. — Mobilization of anterior portion of periosteum and ligaments in the operation of Ober. the bone is greatly deformed a wedge may be removed from the scaphoid or from the astragalus, followed by transplantation of tendons. Both tibial tendons may be buried into grooves in the tibia anteriorly and posteriorly, to act as internal ligaments for the joint. In removing, a wedge of bone from the scaphoid an incision is made one- half inch in front of, and the same distance below the internal malleolus and extends forward to the first metatarsal bone. The incision is carried to the bone and the tissues are dissected up and retracted in one layer. The tendons of the tibial muscles are carefully retracted. A wedge of bone is removed from the scaphoid and adjoining bone. The wedge is sufficiently THE LOWER EXTREMITY 405 large to allow the foot to come in satisfactory position. The tissues are closed ill the usual way. Pure talipes calcaneus is usually due to paralysis of the muscles supplying the tendo Achillis and is corrected by first straightening the foot and then transplanting the tendons of the peroneus muscles into the tendo Achillis, or if the peroneus muscles are affected the posterior tibial or the flexors of the toes can be used. The operation in which this is done and an area of skin removed from the anterior part of the ankle has been described. In "hammer" toe or ''claw foot" tenotomy of the contracting tendons and stretching of the toes is usually sufficient. If it is not, however, and es- pecially if the case is of long standing, a small piece of bone is removed and then tenotomy is done. If bone is to be excised an incision is made three- fourths of an inch long to the inner or outer side of the dorsal tendon down to the bone. The periosteum is divided and raised and the joint excised sub- periosteally by dividing the distal end of the proximal phalanx and the prox- imal end of the second phalanx. Sufficient bone should be excised to permit free extension and flexion of the joint. The deeper tissues are sutured with fine tanned or chromic catgut and the skin is closed in the usual way. A well padded splint is applied to the whole foot and toes and a plaster of Paris bandage over this. The patient can walk with the plaster cast in about two Aveeks and the toes may be given freedom in two weeks longer. A broad shoe should be used. In marked hallux valgus, particularly where there is callus formation, the deformity can be corrected by a curved incision including the callus and with the base below. This is dissected up, according to the method of C. H. Mayo, and a second flap is made of the ligaments and the bursa with its base just back of the head of the metatarsal bone. As much of the head of the meta- tarsal bone is excised as seems necessary to bring the toe in the proper posi- tion, taking the bone only from the inner side of the head. The flap consist- ing of ligament and bursa is carried over the raw surface left by excising the head of the metatarsal bone and is fastened in position by one or two sutures of tanned or chromic catgut. The U-shaped skin flap is sutured and the toe is kept in a splint for about four weeks. After that some padding is placed be- tween the great toe and the next toe for several months and broad shoes should be used. When the deformity is not extreme tenotomy of the extensor of the great toe sometimes affords relief when accompanied by osteotomy through the base of the head of the metatarsal bone. For this operation a longitudinal incision one inch long is made on the inner side of the tendon of the great toe and over the head of the metatarsal bone. Osteotomy is done through the head of the bone and the deformity overcorrected. A wooden plantar splint is applied. All of the head of the metatarsal bone should never be removed as this does away with the weight bearing part of this bone, which is very important. Exostoses may be trimmed or a small wedge-shaped part of the bone removed. 406 OPERATIVE SURGERY If more than this is necessary instead of removing the whole of the head an osteotomy should be done. It will require considerable time for the bone to unite firmly but this operation gives much better eventual results than can be obtained by removing the head of the bone, which has a very important function. INGROWING NAIL An ingrowing toe nail that cannot be cured by proper care of the nail is relieved by an operation that removes about one-fourth of the nail and the adjoining soft tissues. This can be done under a local anesthetic either by infiltrating the base of the toe and blocking the nerves or by directly injecting the tissues that are to be the site of the operation. The incision begins in the soft tissues about on the level with the tip of the nail and is carried back deeply to a point about half way betAveen the base of the nail and the' next joint. Another incision parallel with this and removing about one-fourth of the toe nail is begun by inserting the point of the knife under the nail with the cutting edge upward and splitting the nail from below upward from its tip through its base. The incision is then inclined so as to meet the first in- Fig. 40S. — Lines of incision for operation for ingrowing toe nail. cision at an angle (Fig. 405). The mass of tissue included by these two in- cisions is excised in one piece, including the soft tissues, about one-fourth of the nail and the matrix of the nail. It is quite important to remove the tissue cells that constitute the matrix of the removed portion of the nail so that here the ex- cision of the tissue is carried down to the periosteum, as otherwise a few cells that are left will produce fragments of nail that will be ^^ainful and difficult to remove. The wound is sutured with interrupted chromic or tanned catgut in a sharp needle, the first suture being introduced at the inner angle of the Avound and tied sufficiently tightly to control the bleeding. Two or three other sutures are inserted from the skin flap, bringing the needle through the nail from below upward. In this manner the nail can be easily penetrated. The THE LOWER EXTREMITY 407 tourniquet is removed and if any spurting point is left an additional suture is placed. THE JOINTS In marked paralysis about the ankle when there is complete flail foot, or when the talipes cannot be otherwise corrected, the astragalus may be excised. This is done through an incision beginning back of the external malleolus and one inch above it. The incision is carried down posteriorly to the external malleolus, around its lower extremity to the middle of the anterior portion of the tarsus, and then directly down to the base of the second metatarsal bone. Another incision that may be used is a vertical incision anterior to the external malleolus. It begins just anterior to the fibula and about one and one-half inches above the tip of the external malleolus and is carried down along the inner side of the peroneus tendon. The latter incision is preferable when the operation is for marked paralysis where there is an effort to stabilize the joint, as this incision interferes but little with the circulation. The liga- ments from the external malleolus are separated with an osteotome subperi- osteally and strong retraction is made on the two margins of the incision. The ligaments over the os calcis and those binding the astragalus are also separated subperiosteally. The anterior portion of the incision is strongly retracted and the tissues are lifted from the astragalus and the neck of the astragalus is divided as far forward as possible. An osteotome is inserted above the astragalus, between it and the tibia, and while the foot is adducted the astragalus is cut down upon vertically leaving a flat portion of the as- tragalus next to the internal malleolus. The body of the astragalus is in this manner easily removed as the foot is dislocated inward and the small portion that has been left attached to the internal malleolus can be removed with the osteotome and forceps. After the removal of the astragalus the foot is dis- placed inward to expose both malleoli and any tissue that prevents the back- ward displacement of the foot is removed or corrected. The foot is then displaced backward. In a flail joint silk may often be inserted and the joint thus held moder- ately stiff. This may be done by an open or a subcutaneous method. Silk liga- ments are particularly useful at the ankle to prevent toe dropping, which is a result of paralysis, and they also increase the lateral stability of the joint. The silk ligaments may be placed in an open operation. Here the incision is made over the anterior part of the lower third of the tibia, cutting down to the periosteum, which is incised and stripped up. The silk is quilted in the tw^o edges of the periosteum and a second piece of silk is tied to the two ends that have been quilted. This gives four strands. A curved incision is made over that part of the foot in which the silk is to be inserted and the silk is carried subcutaneously to this incision. It is then quilted in and tied, two strands being used on the inner side and two on the outer side of the foot. Usually the inner incision is made over the scaphoid and internal cuneiform 408 OPERATIVE SURGERY bones and the onter over the cnljoid. The ligaments, as Avell as the periostenm, are eanght in the qnilting sutnre. Bradford nses the snbcutaneons method and begins at a point on the lower third of the tibia. The skin over the bone is retracted so as not to be in its normal position and a drill with an eye at the point is passed through the skin and the tibia. As it emerges from the bone the skin is pulled for- ward before the drill perforates it (Figs. 406 and 407). This procedure pre- vents the opening in the bone being opposite the puncture in the skin. The two ends of a silkAvorm-gut strand are passed through the eye of the drill and the drill is withdrawn. Braided silk is caught in the loop of the silkworm-gut Fig. 406. — Insertion of braided silk for correc- tion of flail ankle joint. The diagram shows the position of the drill holes in the bone. (Method of Bradford.) Fig. 407.- -The drill has entered the tibia. (Bradford.) suture and drawn through. In a similar way the tarsal bones are drilled from within outward, pulling the skin to one side, and drawing through a doubled strand of silkworm-gut (Fig. 408). The silk used is very heavy braided silk, which is first carried through the hole in the tibia. The outer end of the silk is then passed subcutaneously to the loop of silkworm-gut through the tarsus and is thus drawn through the tarsus (Figs. 409 and 410). Then by a carrier the end of the silk that comes through the inner hole of the tarsus is carried subcutaneously to the end of silk that has been left at the inner hole in the tibia (Fig. 411). The silk is tied firmly in three knots, the ends are cut, and the skin is drawn over the knots (Fig. 412). Strips of fascia lata are sometimes used instead of silk ligatures. THE LOWER EXTREMITY 409 Fig. 408. — :The drill hole in the tibia has been made and the silk is being pulled through. (Bradford.) Fig. 409. — A tunnel has been made on the outer side of the foot, and the silk is being pulled through the tunnel. (Bradford.) Fi£ 410. — The loop is being pulled through the drill hole in the tarsus. (Bradford.) Fig. 411. — A tunnel has been made on the inner side of the foot and the second end of the silk is being pulled through to the first end. 410 OPERATIVE SURGERY Excision of the ankle joint is not often necessary, but may be done through a transverse curved external incision which begins on the dorsum of the foot midway between the ankle joint and the articulation of the astrag- alus and scaphoid. The incision is carried backward horizontally below and beyond the external malleolus, and then up between the tendo Achillis and the tendons of the peroneus muscles to a point about three inches above the joint (Fig. 413). The superficial peroneal nerve should be identified and retracted out of the way. The extensor tendons and the tendons of the pero- neus muscles are retracted inward and the sural nerve and the small saphenous vein are protected behind. The incision is carried down to the fibula and the astragalus and divides the capsule of the ankle joint back to the external Fig. 412. — The knots have been tied. The position of the silk in the skeleton of the foot and leg is shown in the diagram. malleolus. The bands of the external lateral ligaments -are separated from the external malleolus. The sheath of the peroneus tendons is incised pos- teriorly to the fibula. The tendons are removed from the sheath and retracted backward by splitting the sheath of the tendons high up. It will be unneces- sary to divide the tendons if they can be retracted. Sometimes, however, they must be divided. The periosteum is incised over the fibula and separated along with the adherent peroneus sheath from the posterior surface of the fibula and tibia. The periosteum is separated from the anterior surface of the fibula and tibia, which also removes the attachment of the capsule of the joint in this region where it is adherent to the periosteum. The foot is bent forci- bly inward until it is completely displaced and the inner side of the foot rests against the leg turning on the internal lateral ligament as a hinge. As much of the bone is removed as is necessary. It is particularly desirable to saw off no more bone from the astragalus than may be necessary and small separate THE LOWER EXTREMITY 411 foci should be chiseled out and not curetted. In this manner healthy bone around the focus is cut with a chisel and the focus is thus removed, whereas the curet often forces diseased tissue further into healthy bone. After a sufficient amount of bone has been removed the peroneus tendons are sutured, if it has been necessary to divide them, or simply replaced in their sheaths, if they have been preserved. Excision of the astragalus for disease of the bone or joint may be done by an external curved incision, or by an external angular and internal curved incision. The external curved incision begins about three inches above the ankle at the anterior border of the fibula and is carried down external to the peroneus tertius tendon and superficial peroneal nerve and then curves for- ward over the outer portion of the astragalus to the base of the fifth meta- tarsal bone. The peroneus tendon is retracted inward and the extensor brevis digitorum is retracted outAvard. In the space thus exposed the capsule of the ankle joint is incised and the neck of the astragalus and the lower ends of the Fig. 413. — L,ines of incision for: A, excision of ankle joint (method of Lauenstein) ; B, excision of os calcis (Oilier); C, excision of astragalus (Oilier). tibia and fibula are freed. The calcaneo-astragaloid ligament and the anterior and posterior bands of the external lateral ligament are divided. The attach- ment between the astragalus and os calcis and scaphoid are cut with a stout knife and the foot is inverted forcibly and the inner surface of the astragalus is freed as much as possible, taking care to avoid injury to the posterior tibial vessels and nerves. The astragalus is removed with bone forceps, any further attachments being divided with scissors. The ends of the ligaments should be brought together with chromic or tanned catgut and the skin closed in the usual manner. In intractable club foot, particularly the type that has recurred after operation, the bony structures of the foot are often so deformed that even correction of the soft parts does not give the desired results. Here the method of bone grafting emploj^ed by Albee may be utilized. In order to see the structures satisfactorily it is necessary to use an Esmarch and a tourniquet. 412 OPERATIVE SURGERY The teudo Acliillis is divided in the usual manner, the contracted plantar fascia is cut subcutaneously, and the foot is forced into as good position as can be attained. In the type of club foot in "which bone grafting is indicated methods such as this with the use of manual force and the foot wrench have already resulted in recurrence, so bone grafting must be done and a U-shaped incision is made on the inner and upper portion of the foot with the base of the flap i^osteriorly. The upper line of the flap begins in front of the middle of the ankle joint and the incision is carried forward on the dorsum of the foot almost to the tarsometatarsal joint where it curves downward and in- ward across the base of the first metatarsal bone and then is carried back to a point just below and in front of the internal malleolus. This flap, in- cluding subcutaneous tissue, is turned back and exposes the scaphoid bone. The bone is split with a thin osteotome into two halves (Fig. 414). The foot is then forced into overcorrection, which widens the gap in the scap- hoid (Fig. 415). Any soft tissues that are markedly resisting the over- Fig. 414. — Incision for bone grafting in intractable club foot. 41 S. — Club foot has been straightened and is ready to receive the bone graft. correction of the foot are divided. The gap in the bone is measured with calipers and after exposing the inner surface of the tibia, by an incision in the skin and turning back the periosteum, a wedge of bone is cut from the internal surface and the crest of the tibia by a motor saw. A thin osteotome can be used for this but a motor saw is preferable. The base of the wedge is at the crest of the tibia and the apex is directed inward and toward the medullary cavity. A hole is drilled in the base of the wedge before it is re- moved so that it can be fixed in its new position with a suture. It is easier to drill the hole before the wedge is entirely free. The wedge of bone is im- mediately transferred to the gap in the scaphoid and should fit so snugly that it prevents the recurrence of bony deformity. The edges of the scaphoid are drilled and kangaroo tendon is passed through the hole in the scaphoid and the hole in the graft and tied so as to hold the graft in position. A bone peg may be utilized for this purpose. When the graft has been inserted and fixed the foot shoukl remain in this overcorrectcd position after it has been released. THE LOWER EXTREMITY 413 I'sually the overcoriH^-rKiii iiiakcs i1 impossible for tlio Ha]) to l)e sutured to cover the \vhoU^ Avouiul, but it will at least cover the grafted bone and the rest of the wound must be left to heal by oi-anulations, or to be closed by a plastic procedure later on. A few layers of smooth gauze are placed between the toes, the foot is dressed, and plaster of Paris applied over the foot to hold it in the over- corrected position, the knee being flexed to almost a right angle, and the plaster east extending to about the middle of the thigh. Soule has modified this operation by mortisiug a piece of bone between the divided halves of the scaphoid. If the method of inserting silk ligatures does not secure satisfactory arthrodesis, the joint surface should be exposed as in excision and the cartilaginous surface removed from the joint. Albee advises, after exposing the ankle joint, the removal of the astragalus without fracturing it. The cartilaginous surfaces of the astragalus are cut away with a motor saw and the astragalus is denuded of its periosteum and replaced in the ankle after the cartilage has been removed from the adjoining surfaces of the scaphoid, OS calcis, tibia and fibula. Here the astragalus acts practically as a bone graft and makes bony ankylosis of the ankle joint almost certain to result. Dislocation of the patella is usually remedied by splitting the tendon of the patella as advised by Goldthwait. The displacement is almost always outward and while it is easily reduced, the inner portion of the capsule has become stretched and there is a tendency to recurrence of the dislocation. An incision is made to the inner side of the median line extending from near the middle of the patella downward for about three inches. The edges of the wound are retracted and the tendon of the patella is exposed, raised, and split longitudinally. The lower end of the outer half of the tendon is de- tached subperiosteally from the tibia, brought under the inner half, and reattached by quilting sutures to the periosteum on the inner portion of the head of the tibia. This prevents the tendon from sliding outward. Displaced semilunar cartilages are more frequent on the inner side than on the outer. The knee is flexed at a right angle, preferably at the end of the operating table according to the method of Sir Robert Jones with the leg and foot hanging down from the table. An incision is made going dowuAvard about half an inch to the inner side of the patella to the tibia and then curving at a right angle along the upper portion of the inner head of the tibia for about two and a half inches. The tissues are dissected and retracted as a flap down to the capsule of the joint. The fibers of the capsule are incised without opening the synovial membrane. This membrane is then incised parallel to the head of the tibia. The inner semilunar cartilage is elliptical in shape and slightly thicker than the external semilunar cartilage. If the cartilage is loose it can be lifted with a pair of forceps and dissected free with scissors from its attachment. It is important not to cut the lateral liga- ment of the joint. All of the cartilage except a small part of the posterior portion is removed. The bleeding is checked by pressure of cotton sponges and by whipping over the synovial membrane with a continuous catgut suture. 414 OPERATIVE SURGERY No knots or exposed sutures or ligatures should ever be left "witliiu the joint. The capsule is brought together with tanned or chromic catgut and the skin united in the usual manner. Exposure of the knee joint for removal of foreign bodies, or for removal of a tumor, or inspection of the knee, is satisfactorily done by splitting the patella into two halves, or by the bayonet incision. Sometimes two lateral incisions may be used. The splitting of the patella gives the fullest view of all the pouches and culdesacs of the joint and of any repair work on the crucial ligaments that may be necessary. The incision begins slightly to the inner side of the midline about four inches above the patella and extends downward over the patella slightly to the inner side of the midline to a point below the insertion of the patella tendon. The tendon and the patella are exposed and the tendon above the patella is split slightly to the inner side of the midline, and then is split below the patella. The leg is held straight and the patella is sawed about two-thirds through when the knee is flexed to about forty-tive degrees and the division of the patella is completed with a sharp osteotome. The patella is divided slightly to the inner side of the midline, because there is less mobility of the inner fragments than the outer and better exposure can be obtained in this way, as the tendons both above and be- low the patella are also split a little to the inner side of the midline. The syno- vial membrane is opened above the patella, laying bare the upper culdesac. The knee is then flexed about ninety degrees and the halves of the patella are re- tracted strongly while the patella ligament is completely split and the fat be- neath it divided. Any foreign body or tumor is removed, or repair work is done upon the crucial ligaments if necessary. The wound is closed by adjusting the two halves of the patella carefully and suturing the fascia and the split tendons together so as to hold the patella firmly approximated. These sutures are best made of tanned or chromic catgut. It is not necessary to place sutures in the patella itself. The leg should be dressed in a posterior splint or Avith plaster of Paris and gentle passive motion of the patella is begun about the seventh day. The knee may be also exposed anteriorly by the bayonet incision, Avhich begins on the inner side of the patella about two inches above it, is carried down, then across the ligamentum patellge about half an inch below the lower border of the patella and then goes down along the outer margin of the ligamentum patellae. The cross incision should not be made at a right angle so that the ligamentum patella can be more readily repaired. This incision requires longer for the ligamentum patella to repair and may leave this ligament somewhat weak. If loose bodies are located in the back of the joint a posterior incision may be made. Here a long vertical incision is made posteriorly in the midline beginning about three inches above the joint and ending two inches below it. Dissection is carried down to the joint with care, avoiding the popliteal vessels and nerves. This incision is very seldom necessary. THE LOWER EXTREMITY 415 Excision of the knee joint is best done by a sliglitly curved anterior in- cision, tliongh a U-shaped incision with its base upward, or an li-shaped incision can be used. The U-shaped incision has the disadvantage of poor nutrition at the tip of the flap, which is also an objection to the H-shaped incision. The curved anterior incision begins at the posterior portion of one of the condyles of the femur, about half an inch above the lowest articular surface, is carried forward and slightly downward across the lower por- tion of the knee and just above the insertion of the ligamentum patellae and ends at the posterior portion of the opposite condyle of the femur. This incision is made while the knee is slightly flexed and is carried through the ligamentum patellae and the capsule of the joint, dividing the ligamentum patellaj about half-way between its insertion into the tibia and the patella. The patella and the tissues of the upper flap are retracted upward and the joint is further flexed while the crucial ligaments are divided. The flaps are retracted, the knee joint is acutely flexed, and a section is sawed from the femur, particular care being taken to guard the popliteal vessels. The femur is held perpendicular and the saw is applied just above the articular line and so far as possible about parallel with the lower plane of the articular surface of the condyles. The articular surface of the head of the tibia is next sawed. The sections are so sawed that the bone surfaces when brought together Avill make a flexion of the knee of about ten or fifteen degrees. This is much better than having an absolutely straight leg. It is important not to remove too much bone. If most of the disease is re- moved the other foci can be chiseled out. It is important not to use a curet as this may force septic material into otherwise healthy bone. The patella is left if it is healthy, or if slightly diseased its articular surface may be removed by a saw or chisel while it is held in bone forceps. The culdesac under the quadriceps tendon is explored and the synovial membrane dissected away. The bone is brought together and fastened in position by sutures of stout kangaroo tendon through the bone along the margins of the incision and by suturing the capsule and fascia with tanned or chromic catgut. The divided ligamentum patellae is sutured with chromic catgut. An excellent method of immobilizing the surfaces of the bone after ex- cision of the knee joint is the inlay graft of Albee, the technic of which has already been described. This makes bony union more certain and it may be used when it would otherwise appear necessary to remove a larger sec- tion of bone. It must be recalled that the more bone removed from the femur above the condyles the narrower the weight bearing surface and con- sequently the greater are the mechanical difficulties of stabilizing the joint. It is the practice of some surgeons to fix the bones together by metal nails or screws. These are very likely to give trouble afterwards. Irri- tating metals, such as iron, cause an osteoporosis around the metal, and so retard union. If the bone cannot be held securely by stout kangaroo tendon it will be best to insert bone pegs, which are made from strips of adjacent 416 OPERATIVE SURGERY Lone by the electric doweling instniinciit. The inlay .urat't method of Alhee not only holds the bones in position bnt adds to the strength of tlie callus. The hip joint may be excised by the external straight incision of Lan- genbeck, the anterior straight incision of Barker, or the posterior angular incis- ion of Kocher. The external straight incision begins over the ilium about three inches above the upper limit of the great trochanter and is carried down five inches in the long axis of the femur just behind the center of the outer surface of the great trochanter, terminating below the base of the great trochanter. The incision after going through the skin and fascia divides the gluteus maximus muscle almost in the line of its fibers. The space between the gluteus medius muscle in front and the pyriformis muscle behind is iden- tified, widened by retraction, and the capsule of the joint together with the periosteum of the great trochanter is incised longitudinally to the bone. The capsule may be further divided by a transverse cut. The capsule with the loeriosteum is raised with a periosteal elevator and the cotyloid ligament is divided by inserting a stout knife between the head of the l)one and the cotyloid ligament and cutting toward the edge of the acetabulum. In this manner the atmospheric pressure on the joint is overcome. If there is diifi- culty in doing this a portion of the rim of the acetabulum is chiseled awa}'. The attachment of the muscles to the outer and posterior surface of the great trochanter is raised subperiosteally if possible while the knee and foot are twisted to rotate the thigh inward and then to rotate the thigh outward. The ligamentum teres is divided and the head of the bone dislocated by maniiDulation of the thigh. The upper end of the femur is cleared of the soft parts and held with stout forceps while the head of the femur is sawed off below the great trochanter. There should be a slight obliquity from above downward and inward. The acetabulum is cleared by a chisel and the pockets of synovial pouches are removed. A drainage tube is inserted. The capsule and muscles are sutured with chromic or tanned catgut. The limb is placed in extension. The anterior incision for excision of the hip joint begins about half an inch below the anterior superior spine of the ilium and goes downward about four inches between the rectus and sartorius muscles on the inner side and the tensor vagina femoris and gluteal muscles on the outer side. The lateral femoral cutaneous nerve is retracted outward and so avoided. The inter- muscular plane between the muscles mentioned is folloAved and the muscles are retracted outward and inward respectively. The branches of the ex- ternal circumflex will require ligation. The joint is reached without the actual division of any other muscle, vessel, or nerve of consequence. The capsule is incised over the front of the joint in the line of the incision and down to the head of the femur. The cotyloid ligament is cut to admit air and the neck of the bone is divided with a narrow finger saAV or with a wire saw while retracting the soft parts. The head of the bone is seized with forceps and twisted out of position after dividing the ligamentum teres. THE LOWER EXTREMITY 417 The cavity of the aee1iil)iiliim is eleared ol' any diseased material and the capsule is sutured after iiisl ilutiiij^' drainage. The posterior angular incision of Kocher l)egins at the base of the great trochanter, is ctirried upward and forward to the anterior angle of the great trochanter, and then ol)li(iuely upward and inward in the line of the fibers of the gluteus maximus muscle. The aponeurosis of the gluteus maximus muscle over the external portion of the great trochanter is divided and the fibers of this muscle are divided in the upper part of the wound where the branches of the gluteal artery must be cut and tied. The interval between the gluteus medius and minimus above and the pyriformis muscle below is identified and retracted and the posterior part of the capsule and of the acetabulum is exposed. The capsule is divided along the upper border of the pyriformis muscle. The femur is rotated outward and the insertion of the gluteus medius is separated subperiosteally from the bone externally and the insertion of the gluteus minimus is similarly separated from the bone along the anterior border of the great trochanter. The insertion of the pyriformis, internal obturator, and the gemelli muscles is similarly separated from the great trochanter and the insertion of the obturator externus into the digital fossa is raised subperiosteally or by a chisel. The thigh is rotated inward and the inner and back portions of the great trochanter are freed. The cotyloid ligament is divided to admit air. The ligamentum teres is cut from behind on the head of the femur while the thigh is adducted and ro- tated inward. The head is then dislocated into the wound and removed. OSTEOTOMY Osteotomy is often necessary to overcome deformities in the leg or knee. It is performed with an osteotome or a saw. If an osteotome is used there should be a set of at least three different thicknesses. It is important to bear in mind that an osteotome has a point that is wedge-shaped and not beveled solely on one side as a chisel. The osteotome of Macewen is a standard m this respect. If a saw is used it should be either the small finger saw or else a Gigli wire saw. The Adams saw has a narrow cutting surface and is shaped somewhat like a rather stout tenotome with the saw teeth occu- pying the cutting portion of the instrument. The handle is large, as in an ordinary saw, so the instrument can be manipulated firmly. Jones' saw has a small button on the tip of the saw which will somewhat protect the soft tis- sue. The Gigli wire saw surrounds the bone completely. Through a small incision it is difficult to protect the soft tissues. The circular motor saw is often used with considerable advantage, especially in cuneiform osteotomy, when the bone can be readily exposed. Linear osteotomy is often performed by what is known as the subcutan- eous method ; that is, through a very small incision. Here the section of the bone is guided largely by the sense of touch with the point of the osteotome. If a wedge-shaped area is removed the exposure of the bone should be ample 418 oim:rativk surgicry aud the operation done by sight. There is not the same objection to a longer incision that formerly obtained, and even the linear osteotomy can often be more satisfactorily done by an incision sufficient to use the sense of sight as well as of touch. In linear osteotomy, as performed by Macewen for knock knee, the outer side of the knee and the lower part of the femur rest on a sand bag which is not too tightly filled. A longitudinal incision is made on the inner side of the thigh, beginning half an inch in front of the tendon of the adductor magnus muscle and about one-half to three-fourths of an inch above the adductor tubercle. A long scalpel is inserted directly to the bone and cutting upward makes an incision down to the periosteum just large enough to admit the large osteotome. The osteotome is inserted beside the knife down to the bone and after it has reached the bone it is turned trans- versely. The edge of the osteotome is passed over the bone until it reaches the posterior portion of the internal border and is driven in from behind forward and outward. After the cortex of the bone is penetrated a finer osteotome is passed into the wound in the bone alongside the osteotome already in position. The wider groove left by the first osteotome readilj^ admits the second one which is thinner. The femur is bent with a little force and the portion of its cortex that remains undivided is broken. The osteotome should never be removed from the bone until the section is complete and it is best to shift its position slightly after each blow of the chisel to prevent it from becoming bound. The osteotome should be driven in such a manner that it points toward the surgeon and not away from him, as in this way it can be handled more satisfactorily. It is moved up and down after each blow of the mallet in order to widen the cut. The internal and posterior surfaces of the bone are first divided and then the osteotome is driven forward and outward, toward the front of the bone. The outer part and a portion of the posterior surface remain undivided and are fractured. After AvithdraAving the osteotome the wound is sutured and dressed and the limb is put up in slightly overcorrected position in plaster of Paris. This is the typical operation of Macewen for knock knee. Cuneiform osteotomy requires a longer incision so the bone can be com- pletely exposed. Indeed there is no serious objection to a long incision in the linear osteotomy. If cuneiform osteotomy is done over the head of the tibia the incision is made and the periosteum is reflected Avitli the soft parts. The osteotome outlines the base of the wedge in the cortex of the bone. The base should correspond with the angle of greatest deformity and should be somewhat smaller than appears to be necessary as it is easy to enlarge it if it is actually too small. The Avhole thickness of the bone is not cut through. After the wedge has been removed and the limb straightened if a sufficient amount of bone has not been removed, more can be chiseled away. Osteotomy by a saw is usually done in the neck of the femur. A long narrow-bladed knife is inserted about half an inch above the tip of the TiiM i,()\vi:u i;xtri;mity 419 troclianler major, aiul pushed iinvartl aiul dowjiwai'd iiiilil it s1rd> Fig. 420. Fig. 421. Fig. 420. — Another method of avoiding cavity formation in the bone. One wall of the involucrum has been mobilized. Fig. 421. — The mobilized wall of the involucrum shown in the preceding figure is so folded as to obliterate the cavity in the bone. After removing the sequestrum and a portion of the involucrum the cavity is curetted and cleaned with gauze and peroxide. The cavity may then be dis- infected with pure carbolic which is followed by alcohol, or tincture of iodine may be applied. If it is quite certain that all the diseased bone has been removed the wound may be closed, filling space that cannot otherwise be obliterated with the Mosetig-Moorhof bone plug. Some surgeons prefer using salt solution and suturing the soft parts to prevent its escape. Some- times in neglected cases, the involucrum is so dense that it does not seem practicable to remove a sufficient amount to bring in the soft tissues. Here the Mosetig-Moorhof plug may be utilized, or one of several plastic proce- dures can be done. One wall of the involucrum may be so separated and mobilized that it will fall in on the cavity (Figs. 420 and 421). The over- lying soft parts may be undermined and fastened to the depth of the wound by pegs or sutures. This, however, leaves a furrow and a marked deform- ity, which is objectionable. Grafting of soft parts into the wound by a 426 OPERATIVE SURGERY pedunculated flap can be done according- to the operation of von Eiselsberg. According to this method if the defect is in the lower part of the tibia a flap with its base downward is fashioned over the upper part of the tibia after the lower defect has been prepared by a curet and chisel and the flap which includes the skin, periosteum, and the whole- thickness of the cortical bone attached to the periosteum is turned doAvn into the defect (Figs. 422, 423 and 424). Care must be taken not to twist the pedicle too greatly. The Fig. 422. — Lines of incision for flap to fill defect in the bone, (von IJiselsberg.) Fig. 423.— The flap has been mo- i-ig. 4.^:4.— The flap is sutured bilized and is ready to be turned in position. (von Eiselsberg.) down in position, (von Eiselsberg.) defect in the upper part of the wound is closed as far as possible by under- mining and sliding the skin. Transplantation of fat into a defect of the bone after the cavity has be- come sterile has been done with some success. Portions of adjacent muscle may also be utilized as a filling if there is but little tendency to reproduce bone. It is best to graft bone only after the cavity has become clean, follow- ing the technic of bone grafting that has already been described. THE LOWER EXTREMITY 427 ELEPHANTIASIS Obstruction of the inaiii lyinpliatie trunks from the leg causes swelling of tlie lower extremity which may assume enormous proportions. This swel- ling is not the result of interference w^ith the blood circulation, but is due solely to obstruction in the lymph current. These cases of elephantiasis are often satisfactorily treated by the operation of Kondoleon, of Greece, Avho eiuloavors to secure an anastomosis between the superficial and the deep S>JTTvpV>y3>.3 Fig. 425. — lyines of incision for operation of Kondoleon on outer surface of the lower ex- tremity. Fig. 426. — lyines of incision for operation of Kondoleon on inner surface of the lower ex- tremity. lymphatic systems of the leg, as the obstruction that produces the swelling seems to be chiefly if not entirely in the lymphatics that drain the skin and deep fascia of the leg and thigh. This operation has been used with consid- erable success by Matas, Royster, Hill and Sistrunk. Sistrunk has modified the operation by making it somewhat more extensive and removing a consid- erable amount of tissue. Long incisions are made on the outer and, if necessary, on the inner sur- face of the leg and thigh, extending externallj' from just below the trochanter 428 OPERATIVE SURGERY major to just above the external malleolus (Figs. 425 and 426). A large slice of the edematous fat is removed and the fascia is opened down to the muscle. A strip of fascia about two inches wide is excised and the edges of the fascia are fastened to the muscle by interrupted sutures of catgut in order to fix the fascia in position. The edges may be tucked in at the point of suture and in this way Avill probably prevent the rapid reunion of the fascia. The skin is closed with a continuous suture of tanned or chromic catgut or with silk. The skin and fat should come together over the exposed muscle. If the incision in the outer portion of the leg and thigh does not relieve, an incision on the inner side can be made a month or two later. Here the incision is made from a point near the perineum directly down to just above the internal malleolus. A mass of fat is re- moved and a strip of fascia lata is excised, the edges of the fascia being fas- tened to the muscle as after the external incision. The skin being closed with continuous sutures without drainage. By careful hemostasis but little blood is lost and the anastomosis between the deep and the superficial lymphatics is usually so satisfactory as to result in a cure. The patient should wear a support and promote the lymphatic circulation by hot applications and massage for several weeks after the operation. VARICOSE VEINS The type of oj^eration for removal of varicose veins of the leg depends upon the extent and the location of the diseased veins. There are three forms of veins in the lower extremity: (1) those without valves in which the blood may run either way, (2) veins in which the valves direct the blood toward the surface, and (3) veins in which the valves direct the blood toward the deep veins. The perforating branches that connect the deep and super- ficial veins are most numerous in the middle and lower part of the leg. In the middle of the leg these perforating branches are surrounded by muscles and consequently the superficial veins are frequently the first to dilate at different points, because the bulk of the muscles prevents drainage into the deep veins. The subcutaneous ligation that was formerly practiced is not now considered satisfactory and division or excision of the vein gives better results. The veins may be divided and ligated in the thigh, excising a por- tion of the main trunk, or a circular incision can be made beloAv the knee and multiple ligations done on the divided veins. Schede encircles the leg with an incision about the junction of the upper and the middle thirds, cutting all tissues down to the deep fascia, tying both ends of the divided veins, and suturing the skin. Friedel, after ligating the long saphenous in the thigh, makes a spiral incison, beginning below the knee and encircling the leg several times ending the incision on the back of the foot. All veins are tied, but the wound is left open. Trendelenburg ligates and resects the saphenous vein in three places, in the middle of the thigh, and above and below the internal condyle. Total THE IjOWER extremity 429 resection in the tliigli can be accomplished through a long incision from the saphenous opening to the posterior border of the internal condyle and this may be continued to the internal malleolus. The scar at the knee, however, is often an annoyance and if an ulcer is present the incision should not extend to it, so as to avoid infection in the wound. The operation of C. H. Mayo is simpler and avoids extensive scarring of the skin. He uses multiple short incisions over the course of the vein be- Fig. 427.— Lines of incision for excision of varicose veins of the leg. ginning just below the saphenous opening. The vein is doubly ligated, di- vided and its distal portion stripped subcutaneously as far as possible (Fig. 427). This may be done by threading the distal end of the vein through an instrument devised by C. H. Mayo called a ''vein stripper." Instead of the vein stripper a medium-sized blunt uterine curet can be used satisfactorily. 430 0['ER;\.TIVE SURGERY When tlie stripping has been cariied as far down Die tliigh as possible the end of the vein stripper is cut doAvn upon and the vein is brought up into a short incision and loosened from the tissues in its neighborhood. The vein strip- per through which the vein is still threaded is again pushed down beneath the skin to a point below the knee if possible, and is again cut down upon (Fig. 428). This avoids making an incision on a level with the knee joint. The vein is brought up through this last incision and ligated below. It is not Fig. 428. — Mobilizing a varicose vein and stripping it from one incision to the other by method of C. H. Mayo. possible to use the vein stripper much below the knee because the varicose veins here are very large and the branches are numerous. Along the inner side of the leg an incision is made either straight or curved and fashioned to give the maximum exposure of the veins, and the veins are excised. If an ulcer is present it should be protected by gauze during the progress of the operation on the veins and after this has been completed, the ulcer may be excised and the raw surface skin grafted with Thiersch grafts. THE SCIATIC NERVE AND BRANCHES The technic of operations upon nerves has already been described, but on account of wounds or tumors it may be necessary to expose the sciatic nerve or its two main branches, the tibial and the common peroneal. In ex- posing the sciatic nerve for stretching or other purposes the patient lies THE IjOwer extremity 431 prone. The tuberosity of tlie isehiiuu autl tlie great troehaiiter are identified and an incision is made midway between these points and, beginning just above the gluteal fold, it goes down the leg for about four or five inches. The small sciatic nerve is then seen. The lower edge of the gluteus maximus will be found about the middle of the incision. The hamstring muscles are demon- strated by bending the knee so as to identify them and are retracted iuAvard. The nerve is a little nearer to the tuberosity of the ischium than to the great trochanter. In exposing the upper portion of the sciatic for suturing, the incision is more extensive. The lower part of the incision is vertical as is made for stretching the nerve, but at. the gluteal fold it curves sharply outward along the outer border of the gluteus maximus and is carried to the level of the tip of the trochanter major, or higher if necessary. A flap is reflected and turned inward, exposing the upper portion of the sciatic nerve. This incision tends somewhat to prevent infection and gives a satis- factory scar. The internal popliteal or tibial nerve, as it is now called, is exposed by an incision that begins opposite the center of the popliteal space and is carried three and one-half inches downward between the two heads of the gastrocnemius muscle. The short saphenous vein and the small nerve are retracted and after dividing the deep fascia the two heads of the gastroc- nemius are separated. The short saphenous vein empties into the popliteal vein beneath the nerve, the tibial nerve being most superficial, the vein next and the artery nearest the joint. The external popliteal or common peroneal nerve follows the outer side of the popliteal space and lies close to the biceps. The nerve passes over the outer head of the gastrocnemius muscle, lying be- tween it and the biceps, and crosses the fibula just below its head beneath the upper fibers of the peroneus longus muscle. When the knee is flexed the nerve may be easily felt just behind the biceps tendon. The incision to ex- pose the nerve is about two inches long and runs along the posterior border of the tendon of the biceps from behind the prominence of the external condyle of the femur toward the posterior border of the head of the fibula. The biceps tendon is exposed and the knee is flexed to relax the tendon. The nerve lies near the attachment of the biceps tendon to the head of the fibula, between this point and the outer edge of the gastrocnemius muscle. Care must be taken to identify the biceps tendon as sometimes a band of fascia may simulate this tendon. CHAPTER XX OPERATIONS ON THE THORAX EXCEPT THE MAMMARY GLAND THE RIBS Operations upon the ribs are done in two types of cases : (1) those in which there is a disease of the rib itself and the operation is designed to remove the disease by removing* the rib, and (2) those in which a healthy rib is re- moved to gain access to the contents of the thorax, to mobilize the chest wall to fill a cavity, as after chronic empyema, or in cardiolysis when the rigid ribs hold the adherent heart and it is necessary to mobilize the chest wall over the heart. Operations for tumors involving the chest wall or ribs cannot, of course, be typical, but whenever the pleura is opened certain definite procedures must be folloAved. The most important of these is to avoid sudden collapse of the lungs. This accident is serious if there is a wdde opening in the chest and the mediastinum is not rendered immobile. The late John. B. Murphy called attention to this danger and the necessity for fixing a collapsed lung by grasping it with forceps in order that the diaphragm may act satisfac- torily. The chest may be considered as two barrels of a syringe, the midline repre- senting a flexible partition between the two barrels. If the diaphragm is likened to the piston of a syringe it can easily be seen that but little change in pressure can be induced in either barrel by the ascent or descent of the piston if there is a large opening in one of the cylinders of the syringe and at the same time the partition between the two cylinders is so flexible that it readily flaps to either side. If, hoAvever, the partition is held rigid, suc- tion can be made in the unopened compartment by descent of the piston, or compression by ascent. So the action of the diaphragm is embarrassed by a large opening in one pleura. If both pleural cavities communicate with each other, which is uncommon in man, but common in some of the lower animals, the prog- nosis is much more serious. If the opening into the pleura is small and can be closed by a pad the embarrassment of respiration is greatly re- lieved, if not done away with, because the pleural cavity being filled with air and the opening into the pleura closed, the median partition is stabilized and respiration goes on satisfactorily. A hole, however, through which the air rushes in and out produces a flapping back and forth of the median partition between the pleural cavities and almost nullifles the function of the diaphragm. In injuries of the pleura, then, the opening must either be closed as soon as possible, or else the collapsed lung must be caught with 432 THE THORAX 433 rubber-covered clamps or gauze and held firmly during some necessary ma- nipulation so that the median partition is stHl)ilized and the lung of the un- opened pleura can expand and contract during respiration. In operations for removal of sections of the chest wall including the ribs, a differential pressure cabinet was formerly employed in which the patient's head and neck were placed in a cabinet with increased atmospheric pressure, and so the danger of collapse of the lung was avoided. These cabinets were expensive, complicated, and unsatisfactory and the simpler method of Metzer and Auer who introduced intratracheal anesthesia is much more satisfactory. Modifications have been numerous. Samuel Kobinson devised an apparatus in which ether may be administered by insufflation through a mask. In intratracheal insufflation anesthesia the electric motor which is used to pump in the air should always be supplemented by a hand or foot bellows to be used in an emergency if the motor breaks down. This bellows as well as the whole apparatus should be thoroughly tested before giving the anesthesia. The pump should be connected with an air filter and a manometer, as well as with a safety valve of ample size, which releases at a pressure of about 25 mm. of mercury. In the early stages of develop- ment of intratracheal anesthesia the lung tissue was occasionally ruptured because of the absence of a safety valve. The intratracheal tubes are pref- erably of woven silk rather than rubber, though a rubber tube of the same consistency as that used in a soft rubber catheter is satisfactory. The sizes vary from 22 to 24 French according to the size of the larynx and the tubes should be marked at two points, one about 12 c.c. from the tip, which indi- cates the distance of the glottis from the teeth, and the other at 26 c.c. from the tip, which indicates the distance from the bifurcation of the trachea to the teeth. The tube should be of such a size as to fill about half the lumen of the trachea so air can readily escape around it. If too small the returning air escapes too ciuickly, while if too large excessive pressure is made in the lung and the interchange of air is interfered with. After sterilization the tube is chilled with ice before introduction. It is best introduced by the direct laryngoscope, according to the teclinic of Jackson, the patient hav- ing been previously etherized in the ordinary manner. The tube is inserted after the patient is under full surgical anesthesia. After the tube has been inserted and protected from the teeth by a wedge or a clamp of some de- vice and after the pumping apparatus has been connected, the epigastrium should be carefully noticed to see if there is any swelling of the stomach as the tube may have been inserted into the esophagus instead of into the trachea. This mistake has happened, particularly if the tube is inserted by the sense of touch, as is the practice with some operators, instead of through the direct laryngoscope of Jackson. One of the chief disadvantages of intratracheal anesthesia or any form of differential pressure is the obstruction to the circulation in the lung. In normal respiration the obstruction to the circulation of the blood in the lung capillaries is greater after deep than after shallow inspirations, so that with 434 OPERATIVE SURGERY the continuous expansion of the lung by any form of intratracheal insuffla- tion or ditferential pressure the circulation of the lung becomes greatly im- paired and this may account for some of the deaths that have occurred after long operations upon the lungs under ditferential pressure. It is best to permit the lungs to collapse about once every minute or even oftener, except at some critical stage of the operation when it is necessary to have a continuous expansion for a longer time. Just before closing the wound and after the last stitch has been inserted but before it is tied, a forceps is intro- duced into the pleural cavity and opened so as to spread the wound slightly, while the pressure within the lung is raised sufficiently to cause it to fill out the pleural cavity. Air left after surgical operations seems to predispose to infection, and drainage in these cases is always undesirable. If, however, the pleura is accidently opened while operating upon the ribs either plugging the opening quickly so as to stabilize the air that has already entered, or, if the wound is a large one, grasping the collapsed lung firmly with gauze or a soft forceps and holding it steady will usually serve to tide over the crisis. In removing sections of the chest Avail for tumors the same general pre- cautions should be exercised as in operating for malignant diseases elsewhere. An effort should be made to remove the tumor in one mass. The general anatomy of the chest wall must be borne in mind. A knowledge of the loca- tion of the intercostal and the internal mammary arteries is important. As little blood must be lost as possible and this can best be accomplished by clamping the vessels as they are divided and by separating the intercostal vessels from the lower border of the rib and doubly ligating them before they are divided. Provision must be made for closure of the pleural cavity after removal of the tumor, if the defect is so large as to prevent approxima- tion of the pleura. A large flap with an ample base and containing as much subcutaneous tissue as possible is turned into the defect. The flap should be outlined, dissected up, and be ready to be placed over the defect, being protected by moist gauze, before the tumor is excised. In this way embar- rassment from the exposure of the open pleura will be as short as possible. If an intratracheal apparatus is unavailable, or if anything goes wrong with it, the opening should be quickly filled with quantities of gauze wrung out of salt solution, the tumor rapidly removed, and the flap which has previ- ously been formed is sutured in position, except at its lower margin, before removing the gauze. Interrupted sutures are inserted into the lower portion of the wound between the flap and the chest wall but not tied. The gauze is then quickly removed and the sutures are tied. The sutures of the flap of the chest should be interrupted silkworm-gut and should be placed close together, but tied not too tightly. The edges of the wound may be covered with strips of iodoform gauze that have been soaked in compound tincture of benzoin. An abundant dressing is applied over the whole wound. Aside from tumors such as carcinomas which will demand the excision not only of the rib but its periosteum and surrounding tissue, there are two THE THORAX 435 indications for operation in wliicli the periosteum should be removed along Avith the rib or its cartilage. Occasionally in a rigid chest wall where the chest is barrel shaped and the ribs are fixed, particularly in certain types of asthma, it may become necessary to mobilize the ribs by excising parts of the costal cartilage. This is done by removing about one and one-half inches of the costal cartilage of the second, third, fourth and fifth ribs. In some cases operation on one side alone may be all that is necessary, but usu- ally a bilateral operation is more effective. It will probably l)e safer to operate upon the two sides at different times. These cartilages may be re- moved through a single long vertical incision Avliich exposes all of the carti- lage, or by multiple incisions over each cartilage. Sometimes a portion of the bony rib is included along with the cartilage. It is doubtless better to use a single incision which begins just below the clavicle and goes down- Avard about three-fourths of an inch from the sternum. Care should be taken not to wound the internal mammary artery. Each cartilage is cut close to the sternum and lifted upward along Avith its perichondrium and dis- sected outward toward the rib. After the cartilages have been removed, the intercostal structures are served together to obliterate the dead space and les- sen the chances of regeneration of the cartilage. The operation can be done under local anesthesia as patients in Avliich the operation is indicated are not good subjects for a general anesthesia. Similarly in certain rib resections to obliterate cavities in the pleura or when the breast or pericardium are ad- herent to the chest wall, the periosteum should be removed along with the rib. This latter operation is known as cardiolysis. It is only applicable to that type of pericarditis which is characterized by adhesions between the pericar- dium, pleura, diaphragm and mediastinum, practically gluing together these structures and the heart. Separation of these adhesions alone does but little good and is commonly folloAved by early recurrence. In instances in which this operation is indicated the "work of the heart is seriously interfered with and the systolic contraction is followed by a marked bulging during diastole. For cardiolysis an incision is made which is curved with its convexity doAvmvard on about the level of the fourth rib and is carried from the left border of the sternum to the anterior axillary line. The incision is carried to the ribs and the skin and muscle on each side of the wound are dissected up, exposing the third, fourth and fifth ribs from the junction Avith their carti- lages for a distance of about four inches. These three ribs are resected, pref- erably Avith their periosteum as otherAvise they are likely to regenerate. This, hoAvever, must be carefully done over the outer portion of the Avound as there is great risk of injuring the pleura at this point. It may probably be Aviser to remove the periosteum Avith the rib over the inner inch and a half where the adhesions are so dense as to obliterate the pleura and in the outer portion of the wound Avhere the pleura is thin and likely to be injured the ribs can be removed subperiosteally. After four inches of the third, fourth and fifth ribs have been removed, the inner inch and a half being removed with the periosteum, the muscle is brought together after hemostasis has been com- 436 OPERATIVE SURGERY pleted. The skin is closed in the usual manner. Sometimes the costal car- tilages are also removed with the ribs. Typhoid ribs occur after typhoid fever and as the incidence of typhoid fever has been greatl,v lessened by preventive medicine and vaccination, this disease is now rare. W. W. Keen brought this alTection into prominence in his monograph on surgical diseases of typhoid fever, in which he reports sev- eral cases. Operation for this condition presents certain features that are different from operations for pure pyogenic infections. The disease often develops months and even years after an attack of typhoid and sometimes, unless a careful history is taken or serum tests are made, the occurrence of typhoid fever may be overlooked. Typhoid bacilli may remain in the ribs in pure culture for months or years after the attack of typhoid. The disease seems particularly likely to occur about the junction of the rib and its costal cartilage, and infection of the costal cartilage is obstinate. A thorough exposure of the diseased rib or ribs is made by an incision parallel to the ribs and the tissue on either side is undermined and retracted. If a fistula exists the incision is so made as to surround the fistula and every care is taken to prevent infection of the soft tissues. By previously disinfecting the superficial part of the fistula and packing it with a strip of gauze soaked in tincture of iodine just before the operation contami- nation of the adjacent flaps may sometimes be prevented. After the flaps of skin and subcutaneous tissue with the muscle over the ribs have been freely mobilized and retracted the periosteum over the rib and the perichondrium over the cartilage are incised and stripped up with a peri- osteal elevator. Great care must be taken in doing this on the under sur- face of the rib because the pleura is here very easily injured. In resect- ing a rib for empyema where the pleura is thick and where the purpose of the operation is to inc4se the pleura there is but little need for care, but with a typhoid rib and normal pleura the opening of the pleural cavity with the possibility of infecting the pleura should be carefully avoided. By hug- ging the posterior surface of the rib and exposing its edges and the costal cartilage thoroughly before attempting to strip the posterior layer, and then working chiefly from above downward, injury to the pleura can usually be avoided. It is best fully to separate the rib and divide it with bone forceps at the outer portion of the wound. It can then be gently lifted and the periosteum along with the pleura stripped off from without inward as the end of the rib is elevated. AVhen the junction with the cartilage is reached it may be necessary to cut across the cartilage and remove the rest of the dis- eased cartilage with a sharp curet. Usually the lower ribs are affected and their costal cartilages are fused together near the sternum. Not only the rib but the costal cartilage must be removed well beyond the visibly affected area, else a recurrence is certain. As soon as the rib has been resected its bed and the stump of the rib should be protected by moist gauze to avoid in- fection of the exposed end of the rib. It is wise to stitch the periosteum over the stump of the rib before proceeding further with the operation. Af- THE THORAX 437 ter removing a sufficient amount of the cartilage well into the healthy tissue the exposed surfaces of the cartilage together with the periosteum or jjeri- chondrium that has been left are swa])l)ed with gauze soaked in tincture of iodine. The wouiul is closed Avith interrupted sutures of silkworm-gut but provision should be made for drainage by a stab wound at a dependent por- tion of the wound through which a rubber tube is inserted. The dressing should be firm so as to fix the ribs and limit respiration, otherwise there will be considerable pain from the motion of the unattached rib. Usually tliere is a congestion of the pleura because of the proximity of the operation and symptoms of localized pleurisy may appear merely from the trauma that has been done over the pleura and not from any infection. Often the ribs and cartilage are at least partially reproduced from the periosteum and perichondrium together with some of the cambium layer which has been left after removal of the rib. EMPYEMA Removal of the ribs to gain access to the contents of the thorax is a much simpler procedure than the operation for typhoid ribs. When resection of a rib is indicated for empyema the sixth or seventh rib in the midaxillary line or the ninth rib just external to the angle of the scapula is best for an unconfined empyema. The operation should, as a rule, be done under local anesthetic and with care it can be almost painless. Before beginning the operation it is definitely ascertained that pus is present by aspirating the pleural cavity just above or just below the portion of rib that the sur- geon intends to remove. After infiltrating the skin and subcutaneous tissues with novocain solution an incision is made down to the periosteum. Bleeding points are clamped and tied or whipped over with catgut in a needle before proceeding with the operation. After the pleural cavity has been opened and pus has contaminated the wound any manipulation, such as tying ves- sels or securing bleeding points, is unwise as the infection may thereby be spread. The periosteum is infiltrated with novocain and incised about the middle of the rib for a space of two and a half inches. Tissues along the lower and upper border of the rib should be particularly well infiltrated. The periosteum is stripped up, hugging the rib closely, especially at its lower bor- der where the main intercostal vessels lie. After exposing the bone above and below, the posterior part of the periosteum is infiltrated with a small, fine needle and the periosteum is further separated from the rib. This can be readily done by inserting the edge of a periosteal elevator and making lateral motions. The periosteal elevator is then placed beneath the rib which is divided with, bone forceps at the outer angle of the wound. The inner portion is raised, the periosteum stripped further back if necessary, and about two inches of the rib are removed. The periosteum is incised longi- tudinally in the middle and pus allowed to escape. It should not fl.ow too freely because this may produce such sudden changes in the lung and in 438 OPERATIVE SURGERY the circulation of tlie lung that the patient may collapse. No effort should be made to irrigate the cavity though any large pieces of fibrin that are loose and protrude from the wound should be removed. A large rubber tube about three-fourths of an inch in diameter and having two or three perforations is inserted into the wound for four or five inches. The outer portion of the tube is split in two pieces and each half is perforated and a long tape tied into the perforations. The tapes are carried around the body and tied to each other. No effort is made to evacuate all of the pus im- mediately, though most of it may be allowed to escape, stopping the flow at intervals if coughing or other symptoms show that the patient is being too much embarrassed by the rapid flow of pus. Abundant dry sterile dress- ings are applied and renewed every few hours until the discharge decreases. The clean dressing should be ready and should be applied promptly after Fig. 429. — A method of drainage of empyema by negative pressure. removing the soiled dressing so as to protect the pleural cavity from the free and unobstructed ingress of air. Eesection of a rib is not ahvays necessary in the treatment of empy- ema. The indications for the proper type of operation must first be ascer- tained. In patients who are desperately ill and, particularly, those with streptococcic infection that follows certain types of pneumonia after influ- enza, resection of the rib is distinctly contraindicated. Here the patient's resistance is at the lowest ebb, the leukocyte count is low, and no more should be done than is absolutely necessary. The ends of the rib, too, are particularly liable to become infected in such cases and will constitute a source of sepsis. Aspiration or puncture with a trocar and cannula in an intercostal space with the insertion of a tube through the cannula after the trocar has been removed, can be quickly done with but little shock to the patient and in this type of cases is undoubtedly preferable to resection of the rib. When the resistance is Ioav, particularly in the early streptococcic infec- THE THORAX 439 tious, operation slioiild be along as conservative lines as possible and always nnder local anesthesia. The diagnosis is definitely determined by aspiration and a short incision is made throngh the skin in the intercostal space through which the drainage Avould be most satisfactory and usually in the midaxillary line. The incision is made close to the upper border of the rib to avoid the intercostal vessels and is only about half an inch long. A trocar and cannula are selected so that a No. 17 French catheter can be threaded through the cannula. The trocar and cannula are thrust through the incision into the empyema. The trocar is withdrawn and a soft rubber catheter with two extra openings near its end is threaded through the cannula until about three or four inches of the catheter remain in the empyema cavity. The can- nula is gradually withdrawn while threading more and more of the catheter into the pleural cavity. The amount of the catheter that remains in the pleural cavity can be readily determined by measuring the portion on the outside of the incision with another catheter. The tube is so adjusted that about six inches remain within the pleura. The catheter is fastened to the Fig. 430. — A rubber tube for drainage of empyema. The wide flange permits the formation of a valve with a sheet of rubber dam. skin with adhesive straps and connected with a rubber tube that carries the drainage into a bottle. Three or four days later negative pressure can be arranged by connecting the drainage tube with a bottle from which the air has been pumped, or with a collapsible rubber bag, such as the Politzer bag (Fig. 429). Irrigation of an empyema cavity, certainly in the early stages, is never advisable. There are many methods of producing negative pressure in the pleural cavity, or at least of preventing the free entrance of air. The patients may often be permitted to walk around with the drainage tube attached to a bottle that is kept at a partial vacuum. While the patient is in bed the entrance of air into the pleura may be effected by connecting the drainage tube with a tube of rubber dam. This is long, easily collapsible, and ter- minates in a bottle containing some antiseptic solution. On expiration or coughing the fluid from the pleural cavity is forced through this tube of rub- ber dam, but on inspiration the tube collapses and prevents ingress of air. This method, which has been suggested by Joseph Ransohoff, of Cincinnati, is simple and may be all that is required. A valve can be arranged over the exit of the tube if there is a shoulder to the tube. A rubber tube that resembles a 440 OPERATIVE SURGERY spool, having a wide outer flange and a narrow or no inner flange is used (Fig. 430). After insertion of tliis tube a little curtain of rubber dam is fastened over the upper margin of the tube, and will act as a valve, permitting the outflow of drainage without the entrance of air. This valve, however, is likely to become displaced though such a tube has distinct advantages in enabling the drainage through the thoracic wall around the tube to be air Fig. 431. — Operation of Estlander for chronic empyema. A flap has been turned uji, the ribs are resected and the cavity of the empyema is exposed. tight. The valve construction can be omitted and the opening of the flanged tube connected with another rubber tube and negative pressure can be pro- vided for by some of the methods that have been described. Any tube used for the drainage of empyema in the intercostal space should be either very stout elastic tube or a rigid rubber or metal tube, for the ribs may compress and occlude it. In an old empyema where for some reason drainage has been inefficient and THE THORAX 441 the lung has collapsed, a space is left which is difficult of closure. Two prin- ciples arc folloAved in operation for the cure of this condition. In one the ribs themselves are removed in order to mobilize the chest wall and permit it to sink into the cavity. In the other an attempt is made to promote expansion of the lung- by removing from it the membrane which binds it down. In mobilizing the chest wall two types of operations have been employed. In one operation, which is called the method of Estlander, sections of several \''Ai \ Fig. 432. — The muscle flap is dissected and is sutured into tlie wound. ribs are removed over the cavity. The upper portion of the pleural cavity is more difficult to close than the lower portion, as in the lower portion the diaphragm frequently ascends to help the obliteration. Care must be taken, then, to remove the ribs as high as possible. This may be done by a U-shaped incision or by straight incisions so fashioned that two ribs can be removed from each incision, which is made in the intercostal space, the soft tissues be- ing retracted above or below. The ribs removed are usually the second, third, 442 OPERATIVE SURGERY fourth and fifth, though more can be resected if necessary. The disadvan- tage of this operation is that often in these old cases the pleura and chest wall are so thickened by the inflammation that the chest wall will not collapse even after the ribs have been removed. Here the operation of Schede may be done. An incision begins at the origin of the major pectoral muscle on a level with the axilla and is car- ried downAvard to a point at the bottom of the pleural sac, which is usu- ally the tenth rib in the posterior axillary line. The incision curves along the lower part of the chest, coming up behind the scapula at a point about the level of the second rib between the spine and the scapula. The flap includes all the tissues down to the ribs and to the intercostal mus- cles and is dissected up freely. The ribs that are exposed are subperiosteally Fig. 433. Ihe skin flap is sutured in position. It is not usually sufficient to cover the whole cavity. resected from their tubercles to the costal cartilage, dividing the rib about its middle Avith bone forceps and dissecting it from this' point outward and forward until a sufficient amount of rib is removed. A long incision is made through the periosteum of one of the removed ribs and the pleural cavity is ex- plored so the exte-nt to which other ribs or tissue should be removed is accurately ascertained. After a sufficient amount of the ribs has been resected, all of the tis- sue is removed that seems to be necessary to expose the cavity thoroughly, includ- ing the periosteum, intercostal muscles and the thickened pleura (Fig. 431). The intercostal vessels are secured if possible before division by clamping and are ligated after the tissues have been removed. Every bleeding vessel is clamped. Granulations are wiped away with dry gauze and the flap which was originally reflected is turned down over the outer surface of the collapsed lung and fastened in position with sutures and pads. (Fig. 432). The flap is not sufficient to cover the whole of the wound but it is tucked in to coA'er the lung THE THORAX 443 surface of the old enipyenia cavity (Fig. 438). It is important not to use strong antiseptics in such an operation as the great extent of raw surface will make absorption of some antiseptics so great as to be toxic. Such an operation is exceedingly dangerous on the class of patients in whom it is indicated and it is frequently best done in two stages, first remov- ing the llap and excising one or more of the ribs, and later removing the chest wall including the rest of the ribs, intercostal muscles, periosteum, and parietal pleura. Frequently the form of flap, as suggested by Scliede, is modified or en- tirely changed. S. Robinson has suggested a T-shaped flap with the horizontal portion under the axilla as this gives greater nutrition to the flaps. It would be difficult to close the opening by this flap if the deepest part of the cavity is at the upper portion of the iDleura. Occasionally muscle, fat or in women the mammary- gland has been transplanted by a flap to flll in the cavity of an obstinate empyema. According to the technie of Robinson the muscles over the chest may be dissected free from the skin and implanted as a flap into the empyema cavity. Carl Beck utilizes skin flaps which are held in position by tampon, no stitches being used. The denuded surface is inclined to heal rapidly. The operation of Fowler embodies the principle of removing the membrane that binds down the collapsed lung. Fowler and others noticed that in most cases of chronic empyema, even though the lung has been collapsed and bound down for years, it has very considerable resiliency if the membrane that covers it is removed. The pleural cavity is freely exposed by the resection of three or four ribs through an incision, which is made to include the ori- fice of the sinus. Four inches of the fifth and sixth ribs are removed and the parietal pleura is widely opened. Blunt dissection is begun, first in the direction of the diaphragm, and the fibrinous membrane is peeled oif from the lung upward and toward the midline. It is finally detached from the lung above. If the empyema has been drained for more than five months the lung is not likely to expand sufficiently to fill the cavity. Ransohoff in some cases Avhere the peeling off of the membrane is difficult made multiple incisions over the collapsed lung which are carried down through this membrane and criss-crossed in such a manner as to permit the lung to expand without the necessity of dissecting off the entire membrane. It is usually best to combine the principle of Estlander in multiple resection of the ribs with that of decortication of the lung. Of course, where the existence of the empyema has been so long that the lung has been hopelessly collapsed and expansion is impossible decortication will be useless. THE LUNG Surgery of the lung necessitates approach to the lung through the pleura. Where the lesion is small this may be done by the same method of re- secting the rib that has been described in empyema. If, however, the opera- 444 OPERATIVE SURGERY tion is to be extensive or a considerable section of the lung is to be removed, the exposure should be ample and is probably best effected by an intercostal incision through practically the whole length of the seventh intercostal space with forcible separation of the ribs by "rib spreaders/' Avhich are controlled by poAverful levers or screws. Or exposure may be aided by resection of a few inches of the fifth, sixth and seventh ribs posteriorly near their tubercles. This makes the mobilization of the chest wall less difficult. Abscess of the lung may demand operation. The abscess should be accurately located by ph3^sical signs, x-ray and an aspirating needle. A. D. Bevan^ practices incision in an intercostal space down to the pleura under local anesthesia. This incision is about three inches long and is carried down carefully through the intercostal muscles which are gently divided to explore the pleura (Fig. 434). If the pleura is normal in appearance the lung can be seen moving through it. The parietal pleura is pressed inward and the ab- Fig. 434. — Diagram showing method of injecting local anesthetic for operation on abscess of the lung. The abscess is represented by the shaded area. (Method of A. D. Bevan.) scess is aspirated for diagnostic purposes. The needle should be a very fine one so its withdrawal will not permit leakage into the pleural cavity. The wound is then packed with iodoform gauze which holds the parietal pleura against the pleura of the lung over a space about two inches in diameter (Fig. 435). In this manner adhesions are produced betAveen the parietal and the vis- ceral pleura without opening the pleural cavity. Four or five days later the packing is removed and the lung abscess is again aspirated. With a sharp- pointed electric cautery a tunnel is cauterized through the lung tissue to the abscess cavity alongside the aspirating needle which is carefully kept in position (Fig. 436). As soon as the cavity is entered a rubber drain- age tube, which is not easily compressed, such as a soft rubber catheter, is inserted into the abscess cavity and fastened in position by suturing it to the edge of the skin wound and also by inserting a safety pin. C. A. Hedblom,- of the Mayo Clinic, reports a series of operations for ab- ^Surgical Clinics of Chicago, April, 1919, W. E. Satniders Co., Philadelphia, pp. 349-354. ^'Med. Rec, New York, September 13, 1919. THE THORAX 445 scess of tlic lung and advises roseetion of ajjout tliree ribs under local anes- thesia with a larger exposure of the abscess cavity. After operation the drainage may persist for months or years and the fistula that is left is difficult to close. Bevan,-^ under local anesthesia, resects the fistulous tract left b}- prolonged drainage of a lung abscess (Fig. 437). Fig. 435. — ^Vn incision has been made down to the parietal pleura, and the wound is packed with gauze. (Bevan.) Fig. 436. — Several days later the abscess is opened with an electric cautery which follows the aspirating needle. (Bevan. j After resecting about three and one-half inches of three or more ribs in order to give ample exposure, the fistulous tract is grasped with forceps and pulled down. The fistulous opening is split up until the abscess cavity is found (Fig. 438). The abscess cavity and the fistula are lined with a tough membrane which Bevan dissects out under local anesthesia, beginning with the lining ^Surgical Clinics of Chicago, December, 1919, pp. 1319-1324. 446 OPERATIVE SURGERY membrane of the abscess and dissecting from tliat dowji to the opening of the fis- tula, using the fistulous tract as a tractor (Fig. 438). A small portion of the adjacent lung tissue is included with the lining membrane of the abscess and the fistula. The bronchus which opens into the abscess is left without a suture (Fig. 439). The cavity is packed with iodoform gauze and no effort is made to close the incision except by a few sutures in the skin at the extremities of the incision. "Wounds of the lung may be sutured, particularly when it is necessary to control bleeding. Often, however, bleeding can be controlled merely by open- ing the pleural cavity, which permits collapse of the lung and so checks hemor- rhage unless a very large vessel is injured. Fig. 437. — The lines of incision for closure of a fistula following abscess of the lung. (Bevan.) In injuries of the lower lobe of the lung an intercostal incision in the sixth or seventh interspace, which extends the complete length of the rib, gives ex- cellent exposure when used in connection with a rib spreader. This is also quick exposure and avoids the necessity of resection, which not only takes more time, but involves additional trauma and loss of blood. At the conclu- sion of the operation the ribs are brought together by stout interrupted silk sutures, which are passed around the ribs and tied. Usually three such su- tures at different portions of the wound are sufficient. The upper lobe is best exposed by a curved incision with its convexity downward, beginning in front at the second intercostal interspace, going down below the angle of the scapula, and up again parallel to the spine. In this way the scapula can be swung upward before incising the third interspace. The rib spreader is inserted. The lung is drawn up into the wound after protecting the pleura as well as possible by carefully packing it off with moist gauze. Bleeding points are sought for and sutured, preferably with chromic or tanned catgut. THE THORAX 447 The mattress type of suture or the ordinary single suture may be used. The sutures shouUT be tied gently, else they A\ilL cut out. 1£ intratracheal anes- thesia is used the pressure should be increased so that the lung barely fills the pleural cavity just before the last sutures that render the pleura air tight are tied. In some instances, as in localized tumor or bronchiectasis, excision of a lobe of the lung may be necessary. In excision, the lung is exposed prefer- ably under intratracheal anesthesia with a long intercostal incision and rib Fig. 438. — The ribs have been resected and the fistulous tract is being dissected. (Bevan.) spreaders, or resection of one or more ribs may be done. After exposure the diseased lobe is isolated and the pedicle crushed as near the hilum as possible with a strong clamp. The lobe is cut aAvay and the vessels are tied. A stout ligature is placed on the stump. A suture is passed from the stump to the chest in order to prevent retraction of the stump and to stabilize the medias- tinum. This suture should not be tight. A large cigarette drain is carried down to the stump of the resected lobe and brought out through the chest wall. S. Eobinson^ has done a number of successful resections of a lobe of the ^Jour. Am. Med. Assn., 1917, Ixix, 355-357. 448 OPERATIVE SURGERY lung and lie prefers doing this operation in two or llirec stages and without any differential pressure apparatus of any kind but simply with the ordinary anesthesia. He does not use intratracheal anesthesia but in bronchiectasis he sometimes inserts a small tube through the larynx into the trachea to remove excessive secretions by suction while he is operating. The incision he pre- fers is crcscentic with its convexitv dowuAvard. It begins at the fifth rib Fig. 439. — The dissection of the fistulous tract has been almost completed. This is facilitated by traction on the walls of the tract. (Bevan.) two inches from the spinal column, is carried across the eighth rib in the scapular line and then up to the level of the sixth rib in the mammary line (Fig. 440). Skin and fat are dissected from the muscle for about one inch. The muscle fibers are divided transversely between clamps. The seventh, eighth and ninth ribs are resected subperiosteally from their an- gles to the anterior axillary line. The intercostal bundles are tied and re- moved. The skin and muscle flap is then replaced and the wound sutured THE THOKAX 449 without dr;iiii;i,uo. A week later tlie seeoiul sta^e r llu' subcutaneous fat and fas- This point is even move imporlani llian skin itself and Avitli llu" extensive renu) Fig 454 -The incisions are extensively undermined in order to remove as much of the subcutaneous fat ^" and fascia as possible. (Rodman.) cia recurrences are probably fewer than where a somewhat more extensive removal of the skin is done without the undermining dissection for the sub- cutaneous tissue. Incidentally the undermining- makes it easier to close the wound. This, however, is a minor consideration. 474 OPERATIVE SURGERY The third incision begins at the outer extremity of the initial incision as the second incision began about its middle. This is carried dowmvard and imvard and meets the second incision at an acute angle about half way between the ensiform cartilage and the umbilir-iis. This inr-ision also is car- Fig. 455. — The breast -.vith its covering of skin, the contents of the axilla, a portion of the sheath of the rectus muscles, and the adjoining fat and fascia have been removed in one mass. (Rodman.) ried only through the skin, and the subcuticular tissue is carefully under- mined and dissected from the skin for several inches, as along the second incision. The tissues are then removed from above downward, cutting the subcuticular tissue down to the deep fascia along the extremity of the undermined dissection, which should be at least three inches from the edge of the skin incision. This includes the fascia over the sternum. The or- THE MAMMARY GLAND 475 igin of the major pectoral muscle is severed and the perforating arteries are clamped. The fascia of the upper portion of the recti muscles and some of the fat betAveen these muscles are included in the hlock dissection. The origin of the minor pectoral is severed close to the ribs while holding the muscle up with the finger to make it tense. The fascia along the edge of the serratus magnus is dissected to the outer limits of the undermined incis- ion (Fig. 455). Care must be taken to include all fascia over the thorax and below the clavicle in this mass, as this fascia is particularly likely to harbor cancer cells. The specimen is removed and should contain in one mass the mammary Fig. 456. — Photograph of patient of the author on whom the Rodman operation was done, taken eleven months after the operation. Note the line of scar which shows that the incision was completely closed at the time of operation, and the mobility of the arm, which is unimpaired by the operation. gland, with the cancer about the center of the excised skin, the pectoral muscles and the contents of the axilla attached to one end of the specimen, with a wide zone of subcutaneous fat and fascia surrounding the breast internally, above, and below, as well as the fascia over the upper portion of the recti muscles. The recti muscles should first be approximated by in- terrupted sutures of catgut and the clamped vessels are tied with catgut. The sutures of the skin begin at the lower angle and are interrupted silkworm- gut. They are placed from below upward until the tension becomes great. Before sutures are placed over the axillary region a stab wound is made in the skin over the lower portion of the axilla and a rubber drainage tube is carried through the stab wound and fastened in position by suturing it to the skin. This 476 OPERATIVE SURGERY not only provides for drainage, but tends to produce a flow of lymph toward the tube and may in this way cause the washing out of cancer cells that might otherwise be absorbed. After the wound has been sutured about half Avay from below, suturing is begun at the upper angle, interrupted sutures of silkworm-gut being placed from this point down to the region of greatest tension. The sutures are introduced in such a manner as will provide for free movement of the shoulder and at the same time not produce too much tension. A fold of skin that runs backward can be sutured so as to re- lieve the tension. The principles of plastic surgery are utilized in closing this Avound. It is wise never to have too fixed a rule for suturing such cases, as the amount of skin to be removed is regulated by the extent and location of the growth. At points of tension caused by the sutures short relaxation incisions are made, carrying the knife just through the skin and making the incision no longer than one-eighth or at most one-fourth of an inch. If this is done freely along the lines of tension, as shown by the appearance of white areas after the stitches are tied, venous drainage is promoted and there is but little likeli- hood of breaking down of the wound on account of lack of nutrition. It is well, however, to cover the wound with some sterile impervious material which may be left on for four days and Avill favor the nutrition of the skin along the suture line somcAvhat better than a simple dry dressing. If, how- ever, the nutrition along the edges of the wound seems to be well established an ordinary dry dressing may be placed, taking care to reinforce the dressing along the exit of the tube. The tube is removed in five or six days (Fig. 456). CHAPTER XXII OPERATIONS FOR HERNIA The emergency of hernia is clue to stranguUition, and this may occur with almost any type of hernia. The strangulation calls for immediate operation. After this is relieved the method of dealing with the bowel or omentum which Avas strangulated depends partly upon the condition of the imprisoned struc- tures and partly upon the condition of the patient. Strangulated inguinal hernia frequently occurs because of the great in- cidence of inguinal hernia, but proportionately the number of cases of stran- gulation of the femoral and umbilical hernias represents a higher percentage. The smaller the opening through which a hernia protrudes the greater the probability of strangulation, solely for mechanical reasons, whereas a large bulging hernia that may afford great discomfort is not likely to be strangulated unless there are bands or adhesions in the neck of the sac through which special loops are caught, or unless there are adhesions to a portion of the sac which fix the bowel at this point and predispose to a volvulus. If the strangulation is in an inguinal or a femoral hernia an incision is made parallel wdtli and just above Poupart's ligament. In an inguinal hernia, after dividing the skin and superficial fascia, the aponeurosis of the external oblique is split with scissors or with a knife on a grooved director. Blunt- pointed scissors are the most satisfactorj^ instrument. The ring of con- striction is divided by splitting it in an upward direction until the con- striction is entirely relieved. The sac of a strangulated hernia is recognized by subperitoneal fat that is usually immediately over it, by its bluish color, and by the fact that it is thin and almost transparent and can be seen to glide over the contents beneath it. The sac should always be opened, but it is best first to divide the constriction. Sometimes, hoAvever, the tenseness of the sac from its contained bowel and fluid is so great that it is wiser to open the sac before attempting to relieve the constriction. If it is a direct inguinal hernia, care must be taken to avoid injuring the deep epigastric artery which lies to the outer side of the neck. In indirect hernia no such structure is present but a division of either type of hernia by carefully cutting down from without inward will make any vessel accessible, so its injury can either be avoided or the vessel can be readily clamped and tied. In femoral hernia the so-called hernia knife or blunt-pointed bistoury is often used. The femoral canal cannot be freely divided without considerable danger of recurrence of the hernia. It is best in this type to make the same incision as in inguinal hernia and after retracting the lower margin of the wound to expose and free the sac. The abdomen is then opened and an ef- 477 478 Ol'KKATUM': RUROERY fort is iiKulc ;il I'cduclion, i);iflly by iii;mipiil;il ion ol" tlio sac Miul ])artly by piilliiiii' on the inlcstinc lliroii^li the ;il)(h)ininal incision. Willi iliis ])imanual manipulation many femoral liernias can be I'cchiced. If this procediii'ii is of no iiNiiil the femoral rini;' can be nicked with a binnt -point ed bislonry or a knife carried down on a. grooveil director or by l)hiid. scissors. The hernia knife may be inserted in the femoral eanal from above after cleariiifj;' Pon- ])ai'l.'s liii'juueid and a cnt is niad(> inward in the direction of the libers (»f tlu^ li^'ameid. The o|)(Mnni>' is then more readily I'cpaired than if the eanal were cnt npwai'd across Poni)art's lif^amcnt. In nnd)ilical hernia the same t^'cneral pi'ineiples apply. The di\ision of the conslrictint'' rin^i;' shonld b(> onlward so that the margins of the rin<;' can be overlapped from above dow invard. In acquired incisional or \-enl I'ai hernia followini;' eit licr accident or opera- tion stranfi'ulation is not a fre(pnMd oecnrrence, thoni^li on acconnt of adhesions obstruction of the bowel may occur. After reduction of the contents of a strangulated hernial sac lli(> bowel shonld always be inspected. ]f there is a suspicion of gangrene and no perforation of the bowel, it is best to return the suspicious loop to the abdominal cavity just beneath the incision for a few minutes. Then the loop is inspected and if the color has improved and it seems that the loop will recover, the hei-nia is treated according to the indications, and the boM^el is further disregai-dcd. If the bowel appears gangrenous, or if tlvere is a suspicion of perforation, the boM'cl shoidd not be r(>turned to the abdominal caxity, but is surrounded for fi\-e minutes to ten minutes with gau/e Avriuig out of hot salt solution, or if the condition of the ])atient permits, until it is apparent what Avill be the elT'ect of the stra]igulali(ui on the bowel. Often when a loop looks cx'cn doubtful ol' re- covery, it will clear up after such tnvitment. If the bowel is fraidcly gangrenous or threatens to perforate and, of course, if a perforation has actuially oc- curred, the surrounding tissues and the peritoneal cavity are protected b}^ being packed off with nu)ist gauze and the bowel is resected. The tech- nic of resection is described in the chapter on Intestinal Surgery. A care- ful resection is nuule, A\itb attention to closure of the mesenteric trian- gles of the bowel before opening Ihe intestine and severing it from the mesen- teric border outward. Union can be rapidly made with a needle and thread. This operation can be done under a local anesthetic. Ivcsection is usually ])referable to a large fecal fistula. If the strangulation has existed for some- time and if the bowel on the proximal side of the strangulation is consid- erably dilated, an enterostomy by Ihe method that is described in the chapter on Intestinal Surgery, in which tln> priiu'i])le of Coffey is employed, affords the greatest saf(>ly. This may be done with or without a resect i(ui. If there is considerable distention of the bowel and resection is done an enterostomy shonld always be ])crformed, using a rubber catheter, making a valve enterostomy, and bringing the tube through a stab wound either before it is inserted into the enterostomy opening, or else clani])ing it near the l)ow(d and then j)ringing it old through a stab wound. In this way HERNIA 479 infection of the tissues from the fecal contents is avoided. If a large loop of bowel is strangulated and dilated and if the condition of the bowel is doubtful after waiting several minutes, the course to be pursued depends upon the ability of the surgeon and the condition of the patient. If the surgeon has had some experience, and particularly experience in animal ex- perimentation, and has mastered the technic of resection, it is probably safer for the patient if resection is done. If, however, the surgeon is doubtful of his technic and has had little or no experience in resecting bowel, it would be safer to return the doubtful loop and let the patient take his chances. In frank gangrene, of course, resection should always be done. Whether the radical cure of a hernia should be undertaken after the relief of the strangulation depends largely upon the condition of the patient. It should al- ways be attempted unless there is strong contraindication. Where the bowel has already ruptured and the tissues have become infected no serious attempt at rad- ical cure should be made, but a few sutures are placed to retain the contents of the abdomen and the wound is abundantly drained, being packed loosely with gauze. Later, when the infection has been fully overcome, an operation for radical cure can be done. INGUINAL HERNIA A type of hernia that is frequently incarcerated, but not often strangu- lated, is "sliding" hernia. This occurs most frequently on the left side, but may be found on the right side. It is possible to have a sliding hernia of large bowel with a loop of small bowel strangulated in the sac. The path- ology of sliding hernia must be understood in order to operate upon it in- telligently. It has been variously explained as a condition in w^hich the large bowel, particularly the sigmoid, slides down between the two layers of its mesentery and appears in such a manner that the wall of the bowel it- self forms part of the sac. This condition has been very satisfactorily ex- plained by Louis Ransohot¥, of Cincinnati, as merely a fusion and disap- pearance of the peritoneal coats. This is quite common in embryologic de- velopment, and is often seen when portions of the ascending or descend- ing colon are so closely attached to the abdominal wall by the fusion of the peritoneum that they are practically as much extraperitoneal organs as the kidneys. Sliding hernia is particularly prone to recur and should be care- fully reduced after freeing the attachments of the bowel through the ring and into the abdominal cavity. In many instances the portion of the sac that is left can be utilized to cover the raw surface of the sliding bowel as a flap somewhat similar to the method used in the ''bottle" operation for hydrocele. The relation of the peritoneum of the sac to a sliding hernia is quite similar to that of the tunica vaginalis to the testicle. The radical cure of inguinal hernia has an interesting history. The op- eration of Bassini has stood the test of time and has proved satisfactory in most cases of inguinal hernia. The only modification of Bassini 's technic 480 OPERATIVE SL'RGERY that appears as a marked improvement is the substitution of the absorbable suture for the nonaljsorbable silk that Avas originally used by Bassini. While fine silk sutures can be employed without the proljability of trouljle resulting, in operations on hernia stouter material must be used and tlie larger nonabsorbable sutures are likely to irritate the tissues and an effort to extrude them often follows. The principle of the Bassini operation is to reconstruct the inguinal canal by suturing the conjoined tendon and the internal oblique and trans- versalis muscles to the shelving edge of Poupart's ligament beneath the spermatic cord, -while the aponeurosis of the external oblique is brought together over the cord. An incision is made over the inguinal canal parallel to Poupart's ligament and about half an inch above it and extending from over the external inguinal ring to an inch beyond the region of the internal ring (Fig. 457). If the operation is done under a local anesthetic, which Fig. 457. — Line of incision for exposure of the ingviinal canal in the Bassini operation for inguinal liernia. can often be satisfactorily used, the incision should extend slightly farther outward than under a general anesthetic, as it is necessary to infiltrate the ilioinguinal and the iliohypogastric nerves in an "early stage of the operation. Here the fibers that lie about the center of the inguinal canal are identified by the bulging and the thinning out of the fibers and by their position in regard to the external ring and are split with a knife at the outer end of the incision (Fig. 458). The edges of the split fibers are seized with hemostatic forceps and gently elevated, while the tissues be- neath are separated until the ilioinguinal and iliohypogastric nerves are identified. Occasionally one or the other of these nerves is absent and not infrequently one is much larger than the other one. Their course and position is somewhat variable, but they can usually be found beneath the split portion of the aponeurosis of the external oblique about two or three inches from the external ring (Fig. 459). These nerves are infiltrated with novocain solution through a fine hypodermic needle if the operation is done HERNIA 481 under local anesthesia, and tlie fibers of tlie apoiienrosis are split down throngh tlie external ring. In operating under a general anesthetic the aponeurosis is usually split from the external ring upward. This method is quicker and somewhat easier, hut not infrequently these two nerves are injured when the aponeurosis is cut in this way and this results in areas of anesthesia and hyperesthesia which are somewhat annoying to the patient. "Whether a general anesthetic or a local anesthetic is used an effort should be made not only to preserve these nerves but to avoid their being included in the su- tures that approximate the structures beneath the cord. The edges of the split aponeurosis are separated from the adjacent tis- Fig. 458. — The external inguinal ring is exposed. sue below and above, and the nerves are kept under observation to prevent injury. The iliohypogastric penetrates the aponeurosis of the external oblique toward the inner and upper portion of the w^ound, usually about an inch from the margin of the split aponeurosis. Unless it is kept under observation it may readily be bruised or torn where it enters this structure. After laying open the roof of the inguinal canal by splitting the fibers of the aponeurosis of the external oblique, the procedure of Bassini is the same whether a local or a general anesthetic is employed. To avoid pain particular care must be used in infiltrating the structures around the internal inguinal ring and around the neck of the sac. The cremaster muscle and a layer of transversalis fascia which cover the cord and the sac are divided, and the cord and the sac are identified. 482 OPERATIVE SURGERY The structures beneath the cord are incised while the cord and sac are lifted up, taking care to make the incision in a bloodless area. These structures are further divided with scissors so that the cord and sac together are separated from the inguinal canal, except at the internal ring. A piece of gauze is carried beneath the cord and sac. The sac is identified and dissected free from the cord. This is usually best done by incising it and stripping it away from the tissues while the finger is inserted to identify and stabilize it (Fig. 460). Often the structures over the incised sac can be seized with hemostatic forceps and pulled aAvay, or else they can be brushed away with Fig. ,459. — The inguinal canal is exposed by splitting the fibers of the external oblique. Note the ilio- hypogastric nerve, which should be protected. dry gauze. It is dissected free from all structures well up into the abdomen and made tense by traction while a ligature of tanned or chromic catgut in a needle transfixes its neck as high up as possible. The ligature is tied by an assistant while the surgeon holds his finger in the sac down to the ligature to prevent a knuckle of bowel or a piece of omentum being caught in the ligature (Fig. 461). The sac is cut away half an inch from the ligature and the ligature is cut short when the neck of the sac, if it has been properly dissected from the surrounding tissues, will retract within the ab- domen behind the cord and practically out of sight. (Fig. 462.) Four or five interrupted sutures of tanned or chromic catgut or kangaroo ten- don approximate the internal oblique and transversalis muscles and the HERNIA 483 conjoined tendon above to the slielvino- edge of Poupart's ligament below. The sutures are inserted from above downward, care being taken to avoid the in- clusion A\ilhin the sutures of the ilioinguinal or the ilioh^ypogastric nerves. The first suture is placed close to the cord as it emerges from the internal inguinal ring. This suture is inserted while the cord is so held that the por- tion emerging from tlie ring is perpendicular to the body. The suture catches a good bite of the internal oblique and transversalis muscle in such a way that when carried across to the shelving edges of Poupart's ligament, the suture is snngly in contact with the cord. In this Avay just enough play is The sac is being freed. left for the emergence of the cord through the internal ring without con- stricting it too greatly. This suture is tied just tightly enough to secure satisfactory approximation. It is best to tie three knots. If tied too tightly necrosis results and there may be recurrence of the hernia. If not tied suffi- ciently tightly the union will not be firm. Three or four sutures are placed below this at intervals of about one-half an inch. The last suture of this row catches in addition to the conjoined tendon a small bite in the under surface of the aponeurosis of the external oblique as it is reflected inward by retrac- tion (Fig. 463). Care must again be observed to avoid the iliohypogastric nerve which enters the aponeurosis of the external oblique near this point. This suture, which like the others that have been inserted, is carried under the cord, catches the edge of Poupart's ligament near the pubic spine. Coley 484 OPERATIVE SURGERY has called attention to the advisability of inserting this last suture in the manner described, as it adds materially to the strength of the abdominal wall in this region. Coley also places one or two sutures external to the in- ternal ring, uniting the internal oblique to Poupart's ligament. The cord is allowed to lie upon this row of sutures and the aponeu- rosis of the external oblique, which was split at an early stage in the opera- tion, is united by a continuous lock stitch of tanned catgut (Fig. 464). The vessels which have been clamped are tied and the skin wound is united in the usual manner. I have found that a continuous mattress suture of fine tanned Fig. 461. — The neck of the sac is ligated. catgut is very satisfactory for suturing the skin in this region (Fig. 465). The Avound is dressed with an abundance of gauze and cotton and a firm spica bandage is applied. This operation is an exceedingly satisfactory one and in indirect inguinal heniia will, if properly carried out, result in the per- manent cure of more than ninety-five per cent of the patients. In some instances, particularly when a local anesthetic is used, the type of operation that has been described by Ferguson or by Andrews is easier and gives satisfaction, though the results in indirect hernia are not supe- rior to those obtained by the Bassini operation and in direct hernia the results are not so good. In dissection around the sac very frequently a considerable deposit of HERNIA 485 fat is foiiiul. This fat yoiiu'tiiiu's is so marked and so eireiunscribed as to be praetically a li])oma and it may extend from the proi^eritoneal fat along the cord or from between the abdominal muscles. It is possible that such deposits have an etiologic relation to the hernia. At anj- rate they should be dissected free so that the cord can be closed in snugly at the internal ring. ]\rany operators follow the suggestion of Coley and place a suture external to the cord as well as one below it so that the cord emerges between the two sutures. If there seems to be a marked deticiency in the origin of the internal oblique and transversalis muscle in Poupart's ligament, as Ferguson has noted, sutures to correct this deficiency must always be placed. The testicles are sup- Fig. 46. -The cord is mobilized. ported by a broad strip of adhesive which runs from one thigh to another and permits the testicles to lie on this adhesive as on a shelf. The operation of E. Wyllys Andrews involves the principle of imbri- cation and in indirect hernia with a strong conjoined tendon the method is very satisfactory. It is also desirable in operations under local anesthesia, for it avoids handling the cord and dissection of the structures beneath the ccrd which sometimes even after blocking the ilioinguinal and iliohypogastric nerves cause some discomfort. In the Andrews operation the incision is made similar to the Bassini operation, that is, half an inch above and parallel to Poupart's ligament and extending four or five inches outward from the external inguinal ring. The external oblique is split from above downward 486 OPERATIVE SURGERY as though the operation Avere to he done under local anesthesia. This is an excellent rule in any liernia operation. xVfter splitting tlie fil)ors of the aponeurosis of the external oblique through the external ring, tlie apon- eurosis is dissected up en each side until Poupart's ligament is well exposed below and the conjoined tendon and about one and a half inches of the internal oblique and transversalis muscles are uncovered under the upper portion of the wound. Xo veins, fascia or portions of the eremaster muscle are removed. The sac is freed and excised as in the Bassini operation. If the sac is large the part that lies in the scrotum is not always re- moved, but that portion in the inguinal canal is resected. In a large hernia when the sac is completely dissected Andrews sometimes folds up the sac Fig. 463. — The conjoined tendon and the internal oblique and transversalis muscles are sutured to Poupart's ligament beneath the cord. Note that the inner suture catches in addition a portion of the under surface of the aponeurosis of the external oblique. by suturing it according to the method of Macewen. From two to five sutures of chromic catgut unite the conjoined tendon and the internal oblique and transversalis muscles, together with the edge of the aponeurosis of the external oblique just above them, to the shelving edge of Poupart's ligament over the cord. This leaves a flap consisting of the outer portion of the apo- neurosis of the external oblique Avhich has been previously split. This flap is then folded over the roAv of sutures and fastened to the aponeurosis of the external obliciue bj^ a continuous lock stitch of chromic or tanned catgut. AndrcAvs finds that in direct hernias the overlapping should be done by placing the first row of sutures beneath the cord so the sutures unite the conjoined ten- HERNIA 487 don and tlie upper edg-e of the split aponeurosis of the external oblique to the shelving edge of Poupart's ligament beneath the cord. The lower flap of the aponeurosis is then folded over the cord and fastened in such a manner that the cord lies in a new canal. The skin is closed in the usual way. This operation has much to commend it in small indirect hernias that are done under local anesthesia, hut it is sometimes followed, particularly in mus- cular individuals, by a sensation of drawing or tightening that may last for months after the operation. In any operation involving the transplantation of the cord, as in the Bas- sini operation, the cremaster muscle which is intimately associated with the Fig. 464. — The incision in the aponeurosis of the external oblique is closed with a continuous lock stitch. transversalis fascia should be preserved by splitting it for the whole length of the cord from the internal to the external ring and shoving it behind the cord. In this w^ay it will lie behind the internal row of sutures and act as a slight support against the intraabdominal pressure. Ferguson has found that many recurrences are due to a deficient origin of the internal oblique and transversalis muscles from the outer portion of Poupart's ligament. Consequently, after the sac had been removed in the usual way, he united the transversalis fascia by a continuous suture and then sutured the internal oblique and transversalis to Poupart's ligament from the outer portion of the wound down to the inner portion, merely leaving a .sufficient opening at the external ring for the cord. The split edges of 488 OPERATIVE SURGERY Fig. 46S. — The skin is closed with a continuous mattress suture of fine tanned catgut. Fig. 466.— A flap is formed from the sheath of the rectus muscle, according to the method of Halsted, as an additional support in direct inguinal hernia. HERNIA 489 the aponeurosis of the external ()l)li(iue are united in the usual "way. The cord is not disturl)e(l. l)ut merely pushed doAvn. Ferguson recommended a curved incision, which seems unnecessary. The most unsatisfactory type of inguinal hernia to deal with is a direct liernia or else a combined direct and indirect in whieli there is a double sac, one protruding to the inner and the other to the outer side of the deep epi- gastric vessels. The difficulty in curing a direct inguinal hernia is be- cause this hernia is due to a defect in the conjoined tendon. This defect may consist in an abnormally weak conjoined tendon or the tendon may be apparently entirely lacking, and there is nothing to support this weak re- Fig. 467. — In addition to the flap from the sheath of the rectus muscle, the fibers of the rectus muscle can also be transplanted according to the suggestion of Bloodgood. giou in the inguinal canal, whereas in indirect hernia Avith a strong conjoined tendon that is almost normally inserted the inner part of the wound can be readily fortified. Several suggestions have been made concerning the best method of strengthening this Aveak spot in the inguinal canal. Blood- good has practiced transplantation of the rectus muscle by splitting the sheath of the rectus and suturing the muscle instead of the conjoined tendon to Poupart's ligament. Halsted makes a flap of fascia from the sheath of the rectus with the base or hinge outward. This flap is sutured under the cord, replacing the conjoined tendon (Fig. 466). In addition to this flap the rectus muscle can also be sutured to Poupart's ligament, which makes 490 OPERATIVE SURGERY a double reinforcement (Fig. 467). It has been objected that the rectus muscle alone will not hold satisfactorily but by splitting its sheath, form- ing a flap, and suturing this under the cord, and then suturing the rec- tus muscle under the cord just over the flap, the rectus will be more likely to maintain its position. Even if it does not, the fascia formed from the flap of the rectus sheath will probably be sufficient reinforcement. In direct hernia and in indirect hernia in which the conjoined tendon appears weak, this modification should be done. In direct hernia it is important to suture the transversalis fascia together over the stump of the sac. There are a number of different operations for hernia. The most satis- Fig. 468. — Exposure of the neck of the sac from within the peritoneal cavity. (Method of G. P. LaRoque.) Fig. 469. — Suturing the neck of the sac from within the peritoneal cavity. (LaRoque.) factory operation in my hands has been the operation of Bas.sini, as has been described, combined Avith the Halsted-Bloodgood modification of transplanta- tion of a flap from the sheath of the rectus muscle and of the rectus muscle itself where the conjoined tendon is very weak. In cases where the in- ternal ring is the only structure at fault and Avhere a local anesthetic is to be used, the Andrews or Ferguson operation is very satisfactory, but the Bassini with some modification can be used in almost every form of in- guinal hernia, either direct or indirect, with excellent results. In any type of operation the cord should be handled gently and no veins or other struc- tures except fat should be removed from the cord. HERNIA 491 The treatment of the sac of either inouinal or femoral liernia is an im- portant step in the operation. It has been objected that tying the sac at its neck ^\■ill Jraxc a (iinij)h' wilhiii Ihc ])eritoneal cavity, Avhich invites a re- currence of the liernia. To obviate this it is always necessary to dissect the sac well nj) beneatli the abdominal muscles, to make moderate traction upon it. and 1(1 i>lace the ligature flush with the level of the external portion of the peritoneal surface. Preferably the ligature should transfix the neck of the sac. This method of ligating is important in any type of operation for hernia. Even such a ligature, however, has been objected to because in sacs with large necks a dimple may still be left. The Macewen method has apparent advantages, but they are more apparent than real. The technic of Macewen 's treatment of the sac is as follows: After partly freeing the sac from the cord the surgeon introduces his finger into the inguinal canal and bluntly dissects the sac from the cord and from the walls of the inguinal canal and the surrounding tissues. He then carries his finger through the internal ring, separating the peritoneum from the abdominal wall for an inch around the internal ring. A chromic or tanned catgut suture is intro- duced at the lowest portion of the sac and quilted through the sac several times toward its neck so that pulling upon the suture will draAV the sac up into a lump. The needle with the end of the suture that has come out at the neck of the sac is then carried through the internal ring and trans- fixes the abdominal muscles an inch above the internal ring, while the skin is retracted to avoid puncturing it. The suture is pulled snugly and folds up the sac under the abdominal muscles so that it lies between the peritoneum and the inner surface of the abdominal muscles. This suture is permanently anchored, whipping it several times through the external oblique. For- merly this method of treating the sac was considerably in vogue, but it does not of necessity avoid the dimpling that has been objected to and it may form an uneven surface at a naturally well protected point which Avill increase the force of the intraabdominal pressure further down on the inguinal canal. In a sac with a very broad neck a satisfactory treatment is to close the neck of the sac flush with the peritoneum with a continuous purse-string suture, just as though an incision had been made through the peritoneum in performing an abdominal section. The treatment of the sac cannot be entirely standardized by one method, because the character and shape of the sac may alter greatly. LaRoque,^ of Richmond, has presented the problem of treating the sac of either inguinal or femoral hernias in an excellent manner. When it is difficult to excise the sac and when it is thin and small he incises the peri- toneum above the neck of the sac, either by strongly retracting the inter- nal oblique and transversalis muscles, or by splitting these muscles in the direction of their fibers. The internal opening of the sac is exposed by traction upon the lower margin of the peritoneal wound with a hemostatic for- ceps, together with retraction of the upper margin (Fig. 468). The orifice ^Surg., Gynec. & Obst., TCov., 1919, p. SC7, et seq. 492 OPERATIVE ST'RGERY Fig. 470. — Method of inverting a large sac from within the peritoneal cavity. (LaRoque.) Fig. 471. — Suturing the neck of a large sac from within the peritoneal cavity. (LaRoque.) HERNIA 493 of the sac is thou "wliipped over Avitli ;i eoiitiiiiious catgut suture and the re- dundant peritoncniiu is folded over the sutured orifice and takes up the slack in the peritoneum in this region, preventing the formation of a dimple (Fig. 469). Where the sac is large, hoM'ever, and presents too bulky a mass to 1)e enclosed along -witli the cord, tlie finger is inserted into it from the peri- toneal opening and it is freed from the spermatic cord and the surround- ing structures. The finger is then withdrawn and a hemostatic or pedi- cle forceps is inti'oduced through the neck of the sac to its lowest por- tion which is caught and pulled up, turning it inside out (Fig. 470). It can then be treated by suturing the upper margin of the wound in the peritoneum to the base of the everted sac, after bringing it up through the peritoneal wound (Fig. 471). By placing the sutures an inch or more beyond the neck of the sac all redundant peritoneum in the neighborhood of the neck is put on a stretch and the peritoneal opening of the internal ring is completely obliterated. The transversalis fascia which is inverted with the sac is included in the peritoneal suturing. This makes most of the sac ex- traperitoneal. A ligature is then placed around it if it is large and the excess is amputated. If the sac is small it is not necessary to excise it. In either event if the muscles are split they are sutured over the sac or its stump and the rest of the hernia operation is done according to some of the technics that have already been described. FEMORAL HERNIA Femoral hernia occurs through the femoral canal and is most frequently found in women. It is peculiarly liable to strangulation because of the com- paratively small caliber and the rigidity of the femoral canal. A number of rather complicated operations has been devised though the simpler meth- ods appear to be quite satisfactory. In the radical cure of a nonstrangulated femoral hernia high excision of the sac together with obliteration of the fem- oral canal as has been practiced by a number of operators, particularly by Coley, seems to give excellent results. The incision for operation on fenroral hernia is similar to that for in- guinal hernia, though it is made closer to Poupart's ligament, being paral- lel to Poupart's ligament and just above it. The aponeurosis of the ex- ternal oblique is exposed and the lower margin of the wound retracted to uncover the sac. Some operators prefer a vertical incision, beginning about an inch above Poupart's ligament and going downward on the thigh. This is objectionable because it leaves a scar that runs transversely to the creases in the groin and may cause discomfort. Then, too, when ligation of the sac high up in the femoral canal is difficult the peritoneum can be opened and the sac inverted according to the method of LaRoque. After exposing the neck of the sac its body is separated from the surrounding tissues. The sac of a femoral hernia is always thickly cov- ered with fat, which is uncommon in inguinal hernia, except in direct in- 494 OPERATIVE SURGERY guinal hernia where the sac is near the bladder. The sac of a femoral hernia is usually easily separated from the surrounding tissue. Its neck, together M'ith the attaclied fat, is dissected well up into the femoral canal while the roof of the femoral canal is strongly retracted with a small blunt re- tractor. The sac is opened and inspected. If there is adherent omentum the adhesions are separated and the bleeding parts of the omentum are li- gated with catgut and the omentum is returned. If the omentum is thick and contains much scar tissue it should be pulled down until healthy omentum is reached and at this point is ligated in small sections and the distal portion removed. It is best to protect the raw surface of the omentum by whipping over it the adjoining healthy omentum. Sometimes, however, this may make too large a bulk to permit reduction of the mass through the femoral canal. To facilitate reduction it may be necessary to ligate and divide the omentum at different levels, but care must be taken to see that there is no severed vessel between the ligatures. The omentum should never be re- turned to the peritoneal cavity until it is certain that bleeding from the stump has been entirely and satisfactorily controlled. Having dealt with the contents of the sac if there are any, the neck is transfixed with tanned or chromic catgut in a needle, firmly tied, and the sac is cut away, leaving a stump about one-third of an inch long so there will be no possibility of the ligature slipping. The stump should then retract well within the femoral canal. It is important to see that the neck of the sac is thoroughly separated high up into the femoral canal before it is ligated and if this is done the stump will retract so it will be practically out of sight. The femoral canal is obliterated by a suture of tanned or chro- mic catgut in a curved needle. This begins over the inner portion of the roof of the femoral canal through Poupart's ligament. The margin of the femoral canal is strongly retracted upward by a small blunt retractor and a second bite is taken in the pectineus muscle and the fascia along the inner portion of the floor of the femoral canal. This is near the origin of the muscle from the pubic bone. The suture is then carried to the outer wall of the femoral canal and a bite is taken in the tissues and fascia in this neigh- borhood, taking care not to injure the femoral vein. Catching a small piece of the fascia to the inner side of the sheath of the femoral vein affords a strong hold. The needle is then carried through the roof of the femoral canal, penetrating Poupart's ligament, but at a point lower down than the beginning of the suture so that a sufficient amount of the fibers of Poupart's ligament lies betAveen the levels of the beginning and the ending of the suture in order not to split Poupart's ligament. The suture when snugly tied obliterates the femoral canal. The skin is closed in the usual manner. A dressing with a spica bandage is applied to maintain firm pressure on the wound and to prevent an accumulation of serum in the space from which the sac was dissected. The so-called sliding hernia has been mentioned. It often occurs in femoral hernia. The portion of the intestine uncovered with peritoneum which was HERNIA 495 formerly tlion<>lit to he a sliding or eversion of tiie mesentery, bnt is now known to be only an obliteration of the peritoneum, is always on the onter side of the sac. The sae shonld be earefully dissected on all sides, except where it is attaelied to the large bowel. The sac is split at the farthest point from the large bowel, re- flected over that portion of bowel which is uncovered by peritoneum, and held in position by a few sutures. The vessels of the bowel are carefully protected in or- der not to impair its nutrition. An operation for femoral hernia hy attacking the sac from above has been proposed by Dujarier and also by M. G. Seelig and Tuholski. This Fig'. 472. — Exposure of neck of the sac of a femoral hernia by the method of Seelig and Tuholski. method has many obvious advantages and should always be used in strangu- lated or incarcerated femoral hernia. It is sometimes difficult in a strangulated hernia to be certain whether the hernia is femoral or inguinal and the incis- ion for femoral hernia should under all conditions be parallel to Poupart's ligament and only slightly lower than the incision for inguinal hernia. The incision extends down-ward and inward somewhat nearer the pubis than in inguinal hernia,- and is about four inches in length. The aponeurosis of the =Seelig & Tuholski: Surg., Gynec. & Obst., Jan., 1914, p. SS, et seq. 496 OPERATIVE SURGERY external oblique is divided along the direction of its fibers as in ingninal hernia, and the upper flap of the aponeurosis together with the conjoined tendon is retracted upward while the lower flap is retracted downward to expose the inner surface of Poupart's ligament. A strip of gauze or tape may be placed under the round ligament or under the spermatic cord to re- tract it out of the way. This exposes the transversalis fascia which is very thin and beneath this is the peritoneum (Fig. 472). The deep epigastric artery is retracted externally or it may be doubly ligated and divided. The Fig. 473. — The neck of the sac is ligated, the sac excised, and sutures are placed to obliterate the femoral canal. (Seelig and Tuholski.) , transversalis fascia is divided and caught in retractors and the peritoneum near the neck of the hernial sac is brought into view. The peritoneum is opened just above the neck of the sac and the hernial contents are pulled out of the sac. This may be aided by pressure over the sac with one hand while the contents are being pulled upon with the fingers of the other hand within the abdomen. If there is strangulation the constriction is overcome by cut- ting the inner margin of the femoral ring, which constitutes Gimbernat's ligament. This is much more easily repaired than the usual method of cut- ting forward which divides transversely the important fibers of Poupart's HERNIA 497 ligament and makes subsequent repair difficult. This incision is made with blunt-pointed scissors or a probe-pointod knife. Any vessel that is injured can be readily exposed and clamped. If the hernial contents are adherent to the sac, sometimes with traction the hernial contents together with the sac, can be delivered into the abdomen through the wound, the sac being inverted. The adhesions are readily dealt with. If the sac is adherent and cannot be delivered in this manner an incision may be made directly over it, though, as a rule, retraction of the skin and subcutaneous fat of the lower margin of the wound will enable the sac to be dealt with without the additional incision. If the hernial contents have been reduced, a pair of hemostatic forceps is inserted through the abdominal wound into the sac to its bottom, which it seizes and inverts. The sac is closed by a transfixion ligature of catgut in such a manner that the stump leaves no dimple (Fig. 473). It is also possible to treat the sac as recommended by LaKoque in inguinal hernia. The femoral ring is easily closed as it is fully exposed by retraction. The horizontal ramus of the pubis is covered with a tough fascia, which is Cooper's ligament. A suture of tanned or chromic catgut in a small full curved needle is passed from Cooper's ligament going down to the periosteum and just internal to the iliac vein through the lower portion of the transversalis fascia and the edge of Poupart's ligament. The other sutures are placed internal to this one, the innermost suture picking up Gimbernat's ligament. These three interrupted sutures effectively close the femoral canal. The first suture is placed close to the iliac vein, which is retracted with a blunt retractor, and the tissues should be well in view be- fore the suture is placed (Fig. 473). A few interrupted sutures of tanned or chromic catgut now approximate the conjoined tendon and the internal oblique and transversalis muscles to Poupart's ligament without transplant- ing the cord, or the round ligament, and the aponeurosis of the external oblique is sutured in a separate layer with a continuous tanned or chromic catgut ligature, as in the operation of Ferguson. This operation of Seelig, Avhich is an elaboration and modification of the operation of A. V. Mosch- eowitz, and of Dujarier, is but slightly more difficult than the simple opera- tion of exposing the sac from below Poupart's ligament and obliterating the femoral canal by a purse-string suture from below. In strangulation or in incarcerated hernia an operation of the type of the Seelig should always be done and where the femoral canal is large this operation will make the only satisfactory closure. Occasionally when there is marked distention of the abdomen and the contents of the strangulated femoral hernia are tense it may be difficult by an internal incision to divide the femoral canal sufficiently to relax the con- striction and deliver the intestines within the abdominal cavity. Then, too, when the bowel is apparently' gangrenous or when perforation is imminent it may be wise to relieve constriction by cutting through Poupart's ligament from without inward and to inspect the strangulated hernial contents before an attempt is made at replacement within the abdomen. In such instances the aponeurosis of the external oblique is split as close to Poupart's ligament 498 OPERATIVE SURGERY ^ ^ ^^^^p ^^^«^^ y y y /^ /''C<&^^ A, . Fig. 474. — When it is necessary to divide Poupart's ligament, the ligament may be reconstructed by a flap from the aponeurosis of the external oblique. The drawing shows the lines of incision for such a flap. Fig. 475. — The flap has been sutured into position so as to reinforce Poupart's ligament. HERNIA 499 as possible and Poiipart's ligament is divided transversely. This should never be done except under the nniisiial conditions mentioned, for when Poiipart's ligament is divided in this manner it is impossible to suture it together satisfactorily. The cut ends may be approximated with mattress stitches Avhich are loosely tied, though it is impossilde to bring them into contact because the sutures will split out. The internal margin of the aponeurosis of the external oblique can be divided transversely for an inch close to its insertion into the pulnc bone and split up so that it has a base externally (Fig. 474). This flap is carried to the region of the divided Poupart's ligament and fastened securely to the outer and inner ends of the divided ligament, so closing the gap and acting as a splice between the two divided portions of Poupart's ligament. The end of this flap should also be sutured to Cooper's ligament along the margin of the pubic bone. The rest of the aponeurosis is brought down over part of its extent and with the conjoined tendon and internal oblique and transversalis is sutured to the reinforced Poupart's ligament (Fig. 475). I was compelled to sever Pou- part's ligament once and this procedure was followed by satisfactory results. UMBILICAL HERNIA Umbilical hernias occur most frequently in fat persons. An operation that merely approximates the edges of the hernial ring after removing the sac is unsatisfactory. The technic devised by the Mayos has greatly improved the results of operations upon this type of hernia and is now generally adopted. The principle underlying the Mayos' operation is that of over- lapping the wound from above downward. Formerly, when attempts were made to close this hernia by suturing the ring from side to side many of these stout patients succumbed to edema of the lungs or to failure of the heart because an extra burden was placed upon the lungs and heart by the constriction resulting from the longitudinal suturing of the hernial ring. If, however, the tissues are overlapped from above downward and if in the after-treatment the patient's thighs are elevated and a pillow is placed under the shoulders and head, there is comparatively slight discomfort. The incision is transverse and is made in an elliptical manner to surround the umbilicus and the hernia. The incision should be generous and if the patient is very fat a considerable amount of fat is included with the skin. The neck of the hernia is exposed and the aponeurosis for at least an inch and a half around the neck is dissected free of fat (Fig. 476). The sac is divided near the neck by an incision parallel with the open- ing of the neck and the hernial contents are exposed. The adhesions are freed and if there is adherent omentum it is ligated in sections and removed along with the sac. Care should be taken, hoAvever, to inspect the contents of the hernia from the opening near the neck of the sac in order to be certain that the nutrition of the bowel is not interfered with before ligating what seems to be merely omentum; for mesentery may be caught in the sac and may appear to be omentum. The edges of the neck of the sac and the 500 OPERATIVE SURGERY Fig. 476. — The neck of the sac of an umbilical hernia is exposed and is ready for incision. Fig. 477. — Mattress sutures for imbrication of the margins of the opening in the aponeurosis of the abdominal wall are placed. HERNIA 501 margins of the umbilical ring are seized with forceps as the incision is con- tinued around the neck of the sac. The sac should not be cut too close to the neck as all the peritoneal tissue and even thin fascia which can be saved add to the strength of the reconstructed abdominal wall. The intes- tinal contents are packed off with moist gauze. Exposure with a retractor should be ample while passing the sutures. The sutures are stout tanned or chromic catgut. The first suture is inserted in the midline about two inches below the lower margin of the umbilical ring, appears in the abdominal cavity and is carried to the upper margin of the umbilical ring where it takes a bite in the peritoneum and fascia, and then returning is passed from the peritoneal cavity outward at. a point about one-half an inch to one side of the point of entrance. The ends are cut long and clamped >* ^^' J^ ■^-f T ^ \ "TxC^ Fig. 478. — The mattress sutures have been tied snugly and the margin of the overlapped aponeurosis is sutured to the surface of the aponeurosis which it overlaps. but not tied. One or more sutures are similarly passed on each side of this central suture. The number of sutures, of course, depends upon the size of the ring (Fig. 477). After the sutures have been placed they are all grasped at the same time and by traction the upper margin of the ring is im- bricated under the lower margin. The sutures are tied one at a time while all are held taut. In this manner no undue tension is placed upon any single suture. The overlapping is ample to provide for a considera- ble retraction of the margins without a recurrence of the hernia. A con- tinuous lock stitch of tanned or chromic catgut fixes the former lower margin of the ring of the umbilical hernia to the aponeurosis over which it noAV lies (Fig. 478). The skin is closed in the usual manner. It is well to introduce a small drain of catgut mat or folded rubber tissue in the outer angles 502 OPERATIVE SURGERY of the wound to give exit to the broken down fat that not infrequent!}^ occurs in stout people after this operation. If the local conditions make it easier to carry the lower margin of the umbilical ring under the upper margin, instead of the reversed procedure which has just been described, this can be done, as it makes no essential dif- ference in results. The important points are to free the external fascia from fat, to introduce the first mattress suture at a sufficient distance from the margin of the ring, to secure ample overlapping, and to bring all sutures up taut before any suture is tied. INCISIONAL OR VENTRAL HERNIA Incisional or ventral hernias follow injury to the abdominal wall, usu- ally an operation, and are prone to occur after infection where union, is poor or in stout individuals where the intraabdominal pressure is great. The com- bination of infection and fat is particularly liable to develop hernia. As in- fection plays a considerable part in the development of an incisional hernia, adhesions of the viscera to the sac are common. The explanation of the formation of these adhesions has been greatly clarified by Hertzler,^ who has shown that adhesions are dense along the periphery of a severe infection and not in its center, as has been commonly supposed. Consequently, after a hernia following an abdominal infection the focus of the beginning of in- fection may be found free from adhesions while the viscera are well plastered to each other or to the peritoneum at some distance away. It is, of course, necessary to free the adhesions from the sac of an incisional hernia Avhen operating to cure the hernia. While all adhesions in the abdominal cavity need not be freed, any single band or strong points of adhesions should be cut because they are more likely than broad extensive adhesions to cause obstruction. The incision is so made as to include the scar in the skin from the previous operation. The peritoneal cavity is opened at the upper or the lower end of the incision, making an effort to enter just above or just below the margins of the hernia. Usually it is better to go in above, because most of these hernias occur in the midline and an incision below may involve the bladder. After entering the abdominal cavity the adhesions are freed, bluntly if possible, and the incision is carried down through the midline, freeing adhesions as the incision progresses. The sac which consists of peri- toneum and thin bands of fascia is split down the middle. AV. J. Mayo has called attention to the great value of jDeritoneum in oiierating on this type of hernias and the sac should never be cut away but should be preserved. After the adhesions have been freed the skin with the subcutaneous fat is separated on each side to a point well beyond the weakened thin wall of the hernia. Often the margins of the hernia are not sharp as in umbilical hernia, but gradually merge into healthy tissue. The margins are overlapped as de- ^Hertzler, A. Tt.: The Peritoneum, i, p. 276, et seq. HERNIA 503 scribed in umbilical lioriiiu, except that they are overlapped from side to side in- stead of from above downward. The first mattress suture of stout tanned or chromic catgut is taken preferably on the right side about one and a half or two inches from the apparent margin of the weak hernial tissue. This may be a distance of four or more inches from the edge of the incision in the hernial sac. The suture is carried in full view to the left margin of the sac and after catching the edge of the sac and its weak fascia a second bite with the needle is made farther back from the edge, taking care to secure at least fairly strong tissue. The bite should not go far enough out from the edge to include the thick healthy abdominal wall, because this would mean too much overlapping and too great strain upon the tissues, and, consequently, too much intraabdominal pressure with its resulting effect upon the heart and lungs. This suture is returned in a reverse direction and the ends are left long and clamped. After a series of these mattress sutures have been inserted care is taken to remove all gauze from the abdomen that may have been placed to pro- tect the viscera while passing the suture. The sutures are held up taut while the margin of the left portion of the sac is slid under the margin of the right half. These sutures are tied one at a time while the others are held taut, mak- ing three or four ties to each knot. The right margin of the sac, which now overlaps considerable tissue, is attached to the fascia on the left side by a continuous lock stitch of tanned catgut. The skin is closed in the usual manner. This operation, which is based on the principles enunciated by W. J. Mayo of the great value of peritoneum in repair of this type of hernias, is much better than the anatomical dissection in the midline, for all tissues are saved, no possible support is wasted, and the double-breasted effect makes a recurrence improbable. Occasionally a hernia occurs after a drainage operation for appendi- citis through the muscle splitting McBurney incision. If the patient is kept in bed sufficiently long, hernia after drainage through a McBurney incision is rare, and when it does occur is usually not large. Occa- sionally, however, the tissue yields. Here an anatomical dissection is pref- erable to the overlapping method, because the wound is closed in layers and in the different planes of closure the lines of sutures are not parallel as in an anatomical dissection of a ventral hernia in the midline of the abdomen. In a ventral or incisional hernia following a McBurney incision the scar in the skin is excised so that only healthy skin is brought together when the wound is closed. This principle should be followed so far as possible in any secondary operation. The fascia of the external oblique is recognized in either the lower or the upper portions of the wound and is split a short dis- tance from the margin of the hernia. The split edges of the aponeurosis of the external oblique are dissected up on each side, freeing them for some distance from the margins of the hernia and trimming away any irregular adhesions or masses of scar tissue. Under strong retraction the internal oblique and transver- salis muscles are exposed and dissected free. The sac is then opened near its neck as in umbilical hernia. The adhesions are freed and damaged omentum 504 OPERATIVE SURGERY is ligated in sections and divided, removing the adlierent omentum with the sac. The peritoneum is closed with a continuous mattress suture of cat- gut, and the margins of the internal oblique and transversalis muscle, which have been thoroughly mobilized, are brought together with sutures of plain or tanned catgut. The mobilization should be so complete that there Avill be no tension upon the sutures. The aponeurosis of the external oblique is sutured with a continuous lock stitch of plain catgut. The skin is closed in the usual manner. EPIGASTRIC HERNIA Epigastric hernia has been occasionally discussed in medical journals since Terrier's publications described this condition and his operations for its cure in 1885. It seems, however, to have attracted but little attention. Not infrequently small epigastric hernias are diagnosticated and treated as ulcer Fig. 479. — An eiaigastric hernia is exposed. It shows the protrusion of the subperitoneal fat through a defect in the aponeurosis in the midline of the epigastric region. of the stomach or gall bladder disease. Epigastric hernia is situated in the anterior abdominal Avail in or very near the linea alba between the umbilicus and the ensiform cartilage. It may occur in the linea semilunaris or some- times in the lineae transversse of the rectus muscle. It varies in size from a small protrusion not more than a fourth of an inch in diameter which contains only properitoneal fat, to a large mass several inches in diam- HERNIA 505 eter. The diagnosis of a large mass is obvious, but a small epigastric liernia with but slight protrusion and containing only properitoneal fat is sometimes easy to overlook. They are not infrequently multiple and this fact should be borne in mind when operating for this condition. The defect is usuall}^ congenital but when the hernia occurs in the linea semilunaris or in a transverse line of the rectus muscle it may follow an enlargement of the perforation of the blood vessels. In the midline a congenital defect such as is the cause of most hernias is the probable explanation for this hernia. The patient himself may discover a small lump no larger than the tip of the finger, which is painful and tender while he stands or sits, but disap- pears along with the symptoms when he lies down. Such symptoms are exceedingly suggestive of epigastric hernia. In very fat individuals it is sometimes difficult to feel the hernia even when the patient is standing. An incision should be carefully made in the midline and carried down to the fascia before the fascia is divided. The fat is stripped away from the fascia for a distance of two inches on each side and the midline and the sheath of both muscles are fully inspected. If the opening is small it merely amounts to a protrusion of some properitoneal fat. This properitoneal tissue is well supplied with sensory nerves and when the intraabdominal pressure forces it through a small aperture pain is produced, which may be relieved when the patient lies down and the fat falls back into its normal place. An epigastric hernia with a large peritoneal sac usually gives but little discomfort unless there are adhesions or strangulation (Fig. 479). If the hernia consists merely of properitoneal fat there is no occasion for opening the abdominal cavity, but the fascia is split in the midline both above and below the hernia and overlapped for a distance of about half an inch, inserting two or more mat- tress sutures of tanned or chromic catgut in order to hold one edge of the fascia under the other and fastening the superficial edge to the fascia beneath it with a continuous lock stitch of tanned or chromic catgut. If the hernia is a large one and contains a well formed peritoneal sac, the sac is removed, leav- ing a sufficient margin of peritoneum in which to apply a continuous mattress suture without too much tension. The edges of the fascia are then overlapped, as has been described. The overlapping, however, should not be more than an inch, as more than this will produce too great intraabdominal pressure in this region and may embarrass respiration. As the sac in such a hernia does not contain elements of fascia as in an incisional hernia it had Ijest be treated by excision of the sac instead of the overlapping described in operation on incisional hernia. DIAPHRAGMATIC HERNIA This condition is one of the many diseases in which x-ray has greatly aided the diagnosis. While, as Balfour says, it is not exceedingly rare it is uncommon. Diaphragmatic hernia may be purely traumatic, as from a stab wound, or a gun shot injury which involves the diaphragm; or it may be the 506 OPERATIVE SURGERY result of a congenital weakness of the diaphragm, usually around the esoph- ageal opening. This weak point may give way from pressure that under normal conditions is readily withstood. Bevan records a case that was ap- parently due to a distended colon from chronic ol)struction due to cancer of the left side of the colon. It is important to recognize whether the hernia is purely traumatic or is due to a congenital weakness, because the location of the incision and the type of operation are usually quite different in these two types. Diaphragmatic hernia due to direct injury is usually along the periphery of the diaphragm and the hernia may occur im- mediately or may follow months or years after the injury. Here the best ap- proach is probably through the thorax. In the congenital type the hernia occurs around the esophageal opening in the diaphragm, and in such a loca- tion the site of the hernia is most accessible through an abdominal incision, as it would be difficult to reach the defect through the thorax. The hernia can often be located by the x-ray. A portion of the stomach is frequently found in these hernias whether they be traumatic or congenital. Other viscera are also often contained in a diaphragmatic hernia. The case of Bevan, which has already been referred to, contained a portion of the di- lated transverse colon through an opening around the esophageal outlet of the diaphragm. Roentgenographic examination should be made not only of the stomach but of the complete gastrointestinal tract. Stuart McGuire, of Richmond, has had some interesting cases in which the approach was through the thorax. Here the incision may be intercostal over the apparent site of the hernia. Such an incision should be long and held open by rib spreaders. Resection of the eighth or ninth rib might give better exposure. In any event the incision should be sufficiently long to afford ample access to the site of the hernia. The lung is packed off with an abundance of moist gauze, which is not too hot, as excessive heat will probably do more harm than having the gauze too cold. After the hernia is reduced the diaphragmatic opening is closed by interrupted sutures of tanned catgut. This closure is made in the line of least resistance and if this does not correspond to a straight line the closure may follow the outline of a T or an L. After inserting the interrupted sutures, if there is not too much tension, a separate row of tanned catgut sutures may be placed over the first row. In the congenital type of diaphragmatic hernia the abdominal approach is much superior to thoracic incision. An excellent exposure is made by the S-shaped incision of Bevan, which begins just below the ensiform carti- lage and goes outward parallel to the costal cartilage to the middle or outer portion of the rectus muscle, then downward to about the level of the umbili- cus and then slants outward again. The hernial contents are reduced by traction. Sometimes this is best done by opening the lesser neritoneal cavity and pulling down the contents from behind the stomach. Traction must be made very carefully, as hemorrhage due to rough manipulation in this neigh-- HERNIA 507 borliood is embarrassing. The suction of the pleural cavity during respira- tion tends to draw the abdominal contents back through the hernial opening and this adds to the difficulty of the operation. The hernial opening is closed with stout tanned or chromic catgut in much the same manner as the conjoined tendon is sutured to Poupart's ligament in an inguinal hernia. The opening is sutured snugly around the esophagus. Balfour found that a large opening in the diaphragm was best closed by suturing it in a T-shaped manner, suturing the anterior portion in a straight line and the posterior por- tion in a line at a right angle to the anterior row of sutures. It is exceedingly important to place the sutures so they will have a minimum of tension. The omentum near the stomach or near the colon may be fixed to the ab- dominal wall by a few interrupted sutures of catgut so there will be less tendency for these viscera to return to the hernial site. If intratracheal anesthesia is available and can be skillfully given it will add considerably to the ease with which this operation can be done, though it is not a necessity. The patient is placed in bed in the head elevated position to reduce the pres- sure upon the diaphragm by the abdominal viscera. Other forms of internal hernia are occasionally met, but they require no special type of operation. The diagnosis of such cases is very infrequently made before operation and the operation is usually performed to relieve symptoms of intestinal obstruction. Hernia of the small intestines through the rent in the mesocolon after gastroenterostomy was formerly a rather common occurrence. This is avoided by suturing the edges of the opening of the mesocolon to the stomach wall, which is best done according to the sug- gestion of McArthur by placing the posterior sutures between the rent in the mesocolon and the posterior wall of the stomach before the stomach and jejunum are clamped. Hernia into any of the intraabdominal fossae re- quires reduction with closure of the fossa if possible by tanned or chromic catgut. The treatment of the intestine depends upon the condition of the in- testine and may demand a resection, or an enterostomy, or both. CHAPTER XXIII ABDOMINAL INCISIONS The first and last stages of every abdominal operation are, respectively, the making- and the closing of the incision; and they constitute an im- portant part of the success or failure of the operation. The location of the incision depends largely upon the region of the abdomen to be oper- ated upon. Satisfactory exposure is always not only desirable, but usu- ally necessary, though there may be different views of what constitutes satisfac- tory exposure. In acute appendicitis, for instance, an incision over the region of the appendix that is just large enough to admit the finger for palpation is often satisfactory, but in chronic appendicitis, or particularly where bands or other pathology are suspected, a short incision which merely permits removal of the appendix without other examination of the abdominal viscera, is often followed by a continuance of the patient's symptoms. Here an incis- ion near the midline with exploration either by palpation or sight of all the abdominal viscera should be made. In operations upon the upper abdomen many surgeons employ a trans- verse incision, claiming that the aponeurosis of the muscles of the abdomen is least injured by it, and that the nerves, particularly the nerves to the recti muscles, are saved. If a transverse incision is made in the upper abdomen it will be necessary to divide the recti muscles, and in order to secure their ends they are sutured to the aponeurosis in front and behind before they are divided. This may be done by making an incision through the skin and superficial fascia down to the aponeurosis, opening the abdom- inal cavity in the midline just enough to admit the finger and then fasten- ing the recti muscles to their sheaths by two parallel rows of sutures through the anterior and the posterior sheath. The abdominal contents are protected during this suturing by inserting the finger through the small median open- ing. These sutures, according to Willy Meyer, should preferably not en- ter the peritoneal cavity, and this may be accomplished by using a strong full curved needle. After these rows of sutures are placed the recti muscles with the fascia are divided transversely between the stitches and the wound is retracted. Occasionally such an incision may be advisable, but as a rule the longitudinal incision or the modified longitudinal incision gives the best exposure and is easily closed. For operations on the gall bladder, the bile ducts, or the pyloric end of the stomach, the Bevan incision or a modification of it gives excellent exposure. . This incision begins just below the ensiform cartilage, runs downward and 508 ABDOMINAL INCISIONS 509 outward to about the middle of the rectus muscle, and then downward to a little above the level of the umbilicus, when it is again carried downward and outward for two or three inches. The fascia is divided along the straight incision and the rectus muscle in the direction of its fibers. If it is neces- sary for a full exposure the rectus muscle is cut across obliquely along with the fascia at the upper part of the wound and also at its lower portion. It is not often necessary to make the ol^lique incision through the rec- tus muscle at the lower portion of the Avound but it can be done with but little complication in closing the wound or in weakening the abdominal scar. Fig. 480. — Lines for abdominal iiKi.-ii.ns. i'lie incisions near the midline in the epigastric region fire the iJevan incisions, right and left. The vertical incision to the outer side of the right Bevan incision is the intraabdominal incision for nephrectomy. The incision near the right anterior superior _ iliac spine is the McBurney incision for appendicitis. The lowest curved incision is the Pfannenstiel incision. ^ Just above this is the transversed incision of Judd for double hernia. An incision to the right of the midline between the navel and the pubis is for general pelvic and lower abdominal work. Through such an incision most operations in the right upper abdomen can be performed and access to the gall bladder and gall ducts, pylorus and pyloric end of the stomach is excellent (Fig. 480). This incision is also quite satis- factory when applied to the left side. A median incision above the umbilicus is sometimes employed though it should, as a rule, be avoided. A median incision either above or below the um- bilicus, while avoiding injury to any nerves that may supply the recti mus- cles, cuts through a thin portion of the abdominal wall where the fascia af- 510 OPERATIVE SURGERY fords unsatisfactory marg'ins for a sound scar. Of course, in epigastric hernia a median incision closed by slight overlapping of the aponeurosis is essen- tial. If an incision is carried through the rectus muscle, closure is more satis- factory because two distinct layers of fascia and the rectus muscle between them add a bulk of large stable tissue to the edges of the wound, instead of merely a thin single plane of fascia as occurs in the median line. If an in- cision is made along the inner third of the rectus muscle, or if the fibers are split along the junction of the middle and inner thirds but little of the rectus muscle is affected by the destruction of the nerve supply, and the proper suturing of the aponeurosis of the large fiat muscles of the abdomen, which constitutes the anterior and posterior sheath of the rectus muscle, should secure satisfactory union. If the surgeon is not fully satisfied of the necessity of a long incision in the upper abdominal region, as in explorations about the gall bladder, the central part of the Bevan incision may be made and, if the occasion demands, the incision can be extended both upward and downward. Not infrequently when it is desired to explore the gall bladder and remove the appendix, the appendix may be removed through a McBurney incision and the condition of the gall bladder ascertained through a short two inch incision through the rectus muscle. This incision over the gall bladder is made first because if the gall bladder is found diseased the incision is extended and the ap- pendix removed through this one incision, but if there is no trouble with the gall bladder or the structures in its neighborhood this wound is closed and the appendix removed through a McBurney incision. Operations on the cardiac end of the stomach, for diaphragmatic hernia, or on the spleen, are satisfactorily done through a left Bevan incision. This begins as on the right side just below the ensiform cartilage, goes downward and outward parallel with the edge of the left costal cartilage to about the middle of the rectus muscle, then vertically down to just above the level of the umbilicus, splitting the fibers of the rectus muscle, and then downward and outward obliquely for a sufficient distance to give satisfactory exposure. By carrying the vertical portion of this incision nearer to the outer border of the rectus muscle a somewhat better exposure of the spleen is obtained than if the vertical part were nearer the middle of the muscle. This, of course, must be left to the exigencies of the case, but it should also be remembered that the nerves of the recti and other abdominal muscles run in the upper abdomen approximately a transverse course and more of the rectus muscle will be saved if the vertical incision is made nearer toward its inner border. Removal of the kidney when indicated because of considerable enlarge- ment, such as a tumor, is often best done through a vertical incision along the outer border of the rectus muscle. This should extend from just below the margin of the costal cartilage to well below the level of the umbilicus. The peritoneal cavity may be opened though often the peritoneum can be stripped away from the abdominal wall and the pedicle of the kidney reached without opening the peritoneum. Whether this is done depends, of course, upon the size, shape, and character of the kidney growth. ABDOMINAL INCISIONS 511 An incision fov iiml)ili(';il liernia should l)c transverse, and usually el- liptical including the umbilicus along with the surrounding skin in the mass of tissue to be excised. If there is occasion to make a long incision near the umbilicus, as for the removal of an intraabdominal tumor in its neigh- borhood, the incision is supposed to be placed to the left of the umbil- icus, because the round ligament to the liver goes somewhat to the right of the midline from the umbilicus to the liver. Such an incision, however, is but rarely indicated. It is best to excise the umbilicus while making this incision in order that the wound may be more satisfactorily closed. Occasionally, in operations upon the cardiac end of the stomach or for a tumor of the liver that is difficult of access an atypical incision must be made. Sometimes it may be advisable to make a flap, such as is used in exposure of the heart, with the base outward over the ribs, with two transverse parallel incisions and a third incision connecting the two ends of the parallel incisions at the midline. The ribs and costal cartilage are divided or fractured and the flap is turned back for full exposure. In operations upon the lateral margins of the abdominal wall the kidney is the most frequent object of attack. Here the incision of W. J. Mayo gives exceedingly satisfactory exposure and inflicts a minimum of injury on the abdominal muscles. This incision can be used in operations on the kidney, the pelvis of the kidney, or the upper ureter. It begins at a point about two and a half inches external to the spinous process of the lower dorsal vertebrae near the outer margin of the erector spinae muscle over the upper border of the twelfth rib, or even higher. (Fig. 590.) The incision is carried downward and somewhat forward along the outer margin of the quadratus lumborum to about an inch above the crest of the ileum, where it is carried forward parallel to the crest of the ileum as far as may be necessary for satisfactory exposure. The tri- angle just beneath the twelfth rib at the upper portion of the wound is exposed by incising the external and the internal oblique, the transversalis and the latis- simus dorsi muscles and the transversalis fascia is freely opened. The twelfth rib is well freed along its lower border almost to its articulation and the rib is retracted strongly upward while the erector spinae muscle is retracted back- ward. Sometimes the twelfth rib may be dislocated or fractured to give even larger exposure. The muscles are divided along the lower part of the wound as far as may be necessary in the general direction of the skin incision. Care should be taken to avoid injury to the iliohypogastric and the ilioinguinal nerves. When fixation of the kidney is contemplated a shorter incision, such as was employed by Edebohls, is satisfactory. Here the twelfth rib and the erector spinae muscle are recognized and a vertical incision is made from the twelfth rib downward close to the outer edge of the erector spinae muscle. This goes almost to the crest of the ileum. The fibers of the latissimus dorsi are exposed and are split, but not cut across. The erector spinae is retracted inward but its sheath is not opened. The sheath of the quadratus lumborum is opened along its outer margin for the whole of the wound. By keeping about 512 OPERATIVE SURGERY one ineli below the rib injury to the pleura may be avoided. The transversalis fascia is divided and the perirenal fat is exposed. The iliohypogastric and the ilioinguinal nerves must l)e protected at the lower portion of the wound. Incisions in the abdomen for operations below the umbilicus are often made. In acute appendicitis where there is no reasonable doubt of the diag- nosis, the McBurney incision is most satisfactory. This is made in the direction of the fibers of the external oblique and is about two inches long with the cen- ter of the incision on a line between the anterior superior spine and the umbil- icus, and about one and a half or two inches from the anterior superior spine. In women when an exploration of the pelvic organs is desired, the in- cision is carried much lower and further inward. After cutting down to the aponeurosis of the external oblique, this aponeurosis is split in the direction of its fibers throughout the length of the skin incision. The iliohypogastric nerve is identified, and the fibers of the internal oblique and transversalis muscles, which run practically parallel in this region, are separated at a sufficient distance above the nerve to avoid its inclusion in the sutures when the incision is closed. Failure to do this is often followed by an unneces- sarily painful scar. The fibers of these muscles are best divided by inserting the points of closed blunt-pointed scissors and then spreading them in the di- rection of the fibers of the muscle. Two fingers are placed between the sepa- rated fibers to enlarge the incision. Then retractors hold the split fibers apart while the peritoneum is incised. (Figs. 561-564.) If this incision is made further inward and downward, not infrequently the deep epigastric vessels ap- pear along its inner margin and they must be retracted or doubly clamped and divided. Here the fibers of the internal oblique and transversalis terminate in an aponeurosis which may be split in the direction of its fibers, and the margin of the rectus muscle is strongly retracted inward without being divided. In general exploration of the lower abdominal cavity an incision just to the right of the midline is very satisfactory. This may be carried from about the level of the umbilicus to the pubis. The sheath of the rectus muscle is cut along the junction of the middle and inner thirds of the muscle. If the incision is made nearer the midline too little support is furnished the sutured wound by the rectus muscle, while further out too much of the rectus muscle is injured by destroying its nerve supply. After incising the fascia the fibers of the rectus muscle are split and held apart by retractors while the peritoneal cavity is opened. Sometimes the epigastric artery runs in this region and not infrequently a large branch is given off which may cross the line of incision at its upper portion. Some operators ad- vise retracting the muscle outward instead of dividing its fibers in order to save all of the nerve supply. As below the semilunar fold all of the aponeurosis that constitutes the sheath of the rectus is in front of the rectus and none behind, this dislocation of the inner edge of the rectus muscle may make a weak spot that would not occur if the muscle were left attached along its inner border and its fibers split. ABDOMINAL INCISIONS 513 Operations upon the sigmoid and the left colon may be done through an in- cision somewhat to the left of the midline made in the same manner as has just been described for incision to the right of the midline. If it is planned to resect the bowel for cancer an ample incision along the outer border of the rectus muscle will be necessary. The incision of Sir Astley Cooper for ex- posure of the iliac vessels is now rarely if ever emploj^ed, because the iliac vessels can be much better exposed by an incision somewhat to one side of the midline with the patient in the Trendelenburg position. The old incision was ad- vised because of the ancient surgical fear of entering the peritoneal cavity. Fig. 481. — The incision of Judd for double inguinal hernia. The bladder may be exposed by a median incision running up from the pubis for a sufficient distance. Here the recti and the pyramidalis muscles over- lap and there is an abundance of muscle fibers to protect the Avound if con- ditions permit of primary suturing of the muscle. A transverse or Pfannenstiel incision is used by some operators for ex- posure of structures in the pelvis. This is carried across the abdomen with a slight convexity downward, the lowest point of the convexity lying about two inches above the pubis. The incision maj^ be so placed that most of it comes within the region of the pubic hair. The skin and subcutaneous tis- sue are dissected up along the upper margin as a flap. The aponeurosis of the external oblique is divided in the general direction of the skin incis- 514 OPERATIVE SURGERY ion. The upper poi-lioii of 1lie flap of tlie ai)oiieiirosis is dissected and a vertical incision is made ))et"\veen the recti muscles. This gives satisfae- tory exposure and in certain instances may be indicated. If there is any suspicion of infection, however, it should not l)e employed for too much raw surface is exposed. It is also difficult to enlarge this incision satisfactorily if the surgeon finds that more space is necessary than he had first anticipated. An excellent incision in double hernias is that which is used by E. S. Judd (Fig. 481). It is a transverse incision from just external to one in- ternal inguinal ring to a corresponding point on the opposite side. Both hernias can thus be readily exposed. It is, of course, only carried through the skin and superficial fascia, the rest of the hernia behig operated upon according to the technic that mav seem indicated. CLOSURE OF ABDOMINAL INCISIONS The method of closing abdominal incisions depends partly upon the character of the incision and largely upon whether it is located above or below the umbilicus. The physiologic action of the muscles of the abdomen and the movement of the abdominal contents is so different in these two regions that the procedures for closing incisions made above or below the navel must differ materially. Below the umbilicus there is but little motion of the abdominal muscles. The aponeurosis below the semilunar fold of Douglas is in front of the recti muscles instead of being half in front and half behind as it is above this point. The recti muscles themselves act as a buffer and take considerable strain from the thick aponeurosis in front but where the aponeurosis splits above the semilunar fold of Douglas, half going in front and half behind the recti, if the posterior layer is not accurately closed its retraction forms a point of least resistance and the abdominal con- tents can easily force apart the fibers of the rectus. A potential hernia re- sults. Incisions beloAV the umbilicus are frequently made just to the side of the midline so that the portion of rectus muscle between the incision and the midline is very small, and even if it looses its nerve supply but little harm is done. Above the umbilicus, howcA^er, incisions are rarely made in the midline and are usually along the middle or outer portion of the rectus so that a considerable portion of this muscle may be deprived of its nerve supply and can hardly be depended upon to resist the intraabdominal pressure. The main reason, however, for the difference in the types of suturing above and below the umbilicus is the motion of the muscles. Below the um- bilicus there is comparatively little muscle movement during normal res- piration, whereas above the umbilicus it is always pronounced. The action of the diaphragm, which forces the liver and stomach up and down during respiration, and the expansion and contraction of the thorax cause consider- able motion of the upper abdominal wall during each respiratory act. When there is vomiting or any unusual tension within the abdomen, particularly with AP.nOMlN'AI; INCISIONS 515 tlie i)atii'iit \y\\\u: in Ix'd, llir luiixiimini force ;i pfx'n rs lo he excrled around the epig-asslriiiiii, as the very act of vomiting means that the stomach itself is eomprossecl by llie ad ion of the diaphragm and the abdominal muscles M'hicli lie o^■el• the stomach. It is not generally safe to trust to layers of catgut sutures in any wound above tlie umbilicus. The insertion of a number of interrupted sutures of catgut may be safe, but the constant motion of the muscles in this neighborhood makes a soft- ened or weakened catgut suture likely to give way and the abdominal contents may protrude beneath the skin or through the skin wound itself. To obviate this some operators insert tension sutures of silkworm-gut in addition to the catgut sutures. These are placed after closing the peritoneum but before suturing the muscles or fascia. The muscles and fascia are then closed with separate layers of catgut sutures and the skin is sutured in the usual manner, the tension sutures being tied last of all and the skin protected either by placing ganze over the skin wound and tying the sutures over them, or by threading the sutures through a segment of fine rubber tubing. This method is usually satisfactory but it seems unnecessary to insert the catgut sutures because it places an ad- ditional burden of absorption on the tissues, cuts ofl a certain amount of nu- trition from the edges of the repairing wound, and to some extent permits small cavities to form between the layers of sutures. If an operator feels that it is necessary for purposes of safety to insert four or five tension sutures of silkworm-gut, as he knows this material will hold, it seems a simpler mat- ter to add a few extra silkworm-gut sutures, making the number eight or ten, and depend solely upon them. This method was found very satisfactory in the early days of surgery and has been used with much success by the late Joseph Price and his successors. The scar left is not as smooth as the scar after careful layer suturing, but Avhen tension sutures are added to layer sutures there is but little difference in the scar. If the wound is closed by through and through sutures of silkworm-gut which are inserted at in- tervals of about three-fourths of an inch it is best not to close the skin with a continuous suture. If this is done any broken down fat or serum that may accumulate in the grasp of the interrupted suture cannot find a ready escape and may predispose to infection. In closing incisions above the umbilicus which are either transverse or nearly transverse, the recti muscles should be fixed to their sheaths before being divided. This method as used by Willy Meyer and others has been described. Here the wound may be closed with interrupted catgut sutures but silkworm-gut is excel- lent. The tension on a transverse wound during straining or vomiting is marked because of the action of the recti muscles. In closing other types of incisions above the umbilicus which are either longitudinal or oblique, the edges of the peritoneum are grasped with liem- ostats so that the peritoneum is drawn w^ell into the wound. Stout silk- worm-gut in a large needle is inserted, beginning at the loAver end of the wound, taking a small bite of skin, a considerable amount of the fascia over the rectus muscle, a small part of the muscle, and a generous bite 516 OPERATIVI': SURGERY of the posterior aponeurosis and peritoneum. The needle is returned from within out in a similar manner and each end of the suture is grasped with a large hemostat. If one wishes to be particularly careful each end of the silkAvorm-gut ma.y be threaded on a needle and inserted from within outward. This, hoAvever, seems to be an unnecessary refinement for unless there are twice as many needles as there are sutures if the needle is passed from within outward it must eventually penetrate the skin, and each time it penetrates the skin it may become contaminated, when it should be either boiled or discarded. As a matter of practice when the skin has been well disinfected there seems but little danger in inserting the needle from without inward on one side and from within outward on the other, as has just been described. These sutures are all placed before they are tied and the ends of each suture are grasped with hemostats. After they are all placed an assistant and a nurse forcibly raise the ends of the sutures on each side of the wound so that the edges of the wound are slightly lifted up. The operator then presses together the abdominal wall on each side of the wound, thus forcing the peritoneum together because it must slide down on each side of the suture to what corresponds to the apex of a triangle (Fig. 482). While the sutures are held in this position they are tied one at a time, just snugly enough to obtain reasonably firm closure. The assistant and nurse hold the other sutures, merely releasing one as it is about to be tied. In this way the sutures are tied under equal tension and evenly. If this precaution is not taken the pa- tient sometimes strains before all the sutures are tied and breaks them or tears the tissues and to secure coaptation it may be necessary to tie the sutures quite tightly which, of course, produces necrosis and predisposes to infection. If there is equal tension on each suture, however, and they are tied in the manner described, the strain on the wound is distributed over the combined sutures in the same manner as the strain on the strands of a cable, which can withstand great tension as long as the strands are together, but if they are separated it will easily snap. Furthermore, the peritoneum is brought well in apposition and as all the structures of the ab- dominal wall are held in uniform tension in the grasp of the same suture there is less tendency for any one structure to be cut by the suture. These sutures are left in about ten days or two weeks. It is best not to take them all out the same day, but to remove half of the sutures at one time and the other half a few days later. In wounds near the midline below the umbilicus layer sutures are satisfac- tory except where pus is encountered in the abdominal cavity or where b,y reason of contamination there seems a probability of infection of the wound. Here through and through sutures should be placed in the same manner as above the umbilicus. In suturing a wound in layers below the umbilicus the peri- toneum is brought together by fine continuous mattress sutures of tanned or chromic catgut. The suture is begun at the loAver angle of the wound and the short end is tied and clamped with a hemostat to hold it steady. The suture is carried back and forth as a continuous mattress stitch, abdo:mixal incisions 517 catehino- a p'oocl orasp on tlie transversalis fascia and the edges of the peritoneum. A mattress -suture used in this Avay turns out the raw edges, exposes no raw surface to the abdominal cavity, and secures a firm hold on Fig. 482. — ^Method of closing incisions above the umbilicus. the delicate peritoneum. The suture is tied at the upper angle of the wound. The wound in the rectus muscle is closed with a continuous lock stitch of plain catgut and is brought together with very little tension. Muscle is highly organized tissue and withstands pressure badly. The merest approximation 518 OPKKATIVE SURGERY of tlie divided fibers of tlie rectus is much better than a tight suture because the tight suture Avill cut the muscle or impair its nutrition. The aponeurosis or the external sheath of the rectus muscle is closed with a continuous lock stitch of tanned or chromic catgut, about number one in size. If this row is accurately ap^Dlied there is no need for further reinforcing it except possibly where it is anticipated that there will be considerable distention. Here a few interrupted sutures of tanned or chromic catgut are placed through the fascia over the continuous lock suture and going well back into the fascia. It must be borne in mind, however, that extra tension sutures are not entirely without danger because the relief of tension on the midline sutures also means cutting off nutrition to the edges of the fascial wound which may delay healing, though in some instances tension sutures may be justifiable. The skin is closed with a continuous subcuticular suture of 00 tanned or chromic catgut. If the skin is very thin and flabby a continuous mattress suture of fine tanned catgut is used. No tension suture other than those just mentioned should be used when an abdominal wound is closed in layers. If tension sutures of silkworm-gut are demanded, it would be much better to use a few more and close the whole wound with silkworm-gut, as has been described for in- cisions above the umbilicus. In the McBurney or muscle-splitting operation the wound is closed in layers with catgut. The peritoneum here may be united with a mattress or a purse-string suture of plain catgut. The transversalis and internal oblique muscles, whose fibers have been split, are closed with a few sutures of plain catgut. A continuous lock stitch of plain catgut is used in the aponeurosis of the external oblique and the skin is closed with a continuous subcuticular suture of fine tanned or chromic catgut. Muscles are particularly irritated by chemicals in catgut, so when muscle is united to muscle, plain catgut which is readily absorbed should be used ; though when muscle is united to fascia, as in a hernia operation, tanned or chromic catgut is advisable. In drainage cases of appendicitis where the McBurney incision has been made, one or two interrupted silkAvorm-gut sutures are used, catching all layers of the abdominal wall and tying the sutures close to the tube or cigarette drain which comes out at the outer angle of the wound. To-prevent pocketing the rest of the wound is lightly packed with iodoform gauze. In operations on the kidney the lower portion of the incision may be difficult to approximate accurately by through and through interrupted sutures, and these wounds can be closed in tAvo layers, using tanned or chromic catgut either in a continuous lock suture or as interrupted sutures. The through and through method, however, is excellent here. At the upper posterior angle a drain is brought out. The transverse ijicision of Pfannenstiel is closed by suturing the peritoneum in the usual way, the fibers of the rectus muscle with a loose continu- ous lock stitch of plain catgut, and the aponeurosis of the external oblicpie and the sheath of the rectus with a continuous lock stitch of tanned or chromic catgut. The skin may be closed by a continuous mattress suture of fine tanned or cliromic catgut, or with horsehair, fine silkworm-gut or silk. These latter materials pro- ABDOMINAL INCISIONS 519 diice somewhat less reaction than catgut and eventually make a somewhat less conspicuous scar than is obtained even by an accurate subcuticular suture of fine catgut. Where tlie inconspicuousness of the scar is a very desirable point, as in operations al)out the face and neck, catgut should not be used, as has already been explained, but in wounds of the abdomen a subcuticular suture of fine eatgut makes a very satisfactory scar with no stitch marks, and the patient is often gratified that there are no stitches to be removed. In suprapubic operations upon the bladder M'here the peritoneum is not entered tliere is nearly always drainage and here interrupted sutures of silk- worm-gut are verj- satisfactory. CHAPTER XXIV OPERATIONS ON THE LIVER, GALL BLADDER, BILE TRACTS, PANCREAS AND SPLEEN Operations upon the liver itself are not common. Occasionally an abscess or a tumor requires operation and this must be done according to a certain definite technic. Sometimes, too, ptosis of the liver requires correction, though, as a rule, when this occurs the presence of other prolapsed organs, together with the peculiar structure of the abdominal wall in these cases, makes an operation for prolapse of the liver unsatisfactory. When the prolapse is in the neighborhood of the gall bladder, suturing the gall blad- der to the abdominal wall helps to correct the ptosis. A U-shaped incision is made in the abdominal wall with its concavity upward and around the lower circumference of the prolapsed portion of the liver. The transversalis fascia is cut down upon but is not incised except at the lowest portion of the wound where a transverse cut is made through the transversalis fascia and peritoneum. The other tissues in the U-shaped incision are raised from the transversalis fascia and peritoneum. At the upper level of the reflected flap another transverse incision is made parallel to the one below it and a por- tion of the loose lobe of the liver is tucked into the pocket thus formed and fastened Avith sutures. When there is complete prolapse, the liver may be replaced and fastened by passing coarse sutures of catgut or silk along the anterior edge of the liver and tying them to the cartilages of the ribs. About six or eight of these sutures may be passed. It is also necessary to take up the slack in the abdom- inal wall below the liver in order to afford support. This may be done by removing an oval-shaped area of skin and fascia from the midline of the ab- dominal wall and suturing the edges together after slightly overlapping them. In the method of Depage, a horizontal incision is made from the tip of the eleventh rib on one side to that of the eleventh rib on the other, and then incisions are carried downward and inward from the extremities of this horizontal incision to about the level of the umbilicus, terminating external to the umbilicus. These incisions are one-half the length of the original transverse incision. From the ends of these incisions on a level with and external to the umbilicus, an ellipse is made Avhich terminates just above the pubis. All the tissues included in these incisions are removed and the wound is sutured to make a T-shaped scar. Operations for hepatic abscess are common in tropical or semitropical countries. The kind of operation depends upon the location of the abscess and may be through the thoracic route or through the abdominal route. 520 LIVER, GALL BLADDER, BTLE TRACTS, ETC. 521 Occasioually the abscess may be so situated as to render either one of these routes permissible, Avhen a choice Avill depend to a large extent upon the adhesions around the abscess. The final diagnosis is the aspiration of the ab- scess. If this is followed immediately by operation through the track of aspiration but little harm is done, but if pus is found and the operation is postponed for a day or two, the pus may leak along the needle track and infect either the peritoneum or the pleural cavity, according to the re- gion through which the needle was introduced. If a fine needle is used such a danger is reduced to a minimum, but the pus is often thick and can- not run through a fine needle so it may be necessary to use a coarser one. If the abdominal route is chosen for opening an abscess which is adher- ent to the parietal peritoneum the situation is much simpler if the in- cision can be made through the area of adhesions. Not infrequently, however, this is impossible and if the liver has been exposed and found to be free from adhesions the region of the abscess must be surrounded with gauze and as- piration repeated. If pus is obtained an opening is made by thrusting in sharp- pointed forceps and stretching them, or by inserting the actual cautery. If it is possible to do so. it would be better to pack around the abscess and then open it after forty-eight hours. Sutures in an inflamed liver will rarely hold and iodoform gauze packing must be used, but a few sutures of coarse catgut inserted at a short distance from the region of the abscess serve to hold the liver against the abdomi- nal wall before the packing is placed. The sutures, of course, cannot replace the packing and alone will not prevent the contamination of the abdominal cav- ity. They merely serve to lessen the amount of packing necessary. The ab- scess cavity is explored with the finger to determine the possibility of a pocket or a secondary abscess before a tube is inserted. After introducing a large tube, gauze is packed around it and to prevent its displacement the tube is fastened to the edge of the wound with a suture of silkworm-gut. The tube may be connected with a retainer into which the pus is drained or it may be necessary for the pus to drain on the dressings which are frequently renewed. It is probably best not to irrigate these cavities. When the abscess points toward the diaphragm it is opened through the thorax. After locating the abscess by an aspirating needle, about two inches of the ninth or tenth rib are excised over the region of the abscess and the pleural cavity is protected by suturing or by packing with gauze held in position by a few catgut stitches. The aspirating needle is again used, and following it as. a guide the abscess in the liver is opened by thrusting in closed sharp-pointed forceps or by the actual cautery. The chief difficulty in excision of a tumor of the liver is the control of hemorrhage. If the tumor is small and situated along the margin of the liver but little trouble is experienced. The incision may be made with an electric cautery and a V-shaped portion of the liver removed, wdiich includes the tumor, the wound being closed with coarse catgut sutures. These sutures are inserted with a large blunt-pointed liver needle, or a large curved needle is V 522 OPERATIVE SURGERY thrust tliroiigli the liver e^'e first, is threaded and then witlidrawn. A probe can also be used in emergency, the suture being hitched around the blunt end of the probe or passed through the eye at the other end if the probe has an eye at its opposite extremity. In a large tumor an effort may be made to con- trol the bleeding temporarily by an elastic tube thrown around the pedicle of the growth or carried through the liver itself by a cannula. A cannula through which a small soft rubber catheter can be carried is, with its trocar, thrust through the liver tissue back of the tumor, the trocar withdrawn, and a rubber catheter threaded through the cannula. The catheter is tied or clamped on one side of the growth and another catheter is similarly placed on the other side of the growth and tied. They act as an elastic tourniquet. McDill compresses the vessels by an enterostomy clamp protected with rubber tub- ing, and others have recommended interlocking sutures of stout catgut placed around the tumor before it is excised. All sutures in the liver should be of stout material and tied no tighter than necessary to secure hemostasis, otherwise they will cut through. Occasionally the incisions can be made in such a Avay as to excise a tongue of liver tissue along the margins of the tu- mor, leaving two flaps to be approximated to each other by sutures. The incision is often made Avith an electric cautery to avoid hemorrhage. It must be remembered that the blood pressure in the liver is very low and firm pressure upon it by packing or by apposition of raw surfaces will control hemorrhage. Either a pedunculated graft or a free graft of omentum can be sutured to the bleeding surface of the liver and will often control the bleeding. If hemostasis is secured by the application of stomach or intes- tinal clamps and sutures Avill not hold satisfactorily, the clamps may be left in position for forty-eight hours and then removed. Exposure of the contents of the upper abdomen, including the gall blad- der and gall ducts, is satisfactorily accomplished by the Bevan incision, or its modifications. The vertical portion of the incision is carried down the inner portion of the rectus in order to preserve the nerve supply for a maxi- mum amount of this muscle. Removal of the gall bladder, or cholecystectomy, is an operation fre- quently performed. A satisfactory method of doing this" is from below up- ward, and it is necessary to have an incision beginning just below the ensi- form cartilage in order to obtain satisfactory exposure. The method as described by E. S. Judd is the technic that has been employed for many years and with much satisfaction at the Mayo clinic. The fundus of the gall bladder is clamped, preferably with a sponge-holding forceps, in order not to tear the tissues, and is pulled upward and forward until the pelvis of the gall bladder is exposed. The liver is brought up into the wound as far as possible and the surrounding tissues are protected by gauze pack- ing. A second sponge-holding forceps is applied to the pelvis of the gall bladder just above the cystic duct. The tissues around the cystic duct are torn with forceps or incised with scissors and by blunt dissection, in- serting closed scissors or forceps and spreading them open, the neck of the LIVER, GALL BLADDER, BILE TRACTS, ETC. 523 Fig. 483. — Exposure of the cystic duct in cholecystectomy. Fig. 4S4. — Double ligation and clamping of the cystic duct. 524 OPERATIVE SURGERY gall bladder and tlie cystic duct are tlioroughly exposed. It is important to demonstrate that the cystic duct runs into the gall bladder and to isolate it thoroughly by blunt dissection before it is clamped (Fig. 483). The cystic duct and the cystic artery may be clamped together or separately if they are not in immediate proximity as often happens. After the cystic duct is doubly clamped with a sufficient amount of the duct between the forceps to prevent retraction, the duct is divided. It is well to disinfect the stump of the cystic duct with a drop of carbolic on a probe, though this is not necessary-. If exposure is difficult for double clamping, the cystic duct may be tied with tanned or chromic catgut close to the common duct and a clamp Fig. 485. — The cystic artery has been clamped and the gall bladder is dissected out from below upward. placed on the neck of the gall bladder. Two ligatures are applied on the cystic duct stump at a short distance from each other. One is cut short and the other is left long and brought out in the wound (Fig. 484). The severed cystic duct and the pelvis of the gall bladder are elevated by gentle traction and a forceps is applied behind and close to the gall blad- der to grasp any vessels in this region. It is important on the one hand not to wound the gall bladder and so soil the field, and on the other to avoid injury to the hepatic duct. By making traction on the pelvis of the gall bladder and the severed cystic duct, the tissues can be brought into such prominence that they can be grasped Avith but little danger of in- juring the gall bladder or the hepatic duct (Fig. 485). If an unusual ves- sel is divided or the cystic artery retracts, a small sponge of dry gauze in LTVKR, GAT.r, l!l,AI)l)i;iJ. lilLI'. TRACTS, ETC. 525 forceps is pressed upon llic l)loedino' spot. If it cannot be isolated satis- factorily a larger amount of dry gauze is held in position a few minutes and gradually I'emoved along the edges of the raw surface until the bleeding vessel is located. The vessel is then grasped, preferably with small forceps, and is tied. Pressure with gauze will control the bleeding temporarily until the oozing has been checked, and then only the larger vessels M'ill bleed. In- discriminate catching of points in a bloody field in this region will al- most certainly result in disaster and will cause the loss of more blood. A firm pack of dry gauze held in position for a few minutes and then care- Fig. 486. — The cystic artery has been tied and the bed of the gall bladder is sutured. fully removed from the margins of the wound until the main injured vessel is demonstrated will greatly aid in securing hemostasis in this region. Any bleeding more than a simple oozing should be thoroughly controlled before removing the rest of the gall bladder, for the gall bladder serves as a point of traction and renders the exposure of the field easier, while even a small amount of blood running down from the bed of the gall bladder makes it more diffi- cult to locate bleeding points around the cystic duct. If the gall bladder is thick it can usually be dissected from the liver so as to leave a small amount of fascia in its bed which facilitates suturing the resulting raw surface. After removing the gall bladder and securing the cystic duct and artery the other bleeding points are controlled by transfixing the tissues immediately around them with a fine curved needle threaded with plain 526 OPERATIVE SURGERY catgut and tying the suture moderately firmly. The stump of the cystic duct, the common duct, and hepatic duct, should be well demonstrated to avoid possible injury to them. The raw surface left by removal of the gall bladder is closed by suturing the tissues together with a continuous lock stitch of plain catgut, beginning at the lower portion of the wound and ending at the margin of the liver (Fig. 486) . The suturing is just tight enough to control bleeding. The ends of this suture are tied at the margin of the liver and left long-. A medium sized rubber tube is carried down to the stump of the cystic duct by cutting one hole near the end of the tube and passing the long ends of one of the ligatures over the stump of the cystic duct through the end of the tube and through this oi^ening. The tube Fig. 487. — A rubber tube is carried to the stump of the cystic dtjct over the long end of the ligature and is fastened to the edge of the liver by the ends of the suture that closes the bed of the gall bladder. The suture line is behind the tube. is further fixed in position by bringing it over the bed of the gall bladder and tying around it the long ends of the suture that had been used to whip over the bed of the gall bladder (Fig. 487). At the beginning of this suture the end should be left quite long and after the tube has been fixed in posi- tion, as has been described, fat from the edge of the omentum or from the round ligament- of the liver, or from both, is brought down to the bottom of the tube and fixed in this position by a needle, into which has been threaded this long end which passes several times through the fat of the omentum or round ligament. Sometimes the fat of the round ligament is abundant and easily available. Occasionally the omentum is short and contains but little fat. Often both of these structures can be utilized. Care must be LIVER, GAT.L BLADDER, BILE TRACTS, ETC. 527 taken to see that ^vhen the omentum is brought up the colon is not unduly constricted or kinked. This covering of the region of the tube with fat is im- portant because it protects the duodenum and prevents it from being drawn up to the raw surface under the liver. In one case of mine after cholecys- tectomy in which this precaution was not taken, adhesions were dense be- tween the duodenum and the liver and caused marked symptoms. In the second operation these adhesions were divided and a free graft of omentum was applied over the duodenum. There has been no recurrence of the symp- toms, the operation having been done about five years ago. The wound is closed with silkworm-gut sutures, as has been described. Murat Willis, of Richmond, buries the stump of the cystic duct and closes the wound without the insertion of a tube. This technic is satisfactory in the majority of cases, but occasionally the cystic duct will open even when securely tied wdth a double ligature and a small amount of bile will escape. This may not be due to an improper application of the ligature, but to the fact that nature makes unusual efforts to overcome obstruction of the bde ducts and pancreatic duets and leakage may occur from necrosis where the suture was applied. Then, too, particularly in thin gall bladders it may be difficult or impossible to leave a sufficient amount of fascia in the bed of the gall bladder to hold the sutures. Here the sutures must be taken in the liver substance and occasionally injury of a small duct will cause leakage of bile. Leakage of bde that accumulates around a fresh wound is irritat- ing and causes numerous adhesions and is best drained away. The tube also directs externally the current of serum or lymph that is poured out from the w^ound, w^hereas otherwise the exudate w^ould accumulate about the cystic duct and probably infiltrate around the foramen of Winslow and the tissues in its neighborhood. AVhile this serum might not be septic it causes considerable irritation. The tube is properly protected by fat. The fatty adhesions that result appear to give less trouble than the firm adhesions that follow the irritation of bde. Hertzler has pointed out that adhesions' are denser along the periphery of a virulent inflammation than in its cen- ter, and that a marked irritation resulting from mechanical or chemical means or from a mdd bacterial infection is followed by firmer adhesions than occur about the center of a virulent infection. This can be demonstrated clinically by finding adhesions to structures around an appendix that has been previously acutely inflamed while the appendix itself is free, or by seeing the scar of a duodenal perforation itself free from adhesions after healing has taken place with dense adhesions at points some distance from it. The method of Murat Willis is excellent when no marked infection is present, or when a connective tissue bed is left after removing the gall bladder, and is particularly indicated when a cholecystectomy is done in conjunction with a pyloroplasty. Cholecystotomy is now employed rather infrequently because in chole- cystitis the infection is in the wall of the gall bladder, just as it is within the substance of the tonsil in tonsillitis, and drainage of the lumen of the 528 OPERATIVE SURGERY gall bladder often fails to cure. When, however, stones are contained in a gall bladder that appears fully to have recovered, or when there is marked infection and the condition of the patient makes it wise to do as little as possi- ble, choleeystotomy is indicated. The gall bladder is exposed and after ex- ploring the other structures to determine any pathology outside of the gall bladder the fundus is clamped, preferably wdth mosquito forceps or Allis forceps, and drawn into the Avound. A trocar and cannula are thrust into the gall bladder and the bile is withdrawn. This may also be done by a large aspirating needle or the cannula may be connected with a suction apparatus. The opening made by the trocar and cannula is enlarged by thrusting in forceps or scissors and spreading the blades apart, or by an incision. The mucosa of the gall bladder is examined and the edges of the incision are grasped with three hemostats at about equal distance from each other. The rest of the bile is removed by gently inserting a strip of dry gauze. Any gall stones that are obvious are removed by a scoop or by forceps. After as many stones as possible have been removed in this manner the finger is inserted in the gall bladder and often imbedded stones may be found that cannot be otherwise detected. A tube about a third of an inch in diameter, of moderately firm rubber, and with one opening cut near its end is inserted. This is fixed in position by passing a fine tanned or chromic catgut suture through the margins of the gall bladder and the wall of the tube. This suture is tied and the ends are left long. A purse-string suture of fine tanned or chromic catgut in a fine nee- dle is inserted. This is passed about half an inch from the margin of the gall bladder wound and as it is slowly tied down the raw edges are tucked in by an assistant, while the gall bladder is steadied by being grasped with forceps just beyond the purse-string suture. After the edges have been com- pletely tucked in the suture is tied snugly three times and fastened with a needle to the parietal peritoneum to hold the gall bladder up. This pre- vents it from sagging and secures better drainage. The tube is brought out at the upper portion of the Avound. There is no occasion for gauze pack- ing around the tube, as such a junction is Avater tight under any reasonable pressure that may occur and the turned in margins of the gall bladder Avound act as a valve. The tube is left in ten days or tAvo Aveeks. In severe infection it should remain in longer. If it is difficult to remove the tube Avhen it should be removed a large safety pin is passed through it near the skin and gauze is tucked under the safety pin so as to make gentle traction on the tube. This is repeated for tAvo or three days, and the suture binding the tube grad- ually cuts through the tissue Avhen the tube is removed Avith but little pain and no bleeding. Operations upon the common bile duct are indicated on account of a con- tained stone or obstruction by a stricture. When stone is present the duct is incised over the site of the stone unless the stone is moA^able or is in an inaccessible portion of the duct. When the stone is movable the common LIVER, GALL BLADDER, BILE TRACTS, ETC. 529 duct is opened just iiil cnial to the cystic duct aud the stone is worked into this incision whore it is extracted. The exposure should be ample and is af- forded 1)y tlie type of incision advised in operations on the gall bladder. The surrounding structures are well protected with gauze, particularly the foramen of Winslow. The gauze should be moist and is gently and carefully placed. Roughness in this region is very likely to cause shock or a reaction of protest by the tissues, which will later excite spasm of the upper ab- dominal muscles with consequent embarrassment of respiration and a tend- ency to congestion of the lung and pneumonia. Any fatty or loose tissue over the common duct is dissected away and the relation of the hepatic artery and portal vein to the common duct is borne in mind. The duct is opened with a longitudinal incision, which is extended if necessary either to- ward the liver or toward the duodenum. Often the duct in obstruction is greatly enlarged and the finger is readily admitted. If the finger can be intro- duced the hepatic ducts should be first explored and then the common duct. If dilatation is not sufficient for the finger the exploration may be made with a uterine sound, a small spoon-shaped curet, or with small forceps. After re- moving the stones a probe is introduced into the duodenum. It is sometimes diffi- cult to ascertain whether the probe is in the duodenum or is merely pushing for- ward the ampulla of Vater. If a small spoon-shaped curet is used it can of- ten be introduced into the duodenum and may withdraw duodenal contents. After an incision in the common duct it should always be drained. This may be done by a T-shaped tube which is inserted into the incision and the wound in the common duct is slightly approximated by one or two sutures. An ordinary drainage tube, however, is usually satisfactory, and is cut with perforations at the end of the tube, or a triangular section is re- moved from the end of the tube so as not to obstruct the way from the hepatic duct to the distal portion of the common duct. A catheter with many perforations can often be inserted through the common duct into the duode- num or up toward the hepatic duct to drain the bile from the hepatic duct through the tube. Another method advocated by McArthur, and used with much success by Matas, is to insert a small rubber catheter through the opening of the common duct into the duodenum and to instill through this tube solutions such as salt solution or Locke's solution, which can be readily absorbed by the small intestine. This, of course, is only necessary in grave sepsis. A cigarette drainage is also carried down to the opening in the com- mon duct. Halsted advises suturing the common duct and draining through the stump of the cystic duct, or, if impossible, through a small stab wound in the common duct. This is an excellent method. Not infrequently such cases are accompanied by dense adhesions to the duodenum. In separating these adhesions the duodenum itself may be per- forated or injured. If it is perforated the wound should be sutured, for a duodenal fistula is an undesirable thing at any time, but when it complicates stone in the common duct with jaundice it is exceedingly serious. If the duodenum has been injured the presence of the drainage tube will very likely 530 OPERATIVE SURGERY divert the flow of lymph toward the tube and away from the injured duodenum and this often results in a fistula. The presence of the tube, however, is entirely necessary for the recovery of the patient and when the duodenum is injured, after the perforation has been closed or even where the injury does not involve a perforation, omentum should be sutured over the in- jured duodenum. This is done by turning up a piece of the gastrocolic omentum or of the great omentum. Sometimes, however, the adhesions in such a case are so dense as to make this impracticable, and here a por- tion of the omentum is resected and applied as a free transplant to the in- jured duodenum, being fastened in position by interrupted sutures of chromic or tanned catgut. This graft will prevent the flow of lymph from the duo- denum to the tube and actually calls for a larger deposit of lymph on the duodenum than would occur if the graft had not been placed. Choleeystenterostomy may be indicated in chronic pancreatitis, in ob- struction of the distal portion of the common duct, or in cancer of the head of the pancreas. The anastomosis is made between the gall bladder and the duode- num or the stomach. This does not provide as satisfactory drainage in inflamma- tion as when a tube is inserted, particularly if a tube is placed in the common duct, because there is no occasion for any marked change in the lymphatic circulation, which is so frequently a prominent factor in the benefleial results of drainage. This operation, however, should relieve the pressure in the common duct and af- ford a satisfactory exit for the bile into the duodenum. In intense jaundice following malignant disease of the head of the pancreas it is a good x^allia- tive measure and in inflammation of the head of the pancreas, which is often difficult to distinguish from malignant disease, the operation will establish a permanent route for the bile which will relieve some of the factors that promote inflammation in the head of the pancreas. The operation, as usually performed, consists in making a longitudinal incision into the duodenum and anastomosing this incision with an opening in the gall bladder. A longitudinal incision splits the longitudinal muscular fibers of the duodenum, which are external, and favors the closure of the opening, as each time the longitudinal fibers contract they narrow the anas- tomotic opening into the boAvel. To avoid this the incision in the duodenum should be transverse instead of longitudinal. After exposing the duodenum and gall bladder through an ample incision a portion of the fundus of the gall bladder that can be placed in contact Avith the duodenum without too much tension is selected and the place for the incision on the duodenum and on the gall bladder is marked by being grasped with Allis forceps. If necessary the duodenum is slightly mobilized by carefully incising the peri- toneum along its outer border. A fold of duodenum caught transversely is fixed with forceps used for lateral blood vessel suturing. The forceps have delicate springs and blades and cannot injure the bowel wall. There is no occasion for protecting these blades with rubber tubes (Fig. 488). The gall bladder is grasped by another pair of forceps after stripping back the bile. LIVER, GALL BLADDER, BILE TRACTS, ETC. 531 Gauze packing is placed beneath the gall Ijladder, and the surrounding tissues arc protected Avitli gauze. The posterior part of the clamped portion of duo- denum is sutured to the posterior part of the clamped x>ortion of the gall l)ladder A\ith a small curved needle carrying fine tanned catgut as in the pre- liminary step for gastroenterostomy. After this row has been completed the ends of the suture are clamped and used as tractor sutures. This avoids undue manipulation of the clamping forceps which may easily be dis- placed. The clamped portions of the duodenum and gall bladder are incised for an inch or more and gently mopped with moist gauze. The duode- num is cut transversely as it is clamped. A continuous lock stitch unites the cut edges along the posterior margin (Fig. 489). This suture may be of Fig. 4SS. — The aiuliur's uK-tlioJ of chuleci-stuiitcrostoniy. The duodenum is clamped at a right angle to its axis with the soft bladed forceps used for lateral blood vessel suturing. tanned or chromic catgut, or if the patient is old and tissue healing is likely to be poor, especially in cancer of the pancreas, the suture material had best be silk or linen. This inner row is begun at either the upper or the loAver angle of the wound. After completing the suturing of the posterior margins of the wound the same suture is continued along the anterior mar- gins. It is here converted into a right angle stitch penetrating the whole wall, or, if the tissues are vascular, it is placed throughout as a continu- ous lock stitch bringing the edges of the wound snugly together to avoid the possibility of hemorrhage. When the point of beginning is reached the suture is tied to the long end left at the first knot of this row of sutures. Three or more knots are snugly tied and the ends are cut short. The original line of sutures is then continued as a right angle continuous stitch, ap- 532 OPERATIVE SURGERY proximating as broad a surface as can be brought together without tension. When this row is completed the thread is tied to the end of the original knot of this line of sutures. As the greatest point of tension is at the ends of the incision, an additional mattress suture is placed at these points. The wound is closed without drainage. If this suturing is properly done the anastomosis should heal satisfactorily, even in cancer cases Avith low nutrition, but if drainage is jDlaced it may cause a breaking down of the suture line. If the duodenum is inaccessible the anastomosis may be made with the nearest portion of the stomach with almost as good clinical results. The Fig. 489. — The gall bladder is similarly clamped and a row of sutures unites the gall bladde_r_ to the duodenum. The gall bladder and duodenum are then incised and a second row of sutures, uniting the margins of the wound, is placed. colon should never be used because of the probability of infection of the bile tract from the colon. Reconstruction of the common duct may be indicated as a result of stricture from long continued inflammation or from the passage of stones, or be- cause of injury during a surgical operation. In such instances the bile usually flows through an external fistula and often there is also inflammation of the bile tracts with 'chills and fever. Numerous efforts have been made to re- construct the common bile duct by grafting or bj" transplantation of tissue. Grafts of fascia- or inverted veins or similar material have proved unsatis- factory. While they may appear to give good results at first, any tissue which is foreign or which has no biologic resistance to bile will react pro- foundly. There will be dense leucocvtic infiltration Avhicli is followed later LIVER, GALL BLADDER, BILE TRACTS, ETC, 533 by cicatricial contraction and obliteration of tlie reconstructed duct. The recon- structed duct closes first at its extremities where the combination of the sutured end and its wall fui'iiishes a maximum contact with tlie bile and where, conse- quently, the reaction to the bile would be greatest. In reconstruction of the bile ducts, of the intestines, or of any hollow viscera, whose contents may irritate other tissues, only tissues should be used which have a biologic resistance to the nor- mal contents of the duct or viscera to be repaired. A sutured intestine, for instance, will heal satisfactorily if the raw edges are inverted and the peritoneum is accurately approximated, though the fecal current is con- stantly passing over the cut raw edges of the bowel which have been turned into its lumen. If, hoAvever, we were to keep a wound in the skin bathed with fecal matter, as the inner portion of the intestinal wound is, we would expect a violent reaction and if healing ever occurred it would be with a pronounced scar. This is because the walls of the intestine have a certain biologic resistance against the irritating effects of the contents of the bowel. This resistance is perfect in the intact mucosa but exists to some extent in the deeper layers of the intestine. The study of a segment of trans- planted vein used in reconstruction of the common bile duct brought these facts vividly to mind.'^ The method of A. G. Sullivan in which a rubber tube is sutured into the hepatic end of the common duct, carried into the duodenum, and sur- rounded by neighboring tissues and the omentum is much more satisfac- tory than the reconstruction of the common duct by fascia, because the tis- sues in the neighborhood of the bile tracts and the omentum have more biologic resistance to the irritating action of bile than fascia transplanted from a distant part! The obvious deduction is that in reconstructing the bile ducts tissues that are accustomed to the presence of bile should be used and should include not merely the epithelial lining but the submucosa. The constriction does not take place in the epithelial lining, but in the submucosa which corre- sponds to the corium or derma of the skin. Even though a tube of fascia by which the common duct is reconstructed may be lined with epithelium, the fascia itself reacts to the irritating effect of the bile and sooner or later complete occlusion occurs. To prevent eventual occlusion, then, it is neces- sary^ not only to have an epithelial-covered surface but a submucosa with biologic resistance to the irritation of bile. This means that the mucosa and submucosa of the bile tracts and the duodenum must be used wherever possible. W. J. Mayo- has frequently operated by bringing the duodenum to the hepatic end of the stump of the common or hepatic duct and suturing it in this position. The duodenum is mobilized and the stump of the duct to be united is fastened to the posterior edge of a short incision in the duodenum by a few interrupted sutures. Other sutures are placed so as to unite more ^Horsley, J. Slielton: Reconstruction of the Common Bile Duct, Jour. Am. Med. Assn., Oct. 12, 1918. ^Collected Papers of the Mayo Clinic, 1915, p. 274. 534 OPERATIVE SURGERY accurately the mucosa of the duct to that of the duodenum. Then a rubber tube is placed of such a caliber that it fits not too snugly into the duct, reach- ing about an inch into the hepatic portion of the duct and a similar distance into the duodenum. It is fastened in position with a catgut suture which is absorbed after a few days and permits the tube to be expelled. The rest of the wound is closed by layers of interrupted tanned or chromic catgut sutures and the omentum is brought over the whole wound and fastened in position with sutures. LeGrand Guerry/^ of Columbia, S. C, has utilized this principle in a num- ber of cases. When there is a fistula present a probe is inserted through the fistulous tract to the bile duct. It is best to dissect outside of this fistula as far as possible until the duodenum has been exposed and the upper end of the bile duct recognized by the end of the probe. The tract is then cut through near its internal termination and the hepatic stump of the duct is demonstrated. He mobilizes the duodenum as much as possible and incises it down to the mucosa. The mucosa protrudes and gives an additional amount of tissue which is more readily mobilized than the whole thickness of the duodenum. A tube is inserted and sutured in a similar manner to the method of W. J. Mayo. If the closure has been satisfactory and the wound well sur- rounded by omentum drainage is unnecessary as it may predispose to the breaking down of the sutures. In ascites, due to cirrhosis of the liver, operations have been devised for side tracking the blood and so relieving the tension in the portal cir- culation. In cirrhosis of the liver all cases of ascites are probably not due solely to the increased tension in the portal circulation, as there may be other factors. A diminution of the portal pressure, however, is often followed by decrease in the ascites. Eck's fistula was supposed to re- lieve this condition by establishing a communication between the portal vein and the vena cava. This has not proved satisfactory in man because the large amount of metabolic products that are contained in the portal circu- lation are transferred directly to the general circulation. These products should first go through the liver, where they are changed- by the liver into nutritive or innocuous material. Unless the liver intervenes, they become deleterious when introduced directly into the circulation. A small part of these products, hoAvever, can be taken care of by the general circulation without serious effect. The operation of Talma produces an anastomosis between the vessels of the portal circulation and those of the general circulation and so relieves portal pressure without admitting to the general circulation more than a small portion of the material absorbed from the intestines. This operation, known as omentopexy, which was devised independently by Kutherford Morison and by Talma, is sometimes satisfactory in ascites due to cirrhosis of the liver. The abdomen is opened to the right of the midline above the umbilicus and all the ascitic fluid is evacuated. With dry gauze the upper surface of the ^Guerry, LeGrand: Jour. Anj. Med. Assn., Oct. 12. 191S. LIVER, GALL BLADDER, BILE TRACTS, ETC. 535 liver is rubbed to form adhesions between the liver and the diaphragm. The spleen is similarly treated. The omentum is then pulled into the wound and united to the anterior parietal peritoneum and the margins of the wound. Usually there has been much distention with the ascites and after the fluid has been evacuated the abdominal wall can be everted to expose a con- siderable area of the parietal peritoneum. The omentum is sutured around the wound as far from the incision as possible, particularly far over on the left side. After both sides are sutured the wound is closed with in- terrupted sutures of silkworm-gut. A muscle splitting incision is made after the manner of McBurney in the right iliac fossa and a tube is inserted to drain off the fluid in the pelvis. This is necessary, for the fluid if allowed to accumulate before the anastomosis of the small vessels has formed, will interfere with the union of the omentum to the peritoneum. This operation can often be done under a local anesthetic. The Mayos have modified this method by making one incision on the right side over the liver as near the deep epigastric and internal mammary vessels as possible and a second incision four inches below this through the rectus muscle, but not through its posterior sheath. After separating the muscle from its posterior sheath extensively, a portion of the omentum is drawn through the upper part of the incision and pulled down into the pocket where it is fixed in position with a few sutures. A similar procedure can be carried out on the left side and the intervening segment of omentum may be united to the parietal peritoneum. These operations done in the early stage afford much comfort and relief from ascites, but, of course, they are not curative of the cirrhosis. In tumors, of the head of the pancreas or the duodenum it may be neces- sary to transplant the end of the common duct in order to resect the head of the pancreas. Coffey has worked out a technic for this operation by transplanting the end of the duct into the duodenum obliquely, first incising the duodenum for about an inch down to the mucosa, then puncturing the mucosa at the end of the incision distal from the duct and fastening the duct at this point with a few sutures. The wound is then closed in such a manner that the duct rests in the length of the incision solely on the mucosa and the submucosa, the muscular and peritoneal coats being closed over it. In this manner the mucosa acts as a valve and prevents back pressure into the duct. Operations on the pancreas are chiefly for relief of pancreatitis. Can- cer of the head of the pancreas is usually inoperable and though Finney has successfully extirpated a growth involving the middle of the pancreas, can- cer is more frequent in the head than in any other portion of this organ. The operation to meet the indications for excision of cancer of the pan- creas should be arranged for excision of the head of the pancreas. Cof- fey* has worked out experimentally on dogs a very ingenious technic for this excision, though the operation has not yet been tried by him on man. It ^Coflfey: Ann. Surg., December, 1909. 536 OPERATIVE SURGERY consists first of extirj^ation of the duodenum with the head of the pan- creas and the adjoining tissues, including the end of the common duct. This would be the type of operation indicated in cancer. The pancreas is excised at a sufficient distance from the malignant growth. The cen- tral vessels are tied. The pancreatic duct is divided so that half an inch or more of the duct is left protruding from the raw surface of the cut pancreas. A loop of jejunum is then brought up and sutured together along its convex border as though a lateral anastomosis would be made. The bowel is incised in such a way as to throw the lumens of both ends together (Fig. 490). This makes the combined capacity of the two limbs of the loop sufficient to contain the stump of the pancreas without too much Fig. 490. — ^Excision of the head of the pancreas. A loop of jejunum is clamped, opened, and sutured in the manner indicated to throw the lumens of both loops into a common .opening (Coffey). tension. The peritoneal surface at the end of the loop is inverted by mattress sutures which grasp the end of the bowel and are inserted further down in the lumen so that when pulled upon the end of the combined loop is in- verted. The stump of the pancreas is placed within this prepared receptacle made from the combined loops of the jejunum. Sutures are taken at some distance from the end of the stump of the pancreas and fasten the pancreas to the edge of the opening of this loop. The end of the boAvel is snugly approximated to the pancreas by a collar suture which buries the other su- tures that have been taken from the pancreas to the bowel (Fig. 491). In this manner a considerable portion of the pancreatic stump is covered. The end of the common duct is implanted obliquely into the adjoining distal stump of the duodenum by making an incision of an inch down to the mucosa (Fig. 492), LIVEE, GALL BLADDER, BILE TRACTS, ETC. 537 piinetiiring the mucosa at the most distal point from the common duct, and after splitting- the common duct for a short distance its tip is inserted into this pundurc and hekl by a suture which passes tlirough the wall of Fig. 491. — Diagram showing the head of the pancreas excised and the stump of the pancreas implanted into the loop of jejunum which has been prepared as shown in Fig. 490 (Coffey). Fig. 492. — The common bile duct is transplanted into the duodenum or into another loop of jejunum. An incision is made -down to the mucosa, which is punctured at the end of the incision farthest from the common duct (Coffey). Fig. 493. — The tip of the common duct is drawn through the puncture of the mucosa as indicated in the drawing (Coffey). 538 OPERATIVE SURGERY the duodenum (Fig. 493). The rest of the wound is closed by intestinal sutures so that the duct is partially protected from the intraintestinal pressure by the valve of n:i,ucosa (Figs. 494 and 495). A gastroenterostomy is done in the usual manner. Operations for pancreatitis vary according to the stage of the pancreatitis. In acute conditions, Avhere the pancreas is greatly swollen, short incisions are made into the pancreas to relieve tension and are enlarged by inserting closed forceps and spreading the jaws. Drainage with tubes and gauze is Fig. 494. — The transplantation of the common duct is complete (Coffey). carried down to the Avound in the pancreas. If there is free oozing the sup- ply of gauze drainage should be abundant. The approach to the pancreas is usually best made through the gastrocolic omentum. If the stomach is prolapsed the pancreas may be approached above the lesser curvature of the stomach. The necessity for incision in the pancreas must be decided by the Fig. 495. — A sectional view of the transplanted duct, showing how the mucosa acts as a valve to prevent back pressure when the bowel is distended (Coffey). character of the inflammation. In subacute or in chronic pancreatitis it is not necessary to make incisions in the pancreas, but drainage should be es- tablished either through the gall bladder or the common duct. This relieves the pressure in the common duct and prevents to some extent the reflux of bile into the pancreatic duct which has been shown by Opie and others to be a very important factor in the causation of many cases of pancreatitis. The drainage tube in the common duct or the gall bladder probably also acts as has been indicated in the chapter on Surgical Drainage by reversing the lymphatic circulation and diverting it toAvard the drainage tube in an effort to extrude LIVER, GALL BLADDER, BILE TRACTS, ETC. 539 the foreign substance, which is the tube. This may divert the lymphatic flow from the pancreas and so cansc a withdraAval of some of the septic products of inflammation. A pancreatic cyst may arise at any portion of the pancreas and when large sometimes points below the colon and may simulate a tumor of the lower abdomen. It is usually best treated by marsupialization. An incision is made over the most prominent part of the growth and the relation of the cyst to the mesentery of the intestine and to the surrounding viscera is care- fully noted. An area of the cyst that approximates the abdominal wall is selected and the structures over it are displaced in such a manner that they will be the least disturbed. Frequently the cyst can be approached through the gastrocolic omentum. The peritoneum of this omentum is split and the cyst either sutured to the parietal peritoneum or packed around with gauze for four or five days until adhesions have formed. A cyst often forms as a re- sult of pancreatitis and is sometimes hemorrhagic. If a large hemorrhagic cyst is emptied suddenly there may be hyperemia and further bleeding which may necessitate packing the cyst. This can best be avoided by emp- tying the cyst gradually if its contents have been proved by diagnostic as- piration to be bloody. The fact that pancreatitis is apparently often caused by inflammatory disease of the bile tracts makes it advisable to explore the gall bladder and bile ducts. If any lesion is found the gall bladder or the common duct is opened and drained. This relieves the pressure within the common duct and prevents the flooding of the pancreas with bile, which is often the cause of pancreatitis. Surgery of the spleen consists largely in splenectomy. Occasionally a wandering spleen is fixed in position, which may be best done by the method of Bardenheuer, by making a pocket in the parietal peritoneum and inserting the lower portion of the spleen into this pocket. The spleen is further fixed by passing one stout suture through the lower end of the spleen and tying it around the tenth rib. As a rule, when the spleen is sufficiently movable to cause trouble an excision is the most satisfactory procedure. The technic of removal of the spleen depends largely upon its size. Ample exposure is always necessary. The incision of Bevan, which has been described, is used on the left side and the gall bladder and liver are first thoroughly ex- plored. If the spleen is not greatly enlarged and is nonadherent it is turned into the wound and the pedicle secured from behind. If the spleen is large and adherent the operation may be exceedingly difficult. Balfour^ emphasizes the following points in splenectomy: (1) The abdominal exploration; (2) the dis- location of the spleen; (3) the use of hot gauze packs; (4) the protection of the stomach and pancreas from injury; (5) the preliminary ligation of adhesions; and (6) the treatment of the pedicle of the spleen. The first step of the operation after exploration consists in mobilizing the spleen by thoroughly separating the adhesions between the surface of the spleen and the parietal peritoneum. If the ^Balfour: Surg., Gynec. & Obst., 1916, xxiii, 1-6. 540 OPERATIVE SURGERY adhesions cannot be stripped satisfactorily they should be doubly clamped and di- vided. If there are many adhesions between the spleen and the diaphragm these may be separated by the finger or if they are large and vascular they should be doubly clamped and divided. The spleen is dislocated inward and a large pack of gauze wrung out of hot salt solution is quickly inserted into the cavity formerly occupied by the spleen. This step, according to Balfour, Fig. 496. — Exposure of the pedicle of tlie spleen in splenectomy. The splenic artery has been doubly tied (Balfour). is very important and serves not only to control bleeding, but acts as a support from which point the spleen may be more readily handled. This pack is not disturbed until after the completion of the operation. The main pedicle of the spleen is then brought into view from its posterior surface. It must be borne in mind that the splenic veins are exceedingly friable and may be readily injured. The dissection of the pedicle is made as close to the spleen as possible, so that bleeding from an injured vein can be more readily located. The gastrosplenic attachment should be divided in sections as close to the spleen LIVER, GALL BLADDER, BTI>E TRACTS, ETC. 541 as possible, tlic division l)eiiio' made between ligatures. The vasa })revia are the chief vessels here. The spleen is often closely attached to the stomach and there is the danger of injuring the stomach if clamps are placed promiscuously in this region. By doubly ligating this portion of the pedicle and then dividing between ligatures this accident may be avoided. The exact relation of the stomach is ascertained before placing the ligatures. Careful dissection of any retaining peritoneal bands or fibers is made so as further to mobilize the spleen, always bearing in mind the very friable nature of the splenic veins. The tail of the pancreas must be recognized. Its position is often very irregular. It Fig. 497. — Another method of treating the pedicle of the spleen when it is difficult to expose the splenic artery (Balfour) . may actually be adherent to the hilus of the spleen, or it may be at such a dis- tance that it is safely out of range of injury. Sometimes, according to Bal- four, the tail of the pancreas lies behind the renal surface of the spleen and sometimes it fits so closely into the hilus of the spleen as to have ac- quired a concave edge; or it may be in front of the splenic vessels in contact with the stomach. After locating the tail of the pancreas it should, of course, be dissected from the spleen and the pedicle with great care. The treatment of the main pedicle that is left after separating the npper portion of the spleen 542 OPERATIVE SURGERY from the stomach depends largely upon the location and the arrangement of the vessels. If the splenic artery can be readily demonstrated it is ligated before the veins are tied (Fig. 496). If, however, this is impracticable, the spleen is clamped by three pedicle forceps at distances of about half an inch apart and the pedicle is cut between the two forceps nearest the spleen (Fig. 497). A ligature of catgut is applied to the pedicle after removing the forceps farthest from the spleen. This ligature is placed in the crushed line left after remov- ing the clamp. A second ligature of similar material transfixes the pedicle just below the distal clamp and is tightened as this clamp is removed. The gauze packing is then carefully withdrawn and any bleeding spots that are left are grasped with forceps and whipped over with catgut in a small round needle. If there is a considerable oozing surface that cannot be readily controlled the packing may be left in position. W. J. Mayo makes a practice of closing the abdomen with the packing in position in the cases in which the bleeding surface is extensive, ve- nous in character and difficult to control except by packing. The sututes in the abdominal wall are through-and-through sutures and are tied in a bow knot. Two or three days later the sutures are untied, the packing is carefully removed, and the abdominal wall is closed permanently with the sutures that w^ere originally tied in a bow knot. This method seems to lessen the danger of infection which is considerable when a large amount of gauze is left in position with the ends of the gauze protruding through the wound. CHAPTER XXV OPERATIONS ON THE STOMACH Operations on the stomach may be for correction of displacements or de- formities of the stomach or for the cure of nicer or malignant disease. Oper- ations for displacement or ptosis are often done in connection with ptosis of other organs, such as the colon. The indications for suturing the stomach in jDosition must be distinct. Often a prolapsed stomach will empty satisfactorily, but when it does not, and particularly when accompanied by marked ptosis of the colon and when roentgenographic examination shows a much delayed emptying of both organs, operation may be indicated. Many operations have been devised to correct this condition. Suturing the stomach to the abdominal wall by various methods has been practiced. The hammock operation of Coffey, while really devised for ptosis of the colon, lifts the stomach upward and forward. In Coffey's hammock operation the gastrocolic omentum is sutured to the parietal peritoneum by a series of interrupted sutures in a transverse line as far above the umbilicus as the sutures can be conveniently placed. This usually is about half way between the ensiform cartilage and the um- bilicus. The chief objection to this procedure is postoperative pain from pulling on the parietal peritoneum though it seems far better than fixing the stomach wall to the parietal peritoneum, or any of the methods of gas- troplication formerly advocated. In the hammock operation the stomach is permitted a considerable amount of freedom as it is suspended from what is really one of its ligaments and the mobility of its wall is but little affected. The pain following this operation, however, is not only severe but often embarrasses respiration. While the pain either completely or in a large part disappears in the course of time it is an annoying symptom for at least a few days after operation and sometimes for many weeks. When the natural anatomical tissues that are intended for suspension of or- gans can be utilized the effect is- more nearly to reproduce normal physiologic function than if an unnatural suspension or fixation is performed. The main ligament that holds the stomach in position is the gastrohepatic omentum. This has been utilized by Beyea, whose operation of gastropexy consists in taking a reef in the gastrohepatic omentum by several rows of sutures. The great objection to this is that the central part of the gastrohepatic omentum is the weakest and yet it is usually opposite this central portion that the ptosis of the stomach is most pronounced. Sutures at this point where the structures are weakest have the greatest strain to bear. Then, too, the insertion of a series of sutures sufficiently high under the liver is not al- ways an easy task if they are placed carefully to avoid blood vessels. 543 544 OPERATIVE SURGERY I have sliglitl.v luodifiod llie Boyea metliod l)y using a single pursestring suture of linen or silk, placed with a small curved needle. This is begun on the lesser curvature of the stomach on the left side of the midline, at the apparent point of beginning of ptosis where a firm bite is taken in the gastro- hepatie omentum just as it enters the stomach. Care is taken to avoid the vessels. The second bite of the needle is in the gastrohepatic omentum at a point vertically above the first bite, well up under the liver and in the thicker tissues in the left of the midline, avoiding the large vessels. Fig. 498. — Shortening the gastrohepatic omentum in ptosis of the stomach. Often this operation is undertaken in very thin individuals and in order to grasp satisfactory tissue it will be necessary to insert the needle near some large vessel where the firmer connective tissue forms a support to the larger ves- sels. This can be done so long as the vessel can be demonstrated and is not injured by the needle. The suture is then carried across the midline to the right side and catches a bite in the gastrohepatic omentum high up under the liver. The fourth bite is taken in the gastrohepatic omentum near the pylorus, vertically beloAV the third bite and on the right side of the midline. It should grasp the omentum just as it enters the stomach (Fig. 498). The stomach is pushed well up under the liver and the suture is gradually tight- ened. This must be done gentl}' to prevent the delicate tissues from tearing. THE STOMACH 545 Tlio knot is tied three times and the ends are cut short. Usually there is also a i)r()lapse of the transverse colon. If so the colon is bronfjht up in posi- tion l)y a series of sntnres of linen or silk, Miiich take a reef in the gastro- colic onientuni l)v beG,iiininook of Surgery, ed. 4. p. 790. AA'arbasse: Surgical Treatment, Philadelphia, 1918, AV. B. Saunders Co., ii, p. 738. ^Binnie: Operative Surgery, ed. 7, p. 385. ^iTurner, G: Surg., Gynec. S: Obst., June, 1912, xiv, S37. 552 OPERATIVE SrRGERY the ulcer. In tins nianiier we remove the pathologic condition and institute rest for these tissues. We Avould not think of treating a fissure in ano by doing a colostomy and side-switching the fecal contents, particularly if the colostomy permitted a small amount of fecal matter to continue to pass through the anus; and yet in performing a gastroenterostomy for the cure of pjdoric or duodenal ulcer we are practically doing just this very thing. By using the well-known surgical principles that have been established for years for the treatment of fissure in ano, namely, temporary paralysis of the sphincter and excision or cauterization of the ulcer, we can cure practically 100 per cent of such cases. If, then, the ulcer in the duodenum or pylorus is not cancerous and is the only pathologic lesion, have we not a right to ex- pect as good results here, so far as ultimate cure is r-onconied. by excision of Fig.^ 503. — Liiu-s <>i iinisuui tor the author's pi'loroplasty. If the ulcer is in the midline, the incision is carried to the ulcer, which is then excised, and the excision forms the duodenal portion of the incision. this ulcer and temporary paralysis of the sphincter muscles, as has been obtained since the early days of surgery by similar treatment of an ulcer within the region of the sphincter ani? The operation here proposed has been con- ceived on these principles, and an effort has been made to carry them out as far as possible, at the same time avoiding the objections that have been noted to other t3'pes of pyloroplasty. The steps of the operation are: 1. The upper portion of the duodenum and the pyloric end of the stomach are exposed through an ample abdominal incision, preferably the Bevan in- cision. A point is selected on the stomach not less than two inches from the pylorus and midAvay between the greater and lesser curvatures, and is grasped with Allis forceps or fixed with a suture. The stomach and duodenum are then surrounded with moist gauze (Fig. 503). 2. The length of the incision for the pyloroplasty depends upon the loca- THE STOMACH 553 tion of the iiUhm', hut the sloiiuicli portion of the incision must always be at least tAviec as loiii>' as the duodenal portion. If the nleer is in the duodenum and is more than threo-fonrtlis of an inch from the i)ylorns, pyloroplasty should not be done, but the ulcer should be excised with an elliptical iiieision transversely across the duodenum, accordino' to the method of E. S. Judd of the Mayo Clinic, and the incision is closed with two rows of sutures placed transversely so that there will be no constriction of the lumen of the duodenum. When an ulcer in the duodenum is not farther from the pylorus than three-fourths of an inch, pyloroplasty gives most satisfactory results. When the ulcer is in the stomach at some distance from the pylorus, pyloroplasty should be done in- stead of gastroenterostomy, and here the total length of the incision need be no longer than two inches, with one-half inch of the incision in the duodenum Fig. 504. — The ra*io of ihe incision should always be at least two parts in the stomach to one in the duodenum. The incision is first carried down through the stomach and then the duodenum is opened. The vessels are tied and the ulcer is exposed. and one and one-half inches in the stomach. For many ulcers near the py- lorus a two inch incision is sufficiently long. A short incision, of course, makes the suturing easier and the operation can be completed more quickly. The incision is carried from the previously fixed point on the stomach to the py- lorus, using a sharp knife and preferably cutting down to the mucosa and clamping and tying the vessels before opening the mucosa. When the mucosa is opened, the pylorus is divided and the ulcer, which is exposed, is removed. It can thus be accurately circumscribed by an incision and no more healthy mu- cosa is sacrificed than is necessary. 3. If there is a tendency for the gastroduodenal contents to regurgitate into the wound, a moist gauze pack is gently introduced into the stomach and a small strip of moist gauze is carefully placed in the duodenum. They should 554 OPERATIVE SURGERY be noted by the nurse, so there ^vill be no possibility of overlooking tlie gauze when the wound is being closed. 4. If the ulcer is in the posterior wall of the duodenum or pylorus, the wound is retracted, the ulcer exposed and excised, the deeper structures are sutured with tanned or chromic catgut, and the mucosa is gently approximated Fig'. 505. — If there is marked stenosis with pocket formation on the duodenal side, the cicatricial band is divided with a superficial incision. Fig. 506. — The posterior part of the pylorus is reconstructed with sutures as sliown in the illustration, after cicatricial bands have been divided or stretched. by a continuous suture. The suture in the mucosa must not be tight, as this might cause necrosis of the mucosa and spread the ulcer. If there is an old contraction resulting in pockets, the mucosa and the contracting band should be divided and the mucosa sutured transversely to the incision. To avoid hemorrhage, the incision that relieves the contracting band should be short and should divide only the superficial part of the band. The neglect of this precaution resulted in a fatal secondary hemorrhage (Figs. 505 and 506). THE STOMACH 555 Fig. 507-A. — ^A tractor or guy suture is placed from one extremity of the suture to the other. Fig. S07-B. — A second tractor suture is placed about one-half inch above the first. The second is tied before the first in order to relieve the strain. 556 OPERATIVE SURGERY 5. The ulcer Jiaving been removed or pockets and contractions remedied, the ends of the incision are ai^proximated by a tanned or chromic catgut suture (Fig*. 507A). A second suture of similar material is placed half an inch above this middle suture and renders suturing the upper half of the incision easier. There is a tendency for a duodenal fold to form if these sutures are too far apart. Both are tied and their ends left long to facilitate suturing and to hold up the edges of the wound and so prevent injury to the posterior portion of the pylorus while suturing. (Fig. 5075.) A No. 1 tanned or chromic catgut Fig. SOS. — The mucosa is united with a continuous lock stitch of tanned catgut. No effort is made to secure inversion but the mucosa is merely approximated to prevent leakage. suture is then started in the mucosa at the lowest portion of the wound, which is in the stomach wall. It is tied, the short end clamped, and the mucous membrane is united by a lock stitch which barely approximates the mucosa and ends at the upper portion of the incision, which is also in the stomach wall. Before completing this suture any gauze packing in the duodenum or stomach is removed. The suture is tied at the upper portion of the wound and the ends are left long and clamped (Fig. 508). 6. A second row of sutures, consisting of the same kind of catgut, in a curved round needle, is inserted, uniting the muscular and peritoneal coats. THE STOMACH 557 This is a simple continuous stitch that approximates the edges of the perito- neal and musenliir coats as a skin wound would be sutured. No attempt is made in this row to invert the edges of the wound as this would make too great a bulk of tissues along the suture line. Only enough tissue is included in the sutures to secure a firm hold. The long ends of the previous row are cut short (Fig. 509). 7. A third row of sutures of fine tanned or chromic catgut is placed, but the gauze around the stomach and duodenum should be removed before this third row is begun, as gauze packing hinders the approximation of the peritoneum. m ~^ "5 1 L \f H| m "y m •~\ R^', -f^' i> "P-i* ^- ■■^ ~^\ ^^ ~N 1 ' Fig. 509. — The tractor sutures have l^een cut. The edges of the peritoneal and muscular coats are ap- proximated with a continuous suture without any attempt to invert the edges. This row includes the peritoneal and muscular coats and buries the first and the second rows of sutures completely. It invests the two ends of the in- cision as teats. This is a continuous mattress or right-angle stitch. If the middle of the wound has not been satisfactorily approximated one or two mattress sutures of fine catgut should be placed there (Fig. 510). 8. A portion of the gastrocolic omentum, or else the right edge of the great omentum, can be brought up over the line of sutures without tension. It is fastened here with interrupted stitches of fine catgut. Care should be taken that it barely covers the upper end of the sutured wound and that it 558 OPERATIVE SURGERY / ./ '■■ /V A \_ ^21 / i ^ j Fig. 510. The third i n\\ of Mitiins is placed as a continuous right angle suture which buries the other two' rows. It is begun by surrounding the lower extremity, which forms a teat, as a pursestring suture. This is inverted as the first knot is tied. By a similar procedure the upper teat is inverted. Fig. 511. — A tag of gastrocolic omentum or of the great omentum is brought up over the suture line and fastened with a few catgut sutures. This not only protects the sutures, but tends to prevent the drawing up of the pylorus under the liver as healing occurs. Insert A shows the contour of the stomach as it is changed by this pyloroplasty. THE STOMACH 559 is not fastened to the gastroliepatie omentum, as this might result in too com- plete a surrounding' of the pyloric end of the stomach (Fig. 511). 9. If the ulcer is not in the duodenum or the pyloric region, the operation, as just described, may be done to relieve the spasm of the pylorus and the ulcer then excised, or cauterized, as advocated by Balfour, through another gastric incision. Where exposure is difficult or where the ulcer is in the cardiac portion of the stomach, a shorter incision in the stomach and duodenum can be effec- tively used. An inch and a half is often sufficient, but the ratio of one part of the incision in the duodenum to two parts in the stomach must always be observed. The advantages of this operation are: 1. It removes the obstruction and the pathologic condition, and permits the normal resumption of the stomach function. 2. The ends of the sutured incision are within the stomach wall. The ratio of the incision should never be less than two parts in the stomach to one in the duodenum. Usually two inches in the stomach and one in the duodenum are sufficient. The anterior stomach wall in the midline can readily be pulled over to the first inch of the duodenum. In the Heineke-Mikulicz operation, and also in the upper part of the Finney operation, the ends of the sutured incision are in the scar tissue at the pylorus, while in this operation the ends of the sutured incision are within the healthy stomach wall, and the scar tis- sue that may remain about the pylorus is approximated, not to other scar tissue, but to healthy stomach wall. Consequently, union should be more sat- isfactory than where scar tissue is opposed to scar tissue, as in the other two types of pyloroplasty. 3'. There is no pouch formation as in the Ileineke-Mikulicz operation, in which the center of the incision is at the pylorus. The operation merely changes the shape of the pjdoric end of the stomach from a funnel with grad- ually approaching walls to a rectangle that empties into a funnel with a more obtuse angle (Fig. 511-a). 4. The parts to be put at rest are the parts most concerned in contraction and relaxation, which are the pylorus and the adjacent portion of the stomach. By making the incision from the duodenum about 2 inches into the stomach, this is effected. A long incision into the duodenum does not help in any way. 5. The function of the pylorus and the pyloric end of the stomach is not permanently destroyed. The stomach wall that is brought over acts as a link between the ends of the pyloric sphincter and, in the course of time (usually a few weeks), the sphincter resumes its action, though, because it has been enlarged, it cannot become spastic as it was before the operation (Fig. 512). 6. The operation is simpler than the Finney operation, in which the duo- denum has to be mobilized and the posterior and the anterior margins of the wound must be sutured separateh\ There is a superficial resemblance between this operation and the Heineke- Mikulicz, because in both operations the pylorus is divided and in both the 5G0 OPERATIVE SURGERY incision is approximately straiglit. Here, however, the resemblance ceases, and the cliit'erences become marked, for, unlike the lleineke-Mikulicz, the operation descriljed was conceived on the principle of giving temporary phys- iologic rest to tissues in the pylorus and the pyloric end of the stomach ; the incision is longer than in the Ileineke-^Mikulicz operation ; it is dilferently placed; it extends not more than one inch into the duodenum and the stomach incision is always at least double the duodenal incision ; it can be considerably prolonged at the stomach end ; it gives an excellent view of the pyloric end of the stomach; it requires a rather definite technic to be closed satisfactorily; it does not form a pouch with a constriction fore and aft; it does not approxi- mate scar tissue to scar tissue ; and an essential part of the operation is the removing or remedying of the pathologic condition by excising the ulcer, ob- literating pockets, or incising constricting bands. In addition, the reenforcing with omentum adds security to the sutures, prevents adhesions to surrounding Fig. 512. — A roentgenogram of a patient. Miss E. D. H., taken four and one-half months after this pyloroplasty was done. The patient had a typical duodenal ulcer with marked ptosis. There were no adhesions. The pylorus as shown is functioning normally, with a perfect duodenal cap. The pylorus is slightly larger than normal. The structure and function of the stomach have not been materially altered by this operation. The patient while using an abdominal support is complaint free. tissues, and counteracts the tendency for the pylorus to become fixed high up under the liver, which sometimes occurs after the Heineke-Mikulicz operation. The postoperative treatment is about the same as that employed for gas- troenterostomy. If there is uny vomiting or marked discomfort, the stomach should be promptly washed out under low pressure, not more than a pint of fluid being- used at a time. Gastric lavage should be resorted to without hes- itation and may be needed oftener than after gastroenterostomy. The head of the bed is elevated from 12 to 18 inches, and the patient is given one-half ounce of hot water every hour for the first twenty-four hours and after that 2 ounces of hot water CA'^ery hour for tAventy-four hours. Enemas of 6 ounces of physiologic sodium chlorid solution Avith one-half ounce of glucose and 1 dram of sodium bicarbonate are giA^en cA'cry six hours for the first tAvo da3'S. At the end of forty-eight hours a small amount of liquid nourishment is com- THE STOMACH 561 menced. jMxtiil llic sc>\(mi11i or ci^lilli day after operation a purg-ative is given and soft diet is begun. The description of this operation was reported before the section on Obstetrics, Gynecology and Abdominal Surgery, at the meeting of the Amer- ican Medical Association, in June, 1919/° The only changes in technic since this report have been in the method of application of the second row of sutures and in placing the second stay suture closer to the first. At that time eleven cases had been operated upon by this method. There were two deaths, both of them from hemorrhage, and in both instances postmortem examinations were obtained. One death occurred on the twenty-first day after operation in a patient with an ulcer of the posterior wall of the stomach near the lesser curv- ature. The ulcer was removed by a transgastric incision and the resulting wound was closed with mattress sutures of stout tanned catgut. Pyloroplast,y was then done. The patient made an uneventful recovery until the eighteenth dav when ^Ui surface vS jc^evi-OT wa\^ lessev cu.- Tvatu,T-°^' o-^^' Fig. 513. — A drawing of the stomach removed postmortem from a patient who died twenty-one days after pyloroplasty. Death was due to hemorrhage from an ulcer involving the lesser curvature. Note the large vessel protruding in the ulcer and the healing of the pyloroplasty, which makes a wide opening. he had a severe hemorrhage from the stomach. This appeared to be con- trolled by gastric lavage with hot w^ater. Twenty-four hours later he began vomiting blood and in spite of gastric lavage and transfusion of blood he died on the tw^enty-first day after the operation. Necropsy was held a few "Jour. Am. Med. Assn., August 23, 1919, p. 575, et seq. 562 OrERATIVE STTRGERY hours after death and the stomach was obtained. It showed that the pylorus had healed satisfactorily, but the ulcer had extended to the lesser curvature and involved a blood vessel of considerable size that was protruding from the ulcer. From this vessel the hemorrhage undoubtedly had come (Fig. 513). The mattress sutures in the stomach ulcer evidently were tied too tightly and caused necrosis of the mucosa and an extension of the ulcer to the lesser curvature where there were large vessels. In the light of this experience I would not close a similar ulcer with mattress sutures, but with layer su- tures, uniting first the peritoneal and muscular coats. The sutures can be applied after placing a tractor suture at each end of the wound to bring it as near the abdominal wound as possible. This death could in no way be attributed to the pyloroplasty which had healed satisfactorily and left a wide open pylorus with perfect union, as shown in the illustration. The next death occurred on the ninth day as a result of hemorrhage which began on the eighth day after the operation. This patient had a marked sten- osis of the pjdorus, which had existed for a number of years. This stenosis was incised posteriorly at the operation to release the constricting bands. There was moderately free hemorrhage after the incision into the bands which was readily controlled by whipping over the surface with tanned catgut. The catgut was absorbed and bleeding began on the eighth day from this incised surface. The post mortem examination showed very small vessels had been opened where the bands had been incised and the catgut was digested and absorbed. The pyloroplasty incision was in perfect condition. This error in technic could have been avoided by not cutting the bands so deeply, but merely nicking them sufficiently, so that the incision would not go through the whole thickness of the bands and reach the vessels posteriorly. Probably, too, silk sutures in this area would be preferable to catgut. Profiting by these two fatalities there has been no hemorrhage in a single pyloroplasty that I have done since this group of cases was reported. In the nine patients that recovered from operation all were complaint free in whom the ulcer was the chief or the sole pathologic lesion present. This operation as shown by roentgenograms restores^ the stomach to a physiologic normal, protects the jejunum from being a dumping ground for the acid contents of the stomach, and at the same time removes the ulcer which is the cause of the patient's trouble. After pyloroplasty it is not unusual to find pain, discomfort, and some- times hunger pain, if there was an adherent gall bladder at the time of the pyloroplasty and the gall bladder was not removed. In order to understand this, we must remember that the ulcer of the duodenum or stomach was, in all probability, originally caused, as shown by RosenoAV, by hematogenous in- fection with streptococci. These bacteria have to some extent a selective action, but usually there is an inflammation of the gall bladder and probably of the appendix and kidne^^s, from the irritation of the products of the bac- teria when the ulcer is originally formed. Often the cholecystitis is rapidly overcome, but if it is severe enough to leave adhesions, that gall bladder is THE STOMACH 563 ponnaiuMitly daniaged. Tf, tlicn, a pyloroplasty is done for ulcer of the duo- (Iciiuiu (ir sloinacli avIumi llie o'all ])]adder is adherent, it may he taken as a defi- nite evidence of a former choU^eystitis. If the adhesions are separated and the iiall l)ladder is manipulated, a latent infection of the gall gladder is often stirred up, adhesions reform with double severity and the patient will have a recurrence of symptoms. If a gastroenterostomy is done, these symptoms will be relieved for a few months or longer, until jejunal lesions begin to give trouble. The cause of this discomfort after pyloroplasty is due to the fact that ad- hesions from the gall bladder to the duodenum or pylorus, in a stomach that is otherwise normal, permit the tugging on these adhesions with each peristal- tic wave and as they lead directly or indirectly to the tissues along the poste- rior parietal peritoneum which are supplied with spinal sensory nerves, an un- usual amount of tugging will give discomfort and pain. Gastroenterostomy re- lieves these sj'mptoms by permitting the stomach to empty more easily and in this way reduces the amount of peristalsis at the pyloric end of the stomach. It relieves, not by removing the pathology, but by ameliorating a symptom. This pain can be best prevented by bearing in mind the etiology of ulcer of the stomach or duodenum and removing gall bladders that are adherent. When doing a cholecystectomy under these conditions, following the tech- nic of Murat AVillis, the stump of the cystic duct should not be drained. In this manner the adhesions that might form because of the presence of the drainage tube are obviated and the stomach and duodenum are returned as nearly as possible to their physiologic normal. There exists, hoAvever, a distinct field for gastroenterostomy. This prob- ably does not constitute more than twenty-five per cent of the lesions of the stomach and duodenum, but there are three types of cases in which a gastro- enterostomy is a better operation than pyloroplasty. (1) In inoperable cancer of the pylorus with obstruction the necessity for gastroenterostomy is obvious. (2) In dense and wide stenosis of the pylorus and upper duodenum when unaccompanied by hemorrhage it is difficult or impossible to mobilize the duo- denum sufficiently to gain access to it and pyloroplasty is much more diffi- cult than in simple ulcer or in a slight stenosis, that is readily accessible. Again, this type of case gives particularly good results after gastroenteros- tomy. (3) In subacute perforation or in large ulcers when the p^dorus and sur- rounding tissues are infiltrated with inflammatory products, the tissues are difficult to mobilize and do not hold sutures satisfactorily. If the infiltration is extensive it is quite probable that stenosis will result and such cases do par- ticularly well after gastroenterostomy. In acute perforations, however, before there is extensive infiltration of the surrounding tissues and when the duodenum and i^ylorus are accessible and the margins of the ulcer can be excised, the pyloroplasty described seems to be an ideal procedure, for it confines the field of operation to the region of 564 OPERATIVE SURGERY the perforation and avoids the possibility of spreading the infection to the lesser peritoneal cavity, Avhich may oecnr if gastroenterostomy is done. If there is marked stenosis and bleeding the pyloroplasty should be done to secure the bleeding vessels or break the scar tissue l)and even though it is more difficult than gastroenterostomy. The pyloroplasty may be short and on ac- count of the tendency of dense scar tis.sue to contract, a gastroenterostomy should also be done at the same time. These three groups will comprise a considera- ble minority of cases usually seen and will remove the type of cases in which py- loroplasty is quite difficult. In the average case with a single ulcer near the py- lorus a pyloroplasty is easier of performance than gastroenterostomy, but with a fixed duodenum and pylorus the pyloro^Dlasty becomes increasingly difficult. It is in this type of case, however, that gastroenterostomy gives the best results. It has often been remarked by operators who have had much experience with pyloric stenosis that gastroenterostomy gives its best results here. Thus Balfour,^^ in speaking of the results of gastroenterostomy in obstruction at the pyloric outlet, says: "Particularly when mechanical obstruction has oc- curred from contraction of the ulcer or by reason of its actual size, operation is followed by eminently satisfactory results." This experience seems to be universal. AVhy should gastroenterostomy give such satisfactory results in stenosis of the pylorus w^hen the results wdthout stenosis leave much to be desired f Sten- osis of the iDylorus, even when incomplete, probably becomes complete after gas- troenterostomy which removes the necessity for strong peristaltic action to empty the stomach and causes a contraction of the whole stomach. It is impossible for the same intragastric pressure to be brought to bear upon the pyloric end of the stomach when a gastroenterostomy is done because the opening of the gastroenter- ostomy makes great intragastric pressure an impossibility. When gastroenter- ostomy is done for stenosis at the pylorus the gastric contents empty entirely through the gatroenterostomy. The duodenal contents with strongly alka- line reaction, W'hich is unreduced by any gastric juice coming through the pylorus, are delivered at the site of the gastroenterostomy with maximum alkalinity. The acidity of the gastric juice is, therefore, quickly and readily neutralized, so the mucosa of the jejunum is protected from the action of a strongly acid gastric juice. When, how^ever, the pylorus is open and gastro- enterostomy is done, part of the gastric contents goes through the pylorus and part through the gastroenterostomy.. That part going through the pylorus greatly reduces the alkalinity of the duodenal contents, so when the duodenal secretion reaches the gastroenterostomy opening its alkalinity is low and the acidity of the gastric contents overcomes it and acts directly upon the jejunum, which consequently registers some reaction to the presence of an acid medium. It seems, then, that the excellent results following gastroenterostomy when there is stenosis of the pylorus occur because the high alkalinity of the duodenal contents protects the jejunum from the presence of an acid medium ^Collected Papers of the Mayo Clinic, 1916, viii, p. 171. THE STOMACH 565 and so the jejunum has no occasion to react against an unphysiologic medium b}^ becoming congested or by ulcer formation. Artificial closure of the pylorus has been disappointing in the attempt to simulate pyloric stenosis because practically every method of pyloric closure except excision results in the pylorus eventually opening again. While the pylorus is closed the conditions are the same as after an organic stenosis, but with the reopening of the pylorus, such as occurs after infolding or ligation, the gastric juice again escapes through the pylorus and reduces the alkalinity of the duodenal con- tents, with the resulting lack of protection of the jejunum. This, of course, quickly causes the same reaction on the part of the jejunum as would have occurred if the pylorus had not been closed. Gastroenterostomy is best performed by the posterior no loop method, which has been developed by the Mayos, Moynihan and others. The operation Fig. 514. — Diagram of the incisions, and direction of the opening in posterior gastroenterostomy. (W. J. Mayo). as performed at the Mayo Clinic is a most satisfactory technic (Fig. 514). The stomach is exposed by an incision a little to the right of the midline and the stomach and duodenum are examined. The transverse colon is drawn out of the wound and pulled upAvard to the right to make the mesocolon taut. The jejunum is recognized as it comes out from the mesocolon and is picked up about three inches from its origin. Sometimes there is a fold of perito- neum passing from the mesocolon to the jejunum which should be divided if it extends far down on the jejunum, as this may prevent the jejunum being caught as high up as it should be. About where this fold joins the mesocolon the mesocolon is opened in a bloodless area and the posterior wall of the stomach is exposed. An opening is made sufficiently large to give exit to a considerable portion of the posterior gastric wall without constric- tion. Following the suggestion of McArthur, the posterior portion of the rent in the mesocolon is now sutured to the posterior part of the stomach wall by a few interrupted sutures of catgut. This procedure is best 566 OPERATIVE SURGERY done at this stage of the operation as the suturing can be more accurately api)lied than after the jejunum and stomach are united (Fig. 515). A gastroenterostomy clamp, preferably the Roosevelt clamp, is applied to the stomach in such a way that the bite on the stomach wall will be from the right side obliquely toward the left and the tip of the forceps includes a portion of the stomach at the greater curvature. The jejunum is caught and clamped in its long axis from two to four inches from its origin, and the clamped portion is applied to the stomach so that the upper part of the jejunum is at the heel of the stomach clamp and toward the right. The surrounding tissues are pro- tected by moist gauze and the jejunum is united to the stomach for a distance of about two and one-half inches by a row of continuous sutures, preferably of tanned or chromic catgut. The short end of the suture is clamped with Fig. 515. — Posterior gastroenterostomy. The posterior part of the stomach is sutured to the rent in the mesocolon. The portion of jejunum to be opened is shown, but the clamp should be reversed, and its tip point to the left. forceps. After the posterior row has been completed the needle and thread are clamped with mosquito forceps and folded in a towel. The sutures may be applied as a simple continuous stitch or as a right-angle suture, preferably the latter. The stomach and duodenum are incised about a third of an inch from this row of sutures. The incision had best be made carefully and any vessels that can be recognized should be doubly clamped and divided before opening the mucosa (Fig. 516). These vessels are then tied with cat- gut. This step consumes but little extra time and makes a much greater assur- ance that there will be no after bleeding. The mucosa of the stomach is divided throughout the length of the incision and then the mucosa of the THE STOMACH 567 cluocleiiiim. The contents of the clamped stomach and duodenum are removed hy sponges. A second row of sutures is begun. This is also tanned or chromic catgut but is larger than the first row, the first being or 00 and the second No. 1 or No. 2. Either a curved or a straight needle may be used. This suture is begun at the end of the incision where the needle and thread of the first line of sutures has been left. The short end is clamped and the suture is continued as a buttonhole or lock stitch, each stitch being held snugly (Fig. 517). When it reaches the other end it is continued on the anterior margins of the gastric and the jejunal wound as a continuous mattress stitch penetrating all coats. A very small margin of the stomach or jejunum is caught with this suture so as not to fold in any more tissue than is necessary. If the stomach wall is quite thick this suture can often be inserted more accurately by carrying the needle from the peritoneal surface through the mucosa and then back from the mu- Fig. 516. — The stomach and jejunum have been clamped and a posterior row of sutures is placed. The stomach and jejunum are incised down to but not through the mucosa. The next step is the clamp- ing and tying of dilated vessels before the mucosa is opened. cosa to the peritoneal surface. This, of course, may be accomplished by a single thrust of the needle, but in a thick stomach wall it causes a larger amount of the peritoneal and muscular coat than the mucosa to be caught in the bite of the needle, whereas if the needle is thrust in perpendicularly and returned in the same way an equal amount of all the layers of the stomach wall are grasped and there is less likelihood of bleeding points in the mucosa escaping. With a curved needle a single thrust is more likely to catch more of the mucosa than with a straight needle. Just before ending this row of sutures the clamps are relaxed to see if there is any bleeding along the pos- terior or the anterior margins of the wound. If there is, additional sutures 568 OPERATIVE SURGERY should be applied at the bleeding point. If not, this second row of sutures is continued to its point of beginning and the thread tied to the short end that was clamped. The line of suture is carefully sponged with moist gauze and the needle and thread left after placing the first posterior row of sutures is taken up and the first row is continued, using preferably a right-angle continuous stitch and going about one-fourth to one-third of an inch from the inner row of sutures. When it reaches its point of beginning this suture is tied to the original end that was left long. An interrupted mattress suture is taken at each end of the gastroenterostomy to lessen the strain on the sutures at these points. The anterior portion of the rent in the mesocolon is sutured Fig. 517. — The second row of sutures has been placed in the posterior margins of the wound and is carried forward to the anterior margins. to the stomach by interrupted sutures of tanned or chromic catgut placed about an inch from the gastroenterostomy opening. It was formerly the cus- tom to suture the rent over the last row of sutures used for gastroenterostomy but W. J. Mayo found that occasionally this opening contracted and produced constriction of the gastroenterostomy stoma. By suturing the rent about an inch higher on the stomach the constriction is avoided. As one of the first steps in the operation consisted in suturing the posterior margin of the mesocolon to the stomach the anterior or lateral aspects are all that require suturing. This, however, is an important step in the operation. If it is not done there may be a hernia of the small intestine into the lesser peritoneal cavity. The location of the gastroenterostomy opening as described above is almost opposite the esophageal opening. A vicious circle which was formerly THE STOMACH 569 common after posterior gastroenterostomy with a loop, is rarely seen when the no loop method is employed. Occasionally, however, there may be an indica- tion for such an operation that would make a vicious circle impossible. This is done according to the method of Roux and is often called the operation **en Y." The structures are exposed as in posterior gastroenterostomy but the jejunum is caught about six inches below its origin, doubly clamped Fig. 518. — The gastroenterostomy of Roux to prevent vicious circle. This operation seems peculiarly liable to be followed by jejunal ulcer. . and divided. The lower end is sutured to the posterior wall of the stomach which is exposed as in the operation of gastroenterostomy just described. The upper end is sutured by the end-to-side method to the jejunum about five inches below the gastroenterostomy opening (Fig. 518). Excision of an ulcer should be done wherever possible. This procedure not only removes a septic focus, but wdien the ulcer is in the stomach it lessens the possibility of cancer which occurs in a certain percentage of ulcers of the stomach. When the ulcer is on the anterior surface of the stom- ach and near the pylorus, excision is readily done. This may be accomplished through the pyloroplasty incision made in such a way that it will be near the edge of the ulcer, which is excised from the mucous surface. It is best to cauterize the ulcer with the cautery to sterilize its surface before removing it. 570 OPERATIVE SURGERY When the ulcer is so located that it cannot be readily brought into the region of the pyloroplasty incision, it is removed through a separate incision. A frequent site of gastric ulcer is along the lesser curvature. The blood vessels in the mesentery are ligated along the edge of the ulcer and the gastro- hepatic omentum is divided. The portion of the stomach containing the ulcer is mobilized as much as possible and surrounded by moist gauze. With a sharp knife an incision is made along the margin of the ulcer cutting down to, but not through, the mucosa. Bleeding points are clamped and tied by trans- fixing them with catgut in a needle. It will be found that the mucosa is more easily mobilized than the other layers of the stomach wall. After circumscrib- ing the ulcer in this manner the mucosa is opened with the electric cautery at its anterior portion and the ulcer is inspected. The rest of the mucosa is then di- vided with the cautery in such a way that there is a small margin of healthy mucosa excised with the ulcer. The mucosa is sutured as a separate layer with tanned catgut, using a continuous lock stitch. If the sutures can be placed in a straight line, without too much tension, it should be done. The incision in the stomach may often be made in an oblique- or diamond-shaped manner which will render such a closure not difficult. The important point is to unite the edges of the mucosa without tension. A second row of sutures of No. 1 tanned or chromic catgut in a curved round needle is placed taking the mus- cular coat and edges of the peritoneum. This may be placed as a right-angle stitch, taking an occasional back stitch in order to anchor the line of sutures at about every fourth insertion of the needle, or if there is tension the second roAV is inserted, as the second row in pyloroplasty. A third row of finer tanned or chromic catgut is inserted as a right-angle stitch. The stumps of the ligated gastrohepatic omentum are brought together over the wound and fastened with interrupted catgut sutures. Suturing the ulcer in this manner will take up a minimum amount of the wall of the stomach and will produce but little tension. If through-and-through sutures are taken as the first layer a large mass of inverted tissue is turned in which not only encroaches greatly on the wall of the stomach, but is likely to cause tension on the sutures and make an unnecessary lump of tissue. Ulcers on the posterior gastric wall are often difficult to approach. If adherent to the pancreas their excision may be complicated. If the ulcer is near the lesser curvature it can be reached by ligating and dividing the gas- trohepatic omentum immediately above it and making a vertical incision over the upper portion of the anterior stomach wall, which will expose the ulcer, and then continuing the incision posteriorly as an elliptical or diamond- shaped incision that will include the ulcer. The wound is then sutured by placing tractor sutures in the posterior angle and drawing the wound forward. Suturing is begun in the mucosa at the posterior angle and carried forward to the anterior end of the incision as a continuous lock stitch of tanned or chromic catgut. The second row is of tanned or chromic catgut to approximate the margins of the wound, and the third is of finer tanned or chromic catgut placed THE STOMACH 571 as a right-angle stitcli. The gastrohepatic omentum is hronght togetlier as in excision of an ulcer on the lesser curvature. When the ulcer is near the middle of the posterior wall it can 1)c reached by a transgastric incision. This may be vertical or longitudinal in the ante- rior wall of the stomach. If a longitudinal incision is made it should be about midAvay between the lesser and greater curvatures so as to avoid the larger blood vessels and to injure as little as possible tlie nerve supply. If the ulcer is nonadherent it may be pushed into the wound by the hand, which invaginates the transverse mesocolon into the lesser peritoneal cavity and mi *"\; ' V'rf:Si Ih ^fe"fe i I mm- / / Fig. 519. — Incision through the gastrohepatic and gastrocolic omentum to expose ulcer in posterior wall of the stomach. shoves the posterior wall of the stomach into the wound. If the ulcer is adherent, the lesser peritoneal cavity is opened either through the gas- trohepatic omentum or the gastrocolic omentum and the region of the ulcer is carefully packed around with moist gauze to prevent soiling of the sur- rounding tissue (Fig. 519). The adhesions may then be carefully separated with the finger in the lesser peritoneal cavity or if they are dense they may be separated after incising the margin of the ulcer from within the stomach through an incision in the anterior gastric Avail. Such an incision should be carried along a margin of the ulcer for a short distance and carefully enlarged and deepened until the stomach has been penetrated. Then with the fin- 572 OPERATIVE SURGERY ger the margins of the ulcer may be separated. If the pancreas is involved a small portion of the pancreas may be cut away and the bleeding surface whipped over with tanned or chromic catgut which is tied just tightly enough to control the bleeding. Here it would be wise to carry a cigarette drain down to the injured pancreas and bring the drain out through the rent in the gas- trocolic omentum. After mobilizing the ulcer it is brought up into the wound, its surface is cauterized with an electric cautery, and the ulcer is ex- cised. Bleeding points are secured by transfixing them with catgut in a needle. The peritoneal and muscular coats are sewed with interrupted mat- tress sutures of tanned or chromic catgut. The ends are securely tied and cut short and a second layer of tanned or chromic catgut right-angle suture is applied to include the muscular wall of the stomach and some of the sub- mucosa. The third row is a continuous lock stitch of fine tanned or chromic catgut in the mucosa. This method is much safer than endeavoring to place interrupted mattress sutures of stout catgut or silk through the whole gastric wall for these sutures must be tied tightly to secure approximation and the blood supply to the tissues within their grasp is either diminished or cut off entirely. There will, consequently, be necrosis, and though the perito- neal surfaces of the stomach may unite, the mass of tissue within the grasp of the sutures in the interior of the stomach, including a considerable amount of mucosa, will probabl}- die. This gives rise to a new ulcer that may be more extensive than the original one. Not infrequently on account of adhesions, the extent of the ulcer, or its inaccessible location it is impossible or exceedingly difficult to excise the ulcer. Here the method of cauterizing the ulcer as devised by D. C. Balfour, should be employed. According to the technic of Balfour, the gastrohepatic omentum in the region of the ulcer is dissected free from the lesser curvature. An ulcer that requires cauterization and cannot be safely excised is always along the lesser curvature. After exposing the region of the ulcer a flap of tissue over it, including the peritoneum and muscular coat, is raised, the crater of the ulcer is demonstrated and is perforated by a Paquelin or an electric cautery at a dull red heat. The cauterization is continued until the whole of the surface of the ulcer has been destroyed. The margins of the cauterized area are then brought together by interrupted sutures of chromic catgut and over this are placed mattress sutures of silk. Lastly a flap of gastrohepatic omentum, which was originally loosened and preserved, is su- tured over the wound. After excision of any ulcer a pyloroplasty should be done to overcome the spasm at the pylorus. The pyloroplasty which has been described will suit admirably and when done to relieve the spasm at the pylorus that follows the excision of an ulcer in the body or cardiac portion of the stomach, the total length of the incision need be only about two or two and one-half inches, taking care, however, that no more than one-third of the total length is in the duodenum and the rest of the incision is in tlie stomach. Any operation upon the stomach interferes with its peristalsis and emptying power. Just as an THE STOMACH. 573 operation upon the urinary bladder interferes with its power to empty and should be followed by the introduction of an indwelling catheter, so an opera- tion upon the stomach must provide easy exit for its contents by overcoming the resistance at the pylorus. The pyloroplasty does this without instituting the unphysiologic conditions already described which necessarily follow a gastroenterostomy, and by the time the wound in the stomach has thoroughly healed the pyloric end of the stomach functions in a practically normal man- ner. There should be no hesitation about the use of a stomach tube after such operations upon the stomach. If the stomach tube is used with reasonable care and if the stomach is washed out with a small amount of soda solution under low pressure, this will be much less trying upon the healing of the wound than the retention of gastric contents or the tension upon the suture line from a stomach dilated with liquid or gas. In old ulcers with pronounced hourglass constriction or where a consid- erable portion of the gastric wall is involved a transverse or sleeve resection of the stomach often produces better results than an extended V-shaped resection. The sleeve or transverse resection is performed after ligating the vessels in the gastrohepatic omentum along the margins of the proposed incis- ions for resection. The gastrohepatic omentum is divided and the lesser peri- toneal cavit}^ is packed with moist gauze. With the hand in the lesser peri- toneal cavity the gastrocolic omentum is raised in such a manner as to avoid injury to the transverse mesocolon. The gastroepiploic arteries are clamped, divided and tied at about the proposed lines for the excision, just as the gastric and pyloric have been tied in the gastrohepatic omentum. This section of the stomach is thus mobilized and packed off from the surrounding tissues with moist gauze. A long rubber-covered stomach clamp is placed as far to the car- diac side as possible in order to occlude the stomach and to leave a margin of about one and one-half inches of stomach after the excision has been done. A similar clamp is placed on the pyloric portion of the stomach. If there is no reasonable suspicion of malignancy the diseased segment of the stomach is now cut away with knife or scissors. If, however, malignancy is suspected the incision in the stomach had best be made Avith an electric cautery. The posterior peritoneal surfaces of the stomach wall are united by a series of in- terrupted mattress sutures of silk or linen, which include the peritoneal and muscular coats. It is best to insert all of these sutures before tying any. After tying them the ends of the sutures are cut short except the ends at the greater curvature and at the lesser curvature. These are left long and act as tractor sutures. The pressure on the stomach clamps should be slightly relaxed to dem- onstrate bleeding points. If there is spurting at any point the vessels are controlled by transfixing the tissues around them with catgut in a needle. The clamps are then tightened and a continuous suture of No. 1 or No. 2 tanned or chromic catgut is begun at the upper margin of the wound and penetrates all coats of the stomach, being inserted from the surface of the mucosa. Care is taken to begin the sutures a little ante- 574 OPERATIVE STTRGERY riorly to the upper extremity of the incision. After tying the knot three times the short end is chimped -with forceps. The suturing is continued as a lock stitch snugly applied over the posterior margin of the wound. When it reaches the greater curvature it is converted into a right-angle con- tinuous suture penetrating all coats, but taking a bite of peritoneum close to the Avound and locking every fourth insertion of the needle by a back stitch, by taking a bite in the tissue a little behind the stitch that has just been inserted. Just before reaching the point of beginning of the su- ture, the clamps are relaxed and bleeding points are again looked for and controlled by interrupted sutures of catgut. The suture is continued and tied to the original end which was clamped with forceps when the first knot was tied. A second layer of either continuous right-angle su- tures of fine tanned or chromic catgut or interrupted mattress sutures of silk or linen is applied. At the upper angle an extra suture is placed to relieve tension at this point. The stumps of the gastrohepatic omentum, where the blood vessels have been tied, are brought over the wound and fastened with interrupted sutures. A similar procedure is done at the lower angle of the wound, fastening the gastrocolic omentum over the wound in this region. A pyloroplasty should be done in order to relieve the spasm at the pylorus. This requires only a short incision in the stomach and duodenum. The technic of excision of the stomach for cancer has been greatly im- proved by the method of Polya which is now ciuite generally adopted. For- merly gastrectomy for cancer, which usually involves the pyloric end of the stomach, was done according to the second method of Billroth. This con- sists in excising the pyloric end, closing the duodenum and the stomach and doing a gastroenterostomy. It was not only a tedious operation, but the technic of gastroenterostomy performed on the small stump of the cardiac end of the stomach is quite difficult and involves tissue whose nutrition is impaired by the ligation of some of the vessels that supply the stomach, which, of course, is necessary in the performance of the excision. The principle of the Polya operation consists in applying the jejunum directly to the wound in the stomach. The advantages of .this procedure are obvious. It enables more of the stomach to be removed because the wound by the old technic was infolded and carefully sutured, which takes at least an inch more of the stomach than when it is sutured directly to the jejunum. Then, too, the nutrition of the stump of the stomach is augmented by applying to it a loop of jejunum whose blood supply has been unimpaired. The time of the operation is shortened by removing the necessity of a gastroenterostomy. According to the original Polya method the jejunum was brought up through a rent in the mesocolon as in gastroenterostomy. D. C. Balfour has added a great improvement in this technic by bringing the loop of jejunum over the transverse colon as when an anterior gastroenterostomy is performed. The technic of Balfour's modification of the Polya operation is as follows: The vessels that supply the pyloric portion of the stomach are ligated at a short distance from the proposed line of excision, the gastric artery being first THE STOMACH 575 doubly elampod, divided and tied in the "astroliepatie omentum and then the pyloric artery is similarly treated. As much of the gastrohepatic omentum as possible is removed, including all enlarged glands and going as high up on the lesser curvature as is practicable. Lymphatic metastases extend along the lesser curvature more rapidly than at other points. After the vessels at the lesser curvature have been secured and the gastrohepatic omentum has been divided, the lesser peritoneal cavity is entered from above by inserting the hand and lifting the stomach forward. The gastroepiploic artery along the greater curvature of the stomach is doubly clamped, divided, and tied. The Fig. 520. — Gastrectomy. The stomach has been mobilized and isolated except at its pyloric and cardiac ends. The crushing clamps have been placed and the lines of incision are indicated. The pylorus is first divided. gastrocolic omentum is divided near the colon, the vessels being doubly clamped before they are divided. Care is taken in this region to avoid in- jury to the blood vessels of the transverse mesocolon. If the colic artery is injured it may be necessary to resect the transverse colon, which would be a grave complication in these cases. By working from the cardiac end toward the pylorus and pushing the transverse colon out of the way such an accident should be avoided. The right gastroepiploic artery is doubly clamped and divided near the beginning of the duodenum. Here the meso- colic vessels are very near. All vessels that have been clamped are now tied so as to have as fcAV forceps in the field as possible. 576 OPERATIVE SURGERY The large Payr crushing clamp is applied to the body of the stom- ach at the line of the proposed resection. Two smaller Payr clamps are placed on the duodenum near the pylorus. The segment to be removed may be clamped with ordinary pedicle or stomach forceps instead of the Payr instrument Avhich should always be used on the remaining stumps. (Fig, Fig. 521. — The duodenal stump is sutured over with a right-angle continuous suture which is drawn tight after the clamp is removed. Fig. 522. — Pursestring sutures are added still further to invaginate the duodenal stump. 520). The stomach is divided with the electric cautery at the pyloric end. The duodenum is closed by a pursestring suture of tanned or chromic catgut. This end is further inverted by a pursestring suture of silk or linen applied about half an inch from the original suture and still another pursestring suture is placed to bury this second suture (Figs. 521 and 522). A few inter- rupted sutures of silk or linen are placed to draw the capsule of the pancreas THE STOMACH 577 and the omentum in the neighborhood over the end of the duodenum and bury it. Tlie diseased segment of stomach is completely severed by dividin"' tlie stomach Avith an electric cautery between the two large clamps. A loop of jejunum is picked up about eighteen inches from the beginning of the jejunum and is carried in front of the transverse colon and omentum. It is lonoitiidi- nalh^ clamped with a long rubber covered stomach clamp and so applied to the stump of the stomach as to make the distal end of the loop approximate the greater curvature of the stomach. In this way the normal peristalsis of the je- junum would go from tlie upper border of the stomach doAvnward to the greater and suU,?eH tn h3 t i! 1^? severed at its cardiac portion and a loop of jejunum is brought up of the stomach In fhl ?n J^'/ Penstaltic curi^ent in the jejunum should run f/om the upper border me stomach to the lower border as indicated by the arrows (Polya-Balfour). curvature. Two interrupted mattress sutures are placed, one at the upper and one at the lower border of the stomach. The ends are left long so they may be used as tractor sutures. The loop of jejunum is united to the posterior wall of the stomach by a continuous right-angle suture of silk or linen. This row is applied about half an inch behind the Payr clamp by turning the clamp to bring this part of the posterior stomach wall prominently forward (Fig. 523). After these sutures are inserted a long, straight, rubber covered clamp is placed on the stomach about two inches, if possible, from the Payr crush- 578 OPERATIVE SURGERY iiig forceps. The Payr clamp is removed and the margin of the stomach wall which was crushed with the Payr clamp is trimmed away with scissors, as this crushed portion will not make a satisfactory union and may cause cica- tricial contraction. A slight relaxation of the pressure of the stomach clamp will indicate where the bleeding points are to be controlled with interrupted catgut sutures. The loop of jejunum is incised along its convexed border in a similar manner as in gastroenterostomy. The incision should not be quite as long as the wound in the stomach. The jejunum is united to the stomach in the same manner as described in the sleeve resection; that is by begin- Fig. S24. — The second row of sutures is placed as the second row in gastroenterostomy. The original first row is then continued anteriorly. ning a tanned or chromic catgut suture at the upper margin of the wound, clamping the short end of the suture, and uniting the posterior margin of the gastric wound to the posterior margin of the wound in the jejunum with a continuous lock suture snugly applied (Fig. 524). At the lower angle of the wound the suture is continued forward as a right-angle con- tinuous stitch penetrating all coats and taking a small margin of perito- neum. This suture may be locked by a back stitch about every fourth inser- tion of the needle. Just before completing the suture the clamps on the stomach and jejunum are slightly relaxed to demonstrate if there is any THE STOMACH 579 '" '--- I marked bleeding point. If so, it is controlled by interrupted sutures of catgut. The suture is then completed and tied to the original end. Another row of right angle sutures of silk or linen is phiced and at the upper end of the ■wound an extra suture is applied. The stump of the gastrohepatic omentum is drawn over the wound at this point and fixed with interrupted sutures. The lower end of the wound is similarly protected. There is no occasion for anastomosis between the limbs of the loop of jeju- num. The loop, of course, should be so selected as to put no tension on the bowel at any point, but at the same time to leave no marked redundanc.y. Sometimes the wound in the stomach seems abnormally large, and this may be treated in one of several ways. The opening in the jejunum may be made not so large as the opening in the stomach and the excessive amount of the wound of the stomach may be closed or sutured to the unopened part of the jejunum. Eecently C. H. Mayo has practiced closing the lower jjart of the gastric wound and uniting the jejunum to the upper portion, as the propulsive waves of peris- talsis force the food current to the pylorus along the lesser curvature. There seems to be no real objection to a large opening^ however, unless there is marked dilatation of the stomach when partial closure of the wound before uniting the jejunum to it can be made according to the method of C. H. Mayo. The removal of foreign bodies may demand an incision into the stomach. This is usually easily accomplished. The stomach is incised either longitu- dinally, about midway between the greater and lesser curvatures, or trans- versely. The surrounding tissues are protected with moist gauze and the wound is closed, preferably by the method described after excision of ul- cers or pyloroplasty; that is with three rows of sutures, the inner row being a continuous lock stitch of fine tanned or chromic catgut in the mucosa, the next a simple continuous stitch of coarser tanned or chromic catgut, and the last a continuous right-angle suture of fine catgut including the peritoneum and muscle. In cancer or stricture of the esophagus it may be necessary to do a gastrostomy to keep the patient from starving to death. This may be done by one of several methods. The choice of operations depends to some ex- tent upon the local conditions. If the stomach is large, Frank's operation is often used. An incision is made through the upper part of the left rectus mus- cle, the fibers of the muscle being split, and after the peritoneal cavity has been opened a cone-shaped piece of the anterior wall of the stomach is brought well into the wound. The base of the cone is fixed to the margins of the pari- etal peritoneum by a continuous suture of silk. A second incision is made about parallel to the costal margin and an inch above its free edge. The sub- cutaneous tissue is undermined between the two incisions so as to raise a bridge of skin, and through this undermined portion the tip of the cone of the stomach is carried until it reaches the second incision. It is here fixed by a few sutures and the skin of the original abdominal wound is 580 OPERATIVE STTRGERY completely closed. The apex of the cone is opened and a tube is inserted. This method can only be used when the stomach is greatly enlarged and even then it is probaljly inferior to the other tube methods, as the stomach is too greatly fixed and its motion is too much interfered with by this operation. In the Senn method, after exposing the stomach through an incision about three inches long through the outer portion of the left rectus, it is pulled into the wound. Usually the stomach is small and retracts under the mar- gins of the ribs. A point on its anterior border is selected for the insertion of a tube. This should be about midway between the lesser and greater curva- tures and as near the cardiac end as possible. This point is pulled well into the wound and, after protecting the surrounding tissues with moist gauze to prevent soiling, a small incision is made into the stomach. Through this Fig. 525. — Gastrostomy, according to the Senn method. opening a large-sized soft rubber catheter with an extra perforation near its eye is inserted and passed toward the pylorus for two or three inches. The tube is fixed in position by a tanned or chromic catgut suture which surrounds the margin of the opening and also takes a bite in the tube. This suture is tied and a series of pursestring sutures of linen or silk is passed in concentric circles in the stomach Avail around the tube (Fig. 525). The first of these is half an inch from the tube and as the suture is being- tied the tube is shoved in, so making an inverted cone. The second purse- string suture is about a quarter of an inch from the preceding suture and is passed and tied in the same manner. Three or four such sutures are applied. The stomach is anchored to the parietal peritoneum by sutures above and below the tube and the abdominal incision is closed in layers, allowing the tube an exit. Six or seven ounces of peptonized milk may be given on the operating table. The tube is clamped after the feeding. The THE STOMACH 581 jitiictioii fil" a 1ul)c inserted in this way is Avater tight and Ihe elanip is only removed Avlien a feeding- is given. In the Witzel o]>eration a tube is introduced in much the same manner as in llie Senn method and fixed by sutures, but the tube is buried by suturing the wall of the stoma eh over the tube so that the tube lies in a groove or furrow instead of in the middle of a cone. These sutures are interrupted and of silk or linen (Fig. 526). The stomach is fixed to the abdominal wall in a similar inanner to that described after the Senn gastrostomy. Eesection of the whole stomach for cancer and anastomosis of the jejunum to the esophagus either according to the "Y" technic of Roux or bringing up a jejunal loop is possible. Excision of the whole stomach has been done but indications for such an operation are exceedingly rare. If it is necessary to remove all of the stomach to eradicate malignant disease, it is highly prob- Fig. 526. — Gastrostomy according to the method of Witzel. able that metastases elsewhere have occurred to such an extent as to make the radical operation of complete gastrectomy exceedingly unlikely to cure. In complete occlusion of the lower end of the esophagus, operations have been devised by which a tube is made from a flap of the stomach taken from the greater curvature and so shaped that it has an abundance of nourishment. This flap is fashioned by sutures into a tube and is brought up beneath the skin and connected by a rubber tube with the esophagus in the neck. The operation has not been tried out sufficiently to have a good standing in surgi- cal operations, but in certain rare instances it might be considered. A peculiar condition of the pyloric end of the stomach, known as congeni- tal p^doric stenosis, occasionally occurs. This is usually observed in infants from one to four weeks after birth. It consists of a great hypertrophy of the muscular coats of the pylorus and the adjacent portion of the stomach. 582 OPERATIVE SURGERY The hypertrophy is so great as to form a tumor Avhich sometimes can be palpated externally. The marked projectile vomiting and the characteris- tic visible peristaltic waves of the stomach, together w^ith the peculiar worm- like peristalsis of the pyloric end which has been noted by A. A. Strauss under fluoroscopic examination, make the diagnosis reasonably certain. The necessity of an operation dej^ends upon the degree of the stenosis. For- merly these cases were operated upon by a posterior gastroenterostomy which carried a rather high mortality, but the operation of Rammstedt is better. This consists in incising the hypertrophied pyloric fibers down to the mucosa, but the mucosa itself is not incised. The margins of the severed hypertrophied mus- i^ig. S27. — The operation of Rammstedt for congenital pyloric stenosis. The hypertrophy is carefully in- cised almost to the mucosa and the margins of the wound are pushed apart as shown in the illustration. cle fibers are pushed apart by spreading the blades of a forceps (Fig. 527). This operation, which is done through a short right rectus incision, can be quickly performed and the results are a distinct improvement over the results ob- tained by gastroenterostomy. A. A. Straass^^ has devised an operation, which, in his hands, has given excellent results with a mortality of only three deaths in one hundred and three consecutive eases. This operation is based on experimental work done by Strauss in 1912 and 1913'. According to his technic an incision about one inch long is made through the fibers of the rectus muscle in the right hypo- i-Surgical Clinics of Chicago, Feb., 1920, Philadelphia, W. B. Saunders Co., 93, et seq. THE STOMACH 583 chondriac region over the pylorus. Often a tumor can be felt which ren- ders the location of the incision more accurate. The index finger is in- serted through the incision and a ribbon-shaped hook is introduced into the Avound nlong the index finger to the hypertrophied pylorus which is brought up into the wound by this hook. If this cannot be readily done or a hook of this type is not available, the incision may be enlarged until the i^ylorus can be delivered into the wound without difficulty. The practice of Strauss, however, is to deliver the pylorus by this hook, working through a small incision in order to avoid unduly exposing the other por- tions of the stomach or the intestines. After delivering the tumor, which con- sists of the hypertrophied pylorus, an incision is made in the more bloodless region of the pylorus. This incision is longitudinal and is made with a sharp knife, going through only the superficial layers of the hypertrophied muscle. The rest of the fibers are separated with the handle of a scalpel to the Fig. 528. — Operation for congenital pyloric stenosis according to Strauss. The mucosa is mobilized around its entire circumference. stomach side of the growth where it merges into the normal musculature of the stomach. Working to the mucosa of the stomach in this manner and in this region gives a line of cleavage between the mucosa and the mus- cular coat that is easily obtained and makes it possible to split down the hypertrophied muscle to the duodenum without the accident of punctur- ing the mucosa of the duodenum, which is a very grave danger in the usual method of performing the Rammstedt operation (Fig. 528). The edges of the divided hypertrophied muscle fibers are caught and pulled apart with the fin- gers and thumb, using a piece of gauze to secure a firm hold. This causes the mucosa to separate from the muscular coats in the stomach and also breaks the few remaining muscle fibers toward the duodenal end. These fibers are often responsible for constriction and when divided with a knife injury to the mucosa of the duodenum is likely to occur. By this method they are torn apart instead of being cut. The mucosa is completely shelled 584 OPERATIVE SURGERY out by blunt dissection from the muscular layers of the hypertrophied py- lorus. This causes the mucosa to unfold. Strauss completes the operation by splitting a flap from the inner portion of the hypertrophied muscle fi- bers as shown in the illustration. This flap hinges along one edge of the incision and is turned over the exposed mucosa and fastened with a few inter- rupted sutures of fine silk to the other edge of the incision (Fig. 529). This covers the mucosa completely. The free end of the omentum is brought over the flap and sutured in position. A cross section of the completed operation shows a lumen well established with the mucosa distended and at the same time protected in its anterior portion by the flap which has been cut from the hypertrophied muscle (Fig. 529-A). The method of completely mobiliz- ing the mucosa Avithout the danger either of perforation of the duodenal mucosa or of leaving a few obstructing flbers, presents two great advantages, the lack of which has been responsible for most of the deaths after the llammstedt operation. Fig. 529. — Operation for congenital pyloric stenosis. A flap from the hypertrophied tissue is made and is sutured in position. Insert A shows a cross section of the completed operation (Strauss). Occasionally for a local lesion a resection of the pylorus is indicated which may be so limited in character as to permit the union of the duo- denum to the stomach. If this can be accomplished the union may be done according to the original method of Billroth in Avhich the duodenum is su- tured to the Avound at the lower border of the stomach and the upper por- tion of the stomach wound is closed. Or the duodenum may be inserted into the posterior w^all of the stomach a short distance behind the line of incision in the stomach. This latter method of Kocher is probably less likely to be folloAved by leakage at the line of union of the duodenum and stomach than is the method of Billroth, though the danger of leakage in Billroth 's original operation can be greatly lessened by reinforcing the line of union with a transplanted flap of omentum. CHAPTER XXVI OPERATION ON THE INTESTINES THE TECHNIC OF SUTURING WOUNDS OF THE STOMACH AND INTESTINES The technic of suturing the stomach and intestines varies consideraljly because of the difference in the anatomical structures of these organs, as "well as in the nature of their physiologic action. The stomach is a large organ with a very thick muscular wall that consists of several layers of muscular- fibers running in different directions. The intestinal wall is much thinner and has only two layers of muscle, the external being longitudinal and the internal circular. The great thickness of the gastric wall together with its peculiar churning and propulsive motions produces considerable strain upon a sutured incision in the stomach. The much greater tendency to ulceration in the stomach than in the intestines, particularly in the small intestine, must also be taken into consideration. Suture material should be provided for the stom- ach that will not remain as a permanent foreign body to become a focus of infection or the site of an ulcer. In the intestine sutures appear to work into the lumen more readily than in the stomach, possibly because the walls are thinner and the peristalsis is usually in a direction that tends to drag any projecting portion of the sutures along with the feeal current. Sutures of the stomach, then, should usualh' be of absorbable material and as the wall is thick, and as the action of the gastric juice may quickly disintegrate plain catgut, the absorbable suture should be well tanned or chromicized. There should always be at least two, and better, three layers of sutures. The first layer unites the mucosa with a continuous lock stitch that merely ap- proximates the edges of the mucosa. This is No. tanned or chromic catgut. The second layer brings together the muscular coats and the edges of the peritoneum on one side to similar structures on the other, using a larger size of the same suture material. The third layer is a continuous right-angle suture of 00 tanned or chromic catgut. It is well to take a back stitch at about every fourth insertion of the needle when using a right-angle continuous suture as this locks the line of sutures and prevents tension on the thread from acting as a basting suture and drawing the tissues too tightly together. AVhen clamps are used, however, the method of suturing the stomach with these three layers is not practicable. With clamps, as in resection of the stomach or in gastroenterostomy, the posterior borders are first united 5S5 586 OPERATIVE SURGERY by a_ peritoneal and musenlar sntnre which is the first row that is placed. This may be of fine 00 tanned or chromic catgut and is inserted with a curved or straight needle in gastroenterostomy. In resection of the stomach for can- cer, however, the healing of the tissues is at a very Ioav ebb and it is prol)alily wiser to use for the outer row silk or linen which will hold longer than cat- gut, even though there may be a chance of the unabsorbal)le material being retained in tlie wall of the stomach. Wlien clamps are used in stomach sur- gery the posterior row of sutures uniting the peritoneum may be either continu- ous as in gastroenterostomy, or interrupted mattress sutures. The second or in- ner row is always a continuous suture, usually a lock stitch on the posterior wall, penetrating all coats and is snugly applied and of size No. 1, tanned or chromic catgut. After completing the posterior sutures as a lock stitch it is best to change into a right-angle stitch, penetrating all coats, and taking short bites through the whole wall of the stomach. This is drawn snugly and is continued around the anterior wall. The clamps should be slightly loosened just before the sutures are completed to demonstrate any bleeding jjoints. The suture is tied to the original short end. The roAV first begun is then completed, so burj'ing the inner row throughout. It is important to put extra sutures at each end of the incision in order to take up the strain that occurs at these points. After gastroenterostomy the tissues of the jejunum usually have low vitality because they are subjected to unphysiologic conditions which have already been discussed. Here the acid contents of the stomach empties into the jejunum which, normally, contains only an alkaline medium. This effect may be partly obviated if the pylorus remains permanently closed, but in any event a trauma or a source of irritation at this point, such as the application of clamps during the performance of the operation, or the pres- ence of silk or linen sutures, may be too great a burden for these tis- sues to carry when they are already struggling against abnormal condi- tions. Consequently, a suture or a trauma that in normal tissue could be readily disposed of, may cause trouble here. In other portions of the in- testinal tract there seems to be but little objection to the use of unabsorb- able suture material. In the small bowel a single row of unabsorbable sutures if properly placed is safe. More than this tends to occlude the lumen of the bowel. In the large intestine because of irregularities of its external surface and the solid character of the fecal matter which produces a greater strain upon the wound, it is best to use an inner row of nonabsorbable sutures and to reinforce this by another row of sutures, preferably interrupted fine tanned or chromic catgut. All sutures for the intestine or stomach should be placed in a round noncutting needle. For resection of the small bowel a straight or- dinary needle, rather long, the kind usually called a "milliner's needle," is excellent. Linen or silk is used. If silk is used it should have ample tensile strength. Linen, though somewhat rougher, is stronger than silk. The needles are threaded with a silk or linen strand about eighteen inches THE INTESTINES 587 loiii^' jiiul four of tliese llircaded needles are worked Ihroiigli a strip of gauze, such as a piece of bandage two feet long. This prevents tangling of the thread. The use of a thimble with a straight needle is readily acquired and adds somewhat to the efficiency of the technic. It also lessens the lia- bility of puncturing the glove. Where the bowel cannot be readily delivered or where the amount of fat is excessive, a straight needle cannot be used satisfactorily and a curved needle is employed. The sutures are inserted through all coats of the boAvel. It has been demonstrated first by W. S. Halsted that an intestinal suture that does not take at least a part of the submucosa of the intestine is unsafe and is likely to tear out. F. G. Coiinell showed the difficulty of catching any portion of the submucosa in the bite of the needle without penetrating to the mucosa. If the safety of the intestinal suturing is dependent upon grasping the submucosa in its bite, it would be best to be certain of this and to make an effort to penetrate to the lumen of the bowel with the insertion of each stitch. Lambert first demonstrated the necessity of broad approximation of the peritoneal coats in intestinal suturing. The so-called Lambert's suture was originally said to be a suture of the peritoneum alone, but this is im- possible. As has alreadj^ been pointed out it is necessary to secure firm union, particularly if only one row of sutures is to be used, and to do this there must be penetration into the lumen of the bowel with each suture. This should be done, hoAvever, in such a manner as to invert the edge of the intestinal wound and to bring together snugly the peritoneal surfaces as called for by Lambert. The two types of intestinal sutures are interrupted and continuous. All, of course, must embody the Lambert principle of inverting the edges of the bowel and approximating the peritoneal coat. No more of the bowel edge should be turned in than is necessary to secure a neat approximation of the wound. If too much is turned in, particularly in circular suturing, too great a diaphragm may be produced and obstruction will result. Then, an unnecessary amount of tissues is placed Avithin the lumen of the bowel which adds to the burden of tissue repair. Different emergencies may call for different types of suturing but, as a rule, if interrupted sutures are used they should preferably be of the mat- tress type. This holds with a firm grip and is not likely to cut out. There is an objection that more nutrition is cut off from the edge of the wound by the interrupted mattress sutures than by the single straight suture. If the sutures are not placed too close together and are not tied too tightly this disadvantage may be overcome. The tying of any intestinal suture is a matter of great importance. The tying of sutures in the skin or fascia may merely result in an ugly defect in that portion of the wound, but an improp- erly tied intestinal suture may cause leakage of the bowel with death. If the tissues are not snugly approximated, leakage may occur around the suture, but an equal or even greater danger is that if the suture is too tight and the nutrition within its grasp is completely cut off the bowel 588 OPERATIVE SURGERY wall Avill become necrotic "within the bite of the suture and leakage is very apt to follow. In experimental work an operator who first attempts intestinal suturing is likely to commit the error of tying the sutures too tightly. It often happens that leakage occurs at points where he is most particular to make the suture secure and not only destroys the nutrition of the tissues but acts as a seton and drains the intestinal contents into the peri- toneal cavity. The dangers from intestinal suturing may be placed in the ratio of their importance; first, tying the suture too tightly; second, not tying the suture tightly enough ; and third, turning in too much bowel. This last danger, of course, presupposes that each suture has been otherwise properly placed and penetrates into the lumen of the intestine. Occasionally, as a reinforcing stitch a simple continuous suture is all that is necessary, but if dependence is to be put on a single row of intestinal sutures, the mattress sutures, par- ticularly the continuous mattress, offers many advantages. This is the same as the continuous right angle suture. Applied from within the lumen of the bowel, as in the first portion of suturing after a resection, it is usually called a mattress suture, but when applied from the peritoneal surface as in the later stages of suturing a resection, it is often referred to as a right angle stitch. The mechanical effect of both is identical though the technic of in- sertion may be different. The bite of the needle is parallel with the edge of the wound, so that the visible part of the suture on the external portion of the wound is at a right angle to the wound, hence the name. The advantages of this type of sutures are several. First, there is a firmer grip upon the tissues. In a simple continuous overhand stitch the bite of the needle is at a right angle to the wound. Consequently, the tension on the thread is concentrated at that portion of its bite which is farthest from the intestinal Avound. This cencentrated tension may produce cutting. In the continuous mattress- or right-angle stitch the tension is more or less equally distributed along the whole length of the loop. It is common knowledge that in suturing such friable material as a muscle a mattress suture that distributes pressure approximately equally along the loop will hold when a straight stitch will cut out. The same principle applies here. An- other advantage is that the thread is more easily buried. After a properly applied right angle suture the thread is often invisible except possibly at the beginning or end of the suture, and sometimes the knots can be buried. In the continuous overhand suture, however, there is always a considerable amount of the thread showing along the suture line. It is necessary to pene- trate the lumen of the boAvel in order to secure a firm hold for the sutures and the effect of capillarity must be borne in mind. A method of suturing that results in the burying of most of the thread in the peritoneal coat has obvious advantages in this respect over a method in which much of the thread is exposed and where, consequently, septic material may drain by capillarity from the lumen of the bowel to the peritoneal surface. THE INTESTINES 589 -As ;i rule. ;i coiil iniKnis siiluri' is ])r('i'er;il)le to an interrupted though^ of course, there is a field for both. The interrupted mattress suture, particu- larly, cuts off more nutrition from the edge of the healing wound than does a continuous mattress, because the interrupted mattress diminishes nutrition to the approximated portions of the bowel within the grasp of the suture on both sides of the intestinal wound; whereas in a continuous mattress or right-angle suture the tissue on the opposite side to the bite of the suture is free from constriction and its circulation is not iiupaired. Crile has had much success with a double mattress or cobbler's stitch. This stitch should be applied with great care for if drawn too tightly it will cut off a maximum amount of nutrition from the healing wound. It gives an even support to the wound and in highly vascular tissue it is very satis- tactoTy. Aside from the question of nutrition further advantages of a contin- uous suture over an interrupted are that the former produces a mild pressure on the peritoneum along the whole surface of the approximated in- testinal wound, and it holds the wound at rest like a splint. With inter- rupted sutures, however, the pressure is greatest in the grip of the suture, very slight in the intervals between the sutures, and there is no splint- like action. The bowel wall can distend and contract with the alternate relaxation and contraction of each peristaltic wave and this constant motion maj" retard healing. The action of the continuous sutures which holds the wound of the bowel as in a splint and prevents the alternate distention or contraction is a very obvious advantage in healing. Small intestinal wounds are best treated with one or tw^o interrupted sutures, or with a pursestring suture that inverts the edges of the wound and that can be applied in small wounds where the inversion is not suffi- cient to interfere seriously with the lumen of the bowel. Wherever possible in suturing the bowel intestinal clamps should be ap- plied at some distance from the site of operation to prevent soiling the wound. If clamps are unavailable tapes or strips of gauze may be utilized by perforating the mesentery with a blunt forceps at a short distance from the bowel and tying the tapes snugly. Care should be taken to use no more pressure than necessary to occlude the lumen. Another method is afforded through the use of hemostatic forceps which are thrust through the mesentery and a rubber tube is grasped in the tip of the forceps. The forceps are locked and the tube is fastened to the handle of the forceps in such a manner as to produce occlusion of the lumen of the bowel. Two wooden tongue depressors and electric bands may be employed. ENTEROSTOMY J. W. Long, of Greensboro, N. C, has been a pioneer in pointing out the life saving value of a simple enterostomy performed before the patient has become overwhelmed with the toxic products of an intestinal obstruc- tion. 590 OPERATIVE SURGERY When obstruction follows shortly after operation and the resistance of the patient has already been greatly reduced, Long^ operates after re- moving one or two stitches of the wound. The point of obstruction is not searched for unless it is easily reached, but the first distended coil of intes- tine is delivered into the wound and a pursestring suture is placed deep in the bowel wall encircling an area at least one-half an inch in diameter. The suture is caught at two points with forceps and the untied ends are grasped with the lingers. By making traction on the forceps and on the untied ends sufficient tension is made to steady the wall of the bowel and also '' A Fig. 530. — Enterostomy of J. W. Long. A pursestring suture has been placed and the bowel is perforated with the cautery. to reduce the soiling of the field of operation. The coil of intestine is lightly packed around with moist gauze and Avliile the ends of the su- ture and the two forceps which grasp the other portion of the suture are held taut, the center of the area that is circumscribed by the pursestring suture is perforated with a thermo cautery (Fig. 530). This prevents bleed- ing and seals the various coats of the intestine together. It also prevents a tendency to eversion of the mucosa which occurs after an incised wound. ■■■Tr. Southern Surg. Assn., xxix, p. 59, et seq. THE INTESTINES 591 A tube, which should he ready, is inserted immediately after the cautery point is Avithdrawii. The tube is of fairly soft rubber that will not readily collapse and should be about twice the size of the opening. It is intro- duced with forceps, stretching the perforation if necessary, and fits so snugly that there is no leakage around it. The two forceps are removed from the pursestring suture and the ends of the suture are tied snugly after Fig. 531. — A rubber tube is introduced and held snugly by a pursestring suture. Insert A shows a cross section of tube in position, and insert B shows omentum sutured around the tube (J. W. I,ong), carefully inverting the edges of the perforation. Sometimes a second purse- string suture may be added, as in the Senn gastrostomy. If omentum is present it is either drawn around the tube and held in position by a few catgut sutures, or a hole may be torn in it and the tube brought through the omentum which is fastened to the bowel on each side of the tube (Fig. 531). He objects to fastening the tube in position by suturing it to the bowel w^all, for he says that the suture will cut through the bowel Avail, in- crease the size of the opening into the intestine, and make the fecal fistula 59f OPERATIVE SURGERY more difficult to close by promoting eversion of the mucosa. Long fastens the tube by narroAv strips of adhesive plaster from the tube to the skin. (Fig. 532). The open part of the al)doniinal wound is lightly packed M'ith gauze. Sometimes the loop of l)0\\el may l)e anchored to the parietal peri- toneum by two or three interrupted sutures, ]}ut this is not always necessary. AVhen the operation does not admit of the delivery of a coil of in- testine into the Avound the operation of J. W. Long is an excellent one and has many advantages. When the bowel can be readily delivered and pac]\ed off, I j^refer an operation based on a principle estal)lished by Fig. 532. — The wound is packed lightly with gauze and the tube fastened with adhesive plaster (J. W. Long). Coffey of making a valve of the mucosa of the bowel, so that when the tube is withdrawn there will be but little if any leakage. A distended loop of bowel is delivered into the wound, clamped at one end with intestinal forceps, stripped of its contents, and again clamped at a point about six inches from the first intestinal forceps. The convex border of the intestine is grasped with mosquito forceps or with Allis forceps about two inches from one of the clamps and another point is similarly caught tAvo inches from the other intestinal clamp. The forceps holding these tAvo points are pulled upon just enough to make the boAvel betAveen them taut, and a tAvo inch in- THE INTESTINES 593 eisioii is iiuidc in 1lie axis of tlic l)()\v('l 1)o1ween them. This should be made Avilli a sharp Iviiifo and care must be taken not to cut through the nuuMisa. After separating the peritoneum and the superficial part of the muscular coat of the bowel the edges of the incised wound are i^ushed apart with the handle of the knife or by dissecting with the blade of the knife turned sidewise to the plane of dissection, which is a stroke often em- ployed in operations on the neck and in anatomical dissections. In this way, even tlunigh the bowel wall is thin, injury to the mucosa can usually be avoided. Considerably more care must be taken, hoAvever, to avoid in- jury to the mucosa than in making a similar incision into the stomach. If the mucosa is injured at either end of the incision but little harm is done. If, hoAvever, it is injured at its middle, the incision should be extended slightly Fig. 533. — Enterostomy, using the principle of Coffey. An incision is made down to the mucosa. At one end of the incision a pursestring suture is inserted and the mucosa is punctured. at one end in order to secure a sufficient amount of exposed mucosa to form a valve. If the mucosa has not been injured and has been exposed over a distance of about two inches, a pursestring suture of linen or silk is placed at one end of the incision including the terminal part of the mucosa within its grasp. The bowel is steadied by the ends of the purse- string suture Avhich are not tied and by forceps which grasp the suture opposite its ends. With a sharp-pointed knife a small puncture is made in the mucosa contained AAdthin the grasp of the suture (Fig. 533). A soft rubber catheter of medium or large size, Avliich has one or two ex- tra perforations near its tip, is inserted through the punctured wound until the upper perforation in the catheter is at least an inch within the boAvel. The pursestring suture is then tied snugly around the catheter and 594 OPERATIVE SURGERY a curved needle is threaded into one end of the suture and thrust through the catheter, the ends of the suture being again tied. In this manner the catheter is held snugly in position and will not be dislodged for several daj^s (Fig. 534). It is then laid on the bed of mucous membrane which has been prepared for it and one or two rows of continuous right-angle sutures of silk or linen bury the catheter effectively (Fig. 535). The catheter may be brought through a stab wound. If this is done, it should have been clamped about its middle before it was inserted in the bowel to prevent fecal material flowing through it and contaminating the stab wound. The clamp on the middle of the catheter is removed after its end has been brought through the stab wound. If the operation is for postoperative ob- struction and the loop of bowel is delivered into the wound previously made, Fig. 534. — A catheter is inserted in the puncture and the pursestring suture is tied snugly. One end of the pursestring suture is threaded on a sharp needle and fixes the catheter in position. The portion of the catheter that lies on the incision is buried with a right angle stitch. the catheter may be connected with a larger rubber tube which conducts the discharges into a receptacle. If omentum is readily accessible it may be sutured around the tube but this is not necessary. A tube sutured in the manner described with linen or silk will remain in position from six to ten days. Although fastened securely by the pursestring suture it practically al- ways cuts loose within ten days, so if it is desired to prolong the drainage from the enterostomy the catheter must be either fastened to the skin by a suture, or, better still, by adhesive plaster strips, as practiced by Long. In any event it should be anchored to the dressing so that there may not be any pulling on the suture through traction on the tube. Coffey has well established the principle of preventing back pressure THE INTESTINES 595 from the abdominal viscera, as when traiisphinliiig a ureter in the bladder or the bile duct in the intestine, by making an incision down to the mucosa and then inserting the duct or the ureter at one end of the incision so that it is buried in tlie wall of the viscus and only separated from the interior by the tliickness of the mucosa for the length of the incision. In this way distention causes the mucosa to press against the transplanted duct and to protect its lumen from the direct effect of pressure to which it would otherAvise be subjected. The advantages of using this method of enterostomy are that it does not materially prolong the operation, and when the patient has recovered from the effects of the obstruction and the catheter is withdrawn there is practically no drainage of fecal matter through the tract left by the catheter. Sometimes a small amount of fecal drainage occurs for a few days, but usually there is none. This, of course, is a great Fig. 535. — The enterostomy is completed. Usually there is no leakage of fecal matter when the catheter is withdrawn, due to the valve formation of the mucosa. advantage over the older method of a large opening w'ith eversion of the mucosa and a fecal fistula difficult to repair. The fecal matter in the small intestine is always liquid and is usually liq- uid in the cecum and in the right half of the colon. The formation of gas in the bowel is one of the most distressing features of obstruction and by producing great intraintestinal pressure undoubtedly forces into the lymphatics or the veins of the intestines toxic products that might not otherwise be absorbed. A medium sized rubber catheter will give ready exit to the gas and the liquid fecal contents of the small intestine, and a somewhat larger catheter would be amply sufficient for the cecum and ascending colon. A large tube can do no more than empty the bowel, which the smaller catheter does. The large tube produces more trauma, may be followed by the necessity of clos- 596 OPERATIVE SURGERY ing the opening by a later operation, and also may encroach too greatly upon the lumen of the bowel after the obstruction has been overcome. The principle of AYitzel is essentially different from that of Coffey. If the bowel is greatly distended and it seems impossible to free the mucosa without injuring it, a tube may be inserted according to the principle of Wit- zel. Here the wall of the bowel is punctured to admit the tube, which is fixed in position, as has been described. Then the 1)owel wall is folded over the tube and sutured (Fig. 536 j. A cross-section will show that this chan- nel is composed of all the histologic layers of the bowel wall. Conse- quently the peritoneum, which lines the tunnel and readily forms a lym- phatic exudate, will make a rigid tube of the tunnel in which the catheter has been laid, so that after the catheter has been withdrawn leakage of fecal matter is much more likely to occur. Besides, there is more encroach- ment upon the lumen of the bowel by the AVitzel principle which folds in all Fig. 536. — Enterostomy according to the principle of \\'itze! without an incision to the mucosa. layers of the bowel Avail than by an operation performed on the principle of Coffey in which the catheter lies on the mucosa and the mucosa forms a valve (Fig. 537-A and B). There is but little exudate from the mucosa and th'e peritoneum does not enter into the floor of the tunnel of an enterostomy performed in this latter manner, so but little lymphatic exudate is thrown out and when the catheter is withdrawn the mucosa is mobilized and the in- traintestinal pressure quickly closes the tunnel. This operation is done not only in obstruction but after resection of the bowel, as in strangulated hernia, when the oral portion of the intestine is greatly distended. After the resection, an enterostomy, as just, de- scribed, is done on the proximal side of the resection, the catheter having been previously introduced through a stab wound and its distal end clamped before the catheter is inserted into the bowel. This avoids infection of the wound. An enterostomy in such cases has a very valuable function. It THE INTESTINES 597 drains off tlie contents of the obstructed bowel and lessens the pressure on the healing intestinal Avonnd where the resection was done. Peristalsis is ahva.vs interfered Avitli in obstruction, even when a resection has been care- fully performed. Tlie peristalsis may be so weak that it cannot take ad- vantage of the removal of the obstructing or gangrenous loop sufficiently to propel the contents of the dilated bowel through this newly sutured area. The enterostomy tube, however, gives immediate exit to the gas in its neighborhood and offers much less resistance to the passage of intestinal contents than would occur if the fecal matter had to be propelled through its normal route. Consequently, weak peristalsis that is sufficient to emptj^ the contents of the bowel through a soft rubber catheter that is contained in an enterostomy wound, may not have force enough to overcome the normal physiologic resistance of the rest of the intestinal tract even though the immediate obstruction has been removed. Fig. 537. — A, a cross section of enterostom\', using the principle of Coffey; B, a cross section of enterostom}', using the principle of Witzel; C, longitudinal section of enterostomy, using the Coffey principle. If liquid feces does not flow sufficiently freely through the enteros- tomy tube an ounce or more of Avarm water is injected through the catheter into the bowel. This will prevent the closing of the openings in the catheter by the mucosa of the bowel or will cause the dislodging of any large particles of fecal matter that may occasionally obstruct the opening in the catheter. This, however, should not be done as a regular practice for it may stimulate the loop of bowel that contains the enterostomy tube to strong peristal- tic contraction. AYhen peristalsis has become normal, which usually oc- curs within a week or ten days, and one or more bowel movements have been secured through the anus by enemas, the enterostomy tube can be safely removed. 598 OPERATWE SURGERY It is au old saying that obstructed bowel should never be returned to the abdomen until it has been thoroughly emptied. This is an unwise practice and has been responsible for the introduction of glass or metal tubes through an opening in the bowel and the threading of almost the whole length of the small intestine on such a tube in order to empty the fecal contents as far as the upper jejunum. This practice tends to disregard the physiology of the intestines, and particularly the physiology that occurs after obstruc- tion. It is well known that even the opening of the abdomen under a gen- eral anesthetic is followed by temporary paresis of the bowels. This is probably a protective phenomenon which is intended to keep the bowel quiet so that a neighboring loop or omentum may plaster over an injured portion of the intestine and prevent infection. It also provides physiologic rest for repair. At any rate, the phenomenon is commonly observed and is more pronounced with increased handling of the viscera. If, then, the whole length of the small intestines is forcibly threaded over a rigid tube it can readily be imagined that the normal reaction would be a complete abolition of peristalsis for a considerable time. This paralysis of the bowel wall will do much more harm in permitting the rapid accumulation of gas and fecal contents than the immediate emptying by such mechanical means will do good. If the obstruction has reached such a stage that peristalsis is com- pletely and permanently abolished nothing can save the patient, but if there is still preserved a weak peristalsis the performance of an enterostomy, such as has been described, with exposure of a single loop of bowel, will relieve the immediate obstruction in this loop and will tend to encourage the emptying of other proximal loops that still have sufficient peristalsis to expel their contents when both the pathologic and physiologic obstruction has been over- come by the enterostomy. But if the whole length of the bowel has been forcibly threaded over a stiff metal or glass tube the manipulation of the in- testine will in all probability completely abolish the weak effort at peris- talsis that still remains. It is in such cases that an enterostomy with a rub- ber catheter performed above the point of obstruction gives the maximum chances for recovery. Whether the diseased loop of bowel is to be removed at the same time the enterostomy is done depends upon the pathology that is present. If the bowel contains a tumor that has caused the obstruction the enterostomy should be pei'formed as the first operation and resection done later, after the effects of the obstruction have been overcome. If gangrene or perfora- tion is present or seriously threatens the loop of diseased bowel should be removed and an enterostomy done on the proximal side of the diseased loop according to the technic that has just been described. If there is a tumor in the transverse or descending colon or sigmoid and the obstruction occurs from this growth, an enterostomy is best done in the cecum. The tumor should be removed at a subsequent operation, probably ten days or two weeks later. THE INTESTINES 599 An enterostomy according to the techuic described should not be done Avith tiie idea of giving- complete rest to the bowel distal to it. If there are multiple ulcerations in the colon, Avithout obstruction, and the purpose of the operation is to rest the colon by diverting the fecal matter, but little good is accomplished by an enterostomy that will not divert all of the fecal con- Fig. 538.— The enterostomy of John Young Brown, with a slight modification as exnlainerl in tJi» text. The proximal end is temporarily sutured till the distal tube is fixed. The sutures mav then h reversed and a tube inserted, or this may be done two days later. tents. Here the operation may be performed either on the right side, using the terminal ileum according to the method of John Young Brown, or on the left side above the growth, using the sigmoid. The bowel is completely divided in either instance. In the operation of BroAvn an incision is made in the right iliac fossa. It may be a muscle-splitting incision according to the McBurney technic. eoo OPERATIVE SURGERY The cecum is recognized and tlie lower ileum is pvdled into the wound. Brown originally advised section of the ileum close to the cecum, and when the con- tinuity of the intestinal current was reestablished it was necessary to im- plant the ileum into the cecum or ascending colon by an end-to-side opera- tion. In this way the action of the ileocecal valve is lost. By selecting a point for division of the ileum about eight inches from the ileocecal valve, the future union of the ileum by the end-to-end method is possible and the action of the ileocecal valve is preserved. The mesentery is first split for about an inch from the bowel wall. The bleeding vessels are controlled by liga- ^m A ^M ■Iftv.^ / / .. i: / t ^ ^1 -^' 1 tl ] -( el e 'V^. V o T ^ a i'-'v-i G" -^ o Fig 539. — Sigmoidostomy according to the method of Mixter. Insert A shows the lines of incision to secure a bridge of skin beneath the sigmoid. tures or sutures which cover the raw surfacesi as fully as possible be- fore opening the ileum. Intestinal clamps are placed on the bowel near the line of division and the ileum is severed with scissors, cutting from the mesenteric border outward. In this way the chances of infection of the mesentery and -of the triangular space where the mesentery separates to in- volve the bowel are reduced to a minimum. In the lower end of the ileum a large-sized rubber catheter is fastened by suturing it to the bowel. The catheter should reach through the ileocecal valve into the cecum. A purse- string suture inverts the edges of the stump of the ileum around the catheter as in operations on the gall bladder (Fig. 538). This tube is clamped. It is THE INTESTINES 601 oiil.y used to irrigate the colon with some fluid that is supposed to have a therainnUie value. In the upper end of the howel a larger tu])e, preferably a rectal tu))e, is inserted in a siniihir manner and is connected to a receptacle. The bowel ends are attached to the parietal peritoneum by a few sutures and the wound is packed lightly Avith iodoform gauze. The tube in the dis- tal end of the bowel is readily kept in position almost indefinitely but the sutures around the proximal tube through which the fecal matter runs soon cut out and leakage occurs at this point Avithin a few days. During this time, hoAvever, granulations have sprung up and the raAv surface of the abdominal Avound has acquired some protection against the septic products of the boAvel contents. An advantage that Brown mentions for this operation is that there t^ . • : : ^ . r 'v ' /■ -■, ' ''■? p \ p ■f\ 1 1 o V Tri 1 11 e„ L_o Fig. 540. — Sigmoidostomy with the bridge of skin sutured in position. The sigmoid is opened and a tube inserted for immediate relief of obstruction. is less odor than Avhen an enterostomy is made in the large bowel, but the great advantage is that it completely diverts the fecal current and it so rests the portion of the intestinal tract distal to this enterostomy as to give it the best possible opportunity for recovery. In inoperable cancer of the rectum often a permanent enterostomy must be done. Here the sigmoid offers a satisfactory site for the operation and the method of Mixter gives good results. An incision is made along the outer portion of the left rectus muscle and is so fashioned that a small tongue or flap of skin and subcutaneous tissue is formed from the middle of the incis- 602 OPERATIVE SURGERY ion with the base outward (Fig. 539-A). After dissecting up this flap with the skin and fascia and turning it outward, the fibers of the rectus muscle are split, the peritoneum is divided and the sigmoid delivered into the wound. All the excess of the sigmoid is shoved vip into the abdomen so that as little of the bowel is left below the eviscerated loop as possible. In this way a reservoir for fecal matter is established. The mesentery of the sigmoid is split for about two inches at right angles to the long axis of the bowel, and the rectus muscle and peritoneum are sutured together through this opening in the mesosigmoid (Fig. 539). The reflected flap of skin and fascia is brought through this opening and is sutured in its original position. In this manner the loop of sigmoid that has been delivered rests upon the — i '-«. k\^ ^i /■ ^^ 'C'--^. ■" --' ~",, -" "1- y"^ ^ '/ Fig. 541. — Several days after the first stage of the operation, the bowel is divided or a section is removed, leaving an upper and a lower opening. flap of skin and fascia which has been sutured under it (Fig. 540). If the need is urgent an enterostomy can be done with a rubber catheter as has been described, but if the obstruction is not complete or if a temporary en- terostomy is done, five or six days later the exposed loop of sigmoid is com- pletely divided and the bleeding points are controlled by whipping them over with a needle and thread (Fig. 541). The two ends retract and are sufficiently wide apart to make a complete break in the fecal current. At the same time the distal end of the sigmoid can be utilized for irrigations to clean out the rectum. THE INTESTINES 603 INTESTINAL RESECTION AVJu'u resection of the boAvel is indicated the technic to be adopted varies somewhat, depending upon whether the large or the small bowel is in- volved, but the same principles that underlie this operation are applicable wherever resection is employed. The type of suture and the advantages of a continuous mattress or right angle stitch that penetrates all coats of the intestine have been described. The two operations usually employed for uniting the bowel after resec- tion are the lateral or the end-to-end, Avith an occasional end-to-side anas- tomosis. As elsewhere in surgery the object of an operation should be first of all to remove or to correct the pathology and, second, to restore the tissues as nearly as possible to their physiologic normal. Lateral intestinal anas- tomosis does not fulfill this latter indication. The work of Cannon and Mur- phy^ has shown that in lateral anastomosis peristalsis in the region of the anastomosis is practically abolished and food can be pushed through the anastomotic opening only when a column of it extends into a proximal (oral) loop where peristalsis is unimpaired, because severing the circular muscular fibers in lateral anastomosis abolishes peristalsis and the blind pouches at the ends cannot be completely emptied. These investigators also found that in end-to-end union there is not the slightest stasis of intestinal contents at the site of operation. Many patients with a lateral anastomosis are able to overcome the handicap of an unphysiologic procedure and have no symp- toms from lateral anastomosis. This, however, is by no means always true, and the eases reported by John T. Moore," of Houston, and many others, show that the complications following lateral anastomosis may be extremely serious. It seems established and admitted that an end-to-end union of intestine is a more physiologic procedure than a lateral anastomosis and other things being equal would be the preferable operation. Because lateral anastomosis does not always give disagreeable symptoms its use has been continued. If the patient did not die it was assumed that he had sufficiently recovered. Similarly, it may be claimed that a perfectly compensated valvular lesion of the heart is of no significance because it gives the patient no inconvenience and causes no symptoms, for nature can often take up a burden that has been imposed and compensate for it in such a manner that the patient does not suffer. The argument against end-to-end union of the intestine has been that the suture line is likely to leak either at the mesenteric junction with the bowel or at a point opposite to this where the nutrition is poor. P have attempted to show in previous communications that while the triangular space where "Cannon and Murphy: Ann. Surg., xliii, 519-520. 'Tr. Southern Surg. Assn.. xxxi, pp. 152-153. ^Ann. Surg., xxxviii, 747; Southern Med. Jour., viii, p. 298; Surgery of the Blood Vessels, St. lyouis. 1915. C. V. Mosby Co.. p. 204, 604 OPERATIVE SURGERY the mesentery splits to envelop the boAvel has been considered responsible for most of the failures of end-to-eud union of the intestine, and "while it has been assumed that because this space is devoid of peritoneum union here is difficult and leakage probable, the real cause for failure is not the absence of peritoneum in this region. AV. J. Mayo has repeatedly stated that peritoneum is only needed on one side and this mesenteric space is usually carefully sutured by every operator before the operation is com- pleted. The great trouble is that many surgeons who have had disastrous experience in end-to-end union infect this triangular area Avhen the lumen of the bowel is opened by cutting the bowel from the convex border toward the mesentery and then clamping and suturing the triangular space between its layers. Dividing the bowel in this manner necessarily carries the con- tents of the bowel into this triangular space because the blades of the scissors that cut through the lumen of the bowel must be contaminated with fecal contents and smear the bacteria from the lumen of the bowel into this space. When the operation is com^Dleted this region is carefully sutured and later when leakage occurs here, it has been assumed that the leakage is due to the lack of peritoneal covering. If we were to dip a i^latinum loop into fecal contents, smear it into an incised wound on the hand, and then later suture the wound verj' carefully, we would not be surprised when the sutures broke down. It is for the same reason that leakage occurs at the mesenteric triangular space which is composed largely of areolar tissue rich in lymphatics and small blood vessels, and which once infected can hardly be sterilized. The question of infection in intestinal wounds is closely allied to the nutrition of the wound. If the infection is mild and in a region such as the free border of the intestine Avhere there is no areolar tissue, the in- fection may be overcome if the blood supply to that part of the bowel has not been impaired. To avoid infection or to render it as mild as possible the ends of the bowel should be cleaned. This should be done with great care, using gauze Avrung out of antiseptic solution, and making an effort to clean the mucosa of the intestine as Ave Avould disinfect the skin before making an incision into it. It may be impossible to sterilize the mucosa of the intestine just as it is impossible to sterilize the skin by any knoAvn method that does not de- stroy the skin, but certainly the majority of the bacteria can be remoA'ed, and then the needle and thread Avill not carry the infection as they do if the fecal matter is simply squeezed out and no further effort is made to clean the boAvel end. Leakage opposite the m.esenteric border in end-to-end union of the colon may be due to lack of cleaning the bowel end with antiseptic solution, so preventing infection where the nutrition is Aveakest. If the end of the bowel, and particularly of the colon, is not made as nearly aseptic as possible, Avhen the thread pierces its lumen it carries bacteria through the whole tissue. This may account for the poor healing and the late infec- tion of the stitches that haA-e sometimes been noted after resection of the THE INTESTINES 605 colon. If liie ciul of liic l)()A\el is clean fecal matter when turned on after removing tiie intestinal clamps will only contaminate that jiortion of the thread within the lumen and there is less chance of infection from the thread that is already buried in the tissues of the bowel. The chief objections, then, that have been urged against end-to-end union are : first, infection or leakage at the mesenteric border and, second, infection or leakage at a point opposite to the mesenteric border. The cause of leak- age at the mesenteric border has been shown to be soiling of this region by the technic of cutting the bowel from the convex border into the mesentery. Leakage opposite the mesenteric border or elsewhere, when the sutures have been properlj^ placed, is probably due to the fact that the ends of the bowels have not been thoroughly cleaned and the suture drags along with it the bacteria of the fecal contents. Fig. 54J. — '1 Ik- author's mechod of intestinal resection. Before the bowel is divided, the mesentery- is cut close tij the bowel wall and the triangular space caused by the separation of the layers of the mesentery just before they cover the bowel is clamped and tied. The rest of the mesentery is then severed and tied, and moist gauze packed under the loop of bowel. The bowel is divided somewhat obliquely from its mesentery border outward. In an effort to obviate these difficulties a technic for end-to-end union of the bowel has been developed in experimental work and employed clini- cally in many cases with great satisfaction. The method when applied to the small bowel is as follows: The segment of bowel to be removed is delivered into the wound and surrounded by moist gauze. An intestinal clamp is placed at a point about four inches from the intended line of resection. The contents of the bowel loop are stripped out as far as possible to a point about four inches beyond the other line of resection, where another intestinal clamp is placed. The mesentery is then doubly clamped, divided, and tied. The triangular space where the mesentery joins the bowel is clamped with hemostats and tied with silk or linen (Fig. 542). The rest of the mesentery may be tied with catgut. If the operation is not for removal of a malignant 606 OPERATIVE SURGERY tumor the mesentery is cut rather eh)se to the bowel. This step avoids any possibility of injuring vessels that may carry nutrition to the healthy intestine. If there is a suspicion of malignancy the mesentery should be cut farther aM'ay, but care is taken to preserve as many of the blood vessels that supply the healthy bowel as possible. If the operation is for gangrene, and particularly if it is for thrombosis of the arteries, great care must be taken to make a sufficiently wide excision to secure bowel that will Ijleed freely. Many disasters have occurred from making resections too close to the ap- parent disease. Aside from the application of a few extra sutures to the mesentery there is no more difficulty in taking out six feet of intestine than six inches, and while, of course, the relation of nutrition to the length of the bowel should be considered, at least a third of the total length of the small bowel can be removed without seriously interfering with nutrition. l-ig. 543. — The margins of the bowel are caught with clamps and the intestinal end is cleaned with wet gauze. It is highly important, then, to see that the resection is made at a point where the blood supply is unimpaired. After severing and ligating the mesentery and clamping and tying the tri- angular mesenteric space, a quantity of moist gauze is packed under the loop that is to be removed, but which up to this time has not been opened. The loop is collapsed because its contents have been emptied before placing the in- testinal clamps. A pedicle forceps is placed on the loop of the bowel as close as possible to the line of resection. The bowel is divided with scis- sors, beginning at the mesentery at the point where the triangular space has been clamped and tied and going upward, slightly inclining toward the healthy bowel so it will not be deprived of its blood supply. This in- cision should be made quickly and moist gauze should at once be placed over the end of the diseased loop. Three or four Allis forceps or mos- quito forceps grasp the margins of the healthy end of the bowel at about equidistant points. The end of the bowel as far as the intestinal clamp is THE INTESTINES G07 tliorouglily cleaiu'd willi gauze sponges that have been dipped in bichlorid solution, while the forceps that have been placed along the edge of the severed bowel hold the Inmen open (Fig. 543). This cleansing should be done by the surgeon Avhile the assistant holds the forceps, and great care is taken to see that every wet sponge that is used to clean the bowel touches nothing but the bowel end and that the used sponge is immediately deposited in some basin or bucket which is a container for dirty dressings. AVhen all the fecal matter has been removed by gentle sponging, the excess of bichlorid is mopped out of the end, and it is covered with a gauze pad wet in salt solution, after clamping and tying with catgut any bleeding points along the cut margin. The clamping of these points may be done immediately when the bowel is cut, but they should not be tied until after it has been cleaned. Whi]3ping the bleeding points over with catgut in a needle is more satisfactory than simple ligation which in their region often loosens. Fig. 544. — The first stitch begins in the end of the buwcl on the operator's right, about one-third of an inch from the mesenteric border, and is tied as a mattress suture. It is continued along the mesenteric border of the bowel as a continuous mattress suture. The other end of the loop to be excised is severed in a similar manner and the other end of the healthy bowel is similarly cleaned. Suturing is begun with a straight needle and linen thread, inserting the needle from the mucous membrane of the right-hand bowel end about a third of an inch external to the mesenteric border. The needle is carried to the other bowel end and pierces it from the peritoneal surface toward the mucosa returning in an opposite direction. It is then carried to the end of the bowel from which the suture started and is thrust through from the peritoneal surface to the mucosa. A knot is tied, which makes a mattress suture with the knot on the mucous membrane (Fig. 544). The short end of this thread is clamped with a hemostat and the suture is continued by carrying- it back and forth across the mesenteric border of the intestine after the manner of a continuous mattress stitch. It should grasp a portion of the ligated triangular mesenteric space on each side to prevent the possibility 608 OPERATIVE SURGERY of the mesentery retracting at this point. As the bowel and mesentery are thicker than the layers of the bowel elsewhere it is essential to draw these structures more snugly together th.in in the other portions of the bowel. After about one-third of the circumference of the bowel has been sutured the needle is thrust through tlie bowel from the lumen of the right-hand end (from Fig. 54S. — After about oue-tliird of the ciixumference has been sutured, the needle is thrust through the bowel from within outward. A back stitch is taken and the suturing is continued as a right angle suture, penetrating all coats. Fig. S4t cnniiiuud a-, a riulii aiiule Miiiiii. turning in a small margin of the bowel and taking a back stitcli aljout cverj- third or fourth suture. the standpoint of the surgeon), which is the end containing the first knot (Fig. 545). After emerging by being thrust through from the lumen to the peritoneal coat, a back stitch is taken by merely taking two stitches at practically the same point. This locks the roAV of sutures that has been placed so far, and it is then continued as a right-angle continuous su- ture penetrating all coats (Fig. 546). The suture is carried about a sixth of an inch from the incised peritoneum along the margin of the intestinal THE INTESTINES 609 wound. If more tliau tliis aniouiit of lK)\vel is turned hi there will be too luucli diaj^liraiiin. Only enouiili periloneuin is inverted to make a secure ap- proximation. At about every fourth insertion of the needle a back stitch is taken by taking two sutures in the same place, or the last stitch just behind the preceding- one. This prevents the thread from being drawn too tightly and so diminishing unduly the caliber of the bowel. The bowel is approxi- mated just snugly enough to have apposition and without the tension used in the mesenteric portion. As the bowel has been cut somewhat obliquely the suturing cannot cause too much diminution of the lumen unless it is drawn too tight or unless too great a diaphragm is turned in. The evils of these two errors have already been discussed under the head of intes- tinal suturing. The suturing is continued toward the operator and is car- ried one stitch beyond the lowest point where the original thread was left when the knot was tied (Fig. 547). This last stitch is on the left-hand end of the bowel, the knot being in the other end. The thread is then firmly tied to the end that was caught in a hemostat at the beginning of the Fig. 547. — The last stitch is taken in the left end of the bowel, slightly beyond the lowest point where the original end of the thread comes out. It is tied snugly to the original end three or four times and the ends are cut short. suturing. The knot is run down parallel to the line of suturing so as to sink in easily and is tied snugly three times. It is then cut short and the ends should disappear in the bowel or should be tucked in with m,osquito forceps. If a back stitch has been taken at proper intervals there is no danger of reducing the lumen by tying this knot too tightly, but, as has already been pointed out, if it is tied too tightly it may cause leakage from necrosis. When the suturing is begun, the gauze that has been laid on the stumps of the mesentery and beneath the bowel loop to be resected must be removed in order satisfactorily to approximate the ends of the bowel when the first knot is tied. If there are weak points along the suture line an extra interrupted suture may be inserted, but this should be avoided by careful attention to the sutures as they are placed, for an extra stitch turns in an additional amount of bowel, makes a broader diaphragm, and places an extra burden upon the tissues at this point. 610 OPERATIVE SURGERY The severed mesentery is approximated with a continuous suture of plain or tanned catgut in a round needle, taking care to avoid injury to any blood vessel and securing only a slight hold along the edges of the incised mesentery. The bowel is sponged with salt solution and, if there is no marked distention on the proximal side of the resection, the intestine may be returned to the abdominal cavity and the wound closed without drainage. If, however, there is marked distention an enterostomj' should be done two inches to the proxi- mal (oral) side of the resected bowel to relieve the tension on the sutures and to secure an early and easy emptying of the bowel contents. If the cecum and ascending colon are resected, the anatomic and the physiologic conditions are somewhat different from what is found in the small bowel. Here it is necessary to unite bowel of unequal caliber and of different gross anatomical structure. It is also desirable, as has been pointed out by Kellogg and others, to reproduce a valve like the ileocecal valve whenever the small intestine is united to the colon. It has been the common experience that when union of small intestine to the colon is made without a provision of this kind the small bowel usually dilates or thickens. This is probably due partly to infection from the colon and partly to the back pressure of gas in the large intestine. While, of course, such a valve cannot prevent the entrance of a small amount of the bacterial flora from the colon, it may act as an ileocecal valve and protect the small bowel from an overwhelming amount of colonic fecal matter which would otherwise flood the ileum with each retrograde peristaltic wave. Resection of the cecum and ascending colon is clone by a modification of the technic used for re- secting the small bowel. The same principles of avoiding infection of the mesenteric spaces and of cleaning the bowel ends are employed. Even greater care should be taken when the colon is involved because of the large amount of bacteria always present. The first step is a thorough mobilization of the cecum, ascending colon, and the lower part of the ileum. This is obtained by dividing the peri- toneum to the outer side of the mesentery of the cecum and ascending colon and retracting the large bowel toward the midline. The .mesentery which supplies the segment to be removed is divided, taking as much as possible of it in malignancy, but being careful not to interfere with the blood sup- ply of the ends of the bowel that are to be united after resection. The transverse colon may be clamped after making an opening in the gastrocolic omentum to insert one blade of the intestinal clamp. This gives a sufficient stump of the right half of the transverse colon to permit the necessary manipulations dur- ing suturing. After severing the mesentery and securing the triangular area, as haf; been described in resection of the small bowel, the ileum is divided first, because this end is probably less septic than the colon. The severed end of the loop is covered with moist gauze and the oral end of the ileum is cleaned. The distal end of the loop is divided by first clamping the colon, protecting thor- oughly the tissues in the neighborhood with moist gauze, and then severing the bowel from the mesenteric border outward. The edges of the stump of the THE INTESTINES 611 transverse colon are caught as the loop is severed in order to hold up the stump of the bowel and prevent leakage of its contents. This end is thoroughly cleaned. Suturing is l)egun with a straight needle and linen thread be- ginning on the mucosa of the colon. Tlie needle is carried through the colon to the ileum and pierces the ileum about an inch from its end. The needle pierces the ileum from without inward and returns in a reversed direction through vhe iUuun and the colon. The thread is tied on the mucosa of the colon, making a mattress stitch. The short end of the thread is clamped \v:th a hemostat (Fig. 548), and the suture is continued by carrying it back and forth after the manner of a continuous mattress stitch, taking more of the colon Ihar. of the ileum in each bite and keeping an inch behind the end of the Fig. S4S. — The author's method of resection of eecum and ascending colon. The bowel ends have been cleaned and the suturing begins from the mucosa of the colon. The needle pierces the colon near Its margin from within out, and then takes a bite in the ileum about an inch from its end, penetrating to the lumen of the ileum. It then returns in a reversed direction to the lumen of the colon and is tied, making a mattress stitch. The short end is clamped. The next stitch is taken in the ileum on the left side as close to its mesentery as possible. The needle is then carried through the colon and the next stitch in the ileum is taken close to the right side of the mesentery of the ileum. In this way the mesentery is brought into the colon without too much compression and at the same tiine is made snug. ileum. The suture is so inserted that at the mesenteric junction of the ileum the suture is close to the mesentery, then goes to the colon and, returning, takes another bite close to the other side of the mesentery of the ileum. This is drawn snugly. Inserting the suture in this manner avoids cutting off the nutrition that may be carried to the stump of the ileum and at the same time makes ap- position sufficiently close to prevent leakage. After the mesenteric border has been well passed the stitch is brought on to the surface by thrusting the needle through the colon from within its lumen and continuing the stitch as a right- angle suture, penetrating all coats. It unites the edge of the colon to the ileum about an inch from its end, while taking a little more of the colon than the ileum in each stitch, A back stitch is made about every third or fourth bite of the 612 OPERATIVE SURGERY needle (Fig. 549). AVhen the suture has reached its point of heginning it is carried on the ileum one stitch beyond tlie short end of the tliread that was left clamped and is tied to the short end. The knot is tied snugly three times in the line of the incision and is cut short. In this operation there is not the danger of turning in too much dia- phragm, which is an error to be avoided m resection of the small intestine, and it is best to place a row of interrupted mattress stitches of fine tanned catgut around the whole line of sutures. This promotes valve formation and adds to the safety of the line of sutures which has an unusual amount of strain due to the back pressure from the large boAvel. An enterostomy is ahvays done before the clamps are removed. This should be performed in the manner already described, utilizing the principle Tig. :-,^. — TL'^ suruiiiiig i= Loiuinuud as a right angle continuous stitch, penetrating all coats of the intestine and uniting the edge of the colon to the ileum about an inch from its end. More of the colon than of the ileum is taken in each bite and at about every third or fourth stitch a back stitch is takea. The suture is completed by tying it to the original short end that was left clamped. Insert A shows a longitudinal section of the bowel after completion of the first row of sutures and the insertion of the catgut mattress sutures. of Coffey but instead of placing the enterostomy in the colon, as I originally advocated, it is made in the ileum about one or two inches above the line of suturing. A medium or small sized soft rubber catheter with several perforations near its end is used and should l)e brought through a stab wound in the abdominal wall to the outer side of the incision and the distal end clamped before tiie catheter is placed in the enterostomy wound (Fig. 550). The end of the catheter should go through the lumen of the sutured bowel and about an inch of it should rest within the colon. The catheter should not be large, for it may cause obstruction, and a small catheter will give suffi- cient exit to gas and liquid feces, which is all that is necessary. The omentum in the neighborhood is brought over the enterostomy and the line of union of the bowel, and fastened in position with a few interrupted sutures of fine THE INTESTINES 613 tanned cato'ut. The AV(nin(l in the mesentery is closed by a continuous suture of catiiut and the inlesiin;il clamps are removed. Abdominal Avounds after resection of the bowel, and particularly- the large bowel, are best closed with interrupted sutures of silkworm-gut in ordtn- to avoid the unfortunate consequences that might follow infection of the wound if catgut sutui-es were used. The advantages of enterostomy after resection of the cecum are obvious. One of the great difficulties after this operation is the accumulation of gas. Some surgeons make a permanent enterostomy to avoid this. Others make an end-to-side union and bring the stump of the colon to the abdominal wall. The great advantage of lessening the pressure of gas on the suture line during the healing process has already been discussed. This is obtained by an enterostomy, such as has been described, and the convalescence proceeds without distention and with but little discomfort. The catheter is removed Fig. 550. — Longitudinal section of the completed operation with the enterostomy tube inserted through the ileum. The enterostomy is done by the technic previously described. The tube should be a medium sized or small catheter. in a week or ten days and its removal is usually followed by no leakage of fecal matter, merely a drainage of purulent serum until the tract closes. The efficacy of the valve formation is shown in the accompanying roent- genogram, which was taken after an enema of about three quarts of barium suspension had been introduced into the rectum. The picture (Fig. 551) was made forty-one days after resection of the cecum and ascending colon. Al- though this pressure is estimated to be greater than the normal pressure in the colon none of the barium reached the ileum. There has been no symp- tom of obstruction, showing that the union at the site of resection is suffi- ciently patent. This method of operating or the principles underlying the method, such as the treatment of the mesentery and of the ends of the bowel, and end-to-end union, I have employed in ten consecutive cases of resection of the cecum and ascending colon without a death and without any compli- cation folloAving the operation. Eesection of any other portion of the colon down to the lower sigmoid can be done bv the method described for resection of the small bowel except 614 OPERATIVE SURGERY that as a matter of precaution, an additional layer of sutures, preferably in- terrupted mattress sutures of fine tanned or chromic catgut, is placed around the boAvel close to the original row. Of course, there is no occasion for any valve formation in such a resection, and as small a diaphragm as pos- sible should be turned in. As the fecal matter in the large bowel is more nearly solid than in the small bowel and as the surfaces of the colon are more irregular, it is well to place this additional row of sutures, which seems unnecessary after resection of the small bowel. There is a marked tendency for gas formation in the colon and if the re- Fig. 551. — A roentgenogram of the valve made after resection of the cecum and ascending colon by the method just described. The roentgenogram was taken forty-one days after the operation. The arrow shows the stump of the colon. Though the valve was subjected to the pressure of three quarts of barium enema, it seems entirely competent. section is on the left side, or on the left of the midline, a rectal tube or a stomach tube should be passed from the anus well through the site of re- section and kept in position for four or five days. This may be done by fas- tening the tube at the anus either by a suture to the skin, or by passing a safety pin through the tube and letting the tube at this point emerge through a perforation in a broad strip of adhesive placed from one buttock to another. If the tube is not stiff it may double up in the rectum and it should always be passed through the point of resection under the guidance of the hand immediately after the intestinal clamps have been removed. If THE INTESTINES 615 Fig. 552. — Lines of incision for excision of the bowel and mesentery in cancer of the cecum or ascending colon. Fig. 553. — Lines of incision for excision of the bowel and mesentery in cancer of the hepatic flexure of the colon. Fig. 554. — Lines of incision for excision of the bowel and mesentery in cancer of the splenic flexure of the colon. Fig. 555. — Lines of incision for excision of the bowel and mesentery in cancer of the descending colon. there seems to be doubt about the tube remaining in position its tip may be fixed to the intestinal wall about three inches to the oral side of the resec- tion by transfixing the intestinal wall and the tube with a catgut suture. This is done by pressing the tip of the tube firmly against the wall and passing 616 OPERATIVE SURGERY the sutiu-e through and tying it in several knots. The suture is of fine tanned or chromic catgut and the l^not of the suture is buried witli a purse- string suture of silk or linen Avliich may be further reinforced by bringing the omentum over to this region. Such a procedure will take only a few minutes and if the surrounding structures are Avell protected with moist gauze and the catgut suture is regarded as a septic suture and immediately buried, there should be little danger of infection. Peristalsis when reestablished will in its efforts to extrude the tube readily loosen the suture. In the right side of the transverse colon an enterostomy should be done according to the method indicated. Wherever the site of operation on the colon, great stress should be placed upon the first step of thoroughly mobilizing the colon by dividing the at- Fig. 556. — Lines of incision for excision of the bowel and mesentery in cancer of the sigmoid. Fig. 557. — Lines of incision for excision of the bowel and mesentery in cancer of the terminal sigmoid. tachments of the peritoneum on its outer side to the abdominal wall. In this manner the descending colon which is difficult of access can, as a rule, be readily brought into the wound. It must also be borne in mind that in opera- tions for malignant tumors a considerable portion of the apparently healthy bowel and mesentery must be excised. The illustrations show approximately the amount of bowel and mesentery that should be removed in cancer of the colon (Figs. 552, 553, 554, 555, 556 and 557). Cancer in the terminal portions of the sigmoid is so near the rectum that a part of the rectum must be removed along with the sigmoid. The operation here involves somewhat different principles from those in Avhieh a resection is done entirely within the peritoneal cavity and will be taken up along with surgery of the rectum. TJIK INTKSTINES 617 ()l)s1nu'1i(m of llie bowel due lo cjiiumm- ol' llic colon iiiiist be managed sonu'wiiat (lirfcmit ly from olisl nicl ion due lo liaiuls or strangulated liernia. In damaged bowel, snidi as a sti'angnlaled liernia oi' intussusception, there is great danger of al)sor])tion of toxic products from the affected loop. These products may arise Avithin tlie mucosa and result from a perversion of the nor- mal function of the glantls of llie mucosa, or tliej^ may to some extent be formed within the lumen of the boA\'el and can more readily gain access to the portal circulation through the damaged bowel than through normal in- testine. Under either condition the necessity of immediately resecting the danuiged loop which is the source of toxic material is obvious. This may frequently be accompanied b}^ an enterostomy. Obstruction due to cancer of the colon, however, is mechanical and death results from the damming back of the fecal current. Such an obstruction is not nearly so quickly fatal as is an obstruction higher up in the intestinal tract or when a loop of bowel has been damaged by strangulation, volvulus or intussusception, be- cause the damaged loop generates toxic material more injurious than that which results solely from a mechanical damming back of the fecal current. The principles, then, of treating obstruction due to cancer of the colon are ; first of all, giving exit to the dammed back bowel contents. This is the main indication and as there is no unusual amount of toxic material being gener- ated by the cancer the operation for removal of the cancer should never be done at the time the obstruction is relieved by an enterostomy. The method of procedure in such instances is first to Avash out the stomach, which should be the first step in the treatment of every intestinal obstruction. The stomach should be thoroughl.y cleaned by a lavage of soda w^ater until the water re- turns clear. If the point of obstruction can be determined before the opera- tion so much the better, but if it is not definitely determined it would be wise to make an incision over the right iliac fossa and do an enterostomy on the cecum if it is apparent that the obstruction is distal to the cecum. The sutur- ing in of a large rubber catheter, utilizing the principle of Coffey as has already been discussed, will be sufficient to relieve the obstruction and draw off the liquid feces. Fecal matter in the cecum is normally liquid. This opera- tion can usually be done under a local anesthetic, which adds considerably to the margin of safety in operating on these patients. From one to two weeks later, depending upon the condition of the patient, the exact location of the growth is determined by a barium enema injected from below, together with a suspension of barium injected through the enterostomy tube. Two days after this has been done a radical operation for resection of the growth may be performed. The technic for this has been described. If the cancer is so located that it is not necessary to excise the cecum, the enterostomy tube is left in place for a week after the second operation and is then withdrawn. This procedure may be carried out when there is only partial obstruction, though if a cancer of the colon can be diagnosed when there is no obstruction, it may be excised at one operation. Formerly excision of cancer of the colon at one sitting was considered a 618 OPERATIVE SURGERY very dangerous operation and the mortality was reduced considerably by adopt- ing the procedure of Mikulicz. Here, in the first stage, the loop of bowel con- taining the growth is mobilized and brought into the wound. Its limbs are su- tured to each other. If there is an obstruction an enterostomy may be done on the cecum or a small tube is inserted in the loop to relieve the gas and liquid feces. AVhether there is obstruction or not, the loop is packed around with gauze until the peritoneal cavity has become well walled off and after a week is excised, preferably with the cautery. This results in an artificial anus. A few weeks later the two segments of colon that were in contact and were sutured together when the mobilized loop containing the cancer was first delivered into the wound are opened into each other by inserting the blade of a pair of for- ceps in one of the open bowel ends and the second blade in the other end, and then clamping the forceps so as to produce necrosis. Later still, the external opening is closed. Though this method resulted in the reduction of operative mortality, it necessitated a rather limited resection of the bowel and reciuired three or four ditferent operations. During intervals between these operations the wound is flooded with the fecal contents. Bevan' has called attention to the disadvantages of the Mikulicz method and practices a right iliac enterostomy with later a resection of the loop con- taining the cancer, and still later closure of the enterostomy opening. This leaves a clean field for the resection. If, however, an enterostomy is done by the method that has been de- scribed and through a muscle-splitting incision it will require no operation for its closure, the mere withdrawal of the tube being sufficient. The end- to-end union Avill permit a resection of a larger amount of bowel than is pos- sible with a lateral anastomosis, and if carried out according to the technic described has other advantages, which have been mentioned. In operations upon the rectum and terminal sigmoid where the fecal matter is largely solid an enterostomy by insertion of a large rubber catheter in the cecum is not satisfactory. Mixter's operation (pp. 600-602) is best here and should always be used in inoi^erable cancer of the lower sigmoid and rec- tum. A permanent anus may be established or, if it is thought Avise later on to restore the continuity of the intestinal tract, this can be done by anas- tomosing the severed ends of the sigmoid. A restoration of the fecal current to normal should not be attempted for a number of weeks, and preferably several months, after the resection of the rectum or lower sigmoid. Often when the patient has learned to care for the colostomy opening he is much more comfortable with a permanent colostomy than he would be if the fecal cur- rent were restored after the sphincteric apparatus of the lower rectum and anus has been destroyed. A diverticulum, called Meckel's diverticulum, is sometimes found. It is an embrvologic remnant left in the ileum about one or two feet from the ileoee- ^Surgical Clinics of Chicago, February, 1920, Philadelphia, W. B. Saunders Co., p. 9, et seq. THE INTESTINES 619 cal valve. This is a congenital deformity but may be the source of obstruc- tion or of adhesions and pain (Fig. 558). It can be removed by first clamp- ing the loop of bowel from which the diverticulum arises, after stripping it of fecal matter, and then surrounding the loop with moist gauze. The further method of dealing with it depends upon its size and the width of its base. Frequentl.y an intestinal clamp can be adjusted at the base of the diverticulum which is then severed close to the clamp, leaving a sufficient mar- gin of tissue for suturing so the lumen of the bowel will not be narrowed at this point. If, as often happens, a mesentery runs along the diverticulum, it is separated and ligated with catgut. It is then divided and the diverticulum is clamped close to the intestine and cut away. The small margin of intestine included in the rubber covered intestinal clamp placed near the base of the Fig. 558. — Meckel's diverticulum in the lower ileum. diverticulum is carefully cleaned by sponges wrung out of bichloride solu- tion and the edges of the wound are approximated with a fine tanned or chromic catgut lock stitch. This is done not only to approximate the mar- gins of the intestinal wound but to control bleeding. The clamp is then re- moved and this line of sutures is buried by a continuous right-angle stitch of linen in a straight needle, taking only a sufficient amount of bowel wall to bury the first line of sutures. Occasionally it is necessary to do a lateral anastomosis in order to overcome an obstruction in the bowel which it is not practical to remove. This may be permanent, as in inoperable cancer of the splenic colon when a lateral anastomosis may be made between the transverse colon and the sigmoid. It may, however, be utilized as would the enterostomy opera- tion in order to overcome obstruction and later to permit a radical op- eration upon the cancer or stricture v^^hich causes the obstruction. Some- 620 OPERATIVE SURGERY times, too, an anastomosis between tlie cecum and tlie si<>nioid is indicated. This, of course, involves the same principle as lateral anastomosis and Avhen there is obstruction along the colon and other portions of the intestine cannot be readily approximated Avithout tension, a cecosigmoidostomy will offer ex- cellent prospects of relief. AVhen performed for stasis, however, though su- perior to ileosigmoidostomy it is stdl very unsatisfactory so far as clinical cure or improvement of the patient is concerned. A lateral anastomosis is performed in much the same way as a gastro- enterostomy. The intestinal loops to be anastomosed are selected so they can be easily approximated and overlapped without the slightest tension. Tension in any operation of this type is fatal to success, for the sutures are certain to cut loose under tension and in cancer, where the vitality of the patient Fig. 559. — Lateral anastiniuisis .if tin- inti ^tiius. 'i'lie ends of the bowel are closed with pursestriiig sutures and the openings are made close to the invaginated ends. The suturing is done as in gastro- enterostomy. and the healing of tissues is at a low ebb, everything possible must be done to promote healing of the intestinal wound. If the anastomosis is between loops of small intestine it should be done along the convex border opposite the mesenteric attachment. If the lateral anastomosis is to be between loops of the large intestine it is preferably done through the anterior band, split- ting the band in the center, as this makes a smoother surface though it may tend late^ to cause a contraction of the anastomotic opening. After selecting the two loops of bowel and arranging for thorough mobilization by incising the peritoneum on the outer side of the mesocolon if necessary, a row of fine linen or silk sutures is placed just on the margin of the band, if the colon is being united, in the same manner as the jejunum is united to the stomach in gastroenterostomy. These sutures are placed with a curved needle THE INTESTINES 621 and arc ri.<>lit-anli its licallliy portion and sutured to the skin. As a rule, too great an effort is made to preserve the function of the sphincter in operations on the rectum. In a very early growth this may sometimes be done, but not infrequently the effort to preserve the sphincter leads to an operation that is not sufficiently complete, and consequently there is an early recurrence. In cancer of the rectum where as much as eight inches of the bowel must be removed and where the lower margin of the cancer is about two and a half inches from the sphincter ani, the method of Kraske is a satisfactory operation. This may be folloAved b}^ bringing the bowel through the anus or by a sacral anus, though a permanent colostomy is, as a rule, more satis- factory. If dissection can be safely made no closer than two and one-half inches to the anus the sphincter may be saved and the bowel ends may be united. The ilpper end of the rectum is much smaller than the lower end and is largely surrounded by peritoneum. The upper end is split on the surface opposite its mesentery for about one and a quarter inches to make it of the same caliber as the lower portion. It is best to rotate the bowel so as to bring the peritoneal surface posterior. This should be done in such a man- ner as not to make too great tension on the mesenteric border. Half a turn of the bowel Avill secure the desired position and at the same time will not interfere too greatly with its nutrition. Through and through sutures of tanned or chromic catgut are placed so as to invert the mucosa, and over this a second row of interrupted sutures of fine silk is inserted. Melted vaseline if poured over the cavity of the wound seems, accord- ing to C. H. Mayo, to prevent infection. Drainage from the dead spaces is provided by bringing tubes out through the sacral wound. The sphincter ani is divulsed and may best be put out of commission by dividing it anteriorly with an electric cautery. In small early cancers in the anterior wall of the lower rectum the pro- cedure as practiced by Bevan'^ seems excellent. Of course, this is only ap- plicable to small beginning cancers that have not infiltrated the whole wall of the bowel and are in the lowest portion of the rectum. The patient is placed face down and with the table broken, similar to the Trendelenburg position, only the patient lies on his abdomen instead of on his back. This position is useful in any sacral operation on the rectum. An incision about five or six inches in length is made from the lower part of the sacrum to the anus in the midline. The coccyx is exposed and excised from the sacrum with bone cutting forceps. The tissues on each side are retracted and, beginning at the anus, posteriorly, the anus and rectum are divided upward for four inches (Fig. 581). The edges of the wound in the rec- tum are caught with clamps as the division proceeds. If in the course of 'Surgical Clinics of Chicago, W. B. Saunders Co., December, 1917, p. 1233, et seq. 646 OPERATIVE SURGERY dissection no metastasis is found and it is demonstrated that the cancer is early and has not penetrated tlie bowel wall, it is removed with an electric cautery, going well beyond the apparent margins of the growth and cutting througli the whole Avail of the rectum until the areolar tissue beneath is recognized (Fig. 582). In a male, a sound in the urethra prevents in- jury to the urethra. The wound left by removing the cancer is closed by interrupted sutures of linen or stout catgut in a large curved needle which approximate the wound and control the hemorrhage (Fig. 583). The pos- terior rectal wound is closed, beginning at the upper end of the incision, with interrupted sutures of linen which are tied wdth the knots inside of the lumen y^ Tfed-rauJ'^ "rTo-rn TSeva'o— Fig. 581. — Operation of ISevan for early superficial cancer of the anterior wall of lower rectum, dotted line shows the site of the incision. The of the boAvel. Over this a continuous suture of tanned or chromic catgut is placed. A piece of iodoform gauze is packed into the rectum over the region from Avbich the cancer was removed and another piece is placed in the upper angle of the skin wound. The incision in the skin wound is closed with interrupted sutures of silkAvorm-gut. For prolapse of the rectum the patient is thoroughly prepared by light diet and mild purgatives for several days before the operation, but no pur- gative should be given for forty-eight hours immediately preceding the opera- APPENDIX, PERICOLIC BANDS, RECTUM, ETC. 647 tion, during \vliicli time the bowel is emptied by soapsiid enemas and the diet restricted to liquids. The operation to be done for prolapse of the rectum depends upon the stage of the disease and the condition of the patient. In children most cases can be cured without operation. Attention to the diet, mild laxatives, and avoiding strain at stool will often effect a cure in young children. In adults, a fresh prolapse may be treated by replacement and by strapping the buttocks together with adhesive plaster. An incomplete prolapse, that is, one in Fig. 582. — The cancer has been exposed and is removed with an electric cautery. (Bevan.) which the mucosa descends, or a complete prolapse in which all coats of the rectum come down but with the sphincter still retaining some of its power, is very satisfactorily treated by linear cauterization with a thermo or elec- tric cautery. The prolapse is pulled down as far as possible with the patient in the dorsal position, and the cauterization begins at the highest internal point of the prolapse, continues downward, parallel with the axis of the bowel, and terminates just above the sphincter. The cautery should be carried through the mucosa and just into the muscular coat. Four or five of these incisions are made parallel to each other and with a narrow 648 OPERATIVE SURGERY strip of healthy mucosa between each line of cauterization (Fig. 584). The prolapse is then reduced and the protrusion is kept above the grasp of the sphincter by suturing the anus. Kellogg Speed* sutures the anus with a stout silk thread in a curved needle, beginning near the median raphe in front and passing the suture completely around the anus. It is then drawn tight and tied so that not even a grooved director can be inserted into the anal canal. Tlie patient remains in bed and has a diet that Avill leave as \ \ \ Tievs- Fig. 583. — The wound left by the excision of the cancer is closed with a few sutures. The posterior wall of the rectum is united with interrupted sutures, tying the knot within the lumen of the bowel. (Bevan.) little residue as possible. He is given a grain of powdered opium by mouth every day. At the end of a week the pursestring is cut, but the patient is kept in bed for another week, being given magnesia by the mouth to keep the fecal matter soft, and using a bed pan for the bowel movements. When the prolapse seems to involve most of the lower part of the rectum an incision may be made from the posterior part of the anus to the coccyx. ^Surgical Clinics of Chicago, W. B. Saunders Co., February, 1920, p. 68. APPENDIX, PERirOLTC BANDS, RECT[TM, ETC. 649 Tho wall of the i-ectiini is sutured to the thick fascia and ligaments in the neighborhood and a reef may he taken in the levator ani muscles. AVith a complete prolapse and weak sphincter, especially in elderly people, the pro- lapse is amputated by carefully cutting through the anterior portion of the prolapsed rectum with a transverse incision near the anus and suturing the part of the bowel near the anus to the anterior Avail of the upper segment of the prolapsed portion as high up as the sutures can be con- veniently placed. Care is taken to avoid injury to any structures that may be in the culdesac and to prevent soiling the peritoneum. This trans- verse incision is continued, cutting a short distance at a time and immediately suturing what has been cut until the whole prolapsed segment has been re- moved. These sutures, which are of linen or silk, are reinforced by a continu- ous suture approximating the mucosa of the boAvel. Fig-. 584. — The prolapse of the rectal mucosa is cauterized with electric cautery. If an abdominal operation seems wiser the operation of Moschcowitz is satisfactory. Here a median abdominal incision is made from the pubis to umbilicus and the patient is placed in the extreme Trendelenburg position. If the prolapse is in a w^oman, linen or silk sutures are passed in a circular manner around the culdesac of Douglas and tied. The lowest suture is one inch above the bottom of the culdesac. Six or eight sutures are passed, one above the other, placing as many sutures as necessary to bring the peritoneum together without too much tension and so obliterating the culdesac of Doug- las. An effort should be made to secure some of the pelvic fascia in each of these sutures, particularly over the levator ani muscles. When the sutures reach the cervix and body of the uterus these structures are included and the peritoneum and muscular coats of the rectum are also grasped in each suture. Care should be taken to avoid the uterine and the internal iliac 650 OPERATIVE SURGERY vessels. In elderly women the nterus is sewed firmly to the anterior ab- dominal wall after the culdesac has been obliterated. No fixation of the colon or sigmoid to the abdominal wall is done, as this is useless. The after-treatment is the same as after any other laparotomy, Moschcowitz's operation is based on the theory that prolapse of the rectum is due to relaxation of the pelvic fascia which permits a descent of the rectum, and that sutures placed in the manner indicated will take up the slack in this fascia and afford a firm support because of the close attachment of this fascia to the peritoneum and the readiness with which the peritoneum unites when firmly approximated. Abscesses around the rectum in the ischiorectal fossa should be opened as soon as the diagnosis can be reasonably made. The incision is so made as to avoid injury to the sphincter, the finger is introduced and the cav- ity explored. The various compartments are gently broken down and the wound is lightly packed with iodoform gauze. This packing is changed at intervals of two or three days. If the abscess is comparatively small it may be opened under local anesthesia, tube drainage instituted for a few days until much of the reaction has subsided and then the wound is gently packed with iodoform gauze which has been soaked in five per cent solution of balsam of Peru in castor oil. The bowels are kept constipated for a few days, and afterwards mild laxatives are taken to keep the bowel movements soft. Such an abscess may result in a sinus but will heal in a short time. If there is communication with the bowel a fistula will result, but if the sphincter is cut when the abscess is first opened an unnecessary amount of raw surface will be exposed to the pus before the local tissues have acquired sufficient resistance against the infection and serious harm may be done. Inconti- nence will frequently follow. After the fistula has well formed, however, operation may be undertaken with the hope of more satisfactory results. A fistula may be small and open near the margin of the anus. The opening usually is much nearer the anus than it is supposed to be. If the opening can be readily demonstrated the old operation of introducing a grooved director and splitting the tissues over it, including the sphincter at a right angle to the sphincter, gives satisfactory results, provided the tract of the fistula is dissected out or thoroughly cauterized with the actual cautery. The wound is packed with gauze every day for a few weeks until the granu- lations have become healthy. The sphincter should always be cut at right an- gles to its fibers. If cut obliquely, control of the sphincter is often lost, but even after a right-angle section incontinence occasionally results. When this does occur a subsequent operation is done to dissect out the ends of the sphincter and unite them with buried sutures of fine tanned catgut. In a complicated fistula, particularly of the horseshoe type, the operation as described for simple fistula is unsatisfactory. Complicated fistulas that arise from the posterior half of the anus almost always unite at a common point at the posterior part of the anus. Here the sphincter is divided at a right angle to its fibers and the various tracts are made to communicate. APPENDIX, PERICOLIC BANDS, RECTUM, ETC. 651 Packing, which is renewed eveiy day or every two days, together Avith the usual treatment for control of the bowels, is carried out. In a few instances the tract of the fistula can be dissected out and the wound completely sutured. This may be done in the simpler fistulas where the tract is well organized and the scar tissue around it presents a defi- nite tube. In a complicated fistula if the opening into the bowel can be closed and the fistula thereby converted into a sinus, the results are often much more satisfactory. The operation of Elting consists of mobilizing the mucosa of the anal canal and lower rectum as in the Whitehead operation for hemorrhoids and dissecting it free for a short distance above the internal opening of the fistula. The mucosa is drawn down and the excess amputated. The mucosa is then fastened to the skin around the anus with interrupted sutures of linen or silk. Only the mucous membrane with its submucosa is dissected free in this operation and the line of cleavage should be carefully observed, for if the muscular coat is included the operation is more difficult and proper mobilization cannot be effected. The chief objection to the Elting operation is that stricture may result. E. S. Judd has modified the Elting operation by making the incision only half way around the circumference of the anus on the side of the fis- tula and extending the dissection well above the internal opening of the fistula. The mucosa of the bowel on this side is pulled down, the excess cut away and the stump sutured to the skin of the anus with silk or linen. This avoids the possibility of a stricture which may occur after a complete circumferential incision of the anus or rectum. The rest of the fistula will usually heal readily if the opening into the bowel has been securely closed. The fistula, however, may be enlarged by an incision parallel with the sphincter, and the tracts curetted and cauterized or dissected out. In a fistula where the tract is tortuous it is followed much more easily if the fistula is injected with some dye, as methylene blue. This is done by inserting a sharp-pointed syringe filled with methylene blue into the opening of the fistula and gradually injecting the dye until the fistula is well dis- tended. The syringe is held in position for half a minute until the dye is well taken up. This will permit the easy following of the fistulous tract which is opened in all its ramifications and cauterized or dissected out. It must always be borne in mind, however, that the sphincter should never be cut but once and then at right angles to its fibers. In rectovesical or rectourethral fistula it is essential to drain the bladder, preferably by a suprapubic cystotomy, before attempting to close the fistula. The fistula may be then closed by a plastic operation involving the principle of Elting, which has been very successfully used by Harvey Stone, of Balti- more. The mucosa of the rectum is mobilized to a point Avell above the open- ing of the fistula into the rectum and a few sutures of catgut are placed into the urethral opening of the fistula. The cuff of the mucosa is brought down 652 OPERATIVE SURGERY to the anus, the excess cut off, and the remainder sutured to the margins of the anus. Fissure in ano is an ulcer in the mucosa of the anal canal and is usually found along the posterior border of the anus. It is about half an inch long. After it has existed for a short time the tissues around it become indurated. There is considerable spasm of the sphincter due to pain, and the spasm also causes pain and prevents healing, so that a vicious circle is established. The passage of fecal matter, together with the more or less constant motion of the sphincter, prevents the healing. The treatment must be directed to se- cure rest and remove the conditions that cause irritation. The sphincter ani should be paralyzed by gradually stretching it under general anesthetic, or the tissues around the sphincter may be carefully infiltrated with one- half of one per cent procaine solution and divulsion of the sphincter can then be accomplished with but little pain. The injections, however, should be made not only in the si3hincter but around the anal canal for a distance of an inch or more toward the rectum. Under local anesthesia the fissure may be cauterized with an electric cautery and the sphincter partly or com- pletely divided in the posterior midline. This sometimes is a more satisfac- tory treatment than simple divulsion, as it can be done more readily under local anesthesia. There is a small skin tag at the external end of the fissure which is called a sentinal pile. Operation for ulceration of the rectum depends upon the type of ulcera- tion. If the ulceration is extensive the sphincter should be divulsed or di- vided, preferably with an electric cautery at its anterior or posterior commis- sure. The posterior division secures better drainage, though the division anteriorly sometimes heals more satisfactorily. This will aid the healing of an ulcer because it affords rest to the lower part of the rectum by preventing^ an accumulation of gas or fecal contents Avhich would occur when the sphincter is intact. Ulceration due to cancer should be treated according to some of the methods of excision depending upon the stage and type of the cancer and also upon its location. Ulcers due to syphilis or to the ameba should have specific treatment. Dysenteric ulcers that are high up in the rectum and in the sigmoid are sometimes treated by cecostomy or appendicostomy in which the appendix is brought up through an incision in the right iliac fossa, part of it cut away, and the appendix fixed to the abdominal Avound. Its lumen is dilated to admit a catheter through which liquids having a sup- posedly therapeutic effect on the ulcer are introduced. A cecostomy is done by using the technic for enterostomy with a tube introduced through the wound for irrigating the bowel. These operations, hoAvever, for this purpose are being generally abandoned because fluids can be introduced through the rectum with considerable satisfaction, and also because the irrigation of the ulcerated areas with fluid which only comes in contact with the ulcers for a very short time does but little good when the fecal current is permitted con- stantly to bathe these surfaces. If any operation is done, it should be a complete diversion of the fecal current and this is best accomplished by the APPENDIX, PERICOLIC BANDS, RECTUM, ETC. 653 John Young- Brown operation in tlie lower ilenm (p. 599). The distal end of the ileum can be used for irrigating the colon and cleaning away the fecal contents that may remain. "Without the presence of the fecal cur- rent, irrigating solutions may be of some value. Strictures of the rectum, when cancerous, are treated by resection of the rectum. Stricture is particularly likely to follow a circumferential suture of the rectum when made below the border of the peritoneal covering. Stric- tures in the lower portion of the rectum or in the anal canal accompanied by dense tissue may be divided by a posterior linear proctotomy. Here the knife is introduced above the stricture and a deep incision is made posteriorly in the midline almost to the tip of the coccyx. Bleeding is controlled by whipping over the bleeding surfaces with sutures and by packing with gauze. B}' making an incision in this manner drainage is facilitated and by keep- ing the incision in the midline the danger of incontinence is usually avoided. The first packing must be placed quite firmly to control hemorrhage, but after- wards the packing with gauze should be loose enough merely to fill the cavity lightly. The treatment after the wound has begun healing consists in reg- ular dilatation with soft rubber bougies. A stricture is very likely to oc- cur unless dilatation is kept up for several months after healing. In obstinate strictures, resection of the lower portion of the rectum by the perineal method, or even the Mayo-Kraske operation, may be justifiable. Ill benign strictures that are uncomplicated constant dilatation, preferably with soft rubber bougies, will usually effect a cure. The patient can be in- structed to pass these bougies first under the surgeon's direction and later by himself. Metal or stiff instruments should be avoided. The bougies are of graduated sizes. In first inserting a bougie to dilate a stricture of the rectum the method of Tuttle should be employed. A proctoscope is introduced up to the stricture and with an electric light attachment the opening in the stricture is demon- strated and the rubber bougie is accurately inserted. This is left in for a few minutes and a larger size is then introduced. Not more than three bougies should be inserted at the same sitting. After the stricture has been sufficiently dilated the bougie may be passed Avithout the speculum, but at first the use of the speculum and the accurate passage of the bougie may prevent un- necessarj^ trauma. Bevan^ operates in strictures that are low down by dilating the stricture fully under a general anesthetic, then freeing the mucous membrane of the rectum to a point just above the stricture, as in the Whitehead operation for hemorrhoids, and bringing it down and uniting it to the anus. If dilatation ruptures the mucosa at the site of the stricture and makes a raw surface, the mucosa above the stricture is brought down and fastened to the margins of the anus with mattress sutures of silk or linen. AVheii the stricture is Ioav and narrow this procedure may be applicable, but it should be followed by passage of bougies or dilatation at intervals for a number of months. ''Surgical Clinics of Chicago, W. B. Saunders Co., February, 1918, p. u" , et seq. 654 OPERATIVE SURGERY HEMORRHOIDS Hemorrhoids are divided into three classes, external, internal and ex- ternointernal. External thrombotic hemorrhoids cause a great deal of pain, which is readily relieved by incision and turning out the clot. This can be done painlessly by the injection of procaine solution with a very fine sharp hypodermic needle. Before injecting the solution the skin over the pile is touched with a probe that has been dipped into pure carbolic. After w^aiting one or two minutes the hypodermic needle is inserted into this point and there is usually no pain. The incision is made in a radiating manner par- allel with the normal folds of the skin about the anus. After the clot is turned out the raw surface is packed with iodoform gauze. If these clots are left they may organize and form tags which are sometimes annoying. Internal hemorrhoids are venous or capillary. The capillary pile is cov- ered with a very thin layer of epithelium and bleeds easily. It resembles a raspberry. Occasionally a polyp is found which is thought to be a hemor- rhoid. Capillary hemorrhoids do not protrude and can hardly be located by touch. They bleed on contact with the instrument for examination and bleed frequently after a bowel movement. The venous internal hemorrhoid comes from a dilatation of the vessels that lead to the superior hemorrhoidal vein and occurs just within the sphinc- ter. This type may be associated with venous external hemorrhoids and both can be treated in the same manner. When there is no complication about the internal hemorrhoid and the sphincter is not too tight, treatment can often be carried out in a satisfactory manner by the method of injection with a solution of quinine and urea, which has been devised by E. H. Terrell, of Richmond, Va. He uses a solution of quinine and urea of three to five per cent strength and occasionally as strong as ten per cent, the weaker solution being given in the first injections. Usually there are three hemorrhoids to be treated and one is injected on each succeeding day until all are treated. If the hemorrhoids are prolapsed they are replaced before treatment is begun. The hemorrhoid to be injected is brought into view through a small conical fenestrated speculum and is painted with equal parts of tincture of iodine and alcohol. Terrell uses a very small needle and a hypodermic syringe such as is employed in giving tuberculin so that it will not block the vision. The needle is inserted well into the substance of the pile and the solution is in- jected slowly until the pile is slightly distended. The needle is held in posi- tion a moment to prevent bleeding at the point of puncture and is then quickly withdrawn. On the following day the hemorrhoid on digital palpa- tion is felt to be thickened and indurated. After three or four days it begins to subside. If the hemorrhoid still persists after ten days or two weeks, the treatment is repeated, using a slightly stronger solution. This treatment should be persisted in at intervals of ten days or two weeks until the piles have disappeared. There is practically no pain from the treatment and the patient is permitted to pursue his usual vocation, though it is usually APPENDIX, PERICOLIC BANDS, RECTUM, ETC. 655 best to rest for a few hours after each injection. If by chance the solution is injected into or immediately beneath the mucosa instead of into the body of the pile, ulceration and necrosis may occur, but this accident is easily avoided by injecting the solution into the upper part of the body of the pile when the effect of the quinine and urea on the blood vessels and sur- rounding tissues will not extend to the surface of the mucosa. It must again be emphasized that the Terrell method of injecting hemor- rhoids with quinine and urea solution, which has just been described, is only applicable in uncomplicated hemorrhoids, that is, when there is no strangu- lation or abscess formation, or when the sphincter is not too tight. It may, however, be successfully used when the hemorrhoids bleed. When the piles are large and, particularly when the patient desires a quick and radical cure, operation must be done. There are three different operations that under different conditions are applicable and are followed by good results. The oldest of these methods and one that is frequently em- ployed with a local anesthetic is ligation and excision. The pile is caught with forceps, pulled down, and the mucous membrane at its lowest border is divided with scissors close to its junction with the skin. This incision is carried upward on each side and then the pile is separated from the tissues beneath by inserting the scissors closed and separating the blades. When the dissection has been carried upward until the hemorrhoid is attached by a pedicle composed of the blood vessels and a small strip of mucosa, the pedicle is crushed with forceps and tied with linen or silk. The hemorrhoid is cut off about one-quarter of an inch below the ligature. Each hemorrhoid is treated in a similar way, taking care to see that there is a small strip of healthy mucosa left between each hemorrhoid. The sphincter ani must be dilated for this operation, though not as thoroughly as would be necessary for clamp and cautery. General anesthesia would be preferable if there are sev- eral hemorrhoids to be ligated. The objection to this operation is that it may be followed by infection and sometimes by secondary hemorrhage. The raw surface left cannot be protected from the bowel contents and if infection begins and abscess formation occurs, complications that are annoying and sometimes grave may arise. When the operation can be followed by rest in bed in a hospital and when the diet is regulated and careful attention is paid to the after-treatment these complications may, as a rule, be avoided. One of the most satisfactory operations for hemorrhoids is the clamp and cautery. If properly performed it does not result in stricture. After ligation and excision there is a certain amount of necrosis and the raw sur- faces must necessarily be bathed with fecal matter, but with the clamp and cautery the heat sterilizes the tissues and seals the wound with an aseptic eschar. The operation is simple though it should be carefully done in order to secure the best results. After thoroughly dilating the sphincter, each hemorrhoid is caught at its apex with a hemostat and dragged well down through the anus. It is clamped with Ferguson's pedicle forceps, parallel with the anal folds (Fig. 585). These forceps have blades that are flat and hold 656 OPERATIVE SURGERY the hemorrhoid firmly. No skin is included within the bite of the forceps. It is best not to make an incision with scissors or a knife because this will leave a raw surface that may be a portal of infection. The object of the clamp and cautery operation should be to have the whole wound thoroughly covered with an aseptic eschar. With a little care a good hold can be obtained upon the hemorrhoid without including the skin. Usually the hemorrhoids are grouped in three locations and three clamps will include all the piles necessarv to be removed. It is particularly important to see that there is Fig. 585. — Clamp and cautery operation for hemorrhoids. The hemorrhoids have been clamped with Ferguson forceps and two have been removed with cautery. a broad strip of healthy mucosa between each clamp. If this precaution is taken, stricture will not result. After all the piles are clamped the last one is pulled down so the tip of the Ferguson forceps emerges from the aims. To protect the surrounding tissues from heat wet gauze is wrapped around the base of the hemorrhoid just beneath the forceps. In the original operation the whole hemorrhoid is cauterized with the actual cautery. This is necessary Avhen a special pile clamp, such as Smith's, is used, because after one hemorrhoid has been cauterized the clamp is taken off and applied to another. In this way the eschar is often broken by the manipulations, and bleeding results. The APPENDIX, PERICOLIC BANDS, RECTUM, ETC. 657 Foroiison clamps, however, are left on ;iiitil the completion of the operation, hold the eschar firmly and so prevent this accident; consequently, time can be saved and satisfactory results obtained by cutting off the hemorrhoid, if it is large, either with scissors or cautery about a quarter of an inch from the clamp. The tissues being thoroughly protected from the heat with wet gauze, the stump of the hemorrhoid is cooked with a thermo or an electric cautery at a low heat. The cautery is applied not only to the hemorrhoidal stump, but slightly to the forceps near the stump, so that a low degree of heat will be conveyed to the pedicle of the hemorrhoid that is within the grasp of the forceps. About one minute is devoted to cauterizing each hemorrhoid. The wet gauze is removed and the next pile is treated in a similar way. After each cauterization the clamp is not removed but its tip is returned Fig. 586. — Clamp and cautery operation for hemorrhoids. The hemorrhoids have been removed with cautery, a tube is inserted, and the clamps are about to be removed. The tube is usually well wrapped with gauze and the gauze covered with rubber dam. This is not shown in the drawing. into the anus and gently pushed up into the rectum so that the forceps will be out of the way while the next hemorrhoid is being treated. After all of the piles have been cauterized a rather firm rubber tube about three inches long and one-third of an inch in internal diameter is wrapped with iodoform gauze, covered with rubber dam, anointed with sterile vaseline, and inserted into the anal canal (Fig. 586). A safety pin is fixed in its outer end. Each Ferguson clamp is then removed gently to avoid breaking the eschar. The tissues are dusted with bicarbonate of soda and gauze is wrapped around the outer end of the tube under the safety pin to prevent the safety pin from pressing on the anus. A strip of adhesive across the 658 OPERATIVE SURGERY buttocks anchors the tube and safety pin more firmly. A pad and a T ban- dage are placed over the end of the tube. If the cauterization is carefully done and if the tube is inserted and forceps are removed without breaking the eschar, there is practically no danger of hemorrhage after this operation. Stric- ture is avoided by leaving a sufficient amount of healthy mucosa between each clamp. The scar tissue that forms after a burn is notoriously greater than that from an incision and so tends to obliterate any dilated vessel in its neighborhood that may not have been caught in the Ferguson clamp. The tube gives exit for gas and thus makes the patient more comfortable. Five or six small punctures in the skin of the anus about half an inch deep along the outer border of the sphincter lessen the swelling and permit the escape of serum and the venous blood that has become congested in the tissues. The Whitehead operation for hemorrhoids is very rarely indicated. It is not only more formidable than the clamp and cautery and more difficult to execute, but is peculiarly likely to be foUoAved by stricture, which is a much worse affliction than hemorrhoids. Occasionally^, however, in very aggra- vated types of hemorrhoids when their borders are not well defined and par- ticularly when they are associated with prolapse of the mucosa the White- head operation is justifiable. After preparing the patient in the usual way and dilating the sphincter, several large hemorrhoids are clamped with for- ceps, pulled down, and an incision is made around the anus at the junction of the skin and mucosa. The mucous membrane is separated from the sphinc- ter by inserting the scissors with closed blades and spreading them open and by occasionally cutting any marked adhesion that may be present. Blunt dissection with gauze may be used after the mucosa has been partly separated. In this manner a cuff of mucosa from the anal canal and lower rectum is pulled down for about three inches. This includes the pile-bearing area of mucosa. This cuff is cut away in small sections, beginning in front with a transverse incision of half an inch and suturing the upper edge of the mucosa to the skin with interrupted sutures of silk, linen or stout catgut. After this segment has been sutured the incision is continued for another half inch and this part of the mucosa is sutured, and so on until the whole cuff of mucosa has been amputated and its margin has been sutured to the skin. By cutting a small section and suturing it in this manner, more ac- curate approximation is attained and retraction of the mucosa is prevented. If there are any bleeding points they are controlled by an extra suture. A rubber tube is prepared and inserted as after clamp and cautery. It is also well to make a number of short stab wounds around the outer margin of the anus, a procedure which has been advocated and practiced by C. H. Mayo. Incontinence of feces may result from injury to the sphincter ani either from childbirth or following operations for fistula. After the inflammatory infiltration has subsided this condition may be corrected by exposing the ends of the divided sphincter and dissecting them for a distance of half an inch on each side. They are then approximated with a mattress suture of fine tanned catgut and this is reinforced by two or three other sutures of the APPENDIX, PERICOLIC BANDS, RECTUM, ETC. 659 same material. Tlie skin is closed Avitli a continuous mattress suture of fine tanned catgut. A mvdU rubber, tube is introduced through the anus to give exit to gas. Tlie patient is kept constipated for five or six days or even longer if possible with comfort. This can l)e done by giving a diet that Avill leave but little residue, such as albumens and broths, and by administering paregoric or, if necessary, opium or morphine when there is an inclination for the bowels to move. PRURITUS ANI One of the most annoying affeetioiis of the rectum that require opera- tion is constant itching. This may be so severe that an operation is de- manded in order to relieve the patient of an intolerable situation. Mild cases Fig. 587.— A sinus in the anal canal (E. H. Terrell). may be relieved by ordinary remedies or salves, but in the obstinate cases of pruritus ani local applications are merely palliative. E. H. Terrell,io of Richmond, has had considerable success with split- ting the pockets that are found in the lower end of the anal canal. These lesions, he says, are sometimes difficult to find and may be blind pockets or sinuses with their openings at or just internal to the anorectal skin line. Little pockets, or diverticula, as anal valves in this region are frequently normally "Terrell, E. H.: Southern Med. Jour., February, 1920, pp. 123-125. 660 OPERATIVE SURGERY found but when tliey are not inflamed or infected they cause no trouble, just as a normal appendix gives no symptoms. "When, however, they are chroni- cally infected they are apparently a focus of toxic material that seems to cause the itching. A bent probe, used by Terrell, as shown in the illustration, will often demonstrate these pockets or sinuses (Fig. 587). If the diverticu- lum is large and forms a pocket instead of a straight sinus its lining is glis- tening in appearance in its upper part, which is very distinct from the pink mucous membrane immediately above it. The opening of the pocket should Fig. 588. — A large pocket or diverliculum in the anal canal (E. H. Terrell). be looked for at the anorectal line. . When the covering of this pocket is removed an ulcerated area, which heals slowly, is found (Pig. 588). Terrell removes the covering of the pocket with an electric cautery. Its floor is injected and incised so that a small portion of the superficial sphincteric fibers is divided to promote healing as in fissure in ano. When there is a sinus it sometimes begins at the bottom of the anal valve but is usually found as a slight xlepression just below the level of the anal valve. A bent probe introduced into such a sinus passes down under the skin, ending in a blind pocket which often appears as a tag of skin or an external pile, but sometimes causes no protuberance (Fig. 587). If the itching is localized to one part of the anus, only one sinus usually exists, but in the severer forms Avhere the itching is general around the anus two or more sinuses or a pocket and a sinus may be found. It is necessary to remove completely the covering from the pocket, though the sinus may be simj)ly laid open from APPENDIX, PERICOLIC BANDS, RECTUM, ETC. 661 its orifice to its termination luider the skin and any redundant skin or mucosa trimmed away (Fig. 589). Opening tlie sinus is best done witli a small elec- tric cautery. The wound is inspected and packed so that it heals from the bottom. Healing is often slow because of the contraction of the sphinc- ter. The operation can ordinarily be well done under local anesthesia, but if general anesthetic is used, the sphincter should be divulsed which will un- doubtedly hasten healing. This method of treatment, which has yielded such excellent results in the hands of Terrell, requires careful searching for the Fig. 589.— Removal of the covering of one of the anal pockets, according to the method of E- H. Terrell. pocket or sinus under a good light, but it seems far preferable to operations which are devised to treat the symptoms by destroying the nerves instead of relieving the cause by removing the focus of infection. SACRAL AND COCCYGEAL DERMOIDS Dermoids or coccygeal cysts are not infrequently found posterior to the anus. If they have become infected they are often treated as a fistula and opened into the rectum. Such an operation, of course, is useless and never curative. Excision of the complete sac, including the epithelial bearing tissue, is necessary for cure. When a sacral dermoid appears over the lower part of the sacrum, a wide excision of the affected tissue is necessary for cure. The skin should be closed with interrupted mattress sutures of silkworm-gut which are so placed as to evert the edges of the skin and prevent the tendency 662 OPilKATlVE SURGERY to a folding in of the epidermis along the edges of the skin wound, whieh may be responsible for a recurrence. A dimple appears over the tip of the coccyx in many infants and in about five per cent of adults. Sometimes it is so deep as to form a sinus which readily becomes infected. Such a sinus should be treated as a dermoid and the epithelial lining completely excised together with a considerable amount of surrounding tissue. If this is not thoroughly done recurrence must be expected. Any suspected fistula poste- rior to the rectum should be examined for hair and the history- of the condition carefully obtained. If the patient states that hair has been passed from the fistula it must be regarded and treated as a coccygeal cyst or fistula, and not as a fistula in ano. If there is any reasonable doubt as to the diagnosis it is best to treat the condition as a dermoid and not as a simple fistula in ano. GHAPTER XXVIII OPERATIONS ON THE KIDNEY, URETER AND BLADDER THE KIDNEYS Incisions for exj)osure of the kidney have, been mentioned but as they are so important in the technic of kidney operations they should be con- sidered at some length. Personally, I find that three incisions for exposing the kidney cover all indications for operations on this organ. Two are lum- bar incisions. The simplest, of these, the vertical incision of Simon, may be used in operations for fixing the kidney or for a simple exploration in a thin patient. This incision is made along the outer edge of the erectbr spinae muscle and goes vertically from the last rib downward to near the crest of the ileum. The fibers of the latissimus dorsi are separated and retracted but not cut. The erector spin^e muscle is retracted inward and the sheath of the quadratus lumborum is opened along the length of the wound. The in- cision approaches the lower rib but if carried too close to the rib the pleura may be injured. This accident, however, can usually be avoided by pushing the tissues out of the way and by separating the tissues chiefiy by blunt dis- section up to the lower border of the rib. The transversalis fascia is recog- nized and opened at the upper part of the wound and the fatty capsule of the kidney bulges into the wound. The iliohypogastric and ilioinguinal nerves lie between the quadratus lumborum and the kidney and are protected by careful retraction outward and downward. They should also be recognized when the wound is closed so they will not be included in the bite of the suture. This incision is very satisfactory for exposure or fixation of a loose movable kidney in a thin person or for removal of a stone in such an indi- vidual. As a rule, however, when operation for stone is indicated, or when the kidney is to be removed, a more extensive lumbar incision should be made. The lumbar incision of W. J. Mayo gives excellent exposure. This is made by beginning about two and one-half inches external to the dorsal spine along the outer margin of the erector spin^ muscle well above the twelfth rib. The incision is carried downward and slightly forward along the anterior margin of the quadratus lumborum to about an inch above the crest of the ileum Avhere it curves forward parallel to the crest of the ileum (Fig. 590). It is carried as far forward as the indication may demand. After dividing the skin and superficial and deep fascia, the posterior superior lum- bar triangle just beneath the twelfth rib is opened by cutting through the external and internal ol)lique, the transversalis and the latissimus dorsi mus- cles and so exposing the lumbar portion of the transversalis fascia. This fascia 663 664 OPERATIVE SURGERY is freely incised, the ilioinguinal and iliohypogastric nerves are identified and retracted out of the way and the lower part of the incision is completed. The posterior part of the twelfth ril) is cleared backward and upward al- most to the articulation of the rib with the twelfth dorsal vertebra and the pleura is pushed upward. When the attachments of the quadratus lumborum and the lateral arcuate ligament which jjinds down the twelfth rib are di- vided, the twelfth rib can be retracted upward and outward Avhich gives an excellent exposure. The edge of the erector spinae muscle is retracted toward the spine. This incision can be used for all operations upon the kidney in which the kidnev is not more than two or three times its normal size Fig. 590. — The incision of W. J. ?iIayo for operation on the kidney. and where the procedure is more extensive than merely fixing a floating kidney or removing a small stone in a thin patient. When the kidney is considerablj^ larger than normal, and especially in large tumors of the kidney, an anterior abdominal incision should be made. This, called the incision of Langenbuch, begins just below the rib about three inches from the midline and is carried downward along the outer border of the rectus muscle in the linea semilunaris. The peritoneum is opened and the opposite kidney is examined Avith the hand before proceeding with the operation. The colon and its mesentery are retracted toward the midline and the kidney is exposed. Nephropexy, or suturing a floating kidney in place, is an operation that KIDNEY, URETER, AND BLADDER 665 is seldom hulicnti'd. It formerly had great vogue and many symptoms caused by nervous coiidilions, or l)y stasis or intraabdominal lesions were supposed to be due to a movable kidney. Occasionally, however, when excessive mo- bility of the kidney may cause it to be damaged, or where symptoms result because of traction or twisting of its pedicle or from kinks in the ureter nepliropex^y is indicated. When this operation is demanded the patient is always thin and the vertical incision of Simon can be satisfactorily employed. After exposing the kidney with the patient either prone or well over on the opposite side, the kidney is delivered into the wound and its fatty cap- sule which is scanty in these patients, is stripped backward and down- ward. It should not be removed for, as has been pointed out by Wil- lard Bartlett, if the fatty capsule is shoved to the lower portion of the kidney it affords some support. The capsule of the kidney is carefully in- Fig. 591. — Nephropex}'. The sutures for fixation liave been passed and the kidney is ready to be returned into position. cised in the midline and is bluntly stripped until about tAvo-thirds of the renal surface is exposed. Four sutures of tanned or chromic catgut are placed in the capsule as mattress sutures, two being near each pole. They are passed from the surface next to the kidney and close to the reflected capsule, catching a wide bite in the capsule. The needle is unthreaded and the ends of the sutures are left long and clamped (Fig. 591). The kidney is replaced and the ends of the upper suture are threaded into large curved needles and passed through the abdominal wall from within outward, pene- trating all the structures except the skin. The needle is first inserted in the ex- treme upper margin of the wound so that the upper pole of the kidney will 666 OPERATIVE SURGERY be drawn up under the twelfth rib when the sutures are tied. The lower sutures are passed in a similar manner, avoiding the ilioinguinal and ilio- hypogastric nerves. The sutures are tied after all of them are placed and while they are held taut to bring the denuded cortex of the kidney in close contact with the abdominal wound when it is closed. The wound is closed Avitli interrupted sutures of catgut. While the kidney is brought Avell up to the upper angle of the wound it is still not as high as it would normally be, but if it retains the position in which it is sutured the result will be satisfactory if the symptoms have been due to the mobility of the kidney. Some operators advocate fixing the kidney by passing the upper sutures around the twelfth rib. This should not be done unless there has been a recurrence, or unless the case seems to require unusual measures. Sutures should not be passed through the substance of the kidney itself, as they will cause a destruction of a certain amount of renal substance and this tissue does not hold sutures well. A sufficiently firm grasp can be obtained by passing the sutures through the reflected capsule of the kidney as mattress sutures. In nephrectomy for a condition in which the kidney is not much above the normal size the lumbar route is very satisfactory. After exposing the kidney by the incision of Mayo, the fatty capsule is split and bluntly dissected away. It is important to recognize the true capsule of the kidney after splitting the fatty capsule. The kidney is seized with the hand and by gentle traction, delivered into the wound. By strong retraction of the abdominal wound the pedicle is recognized. Fat is carefully separated from the renal artery and vein. If the pedicle is sufficiently long a ligature of catgut is carried around the renal artery and vein together and tied. The ligature should be placed as far from the kidney as possible and then a sec- ond ligature toward the kidney is placed half an inch from the first ligature. The ureter is separated from the rest of the pedicle and a clamp is applied to the renal artery and vein close to the kidney to prevent soiling with re- flux blood. The renal vessels are divided close to the clamp, leaving the kidney attached solely to the ureter. As much of the ureter as is thought necessary is stripped up and the ureter is doubly ligated, with catgut at the lower angle of the wound and divided between ligatures, preferably with a cautery. Not infrequentlj", there are anomalous polar arteries which must be identified and tied. Often when the pedicle is difficult to expose it can- not be satisfactorily ligated before the kidney has been removed. Here the pedicle is treated by seizing it with two forceps, as practiced by W. J. Mayo, after the ureter has been divided between two ligatures. The stump of the ureter is disinfected and in tuberculosis five to ten minims of carbolic acid are injected into the lumen of the distal part of the ure- ter with a hypodermic syringe. This in the practice of Mayo has been sat- isfactory when the ureter was tuberculous and there was no mixed infection. It is better to inject the carbolic acid before the ureter is clamped or tied. The portion of the ureter attached to the kidney is dissected up KIDNKY, URETER, AND BLADDER 667 well to the pelvis of the kidney so that it will not be included in the clamp on the pedicle. As much fat as possible is removed from the pedicle and then the pedicle is clamped with two forceps about three-quarters of an inch apart and another forceps near the Ividney. The kidney is cut away by severing the pedicle between the distal two forceps. A catgut ligature is thrown around the pedicle beneatli the deeper pair of forceps and is tied as this clamp is sloAvly unlocked so that it sinks into the groove made by the forceps. A second ligature, which is placed with a needle that transfixes the pedicle, is tied Avhile slowly removing the distal forceps. Both ligatures are of catgut. The first knot is single and may be held with mosquito forceps to prevent slipping Avhile running doAvn the second knot. If the nephrectomy is for sepsis or tuberculosis the infiltration of the tissues may make it impossible or unwise to ligate the renal vessels separately and the support of the sur- rounding tissue which has been crushed by forceps in the manner indicated adds to the safety of the ligatures. If on account of the obesity of the pa- tient or the shortness of the stump it is impossible to apply two forceps, one forceps may be used and the ligature passed through a margin of the pedicle and tied in a single knot in order to fix it in position. The ends of the liga- ture are then carried around the pedicle and securely tied in the groove left by the forceps. This procedure, however, W. J. Mayo has not found neces- sary in ligating the kidney pedicle for he has always been able to use the two forceps method. Occasionally instead of a ligature, the forceps may be left on and removed after forty-eight hours. The treatment of the pedicle in a nephrectomy is an exceedingly impor- tant part of this operation, first, because of the control of hemorrhage, and, second, because if the nephrectomy is done for a malignant tumor of the kidney, fragments of this tumor may project into the renal vein and if the pedicle is not carefully dissected and secured close to the vena cava at as early a stage in the operation as it can be exposed, manipulations may dis- lodge some fragments of the growth and force them into the renal vein. It is probable that this accounts for the early hematogenous metastases that occur after nephrectomy for hypernephroma. If the vessels are in- jured and the bleeding is profuse, pressure with a large piece of dry gauze should be made immediately over the bleeding point. If this controls the bleeding the edges of the gauze are gradually removed until the bleeding points are exposed and clamped. If the hemorrhage is arterial the suggestion of W. J. Mayo should be followed and the injured vessel siezed with the fingers. Pulsations of the artery and of the blood stream will lead the fingers to the injured artery. A clamp can then be applied safely. It is a great mis- take to attempt to clamp blindly in this region and forceps should not be applied until the bleeding point has been accurately located. Injuries to the vena cava and to the duodenum from indiscriminate and blind clamp- ing may occur and may be fatal. If the nephrectomy is for a kidney that is infected Avith pyogenic bacteria and if there is also some lesion of the bladder and of the other kidney the 668 OPERATIVE SURGERY ureter may be brouglit into the lower angle of the Avound, stitched to the skin, and left open. Mayo, who suggests this treatment, says that the ure- ter may discharge for a few days or even weeks, but will soon heal sponta- neously in most instances and when it does not heal it can be removed at a secondary operation. This treatment of the ureter, of course, is only in- dicated where there is marked infection with pyogenic germs and where the dropping of the stump of the ureter into the depth of the wound may cause infection of the whole wound. Before closing the wound the pedicle is examined and the Avhole field of the operation reviewed to see if the peri- toneal cavity has been opened or any injury has been done to the duodenum or colon. It is safer to apply drainage either with a tube or a cigarette drain at the upper angle of the wound. The wound is closed in layers with tanned catgut, using a continuous lock stitch, or with interrupted sutures of silkworm-gut, but always taking care not to include the ilioinguinal or the iliohypogastric nerves in the sutures. If there is no infection drainage can be removed in three days. The method of procedure during different stages of lumbar nephrectomy depends largely upon the indications for the operation. If done for a malig- nant growth the chief point is to expose and tie or clamp the renal blood vessels as soon as possible and as far from the kidney as can be safely done. This Avill prevent metastasis and the ureter may be attended to later, unless its location renders it difficult to secure the blood vessels of the pedicle before scA'Cring the ureter. When there is marked sepsis a double catgut ligature is placed on the ureter as far from the kidney as possible to occlude the ureter and prcA^ent forcing an unnecessary amount of septic material into the bladder. The blood A^essels can then be secured and divided, leaA-ing the kidney attached solely by the ureter. The ureter is surrounded by moist gauze and divided Avith a cautery betAveen the ligatures after being in- jected with carbolic acid. The changes that haA^e been indicated may be adopted according to the indications that arise. In some old tubercular kidneys, or in old infected kidneys Avith stone, de- livery of the kidney into the Avound is exceedingly difficult. Here subcap- sular nephrectomy is indicated. If there has been no previous operation and if no sinus or fistula exists the lumbar incision is made doAvn to the capsule of the kidney and the capsule is split along the outer border of the kidney and stripped doAvn to the pelvis. Here, according to the method of Federoff as used by W. J. Mayo, the capsule is divided near the pehas of the kidney and pushed back, leaving the capsule attached to the fat and the tissues in its neighborhood. The ureter is doubly ligated, and the A^essels of the pedicle are exposed. In such cases it is occasionally difficult to secure the pedicle by ligature, partly because of the infiltration of inflammatory prod- ucts which necessitates the subcapsular method of removing the kidney. Here the pedicle may be clamped Avith a stout pedicle forceps. The clamp is left on tAvo or three days and is then unlocked but left in position twelve hours longer, Avhen, if there is no bleeding, it is gently removed. KIDNEY, URETER, AND BLADDER 669 When the kidney is niiieli enhirged and particularly from malignant growths the nephrectomy should be done through an anterior abdominal incis- ion. Ample exposure is made by the incision that has been described along the linea semilunaris. The peritoneum at the root of the outer mesentery of the colon is incised and the colon with its mesentery is mobilized by gauze dissection and pushed toward the midline. The intestines are kept out of the way and protected by packs of warm moist gauze. The pedicle of the kidney is approached if it is possible to do so before any effort is made to mobilize the kidney. The renal vessels are exposed by careful dissection and tied with two catgut ligatures half an inch apart, the inner ligature being close to the vena cava. The vessels are next clamped near the kidney and the pedicle is divided. If this procedure is impossible on account of fat or infiltration of tissue the two forceps method as described in lumbar nephrectomy is used. The kidney is then mobilized, keeping a sharp look- out for anomalous arteries and veins. With a large tumor the adhesions may be very vascular and thin walled veins often develop along the adhes- ions. The ureter is doubly ligated and divided with a cautery as the last step of the operation, though it may be well to place a double ligature around the ureter immediately after securing the pedicle in order to prevent forcing infectious or malignant material into the bladder. The ureter is divided after the kidney and its tumor have been delivered. With a sufficient incision and careful exposure it is not often necessary to tap a tumor of the kidney before its removal and whenever this is done the danger of infection or metastasis is greatly increased. The wound is carefully reviewed to see that no accidental injury has occurred and all bleeding points are secured with catgut ligatures. Drainage is established by inserting a pedicle forceps into the cavity left after removing the kid- ney and pushing the forceps through to the back just external to the margin of the quadratus lumborum until the skin is reached. The skin is then in- cised over the tip of the forceps after separating the blades and the forceps are thrust through this skin incision and grasp a soft rubber tube about one- third of an inch in diameter which is drawn into the wound. The tube is fixed to the skin by a suture. The tube should project only about an inch into the cavity left by re- moving the kidney. The posterior parietal peritoneum is sutured to the outer di- vided layer of the mesentery of the colon by a continuous suture of catgut. The abdominal incision should be closed with interrupted sutures of coarse silk- worm-gut. In congenital cystic kidneys the disease is usually bilateral and the chief damage is probably done by pressure of a large number of cysts upon the secreting substance of the kidney. Lund has operated successfully in such cases by exposing the kidney and puncturing the cyst through the posterior surface of the kidney. As the cysts are punctured the kidney diminishes in size and can be delivered into the wound, when other cysts are palpated and emptied with a large aspirating needle or a small trocar and cannula. The 670 OPERATIVE SURGERY kidney is returned to its bed without drainage. Because congenital cystic disease of the kidney is usually bilateral, a nephrectomy sliould never be done unless it has been thoroughly established that the condition is unilateral and that the other kidney is functioning satisfactorily. Before any operation upon the kidney and, particularly, before a neph- rectomy is done the condition of the supposedly healthy kidney should be carefully ascertained by catheterizing the ureters and examining the urine from this kidney. Except in grave emergencies a nephrectomy is not justi- fied unless this is done. In abdominal nephrectomy advantage should also be taken of the incision to palpate the healthy kidney before the diseased one is removed. In nephrectomy following a previous nephrotomy there are naturally many adhesions. After making the usual incision and surrounding the fistula the capsule is best reached by splitting the fistula down to the cortex of the kidney and then stripping the capsule and proceeding as has been described with a subcapsular iiephrectomy. Operations for stone in the kidney are done either by splitting the kid- ney and extracting the stone through the renal cortex or by pyelotomy. Splitting the kidney, or nephrotomy, involves considerable hemorrhage and destruction of some of its parenchyma. This operation should be reserved only for those stones deep in the substance of the kidney or for very large stones that cannot be extracted through the pelvis without too great damage. The average stone can be removed from the pelvis of the kidney if satisfactory exposure is obtained. The kidney is exposed, preferably by the Mayo incision, and is delivered into the wound. The kidney and its pelvis and ureter should be palpated to determine the pathology present. It is then surrounded with moist gauze. Some operators temporarily clamp the pedicle with soft forceps or surround it with a rubber band to prevent hemorrhage during the incision into the kid- ney. It has been shown, however, that a kidnej^ withstands suspension of its cir- culation very poorly and such measures are not advisable. If the hemorrhage is profuse an assistant can usually control it for a short time by pressing with his fingers on the hilum of the kidney, using the fingers of one hand in front and of the other behind. This pressure can be relaxed if necessary to restore circulation or altered to suit the circumstances. If the Broedel line is followed the hemor- rhage is greatly lessened. Broedel has shown that the arteries in the cortex of the kidney are distributed into an anterior and posterior group and that the anterior group is wider than the posterior. The A'essels of these two groups to the renal cortex are smallest in size and least in number on a line slightly posterior to the external convex border of the kidney, because the anterior group of vessels supplies a little more than half of the organ. If it is impossible to deliver the kidney into the Avound, as sometimes occurs in fat people or where the pedicle is short, too much traction must not be made on the pedicle, but the finger is passed under the kidney to KIDNEY, URETER, AND I'.LADDKR 671 bring its convex bortler into tlie wound. An incision is then made slightly posterior to the apex of the convex border and just long enough for the finger to be passed into tlie pelvis. The stone is located and removed with forceps. The wound in the kidney is closed with interrupted sutures of stout plain catgut, preferably bringing a small tube out through the middle of the Avound but suturing the kidney substance around it as snugly as possible. A mat- tress suture in the kidney controls the hemorrhage better than an ordinary single stitch but it has been demonstrated experimentally by James E. Moore and J. F. Corbett that the mattress suture produces more injury to the kidney substance than a simple interrupted stitch. If the suture is tied just snugly enough to approximate the incision and the first tie of the knot is held with mosquito forceps w^hile the second tie is being run down, hemorrhage will be controlled, the kidney wound coapted, and a mini- mum of damage will be done to the kidney substance. If too much tension is put on these sutures they cut loose and cause additional hemorrhage. Thomas Cullen and others have recommended that the kidney be opened by a long, blunt, flat needle which is passed through the kidney from pole to pole and carries a fine silver wire. The kidney is cut with the wire from within out- ward with a minimum amount of hemorrhage. In kidneys where there is no scar tissue this method is excellent when it is intended to make a long incision in the kidney, but when scar tissue is present the wire will cause more trauma than the knife. It is not always necessary to open the kidney widely. After making a short incision to admit the finger, if it is found that the stone cannot be extracted through it, the incision may be enlarged following the line of Broedel either with the knife, or with a wire suture as suggested by Cullen. Nephrotomy for abscess is sometimes indicated, though nephrotomy, as a rule, is not satisfactory in tuberculosis of the kidney. If both kidneys are affected with tuberculosis and one is much worse than the other, nephrotomy may be indicated, but sometimes even here nephrectomy gives better results. F. S. Watson resorts to a double nephrostomy where it is necessary to divert the urine completely from the bladder, either in inoperable malignant growths of the bladder, or as a preliminary to total excision of the bladder. After exposing the kidney it is incised through Broedel's line and a tube is inserted. The ureter is then ligated as close to the pelvis of the kidney as pos- sible. After the fistulous tract into the kidney, which follows the drainage tube, has been well established a receptacle devised by AVatson is used. Es- sentially it consists of a cup shaped funnel that is placed over the fistula and is connected by a rubber tube with a metal receptacle that can be easily emptied. In most cases of stone where the stone is not very large the operation is best done through the pelvis of the kidney. It is necessary to deliver the kidney into the wound and to expose the posterior surface of the pelvis by turning the kidney forward. The fat over the pelvis is incised 672 OPERATIVE SURGERY and dissected back on each side. It should not be cut away, as W. J. Mayo has shown that it is very useful in covering the line of sutures and it prevents leakage. Before opening the pelvis the tissues around the kidney are thor- oughly protected with gauze in order to prevent soiling of the wound with the escaping urine. After exposing the pelvis it is incised in the general axis of the ureter. The incision should not be carried too close to the kidney substance because large vessels may be injured and it is difficult to suture this reo'ion satisfactorily. A suture of fine tanned catgut is placed in each Fig 592. — The pelvis of the kidney has been opened and a forceps is thrust through to the cortex, where it grasps a soft rubber catheter. lip of the wound in the pelvis and the ends are left long to act as tractor sutures. The incision is extended until it is large enough to permit explora- tion of the pelvis and extraction of the stone. The stone is caught wdth for- ceps made for that purpose and should be handled gently to prevent crush- ing it. If fragments are left behind they may form a nucleus for another stone, so it is important to remove the calculus intact. After extracting the stone the pelvis is explored with the little finger if the opening is too small to admit the index finger, but the exploration should be as gentle as pos- KIDNEY, URETER, AND BLADDER 673 sible because the fiuo'er eaii easily rupture veius about the calices that will cause consitlerable luMuorrliage. The ]iext step of the operation depends on whether the pelvis of the kid- iu\y is to be drained. The great objection to pyelotomy is that if a drainage tube is placed into the pelvis of the kidney the fistula that results is some- times very slow in closing. Many operators practice suturing the pelvis with- out drainage when there is no demonstrable infection. As the stone is of- ten the result of infection and is frequently accompanied by infection even though it is mild, it seems that drainage as a rule would be beneficial. This is particularly true since A. J. Crowell, of Charlotte, N. C, has shown that lavage of the kidney pelvis with silver solution carried out for some time after removal of the stone appears to prevent its recurrence. Drainao-e Fig. 593.— The catheter is drawn through so that its tip barely rests in the pelvis of the kidney. The catheter is fastened to the capsule of the kidney with a single stitch. of the pelvis of the kidney is best provided by inserting a small blunt pedicle forceps through the wound in the pelvis and thrusting it up through the substance of the kidney toward the middle point of Broedel's line, where it is shoved through the cortex. A new soft rubber catheter with one or two additional perforations cut near the end is caught and the tip of the catheter is drawn through into the pelvis of the kidney (Fig. 592). The tip should rest well within the pelvis but not far enough down to occlude the ureter. It is fastened in position by a mattress suture of fine tanned catgut 674 OPERATIVE SURGERY which passes through the capsule of the Ividney and then through the wall of the catheter (Fig. 593). The incision into the pelvis is closed by a continuous suture of fine tanned catgut. The fat and fascia which were dissected from the pelvis are brought together over the suture line and fastened with a few interrupted catgut sutures. The packing is removed and a small ciga- rette drain is carried down to near the pelvis of the kidney to conduct away any urine if there happens to be leakage. Both the cigarette drain and the catheter are brought out at the upper portion of the wound and the wound is closed in the usual manner. The catheter is connected to a bottle to prevent soiling of the dressing and if there is much infection in the pelvis of the kidney the catheter is kept in position three or four weeks and after a few days installa- tions of silver solution are made into the pelvis. In this manner we have the advantage of the incision through the jDelvis, together with drainage of the pelvis, but without the prospect of a prolonged fistula which may occur if the drainage is inserted into the wound in the pelvis. At the same time the catheter introduced in the manner indicated causes almost no destruction of the renal parenchyma and only a very small amount of bleeding. Usually there is no leakage around the catheter and the wound can be kept dry. Aside from the extraction of stones pyelotomy is but seldom indicated. Occasionally pyelitis demands drainage in this manner, but as a rule the urol- ogist can treat pyelitis satisfactorily by catheterizing the ureters and lavage of the pelvis. The beneficial action of catheterization of the ureters may be due to the dilatation of the ureter which makes better drainage from the pelvis. Hunner, of Baltimore, has obtained satisfactory results in many types of obscure pain merely by dilating strictures of the ureter. Hydronephrosis was formerly treated by plastic operations. Various op- erations have been devised for the infolding of the hydronephrotic sac or for the removal of a valve or a lateral anastomosis of the ureter to the lower portion of the hydronephrotic sac. These operations have been on the whole disappointing. Occasionally the hydronephrotic sac may be drawn up onto the kidney around its whole circumference and stitched to the capsule of the kidney. The kidney is thus invaginated into the sac. This procedure, which is recommended by C. H. Mayo, lessens the cavity of the hydronephrotic sac and tends to straighten kinks and folds. Even here, however, recur- rence of the hydronephrosis occurs. Sometimes hydronephrosis is due to plugging of the ureter with a stone or to a kink from adhesions, or from a low artery of the kidney which produces a fold in the ureter just after the ureter leaves the pelvis of the kidney. Obviously, such obstructions must be removed and if a stricture is found it may sometimes be corrected by incising the stricture longitudinally' and suturing the wound transversely to the axis of the in- cision, which is a common principle in plastic surgery. The excision of so-called valves is usually unsuccessful in producing a cure. If there is no obstruction that can be demonstrated and if the opposite kidney is sound nephrectomy offers the best solution of the problem. KIDNEY, URETER, AND BIjADDER G75 THE URETER Oj)oratioiis upon llio iirolci' e(ni,sist in incising' a stricture, in delivery of a stone, in suturing a avouiuI in the ureter, in uniting the ureter when divided, or in transplanting it. A stricture of the ureter is best treated by gradual dilatation if it can be en- tered by a bougie or catheter. If the stricture is in the lower end of the ureter just as it enters the bladder and it is imjiossible to pass a bougie or catheter, the ureter is exposed and incised about the brim of the pelvis. This may usually be done through a muscle splitting incision. An attempt is made to pass a sound or bougie from above downward and if this is impossible a stout probe is introduced to the stricture Avliich lies close to the bladder. The blad- der is then opened by a suprapubic cystotomy and, with the finger in the blad- der, the probe is gradually shoved through into the bladder and out at the su- prapubic wound. Two stout linen or silk threads are tied to the end of the probe and the probe is withdrawn, pulling the threads along with it. Both Fig. 594. — A stricture of the lower end of the ureter. A communication has been established with the bladder by the method described in the text, and a large silver wire or a ureteral catheter is drawn through. of these threads are long and the ends of one of them are tied together. The other serves as a guide to carry through either a large silver wire or a ureteral catheter, which is passed from the wound in the ureter downward through the bladder. If desired, a larger catheter can be passed after a few daj's. On account of the possibility of sepsis a stout silver wire probably does as well as the catheter and is less likely to produce infection. The wound in the ureter is drained by a cigarette drain which comes out at the abdominal wound (Fig. 594). If a ureteral catheter is used it should not 676 OPERATIVE SURGERY be permitted to stay in place more than a weelc and is tlien succeeded Ly a silver wire for the rest of the period of drainage. After two or three days the catheter or Avire is gently sawed back and forth to widen the tract. This pro- duces a large fistula between the ureter and the bladder slightly to the distal side of the stricture. Of course, the stricture must be in a location where the ureter either enters the bladder wall or is in juxtaposition to the bladder. In operations for stone in the ureter the stone is localized by roentgen rays, the ureteral catheter, or both, and an incision is made at a point where the stone will be most accessible. Frequently the stone is found in the ureter just as it crosses the brim of the pelvis or further down just as it enters the bladder, as these are points of natural constriction of the caliber of the ureter. The incision may be made as a muscle-splitting incision as in the McBurney operation for appendicitis, only the muscles are split more widely than in the appendicitis operation. When the peritoneum is reached it is not incised but is stripped up. This is readily done with dry gauze on a sponge forceps, the stri^Dping being toward the midline. A long retractor is inserted toward the midline and the iliac arteries are demonstrated. The ureter practically always adhers to the peritoneum and is recognized as a band. If a good light is obtainable and the ureter can be watched for a mo- ment peristalsis will often be seen. The ureter may be dilated above the stone. The stone can frequently be felt and the ureter thereby is readily recognized. When the peritoneum has been stripped up as far toward the spine as can be readily done the ureter v/ill be found adherent to the peritoneum and just external to the line of attachment of the peritoneum to the spine. If the pelvic portion of the ureter is to be exposed an incision along the outer bor- der of the rectus muscle is made, or a lower muscle-splitting incision. A use- ful guide to the ureter is the point at which it crosses the iliac artery at the bifurcation of ^ the common iliac. After the stone is located the ureter is isolated by blunt hooks or by passing a stout catgut ligature around it without tying the ligature. The ureter is brought toward the wound. It should not be dissected any freer from the surrounding tissues than is necessary because this may interfere with its nutrition and consequently delay healing. After protecting the sur- rounding tissues with gauze packing a longitudinal incision is made over the stone which is extracted. It is best, as a rule, not to attempt to suture the ureter, though if the incision is unusually long a few interrupted sutures of fine tanned or chromic catgut may be placed. They should not penetrate the whole thickness of the ureteral wall. A cigarette drain or a strip of rubber tissue is carried down to the wound in the ureter. If the wound in the ureter is in the pelvis a soft rubber tube should never be used for drainage. Sev- eral cases are on record where the resting of a soft rubber tube on the iliac artery unprotected by peritoneal covering has produced secondary hemor- rhage by pressure necrosis in the artery. A cigarette drain or a strip of rubber tissue will hardly cause this. In extraction of a stone from KIDNEY, URETER, AND BLADDER 677 the ureter above the ])elvis, wliere tlie drainage will not be in contact with any large vessels, a soft rnbber tube may be used. Many ureteral stones can be removed with a cystoscope in the hands of an ex- pert urologist. If this seems possible after the size and location of the stone have been determined, an effort should be made to extract the stone in this manner be- fore resorting to operation. Only one well trained in such work should attempt this, hoAvever, as it requires much skill and practice. The ureter is sometimes divided accidentally in operations in its neigh- borhood, particularly in extensive operations for malignant growths of the uterus. If the other kidney is sound the Mayos practice simple ligation of the ureter and find that the kidney is obliterated with but little or no pain and that the other kidney takes up the work satisfactorily. If, however, there is any suspicion of the function of the opposite kidney, this should not be done. If it is possible to do so without too great risk to the patient an effort should be made to reestablish the continuity of the ureter. Various operations have been devised for this purpose, but it has been quite clearly proved, particularly by the Avork of R. J. Payne, of Norfolk, Va., that all of the methods of uniting a divided ureter are likely to be followed by stric- ture except the simple eud-to-end method. This is logical because here the minimum amount of raAv surface is apposed and consequently there is less scar tissue to cause later contraction. If a satisfactory exposure can be had the suturing together of a divided ureter is not a very difficult procedure. The sutures may be of ver}^ fine silk or preferably of fine tanned or chromic catgut. The objection to silk is that it may work into the lumen and as a foreign body form a nucleus for a stone. Three interrupted sutures are passed at equal distances around the circum- ference of the ureter and approximate the divided ends of the ureter in much the same manner as Carrel uses in suturing blood vessels. All of these sutures should be passed before any of them is tied. In this manner they can be simultaneously draAvn taut and tied one at a time Avhile the others are held taut, so keeping unnecessary strain from the suture that is being tied. The ends of the sutures are left long, the margins of the wound are whipped over with a continuous suture of fine tanned or chromic catgut in a fine curved needle Avhile holding the three tractor sutures in such a manner as to render the part of the wound that is being sutured readily accessible and moderately tense. While suturing between two tractor sutures the third should be slightly pulled away to prevent the possibility of catching the opposite Avail of the ureter in the sutures. The sutures should not be draAvn too tightly, but just enough to secure accurate approximation. After the AAiiole circumference of the divided ureter has been sutured, the ends of the tractor sutures are cut rather long and the ureter is returned to its bed. When a considerable portion of the ureter has been sacrificed it is impossible to approximate the ends of the ureter Avithout too much tension. As suggested by Payne, of Norfolk, much can often be gained by mobiliz- ing the kidney and its pelvis and the upper ureter through an incision 678 OPERATIVE SURGERY made as tlioiigli a nephrectomy were to be done. The kidney and ureter may be shoved down to such an extent as to overcome a considerable de- fect in the ureter and permit approximation of its ends which would other- wise be impossible. In a contemplated excision of the bladder or in injury of the ureter near the bladder a direct anastomosis cannot be made and here the question of the disposition of the ureter must be settled. There is a choice of four different methods. 1. The ureter ma^^ be tied and, as has already been mentioned the kidney will, as a rule, eventually atrophy and give no further trouble. This method may be used in emergencies when the patient is in shock or the condition is so grave as to demand the quickest procedure and when there is assurance that the ureter and kidney on the other side are normal. Such a method should be only exceptionally resorted to as the aim in surgery should be, first, to preserve life and, second, to preserve function. It is only when these two aims are in conflict that function should be destroyed. 2. The ureter may be transplanted to the skin as originally proposed by Harrison and by Bottomley.^ Here the ureter is brought to the skin of the loin and a special apparatus used to collect the urine. This transplan- tation can be done either extraperitoneally or transperitoneally, transplant- ing preferably one ureter at a time. Instead of doing this the ureter may be ligated and a nephrostomy done according to the method of Watson, using a special apparatus to collect the urine from the nephrostomy wound. Such procedures may be resorted to in patients that are past forty years wdiere both ureters must be transplanted. 3. The ureter may be transplanted into the bowel. This may be neces- sary because of the extensive disease of the bladder or in exstrophy of the bladder. 4. The ureter may be transplanted into the bladder. This, of course, is the most desirable disposition of the ureter but unfortunately it is not always possi- ble. In resection of a portion of the bladder for malignant disease when the orifice of the ureter is involved, the ureter may be transplanted into the bladder with considerable assurance of a permanent preservation of the function of the kidney from which the ureter comes. The technic of this transplantation depends to some extent upon the amount of bladder that must be removed. The Coffey operation should be used wherever possible in order to prevent back pressure from the bladder and to establish a valve of the mucosa. This operation consists in making an incision about an inch long through the serous and muscular coats of the bladder and down to the mucosa. After undermining the muscular coat on each, side a small stab wound is made through the mucosa at the distal end of the incision. The ureter is split and caught near the tip with a single suture of plain catgut which has a needle on both ends. First one needle and then the other is passed through' the stab wound in the mucosa and ijour. Am. Med. Assn., 1907, xlix, 141, et seq. KIDNEY, URETER, AND BLADDER 679 penetrates the bladder from Avitliin outward at a point about three-quarters of an incli from the stab Avound. There sliould be a short space between the points of exit of the needles. The suture is then gradually pulled upon until the ureter is drawn into tlie bladder. The ureter is fixed by tying this suture and the muscular and peritoneal coats of the bladder are sutured too'other over it. An additional stay suture of catgut fixes the ureter to the bladder Avail about a (|uarter of an inch from the site of the anastomosis. If it is possil)le to do so it is best to place a second row of sutures to bury the first row, though care must be taken not to constrict the ureter, as this Avill have the effect of damming back the urine and may produce a hydronephrosis with destruction of the kidney, just as Avould occur af- ter ligation of the ureter. The ureter should be handled as gently as pos- sible during all of these manipulations. It should never be clamped at the end or elscAvhere even with a soft nose forceps and its mucosa should not be sutured except with the first fixation suture which is of catgut and passes through the tip of the ureter, fixing the end of the ureter within the lumen of the bladder. The next fixation suture which is passed about one-quarter of an inch from the site of anastomosis does not penetrate to the mucosa of the ureter. Frequently, however, such an ideal technic cannot be carried out and it may be necessary to make a direct transplantation. Whenever a trans- plantation is done there should be no tension at the junction of the ureter and bladder for this Avill surely imdte failure. If so much of the bladder and ureter are sacrificed, as after an operation for cancer, that it is im- possible to implant the ureter after the method described without tension, the direct implantation should be done. Here the inch of the ureter that is imbedded in the bladder wall is not needed so tension may be avoided. In any instance, no more of the ureter should be separated from its bed than is necessary for the manipulation because an extensive dissection Avill de- stroy the blood supply of the ureter and predispose to fistula formation or to poor healing. In direct transplantation, after mobilizing the ureter and cutting its end either obliquely or splitting it, a single mattress suture of linen is passed through the tip of the ureter and left long. A uterine probe is introduced through the urethra, either in man or Avoman, and the tip of the probe is pushed into the Avail of the bladder at a point Avhere there Avill be least tension betAveen a transplanted ureter and the bladder Avail. A short stab in- cision is made over the point of the uterine probe and the long ends of the linen suture in the ureter are fixed in a loop knot around the end of the uterine probe (Fig. 595). The probe is then AvithdraAvn, leaving the suture protrud- ing from the the external urethral meatus. A catgut suture is passed through part of the Avail of the ureter about one-half an inch from its end. The linen tractor suture is pulled upon until the ureter is draAvn into the bladder and the catgut suture is flush Avith the external surface of the bladder Avail, when the catgut suture takes a bite in the bladder and is tied. A similar suture 680 OPERATIVE SURGERY is inserted on the opposite side of the ureter, cateliing only the muscular coat, and further fixes the ureter to the bladder wall. Several other sutures are placed still further to invaginate the ureter. If it is possible to do so the ureter is best implanted into a portion of the bladder that is covered with peritoneum, or sometimes a strip of peritoneum can be left on the anterior surface of the ure- ter which will greatly facilitate the healing. Slight traction is made on the linen tractor suture to determine accuratelv the amount of tension that will Fig. 595. — A method of transplanting the ureter. A probe has been thrust through the bladder wall and the suture on the end of the prepared ureter is fastened to the tip of the probe. be needed to keep the ureter in position. When this is established the tractor suture is fastened to the vulva in the female or attached to a thin rubber band and fastened to the leg of the patient in a male (Fig. 596). If too much traction is used the suture quickly cuts out and if too little is made there is not sufficient relief of whatever tension exists between the ureter and bladder at the point of junction. Therefore, it is important to determine this point when the anastomosis has been finished and before the wound is closed. The dissected portion of the ure- ter is covered with a peritoneal flap (Fig. 596) or with the sigmoid. A small KIDNEY, URETER, AND BLADDER 681 piece oL' rubber clam is carried clown to the site of the anastomosis to conduct away any urine if there is lealaige. All sutures that involve the bladder mu- cosa should be of ]>lain catgut and olliers in the bladder wall may be of fine tanned or cliromic catgut. The tractor suture of linen will come away in five or six days and in this time union will be sufficiently firm for ]io leakage to occur, particularly if peritoneum can be utilized either on the anterior surface of the ureter or on the bladder wall. The blacl- ^'^' ^^^^'^^^ ureter has been drawn into the bladder by the method shown in the preceding illustration, ilie peritoneum has been dissected so as to form a flap and completely envelops the ureter. der is drained either by an indwelling catheter in the female, or by a perineal or suprapubic cystotomy in the male. It may be necessary to transplant both ureters into the bowel in exstrophy of the bladder or where a malignant growth involves so much of the bladder wall as to render a radical operation impossible or to necessitate removal of the wdiole bladder. In exstrophy of the bladder, the operation should not be done until the child is about four years old when he can attend to the 682 OPERATIVE SURGERY emptying of the bowels at sutHcient intervals to prevent too great an accu- mulation of urine in the colon. In operation for exstrophy many plastic pi'oce- dures have been advised, such as turning in skin flaps from the margin of the ectopic bladder and reconstructing a urethra. Such operations, even if successful, do not give control of the urine, which is the most desirable thing to be attained. Besides, turning in flaps from the margins of the bladder necessitates the turning in of some portion of the skin in Avhich hair will later form, and this becomes a perpetual source of inflammation and a nucleus for stone formation. Plastic operations for exstrophy of the bladder, then, seem to accom- plish very little. The operation of Maydl consisted of dissecting out that portion of the base of the bladder containing the ureters and transplanting this segment into the rectum as a transperitoneal operation. In this manner the natural valves of the ureters are preserved but the terminal nerve sup- ply is, of course, destroyed. Moynihan has slightly modifled the Maydl operation by taking a large portion of the bladder. Operations after the Maydl principle have been followed by a large mortality. The injury to the nerve supply of the lower portion of the ureters and the necessarily poor blood supply to the transplanted segment of bladder which, of course, demands more blood the larger the segment that is transplanted, are probably responsible for the unsatisfactory results. Then, too, the transplantation of both ureters at the same operation greatly increases the danger. As pointed out by C. H. Mayo a considerable portion of the urine is carried to the right side of the colon as after the Murphy drip and is here absorbed. If both ureters are transplanted at the same time uremia may result, but if there is an interval of two weeks or more between the transplantations, the patient will have developed sufficient protective reaction against the unphysiologic disposi- tion of the urine to withstand the result of the second transplantation. This is shown by the fact that C. H. Mayo^ reports that since 1896 six patients with exstrophy of the bladder have been operated upon by plastic methods and none has control of the urine ; three were operated upon by the Maydl- Moynihan method and two of these died in the hospital from uremia; while thirteen patients were successfully operated upon by the transplantation of the ureters wdth only one operative death. These statistics point clearly to the wisdom of transplantation of the ureter into the sigmoid at separate sit- tings as the operation of choice in exstrophy of the bladder. Exactly the same technic, of course, could be used when malignant disease of the bladder is so extensive as to necessitate the transplantation of the ureters elsewhere, though Avith the ditference that in the young the transplantation into the sigmoid is the most satisfactory method, Avhereas in the elderly it may be safer to bring the opening of the ureters to the skin in the loin as practiced by Bottomley or to use the double nephrostomy of Watson. The indica- =Mayo, C. H.: Jour. Am. Med. Assn., 1917, Ixix, 2079, et seq. KIDNEY, URETER, AND BLADDER 683 tions for tlio dinVreiit ])ro('(Mlur(',s clei)0jul to some extent upon the desire of the patient. If the ureter is to be transphinted into the sigmoid either for exstrophy of the hhidder or for malignancy, the first operation is best done on the right side, making an incision slightly to the right of the midline, because the sigmoid is on the left and, as pointed out by C. H. Mayo, if the operation on the left side is first done it may be more difficult to mobilize the sigmoid in the second operation which must be on the right side. After exposing the sigmoid and determining the point at which the anastomosis should be made, and particularly with regard to a subsequent operation on the left side, this point is fixed by clamping the sigmoid with a large curved intes- tinal clamp. The lower end of the ureter is dissected out and divided close to the bladder and the proximal end is split for a quarter of an inch. In order to preserve the nutrition of the ureter, as in operations for trans- plantation of the ureter into the bladder, no more of the ureter is dissected free than is necessary for the purposes of the operation. The distal end of the ureter is tied and in exstrophy it may be buried in the tissues around it by a few catgut sutures. The peritoneum and muscular coats of that portion of the sigmoid in the grasp of the curved intestinal clamp is incised for about an inch and a half. It is best to make this incision through the firm longi- tudinal bands in the Avail of the sigmoid. The incision is carried down to the mucosa but not through it. At the distal portion of the incision the mucosa is punctured and a fine tanned catgut suture which transfixes the tip of the ureter is threaded with a needle at each end, carried through this punctured wound in the mucosa, and penetrates the bowel half an inch distal to the punctured wound. Both needles are carried through a short distance from each other and the suture is tied, so fixing the ureter in its new position. The wall of the ureter is caught in the bite of a catgut suture just as it penetrates the mucosa and the suture also catches a bite in the muscular and peritoneal coats of the sigmoid on each side. This suture is tied so as still further to fix the ureter in the wall of the sigmoid. The incision is closed by continuous sutures of tanned or chromic catgut which bury the ureter on the mucosa. A valve is formed of the mucosa which pre- vents back pressure. This method of Coffey tends greatly to diminish as- cending infection of the kidney. By using this principle of his, pressure within the bowel produces a valve-like effect on the mucosa and occludes the end of the ureter against the gas pressure within the bowel, but at the same time does not produce sufficient pressure to prevent delivery of the urine into the bowel. The wound is closed without drainage, or else with a small soft tube of rubber dam. The sphincter is dilated and a tube inserted a few inches in the rectum for the first four or five days in order to facilitate the emptying of the urine until the bowel gradually becomes accustomed to it. The second ureter is transplanted about two weeks later if the patient is in good condition. 684 OPERATIVE SURGERY THE BLADDER Tumors of the bladder may require operation. Many tumors, particu- larly the benign papillomas, are cured by fulguration, and radium in some cases IS beneficial. If the tumor is malignant and involves a considerable portion of the bladder wall, and particularly if it does not readily respond to fulguration or radium, operation is the best method of treatment. If the growth has a distinct pedicle the mucosa can be excised around the pedicle Avith a cautery but usually the resection should include the whole thickness of the bladder wall, going some distance beyond the apparent margins of the growth into what seems to be healthy tissue. Excision of the total thickness of the bladder wall is no more difficult than excision of a portion of the wall and is more likely to result in cure. If the growth involves the part of the bladder that is covered with peritoneum the peritoneal cavity is opened and packed off and the diseased section is removed. If, however, other portions of the bladder are involved, the operation should be done ex- traperitoneally if possible. Most tumors of the bladder originate in the base of the bladder and many of these involve one of the ureteral openings, so that excision of this section of the bladder will involve transplanta- tion of the ureter, or else ligation of the ureter if the remaining kidney is healthy and it is impossible to transplant the ureter. Occasionally, both ureters require transplantation. Whether the peritoneal cavity is opened or not the patient is placed in the Trendelenburg position and good exposure is obtained by a large incis- ion in the bladder. Care is always taken to protect the prevesical space by packing it with gauze. The incision is preferably made transversely, though the location of the disease will control its direction. The excision of the bladder w^all is made with an electric cautery wherever possible. The blad- der wound is closed with two layers of catgut sutures, the inner layer of plain catgut and catching as little as possible of the mucosa. The outer layer of tanned or chromic catgut is inserted through the muscular coat only and like the inner layer is a continuous suture. Drainage is always placed either through a portion of the incision, preferably as close to the peritoneal fold as possible, or the incision may be closed completely and drainage instituted through a stab wound at about the apex of the bladder and an inch or more from the sutured incision. If it is necessary to dissect the space of Retzius extensively, a gauze cigarette drain is placed to the bottom of this space in addition to the drainage in the bladder. Diverticula of the bladder are treated satisfactorily by operation. The diverticulum s}iould be accurately located by roentgen rays and by cysto- scopic examination before the operation is attempted. The bladder is opened suprapubically and the diverticulum explored with the finger and by inspection with the patient in the Trendelenburg position. If the pouch is not very ad- herent it may be pulled into the bladder with forceps, or, using the technic of H. H. Young, it may be everted by a suction apparatus that is attached KIDNEY, URETER, AND BLADDER 685 to a large tiil)e M'liieli is placed over the neck of the divei-ticulum. Small non- adherent diverticula are treated satisfactorily in this way. When the diver- ticulum is large or when it is adherent it is necessary to dissect it externally. After opening the bladder M'idely through the prevesical space and pro- tecting the prevesical space with gauze packing, the diverticulum is ex- plored with the finger. It may be packed with gauze to identify it, as sug- gested by Lower, or with one or two fingers in the diverticulum, as practiced by Judd, dissection is carried through the prevesical tissues to the sac which is lifted up by the fingers within it. If the sac is covered by peritoneum the peritoneum may be opened though usually this is not necessary. The vas deferens and the ureter must be identified and injury to these structures avoided. Occasionally the ureter is involved in the diverticulum and it may be necessary to divide it and reimplant it into the bladder. If the prostate is en- larged it should be removed at the same operation. When the sac has been com- pletely freed the internal relation of the neck of the sac to the ureter is noted and the diverticulum is then cut away. The opening in the bladder is closed as after operations for tumors. The suprapubic opening is sutured except for a drainage tube which comes out at the upper part of the bladder wound near the peritoneal fold. A cigarette drain is carried down through the prevesical space to the site of the old diverticulum. Approach to the bladder for the operations that have been mentioned, or for stone or for drainage is frequently indicated. This operation of supra- pubic cystotomy may be exceedingly simple when the bladder is distended or capable of being distended, or it may be difficult if the bladder is thick and contracted. Where it is possible to do so it is best to distend the bladder with some mild antiseptic solution, such as boric acid solution, just before the operation. A soft rubber catheter is inserted into the bladder and the warm boric acid solution is gradually introduced by gravity until the bladder is filled. If the irrigating can is not more than two feet above the level of the patient's body it is hardly possible for the bladder to be damaged by the irrigation. The catheter is left in position. The bladder should never be filled by a piston syringe, as several cases are recorded in which an appar- ently low degree of pressure with such a syringe ruptured the bladder. If gravity is used slowly and carefully such an accident is impossible. It must be borne in mind, however, that in manipulating a well filled bladder strong pressure upon it may cause it to rupture. A tape is tied around the penis in order to prevent the escape of the fluid around the catheter. An incision is made in the abdominal wall, usually a longitudinal incision, and after separating the fibers of the recti and pyramidalis muscles the fascia immediately beneath them is incised and the prevesical fat exposed. The peritoneal fold in the upper portion of the wound is recognized and gently stripped upward with gauze. If it is opened it may be immediately sutured without danger. The fat is divided down to the anterior wall of the bladder and is then pushed to the side and down- ward into the space of Retzius, It is well to place a small gauze pack at the 686 OPERATIVE SURGERY Tipper angle of the wound in order to protect tlie peritoneal cavity from being accidentally opened while enlarging tlie incision. If the operation is done merely for drainage and exploration a short vertical incision that will admit the finger is all that is necessary, but if a large tumor is to be removed a more ample exposure is required. Here the incision in the bladder wall should be transverse, keeping along its apex and as close to the peritoneal fold as seems safe. If it goes down into the space of Eetzius and near the urethral opening it is difficult to suture and to heal. The bladder wall having been recognized may be fixed either by two Allis forceps or by two sutures of catgut or silk that are inserted with a round curved needle. The fluid is then drawn off through the catheter in the urethra and the bladder is incised between the two forceps or sutures. In this way the prevesical tissues are not flooded with the vesical contents and infection is less likely to occur. Where the bladder is distended from an impermeable obstruction, the urine may be drawn off by thrusting a trocar and cannula through the bladder wall -which is incised after withdrawing the trocar and cannula. It may occasionally be difficult to recognize the bladder wall if not distended, but when filled with fluid it is easih' identified. After opening the bladder the incision is extended for better exposure or the stone is extracted, or drainage instituted, according to the indications. The bladder should always be explored thoroughly with the finger before drainage is placed. If the incision in the bladder wall is short a drainage tube is brought out at the upper portion of the incision and the lower margin of the wound is closed with catgut sutures. These sutures in a short w^ound are interrupted, of tanned catgut, and take either none of the mucosa or as small an amount of it as possible. In a larger bladder wound the two layers of sutures that have been mentioned are the best method of closing the wound. Bleeding in the bladder wound is controlled by whipping over the bleeding spot Avith small plain catgut in a round noncutting needle. Occasionally, drainage is done through the perineum and the supra- pubic wound is closed entirely. With the patient in the dorsal position pedicle forceps or long dressing forceps are inserted into the bladder and through the internal meatus into the urethra. Pressure is made on the for- ceps so that the tip bulges in the perineum and is cut down upon in the peri- neum. A rubber drainage tube or a large soft rubber catheter is grasped with the forceps, drawn through into the bladder, and fixed to the skin of the perineum with a silkworm-gut suture. The end of the catheter should not be more than two inches within the bladder as otherwise it will cause an unnecessary amount of irritation. The suprapubic wound in the bladder may then be entirely closed. If a suprapubic cystotomy is done with the bladder collapsed the abdom- inal incision is the same as when the bladder is distended, but the vesical wall is much more inaccessible. Having the patient in the Trendelenburg posi- tion is a great help. Dissection is carried down to the pubic bone and then the prevesical fat is cut through until the bladder is demonstrated. After it has been recognized it is incised and the operation finished in KIDNEY, URETER, AND BLADDER 687 the usual maiiiuM-. If a sound or a callietiT can he inlroduccd into the l)lad- der usually it can l)c dislcndcd, but careful dissection without a sound will, as a rule, expose the bladder wall Avithout much difficulty. With an iini)ernieal)le stricture or a prostatic obstruction it is sometimes impossible to enter the bladder with an instrument through the urethra. These patients are often poor surgical risks and it is necessary to evacuate the urine by as simple a process as possible. Here a puncture with a tro- car and cannula is satisfactory. A trocar and cannula are selected so that the trocar can be removed and a small soft rubber catheter threaded through the cannula into the bladder. The trocar and cannula should be of such a type that the urine can be drawn off through a lateral projection near the end of the cannula. Before the operation the catheter is tested to see that it will go through the cannula easily. The skin of the abdomen is infiltrated and an incision of half an inch is made just above the pubis and close to the pubic bone. The deeper tissues are infiltrated with procaine solution, a proper trocar and cannula are grasped firmly, and thrust quickly into the bladder in a direction inward and upw^ard. Of course this is never done except Avlien the bladder is fully distended. If the trocar and cannula go straight inward the prevesical space may be injured, the trocar will sometimes cut the bladder wall obliquely and if there is a large prostate it may not en- ter the bladder at all. By directing the thrust upward as well as inward this accident to the prevesical space is avoided and there is no danger of injuring the peritoneum if the bladder is distended, provided the entrance point in the abdominal w^all is just above the pubic bone. The trocar is pulled back and the urine allowed to flow. After the bladder has been emptied the trocar is unscrewed, the cannula being left in position. The cannula must be kept well within the bladder wall, because if it is once withdrawn after the bladder has been emptied it will not only be impossible to reinsert it but leakage will certainly occur into the prevesical space. The previously selected soft rubber catheter with an additional eye cut near the end is threaded through the cannula w^hich is then withdrawn. The amount of catheter to be left in the bladder is determined by compar- ing it with another catheter of equal length. There should be four inches of it below the level of the skin and if the patient is stout five inches w^ould be better. It is wrapped around with adhesive at the skin level and fastened in position by a suture of silkworm-gut which goes through the skin and through the adhesive that is wrapped around the catheter but does not penetrate the wall of the catheter itself. The catheter should be new and should be tested before it is used. An old one will sometimes break and may leave a portion of it in the bladder. This method of drainage will not cause leakage around the catheter and the patient can be kept perfectly dry. The catheter must not be removed, however, for at least two weeks unless as a preliminary step to an operation, because it takes about this time for the granulations to produce firm tissue around its wall and so prevent infiltration of urine into the prevesical 688 OPERATIVE SURGERY siDaee. If the catheter has Ijecome aeeideiitally displaced in the first few days after such an operation and cannot be readily reintroduced, a supra- pubic cystotomy should be done at once to protect the prevesical space from infiltration of urine. Total excision of the bladder may sometimes be indicated. The first stage consists of an anastomosis of the ureters to the sigmoid, or bringing them to the skin of the groin, or establishing the bilateral nephrostomy of Watson. Some weeks after this has been done the bladder is excised as though it were a cystic tumor. The anterior surface of the bladder is exposed through an ample incision and separated from the peritoneum anteriorly and laterally. It is gradually delivered into the wound and the dissection continued until the neck of the bladder, the inferior vesical arteries, and the stumps of the ureters have been reached. The vessels are doubly clamped and the base of the bladder is separated from the rectum as far as possible. The neck of the bladder is divided, preferably with the cautery, while making traction to pull up as much of the urethra as possible. Such an operation is rarely indicated. Perineal section is not done as frequently as in preantiseptic days, but is occasionally indicated particularly for deep stricture. If a grooved sound can be passed into the bladder the patient is placed in the dorsal posi- tion and an incision is made in the perineum just back of the scrotum down to the urethra, which is opened. This incision can be carried to an inch of the anus if kept in the midline. The urethral bulb must not be injured and is pulled forward in the midline so that the urethra is opened on the grooved staff" and freely incised to the apex of the prostate. The staff is remoA'-ed and a grooved director or Teale's gorget, is inserted and the finger is pushed into the bladder with a boring motion along the direc- tor or gorget. A drainage tube is inserted. A soft rubber rectal tube does well for this purpose. It should be so placed as not to project into the bladder more than an inch. It is fixed in position by suturing it to the skin with an interrupted silkworm-gut stitch. Bleeding is controlled by whipping over the bleeding points with catgut in a needle before inserting the drainage tube and by iodoform gauze packing around the tube down to the urethra. If there is but little infection in the bladder and the operation IS done for stone or for exploratory purposes, the tube may be removed in three days. In cj'stitis, drainage must be kept up for several weeks. "When necessary to gain greater room the incision may be continued into the prostatic portion of the urethra along the midline. When it is impossible to introduce a sound or staff into the bladder, ex- ternal urethrotomy becomes more difficult. A sound is introduced down to the point of obstruction, which is usualh' in the membranous urethra. The in- cision is carefully carried down to the sound and the bleeding is controlled by clamping or by whipping over the bleeding points with plain catgut. The urethra is incised as far as the obstruction. Sometimes a view of the stric- ture can be obtained and a probe or bougie accurately introduced through the KIDNEY, URETER, AND 1!I. ADDER 689 stricl iiri". It' ;i sluirp-pniiilcd liciiioslat ran Ix' iiil I'dduccd tlio jaws are spread aparl and Ihc si ricliirc is dilated. A pair (if larger forceps is then inserted and tlie jaws are sjiread. When tlie stricture is very dense or wlieii tliere is a consid- erable amount of intlaniniatioii it may be divided by au incision with a knife. Vvvy dense strictures luive l)een excised and efforts have 1)een made to ap- proximate tlu^ ends of the urethra. This, however, is tedious and recurrence is freciuent, though wliere there is a local heavy deposit of scar tissue ex- cision nuiy be attempted. ]f the opening in the stricture cannot be inspected a filiform bougie is introduced through the urethral wound. This Avill serve as a guide for the introduction of a large instrument or a pair of sharp nose forceps, or a knife to divide the stricture. The stricture is thoroughly divided so that the finger can be introduced into the bladder. A large soft rubber catheter or a small rectal tube is carried into the bladder and held in position by su- turing it to the skin. This should be removed in three or four days, the tube boiled, and reinserted. The wound is irrigated several times a day with hot boric acid solution. The patient is given hexamethylenamin if the kidneys are in a condition to stand it without tf»o much irritation and every effort is made to prevent infection. Occasionally after a rupture of the urethra it is impossible to enter the bladder from below. Here a small suprapubic incision is made and the urethra catheterized or a sound introduced into the urethra from within the bladder. This will demonstrate the location of the urethra in the perineal wound and is a much safer procedure than a prolonged blind dissection in the perineum. CHAPTER XXIX OPERATIONS ON THE PROSTATE GLAND, THE TESTICLES AND TlHE PENIS Prostatectomy may be done by tlie perineal or the suprapubic route. There are ardent advocates of both routes though the suprapubic has be- come more popular. The operation of H. H. Young is probably the most satisfactory for removal of the prostate through the perineum. The supra- pubic method is simpler and the enucleation following the general principles of the technic of Squiers has given excellent results. The operator should have the technic of either route at his command. In the small fibrous prostate, especially if there is a possibility of malignancy, the perineal route is preferable. In the large adenomatous prostate, removal by the suprapubic route seems better. The objections to the perineal route are: 1. It is more complicated and the operation takes somewhat longer to perform. 2. There is a possibility of injury to the rectum and fistula formation. 3. It is somewhat more difficult to control the bleeding by the perineal route. 4. Persistent urinary fistula is probably more frequent by the perineal route. The objections to the suprapubic route are: 1. The removal of the whole urethra contained in the prostate is some- times folloAved by stricture. 2. If the prostate is cancerous and very adherent it can be removed more satisfactorily by sharp dissection through the jDerineal route than through the suprapubic. 3. It is claimed by some operators that on account of the extensive manipulation within the bladder by the suprapubic route uremia is more likely to result. The choice of these two routes depends somewhat upon the experience of the surgeon. The operation, particularly the suprapubic operation, is technically not very difficult, though it is particularly necessary to have had training in assisting and observing these operations done bj' one who is skilled in this work before the surgeon attempts the operation. It is most important to have the patient in the proper condition to stand the operation. The high mortality for prostatectomy in the early history of this operation was partly due to a crude technic but more to the inability to determine the functional capacity of the kidneys. "When there is much 690 PROSTATE, TESTICLES, AND PENIS 691 residual ui'iiic 1l)r l)ii('k ])Tessure ii])()ii tln' kidneys gradually alters the con- ditions iiiidrr wliit'li tliey finu'tiou and tiicy gradually meet these changed conditions. A sudden and permanent i'ein()\al of this l)ack ])ressure may affect the kidneys profoundly. For this reason the patient should either be catheterized or drained for some days or for some weeks before a pros- tatectomy is done. The I'cnal function should be accurately determined, partly by chemical analysis of the urine, but chiefly by functional tests of the kidneys. As pointed out forcibly by Louis Frank,^ not only should the function of the kid- neys be determined by the phenolsulphonephthalein secretion, but by the estimate of the blood urea, and if greater accuracy is demanded by the determination of Ambard's coefficient. No matter how skillful the operative technie may be, if these patients do not show satisfactory renal function, disaster is likely to follow. If in doubt, it is wise to drain, either by an indwelling catheter or by a suprapubic drainage, until such a time as the blood urea shows that the kidneys are working satisfactorily. Suprapubic prostatectomy with enucleation of the prostate according to the method of Squier gives very satisfactory results in most cases. Before the operation is begun a large soft rubber catheter is introduced through the penis and left in position. This catheter should be new so that it will not break. The bladder is exposed suprapubically, as in suprapubic cystotomy. If there has been suprapubic drainage the incision is made from the drainage tract to the pubis. The attachments of the bladder above the drainage tract to the peritoneum are not disturbed. If an effort is made to enter the blad- der simply by dilating the old drainage tract, the peritoneum, being the loosest attachment, may be torn. If suprapubic drainage has not been previ- ously established the prevesical space should be protected by gauze packing before the bladder is opened. After opening the bladder the index finger of the right hand is inserted into the internal meatus and enucleation is begun by breaking through the prostatic urethra with the finger near the roof of the urethra and a little to the right side. It is best to enucleate the prostate with the ungloved hand. The gloved left index finger may be inserted into the rectum and the prostate pushed up, which though not necessary, will aid materially in the manipulation (Fig. 597). If the prostate is densely adherent and there is no definite line of cleavage it is probably cancerous and operation by the suprapubic route should be abandoned. The patient is then drained and a radical operation for cancer of the prostate undertaken by the peri- neal route several days later, unless the disease had progressed to such an extent that the cancer is inoperable. If the prostate separates fairly easily the finger is swept down on its side, keeping close to it, and loosening it from the apex of the gland backward (Fig. 598). A similar procedure is repeated on the left side. Wherever possible at least a small strip of mucosa of the urethra should be left. After enucleating the anterior portion of the pros- tate on both sides the enucleation is continued from before backward, still ^Surg., Gynec. and Obst., Februarj% 1920, p. 182, et seq. 692 OPERATIVE SURGERY clinging witli tlie finger close to the prostate. After it has been sufficiently loosened the left finger is removed from tlie rectum, the glove is taken off: by a nurse and a fresh glove is put on the left hand. The loosened prostate is caught with sponge holding forceps and moderate, steady traction is made on the forceps while the enucleation is completed. Dry gauze is packed firmly into the cavity left by the prostate and kept in position for three or four minutes. The clots are removed and the end of the catheter that is within the Fig. 597. — Cross section of the first stage of the suprapubic prostatectomy of Squier. The finger is about to break through the roof of the prostatic urethra. (After R. C. Brj'an.) bladder is seized and brought up through the suprapubic wound. A stout black linen thread is tied on the catheter four inches from its tip with a loop knot. Into this linen thread are folded strips of iodoform gauze twisted as a cable. The linen is tied over the gauze, preferably in a bow knot, and the ends are left long. The gauze packing that was in the bed of the prostate is removed, and the iodoform gauze held by the linen thread is gradually introduced into the bladder Avhile an assistant makes traction on the end of the catheter protruding from the penis. The iodoform gauze is molded and packed into the cavity left by removal of the prostate. An end of the gauze and the ends of the linen thread around the gauze are brought out PROSTATE, TESTICLES, AND PENIS 693 1 lirouiili llu' wduihI. a liWixc nil)l)('i' 1ul)t' I'dr ilraiiiajj,!' is inserted in 1lie l)la(l- cler at tlu' upper portion of the M'ountl (Fig. 599). If there lias not been a pre- vious suprapultie drainage it is best to place a cigarette drain down to the pre- vesical s])aee. The wound is partly closed by interrupted sutures of silkworm- gut. C)ne sutuic of silkworm-gut just belo.w the tube is inserted but not tied till after the })acking has been removed. The base of the catheter that protrudes from the urethra is clamped with pedicle forceps, a stout cord is tied to the handle of the forceps and, after the patient has been placed in bed, this cord is carried over the foot of the bed and a two pound weight is attached to it. This Aveight should be lifted for ten minutes ever,y hour unless there is considerable bleeding. This pre- vents the continuous ischemia of the tissues that are pressed upon hy the gauze. Eight hours after the operation, the weight is removed entirely if Fig. 598. — The finger has broken through the prostatic urethra and the prostate is being enucleated, be- ginning at its apex on the right side. (After R. C. Bryan.) the bleeding has ceased. The gauze is left in place, however, for forty- eight hours and after taking out the drainage tube, is removed by pull- ing up the ligature around the iodoform gauze. This ligature is either untied or divided with scissors and the gauze is removed. If the gauze has been inserted as a long strip and an end brought out of the wound along with the drainage tube, the removal is easier. A mushroom catheter is inserted and the silkworm-gut suture that was placed at the time of operation, but not tied, is tied and reduces the extent of the wound. This method of controlling hemorrhage which I have tried in recent cases is usually satisfactory. The gauze can be molded and packed into the cavity 694 OPERATIVE SURGERY left by removal of the prostate very accurately and it not only checks bleed- ing more promptly than rublu'r. l)ut may be made to exert more nearly uniform pressure on the irreguhir contour of the prostatic bed than an inflataljle rubber bag. Besides, it is easy to obtain and is not subject to accidental punctures which may be disastrous with a ruljber bag. Fig. 599. — The prostate has been removed and the drawing shows a satisfactory method of con- trolling hemorrhage, which is fully explained in the text. The gauze has several obvious advantages over a rubber bag. It has greater hemostatic properties, can be molded more accurately into the bed of the prostate, it can be removed without dragging all of the catheter through the bladder, and it is readily obtainable in any operating room. When the urethra is irritable, an excellent method of controlling bleeding is to pack the bed of the prostate with a long strip of iodoform gauze and gra.sp the last portion of the gauze with sponge forceps. By elastic bands going from the handle of the forceps, which protrudes from the wound, to adhesive on the patient's skin, constant pressure is made on the packing. PROSTATE, TESTICLES, AND PENIS 695 AVliile tlie sui)rai)ul)ir route is preferable in most prostatectomies there are certain (•(uulii imis tliat have already been mentioned which make the perineal operation of II. 11. Young more desirable. Here, a curved incision is made from just in front of one tuberosity of the ischium to a similar point on the other side. It curves forward so the apex reaches just behind the posterior margin of the scrotum. A flap is turned down. A curved sound is inserted into the urethra and, with the finger, blunt dissection is made on each side of the urethra and the rectum is gradually pressed back- ward. The central tendon and the rectourethralis muscle are divided close to the urethra. The bifid retractor of Young m^y be used to push the rectum back while these structures are divided, or better still, the rectum can be held back by the index and middle fingers of the left hand. The recto- urethralis musele holds the rectum very close to the urethra and it is im- portant to avoid injury to the rectum at this point. The bulb of the penis is retracted forward. An injury to it will cause an annoying bleeding. The membranous urethra is exposed and divided by a longitudinal incision down to the sormd. Each margin of the wound in the urethra is caught with for- ceps and the finger is introduced and the bladder explored. Often the finger cannot reach even the limits of the prostate but it will at least serve to dilate; the passage and to determine any unusual conditions that may lie within the prostate. The finger is withdrawn aiid the prostatic tractor of Young is introduced closed. It is spread open and with this tractor the prostate is draAvn into the wound. The fascia at the apex of the pros-^ate with the muscle fibers that overlie its capsule are stripped to each side by blunt dissection so that the capsule of the prostate is freely exposed. The rectum is firmly retracted and the prostate steadied by the prostatic tractor while two incisions are made, one on each side of the midline about an inch and a half apart. These incisions are carried from a point external to the insertion of the prostatic tractor downward and backward and are made well into the sub- stance of the prostate. It must be recalled that in this portion of the prostate there is usually a considerable thickness of normal tissue and unless this is cut through to the adenomatous portion of the prostatic enlargement, the true line of cleavage will be missed and not only will the operation be more diffi- cult but it will be unnecessarily bloody. The capsule of the adenomatous enlargement is demonstrated, and is peeled up by the insertion of a blunt instrument, such as a blunt dissector or the handle of a knife, or closed blunt scissors the blades of which are then spread. After the separation has begun sufficiently to admit the finger without tearing the tissues, the finger is introduced and the enucleation continued. It is best to enucleate partially one lobe, then completely enu- cleate the other, and after this remove the first lobe. In this way, com- plete collapse of one side before loosening the other side is avoided. As the enucleation proceeds the prostate is grasped with sponge-holding forceps and pulled down, which aids the manipulations considerably. Traction on 696 OPERATIVE SL'RGERY the prostatic tractor also lielps. After Ijoth loljes have been delivered the prostatic tractor is turned to one side so tliat any enlargement of the middle lobe may be brought into the lateral incision in the capsule and enucleated. The prostatic tractor is folded together and withdrawn, and the finger is again inserted into the Ijladdcr to determine whetlier any stones or divertic- ula are present. The cavitj^ left by removal of the prostate is firmlj^ packed Avith strips of iodoform gauze. If the prostatic capsule has not been ex- tensively torn 1)y tlie removal of the prostate the capsule encloses a cav- ity which can be readily packed. This aids greatly in controlling hemorrhage. Fig. 600.— |-The operation of H. H. Young for cancer of the prostate. The urethra has been opened through the perineal incision, the tractor is inserted into the bladder, and the posterior surface of the prostate is cleared, showing the anterior layer of the fascia of Denonvillier. The dotted line shows where the dissection should proceed in order to keep between the anterolateral fascia and the lateral aspect of the prostate. Unfortunately, however, with a large prostate the mucosa of the bladder is often torn during the enucleation and the gauze cannot always fill the cavity firmly. This is an objection to perineal prostatectomy because in the suprapubic method by the t?t'hnic already described firm pressure can always be made with gauze. In small firm prostates, however, enough of the capsule can usually be left by perineal extraction to permit satisfactory packing. A large drainage tube is inserted into the bladder through the opening in the membranous ure- thra and the fascia and fibers of the levator ani muscles are brought together PROSTATE, TESTICLES, AND PENIS 697 by one or two sutiu'cs of (•atfkago of soiiu' jxu'tion ol' ilic \as or of llie epididymis. The epi- didymis and vas may be satisfactorily exposed through an incision iu the posterior part of the scrotum. The veins and larger blood vessels should be avoided. Before undertaking this operation any stricture that may be in the urethra or inflammation of the seminal vesicles should be cured and the patency of the vas from the epididj'mis to the prostatic urethra should be demonstrated by injecting into the vas methylene blue and noting if it appears in the ure- thra. The vas is exposed and split longitudinally and about twenty or thirty drops of methylene blue are sloAvly injected. The dye will appear in the urine if there is no obstruction or in the seminal discharges after massage of the seminal vesicles. If this test is satisfactory the epididymis is opened by cutting off a small piece with a pair of scissors. It must be demonstrated by a microscope that the fluid within this portion of the epididymis con- tains spermatozoa, and if thev' are not found at this point other openings must be made into the epididymis or into the testicle until spermatozoa are found. The widely split vas is then sutured, with a few interrupted sutures on a fine needle to the opening in the epididymis or testicle. Arterial silk is an excellent suture for this purpose. Anastomosis of the vas and the epididymis done by the method described, which was devised by Martin, of Philadelphia, is more or less indirect. Af- ter the capsule of the epididymis has been incised and a portion of the epi- didymis tubule cut the vas is split and the open incision in the vas is sewed to the capsule of the epididymis over the raw surface of the incised tubule of the epididymis. There is conseciuently considerable distance to be bridged by the epithelium lining the vas and the epididymis. V. D. Lespinasse,^ of Chicago, has devised an operation which is a direct anastomosis between the epididymis tubule and the vas. An incision is made in the scrotum and through the tunica vaginalis. The epididymis is exposed and the point of obstruction is found. The vas is opened by a short longi- tudinal incision and a colored fluid, as methylene blue, is injected into the central end of the vas. If the fluid appears in the urethra it is a demonstra- tion that the vas is open from the point of incision to the urethra and the operation can be proceeded with. If the vas is not open the operation, of course, will be abandoned unless the point of occlusion can be found farther up. If the operation is to be completed the capsule of the epididymis above the obstruction is carefully incised down to the tubule. All of the layers of the capsule are removed from the epididymis tubule with great care and the epididymis tubule itself should not be injured or opened at any point. It protrudes through the opening thus made and a loop of the tubule is selected whose direction is in the long axis of the body of the epididymis. A suture of fine arterial silk (00000) on a Xo. 19 bayonet pointed needle is passed through the wall of the epididymis tubule, down its lumen, and out again through the wall of the tubule about three mm. from the point sLespinasse, \*. D. : Jour. Am. !Med. Assn. Ixx, Feb. 16, 191S. p. 448 et seq. 702 OPERATIVE SURGERY of entrance (Fig. 604). This is followed by leal^age of epididymal secretion Avliieh is drawn into a small syringe and examined for spermatozoa. If spermatozoa are present this suture is passed through the incision that has been previous!}' made into the vas and out through its wall. The other end of the suture is threaded into a needle and passed through the wall of the vas in a similar manner at the other end of the incision in the vas. In this way the epididymis tul)ule is drawn into the longitudinal incision in the vas (Fig. 605). Sutures of catgut are placed on each side of Fig. 604. — The operation of Lespinasse for anastomosis of the vas and the epididymis. A fine silk suture is inserted into a tubule of the epididymis. Fig 605. — The suture in the tubule is carried through the incision in the vas, as explained in the text. (Lespinasse.^ Fig. 606. — The other sutures are placed to hold the vas to the capsule of the epididymis. (Lespinasse.) the longitudinal incision in the vas, include the full thickness of the wall of the vas, and are carried to the capsule of the epididymis. These hold the incision in the vas open. Two other sutures are placed into a portion of the Avail of the vas but do not penetrate to its lumen or epithelial lining and hold the vas to the capsule of the epididymis a short distance from the ends of the longitudinal incision into the vas (Fig. 606). When these two sutures are tied they should leave the intervening segment of the vas without tension so that the union between the vas and the epididymis tubule is in accurate approximation and without strain. The upper end of the PROSTATE, TESTICLES, AND PENIS 703 ori^'iiKil suliii-c is t ln'ciidcd on ii loii^' li;i j^'cdoni iummIIc and al'ler the lesticle lias l)(M'ii r('|)lai'(>(l in llic sc-rdliim the iummIIc ])ierees the scrotum from williiii outA\ar(l. In from one to tAVo woel' the hydrocele a point is selected on the anterior sur- face of the scrotum that is free from veins. While the hydrocele is steadied ^vitli the hand a small amount of novocaine solution is injected into the scro- tum and a short incision of about one-quarter of au iuch is made with a knife. Through this incision a large aspirating needle or a small trocar and cannula are inserted. The trocar is withdrawn, the fluid evacuated and the carbolic is slowly injected through the cannula. The skin surrounding the point of puncture is anointed with vaseline to protect it from the carbolic when the cannula is withdrawal. The cannula is then quickly removed, Avhile grasping the punctured scrotum with a piece of gauze v^diich will absorb any carbolic that may leak from the end of the cannula. The scrotum is gently massaged to distribute the carbolic evenly over the inner surface of the tunica vaginalis. Carbolis is less painful for injection and less dangerous than iodine. Considerable swelling follows this procedure which gradually subsides in most cases. If it has not all disappeared in three weeks the injection may be repeated. This procedure wall cure many cases of simple hydrocele. If the hydrocele is not cured after tw-o or three injections at intervals of several weeks the sac is excised or everted. Eversion of the sac, or the so- called bottle operation, is done by making an incision through the anterior surface of the scrotum. The testicle is delivered into the w-ound, the sac opened, and its edges are sutured behind the testicle so as to turn its inside out and appose the whole of its interior to the raw surface of the wound which will usually absorb the secretion from the sac. In many cases, however, pock- ets form and this operation is not satisfactory. Excision of the sac neces- sarily gives the largest number of cures of hydrocele and if carbolic injections have not been successful excision, particularly in a large thick sac, is the op- eration of choice. An incision is made through the anterior surface of the scrotum down to the hydrocele sac. The various coverings are separated until the sac is reached but not opened. It is then bluntly dissected free from its surroundings as far as possible and delivered into the wound. Oc- casionally the hydrocele sac is of such a nature that it can be dissected free and removed without being opened. This, of course, is an anatomic peculiarity and does not often occur. After freeing as much of the sac as possible it h opened and trimmed away close to the testicle, taking care to leave no re- dundant fold. The vessels are clamped and tied and the scrotal w^ound is closed wath a continuous mattress suture which everts the edges of the skin wound and prevents the dartos muscle from pulling it in. An operation for varicocele should be performed only wdien enlargement of the veins of the cord is marked and has resisted medical treatment for many months. It should not be done in a youth about the age of puberty except when the disease is very marked and the symptoms are decided. When it is necessary to remove varicose veins resection of the scrotum is also in- dicated. A varicocele that is not sufficiently pronounced to be accompanied 706 OPERATIVE SEKGERY with a markedly relaxed scrotum does not, as a rule, require operation. It is just as essential to remove the redundant scrotum and so afford support to the testicle as it is to remove the enlarged veins. The scrotum is caught with an Allis forceps in the median raphe at about the junction of its upper and middle thirds and also at the junction of its middle and posterior thirds. The scrotum is lifted up and the re- dundant portion is clamped with pedicle forceps. This part is cut away with scissors while making tension upon it. The incision is just on the proxi- mal side of the forceps so the tissues that are injured l)y the clamp are excised. The bleeding vessels are quickly caught with hemostats. Every bleeding point must be clamped. After complete hemostasis has been secured with the clamps, the vessels are tied with fine plain catgut. The varicose veins over the left cord are exposed by an incision along the cord and the vas deferens, together with the spermatic artery, are freely delivered into the wound. The spermatic artery is identified if possible. If this can be done the spermatic artery Avitli one or two veins and the vas deferens are gently isolated and separated from the rest of the dilated veins, but if it is impossible the largest varicose veins are freed and about three inches are removed after doubly ligating wnth catgut the upper and lower portions of the veins. If the spermatic artery can be recognized and isolated along with the vas deferens and a few other veins the rest of the veins may be safely removed after ligating them with catgut close to the testicle below and at the upper portion of the scrotum. It is best to put two ligatures on each end to avoid the possibility of the ligature slipping. The ends of one set of liga- tures are left long. After excising the intervening segment of vein the stumps are tied together by the long ends of the ligatures. When in doubt it is much better to take out too few veins than too many, as the resection of the redundant portion of scrotum will give such support to the testicle and structures of the cord that extreme radical procedures in removal of veins of the cord are not necessary. It is highly important to leave the spermatic artery for, as has already been mentioned, the excellent experimental work of Gessner, of New Orleans, has demonstrated the prob- ability of complete atrophy of the parenchyma of the testicle after ligation of the spermatic artery. After carefully securing all bleeding points and tying them with fine catgut the wound is closed Avith a continuous mattress suture of tanned catgut. The suture is applied in the line of incision. A second row of sutures uniting the edges of the skin may be placed to secure more accurate apposition. Such a wound makes a scar that resembles very closely the median raphe and if the incision has been properly made there are no teats or irritating protuberances that often follow a transverse incision for removing the redundant scrotum. External urethrotomy for deep strictures has already been described. Internal urethrotomy is but seldom practiced. Occasionally, however, there may be a marked decided narrowing of the external meatus which it is neees- PROSTATK, TESTICLES, AND PENIS 707 s;iry 1o split. Tliis is done undvr local ancs1liesi;i by iiijcetiiig tiie tissues around the lucalus and incising' the meatus at its lowest i)oint. Cireiiuu'ision may l)e done under loeal auesthesia. Jf ou an infant care must be observed to see that the adhesions between the glans penis and the l)rei)uee are well separated. By cutting down the prepuce without separating these adhesions anteriorly, the meatns may be split and the glans injured, which will be followed by considerable bleeding. The prepuce is grasped anteriorly on each side of the midline by two small hemostats. Slight trac- tion is made and if there is any reason to expect adhesions between the glans and the prepuce a pair of curved scissors is inserted within the prepuce and gently spread so as to separate the adhesions sufficiently to make a dorsal incision in the prepuce without injuring the glans. A straight incision is then carried down the dorsum of the prepuce to a point about opposite the corona (Fig. 607). This must be determined before too much traction is made upon the prepuce, as otherwise the incision may be carried too far. Any further Fig. e07. — Tl-e first stage of circumcision. Tlie Fig. 608.— The circumcision is completed, dorsal incision is made and the dotted line shows the incision for removal of the prepuce, which should be just distal to the corona. adhesions are noAV thoroughly separated and the prepuce is trimmed from the upper extremity of this dorsal incision around to the frenum on each side parallel with the corona. Sufficient tissue should be left at the frenum to allow- for suturing without contraction. The bleeding points are caught with mosquito forceps and tied with fine catgut. The wound is closed with a continuous suture of fine tanned or chromic catgut which begins on the right of the frenum, is carried around the incision and terminates a short distance from its beginning (Fig. 608). This leaves a slight in- terval betAveen the beginning and the end of the suture, which allows for swelling or erection. If the tissues in the frenum are not entirely covered by this suture one or two additional interrupted sutures of fine catgut are placed. In epispadias the urethra is merely a groove on the dorsum of the penis. Such a deformity often accompanies exstrophy of the bladder and as the best operation for exstrophy of the bladder is transplantation of the ureters, the 708 OPERATIVE SURGERY chief object of the ()j)erati<)ii Jur episjjadias in the presence of exstropliy of the bhidder will be for sexual intercourse. The operation of CantAvell is probabl}" the most satisfactory operation for epispadias. This depends upon the fact that in this disease the two corpora cavernosa are much more looseh' attached to each other than in a normal penis and can be readily separated. The first step in this as in any plastic operation on the penis is to provide for drainage of the bladder, either through the perineum or sui)rapul)ically, in order to divert the stream of urine while the wound in the penis is healing. The perineal operation is best here and can be quickly done by a short incision through the perineum on a sound in the urethra. On each side of the groove of the epispadias that represents the urethra an incision is made along the junction of the mucosa and the skin extending from the symphysis to the extremity of the glans. These incisions extend down to the corpora cavernosa but not into them. The urethra is freed as a flap from its bed and held up while the two cor- Fig. 609. — The operation of Cantwcll for epispadias. A, shows the epispadias, with the dotted line indicating the incision for the formation of the urethra. B, shows the relation of the skin flap which is to form the new urethra. The corpora are not firmly attached to each other in epispadias. C, the flap for the urethra is made and is sunk between the two corpora which are easily separated in this deformity. D, cross section representing the operation completed. pora cavernosa are separated from each other until the skin on the lower surface of the penis is reached. The mobilized urethra is now placed in the bottom of this wound and fixed by sutures. A sound is laid in the urethra and the skin of the urethra is sutured over it. The corpora cavernosa are brought together hy a few sutures and the skin is closed over them in the usual manner. The illustrations show the steps of the operation (Fig. 609). The base of the flap of the urethra is at the root of the penis so that there should be no trouble about the nutrition of this transplanted mucosa of the urethra. Hypo.spadias is more common than epispadias and may exist in various degrees. When the defect is slight the operation of Beck may be done. An incision is made around the urethral orifice and over the under surface of the urethra toward the perineum. The urethra with the corpus spongiosum is dissected from the corpora cavernosa for a sufficient distance so that it can be readily drawn through a stab wound in the glans penis. A stab wound is made with a sharp narrow knife and the urethra is brought through PROSTATE, TESTICLES, AND PENIS 709 and fastened l)y a few sntnres to llic ed^cs o\'. the artiiieial meatus. The skin is then sutured over that ])oi1ion of the urethra that has been trans- phnited. This operation ean only be done when there is a very slight defect and but little curvature of the penis. If there is a marked contraction the operation of Beck is likely to reproduce it. If the penis is bowed the first procedure is to straighten it. This may be done by a transverse incision on the under surface of the penis just be- hind the g'lans and the incision is sutured longitudinally. When this de- formity is marked the operation of straightening the penis should be under- taken some time before the plastic operation is done for constructing the urethra. J. E. Thompson,-* of Galveston, Texas, has described the embryology of hypospadias together with plastic procedures for correcting this deformity is a very excellent article. As he has said it is important that no skin which contains hair follicles should be used for construction of the urethra. Fig. 610. — The Thompson-Russell operation for hypospadias. The penis is straightened by a trans- versed incision which by traction becomes diamond shaped. A tunnel is made in the head of the penis which is enlarged later on. The dotted lines indicate the incision for the flaps. An operation that can often be done and which gives satisfactory results is that of C. H. Mayo. After straightening the penis the wound is allowed to heal and at the second operation a large tunnel is made through the glans penis to a point a little to one side of the site of the normal opening. A flap long enough to reach without tension through this tunnel in the glans to the urethral opening is cut from the dorsal surface of the penis and prepnce with its base at the anterior margin of the prepuce. It must be wide enough to be rolled into a tube of about the size of a normal urethra. It is sutured together as a tube with the skin surface inside, using fine sutures of tanned or chromic catgut. This tube is drawn through the tunnel in the glans, and the tip is sutured to a bed prepared for it close to the urethral opening. The tube is allowed to heal in position and after an interval of a few weeks the 4Thompson, J. E.: Tr. Southern Surg. Assn., 1916, p. 223, et seq. 710 OPERATIVE SURGERY base of the flap is cut. A few weeks later this tube made from the transplanted fold of prepuce is united to the end of the urethra. In the operation of Russell, flaps are taken from the side of the penis ad- joining the groove which represents the defective part of the urethra. In all of these operations perineal drainage of the bladder must be the first stage. In Thompson's modification of the Russell operation the penis is first straight- ened by a transverse incision just under the glans. The penis being straight- ened, a large tunnel is made through the glans with a narrow-bladed knife (Fig. 610). This tunnel, which begins about the normal site of the meatus, emerges a short distance below the glans. An incision is carried around the penis in the prepuce about one-eighth of an inch from the corona. A second in- cision is made in the skin of the penis beginning one-eighth of an inch be- Fig. 611. — The flaps are dissected and are united, so forming the new urethra. (Thompson-Russell.) Fig. 612. — The new urethra is brought througn the enlarged tunnel in the head of the penis. The lower skin incision is sutured over the new urethra (Thompson-Russell). hind the urethral opening, and curving backward and outward on each side around the urethral opening. It is then carried forward about one-third of an inch from the margin of the urethral opening and parallel to the groove which represents the defective part of the urethra. This incision is carried over the dorsum of the penis and along the prepuce from one side to the other, parallel to and behind the incision that has been previously made in the prepuce. The dorsal part of this incision is parallel to and behind the first incision made through the prepuce, so these two incisions form a flap of the prepuce which resembles a clergyman's stole. This flap is about one- quarter of an inch wide. It is carefully dissected so as not to separate the outer edges of the posterior portion of the flap any further than possible. PROSTATE, TESTICLES, AND PENIS 711 111 this ^\•ay the A'aseuUir supply of tlie Uap Avill be preservetl. The skin sur- faces of these flaps are turned to face each other and the edges are sutured with fine tanned or chromic catgut. The suturing is so applied as to turn in the skin edges (Fig. 611), The tube, which is formed by suturing these flaps, is drawn through the tunnel in the glans and is fastened in position Avith a fcAV sutures. The margins of the skin on the side of the penis are sutured together over this urethra from behind forward so as to cover the urethra as far as the glans (Fig. 612). The defect left on the prepuce by raising this flap is easily corrected by suturing the margins of the skin on the prepuce to- gether (Fig. 613). One advantage of the operation is that it can often be done in one stage. Amputation of the penis may be partial or complete. Before beginning amputation of the penis, the cancerous area is thoroughly cauterized with the actual cautery. This not only prevents infection by sterilizing the septic tissues but guards against an even greater danger of implantation of Fig. 613. — The completed operation (Thompson-Russell). the cancer cells in the raw surface. In amputation, after applying a tourniquet at the root of the penis an incision is made through the skin completely around the penis and about three-fourths of an inch or more from the apparent border of the disease. The skin is dissected back for half an inch and the dorsal artery and vein are exposed, ligated and divided. Both corpora cavernosa are divided transversely and the urethra with its sur- rounding tissue is divided half an inch in front of the corpora cavernosa. The ends of the corpora cavernosa are whipped over with catgut sutures to control the bleeding. A short incision is made in the skin just over the urethra, which is slightly split opposite this point and is sutured to this in- cision in the skin. Usually it is wise to dissect both inguinal regions whenever the penis is amputated for cancer. This is done by making an incision parallel with Poupart's ligament and just above it. The upper margin of the skin is re- tracted and the fat and fascia are dissected down to the aponeurosis of the 712 OPERATIVE SURGERY external oblique. This mass of tissue is dissected with gauze down to the border of Poupart's ligament. At the outer extremity of the incision the mass is dissected to the fascia lata and then inward to the tissues over the femoral arterj-. Dissection is then begun at the inner portion of the wound and is carefully carried toward the femoral canal. Care is taken to avoid injury to the saphenous vein, or at least to recognize it and clamp it before it is divided, if it appears to be involved. By working along the plane of the fascia lata and the aponeurosis of the external oblique block dissection can be readily accomplished. The region at the femoral canal requires care- ful dissection with a good light and a sharp knife. The mass is finally freed from the femoral artery and vein. If the inguinal region is to be dissected for cancer it should be done as a block dissection that has just been described. This, however, is unneces- sarily radical in inflammatory conditions, and while it is really easier than removing isolated glands there is a danger of edema of the scrotum following the block dissection if done on both sides. When complete amputation of the penis is necessary the scrotum is split along its median raphe which gives thorough exposure of the corpus spongio- sum. The corpus spongiosum is separated from the corpora cavernosa and divided. The urethra is dissected as far as the triangular ligament. The in- cision is carried around the root of the penis, the suspensory ligament is di- vided, and the crura are separated from the pubic bones. The vessels of the crura are clamped and tied. The urethral stump is split and the edges of the urethra are sutured to the posterior part of the scrotal Avound. The skin is closed in the usual manner after providing for drainage. Both inguinal re- gions should always be dissected when cancer is sufficiently advanced to re- quire complete amputation of the penis. INDEX Abbe, operation on stricture of esophagus, 323 operation for "trigger" finger, 359 Abdominal incisions, 508-519 closure of, 514-519 Adson, operation on facial nerves, 153 on gasserian ganglion, 285-287 on liypoplivsis, 276 Albee, inlay method of bone graft, 164-167 method of bone graft in Pott 's disease, 168-171 operation on spina bifida, 301, 302 Amputation, arm, 331-350 at elbow, 343-345 at hip joint, 383-385 method of Wyeth, 383-384 at knee joint, 379-380 method of Gritti-Stokes, 380-381 at shoulder joint, 347-349 at tarsometatarsal joiiit, 374-375 cineplastie, 341-343 Lisfranc, 374-375 motor stump in, 341-343 of arm, general principles of operations in, ^331-336 of fingers, 336-339 of forearm, 341-343 of foot, method of Chopart, 375 method of Pirogoff, 375 method of Syme, 375-376 of hand, 339-341 of leg, 376-379 method of Hey, 376-379 of lower extremity, 370-385 general principles in, 370-371 observation by Starr on, 370-372 of thigh, 380-383 of toes, 371-373 of upper arm, 345-347 of upper extremity, 349-350 method of LeConte, 249-250 method of Crile, 349-350 Andrew, operation for hernia, 485-487 Anesthesia, intratracheal, 433-434 spinal, 289-290 Aneurisms, arteriovenous, 133-140 treatment of, by Matas, 135 by quadruple ligation, 139 by quintuple ligation, 139-140 excision, by Lexer, 75 extirpation of, 125-126 needling of, Macewen, 118 of special arteries, treatment of, 126-132 traumatic, treatment of, 132 treatment of, by digital compression, 120 method of Finney, 118-119 bv gradual obliteration, Halsted, 119-120 Matas, 119-120 Aneurisms, treatment of — Cont "d by introduction of wire, 118, 119 by ligature method of Anel, 121 ^f Antyllus, 121 of Bi-asdor, 121-122 of John Hunter, 121-122 of Pasquin, 121-122 of Purmann, 121-122 of Wardrop, 121-122 by Matas, 122-125 by Eeid, 120 method of Finney, 118-119 Ani pruritus, operation for, 659-661 operation of Terrell, 659-661 Ankle joint, operation for deformities of, 401- 413 for flail joint in, 407-409 for flail joint in, Bradford, 408-410 for excision of, 411 Aorta, abdominal, experimental resection, 89 ligation of, 110 Appendicitis, operations for, 623-637 Appendectomy, 623-637 McBurney incision for, 623-627 treatment of stump in, 628-631 results of;, 632-634 Appendix, operation for abscess in, 634-637 Arm, amjDutations of, 331-350 lymphedema of, operations for, 366-368 operation for, method of Handley, 366- 367 operation for, method of Kondoleon, 368 operations on, 331-369 upper, amputation of, 345-347 Artery, anterior tibial, ligation of, 116 axillary, ligation of, 108 brachial, ligation of, 109 common carotid, ligation of, 101-102 common iliac, ligation of, 110-111 dorsalis pedis, ligation of, 116 external carotid, ligation of, 102-103 external iliac, ligation of, 112-113 femoral, ligation of, 113-115 inferior thyroid artery, ligation of, 107- innominate, ligation of, 100-lOi internal carotid, ligation of, 105 internal iliac, ligation of, 111-112 popliteal, ligation of, 115-116 posterior tibial, ligation of, 117 radial and ulnar, ligation of, 109-110 subclavian, ligation of, 105-107 superior thyroid, ligation of, 104 temporal, traumatic aneurism of, 132 vertebral, ligation of, 107 Arteriovenous aneurisms, 133-140 treatment of, by Matas, 135 Arthi'odesis of elbow, 355-356 713 714 INDEX Arthroplasty, 420421 of knee joint, 420 of hip joint, 420-421 Ascites, operation for, 534-5?)5 Ashhurst's operation for excision of the tongue, 248-249 Astragalus, excision of, 411 Babcoek's operation on spina bifida, 300-302 Baldwin's operation for reconstruction of the nose, 232-233 Balfour 's modification of operation for ex- cision of stomach, 574-578 ojieration for removal of the spleen, 539- 542 operation on thyroid glands, 330 Bands, pericolonic, 637-639 Bartlett's operation on thyroid glands, 330 Beck's, Carl, operation for chronic empyema, 443 operation for hypospadias, 708-709 Biernheim's extirpation of aneurism, 126 method of transfusion of blood, 64-65 Bevan's operation for abscess of lungs, 444- 448 operation for diverticulum of esophagus, 323 operation for early cancer of rectum, 645- 648 operation of laryngectomy, 318-321 operation for undescended testicle, 705-700 Beyea's oi^eration for ptosis of stomach, 545- 546 Bifid spine, 296-302 classifications of, 296-298 with hydrocephalus, 297-298 Bile duct, operations on, 528, 529, 532-534 reconstruction of, 34, 532-534 Guerry, 534 Mayo, W. J., 533-534 Sullivan, 533 Binnie 's operation for ligation of blood ves- sels, 98-99 operation for excision of upper jaw, 253- 254 Bladder, operations on, 684-689 operation for diverticulae, 684-685 Blair, operation for deformity of lower jaw, 255-256 operation for excision of tongue, 249-251 Bloodgood, operation for direct inguinal her- nia, 489 Blood vessels, lateral wounds of, 90-91 ligation of, 97-117 ligation of, method of Binnie, 98-99 method of Horsley, 77-86 suturing, 69-91 indications for, 69-70 instruments used in, 76-78 Bone, plating fractures of, 33 Bone wax, 57 in hemorrhage from skull, 264 Bones, operations on,' 157-171 biologic repair, in injured, 157-160 Bones — Cont 'd fractures of, 162-165 graft, inlay method of Albee, 164-167 intramedullary, metliod of Hoglund, 163- 104 nutrition in, 159 in Pott 's disease, method of Albee, 168- 171 principles of, 157-161 Wolff 's law in, 158 plating of, 33, 160, 161 ununited fractures of, 166-168 Bowel (see Intestine) Bradford, operation for flail joint of ankle, 408-410 Brachial plexus, operations on, 153-155 method of Sharpe, 154-155 paralysis, transplantation of muscles for, 155-156 Ba-ain, adhesions of, 269-272 congenital hernias of, 276-279 control of hemorrhage for, 266 decompression, operations on, 279-283 method of Gushing, 279-281 location of centers in, 264-266 method of Chipault, 264, 265 method of Eeid, 265 method of Einkenberger, 265, 266 meningocele of, operation for, 277-279 operations on, 261-287 puncture of corpus callosum in, 274-275 puncture of ventricle of, 275 Branchial cysts, operations on, 305 fistula of, operations on, 305 Breast, operations on, 462-476 Brickner, operation for subacromial bursitis, 369 Brown, John Young, method of enterostomy, 599-601 Bunion, operations for, 405-406 C Cannon and Murj^hy, lateral intestinal anasto- mosis, 32 Cannon and Washburn, gastric pain, 31 Cantwell, operation for epispadias, 708 Cardioh'sis, 435-436 Carotid gland, operations on, 323-324 Carrel, method of suturing blood vessels, 71- 73 Castration, 703-707 Cecosigmoidostomy, 622 Cecum, resection of, m.ethod of Horsley, 610- 613 Cerebellum, operations on, 267-268 Cerebrospinal fluid, pressure of, 289 Cervical ribs, 308 Cervical sympathetic, operations on, 325-326 method of Jonnesco, 326 method of C. H. Mayo, 325-326 Cheeks, operation on defect of, 207-210 Chipault, method of location of centers in brain, 264-265 Cholecystectomy, 522-527 method of Willis, 527 INDEX 715 C'lioltH-ystoeiitoidstoniy, 5;50-5.">2 mothod of Horslcy, r);50-5o2 Cholooystotomy, 527-i528 Cliolocystostomy, G02 Choledocluis, operations on, 528, 529, 532-534 reeonsti'iiotion of, 532-53-1 Cineplastie amputation, 341-343 Circulation, reversal of, 30, 31 Circumcision, 707, 708 Citrate, niethoil of transfusion of blood, Lew- isolin's, 66-68 Clavicle, excision of, 461 Cleft palate, operations on, 195-198 method of Lane, 195, 198 method of Langenbeek, 195-198 Closure of abdominal incisions, 514-519 Club foot, operations for, 401-413 intractable, operations for, 411-413 Coagulation of blood, 70, 71 Coccygeal dermoid, operation for, 661, 662 Codman, operation for subacromial bursitis, 369 Coffey, operation for cancer of the pancreas, 535-538 operation for ptosis of stomach, 543 principles in enterostomy, 592-597 Colev, modification of Bassini operation for hernia, 483, 484 Colon, obstruction of, 617, 618 resection of, 610-618 method of Mikulicz, 618 Complications of oj^eration; infection, shock and hemorrhage, 51-58 Corpus eallosum, puncture of, 274, 275 Crile, block operation on neck, 312-316 oi^eration for amputation of upper extrem- ity, 349-350 method of transfusion of blood, 62 Cubbins and Abt, irritating lubricants in the peritoneum, 74 Cunningham, operation on seminal vesicles, 700 Cystotomy, perineal, 688-689 suprapubic, 685-688 T> Dandv, W. E., operation for hvdrocephalus, 273, 274 Davis, J. S., method of skin grafting, 182 operation on columna of nose, 228 operation on orbital socket, 220-222 Dermoid, coccygeal, operations for, 661-662 sacral, operations for, 661, 662 Diaphragmatic hernia, operations for, 505-507 Diffuse lipoma of neck, 324, 325 Diverticulum of esophagus, 321-323 Dowd, method of operation on tuberculous glands, 309, 310 Drainage in surgery, 35-43 surgical, classification of, 36 surgical, material, 41 Dupuvtren, contraction of fingers, operation for, 358 Dura, transplantation of fascia for defect in, 269-272 E Ears, operations on, 222-224 for reconstruction of, method of Roberts, 224 method of Szymonowski, 223-224 Edema, local, cause of, 38 operation for, Handley, 38 Ivondoleon, 38 Elbow, amputation at, 343-345 arthrodesis of, 355, 356 method of Jones, 355, 356 excision of, 351-353 Elephantiasis, operations for, 427, 428 method of Ivondoleon, 427, 428 Elsberg, method of repair of defect of nerve, 146-148 Embolism, pulmonary, Trendelenburg opera- tion for, 454-458 Emjivema, chronic, operations for, method of- Beck, 443 method of Estlander, 440-442 method of Fowler, 443 method of Robinson, 443 method of Schede, 442-443- operations for, 437-443 Endo-aneurvsmorrhaphy, method of Matas, 123-125 Enterostomy, 589-602 method of Brown, John Young, 599-601 using principle of Coffey, 592-597 method of Long, 589-592 Epididymis, operations on, 703 Epigastric liernia, operations for, 504, 505 Epilepsy, operations for, 268-272 Epispadias, operation for, 70S method of Cantwell, 708 Esser, method of treatment of depressed sears, 186 Esmarch, operation for ankvlosis of lower jaw, 257, 258 Esophagus, operations on, 322, 323 for cliverticulum of, 322, 323 method of Bevans, 323 method of Judd, 322, 323 stricture of, method of Abbe, 323 method of Mixter, 323 method of Ochsner, 323 Excision of joints, 350-355 elbow, 351-353 shoulder, 353-355 wrist, 350, 351 Extremity, lower, operations on, 370-431 Eye lids, operations on, 210-222 method of Gibson, 215, 217, 218 method of Gillie, 210-213 Face and mouth, oxjerations on, 187-260 Face, operations for tumors of, 238-240 Facial paralysis, operation for, 150-153 method of Adson, 153 Ferguson, oi^eration for hernia, 487-489 Fifth nerve, j^eripheral operations on, 258-260 Fingers, amputation of, 336-339 deformities of, operation for, 358-366 ' ' drop ' ', operation for, 358, 359 716 INDEX Fingers — Cont M Dupiiytrcn's contraction of, operation for, 358 "liammer", operations for, o.j8, 359 infection of, 356, 357 reconstruction of tendons of, 361-30G method of Dean Lewis, 361-363 transplantation of tendons of, method of Murphy, 364-366 ''trigger", operations for, method of ALbe, 359 metliod of Weir, 359 ' ' web ' ', operations for, 360, 361 Finney, method of treating aneurisms, 118, 119 operation for pyloroplasty, 549-551 Fistula, in ano, operation for, 650-652 branchial, operations on, 305 of rectum, operations for, 650-652 rectovesical, operation for, 651, 652 salivary, operation for, 240-242 Fissure in ano, operation of, 652 Flail joint of ankle, operations for, 407-409 Foot, amputation of, method of Chopart, 375 method of Pirogoff, 375 method of vSyne, 375, 376 club, operations for, 401-413 Forearm, amputation of, 341-343 transplantation of tendon, method of Mur- phy, 364-366 Forehead, operations on, 236-238 Foreign bodies in the peritoneum, 42 Fowler, operation for chronic empyema, 443 Fractures of bone, plating of, 33, 161-165 Frazier, operation on gasserian ganglion, 283- 285 operation for spina bifida, 298-300 Frisch, method of tendon suture, 362 Fuller, operation on seminal vesicles, 700 G GaU bladder, removal of, 522-527 method of Willis, 527 Ganglion, gasserian, operations on, 283-287 Gangrene, threatened, ligation of femoral vein, 95, 96 surgical treatment of, 30, 31, 94-96 Gasserian ganglion, operations on, 32, 283-287 method of Adson, 285-287 method of Frazier, 283-285 Gastrointestinal tract, surgery of, 31-32 Gastroenterostomy, indications for, 563 method of Eoux, 569 posterior technic of, 564-568 Gastrostomy, 578-581 Gastrotomy, 578, 579 Gessner, on ligation of si^ermatic vessels, 706 Gibson, operation on eye lids, 215, 217, 218 Gillie's method of tubing j^edicles in plastic surgery, 178-180 operation on eye lids, 210-213 Gland, carotid, operation on, 323, 324 Goldtliwait, operation for chronic dislocation of patella, 413 Grant's metliod of tying knots, 48-50 Guerry, opei'ation for reconstruction of bile duct, 535 H llalsted, treatment of aneurism by gradual obliteration, 119, 120 ox^eration for cancer of mammary gland, 467-469 operation for direct inguinal hernia, 489, 490 Hallux valgus, operation for, 405, 406 method of C. H. Mayo, 405 Hand, amputation of, 339-341 infection of, 356, 357 Handley, operation for local edema, 38 for lymphedema of arm, 366-367 Harelij), operations on, 187-192 operation of C. H. Mayo, 168 oiJeration of Owen, 190-191 operation of Eose, 188-190 double, operations on, 191-193 Harris, operation for hernia of mammary gland, 465-467 Heart, operations on, 453-458 Heineke-Mikulicz, operation of i^yloroplast}-, 551 Hemorrhage from bone, 57 from brain, control of, 266 from skull, control of, 264 in surgical o]3erations, 56-58 Hemorrhoids, operation for, 654-659 method of Terrell, 654, 655 Hernia, 477-507 diajahragmatic, oj^erations for, 505-507 direct inguinal, operations for, method of Bloodgood, 489 method of Halsted, 489, 490 double inguinal, incision of Judd, 513, 514 epigastric, 'operations for, 504, 505 femoral, operations for, 493-499 method of Seelig, 495-497 femoral, reconstruction of Poupart's liga- ment, method of Horsley, 497, 498 general principles in operations for, 477- 479 incisional or ventral, operations for, 502-504 method of W. J. Mayo, 503 inguinal, operations for, 479-493 method of Andrews, 485-487 method of Bassini, 480-488 Coley's modification of, 483, 484 methocl of Ferguson, 487-498 method of LaRoque, 490-493 method of Macewen, 491 of the brain, 256-279 umbilical, operations for, 499-502 Hip joint, anrputation at, 383-385 method of Wyeth, 383, 384 arthroplasty of, 420, 421 excision of, 416, 417 Hoglund, method of intramedullary bone graft, 163-164 Horsley, J. S., modification of operation of Beyea for ptosis of stomach, 545, 546 iXDi:x 717 Iloi'sloy — Cunt M operation on eliolocystontorostomy, 530- 532 operation for pyloroplasty, 552-564 veeonstruc'tion "of Poupart's ligament in femoral hernia, 497-499 resection of eeeinn, 610-(il.3 resection of laroe intestine, 610-616 resection of small intestine, 605-609 reversal of circulation of blood, 92-95 suturing- blood vessels, 77-86 transfusion of blood, 60, 77-86 Iluber and I.ewis, method of prevention of neuromas, 334 Huer, method of operation on hypophysis, 276 Hydrocele, operation for, 705 Hydrocephalus, operations for, 33, 272-275 method of W. E. Dandy, 273, 274 with bifid spine, 297, 298 Hydronephrosis, operations for, 674 Hypophysis, operations on, 275, 276 method of Adson, 276 method of Heuer, 276 method of McArthur, 275, 276 Hypospadias, operations for, 708-711 method of Beck, 708, 709 method of C. H. Mayo, 709, 710 method of Eussell, 709-711 method of Thompson, 709-711 Incisions, abdominal, 508-519 Infection in surgical operations, 51-55 Infusion, intravenous, 66, 67 Ingrowing nail, operations for, 406, 407 Instruments in surgery, 44, 45 Instruments used in blood vessel suturing, 76-78 Intestines, operations on, 585-622 lateral anastomosis of, 619-622 Meckel's diverticulum of, 618, 619 obstruction of, 598-602 general j)rineiples of resection of, 603-605 resection of large, method of Horsley, 610- 616 resection of small, method of Horsley, 605- 609 Intestinal resection, 603-622 suturing, 585-589 Intratracheal anesthesia, 433, 434 Intravenous infusion of Locke's solution or salt solution, 66, 67 Jackson, operation for cancer of mammary gland, 469 for pericolonie bands, 638 Jaw, lower, operations on, 254-258 ankylosis of, 256-258 method of Esmarch, 257, 258 defects in, 206-208 operation of Blair for deformities of, 255, 256 upper, operations on, 252-254 operation of Binnie for excision of, 253, 254 operation of "Weber for excision of, 252 253 Jones, method of arthrodesis of elbow, 355, 356 method of transplantation of tendons, 392-401 Jonnesco, o])eration for cancer of mammary glands, 469 ,ludd, incision for operation on double ingui- nal hernia, 513. 514 Judd, operation on diverticulum of esoph- agus, 322, 323 K Keen, operation for puncture of ventricle, 275 Kidney, operations on, 663-674 congenital cystic, method of Lund, 669, 670 fixation, 664-666 incisions for, 510-512 Kimpton and Brown, method of transfusion of blood, 65 Kirk and Lewis, regeneration of nerves, 141 Knee joint, amputation at, 379, 380 method of Gritti-Stokes, 380, 381 method of Stephen Smith, 379, 380 arthroplasty of, 420 excision of, 415 excision of semilunar cartilage from, 413, 414 operation for foreign bodies in, 414 Knots, tying of, 47-50 :nethod of Grant, 48-50 Kondoleon operation for elephantiasis, 427, 428 for lymph edema of arm, 368 for local edema, 38 Laminectomy, 290-296 LaEoque, operation for inguinal hernia, 490- 493 Larynx, operations on, 316-321 Laryngectomy, 318-321 method of Bevau, 318-321 Laryugotomy, 316 LeCoute, operation for amputation of upper extremity, 349, 350 Leg, amputation of, 376-379 method of Hey, 376, 377 Lespinasse, operation on vas deferaus, 701-703 Lewis, Dean, operation on mammary gland, 464, 465 reconstruction of tendons and fingers, 361- 363 regeneration of nerves, 141 regeneration of tendons, 362 use of fascial tube in suturing nerves, 145, 146 Lewis and Huber, method of prevention of neuromas, 334 LeT\-isohns, citrate method of transfusion of blood, 66-68 Lexer, excision of aneurism, 75 Ligation of blood vessels, 97-117 method of Binnie, 98, 99 abdominal aorta, 110 anterior tibial artery, 116 718 INDEX Ligation of blood vessels — Cont'd axillaiy artery, 108 brachial artery, 109 common carotid artery, 101, 102 common iliac artery, 110, 111 dorsalis pedis artery, 116 external carotid artery, 102, 103 external iliac artery, 112, 113 femoral artery, 113-115 innominate artery, 100, 101 internal carotid artery, 105 internal iliac artery, 111, 112 inferior thyroid artery, 107 popliteal artery, 115, 116 posterior tibial artery, 117 radial and ulnar artery, 109, 110 subclavian artery, 105-107 superior thyroid arteries, 104 vertebral artery, 107 Ligation of femoral vein for threatened gan- grene, 95, 96 Ligature material, 45-47 Lindemann, method of transfusion of blood, 65, 66 Lips, operations on, 198-210 lower, 200-205 mucosa of, 206-208 upper, 198-200 Liver and bile tracts, operations on, 520-535 operation on abscess of, 520, 521 on cirrhosis of, 534, 535 on tumors of, 521, 522 Long, J. W., method of enterostomy, 589-592 operation for pericolonic bands, 638 Lower extremity, amputation of, 370-385 neuromas in amputation of, 370 general principles in amputation of, 370, 371 operation on tendons of, 385-401 transplantation of, 387, 388 Lumbar puncture, 288-290 Lund, operation for congenital cystic kidney, 669, 670 Lungs, operations on, 443-458 abscess of, method of Bevan, 444-458 resection of, 447-451 method of Robinson, 447-451 Lymph circulation, reversal of, 35-43 Lymph edema of arm, operation for, 366-368 methods of Kondoleon, 368 Lymphatic glands of neck, 310-312 M Mammary gland, operations on, 462-476 for cancer of, method of Halsted, 467- 469 method of Jackson, 469 method of Rodman, 470-476 for hernia of, method of Harris, 465- 467 general princij)les of, 462, 463 method of Dean Lewis, 464 method of Warren, 463 Mann, Frank, on sequestration anemia, 58 Matas, treatment of aneurism, 122-125 treatment of aneurism by gradual oblitera- tion, 119, 120 treatment of arteriovenous aneurisms, 135 metliod of endo-aneurismorrhaphy, 123-125 Mayo, C. H., operation for cancer of rectosig- moid, 640-646 operation on cervical sympathetic, 325, 326 operation on harelip, 188 operation for hallux valgus, 405 operation for hypospadias, 709, 710 operation on thyroid gland, 327-329 operation on varicose veins, 429, 430 Mavo, W. J., incision for nephrectomy, 663, 664 method of Kraske 's excision of rectum, 641- 644 operation for incisional or ventral hernia, 503 operation for reconstruction of bile duct, 533, 534 operation for umbilical hernia, 499-502 Meckel, diverticulum of intestine, 618, 619 Mediastinum, oi^eration for tumors in, 451, 452 Meningocele of brain, 277-279 Metal in bone plating, 160, 161 Metatarsal bones, excision of, 573, 574 Mischowitz, operation for prolapse of rectum, 649, 650 Mixter, method of sigmoidostomy, 602 operation on stricture of esophagus, 323 Mosetig-Moorhof, filling, 423 Mouth, operation on angle of, 205, 206 Murphy, John B., transplantation of tendons in finger, 364-366 transplantation of tendons in forearm, 364- 366 transplantation of tendons in wrist, 364-366 MC McArthur, operation on hypophysis, 275, 276 Macewen, needling of aneurisms, 118 N Nail, ingrowing, oj^erations for, 406, 407 Neck, operations on, 303-330 arrangement of lymphatic glands in, 310- 312 block dissection of, 312-316 block operation on, method of Crile, 312- 316 branchial cysts of, 305 branchial fistula of, 305 cancer of, 310-316 cysts of, 304-308 diffuse lipoma, 324, 325 general principles of, 303, 304 malignant gro^rths of, 310-316 metastatic cancer of, 312-316 tuberculous glands of, 309, 310 method of Dowd, 309 to 310 Nephrectomy, 666-670 incision of W. J. Mayo for, 663, 664 subscapular, 668 INDEX 719 Ncpliropi'xy, (i(i4-G60 Nophrotoiny, ()70, (i7l Norvos, operations on, 141-1;")G bridoini^- defects, 146-150 facial, repair of, 150-153 facial, operations on, 153 reoeneration of, method of Kirk and Lewis, 141 repair of defect of, method of Elsberg, 146-148 treatment of amputation, 334 use of fascial tube in suturing, method of Dean Lewis, 145, 146 bi'achial plexus, 153-155 method of Sharpe, 154, 155 brachial plexus paralysis, transplantation of muscles for, 155 to 156 Neuralgia of 5tli nerve, peripheral operations for, 258-260 Neuroma in amputation of lower extremity, 370 in amputation of stumps, prevention of, method of Huber and Lewis, 334, 370 Nose, operations on, 224-235 operation on columna of, 228 reconstruction of ala, 225-228 method of Baldwin, 232, 233 bv Indian method, 229-231 by Italian method, 231, 232 ' ' saddle ' ', operations for, 234-236 O Ochsner, operation on stricture of esophagus, 323 Orbital socket, operation of J. S. Davis on, 220-222 Osteotomy, 417-420 cuneiform, 418 method of Macewen, 417, 418 method of Ogston, 419, 420 method of Reeves, 419, 420 Osteomyelitis, operations for, 421-426 method of Mosetig-Moorhof, plug in, 423 Owen, operation on harelip, 190, 191 Pancreas, operation for cancer of, method of Coffey, 535-538 operation for cyst of, 539 Pancreatitis, operation for, 38, 539 Parotid gland, operations on, 240-245 Patella, operation for chronic dislocation of, method of Goldthwait, 413 Penis, operations on, 707-712 amputation of, 711, 712 excision of, 711, 712 Percy, method of transfusion of blood, 65, 66 Pericardium, operations on, 452, 453 Pericolonic bands, 637-639 Peritoneum, drainage of, 36, 37 foreign bodies in, 42 irritating lubricants in, Cubbins and Abt, 74 Peroneus, traiisi)hintatiou of tendons of, 389- 394 Pfannenstiel, incision of, 509, 513, 514 Pharynx, operations on, 321, 322 Pharyngotomy, 321, 322 Physiologic principles in surgical operations, 29-34 Plastic surgery, principles of, 172-186 defects in, 175-178 development of blood supplv of pedicle in, 175, 178-181 "jumping" and "waltzing" flaps in, 180 suture in, 45-47 treatment of depressed scars, method of Es- ser, 186 treatment of pedicles of flaps in, 175, 178- 181 tubing pedicle in, 178-180 types of operations in closing defects in, 175-178 Plating of bone, 160, 161 Pneumothorax, artificial, 449-451 Polya-Balfour excision of stomach, 574-578 Prostate gland, operations on, 690-700 Prostatectomy, 690-700 operation for cancer of, method of Young, 697-700 perineal, method of Young, 695-697 suprapubic, 691-694 Pruritis ani, operations for, 659 to 661 method of Terrell, 659-661 Pulmonary embolism, operation for, 454-458 method of Trendelenburg, 454-458 Pyelotomy, 671 to 674 Pylorus, congenital stenosis, operation for, 581-584 method of Rammstedt, 582 method of Strauss, 582 to 584 Pyloroplasty, according to Finney, 549-551 according to Heiueke-Mikulicz, 551 according to Horsley, 552-564 E Eammstedt, operation for congenital stenosis of pylorus, 582 Reconstruction of the bile duct, 34 Seid, treatment of aneurism, 120 method of locating centers in the brain, 265 Rectum, operation for abscess of, 650 for cancer of, 639-648 for eaz-ly cancer of, method of Bevan, 645-648 for fistula of, 650-652 Kraske's excision, method of W. J. Mayo, 641-644 for prolapse of, 646-650 method of Moschcowitz, 649, 650 for stricture of, 652, 653 for ulceration of, 652, 653 Rectosigmoid, operation for cancer of, 639- 643 method of C. H. Mayo, 640-646 Reverdin, method of skin grafting, 182 Reversal of circulation of blood, 30, 31, 92-90 method of Horsley, 92-95 720 INDEX Reversal of circulation of blood — ('out "d method of DeWitt Stetton, 93, 94 method of Wliitehead, 92-94 Reversal of lymph circulation, 35-43 Resection of abdominal aorta, experimental specimen, 89 Ribs, operations on, 432-443 cervical, 308 typhoid, operation for, 43(i, 437 Rinkenberger, F. W., method of location of centers of brain, 265, 266 Robinson, operation for chronic empyema, 443 operation for resection of lung, 447-451 Rodman, operation for cancer of mammary gland, 470-476 Rose, operation on harelij?, 188-190 Roiix, operation of gastroenterostomy, 569 Russell, oi^eration on hypospadias, 709-711 S Sacral dermoid, operation for, 661, 662 Salivary fistula, operations for, 240-242 Scalp, operations on, 261-264 Scapula, excision of, 560, 561 Sears, depressed, method of treatment, 186 gradual excision of, 172, 173 Sciatic nerve, operation for neuralgia of, 430, 431 Sciatica, operation for, 430, 431 Scrotum, redundant, resection of, 706 Seelig, operation for femoral hernia, 495-497 Semilunar cartilage, excision of, 413, 414 Seminal vesicles, operations on, 700 method of Cunningham, 700 method of Fuller, 700 Sequestration anemia in surgical operations, 57, 58 Sharpe, method of operation on brachial plexus, 154, 155 Shock in sui'gical operations, 54-56 Shoulder joint, amputation at, 347-349 excision of, 353-355 Sigmoid, operation for cancer of, 639-643 Sigmoidostomy, 602 method of Mixter, 602 Sistrunk, operation on thvroglossal cvsts, 305-308 operation on thyroglossal fistula, 305-308 Skin grafting, 34, 173, 174, 180-186 contractions after, 173, 174 method of J. S. Davis, 182 method of Reverdin, 182 method of Thiersch, 180-184 method of Wolfe-Krause, 184-186 transplantation of whole, 180, 184-186 Skull, operations on, 261-287 control of hemorrhage from, 264 old depressed fractures of, 269-272 osteoi)lastic flap of, 263-265 Spine, operations on, 288-302 lumbar puncture of, 288-290 Spina bifida, 296-302 classifications of, 296-298 operations on, method of Albee, 301-302 method of Babcock, 300-302 Spina bifida, (l() Tlii-onil)iis foniiatiou in sulurins' blood ves- sels, 70, 7-1 Thyroid gland, operations on, 32l)-3o0 method of Balfour, 330 method of Bartlett, 330 method of C. H. Mayo, 327-329 Thyroglossal cysts, operations on, 305-308 method of Sistrunk, 305-308 fistula, operations on, 305-308 method of Sistrunk, 305-308 Toes, amputation of, 371-373 operation for ingrowing nail of, 406, 407 Tongue, oj)erations on, 245-251 excision of, method of Ashhurst, 246, 249 method of Blair, 249-251 Torticollis, 308, 309 Trachea, operations on, 316-318 Tracheotomy, 316-317 Transfusion of blood, 59-68 citrate method of Lewisohn, 66-68 method of Bernheim, 64, 65 method of Crile, 62 method of Horsley, 60, 77-86 method of Kimpton and Brown, 65 method of Lindemaun, 65, 66 method of Percy, 65, 66 Transplantation of organs, 34 Trendelenburg, operation for pulmonary em- bolism, 454-458 Trifacial nerve, jDeripheral operations on, 258- 260 Tuberculous glands of neck, 309, 310 Tuberculous peritonitis, treatment of, 30 Tubing pedicle in plastic surgery, method of Gillie, 178, 180 Tying knots, 47-50 Typhoid rib, operation for, 436, 437 U Umbilical hernia, operations for, 499-502 Ununited fractures of bones, 166-168 Upper extremity, ox^erations on, 331-369 Ureter, operations on, 331-369 transplantation of, 678-683 Urethrotomy, external, 688, 689 V Varicose veins, operations for, 428-430 method of C. H. Mayo, 429, 430 Varicocele, operations for, 701-707 method of Lespinasse, 701-703 Vas deferens, operations on, 701-703 Vein, varicose, operations for, 428-430 Ventricle, brain, puncture of, 275 Ventral hernia operations for, 502-504 W Warren, operation on mammary gland, 463 Web fingers, operations for, 360, 361 Weber, operation for excision of upper jaw, 252, 253 Weir, operation for ' ' trigger ' 'finger, 359 Whitehead, E. H., on reversal of circulation, 92-94 Willis, operation for cholecystectomy, 527 Wolff's laAv in bone grafting, 158 Wolfe-Krause, method of skin grafting 173, 184-186 Wrist joint, excision of, 350, 351 Wrist, transplantation of tendons of, method of Murphy, 364-366 Wry neck, 308, 309 Wyeth, amputation at hip joint, 383, 384 Y Young, H. H., operation for cancer of pros- tate, 697-700 method of perineal prostatectomy, 695-697 COLUMBIA UNIVERSITY Tliis book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangeinent with the Librarian in charge. DATE BORROWED JV.UV I a m DATE BORROWED C2ei638IM50 COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD 32 H78 C.1 Operativii ■iiniii 2002105675 *»'« i 7 1922 v3k ><>>«^ <^ O ^ [tC^